关于病理会诊问题的做法和意见

众所周知 ,病理会诊是一种特殊的、同行间关于疑难病例的讨论 ,对于解决临床诊断问题 ,提高病理诊断水平和培养人才都具有重要意义。在国内外 ,病理会诊都很普遍。我们很愿意在此将我们的做法和一些意见表达出来 ,供国内的同行参考。一、我单位介绍病理会诊的情况1.病理会诊在我科病理科工作中的地位 :华西医院是我国西南地区最大的综合医院 ,现有床位 32 0 0余张 ,年门诊患者超过 15 0万人次。年手术超过 2 30 0 0台次。病理科的年外检量达到 2 80 0 0例。年院外病理会诊超过 30 0 0例。从会诊病例的来源看 ,省内的病例占绝大多数。外省病…     

关于病理会诊的一些思考

病理会诊是一个普遍现象 ,并有增多趋势 ,在其中存在着诸多亟待解决的问题。本刊发表赖日权和熊敏教授的来稿 ,并组织一些专家谈谈自己的体会和 (或 )本单位的做法 ,以求得共识和问题的妥善解决     

会诊组织在免疫组化检测中的质量分析

病理会诊是病理科的常规工作之一,随着我国各地区医院医疗技术操作规范细则的实施,临床病理工作中会诊病理越来越多,主要包括疑难性病理会诊、依懒性病理会诊和确认性病理会诊[1].免疫组化技术是会诊工作的重要手段,其有利于提高病理会诊的质量,减少病理会诊带来的医疗风险.然而,送检的会诊蜡块或切片常常组织处理欠佳,这给病理会诊工...     

远程病理会诊回顾分析

病理图像远程会诊，既为基层病理医生解决疑难、罕见或一些复杂的诊断问题提供了方便，也为提高自身专业水平创造了有利条件。现将我院进行远程病理会诊的情况回顾分析如下。     

病理图像远程会诊12例体会

计算机多媒体技术、通讯技术的迅速发展 ,超大规模集成电路和图像专用芯片的问世及微机图像分析系统的运行 ,为病理图像实行远距离传输 ,异地会诊提供了可能。 1999年3月～ 1999年 12月 ,我们对 12例疑难患者病理图片向北京30 1医院病理科申请远程会诊 ,取得较好效果 ,现报告如下 :1　设备配置1.1　硬件配置　 IBM5 86微机 2台 ,15英寸和 2 0英寸显示器各一台 ,显微彩色 CCD摄像机 ,彩色图像采集板 ,OL YMPU S BX40显微镜 ,花王 5 6 K调制解调器。1.2　软件配置　高清晰度彩色病理图文分析系统 (同济医科大学千屏影像工程公司 ) ,全…     

地市级医院292例远程病理会诊病例分析

目的探讨远程病理会诊在帮助解决地市级医院疑难病理诊断和病理质量控制问题中的应用价值。方法回顾292例远程病理会诊病例,分析会诊病例的系统分布特点,计算远程病理会诊确诊率及获得报告的时长等指标,评价远程病理会诊在帮助解决基层医院病理科疑难病理诊断与质量控制中的应用价值。结果会诊病例中占前五位的分别是妇产科(62/292、21.23%)、软组织(34/292、11.64%)、淋巴造血系统(26/292、8.90%)、呼吸系统(19/292、6.51%)、皮肤(18/292、6.16%)。会诊病例最快可在30 min内获得会诊报告,88.7%(259/292)的病例可在48 h内获得会诊报告,获得会诊报告的平均时长约12 h。292例远程病理会诊病例的总体确诊率为90.07%(263/292),其中首次会诊的确诊率为69.86%(204/292);20.2%(59/292)的病例接受专家建议进行免疫组化或特殊染色检测,经检测后均获得确诊;仅有0.34%(1/292)的病例经多点会诊后仍存在良恶性诊断分歧。结论远程病理会诊可提供准确、及时的专家咨询病理报告,帮助提高基层医院病理诊断水平,值得在基层医院病理科推广应用。建设和发展区域远程病理会诊平台是一个新的病理质量控制发展方向。     

淋巴瘤误诊4例临床病理分析

目的提高淋巴瘤的病理诊断水平。方法回顾性分析4例淋巴瘤误诊病例的临床资料及组织病理学切片,增加免疫标记予以协助确诊并复习相关文献。结果例1,低级别滤泡性淋巴瘤(follicular lymphoma,FL)误诊为淋巴结淋巴组织反应性增生,与对BCL-2阴性低级别FL的形态学认识不足有关。例2,乳腺ALK-1~+间变性大细胞淋巴瘤小细胞变异型,误诊为套细胞淋巴瘤,与对ALK-1~+的间变性大细胞淋巴瘤小细胞变异型的形态学认识不足和对免疫标记Cyclin D1(+)定位误判有关。例3,结外NK/T细胞淋巴瘤、鼻型,误诊为直肠黏膜溃疡伴穿孔,与诊断时对增生、浸润细胞观察不细,缺乏相关标志物协助有关。例4,淋巴结边缘区淋巴瘤,误诊为反应性增生,与对边缘区淋巴瘤形态学认识不足有关。结论淋巴瘤的诊断是建立在形态学基础之上,并合理选择免疫标志物、密切结合临床资料综合分析的结果,必要时借鉴基因学及遗传学检测协助诊断,必须提高对该类淋巴瘤的认识,提高诊断水平,以指导临床为患者提供规范化、个体化治疗。     

