Original Title: Avis: Pertinence et indications de transmission des prélèvements chirurgicaux au laboratoire d’anatomopathologie : la chirurgie orthopédique et la neurochirurgie

Authors' objectives: To promote optimal utilization of anatomic pathology resources and ensure a certain level of consistency between institutions, the Ministère de la Santé et des Services sociaux (MSSS) asked the Institut national d'excellence en santé et en services sociaux (INESSS) to make recommendations to guide clinicians in their decision to submit or not submit certain surgical specimens to the anatomic pathology laboratory, based on the anatomical region and area of surgical expertise concerned, and on the relevance of an anatomopathological examination. To this end, this project has been divided into six parts, each of which has examined a surgical specialty or group of related specialties: orthopedic surgery and neurosurgery; general and plastic surgery; obstetrics, gynecology, and urology; cardiovascular and thoracic surgery; otolaryngology and maxillofacial and cervicofacial surgery; and ophthalmology. The present report deals with surgical specimens and materials from orthopedic surgery and neurosurgery. Which orthopedic surgery and neurosurgery specimens could be part of a selective anatomic pathology submission process, that takes into account situations where the pathologist’s report is unlikely to provide any useful information for patient management?

Authors' results and conclusions: RESULTS: The scientific literature review yielded 30 studies that compared the clinical and anatomopathological diagnoses of orthopedic surgery or neurosurgery specimens, i.e., material from arthroscopies and joint arthroplasties, corrective procedures for the foot or hand (hammertoe, hallux valgus and thumb osteoarthritis), neuromas, synovial cysts, tissue from discectomies and laminectomies, and orthopedic implants removed during procedures. Most of these studies (26/30) were retrospective cross-sectional and based on medical chart review. According to the studies reviewed, the probability of a clinically significant anatomopathological finding, i.e., one that would lead to a change in patient management, is between 0% and 1.6% for joint tissue. One of these studies, a systematic review with meta-analysis, observed a probability of 0.04%. The indications for submitting joint tissue include an unusual clinical presentation, a history of dysplasia or malignancy, a case involving a controversial primary diagnosis, unexpected intraoperative findings (e.g., synovial hyperplasia or a suspicious cortical or medullary bone lesion), and prosthetic revision to identify the cause of a loosening (aseptic or septic). Furthermore, according to the retained studies, the probability of a clinically significant anatomopathological finding upon examining material from corrective surgery for hammertoe, hallux valgus or thumb carpometacarpal osteoarthritis is nil. According to the studies reviewed, the probability is also nil for material from the excision of synovial cysts and Morton’s neuromas. However, according to the United Kingdom’s Royal College of Pathologists (RCP), this material needs to be examined histologically XII because of the risk of juxta-articular synovial sarcoma, epithelioid sarcoma and other similar pathologies. In cases of routine discectomy or laminectomy, where no neoplastic or infectious process or other condition of concern is suspected, the probability of a significant fortuitous finding is between 0% and 0.1%.

Authors' recommendations: INESSS is of the opinion that it would be fair and reasonable to no longer systematically submit certain surgical specimens to anatomic pathology laboratories for analysis, and that this applies throughout Québec. These specimens could be submitted on a selective basis according to clinical judgment. To qualify for selective submission, a specimen should: • be on a list of specimens eligible for selective submission to anatomic pathology; and • arise from a surgical procedure for which no neoplastic or infectious process or other significant medical condition, which would warrant an anatomopathological examination, is suspected by the clinician, based on the pre- and intraoperative findings. All surgical specimens (organs, tissues, apparatuses, medical devices and foreign bodies) not sent to the anatomic pathology laboratory must be visually examined by the surgeon to confirm that they do not exhibit any unexpected abnormalities and that the pre- and intraoperative findings are in line with expectations9, 10. The surgeon must record the removal, visual examination findings, intraoperative findings, and nonsubmission of the specimen to anatomic pathology in the patient’s medical chart2, 11. The selective submission lists proposed in this report should not, under any circumstances, be used as a substitute for clinical judgment. Therefore, the specimens on these lists can be sent to the anatomic pathology laboratory at any time at the clinician’s discretion if there is some uncertainty or concern about the patient’s health. The relevant clinical information justifying submitting a specimen on a selective submission list to anatomic pathology must be indicated on the examination requisition to guide the anatomopathological investigation12. Any surgical specimen that is not on a selective submission list should be sent to the anatomic pathology laboratory for examination.

Authors' methods: To fulfill this mandate, a rapid, structured review was carried out in the scientific literature and using publications presenting or containing positions, recommendations or guidance on the subject. Contextual information and the perspectives of various stakeholders were gathered to document perceptions of and level of acceptability associated with the selective submission of certain surgical specimens and materials to the anatomic pathology laboratory, and to examine potential organizational, clinical, ethical and legal issues. XI To gather different perspectives, INESSS created an advisory committee consisting of orthopedic surgeons, neurosurgeons and anatomic pathologists. In addition, electronic surveys were sent to the directors of professional services and OPTILAB co-directors, to obtain information on surgical specimen submission practices and anatomic pathology resources utilization in Québec’s healthcare facilities. The Canadian Medical Protective Association (CMPA) and the Régie de l’assurance maladie du Québec (RAMQ) were consulted to validate certain medicolegal issues potentially associated with selective submission of surgical specimens to anatomic pathology and to examine the impact this change in practice could have on the billing and auditing process for medical procedures. The recommendations concerning orthopedic surgery and neurosurgery specimens that could be submitted to the anatomic pathology laboratory according to a selective approach are based on a simplified Delphi consultation process with three rounds. This process was carried out with the advisory committee members in the light of the data and information collected from the literature review and from informant and stakeholder consultations.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/pertinence-et-indications-de-transmission-des-prelevements-chirurgicaux-au-laboratoire-danatomopathologie.html

Year Published: 2021

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/pertinence-et-indications-de-transmission-des-prelevements-chirurgicaux-au-laboratoire-danatomopathologie.html

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: Gouvernement du Québec