![](media/image1.emf){width="2.14375in" height="2.201388888888889in"}

![](media/image2.emf){width="1.6465277777777778in"
height="0.7986111111111112in"} **EM News**

**Volume 3 Issue 3 January 1998**

Annual EM reports and review cases

The FY 1997 EM annual reports have been compiled and the review cases
sent to us have been distributed to the EM Ad Hoc Review group members.
The information you provided on questions within the annual report were
distributed to all the members of the Ad Hoc group. The reviewers will
send back their case evaluations which will be summarized and presented
to the whole group at the next annual Ad Hoc review group meeting being
held on February 28, 1998 in Boston, MA just prior to the annual USCAP
meeting. The review emphasis will be on the quality and clinical
relevance of the cases and not on any specific numerical standards as in
the past. We're hoping to have the annual review letters mailed to your
VISN and Medical Center Director by the end of March, 1998.

VANTS Teleconference

Was held Sept. 2nd, 1997 at - 1:00PM -Eastern time. The conference had
36 EM facilities dialing in according to VANTS operator records.

A brief summary of the call for those with schedule conflicts and not
able to participate is provided:

Dr. Shelburne greeted the teleconference participants and introduced Dr.
Beals who made a few introductory remarks. The agenda was generally
divided into the following topics.

\(1\) Sharing agreements, (2) Annual report explanations and comments,
(3) Ad Hoc Review group comments (4) possible national meeting of EM
Program Directors (5) Comments on interactions by Dr. Beals and Dr.
Shelburne with VISN Directors and Clinical Administrative staff.

**Sharing agreements**: These are important due to the President's
balanced budget proposal and the VHA goal to earn 10% of operating
budget from outside sources. EM labs can help in this effort. It used to
be very difficult to set up sharing agreements. Now it is getting easier
with new regulations.

Examples include a microwave tower leasing space on top of a VA Hospital
roof, leasing vacant wards to affiliates. Almost anything can be done to
generate revenue.

Successful EM sharing agreement labs were asked to make comments. The
Miami VA has been the most successful in sharing agreements for a number
of years.

Dr. Pardo stated that they have had local medical facility contacts for
about 30 years in the Miami area. They've maintained and nurtured
contacts via phone calls, and personal physician communication. They
currently do EM work for about 24 different facilities.

Albany- Dr. Singh... Has had sharing agreements for about 20 years. A
new Department chairman at the affiliated facility has been very
supportive and has

essentially sent all their EM work to the VA since they have the new
equipment. The Albany program is also involved in environmental
pathology and are using microprobe analysis. They have established a fee
schedule for the different types of sharing services they provide. A
liaison within the medical center administration staff takes care of
setting up sharing agreements and has made it very easy for the lab to
do that kind of work. In past years they have had about 20-25 sharing
agreements in place at any one time.

Little Rock- Dr. Pat Walker, the Asst EM Chief states that they have
done a lot of referral work in

renal pathology, muscle biopsies, tumors. They have excellent support
from the local affiliate and are also doing all their EM work.

San Francisco also does a significant amount of sharing agreement work,
but they were unable to be on this call.

Durham...Dr. Ann LeFurgey. Durham has a sharing agreement with Duke
Medical Center. The microprobe technical work on both VA and Duke
patients is done at the VA. Duke pays the VA for these studies.

Dr. Beals emphasized that all such agreements have to be in writing, and
signed and renewed on a regular basis, i.e., not informal. Comment on
pricing - one can charge more than actual formula cost, i.e., can bring
pricing up a little bit over actual cost to have slight margin of
revenue gain. This was not allowed in the past.

Dr. Beals - If doing work for another VA facility, any charge should be
cost of materials only. Within a VISN the concept should be that there
is one pot of money for all the VISN facilities. Rather than charging
each other there should be contact with the VISN budget people to see if
this can be handled as a budget distribution, rather than actual
billing. The VISN core lab(s) should receive additional budget for work
being done within the VISN facilities.

