SDN members see fewer ads and full resolution images. Join our non-profit community!

Palmetto sets standards for the workup of stomach, breast cases

Discussion in 'Pathology' started by stickyshift, Jun 6, 2014.

  1. SDN is made possible through member donations, sponsorships, and our volunteers. Learn about SDN's nonprofit mission.
  1. stickyshift

    stickyshift 7+ Year Member

    180
    9
    Jun 16, 2008
  2. SDN Members don't see this ad. About the ads.
  3. stickyshift

    stickyshift 7+ Year Member

    180
    9
    Jun 16, 2008
  4. hesperion

    hesperion 2+ Year Member

    22
    3
    Mar 17, 2011
    Good. Ki-67 is totally bogus in breast.
     
    RustBeltOnc likes this.
  5. pathstudent

    pathstudent Sound Kapital 10+ Year Member

    2,981
    67
    Mar 17, 2003
    I disagree. I think it helps corroborate or question the grade of the tumor. It also gives insight when some grade 3 tumors have a ki67 of 27% and others have ones of 95%. I think that means some about its aggressiveness and possible response to cytotoxic therapy.

    And when they say gene expression are they talking about ISH for her-2. That can't be correct.
     
  6. hesperion

    hesperion 2+ Year Member

    22
    3
    Mar 17, 2011
    And I respectively disagree with you. An accurate mitotic count is more objective in my opinion than a Ki-67 count. There is no consensus on which regions of tumor to count (do you count hot spots), how dark of a nucleus counts is positive (does a dot count), and how many cells to count. I believe data was presented in 2012 at San Antonio about this. And yes, I think it's bogus that clinicians rely on such a subjective test.
     
    RustBeltOnc likes this.
  7. mikesheree

    mikesheree 7+ Year Member

    863
    64
    Feb 27, 2010
    Physician
    i pretty much agree with what Dr. Silverberg said about 20 years ago--- the concept of "mitotic counts" is pretty much bulls*it". It really comes down to a sense of "mitoses per minute" as far as experienced pathologists are concerned. I thought the Ki-67/MIB-1 was a useful adjunct. But I'm just a retired old pathologist.
     
  8. pathstudent

    pathstudent Sound Kapital 10+ Year Member

    2,981
    67
    Mar 17, 2003
    Subjective? I examine over 2000 breast biopsies a year. A mitotic count is so subjective. I scan the ki67 and use software that analyzes 10s of thousands of cells.

    I have reviewed cases that have been called idc 3 because it consists of sheets of tumor cells that have large nuclei with macro nucleoli but the ki67 was 5%. So basically it is a grade 1 tumor. Brs grading is way more subjective than computer aided morphometry of ki67.

    **** palmetto. Hopefully cap can reverse their bull shot.
     
  9. hesperion

    hesperion 2+ Year Member

    22
    3
    Mar 17, 2011
    I examine over 2000 breast biopsies a year too. I trained with one of the top people in the field. I'm not getting into a fight with you over this since it's a topic people don't agree on. But given my experience, an accurate mitotic count (you know sitting and counting each mitotic figure in 10 high power fields) is more reproducible (in terms of proper categorization). I know a lot of people eye ball mitotic counts and that is bull****.
     
  10. hesperion

    hesperion 2+ Year Member

    22
    3
    Mar 17, 2011
    (lol, I typed bulls*** and it autocorrected to bullcrap)
     
  11. coroner

    coroner Peace Sells...but who's buying? 10+ Year Member

    487
    137
    Aug 3, 2007
    22 Acacia Avenue
    Physician
    Some studies have failed to link Ki-67/MIB-1 expression with prognosis, while others have found substantial correlation. So both of you could prove your points by citing opposing sources. At least no one's touting ploidy analysis on here, which still has some old timers still trying to milk the the cow on that one... :greedy:
     
    Last edited: Jun 6, 2014
  12. Eostar

    Eostar 2+ Year Member

    9
    0
    Dec 12, 2013
    I was at an ASCP meeting where the speaker (a well know GI expert) asked the audience to raise hands if they routinely ordered H.p stains up-front on stomach biopsies and about 85% of the hands in the room went up. Compared to some of the other BS that goes on in AP this seems like a very mild problem. Go through the CMS payments data that was released a few weeks back and you will find individual pathologists doing three times as many 88342s as they are 88305s. Those are the people who deserve some scrutiny.
     
