Bone Marrow Cytogenetics Is Ineffective for Staging Lymphoma and Can Be Reduced by Test Utilization Guideline Implementation
Rebecca L King, Curtis A Hanson, Rhett P Ketterling, Daniel L Van Dyke, Paul J Kurtin. Mayo Clinic, Rochester, MN
Background: Bone marrow (BM) sampling is routinely performed to stage patients with newly diagnosed malignant lymphoma (ML). Although there is little data to support its use, karyotyping is often performed on these specimens. With rising healthcare costs and falling reimbursements, identifying areas for waste reduction in the laboratory is critical. Our primary goal was to evaluate the utility of CG in the setting of BM ML staging, and implement hematologist-approved test utilization guidelines based on the results. We then reanalyzed our practice after implementation to assess compliance with and effectiveness of the guidelines.
Design: Cases of ML diagnosed and classified by non-BM tissue biopsy with concurrent staging BM sampling over 8 months were included in the initial phase of the study. We reviewed BM and CG reports for presence of ML, myeloid neoplasm (MN), CG abnormalities. Based on the review, guidelines were established for the pathologist to cancel CG analysis, but save CG samples on ML staging BM unless the patient was pre-transplant or BM morphology showed features of a MN. We then collected similar data on all cases of ML with concurrent staging BM sampling over a 4 month period post-guideline implementation.
Results: Pre-implementation: 374 patients with ML and concurrent BM biopsy were identified. CG was performed on 143 samples (38%). 52 BM with CG were involved by ML, only 13 of which had abnormal CG. In all 13 the abnormality was expected based on the previously diagnosed ML. In the 91 BM that showed no ML, 11 had abnormal CG. Eight had normal BM morphology and non-clonal, nonspecific CG findings. In 3 cases with abnormal CG and no ML by histology, the BM morphology indicated a MN.
Post-implementation: 179 cases of ML had staging BM performed and 59 of these had CG (33%). Of the 120 BM without CG, 47 were canceled by the pathologist per guidelines with no impact on final diagnosis. If the 47 CG were performed, 60% of BM would have had CG during this period. In 25 cases, CG was inappropriately performed. If these 25 CG were canceled, only 19% of BM would have had CG. Of these 25 cases, 22 had normal CG and 3 showed non-clonal non-specific abnormalities.
Conclusions: CG does not add useful information in BM staging for ML and should only be performed when morphology suggests a concurrent MN. Implementation of utilization guidelines can reduce unnecessary testing and save laboratory and personnel resources. However, monitoring and communication is paramount to ensure compliance among pathologists.
Wednesday, March 21, 2012 1:00 PM
Poster Session VI # 240, Wednesday Afternoon