Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
Pathology Associates Of Lexington, P.A.
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        Standard Pathology Practices for the Lexington Medical Center Breast Program
      

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We are an 8-pathologist independent private practice group in a very fine acute care general community hospital (of the Lexington County Health Services District) of over 300 beds having the busiest (or 2nd busiest) ER in S. C. and an over-150-doctor Medical Services Organization (MSO) of employed physicians. We have an excellent, NAPBC-accredited Breast Cancer program here but are not a breast specialty hospital. That is, we are having to deal with a wide variety of non-breast patient problems, too. So, dealing with breast specimens has to work in with everything else.

When conservative breast surgery diagnostic (and possibly therapeutic) lumpectomies began in the mid-1980s, we were challenged by Dr. Curtis McGown to have a benign or malignant answer to the surgeons office by noon the next day at the time of drain removal. We were probably able to do this about 50% of the time; half the time, we felt that overnight fixation was needed in order not to compromise detailed histological evaluation, especially of margins. Fixation could be speeded up with initial inking and fixation followed an hour or so later by serial slicing back into fixative free or in cassettes and, when desired, fixation in alcoholic formalin for the faster penetration of the alcohol. By 2007, as with many practices, we were transitioning to rapid transfer of resected tumors into just 10% NBF within an hour or less and with fixation between 8-48 hours prior to processing & embedding.

Not being peer-recognized breast experts, we have designed & refined our reports to help clinicians and to "tell the story" to patients and any subsequent knowledgeable layperson or physician, local or at a distant location, who might impact on the patient's situation. Reports sometimes include "photo reports" designed to help both the clinical doctors and patient understand the situation better...most often color-printed non-microscopic photos blended with the written report & rarely a web-based report.

On bigger specimens, Hartmann's fixative is a considerable help in locating malignant foci (turns them white) as well as in helping to visualize close margins with the naked eye. BUT, if breast marker studies have not been done yet, one must get some tumor and adjacent normal breast into formalin fixative as formalin (10% NBF)...the internationally standardized fixative for these semi-quantitative IHC (or even FISH or CISH) determinations and for the genomic studies.

Our rapid turn around time is focused primarily on core biopsies, IHC (done on site) markers usually taking another day. Path reports are in prose (NOT synoptic) and include gross details, micro details, and diagnostic parameters of importance to our clinicians. We do use templates (macros) to help us be sure to address all factors. If, for example, it seems to be a cancer or initial slides show cancer, one dictate to the transcriptionist something like, "On case L05-444, Mrs. Jones, micro is standard template 'mbrca' and diagnosis is template 'B4'." Then one can view those "macros" within the working copy of the path report and be sure that all desired parameters are addressed pertinent to the particular case (as one studies the case).

  1. Receipt of any breast specimen: the surgical pathology technical assistant (person logging the specimen in) checks the pathology information system for any previous anatomic pathology reports or breast conference or case notes & prints them off for the pathologist and may also check the hospital information system (HIS) for mammogram, ultrasound, or MRI reports that might pertain to the case. This is done to help assure that the pathologist has "case context" to work with when grossing the specimen in. In rare instances, we may have to review the specimen with the surgeon or radiologist prior to dissection.

  2. dealing with cytology specimens: we try to turn around FNA diagnoses by FAX or phone same day; aspiration fluid cytologies from radiology come to us with a standard sheet filled out to give us enough clinical information such that we pathologists are better enabled to issue a more decisive report as to negativity or positivity and avoid issuing reports and overusing such CYA terminology as "a few atypical cells noted & can't rule out malignancy".
  3. handling core biopsies:
    • path report, gross: we have a standard gross paragraph that, among other things, notes that radiologist gets cores rapidly into formalin and details the specimen according to whether supposedly has calcifications or not.

    • fixation: provided the cores get currently national standard formalin fixation prior to being placed on the tissue processor, we have routine H&E sections of cores ready beginning by 7:30AM the next business day aftre biopsy.

    • "yellow breast biopsy FAX sheet": coming from Breast Center with core specimens is a standard information sheet which tells us the "gross pathology" of the tumor, physical exam information as to location, etc., about whether a "calcifications" case or "density" case, and what the radiologist's differential diagnosis is. As soon as diagnosis is made next morning from H&E slides, a note is made onto the yellow FAX sheet as to diagnosis and concordance or discordance & sheet is FAXed to the Breast Center & they make contacts to patient and referring doctor. We make sure referring doctor, breast center, breast health services, and surgeon get path report copies.

