Double reporting and second opinion in head and neck pathology

An insight into perceptions of general pathologists about the need for oral pathology services: An observational study

Objective

The objective of this study was to identify the degree of perception of oral pathology as a specialty among the general pathologists and the need of utilizing oral pathologists in assisting to identify oral lesions in diagnostic challenges.

Methods

A questionnaire-based survey was conducted among qualified general pathologists to collect the data. The survey items focused on various aspects, including the analysis of oral pathology as a specialty, the importance of employing oral pathologists for identifying oral lesions in diagnostic challenges, and the difficulties encountered in managing such lesions. The data collected was analyzed using descriptive and inferential statistics. For comparing the relationship between work experience and the referral of odontogenic cysts and tumors cases, a Chi-square test was employed. A significance level of p ⩽ 0.05 was deemed as statistically significant.

Results

Two hundred and fifty general pathologists responded to the questionnaire. Two hundred and thirty two (92.8%) participants showed awareness of oral pathology as a specialty. For the diagnosis of oral, jaws, and salivary glands pathologic lesions, the majority 198 (79.2%) respondents believed that oral pathologists are required for the diagnosis. Regarding the referrals of lesions to oral pathologists, 137 (54.8%), participants did not refer. In terms of training in oral pathology, all of the participants agreed that they would undertake short-term posting in oral pathology. For challenging cases, all the general pathologists believed that oral pathologists should be part of the team.

Conclusion

The general pathologists recognized oral pathology as a specialty and feel the need for an oral pathologist opinion in diagnosis. However, most of the general pathologists did not refer the complex cases to oral pathologists. Therefore, it is of paramount importance to encourage oral pathologists and their hiring at histopathology laboratories that are diagnosing complex head and neck cases.

The value of a specialized second-opinion pathological diagnosis for oral and maxillofacial lesions

OBJECTIVES

An error in the diagnosis of an oral or maxillofacial lesion could potentially be detrimental to a patient's prognosis and management. Major discrepancies between the initial and subsequent diagnoses of head and neck pathologies range from 7 to 53%. This study determined the rate of discrepancies found in the diagnoses of oral and maxillofacial lesions after a second opinion in Saudi Arabia.

METHODS

A retrospective single-center study was conducted by oral and maxillofacial pathology consultants to review all cases referred for a second opinion to the oral and maxillofacial pathology laboratory between January 2015 and December 2020. If the second-opinion diagnosis matched the original diagnosis, this was described as "agreement." If the second-opinion diagnosis did not match the original diagnosis but would not change the management or prognosis of a patient, this was classified as a "minor disagreement." If the second-opinion diagnosis resulted in the changing of a patient's management or prognosis, this was categorized as a "major disagreement." Chi-square test and Fisher's exact test were used to compare data between original and second-opinion diagnoses. A p-value of less than 0.05 was considered significant.

RESULTS

Of 138 cases, 59 (43%) had an initial diagnosis and a second-opinion diagnosis that were in major disagreement. The most common tumor for which there was a major disagreement was squamous cell carcinoma. No single factor influenced the occurrence of major disagreements.

CONCLUSIONS

Our evaluation reiterates the importance of obtaining a second opinion from a specialist in oral and maxillofacial pathology to improve the diagnostic accuracy for lesions. A formal system for this step, in addition to the obtaining of adequate clinical and radiographic information about a patient, is mandatory for the review of difficult cases.

Substantial improvement of histopathological diagnosis by whole-slide image-based remote consultation

Consultation by subspecialty experts is the most common mode of rendering diagnosis in challenging cases in pathological practice. Our study aimed to highlight the diagnostic benefits of whole-slide image (WSI)-based remote consultation. We obtained diagnostically challenging cases from two institutions from the years 2010 and 2013, with histological diagnoses that contained keywords “probable,” “suggestive,” “suspicious,” “inconclusive,” and “uncertain.” A total of 270 cases were selected for remote consultation using WSIs scanned at 40 × . The consultation process consisted of three rounds: the first and second rounds each with 12 subspecialty experts and the third round with six multi-expertise senior pathologists. The first consultation yielded 44% concordance, and a change in diagnosis occurred in 56% of cases. The most frequent change was from inconclusive to definite diagnosis (30%), followed by minor discordance (14%), and major discordance (12%). Out of the 70 cases which reached the second round, 31 cases showed discrepancy between the two consultants. For these 31 cases, a consensus diagnosis was provided by six multi-expertise senior pathologists. Combining all WSI-based consultation rounds, the original inconclusive diagnosis was changed in 140 (52%) out of 266 cases. Among these cases, 80 cases (30%) upgraded the inconclusive diagnosis to a definite diagnosis, and 60 cases (22%) changed the diagnosis with major or minor discordance, accounting for 28 cases (10%) and 32 cases (12%), respectively. We observed significant improvement in the pathological diagnosis of difficult cases by remote consultation using WSIs, which can further assist in patient healthcare. A post-study survey highlighted various benefits of WSI-based consults.

