Test Directory

AUTOPSY

Related Terms:  Necropsy, Postmortem Examination,

Availability:  Mon-Fri, 0800-1700. Anatomic Pathologist on call at all times for consultation and approval of the procedure.

Special Instructions: An autopsy cannot be performed until a properly signed and witnessed Autopsy Authorization Form is received.  A valid permit must contain the signature of the next-of-kin or other responsible party.  Customary practice within Hawaii Revised Statutes for responsibility priority are 1) spouse (unless divorced) 2) adult child (usually eldest), 3) parent or legal guardians 4) grandparents and other next-of-kin 5) in the absence of next-of-kin, a friend or person charged by law with the responsibility for the burial.  The attending physician or physician pronouncing death is responsible for obtaining permission for an autopsy and for completion of the death certificate. 

Analytic Time:  Preliminary findings - 48 hours.  Final report - 30 days (45 days for complex cases).

Interpretive Use:  Ascertain the main disease and ancillary diseases, elucidate their pathogenesis and study their evolution; determine the cause(s) of death and if possible, the reasons for therapeutic failure; provide education at all levels: students, house staff, attending staff.

Limitations: Medical Examiner's cases: In possible medical-legal cases, the Department of the Medical Examiner must be contacted prior to any suggestion regarding autopsy permission or organ donation is made to the family of the deceased. Cases falling under the jurisdiction of the medical examiner include all violent deaths (homicide, suicide, accident), sudden unexpected death, death within 24 hours of admission to the hospital or when not under the care of a physician or in any suspicious or unusual circumstances. In general all violent deaths will be autopsied at the Department of the Medical Examiner and do not require an autopsy permit Other cases under their jurisdiction may be released by the Medical Examiner if the probable cause of death can be arrived at from clinical examination and if this cause of death is natural.  Documentation of the Medical Examiner's release is required prior to an autopsy at the Queen's Medical Center for any of these other cases falling by law under their jurisdiction.  Honolulu Medical Examiner's phone number (808) 527-6777. 

Additional Information: The College of American Pathologists recommends that deaths in which autopsies should be especially encouraged are:

  • Deaths in which autopsy may help to explain unknown and unanticipated medical complications to the attending physician
  • All deaths in which the cause of death is not known with certainty on clinical grounds
  • Cases in which autopsy may help to allay concerns of the family and/or the public regarding the death, and to provide reassurance to them regarding the same 
  • Unexpected or unexplained deaths occurring during or following any dental, medical, or surgical diagnostic procedures and/or therapies
  • Deaths of patients who have participated in clinical trials (protocols) approved by institutional review boards
  • Unexpected or unexplained deaths which are apparently natural and not subject to the Medical Examiner's jurisdiction
  • Natural deaths which are subject to, but waived by the Medical Examiner such as persons dead on arrival at the hospital, deaths occurring in the hospital within 24 hours of admission, and deaths in which the patients sustained or apparently sustained an injury while hospitalized or under institutional care
  • Deaths resulting from high-risk infectious and contagious disease
  • All obstetric deaths
  • All neonatal and pediatric deaths
  • Deaths at any age in which it is believed that autopsy would disclose a known or suspected illness which also may have a bearing on survivors or recipients of transplant organs
  • Deaths known or suspected to have resulted from environmental or occupational hazards.

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B-CELL/T-CELL GENE REARRANGEMENT

Related Terms:  B- or T-cell clonality

Test Method:  Polymerase Chain Reaction/Fragment Analysis with Capillary Electrophoresis

Specimen Type:  Blood, Formalin fixed paraffin embedded tissue

Availability:  Mon-Fri 0800-1700; Pathologist on call at all times for consultation.   

Special Instructions:  Specify pertinent oncologic history.

Analytic Time:  10 days.

Causes for Rejection:  Unlabeled specimen.  Insufficient demographic or clinical information for processing.  Insufficient DNA extracted from the sample.

