UW Medicine Anatomic Pathology Specimen Collection Manual
UW MedicineAnatomic Pathology Specimen Collection ManualUW Medicine Pathology Mission StatementThe Division of Anatomic Pathology is committed to excellence in the diagnosis of human disease. Ourdepartment and team members are committed to: Delivering timely and accurate diagnoses that support outstanding patient care and informeffective and appropriate treatment options for patients.Providing fellows, residents and medical school students with exceptional education andexperience, creating leaders within pathology and within healthcare.Striving to provide educational services within UWMC that enhance the clinical expertise of ourmedical colleagues and promote the advancement of medical knowledge through basic andclinical research.Employing compassion throughout all diagnostic services.Focusing on patient and employee safety and on quality.UW Medicine Pathology Vision StatementThe Division of Anatomic Pathology is a recognized leader in quality diagnostic services, state of the artresearch, comprehensive teaching and is engaged in continually evolving methods to offer excellent andmeaningful diagnoses.
ContentsGeneral Information .1-11.1Laboratory Contact Information . 1-11.2Specimen Labeling and Submission . 1-21.3Specimen Rejection. 1-3Gynecological Cytology Service .2-12.1Gynecological ThinPrep Pap Test . 2-1Non-Gyn Cytology Services .3-13.1Bladder Washing . 3-13.2Body Cavity Fluid (peritoneal wash, pleural ascites, pericardial, etc.) . 3-23.3Bronchial Brushing . 3-33.4Bronchial Washing . 3-43.5Cerebrospinal Fluid (CSF) . 3-53.6Fine Needle Aspiration (FNA) . 3-63.7Miscellaneous Aspiration (Cysts, Joints, Etc) . 3-73.8Miscellaneous Brushing (Renal, Gastric, Common Bile Duct, Endocervical Cytobrush, Etc) . 3-83.9Sputum . 3-93.10Sputum for PCP . 3-103.11Thyroid Aspirate . 3-113.12Urine – Voided . 3-123.13Urine – Catheterized . 3-13Molecular Diagnostics Services .4-14.1Human Papilloma Virus (GYN in ThinPrep Pap Test Media) . 4-14.1.1 GYN in SurePath Media . 4-24.1.2 GYN in Qiagen Specimen Transport Media (STM) . 4-34.1.3 Anal in Qiagen Specimen Transport Media (STM) . 4-44.1.4Anal in ThinPrep Media . 4-5Histology Services .5-15.1Frozen Sections UWMC-MT . 5-15.2Frozen Sections UWMC-NW . 5-25.3Frozen Sections HMC . 5-35.4Gross Examination . 5-4ii
5.5Bone Marrow Biopsy Specimens . 5-55.6Renal Biopsy Specimens. 5-65.7Surgical Tissue Specimens . 5-75.8Tissue Biopsy Specimens. 5-8Neuropathology Services .6-16.1Brain/Spine Biopsy Specimens . 6-16.2Brain Tumor Specimen for Fluorescent In Situ Hybridization (FISH) . 6-26.3Muscle Specimens. 6-36.4Nerve Specimens. 6-46.5Ocular Biopsy Specimens . 6-5Immunofluorescence .7-17.1Direct Immunofluorescence. 7-17.1.1 Oral Biopsy Specimens . 7-17.1.2 Skin Specimens . 7-27.2In-Direct Immunofluorescence . 7-37.2.1 Serum Specimen. 7-3Cytogenetics Services.8-18.1Amniotic Fluid . 8-18.2Bone Marrow / Oncology Blood . 8-28.3Chorionic Villi . 8-38.4DNA Samples . 8-48.5Peripheral Blood . 8-58.6Solid Tissue (including Products of Conception, Skin Biopsies, Stillbirths) . 8-68.7Urine. 8-78.8Biliary Duct Brushing . 8-8Additional Testing Services .9-19.1Electron Microscopy Services: . 9-19.2DNA Flow Cytometry. 9-2Outside Slides/Block Review Services .10-110.1Slide Reviews (UW Medicine Patients) . 10-1Slide Consults (External consultation with UW Medicine Pathologists) . 10-1Requisitions/Forms.11-1iii
General Information1.1 Laboratory Contact InformationHarborview Medical CenterNinth and Jefferson Building – 2nd Floor (2NJB-244)Telephone: (206) 744-3145Fax: (206) 744-8240University of Washington Medical Center – Montlake2nd Floor (BB220)Telephone: (206) 598-6400Fax: (206) 598-5068University of Washington Medical Center – NW1550 N 115th St, #A-220Telephone: (206) 668-1779Fax: (206) 668-11631-1
