Is It Always Necessary to Send Ganglion Cysts for a Pathology Check?Experts in hand surgery from Harvard Medical School say it is not necessary to routinely send all ganglion cyst specimens removed from the wrist to the lab. The practice of examining all tissue surgically removed is well-established. But the results of this study suggest the chances that a ganglion cyst being something more serious (like a cancerous tumor) are nil.
How can they be so sure? They examined 424 cysts removed from the hands (wrists, thumbs, fingers) of patients from ages three up to age 90. Three separate diagnoses were made and compared before and after surgery. There was the preoperative clinical diagnosis, the surgical diagnosis, and the postoperative pathologic diagnosis.
The clinical diagnosis is what the surgeon thinks is wrong with the patient before surgery is done. This opinion is based on the patient's history and physical exam (tests, measures, observations) conducted in the surgeon's office.
The surgical diagnosis takes place in the operating room as the surgeon examines the tissue removed. A telltale sign that a cyst is a benign ganglion is the presence of a clear, jelly-like fluid inside the cyst.
The final and most accurate diagnosis is the pathologic diagnosis. The pathologic diagnosis is made by the pathologist, a specially trained medical doctor who examines the tissue under a microscope and confirms what it is. Looking at the individual cells of the cyst while performing what's called a histopathologic exam, the pathologist is able to give the patient and surgeon the true diagnosis.
In this study, the before and after results (diagnoses) were labeled as concordant, discrepant, or discordant. Concordant means the surgeon's clinical diagnosis was the same as the pathologist's postoperative diagnosis. Discrepant means the two diagnoses were different but treatment was the same. And discordant describes a difference between surgeon and pathologist diagnosis that required a change in treatment from what was originally planned based on the clinical diagnosis.
Discrepancies occurred when the cyst turned out to be fibrous tissue that wasn't a ganglion cyst but also wasn't a tumor. Removal was all that was required, which is what was done anyway. There was one case of a benign tumor involving the blood vessels. Again, removal was the treatment of choice. There were a total of five out of the 424 cases where the clinical diagnosis differed from the pathologic diagnosis. And in all five cases, the surgeon recognized the tissue as nonganglionic at the time of removal.
In the end, there were no cases of a discordant (inaccurate or wrong) diagnosis. Given the costs of the pathologist consultation fee, lab costs, and postage for mailing the results, the costs of over 400 pathologic tests could have been saved. And that was just at one hospital.
The results of this study support the mounting evidence that 25 to 40 per cent of all lab tests aren't needed. Surgeons and pathologists have questioned the need for routine lab testing of body parts removed. This includes tissue such as the appendix, tonsils, gallbladders, hernias, and intervertebral discs. They have even questioned the need to test arthritic bone removed when joint replacements are done. But in some cases, there's a state law in place requiring it, the patients expect it, or there is a concern about lawsuits.
The authors concluded that the surgeon's physical exam of the patient and problem area along with inspection during surgery are enough to make an accurate diagnosis of ganglion cyst in the wrist and hand. Patients, hospitals, and insurance companies can save the cost of this routine lab test. Surgeons who are suspicious that something's not quite right can always send the tissue to the lab for evaluation.
Recommendations like this have already been made and put into place in Europe. With more attention being paid to reducing health care costs, we can expect to see similar changes made in the U.S. policy. Surgeons will be allowed (and even encouraged) to limit pathologic testing when there is limited or no need/benefit for the test.
Thierry G. Guitton, MSc, et al. Necessity of Routine Pathological Examination After Surgical Excision of Wrist Ganglions. In The Journal of Hand Surgery. June 2010. Vol. 35A. No. 6. Pp. 905-908.
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