Interpretation:  Interpreted by molecular pathologist

Limitations: This assay is intended to only identify clonal populations that can be detected using the primers provided by InVivoScribe Technologies (Immunoglobulin heavy chain (IGH) and Immunoglobulin kappa light chain (IGK); or T-Cell Receptor beta chain (TCRB) and T-Cell Receptor gamma chain (TCRG)).

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BODY FLUID AND WASHING CYTOLOGY

Related Terms:  Body cavity fluid cytology; bronchial washing; cerebrospinal fluid (CSF) cytology; effusions cytology; esophageal washing; fluid cytology; ascites fluid cytology; cyst fluid; culdocentesis; paracentesis fluid cytology; pelvic washing cytology; pericardial fluid cytology; pericardiocentesis fluid cytology; peritoneal fluid cytology; peritoneal washing cytology; pleural fluid cytology; seroma fluid; synovial fluid cytology; thoracentesis fluid cytology.

Test Includes: Cytologic evaluation of smears, cytocentrifuge preparations,
and/or cell block when indicated.  Special stains and flow cytometry may be used in selected cases.

Availability: Mon-Fri 0800-1700, Sat, 0800-1200; Pathologist on call at all times for consultation. 

Special Instructions: For bloody samples, add 1 mL heparin (1000 units heparin/mL) per 100 mL fluid.  Information regarding previous malignancy, cancer treatment, or other major conditions is essential to appropriate interpretation and should be received with specimen. If prolonged storage at room temperature (more than 6 hour) is unavoidable add equal volume of 50% ethanol.  Specify clinical differential diagnosis (malignancy, infection, other).

Analytic Time: 1-2 day after receipt, depending on procedures required.

Specimen:  Fresh body fluid.

Minimum Volume: Submit as much as is available - Larger volumes will permit additional studies if malignant cells are present and may increase the accuracy of the study. 

Container: Any dry container.

Storage Instructions:  Refrigerate specimen if it cannot be processed promptly.

Causes for Rejection:  Gross contamination due to spillage, prolonged storage period (over 6 hours) at room temperature, and unlabeled containers.  Unlabeled specimen.  Insufficient demographic or clinical information for processing.

Interpretive Use: To establish the presence of primary or metastatic neoplasm and to aid in the diagnosis of certain benign or infectious conditions

Limitations:  Allowing fluid to stand for a prolonged period before processing may cause deterioration and cellular artifacts.

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BONE MARROW BIOPSY AND ASPIRATION

Test Includes:  Wright stained smears and imprints, histopathology, and special procedures if needed (histochemistry, immunohistochemistry, flow cytometry, cytogenetics, molecular studies).

Availability: Mon-Fri 0800-1700, Sat, 0800-1200; Pathologist on call at all times for consultation. 

Special Instructions:  Appropriate clinical history is essential to an appropriate interpretation and should be submitted with the specimen.

Analytic Time:  2 to 10 days depending on ancillary studies.

Specimen:  1 cm core of bone marrow. 2-5 mL aspirate.  Submit peripheral blood smear with recent CBC if applicable. 

Container:  Core - buffered formalin; marrow aspirate - half in lavender EDTA tube and half in green heparin tube.  If an infection is suspected, submit a portion of the aspirate in a sterile container to microbiology. 

Causes for Rejection:  Unlabeled specimen.  Insufficient demographic or clinical information for processing.

Interpretation:  Results interpreted by hematopathologists.

Special Studies:  Specify if special stains, cytogenetics, or molecular studies are needed.  Gross and microscopic photo images are available on request (PDF reports available through Atlas Medical web reporting).

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BRUSHING AND DIRECT SMEAR CYTOLOGY

Related Terms:  Bile duct brushings, bronchia brushings cytology; colonic brushings, esophageal brushings cytology; gastric brushing cytology; oropharyngeal brushings cytology; galactorrhea; nipple discharge/imprint cytology; oral brushing cytology; small bowel brushing; tracheal brushings; Tzank smear; ureteral brushing cytology; urethral brushings.

Test Includes:  Cytologic examination of prepared smears. Possible special stains.

Availability:  Mon-Fri 0800-1700, Sat, 0800-1200; Pathologist on call at all times for consultation. 