Thyroid diagnostic modalities (fine needle aspiration and core needle biopsy) with histology correlation: a tertiary centre experience

AIMS

To determine the proportion of thyroid fine needle aspiration (FNA) and core needle biopsy (CNB) cases reported at a single institute into each UK Royal College of Pathologists (RCPath) Thy1-5 and local T category, respectively. Where subsequent histology was available, malignancy rates, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy were compared for both procedures.

METHODS

1591 FNAs (2010-2018) and 514 CNBs (2013-2018) cases were identified, together with paired histology excision specimens.

RESULTS

The FNA samples were classified as: Thy1: 45.3%, Thy2/Thy2c: 22.1%, Thy3a/Thy3f: 28%, Thy4: 1.6% and Thy5: 3%; while the CNB were classified as: T1: 7.2%, T2: 22.4%, T3 59.3%, T4: 1% and T5: 10.1%. Comparison of FNA and CNB classified as Thy5/T5 showed a 100% risk of malignancy (ROM), sensitivity (98% vs 100%), specificity (14.1% vs 12.1%), PPV (29.4% vs 29.4%), NPV (94.9% vs 100%) and accuracy (36.5% vs 35.6%), respectively, for a diagnosis of malignancy. ROMs for other categories were: Thy1/T1 (9% vs 6.7%), Thy2/T2 (5.1% vs 0%), Thy3/T3 (17.5% vs 18.4%) and Thy4/T4 (73.3% vs 100%).

CONCLUSIONS

The proportion of cases in each RCPath Thy category has remained relatively stable during the 9-year study period, with the exception of the Thy3a category, which has increased over time. This finding is in line with other more recent reports in the literature and the proportion of T3 cases in the CNB group. The proportion of Thy2/Thy2c cases has also reduced over time, reflecting a local change in the triaging protocol for probable benign lesions. Both FNA and CNB showed comparable performance in our study.

Why is the histomorphological diagnosis of tumours of minor salivary glands much more difficult?

AIMS

There is a widespread perception among clinicians and pathologists that the histomorphological assessment of minor salivary gland (MinSG) tumours is more difficult and hampered by more misdiagnoses than that of major salivary gland tumours. This is based on a vague, subjective clinical impression, lacking scientific proof. The aim of the present study was to identify and statistically verify potential reasons that could explain this difference.

METHODS AND RESULTS

We identified 14 putative clinical, pathological and combined clinicopathological reasons that, altogether, could explain the phenomenon of the perceived greater diagnostic difficulty associated with MinSG tumours. We performed a comprehensive literature search and a statistical comparison of data from a large personal consultation series (biased for difficult cases) with cumulated data from straightforward, unselected (non-consultation) series from the literature. By performing this comparison, we identified, with statistical significance, a comprehensive series of reasons, as well as of consequences, of the greater difficulty in diagnosing MinSG tumours.

CONCLUSIONS

Among the 14 criteria, high frequencies of initial incisional biopsies and of a low-grade category in malignant tumours emerged as the two most important reasons for enhanced diagnostic difficulty. Very rare entities, unusual locations, shortcomings in clinicopathological communication, and pecularities of the special anatomical location of the hard palate, such as tumour necrosis, mucosal ulceration, pseudoinvasion, and the peculiar phenomenon of 'tumoral-mucosal fusion', contribute to further diagnostic difficulties. The awareness of these shortcomings and pitfalls enables us to provide a series of recommendations for clinicians and pathologists that might aid in assessment and reduce the rate of misdiagnosis of MinSG tumours.

Questionnaire-based survey regarding the opinion of general pathologists on the need for oral pathology services

Context:

Oral and maxillofacial pathology (OMFP) is a subspecialization having a masters course in India. Due to lesser number of oral pathologists in the country, the biopsy material from the head and neck is catered to by the general pathologist.

Aim:

This survey was conducted to acquire responses from general pathologists and gathering knowledge on their perspective of oral pathology.

Methods:

Pathologists at various medical institutions and at laboratories all over Karnataka were requested to answer a questionnaire comprising 13 questions pertaining to the need and scope of oral pathology.

Results:

In total, 37 (57%) general pathologists completed the questionnaire, of whom 97% (36) were aware of the specialty and 30 (81%) perceived a need for it. Eleven (30%) of them referred oral biopsy specimens to oral pathologists. The most common sources of diagnostic difficulty were identified as odontogenic tumors and cysts. Twenty-six (70%) pathologists felt the need for a short-term posting for their postgraduates in oral pathology, while 28 (76%) of them expressed their opinion about considering an oral pathologist as a part of their team when diagnosing complex head and neck pathologies. Twelve (71%) of them mentioned that they sometimes found that head and neck lesions took longer time to diagnose.

Conclusion:

Although the utilization of OMFP specialists’ services in the state is quite low, general pathologists strongly feel the need for OMFP training as head and neck specimens form a considerable proportion of biopsies received by them.

