Surgical pathology specimens for gross examination only and exempt from submission: a College of American Pathologists Q-Probes study of current policies in 413 institutions

OBJECTIVE: To survey the scope of current written institutional policies for types of surgical pathology specimens exempt from submission to the laboratory and those that may be examined by gross inspection only. DESIGN AND SETTING: In the first quarter of 1997, a total of 413 voluntary participant institutions enrolled in the College of American Pathologists Q-Probes quality improvement program completed a checklist of 115 proffered specimens. Also included was a questionnaire defining demographic, practice, and reimbursement variables. MAIN OUTCOME MEASURES: The number and types of specimens exempt from submission and submitted for gross examination only based on written institutional policy rather than on unapproved actual practices. RESULTS: Most institutions had a written policy for types of specimens deemed exempt from submission to pathology (87.1 %) and for types of specimens subject to gross examination only (76.6%). There was a wide range of numbers of specimen types with a median number of 17 (range, 2-40) in the exempt category and 29 (range, 6-57) in the category of gross examination only. Significantly higher absolute counts of specimens exempt from submission to pathology were reported by institutions with a greater surgical pathology volume in 1996 and by nonteaching institutions. No aspect of practice was associated with numbers of specimens for gross examination only. CONCLUSIONS: This Q-Probes study creates a multi-institutional reference database of current practices to assist pathologists and clinical staff in the development of written guidelines pertaining to surgical pathology specimen submission exceptions and gross-only examinations.     

Pathologists' Assistants productivity – a new way to look at the numbers

Pre-existing productivity monitoring methods of assessing number of specimens grossed or number of blocks submitted are no longer granular enough in a milieu of Pathologists' Assistants (PA) grossing different types of specimens of varying complexities and performing other operational tasks. Workload capture in the gross lab should be consistent and accurate not only to submit accurate figures to finance but also in order to provide administrative staff with data that is useful in assessing how many PAs they need to accommodate specimen volumes. Capturing workload using real time, bench level entry of unit values from the Canadian Institute for Health Information (CIHI), Management Information System (MIS) standards by the unit producing personnel (UPP) will allow for more accurate and consistent capture. Interfacing this method with actual time worked by PAs provides the individual and leadership the ability to assess their productivity.     

Factors that impact turnaround time of surgical pathology specimens in an academic institution

Turnaround time of laboratory results is important for customer satisfaction. The College of American Pathologists' checklist requires an analytic turnaround time of 2 days or less for most routine cases and lets every hospital define what a routine specimen is. The objective of this study was to analyze which factors impact turnaround time of nonbiopsy surgical pathology specimens. We calculated the turnaround time from receipt to verification of results (adjusted for weekends and holidays) for all nonbiopsy surgical specimens during a 2-week period. Factors studied included tissue type, number of slides per case, decalcification, immunohistochemistry, consultations with other pathologists, and diagnosis. Univariate and multivariate analyses were performed. A total of 713 specimens were analyzed, 551 (77%) were verified within 2 days and 162 (23%) in 3 days or more. Lung, gastrointestinal, breast, and genitourinary specimens showed the highest percentage of cases being signed out in over 3 days. Diagnosis of malignancy (including staging of the neoplasia), consultation with other pathologists, having had a frozen section, and use of immunohistochemical stains were significantly associated with increased turnaround time in univariate analysis. Decalcification was not associated with increased turnaround time. In multivariate analysis, consultation with other pathologists, use of immunohistochemistry, diagnosis of malignancy, and the number of slides studied continued to be significantly associated with prolonged turnaround time. Our findings suggest that diagnosis of malignancy is central to significantly prolonging the turnaround time for surgical pathology specimens, thus institutions that serve cancer centers will have longer turnaround time than those that do not.     

Breast specimen radiography. Obligatory, adjuvant and investigative.

The development of mammography and that of breast specimen radiography, which have paralleled one another, are reviewed. The preparation of radiographs of breast specimens is obligatory when biopsy is performed for purely mammographic indications and when no palpable mass is present. Such cases are being encountered with increasing frequency because of the development of centers for breast cancer screening. Close collaboration among pathologists, radiologists and surgeons and precise attention to procedural detail are necessities wherever this situation arises. The application of specimen radiography as a routine to all breast specimens is regarded as an adjunct to gross examination. While useful, its yield of otherwise undetected occult carcinoma is low. Whether other advantages outweigh the cost appears to be a matter for individual decision. Investigative uses of breast specimen radiography have received little attention. Some possible applications are suggested.     

