Case Study # 1

This post presents a grossing case study of a so-called “routine” specimen, often referred to as a small specimen which might be an amputated leg, a placenta, a ganglion cyst, or a tendon. As opposed to very significant biopsies and large, more difficult, specimens, such as breasts, lungs, or colon, the “routine” specimens are considered insignificant and lacking in diagnostic value. In the presented case, the specimen is the product of open heart surgery, in which both the aortic valve and a part of the 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 with the clinical part. These data are not in the possession of a grossing person, but the pathologists usually have no desire to see these even if they are in the computer medical history.

Clinical history.

A man in his early 70s, with a history of atrial fibrillation and mild evidence of chronic heart failure was diagnosed with severe aortic valve stenosis, tricuspid insufficiency with mild regurgitation, and an ascending aorta aneurysm. Surgery was performed. Below is the pathology report. The names of the patient, attending, and the institution were omitted.

aortic valve calcifications

aorta wall

Although there were some remarks about the pathology diagnosis, the goal of this post is to analyze how the grossing could be useful to the pathologist to in generating a diagnosis.

I have reviewed the final pathology report line-by-line.

The  first line of the pathology report states: Aortic valve disorder. This vague definition is  acceptable as ICD-9-CM code 421.4, but as a pathology diagnosis is open to guesses what kind of disorder.

The sentence:  “portion of vessel wall and valvular tissue with extensive nodular fibrosis and calcifications” is misleading, insufficient, and simply incorrect.  Although the aorta is technically a vessel, but it is a specific one. Therefore, the diagnosis should confirm that the portion was definitely an aorta with characterization of the wall, especially keeping in mind the absence of any signs of atherosclerosis in a over 70- year old man. The pathology diagnosis should reflect any attempt to find out the reason of the ascending aorta aneurysm (Marfan syndrome or unspecified).

The pathology diagnosis did not characterize 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).

All those pathology report insufficiencies are determined by the insufficiencies in grossing, 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 is significant because the specimen is assigned one surgical number, but has parts A and B. The pathology department should insist that the surgery department sends separate specimens in different containers.  Besides some medical significance (a different designation, specific attention), such wrong practices have billing implications in the computer generated CPT coding system 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 are also incorrect (the diameter of the valve is 2.7 cm and, in the case of placement of a prosthesis, this measurement is significant). However, most important is that size and appearance of the annulus and the leaflets were not presented separately, and this has clinical significance.

In the description of the aorta, the most important measurement is the thickness of the wall and this was only referred to once, however, in the case of aneurysm, the thickness of the second fragment is not presented. It is mentioned that the second cylindrical portion ranges from 4 to 5 cm. The thickness of this portion has clinical significance in an aneurysm.

If an absence of something is mentioned, the definition of “discrete” becomes confusing. In this case is important to mention the presence or absence of atheromatosis or athteroscerotic plaques. In old days, a syphilitic gumma would be appropriate to mention.

A 0.1 cm defect was mentioned that generates questions such a ” what kind?” It is likely, that this was a surgical procedure artifact, but it was mentioned the description as something requiring attention (i.e., presence or absence of hemorrhages, depth). The pathologist ignored this ‘defect’. The rule of grossing description states: ’do not let the pathologist to fight with the gross description.’

The specimen’s representative sections were placed in two cassettes. However, the case required five cassettes:

Two cassettes are needed for the aortic valve (one for leaflets with minimal calcification, the second for annulus with intensive calcification; decalcification inevitably damages the fragile endothelial layer of the leaflet that might be important in the diagnosis of an endocarditis or other valve pathology.

Three cassettes for the aorta (one for a representative of the first portion, another for representative of the cylindrical portion, including the maximal diameter, and the third for the defect which was mentioned in the description; such a small 0.1 cm required special orientation; otherwise it could be embedded in the opposite side of the wall or trimmed from the block if it was placed in the cassette flat.

This typical “routine” surgical pathology case illustrates how insufficient clinical data and defects in grossing a specimen can contribute to the insufficiency of the pathology diagnosis and ultimately the loss of the patient. The discharge summary in this particular patient recommends all first degree relatives get screening for diseases of the thoracic aorta. The pathology report is not helpful in this regard.

This case analysis of a simple “routine” specimen attempts to show how professional clinically-oriented grossing can contribute to the informative pathology diagnosis. However, cooperation between clinic and pathology departments is essential. In this case, the surgeon had 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 effort at the expense of people who rely on this medical care.

 

 

 

 

 

 

 

 

 

 

 

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