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SURGICAL PATHOLOGY

GENERAL INFORMATION  

SUBMISSION REQUIREMENTS:  Unless specifically exempted, all material surgically obtained, e.g. tissue, calculi or foreign bodies, from patients at this institution must be examined by the Department of Pathology (see letter B for exemptions).  This is done by submission of the specimen in a properly labeled container with the patient's name, family member prefix number, social security number, date obtained and type of specimen.  Order must be entered in CHCS along with pertinent clinical information and diagnosis.  Multiple specimens from the same patient should be submitted in separately labeled containers which should be listed as A, B, C.  Improperly labeled specimens or specimens not ordered in CHCS will not be processed until the submitting service makes the appropriate requirements.  Unless otherwise indicated, all tissue should be submitted in 10% phosphate buffered formalin in a ratio of 10 volumes of formalin to 1 volume of tissue, formalin is available from the hospital pharmacy.
 

SPECIMENS EXEMPT FROM SUBMISSION:  In accordance with JCAHO requirements, Evans Army Community Hospital has determined the following surgical specimens are exempt from mandatory submission:
 
           1.  Specimens that by their nature or condition do not permit productive examination, such as a cataract, orthopedic appliance, foreign body, or portion of rib removed only to enhance operative exposure.

           2.  Therapeutic radioactive sources, the removal of which is guided by radiation safety monitoring requirements.

           3.  Foreign bodies (i.e., bullets) that, for legal reasons, are given directly in the chain of custody to law enforcement representatives.

           4.  Specimens known to rarely, if ever, show pathologic change and removal of which is highly visible postoperatively, such as the foreskin from the circumcision of a newborn infant and skin and soft tissue from non-malignant, plastic surgical procedures.

           5.  Placentas that are grossly normal and have been removed in the course of operative and non-operative obstetrics.

           6.  Teeth, provided the anatomic name or anatomic number of each tooth or fragment of each tooth, is recorded in the medical record.
 

GUIDELINES FOR PLACENTAL SUBMISSION:

           1.  Criteria for laboratory examination of a placenta resulting from a cesarean section are the same as those for normal delivery.  These specimens should not routinely be submitted to the laboratory based solely on derivation from cesarean section.
 
           2.  The physician performing the cesarean section or vaginal delivery should determine disposition of these specimens in accordance with the following suggested guidelines:

    Indications for Placental Pathology Requests

      Maternal

    • Severe preeclampsia
    • Eclampsia
    • Rh isoimmunization
    • Rubella
    • Insulin dependent diabetes
    • Stillbirth
    • Prematurity (less than 34 weeks)
    • Substance abuse
    • Chorioamniontic
    • Severe oligohydramnios
    • Hx of active herpes during pregnancy

      Placental

    • Abruption
    • Infarcts
    • Vasa previa
    • Amnion nodosum
    • Chorioangioma
    • Masses
    • True knot in cord
    • Abnormal prenatal sono
    • Circumvallate

     Fetal

    • Multiple gestation
    • Congenital anomalies
    • Fetal distress
    • Erythroblastosis fetalis
    • Meconium staining
    • Low apgar score (less than 6 at 5 minutes)
    • Suspected sepsis
    • IUGR-BW (10th percentile)
    • Neurologic signs
    • Seizures
    • Hypotonia

    PLUS:  Any case with unusual or abnormal clinical circumstances or with an abnormal appearance of the placenta or cord. 

DELIVERY OF SPECIMENS:  Tissue specimens from the Operating Room  and Clinics need to be delivered to the laboratory by 1400 hours in order to be processed that night for review by the Staff Pathologist the next day.  Specimens delivered after this time will be held until the following work day.
 

RUSH SPECIMENS:  All urgent specimens requiring rapid turnaround time for direction or initiation of therapy should be designated with the word "RUSH" written across the container in red.  Any "RUSH" must be hand carried to the Anatomic Pathology Service prior to 1500 hours if the specimen is to be processed that night.  This service is not available on weekends.  The "RUSH" specimen service should not be abused and physicians are encouraged to use this service only in cases in which patient care will be affected by a rapid turnaround time.
 

REPORTING PROCEDURES:

           1.  Routine reports will be ready within two working days of receipt of the specimen.  Cases requiring special study or consultation may require additional time.

           2.  Reports on "RUSH" cases are called to the submitting physician with the reports distributed the day following submission of the specimen.

           3.  Malignant, infectious or unexpected diagnoses which could have an immediate impact on patient care and/or management are called to a physician, physician's assistant, or RN. 

REVIEW OF SLIDES ON PATIENTS TRANSFERRED TO EACH:

           1.  The Anatomic Pathology Section MUST review the slides that accompany patients to EACH from other hospitals.  The Surgical Pathology report from the referring institution together with a properly completed CHCS order must accompany the slides in order to accession the case.  A report will routinely be available within two working days.

