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Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 33-38

Preanalytic determinants of surgical pathology practice in Uyo

1 Department of Pathology, University of Uyo, Uyo, Nigeria
2 Department of Histopathology, University of Uyo Teaching Hospital, Uyo, Nigeria

Date of Web Publication16-Apr-2018

Correspondence Address:
Chukwuemeka Charles Nwafor
Department of Pathology, University of Uyo, Uyo
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sjhs.sjhs_76_17

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Context: The aim of this study is to evaluate the various determinants of the preanalytic phase of surgical pathology (SP) in Uyo. Materials and Methods: This is a cross-sectional descriptive study (prospective) of all SP specimens that were sent to the histopathology laboratory of University of Uyo Teaching Hospital, Uyo. A special pro forma/questionnaire was designed taking into account the various determinants of the preanalytic phase of SP. Results: The request form had the patients' name and sex in all cases reviewed. In all but 3%, the age was stated while the hospital number and site of biopsy or tissue were stated in 89% and 95%, respectively. Only 49% of cases had an adequate history. In majority of cases, the examination findings (63%) and previous investigations (83%) were not stated. The provisional diagnosis was indicated in 92% of cases while the requesting/managing clinicians' name was indicated in 94% of cases. Seventy percent of the request forms were written on behalf of the consultant by the resident doctors. The fixative was adequate in 92% of cases and all specimens came in formalin (though it was of different concentrations). Majority (92%) of the specimens came in plastic containers, which was adequate (large enough) for the size of the specimen. The provisional diagnosis was same with the histological diagnosis in 66% of cases. Conclusion: An adequately filled request form well labeled adequate specimen container containing the right amount of fixative will positively affect the preanalytic stage of SP.

Keywords: Preanalytic phase, request form, surgical pathology

How to cite this article:
Nwafor CC, Obioha K. Preanalytic determinants of surgical pathology practice in Uyo. Saudi J Health Sci 2018;7:33-8

How to cite this URL:
Nwafor CC, Obioha K. Preanalytic determinants of surgical pathology practice in Uyo. Saudi J Health Sci [serial online] 2018 [cited 2022 Jun 27];7:33-8. Available from: https://www.saudijhealthsci.org/text.asp?2018/7/1/33/230231

  Introduction Top

Surgical pathology (SP) request in patient management serves the main functions of disease identification, documentation of surgical procedure, and release of tissue for research.[1] All these are enhanced toward a better patient management. Just like every laboratory procedure, which is divided into preanalytic, analytic, and postanalytic stages, SP has all stages, with a short but very important preanalytic phase.[1],[2],[3] Cumbersome tissue processing, subjectivity in reporting, and lack of numerical data are the main reasons for reduced implementation of quality control programs in SP.[2] The major events of the short but crucial preanalytic stage of SP that would affect results include:[1],[3] patient identification, identification of individual(s) requesting the examination, procedure time, adequate clinical history, instructions for the disposition of the gross specimens, specimen preservation/transportation in ideal container using ideal solution, and specimen identification. All except the last are usually written on the request form while the last is for the specimen container. Of all these, patient identification, specimen identification, and the availability of reliable clinical history (information) are said to be the most important.[3],[4],[5] The accuracy and completeness of pathology reports have been shown to be affected by clinical history while errors in specimen identification have led to unwarranted procedures (wrong site or wrong patient surgery or therapy) with severe consequences.[1],[6],[7] Once the SP specimen (SPS) is generated, it is put into an ideal container containing an ideal quantity (10 times the size of the specimen) of phosphate-buffered formalin (PBF).[8],[9] Recently, in a bid to achieve standardization of fixation times, grossing has to be done on fresh tissues, sectioning tissues into 3–4 mm thick tissue slices in cassettes and for strictly definite times: for a minimum of 5 h for small specimens and for an average of 24 h (maximum 48 h) for large specimens.[8] Better still, the fresh tissues can be immersed (packaged) in a plastic bag (with identification label), then into the under vacuum (UV) machine. In a matter of seconds, the tissue is UV. The bag is left in the fridge.[8]

Preanalytic phase of SP is multifactorial, originating from either the theater or ward and involves many individuals (laboratory and nonlaboratory staff). There are few studies dedicated only to all segments of preanalytic phase of SP.[10],[11] The aim of this study is to evaluate the various determinants of the preanalytic phase of SP in Uyo.