1.2 Specimen Labeling and SubmissionThe College of American Pathologists (CAP) and other accrediting agencies require strict adherence tospecimen labeling and specimen submission guidelines. In order to avoid delays in testing, diagnosis andto prevent specimen rejection, the following requisition and specimen container requirements must befollowed.Requisition:Patient’s First NamePatient’s Last NamePatient’s Middle Initial (if applicable)Patient’s Medical Record NumberPatient’s Date of BirthDate of Specimen CollectionTime of Specimen CollectionReferring Providers NameClinical Data including history, planned procedures and differential diagnosis (if applicable)Exact anatomical source/site, whenever possibleName and Contact Phone Number of Person Completing the FormSpecimen Container:Patient’s First NamePatient’s Last NamePatient’s Middle Initial (if applicable)Patient Medical Record Number and/or Patient Date of BirthExact anatomical source/site whenever possibleFor Cytopathology:Each prepared slide must be labeled separately and any specimen containers with patient materialsmust also be labeled correctlyFor ALL specimens submitted to Anatomic Pathology:All containers must be sealed appropriately to prevent loss of specimens and to reduce employeeexposure to chemicals. Specimen containers must be completely sealed in order to ensure thatspecimens or collection media does not leak.A common reason for specimen rejection is the incomplete or improper closure of caps on specimencollection containers, causing container leaks. This can result in loss of irretrievable specimens orunreadable specimen labels due to leaked fluid or collection media. Please double-check specimencollection containers in order to ensure containers are closed properly. Additionally, all specimencontainers must be placed in a biohazard bag of appropriate size and a complete seal attained.A report within the Patient Safety Network System (PSN) and/or the Laboratory Event ManagementSystem (LEMS), will be submitted for documentation, if insufficient specimen submission practicesoccur.1-2
1.3 Specimen RejectionAll specimens must be properly labeled in order to ensure patient safety and to prevent errors indiagnosis and treatment. Anatomic Pathology does not accept unlabeled and/or mislabeled specimens.Definitions of Unlabeled and Mislabeled Specimens:Unlabeled Specimen:Specimen with no patient identifiers (i.e. patient name, patient medical record number)/specimen thathas not been labeled.Mislabeled Specimen:Specimen that has not been labeled with two patient identifiers.Specimen labeled with a patient name and/or medical record number that are different from that onthe accompanying laboratory request form.Specimen retrieved from correct patient but labeled with a wrong name and/or medical recordnumber/date of birth.1-3
Gynecological Cytology Service2.1 Gynecological ThinPrep Pap TestDay(s) / Time (s) Performed:Turnaround Time**:Specimen Collection Supplies:Monday – Friday 8:00 am - 5:00 pm5 Business Days ThinPrep Pap Test (PreservCyt) Vial (Not CytoLyt) Plastic Spatula Endocervical brush Biohazard Safety Bag Cytology RequisitionSpecimen Collection:For Conventional Smear: Glass Slide 95% Ethanol Fixative Specimen Collection ContainerLabel vial with two patient identifiers. Obtain adequate samplefrom ectocervix and endocervical canal using plastic spatula andendocervical brush. Immediately rinse vigorously 10 times insolution to remove any residual sample from spatula and brush.Discard the collection device. Tighten cap and place vial andrequisition in bag for transport to laboratory.Specimen Handling:Specimen Requirements:If conventional smear is desired, label glass slide and immediatelyplace into 95% Ethanol fixative. Label fixative container, markappropriate boxes on requisition, and place both in bag fortransportation to laboratory.Room Temperature Label with two (2) patient identifiers Completed Cytology Specimen RequisitionDeliver/send to laboratory as soon as possibleDo not use formalin as a fixativeTransportation:Comments / SpecialInstructions:Rejection Criteria:Retention Time of Specimen:Laboratory Subsection: Inadequate Information/missing requisition Unlabeled / Mislabeled Specimen Specimen received in inappropriate fixative Specimen received with collection device still in vialSix (6) Weeks After Final Report is IssuedCytopathology - Harborview** Turnaround times vary depending on multiple specimen and laboratory factors.2-1
