I. GENERAL INFORMATION [Top]

II.  EXTENT OF SERVICES [Top]

Surgical Pathology is that part of Anatomic Pathology concerned with the study of tissue and organ samples removed from patients, either by biopsy or through a surgical procedure, in an attempt to obtain diagnosis of a lesion or disease. The pathologist is therefore able to advise the attending physician as to the nature of the disease, the prognosis, and the need for additional sampling or exploration.  Cytopathology is the study and evaluation of cells present in smears, fine needle aspirates and body fluids. Analysis of nuclear and cytoplasmic characteristics permit diagnosis of various disease processes.

III. SURGICAL PATHOLOGY [Top]

Hours of Operation [Top]

The Surgical Pathology Laboratory is open from 7:30 a.m. to 5:00 p.m.(Monday-Friday), and the Surgical Pathology Office is open from 7:15 am to 6:00 pm, Monday through Friday, excluding holidays. For assistance after hours and/or on weekends, the Surgical Pathology Resident can be reached through personal pager. An Attending Pathologist is always on-call and can be reached through their personal pager. Personal pager numbers of the on-call staff and the on-call schedule are available through the hospital operator.

Surgical Pathology Requisition Form [Top]

A completely filled out requisition form must accompany each specimen.  It should be stamped with the patient’s name (per label) or, if hand written, should include the patient’s full name, hospital identification number, encounter number, birth date and hospital ward or clinic. The clinical information must include sufficient detail for the pathologist to clearly understand what questions are to be answered. The attending physician’s name and/or the name of the responsible physicians, as well as clinical service, must be included and must be legible. It is helpful to include pager numbers if you wish to be contacted with results or a telefax number if you wish the report faxed to your office. The identity of the specimen should be clearly stated on the requisition and should correspond to the labeling of the specimen itself. If the specimen is infectious, this must be indicated on the form.

The Routine Specimen [Top]

 a. Labeling: [Top]

Each specimen must be labeled with the patient’s name, hospital number, source of the tissue and site and side of the body. This information must be on a label on the container, not on the lid of the container. When each of multiple specimens is to be examined and diagnosed individually, each must be submitted in a separate, appropriately labeled and identified container.

b. Specimen Fixation: [Top]

Universal precautions are to be exercised in handling and transporting all surgical pathology specimens. Specimens (see exceptions below) should be placed in appropriately sized, tightly sealed, approved containers with a volume of 10% formalin at least 10 times that of the tissue, and each container should then be labeled with a biohazard/formalin warning label. Proper and timely fixation is a critical step in tissue preparation for diagnosis and the importance of this step cannot be overemphasized.

Formalin is available in the Operating Room and most clinics or it may be ordered as listed below. The specimen container should then be placed inside a secondary container (i.e. ziplock bag) prior to delivery to the laboratory.  Failure to do this may result in rejection of the specimen and delay in diagnosis.

c. Supplies for Surgical Pathology: [Top]

-Containers:

   . 6oz McKesson (1-800-525-3000), catalog #265816

   . 8 oz McKesson, catalog #497384

   . 16 oz McKesson, catalog #27772

   . 1 gal McKesson , catalog #264477

-Formalin: Fisher Scientific (1-800-766-7000), Catalog #23-042601 (5 gallon container), Smaller, pre-filled containers are also available.

-Formalin Warning Labels: Richard Allen Medical (1-800-253-7900) Catalog # 4090 (500 labels)

-Ziplock bags, McKesson, 12 x 15, catalog #413251

   . McKesson, 9 x 12, catalog #413250505050

   . McKesson, 5 x 8, catalog #413248

d. Specimen Delivery: [Top]

Specimens may be brought directly to the Surgical Pathology Laboratory, Room 3.124 in the AIP between the hours of 7:30 am and 5:30pm. After 5:00 pm biopsies or other small specimens may be delivered to the Clinical Laboratory (Room 253, Leprino Office Building) by pneumatic tube or hand-delivery at the Specimen Receiving window. The last pickup each day is at 5:00 pm. Specimens received after this time will not be processed until the following day unless delivered directly to the Surgical Pathology Laboratory.

