Telepathology at presence and in the future

Telepathology is the performance of pathology at distance using available telecommunication links such as optic fiber, communication satellite, and integrated services digitized network (ISDN). The main applications of telepathology are to provide frozen section service, consultation between pathologists at a distance, and conducting conferences using displays. These activities are required due to the shortage and disproportional distribution of pathologists. Telepathology for frozen section service is fairly effective in providing indications for surgical procedures by discriminating malignant tumor from benign tumor, confirming metastasis to distant organs or lymph nodes, and decisions regarding the surgical margin. However, there are several public insurance problems in the spread and practice of telepathology. To solve these problems, not only from a medical approach but also from the development of mechanical engineering, economic and legal issues must be considered.     

Critical values in pediatric surgical pathology: definition, implementation, and reporting in a children's hospital

Timely communication of significant or unexpected findings in surgical pathology can significantly improve patient care. Although surgical pathology critical values have been published, no systematic assessment in pediatric surgical pathology has been published. We surveyed pediatric pathologists and pediatric subspecialists to develop pediatric surgical pathology critical values for verbal reporting before the final pathology report. A policy and process for reporting and documentation was implemented, with retrospective and prospective quality review. Critical values cases constituted 9.4% of surgical pathology accessions. Retrospective analysis revealed that 80% (73/91) had been reported and documented before policy implementation. Following implementation, 97.3% (402/413) were verbally reported and documented. A multidisciplinary group provided valuable information about critical values that might not have been obvious to pediatric pathologists but are important for patient care. Although the term critical values has become embedded in the surgical pathology literature, we would propose an alternative term for significant or unexpected findings that require timely communication and documentation.     

Intrapancreatic schwannoma diagnosed by endoscopic ultrasound‐guided fine‐needle aspiration cytology

Schwannoma is a tumor of neuro‐ectodermal origin, usually occuring in the head and neck and extremities. A retroperitoneal, and particularly intra‐pancreatic presentation is very rare, and poses a clinical and diagnostic challenge. We report a case of a male patient who underwent an Endoscopic Ultrasound‐guided Fine Needle Aspiration (EUS‐FNA) biopsy of a hypoechoic, intra‐pancreatic mass. The onsite cytological evaluation was consistent with a spindle cell neoplasm. Further evaluation, aided by immunohistochemical stains, defined the mass as a Schwannoma. The patient then underwent a pancreaticoduodenectomy and the histopathological diagnosis of the surgical specimen confirmed the cytological diagnosis. To our knowledge, this is the first report of intra‐pancreatic Schwannoma diagnosed preoperatively by EUS‐FNA cytology. Diagn. Cytopathol. 2009. © 2008 Wiley‐Liss, Inc.     

Intraoperativer Gefrierschnitt der Schilddrüse

The goal of evaluation of intraoperative frozen sections of the thyroid gland is to achieve a definitive diagnosis which determines the subsequent surgical management as fast as possible; however, due to the specific methodological situation of thyroid frozen sections evaluation a conclusive diagnosis can be made in only some of the cases. If no conclusive histological diagnosis is possible during the operation, subsequent privileged processing of the specimen allows a final diagnosis at the latest within 48 h in almost all remaining cases. Applying this strategy, both pathologists and surgeons require a high level of communication and knowledge regarding the specific diagnostic and therapeutic peculiarities of thyroid malignancies because different surgical strategies must be employed depending on the histological tumor subtype.     

Impact of pathology review of stage and margin status of radical prostatectomy specimens (EORTC trial 22911)

Pathological staging and surgical margin status of radical prostatectomy specimens are next to grading the most important prognosticators for recurrence. A central review of pathological stage and surgical margin status was performed on a series of 552 radical prostatectomy specimens of patients, participating in the European Organisation for Research and Treatment of Cancer trial 22911. Inclusion criteria of the trial were pathological stage pT3 and/or positive surgical margin at local pathology. All specimens were totally embedded. Data of the central review were compared with those of local pathologists and related to clinical follow-up. Although a high concordance between review pathology and local pathologists existed for seminal vesicle invasion (94%, κ=0.83), agreement was much less for extraprostatic extension (57.5%, κ=0.33) and for surgical margin status (69.4%, κ=0.45). Review pathology of surgical margin status was a stronger predictor of biochemical progression-free survival in univariate analysis [hazard ratio (HR)=2.16 and p=0.0002] than local pathology (HR=1.08 and p>0.1). The review pathology demonstrated a significant difference between those with and without extraprostatic extension (HR=1.83 and p=0.0017), while local pathology failed to do so (HR=1.05 and p>0.8). The observations suggest that review of pathological stage and surgical margin of radical prostatectomy strongly improves their prognostic impact in multiinstitutional studies or trials.     

