I've dealt with this topic in the past but it is well worth revisiting. Academic pathology departments thrive on consultation material. These difficult, instructive and often fascinating cases are the "bread and butter" of senior resident and fellowship training. I'm sure I speak for everyone who looks at these cases when I say, "Thank you!" and "Keep 'em coming!" In that spirit of appreciation, I'd like to offer a few tips to "maximize consultation benefit" and timeliness of diagnosis.
1. Please include all necessary patient and insurance information, and include a fax number for rapid transmission of the final consultation report. Include your phone number both for rapid communication of our diagnosis and in case we need additional information or material.
2. Include a pertinent clinical summary. Where is the lesion? How big is it? How long has it been there?
3. What are your specific thoughts, questions or concerns, other than "What is it?"
4. Include radiographs for osseous lesions. It is never wise and often impossible to render a specific diagnosis on an osseous lesion without radiographic correlation. Since the skills and experience of skeletal radiologists vary considerably, copies of digital images on a CD/DVD are preferrable to reports.
5. Screen the slides and only send representative/pertinent ones. If every slide in a case is submitted, the problematic issue may not be as easy to identify. One to three slides are almost always sufficient.
6. Supply paraffin block(s) or at least a number of unstained slides. If the contributor doesn't know what the case is then by definition it's a problematic one. It's highly likely that immunohistochemical stains or even ISH are going to be necessary to make or confirm a diagnosis. We don't abuse the system. You'll only get extra studies that are needed and a lot of time will be saved not having to wait for the additional material.
7. Expect some of your material to be retained. These cases are of inestimable value for future training and research. If a paraffin block is submitted, the retained material can be cut from the block and the original slides (and block) returned to the contributor.
8. If there are specific areas of question, mark them on the slide(s) and indicate the issue in your cover letter. Marks on slides without comment are sometimes obvious, but often puzzling. My fellows and I spend a fair amount of time wondering about, "Why is that dot there?"
9. Understand that it is very difficult to comment on someone else's margins. Ink often runs everywhere. Margins may be perpendicular or tangential. Additional tissue may have been obtained from areas that appear to have involved margins. If you weren't there at the time the specimen was grossed it can be dangerous to call other lab's margins.
10. Package the slides carefully. If you think there is even a remote possibility that they can break given how you've packaged them..... trust me, they will!
A note about outside immunohistochemical stains. Most labs today do a good job with these, but there is definitely some variability. Cytokeratin stains, in particular, remain a somewhat problematic area. AE1/AE3 does not constitute a broad spectrum cytokeratin and neither does separate stains for CK7 & CK20. We have seen many examples of carcinomas considered to not be epithelial because of lack of staining with these markers. We use a multi-antibody cocktail that his much more sensitive and covers virtually all cytokeratin subtypes.