**Annual EM Program report**

Dr. Shelburne explained that this year we are no longer using numerical
standards in the EM program review and evaluation process and that the
annual report instructions emphasize that submitted EM review cases
should be clinically justified. We are still focusing on the accuracy of
LMIP workload data capture and have again asked questions about that
process. Also explained was that the case review cover sheet has some
additional questions this year and we briefly went over those questions.
There have also been a few questions concerning the use of referrals in
the cases submitted for the annual review. There is no restriction on
using these, provided there is clinical justification for the use of EM.

**Ad Hoc Review Group Comments** This committee is composed of VA and
private sector pathologists who have extensive experience in EM.
Included in comments from the last annual meeting of the Ad Hoc group
were that the members asked that clinical relevance of the five annual
EM review cases be emphasized. Turn around time is becoming more
important with the emphasis on decreasing length of stay. One Ad Hoc
member proposed a three day TAT for certain cases (kidney bx) instead of
the usual week or more. One way to help with shorter TAT is the use of
digital cameras and microwave techniques.

A short discussion on use of digital cameras followed with questions and
comments about quality of resolution and the cost of retrofitting
existing instruments.

Another Ad Hoc group comment was that there are some excellent
scientific papers comparing diagnostic techniques but there is still a
misconception that EM is not necessary in many cases and additional
scientific studies are needed to show that is not correct. Question
brought up was "Would you within VHA be willing to collaborate with
others on studies of this nature to compare EM with
Immunohistochemistry". More scientific studies are needed to compare
these different technologies VA EM Labs are encouraged to participate
and initiate such studies.

**Possibility of National EM meeting** Dr. Shelburne explained that many
years in the past the EM Directors used to meet as a group about every
two years. However funding for national meetings has not been available
and therefore the group has not met for a long time. This year a
proposal was made to have a national meeting in 1998 in conjunction with
the meeting of the Society for Ultrastructural Pathology in Asheville,
NC. Travel support request for EM Program Directors to attend this
meeting was submitted by the EM Program to National VHA Education Center
leadership a few months ago. It was recently determined that the
National Education Center Program has also decentralized and their
travel funding support was distribured to the individual VISNs and those
VISNs now have control of the travel and meeting support funds instead
of the National office. Therefore the initiative for centralized travel
support for this EM meeting from National Headquarters Education Center
cannot proceed any further and the individual EM Program Directors will
have to go through their local VISN staff to apply for travel fund
support to attend educational meetings, such as this upcoming meeting in
Asheville.

**EM Program contacts with VISN Directors** - Dr. Beals and Dr.
Shelburne have had contacts with VISN Directors and clinical staff about
EM Program matters. Whenever we hear that the VISN's are trying to save
money by cutting back on EM, we contact Directors and Clinical Managers
by phone and mail, sending them scientific papers and information about
the value and importance of diagnostic EM.

It is important in these tight fiscal times to have as many friends and
support groups as possible. The ACOS for Research, Department Chairs,
nephrologists who want to see their kidney cases stay in the hospital,
are all good resources. If you are bringing in income, you will have
support from the fiscal and administrative offices.

A question came up about instrument maintenance / service contracts.
Some facilities are looking into the high cost of these contracts and
are either dropping vendor contracts and using in house
bio-medical/engineering support or are restricting the access to vendor
provided service contracts. These are very complex instruments and most
Engineering services are aware that if they drop service contracts they
have to maintain the instrument. Engineering/Bio-med will likely try to
reduce these service costs by blanket agreements or with only "as need
arises service" by utilizing fee for service arrangements.

Dr. Beals indicated that the M-2 Standards for Pathology Service have
been rescinded and National Headquarters is in the final stages of
editing the replacement "Policy" handbook. They will have that document
to the printing office for publication in the near future. Estimated
release date for the handbook is somewhere in the January to February
1998 date range.

Some of the information which has been provided to VISN Directors and
VISN Clinical Managers when questions about use of EM have come up is
summarized below. We thank Dr. John Guccion of the Washington, DC VAMC
for this summary and related references.

