Malignant neoplasms: discordance between clinical diagnoses and autopsy findings in 3,118 cases

BACKGROUND: During the past few decades, hospital autopsy rates have steadily declined throughout the Western world. This decline is mainly attributed to the introduction of advanced diagnostic techniques. Despite technological developments, discrepancy rates between clinical diagnoses and autopsy findings remain high. Few studies have addressed discrepancy rates exclusively with regard to malignant neoplasms. In the present study, we reviewed the records of 3,118 autopsies performed at Mayo Clinic during a 6-year period (1994-1999) and identified clinically undiagnosed malignancies found at autopsy and clinically diagnosed cancers not confirmed at postmortem examination. MATERIALS AND METHODS: Autopsy protocols, provisional and final anatomic diagnoses, and data from the Mayo Autopsy Pathology Quality Assurance program were reviewed in an attempt to identify discrepancies between clinical diagnoses and autopsy findings regarding malignant neoplasms. RESULTS: In 3,118 autopsies performed at Mayo Clinic between 1994 and 1999, a malignant tumor was identified in 768 cases (25%). In 128 of 3,118 cases (4.1%), the malignancy was not diagnosed clinically. In 14 of 3,118 cases (0.45%), autopsy failed to confirm a clinically diagnosed cancer. A review of the literature is presented. CONCLUSIONS: Autopsy remains an effective tool for the confirmation and refutation of clinical diagnostic findings regarding malignant neoplasms.     

Diagnostic yield from 231 autopsies in a community hospital

Autopsy reports of 231 adult autopsies were examined for clinically unexpected diagnoses. Analysis of data showed that 97 of 188 autopsy diagnoses were clinically unexpected. The diagnosis of pulmonary embolism was clinically the most frequently missed diagnosis relative to its actual occurrence. Also noted was that the proportion of cases with unexpected diagnoses increased from 1983 to 1987.     

The autopsy as a performance measurement tool--diagnostic discrepancies and unresolved clinical questions: a College of American Pathologists Q-Probes study of 2479 autopsies from 248 institutions

OBJECTIVE: To develop a multi-institutional reference database for quality improvement purposes using the autopsy to define clinical diagnostic discrepancies and resolve clinical questions. DESIGN: Using the College of American Pathologists Q-Probes format, institutions prospectively assessed a maximum of 15 consecutive autopsies each, excluding forensic cases and stillborn infants, conducted over a 6-month period. They documented answers to clinical questions provided at autopsy and classified unexpected disease diagnoses according to a standardized system. SETTING AND PARTICIPANTS: Hospital-based autopsies performed at 248 institutions participating in the 1993 College of American Pathologists Q-Probes Quality Improvement Program. MAIN OUTCOME MEASURES: Percentages of clinical questions resolved by the autopsy and percentage of autopsies with unexpected findings of graded clinical impact. RESULTS: In the aggregate database of 6427 questions from 2479 autopsies, overall 93.0% were answered by the autopsy. The 3 most common question categories were (1) identify pathology to account for clinical signs or symptoms (28.0%); (2) establish the cause of death (21.0%); and (3) confirm a clinical diagnosis (19.0%). At least one major unexpected disease finding that contributed to the patient's death was discovered in 39.7% of the total number of autopsies. There were no differences in the percentages of autopsies with these major unexpected findings when the data were stratified by institutional demographics or decedent characteristics. CONCLUSION: This multi-institutional study underscores the clinical relevance of postmortem examination in current medical practice by consistently providing answers to unresolved clinical questions and frequently revealing major unexpected findings that contributed to the patient's death. It is our strong belief that this postmortem-derived clinicopathologic information is a key indicator of effectiveness of care. Integration of this information into institutional quality improvement programs will improve system processes and clinician performance.     

Concordance between premortem and postmortem diagnosis in the autopsy: results of a 10-year study in a tertiary care center

We describe the concordance between clinical diagnoses and autopsy findings in a tertiary care center. Clinical autopsy is a useful tool for the evaluation of accuracy of the clinical diagnoses. However, autopsy rates have declined around the world recently. We randomly evaluated 500 of 2,211 autopsies performed in the department of pathology of a tertiary care hospital during a 10-year period. We computed the sensitivity, specificity, predictive values, and concordance scores between premortem and postmortem diagnoses. The autopsy diagnoses were used as the "gold standard." Four-hundred twenty-two (84.4%) of the autopsies met inclusion criteria. Diseases of the respiratory tract were diagnosed in 44.1% (186) of all autopsy reports reviewed. The higher sensitivity for diagnosis was observed in congenital anomalies (87.5%), while the higher specificity was observed in diagnosis of complications of pregnancy, childbirth, and the puerperium (98.98%). The higher concordance between premortem and postmortem diagnosis was observed with the diagnoses of neoplasms (kappa = 0.76), and for the group of complications of pregnancy, childbirth, and the puerperium (kappa = 0.76). A clinical diagnosis successfully addressed the cause of death in 40% of the cases Low values for concordance between autopsy reports and clinical diagnoses were present in most of the autopsies reports reviewed. We encourage physicians to continue considering the autopsy as an important tool that extends our understanding of diseases.     

