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Histopathology

Introduction

Surgical, anatomical and consultative pathology services are available through pathologists in the Division of Pathology. The services available include:

  1. Routine surgical biopsies
  2. Frozen section service / Mohs surgery
  3. Specialised biopsies (e.g. renal biopsies, bone marrow trephine biopsies, gastrointestinal biopsies, liver biopsies)
  4. Immunofluorescence for renal and skin cases
  5. Immunohistochemistry
  6. Electron microscopy
  7. Tissue preparation for Polymerase Chain Reaction (PCR)/Molecular
  8. Autopsy service
  9. Tissue for crystal detection (preferably without fixative)
  10. Consultation Service

Special instructions on Specimen Handling

  • Specimens are to be sent in clean leak proof containers placed within sealed bags or double sealed leak proof bags completely immersed in 10% buffered neutral formalin (volume of 10% buffered neutral formalin are to be at least double the volume of the specimen) unless otherwise indicated. Lymph nodes and samples requiring additional tests such as PCR and Fluorescence in situ hybridisation (FISH) are to be fixed in formalin as well. Specimens for immunofluorescence microscopy are to be sent fresh without fixative to the laboratory immediately to prevent drying up of tissues. Specimens for electron microscopy are fixed in 2.5% glutaldehyde.
  • Label each container or bag with the correct corresponding electronic barcode label.
  • Specimens requiring urgent reporting should be labelled 'URGENT' at 'Special Instruction' and dispatched immediately.
  • Specimens should be delivered in its entirety without any removal of parts thereof without the approval of the pathologist.
  • There should be one specimen per container appropriately labelled with correct corresponding electronic barcode label.
  • Multiple small specimens, such as gastrointestinal biopsies, should be mounted on a piece of filter paper and properly labelled.  In the CPOE system, clear indication should be made as to where the specimens are taken from.
  • Large specimens such as small and large bowel resection are to be cut opened with faecal contents removed prior to dispatch.  The specimens should be immersed in 10% buffered neutral formalin.
  • For specimens where orientation is important, mark or tag the specimen and resection margins with sutures. Indicate this information in the CPOE system.
  • Do not force a large specimen into a smaller container.  Large specimen must be completely immersed in formalin for proper fixation.
  • Do not crush specimens with forceps, hemostats or other instruments.  Avoid extensive cautery when possible.
  • Cold ischemia time should be indicated in the CPOE order under "Routine> Site & Nature of Specimen". E.g. 1) BREAST LUMP LEFT [Spec Out : 17:20:00][Spec Fix : 17:25:00]
  • For submission of prepared blocks/slides, please securely submitted blocks/slides in a container labeled with two identifiers, if blocks/slides only contain one identifier.
  • All specimens are collected in their respective centres for collective delivery to the Histopathology Laboratory.
  • Specimens for routine histopathology examination are delivered by porter from the respective departments to the Histopathology Laboratory.
  • DO NOT DISPATCH SPECIMENS VIA THE PNEUMATIC TUBE SYSTEM (PTS). Staff at Histopathology laboratory will acknowledge receipt of specimens by signing the dispatch list that accompanies the specimens.

The Histopathology Request Form

All specimens are to be accompanied by barcode labels (CPOE- Computerised Physician Order Entry system).

Quickguide Doctor CPOE HistoCyto - OT.pdf

Quickguide CPOE HistoCyto - Clinic_Ward.pdf

Information entered into the CPOE system must include:

  • Patient's name, NRIC number, visit account number, age and sex
  • Hospital, department and ward number, or name of clinic
  • Clinical Diagnosis
  • Clinical summary/ procedure
  • Nature of specimen, anatomical site, and date and time specimen taken
  • Name of consultant-in-charge, doctor performing procedure and their MCR number

The following are also useful information:

  • Operative findings
  • Treatment rendered
  • Provisional diagnoses
  • Previous biopsy number or date of previous operation, if any
  • Additional tests required

Submit one electronic order for the same patient at the same operation, irrespective of the number of specimens. Make sure "Specimen Label Completed" and "Vetted & Order form completed (Dr Only)" are ticked before despatching specimens.

Additional tests ordered (immunohistochemistry, molecular, FISH or special stain), after a case has been reported, are to be accompanied by a hardcopy Histopathology request or CPOE order. The request form must include:

  • Patient's name, NRIC number, visit account number, age, date of birth and sex
  • Hospital, department and ward number, or name of clinic
  • Name of consultant-in-charge, doctor performing procedure and their MCR numbers
  • Any additional important information not previously presented

Criteria for Unacceptable Samples

The laboratory cannot process the specimen if the request form is incompletely filled or if data are discrepant. This will result in delay of the turnaround time for the histopathology report.

