May 2006
ANATOMIC PATHOLOGY
Cutaneous squamous cell carcinoma: a
comprehensive clinicopathologic classification
Cassarino DS, Derienzo DP, Barr RJ
Cutaneous squamous cell carcinoma (SCC) includes many subtypes with widely
varying clinical behaviors, ranging from indolent to aggressive tumors with
significant metastatic potential. However, the tendency for pathologists and
clinicians alike is to refer to all squamoid neoplasms as generic SCC. No
definitive, comprehensive clinicopathological system dividing cutaneous SCCs
into categories based upon their aggressiveness has yet been promulgated.
Therefore, authors have proposed the following based upon the malignant
potential of SCC variants, separating them into categories of low (</=2% metastatic
rate), intermediate (3-10%), high (greater than 10%), and indeterminate
behavior. Low-risk SCCs include SCC arising in actinic keratosis,
HPV-associated SCC, tricholemmal carcinoma, and spindle cell SCC (unassociated
with radiation). Intermediate-risk SCCs include adenoid (acantholytic) SCC, intraepidermal
epithelioma with invasion, and lymphoepithelioma-like carcinoma of the skin.
High-risk subtypes include de novo SCC, SCC arising in association with
predisposing factors (radiation, burn scars, and immunosuppression), invasive
Bowen's disease, adenosquamous carcinoma, and malignant proliferating pilar
tumors. The indeterminate category includes signet ring cell SCC, follicular
SCC, papillary SCC, SCC arising in adnexal cysts, squamoid eccrine ductal
carcinoma, and clear-cell SCC. Subclassification of SCC into these risk-based
categories, along with enumeration of other factors including tumor size,
differentiation, depth of invasion, and perineural invasion will provide prognostically
relevant information and facilitate the most optimal treatment for patients.
J Cutan Pathol. 2006 Apr;33(4):261-79.
Lysozyme Amyloidosis: Report of 4 Cases and a Review of the Literature
Granel, Brigitte; Valleix, Sophie; Serratrice, Jacques et al
Autosomal dominant hereditary amyloidosis represents not 1 disease but a group of diseases, each the result of mutations in a specific protein. The most common form is transthyretin amyloidosis, which has been recognized clinically for over 50 years as a familial polyneuropathy. Nonneuropathic amyloidoses (Ostertag type amyloidosis) include those due to abnormalities in lysozyme, fibrinogen A[alpha]-chain, and apolipoprotein A-I and A-II. The role of lysozyme in amyloid-related human disorders was first described in 1993; to date, there have been only 9 publications describing this disorder, which is a nonneuropathic form of hereditary amyloidosis. Reported cases have involved 7 unrelated families. Authors describe here their experience with 4 families suffering from lysozyme amyloidosis: the first had prominent renal manifestations with sicca syndrome, the second and third had prominent gastrointestinal symptoms, and the fourth had a dramatic bleeding event due to rupture of abdominal lymph nodes. To authors knowledge, this last symptom has not been reported previously, but is reminiscent of the hepatic hemorrhage seen in a previously reported case of a patient with lysozyme amyloidosis. To characterize the manifestations of this disorder, authors performed an exhaustive literature review.
Although hereditary amyloidosis is thought to be a rare disease, it is probably
not as rare as we think and may well be underdiagnosed. Moreover, some cases of
lysozyme amyloidosis are probably confused with acquired monoclonal
immunoglobulin light-chain (AL) amyloidosis, formerly known as primary amyloidosis,
which is the most frequent type of amyloidosis. Because treatment for each type
of amyloidosis is different, and because therapy directed at 1 type may worsen
symptoms of the other types, it is important to determine precisely the nature
of the amyloid protein. Thus, hereditary lysozyme amyloidosis should be
considered in all patients with systemic amyloidosis, particularly in patients
who present with renal, gastrointestinal, or bleeding complications without
evidence of AL or AA (secondary) amyloidoses.
Medicine. 85(1):66-73, 2006.