Non-Gyn Cytology Services3.1 Bladder WashingDay(s) / Time (s) Performed:Turnaround Time**:Specimen Collection Supplies:Specimen Collection:Specimen Handling:Specimen Requirements:Transportation:Comments / SpecialInstructions:Rejection Criteria:Retention Time of Specimen:Laboratory Subsection:Monday - Friday 8:00 am - 5:00 pm5 business days Specimen Collection Container Biohazard Safety BagIf delay is anticipated to be longer than 24 hours for delivery: CytoLyt or 50% EthanolCollect specimen and deliver fresh specimen to laboratoryimmediately.If a delay of more than 24 hours to deliver is anticipated, add equalvolume CytoLyt or 50% ethanol.Room Temperature if specimen is delivered upon collection.**If slight delivery delay is anticipated, refrigerate*If a longer delivery delay is anticipated, add equal volumeCytoLyt or 50% ethanol Label with two (2) patient identifiers Completed Cytology Specimen RequisitionDeliver/send to laboratory as soon as possibleBladder washing is a valuable addition to cystoscopy insymptomatic patients. Typically it is performed prior to cystoscopywith the injection of 50-75ml of physiological saline through acatheter or the cystoscope. Bladder visualization is performed byinjecting water to dilate the bladder.Cystoscopic examination should be performed after the irrigationfor cytology, because water causes cellular degeneration. Highlycellular specimens are obtained in this manner. Inadequate information/missing requisition Unlabeled/mislabeled specimen Specimen received in inappropriate fixative. Do not useformalin as a fixative.One (1) Week After Final Report is IssuedCytopathology – Harborview** Turnaround times vary depending on multiple specimen and laboratory factors.3-1
3.2 Body Cavity Fluid (peritoneal wash, pleural ascites, pericardial, etc.)Day(s) / Time (s) Performed:Turnaround Time**:Specimen Collection Supplies:Specimen Collection:Monday - Friday 8:00 am - 5:00pm5 business days EDTA or Sodium Heparin Specimen Collection Container Biohazard Safety BagOptimum volume is 100-300ml (more if available).Specimen Handling:For bloody specimens, add 0.5 EDTA or Sodium Heparin for every100ml collected into a clean container.Room temperature if specimen is delivered upon collection*Specimen Requirements:Transportation:Comments / SpecialInstructions:Rejection Criteria:Retention Time of Specimen:Laboratory Subsection:*If delivery delay is anticipated, refrigerate Labeled with two (2) patient identifiers Completed Cytology Specimen RequisitionDeliver/send to laboratory as soon as possibleDo not use formalin as a fixativeInadequate information/missing requisitionUnlabeled/mislabeled specimenSpecimen received in inappropriate fixative. Do not useformalin as a fixative.One (1) Week After Final Report is IssuedCytopathology - Harborview **Turnaround times vary depending on multiple specimen and laboratory factors.3-2
3.3 Bronchial BrushingDay(s) / Time (s) Performed:Turnaround Time**:Specimen Collection Supplies:Specimen Collection:Specimen Handling:Specimen Requirements:Transportation:Comments / SpecialInstructions:Rejection Criteria:Retention Time of Specimen:Laboratory Subsection:Monday - Friday 8:00 am - 5:00 pm5 business days Bronchial Brush Specimen Collection Container CytoLyt Solution Biohazard Safety Bag1. Label specimen container with 2 patient identifiers2. Collect specimen on brush.3. Cut off brush end and immediately submerge brush in CytoLytto avoid air-drying effectsRoom temperature if specimen is delivered upon collection**If delivery delay is unavoidable, refrigerate Labeled with two (2) patient identifiers Completed Cytology Specimen RequisitionDeliver/send to laboratory as soon as possible Do not fix brush in formalin or let dry. Do not fix slides in formalin or let dry CytoLyt solution can be obtained from Cytology at HMC or thePathology Gross Room at UWMC Inadequate Information/missing requisition Unlabeled/mislabeled specimen Specimen received in inappropriate fixative. Do not useformalin as a fixative.One (1) Week After Final Report is IssuedCytopathology – Harborview**Turnaround times vary depending on multiple specimen and laboratory factors.3-3