  Materials and Methods Top

This is a cross-sectional descriptive study (prospective) of all SPSs that were sent to the histopathology laboratory of University of Uyo Teaching Hospital (UUTH) for 2 months (February and March 2016). UUTH is the only tertiary hospital in Akwa Ibom State and its histopathology laboratory renders services to the hospital and many privately owned hospitals within Akwa Ibom State. A special pro forma/questionnaire was designed for this study taking into account the origin of the SPS (whether internal or came from outside), checking if the request form had basic information such as name, age, sex, hospital number, department, site of body tissue came from, clinical history, examination findings, and investigations done with their results. Other information extracted from the request form was the provisional/working diagnosis, presence of the name of the requesting doctor (consultant in charge), and the person that filled/signed the request form (resident doctor or consultant or medical officer). Another parameter evaluated for was the type of preservative used and if the quantity was adequate. Container used in transporting the specimen was also assessed: the type (plastic or bottle), whether it was large enough, widemouthed with a tight lid. The labeling of the specimen container was also assessed for name of patient, hospital number, ward, and site from which tissue specimen was taken from. The histological diagnoses of SPS were later compared with the provisional diagnoses. The pro forma was used to assess all specimens that arrived during the period of study. Information from these questionnaires was later entered into an Excel sheet and analyzed using predictive analytical software, version 17 (IBM, SPSS Inc., Chicago, IL, USA). The requesting clinicians were unaware that request forms filled by them and specimens sent for histological examination were evaluated for quality control parameters.

Major limitation of this study is the small sample size.

The research was approved by review board of the hospital.

  Results Top

A total of 100 SPSs were received and reviewed during the period. Eighty-five percent of them were sent in by patients/relatives of patients managed in the hospital while 15% were from outside the hospital (private hospitals). The request form/note (those from private hospitals) had the patients' name and sex in all cases reviewed. In all but 3%, the age was stated while the hospital number and site of biopsy or tissue were stated in 89% and 95%, respectively as shown in [Figure 1].
Figure 1: Basic demographic information available

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[Figure 2] shows other information from the request form. Only 49% of cases had adequate history, while in 5%, no history was stated. In majority of cases, the examination findings (63%) and previous investigations (83%) were not stated. The provisional diagnosis was indicated in 92% of cases while the requesting/managing clinicians' name was indicated in 94% of cases.
Figure 2: Information from the request form

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[Figure 3] shows the category of the doctor that filled the request form. Majority of them were written on behalf of the consultant by the resident doctor in 70% of cases while consultants filled the form in 11% of the cases.
Figure 3: The category of doctor that filled the request form

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In 92% of the specimen containers, the patients' name was written. In 64% of them, the tissue or biopsy site was indicated while hospital number and ward were indicated in 50% and 10%, respectively, as shown in [Figure 4]. The fixative was adequate in 92% of cases and all specimens came in formalin (though it was of different concentrations).
Figure 4: Information on from specimen container

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[Table 1] shows the characteristics of the specimen container. Majority (92%) came in plastic containers, which were adequate (large enough) for the size of the specimen in those cases. Only in 3 (3%) cases were the container lid ineffective (not tight fitting).
Table 1: Specimen container characteristics

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The provisional diagnosis was same with the histological diagnosis in 66% of cases as shown in [Table 2].
Table 2: Diagnostic concordance

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[Figure 5] and [Figure 6] show different types of wrong containers that were infrequently used.
Figure 5: (a) A wide-mouthed container with a tight lid, but too small for the specimen, leading to poor fixation. (b) Other types of inadequate specimen containers, an injection bottle and a syringe

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Figure 6: (a and b) An antibiotic infusion bottle cut to gain access and an improvised ineffective plaster lid

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  Discussion Top

Although may seem inconsequential for the inexperienced, the request form is an integral part of SP. It serves both as a communication between peers and as a letter of contract, stating what the surgeon wants from the service provider (the pathologist) regarding the patient.[10] UUTH SP request form has the following basic segments: columns for patient name, age, sex, hospital number, date, name of requesting clinician, clinical history, provisional diagnosis, type of specimen, and the name of the individual that filled/wrote on the form. All request forms in the index study had the patients' name, sex, and age except for 3 without age. This is different from observations in Kano, where sex was not documented, and 25% of the requests did not indicate age.[10] Furthermore, in Pakistan, sex and age were not indicated in 14% and 5.8%, respectively.[11] The presence of demographic data helps in patient identification and search for any other previous investigations through laboratory computer software. Age and gender helps in the differential diagnosis of the lesions since some pathologies tend to occur more in a particular sex or within an age range.[12]

