Oesophageal and gastric cancer pathology reporting: a regional audit

AIM: To audit the information content of pathology reports of oesophageal and gastric cancer resection specimens in Wales. METHODS: All such reports from the 16 NHS histopathology laboratories in Wales in a one year period were evaluated for their information content. Two standards were used: (1) best practice reporting, and (2) a minimum dataset required for informed patient management that included clear statements on histological tumour type, depth of tumour invasion, lymph node involvement, and completeness of excision. RESULTS: 282 reports were audited. Minimum standards were achieved in 77% of gastric resections (156/203) and 53% of oesophageal resections (42/79). All laboratories achieved minimum standards in some gastric cancer reports (range 50-100%); three laboratories did not achieve minimum standards in any oesophageal cancer reports (range 0-100%). Best practice reporting was achieved in only 20% of gastric and 18% of oesophageal cancer reports. Failure to include an explicit statement on completeness of excision or involvement of the oesophageal circumferential resection margin were the most frequent causes of inadequate reporting. Most other data items were generally well reported, but apparent inadvertent omission of just one item was noted in many of the substandard reports. CONCLUSIONS: This audit shows the need to improve the information content of pathology reports in gastric and oesophageal cancer. The widespread implementation of template proforma reporting is proposed as the most effective way of achieving this. Multidisciplinary meetings of clinicians involved in cancer management should provide a forum for greater communication between pathologists and surgeons, and help to maintain standards of pathological practice.     

Upper gastrointestinal cancer pathology reporting: a regional audit to compare standards with minimum datasets

AIMS: Accurate pathological (pTNM) staging of oesophageal and gastric cancer provides important prognostic information. The aim of this study was to compare the standard of pathology reporting of oesophageal and gastric cancer resections from a cancer network with standards set by the Royal College of Pathologists. METHODS: All reports for oesophageal and gastric cancer resections from the five hospitals in the cancer network in 2001 were collected. Individual items of information were compared with minimum datasets provided by the Royal College of Pathologists. Items were classified as "complete", "partially complete", or "absent". RESULTS: One hundred and ten reports were audited (54 oesophageal and 56 gastric). Fourteen gastric and 17 oesophagectomy reports were over 75% complete. Clinically important missing data occurred most frequently for the pM component of TNM staging (pMx omitted in 87 reports) and completeness of resection expressed as a bold statement (absent in 50 reports). Twelve reports could not be classified because the specimen contained no residual tumour after neoadjuvant treatment. CONCLUSION: The use of a standard proforma for reporting upper gastrointestinal cancers based on a minimum dataset provided by the Royal College of Pathologists is recommended, with modifications to allow for specimens with no tumour after neoadjuvant treatment.     

Completeness of reporting on prognostic factors for breast cancer: a regional survey.

BACKGROUND: Effective management of breast cancer is dependent on adequate pathological reporting of the surgical specimen. OBJECTIVE: To describe the frequency with which histopathological features of known prognostic importance are routinely recorded. STUDY POPULATION: 885 cases of invasive breast cancer diagnosed in NHS laboratories in Lancashire and Greater Manchester. METHODS: Pathology reports were reviewed for details for tumour histological type, size, and grade, the presence or absence of tumour in blood or lymphatic vascular channels, and a comment on the proximity of tumour to the lines of surgical excision. Laboratories were categorised according to their throughput of cases of breast cancer, involvement in the breast screening programme, and whether they were attached to a teaching hospital. RESULTS: Histological type, tumour size, presence or absence of tumour in vascular channels, and adequacy of excision were recorded for 843 (95%), 803 (91%), 436 (49%), and 761 (86%) cases, respectively. Non-screening and low throughput laboratories were significantly less likely to record certain histopathological features. No significant differences were observed between teaching and non-teaching hospitals. CONCLUSIONS: The substantial interlaboratory variation in the histopathological reporting of breast cancers can, in part, be related to throughput of cases and involvement in the breast screening programme.     

Colorectal cancer pathology reporting: a regional audit.