Tissue Processing Re-Visited: A Shifting Paradigm in Surgical Pathology
[Editorial]
Several times in the recent past the author has been asked to give his vision of the “surgical pathology laboratory of the future.”1,2 His vision includes a combination of total digital histologic examination and archiving combined with laser microdissection and robotic workstations that shunt tissue samples to various molecular assessments of DNA, RNA, and protein content. Note that whereas my vision may not include the standard light microscope that is the workhorse instrument of today's surgical pathologist, He does not foresee a time when the art and science of histologic examination and classification is absent from the clinical assessment of tissue. The vagaries of gross anatomy, microanatomy, and pathologic processes leading to heterogeneity of cellular constituents in tissue samples will continue to bedevil quantitative molecular assessments unless they are calibrated by some knowledge of the types and sources of this heterogeneity. Whereas at the current time all of the technological pieces are in place to theoretically allow global DNA, RNA, and protein assessment of tissue samples, there is no technology that could be practically (or even impractically) applied to a tissue specimen to match the speed and universality of a simple histologic examination to determine the type and distribution of cellular constituents.
However, it is also a universal truth that the appearance of a thing does not always reflect its inner attributes. What is true of people (sometimes beauty is only skin deep) and books (don't judge them by their cover) is also true of diseased cells. With the inexorable scientific advances in the understanding of the molecular basis of disease and with the application of that knowledge to molecular-based therapies, it will become increasingly incumbent upon the surgical pathologist to make molecular characterizations of tissue samples that cannot be deduced from morphologic examination alone. The catch 22, however, is that the preferred method of histologic examination, formalin fixation and paraffin embedding (FFPE), wreaks havoc on the molecular constituents of tissue, causing chemical cross-links and molecular fragmentation that interferes with many molecular assessments.3-5 What is needed is the development and adoption of methods that resemble the histologic quality of FFPE tissue sections but which preserve the integrity of the constituent biomolecules suitable for molecular analysis.
In this issue of Diagnostic Molecular Pathology, Vincek et al 6 describe one possible technique to achieve this goal. Building on the experience with microwave processing of tissue,7-11 they show that RNA obtained from paraffin-embedded tissues processed in this manner rivals that obtained from fresh tissues, with preservation of excellent histologic detail. They show that laser microdissection can be combined with RNA profiling techniques, so that the RNA profiling can unequivocally be attributed to a single-cell type. In addition to preservation of biomolecules, microwave processing yields the added benefit of allowing routine histology turn around in less than 1 workday. Could it be possible that in the future a combined histologic and molecular diagnosis could be rendered in the same time frame that an exclusively histologic diagnosis is rendered today?
One major drawback is the expense of bringing this new technology online. The full-featured fully automated instrument used by these authors currently lists at over $150,000. Only the justification of a major shift in workflow may allow the acquisition of such an apparatus into a typical surgical pathology laboratory. Unfamiliarity with this technique, the fear of altered tissue characteristics, and the lack of universal indications for molecular tissue analysis are additional barriers to the adoption of this technology. There are other less expensive options available, however, including specially adapted microwave ovens for approximately a tenth of the cost of an automated platform. Whereas these could not possibly handle the workflow of a typical histology laboratory and lack the ease of use of larger automated systems, such instruments could be useful in the processing of “special samples” and to acquaint surgical pathologists with this technology at a much lower capital expense. It is also possible that simply adapting alternative non-cross-linking fixatives to standard processing procedures and instruments will suffice. For instance, several groups have shown that 70% EtOH may be a suitable substitute for formalin and yields good-quality RNA after “standard” processing, suitable even for microarray gene expression.3,4,12,13 More formal comparison between these various methodologies is probably in order.
The advent of molecular classification of tumors has already arrived. Whereas some assessments can be made in FFPE tissue, such as immunohistochemistry, in situ hybridization, and some PCR techniques, there will be continuing pressure to bring the full armamentarium of molecular techniques to tissue diagnostics. The adoption of histologic processing techniques that allows paraffin-embedded tissue to be a high-quality source of constituent biomolecules will hasten this diagnostic transformation and may help ensure that surgical pathologists continue to guide and inform tissue diagnostics with histologic assessment.
