1. Clinical history is important. What did you see when you took the biopsy? Was there a mass there? Does the patient have a history of malignancy? These are all important questions, and they help pathologists arrive at the most accurate diagnosis possible. Rarely, the best we can give you is a differential, but the more clinical information given to us, the more likely we can narrow things down and pinpoint exactly what is going on. Radiologic characteristics can also be helpful, especially in cases of bony lesions. In neuropathology, it’s like real estate- location, location, location. Particular tumors like to grow in particular places. The more supplemental information you can provide, the more specific our diagnosis can be.
2. We’re slow, but not that slow. “The lab” has the reputation of taking forever to produce surgical pathology reports. Sometimes this is deserved. Today there are many ancillary tests that can help pathologists make the best diagnosis. Immunohistochemical stains, or “immunos” as we tend to call them, usually take a couple of days, depending on if the particular stain is available at the institution. Sometimes pathologists need a less common stain and have to send tissue to a larger lab. Transport time eats a day each way. Other tests such as cytogenetics, flow cytometry, and rarely microbiology, are sometimes needed to interpret a case. If it’s been more than 48 hours for a biopsy, give the pathologist assigned to the case a call. For a larger resection, tissue often has to sit in formalin overnight to process, so wait at least 72 hours before calling for a preliminary report.
3. Bringing a new lab test on board is not that easy. We appreciate that the latest quantiferon gold test for TB is very sexy and would make your life easier. But deciding to onboard a new lab test requires serious considerations. Is new capital equipment required to perform this test? What is the reimbursement to the lab for this test? Is this test high liability? Is personnel trained to perform and possibly interpret this test? And once a lab goes forward with a test there is a validation process that is time-consuming. Proficiency testing may also be required for personnel. Lab inspections, accreditations, and licensing are lengthy processes for the lab and involve a lot of red tape. According to a 2016 editorial published in the American Journal of Clinical Pathology, “In the United States, the practice of pathology and laboratory medicine is one of the most heavily regulated parts of health care.”1 As such, bringing a new test into the laboratory may not be as simple and straight-forward as you think.
4. Frozen sections are for management changes. In a strict sense, intraoperative consultations, typically by frozen section, are performed if results could necessitate an intraoperative management change. If a malignant omental nodule would bump a patient to stage four requiring systemic chemotherapy instead of surgery, by all means, call us! We are happy to help with this critical decision affecting patient care. On the other hand, if we track you down in the PACU to tell you the nodule is malignant and you say, “Yes there was extensive disease grossly, so I closed,” then it appears the frozen section was unnecessary. Remember the frozen section process imparts artifact to the tissue making interpretation more challenging. If an immediate diagnosis is truly not needed for intraoperative management purposes, then it is better to send the tissue for permanent sections where it can be optimally processed and interpreted. And please don’t ask us to freeze pigmented lesions or bone. Pigmented lesions need to be evaluated with optimal histology- melanoma can be very tricky. And bone just doesn’t cut. It has to be decalcified first before it is soft enough to cut.
5. Treatment is our weakness. Working exclusively on the diagnostic end of things, we pathologists sometimes don’t know as much about treatment as we would like. We try to pick up on treatment strategies at tumor boards, but sometimes we don’t see the whole picture. Letting us know where your decision points are helps us. For example, letting us know that if the extent of myometrial invasion in an endometrial tumor is over 50 percent, you will perform lymph node sampling tells us to evaluate this metric carefully and include this finding prominently in our report. While synoptic reports address many of these specifics, we can serve you and your patients better if we know why certain metrics are important and how they affect patient care. Sometimes metrics are for completeness and other times they impact the modality or intensity of treatment. We want to know if a 1 mm margin buys your patient radiation, whereas a 2 mm margin means no further treatment. Measurements will be double and triple-checked if they are close to a decision point.
Collin O’Hara is a pathologist.
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