对病理会诊切片标识制作的建议

个体化医学模式是21世纪临床医学的发展趋势,而临床医师在给患者制定个体化治疗方案前需要精确的病理诊断报告.由于人体疾病的复杂性,病理诊断水平参差不齐的状况难以在短时间内解决,因此造成会诊现象非常普遍[1].近年来,病理会诊的病例在各大医院呈明显上升趋势[2-4].由于各种原因来我院病理会诊的病例亦逐年增加,同时,从本单位借出会诊的切片也不断增多.病理会诊切片质量的优劣与否,直接影响病理医师进行病理诊断的及时性和精确性,所以,各家会诊单位都十分重视会诊切片[4].     

消化道颗粒细胞瘤的12例临床病理分析

目的探讨消化道颗粒细胞瘤(granular cell tumor,GCT)的临床病理特点、诊断及鉴别诊断。方法对12例消化道GCT进行临床资料分析,病理形态观察及免疫组织化学检测。结果 12例消化道GCT形态相似,肿瘤细胞多呈巢状和片状排列,瘤细胞体积大,形态单一,多边形或梭形,胞质丰富,嗜酸性颗粒状。免疫组化显示肿瘤细胞呈S-100和vimentin弥漫阳性;CD68散在阳性;而上皮细胞标记EMA、CK(AE1/AE3)呈阴性。结论消化道GCT是一种少见的神经源性肿瘤,多为偶然发现,内镜和形态学上容易误诊,免疫组化对鉴别诊断有重要意义。     

肛管直肠原发性恶性黑色素瘤临床病理分析

目的 探讨肛管直肠原发性恶性黑色素瘤的临床表现、手术方式、病理特征、免疫组化特点及误诊原因.方法 分析13例肛管直肠原发性恶性黑色素瘤的临床及病理资料,所有标本均行HE及免疫组织化学染色,免疫组织化学采用SP法.结果 本组男4例,女9例,平均年龄56.5岁.主要临床症状为排便习惯改变、便血、肛门口脱出肿物、肛门坠胀和肛周疼痛.临床误诊率为100%.肿物距肛缘1～4 cm,肉眼呈结节状、息肉状、菜花状、溃疡型及平坦型,镜下形态多样,以上皮细胞及梭形细胞为主,11例检见黑色素颗粒.结论 肛管直肠原发性恶性黑色素瘤是一种相对少见、恶性度极高的肿瘤,临床误诊率高,病理活检难以准确分型,S-100、HMB-45免疫组织化学染色有助于诊断,且特异性高,特别是对于无色素者.     

Immunohistochemistry in bone marrow pathology: a useful adjunct for morphologic diagnosis

Pathomorphological examination of trephine biopsies of the bone marrow (BM) represents a standard method for the diagnosis and staging of hematologic neoplasms and other disorders involving the BM. The increasing knowledge about the genetic basis and biology of hematologic neoplasms, as well as the recently proposed WHO classification system, provide the framework for an accurate diagnosis. Although conventional morphology remains the gold standard for paraffin-embedded BM trephines, immunohistochemical stainings have become an integral part of the diagnostic workup. Antibodies suitable for paraffin sections are generally applicable to BM trephines, but modifications of staining protocols may be necessary due to the alternative fixatives and decalcification procedures used for BM biopsies. The indications for immunostainings range from confirmation and classification of lymphoma involvement, subclassification of acute leukemias, and estimating blast counts in myelodysplastic and myeloproliferative syndromes to characterization of BM involvement in nonhematologic neoplasms. Although subtyping of NHL in the BM is more difficult from the point of morphology, classification of the entities that frequently involve the BM, especially the small B-cell lymphomas, can easily be achieved with the help of immunohistochemistry. In this review, we try to summarize the current state of the art in BM immunohistochemistry for the diagnosis of hematologic disorders. Moreover, diagnostic algorithms and useful antibody panels are proposed for a rational and cost-effective approach.     

Surgical pathology of the truncal valve: a study of 12 cases

The truncal valves of 12 patients (eight females and four males) who had undergone valve replacement were studied. The patients ranged in age from 14 months to 21 years (mean, 10 years). All truncal valves were purely regurgitant: nine were severe, two were moderate, and one was mild. Eight of the valves were tricuspid, two were bicuspid, one was quadricuspid, and one was unicommissural. Each valve was thickened, but none was the site of endocarditis. The thickening tended to be greatest along the distal portion of each cusp and resulted primarily from expansion of the spongiosa and fibrosa layers. In seven of the 12 valves, the spongiosa disrupted the fibrosa. In 11 valves, fibrous pads were also observed along the cuspid surfaces. These histopathologic features are indistinguishable from those described for floppy mitral valves and support the concept that floppy valves may result from a congenital abnormality in valvular structure.     