Clinicians are from Mars and pathologists are from Venus

CONTEXT: Text reports convey critical medical information from pathologists, radiologists, and subspecialty consultants. These reports must be clear and comprehensible to avoid medical errors. Pathologists have paid much attention to report completeness but have ignored the corresponding issue of report comprehension. This situation presents an increasingly serious potential problem. As laboratories are consolidated and as reports are disseminated in new ways (eg, via the World Wide Web), the target audience becomes more diverse and less likely to have any contact with pathologists beyond the written reports themselves. OBJECTIVE: To compare clinician comprehension with pathologist intent in written pathology reports. METHODS: Typical surgical pathology reports relevant to surgeons and covering a range of specimen complexity were taken from our hospital files. Questionnaires based on these cases were administered open-book-examination style to surgical attending physicians and trainees during surgical conferences at an academic medical center. MAIN OUTCOME MEASURES: Scores from questionnaires. RESULTS: Surgeons misunderstood pathologists' reports 30% of the time. Surgical experience reduced but did not eliminate the problem. Streamlined report formatting exacerbated the problem. CONCLUSIONS: A communication gap exists between pathologists and surgeons. Familiarity with report format and clinical experience help reduce this gap. Paradoxically, stylistic improvements to report formatting can interfere with comprehension and increase the number of misunderstandings. Further investigation is required to reduce the number of misunderstandings and, thus, medical errors.     

Essential knowledge,precautions and preventive methods required for reaching an accurate intraoperative frozen diagnosis of gastrointestinal cases

Intraoperative frozen consultation is one of the central components of modern pathology, with a primary purpose to provide on-the-spot diagnosis; a decision that instantly impacts and alters the course of the surgical procedure and patient management. Frozen section diagnosis is a critical and demanding procedure including: gross inspection, specimen orientation, sampling, embedding, freezing, sectioning and staining, followed by microscopic interpretation that must be relayed to the operating team swiftly and precisely. A solid knowledge of basic histopathology, good communication, fine-tuned histotechnology and instruments are essential components for an ideally executed intraoperative consultation. Reaching an accurate frozen section diagnosis requires the pathologists to be fully aware of a spectrum of traps and pitfalls. Some basic rules and key components of insuring a correct frozen diagnosis are discussed in this review.     

Massive retroperitoneal angiomyolipoma. A lesion that may be confused with well-differentiated liposarcoma

A benign massive retroperitoneal lipomatous tumor is described. The tumor, from a 72-year-old woman with increasing abdominal girth, consisted of a mixture of mature lipocytes, smooth muscle cells, and thick-walled medium-size blood vessels. Although the tumor focally involved the uterine serosa, suggesting the possible diagnosis of uterine leiomyoma with fatty change, the authors think that, because the bulk of the tumor was located in the retroperitoneum and because the tumor contained characteristic thick-walled blood vessels from which smooth muscle cells radiated, this tumor would be best classified as a retroperitoneal angiomyolipoma. Although both angiomyolipomas and leiomyomas with fatty change presenting as large retroperitoneal tumors are rare, and therefore are not well-recognized by surgical pathologists, they are benign and must be distinguished from liposarcomas.     

Microcalcifications of the breast: a mammographic-histologic correlation study using a newly designed Path/Rad Tissue Tray

The introduction of screening mammography has brought about a greater knowledge of early breast cancer characteristics. These improvements have led to a reduction in size of suspicious lesions and a shift from surgical to image-guided core needle biopsies (CNBs). Establishing correlation between histologic and imaging findings is required for accurate diagnosis. Currently, there are no standardized multidisciplinary protocols for evaluating such lesions. We correlated histologic and radiologic findings in mammographically detectable calcified lesions in CNBs using specially designed Path/Rad Tissue Trays (patent pending, University of Kansas). Evidence of calcification was analyzed in 440 with and without the use of tissue trays. After mammographic identification of the lesion, CNBs are harvested, placed in tissue trays, and x-rayed to confirm sampling of the lesion. Images of CNBs with calcifications are marked by the radiologists and sent to the pathologist along with the biopsies. Trays with CNBs are then placed into cassettes and sent to the laboratory where they are embedded without disturbing orientation. Identification and localization of targeted microcalcifications were accomplished by radiologists and pathologists in 68 of 71 cases when using the tissue trays compared with 292 of 369 without tissue trays. Confirmation of microcalcifications was accomplished after deeper sectioning into tissue blocks from discordant cases. In conclusion, a systematic approach is recommended to standardize reporting of calcifications. The use of Path/Rad Tissue Trays has created a level of concordance between pathologists and radiologists that previously did no exist. It improved diagnostic reliability, encouraged communication between pathologists and radiologists, and minimized false diagnoses and/or delays in cancer diagnosis.     

