Department of Laboratory Services
Laboratory Services
Issue Date: November 19, 2003
Revision Date:
Status : DRAFT
Anatomical Pathology
Histology
Page 1 of 7
Approved by: J. Russell Rogers, MLT
Authorized by : Medical Director, Laboratory Services
All Submitting
Surgical Pathology
Departments
Specimens
I. Introduction/Purpose
A variety of specimens retrieved by health care providers are sent to the Pathology
Department on a daily basis for pathologic examination.
From the time of removal from the patient to the time the tissue is processed in the
laboratory, proper handling and delivery of the specimen to the laboratory is critical and
ensures accurate and timely examination and diagnosis.
The purpose of this document is to provide health care providers with a procedural
protocol for the handling and delivery or surgical specimens to the Pathology
Department.
II. Procedure for Submitting Tissue Specimens for Surgical Pathology
II.1. All specimens must be accompanied by a completed Surgical Pathology Card
(form PATH_6707_0103).
The following information is required on the card, clearly written in ink:
(a) Patient identifiers(i) patient's first and last name
(ii) unique number
(iii) date of birth
(iv) Ontario Health Insurance Number with version code.
(b) Submitting area identifiers: Hospital site (BGH or The Willett) and the submitting
department (Emergency, Ambulatory Care etc.).
(c) Submitting physician's name.
(d) Date of surgery
(e) Pre- and post-operative presumptive diagnosis.
(f) A brief clinical history.
(g) Specimen information(i) tissue type (ie. Breast)
(ii) anatomical site (ie. Right side)
(iii) surgical procedure (ie. wire localization biopsy)
D:\685609800.doc
02/05/16
Department of Laboratory Services
Laboratory Services
Issue Date: November 19, 2003
Revision Date:
Status : DRAFT
Anatomical Pathology
Histology
Page 2 of 7
Approved by: J. Russell Rogers, MLT
Authorized by : Medical Director, Laboratory Services
All Submitting
Surgical Pathology
Departments
Specimens
II.2. The specimen container must be labeled. Addressograph labels are preferred,
otherwise the following information must be provided, clearly written in ink:
(a) Patient identifiers (i) patient's full name
(ii) unique number
(iii) and at least one other unique additional identifier (ie. date of birth, OHIN).
(b) Date of surgery.
(c) Specimen name, anatomic site and surgical procedure, as it is written on the Surgical
Pathology card.
This information must be recorded on the side of the specimen container and not the lid.
If a specimen is known or suspected to contain unique or extreme biohazard (e.g. CJD)
the container shall be so marked.
II.3. Most routine surgical specimens must be placed in 10% Neutral Buffered Formalin
(10%NBF) for fixation. There are exceptions; please see section III. Special
Circumstances and Requirements.
Specimens must be placed in an appropriate sized container with an amount of
formalin equal to or greater than fifteen times the volume of tissue.
II.4. Place smaller specimen containers in a biohazard bag. The surgical card should be
placed in the outer pouch of the biohazard bag.
Larger specimen containers, with their Surgical Pathology cards, should be
transported in a manner that would facilitate spill containment should the container
open during transport.
II.5. Transport specimen containers to the Grossing Room in the Department of
Anatomical Pathology (Room B5-21, Westview fifth floor).
II.6. Inform histology staff that you have delivered a specimen or specimens.
II.7. After hours: Fresh specimens should be delivered to the Lab triage area, on the
sixth floor, where they will be refrigerated until processed by Pathology staff.
Specimens in NBF can be delivered to the triage area or held by the submitting
department at room temperature until day staff responsible for specimen delivery
arrives.
D:\685609800.doc
02/05/16
Department of Laboratory Services
Laboratory Services
Issue Date: November 19, 2003
Revision Date:
Status : DRAFT
Anatomical Pathology
Histology
Page 3 of 7
Approved by: J. Russell Rogers, MLT
Authorized by : Medical Director, Laboratory Services
All Submitting
Surgical Pathology
Departments
Specimens
III. Special Circumstances - Special Requirements
III.1 Breast biopsies:
Place the specimen in an appropriate volume of formalin as soon as possible following
surgical removal. If the specimen is a needle localization lumpectomy which is
radiographed for microcalcifications, delivery it fresh to Pathology as soon as possible
and inform staff that a fresh specimen is being dropped off.