2022例乳腺病理会诊病例分析

目的通过总结华西医院病理科院外乳腺病理会诊的疾病构成、申请会诊原因和会诊前后诊断符合率等,探讨乳腺病理会诊的特点、常见会诊病例病理诊断及鉴别诊断的难点和要点,避免误诊和漏诊。方法参照WHO乳腺肿瘤分类及相关文献对2004~2008年华西医院乳腺会诊病例进行分类整理。结果该组共2 022例乳腺会诊病例,良性669例(33.1%),恶性1 328例(65.7%),交界性25例(1.2%)。申请会诊的原因包括明确病理诊断(1 379例)和进行肿瘤标记物检测(643例),前者中最常见的疑难会诊是导管内增生性病变、纤维上皮性肿瘤和导管内乳头状肿瘤。本组会诊前后诊断的整体符合率为79.3%。误诊病例中,将良性、交界性病变过诊断为恶性者居多,主要原因是切片质量不佳、对诊断标准和假恶性病变缺乏充分认识以及缺少IHC的辅助。鉴别诊断经常使用的免疫组化标记是基底型细胞角蛋白、肌上皮标记和E-cadherin。结论乳腺病理会诊在确诊乳腺疑难病例、准确检测肿瘤标记物和减少医疗差错等方面具有重要作用。掌握常见乳腺会诊疾病的病理特征,合理和适时地选择病理会诊将有助于避免常见的误诊。     

Clinico-pathological discrepancies in the diagnoses of solid malignancies

Autopsy is a valuable tool in evaluating diagnostic accuracy. Solid malignancies may have a protracted presentation, and diagnosis frequently requires imaging and deep-sited biopsies; clinical and postmortem diagnosis discrepancies may occur in a high rate in these diseases. Here, we analyzed the occurrence of clinico-pathological discrepancies in the diagnoses of solid malignancies in a Brazilian academic hospital. We reviewed charts and autopsy reports of the patients that died from 2001 to 2003 with at least one solid neoplasm. Patients were classified in concordant and discordant cases regarding cancer diagnosis. Discordant cases were categorized in undiagnosed cases (no suspicion of cancer) and in misdiagnosed cases (clinical suspicion of cancer but incompletely diagnosed). Among the 264 patients with a single non-incidental solid neoplasm, the clinico-pathological discrepancy rate was 37.1%. Liver (22.5%), lung (19.4%), and pancreatic cancer (15.3%) were the most frequent malignancies in the discordant group. Misdiagnosis category comprised 68% of the discordant cases, i.e., there was no correct knowledge about the tumor primary site and/or the histological type during life. Our data show that a high rate of discrepancies occurs in solid malignancies. Autopsies may provide the basis for a better understanding of diagnostic deficiencies in different circumstances.     

应用自制新型气动式套扎器进行内镜套扎术206例体会

目的总结消化内镜套扎术在临床应用中的经验并评价其扩展适应证。方法 206例消化道病变患者,其中男性133例,女性73例;年龄2～73岁,平均年龄54岁。病变主要包括食管胃静脉曲张、间质瘤、息肉样隆起、良恶性黏膜扁平病灶和黏膜血管发育异常等。先常规应用内镜确认病变可以套扎处理后,退出内镜,在其前端安装自行研发的新型气动式套扎器,再次进入消化道,在内镜直视下对病变实施有效负压吸引后释放高弹性套扎圈,完成消化内镜套扎术治疗。每次操作套扎的数量依据不同的病变性质和多少而灵活掌握。结果大部分病例经过一次套扎即获得满意疗效,少数病灶首次套扎不能完全消除,追加实施第二次套扎后病变消失。全部病例均获得显著疗效,套扎术后复查显示所有被套扎病灶明显减轻或消失。结论消化内镜套扎术简单易行,安全可靠,适应证多,实用性强,值得大力推广应用。     

12例甲状腺微小乳头状癌形态学观察及病理学分析

甲状腺乳头状癌是甲状腺癌中最常见的类型,约占甲状腺癌的60%左右.诊断甲状腺乳头状癌一般情况下并不难,但甲状腺微小乳头癌容易被忽视.本文就我院2000年至2004年确诊12例甲状腺微小乳头状癌的诊断情况报告如下.     

Sources of diagnostic discrepancies in fine-needle aspiration of the breast

Fine-needle aspiration (FNA) is a valuable technique to use in the evaluation of breast lesions; however, inadequate and discrepant diagnoses do occur. To identify the source and nature of inaccuracies related to the method we studied 39 cases in which FNA posed diagnostic problems. These problems could be attributed to sampling errors (71.8%), to the criteria of adequacy we use at our institution (25.6%), and to interpretation (2.6%). The nature of the breast lesion (68%) was the most common cause of inadequate sampling, followed by the experience of the aspirator (32%).