Lydia Pleotis Howell, MD
Barbara A. Crothers, DO
Are cytology labs required to exclude some specimens from cytologic evaluation due to the addition to the checklist of CYP.01650 (PDF, 627 KB), “There is a policy that lists specimens that an institution may choose to exclude from routine submission to the cytology department for examination.”
A. Laboratories are not required to exclude specimens from cytologic review. The checklist item is not applicable if a laboratory prefers that all institutional specimens be sent to cytology or if the institution does not process cytology specimens. This item is intended to give a laboratory the flexibility to exclude certain specimens from submission and parallels the policy in the surgical pathology checklist. The list of cytology exclusions will usually be much smaller than that for surgical pathology. Examples of specimens that might appear on a cytology exclusion list include effusions with a prior cytologic diagnosis of malignancy in which drainage is performed for symptomatic relief, and non-bloody yellow breast cyst fluid following fine-needle aspiration. The list of exclusions should be made in consultation with the medical staff to ensure that the needs of patients and their providers are fully considered. The checklist item conveys the message that the majority of specimens removed from patients—including cytology specimens—should be submitted to the laboratory for evaluation. Creating a list of exceptions with the medical staff provides an opportunity to discuss situations in which specimens are inappropriately discarded in operating and procedural rooms or sent for research studies without consideration of patient care requirements.
Are cytology labs required to monitor and enforce CYP.01650 to ensure that all non-excluded specimens are submitted to the laboratory?
A. No. The checklist item does not require that laboratories monitor or enforce the policy. It is impossible for laboratories to know about specimens that are never sent to them and it would be unrealistic to expect the laboratory to assume this responsibility. In addition to mutually agreeing to specimen types on the exclusion list, the medical staff and hospital should take responsibility for any monitoring and/or enforcement.
Q. Can the laboratory choose to apply its exclusion policy on a specimen after it arrives in the laboratory?
A. Yes. Laboratories can exclude a specimen from cytologic processing and review if there is appropriate clinical history to indicate that a specimen falls into the exclusion category. For example, a laboratory could choose to do a gross-only exam on a breast cyst fluid that fits the exclusion criteria and thus not process the specimen for microscopic evaluation. Many laboratories find it too time-consuming or difficult to acquire sufficient history to make that determination. Most labs will process all specimens that arrive in the laboratory, even if present on the exclusion list, under the assumption that the submitting provider wishes a full evaluation. If a laboratory perceives that it has received “exclusion” specimens inappropriately, the next step would be to notify and educate the caregiver, as well as ask for his or her consent to discard the specimen without processing. Alternatively, the medical staff could allow the laboratory to discard specimens from the exclusion list as part of the hospital’s policy.
Dr. Howell, a member of the CAP Cytopathology Committee, is professor and chair of the Department of Pathology and Laboratory Medicine, University of California Davis Health System. Dr. Crothers, vice chair of the Cytopathology Committee, is a pathologist at Walter Reed National Military Medical Center and National Capital Consortium Pathology Program Director.
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