Only 5% of cases were no history of the patient's illness indicated, while in the remaining, some form of information was given, whether adequate or inadequate. Only 37% of requests were examination indicated while only 17% made mention of any previous investigations done. These observations are similar to findings by Atanda and Raphael [10] The requests that indicated previously performed investigations almost all came from urology clinic, where every request indicated prostate-specific antigen value and also documented the digital rectal examination finding. Inadequate patient clinical information and none clinical information were seen in 51% of cases. The clinical information given by some clinicians was a phrase stating the tissue and site where the specimen came from. This is similar to observation by Atanda and Raphael. Studies from other countries by Muhammad et al., Burton and Stephenson, and Nakhleh and Zarbo observed adequate history in 66%, 93.9%, and 97.6% of cases.[10],[11],[12],[13] The difference is significant and calls for increased awareness among clinicians in our health facility on the need to give adequate clinical information. The importance of an adequate clinical history (information) cannot be overemphasized. Studies have shown that viewing glass slides under the microscope cannot always predict clinical information. Adequate clinical information helps define the need for and the nature of special studies that can be performed. Another advantage of availability of clinical information is the fact that it enables the pathologist to narrow down the differential diagnosis.[2] SPS should not only be accompanied by pertinent clinical information but also include pre- and postoperative diagnoses (even if they are provisional diagnosis).[l] Inadequate information noticed in the index study may be because the SP request form in UUTH did not indicate nor has columns specifically for investigations and examination findings. The observation that most request forms in the index study (70%) were filled by house officers or rotating residents (who usually have limited knowledge of the patient) may also be a contributing factor. This crop of young doctors should be made to understand that good request form filling is an integral step into getting the desired result from SPS. The ideal person to fill the request form has generated controversies because the owners of the patients (consultants) most times do not fill the request form themselves.[10] We suggest that that generating a request is a serious component of an investigation and that forms should be filled by either the consultants or other senior members of the unit. Lack of or inadequate clinical information causes delay in making a diagnosis and releasing the report (thereby prolonging the turnaround time). Lack of clinical information leads to extraneous, unnecessary additional tests or application of broad-spectrum immunohistochemical stain panels, which has definite resource management and demand implications.[11] Occasionally, when appropriate clinical information is provided later, it could lead to change of diagnosis.[2],[4] Another reason for inadequate clinical information is the belief by some clinicians that it will cause bias for the pathologist.[11] Obtaining better clinical information in SP will come from improvement in information technology.[14] With the introduction of the electronic medical record by many advanced medical institutions, the pathologists can access clinicians' notes (clinical information) as well as laboratory results, radiographic and endoscopic findings done by the patient, leading to improved clinicopathologic correlation.[4],[14],[15]

SPS container is not a special container as seen in other aspects of laboratory medicine, rather it is a plastic container with a screw cap or tight lid, widemouthed or opening, that is clean (free of grease, chemical, or oil) and big enough for the specimen in question (thus container size is specimen dependent), having enough space for the complete submergence of tissues. Majority of specimens (92%) seen in the index study came in ideal containers, both those from within and those from outside the hospital. Some specimens (8%) came in inappropriate containers Which include, (antibiotic injection glass bottles, infusion giving sets with improvised leak prone covers. Others were; screw lid-wide mouthed but small for specimen / too large a specimen for containers size which lead to having containers that were tightly packed and force closed. Assessing these SPS during surgical cut up could be difficult at times and posed enormous risk. Extra precautions were taken in opening none tight/leak-proof lids to avoid spillage. SPSs forced into injection glass bottles were broken to bring out the specimens while the “too large a specimen for container size” had prolonged turnaround time due to initial poor fixation. Such specimens run a risk of been anatomically distorted or lost during transportation.[11] Similar observations were noticed by previous authors though our rate of 8% (for inappropriate containers) was <16.5% and 29% reported by Atanda and Raphael and Muhammad et al., respectively.[10],[11]