**Indications for the use of transmission electron microscopy (TEM) for
pathologic diagnosis fall into six major categories.**

**[NEOPLASMS]{.underline}**: The important role of TEM in the diagnosis
of neoplasms is well documented in two major surgical pathology texts:
Silverberg's ***Principles and Practice of Surgical Pathology*** (2) and
Rosai's ***Ackerman's Surgical Pathology*** (18). Their indications for
the use of TEM in the diagnosis of tumors include:

**Poorly differentiated carcinomas.** In these neoplasms, TEM is
indicated for the identification of squamous, glandular, and
neuroendocrine differentiation which may be easily missed light
microscopically.

**Poorly differentiated round cell neoplasms** with the differential
diagnosis of carcinoma, lymphoma/leukemia, malignant melanoma, and
sarcoma.

**Poorly differentiated neoplasms** of endocrine versus non-endocrine
nature.

**Neoplasms** having a differential diagnosis of adenocarcinoma versus
diffuse malignant mesothelioma.

**Poorly differentiated spindle cell neoplasms** with differential
diagnosis of spindle cell carcinoma, spindle cell melanoma, and soft
part sarcomas, especially fibrosarcoma, leiomyosarcoma, malignant
schwannoma, and malignant fibrous histiocytoma.

The above indications are further documented in the literature (4,5)

Additional indications for use of TEM in tumor diagnosis include:

**Poorly differentiated hematopoietic and lymphoreticular
malignancies**, especially where light microscopic determinations of
exact cell type is very difficult (1,6). These include anaplastic
plasmacytoma, lymphoplasmacytic lymphoma, granulocytic sarcoma, acute
myeloblastic leukemia, and erythroleukemia. (1,6)

**Bone marrow biopsies from patients suspected of having myelodysplastic
syndrome**. TEM is helpful in documenting the pathologic changes of
myelodysplastic syndrome which may be difficult to discern by light
microscopy (1,3).

**Possible cutaneous T-cell lymphomas**. Use of TEM is indicated for the
pathologic study of skin and lymph node biopsies as well as buffy coats
of peripheral blood from patients suspected of having cutaneous T-cell
lymphomas, for mycosis cells and Sezary cells may be inapparent by light
microscopy, but are readily seen with TEM (1,6,7,19). Use of TEM also
facilitates recognition of mycosis cells in the very early stage of
mycosis fungoides presenting as psoriasiform dermatitis, parapsoriasis,
poikiloderma, and alopecia mucinosa (7).

**[INFECTIOUS DISEASE]{.underline}:** The important role of TEM in the
diagnosis of infectious diseases has recently been reviewed by Orenstein
(16). In general, use of TEM is indicated whenever the etiology of a
suspected infectious disease is unknown. More specifically, use of TEM
is indicated:

Whenever an infectious disease (viral, bacterial or protozoal) is
suspected, but an infectious agent is not visible in tissue sections
studied by light microscopy. Examples of this situation include
infections of the intestine due to microsporidia and very small, Gram
negative bacteria which are barely visible or invisible light
microscopically. They are readily apparent in tissue sections studied
with TEM, however (11,16).

Whenever there are differences of opinion among pathologists using light
microscopy as to the etiology of an Infectious disease. An example of
this situation was recently published in ***Ultrastructural Pathology***
(9).

Whenever there are conflicting evidences (clinical, light microscopic,
immunohistochemical, serologic, and cultural) for the cause of an
infectious disease.

**[RENAL DISEASE]{.underline}**: The very important role of TEM in
diagnosis of renal disease is well documented (13,18). In many renal
diseases, a diagnosis cannot be rendered without the use of TEM. In
other instances, TEM contributes to refinement of the diagnosis (e.g.,
subclassification of lupus nephritis) or provides crucial corroborative
information. From a practical standpoint, TEM is ideally suited to the
analysis of percutaneous renal biopsies, which yield a limited amount of
tissue. Examination of a single glomerulus by TEM may be sufficient to
allow a definitive diagnosis.

**TEM in the Diagnosis of Renal Disease.** TEM often plays a crucial
role in the evaluation of medical renal disorders. It allows direct
visualization and precise localization of a wide variety of primary and
secondary abnormalities affecting the renal glomerulus and other
compartments in the renal parenchyma, including:

1.  **Proteinaceous deposits.**

-   Immune complexes (seen as electron dense deposits).