Quantitative Estrogen - Progesterone Receptor (ER/PR Status) analysis is no longer
performed. Qualitative / semi-quantitative testing for ER/PR status is performed
immunohistochemically on formalin fixed, paraffin embedded tissues. HER-2 Neu
(immunohistochemically) and DNA aneuploidy analysis can also be performed on
processed tissue blocks. Immunohistochemical testing is dependent upon proper fixation
and requires 24-48 hours fixation in formalin to preserve diagnostically important
epitopes prior to processing.
III.2 Lymph Nodes:
Lymph nodes or other soft tissues removed for suspected lymphoma should be sent to
Pathology fresh for the Lymph Node Protocol processing. A viable portion of the tissue
received will be sent for flow cytometry (Immunophenotyping) to better characterize
the hematopoietic cells present in the tissue. Lymphomas and sub-types of lymphomas
are determined by the presence of a monoclonal population of lymphocytes. The balance
of the tissue will be formalin fixed, processed and be examined for histological
abnormalities.
When sending a specimen to Pathology for Lymph Node Protocol processing the
following conditions apply:
(a) Inform Pathology staff regarding the need for lymph node protocol processing prior to
the surgery, if possible.
(b) Fresh tissue specimens must be transported in a sterile container. If a delay in
processing is anticipated, the tissue must be placed in gauze soaked with sterile
normal saline to prevent drying.
(d) Requirements for the proper labeling of the Surgical Pathology card and the
specimen container, also apply (see Sections II.1 and II.2).
(e) Transport the specimen to the Grossing Room in the Department of Anatomical
Pathology (Room B5-21) as soon as possible.
(f) Inform Pathology staff that a fresh specimen has been delivered.
D:\685609800.doc
02/05/16
Department of Laboratory Services
Laboratory Services
Issue Date: November 19, 2003
Revision Date:
Status : DRAFT
Anatomical Pathology
Histology
Page 4 of 7
Approved by: J. Russell Rogers, MLT
Authorized by : Medical Director, Laboratory Services
All Submitting
Surgical Pathology
Departments
Specimens
III.3 Frozen Section - OR Consultation:
Frozen sections or Operating Room consultations should be pre-booked if possible. If
pre-booking is not possible, as much prior notice of a pending frozen section should be
given. Ensure that Pathology is aware that the specimen is coming. Do not leave a voice
mail message; have the Department paged if necessary. Tissues for evaluation must be
forwarded as soon as possible to Pathology. Staff delivering the tissue must inform
Histology staff that they have delivered a specimen for frozen section.
Tissues submitted for a frozen section diagnosis, should be accompanied by a
completed Surgical Pathology Card or a completed Intraoperative Consultation
Requisition (Frozen Section) form.
The surgeon requesting the consultation will be contacted directly by the Pathologist on
duty with the preliminary diagnosis.
III.4 Biopsies for Immunofluorescence:
Contact the Department of Anatomical Pathology prior to performing any procedure
which may involve Immunfluorescent Studies (IF) on Biopsies. IF studies play an
important role in the evaluation of lesions for autoimmune bullous diseases, pemphigus
and pemphigoid lesions and vasculitis.
The appropriate fixative (Michel's Medium) and a requisition from the reference
laboratory will be provided to the clinician on request.
When sampling the lesion:
(a) Place a portion of the lesion in the IF fixative and representative portion in 10%
neutral buffered formalin.
(b) Forward both specimens to the Pathology lab with a completed Surgical Pathology
card and IF studies requisition. The reference laboratory has requested that the IF
studies requisition be completed fully to assist them in properly handling and
evaluating the specimen.
(c) The requirements for the proper labeling of the Surgical Pathology card and
specimens containers also apply (See Sections II.1 and II.2).
D:\685609800.doc
02/05/16
Department of Laboratory Services
Anatomical Pathology
Histology
Laboratory Services
Issue Date: November 19, 2003
Revision Date:
Status : DRAFT
Page 5 of 7
Approved by: J. Russell Rogers, MLT
Authorized by : Medical Director, Laboratory Services
All Submitting
Surgical Pathology
Departments
Specimens
III.5 Microorganisms / Microbiology:
Tissue specimens requiring culture and sensitivity studies must be sent to the
Microbiology Department in accordance with their specimen handling protocol.
Representative tissue can also be sent to Pathology following the protocol for routine
surgical specimens (see Section II).