  13. WEBB PINKERTON

    WEBB PINKERTON 5+ Year Member

    1,189
    114
    Dec 16, 2010
    The pathology "pseudo" market is going away. It's a shame our field has been so full of waste, creating more jobs than are really needed.

    If there was any question about cutting residency spots, it obvious that many must go.
     
  14. 2121115

    2121115 7+ Year Member

    1,674
    38
    Jan 23, 2007
    This is common practice in many places, including respected academic centers where the pathologists have no financial incentive to order the Helicobacter IHC. In those places, it is considered standard of care - you have a stain that is sensitive and specific for the very reason the biopsy was done. These academic centers feel very strongly about the HP IHC, and I expect this to be fought tooth and nail. Some immuno stains are wasteful, but to put the gastric HP stains in the same category as that mentioned in the other thread with the guy ordering CD3 and trichrome or whatever on every small bowel biopsy is not fair.
     
  15. Thrombus

    Thrombus Member 10+ Year Member

    653
    51
    Sep 27, 2004
    We have 100k drug regimens that are commonplace which may give someone a couple more miserable months at the end of their life and they are going after a 100$ stain which helps people after a procedure that is not pleasant and costs thousands. Someone needs to tell "palmetto" that the tyranny stops at my desk. They can kiss my ass.
     
  16. coroner

    coroner Peace Sells...but who's buying? 10+ Year Member

    487
    137
    Aug 3, 2007
    22 Acacia Avenue
    Physician
    Well, I've seen worse. Try a CD117 on every colon bx to r/o mast cell colitis... o_O
     
  17. 2121115

    2121115 7+ Year Member

    1,674
    38
    Jan 23, 2007
    If the indication is diarrhea and the biopsy is morphologically normal, you can make an argument for the CD117. We have had patients with diarrhea see it resolved with high dose antihistamines.
     
  18. coroner

    coroner Peace Sells...but who's buying? 10+ Year Member

    487
    137
    Aug 3, 2007
    22 Acacia Avenue
    Physician
    Correct given that scenario where it is clinically indicated, but certainly not it every colon bx as I mentioned. It would be just like just like that guy doing routine CD3's and trichromes on every small bowel.
     
  19. 2121115

    2121115 7+ Year Member

    1,674
    38
    Jan 23, 2007
    Agree. No doubt.
     
  20. coroner

    coroner Peace Sells...but who's buying? 10+ Year Member

    487
    137
    Aug 3, 2007
    22 Acacia Avenue
    Physician
    I wouldn't have been surprised either if that guy was even throwing in a PAS on all of those small bowel bx's either to r/o Whipple's and Cryptosporidium. While this type of practice isn't fraudulent per se, it certainly does puts certain aspects of our profession under scrutiny by the watchdogs. And the greed of few in the short run sometimes has permanent effects for the rest of us...
     
    Last edited: Jun 10, 2014
  21. icpshootyz

    icpshootyz 7+ Year Member

    477
    62
    Sep 17, 2009
    There is NO reason to do H. pylori immunostain on every gastric biopsy. We all know (or should know) that you have a virtually 0% chance of finding H. pylori without seeing accompanying inflammatory changes. My institution used to do this, then did an actual in house study and only found 1 case out of over a thousand that looked negative histologically but had a single bacteria c/w H. pylori on stain. That is not medicine, that is pure profit. We stopped doing up-front IHC and only order on inflamed cases where we don't physically see the bacteria on H&E. If you don't see neutrophils, there's minimal if any chance you'll see H. pylori. I don't care what some academic center says.

    And since when do academic centers not have financial incentive to over-stain cases? Academic centers are businesses just like the rest of us, and in most of them the salaried pathologists get bonuses and incentive pay depending on volume and profits. They are often some of the worst offenders, as they seem to get a free pass just like people on here are giving them.

    Practice medicine, people, that's what you are trained to do. Don't try and line your pockets or you're only going to drive further slashes in reimbursement when you get caught. But thanks in advance for ruining it for the rest of us.
     
    Last edited: Jun 10, 2014
    BlondeDocteur likes this.
  22. pathstudent

    pathstudent Sound Kapital 10+ Year Member

    2,981
    67
    Mar 17, 2003
    Agree 100%. One of my favorite smart ass things to do as a resident at gi biopsy slide conferences was say H Py was not present while looking at the slide at 4x when there was no inflammation.
     
