The surgical pathology laboratory in Mwanza, Tanzania: A survey on the reproducibility of diagnoses after the first years of autonomous activity

Background: In 2000, an Italian non-governmental organisation (NGO) began a 9-year project to establish a surgical pathology laboratory at the Bugando Medical Centre (BMC) in Mwanza, Tanzania, a country with a low Human Development Index (HDI), and as of 2009, the laboratory was operating autonomously. The present survey aims to evaluate the reproducibility of histological and cytological diagnoses assigned in the laboratory's early years of autonomous activity. We selected a random sample of 196 histological and cytological diagnoses issued in 2010-2011 at the BMC surgical pathology laboratory. The corresponding samples were sent to Italy for review by Italian senior pathologists, who were blinded to the local results. Samples were classified into four diagnostic categories: malignant, benign, inflammatory, and suspicious. The two-observer kappa-statistic for categorised (qualitative) data was then calculated to measure diagnostic concordance between the local Tanzanian pathologists and Italian senior pathologists. The k-Cohen was calculated for concordance in the overall study sample. Concordance and discordance rates were also stratified by subset: general adult, paediatric/adolescent, and lymphoproliferative histopathological diagnoses; fluid and fine needle aspiration (FNA) cytological diagnoses; and PAP tests. Discordance was also categorised by the corresponding hypothetical clinical implications: high, intermediate, and not significant. Results: Overall concordance was 85.2% (167 of 196 diagnoses), with a k-Cohen of 0.7691 (P = 0.0000). Very high concordance was observed in the subsets of adult general pathological diagnoses (90%) and paediatric/adolescent pathological diagnoses (91.18%). Concordance in the subset of PAP tests was 75%, and for fluid/FNA cytological diagnoses it was 56.52%. Concordance among 12 histological subtypes of lymphoma was 75.86%, with substantial discordance observed in the diagnosis of Burkitt lymphoma (five cases diagnosed by Italian pathologists versus 2 by local pathologists). The overall proportion of discordance with high hypothetical clinical implications was 6.1% (12 diagnoses). Conclusion: This blind review of diagnoses assigned in Tanzania, a country with low HDI, and in Italy, a country with a very high HDI, seemed to be a sensitive and effective method to identify areas of potential error and may represent a reference point for future, more detailed quality control processes or audits of surgical pathology services located in limited-resource regions

Small-cell osteosarcoma of the mandible. Case report

A case of small-cell osteosarcoma of the mandible in an 8-year-old girl is reported. This unusual variant may simulate Ewing's sarcoma and other small-cell neoplasms affecting jaws in children. The correct recognition of this type of tumor may be important for an appropriate choice of treatment

An Innovative Telepathology Solution For Developing Countries

INTRODUCTION / BACKGROUND: The increasing incidence of pathologies like tumors and infections is a significant public health burden in developing countries. The ability to provide early diagnosis, treatments, follow-up care has a strong impact on the survival. Telemedicine is of great utility in countries lacking appropriate healthcare facilities by allowing for the performance of good level healthcare practices. Sub-Saharan African Countries suffer a dramatic shortage of medical pathologists (in the range of 1 to 10 pathologists per 10 million people) and are also victims of digital divide. Vittorio Tison Association (Tison), IRST research cancer hospital and Patologi Oltre Frontiera NGO (APOF) cooperate in the sanitary mission founded in 1999 in Bugando Medical Centre (BMC), a hospital located in Mwanza, Tanzania. In that mission, during 2011 we started the development of our telemedicine project. The project utilizes a novel telematic platform oriented to several sanitary branches with a special focus in pathology and oncology. AIMS: The main project goals are: to provide ICT and TLC services between healthcare facilities in developed and developing countries; to allow for simultaneous telepathology counselling sharing microscopy and radiology images, conference calling, remote diagnosis, double-blind evaluation, second opinion and the remote control of medical instrumentation; to perform e-learning and remote quality control; to carry out GCP clinical trials through data collection, monitoring and evaluation; to encourage and support scientific research; to reduce the knowledge gaps inherent to the digital divide. METHODS: APOF has been developing the BMC pathology lab from 2000 to 2008. In the meantime Tison took care of training in Oncology of local medical doctors, opened the BMC Oncology Department in 2010 and patronized the building of a new clinic dedicated to the Oncologic Institute. We started the development of the project in 2011 with a general assessment of the needs and lacks in local working procedures, related to the possible improvements in ICT. Our first step involved the Internet connections activation and the implementation of the project informatic core in the IT room of the BMC Oncologic Institute. The telematic link between IRST’s Italian site and BMC has been realized during the early pilot phase. We carried out several experimental sessions to investigate the compatibility of the main third-parts digital pathology products with our platform, choosing digital microscope Menarini D-SIGHT in association with D-SIGHT+ telepathology web-based application. Finally, on June 2015 we launched the BMC Telepathology Facility performing a complete demo of the system during the AORTIC East African Regional Meeting. RESULTS: We validated the system in a wide range of conditions. Experimental data indicate an improvement of a factor up to 100 in the overall images transmission rate in comparison to the previous models. The pathology images remotely viewed are fully compliant with the diagnostic requirements in terms of definition and magnification. The platform is easy-to-use, all sanitary operators involved in the testing found it friendly and effective. The images browsing on the screen is very fast and precise, professional operators evaluated this solution equivalent to the use of the microscope. Our project is characterized by a high level of innovation which increases efficiency and efficacy of health practices and can boost the use of telepathology in developing countries