REFERENCES
1. Moskaluk CA. Tissue microdissection: Where have we been? Where are we going? in National Institutes of Health conference on “Molecular profiling of normal development and pathology in tissue: Integrating laser microdissection and microanalysis. ” Bethesda, MD; 2002. [Context Link]
2. Moskaluk CA. Molecular pathology laboratory of the future. In: Emmert-Buck MR, Gillespie JW, Chuaqui RF, editors. Dissecting the Molecular Anatomy of Tissue. Heidelberg: Springer-Verlag; 2004:3-15. [Context Link]
3. Kabbarah O, Pinto K, Mutch DG, et al. Expression profiling of mouse endometrial cancers microdissected from ethanol-fixed, paraffin-embedded tissues. Am J Pathol. 2003;162:755-762. Bibliographic Links [Context Link]
4. Ben-Ezra J, Johnson D, Rossi J, et al. Effect of fixation on the amplification of nucleic acids from paraffin- embedded material by the polymerase chain reaction. J Histochem Cytochem. 1991;39:351-354. Bibliographic Links [Context Link]
5. Rait VK, O'Leary TJ, Mason JT. Modeling formalin fixation and antigen retrieval with bovine pancreatic ribonuclease A: I-structural and functional alterations. Lab Invest. 2004;84:292-299. Bibliographic Links [Context Link]
6. Vincek V, Nassiri M, Block N, et al. Methodology for preservation of high molecular weight RNA in paraffin-embedded tissue: Application for laser capture microdissection. Diag Mol Pathol. 2005;14:127-133. [Context Link]
7. Morales AR, Nassiri M, Kanhoush R, et al. Experience with an automated microwave-assisted rapid tissue processing method: validation of histologic quality and impact on the timeliness of diagnostic surgical pathology. Am J Clin Pathol. 2004;121:528-536. Bibliographic Links [Context Link]
8. Ruijter ET, Miller GJ, Aalders TW, et al. Rapid microwave-stimulated fixation of entire prostatectomy specimens. Biomed-II MPC Study Group. J Pathol. 1997;183:369-375. Bibliographic Links [Context Link]
9. Leong AS. Microwave fixation and rapid processing in a large throughput histopathology laboratory. Pathology. 1991;23:271-273. Bibliographic Links [Context Link]
10. Kok LP, Visser PE, Boon ME. Histoprocessing with the microwave oven: an update. Histochem J. 1988;20:323-328. Bibliographic Links [Context Link]
11. Morales AR, Essenfeld H, Essenfeld E, et al. Continuous-specimen-flow, high-throughput, 1-hour tissue processing. A system for rapid diagnostic tissue preparation. Arch Pathol Lab Med. 2002;126:583-590. [Context Link]
12. Gannot G, Gillespie JW. Tissue processing. In: Emmert-Buck MR, Gillespie JW, Chuaqui RF, editors. Dissecting the Molecular Anatomy of Tissue. Heidelberg: Springer-Verlag; 2004:27-42. [Context Link]
13. Gillespie JW, Best CJM, Bichsel VE, et al. Evaluation of non-formalin tissue fixation for molecular profiling studies. Am J Pathol. 2002;160:449-457. Full Text Bibliographic Links [Context Link]
Diagnostic Molecular Pathology, Volume 14(3), September 2005, pp 125-126
Methodology for Preservation of High Molecular-Weight RNA in Paraffin-Embedded Tissue: Application for Laser-Capture Microdissection
Vincek, Vladimir; Nassiri, Mehdi , Block, Norman et al
Laser-capture microdissection techniques have enhanced the ability to perform molecular studies of pure-cell populations. Although many technical factors affect the outcome of the procedure, none is more critical than the appropriate handling of the tissue. Because extraction of intact RNA from paraffin-embedded tissue is a difficult and inconsistent process, frozen sections with their attendant problems are used for this purpose. The major limitation of frozen section is its inferior morphologic quality compared with paraffin-embedded sections that may complicate accurate identification of cells during microdissection. We have developed a procedure that provides both high-quality histomorphology and RNA preservation in paraffin-embedded tissue. It is based on the use of a methanol-based fixative coupled with microwave-assisted rapid tissue processing. This technology in conjunction with a modified hematoxylin-eosin stain and a RNA extraction method allows isolation of high molecular-weight RNA from laser-capture microdissected, hematoxylin and eosin-stained paraffin sections. The high quality of the extracted RNA was confirmed by capillary electrophoresis and RT-PCR. The combination of a methanol-based fixative, rapid microwave tissue processing, and a modified hematoxylin and eosin stain produces paraffin sections that yield high molecular-weight RNA upon microdissection. This methodology opens the door for a wide range of gene expression analyses using paraffin-embedded tissue.
Diagnostic Molecular Pathology. 14(3):127-133, September 2005.