The retroperitoneal surface in distal caecal and proximal ascending colon carcinoma: the Cinderella surgical margin?

BACKGROUND: Mesorectal margin tumour involvement is a predictor of local recurrence in rectal carcinoma and an indication for postoperative radiotherapy in suitable patients. However, the prevalence of non-peritonealised surgical margin involvement in ascending colon carcinoma is unknown. AIMS: To test the hypothesis that retroperitoneal surgical margin (RSM) tumour involvement occurs in distal caecal and proximal ascending colon carcinoma. METHODS/RESULTS: One hundred right hemicolectomy specimens, removed for adenocarcinoma of the caecum or proximal ascending colon, were studied. During routine specimen dissection, at least one additional tissue block was taken to include the tumour and the RSM. The tumour distance from the RSM was recorded. RSM tumour involvement was present in seven cases (7%). Direct (non-nodal) RSM tumour involvement (five cases) only occurred in posterior or circumferential tumours. CONCLUSIONS: RSM tumour involvement occurs within a considerable number of distal caecal and proximal ascending colon carcinomas. The rate of RSM tumour involvement identified here is similar to a previously published local recurrence rate of 10% in caecal carcinoma, suggesting that RSM tumour involvement may be a predictor of recurrence in these tumours. Therefore, patients with distal caecal or proximal ascending colon carcinoma and RSM tumour involvement may benefit from postoperative radiotherapy.     

The usefulness of pathologists' assistants.

The usefulness of pathologists' assistants (PAs) has not been assessed rigorously. Data from a time-motion self-report log generated by an Allegheny General Hospital (Pittsburgh, PA) PA and from the corresponding surgical specimen logs were reviewed to determine the daily distribution of PA time and multiple parameters of practice for gross examination of specimens. Using these data in specific scenarios, PA and non-PA practices were compared. The majority of the PA's time (56.5%) was spent performing gross examination of surgical biopsy specimens. The average cost of gross examination per specimen for a PA and a pathologist was $4.37 and $15.19, respectively. In this practice setting, $91,970.00 is saved per year by the use of a PA. The use of PAs instead of pathologists results in considerable practice cost savings ($560,000 in a practice of 50,000 specimens) or saves pathologists time to perform other necessary functions. PAs are highly useful in an era of cost containment.     

Adrenal cortical neoplasia: from histology to molecular biology

Characterization of adrenal cortical proliferations requires integration of dynamic endocrine tests with imaging and histopathological characteristics. While pathologists are more frequently exposed to adrenalectomy specimens from patients with presumed adrenal cortical neoplasms, pre-operative biopsy specimens from non-functional adrenal lesions have also expanded the clinical tasks of pathologists. Confirmation of the adrenal cortical origin and distinction of benign cortical proliferations from adrenal cortical carcinomas are well-defined clinical responsibilities of pathologists. However, application of immunohistochemical and/or molecular biomarkers in adrenal cortical neoplasia and careful correlation of morphological features with laboratory findings and disease pathogenesis have evolved the impact of pathologist's role in the multidisciplinary team of endocrine disorders. This review provides an overview of what surgical pathologists need to know about the clinical, morphological, immunohistochemical and molecular features of various forms of adrenal cortical neoplasms (ACNs) in order to advance the clinical care.     