Extracellular matrix of small round cell tumors of childhood: an immunohistochemical study of 67 cases

Sixty-seven childhood tumors were studied immunohistochemically for the extracellular matrix element type IV collagen, laminin, and fibronectin. Tumors included Ewing's sarcoma, primitive neuroectodermal tumor, small cell osteosarcoma, neuroblastoma or ganglioneuroblastoma, rhabdomyosarcoma, and lymphoma. It was found that small cell osteosarcoma was often positive for fibronectin but not type IV collagen or laminin, a new observation. In the lymphomas, matrix proteins were rarely found. Ewing's sarcoma was variably positive for type IV collagen and laminin, but fibronectin was absent. Extracellular laminin and fibronectin were found in one of two cases of primitive neuroectodermal tumor. In neuroblastoma and ganglioneuroblastoma, the matrix components were rarely found. These results, discrepant with findings in cultured cells, may reflect the altered capacity of tumors to produce these proteins in vitro, which suggests that caution should be exercised in drawing conclusions regarding the nature or histogenesis of tumors from data obtained with cultured tumor cells. Embryonal rhabdomyosarcoma frequently contained all matrix elements in the extracellular space and in a dotlike pattern in the cytoplasm; alveolar rhabdomyosarcoma rarely contained these proteins and never exhibited the dotlike pattern. The frequent finding of matrix proteins in embryonal rhabdomyosarcoma but only rarely in alveolar rhabdomyosarcoma and the unique immunostaining pattern in embryonal rhabdomyosarcoma may prove to be a useful adjunct in the diagnosis of childhood tumors

Primary gastric CD30 (Ki-1)-positive large cell non-Hodgkin's lymphomas. A clinicopathologic analysis of six cases

BACKGROUND. The CD30/Ki-1 antigen characterizes a series of non-Hodgkin's lymphomas (NHL) predominantly showing anaplastic large cell (ALCL) morphology and frequently involving the skin and other extranodal sites. In cutaneous large cell lymphomas, the CD30 expression was indicated as a favorable prognostic marker independently from cytology, anaplastic versus nonanaplastic. The stomach is the most common site of extranodal lymphomas in the adult population, but primary gastric CD30+ lymphomas have been reported rarely. METHODS. The clinical, morphologic, and immunohistochemical features of six cases with primary CD30/Ki-1+ gastric large cell lymphomas were analyzed. RESULTS. The mean age of patients was 64 years with a prevalence of women (M:F ration = 1:2). Patients were assigned to Stage IE or IIE. Three of them died of disease, whereas the others are still alive (mean follow-up, 18 months). Three of six cases had ALCL morphology, whereas other cases had centroblastic, immunoblastic, and high-grade mucosa-associated lymphoid tissue lymphoma. Immunohistochemistry revealed a B-cell phenotype in three of six cases; a T-cell phenotype in one of six cases; and a null, non-B, non-T phenotype in two of six cases. CONCLUSIONS. Within CD30+ primary gastric large cell lymphomas, cytology, anaplastic versus nonanaplastic, did not affect clinical presentation and/or prognosis. The survival rate of the patients studied is in keeping with literature reports regarding prognosis of primary high-grade gastric NHL. The findings suggest that clinical behavior of this extranodal lymphoma is more closely related to clinical symptoms and initial stage of disease than to CD30 expression