A prospective study of 1152 hospital autopsies: I. Inaccuracies in death certification

Comparison of certified clinical diagnoses with autopsy findings showed that, while the major cause of death was confirmed in 61 per cent. of cases, many diagnoses—both major and contributory—were wrong; many clinical diagnoses were either disproved or relegated to a less important role, and many autopsy findings had not apparently been anticipated. Accuracy was particularly poor in some clinical categories: notably cerebro-vascular disease and infections. In these, the diagnosis was more often wrong than right. Thus, death certificates are unreliable as a source of diagnostic data. The clinician's confidence in his major diagnosis bore a fairly close relationship to the frequency of its confirmation. Nevertheless, even when certified as “fairly certain”, the major diagnosis was wrong in about one-quarter of these cases. An attempt was made to assess the significance of incorrect diagnoses; one half of these might be clinically significant. Diagnostic accuracy did not improve with the time spent in hospital, and it bore an inverse relationship to the patient's age.     

Herpetic esophagitis. A common cause of esophageal ulceration

Although herpetic esophagitis is generally believed to be rare, a microscopic study of 55 cases of esophagitis encountered in a review of autopsies revealed 14 cases (approximately 25 per cent). The pathology of herpes esophagitis is described and reasons it has been overlooked are discussed. Possible predisposing factors include immunosuppressive therapy and trauma from nasogastric intubation. Herpetic esophagitis was clinically significant in only one patient, but four patients also had herpes pneumonia, a life threatening infection that occurs concomitantly with esophageal involvement. This association should be kept in mind when herpetic esophageal ulcers are observed at autopsy.     

Missed diagnosis in hematological patients—an autopsy study

Autopsy findings of missed diagnoses that would probably have changed management or prognosis occur in up to 29% of cases in general hospitals. Such proportions may be higher in subsets of patients with complex diseases. We reviewed 2908 consecutive autopsies performed over a period of 29 months in a large-volume hospital, analyzing 118 autopsies of patients with hematological malignancies or severe aplastic anemia. A review of macroscopic reports as well as microscopic examination of tissue samples was performed. Medical records were reviewed for clinical diagnoses. Discordances between clinical and autopsy diagnoses were classified using Goldmans criteria. Additionally, we searched for clinical parameters correlated with occurrence of class-I discrepancy using a multivariate method. Median age was 46.5 years, and 25.4% had received a hematopoietic stem-cell transplant. Overall, 11.9% (6.6–19.1%) of patients died before conclusion of the hematological diagnosis and 33% (24.6–42.3%) died with no active hematological disease. We found class-I discrepancy in 31.3% (23.1–40.5 %) of cases. The most common among these diagnoses were hematological disease, pneumonia and gastrointestinal bleeding. In a univariate analysis, being elderly (P=0.04) was positively correlated with the finding of class-I discrepancies; while, having received previous specific hematological treatment (P=0.0005) or hematopoietic stem-cell transplants (P=0.013), or being admitted to a specialized hematology unit (P=0.0006) were negatively correlated to the occurrence of such discrepancies. Multivariate analysis showed that care in a specialized hematology unit (OR 0.34, 0.12–0.93) was independently associated with lower occurrence of discrepancies. We concluded that critical diagnoses are often missed in highly complex hematological patients especially in the absence of admission to specialized hematology units.     

Chronic rheumatic valvular heart disease. An autopsy study.

The incidence of chronic rheumatic valvular heart disease in Iceland was investigated via autopsies performed from November 1965 through December 1974. During this period, approximately 12.400 Icelanders died at the age of 16 years and older and 28.8 per cent of these are included in the study. At autopsy, males were found to outnumber females by 2:1. Rheumatic valvular heart disease was found in 38 subjects, i.e. in 1.08 per cent of the cases, the sex distribution being 0.67 per cent males and 1.83 per cent females. As regards the hearts with chronically deformed valves, the deformity was of rheumatic origin only in 20 per cent of the cases; the majority, or 69 per cent, presented calcified aortic stenosis. Hospital records applying to most of the subjects were available and according to these, only 18 per cent disclosed a history of rheumatic fever. The diagnosis of rheumatic valvular disease was first established at autopsy in 71 per cent of the cases. An evaluation of the functional derangements of the diseased valves was not attempted, but there is reason to believe that many of the lesions were too mild to provoke significant symptoms and signs. Previous doubts about the existence of rheumatic heart disease in Iceland have been settled in this study.     

