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Tuesday, 22 January 2019 20:50

The pitfalls of immunohistochemistry

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Short accounts of interesting cases, some medical disasters, involving pathology and clinical practice, from the recollection of Prof. Albert Cilia-Vincenti.

This is 1996.  I had returned to a consultant histopathologist’s post at St Luke’s Hospital the year before, and had become acquainted socially with a Maltese commercial lawyer and his ex-pat wife.  Shortly afterwards, he informed me that his wife hasn’t been well and that Dr Mario Vassallo had just performed a private gastroscopy, was worried she had something serious and whether I would mind looking at the biopsy material.  Mario Vassallo found a large gastric ulcer with rolled edges, practically diagnostic of a carcinoma.  Fortunately the histology showed a low grade lymphoma of “mucosa-associated lymphoid tissue” (MALT) type, which carried a far better prognosis. 

 

The biology of MALT lymphoma had been worked out by Peter Isaacson in Dennis Wright’s histopathology department in Southampton.  He had also elucidated the intestinal high grade T-cell lymphomas that might complicate gluten sensitivity, although he had originally described them as intestinal histiocytic lymphomas before better immunohistochemical cellular diagnostic markers became available.  Both these lines of research eventually led Peter Isaacson to the chair of pathology at University College Hospital in London and to the highest accolade in British science – Fellow of the Royal Society.

 

Professor Isaacson had also found that some low grade gastric MALT lymphomas regressed and totally resolved with anti-Helicobacter antibiotic therapy, but this course of therapy had no effect on the large gastric lesion Dr Vassallo was dealing with.  The patient’s husband asked me for the histological slides as they were visiting their daughter, a medical intern at the Memorial Sloan Kettering, New York’s premier cancer hospital, where they would seek an oncology opinion.

 

On their return, the husband informed me that New York had not agreed with my diagnosis of low grade MALT lymphoma and had recommended a total gastrectomy and systemic chemotherapy.  When he showed me their pathology report, I realised that in spite of the innumerable immunohistochemical stains they had performed, they issued two reports, one diagnosing a chronic peptic ulcer and the other a high grade lymphoma.  They had returned the slides and paraffin block and I sent them to Professor Dennis Wright in Southampton who, like Peter Isaacson, was a lymphoma pathologist of world repute.  He phoned me to ask, “what’s the problem with this low grade MALT lymphoma?”  He couldn’t believe New York’s interpretation of the pathology and the drastic treatment recommended.  An oncologist from the Memorial subsequently phoned the husband to apologise for the mistake.

 

I phoned Professor Michael Whitehouse, oncologist at Southampton for guidance on treatment and he only recommended a six-month low dose course of chlorambucil.  Her gastric lesion melted away and Mario Vassallo followed her up. More than 20 years later she’s remained disease-free.

 

 

 

Additional Info

  • TheSynapse Magazines: 2016
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Professor Albert Cilia-Vincenti MD FRCPath is a private consultant pathologist in Malta and Chairman of the Academy of Nutritional Medicine (London) and former scientific delegate to the European Medicines Agency (London). He is a former pathology services director to the British and Maltese health services, and a former teacher of London and Malta Universities. He trained at London’s Royal Marsden, Royal Free, St George’s, Charing Cross and The Middlesex hospitals.

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