Uropathology macroscopy: a pragmatic approach

Macroscopic examination and sampling are the critical initial steps in the histopathological assessment of a surgical specimen. Meticulous macroscopic assessment is critical as abnormalities missed at this stage are unlikely to be identified by histological examination. Complete recording of all relevant macroscopic data is also critical as unlike microscopic data, the former cannot be retrospectively collected. Careful gross examination and targeted sampling is paramount as only about 0.2% of an “all embedded” specimen would actually be microscopically evaluated. In this review, current macroscopy practice is critically appraised and some issues with standard guidelines highlighted. For example, it is unclear whether the common recommendation to submit a prescribed number of blocks per cm tumour diameter refers to tissue blocks or paraffin blocks. This review focusses on specific issues related to the macroscopic examination of some common urological resection specimens and discusses the clinical relevance of macroscopic data in these specimens.     

One hospital's successful 20-year experience with physician assistants in graduate medical education.

The downsizing of residencies and the migration of residents to outpatient settings create an increasing need to protect residents' educational experiences and to maintain standards of hospital care. Some hospitals have solved this dilemma by using mid-level practitioners (MLPs), including physician assistants (PAs), to augment the diminished staffs of residents in their surgical residencies. The authors describe how their hospital has done so. Their surgical PA program, begun in 1979, seeks to meet the hospital's expectations for in-house coverage of surgical patients, to protect the educational integrity of the physician residency program in surgery, to allow protected time for residents' conferences and clinics, and to prepare residents for future practice in multidisciplinary teams. The PA and residents' services are partly separated, which reduces the potential for resident-PA conflict. Responsibilities for both residents and PAs are stratified (junior vs senior status). Both services are teaching services, which helps motivate PAs to be committed to the service and helps foster the equality between residents and PAs that the program strives for. The residents have come to value the PAs, and the program's goals have been achieved, including protecting time for residents' education and maintaining humane on-call schedules for residents. The authors discuss job satisfaction, turnover, and the hard financial realities of paying for PAs' salaries, benefits, and educational programs, as well as the loss of Medicare DME and IME reimbursements when a PA replaces a resident. Ways some of these costs can be recovered are outlined. The authors conclude with recommendations on how to deal with six key issues of PA or other MLP programs: need for institutional commitment; importance of local circumstances; emphasis on partnership, not competition, between PAs and residents; value of an education component; need to build a cohesive program, and the importance of effective PA leadership.     

Evaluation of the CampyPak II gas generator system for isolation of Campylobacter fetus subsp. jejuni

The CampyPak II (BBL Microbiology Systems, Cockeysville, Md.) method for isolating Campylobacter fetus subsp. jejuni was evaluated with clinical specimens by comparison with an evacuation replacement procedure. Of 757 specimens, 26 (3.4%) were positive for C. fetus subsp. jejuni. All 26 were recovered by both systems. No difference was found in the time necessary for isolation, except with one isolate that required 3 days for isolation with CampyPak II and 2 days with the established procedure. Although the average colony size was slightly smaller for colonies incubated in the CampyPak II system (P less than 0.02 by a paired t test), this is probably of no practical consequence. In terms of technical performance, therefore, the CampyPak II system appears to be an excellent alternative method for establishing microaerophilic conditions necessary for isolating C. fetus subsp. jejuni. The only difference between the two systems was the cost of using the CampyPak II envelopes. Excluding the initial equipment costs, CampyPak II envelopes cost approximately $0.74 per specimen, whereas the standard Torbal jar technique cost about $0.10 per specimen.     

Examination of tumor and tumor-like conditions of bone

Surgical pathology specimens composed of bone, ranging from core biopsy to limb amputation specimens, require special attention, processing, and often unique equipment. This readily translates into additional handling steps and time, especially when one factors in clinical correlation with the surgeon and radiologic review of all images with a knowledgeable musculoskeletal radiologist. When these factors are superimposed on the rarity of these lesions in routine practice, it is not surprising that most trainees, as well as seasoned pathologists, are wary of these lesions. In this report, we use a case of osteofibrous dysplasia (Campanacci's disease) to demonstrate the dissection of such a surgical specimen and complete the report with a brief discussion of the entity.     