Utility of Autopsy among Pediatric Allogeneic Hematopoietic Stem Cell Transplant Recipients: One Last Chance to Learn?

Autopsy may confirm clinical diagnoses or identify conditions that were not suspected prior to a patient's death. Previous studies evaluating the utility of autopsy in hematopoietic stem cell transplant (HSCT) recipients yielded conflicting results.We conducted a retrospective cohort study of children (<18 years of age) undergoing allogeneic HSCT at Duke University who died of any cause between January 1, 1995, and December 31, 2016. We evaluated associations between patient characteristics and autopsy performance using chi-square or Fisher exact tests. We reviewed autopsy reports to determine the concordance between preautopsy causes of death and pathological diagnoses identified on autopsy. We classified unexpected diagnoses on autopsy using criteria developed by Goldman et al. We evaluated for temporal changes in the autopsy consent rate and the frequency of unexpected diagnoses on autopsy using Cochran-Armitage tests.During the 22-year study period, 475 patients died and had data available on autopsy performance, and 130 (27%) of these patients underwent autopsy. The autopsy consent rate declined over time (P < .0001), with autopsies being performed for 40% of deaths in 1995 to 1999 and 17% of deaths in 2009 to 2016. White patients were more likely to undergo autopsy than nonwhite patients (P?=?.03). There were no associations between autopsy performance and patient age, sex, HSCT indication, or HSCT donor. Unexpected diagnoses were identified in 31 (24%) autopsies. The proportion of autopsies with an unexpected diagnosis did not change during the study period (P?=?.45). However, infectious diagnoses that would have led to a change in management were more frequently identified on autopsies in 1995 to 2003 than in 2004 to 2016 (20% versus 0%; P?=?.001).The autopsy consent rate for pediatric HSCT recipients at our institution has declined substantially over the past several decades. The utility of autopsy in this patient population remains high despite a reduction in the identification of unexpected infections.     

Evaluation des klinischen Nutzens der Obduktion

Background

The aim of this study of autopsies performed in our institute was to investigate whether clinical requirements had been met and specific clinical questions answered.

Method

With each autopsy report, a questionnaire was sent to the clinic where the patient had died. The clinicians evaluated how often additional diagnoses were made and whether these were clinically relevant.

Results

Seventy-two percent of all autopsies resulted in further diagnoses. Clinicians estimated that these could have influenced their clinical management in 36% of cases. Weaknesses in interdisciplinary cooperation were uncovered and solved.

Conclusion

The great benefit of the autopsies conducted in our institute was demonstrated. The results emphasise once again the importance of autopsy for quality assurance in clinical medicine.     

Infectious diseases detected at autopsy at an urban public hospital, 1996-2001

Previous studies have demonstrated significant discrepancy rates between clinical and autopsy diagnoses. However, infectious diseases have not received emphasis in these studies. We conducted a study to determine whether the clinical and autopsy diagnoses of infectious diseases are concordant or discrepant and to determine discrepancy rates. Retrospective reviews of the records of 276 patients (adults, 182; fetuses and neonates, 94) who underwent autopsy during the years 1996 through 2001 were performed. Comparison of clinical and autopsy diagnoses was performed using the Goldman classification scheme. Of 182 adult patients, 137 (75.3%) had an infectious disease at autopsy. In 59 (43.1%) of 137 patients, the infectious disease diagnoses were unknown clinically. Of 94 fetuses and neonates, 45 (48%) had an infectious disease at autopsy. In 26 (58%) of 45 patients, the infectious disease diagnoses were unknown before death. There are substantial discrepancies between clinical and autopsy diagnoses of infectious diseases. In adults, acute bronchopneumonia is the infectious disease most often missed clinically; in fetuses and neonates, it is acute chorioamnionitis.     