AIMS: To audit the information content of pathology reports of colorectal cancer specimens in one National Health Service region. METHODS: All reports of colorectal cancer resection specimens from the 17 NHS histopathology laboratories in Wales during 1993 were evaluated against: (a) standards previously agreed as desirable by pathologists in Wales; and (b) standards considered to be the minimum required for informed patient management. RESULTS: 1242 reports were audited. There was notable variation in the performance of different laboratories and in the completeness of reporting of individual items of information. While many items were generally well reported, only 51.5% (640/ 1242) of rectal cancer reports contained a statement on the completeness of excision at the circumferential resection margin and only 30% (373/1242) of all reports stated the number of involved lymph nodes. All of the previously agreed items were contained in only 11.3% (140/1242) of reports on colonic tumours and 4.0% (40/1242) of reports on rectal tumours. Seventy eight per cent (969/1242) of colonic carcinoma reports and 46.6% (579/ 1242) of rectal carcinoma reports met the minimum standards. CONCLUSIONS: The informational content of many routine pathology reports on colorectal cancer resection specimens is inadequate for quality patient management, for ensuring a clinically effective cancer service through audit, and for cancer registration. Template proforma reporting using nationally agreed standards is recommended as a remedy for this, along with improved education, review of laboratory practices in the light of current knowledge, and further motivation of pathologists through their involvement in multidisciplinary cancer management teams.     

Evidence of effectiveness of clinical audit in improving histopathology reporting standards of mastectomy specimens.

AIM: To assess the effectiveness of clinical audit in improving standards in histopathological reporting of mastectomy specimens. METHODS: Reports on mastectomy specimens containing tumour issued by non-specialist histopathologists in 1990, 1992, 1994, and 1996 were scored for their information content. There were 10 reports evaluated from each year. Before 1990 no reporting guidelines had been formulated within the department. The audits in 1992 and 1994 were performed after agreed written guidelines (including the establishment of six essential pieces of information), and in 1996 the specimens were reported using a proforma. RESULTS: There was a significant increase in information after the introduction of written guidelines but there was a reduction in information over time. In 1990 none of the 10 reports included all six pieces of mandatory information; in 1992 four of the reports contained all mandatory information; in 1994 only one report contained all mandatory information. The introduction of a proforma for reporting resulted in further significant improvement with all 10 reports in 1996 containing all mandatory information. CONCLUSIONS: Successive rounds of audit increases the standard of reporting in histopathology. There is a need for continuing monitoring of standards as these may deteriorate over time. Reporting complex specimens on a proforma has a significant beneficial effect on information content.     

The effect of four interventions on the informational content of histopathology reports of resected colorectal carcinomas.

AIM: To investigate the effect of different interventions on the inclusion of data items in the histopathology reports of resected colorectal carcinomas. STUDY POPULATION: 272 routine histopathology reports on colorectal carcinomas from the department of histopathology, Royal Hallamshire Hospital, Sheffield. METHODS: The presence or absence of 10 specific data items was recorded for each report. The reports were divided into five audit periods. In the initial period reports were generated using free text with no agreed guidelines. In period 2, text guidelines had been issued; in period 3, flow diagram guidelines had been issued; and in periods 4 and 5, template proformas were attached to each specimen request form. RESULTS: All interventions produced some increase in inclusion rate for some features, but only with the introduction of template proformas did these rates approach 100% for all data items. Inclusion rates were 100% for all items in all cases reported using a proforma. In the final audit period 96% of specimens were reported using proformas. CONCLUSIONS: Template proformas produce a high rate of inclusion of data items in reports of colorectal carcinoma resection specimens.     