MRI-directed, wire-localized breast excisions: incidence of malignancy and recommendations for pathologic evaluation

Magnetic resonance imaging (MRI) has an evolving role in the evaluation of breast lesions and is currently being used for the screening of high-risk patients (eg, women with a personal or family history of breast cancer), for the evaluation of extent of disease in patients with a current diagnosis of cancer, and for patients with suspicious, but indeterminate, findings by other imaging modalities. If a suspicious lesion detected by MRI is not well visualized by another method, an MRI-directed core biopsy or breast excision may be performed. MRI cannot be used to verify the lesion in the specimen because MRI lesion detection is dependent on uptake of gadolinium after intravenous injection. Accordingly, these breast excisions present unique challenges to pathologists. The purpose of this report is to define the surgical pathology issues involved in processing MRI-localized excisions. Retrospective review of 85 consecutive MRI-directed breast excisions from 77 patients was performed. Malignant lesions were present in 20 (24%) of 85 excisions, including 10 cases of invasive carcinoma (median size, 0.4 cm), 9 cases of ductal carcinoma in situ, and 1 case of lymphoma. Most of the malignancies (85% or 17/20) had no associated gross finding and only 5 (25%) of 20 of these malignancies were associated with a definite finding on the specimen radiograph. This study demonstrates that gross examination and specimen radiography do not identify most of the malignancies in MRI-localized biopsies and, therefore, optimal processing requires complete microscopic examination of these specimens.     

Primary virus isolation by a satellite laboratory

A hospital-based satellite laboratory designed to isolate viral pathogens frequently found in renal transplant and hematology-oncology patients was compared with a system based on isolation by a state-wide reference laboratory. The hospital-based laboratory identified 12 viral isolates from the total 97 clinical specimens submitted. The hospital-based laboratory identified seven viral isolates from the first 50 clinical specimens, whereas the statewide reference laboratory identified six isolates from identical paired specimens. The average time from specimen collection to reporting results for the 97 specimens was 9.2 days for the hospital laboratory, as compared with 11.2 days for the first 50 duplicate specimens sent to the state laboratory. The cost per clinical specimen was $18.10, which compares favorably with costs for routine aerobic bacteriology. The use of a satellite laboratory system for primary viral isolation appears to provide rapid, accurate, and accessible viral diagnosis at an affordable cost.     

Bone grossing techniques: helpful hints and procedures

The present article is intended to offer pathologists and pathology residents helpful hints and procedures as well as some general approaches to technical questions of bone grossing in a surgical pathology laboratory. An emphasis on the personal experience of the author in grossing bones has been made. Three main conditions determine successful gross bone sections: specimen immobilization, the appropriate cutting instrument, and correct specimen orientation. From the technical point of view, the most important seems to be immobilization. A variety of devices and gadgets can be used to make the bone specimen stable while sectioning. Among them, hard-pressed cardboard cartons are the most helpful. They have the advantage in complicated bone specimens to allow the grossing person to cut through the immobilization device, thus assuring a complete section. There are definite particularities in technical approaches to different bone specimens. Even a femoral head, the most popular specimen, requires different grossing techniques depending on the clinical circumstances. Examples of grossing techniques for different bone specimens are described in detail. The technique can be applied in similar clinical situations to other bone specimens.     

Preserving and sharing examples of anatomical variation and developmental anomalies via photorealistic virtual reality

Computer graphics technology has made it possible to create photographic-quality virtual specimens from real anatomical material. One technique for doing this, QuickTime Virtual Reality (QTVR), results in virtual specimens that are easily shared on the Internet and displayed as standalone entities or incorporated into complex programs or Web sites. A compelling use of this technology is the sharing of rare specimens such as unusual variations, developmental anomalies or gross pathology. These types of specimens have traditionally been confined to anatomical museums, but could serve a much more useful existence as freely shared virtual specimens. An example presented here is a relatively rare developmental defect in the embryonic aortic arches that results in a right-sided aortic arch coursing posterior to the trachea and esophagus. In a time of ever increasing restraints on the practical side of anatomy education, an Internet-based library of human variation and other rare specimens would be a useful supplement to students' limited exposure to the human body. Since the discovery and preparation of specimens would be the rate-limiting step in producing such a collection, we propose the establishment of a center for virtual specimen creation and preservation through a cooperative effort by gross anatomists and pathologists in contributing the source material. This collection, a work in progress, is available at www.anatomy.wright.edu/qtvr.     

Economical laboratory support system for influenza virus surveillance.