  23. path24

    path24 7+ Year Member

    260
    20
    Sep 29, 2009
    We told our clinicians/clients about this. They are pissed."I want it on every ?!#*$# one." Not sure an article will change that. Will see how this plays out. Hopefully we don't lose the business or have to start doing it for free. It sucks being a commodity.
     
  24. lailaa

    lailaa 7+ Year Member

    4
    0
    Oct 6, 2008
    Hi,

    Just out of interest which Ki-67 counting program are you using? We're using the ever reliable eyeball method, and would like to get into using Ki-67 counting using slides when we're reporting.
     
  25. sohsie

    sohsie Member 10+ Year Member

    331
    24
    Mar 20, 2004
    Physician
    I am a GI fellowship trained pathologist and I vehemently disagree. The studies I have seen on this make my blood boil because they miss the whole of doing these stains (H pylori and Alcian Blue) up front and do not take into account real world pathologists trying to sign out a heavy daily case load instead of an academic pathologist who doesn't deal with a private pathology case load (and yes, I know some academic pathologists whose case loads are really, really large but that is the exception and not the rule).

    1) I can tell you from my experience that there are occasional h pylori cases that show little to no inflammatory changes. I have a handful saved up in my "teaching" cases pile that I guarantee would be missed by any pathologist who did not order H pylori up front. I even had a case in training where there was at best minimal inflammation on H&E, h pylori present on the Giemsa, and the attending refused to believe that it was real. The h pylori IHC confirmed their presence. That's h pylori. Intestinal metaplasia is very often very focal and subtle and I have seen that missed by people who just read H&E all the time.

    2) Gastroenterologists perform these biopsies specifically to look for H pylori and IM. The H pylori and Alcian Blue stains (when performed by a competent lab) are super sensitive, super specific, and super easy to read in an efficient manner. These diagnoses have actual real world implications and directly affect treament and followup decisions. More importantly, this is the exact reason why these biopsies are being done and they are very common findings on biopsy. Why skimp here to "save a few bucks" and cause (not theorectically, but in actuality) cases to be missed which will adversely affect treatment.

    3) Most importantly, and something which NONE of the published studies arguing against upfront H pylori and Alcian Blue stains address, is the issue of pathologist time and fatigue, both physical and mental. Its great that in study A, a pathologist reading x h pylori cases in their spare time at a leisurely pace can spot all the h pylori cases. But do they mention how long it took them to read the cases vs someone using the h pylori IHC stain? A pathologist who is just reading an H&E without an Alcian Blue has to spend AT LEAST double the time reading a to make sure they don't miss intestinal metaplasia that will take them all of 10 seconds to find on an Alcian Blue stain. Heaven forbid there is significant inflammation on the biopsy, because now you quadruple the time looking for H pylori on the H&E which can be found about 5-30 seconds (depending on how many there are) on the H pylori IHC. And if you don't find them, then A) you probably spent 10 minutes looking for them) and B) now you get to waste time ordering the IHC, setting aside the case, then reassembling the case when the IHC comes out the next day.

    4) Oh, and by the way, I don't care what these studies allege to show, if one has a partially treated patient with residual h pylori, it will be missed on H&E. Why? a) There will be no indication on the requisition that this patient was treated already. 2) The h pylori will be hiding deep in the glands and will NOT be seen on H&E no matter how hard one looks. 3) The diminished inflammation from treatment will cause the pathologist not to be suspicious and order the IHC.

    Maybe those things sound like small potatoes, and they probably are when one is looking at 10 stomach biopsies a day at an academic institution and have a resident and fellow screen the slides before signout. But when one is at a high volume lab and has to be efficient, those little things add up and lead to significantly lower throughput as well as significantly increased physician mental fatigue. If I have to spend 10 minutes on each stomach biopsy instead of 2 minutes with stains ordered up front, that loss of time will add up really really quickly.

    All of this is done in the name of "saving money". Yes, it would save money if one looks at it from the perspective of reimbursement. But if, heaven forbid, one actually puts a value on pathologist time, then this is a terrible strategy. The significantly decreased pathologist output coupled with the increased mental fatigue way overshadows the savings from not ordering stains up front. Ordering H pylori IHC and Alcian Blue stains up front on GI biopsies directly causes greater accuracy and increased pathologist throughput. Why would pathologists argue to sacrifice that so they can get paid less?
     
    jp123ok likes this.
  26. pathstudent

    pathstudent Sound Kapital 10+ Year Member

    2,981
    67
    Mar 17, 2003
    There are a number of image analysis software programs. For years we used vias by ventana. It has been put out to pasture and now we are using a slide scanner in combination with image analysis software.
     