Critical Diagnoses (Critical Values) in Anatomic Pathology
Association of Directors of Anatomic and Surgical Pathology
Similar to critical values in clinical pathology, occasional diagnoses in surgical pathology and cytology may require urgent contact of the physician to facilitate rapid intervention or treatment. However, there are no established critical value (critical diagnosis) guidelines in anatomic pathology. As discussed herein, the Association of Directors of Anatomic and Surgical Pathology (ADASP) believes that establishing anatomic pathology critical diagnosis guidelines represents a practice improvement and patient safety initiative. ADASP also recognizes that a generic anatomic pathology critical diagnosis guideline such as this should be used only as a template because the list needs to be customized at each individual hospital following consultation with relevant clinical services. Based on surveys of the membership of the ADASP, this document provides examples of possible critical diagnoses in anatomic pathology.
The concept of critical values (CVs) was introduced by Lundberg1 in 1972 as a pathophysiologic derangement at such variance with normal as to be life threatening if therapy is not instituted immediately.
Examples of possible critical diagnoses cases in anatomic pathology based on surveys of the ADASP membership are:
|
· Cases with immediate clinical consequences |
|
· Crescents in >50% of glomeruli in a kidney biopsy specimen |
|
· Leukocytoclastic vasculitis |
|
· Uterine contents without villi or trophoblast |
|
· Fat in an endometrial curettage specimen |
|
· Mesothelial cells in a heart biopsy specimen |
|
· Fat in colonic endoscopic polypectomy specimens |
|
· Transplant rejection |
|
· Malignancy in superior vena cava syndrome |
|
· Neoplasms causing paralysis |
|
· Unexpected or discrepant findings |
|
· Significant disagreement between frozen section and final diagnoses |
|
· Significant disagreement between immediate interpretation and final FNA diagnosis |
|
· Unexpected malignancy |
|
· Significant disagreement and/or change between diagnoses of primary pathologist and outside pathologist consultation (at the original or consulting institution) |
|
· Infections |
|
· Bacteria or fungi in cerebrospinal fluid cytology in immuno- compromised or immunocompetent patients |
|
· Pneumocystis organisms, fungi, or viral cytopathic changes in bronchoalveolar lavage, bronchial washing, or brushing cytology specimens in immunocompromised or immuno- competent patients |
|
· Acid-fast bacilli in immunocompromised or immuno- competent patients |
|
· Fungi in FNA specimen of immunocompromised patients |
|
· Bacteria in heart valve or bone marrow |
|
· Herpes in Papanicolaou smears of near-term pregnant patients |
|
· Any invasive organism in surgical pathology specimens of immunocompromised patients |
Am J Clin Pathol 2006;125:815-817
Sentinel lymph node in oral and oropharyngeal
epithelial tumors.
[Article in German]
Cizmarevic B, Zargi M.
Carcinomatous metastases in regional lymph nodes worsen substantially the
prognosis of patients with oral cavity and oropharyngeal cancer. Due to the
high probability of occult metastasis (about 30%), during surgical resection of
the primary tumor usually also elective dissection of lymph nodes is performed.
Opinions on the extent of the elective neck dissection still differ, whereas
selective dissection increasingly gains in importance. The aim of selective
dissections, based on the predicdability of formation of metastases, is the
identification and exstirpation of the sentinel lymph node. In this prospective
study the applicability of the concept of the sentinel lymph node in patients
with oral cavity and oropharyngeal cancer was analysed. 12 patients with oral
cavity and orophangeal cancer, staging T1-T3, all N0 (examined by palpation and
sonography) were included. The localization of the sentinel(s) was determined
preoperatively by radioisotope (Tc Nanocolloid). Sentinel(s) were identified
first with a gamma probe (Neoprobe 2000); we then injected methylene blue into
the peritumoral area for easier detection of the sentinel(s). The sentinels
were removed and sent for frozen section examination. Regardless of the
findings of the frozen section examination modified dissection was carried out.
Later we compared frozen sections with paraffin microtome sections of
sentinel(s) and of other exstirpated neck lymph nodes. Authors could identify
the sentinel lymph node in all patients, in 6/12 patients we found several
sentinels. If sentinels were not affected by tumor cells, there were no
metastases in the downstream neck lymph nodes either. If in the sentinel lymph
nodes no metastases can be determined, eliminating the environment alone could
be sufficient. However, this assumption requires verification in a larger
patient group.