When increases in influenzalike illnesses were first detected during the 1984 to 1985 and 1985 to 1986 influenza seasons, throat swab specimens were mailed by physicians across the United States to one hospital laboratory, and each specimen was inoculated into a single tube of cell culture. Of 165 specimens, 52 (32%) were positive for influenza A or B virus within 3 days of receipt when tested by fluorescence microscopy, permitting positive results to be received by the physicians within 1 week on the average. Approximate direct cost was $16 per specimen.     

Routine evaluation of adult tonsillectomy specimens: toward establishing a new standard of care

Tonsil excision is a common surgery for both children and adults. Prior studies have consistently shown that the rate of malignancy in tonsil specimens is low and that the possibility of true, occult malignancy is remote. Practice trends accept triage of pediatric tonsillectomies for exemption or gross exam only. However, for adults, despite a low malignancy rate, routine histological evaluation of tonsillectomy specimens is standard of care at most health care facilities. The authors performed a retrospective review of all tonsil specimens received in their department over 45 months with categorization of pathological diagnosis and surgical indication. Of 1746 adult tonsillectomy specimens removed during this time, there were no incidental/occult malignancies. These data indicate that gross examination of adult tonsillectomy specimens excised for chronic tonsillitis or sleep apnea is sound practice, and this, taken together with other published data, provides a basis for consensus-derived practice guidelines.     

The decreasing cost of telemedicine and telehealth

The teleoncology practice based at the University of Kansas Medical Center (KUMC) in Kansas City, Kansas, is one of the longest running practices of its kind worldwide. The practice began in 1995 and connected an oncologist at KUMC with a rural medical center in Hays, Kansas. Fifteen years later, the practice continues to thrive at Hays Medical Center and has also expanded to include two additional sites within the state-the Northeast Kansas Center for Health and Wellness in Horton and Goodland Regional Medical Center in Goodland-that offer regularly scheduled teleoncology clinics. While the KUMC practice has witnessed an expansion in service sites throughout its history, the practice has seen a significant decrease in the costs associated with providing such services since its inception. The cost decrease can, in part, be attributed to an increase in the number of teleoncology visits conducted through the practice since it began. In Fiscal Year 1995 (FY 1995), 103 teleoncology visits resulted in a cost per visit of $812. Five years later, the FY 2000 $410 per visit cost for 121 visits was almost half the cost identified in the initial cost analysis. The FY 2003 cost per visit for 219 visits saw another decrease to $401, and the most recent FY 2005 cost analysis yielded another decrease to $251 per visit for 235 visits. The data reported below are likely to be the best now available to track time trends in the cost of providing telemedicine or telehealth consultations. The Conclusion and Policy Recommendations at the end of this article will focus on both the cost-time profile and some other challenges and lessons learned.     

Cost and time savings following introduction of rejection criteria for clinical specimens.

We have evaluated the yield of several tests and have instituted specimen rejection criteria to reduce costs and save time. For a 12-month period, we recorded the reduction of these tests and calculated the resultant cost and time savings. Seven changes were analyzed: not performing fungal or mycobacterial (acid-fast bacillus) cultures on cerebrospinal fluid (CSF) specimens from patients without known immunosuppression when chemistry and cell count are normal; not performing routine stool culture or ovum and parasite examination on specimens from patients in the hospital for > 3 days; not culturing endotracheal suction aspirates when no organisms or > 10 squamous epithelial cells are present; discontinuing broth cultures on all specimens except for tissue, continuous ambulatory peritoneal dialysis fluid, and CSF from patients with shunts; and eliminating bacterial antigen tests. For each test, the number not performed (n), reagent savings, and technologist time saved, respectively, were as follows: CSF fungal culture, 267, $999, and 67 h; CSF acid-fast bacillus culture, 275, $1,662, and 124 h; stool cultures, 320, $2,991, and 98 h; ovum and parasite examinations, 216, $525, and 108 h; endotracheal suction aspirate cultures, 1,505, $4,447, and 306 h; broth cultures, 5,218, $4,931, and 80 h; and bacterial antigen tests, 2,598, $2,293, and 299 h. Overall, 5,181 tests were rejected and 5,218 broth cultures were omitted. Achievable savings were $28,000 in reagent costs and 1,082 h of technologist time. In conclusion, rejecting specimens of proven low yield saves reagent costs and, more importantly, saves technologist time. This time can be spent on specimens having greater diagnostic utility.