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The Pⁿ Blog is a forum for opinions, questions, controversies, and instructive discussions across the field of pathology and its relevant subspecialties.
Monday, November 12, 2012
Overuse of immunohistochemistry.
With some trepidation, I'd like to discuss a topic that I think has significant implications for our profession, the over use of and over billing for immunohistochemistry stains. 
I do not think this is a widespread abuse, but it definitely does exist in isolated practice foci. There's no doubt whatsoever that immunohistochemical stains, properly applied, are one of the most valuable, if not THE most valuable diagnostic tools in our surgical pathology armamentarium.  However, it is also clear when viewing cases from other institutions and speaking to colleagues across the country, that a few surgical pathologists are overly and inappropriately "generous" in their application.  In some cases this may well be the result of nothing more than a haphazard and not well thought out approach to trying to diagnose a difficult a case.  In other instances, however, I suspect a more clear-cut and less noble motive.  Why, for example does one need to order a panel of nearly a dozen cytokeratin subtypes on a pleomorphic malignancy before initially determining that the tumor is entirely cytokeratin negative with an appropriate cocktail?   Why order a large panel of hematopoietic markers as an initial diagnostic foray before demonstrating positivity or negativity with a CD45 study?  Why order basal cell markers on every prostate biopsy? I could go on at length, but I think you get the picture. 
The reality is that these abuses constitute a form of inappropriate self-referral.  They're coming under increasing scrutiny, and the result may well be some Draconian ruling outside of our control that, for example, may state that no payer will reimburse for more than three immunostains on any given case.  Witness the recent radical cut in reimbursement for the technical component of 88305 (and other codes) by the CMS, based on perceived abuses.  Even worse, imagine if no immunostains could be ordered without clinician approval. 
In order to avoid the above we really need to police ourselves, and soon!  This will require developing and using "best practice" algorithms for working up cases needing immunohistochemical studies.  My friend and collague Dr. Mark Wick has spent a signficant portion of his career developing such algorithmic approaches to light microscopically undifferentiated tumors.  I'm not remotely suggesting that immunostains be ordered one by one, day after day, until the answer is realized, an approach that would add tremendous delay to the diagnosis.  Nor am I suggesting that we can or should eliminate cases where, once the diagnosis is known, a shorter immunohistochemical path to the diagnosis becomes obvious.  Hindsight is always 20:20!  Rather, I'm advocating that staining panels proceed in a logical, one, two or even three-step process from the broader to the more specific markers, instead of "bathing" the specimen up front with huge numbers of markers.  And, needless to say, I'm suggesting that immunostains should not be used unless they are truly needed.
Dr. Gerson Paull said:
As the late, beloved Dean of Student Affairs at the University of Florida College of Medicine, Dr.Hugh "Smiley" Hill used to say: "The top third of the medical class make the best researchers, the middle third make the best doctors, and the bottom third make the most money."
Dr. Christopher H. Cogbill said:
Thanks for bringing attention to this topic, Dr. Mills. Many of my colleagues are outraged and feel that a few "rogue" pathologists may be threatening reimbursement and our reputations. Best practice-type guidelines and a healthy debate might get us off on the right track! ~Chris Cogbill, Hematopathology Fellow
Dr. Pathmanathan Rajadurai MD said:
In my experience, this is a malaise prevalent among self- professed "academic pathologists"; and greedy surgical pathologists in private practice.
About the Author

Stacey E. Mills, MD
Stacey E. Mills, MD, a graduate of University of Virginia (UVA) and the UVA Medical Center, has authored nearly 230 articles, 20+ books, atlases and monographs—including the renowned Sternberg's Diagnostic Surgical Pathology. He has been a practicing Professor and Staff Pathologist at UVA for 30+ years and is Director of Surgical Pathology and Cytopathology. His clinical specialty is general surgical pathology with emphasis on neoplasms and neoplasm-like lesions. Dr. Mills is also Editor-in-Chief of The American Journal of Surgical Pathology.