College of American Pathologists
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  Q & A





May 2012

Fredrick L. Kiechle, MD, PhD

Question Q. We are reviewing our difficult draw procedure for phlebotomy. Most literature warns against drawing from the mastectomy arm of a patient. Surgeries are now limited to sentinel node removal, and lymphedema is less common. When faced with double mastectomy or a single mastectomy when the opposite arm is not a viable arm for phlebotomy, can we draw from a mastectomy arm? What fail-safes can we put into our procedure to know when this is safe?

A. The preference is to not draw blood from the arm of patients who have had axillary dissections (lumpectomy or mastectomy) on that side. Mastectomy per se is not a contraindication for a blood draw; a blood draw is acceptable if a mastectomy only (without axillary dissection) has been performed and sufficient circulation is intact. Surgical oncologists are also fine with blood draws from patients who have had only a sentinel node biopsy; however, if the other arm is available it would be the first choice. As of now, there are no data that say patients who have had a sentinel node biopsy are at risk for an arm infection.

Henry M. Kuerer, MD, PhD
Professor, Surgical Oncology
University of Texas
MD Anderson Cancer Center

A. We follow the specific directions of the physician, as communicated through the nurses on the inpatient side or by the patients on the outpatient side. On the inpatient side, nurses use additional signage by the bed to communicate draw side preferences. On the outpatient side, the patient typically is aware and informed by the physician of the proper side for phlebotomy. If questions arise, phlebotomists will contact the physician directly and ask for further instruction.

Robert E. Del Guidice, MBA, MT(ASCP), DLM
Clinical Administrative Director
Laboratory Medicine—General Services
University of Texas
MD Anderson Cancer Center

Question Q. Is there a good way to estimate the number of full-time histotechnologists needed for a histopathology section in a mid-size tertiary hospital with pediatric and adult hematooncology/neurosurgery/transplant/renal services? Most articles base estimates on number of blocks, which we think is a poor way to estimate the workload, and they don’t take into account other tasks the histotechnologists perform.

A. Productivity in the histology laboratory has always been difficult to address. Histology is a unique area of the laboratory because completing the required tasks still requires a significant amount of manual labor. Determining staffing requirements and measuring productivity are extremely difficult because of the many variables and differing dynamics of operation that exist among individual laboratories. Articles addressing the issue have determined productivity using different units of measurement (case/specimen number, paraffin blocks, slides, for example) at different time intervals (seconds, hours, years) or number of personnel (full-time equivalent, or FTE).

Members of the CAP/NSH Histotechnology Committee have examined this issue, and we feel, as do others, that the best measurement of productivity within the routine histology laboratory is the number of paraffin blocks processed per year per nonmanagerial FTE.1 The paraffin block is the best unit of measurement, in our view, because it represents the central connecting work product through all areas within the anatomic pathology laboratory (grossing to final slide preparation) and is central to all of the main tasks of a histotechnologist. However, we understand that the paraffin block may not be the best measurement of productivity for every laboratory or area of histotechnology, especially in institutions that have subspecialty areas within the laboratories that handle single tissue types or require methods that do not involve the routine paraffin block—procedures such as immunofluorescence and electron microscopy.

Literature addressing productivity in these specific areas is extremely limited. A 2010 Annals of Diagnostic Pathology article by R.J. Buesa,2 published after the CAP/NSH workload study, mentions these areas and discusses issues that should be considered when trying to establish workload per FTE within any area of the histology laboratory.

There is a comprehensive Management Information System in Canada that uses standardized values to measure every procedure completed in the histology laboratory from the time the specimen arrives until the report is issued. One of the CAP/NSH Histology Quality Improvement Program Committee members uses the MIS, and she has provided the link to the “Standards for Management Information Systems in Canadian Health Service Organizations” Web site,3 where you can find information about the workload/productivity program.

These additional resources will provide you with information that you may be able to adapt and use in determining your staffing requirements.


1. Kohl SK, Lewis SE, Tunnicliffe J, et al. The College of American Pathologists and National Society for Histotechnology workload study. Arch Pathol Lab Med. 2011;135:728–736.

2. Buesa RJ. Productivity standards for histology laboratories. Ann Diagn Pathol. 2010;14:107–124.

3. Canadian Institute for Health Information. Standards for Management Information Systems in Canadian Health Service Organizations.

Shane K. Kohl, MD
Chair, CAP/NSH
Histotechnology Committee
With and for the other members of the
CAP/NSH Histotechnology Committee
Methodist Hospital
The Pathology Center
Omaha, Neb.

Question Q. Is it appropriate to draw a specimen for the prostate-specific antigen test immediately after a digital rectal exam has been performed? Or should one wait 24, 48, or more hours to draw such a sample?

A. Traditionally, physicians were warned not to draw blood for PSA immediately after a digital rectal exam because there was evidence that levels of prostatic acid phosphatase (the test for prostate cancer before PSA) might be elevated by the pressure applied to the gland. Several studies showed, however, that the increase of PSA after DRE was minimal and unlikely to alter the clinical significance of the test result. The only exception, perhaps, would be the interpretation of results just above the cutoff. Interestingly, new tests that may one day replace PSA, such as PCA3 and the TMPRSS2:ERG fusion transcript, actually require prostatic massage in order for the urine to be suitable for examination.


Internal Medicine Clinic Research Consortium: Effect of digital rectal examination on serum prostate-specific antigen in a primary care setting. Arch Intern Med. 1995;155:389–392.

James D. Faix, MD
Stanford Clinical Labs at Hillview
Stanford University School of Medicine
Palo Alto, Calif.

Member, CAP Chemistry Resource
Committee, Standards Committee,
Council on Scientific Affairs

Dr. Kiechle is medical director of clinical pathology, Memorial Healthcare, Hollywood, Fla. Use the reader service card to submit your inquiries, or address them to Sherrie Rice, CAP TODAY, 325 Waukegan Road, Northfield, IL 60093;