Issue 4 - August 2010 - Pacini Editore

154
In total there are twelve hospitals, one health hub, nine accredited
clinics and seven districts; this means that any action or
change regarding the system requires substantial organisation
work. The privatization of health trusts and the complexity
of the established facilities mean that it is becoming increasing
urgent to plan, streamline and control the health services
rendered. Within this framework and in order to meet these
requirements, a reorganisation process has been started as regards
urinary cytology in the whole province of Bologna, involving
all stakeholders in the process, first and foremost the
Pathological Anatomy and Unified Booking (CUP) services.
The project included all four Pathological Anatomy departments
dealing with this type of test: in Bologna these are the
Ospedale Maggiore, the Ospedale Bellaria and the S. Orsola
Hospital; in Imola it is the Pathological Anatomy department
of the Imola Hospital. The project started with an assessment
of the various process phases.
The analysis revealed differences both regarding the sampling
indications and the way the test was booked through the CUP;
on the other hand, consistent features emerged both as regards
the test’s setting-up, a single filtering layer with polycarbonate
membranes, and the waiting times which could be as long
as 60 days. The old method required delivery of a fresh urine
sample for three days; this means that the patients had to go
through five “steps” before getting the result (one booking
from the CUP, three deliveries to the sample delivery Point,
one report collection from the office in charge), and that the
Pathological Anatomy departments needed to receive and
process the three samples separately and then draft the reports
on different days. The new method was introduced in April
2009; it involves the use of an alcohol-based fixative liquid to
correctly preserve the cellular elements in the sample which
can be stored in a cool place for up to a week. The appropriate
amount of fixative is stored in the three jars contained in
the sponge housings which are part of the Kit provided by the
manufacturer. The Kits are delivered both to CUP offices and
to the chemists’ authorised to book these tests (about three
hundred booking points). The Kit is delivered to the patient
when the test is booked, together with a fact sheet explaining
both the precautions and sampling method to be followed,
plus the simplified questionnaire on the patient’s medical history
which he/she has to fill in. This information is necessary
in order to reconstruct a clinical record of patients who, in the
case of the Bologna area, can choose between three different
Pathological Anatomy departments which are not part of a
network.
Results. The patient returns the Kit, all of it at the same time,
after having collected the urine at home for three days, following
the method illustrated; an efficient transport system connects
the delivery point to the Pathological Anatomy service
in charge of the area, making sure that the material is promptly
delivered. Here the material is all received together, which
means that the Service secretariat has less work to do in the
process; the setting-up involves completely filtering the three
samples, all together, for each patient, then collecting the cells
onto a single slide. As a consequence the process is less timeconsuming
for the professionals involved, and it also allows
for the production of a single report. The patients collect their
reports on the set date from the booking structure; as a whole
their number of visits to public facilities when a urine cytology
examination is required have been reduced to three (one
booking from the CUP, one journey to the delivery point, and
one to collect the report). The delivery point staff has reduced
the amount of time necessary for each user because there is
only one delivery to be received, as opposed to three for the
5 th triennial congress of the italian society of anatomic Pathology and diagnostic cytoPathology
same number of days. The new process is proving advantageous
for everybody, with the exception of the laboratory staff
in charge of setting up the material because the filtration time
has increased. In any case, the implementation of the system,
after the necessary trial period, has led to easier accessibility to
the test, and at the same time to a reduction of the waiting time
required. The waiting times for a urine cytology exam now
range between 3 and 15 days. Moreover, an agreement with
the CUP2000 company, allows the Pathological Anatomy services
to directly manage the booking schedules. A statistical
report, provided on a regular basis by the CUP booking office
management, makes it possible for the Pathological Anatomy
departments to monitor the relevant trends, thus extending or
reducing the booking schedules in order to meet the demand.
The new method has been extended to hospital wards and
homogeneously covers the whole provincial area.
emerging prognostic and predictive factors
in breast cancer: where are we?
M. Mottolese, A. Di Benedetto, E. Melucci, S. Buglioni,
L. Perracchio.
Pathology Department, Regina Elena National Cancer Institute,
Rome, Italy
Background. Breast cancer (BC) is the most commonly
occurring malignancy in women and is responsible for approximately
500 000 deaths per year worldwide. Due to the
remarkable heterogeneity of BC, mostly driven by genetic
variability, a number of clinical and bio-pathological factors
are routinely used to determine prognostic predictions of
clinical relevance. Furthermore, decisions about the adjuvant
chemotherapy (CT), mainly in early stage of the disease, are
affected by a complex interplay of factors and guidelines
stratify BC patients into prognostic subsets suggesting treatment
protocols on the basis of the reported estimates of efficacy
1 2 . Classical prognostic parameters include patient age,
axillary lymph node status, tumor size, histological features
(especially histological grade and lymphovascular invasion),
estrogen receptor (ER)-progesterone receptor (PgR), and
HER2 status. In addition, a recent report from the St Gallen
International Expert Consensus recommends the use of proliferation
markers (eg, Ki-67 and mitosis) and multigene assays
when choosing appropriate systemic CT 3 . Although these factors
may be of great clinical value, their role in determining
prognosis and evaluating risk in an individual patient with BC
is more limited, since patients with similar combinations of
features may have very different clinical outcomes. In recent
years gene expression profiling have been increasingly used
aimed to improve BC classification and to assess prognosis
and response to therapy 4 . Although the precise role of these
novel molecular techniques in the routine management of BC
patients is yet under investigation, certainly they may provide
prognostic and predictive information often more useful than
those provided by the traditional clinical and pathological
factors 5 . In addition, thanks to this extended biological knowledge,
we have the opportunity of identifying genes involved
in responsiveness to therapy acquiring relevant information
on drug resistance mechanisms. This may lead to the characterization
of new therapeutic targets and the subsequent availability
of more treatment options for patients with resistant
disease 6 .
HER2 Expression and Response toTrastuzumab and
Chemotherapy. It is well established that expression of
HER-2 is predictive of response to trastuzumab 7 . Retrospec-