Specimen Dissection Back to basics

Transcription

1 Carol Turnbull FIBMS PGDipHSSM BSc. What is Northern Ireland is famous for? Specimen Dissection Back to basics A few famous faces from Northern Ireland recognise anyone? And apparently we are not too bad at golf either!! 1

2 The Plan Why BMS cut?, the benefits and current attitudes. Governance and Risk (patient focused) and getting it wrong!! Good Practice Clinical history and block selection How to write a good gross description What is normal and abnormal? A few practical tips History and Culture In 2010, BCH delivered 26,000 cases but 90-95% were cut by BMS staff Needs driven due to increased demands on Consultant Path. Pioneered in the Belfast City Hospital but now rolled out across the UK Held in very high regard by our national accreditation body (CPA) Disapproved of by many Frowned on by many Consultant pathologists who thought this can t be safe, BMS can t be competent Dubious CPA inspectors st CPA visit. BCH identified as a pilot site 2000 IBMS and RCPath set exams at post masters level in tissue dissection Decades later, system gradually accepted with appropriate safeguards The benefits Consistently high standard BMS job satisfaction and career progression Effects on staff retention Work with existing resources. Major savings. Releases medical staff for reporting and other clinical duties therefore better use of consultant time. 2

3 Online survey of UK Consultant Pathologists (take home messages) Vast majority of UK Consultant Histopathologists taking part in the survey support BMS cut-up Utilisation limited at present due to staffing, funding and concerns over quality Training, examinations and audit of practice will provide assurance of quality Pathology managers need to be provided with more evidence of the fiscal benefits. To err is human J Clin Pathol 2011; 64: Risk We can never eliminate risk, however we can put measures in place to minimise risk. How does clinical governance relate to specimen dissection? Clinical Governance is how we handle the specimen from receipt in the lab to the final report, ensuring optimal handling and without risk of an incorrect report or diagnosis. 3

4 Ensuring continuity, where do errors occur? Specimen receipt and booking in In the cut up room In the main lab In the pathologist s office Final reporting and authorising F*** ups seen in all areas Minimising the risks to the patient Check PID against labels on pots 3 TICKS name, lab number and/or DOB and specimen number, required for audit. (preferably unique identifier) Check part numbers correspond to the labels on the specimen pots e.g.. X2 X3 Log / record any/all discrepancies, check against theatre lists. Getting it wrong! Mixing specimens can have dire consequences Inappropriate treatment can be given. (surgery, chemo, DXT) Treatment can be delayed or omitted. Psychological trauma Costly damages against the trust. 4

5 Clean, tidy, orderly workstation Good Practice!! The principles of Good Practice Tidy, clean and orderly workstation Work in pairs to cross check data Clean paper towel for each specimen and/or part Wash and wipe forceps and blades before, during and after dissection of each specimen (preferably under a running tap) Now on to the messy stuff!!! The surgical cut up 5

6 We need to Read and Understand the clinical history /comments Biopsy or excision (really only 2 types). This tells you the purpose, diagnostic, reexcision, therapeutic If required, helps you to decide how to open the organ to allow maximum fixation of the lesion Orientation markers should not be removed until after photography and protocols for inking have been carried out. Gross measurements usually taken before dissection Ask yourself these questions! 1. What structures are present? 2. Is there a tumour present? 3. What type of tumour is it? 4. Is it benign or malignant? 5. Is it completely excised? 6. How far has it spread (stage) 7. What is the likelihood of it returning and or metastasising to other locations? The importance of the gross description!! Important skill for diagnosis and prognosis Provides a permanent record Used for staging, eg tumour size, location, distance to margins, multiple tumours etc. (TNM) Correlation between micro and macro Accuracy of block selection (good block key) Example of block key for a right hemi-colectomy A = limit node B and C = tumour and serosa x2 D and E = tumour and mesentery x2 F = appendix G = polyp distal to main tumour mass H J K L = nodes 6

7 How do we write a gross description? 1. Identify the structures present, weights and measurements 2. Main findings of lesion and its relationship to normal structures and distance to margins 3. Secondary pathology not yet described, e.g. other lesions, polyps, cysts and contents Qualities of a good gross description Be succinct and precise Good organisation (the information should flow) Adequate dissection (thoroughly examine as measurements may change) Use? (If unsure of involvement) Standardization (use of proformas) Use photos and diagrams as an aid to description Good block key How do we describe lesions? LOSSCCC Location..where the lesion is Outline..what does the border look like Size..the exact measurements Shape..encapsulated, nodular Colour..tan, white, yellow Consistency..keratotic,mucinous,firm Cut surface..homogenous, heterogenous that s all well and good!!! but how can we recognise tumours? 7

8 What do these tumours look like? Benign versus Malignant Benign Circumscribed (thin membrane) Encapsulated No necrosis Rubbery fibrous tissue Malignant Irregular infiltrative edges May have necrosis and haemorrhage Very hard How do tumours spread and metastasise? 1. Local invasion most common, direct growth into adjacent tissues 2. Lymphatic spread forms secondary tumours in lymph nodes 3. Blood borne spread eg bronchus, breast, thyroid, kidney and prostate 4. Transcoelomic spread in pleural, pericardial and peritoneal cavities How do we select the right blocks? Blocks of tumour in relation to other structures (select viable tissue) Blocks of tumour with the nearest excision margin Blocks showing the deepest point of invasion. Block all lesions / abnormalities mentioned in the description (and tissue between) Shave margins if necessary. Lymph nodes and vessels Block of normal tissue as a comparison of what is normal for each individual 8

9 How do we select the correct type of margin? Shave margin.. e.g. oes, vaginal cuff, prostate, bronchus, ureter Perpendicular margin..used particularly where a small rim of uninvolved tissue would be considered a negative margin eg. Intestine, skin, thyroid nodule If inking margins, care not to transfer ink onto non-marginal tissue. Shave Advantages are greater surface area and view entire structure with lumen Disadvantages are the exact distance cannot be measured Margins (2 types) Perpendicular Advantages are exact distance can be measured. Disadvantages are there is a small sample of the tissue margin. A few good tips!! If blocks contain fatty tissue, remember to keep them thin (<3mm) to aid processing. Float out fatty and fresh tissue! One patient at a time please!! After each case is finished put the blocks away in fixative ready for processing. Do not leave partially dissected specimens on the bench without appropriate labelling No distractions A few more!! No open containers on the bench Rinse larger specimens with running water to reduce formalin exposure Check the lids for tissue!! Care not to transfer cells on paintbrushes, e.g. lletz bx of cervix Final check of labelled cassettes and number of cassettes taken 9

10 In conclusion!! Biomedical scientist involvement in specimen dissection provides a quality safe and cost effective service. Helps to address the shortage of Consultants Require Consultant support 1 st do no harm!! ( its ok to ask for preview) Learn to recognise normal from abnormal tissue, life long learning!! And finally, this is a great way of working within your existing resources. Remember that You are the most valuable resource. Thank you. Any questions? 10