Special Instructions:  Specify clinical differential diagnosis.  Apply brushing or scraped sample on glass slide and fix the slide immediately by placing in 95% alcohol or using spray fixative.  Label slides with patient name.  Label slide holder with exact body site and patient's name.  Alternatively, brush tips may be submitted in saline or cytology transport fluid (CytoLyt) for additional cytologic preparations or cell blocks.

Analytic Time:  1 day.

Causes for Rejection:  Improper/delayed fixation with air-drying artifact.  Unlabeled specimen.  Insufficient demographic or clinical information for processing.

Interpretation:  Results interpreted by cytopathologists.  Brushings may increase the sensitivity of endoscopic procedures when performed prior to tissue biopsy.

Limitations: Allowing smears and brushings to dry before they are fixed may render them unsatisfactory for cytologic evaluation. 

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CERVICAL CYTOLOGY, LIQUID BASED

Related Terms:  SurePath, ThinPrep

Test Includes:  SurePath with BD FocalPoint GS Imaging System or ThinPrep Pap Test; HPV reflex testing according to ACOG guidelines (age dependent); HPV co-testing on request; STD panel or Chlamydia/GC testing on request.

Availability:  Mon-Fri 0800-1700; Pathologist on call at all times for consultation. 

Special Instructions:  Specify pertinent gynecologic and oncologic history, treatment, signs, symptoms, and risk factors.  Label vials with patient name.  Call laboratory for detailed information on collection technique. 

Sample Collection:

Analytic Time:  2-4 days. 

Causes for Rejection:  Obscuring blood, inflammation, lubricants, or mucus.  Scant cellular samples.  Unlabeled specimen vials.  Insufficient demographic or clinical information for processing.

Interpretation:  Results interpreted by cytotechnologists or cytopathologists.  Modified Bethesda System terminology. 

Limitations: The Pap smear is a screening procedure only.  Annual screening increases and improves the reliability of the test and the rate of detection for premalignant lesions.  Patients with signs and/or symptoms of gynecologic abnormalities may require diagnostic procedures despite negative cytologic findings. 

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CERVICAL-VAGINAL CYTOLOGY, CONVENTIONAL

Related Terms:  Cervical smear; gynecologic cytology; Pap smear; Pap test; vaginal cytology; liquid based cytology.

Test Includes:  Conventional smears with BD FocalPoint Slide Profiler System.

Availability:  Mon-Fri 0800-1700; Pathologist on call at all times for consultation. 

Special Instructions:  Specify pertinent gynecologic and oncologic history, treatment, signs, symptoms, and risk factors. 

Sample Collection:  Label frosted end of slide with patient name. 

  • Endocervical sampling - Cervical brush of endocervical canal.  Use a tapered synthetic fiber brush (cytobrush) to sample endocervical cells.  Rotate brush 90o to 180o in canal gently to limit bleeding.  Apply material onto glass slide by rotating on surface.  Do not scrub material on slide.
  • Ectocervical scrape - With wooden spatula, thoroughly scrape the entire ectocervix with emphasis on the squamocolumnar junction.  If excess mucus or inflammatory exudate covers the mucosa, wipe it off gently using cotton tipped swab prior to sampling.  Spread material evenly onto labeled glass slide and fix immediately by placing in 95% alcohol or using spray fixative.  Both the endocervical and ectocervical specimen are placed on the same slide.
  • Place slides in holders when dry.

Analytic Time:  2-3 days. 

Causes for Rejection:  Improper/delayed fixation with air-drying artifact.  Unlabeled slides. Obscuring blood, inflammation, or mucus.  Scant cellular samples.  Insufficient demographic or clinical information for processing.
Interpretation:  Results interpreted by cytotechnologists or cytopathologists.  Modified Bethesda System terminology. 

Limitations: Allowing smears and brushings to dry before they are fixed may render them unsatisfactory for cytologic evaluation. The Pap smear is a screening procedure only.  Annual screening increases and improves the reliability of the test and the rate of detection for premalignant lesions.  Patients with signs and/or symptoms of gynecologic abnormalities may require diagnostic procedures despite negative cytologic findings.

