Utility of Routine Pathologic Specimens in Ganglion Wrist Excisions

Abstract

INTRODUCTION: As healthcare costs continue to rise, increased emphasis has been placed on cost-benefit optimization. One area of investigation has been the utility of pathologic examination of specimens from routine procedures with low preoperative suspicion for malignant pathology. Previous literature has challenged the established pathology guidelines in other surgical subspecialties, but no studies have been conducted on the value of routine pathology within hand surgery. The goal of this study was to assess the utility and cost of routine pathologic analysis for one of the most commonly performed procedures in hand surgery, ganglion cyst excision. METHODS: A retrospective cohort study was performed following institutional review board approval. Billing records were searched for CPT code 25111-25112 (Ganglion Cyst Excision) over a 5-year period. All identified records were then searched for associated pathology billing codes, preoperative diagnoses, and postprocedural diagnoses. Pathology reports were then reviewed for final surgical diagnoses. Lastly, associated pathology charges were obtained from our institutions billing department. RESULTS: A total of 407 patients underwent ganglion cyst excision at our institution between 2015 and 2019 by 7 different fellowship-trained hand surgeons. Of those patients, 318 (78.1%) had specimens sent for pathologic review. Thirty-two of those patients (10.1%) had nonganglion cyst diagnoses preoperatively. All 32 charts were reviewed and 31 of the 32 patients had high suspicion for “ganglion cyst” preoperatively with confirmation of diagnosis after intraoperative findings. One patient had abnormal pathology (0.3% of specimens), which was diagnosed preoperatively as a “cystic vascular malformation” on preoperative imaging. All reviewed specimens were associated with a “Level 3 Surgical Pathology” and “Tissue Exam Level 3” billing code, which corresponded to a billing charge of $258. CONCLUSION: Current national guidelines for pathologic review of intraoperative specimens are the result of recommendations proposed in 1996 by the College of American Pathologists and do not take into consideration the surgeon’s clinical acumen. Of the 407 patients who underwent excision of a ganglion cyst, 78 percent had specimens sent for pathology, with only 1 nonganglion diagnosis (0.3%) following pathology evaluation. The 1 nonganglion diagnosis identified was suspected to be “nonganglion” pathology on preoperative evaluation. Over the past 5 years, $81,786 was spent at our institution to confirm a benign pathologic finding that was correctly diagnosed by the physician preoperatively/intraoperatively. These findings would suggest that routine pathology specimens are not indicated in cases where surgeons have a high clinical suspicion for ganglion cyst, and pathologic review should be reserved for cases with atypical findings.