A new method of margin evaluation in breast conservation surgery using an adjustable mould during fixation

AIMS: We have developed a new method of breast resection margin assessment in quadrantectomy using an adjustable mould to prevent the three-dimensional specimen from distorting during fixation. METHODS AND RESULTS: The new method has been applied to 10 consecutive quadrantectomies (six invasive duct carcinomas, four duct carcinoma in situ with or without microinvasion). The precise configuration of the fixed specimen enabled pathologists to examine the side slices, the 5 mm thick slices cut parallel to the flat lateral margins of the specimen, permitting the separation of margin evaluation from tumour characterization. Eight cases with negative margins by our method would also be negative by assessment of inked margins since the margin widths were estimated to be from 5 to 30 mm (average 16.3 mm); two cases with positive margins would also be positive by inked margins. CONCLUSIONS: Our new method was as reliable as the inked margins employing sequential slicing of the entire tissue, although it reduced the number of blocks by more than half in invasive carcinomas. A further advantage of this method is that the accuracy in margin evaluation is not influenced by the extent of tumour sampling. In addition, our system can pinpoint the positive margins facilitating re-excision to obtain tumour-free margins.     

Division of the right posterior attachments of the head of the pancreas with a linear stapler during pancreaticoduodenectomy: vascular and oncological considerations based on an anatomical cadaver-based study

Background  Section of the right posterior attachment (RPA) of the pancreatic head from the adventicia of the superior mesenteric artery (SMA) is the last step of pancreaticoduodenectomy. This procedure might be technically demanding, time consuming and potentially dangerous. A method using a stapler has been proposed to simplify this step of the pancreaticoduodenectomy. Methods  To evaluate the potential consequences of RPA section using this new method, we used an experimental model of pancreaticoduodenectomy in 20 cadavers. After RPA stapling, the residual areolar tissue located between the staple line and SMA was removed (by sub adventicial dissection) and weighed. This allowed an evaluation of: (1) the theoretical risk of SMA injury and (2) the potential carcinological consequences of using stapling division, in comparison with the lymphadenectomy obtained with the conventional sub-adventicial dissection. Results  A right hepatic artery was accidentaly injured in 10% of cases because of the lack of arterial dissection and arterial anatomy recognition. Forty-three percent of the RPA containing nerves and lymphatics remains in place. Using the stapling technique for RPA division theoretically increases the risk of micro or macroscopically positive margin after surgical resection. Conclusion  The result of this human cadaver-based dissection suggests that the use of the mechanical stapling device for final division of the RPA might increase the risk of SMA injury. The risk of vascular injury has been reported in surgical literature and is confirmed by this study. Such results (10% of accidentaly injury) may not be representative in leaving human patients, thanks to the use of a detectable palpable pulse of the SMA. The latter is important in avoiding vascular injury during RPA division. This study also shows that this new technique may increase the risk of incomplete tumor resection.     

Low-grade fibromyxoid sarcoma metastatic to the prostate

Spindle cell tumors of the prostate are rare and mostly primary. We report a case of retroperitoneal sarcoma, which is a low-grade fibromyxoid sarcoma involving the prostate secondarily by metastasis. The patient was a 44-year-old man who presented with progressing abdominal pain. Computed tomography showed a large retroperitoneal mass. The patient underwent surgical resection. Intraoperatively, a second smaller mass was identified in the pelvis and was left untouched. The resected retroperitoneal specimen and prostate transrectal needle biopsies taken afterward showed the same mesenchymal tumor. Radical cystoprostatectomy was performed. Metatatic tumor involving the prostate, bilateral seminal vesicles, and base of the urinary bladder was found. Microscopic examination revealed typical histomorphologic features of low-grade fibromyxoid sarcoma. The patient is without evidence of disease 3 years postoperatively. This case is the first documentation of metastatic sarcoma to the prostate and expands the list of malignant mesenchymal neoplasms that may involve this organ.     

Medicolegal liability in surgical pathology: a consideration of underlying causes and selected pertinent concepts

Malpractice actions against surgical pathologists are still relatively uncommon, but they have increased in frequency over time and are associated with sizable indemnity figures. This discussion categorizes areas of liability in surgical pathology into three groups: those that represent health system flaws (problems with specimen identification, or transportation, or both; lack of clinical information or erroneous information; sampling effects and defects; and poorly reproducible or poorly defined diagnostic or prognostic criteria), others that exist at the interface between the system and individuals (allowing clinicians to bypass pathologic review of referred specimens; acceding to clinical demands for inadvisable procedures; and working in a disruptive environment), and truly individual errors by pathologists (lapses in reasoning; deficiencies concerning continuity in the laboratory; invalid assumptions regarding recipients of surgical pathology reports; over-reliance on the results of "special" tests; and problems with peer consultation). Finally, two important topic areas are discussed that commonly enter into lawsuits filed against surgical pathologists; namely, "delay in diagnosis" of malignant neoplasms and "failure to provide adequate prognostic information." Based on a review of the pertinent literature, we conclude that the clinical courses of most common malignancies are not affected in a significant manner by delays in diagnosis. Moreover, the practice of using "personalized external validity" for supposedly prognostic tests is examined, with the resulting opinion that prognostication of tumor behavior in individual patients is not reliable using anything but anatomic staging systems.     