Examples of criteria for Unacceptable Samples

Insufficient Specimen – Insufficient specimen to perform analysis.

Specimen Leaked – Container improperly secured.

Specimen Leaked – Broken Container.

Mislabelled – Serial number on specimen and request form do not correspond.

Mislabelled – Name/NRIC no. on specimen and request form do not correspond.

Mislabelled – Test(s) requested on specimen and request form discordant.

Mislabelled – Incomplete patient data.

Mislabelled – No Label on specimen and/or request form.

Mislabelled – Request form/ specimen label incomplete or illegible.

Specimen Problem – Wrong/ unsuitable sent.

Specimen Problem – Specimen not taken/ Swab stick seal not broken/ empty container.

Specimen Problem – Swab dried out/ no transport media used.

Specimen Problem – Specimen without request form/ Request form without specimen.

Specimen Problem – Specimen sent is not suitable for the test(s) requested.

Specimen Problem – Unsuitable specimen.

Miscellaneous Reasons – Test not offered by SGH laboratories.

Miscellaneous Reasons – Test cancelled

Specimens for amendments should not be sent through the porter with effect from Sep 2017. This is to mitigate any loss of specimen. Telephone/ email to inform the respective department/ ordering clinician to rectify the discrepancy on site at the laboratory. Histology orders requiring amendment will be rejected for documentation and a new histology order should be made. Staff making correction on site is to fill up the "Collected/ Amended By" section.

Name of Staff nurse, location, telephone number, technologist rejecting and reason sent to EMR.

Collection through Central porter/ Transport services/ E-porter

  1. The ward/ department inform the Lab staff over the phone that they will be using central porter/ transport services/ E-porter to collect the rejected requests and specimen.
  2. Lab staff to ask for a verbal agreement from the ward/ department that the porter collecting the specimen is authorized to collect the rejection request on their behalf.
  3. When the staff arrives for collection, they are to fill up the "Collected By" section of the rejection form. The authorization section at the bottom of the rejection form is then filled up by the Processing I/C with the necessary details of the ward/ department staff and the porter.

EQA

Histopathology

Disciplines  Programme Title Frequency
Histopathology College of American Pathologists Performance Improvement Program in Surgical Pathology (PIP) 4 times/year
College of American Pathologists Immunohistochemistry Survey 2 times/year
NSH/CAP Histo QIP 2 times/year
CAP Her-2 immunohistochemistry, tissue microarray 2 times/year
CAP In Situ Hybridisation Survey 2 times/year
CAP DNA mismatch repair by immunohistochemistry 2 times/year
CAP CD117 1 time /year
CAP ER and PR 2 times/year
CAP CD20 1 time/year
CAP PDL1 1 time/year
CAP Anaplastic Lymphoma Kinase IHC 1 time/year
CAP/NSH Gynecologic Biopsy 2 times/year
CAP/NSH HistoQIP Mismatch Repair IHC 2 times/year
HQIP Non-small Cell Lung Carcinoma IHC

2 times/year

Routine Biopsy Specimens

Specimens submitted for routine histology are categorised as indicated below, with a separate charge for each category. Multiple charges apply for multiple containers submitted.

Specimen Categories

SMALL
Abscess
Appendix
Breast lump (<4cm)
Cyst
Ear bx
Fibroma
Gall bladder
Ganglion (hand/feet lump)
Keloid
Lipoma (<4cm)
Margin (<4cm)
Mass
Nodule
Polyp (non-GI)
Product of conception
Proximal/Distal Donut
Skin
    mole/papilloma/wart
    lesion/lump/cyst/naevus/shave/BCC/SCC
    (all skin type except for punch)
Vas
Vocal cord
Tonsil
Wedge bx (lung/liver)<4cm

 