It is critical that a specimen is reported on the correct patient and this begins with specimen labeling and accessioning. Improperly labeled specimens should not be accepted. Labeling errors may lead to inappropriate therapy or the withholding of therapy in patients with unrecognized malignancies.[5] Minimum requirements for specimen identification that must be attached firmly on the specimen container are patients' full name, date of birth, and hospital number.[1] In our setting, age rather than year of birth is one of the items indicated in the labeling of SPS. Only 3 specimens (3%) had all 4 items (patients' name, hospital number, ward, and tissue site/origin) indicated on the specimen label. The two most common items in our labeling were name and tissue site. Sherif et al.[11] and Raab et al.[16] reported no labeling in 4.3% and 1.7% of their cases, respectively, which is much lower than 8% in the current study. Although the small sample size may have contributed, this rate is significant. Avoidance of batch processing and the use of newer technologies such as bar codes on specimen containers, requisition forms, cassettes, and slides or the use of radio frequency chip technology may significantly reduce the incidence of specimen mislabeling.[5] An alternative in our environment since barcoding is not yet available will be providing a structured labeling sticker placed on the SP container before the surgical procedure. The doctor/assistant on labeling the container after surgery will provide information in all the spaces available on the labeling sticker.

One of the most important steps in SPS handling is tissue fixation because autolysis sets in immediately after surgical removal of tissue. A range of fixatives is used in SP including 10% PBF, Bouin's solution, B-5 fixative, Zenker's acetic fixative, glutaraldehyde, and alcohol. The fixative used is dependent on the tissue in question, the targeted result, and the opportunity for other special studies. Other advantages of fixation are hardening of tissue (to allow for thin sectioning), stabilization of tissue components, enhancement of avidity for dyes, and devitalization/inactivation of infectious agents.[1] Fixation also has the following disadvantages: alteration of protein structure, solubility of tissue components (lipids and carbohydrates), shrinkage of tissue, and DNA and RNA degradation.[1] Currently, formalin is the most commonly used fixative in tissue processing because it ensures an optimal preservation of tissue morphology.[8],[9] Ten percent PBF has remained the best fixative over the years because it can be used in many special stain and immunohistochemistry studies and due to its compatibility with many histological stains.[1] In UUTH, 10% PBF is used except for testicular biopsies where Bouin's fluid is used. In the index study, no single SPS arrived the laboratory without been inside a container containing formalin at least 2–3 times the size of the specimen (for large specimens). Although the standard is 10 times the size of the specimen, this is not usually feasible with large and very large specimens.[17] Eight percent of the SPS had inadequate amount of formalin, which is far <39.2% observed by Sherif et al. and 20% by Atanda and Raphael.[10],[11] In UUTH, formalin is always available in the theaters, with a dedicated staff that monitors the quantity available at all times. The SPS from outside, though preserved were mostly done with raw undiluted and unbuffered formalin (40% formaldehyde in water), usually obtained from local privately operated mortuaries, which are common and randomly sited in various parts of Uyo and other towns and villages in the state. This raw formalin usually poses great difficulty and danger (harsh fumes) for the pathology-resident doctor, technologist, and scientist during surgical cutup and further studies, apart from routine hematoxylin and eosin preparation. Disadvantages of tissue overfixation are of loss of antigens during immunohistochemistry and tissue alteration.[18] Although PBF has great qualities, the following disadvantages have been noted, especially in large specimens: degradation usually continues in deep areas (not reached by the fixative), frozen tissue banking is hampered, formalin-containing vessels are heavy to carry, spilling of formalin may occur, and fumes are dispersed while grossing. At times, the surgeon forgets to send the tissue immediately after the surgical procedure to the pathologist because he beliefs that it is “already safe in formalin” while several fixation-related variables can affect the recovery of macromolecules.[8],[9]

Provisional diagnosis was indicated in 92% of situations, though in some situations, it was the only clinical information on the request card. Diagnostic concordance was seen in 66% of cases, which is similar to 69% documented by Atanda and Raphael. A reason why surgeons do not like indicating provisional/working diagnosis on the request forms is the belief that it will bias the mind of the pathologist.[10] Whereas the fact remains that pathologists are first and foremost clinicians and will require these information like other clinicians, which usually serve as a guide toward making a good diagnosis. A properly filled request form assists all parties involved (patient, surgeon, and pathologist).

