Staging bladder biopsies in addition to reporting microscopic extension

[coroner]

So I got a call from a new Urologist today asking me to give a primary tumor classification on bladder biopsy. My dx: Noninvasive, high grade papillary urothelial carcinoma. But, he wanted to know what the pT stage was on top of that (pTa). Wth?!?! I always mention if detrusor muscle is present and the degree of microscopic extension if present. And that has always sufficed in the past as well as been standard of care to my knowledge. But, I'm thinking using pT classification/nomenclature on biopsies (let alone noninvasive ones) is overkill. Am I alone here? Does anybody else do this or gotten such requests from clinicians?

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[caffeinegirl]

We get this all the time, and now routinely include a staging summary on all of our malignant bladder biopsies (including the non-invasives..which is just overkill)

 

[univlad]

We get this all the time, and now routinely include a staging summary on all of our malignant bladder biopsies (including the non-invasives..which is just overkill)

Same here. After a number of calls, we just added a pT staging section to the bladder biopsy/TURB tumor summer.

 

[Ziehl-Neelsen]

We're such doormats.

Staging bladder tumors on a biopsy or TURB is not a required element of synoptic reporting. Plus the (preliminary) stage can easily be determined from the language of the synoptic report. These requests are totally redundant, and IMO are made because it makes less work for the urologist or their minions to copy down a stage and fulfill the NCCN's new requirement that staging information be provided for every patient discussed at multidisciplinary tumor planning conference. Never mind the objection that we're rendering what most perceive as a definitive stage in a situation where such staging is totally inappropriate What if there is no muscularis propria in the specimen? How do you distinguish between 2a and 2b disease?

I should have listened to my medical school classmates and gone into gas or rad-onc.

 

[Over9000]

I hedge. There's no other option.

Really, taking some of a bladder tumor, half of it being burnt to a crisp, and expecting me to give it a final stage is like asking me to pull rabbits out of my ass.

The most I can say is either lamina propria invasion or muscularis propria invasion present or absent, with the caveats that a) this may not represent the entire lesion if not entirely excised, and b) its burnt which makes examination of those regions futile.

T3 cannot be graded on a biopsy. Neither can T4. The urologists should know this. Their NCCN billing concern is irrelevant to me.

I'd give them a polite but firm schooling about the realities of the situation. They certainly don't get calls from me on the phone demanding they plunk down hard cash on a cold knife so the biopsies aren't half trash. No other specialist will dictate how I practice. This should be the case for all pathologists. Full stop.

Ziehl-Nielsen is right; pathologists are doormats, probably because half of our ilk couldn't get a job in another specialty due to English-language difficulties, academic sub-mediocrity, frank racism and prejudice, or fraud. People are more likely to supplicate when desperate.

I should have gone for derm. Or urology. Ha.

 

[coroner]

Thanks for everyone's feedback, just wanted to get an idea of what other people are doing.

No other specialist will dictate how I practice. This should be the case for all pathologists. Full stop.

In principle, I agree. But, I will begrudgingly concede Don't want to lose those prostate biopsies, and gotta keep the lights on...

 

[Ziehl-Neelsen]

Thanks for everyone's feedback, just wanted to get an idea of what other people are doing.

I'd give them a polite but firm schooling about the realities of the situation. They certainly don't get calls from me on the phone demanding they plunk down hard cash on a cold knife so the biopsies aren't half trash. No other specialist will dictate how I practice. This should be the case for all pathologists. Full stop.

You can live vicariously through me...

I work in a system where the tissue can't go anywhere else. I told the urologists to pound sand.

 

[yaah]

Part of the reason it helps is that it's kind of a double check for accuracy. The move from T1 to T2 in bladder is a massive clinical difference in all but the old and infirm. Additionally, it makes it easier for the coders and clinical care coordinators to document things correctly.

I think also part of the reason CAP recommends (requires?) staging is because TURBT is technically a "resection" procedure. It gets a resection CPT code, 88307, which typically otherwise requires you to stage a tumor. On true biopsies, no, it probably isn't required. But the difference can be hard to tell sometimes. And operative procedures will initially say biopsy but then convert to TURBT, or vice-versa.

You don't substage beyond pT2. It's just pT2. That's the cutoff on TURBT.

I fail to understand why this is such a big deal to people. It's very easy to do. It makes you look petty to refuse. It doesn't make you a doormat at all. Do clinicians complain that writing clinical histories on requisitions makes them doormats?

 

[Alteran]

I don't report stage on TURBT specimens and I make it a point to say in the comment that it's not an element of the synoptic report just so I don't get the phone call. On the rare occasion when I'm asked for something like this though, I say At Least T_ and offer a comment about the limitation of a TURBT in comparison to cystectomy (I have them as canned comments on my AP-LIS).