Surgical Pathology

Laboratory of Pathology Consultations Policy

The Laboratory of Pathology is not a Reference Laboratory.

Intra-departmental Consultation

Intradepartmental consultations are encouraged in difficult cases and when an expert opinion is needed. Upon review of cases, the staff on service may decide to seek an additional opinion. The consultation will be sought by the resident or the attending on the case. If the consulted pathologist requests further information or special tests are deemed necessary, these should be obtained. If further information or special tests are not necessary, a consultation should ideally be completed within 24 hours (exception-case submitted for review by multiple consultants).  A case should be resubmitted for consultation following receipt of additional material, further clinical information or completion of special studies. The pathologist in charge of the surgical pathology case must decide whether the results of intra-departmental provide relevant information for inclusion in the patient’s report. If the views of the consulted pathologist are to be reflected in the final report, the interpretation should be included in the note and/or flagged in SoftPath, Results section, under Intradepartmental consultation.  The consulted pathologist may initial the report and may receive a copy of the final report, if requested.

Extra-departmental Consultation

The accompanying letter to an outside consultant should provide the reason for the consultation, specific questions to be answered, and the referring NIH pathologist’s working diagnosis or differential. The outside consultant should be provided with all available information on the case: clinical history; representative H&E sections of all pathologic findings; the original immunoperoxidase slides or unstained slides and/or blocks; electron microscopy prints (if EM was performed), and flow cytometric data (if flow was performed); results of molecular testing. Upon receipt of formal consultation report, the external consultation should be incorporated in the NIH report (if the case was not signed out yet) which will then be included in the patient’s medical record. Copies are provided to all NIH staff pathologists who may have reviewed the case.  Documentation should include:  the letter sent to the outside consultation and the written response from the consultant. Documentation of extra-departmental consultations must be readily accessible within the pathology department. A copy of the consultation surgical pathology report is maintained with the official NIH surgical pathology report (either in the final report, or in a supplemental report). Additionally, a copy of the consultation report is kept separately, and is readily linked to the patient.

Extra-departmental cases submitted to the NIH Pathology Laboratory

These are entered as submitted cases and they are accessioned according to standard practices of the laboratory, and a report issued. Copies of the NIH generated report are sent to any referring physicians within the NIH (patient’s treating physicians) and to originating Laboratory.

Informal Inter or Extra-institutional Consultation:

Informal inter or extra-institutional consultation for other than personal interest, research or educational purposes is strongly discouraged.  When consultation is for diagnostic purposes, a formal reading is absolutely necessary. Under no circumstances, an informal “consultation” by an NIH pathologist can be reflected in any outside surgical pathology report, or used to decide patient’s treatment.

Consultations provided to clinicians prior to accessing (Curb Side Consultation).

When a diagnosis is sought before accessioning (i.e. curb side consult), the pathologist may verbally inform a clinician of a preliminary diagnosis with the sole purpose for supporting potential patient protocol enrollment. A formal written NIH surgical pathology report is needed to initiate patient treatment.

The Laboratory of Pathology’s normal operational hours are from 6:00 am to 5:00 pm, Monday through Friday. The following guidelines are for requesting physicians, Pathology Residents, attending pathologists and Histology staff to use when the operating rooms and clinics need to deliver Surgical Pathology specimens to the Histology grossing room after hours and when Stat cases are requested.

Note to the Requesting Physician

1. For questions concerning any Surgical Pathology specimens after 5:00 p.m. or on weekends, please contact the page operator and ask for the operator to contact the on-call Surgical Pathology Resident.
2. The requesting clinic or Operating room staff must provide the Surgical Pathology Resident with basic information about the case (diagnosis, type of surgery). This will enable the Resident to make an informed decision about how to best handle the specimen. A final decision may require discussions with the clinician and attending pathologist regarding the nature of the stat request and/or review of previous pathology material.
3. Specimens delivered from the operating room or the clinics must include the following:
   1. patient’s name,
   2. medical record number (MRN), and
   3. specimen source.
4. All specimens delivered from the operating room must be accompanied by a CRIS order and the O.R. sheet.

