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Case study
This post presents a grossing case study of a so-called "routine" specimen,or often called a small specimen that might be an amputated leg or placenta or ganglion cyst or tendon. In opposite to very responsible biopsies and more difficult large specimens ( breasts, lungs, colons etc.) the " routine" specimens are considered trivial without any diagnostic value. They are often delegated to assistants with minimal for without pathology training. (see details about this issue in the post "Grossing Histotechnologist ). Perhaps, this case study might confirm some suggestions brought up in the article, as well as show the way of thinking at the grossing table.
In the presented case the specimen is the product of open heart surgery when both the aortic valve and a part of ascending aorta were removed and replaced with prostheses. It is definitely a "routine" in grossing room parlance.
This case was chosen due to high degree of my familiarity of clinical part. These data usually are note in a possession of a grossing person, but the pathologist does not have any desire to look at even if they are available in the computer medical history.
Clinical history.
A man in the early 70th with history of atrial fibrillation and mild evidence of chronic heart failure was diagnosed with severe aortas valve stenosis, tricuspid insufficiency with mild regurgitation, ascending aorta aneurysm. A surgery was performed. below are clinical data and the pathology report. The names and institution were omitted.
Although some remarks about the pathology diagnosis were made, the goal of this post is the analysis of how the grossing was useful for the pathologist to generate a diagnosis. This is the purpose of grossing in surgical pathology.
Let’s go over the final pathology report on the line by line basis.
The first line of the pathology report states: Aortic valve disorder. This fuzzy definition is acceptable as ICD-9-CM code 421.4, but as a pathology diagnosis is open to guesses what kind.
The sentence: "portion of vessel wall and valvular tissue with extensive nodular fibrosis and calcifications" is misleading, insufficient, and simply wrong.
Although the aorta is technically a vessel, but a specific. Therefore the diagnosis should confirm that the portion was definitely an aorta with characterization of the wall, especially keeping in mind absence of any signs of atherosclerosis in a over 70th man. The pathology diagnosis should reflect any attempt to find out the reason of the ascending aorta aneurism (Marfan syndrome, or unspecified).
Actually, the pathology diagnosis is wrong because the aorta does not have any evidence of "extensive nodular fibrosis and calcifications" in opposite to valvular tissue.
The pathology diagnosis did not characterized the morphology of aortic valve leaflets and the 0, 1 cm defect that was mentioned in the gross description (the latter was omitted completely justified), but all those pathology report insufficiencies are determined by the insufficiencies in grossing. They are the subject of this case study.
The specimen was received in one container designated as "portion ascending." Actually, there were two separate specimens : aortic valve and ascending aorta. This detail has an accession significance because they have one surgical number but parts A and B. The pathology department should insist that surgery department sends separate specimens in different containers. Besides some medical significance ( different designation, specific attention), such wrong practice has billing consequences in the computer automatic CPT coding which follows the surgical number and parts. For example, in this case CPT codes for aortic valve would be 88305 and 88311 (decalcification) and ascending aorta aneurysm 88304.
The measurements of the aortic valve fragments is wrong ( the diameter of the valve is 2.7 cm and in the case of placement of a prosthesis this measurement is significant) but most important that size and appearance of the annulus and the leaflets was not presented separately that has clinical significance.
In the aorta description, the most important measurement of the thickness of the wall is mentioned only in one portion, but in the case of aneurysm the thickness of the second fragment is not presented, but while mentioning that the second cylindrical portion ranges from 4 to 5 cm, the thickness of this portion has a clinical significance in the aneurysm.
If an absence of something is mentioned, the definition off "discrete" is confusing. In this case is important to mention presence of absence of atheromatos or athteroscerotic plaques. In old days, a syphilitic gumma would be appropriate to mention
A 0.1 cm defect was mentioned that generates questions like " what kind?" More than likely, this was the surgical procedure artifact, but it is mentioned a description of if ought to be done (presence or absence of hemorrahes, depth). The pathologist ignored this defect but the golden rule of grossing description states: Do not make the pathologist to fight with the gross description.
The specimen's representative section were placed in two cassettes.
Actually, the case required five cassettes. Two cassettes for the aortic valve (one for leaflets with minimal part of calcification, the second for annulus with intensive calcification because decalcification inevitably damages the fragile endothelial layer of the leaflet that might be important in diagnosis of an endocarditis or other valve pathology. The aorta should be placed in three cassettes ( one representative of the first portion, second of the cylindrical portion, including the maximal diameter, third the defect because it was mentioned in the description, but such a small 0.1 cm required special orientation; otherwise it could be embedded in opposite side of the wall or trimmed from the block if it was placed in the cassette flat.)
This typical "routine" surgical pathology case is presented how insufficient clinical data and defects in grossing the specimen can contribute to the insufficiency of the pathology diagnosis and ultimately the loss for the patient. The discharge summary in this patient recommends all first degree relatives get screening for diseases of the thoracic aorta. The pathology report does not provide any clue and has not attempted even to make any effort in this regard.
This is the reason that the surgeon has not even read the report and for his part sent the specimen with insufficient clinical data. The pathology in this situation works on idle gear. It is a waste of money and efforts on the expense of people who receive this medical care.
This case analysis of a simple "routine" specimen tries to show how professional clinically oriented grossing can contribute to informative pathology diagnosis. However,cooperation between clinic and pathology department is essential.