A histotechnologist’s opinion on prostate biopsies

I have talked quite a bit about urologist self-referral and prostate biopsies and how placing each core in its own container is medically unnecessary and serves only to enrich the self-referring urologists.  My opinion on this matter has been formed by the expert opinions of the NCCN and Dr. Jonathan Epstein, as well as many others, who all agree twelve containers are not necessary.

I most recently talked about prostate biopsies just a few days ago, when I discussed a “study” put together by Dr. Deepak Kapoor and Dr. David Bostwick that supposedly proved urologists who submitted each prostate core in its own container were doing it for medically legitimate reasons and not because every container they submit just happens to generate more revenue.

For reasons I discussed at the time, this “study” has the appearance of something put together to “prove” a predetermined conclusion and to add to a body of literature that, to an unsophisticated observer, gives the superficial appearance of legitimacy to an unnecessary practice.

A couple of days after that post, I received an email from a histotechnologist who was kind enough to point out a facet of the debate I have not addressed.

I am a histotech and have worked on a lot of needle cores and designed urology labs.

I understand exactly where you come from in regard to a lot of the debate with separate containers for pbx’s. I think something is definitely missing from the debate.

The elephant in the room that I never see discussed is how histotechnologic skill and understanding relates to the process. Only the most talented and careful of histotechs can be charged with microtomy on such specimens even if only one core is embedded per block. Place two or more fragments per block, and the skill necessary goes up….in the embedding and the cutting.

One huge problem that is never discussed which is totally germaine to the issue is how there is no standardization to embedding and cutting these things. I have seen more neede cores cut away in my time than I could ever feel comfortable with because they are not dealt with appropriatley….usually not embedded on the same plane of sectioning in the block.

I think that a discussion of histologic techniques with regard to embedding, cutting, and even IHC PTEN/ERG, PIN4 staining should part of the overall discussion. It matters…from the grossing to the processing to the embedding/ cutting …to the interpretation and how neatly and methodically the sections are placed on the slide. As the number of cores per block goes up, I would virtually guarantee the quality of the technical preps goes down, depending of course on the skills of the histotechs. I am certain, for example, that Johns Hopkins pbxs are cut by expert histotechs! I have worked in labs that made multiple blocks out of multiple cores per container….just to ensure the highest quality…but that gets into a lot of steps and a lot of slides and a lot of IHCs!!!!

Anyway, thank you SIR! I really think that the debate over this should include histotechs and histotechnologic skill and practice. It affects cost and quality greatly. I never see or hear this component of the debate covered.

I would like to thank the histotechnologist (who wishes to remain anonymous at this time) for providing this insight.

I completely agree histotechs play an absolutely vital role in patient care.  A poor quality slide can make the pathologist’s job extremely difficult, if not impossible, to render an appropriate diagnosis.

This person’s opinion goes along perfectly with Dr. Jonathan Epstein’s recent Letter to the Editor published in the January 2013 Journal of Urology where he says the the quality of pathology in in-office labs could be “less than optimal” if the clinician owners do not commit fully to putting out quality pathology results.

If these in-office pathology lab owners, in their haste to maximize profits, skimp on hiring a skilled histotech, then patient care can truly suffer.