III.6 Cytogenetic Studies of Products of Conception:
Cytogenetics studies are not performed in The Brantford General Hospital Laboratory.
Clinicians and departments requesting this testing must contact the Regional
Cytogenetics Laboratory at McMaster University Medical Centre (see section V.) to
determine if the specimen meets testing criteria and for specific handling instructions.
Costs for testing and specimen transport are the responsibility of the submitting
department and are not paid for by the Department of Laboratory Services. Forms for the
Regional Cytogenetics Laboratory (Requisition for Chromosomal Analysis Other than
Cancer), sterile specimen containers and tissue culture medium (Minimum Essential
Medium) can be obtained through the Anatomical Pathology - Histology Laboratory.
Departments sending a large number of specimens for testing must supply their own
tissue culture medium.
III.7 STAT or Urgent Requests:
Specimens sent as RUSH, URGENT or STAT to Anatomical Pathology will be processed
and results reported as soon as technically possible. Include on the requisition any
clinical information upon which the decision to send the specimen as a rush is based.
Breast tissue, which may be subsequently tested for Estrogen / Progesterone Receptor
status through immunohistochemical methods, must fix in 10% neutral buffered formalin
for 24 hours prior to routine processing.
D:\685609800.doc
02/05/16
Department of Laboratory Services
Laboratory Services
Issue Date: November 19, 2003
Revision Date:
Status : DRAFT
Anatomical Pathology
Histology
Page 6 of 7
Approved by: J. Russell Rogers, MLT
Authorized by : Medical Director, Laboratory Services
All Submitting
Surgical Pathology
Departments
Specimens
III.8 Bone Marrow's
Bone marrow specimens should be transported to the Grossing Room in the Department
of Anatomical Pathology (Room B5-21) as soon as possible by the core LTA. Record the
bone marrow in the Bone Marrow Log and place the two properly labeled containers,
with the completed surgical card and smears on the bench for processing. The time of
collection should be recorded on the top of the containers. Furthermore, the marrow
specimen should be designed with a 'M' and the plug specimen with a 'P'. This will
prevent any confusion if the plug specimen was not a solid core.
IV. Rejection of Specimens
IV.1. Unlabeled specimens:
Unlabeled specimens will be rejected by the Pathology Department and will be returned
to the originating department, if known.
An Incident Report will be completed and forwarded to the submitting department's
manager and to Risk Management.
IV.2. Mislabeled specimens:
Mislabeled specimens (i.e. wrong patient name or container labeled left, requisition
labeled right) will be rejected by Pathology and will be returned to the submitting
department.
An incident report will be completed and forwarded to the submitting department's
manager and to Risk Management.
IV.3. Incomplete information:
Specimens received with incomplete information will be held by Anatomical Pathology.
The submitting department will be contacted, informed of the problem and will be
required to provide the missing information.
Delays (one working day or greater) in processing, which results from poorly labeled
surgical cards or specimen containers, will be documented through an incident report.
D:\685609800.doc
02/05/16
Department of Laboratory Services
Laboratory Services
Issue Date: November 19, 2003
Revision Date:
Status : DRAFT
Anatomical Pathology
Histology
Page 7 of 7
Approved by: J. Russell Rogers, MLT
Authorized by : Medical Director, Laboratory Services
All Submitting
Surgical Pathology
Departments
Specimens
IV.4. Wrong Fixative:
The floor in which the specimen was originated from will be notified of their error and
reminded of what the correct fixative is for that specimen. The specimen if suitable will
be processed. When possible the specimen will be transferred to the appropriate fixative
and a notation will be made within Meditech comment section.
IV.5. Insufficient Fixative:
The histology department will add more fixative (10% NBF) to the specimen and will
make a note within the Meditech system that insufficient formalin was originally added to
the specimen.
Note: All discrepancies between a specimen and requisition would be clarified and
corrected prior to any processing. No exceptions are made.
V. Contacts
Department of Anatomical Pathology
Histology - Main Laboratory, Fifth Floor Westview
Extension 2456
Histology - Grossing Room
Extension 5460
Dr. Paul Wentworth, Pathologist - Medical Director, Laboratory
Extension 2446
Regional Cytogenetics Laboratory
McMaster University Medical Center Site
Room 3H45
Hamilton Health Sciences
1200 Main Street West
Hamilton, ON L8N 2Z5
1-905-521-5084 or 1-905-521-2100 extension 3710
D:\685609800.doc
02/05/16