Specimens at AOP should be placed in containers with screw top lids and deposited in the blue cooler just inside the Breast Center Lab door (Rm 3126).  OR specimens are deposited in the basket in the AOP (2.140). Transportation takes the specimens from the OR to the Gross Lab.  A courier picks up specimens from the Breast Center at AOP on the hour, at which time the specimens are delivered to Surgical Pathology.  Specimens are picked up from Clinical Lab throughout the day with the last pickup being 5:00 pm.  Specimens received after this time will not be processed until the following day, unless they are delivered directly to the Surgical Pathology Lab (AIP 3.124).

Specimens obtained in the Operating Room and not requiring immediate attention may be taken to the Specimen Storage area in the OR Suite and placed on the storage shelves, after recording the specimen in the “OR Pathology Log Book”. These specimens are picked up and taken to Surgical Pathology several times a day, the last time being 5:00 pm. If a specimen is obtained after this time and the clinical service wishes to have it processed for the following working day, Surgical Pathology should be notified (720-848-4653) and then the orderly may take it to Surgical Pathology before 5:30 pm.

Specimens which are too large for a container (i.e. limbs) should be placed into two large red biohazard bags, labeled on the outside with the patient’s name, hospital number and source of specimen as above. The orderly should bring this directly to the Surgical Pathology Laboratory and place specimen into the refrigerator.

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 Frozen Sections [Top]

The frozen section, which is performed intraoperatively, is one of the most important procedures that the pathologist performs, and when effectively utilized can influence the course of an operation. The purposes of a frozen section are 1) to establish the presence and nature of a lesion, 2) to determine the adequacy of surgical margins, 3) to establish whether the tissue obtained contains diagnosable material (even if the exact diagnosis cannot be made on the frozen sample) or whether additional sampling is indicated. The indication and limitations of frozen section diagnosis vary from organ to organ. To request a frozen section on weekdays between the hours of 8:00 am and 5:00 pm, call the Surgical Pathology office (720-848-4421) and notify them of the OR room number, requesting surgeon, type of tissue being sent and if it is infectious (e.g., TB, hepatitis B/C), as well as any other special requests.  After hours, the pathologist should be notified sufficiently in advance (> 30 minutes if possible). The Surgical Pathology On-Call Resident should be reached by personal pager.  The on-call resident will then notify the Surgical Pathology Attending.  Personal pager numbers of the on-call staff are available through the hospital operator.

Specimens Requiring Special Handling [Top]

Several types of specimens should be submitted to the pathology laboratory fresh (without formalin), in a sterile container, in order that special studies (i.e. cytogenetics, flow cytometry) may be done.

These include:

·                                                          Lymph node biopsies

·                                                          Lung resection specimens

·                                                          Biopsies of tumor with unknown primaries

·                                                          Tissue required for various tumor protocols

·                                                          Any specimen in which a diagnostic problem is             anticipated.

With many of the foregoing, it is advisable to discuss the case with the attending pathologist so that appropriate arrangements may be made ahead of time. These specimens may be brought to the Surgical Pathology Laboratory, for review of the specimen in the Frozen section room. This may be arranged during regular hours by calling 720-848-4421; after hours please contact the resident on-call by personal pager (available through hospital operator).

On requisitions accompanying breast biopsies, the initial time the breast biopsy is placed in formalin must be recorded on the requisition. 

Bone Marrow Biopsies and Aspirates [Top]

The Clinical Lab no longer provides assistance with bone marrow collection; we only provide Bone Marrow Biopsy fixative which can be obtained by calling 720-848-4401. Contact the HemeOnc Fellows to perform the aspiration.  The aspiration collected in B+ fixative and the unstained aspirate smears are delivered to the Surgical Pathology Laboratory accompanied by a Surgical Pathology requisition. 

 Renal Biopsies [Top]

Tissue obtained from biopsy of a native kidney is typically submitted for light microscopy, lmmunofluorescence and electron microscopy. Biopsies from a transplanted kidney may be submitted only for light microscopy with other stains and procedures being performed at the discretion of the pathologist and/or clinical service. Immediately after a biopsy is obtained, it is examined for adequacy using a dissecting microscope prior to dividing it for each of these various activities. Assistance is available from the Surgical Pathology Laboratory by calling 720-848-4653 or the Renal Biopsy Pager (266-0938) and should be arranged ahead of time. Because of the complicated nature of these specimens, the turnaround time is typically between 2 and 7 days.

