Letters

July 2007
Feature Story

Critical values

The answer to the question about critical values reporting (Related article: Q&A, May 2007) could give the impression that it is sufficient to leave a voicemail callback message for a physician about a critical value. Such is only satisfactory if the laboratory makes further contact efforts should the physician not call back promptly. Further efforts might include, for example, paging the physician, calling him or her at home, or calling his or her on-call partner. Each laboratory may have different systems based on local factors and whether the patient is an inpatient or an outpatient. The system should be well defined and might include, as a fail-safe end step, the pathologist quickly reviewing the case and contacting the patient to suggest seeking care, as appropriate.

In particular, with outpatients there are instances of voice or fax notification to a closed physician office, wherein the missed message resulted in harm to the patient and litigation.

Laurence Sherman, MD, JD
Professor Emeritus
Northwestern University
Medical School
Chicago

Lymph node numbers

I read with interest the article by Anne Paxton, “In colorectal cancer, a lymph node debate” (May 2007) and would like to expound on one “clearing” agent in particular (in which I have no financial interest).

In our group of 21 board-certified pathologists, we visited the lymph node number with a fourth-quarter 2006 quality assurance study. We found that of nine sites where colectomies with node dissection are performed, only four consistently found 12 nodes or more. In analyzing why, I discovered that some of the sites had quite compulsive technicians, and one used a clearing agent (Dissect Aid). I then performed the following study at my hospital, which has 3.5 FTE pathologists, a pathologist assistant (PA) who grosses 95 percent of our cases, and two GI surgeons who perform 95 percent of colon cancer resections.

Twenty colon cases were pulled from before and 20 cases after Dissect Aid was used, and then all colon cancer cases were separated and analyzed.

Before:
Eight analytic cases
All by GI surgeons
Same PA prosector 8/8
Nodes per case: 5, 5, 6, 10, 8, 13, 8, 12
Mean nodes: 8.38

After:
Six analytic cases
Five of six by GI surgeons
Same PA prosector 5/6, Dr. X 1/6
Nodes per case: 13, 25, 33, 27, 21, 45
Mean nodes: 27.67

A few comments:

• 3.3 times more nodes were obtained using Dissect Aid.
• The same prosector searched for nodes in 13/14 cases.
• Two GI surgeons performed the surgery in 13/14 cases.
• The commercial Dissect Aid was used; I have not tried the homemade.
• During spring break week (the PA was away), I dissected three colon cancer cases and noted that it is all visual, as even the large nodes turn pure white. No more squeezing fat, following vessels—just section at 0.5-cm intervals. The dissections of the nodes took me about 10 minutes each.

In our experience, this is more of a lymph node “whitener” than a fat-clearing agent. We use it as per instruction and now fix all cancer cases until the next day. We first remove the fat and place in Dissect Aid, and we mark the mesenteric margin when appropriate. The remainder of the colon is placed in formalin, and both are grossed in the day after the procedure.

David L. Pittman, MD
Boyce & Bynum
Pathology Laboratories
Columbia, Mo.