3.4 Bronchial WashingDay(s) / Time (s) Performed:Turnaround Time**:Specimen Collection Supplies:Specimen Collection:Specimen Handling:Specimen Requirements:Transportation:Comments / SpecialInstructions:Rejection Criteria:Retention Time of Specimen:Contact Information:Monday - Friday 8:00 am - 5:00 pm5 business days Specimen Collection Container Biohazard Safety Bag SpecimenDuring a bronchoscopy, washings are obtained after the insertionof about 10 ml of physiological saline. This is instilled in smallportions of 2-3ml at a time and collected in a tube connected as atrap in the vacuum line, via the bronchoscope while the patientcoughs. The flexible tip of the scope may be directed towards theopening of the smaller bronchioles and several areas sampled.Additional material may be obtained by rinsing the bronchoscopeafter withdrawal. In order to localize the lesion, separatebronchoscopes must be used for each lobe in question.The diluted lavage or wash is sent immediately to the lab forprocessing, in the capped collection tube.Room temperature if specimen is delivered upon collection*(up to four [4] hours)*If delivery delay is anticipated, refrigerate to prevent bacterialgrowth.*If delay is longer than overnight, add equal amount of CytoLyt or50% ethanol for proper fixation. Labeled with two (2) patient identifiers Completed Cytology Specimen RequisitionDeliver/send to laboratory as soon as possible If specimen is too large for an equal volume of fixative in thecollection tube, divide in between two containers and add anequal volume of CytoLyt or 50% ethanol to each Inadequate information/missing requisition Unlabeled/mislabeled specimen Specimen received in inappropriate fixativeOne (1) Week After Final Report is IssuedCytopathology - Harborview**Turnaround times vary depending on multiple specimen and laboratory factors.3-4
3.5 Cerebrospinal Fluid (CSF)Day(s) / Time (s) Performed:Turnaround Time**:Specimen Collection Supplies:Specimen Collection:Specimen Handling:Monday - Friday 8:00 am - 5:00 pm5 business days Specimen Collection Container Biohazard Safety BagIf delay is anticipated to be longer than 24 hours for delivery: CytoLyt solution1. Discard the first drops from the tap.2. Obtain as much spinal fluid as clinical judgment allows.3. Place a screw-top tube supplied by the floor. Prioritize thenecessary lab tests, i.e. microbiology, hematology, cytology.Room temperature if specimen is delivered upon collection.**If slight delivery delay is anticipated, refrigerateSpecimen Requirements:Transportation:Comments / SpecialInstructions:*If a longer delivery delay is anticipated (more than 24hours),record the volume of the specimen and deposit the specimen inCytoLyt solution. Labeled with two (2) patient identifiers Completed Cytology Specimen RequisitionImmediately deliver/send to laboratoryCSF is a highly perishable specimen; if specimen is to be obtained inthe afternoon notify the laboratory.CytoLyt solution can be obtained from Cytology at HMC or thePathology Gross Room at UWMCFor Lymphoma/Leukemia send directly to Hematopathology inSCCA (206-288-7060)Rejection Criteria:Retention Time of Specimen:Laboratory Subsection:Do not fix in formalin Inadequate Information/missing requisition Unlabeled/mislabeled specimen Specimen received in inappropriate fixative CSF that has been frozen or spunOne (1) Week After Final Report is IssuedCytopathology - Harborview**Turnaround times vary depending on multiple specimen and laboratory factors.3-5