Wien Klin Wochenschr. 2006 Mar;118(3-4):114-9.
CYTOLOGY
Fast drying of Fine Needle Aspiration slides using a hand held fan: impact on turn around time and staining quality
To analyze the impact of using a hand held fan to speed the air-drying process during immediate adequacy evaluation of Fine Needle Aspirations. The effect on turn around time and staining quality is evaluated. Two mirror image air-dried smears for each pass were prepared. One was subjected to a small hand-held fan with a fan diameter of 7 cm held an average distance of 3 to 5 cm from the slide. The other smear was left to dry without a fan. A total of 93 consecutive pairs were evaluated over a 2-month duration. The average time needed for air-drying using the fan was 73 seconds (range 10-300 seconds, standard error 6.986), while it was 200 seconds (range 15-645 seconds, standard error 17.799) for those without fan. This difference was statistically significant ( p <0.001). Smears were then evaluated for single cells, cell clusters and background material and no appreciable difference in stain quality was noted between the 2 groups. The use of a small hand-held fan for air-drying shortened the drying time for FNA adequacy by an average of 127 seconds (63% time reduction) for each pass. The quality of staining was comparable. Using a fan is highly recommended.
CytoJournal 2006, 3:12 doi:10.1186/1742-6413-3-12
MICROBIOLOGY
Blood agar for susceptibility testing of Mycobacterium tuberculosis against first-line drugs.
Coban, A.Y.; Cihan, C.C.; Bilgin, K.; Uzun, M. et al
OBJECTIVE: To evaluate the performance of blood agar for the susceptibility testing of 50 Mycobacterium tuberculosis clinical isolates against isoniazid (INH), rifampicin (RMP), streptomycin (SM) and ethambutol (EMB).
DESIGN: The activity of the drugs was determined by the proportion method on blood agar instead of Middlebrook 7H10 agar according to Clinical Laboratory Standard Institute recommendations. The final concentrations of INH, RMP, SM and EMB were 0.2 μg/ml, 1 μg/ml, 2 μg/ml and 5 μg/ml, respectively.
RESULTS: The results were compared with the radiometric proportion method as the reference, and the agreements were determined as 100% for INH and RMP, 92% for SM and 96% for EMB. The specificity, sensitivity, positive predictive value and negative predictive value were 90.4% and 97.5%, 100% and 90%, 66.6% and 90% and 100% and 97.5% for SM and EMB, respectively, while these values were 100% for INH and RMP. The results of susceptibility testing were obtained on the 14th day of incubation.
CONCLUSION: According to this preliminary study, authors results suggest that blood agar can be used as an alternative medium for the susceptibility testing of M. tuberculosis strains against INH, RMP, SM and EMB in resource-limited countries. However, further studies are needed before implementating the method in diagnostic laboratories.
The International Journal of Tuberculosis and Lung Disease, Volume 10, Number 4, 2006, pp. 450-453(4)
BOTTOM LINE
Why I became a haematopathologist
[VIEWPOINT]
The Editor has suggested that the Journal’s readers would be interested to know how I came to follow my particular career pathway. Why this interest? Is it because it is an unusual career to have chosen? Has my career has been unusually long or unusually productive? Naturally, I like to think it is because of the latter but it is probably a mixture of all three. In any event, it was not the career I chose but the career that chose me.
Perhaps I should first explain why I chose to become a pathologist at all. I entered medical school, at the University of Cape Town, without the slightest knowledge of what was entailed in studying medicine. A year of general science was followed by the grind of anatomy and physiology, interesting in their own right but hardly the exciting stuff of medicine. The third year of medical school was an eye opener. We were still not exposed to patients and most of the year was devoted to pathology (histopathology, haematology, chemical pathology, and microbiology), at 592 hours by far the longest course of the entire curriculum. The pathology course comprised a mixture of lectures (unillustrated), a daily necropsy, comprehensive practical classes, and small group tutorials. Most of what we did would today be considered a colossal waste of time but the enthusiasm of our teachers was infectious and at last I realised what medicine was all about. What attracted me most to pathology was its logical, evidenced based nature, something distinctly lacking in other ingredients of the curriculum at that time. Not surprisingly, I chose to become a pathologist.