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FINE NEEDLE ASPIRATION (FNA) CYTOLOGY

Related Terms: FNA biopsy; FNA cytology; needle biopsy service.

Test Includes:  Interpretation of smears and/or cell block material by pathologist.  Biopsy of palpable lesions by pathologist on call.

Availability:  Mon-Fri 0800-1700, Sat, 0800-1200; Pathologist on call at all times for consultation.  Immediate on-site smear preparation, adequacy assessment, and needle biopsy service by cytopathologist available on campus.  Off campus physicians may send patients with palpable masses to laboratory for needle biopsy by cytopathologist - call pathology for instructions.

Special Instructions:  Specify clinical differential diagnosis and pertinent past history.  Label slides with patient name.  Label slide holder with exact body site and patient's name.  Tissue fragments may be submitted in formalin for cell block preparations.  Aspirated cystic fluid may be submitted in capped syringe (without needle) or placed in a dry container.

Sample Collection:

  • Consult with cytopathologist for detailed instructions on obtaining FNA specimen.  Clean skin overlying the mass with alcohol wipe.  A small amount of local anesthesia may aid patient comfort.  Localize mass by palpation or imaging device. Use 23- to 26-gauge needle to collect sample by aspiration or non-aspiration technique. Place a drop of aspirated material in middle of glass slide.  Place an inverted slide on top of the first slide and press the slides together to spread the material.  Slide the slides apart and fix slide immediately if applicable.  Excess sample material may be rinsed in formalin for cell block preparation.  If lymphoma is suspected, the sample from at least one pass should be rinsed in RPMI solution for flow cytometry.
  • Label frosted slides with patient's name. Repeat twice for a total of three samples.  Label slide container with type of specimen and patient's name.

Analytic Time: 1-2 days.

Specimen:  At least one air-dried or fixed slide (in 95% alcohol or spray fixed).  Air-dried smears are especially preferred for lymph nodes and salivary gland biopsies.  Fixed slides are preferred for thyroid FNA.

Causes for Rejection:  Unlabeled specimen.  Insufficient demographic or clinical information for processing.

Interpretation:  Results interpreted by cytopathologists.  Cell block preparation may permit special studies and facilitate more acute diagnosis.

Limitations: Adequate sampling of the mass lesion is usually critical for diagnosis.  Obscuring blood, necrotic material, or overly thick material on the slide may compromise diagnosis.  Lesions with densely fibrous stroma, low cellularity, or cystic neoplasms may be difficult to diagnose with needle biopsy.

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HERPES SIMPLEX VIRUS DETECTION BY DFA

Test Includes:  Direct immunofluorescence testing.

Availability:  Mon-Fri 0800-1700, Sat, 0800-1200; Pathologist on call at all times for consultation. 

Special Instructions:  Scrape the basal rim of a freshly opened vesicle and apply to glass slide. 

Analytic Time: 0-1 day.

Causes for Rejection:  Unlabeled specimen.  Insufficient demographic or clinical information for processing.

Interpretation: Interpreted by dermatopathologist. 

Limitations: Lack of sufficient epithelial cells and/or obscuring inflammation may compromise test sensitivity.

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HUMAN PAPILLOMA VIRUS HIGH RISK

Related Terms:  HPV HR

Test Method:  Invader method (Molecular based testing).

Specimen Type:  BD Surepath

Availability:  Mon-Fri 0800-1700; Pathologist on call at all times for consultation. 

Special Instructions:  Specify pertinent gynecologic and oncologic history, treatment, signs, symptoms, and risk factors.  Label vials with patient name.  Call laboratory for detailed information on collection technique.

Sample Collection:  Submit collection vial with detached Cervex-brush (broom) head in fixative solution.  Vaginal specimens are not recommended.  See BD web site for collection technique: http://www.bd.com/tripath/physicians/surepath.asp. 

Analytic Time: 3-7 days. 