Specimen and Requisition Delivery (off-duty hours drop-off)

If the Pathology Resident is not on campus at the time of the request, the Resident may instruct the requesting clinician to leave the specimen(s) either:

• In the Laboratory of Pathology's Tissue Procurement and Processing Facility (TPPF) in room 2C533 (for O.R. specimens), or
• In the Clinical Center's Department of Laboratory Medicine (DLM) in a refrigerator labeled "Chemistry 8" (all other cases).

The DLM is located in Building 10, Room 2C306 on the second floor, across from the cafeteria. The fridge is located in the Clinical Chemistry section, across from DLM's Central Accession area.

For specimens being delivered to the Department of Laboratory Medicine (DLM) Chemistry holding fridge between 7:00 pm and 6:00am, call 301-496-3386 for laboratory access.

For specimens being delivered to the TPPF, access is gained through the Operating Rooms' entrance.

Please note: This location was chosen because DLM is a 24-hour laboratory with secured access.

Handling After Hour Specimens for Pathology Residents

When the Resident receives a page from a requesting physician concerning a specimen that must be processed after hours, the Resident must ask the requesting physician the following information:

1. Patient’s Name
2. Patient’s Clinical History
3. Specimen Source
4. What fixative was used for the specimen?
5. How long has the specimen been in the fixative?

The Resident should conclude the phone call by telling the requesting clinic or operating room that they will be notified when the slides will be completed. This will be accomplished after the Resident has discussed the stat request with the attending pathologist and the Histology on call staff.

Communicating the Details of the STAT Case to Histology

In many instances when the specimen is brought down late Fridays, the Histology laboratory can run a STAT processing cycle and complete the cutting and staining of the case on Friday afternoon. However, if the staining cannot be completed on Friday, the Histology laboratory will send an email to the Resident and the Attending to inform the pathologist when the case(s) will be completed on Saturday. The H&E’s will always be completed before 9:00 am on Saturday. The special stains will vary depending on the special stain requested. All special stains will be completed by 11 a.m. on Saturday.

Please note: If a request is received on Saturday and the attending pathologist determines it is a stat case, the same process will be followed and the special stains will be completed by 11 am on Sunday.

If the Resident is in doubt throughout this process, the Resident must contact the attending pathologist, Chief Resident or the histopathology supervisor for clarification.

     Information the Resident Must Relay to the Histology Laboratory:

1. Patient’s Name
2. Specimen Type
3. Date and time the specimen will be brought down to the Histology laboratory
4. The number of hours the specimen has been in a fixative
5. Provide the name of the fixative used
6. What stains are to be performed?
7. Name of the Attending Pathologist who will be responsible for the case

Gross Analysis and Tissue Processing when Specimens are Received During Non-Routine Work Hours

For specimens that need to be diagnosed on the following day or the next routine work day, the case will not be accessioned until the next routine work day.

The Resident will manually document the gross dictation and staple this written gross dictation to the CRIS order or O.R. Sheet.

The CRIS order, the O.R. sheet and the written dictation will all be placed on the Histology accessioning counter.

The Pathology Resident should refer to the Surgical Pathology manual for instructions on the proper grossing and handling of each specimen.

If the pathology Resident is unsure about any part of the handling or grossing of the specimen, they should contact the pathology attending, the Chief Resident or the histopathology supervisor.

Tissue Processing

Once the gross analysis has been completed, the Pathology Resident will write the patient’s Last Name, First Initial and the Date the specimen was received on the tissue cassettes.

The tissue cassettes will be placed on the tissue processor by the Resident to be cut and stained by the Histology lab the following day or the next routine work day.

Once the slides have been stained by the Histology staff, the Resident and the attending will be paged to collect the slides.

Completion of Slide Staining by Histology

After the slides have been stained by the Histology laboratory, the Pathology attending and Resident will be paged along with a follow-up email being sent directly after. Once the Pathology attending and Resident have reviewed the case, the Pathology Resident and/or attending pathologist should notify the requesting physician via telephone of the preliminary results.

Please note: If the Resident and attending will be reviewing the slides on a regular work day, the case will be signed out as usual by the in-house Resident as a STAT case. For example, for a case received and grossed on Sunday, the slides will not be reviewed until Monday morning. However, if the case must be reviewed on Sunday or during an extended holiday, the on-call Resident and attending will have to review the case once the Histology processing has been completed.