-   Subendothelial granular deposits in kappa light chain disease.

-   Amyloid fibrils

-   Cryoglobulins

-   Other fibrillary deposits (non-amyloidotic fibrillary
    glomerulopathy)

1.  **Intrinsic and acquired glomerular basement membrane
    abnormalities.**

-   Hereditary nephritis/Alport's syndrome.

-   Thin basement membrane nephropathy.

-   Diabetic nephropathy.

-   "Dense deposits" of membranoproliferative glomerulonephritis, type
    II.

4.  **Damage to visceral epithelial cells and their foot processes.**

-   Minimal change disease.

-   Focal segmental glomerulosclerosis.

4.  **Damage to endothelial cells (e.g., thrombotic
    microangiopathies).**

5.  **Inclusion bodies.**

-   Tubuloreticular structures (most common in lupus and HIV
    infections).

-   Zebra bodies (Fabry's disease).

-   Crystals (e.g., cystine crystals in cystinosis).

-   Viral Inclusions.

[**METABOLIC DISEASES**:]{.underline} Indications for the use of TEM in
the diagnosis of metabolic diseases include the following:

**Possible amyloidosis** in which histochemical stains are negative or
equivocal (8)

**Skeletal muscle biopsies** **possibly having mitochondrial myopathy**
in which light microscopic changes are absent (17,20)

**Peripheral nerve biopsies** from patients suspected of having
neuropathies in which light microscopic changes are absent (17,20)

**Liver biopsies from patients suspected of having alcoholic liver
disease**. Alcoholic liver disease is associated with characteristic
ultrastructural findings of mitochondrial hyperplasia and gigantism and
fibrillar Mallory bodies which may be present when light microscopic
changes of alcoholic liver disease are minimal or absent (21). Use of
TEM in the study of liver biopsies from patients suspected of having
alcoholic liver disease is indicated when light microscopic changes
typical of alcoholic liver disease are absent or minimal.

**Hypersensitivity diseases of the skin.** Use of TEM is indicated in
the study of skin biopsies from patients suspected of having
hypersensitivity diseases of the skin (including drug eruptions), for
TEM may on occasion reveal dermal vascular injury (especially acute
degeneration of endothelial cells and electron dense deposits in dermal
vascular walls) which may be very difficult to see light microscopically
and/or immunohistochemically (12,15,22).

**[DISEASES OF OBSCURE NATURE AND/OR UNKNOWN ETIOLOGY]{.underline}**:
Use of TEM is indicated in the study of tissues having diseases of
obscure nature and/or unknown causes. An example of this situation was
recently published in Ultrastructural Pathology (10).

**[MICROPROBE ANALYSIS:]{.underline}**

Microprobe analysis is currently primarily used for the pneumoconioses,
especially asbestosis (23). New applications using new devices such as
laser probes are being detailed by Dr. Roggli of the Durham VAMC in a
new edition of reference 23, scheduled for release in 1998.