3.6 Fine Needle Aspiration (FNA)Day(s) / Time (s) Performed:Turnaround Time**:Specimen Collection Supplies:Specimen Collection:Specimen Handling:Specimen Requirements:Transportation:Comments / SpecialInstructions:Monday - Friday 8:00 am - 5:00 pm5 business days Slides Pap fixative (95% Ethanol) Needle Syringe Physiological Saline Biohazard Safety BagIf Delayed: 50% Ethanol or, CytoLyt Solution1. Label slides with at least 2 patient identifiers2. Express one drop of aspirated material on a labeled slide. Theneedle tip should be brought close to the slide with thebeveled edge of the tip facing down towards the slide.3. Touch the drop of material with another clean labeled slideand apply gentle pressure to procedure a monolayer of cells onboth slides.4. Immediately drop the two slides back to back into pap fixative(95% ethanol).5. Rinse the needle by drawing saline into the syringe and expelback into the saline container.If slides and pap fixative are not available, deposit and rinse theentire sample in CytoLyt solutionRoom temperature if specimen is delivered upon collection.**Refrigerate if delay is anticipated*If more than a 24 hour delay is anticipated, express the sampleinto CytoLyt solution. Labeled with two (2) patient identifiers Completed Cytology Specimen RequisitionImmediately deliver/send to laboratoryTo request a fine needle aspirate (performed by a Cytopathologist)call Harborview Pathology to schedule assistance.CytoLyt solution can be obtained from Cytology at HMC or thePathology Gross Room at UWMCRejection Criteria:Retention Time of Specimen:Laboratory Subsection:Do not fix in formalin Inadequate information/missing requisition Unlabeled/mislabeled specimen Specimen received in inappropriate fixativeOne (1) Week After Final Report is IssuedCytopathology - Harborview**Turnaround times vary depending on multiple specimen and laboratory factors.3-6
3.7 Miscellaneous Aspiration (Cysts, Joints, Etc)Day(s) / Time (s) Performed:Turnaround Time**:Specimen Collection Supplies:Specimen Collection:Specimen Handling:Specimen Requirements:Transportation:Comments / SpecialInstructions:Rejection Criteria:Retention Time of Specimen:Laboratory Subsection:Monday - Friday 8:00 am - 5:00 pm5 business days Needles Syringe Specimen Collection Container CytoLyt Solution Biohazard Safety Bag1. Collect fluid in syringe.2. Transfer fluid into a clean labeled container.Or remove the needle, cap off the syringe and submit thespecimen in the syringe.3. Label the syringe or container with patient identifiers.For small volume of fluids (less than 5ml) and/or if delivery delayis anticipated, deposit the fluid in CytoLyt solution. Fresh unfixed specimen Room temperature if specimen is delivered upon collection.**Refrigerate if delay is anticipated*If delivery is delayed by more than 24 hours, deposit inCytoLyt solution. Labeled with two (2) patient identifiers Completed Cytology Specimen RequisitionImmediately deliver/send to laboratoryDo not use formalin as a fixativeCytoLyt solution can be obtained from Cytology at HMC or thePathology Gross Room at UWMC Inadequate Information/missing requisition Unlabeled/mislabeled specimen Specimen received in inappropriate fixativeOne (1) Week After Final Report is IssuedCytopathology - Harborview**Turnaround times vary depending on multiple specimen and laboratory factors3-7
3.8 Miscellaneous Brushing (Renal, Gastric, Common Bile Duct,Endocervical Cytobrush, Etc)Day(s) / Time (s) Performed:Turnaround Time**:Specimen Collection Supplies:Specimen Collection:Specimen Handling:Specimen Requirements:Transportation:Comments / SpecialInstructions:Rejection Criteria:Retention Time of Specimen:Laboratory Subsection:Monday - Friday 8:00 am - 5:00 pm5 business days Brush CytoLyt Solution Specimen Container Biohazard Safety Bag1. Obtain specimen on brush by brushing lesion. For endocervicalbrushings, the cytobrush is passed into the endocervical canaland rotated 360 five times.2. Cut off brush end and place