  27. icpshootyz

    icpshootyz 7+ Year Member

    477
    62
    Sep 17, 2009
    I'm glad you have a few cases in your teaching file that showed H. pylori that weren't seen on H&E and didn't have accompanying inflammation. As I said, we had 1 case out of 1000 reviewed that showed that as well. But that's the point - you don't order 1000 tests just to catch one case unless you're talking about something so malignant that NOT treating it would cause a patient irreparable harm, morbidity, or death. Did you miss this part of medical school where it actually IS a concern regarding the cost/benefit nature of a test? Where we as the ordering physicians must consider the expense to the patient (and healthcare in general) when ordering a test? You haven't noticed this is a massive concern in healthcare right now? No, ordering an expensive IHC test on EVERY stomach biopsy is not good medicine. In any way. Just like we don't order an MRI on every patient with a headache. The benefit does not outweigh the cost. What you are essentially arguing for is a GI biopsy mill, and you're mad that you might actually have to look at the slide rather than just trying to pick out a brown spot on an IHC stain. I'm in private practice, not academia. We realized that our ordering IHC on every stomach biopsy was, while certainly good for our pockets, BAD MEDICINE. And Alcian blue? Give me a break. I trained under some GI heavy hitters and maybe saw a mucin stain ordered a handful of times in my whole residency. I'm guessing you work somewhere that makes you push way too much glass and you're looking for shortcuts to keep the revenue flowing. That, again, is bad medicine.
     
  28. sohsie

    sohsie Member 10+ Year Member

    331
    24
    Mar 20, 2004
    Physician
    Firstly, I am glad your academic institution self certified their own stellar accuracy rate, in a place where the cases are reviewed by a resident and attending not in a private practice environment, but in the real world these cases are missed much more often than one in a thousand, especially in partially treated patients. You are missing a symtomatic disease that can be treated easily to save tens of dollars, not thousands like the unnecessary MRI.

    I guarantee you intestinal metaplasia is missed all the time, especially when it is a small focus in a background of no inflammation, the very time when it isn't suspected and the slide gets glossed over. Ive seen it all the time by people who do a lot of GI. They don't order the stain because they don't realize they are missing it. In retrospect you dont need it because if it shows up on the Alcian Blue, you can go back to find it on the H&E (usually, ive seen cases where it wasnt on the initial level but for that I wouldnt justify the stain), but no one practices pathology with a retroscope.

    And secondly, if the clinician is performing a test specifically to look for a particular disease, one in which there is a decent likelihood of finding it since people don't get EGDs for nothing but rather specifically because they are symptomatic, then it behooves us to be as accurate as possible. We are talking about an IHC stain, that for a cash patient (I know insurance companies are charged a lot more) is $75, not a thousands of dollars MRI. Cost is part of the cost benefit analysis, and thats quite a small cost to bear for greater accuracy.

    Finally, it is not the role of the pathologist to sacrifice their time and energy so the govt can justify chucking money down the drain. Can you imagine a hospital going to a surgeon and saying "Sorry, you cant use the scalpels and equipment that you prefer because it costs the hospital $100 extra per surgery and we want to bill the patients $100 less, so too bad and sorry if it affects your surgeries. It doesn't affect the surgeries of surgeon B who proposed this change so deal with it. Heaven forbid someone consider the time and energy of the pathologist before making these decisions.

    This post was corrected to correct the cash price my lab charges for IHC from $61 to $75.
     