Infectious Specimens requiring culture for Microbiology [Top]

These include infectious (TB, MAI, or other microbiologic agents) tissue specimens that may require cultures.  Specimens for culture are collected by OR staff and submitted to the Clinical Laboratory.  Fresh specimens should thus be placed in a sterile specimen container, inserted upright in a Ziplock bag and an “infectious precaution” sticker should be placed on the outside of the bag. This should then be placed inside a secondary container/Ziplock bag. Universal precautions are to be exercised in handling and transporting of all surgical pathology specimens. For infectious specimens the Surgical Pathology requisition form should be completed and clearly indicate the infectious nature of the specimen, and the presumed microorganism, if possible. The specimen is placed in a container with formalin and transported in a Ziplock biohazard bag.  The specimen can then be removed and examined by the pathologist in the isolation room of the gross lab. 

Radioactive Specimens [Top]

These include some breast and lymph node excisions. To ensure that all of the radiation has dissipated before the specimen is processed the specimen is placed in a container of formalin; this container is then placed in a secondary 175 oz. container, labled with the date that the specimen was removed, as well as the date 24 hours later in which the specimen may be safely examined. 

Medical Legal Cases [Top]

These may include, but are not limited to, breast implants, hardware and bullets.  Surgical Pathology paperwork pertaining to medical legal cases should be clearly marked as such.  In order to maintain “chain of custody” of the specimen, O.R. Staff should carry over the medical legal specimen from the Operating Room directly to the Surgical Pathology lab (AIP - Room 3.124) and hand it over, in person, to a Pathology Staff member.  The specimen should have the necessary Surgical Pathology Form as well as an accompanying “Case Record Sheet” which should be sent over to Surgical Pathology along with the specimen.  The Pathology Resident will fill out the Case Record Sheet with specimen details and a copy of the sheet will be sent back to the O.R. for patient file records.  After the specimen is received by Pathology it will be retained in Pathology indefinitely and will not be returned to the O.R. unless patient consent has been obtained.

Submitting Tissue for Electron Microscopy [Top]

Ultrastructural analysis can be invaluable in the examination of unusual tumors, renal biopsies, ciliary dysmotility syndromes and in specimens suspected of harboring unusual pathogens. Minute fragments (averaging 1 cubic mm) of fresh tissue should be ideally placed in buffered glutaraldehyde, with a tissue volume:fixative volume of approximately 1:30. It is possible, however, to post-fix formalin fixed tissue. Pre-measured vials of Glutaraldehyde are available in the Surgical Pathology Laboratory (AIP Room 3.124).  As with all specimens, tissue submitted for ultrastructural analysis should be accompanied by a properly filled out Surgical Pathology Requisition Form and a Department of Pathology Request for Diagnostic Electron Microscopy form, the latter of which is available in the Surgical Pathology Laboratory.

Order of Specimen Processing [Top]

Routine surgical pathology specimens, including biopsies and resection specimens are accessioned in the Surgical Pathology Laboratory between the hours of 7:30 am and 5:30 pm. Specimens submitted after that time will be accessioned the following day. Slides from biopsies and small specimens are available for review the first working day following accessioning. Turnaround time for these specimens is between 24 hours and 48 hours, depending on whether special stains or studies are required. Larger specimens, i.e. colectomies, mastectomies, may require more prolonged fixation and may not be available for examination until the second day after processing. Surgical Pathology Reports are available through the MedXplore/Clinical Workstation and can be accessed as described below. If a case is still in progress, you may contact the Surgical Pathology Office and ask to speak to the responsible attending and/or resident who will inform you about the status of the case.

Products of Conception (POC’s) and fetuses (6 weeks or less) must be submitted in formalin, with proper patient identification on the container, which includes patient name and hospital number.* Fetuses 12 weeks and above must be accompanied by a disposition form signed by the mother.* All intact fetuses 20+ weeks gestation are sent to the pathology morgue.* A Surgical Pathology requisition form must accompany the specimen. The requisition must state the patient name, hospital number, attending clinician, specimen type (ie, POC), # of containers, procedure, location, clinical history, and pre-op diagnosis. If Cytogenetic studies are requested, please call the Colorado Genetics Lab (303-724-5701) for assistance.

*Contact Susan Lawrence in Decedent Affairs for specific details (303)266-7259.