**REFERENCES:**

**1. Diagnostic Electron Microscopy. New York: John Wiley & Sons. 1979;
Vol.2:47-162**

**2. Principles and Practice of Surgical Pathology. New York: Churchill
Livingstone. 1990:119-144**

**3. Neoplastic Hematopathology. Baltimore: Williams & Wilkins 1992;
1367-1404**

**4. Am J Surg Pathol. 1995;19:247-250**

**5. Arch Pathol Lab Med. 1994;118:922-926**

**6. Diagnostic Electron Microscopy of Tumours. Boston: Butterworths.
2nd ed. 1985**

**7. Cancer Treatment Reports. 1979;63:565-570**

**8. Oral Surg Oral Med Oral Pathol. 1989;68:618-623**

**9. Ultrastruct Pathol. 1995;19:95-99**

**10. Ultrastruct Pathol. 1996;20:195-202**

**11. Ann Int Med. 1996;125:523**

**12. Hum Pathol. 1993;24:384-390**

**13. EMSA Bulletin 1991;21:68-73**

**14. Diagnostic Electron Microscopy. New York: John Wiley & Sons.
1979;Vol 2:309-350**

**15. Hum Pathol. 1979;10:313:325**

**16. J Histotechnol. 1995;18:211-224**

**17. Diag. Ultrastructure of Non-Neoplastic Diseases. New York:
Churchill Livingstone 1992;594-614**

**18. Ackerman's Surgical Pathology. St. Louis: The C.V. Mosby Co.
1989;34-36 and 820-853**

**19. Cancer Treatment Reports. 1979;63:571-574**

**20. Muscle Biopsy: A Practical Approach. Philadelphia: Bailliere
Tindall. 1985;129-183**

**21. Diagnostic Electron Microscopy. New York: John Wiley & Sons.
1979;Vol 2:15-46**

**22. J Am Acad Dermatol. 1990;22:359-361**

**23. Microprobe Analysis in Medicine. Washington: Hemisphere, 1989.**

**E-Mail, Web sites**

**[MicroWorld News]{.underline}** is an e-mail newsletter for
microscopists and microanalysts. The issue lists a large number of web
sites, resources, meetings and conferences in the area of EM, imaging,
etc. To subscribe to the e-mail newsletter send an e-mail message to
MWN@mwrn.com

To subscribe to the e-mail Microscopy newsgroup or discussion group send
an e-mail message containing the message "Subscribe Microscopy
YourUserID@YourDomain" to Listserver@MSA.Microscopy.com

An example message from John Doe in FORUM might be:

Subscribe Microscopy doe.john@forum.va.gov

A few sample entries from the e-mail discussions and the Microworld
newsletter are provided in the meetings calendar section and in the
following web site listings.

**[From MicroWorld Resources, your guide to microscopy on the Internet
at]{.underline}**

http://www.mwrn.com/

http://www.mwrn.com/guide.htm

(the above location contains articles on electron microscopy, laser and
confocal microscopy, light microscopy, job postings, etc,)

**[University of Washington]{.underline}**

http://www.pathology.washington.edu./

**[University of Pittsburgh]{.underline}**

http://path.upmc.edu/

**[Uniformed Services University]{.underline}**

http://wwwpath.usuf2.usuhs/mil/

**[Virgil's Web]{.underline}**

http://virgil.mc.vanderbilt.edu/

**[GI and Liver Pathology]{.underline}**

http://www.pds.med.umich.edu/users/ greenson/

**[Osaka Medical College]{.underline}**

http://www.osaka-med.ac.jp/

**[Microscopy Society of America]{.underline}**

http://www.msa.microscopy.com/

***[MSA - FTP site address]{.underline}***

ftp.msa.microscopy.com

**[Emory University School of Medicine]{.underline} just developed a Web
page for the residency program**

http://www.emory.edu/PATHOLOGY/ RESIDENT/

**Government sites of possible interest**:

***[Armed Forces Institute of Pathology]{.underline}***

http://www.afip.mil

**[CancerNet]{.underline}**

gopher.nih.gov:70/11/clin/cancernet

**[National Cancer Institute]{.underline}**

http://www.nci.nih.gov

**[National Library of Medicine]{.underline}**

http://www.nlm.nih.gov

**[Institute of Medicine]{.underline}**

http://www2.nas.edu/iom

**[Morbidity and Mortality Weekly Review]{.underline}**

http://www.cdc.gov/epo/mmwr/mmwr.html

**[National Institutes of Health]{.underline}**

http://www.nih.gov

**[Visible Human Project]{.underline}**

http://www.nlm.gov/research/visible/visible_human.html

**[Cumulative Survey or Histopathological and Cytological Findings
1989-1996]{.underline}** (more than 55,000 aspiration biopsy findings
and more than 90,000 histopathological findings) is available on the
internet on:

http://www.mpt.com.mk/stavric/survey96.zip

For additional information on internet resources for pathologists and
laboratory professionals see "***A full menu for labs that navigate the
NET***" by Carl Graziano in **[CAP TODAY]{.underline}** (Vol. 9, No. 8,
August 1995). On page 40 of that issue, a table lists many additional
internet site addresses including details about signing up for pathology
related "mailing lists" on the internet.

