[Histonet] Needle biopsies

Thu Dec 30 10:46:03 CST 2004

Wanted to chime in from a pathologist perspective.

I've always found it useful to think of each piece of tissue as a patient, 
and to let that guide my requests and management.  I depend on histologists 
for the very quality of my work and the patients that I am rendering 
diagnoses on - and I try to remember that daily and treat our relationship 
as such.  I need you guys!!!!

As I've become more seasoned, the whole risk management/lawsuit avoidance 
mentality has influenced my practice - as it seems to have influenced some 
of the other pathologists you are dealing with.  The study referred to in 
this thread appears to blame the histologist for microcalcifications that 
were cut through and potentially discarded.  Unless there is a alteration in 
the procedure and the pathologist and histologist working together - what's 
the point of blame and shame?  Sounds pretty crappy.

It's true that any legal action for the cut away microcalcifications will 
rest squarely with the pathologist.  Rather than blaming the histologist 
(misery loves company) it seems like a good time to be working WITH the 
histologist in the best interest of the patient.

I don't enjoy the position that the decreasing amounts of tissue and 
clinician demands for diagnosis nonetheless leave all of us in.  But our 
role is to serve our patients, to facilitate communication between the 
clinician and the patient and to accomplish this - we (pathologists and 
histologists) must be a unified team.  How often do you really experience 
this?  Do you have time or the opportunity to be at the microscope with your 
pathologists?  Probably not.

The reality in most practices is:  If you surface cut the block - you'll be 
told to "go deeper" - if you throw away a level, you'll be told "what the 
hell were you thinking?"  If you give the pathologist 8 slides, we're likely 
to claim "slide innundation!!!!"  TOO MUCH WORK!!  You're damed if you do 
and damned if you don't.

Is there a winning situation?

It seems very prudent to surface cut the block initially, but if diagnostic 
features aren't present histologically, there is the risk that the block 
will be recut on a different microtome, causing unnecessary loss of tissue.  
If you use this methodology, there MUST be a safeguard in place such that 
the same histologist and microtome are used to cut the deepers.  And the 
pathologists have to be "on board" with the policy (particularly if the 
person cutting recuts until 3:00 p.m. won't be allowed to cut the needle 
core biopsy unless the pathologist signs a waiver of the policy - I'm sure 
many of you are getting red-faced pathologist mental images).  [Yeah, we can 
be an "interesting" bunch, hm?]

The Mayo method of cutting all the tissue on the same microtome up front is 
one solution.  Something to keep in mind from a risk management standpoint, 
though, is that if there is any legal action - some lawyer is going to see 
slides labelled 1, 3, 5 and 7 and say "where are 2, 4, 6 and 8."

Then someone is going to write a check to the plaintiff.

At UWashington (where I trained and did a breast/immuno fellowship) - all 
the needle core biopsies were trimmed close to the tissue, to provide 
ribbons on each slide (usually 6 - 8 on biopsies less than 1.5 cm), and we 
reviewed two slides.  Recuts were kind of a disaster, since UW didn't have a 
policy in place when I was there (1999) to ensure the same histologist and 
microtome.

I suppose that besides offering up some risk management perspective and a 
bit of humor - the only other perspective that I can share is to use these 
situations to BUILD relationship with your team of histologists 
(communicate, communicate, communicate) and with your pathologists.   We 
have more in common (we work for the sake of the patient) than we have 
differences.

Julia Dahl MD

>From: "Bauer, Karen" <Bauer.Karen <@t> mayo.edu>
>To: "Jim Ball" <histo007 <@t> hotmail.com>, <histonet <@t> lists.utsouthwestern.edu>
>Subject: RE: [Histonet] Needle biopsies
>Date: Thu, 30 Dec 2004 09:35:16 -0600

>Hi Jim,
>
>This is the way we treat all of our needle biopsies:
>
>As soon as we face into the block and see some exposed tissue, we start
>taking our sections.  We cut 8 slides (charged slides), two levels on
>each slide.  For example; face in a little, take the first section, face
>in a little more, take the next section, and so on until 8 slides have
>two levels on each of them.  The rule of thumb here is to start with a
>little tissue and end up with a little tissue so the pathologists know
>that all of the biopsy has been sampled.  We then stain slides 1, 3, 5,
>and 7 with H&E and save 2, 4, 6, and 8.  These saved slides are for
>possible specials or IP's.  One pathologist just has us stain the rest
>with H&E if he doesn't need any further stains.  This seems to keep the
>pathologists happy, we have had no complaints.  All of the saved slides
>are kept for a month or so, just in case, otherwise they are thrown
>away.
>
>Hope this helps you out a bit and good luck,
>
>Karen Bauer HT(ASCP)
>Histology Supervisor
>Luther Hospital
>Eau Claire, WI
>
>-----Original Message-----
>From: histonet-bounces <@t> lists.utsouthwestern.edu
>[mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of Jim Ball
>Sent: Wednesday, December 29, 2004 3:56 PM
>To: histonet <@t> lists.utsouthwestern.edu
>Subject: [Histonet] Needle biopsies
>
>I am a tech with 25+ years of experience and have been bitten by about
>every snake in the garden of eden (Histology), and I guess that is one
>of the main reasons I will error on the side of caution at every turn. I
>really try to be as conservative as possible with tissue when trimming
>into a needle biopsy, as soon as I have a full face on properly enbedded
>needles(usually not more than 20 microns or less I start taking slides).
>The sections are 3microns and may produce as many as 5 to 10 sections
>suitable for mounting.
>This acounts for max 30 more micrones into the block.  It is at this
>point I would like to preserve the remainder of the tissue until it is
>reviewed by a pathologist. I refer to my madness as scouting (a
>procedure if used by General Custer would have saved alot of lives), but
>as we all know  there are some patologist that will declare we did not
>trim enough if what they are looking for is 100 micrones into the block.
>    While I have been reseaching a procedure that will keep everyone
>happy I ran across an article that state there was a study done to
>determine if histologists were trimming away microcalcifications in
>needle biopsies, and according to the high lights of the article (one
>they wanted me to purchase to add insult to injury) it was determined
>that after x-raying the histology shavings from trimmed breast biopsies
>the culprit once again was the histologist.  Go figure.
>   At the present time I am on a public computer and some one needs to
>use it, but before I leave please foward any ideas you may have on this
>subject via this server or directly to my e-mail address listed with
>this posting
>
>
>
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