SPECIALISED
Aortic valve
Artery bx
Basal cell ca (BCC) (<4cm)
Bone
Duodenum bx
Bone, exotosis
Brain
Breast trucut
Bronchial bx
Cervix bx
Colonic bx
Cornea
Duodenum bx
Esophagual bx
Gastric bx
Gynaecological specimen
       Endometrial Curetting
       Cervical/ Endocervical Biopsy
       Vagina Biopsy
       Vulva/labial biopsy
       Fibroid Polyp
Heart bx/ valve
Liver bx
Lung bx
Lymph node (<3cm)
Mitral valve
Muscle bx
Myocardium bx
Nerve bx
Oral and nasal cavity
       Buccal
       Choana
       Ear Canal
       FESS
       Hard palate
       Larynx
       Lip
       Maxilla
       Nasopharynx
       Post Nasal Space/ PNS
       Paranasal sinus
       Septum
       Soft palate
       Tongue
       Turbinate
       Tonsillar mass, etc.
Pancreas bx
Parathyroid gland
Pericardium bx
Pituitary
Pleural bx
Polyp from GIT (<4cm)
Prostate TRUS
Renal bx
Salivary gland bx
Skin punch
Small intestine bx
Stomach bx
Transbronchial bx
Ureter bx
Urethra bx
Urinary bladder bx

 

LARGE
Thyroid gland
Bowel resection (benign) e.g. Ischemia, sleeve
Cervix cone/ LEEP
Endoscopic Mucosa Resection / Endoscopic submucosal Dissection (any size)
Eye, enucleation
Femoral head
Finger
Ovary & Tube (Any Size)
Prostatic chips (TURP) (>2 blks)
Toe
Uterus (benign)
Lymph node (>3cm)

 

COMPLEX
Bone resection
Breast ca (mastectomy/wide excision-any size)
Colon ca (total/partial)
Esophagus (total/partial)
Fetus, w/dissection
Hand
Head and neck (tongue, maxilla)
Heart
Kidney (total/partial)
Larynx (total/partial)
Leg
Liver ca (total/partial)
Lung ca (total/partial)
Pancreas (total/partial/Whipple's)
Placenta
Prostate, radical resection
Radical neck dissection
      (Each main specimen to charge as one complex, disregard number of bottles)
Small intestine tumour
Soft tissue tumour (extensive resection)
Stomach (total/partial)
Urinary bladder (total/partial)
Uterus with cervix ca/CIN
Uterus (endometrial tumour)
Uterus tubes & ovaries for ovarian tumour
Vulva (total/subtotal)

Specialised Investigations

Type of Examination and Their Submission Requirements

Frozen Section

  1. The circulating nurse places the specimen for frozen section examination into a properly labelled container without preservative. Specimens from different sites requiring separate diagnosis should be placed in individual containers and labelled appropriately.
  2. The operating room number and telephone number must be included in the CPOE system.
  3. The attending pathologist is stationed at the Frozen Section room in the operating theatre suite from 8.30 am to 5 pm from Monday to Friday. Tel No. 6321 3530/3763.
  4. For exceptional request for Frozen Section support on Saturday morning, the requesting surgeon will have to make special arrangement with the pathologist-on-call the day before. Alternatively, in special circumstances after office hours, the on-call technologist and pathologist can be reached by phone.
  5. The specimen with correct CPOE order information and the frozen section dispatch book must be submitted to the attending pathologist stationed at the Frozen Section room. Acknowledgement of receipt of specimens will be made by signing the dispatch book.
  6. Once the result is ready, the pathologist will either call the operating room for the report to be collected or deliver the report personally.
  7. The report will then be filed in the case notes if no further investigation is required.
  8. Additional specimens obtained for routine histology from the same patient are dispatched according to "Special instructions on Specimen Handling".

Liver Biopsies

  1. Place in container with 10% buffered formalin.

  2. Label containers and complete Histo CPOE order.

Muscle and Nerve Biopsies

1. Notify the lab at least TWO days in advance of procedure. The following persons are to be notified:

a. Chua Huimin, Medical Laboratory Scientist: (HP) 93638905 email: chua.hui.min@sgh.com.sg

b. Lee Ming , Consultant Pathologist: (HP) +65-81257461 email: lee.ming@singhealth.com.sg

2. Procedure for obtaining and sending  biopsies:

    A surgeon familiar with the procedure should perform the muscle biopsy.

a. Technical pointers: Ideally, two strips of muscle approximately 2 cm x 0.5 cm are obtained. The long axis of the specimens should parallel to the direction of the muscle fibers. Where possible, aim for the belly and avoid myotendinous junctions. . A muscle that is moderately but not severely affected should be used for the biopsy. Prior discussion with the neurologist is helpful.  Avoid using muscle that has been probed with an EMG needle. Avoid electrocautery completely when opening muscle and harvesting the specimen. If using local anaesthetic, ensure the muscle is not directly injected. ,

b. Ideally, schedule the biopsy early in the morning so that specimen arrives at the Pathology Laboratory before 12 noon.