Structured electronic template for histopathology reports on colorectal carcinomas: a joint project by the Cancer Registry of Norway and the Norwegian Society for Pathology

Both individual patient treatment and cancer registries depend on adequate histopathology reports. To ensure the quality of these reports, professional organizations have published guidelines on minimum data sets for various cancer types. Norway has a population of 4.6 million, and all individuals have a unique identification number. As required by law, relevant information on cancer is submitted to the Cancer Registry of Norway. A closed, national health data network has been established facilitating electronic transferal between various institutions. The Cancer Registry and the Norwegian Society for Pathology have jointly established a nationwide project to (i) develop standardized templates in database format for histopathology reports on cancer resection specimens and (ii) develop an Extensible Markup Language (XML) standard to facilitate future electronic transfer of cancer reports from hospitals to the Cancer Registry. A minimum data set template for reporting colorectal carcinoma resection specimens and the Extensible Markup Language standard have been established. The template is based on international guidelines and classification systems. For most key parameters, pull-down menus with predefined alternatives have been constructed. The template is fully integrated into software being used by all pathology laboratories in Norway. Since the introduction of the template in April 2005, the template had been used for reporting 430 (93%) of 462 colorectal resections at 2 pilot laboratories (Akershus University Hospital [L?renskog, Norway] and Stavanger, University Hospital [Stavanger, Norway]), demonstrating that high and consistent quality can be ascertained. Pathologists have found the template both time saving and user friendly. The template is now gradually implemented nationwide.     

Agreement between preoperative core needle biopsy and postoperative invasive breast cancer histopathology is not dependent on the amount of clinical material obtained

AIMS: To establish the relation between the amount of breast core needle biopsy (CNB) material examined and agreement between preoperative and postoperative histopathology parameters in invasive breast cancer. METHODS: The CNB and surgical specimen histopathology reports of 113 patients with invasive breast carcinoma were reviewed and the total amount of CNB material examined for each case was determined. Agreement was calculated for tumour type, grade, mitoses, nuclear pleomorphism, and tubule formation. Associations between the amount of CNB material and histopathology agreement before and after surgery were explored using binary logistic regression. RESULTS: Tumour type and grade agreed in 65.4% and 61.6% of cases, respectively. The components used to calculate grade--nuclear pleomorphism (57.4%), mitoses (59.4%), and tubule formation (55.6%)--agreed slightly less frequently. The proportion of cases with preoperative and postoperative assessments that agreed did not depend on the number of cores collected or the total amount of material examined. CONCLUSION: Neither tumour type and grade, nor the individual components used to calculate grade agreed consistently between the CNB and surgical specimen. The number of cores collected and the total amount of material reviewed by the pathologist does not influence the likelihood of agreement between preoperative and postoperative histopathology reports.     

Implementation of TMA and digitalization in routine diagnostics of breast pathology

To ensure optimal treatment of breast cancer patients, breast tumours are classified based on clinico-pathological features. As part of this process, routine diagnostics of breast tumours includes histological typing and grading, as well as profiling by use of an immunohistochemistry panel of antibodies, probes and in situ hybridization. This will, as a minimum, include assessment of oestrogen receptor (OR) and HER2. The individual preparation and staining of many breast tumours in a large laboratory with this standard panel is thus time consuming and costly. Herein, we show that in breast cancer routine diagnostics the use of the tissue microarray technique in combination with digitalization of the stained multi-slides is not only economical, with a considerable cost reduction, but it also enhances standardization of tumour profiling. We demonstrate that 2 mm breast tumour cores correlate with the corresponding tumour on whole mount slides, regarding staining/hybridizing results with the biomarkers in our panel consisting of human epidermal growth factor receptor 2, OR and Topiomerase IIa. Furthermore, we show that simultaneous staining/hybridizing of multiple breast tumour specimens reduces variation of staining/hybridizing quality, hereby increasing reliability of interpretation. By scanning and digitalization of the stained and hybridized multi-slides, we could optimize documentation and filing of the results. Our work is an example of translational research by implementing a tool in daily diagnostics originally developed for high throughput analyses in the search for prognostic and predictive markers in targeted medicine.     

Characterization of basal-like breast cancer: an update

Basal-like breast cancers express genes and proteins associated with the basal layer of mammary epithelium and account for 10-25% of breast cancers. These tumours are of particular interest because they follow an aggressive clinical course and currently lack any form of standard targeted systemic therapy. Over recent years, numerous studies have sought to further characterize this sub-group and dissect out the molecular features that define them. Several biomarkers represent credible novel therapeutic targets and can be evaluated using routine laboratory techniques. As such the basal-like sub-type is becoming increasingly relevant to the histopathologist. However, since recognition of this sub-type is not part of the minimum dataset for breast cancer reporting, many will be unfamiliar with diagnosing these lesions. In this paper, we review the key characteristics of basal-like cancers, discuss closely related entities (triple negative and hereditary breast cancer), and consider the role of molecular markers implicated in these tumours.     

