Background: Sikkim, a Himalayan state in far Northeastern region of India, have an alarming increase in cancer cases. Two of the major referral hospitals, with one as teaching hospital and other with a separate Oncology unit in Gangtok, the capital of Sikkim, serves to majority of health issues with improved facilities and treatment options over the years.
Cancer prevalence rate stands at 91.8 per 100,000 individuals. Effective cancer infrastructure relies heavily on the quality pathology services. Immunohistochemistry (IHC) plays a crucial role in cancer care, providing essential diagnostic insights that guide targeted therapies and predict treatment response. Here, we present our experience in establishing a cost-effective IHC laboratory only one in the region to support the expanding cancer care services in a teaching hospital with limited resources available.

Objectives: Over past decade cancer care facilities in terms of treatments have evolved and improved a lot in the region but a major barrier in such treatment is the insufficient diagnostic services. Pathologic laboratory services face major challenges of limited skilled technician and pathologist, unavailability of equipment and interrupted supply of consumables. This results in exports of tissue specimens to center outside state. Development of IHC service was planned and achieved through strategic investment and workforce training, leveraging an established histology laboratory. Financial support was provided by Department of Biotechnology, government of India through a collaborated research project with teaching hospital at All India Institute of Medical Sciences (AIIMS), Bhopal.

?Methods and Results: Building upon the foundations of a histology laboratory, a facility of IHC was planned at Central Referral Hospital. Major guidance and experts’ opinion from pathology department at AIIMS, Bhopal contributed fully to setting up the facility. The plan followed a step wise process beginning with identification, and reimbursement of dedicated space for IHC laboratory. This was followed by identification of skilled team of doctors and technical staff who underwent training conducted by IHC experts as well through exposure and field visit to well established IHC lab out of the state. Challenges of procurement of equipment and regular supply of reagents were frequently experienced due to poor connectivity of road to suppliers located outside state. With a background of resource limited setting, protocol was formulated for manual, small-batch IHC using microwave for antigen retrieval instead of expensive and maintenance-intensive automated techniques. Standards and guidelines were set up through multiple trials which included titration of buffers, change in fixation time and 3-4µm thickness of tissue, reducing folds, background staining and improved techniques in washing slides and staining. Results validations were done through exchange of photographs of IHC slides to experts. Feedback and engagement of outside expertise led to development of standard operating procedures for reagent efficient protocols.  Estrogen, progesterone and HER2 staining for breast cancer treatment are now the regular IHC tests performed at our facility.

?Conclusion: Adding to the comprehensive care facilites available in our state, we could establish a low volume IHC facility centre with limited resources and catering to the increasing number of cancer cases.