**Future**![](media/image2.emf){width="0.2791666666666667in"
height="0.16944444444444445in"} **EM Newsletters:**

If you have any comments, suggestions, article submissions for use in a
future Newsletter, please send to: Alex Tuszynski (EM-QA/QM) Coordinator
via FAX 919-286-6818 or call 700-671-6925x5218 or E-Mail
tuszynski.a@forum.va.gov

**Microscopy Calendar**

**FOR INFORMATION** on specialty and regional meeting and links to
additional meeting information, **visit** the MicroWorld Resource\'s
Meetings and Conference at **www.mwrn.com/feature/meeting.htm**

**[The 15th Australian Conference for Electron Microscopy, Feb 1 - 6,
1998]{.underline}**, Hobart, Tasmania, Australia Contact: Mures
Convention Management, Victoria Dock, Hobart, Tasmania, 7000, Australia
Tel: +61 (0)3 62 31 21 21 Fax: +6 (0)3 62 34 44 64, e-mail
conventions@mures.com.au or http://www.antdiv.gov.au/acem/

**[Microscopy & Microanalysis-98 (Joint Annual Meeting), July 12 -16,
1998]{.underline}**, Atlanta GA, Contact: MSA Business Office
(800)-538-3672 or 508-563-1155 Fax: 508-563-1211, e-mail
BusinessOffice@MSA.Microscopy.com

**[Society for Ultrastructural Pathology - Mar 1, 1998]{.underline}**
meeting in conjunction with **USCAP meeting Feb 28 - Mar 6, 1998** in
Boston, MA at The Sheraton Boston.

**[Society for Ultrastructural Pathology - ULTRAPATH IX August 2 -7,
1998]{.underline}** at Grove Park Inn Resort, Asheville, NC When making
reservations for the hotel, mention **[Society for Ultrastructural
Pathology]{.underline}** for special meeting rates. Contact Hotel
Reservations, The Grove Park Inn Resort, 290 Macon Ave. Asheville, NC
28804-3799 (704) 252-2711 or (800) 438-5800 or FAX (704) 252-6102 For
additional information and to receive a registration application
contact: John D. Shelburne, Dept. of Pathology, Box 3712, Duke
University and Durham VA Medical Centers, Durham, NC 27710 Phone (919)
286-6925 FAX (919) 286-6818 or e-mail shelburne.john@forum.va.gov

Also take a look at the following URL for updates on information
concerning the Ultrapath IX meeting and on the Grove Park Inn Resort
meeting site.

http://sup.ultrakohl.com/ultrapat.htm

**ICEM-14 \-- 14th International Congress on Electron Microscopy August
31 - Sept. 4, 1998** Cancun, Mexico Col. Hipodromo Condesa. C.P. 06100,
Mexico, D.F. MEXICO (525) 553-4507/4509 FAX (525) 553-4500
http://icem.inin.mx

**MSA/MAS Meetings: continued\....**

**[Aug 1/5, 1999]{.underline}** Portland, OR

(***Congratulations to Charles Meshul of the Portland VAMC ! Charles has
been selected by the Microscopy Society of America to be the local area
coordinator for this important and very large meeting***)

**MSA/MAS Meetings: continued\....**

**July 30 - Aug 3, 2000** Philadelphia, PA

**Aug 5/9, 2001** Long Beach, CA

**[Short Courses and Training]{.underline}**

**A list of short courses and consultants that offer on-site training
for microscopists is available in the Products and Services Directory at
http://www.mwrn.com/products.htm**

**LOM/AFM/SEM/TEM Specimen Preparation Workshops -** contact AMC Group,
7620 E. McKellips Rd. No 4109, Scottsdale, AZ 85257-4600 for schedule &
locations.

**[EM Training Schools]{.underline}:**

**Microscopy Technology Center**, San Joaquin Delta College, 5151
Pacific Avenue, Stockton, CA 95207 (209) 474-5284 FAX: (209) 474-5600
e-mail: murphy@ms.sjdccd.cc.ca.us

**Madison Area Technical College - Electron Microscopy Program**, 3550
Anderson Street, Madison Wisconsin 53704 Glenn Boda (608) 246-6254
Michael Kostrna (608) 246-6762