Histopathological features of breast cancer in carriers of ATM gene variants

AIMS: Germline variants in the ataxia telangiectasia mutated (ATM) gene have been implicated in increased breast cancer risk. The aim of this study was to determine whether the histopathology of breast cancers occurring in ATM variant carriers is distinctive or resembles the described BRCA1 mutation-associated phenotype. METHODS: The histopathological features of breast cancers occurring in ATM variant carriers from multiple-case breast cancer families were compared with matched controls. The test group included 21 cases of in situ and/or invasive cancer from carriers of either the IVS10-6T-->G, 2424V-->G or 1420L-->F ATM variants in the absence of BRCA1 or BRCA2 mutations. An additional four invasive cancers from carriers of a pathogenic BRCA1 mutation in the context of a familial ATM variant were also examined. RESULTS: The histopathology of breast cancers in ATM variant-only carriers was not significantly different from controls and known features of BRCA1 mutation-associated cancer were rarely seen. In contrast, these features were prominent in the small group of cases with a pathogenic BRCA1 mutation. CONCLUSIONS: Breast cancer occurring in carriers of ATM variants is not associated with distinctive histopathological features and does not resemble the tumour phenotype commonly observed in BRCA1 mutation carriers.     

The Irish National Histopathology Quality Improvement Programme: an overview

The National Quality Improvement Programme in Histopathology was launched in January 2009 as a matter of priority following high-profile cancer misdiagnosis cases in Ireland. The purpose of the programme is to document and improve the accuracy, consistency and quality of service with the aim of improving patient safety and enhancing patient care. Currently, 32 laboratories participate in the programme and contribute to the dataset. Every year an annual report is composed of anonymised, national data collected from the reporting tool, the National Quality Assurance and Improvement System (NQAIS). The report includes analysis on targets and recommendations released by the programme, providing high quality data on a range of quality indicators. It gives an indication of the quality of histopathology practice in Ireland and enables individual laboratories to compare their performance against the national average. Thanks to the programme, we can report on national metrics in histopathology, making Ireland the first country in the world to do so.     

Diffusion‐weighted imaging features of breast tumours and the surrounding stroma reflect intrinsic heterogeneous characteristics of molecular subtypes in breast cancer

Breast cancer heterogeneity is the main obstacle preventing the identification of patients with breast cancer with poor prognoses and treatment responses; however, such heterogeneity has not been well characterized. The purpose of this retrospective study was to reveal heterogeneous patterns in the apparent diffusion coefficient (ADC) signals in tumours and the surrounding stroma to predict molecular subtypes of breast cancer. A dataset of 126 patients with breast cancer, who underwent preoperative diffusion‐weighted imaging (DWI) on a 3.0‐T image system, was collected. Breast images were segmented into regions comprising the tumour and surrounding stromal shells in which features that reflect heterogeneous ADC signal distribution were extracted. For each region, imaging features were computed, including the mean, minimum, variance, interquartile range (IQR), range, skewness, kurtosis and entropy of ADC values. Univariate and stepwise multivariate logistic regression modelling was performed to identify the magnetic resonance imaging features that optimally discriminate luminal A, luminal B, human epidermal growth factor 2 (HER2)‐enriched and basal‐like molecular subtypes. The performance of the predictive models was evaluated using the area under the receiver operating characteristic curve (AUC). Univariate logistic regression analysis showed that the skewness in the tumour boundary achieved an AUC of 0.718 for discrimination between luminal A and non‐luminal A tumours, whereas the IQR of the ADC value in the tumour boundary had an AUC of 0.703 for classification of the HER2‐enriched subtype. Imaging features in the tumour boundary and the proximal peritumoral stroma corresponded to a higher overall prediction performance than those in other regions. A multivariate logistic regression model combining features in all the regions achieved an overall AUC of 0.800 for the classification of the four tumour subtypes. These findings suggest that features in the tumour boundary and stroma around the tumour may be further assessed as potential predictors of molecular subtypes of breast cancer.     