Communicating diagnostic uncertainty in surgical pathology reports: Disparities between sender and receiver

Surgical pathologists use a variety of phrases to communicate varying degrees of diagnostic certainty which have the potential to be interpreted differently than intended. This study sought to: (1) assess the setting, varieties and frequency of use of phrases of diagnostic uncertainty in the diagnostic line of surgical pathology reports, (2) evaluate use of uncertainty expressions by experience and gender, (3) determine how these phrases are interpreted by clinicians and pathologists, and (4) assess solutions to this communication problem. We evaluated 1500 surgical pathology reports to determine frequency of use of uncertainty terms, identified those most commonly used, and looked for variations in usage rates on the basis of case type, experience and gender. We surveyed 76 physicians at tumor boards who were asked to assign a percentage of certainty to diagnoses containing expressions of uncertainty. We found expressions of uncertainty in 35% of diagnostic reports, with no statistically significant difference in usage based on age or gender. We found wide variation in the percentage of certainty clinicians assigned to the phrases studied. We conclude that non-standardized language used in the communication of diagnostic uncertainty is a significant source of miscommunication, both amongst pathologists and between pathologists and clinicians.     

Breast cancer screening pathology: an assessment of the practise and needs in Belgium and Luxembourg

Education and quality assurance (QA) in breast screening pathology have been encouraged by the Europe Against Cancer programme. As a prerequisite for the set-up of a QA programme in Belgium and in the Grand Duchy of Luxembourg, an inquiry was initiated to evaluate the daily practise in breast pathology, the modalities in handling and analysing breast specimens and the willingness of the pathologists to participate in a QA scheme. Of the 278 mailed questionnaires, 109 confidential and valid questionnaires were returned, meaning a participation rate of 40%. All 109 respondents indicated their willingness to voluntarily participate in the further QA programme. Segmental resections for conservative surgery and excision biopsies ranked first and second, respectively, in examination requests. Of the respondents, 50% complained about the lack of clinical information on the pathology request form. A multidisciplinary team approach for the diagnosis of screen-detected lesions was deemed desirable by 87% of the respondents, but only 16% of them actually participate in such pre-operative meetings. Even more puzzling is that 75% of the respondents report regular unavailability of the control radiogram of the surgical specimen removed for non-palpable lesions. One-quarter to one-third of the pathologists still regularly perform frozen sections on microcalcifications or tumours smaller than 1 cm. However, 81% of the respondents estimate that pre-operative diagnosis is not appropriate for this type of lesion. The results of this inquiry show that the guidelines for the diagnosis of screen-detected breast lesions are not yet fully applied in daily practise. The development of local comprehensive breast teams involving a pathologist should improve the co-ordination between the medical disciplines, represent an important way of disseminating the guidelines on breast screening pathology and stimulate the relay unit to conduct QA programmes. Received: 31 March 2000 / Accepted: 9 May 2000     

Pancreatectomy for adenocarcinoma: prognostic factors,recommendations for pathological reports

The ductal adenocarcinoma of the pancreas is a tumor with very poor prognosis, often diagnosed at an advanced stage of evolution. The surgical resection of the tumor is performed in only 15% of the patients but only 10% of them are alive 5 years later. The bad prognostic factors individualized on surgical specimens are the tumor size (>2 cm), lymph node metastases, the poor differentiation of the tumor on microscopic examination, the infiltration of the portal vein and mesenteric vessels by the tumor, the infiltration of the surgical margins, especially the retroperitoneal margin of the tumor. We propose a pre-established form including these items for pathological reports of pancreatectomy for adenocarcinomas.     

Update der S3-Leitlinie für das Pankreaskarzinom

The S3 guidelines for pancreatic cancer were revised in 2013. Besides the oncological and palliative therapy modalities and surgical therapy, the guidelines for pathologists in topic 3 were updated. The modifications essentially concern the histopathological assessment of surgical specimens and in particular the circumferential resection margin and the R classification. In addition, the current recommendations were amended by recommendations concerning the pathohistological records, which should include the lymph node ratio in the future.