    Last edited: Jul 8, 2014
  29. path19

    path19 Member 10+ Year Member

    100
    5
    Sep 5, 2003
    Agree with this. The discussion needs to include the amount of time it takes a pathologist to search for bugs on H&E stain (especially the negative cases). And this is what is often not addressed in these studies that only look to save money to the patient/heatlhcare system without realizing that my time is also valuable to the healthcare system. And put in the context of healthcare spending, this is a small cost for finding an infection that can be easily and cheaply treated (similar to the way I believe pathology in general provides lots of bang for our buck considering the implications of what we do).
     
    sohsie likes this.
  30. icpshootyz

    icpshootyz 7+ Year Member

    477
    62
    Sep 17, 2009
    That 1 in a 1000 was performed at my private practice, not at the academic institution where I did residency. We USED to do up-front H. pylori on all our stomach biopsies, and it was a great revenue stream. We retroactively went back and reviewed 1000 positive cases, and out of those 1000 only 1 did not show features on H&E that were either obvious for H. pylori or would have led us to order the stain after reviewing the H&E. I'm not saying never order the stain. I'm saying a good pathologist should always review an H&E before ordering ANY stain. Our 15 person private group orders nothing upfront because we realized doing so was more about money than anything else. We both know your argument boils down to money. Heck, realistically the GI docs should probably just presumptively treat patients with symptoms and positive endoscopy findings. And on a follow-up biopsy, when suspicion is higher, sure it probably makes sense to get the stain even if things look normal on H&E. But upfront on EVERY stomach biopsy? No way, no how. That's a money grab and you know it. And it's part of what is leading to the slashing of IHC reimbursement as well as the 88305. So kudos, get your money while you can, but know full well that you're part of the problem. And maybe don't go through your biopsies so fast that your missing H. pylori and IM on H&E so often.
     
  31. sohsie

    sohsie Member 10+ Year Member

    331
    24
    Mar 20, 2004
    Physician
    As someone who rails against what is real misuse of IHC (Melan-A on all nevi, CD3 on small intestinal biopsies, and double IHC stains on all prostates, for examples) I am not out there to make money wherever possible. You don't know me and you are wrong. Dead wrong. And no, this isn't about money. If the CLO test is more accurate than biopsy for H pylori (and if it isn't now some variation will be in the future), then I am all for endoscopists using that instead of biopsy, even though it would be a huge revenue hit on AP labs. For another example, if fungal culture were more accurate for nail clippings than PAS, then i would advocate for that as well (I am also a board certified dermatopathologist as well). For another example, I am glad that it appears that pap smears are going to decrease significantly because of HPV testing and patients being immunized against HPV even though again that ultimately means less work for the AP pathologist such as me. If the H pylori costs nothing to the lab to perform, or even if it cost a minimal amount (say $5 each), and it wasn't reimbursed, I would still advocate for it to be used prospectively on stomach biopsies. So please keep your attitude to yourself.

    And please keep your opinion of my pathology skills and my dedication to every patient to yourself, because you are dead wrong about that as well. DEAD WRONG. I am way more dedicated than you will ever be and way more careful than you. I know from my experience how often I pick up subtle findings that other pathologists miss. That is why I do advocate for the H pylori and Alcian Blue up front. Because I have seen time and time again those cases missed by other pathologists because the inflammation was low. And unlike your self-righteous attitude, I also am able to see my own flaws and know that despite my extreme care in looking at the H&E first (and yes, unlike your unwarranted presumption, I am really careful with each H&E) there are cases I would have missed them as well if not for these stains. I have seen your attitude in other pathologists and then I see them miss these cases and be completely oblivious about it.

    You are the problem with pathology because you would rather decrease pathologists throughput, accuracy, and well being be sacrificed to the altar of "Look at me, I saved Medicare a few bucks on the backs of my fellow pathologists. Aren't I special!" No you aren't.
     
  32. icpshootyz

    icpshootyz 7+ Year Member

    477
    62
    Sep 17, 2009
    Haha, yep, you're not self-righteous at all! So you think it was worth $75K in IHC testing to find ONE case of H. pylori that would not have been picked up otherwise? That's 1000 needed to treat for 1 case. Not to mention there are plenty of cases of H. pylori infection that are obvious on H&E alone, which would also not require IHC if the H&E was reviewed first. Our fellowship trained GI paths came to the opposite conclusion from you - we were adding massive expense to the system with minimum benefit. Go ahead, do your own retrospective study and show us the results. In the meantime, I will wholeheartedly argue that an H&E should be reviewed before any special stain or IHC is ordered.
     
  33. WEBB PINKERTON

    WEBB PINKERTON 5+ Year Member

    1,189
    114
    Dec 16, 2010
    I think you need to do "Know Error" DNA testing as well on all these cases of H pylori. Go ahead and add another 450 bucks to the bill. It is that important. You may find one mixed up biopsy out of the thousands of accessions.
     