After starting my postgraduate training in pathology in the USA, I soon realised that surgical pathology was quite different from the pathology taught to me at medical school. The “evidence” for disease processes provided by data from animal experiments, tissue culture, and so on was largely irrelevant to the interpretation of surgical biopsies. The excitement of surgical pathology lay in other directions—the interface with clinical medicine and the gradual flowering of skills in pattern recognition, more art than science. Surgical pathology had emerged in the 1850s following Virchow’s seminal publication on the cellular theory of disease, and gradually diverged from the science of pathology, branching out to become a largely different although still related discipline. Since the 1850s, advances in surgical pathology principally comprised technical improvements allowing more detailed and reproducible morphological observations of diseased tissue. This culminated in the 1950s with ultrastructural images obtained with the electron microscope. Surgical pathologists were concerned with correlating microscopic morphology with specific diseases and not really interested in mechanisms; thus, true hypothesis driven research was not something commonly undertaken by them. The choice for the aspiring pathologist lay between so called academic pathology, which largely involved laboratory experiments, and human diagnostics; I had chosen the latter and at the end of my training embarked on lucrative private practice.
Despite the attractions of life in metropolitan Boston, I continued to miss the intellectual excitement that I had felt during my year of pathology in medical school. Interesting questions were, indeed, continuously thrown up by my surgical pathology cases but the means of answering them were not obviously apparent. The research techniques current in academic pathology departments at that time seemed remote from the clinic, too complex and anyway inaccessible to a diagnostic pathologist. Curiously, however, it was an academic experimental pathologist who provided the means to revolutionise diagnostic surgical pathology. Searching for a marker to attach to proteins so their migration in inflamed tissues could be traced, Professor Morris Karnovsky of Harvard Medical School lighted on the small molecule, horseradish peroxidase. This enzyme, as every surgical pathologist now knows, oxidises colourless diaminobenzidine to form an insoluble brown precipitate. By conjugating peroxidase to antibodies and using diaminobenzidine as a developing agent, the pathologist is potentially able to view any protein to which an antibody is available in the context of the structure of the tissue. At a stroke the number of “special stains” available to the surgical pathologist exploded from a handful to an almost infinite number. Immunohistochemistry finally enabled the pathologist to observe not only the structure of cells and tissues but also their function.
The advent of immunohistochemistry was the catalyst that caused me to abandon the private practice of pathology and embark on a career as an “academic” surgical pathologist in Britain. Throughout my career I had been fortunate in working with remarkable pathologists who were broadminded and encouraged free thinking. In joining Professor Dennis Wright’s department in Southampton I encountered this same atmosphere. Although grantless, I was given the time and resources to pursue my original and as it turned out naive idea of using the immunoperoxidase technique to detect carcinoembryonic antigen in colonic biopsies with a view to developing a “special stain” for detecting colon carcinoma. After working for a few years on this and other gastrointestinal pathology projects, a single case changed my focus. In 1976, I received a small bowel resection specimen from a patient with refractory coeliac disease and so called idiopathic ulcerative jejunitis. Unwilling to accept the designation “idiopathic” for the ulcers, I doggedly sectioned ulcer after ulcer, all of which showed non-specific inflammatory changes until, in the base of one ulcer, I observed a minute focus of malignant lymphoma. Together with Professor Wright, who, conveniently, was already an internationally renowned haematopathologist, I set about using the new technique of immunohistochemistry, and later molecular biology, to study the association of lymphoma with coeliac disease and later to challenge and change long held concepts of intestinal and subsequently other lymphomas. I had become a haematopathologist.
It is difficult to describe the intellectual excitement that I have experienced from a career in the “new” post 1960s discipline of surgical pathology, and particularly haematopathology. The nature of the surgical pathologist’s work permits privileged insights into human disease and provides unparalleled opportunities for formulating and testing new hypotheses. All he or she needs is the time (and relatively few resources) to take advantage of this privilege. But there lies the rub. The time is no longer available. Surgical pathology training has changed, become more formalised, shorter, more focused and examination centred. The deadly division between the surgical and academic pathologist has been resurrected. A few selected trainee pathologists may have the opportunity of embarking on an “academic” career which now means answering a question posed by his or her PhD supervisor, but the opportunity of asking their own questions and formulating and testing their own hypotheses seems to have been lost. I doubt that I could have pursued my career today.
Journal of Clinical Pathology, Volume 59(5), May 2006, pp 477-478