Discrepancies between clinical and autopsy diagnosis and the value of post mortem histology; a meta-analysis and review

The autopsy is in decline, despite the fact that accurate mortality statistics remain essential for public health and health service planning. The falling autopsy rate combined with the Coroners Review and Human Tissue Act have contributed to this decline, and to a falling use of autopsy histology, with potential impact on clinical audit and mortality statistics. At a time when the need for reform and improvement in the death certification process is so prominent, we felt it important to assess the value of the autopsy and autopsy histology. We carried out a meta-analysis of discrepancies between clinical and autopsy diagnoses and the contribution of autopsy histology. There has been little improvement in the overall rate of discrepancies between the 1960s and the present. At least a third of death certificates are likely to be incorrect and 50% of autopsies produce findings unsuspected before death. In addition, the cases which give rise to discrepancies cannot be identified prior to autopsy. Over 20% of clinically unexpected autopsy findings, including 5% of major findings, can be correctly diagnosed only by histological examination. Although the autopsy and particularly autopsy histology are being undermined, they are still the most accurate method of determining the cause of death and auditing accuracy of clinical diagnosis, diagnostic tests and death certification.     

Clinical autopsy evaluation

The hospital autopsy rate in Japan dropped from 63.5 per cent in 1972 to 20.9 per cent in 1995. This reduction is attributable to declining interest by clinicians, surgeons and pathologists. The decline is a very serious problem, because the autopsy contributes to what has been called "quality control" of medical care. However, the method of autopsy should change along with advances in diagnostic technology or various changes in the circumstances surrounding medical practice. The most important problem at present is that autopsies require both time and effort. Delayed autopsy reports by pathologists may result in declined interest by clinicians and thus limit the benefits. To shorten the time delay for autopsy reports, clinicians must clarify their clinical questions concerning the deceased patient so that pathologists can readily identify the patients' problems and determine the causes more promptly, clearly and diplomatically. Other suggestions for improvement include the following: the reports should be simpler; the concept that all autopsies must be complete should be eliminated; a hospital accreditor must emphasize that clinicians intend to gain more precise diagnoses by obtaining post-mortem tissues of various organs using biopsy instruments. In addition, communication between pathologists and clinicians must be active to determine the pathogenesis of disease.     

Impact of the COVID-19 pandemic on pathological autopsy practices in Japan

During the coronavirus disease 2019 (COVID-19) pandemic, autopsies have provided valuable insights into the pathogenesis of COVID-19. The precise effect of this pandemic on autopsy procedures in Japan, especially in instances unrelated to COVID-19, has not yet been established. Therefore, we conducted a questionnaire survey from December 2020 to January 2021 regarding the status of pathological autopsy practices in Japan during the first year of the COVID-19 pandemic. The questionnaire was sent to 678 medical facilities with pathologists, of which 227 responded. In cases where a confirmed diagnosis of COVID-19 was not made at the time of autopsy, many facilities counted them as suspected COVID-19 cases if pneumonia was suspected clinically. At around half of the sites, autopsies were prohibited for suspected COVID-19 cases. In addition, the number of autopsies of non-COVID-19 cases during the pandemic period was also investigated, and a significant decrease was observed compared with the incidence in the pre-pandemic period. The COVID-19 pandemic has affected not only the autopsies of COVID-19 cases but also the entire practice of pathological autopsies. It is necessary to establish a system that supports the implementation of pathological autopsy practices during the pandemic of an emerging infectious disease.     

Immunohistochemistry utilization in autopsy pathology: a Canadian experience

Immunohistochemistry (IHC) is an important part of the diagnostic work-up in surgical pathology, but the use of IHC in autopsy pathology is poorly defined. We measured IHC utilization by pathologists performing 609 consecutive non-medicolegal, hospital-based, adult autopsies over a three-year period. IHC requests on non-neurologic and neurologic material were analyzed separately. Total stains, number of tissue blocks, specific antibody requests, resident trainee involvement, and ordering pathologist were recorded. For all autopsies on which IHC was requested, the final autopsy report was reviewed. IHC was requested on 345 cases (57%), and a total of 4612 stains were performed (mean 13.5 per autopsy). For non-neurologic autopsy tissues, IHC was used most commonly for the accurate diagnosis of malignancy. For neuropathologic autopsy examinations, IHC was employed most commonly to exclude neurodegenerative conditions and correlate ante-mortem clinical neurologic findings. Resident involvement did not significantly impact utilization. Individual pathologists demonstrated a wide variation in IHC utilization. We conclude that IHC is used extensively in Canadian non-medicolegal autopsy pathology reflecting the complexity, extent, and severity of disease in patients dying in a tertiary-care, academic hospital setting. Utilization is strongly influenced by the neuropathology component of these autopsies. The results provide a point of reference for IHC utilization in autopsy pathology.     