    KluverB likes this.
  34. pathstudent

    pathstudent Sound Kapital 10+ Year Member

    2,981
    67
    Mar 17, 2003
    I've developed a "know H Pierror" to make sure the h py is not contaminant h py from the positive control. I recommend it up front on every block you process
     
    Euchromatin likes this.
  35. Tiki

    Tiki Girl named after a Giant 10+ Year Member

    955
    16
    Jan 6, 2004
    East Coast
    I'm a subspecialty GI pathologist and I have never used an ALCIAN Blue, and I am not missing tons of IM. I am in academics, but my case load is very heavy. I order H.py immunostains if I can't see the bugs on H&e and I'm suspicious, or if the person has a history of being treated. That's it.
     
    icpshootyz likes this.
  36. LADoc00

    LADoc00 There is no substitute for victory. 10+ Year Member

    6,083
    151
    Sep 9, 2004
    Huh..I thought everyone did a H pylori IHC on gastric biopsies. My clinicians demand it. Sort of like classic cytogenetics on every marrow. Although I did help sign out some cases for a friend's practice where I ordered a bunch of H pylori IHCs on gastric biopsies, some of which were positive and one of partners questioned me about it. To which I replied: "Why the f--k do you have the stain in house if you dont use it?"

    I then proceeded to site the cost of untreated h pylori gastritis to the US economy vs. the paltry cost of IHC testing on every gastric biopsy...dont be pennywise but pound-foolish.
     
    sohsie likes this.
  37. sohsie

    sohsie Member 10+ Year Member

    331
    24
    Mar 20, 2004
    Physician
    Next time don't accuse me of being solely about the money (not to mention the other insinuations in your posts and your own self-righteousness) and I won't get self-righteous.

    Despite all this, I am actually curious about your retrospective study. Did you have the pathologists re-read the slides blind without knowledge of the diagnosis, decide whether there was HP or not, then look at the IHC to confirm yes or no? Or did the pathologists just look at all the H&Es with knowledge of what was in the reports and/or IHC and see if they could find the h pylori on the H&E?
     
  38. sohsie

    sohsie Member 10+ Year Member

    331
    24
    Mar 20, 2004
    Physician
    Yeah, that's what I'm advocating. Its absolutely the same. Whatever.
     
  39. sohsie

    sohsie Member 10+ Year Member

    331
    24
    Mar 20, 2004
    Physician
    I have nothing wrong with this approach. Its how I was trained. But practically I do see this stuff missed (but its not like missing melanoma so no one notices) and more importantly, I do see the enormous efficiency gain when a good IHC is done up front. (I've also seen a lot of bad IHC where it really is a waste of time and money). Its something that shouldnt be dismissed.
     
  40. AZpath

    AZpath 5+ Year Member

    250
    30
    Nov 1, 2012
    I think almost everyone is missing a few points here. I realize that Palmetto-CMS is trying to prevent over utilization.
    However, they are now practicing medicine for us.

    The H. pylori decision was based on very limited published information. Moreover, these efforts might have the effect of dampening publication on the cost effectiveness of testing and treatment in the future. Some authors might not be too eager after seeing these CMS decisions.

    Also, the implication is that you committed fraud test if your testing for H. pylori is greater than 20%. Does this fit all populations?
    There are populations in the inner city and near the Mexican boarder that are have 40% prevalence.
    Also, what happens when all your requisitions have to rule out HP signed by the clinician?
    Call them tell the your maxed out at 20% this month?

    HP testing is an interesting and problem with a few wrinkles in it. The last GI conference the speaker suggested use of more IHCs on gastric biopsies not less. Their experience was that amount of inflammation and number of bugs drops markedly after PPI initiation. You can easily miss HP when this happens. He showed several examples were only a few HPs were seen. They go deep into the glands where there is more acid. They are much harder to spot. I will bet 50-60% of cases are already on PPIs. So are you missing rare organisms in these cases? Have you looked? I was taught to screen the surface glands. Food for thought not CMS action, IMO.
     
    jp123ok likes this.
  41. yaah

    yaah Boring SDN Administrator 10+ Year Member

    This is definitely institution dependent.

    Our GI paths do not do it routinely. I don't know the %. Our quality is very high and our clinicians are very happy. But we have inspected labs where it is done on every case.
     
  42. Weinberg Angle

    Weinberg Angle Banned Banned 7+ Year Member

    99
    0
    Dec 22, 2007
    ..
     