  Conclusion Top

Surgeons should be continuously reminded about how their actions could positively or negatively affect the turnaround time of SPS of their patients. The Pathology Department of UUTH, Uyo, should modify the pathology request form to indicate time of tissue/specimen harvest, major examination findings, and investigations done, before sending the specimen for histological examination.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Lester SC. Requests for pathologic evaluation. In: Lester S C editor. Manual of Surgical Pathology. 3rd ed. Elsevier Saunders, Philadelphia United States of America;2010. p.1-44.  Back to cited text no. 1
Rao S, Masilamani S, Sundaram S, Duvuru P, Swaminathan R. Quality measures in pre-analytical phase of tissue processing: Understanding its value in histopathology. J Clin Diagn Res 2016;10:EC07-11.  Back to cited text no. 2
Nakhleh RE. What is quality in surgical pathology? J Clin Pathol 2006;59:669-72.  Back to cited text no. 3
Nakhleh RE. Patient safety and error reduction in surgical pathology. Arch Pathol Lab Med 2008;132:181-5.  Back to cited text no. 4
Layfield LJ, Anderson GM. Specimen labeling errors in surgical pathology: An 18-month experience. Am J Clin Pathol 2010;134:466-70.  Back to cited text no. 5
Nakhleh RE, Gephardt G, Zarbo RJ. Necessity of clinical information in surgical pathology: A College of American Pathologists Q-probes study of 771, 475 surgical pathology cases from 341 institutions. Arch Pathol Lab Med 1999;123:615-19.  Back to cited text no. 6
Makary MA, Epstein J, Pronovost PJ, Millman EA, Hartmann EC, Freischlag JA, et al. Surgical specimen identification errors: A new measure of quality in surgical care. Surgery 2007;141:450-5.  Back to cited text no. 7
Daniele L, D'Armento G, Bussolati G. Preanalytical time interval (PATI) and fixation. In: Stanta G, editor. Guidelines for Molecular Analysis in Archive Tissues. New York: Springer-Verlag Berlin Heidelberg; 2011. p. 5-11.  Back to cited text no. 8
Bass BP, Engel KB, Greytak SR, Moore HM. A review of preanalytical factors affecting molecular, protein, and morphological analysis of formalin-fixed, paraffin-embedded (FFPE) tissue: How well do you know your FFPE specimen? Arch Pathol Lab Med 2014;138:1520-30.  Back to cited text no. 9
Atanda AT, Raphael S. Role of surgeons in determining outcome of histopathology specimens. Niger J Surg 2013;19:68-72.  Back to cited text no. 10
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Muhammad AS, Sajid M, Nadira M, Shahid J, Muhammad L. Clinician's responsibility in pre-analytical quality assurance of histopathology. Pak J Med Sci 2007;23:720-3.  Back to cited text no. 11
Burton JL, Stephenson TJ. Are clinicians failing to supply adequate information when requesting a histopathological investigation? J Clin Pathol 2001;54:806-8.  Back to cited text no. 12
Nakhleh RE, Zarbo RJ. Surgical pathology specimen identification and accessioning: A College of American pathologists Q-probes study of 1004, 115 cases from 417 institutions. Arch Pathol Lab Med 1996;120:227-33.  Back to cited text no. 13
Bull AD, Cross SS, James DS, Silcocks PB. Do pathologists have extrasensory perception? BMJ 1991;303:1604-5.  Back to cited text no. 14
Bates DW. The quality case for information technology in healthcare. BMC Med Inform Decis Mak 2002;2:7.  Back to cited text no. 15
Raab SS, King AM, Grzybicki DM. Root cause analysis of surgical pathology identification and information defects. Mod Pathol 2009;22 Suppl 1:366A.  Back to cited text no. 16
Buesa RJ, Peshkov MV. How much formalin is enough to fix tissues? Ann Diagn Pathol 2012;16:202-9.  Back to cited text no. 17
Werner M, Chott A, Fabiano A, Battifora H. Effect of formalin tissue fixation and processing on immunohistochemistry. Am J Surg Pathol 2000;24:1016-9.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2]


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