Saturday, October 22, 2005

BIOPSIES-GENERAL INSTRUCTIONS FOR PROCESSING

ACCESSIONING CASES
The anatomic location for the specimen is given by what is written on the specimen bottle. If the location only appears on the requisition that accompanies the specimen then the gross description should so indicate: "Specimen, in formalin, labeled with the name of the patient and designated diagrammatically on the accompanying requisition as "right upper eyelid" consists of..."
Cases are accessioned in our system with a letter S if the biopsy originated from UCLA or JSEI and R if it is outside this facility. The resident must assign the R or S number according to the location. Some cases will be delivered from UCLA Pathology Outreach with R numbers already assigned. These cases have already been accessioned and will keep the R number assigned by outreach. The resident simply needs to log them in the book to complete the accessioning. The basic tenet is that every specimen that is received by the lab is entered in the computer and in the log book by the resident.


BIOPSIES

The work-up of surgical biopsies is only begun when adequate clinical information is available; the work-up contains 3 parts: a narrative gross description, a narrative microscopic description, and a diagnosis. Be sure to obtain adequate clinical information and type everything listed clinically on the requisition form. If the information on the requisition form is incomplete then request history by emailing the assigned physician using your UCLA email account. Alternatively, you can call them or review the patient's chart in the originating physician's suite with their permission. Abbreviations should be typed out as complete words. Mistyped or mis-spelled words can followed by [sic] to indicate the mistake. Some use [sic] to follow the corrected error. Either usage seems to acceptable although most grammar texts use to follow the error left in place.







Gross Examination. The examination of the specimen under the stereomicroscope is critical not only for an accurate description but also for correlation to the clinical specimen. This examination permits identification of the abnormal areas and guides further decisions regarding sectioning and processing. Here are some examples: 1. A full thickness wedge resection of the eyelid does not need fiducials placed by the surgeon to be oriented by the pathologist. Under the stereomicroscope the presence of the lid margin will be obvious and orientation simple and margins can be inked. A decision to cut coronally or sagitally will be determined by the location of the tumor, and the gross appearance.







Processing. Instructions for Processing are dealt with in other sections. However, the resident should understand that processing will more the specimen from aqueous based solvents to organic solvents and finally to paraffin. Details of fixation and processing are discussed elsewhere.

Microscopic Examination.
Microscopic examination is performed on most surgical specimens (except most gross only cases) and some autopsy eyes. The residents will learn to evaluate microscopic sections of most common ocular disorders during this rotation.

Microscopic descriptions should be written in a concise and systematic manner to include, sequentially, the architecture of the lesion and the cytologic features. Do not begin your description until you have thoroughly read up on your case. 95% of the diagnoses can be found on line at MissionforVision.org or in the books referenced in this manual. Get these references from the Biomedical Library or the bookstore.

For a simple case with one block and one section, begin your description with "Sections show". In this case you do not need to indicate a location or specimen since there is only one. For cases involving more than one specimen or cases in which more elaborate sectioning was done, you may begin by "Sections of the specimen labeled ‘x’ show” or Step sections through the block of the specimen labeled ‘x’show or Step sections of the specimen labeled ‘x’ show. Tailor your report to the way the specimen was sectioned. The term "sections show" is applied to a simple case where a ribbon of more than one section at the same level was taken of the biopsy. "Step sections show" refer to a case where levels were taken at 250 micron intevals to more thoroughly sample the tissue, e.g. deeper every 50th section x 5). "Step sections through the block" is used when sections were taken at 250 micron intervals all the way through the paraffin block exhausting all remaining tissue. This is often used when a neoplasm was strongly suspected and needs to be excluded. Include a description of all special stains that were performed in your report. If a case consists of more than one specimen, each specimen may be described separately. While specimens with the same microscopic findings may be described collectively, diagnoses are listed separately under "FINAL DIAGNOSIS" on our reports for each specimen (see example). Usually the main feature is detailed first (such as focus of cancer, ulceration, or the like), and then the secondary features are described. Occasionally, one may finish the description with pertinent negative statements (e.g. "granulomatous inflammation is lacking") or special features (e.g. "tumor is present in the lateral surgical margin"). In general pertinent negatives are not needed. Each specimen requires its own line and separate heading for "FINAL DIAGNOSIS". There are no exceptions. If a case has 23 specimens that all show the same thing, it may require a single microscopic description but there must be 23 listed separately each beginning with the heading "FINAL DIAGNOSIS" to include the respective anatomic sites. Be sure to comment on margins of all tumors.

Do not expect to be able to write perfect microscopic descriptions in the beginning of your rotation. Please always check your work to eliminate errors of omission, grammar, and orthography. You may use the descriptions in the work file or glossary as a guide for your gross and microscopic descriptions. You should expect that most of your work-ups will be significantly modified. The microscopic work up will reveal areas of ignorance, and is an excellent way for the pathology faculty to plot your progress through the rotation. Expect that you will be asked to rewrite the descriptions if they contain errors.

Format for Final Diagnosis.
In general the procedure for final diagnosis is the same as that for the specimens requiring the gross. The tissue type is that which you see under the microscope. So if there is keratinized stratified squamous epithelium with hair shafts and adnexal structures the tissue is "skin".

Next in quotation one puts either exactly the wording on the specimen label or that which conveys accurately the type of specimen submitted and laterality from the requisition. Next the procedure rendering the speciem is put in parentheses. Finally the diagnoses are given.

FINAL DIAGNOSIS: Tissue type, "specimen label on the bottle" (surgical procedure)-1st diagnosis
-additional diagnoses,from this first specimen


FINAL DIAGNOSIS: Tissue type, "specimen label on the bottle" (surgical procedure)-1st diagnosis

-additional diagnoses,rom this second pecimen
or e.g.:

FINAL DIAGNOSIS: Skin, "left lower eyelid" (biopsy)- seborrheic keratosis































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