           2.  To request a review of outside slides, submit request to the Anatomic Pathology Service that includes the patient's name, Family Member prefix number, Sponsor Social Security Number, submitting UCA code, date tissue was obtained and referring hospital.  A completed DA Form 5006-R (Authorization for Disclosure of Information) should be signed by the patient and accompany the request.  The Anatomic Pathology Service will then request the material from the originating pathology department, render an interpretation and return the slides. 

SPECIAL PROCEDURES:

           1.  Intraoperative Consultations (Frozen Sections):

                 a.  The purpose of the an intraoperative consultation (frozen section, touch/scrap preparations, gross examinations) is to direct therapy and assist the surgeon or physician in making an immediate decision on patient management.  If there is no immediate consequence to patient management, intraoperative consultations is not indicated.  Because of the freezing artifact introduced during a frozen section, it should be avoided in all situations when not needed, especially if only a small piece of tissue is available for the permanent sections

                 b.  Two copies of FC MEDDAC Form 248 (Frozen Section Report) must accompany tissue for frozen section examination.

                 c.  Requests for intraoperative consultation during duty hours should be placed when the tissue is surgically removed by calling the Anatomic Pathology Service at 526-7306 or 7309.  Consultation with the pathologist prior to surgery is recommended in unusual cases.  Intraoperative consultation service after normal duty hours is available by contacting the pathologist on call at least 1 hour prior to the need for an inoperative consultation to allow time for the pathologist to reach the hospital.

           2.  Bone Marrow Aspirates and Biopsies:

                 a.  Technical assistance should be arranged 24 hours prior to the procedure with the Hematology Section 526-7118.

                 b.  Biopsies should be submitted in Bouin's Fixative which is available from the Anatomic Pathology Service.

                 c.  Consultation must be obtained from the Pathologist prior to ordering flow cytometric or chromosomal studies on Bone Marrow aspirates.

           3.  Any tissue requiring microbiological cultures should be divided on the sterile fluid at surgery and a portion placed in a sterile container and submitted directly to the Microbiology Section.  Tissue for culture must not be placed in formalin.  The remaining portion can be put in formalin and submitted to Anatomic Pathology.

           4.  In cases of suspected lymphoma, the Pathologist should be consulted beforehand to assure proper handling of the specimen.

           5.  Estrogen and progesterone receptor assays (tissue) are offered by the Anatomic Pathology Service through Wilford Hall Medical Center.  They are obtained from routine formalin fixed material.

           6.  Calculi for chemical analysis should be sent to the lab unfixed.  A separate report will be issued.

           7.  Consultation must be obtained from a Staff Pathologist prior to obtaining a muscle biopsy.  These biopsies require special processing and are shipped to the AFIP for evaluation.  Three biopsies should be submitted as follows:  a biopsy in a large muscle clamp in formalin, a biopsy in a small muscle clamp and a biopsy immediately frozen in liquid nitrogen and transported to the lab.

           8.  Gout crystals, tissue to be examined for crystal must be submitted in ethanol rather than formalin which dissolves the crystals.  Ethanol is available through the Histology section (526-7306/7309).

           9.  Medicolegal specimens must be accompanied by a Chain of Custody Form 4137 and put in CHCS.  The submitting service should make arrangements with the Anatomic Pathology Service prior to bringing the specimen to the lab.

           10. Consultation must be obtained from a Staff Pathologist prior to submitting tissue for electron microscopy, immunofluorescence, flow cytometry or special stains. 

GROSS EXAMINATION ONLY:  The following specimens have been approved by Evans Army Community Hospital for gross examination only:
  • Cataracts
  • Orthopedic appliances
  • Teeth, provided the anatomic name or anatomic number of each tooth or fragment of each tooth, is recorded in the medical record
  • Foreign bodies of certain identification and not of known legal/forensic importance
  • Foreskins in patients less than 15 years of age
  • Bone fragments of known non-infectious or non-neoplastic processes
  • Nasal cartilage and bone from rhinoplasties
  • Skin from blepharoplasties
  • Surgical scar excisions (for non-neoplastic lesions)
  • Hernia sacs in adults
  • Tonsils from patients less than 12 years of age
  • Liposuction material
  • Vaginal mucosa from anterior/posterior repairs
  • Colostomy storma for uncomplicated revisions of non-neoplastic processes
  • Menisci/cruciate ligaments and fragments
  • Traumatic amputations
  • Atherosclerotic plaques from endarterectomies
  • Blood clots
  • Ingrown toenails
  • Calculi/stones
  • Varicose veins

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