The New Zealand Laboratory

Schedule and Test Guidelines:

Anatomic Pathology Tests
The New Zealand Laboratory Schedule provides Anatomic pathology comprises histology and
clinicians with consistent guidance when cytology
considering requesting laboratory tests. It will The information about anatomic pathology tests in the
ensure the uniform availability of tests across Laboratory Schedule is divided into two sections:
District Health Boards (DHBs) in the future. Tests ■ Histology
are divided into Tier 1, which all referrers can order, ■ Cytology – further divided into gynaecological and
and Tier 2, meaning that the test must be ordered non-gynaecological sections
in conjunction with another health professional
with a particular area of expertise. In addition,
As in other specialities, the histology and cytology tests are
clinical guidance is provided on the use of some defined as Tier 1 (all referrers can request) and Tier 2 (specialist
tests. In this article, with the assistance of Dr Cynric guidance is required) in the Laboratory Schedule.
Temple-Camp (Chair of the Laboratory Schedule
Anatomic Pathology subgroup), we focus on the
Histology testing
anatomic pathology tests in the Schedule.
Tier 1 tests for histology include the majority of specimens
clinicians send for histological examination. In primary care
  For further information on the New Zealand Laboratory this predominantly consists of shave, punch, incisional and
Schedule see: www.dhbsharedservices.health.nz/Site/ excision biopsies of superficial soft tissue lesions of the skin.
Laboratory/Laboratory-Schedule-Review-Project.aspx Specimens may therefore include: tissue from the biopsy or
excision of basal or squamous cell carcinomas, pigmented
naevi, lipomas and sebaceous cysts as clinically indicated.

The Laboratory Schedule also defines a number of activities

as Tier 1 tests that are not directly diagnostic but that are

12 | April 2015 | best tests

important at the clinical-pathology interface. These include No specific additional guidance has been
the presentation of pathology at multidisciplinary meetings, developed for anatomic pathology testing
referral of material for a second opinion and the increasingly
common process of returning tissue specimens to patients. There are no specific referral guidelines for anatomic
pathology in the Laboratory Schedule. All tissue and
Tier 2 tests for histological examination are usually aspirated fluid recovered by a medical procedure should
requested from a hospital setting and include larger surgical ideally be submitted for examination. However, in practice,
specimens such as breast tissue from mastectomies, and there are a number of exceptions to this, although these are
specialist biopsies from lesions in organs such as kidney, lung, of more relevance in a secondary care setting. Tissues that
bone or brain, often collected intra-operatively. are not usually submitted for testing include tonsils, hernia
and hydrocele sacs, femoral heads from patients undergoing
In some circumstances, usually in a secondary care setting, hip joint replacement and placentas from women who have
additional Tier 2 tests are requested by the pathologist normal vaginal deliveries at term. The Laboratory Schedule
providing the initial diagnostic work-up of a specimen. There therefore makes no recommendation to clinicians over which
are many hundreds of immunohistochemical antibody tissues or fluids not to submit, but leaves this as a clinical
tests available that have a wide variety of applications. The judgement.
selection of these studies in addition to standard histology
can, for example, enable the diagnosis of a tumour’s
Future planning
histogenesis and therefore assist in tumour identification.
These additional tests may also be important for prognosis In the future, molecular diagnostic testing in anatomic
and to guide future treatment, e.g. the identification of the pathology will become increasingly important and the
endocrine status of a breast tumour by detecting oestrogen, selection of these tests will become a critical part of clinical
progesterone and HER2 receptors. management. Molecular pathology is a multi-disciplinary field
encompassing aspects of anatomic and clinical pathology,
molecular biology, biochemistry and genetics. It is a growing
Cytology testing
field utilising diagnostic tests such as polymerase chain
Tier 1 tests for cytology include both gynaecological and reaction (PCR), fluorescence in situ hybridisation (FISH) and
non-gynaecological cytology. Tests can be requested by gene mutation testing. There is increasing use of molecular
any registered medical practitioner as well as other relevant testing in patients with cancer and the results are useful in
practitioners, such as midwives and cervical smear takers. both diagnosis and selection of treatments. Molecular tests
are not performed in all laboratories and are only available
Tier 1 tests for gynaecological cytology include conventional at some local, national and international specialised centres.
and liquid based cytology (LBC). In the New Zealand The selection of molecular tests is usually made by a
context, tests for cervical, vaginal and vulval cytology now secondary care clinician or pathologist and therefore these
predominantly utilise LBC. The schedule also includes HPV tests are likely to be Tier 2, however, this will depend on local
PCR testing as a Tier 1 test as defined by the requirements of availability and whether or not they are funded.
the National Cervical Screening Programme.
The Laboratory Schedule leaves the introduction of future
Non-gynaecological examples of Tier 1 tests requested in molecular testing open, however, tests will have to meet
general practice include the assessment of sputum and urine the criteria of appropriate clinical relevance as well as cost
samples. Aspirates from cysts or other lesions, and material effectiveness. The Schedule provides a background basis
from fine needle aspiration (FNA), sent for routine cytology on which current and future evidence-based spending on
are also included as Tier 1 tests. pathological testing can be developed.

Tier 2 tests for cytology include material from investigations ACKNOWLEDGEMENT: Thank you to Dr Cynric
requiring more specialised collection techniques, usually Temple-Camp, Anatomical Pathologist, Chair of the
in a secondary care setting, such as bronchial washings, Laboratory Schedule Anatomic Pathology subgroup
bronchiolar alveolar lavages and those collected during for contribution to this article.
operative procedures.

best tests | April 2015 | 13