c. It is preferable that the specimen be delivered fresh STAT or within one hour after excision. Wrap the muscle in a piece of saline-moistened gauze (moistened, not soaking wet) and place it in a container or plastic bag. DO NOT IMMERSE BIOPSY SAMPLES IN  NORMAL SALINE. Send immediately to: Specimen Reception, Department of Anatomical Pathology, Level 10 Diagnostics Tower, Academia

d. If biopsy done outside SGH campus and specimen will take more than 1 hour but less than 3 hours to arrive, use the method in c, but transport the specimen in a cooler box filled with ordinary ice. ENSURE THAT THE MUSCLE DOES NOT COME INTO DIRECT CONTACT WITH THE ICE.

Gastrointestinal Biopsies

These have different charges depending on the number of specimens.

  1. Gastrointestinal biopsies are best orientated so that the plane of sectioning is perpendicular to the mucosal surface. Whenever possible, endoscopic biopsies of the gastrointestinal tract should be mounted on to a piece of filter paper, numbered and put immediately into fixative.
  2. The anatomical sites of the biopsies should be clearly entered into CPOE order and the specimens similarly numbered on the strip of filter paper.
  3. Preferably, biopsies from different anatomical sites e.g. stomach, ascending colon, transverse colon etc, should be placed in separate containers.

Surgically Resected Gastrointestinal Specimens, e.g. Colon, Stomach

  1. The specimen should be opened and the contents cleaned out. 
  2. Immerse the entire specimen in 10% buffered formalin. The volume of 10% buffered neutral formalin should be at least 10 times the volume of the specimen as recommended  by the College of American Pathologists. Make sure that the entire specimen is submerged completely in formalin.

Renal Biopsies

  1. Label containers and complete Histo CPOE order.
  2. Renal biopsies are subjected to examination by light microscopy, electron microscopy and immunofluorescence. After the biopsy is done, samples must be divided carefully using a sharp blade to avoid crush artefact. A dissecting microscope is helpful in identifying tissue with glomeruli. The pieces of tissue are to be placed as quickly as possible into suitable containers with appropriate fixatives as indicated:
    (a) Light microscopy – modified Bouin's fluid (Dubossey fixative)
    (b) Electron microscopy – 2.5% glutaraldehyde in cacodylate buffer (the time for which the tissue is placed into fixative must be recorded)
    (c) Immunofluorescence – Fresh tissue is required. Specimen is wrapped in aluminum foil, placed in a cryotube and delivered to the lab on ice. Contact the laboratory (Tel: 6321 4008) for further information, if necessary.

Testicular Biopsies

  1. Submit specimens in Bouin's fluid. It may be necessary to contact the laboratory (Tel: 6321 4008) for the necessary fixative.
  2. Label containers and complete Histo CPOE order.

Bone Marrow Trephine Biopsies

  1. Specimens should be placed in 10% buffered formalin.
  2. Label containers and complete Histo CPOE order.

Immunohistochemistry

Please raise a CPOE histopathology request with the following information or please fill up a histopathology request form with the following information:

  1. Patient's name, NRIC number, sex, age, date of birth
  2. Clinical diagnosis, relevant clinical information
  3. Specimen type:
    • For SGH specimens please provide Biopsy number/Or nature of specimen and when the specimen was taken
    • For external material: Please arrange for material to be sent to SGH Histolab
  4. Name of consultant-in-charge with MCR number, clinic, telephone/fax number
  5. Test required
  6. Please ensure that all compulsory fields in CPOE are filled up and the relevant boxes are ticked "Y" before saving and sending the CPOE order
  7. Print the CPOE labels and send to SGH Histolab via e-porter (labels only)

Contact laboratory (Tel: 6321 4956) for stains or for further information, if necessary.

Immunofluorescence

Fresh tissue is required. Specimen is wrapped in aluminium foil, placed in a cryotube and delivered to the lab on ice. Contact the laboratory (Tel: 63214008) for further information, if necessary.

Electron Microscopy

Specimen is placed in 2.5% glutaraldehyde in cacodylate buffer (the time for which the tissue is placed into fixative must be recorded).

Contact the laboratory (Tel: 6321 4008) for further information, if necessary.