  4. handling sentinel lymph nodes: If our surgeons find the sentinel node and it looks "suspicious" to them and the situation is OK to do an axillary dissection, he/she may send the node for frozen section...we do not do routine SLN frozen sections. In such a case, the pathologist will record node features, serially section it and chose any slice with any abnormal-looking area (or, if no area be looking abnormal, just chose a cross-section) for th FS block. Pathologist might decide to also do a cut surface touch prep additionally or even alternatively to a frozen section. At any rate, every attempt is made to conserve node for permanent, "intense protocol" processing should the FS be benign. [surgeon's method] [intense histological assessment analysis & vaue]

    [the intense protocol].
  5. processing lymph node dissections:...the patient's life depends on us!
    • you must find all nodes: who dissects & how

    • you must detect cancer if is in any node: intense processing using agar & agar depth sticks to assure step-cutting
  6. processing diagnostic lumpectomies:......weigh, measure, & describe.
    • surgical margins: by visual exam and palpation and exam of any accompanying specimen radiograph, try to see if there is a close or positive margin & mark that spot with a non-black dye; then ink margins with India ink (black) & briefly dip in vinegar (dilute acetic acid) to seal the ink to the surgical margin surfaces, and then put into fixative. Have IHC markers already been done (see above)?...if not, get some tumor & benign glandular tissue into 10% NBF.  Place other into proper fixative (possibly needing overnight fixation); later select blocks, process, and sign out.
    • written grossing notes: sometimes use "scratch paper" to sketch the specimen & key notes on it as to where blocks came from (we don't necessarily submit all of a lumpectomy for microscopic exam).
    • FAX diagnosis: at time of dictation, we write diagnosis on a FAX sheet for each surgery group [example] & FAX note to his/her office. Case updates can also be additionally FAXed out of CoPath.
  7. processing conservative cancer treatment lumpectomies:......weigh, measure, & describe.
    • surgical margins: by visual exam and palpation and exam of any accompanying specimen radiograph try to see if there is a close or positive margin & mark the spot with a non-black dye; then ink margins with India ink (black) & briefly dip in vinegar (dilute acetic acid) to seal the ink to the surgical margin surfaces. Have IHC markers already been done (see above)?...if not, get some tumor & benign glandular tissue into 10% NBF.  Place into proper fixative (possibly needing overnight fixation); later select blocks, process, and sign out.
    • written grossing notes: sometimes use "scratch paper" to sketch the specimen & key notes on it as to where blocks came from (we don't necessarily submit all of a lumpectomy for microscopic exam).
    • FAX diagnosis: at time of dictation, we write diagnosis on a FAX sheet for each surgery group & FAX note to his/her office. Case updates can also be additionally FAXed out of CoPath.
  8. processing mastectomies:
    • block selection: The above report copies are used to see how extensive the exam must be. We look for multifocal lesions, skin/nipple involvement, and closeness & negativity/positivity of surgical margins. Have IHC markers already been done (see above)?...if not, get some tumor & benign glandular tissue into 10% NBF.  I almost always fix mastectomies (I usually make some incomplete cross-sections to aid fixation) with Hartmann's and at least overnight & select blocks, process, and sign out.

    • written grossing notes: sometimes use "scratch paper" to sketch the specimen & key notes on it as to where blocks came from.
  9. Special studies: we do a wide variety of IHC stains on campus; FISH studies for such as HER-2 and any DNA ploidy studies (10% NBF fixation required) are performed at PhenoPath Labs in Seattle. The OncotypeDX genomic studies by TAQMAN technique are performed at Genomic Health Lab in Redwood City, Calif. One of our pathologists selects the appropriate block to be sent for such tests.
  10. multidisciplinary conference:
    • presenting pathology: In that most clinicians are unequipped to appreciate fine points of histology & cytology, we only actually show "slides" to actually make a point...often to illustrate the attention to detail needed for precision evaluation in breast pathology.
    • getting information: Just as a clinician needs history and physical exam and ancillary information to properly work with a patient, the patient is often best served when we approach a breast specimen armed with information. The conference is often the only place to get really accurate information as to potential maximum size of lesion, exact lesion location, and maybe another detail unique to that case.
    • in-house conference notes: Immediately following conference, pathologist coordinator dictates "heads up" or FYI notes into the pathology LIS. And, since these do not appear in the patient's global medical record, note might say such as, "Watch out, tumor close to chest wall so closest lumpectomy margin is likely that chest wall margin."...or, "Watch out, imaging thinks there could be two tumors vs. a dumbbell-shaped single tumor."...being sure of which might profoundly affect the tumor size for TNM staging.
  11. processing reduction mammoplasties: Since about 1% of such cases harbor an occult cancer, we use Hartmann's fixative as a "subgrossing" process in that it causes foci rich in nuclei to stand out as white foci or nodules within an otherwise non-descript fibrofatty stromal background. Even this process can miss lobular; so, careful inspection visually and by palpation is also needed. The typical case gets two cassettes per breast.
(posted 22 April 2005; latest addition 27 December 2008)

 
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