Developing and expanding pathology services to support clinical care and research efforts in Malawi

• The care of patients with lymphoma relies heavily on accurate tissue diagnosis and classification.

• In sub-Saharan Africa (SSA), where the lymphoma burden is increasing due to population growth, aging, and continued epidemic levels of HIV infection, pathology services are extremely limited.

  • Cancer registry data show that only 18% of all cancers diagnosed in Malawi were pathologically confirmed.

  • Diagnostic pathology services were not previously available in Lilongwe, the capital city of Malawi.

• In 2011, through a joint effort between the Malawi Ministry of Health, the Kamuzu Central Hospital (KCH), and the University of North Carolina (UNC), a pathology laboratory was established in Lilongwe at KCH to support a prospective lymphoma clinical trial.

• The laboratory provides routine diagnostic service, clinical trials, and a research program that has attracted Malawian pathologists and technologists to a center that lacked any pathology services 6 years prior.

• The initial equipment and laboratory start-up costs were ∼$200 000 US dollars, including a digital microscopy system and infrastructure for basic tissue processing and histology.

• Current equipment and available immunohistochemical stains (IHC) are listed in Table 1.

• All cases are reviewed by local pathologists, and difficult cases as well as diagnostic specimens from all patients enrolled in the ongoing KCH Lymphoma Study are reviewed at a weekly telepathology conference (basic workflow: Figure 1)

• Telepathology conferences are attended by Malawian clinicians, Malawian pathologists, and their counterparts in the United States.

• Diagnoses are issued by local pathologists.

• To ensure quality control and facilitate research studies, tissue blocks and glass cytology slides for all KCH Lymphoma Study patients are sent to collaborators at UNC quarterly.

  • Histology cases are further characterized by a broader panel of IHC and in situ hybridization stains, and a final diagnosis is rendered.

  • Diagnostic agreement was assessed using a 4-tier scoring system to quantify concordance between real-time diagnoses rendered at weekly telepathology conferences and final diagnoses rendered in the United States.

• By 2016, the laboratory processed 5611 histology and 1998 cytology cases, the majority of these interpreted by 1 of 2 local pathologists without international consultation or additional stains (Figure 2).

• Although the expanded immunophenotyping offered in the United States permits more granular classification of some lymphomas, an initial diagnosis made in Malawi led to appropriate treatment in 95% of cases (n = 79 of the first 83 diagnosed lymphomas) (Table 2).

• Concordance mirrors that seen in the United States after central review for cancer diagnosis.

• Pathologists and the laboratory have passed the accreditation exam for participation in the AMC-068 HIV lymphoma trial.

• Expand panel of IHC stains.

• Increase automation of laboratory workflow to accommodate increasing clinical volume.

• Continue mentoring for Malawian pathologists and technicians.

• Implement validated molecular diagnostic assays.

• Support expansion of the National Institutes of Health research initiative.

• Develop regional collaborations with other African pathology centers of excellence.

• Hematologic disorders, including lymphoma, in SSA are a major cause of morbidity and mortality.

• Developing high-quality pathology services for routine care, clinical trials, and basic research in resource-limited settings is feasible.

• Improvement of the regional capacity to accurately classify tumors is paramount to understanding true disease epidemiology and to establish effective treatment strategies.

Conflict-of-interest disclosure: No competing financial interests declared.

Correspondence: Y. Fedoriw, Department of Pathology and Laboratory Medicine and Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC; e-mail: Yuri.Fedoriw@unchealth.unc.edu.