An international unified approach to reporting and grading invasive breast cancer. An overview of the International Collaboration on Cancer Reporting (ICCR) initiative

Standardised reporting of breast cancer key pathology data has become the norm in some parts of the world, but are based on national or regional guidelines that differ in certain aspects, resulting in divergent reporting practices and a lack of comparability of data internationally. The International Collaboration on Cancer Reporting (ICCR), a global alliance of major (inter-)national pathology and cancer organizations, have recently produced a new international dataset for the pathology reporting of breast cancer, including resection specimens with invasive cancer and ductal carcinoma in situ (DCIS) of the breast. This initiative aims at providing an international unified approach to reporting cancer. The guidance was prepared by an international expert panel consisting of experienced breast pathologists, a surgeon, and an oncologist. The dataset includes core (essential) and noncore (optional) data items based on a critical review and discussion of current evidence. Commentary is provided for each data item to explain the rationale for selection, its clinical relevance, and to highlight potential areas of disagreement or lack of evidence, in which case a consensus position was formulated. The process concludes with international public consultation, before ratification and publication on the free open access ICCR website, with a synoptic reporting guide. The key aim is to promote high-quality, standardised pathology reporting that can be used worldwide. Histological grade, tumour size, and oestrogen receptor status are used in this article to illustrate this process and the detail provided to support its inclusion.     

The quality and value of sudden infant death necropsy reporting in Ireland

BACKGROUND: Infant necropsies are important for identifying cause of death. Recently issued guidelines have recommended investigations to be performed following sudden unexpected death in infants. AIMS: To evaluate the quality and value of infant postmortem reporting. METHODS: Postmortem reports from 1994-1996 and 1998-2000 in Ireland were evaluated using the National Sudden Infant Death Register. Scoring was by a modification of the Rushton system based on the extent of the postmortem data. The finding of additional pathological information was also assessed. RESULTS: Of the 274 cases registered during the selection period, reports were available for 245. Overall quality of necropsy reporting was below the minimum accepted standard in 55.5%; 47% of the necropsies were performed in regional paediatric pathology centres. The quality of necropsies performed in regional centres was significantly higher than those performed elsewhere. Although 86% of the cases were defined as sudden infant death syndrome (SIDS; no cause of death found), the finding of additional pathological information was significantly related to the extent of the necropsy. There was a significant improvement in the quality of necropsies after the postmortem guidelines were issued. CONCLUSIONS: The overall quality of sudden unexpected infant death necropsies in Ireland is less than adequate. A minimum accepted standard of necropsy is required before a diagnosis of SIDS can be made. Although standards have improved recently, this study highlights the need to adhere to published guidelines and the importance of auditing the effect of introducing practice guidelines on clinical practice to complete the audit loop.     

Classification of breast masses in mammograms using genetic programming and feature selection

Mammography is a widely used screening tool and is the gold standard for the early detection of breast cancer. The classification of breast masses into the benign and malignant categories is an important problem in the area of computer-aided diagnosis of breast cancer. A small dataset of 57 breast mass images, each with 22 features computed, was used in this investigation; the same dataset has been previously used in other studies. The extracted features relate to edge-sharpness, shape, and texture. The novelty of this paper is the adaptation and application of the classification technique called genetic programming (GP), which possesses feature selection implicitly. To refine the pool of features available to the GP classifier, we used feature-selection methods, including the introduction of three statistical measures—Student’s t test, Kolmogorov–Smirnov test, and Kullback–Leibler divergence. Both the training and test accuracies obtained were high: above 99.5% for training and typically above 98% for test experiments. A leave-one-out experiment showed 97.3% success in the classification of benign masses and 95.0% success in the classification of malignant tumors. A shape feature known as fractional concavity was found to be the most important among those tested, since it was automatically selected by the GP classifier in almost every experiment.