A prospective study of 1152 hospital autopsies: II. Analysis of inaccuracies in clinical diagnoses and their significance

A further analysis of 1152 hospital autopsies provides data on inaccuracies of specific diagnoses; there are many examples of overdiagnosis and underdiagnosis. All were encountered in a routine hospital autopsy service and their frequency confirms the importance of the hospital autopsy in medical audit. A knowledge of the misdiagnoses which recur frequently could provide guidance in the selection of cases for autopsy.     

Diagnostic yield of the autopsy in a university hospital and a community hospital

To determine the extent to which autopsies yield unexpected findings that are relevant to the patient's death and whether cases with a high yield of such findings can be identified selectively, we studied a total of 233 autopsies at a university hospital and at a community hospital. The rates at which autopsies detected major unexpected findings whose premortem diagnosis would probably have improved survival were 11 percent at the university hospital and 12 percent at the community hospital. Major unexpected findings whose premortem diagnosis would not have prolonged survival were found in another 12 and 21 percent of cases, respectively. Pulmonary embolism and fungal infections in immuno-compromised hosts were the most common major unexpected findings. Neither we nor the patients' physicians were able to identify from the clinical data the autopsies likely to have high yields. Furthermore, the physicians' estimates of an autopsy's expected yield were similar for patients evaluated by autopsy and for matched patients who were not. We conclude that the autopsy continues to yield clinically relevant findings at a high level and that it is not currently possible to predict which cases will have high yields. Autopsies are vital to ensure the quality of medical care, and autopsy rates must be increased substantially if this role is to be fully realized.     

Discrepancies between clinical and autopsy diagnoses: a comparison of university, community, and private autopsy practices

Although it is known that autopsies often disclose unexpected findings, few studies have been published that address the effect of institutional setting, selection bias, and length of hospitalization. Records of medical autopsies from 3 institutional settings were studied for discrepancies between clinical and autopsy findings. The settings were university hospital (n = 85); community hospital (n = 146); and private autopsy (n = 60), which were referred from various community hospitals and paid for by family members. The same prosector performed the autopsies in the community and private settings. The overall rate of major discrepancy that involved the cause of death was 17.2%. Factors that increased the likelihood of missed diagnoses were private setting (P = .0005), community setting (P = .02), and short hospital stay before death (P = .02). Additional major findings were present in 28.5% of autopsies. Length of hospital stay before death, institution, and selection bias all affect the rate of major unexpected findings in hospital-based autopsies.     

Clinical utility of autopsy after hematopoietic stem cell transplantation.

Autopsy is the gold standard for establishing the cause of death. We present results of the largest retrospective review of complete autopsies of subjects after hematopoietic stem cell transplantation to better define the role of the autopsy in discovering a missed diagnosis. We reviewed the medical chart and autopsy records of 111 patients who had undergone hematopoietic stem cell transplantation from July 1986 to June 2003 from a single center. We compared the cause of death as charted by the clinical team with data obtained from postmortem chart review and autopsy reports. Of 29 (26%) cases when the premortem and postmortem major diagnoses did not agree, only 4 (4%) autopsy records provided data that might have led to the initiation of new treatments, and none of these diagnoses would be missed today with more sensitive and specific diagnostics and improved supportive care. Although autopsies after transplantation can be important educational, research, and epidemiologic tools and provide an emotional benefit to patient's families, in our series they rarely provided missed diagnoses that would alter the management of subsequent patients. Improvements in noninvasive tests for relapse or occult infections may further erode the role of autopsies in discovering missed diagnoses.     

The autopsy: its decline and a suggestion for its revival

The hospital autopsy rate in the United States dropped from 41 per cent in 1964 to 22 per cent in 1975. This reduction is attributable to a declining interest for many reasons by clinicians, surgeons, pathologists, families of the deceased and hospital administrators and hospital accreditors. Various advances in medicine and surgery in recent years have not replaced the value of the autopsy; indeed they have increased the potential information to be gained from it. For interest in autopsies to be revived among physicians and surgeons, pathologists must provide more expert information from the autopsy. To provide the type of information sought from autopsies by physicians and surgeons, the training of pathologists must be altered so that there can be more specialization in anatomic pathology and more subspecialization in the various organ systems, as in internal medicine. In addition, the means of communication between anatomic pathologists and clinicians needs altering so that important clinical questions are recognized by pathologists, and the answers sought and promptly, understandably and diplomatically communicated to physicians and surgeons. Moreover, the large body of information obtained in recent years from autopsies alone needs to be better recognized by clinicians so that they may better understand the value of these examinations.