Req: breast pathology - resection specimen fixation, processing and hormone receptor assessment

dhous007

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    I wanted to ask what is your departmental policy for

    1) specimen fixation - do you deny specimens sent in small amount of formalin and small jars? Do you require breast resection specimens to be fully submerged when received? I know most of them tend to float in the jar. Do you still process them and just make a note during grossing?
    2) Do you receive specimens fresh or in formalin? If in formalin, do you require them to be already sliced to 5mm slices and slices separated by gauze when transported from remote areas?
    3) Do you get requests to repeat POSITIVE hormone receptor status on definite resection specimens? If so, what is your approach? Refuse because of possible problem with poor fixation and discrepant results? What do you do if repeated and POSITIVE core biopsy is followed by NEGATIVE hormone status in resection specimen (likely related to poor fixation)?
     

    mikesheree

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      Wow, so much of this depends very much on your practice circumstance. In my case, I was solo at an~180 bed place. And I was there for 23 years. So. i just told all the or folks and surgeons that when they have a big ugly specimen like a breast, etc to just send it to me fresh so i could assure proper fixation, special studies sampling, etc. I did not do frozens on such cases(unless of course one was required for whatever).
      This was pretty easy at my shop and not very demanding but the larger your shop and the more or’s, surgeons, cases, pathologists, etc this could be quite cumbersome.
      If that is the case you need to have a resident (or other assigned person) keep tabs on what is coming down and make sure it is fixed, etc.
      This turned out to be one of those situations for me that if i wanted it done right, i was going to have to do it myself.


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      RE-Tired

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        Fixation : In about 20 of my 40 years of years as a Chief of AP in three different hospitals, no matter what policies about surgical specimen handling are made they will NEVER be followed in all cases. I think this is due to the constant change in personnel. You can have instruction to OR personnel on a regular basis and there will still be specimens without enough or sometimes no fixation. Sorry to be so cynical. The only thing that came close to being perfect was in my fellowship where they had a pass through fridge and all specimens were put in fresh and the residents cut them in fresh within few hours. We had no fixation problems. I had a OR supervisor once pass down a memo to get rid of formalin in the OR. The supervisor wanted to substitute the post formalin preservative used for educational specimens. Had to spend several hours of my time to address this as you know anyone can get online and in 10 min and know more about your profession than you do. At least I was consulted, got to give 'em credit for that.

        Receptor studies- In my opinion and I believe this is best practice, if positive they should only receive a repeat if the resection show a second tumor/ whoever is requesting this needs to be educated. I was a breast pathologist and I cannot recall ever having this request.
         
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        AZpath

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          Cores are not much of a problem since they go directly into formalin.
          I don't repeat most receptor studies. ER and PR tend to be pretty good unless the core it is tiny.
          It may be worth repeating negative Her2 on poorly differentiated tumors due to heterogeneity.

          We have so much turn over in OR training staff resections are always a problem.
          It is almost impossible if resections are transported from off site location.
           
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          yaah

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          Fixing in 10% neutral buffered formalin
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            I'm not sure what you mean about denying specimens. No matter what the quality of the specimen you receive, you should do your best with it. It's not like they can go back and try again. If whoever is submitting it is not following guidelines for proper processing, then that becomes another issue and a limiting factor to interpretation - but it could still end up being your responsibility if you're responsible for transport and such. One issue we have had is with nuclear medicine breast specimens, that won't be released from the offsite hospital for transport for grossing until cleared by nuclear med. So we send PAs out to gross them remotely or at least partially section them so they'll fix. Better they sit and wait for clearance in cassettes or partially sectioned as opposed to floating in formalin.

            If you continue to have significant problems with surgeons or centers not following processing guidelines, you take it up with those who have responsibility over their sites. When they realize their inactions are leading to non-valid receptor studies and substandard histology, they will act.
             

            LADoc00

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              I like the denying specimens thing...do you request it is put back into the patient as well?

              That would be awesome. You have to video that interaction and post it up here.
              giphy.gif
               
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