    Last edited: Jul 16, 2014
  43. bioguy

    bioguy 7+ Year Member

    52
    2
    Apr 10, 2008
    What about acute inflammation in GE junction? Do you do H. pylori IHC then.
     
  44. Tiki

    Tiki Girl named after a Giant 10+ Year Member

    955
    16
    Jan 6, 2004
    East Coast
    I do not order H.py IHC on GEJ biopsies with acute inflammation. I do look for organisms, esp. when the Antrum or body have not been biopsied. Most of the GEJ bxs I see have some acute inflammation secondary to reflux. I'm not about to start ordering it on every GERD GEJ.
     
  45. Alteran

    Alteran 7+ Year Member

    191
    34
    Feb 9, 2008
    Border war zone
    We routinely do Ki-67 on our breast specimens and I have found it to be extremely useful in the neoadjuvant setting where only a handful of cells are left. Irrespective of what NCCN tells my oncologists, and they follow that religiously, they still want Ki-67. The fun for me happens when I get a mitotic score of 1, but an overall Ki-67 of >30%. I've managed to concoct a statement explaining the discrepancy that hasn't led to me getting any nasty phone calls.

    As for Helicobacter stains (Diff Quik for us) and Alcian blue, we do it routinely. Quite honestly, if Palmetto is going to fret over a couple of bucks in special stains, they've got their head screwed on backwards. They really should be going after the GP and IM docs who order thousands of dollars in unnecessary laboratory testing per patient because they're too lazy or inept at drawing proper conclusions from routine simple laboratory tests.
     
    Autopsy101 likes this.
  46. ygdrasil

    ygdrasil No, there are no gigs. 10+ Year Member

    71
    4
    Apr 3, 2007
    For breast carcinomas I usually order PHH3 on those grade IIs with totally solid growth and marked nuclear atypia with only scattered mitotic figures. Fairly frequently I'll find more mitotic figures on IHC than on H&E and can call it a grade III, which will hopefully prevent an oncotype order from oncology. Defensible? Quackery? Weigh in, colleagues!
     
  47. Alteran

    Alteran 7+ Year Member

    191
    34
    Feb 9, 2008
    Border war zone
    Haven't thought of doing that before.....

    Perhaps I'll use it for some of those discrepant cases with low mitotic scores but demonstrate elevated Ki-67 proliferation indexes.
     
  48. AZpath

    AZpath 5+ Year Member

    250
    30
    Nov 1, 2012
    With regard to H. Pylori, we often forget that H&E is not one standard stain. I have noted some H&E stain HP much better than others.
    I suspect this effects the sensitivity of using H&E upfront. This something none of the published articles addressed. We all talk as we know the answer.

    I find it interesting is that H.P is the main actionable diagnosis for a gastric bx besides malignancy.

    We are kind of dumb too. If we think this going to be our contribution cost effective pathology, guess again.
    Clinicians and smart labs will start doing PCR on every case at 3x the cost. It is more sensitive and can id resistance.

    The LCD as it stands now makes many questionable determinations. It will likely continue to grow now. We should recognize it for what it is , an attempt to limit our practices without our input.
     
  49. yaah

    yaah Boring SDN Administrator 10+ Year Member

    I tend to be very skeptical about anything that is "routinely" ordered. Every case should be its own case.
     
  50. Pathbusiness

    Pathbusiness

    73
    15
    Oct 3, 2016
    Sorry waking up an old thread. A GI friend of mine told me there is something in the works which might end the practice of upfront H pylori and AB PAS staining on gastric and esophageal biopsies. If true that would put a lot of dent on revenue of private groups who do inter state pathology and of course big guys like Quest, Labcorp, Ameripath, and Miraca etc. Has anybody heard it? Everyone else except us tells us what to do!!
     
  51. octopusprime

    octopusprime

    77
    21
    May 6, 2016
    lmao...if anyone is relying on upfront (read "unnecessary") Hpys, ABs, and PASs to pad their income, there are likely serious organizational / ethical problems at play, or laziness.
     

Similar Threads
  1. tashka
    Replies:
    3
    Views:
    2,106
  2. Reaganite
    Replies:
    24
    Views:
    3,209
  3. BraggPeak
    Replies:
    12
    Views:
    1,565
  4. Reaganite
    Replies:
    9
    Views:
    1,256
  5. seper
    Replies:
    10
    Views:
    1,078
Loading...

Share This Page