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STAT specimens received after 2:00 pm or those specimens requiring processing to extend beyond this time will be processed only after consultation with the Surgical Pathology attending. Processing of tissue for STAT specimens requires about five hours. Circumstances requiring STAT processing of paraffin-embedded tissues are few and the alternative of frozen section diagnosis is felt to be more efficient and, in most circumstances, preferable to STAT processing, which is costly to our laboratory and to the patient. [Top]

Policy for Rejection of Specimens [Top]

In accordance with CAP guidelines, it is necessary to monitor the adequacy of specimens in terms of fixation, safety requirements and proper identification. All specimens received by Surgical Pathology should be examined for the deficiencies listed below:

1. Requisition Form missing

2. No patient name on container or Requisition Form

3. Patient name on container or specimen designation differs from that on form

4. No Specimen

5. No Physician name

6. No clinical history provided if necessary or otherwise incomplete requisition

7. Inadequate amount of fixative

8. Container lid improperly sealed/fluid spill contamination

To prevent specimens from being lost during the transport process, specimen cases with deficiencies that are received from clinics will not be returned back to the clinics. Instead, those specimens with inadequacies 1, 2, 3, 7, 8 will require that a clinical staff member come to the Surgical Pathology lab to correct the discrepancy.

Clinical specimens that are deficient in areas 1, 5, 6 may be handled as follows:

• the clinic must fax over the Requisition Form with the required information

• the Pathology technicians must fax over a Surgical Pathology Specimen Correction Sheet requesting specific information to be filled out by the individual responsible for the discrepancy. This form and the new requisition must be faxed back to Pathology in order to process the specimen. Please note that specimens will not be processed until the discrepancy is corrected!!

If the specimen with discrepancies is received from an out of state or out of town clinic, the above mentioned forms may be used to fax over corrections. Copies of all corrections forms received should be maintained in the monthly Specimen Inadequacy File in the slide filing room.

In all cases a resident or attending pathologist should be informed of the nature of the problem and the action being taken.  A PSN (Patient Safety Net) incident report is filed with Risk Management and a copy kept in the Surgical Pathology Specimen Correction Log.  Additionally, a report is filed on the UCH/HSC electronic error log. 

Missing specimen  Discrepancies should be reported immediately to the Surgical Pathology resident responsible for the case.  The resident will be responsible for conveying this information to the clinician and a missing specimen report may be generated. [Top]

In addition, the Gross Room personnel should keep a record (in the Specimen Inadequacy Log) of all specimens received with the any of the listed inadequacies.  Each month a copy of this record should be filed with the Quality Improvement Coordinator,  who will then review these forms quarterly and tabulate the findings according to the type of problem and the particular service involved.  These results should then be presented at the quarterly QI meeting.  If there is a particular service that appears over-represented, the service chief should be notified in writing by the QI Chairperson.

Formalin Spill and Waste

Formalin is extremely harmful if inhaled and may be absorbed through the skin. In case of contact flush skin or eyes with plenty of water for at least 15 minutes.

Spill Cleanup Procedure [Top]

 Small spill (few ml)

Wear a lab coat and gloves. Wipe up the spill with paper towel and dispose in a red biohazard trash bag. Wash your hands and forearms.

Moderate to large spill

Only small spills of formalin (one pint or less) can be cleaned up without respiratory protection by qualified personnel. Do not call Environmental Services to cleanup a spill. Wear a lab coat, gloves and goggles if there is any chance of a spill. Obtain a Solvent Spill kit (available from the UCD-School of Medicine Department of Environmental Health and Safety, (303-724-0345) and sprinkle the granules of Spill-X- FP powder around the edges of the spill to contain it and then sprinkle over the rest of the spill. Remove any glass with forceps and dispose in a sharps container. Leave the area to minimize your exposure and allow the absorbent granules to stand for 10-15 minutes. This will allow the vapors to dissipate. Sweep up the granules and carefully flush this down a sink or toilet. Wash the spill site with a sponge and water. Discard the rinse water down a sink or toilet. Carefully check the spill area for leaks into crevices or onto absorbent materials. Contaminated items must be wrapped airtight in plastic bags to eliminate odor problems. Dispose of contaminated materials through Environmental Health and Safety (303-724-0345). For additional information please refer to the UCD-School of Medicine Safety Manual. Report all accident to the UCD-School of Medicine Department of Environmental Health and Safety (303-724-0345). If the spill results in an injury of illness, report immediately to Health Service or to the Emergency Room.

WE WILL NOT PROCESS

Any specimen received in a glass bottle, specimens with needles,

specimens in a  pleurevac container,  or in excess of 500 ml in volume

Please use proper containers, sealed and labeled for universal precautions.

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