Causes for Rejection:  Unlabeled specimen.  Insufficient amount of epithelial cells, demographic or clinical information for processing.

Usage:  HPV HR testing may be used together with cytologic screening (co-screening in patients over age 30 or has a high risk history), reflex testing after certain cytologic diagnosis (ASCUS diagnosis in patients over age 20, LSIL diagnosis in post-menopausal women), or in some cases with lack of correlation between cytologic and histologic findings.  The high-risk HPV test detects HPV genotypes 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68, which are associated with cervical cancer and its precursor lesions. However, cross-reactions with other genotypes can occur. The presence of human papillomavirus in the female genital tract is associated with a number of conditions, including genital condyloma, Bowenoid papulosis, and cervical, vaginal, and vulvar intraepithelial neoplasia, carcinoma, and asymptomatic carriers. The results of this assay should be used in conjunction with cytologic findings, biopsy results, physical exam, and medical history, and should not be used as the sole basis for clinical assessment and treatment of patients.

Limitations: The HPV High Risk screen is a screening procedure only and does not indicate which HPV genotype is present.

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SKIN BIOPSY IMMUNOFLUORESCENCE

Related Terms:  Direct immunofluorescence (DIF); vesicular and bullous skin lesions; cutaneous lupus.

Test Includes:  Light microscopy and direct immunofluorescence.

Availability:  Mon-Fri 0800-1700, Sat, 0800-1200; Dermatopathologist on call at all times for consultation. 

Analytic Time: 1 to 5 days.

Specimen:  4 mm skin punch biopsy is optimal.  Consult with dermatopathologist prior to biopsy for selection of most appropriate site.

Container:   If available, submit tissue in immunofixative.  Call pathology for Michels solution.  If fixative is not available, the fresh tissue should be wrapped in a sterile Telfa or gauze pad moistened with sterile saline. Deliver to laboratory immediately. 

Causes for Rejection:  Formalin fixation or poorly preserved unfixed tissue.  Unlabeled specimen.  Insufficient demographic or clinical information for processing.

Interpretation:  Interpretation by dermatopathologist.

Special Studies:  Specify clinical differential diagnosis.  Microscopic photo images provided (PDF report available through Atlas Medical web reporting).

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SLIDE REVIEW

Related Terms:  Pathology second opinion; outside case review.

Test Includes:  Microscopic examination and diagnosis of previously histologic and cytologic slide preparations from outside laboratories; additional studies including molecular studies and special stains are possible if the original paraffin blocks with lesional material are available.

Availability:  Mon-Fri 0800-1700, Sat, 0800-1200; Pathologist on call at all times for consultation. 

Analytic Time: 1-2 days for routine cases.

Specimen:  Submit or request slides and/or paraffin blocks from outside laboratory.  A signed release from the patient may need to be sent to the original laboratory.  The original pathology report from the outside laboratory should accompany the request.

Causes for Rejection:  Unlabeled specimen.  Insufficient demographic or clinical information for processing.

Interpretation:  Microscopic evaluation by pathologist.

Special Studies:  Specify if additional studies are needed.  Microscopic photo images are available on request (PDF report available through Atlas Medical web reporting).

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SPUTUM CYTOLOGY

Related Terms:  Pulmonary cytology.

Test Includes:  Three consecutive first morning deep cough sputum specimens.

Availability:  Mon-Fri 0800-1700, Sat, 0800-1200; Pathologist on call at all times for consultation. 

Special Instructions:  Refrigerate sample and send to laboratory immediately.  Label container with patient name and specimen date.  Alternatively, submit in cytology transport fluid (CytoLyt) at room temperature.

Analytic Time: 1 day. 

Causes for Rejection:  Unlabeled specimen.  Lack of refrigeration or proper transport media.  Insufficient demographic or clinical information for processing.

Interpretation: Interpreted by cytopathologist. 

Limitations: Lack of pulmonary alveolar macrophages, improper fixation, delay in delivery of specimen resulting in cellular degeneration, or allowing specimen to freeze may lead to specimen rejection or unsatisfactory results.

