IF THERE IS A DISCREPANCY OR PROBLEM, SHOULD I CONTACT THE PATHOLOGIST?
Contacting the pathologist is recommended if a practitioner has concerns about a pathology report (e.g. has questions about the diagnosis, prefers clarification of an interpretation, or needs help with narrowing the differential
diagnoses) or the report correlates poorly with the clinical findings. However, if information such as the sample source,
patient history, and pertinent clinical abnormalities was not included with the original submission form, be sure this information
is readily available when the pathologist is contacted. Proper communication is essential to a positive outcome.
WHAT CAN I EXPECT WHEN I SPEAK WITH A PATHOLOGIST?
Practitioners may be apprehensive about contacting pathologists. One concern is that pathologists are too busy to discuss
a particular case. However, inquiries from practitioners are relatively common, and pathologists typically correspond with
practitioners in a timely manner. Another concern is that practitioners may think pathologists perceive questions as a challenge
to their interpretation. Pathologists are generally receptive to discussing their interpretation, other possible differential
diagnoses, and any additional test results that may strengthen the confidence in the diagnosis.
Conversely, pathologists may contact practitioners about a challenging case or if they identify a potential problem. Pathologists
may also seek additional information to solidify a diagnosis or narrow their list of differential diagnoses.
Practitioners and pathologists benefit from a good working relationship established through proper communication and cooperation
when challenging cases arise.
DO I NEED A SECOND OPINION?
Obtaining a second opinion is an option when a practitioner has concerns about a pathology report. However, before this option
is elected, it is important to determine if the pathologist was provided an appropriate patient history, a sample source,
and pertinent clinical findings. Contacting the pathologist before requesting a second opinion may resolve a case issue and
alleviate concerns. Furthermore, the practitioner may find that the pathologist obtained a second opinion before completing
the report, which is fairly common when dealing with challenging cases.
Another important factor to consider is why a second opinion is needed. If the interpretation does not correlate with the
clinical findings, requesting a second opinion is reasonable. But when pathologists express concern that a sample is poorly
representative of a lesion, obtaining a second opinion is unlikely to provide much additional information or result in a definitive
diagnosis. For example, obtaining representative tissue samples can be particularly challenging with lesions involving bone
or masses arising within the oral cavity (e.g. gingival or odontogenic tumors). It is not uncommon for core biopsies of bone masses to predominantly contain secondary reactive
bone, with no clear evidence of the primary underlying lesion. With these types of cases, additional sample collection may
be necessary to obtain a diagnosis.
COMMENTS AND RECOMMENDATIONS
Pathology reports often include a section containing comments about the case. Depending on the sample and information provided
by the practitioner, the comments may be case-specific or relatively generic. In the absence of key information, when the
sample quality is not ideal, or when faced with complicated cases, the pathologist may be hesitant to provide a definitive
diagnosis or express a high degree of confidence in his or her interpretation. In these cases, it is common for the practitioner
to receive a list of differential diagnoses and recommendations for other tests or procedures (e.g. histologic examination, special stains, serology, culture, molecular assays, or collection of additional tissue samples).
AVOID THESE COMMON PROBLEMS
Below are several tips that may be useful in preventing common sample submission and interpretation problems.
Problem: Poor tissue exfoliation or low cellularity cytology samples
Avoid using small syringes (1 ml or 3 ml) and select a 20- to 25-ga needle. A 22-ga needle with a 5-ml or 6-ml syringe seems
to work well in most situations.
Certain lesions may exfoliate poorly regardless of the technique used (e.g. mesenchymal neoplasms). Aspirates from lipomas are often of low cellularity when lipid material is lost from the slide during
Aspiration of fluctuant areas of a mass can also be problematic, as many different lesions can be cystic. Cells from the cyst
wall may not exfoliate in significant numbers into the fluid, and evaluation of fluid alone is unlikely to be diagnostic.
A fluctuant or cystic area could also be due to tissue necrosis or secondary inflammation that might not be representative
of the lesion. Consequently, aspiration or biopsy of the lesion wall (more solid area) is recommended.
Problem: Blood contamination of cytology samples
Some practitioners prefer to collect cytology samples by using an aspiration technique (e.g. 22-ga needle attached to a 5-ml syringe). For this method, the needle should be inserted into the mass or tissue and the
plunger rapidly withdrawn once to develop negative pressure. Excessive withdrawal of the plunger will not result in a better sample but will increase the
likelihood of blood contamination and cell rupture. This negative pressure is maintained while the needle is partially withdrawn
and carefully redirected into several areas for aspiration. Redirection should be done carefully to avoid excessive tissue
trauma and bleeding. The negative pressure is then gently released before fully removing the needle, to avoid loss of cells
into the syringe. After removal, the needle is detached from the syringe, and air is drawn into the barrel. The needle is
then reattached to the syringe, and the sample is expelled onto the slide. The sample is then prepared for staining using
techniques discussed in the next section.
A sewing machine, or woodpecker, technique, which uses only the needle hub without syringe aspiration, is an excellent alternative
to the aspiration technique described above. The needle is placed into the lesion followed by a controlled sewing machine
motion for cell collection. The needle may be partially or fully withdrawn and redirected to sample additional areas of the
lesion. The needle is then attached to an air-filled syringe, and the sample is expelled onto a slide for further preparation.
Keep in mind that certain lesions such as hemangiomas, hemangiosarcomas, thyroid tumors, and mast cell tumors are frequently
associated with marked blood contamination because of the intrinsic vascular nature of the lesion.