Inappropriate Use of Immunostains

[zao275]

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After looking at almost 2 trays of immunostains on a single case, I felt that it was time for another "educational" video. It is a nice outlet for the frustration of looking at so many immunos, and hopefully it serves to teach a valuable lesson as well. Hope you all enjoy.

http://www.xtranormal.com/watch/7202985/

PS - By the way, this is not intended to be arrogant, insulting, or rude. It is a generalized (and exaggerated) version of real situations, but is not directed at any one individual. That is my disclaimer.

 

[TMZ2007]

After looking at almost 2 trays of immunostains on a single case, I felt that it was time for another "educational" video. It is a nice outlet for the frustration of looking at so many immunos, and hopefully it serves to teach a valuable lesson as well. Hope you all enjoy.

http://www.xtranormal.com/watch/7202985/

PS - By the way, this is not intended to be arrogant, insulting, or rude. It is a generalized (and exaggerated) version of real situations, but is not directed at any one individual. That is my disclaimer.

Two trays?! And this was a soft tissue case or an unknown primary or what?

 

[levels x3]

That was great! Even better than the vimentin video.

 

[gbwillner]

After looking at almost 2 trays of immunostains on a single case, I felt that it was time for another "educational" video. It is a nice outlet for the frustration of looking at so many immunos, and hopefully it serves to teach a valuable lesson as well. Hope you all enjoy.

http://www.xtranormal.com/watch/7202985/

PS - By the way, this is not intended to be arrogant, insulting, or rude. It is a generalized (and exaggerated) version of real situations, but is not directed at any one individual. That is my disclaimer.

LOL!!!! keep it up!!!!

PS- why on earth didn't they order Melan-A? Surely their lab had it. Both brown AND red. I mean really...

//I'm sure not every lab stops billing patients after the 10th immunostain.

 

[pathstudent]

The most I have ever seen on one case was 62. It was a case that was worked up by Mayo. That would take 4 trays.

Mayo probably charges 300 or so for the global on an immuno, Medicare only pays about 100 (if the patient was medicare). That would be over 6000 dollars and about 50+ immunos were negative. Can you imagine collecting over 5000 just to read 50 blank immunos?

 

[LoaLoa]

Two months ago, I would have empathized with the resident, but now after a couple of months of signing out . . . .. . how quickly i forget.

 

[deleted314957]

I look back on a number of cases over the years where I had an embarassing number of immunos and it was often a screw-up on my part. Either chasing a truly positive keratin case that had, for one reason or another, a false negative ( and then you are really screwed) or mis-interpreting one of the "guiding" immunos and you are equally screwed.

 

[zao275]

I look back on a number of cases over the years where I had an embarassing number of immunos and it was often a screw-up on my part. Either chasing a truly positive keratin case that had, for one reason or another, a false negative ( and then you are really screwed) or mis-interpreting one of the "guiding" immunos and you are equally screwed.

You make a really good point. One misinterpreted or suboptimal (read- "didn't work") stain can cascade into a wild goose chase. The plus side of seeing all of these immunos is that I am starting to feel pretty comfortable with how to interpret them and what to do when something unexpected happens. I am trying to post the things I am learning on the Immunostain Wiki (http://pathinfo.wikia.com/wiki/Pathology_Immunostain_Wiki). I will also post a lot of pics of normal and tumor with various stains (as soon as I finish my USCAP abstract!). So keep checking there for updates (don't worry, I will spam SDN like I usually with a post about new info on the wiki! 😉 )

@TMZ2007: Yes, it was one case. A sarcoma. Most people are more reasonable, but getting 20+ immunos on a soft tissue consult case is fairly common. Don't get me wrong...some cases do need a lot of stains, such as when there is focal but true staining for keratin, and you are trying to decide if it is a metastatic carcinoma versus a primary sarcoma with some keratin expression. That diagnostic difference is a big deal for the patient's treatment. But sometimes the stains are ridiculous and outlandish (as I tried to illustrate in the video), and I can't for the life of me figure out why people are ordering them. CD117 (ckit) seems to be very popular...on just about any spindle cell tumor in any location! I still don't know why that trend exists, but it seems that pathologists just love to order ckit. I have still never seen a GIST in the skin, but I have looked at plenty of negative ckit immunos on spindle cell tumors in the skin!

@pathstudent: I have never seen 62 stains. That is insane. What was the diagnosis? Was it a hemepath case?

Thanks for the feedback, everyone! I thought maybe I was getting too nerdy but since you all seem to like these, I might try to make another one sometime soon. Any ideas for possible topics? I am running out of things to poke fun at (surprising, I know!).

 

[zao275]

LOL!!!! keep it up!!!!

PS- why on earth didn't they order Melan-A? Surely their lab had it. Both brown AND red. I mean really...

//I'm sure not every lab stops billing patients after the 10th immunostain.

In the video, I used Mart-1, which is another name for Melan-A. These stains all have too many names!

 

[malchik]

Agree with your observation about kit. In the same vein, there is also an overrepresentation of academic pathologists doing research with kit and kit-related things as I noticed at least year's USCAP. Is it because "kit" is such a catchy and fun word to say, with possibilities for off-color jokes and allusions?

 

[zao275]

Agree with your observation about kit. In the same vein, there is also an overrepresentation of academic pathologists doing research with kit and kit-related things as I noticed at least year's USCAP. Is it because "kit" is such a catchy and fun word to say, with possibilities for off-color jokes and allusions?

At least the research I understand, because there is a potential treatment for tumors that express kit. But using it diagnostically is a different story. Good for GISTs, and also for mast cell disease, some germ cell tumors, and maybe myeloid leukemias (i think, but I am not a hemepath). And, yes, it is fun to say, too. Although DOG1 is also an interesting name (and it works pretty well).