Special Studies:  Specify if patient is immunocompromised and needs evaluation for opportunistic infections [Pneumocystis jiroveci (formerly Pneumocystis carinii), fungal organisms, HSV, CMV].  Additional stains and/or microbiology evaluation may be necessary. 

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SURGICAL PATHOLOGY

Related Terms:  Biopsy; gross and microscopic pathology; histopathology; tissue examination; gross identification; stone analysis; frozen section.

Test Includes:  Gross examination only or gross and microscopic
examination and diagnosis; frozen section or tissue imprints on fresh tissue samples; special stains, flow cytometry, cytogenetics, molecular studies, and other analysis performed on selected cases.

Availability:  Mon-Fri 0800-1700, Sat, 0800-1200; Pathologist on call at all times for consultation. 

Analytic Time: 1-2 days for routine cases.

Specimen:  

  • For routine processing, place tissue in appropriately sized container of 10% phosphate buffered formalin.  The fixative to specimen ratio should be 10:1 or greater. 
  • Breast tissue and suspected breast cancer tissue may be subject to prognostic marker analysis.  ASCO and College of American Pathologists (CAP) guidelines stipulate limiting warm ischemia time and adequate tissue fixation time to insure accurate prognostic marker study results.  When submitting breast tissue or suspected metastatic tumor tissue, indicate on the requisition the time and date the sample was 1) taken from the patient and 2) when the sample was placed in the fixative.  Documentation of these times is a CAP requirement. 
  • Fresh tissue should be submitted in cases that require frozen sections, imprints, cytogenetic studies, lymphoma work up, cultures, or require special fixatives that are not available at the time of operative procedure (kidney biopsies, DIF).  The tissue should be wrapped in a sterile Telfa or gauze pad moistened with sterile saline. Prolonged warm ischemia time prior to fixation may render the specimen uninterpretable, especially small tissue samples that may be subject to drying artifacts.  Call the laboratory for immediate processing when submitting unfixed tissue. 
  • Foreign bodies or stones for gross identification/stone analysis can be submitted in a clean dry container.
  • Large samples that do not fit in containers can be wrapped in clean watertight material.  Notify the laboratory for special specimen pickup if applicable.

Causes for Rejection:  Unlabeled specimen.  Insufficient demographic or clinical information for processing.

Interpretation:  Gross and microscopic evaluation by pathologist.

Special Studies:  Specify if special stains, cytogenetics, specimen x-ray, or molecular studies are needed.  Gross and microscopic photo images are available on request (PDF report available through Atlas Medical web reporting).

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URINE CYTOLOGY AND UROVYSION

Related Terms:  Bladder washing; catheterized urine; renal pelvic washing; ureteral washings; voided urine cytology; fluorescent in-situ hybridization (FISH) for bladder/urothelial carcinoma.

Test Includes:  Microscopic analysis of cytologic preparation and/or FISH testing.

Availability:  Cytology - Mon-Fri 0800-1700, Sat, 0800-1200; UroVysion - one run per week; Pathologist on call at all times for consultation.

Special Instructions:  Refrigerate sample and send to laboratory immediately.  Alternatively, submit in cytology transport fluid (equal volume of CytoLyt).  For UroVysion testing, use of CytoLyt will insure specimen stability for FISH analysis.  Label container with patient name and specimen date. 

Analytic Time: 1 day for cytology; up to 7 days for UroVysion.

Specimen:  Voided or catheterized urine; intraoperative washings of bladder, ureter, or renal pelvis. 

Minimum Volume:  Not less than 50 mL. 

Causes for Rejection:  Unlabeled specimen.  Lack of refrigeration or proper transport media.  Insufficient demographic or clinical information for processing.

Interpretation: Interpreted by pathologist. 

Limitations: Delay in delivery of specimen resulting in cellular degeneration may lead to unsatisfactory results.

Special studies:  Indications for UroVysion testing include past history of urothelial carcinoma and high-risk patients presenting with hematuria.

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We are certified by the American Board of Pathology, CLIA, JCAHO and CAP.