Tissue Preparation for Polymerase Chain Reaction (PCR)/Molecular

Tests perform by Histomolecular and molecular lab:

EGFR Sanger Sequencing, EGFR COBAS Real time PCR, KRAS/BRAF, NRAS, BRAF V600E, BRAF Sanger Sequencing, MSI PCR, C-KIT (Exon 9, 11), C-KIT (Exon 13, 17), PDGFRA, T & B Cell Clonality test, TB PCR, SSTP(Somatic Solid Tumour Panel)

  1. Refer to Immunohistochemistry for creating CPOE order.
  2. Requirements for external materials for Molecular test:
  3. For requests from external institutes, please raise a memo with the same information as above in point 1 and a copy of pathology report. Please indicate the billing location.
  4. Upon receiving or retrieving of sample, Histopathology lab takes 4-5 working days to submit the sample to the respective laboratory for testing. Please check with the respective laboratory (Molecular lab, Translational Pathology Centre, Cytogenetic lab and Central TB lab) for turnaround time of individual test performed by them.

Sample requirements:

Test  Testing Laboratory Sample requirements Tumour content
EGFR Sanger Sequencing SGH Molecular Lab 1 HE, 8 unstains at 8µm for resections, non coated slides Minimum 30%
tumour content
1 HE, 12 unstains at 5µm for biopsies, non coated slides
EGFR Real Time PCR
(cobas)
SGH Molecular Lab 1 HE, 8 unstains at 8µm for resections, non coated slides Minimum 10%
tumour content
1 HE, 12 unstains at 5µm for biopsies, non coated slides
KRAS/BRAF SGH Molecular Lab Refer to requirement for EGFR Minimum 30%
tumour content
NRAS  SGH Molecular Lab Refer to requirement for EGFR Minimum 30%
tumour content
BRAF V600E SGH Molecular Lab Refer to requirement for EGFR Minimum 30%
tumour content
BRAF Sanger Sequencing SGH Molecular Lab Refer to requirement for EGFR Minimum 30%
tumour content
MSI PCR SGH Molecular Lab Please provide both tumour and normal tissue Minimum 30%
tumour content
1 HE, 8 unstains at 8µm for normal
1 HE, 8 unstains at 8µm for tumour
C-KIT (Exon 9,11) SGH Molecular Lab Refer to requirement for EGFR Minimum 30%
tumour content
C-KIT (Exon 13, 17) SGH Molecular Lab Refer to requirement for EGFR Minimum 30%
 tumour content
PDGFRA SGH Molecular Lab Refer to requirement for EGFR Minimum 30%
tumour content
T or B Cell
Clonality
SGH Molecular Lab 1 HE, 8 unstains at 8µm for resections Minimum 1%
lymphocyte content
1 HE, 20 unstains at 5µm for biopsies/ bone marrows
1p19q FISH Cytogenetic Lab 1HE, 4 unstains on coated slides Minimum 100 nuclei
Lung Cancer FISH Panel Cytogenetic Lab 1HE, 8 unstains at 4µm on coated slides Minimum 100 nuclei
Her-2 FISH Cytogenetic Lab 1HE, 3 unstains on coated slides Minimum 100 nuclei
TB-PCR Central TB Lab 1 HE, 8 unstains at 8µm for resections, non coated slides Not applicable 
1 HE, 15 unstains at 5µm for biopsies, non coated slides
SSTP Translational Pathology Centre Refer to requirement for EGFR Minimum 30%
tumour content

Contact laboratory (Tel: 6321 4008) for further information.

Autopsy Service

Contact pathologist-on-duty (Tel: 6321 4008) for information on procedure.

Specimen Collection Services

SGH Operating Theatres


By Operating Theatre porters: 9.00 am & 3.00 pm (Monday – Friday) / 9.00 am only (Saturday)

Do not despatch specimens via the telelift system

SGH Specialist Outpatient Clinics, Endoscopy Centre, Wards and Diagnostic Xray


The porters from these departments will deliver the specimens to the laboratory.
Do not despatch specimens via the telelift system

Non-SGH sources


Send specimens to 
            20 College Road
            Academia
            Level 10, Diagnostic Tower
            Singapore 169856

Please call Tel: 6326 6632 or 63214008.

Turnaround Time


Type of examination Turnaround time
Routine Histopathology
Urgent Histopathology
2 – 3 days
12 hours
(NB: If specimen is small and sent before mid-day, results may be available in the same afternoon.)
Immunohistochemistry 5 days

An inadequately-filled histopathology request form will result in delay of turnaround time.

Click here to view all Histopathology tests

Last Modified Date :22 Mar 2019