in CytoLyt solution immediately.Room temperature if specimen is delivered upon collection. Labeled with two (2) patient identifiers Completed Cytology Specimen RequisitionImmediately deliver/send to laboratoryDo not fix specimen in formalin or let dry.CytoLyt Solution can be obtained from Cytology at Harborview orUWMC Pathology Gross Room Inadequate Information/missing requisition Unlabeled/mislabeled Specimen Specimen received in inappropriate fixativeOne (1) Week After Final Report is IssuedCytopathology - Harborview**Turnaround times vary depending on multiple specimen and laboratory factors3-8
3.9 SputumDay(s) / Time (s) Performed:Turnaround Time**:Specimen Collection Supplies:Specimen Collection:Specimen Handling:Specimen Requirements:Transportation:Comments / SpecialInstructions:Rejection Criteria:Retention Time of Specimen:Laboratory Subsection:Monday - Friday 8:00 am - 5:00 pm5 business days Specimen Collection Container Biohazard Safety BaEarly morning spontaneous deep cough technique is appropriatefor symptomatic patients with pulmonary disease and free airways.The patient should be given three, wide mouth, disposable, labeledcontainers and instructed as follows:1. For three successive mornings, upon waking, clear throat ofany material that accumulated overnight and discard.2. Rinse mouth out with water several times.3. Cough deeply several times during the waking hour eachmorning.4. Spit whatever rises with the coughs into the specimencollection cup, using different cups each morning.5. Refrigerate containers until delivered to laboratory.Refrigerated Labeled with two (2) patient identifiers Completed cytology specimen requisitionDeliver/send to laboratory as soon as possibleThree consecutive early morning specimen's increase they yield ofmalignant cells.Do not use formalin as a fixative Inadequate information/missing requisition Unlabeled/mislabeled specimen Specimen received in inappropriate fixativeOne (1) Week After Final Report is IssuedCytopathology - Harborview**Turnaround times vary depending on multiple specimen and laboratory factors3-9
3.10 Sputum for PCPDay(s) / Time (s) Performed:Turnaround Time**:Specimen Collection Supplies:Specimen Collection:Specimen Handling:Specimen Requirements:Transportation:Comments / SpecialInstructions:Monday - Friday 8:00 am - 5:00 pm5 business days Specimen Collection Container Biohazard Safety BagCollect fresh unfixed induced specimen.Refrigerated Labeled with two (2) patient identifiers Completed cytology specimen requisition, include r/o PCPrequestDeliver/send to laboratory as soon as possibleSputum induction is intended primarily for the detection of earlylung carcinoma in asymptomatic persons who have too littlesputum to be raised naturally. It is also used for the detection ofPCP.Non-induced specimen will not be processed for PCP.Rejection Criteria:Retention Time of Specimen:Laboratory Subsection:Do not use formalin as a fixative Inadequate information/missing requisition Unlabeled/mislabeled specimen Specimen received in inappropriate fixative Non-induced specimenOne (1) Week After Final Report is IssuedCytopathology - Harborview**Turnaround times varies depending on multiple specimen and laboratory factors3-10
3.11 Thyroid AspirateDay(s) / Time (s) Performed:Turnaround Time**:Specimen Collection Supplies:Specimen Collection:Monday - Friday 8:00 am - 5:00 pm5 business days Slides Pap Fixative (95% ETOH) CytoLyt Fixative Biohazard Safety Bag1. Label each slide with patient's name.2. Once aspiration is obtained, express one drop of aspiratedmaterial on a labeled slide with the bev
Specimen Collection Container CytoLyt Solution Biohazard Safety Bag Specimen Collection: 1. Label specimen container with 2 patient identifiers 2. Collect specimen on brush. 3. Cut off brush end and immediately submerge brush in CytoLyt to avoid air-drying effects Specimen Handling: Room temperature if specimen is delivered upon .
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