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Submitting specimens for histopathology - sharing the observations.

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This is not reinventing the wheel but just a sharing of some of my personal observations as a histopathologist, because still some times we get autolysed specimens, crushed specimens, very small non diagnostic biopsies etc.

The biopsies range from very tiny needle biopsies to very large specimens including whole organs. Their submission require proper clinical details like patients name, age, gender, site/type of biopsy, site of origin, radiological details (particularly in bone pathology)1,2. Another important thing in the present era of easy communication, is to give the cell or contact number of clinician to whom the reporting pathologist, in case of any query can reach. After practicing histopathology, believe me that still sometimes we receive the specimens, labeled as, "Tissue for histopathology" without any other detail, even signature of the clinician. Another observation is that this tendency is more among the younger doctors, like house officers, junior MOs rather than the senior consultants. Indeeed the consultants have the ultimate responsibility, because it is their juniors and it is their responsibility to train them.

The next step is fixation. The specimens should be immediately put in a proper fixative i.e. 10% formalin (10% neutral buffered formalin) for preservation of tissue3. It is not very common but still we sometimes find the specimens which are sub-optimally fixed, particularly when we receive the specimens from out station. Although the formalin is prepared by the operation theater staff, but if they find any difficulty or they receive the reports that the tissue is not properly fixed, then the operation theater staff should contact the histopathology department for guidance. Another thing is the amount of the fixative which should be adequate2.

The special precautions for the whole organ and larger specimens like intestine (hemicolectomy) should be followed and the same is true for some of the special biopsies like muscle, skin, small endoscopic etc. If the specimen is not properly fixed, it not only hampers the diagnosis on H&E staining but later on, the results of immunohistochemistry (IHC), if required, are also not very encouraging4.

Another observation is that the tissue like lymph node is being submitted for a clinically suspected case of lymphoma and biopsy received is crushed and fragmented, because most of the time the lymph node biopsy procedure is left to a junior/trainee surgeon. The exact determining of the size and shape of lymphocytes in the biopsy is very important in determination of the type of lymphoma, in addition to its Immunohistochemical marker studies5. The applications of IHC markers become very difficult in such cases.

The frozen section is another test which is to be submitted after prior discussion with the histopathologists, as it has to be reported upon immediately. Also it requires the frozen section microtome to be set at a specific temperature (-20OC). Hence prior discussion will not only enable the department to have 'all set' before the tissue is received, but will also clarify the proper requirement of frozen section, like for margins, peroperative diagnosis, lymph node status etc6.

The observation regarding cytopathology specimens like, pap smears, sputum smears and FNA smears is that two types of stains are applied on such smears. One is the Giemsa stain or one of its modifications, which is applied on air dried smears and other is the pap/H&E stains which are applied on wet fixed smears. The concept of wet fixed smear is that the slides should be immediately immersed in the cytological fixative (95% ethanol). Sometimes the perception of the junior consultants is that immediately putting the specimen in the fixative, will take away all the material on the slide, which is not true. Conversely, the delay of just a few seconds may lead to air drying effects and thus hamper interpretation7. Immediate wet fixation therefore, is absolutely mandatory, which is to be realized by the helping nursing staff as well, if he/she is preparing the slides and consultant is looking after the patient.

If after the procedure both types of slides i.e wet fixed and air dried are prepared then these should be labeled separately, put in two separate containers/envelops and then submitted for cytology examination/reporting. As if these are mixed together and Giemsa stain applied on wet fixed slides or vice versa, then again interpretation becomes very difficult. Sometimes spray fixative is also used particularly for pap smears. The spraying should be done from a proper distance, neither too close as it will blow the material on the slide and nor too distant, because then fixation will be suboptimal. The ideal distance is about 6 inches from the slide or as recommended by manufacturer8.

The purpose of sharing the experience regarding submission of specimens is to help the histopathologists & cytopathologists for the proper diagnosis and of course for the better care of patients.

Reference

1.Rosai J, Gross techniques in surgical pathology. In: Juan Rosai, editor ; Rosai and Ackerman's surgical pathology. London UK. Mosby;2004: 25-36.

2.Sharif MA, Mushtaq S, Mamoon N, Jamal S, Luqman M. Clinicians responsibility in pre analytical quality assurance of histopathology. Pak J Med Sci 2007,23(5):720-3.

3.Freida CL, Hladik C, Histotechnology; A self instructional text (3rd ed),2009. Hong Kong.nAmerican society for clinical Pathology press pp2.

4.Andrei FM, Neagn M, Ceausu M, Georgescu A, Vasilescu F, Mihai M et al. Advantages of hope fixation for Immunohistochemistry. Histopathology, 2008;53 Suppl1: 294-5

5.Lenhard RE, Osteen RT, Gansler T. Clinical oncology. (1st ed) Blackwell Science Inc, 2001.

6.http://www.doctorslabinc.com/pdf/collection/instructions_for_submitting_tissue_specimens_to_histology.pdf.

7.Gottschall EB, McGinley TN, Spoelstra N, Knott K, Wolfe P, Rose C et al. Effects of cytological fixative and environmental conditions on nuclear morphometric characteristics of squamous epithelial cells in sputum. Cytometry B Clin Cytom 2005,67(1):19-26.

8.(http://www.1cascade.com/ProductInfo.aspx?productid=1881

Brig Shahid Jamal

Professor of Pathology AFIP, Rawalpindi, Pakistan.
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Author:Jamal, Brig Shahid
Publication:Pakistan Armed Forces Medical Journal
Date:Mar 31, 2011
Words:994
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