A Comparative Study of the Perspectives of General and Oral and Maxillofacial Pathologists about the Rate and Value of Second Referral in Assessment of Oral and Maxillofacial Pathologic Lesions

The main purpose in the practice of pathology is to provide an accurate diagnosis. Second referral and reassessment by a second pathologist significantly cause diagnostic errors, help to make an accurate diagnosis, and improve patient management. This study was aimed to assess the general perspectives of general and oral and maxillofacial pathologists in Iran on second referrals. In this cross-sectional, descriptive-analytical study, a 20-item questionnaire on second referrals was used to assess the general and oral and maxillofacial pathologists' perspective in Iran. The obtained data were analyzed by chi-square and Mann-Whitney tests (α = 0.05). A total of 64 questionnaires from general and 45 questionnaires from oral and maxillofacial pathologists were collected. The findings showed 70.9% of pathologists were in favor of seeking a second opinion when faced with diagnostic challenges. Significant differences were found between the oral and general pathologists in terms of the most challenging oral and maxillofacial lesions (p value < 0.001). In total, 74.8% of pathologists suggested second opinion to be useful and productive. Both groups of pathologists approved of the second referral. However, this pattern is still different, and it is possible to improve the referral rate among both groups and to enhance the knowledge of general pathologists about second referral to oral and maxillofacial pathologists.

Review of diagnostic error in anatomical pathology and the role and value of second opinions in error prevention

Aims

Diagnostic/interpretative accuracy can be challenging in anatomical pathology due to the subjective element of the diagnostic process. This can lead to false-negative or false-positive diagnoses of malignancy, variations in grading and diagnostic misclassification of a condition.

It is imperative that an accurate diagnosis is achieved so that an appropriate and timely treatment is administered to the patient, for example, the success of targeted molecular therapeutic options for treatment of cancer is dependent on accurate anatomical pathology diagnoses being issued.

Methods

A literature review of diagnostic accuracy in selected specimen categories was undertaken and was compared with data on metropolitan and regional pathologist diagnostic proficiency performance in an external quality assurance programme from surveys provided 2015–2017. For each specimen category, cases having attracted a diagnostic inaccuracy (ie, major discordance) of ≥20% and cases attracting a combined error rate (ie, major and minor discordance) of ≥30% are reviewed and discussed.

Results

The rate of inaccurate diagnoses (assessed as a major discordance) ranged from 3% to 9% among the different specimen groups, with highest mean percentage of inaccurate diagnoses in gynaecology, dermatopathology and gastrointestinal specimens.

Conclusions

It was possible to ascertain that gynaecology, dermatopathology and gastrointestinal specimens had presented the greatest diagnostic challenge to the participant pathologists, determined as highest rate of diagnostic inaccuracy, that is, major discordance with respective case target diagnoses.

Through a combination of routine second opinions, directed retrospective peer review and participation in appropriate external quality assurance schemes, the risk associated with these diagnoses can be minimised.

The use of oral and maxillofacial pathology services by general pathologists and their attitude towards it in Saudi Arabia

OBJECTIVES

To investigate the awareness and usage of oral and maxillofacial pathology (OMFP)  subspecialty services among pathologists in Saudi Arabia. Methods: In this cross-sectional study, we conducted an electronic questionnaire survey of pathologists in all regions of Saudi Arabia. The study was conducted between July 2015 and August 2016.  The questionnaire comprised 19 questions to evaluate the knowledge of pathologists regarding microscopic OMFP and their perceptions towards this subspecialty. Results: Most of the pathologists surveyed (94.6%) were aware of the OMFP subspecialty and its scope of practice. Although most of the pathologists recognized the importance and need of this subspecialty, 70% of them never referred or consulted an oral pathologist as they either diagnosed the cases themselves or  did not know any oral pathologist (57.7%). The pathologists had the greatest difficulty in identifying and diagnosing odontogenic tumors, salivary gland tumors, and odontogenic cysts.  Conclusion: Pathologists are aware of the OMFP subspecialty, but their utilization of the services offered by OMFP specialists in Saudi Arabia is quite low despite the strong demand for OMFP services.

Intra-institutional second opinion diagnosis can reduce unnecessary surgery for indeterminate thyroid FNA: A preliminary report on 34 cases

INTRODUCTION

Indeterminate diagnoses are rendered on 15%-30% of thyroid fine-needle aspirates (FNA). Thus, a second diagnostic opinion given by an outside expert pathologist is a common practice that facilitates a more appropriate clinical management. Conversely, the role of an intra-institutional second opinion diagnosis (iSOD), which is usually informally performed in-house, has not been well established.

METHODS

To assess the contribution of iSOD, a retrospective series of 34 thyroid FNA diagnosed as follicular neoplasm/suspicious follicular neoplasm (FN/SFN) with matched histological follow-up and a malignancy rate of 17.6% was selected and independently reviewed by two cytopathologists (CYT1 and 2). Cases with discrepant diagnoses were referred to a third in-house senior cytopathologist for the iSOD. The malignancy rates (MR) obtained after single independent reviews and iSOD were compared.

RESULTS

MR obtained after CYT1 and CYT2 re-screening was similar (14.28% and 19.04%, respectively) and did not improve the original MR (17.64%). Conversely, after the iSOD of discrepant diagnoses, the overall malignancy rate increased up to the 27.27%, potentially sparing unnecessary surgical procedures.

CONCLUSIONS

Intra-institutional second opinion practice for "indeterminate" thyroid FNA avoids unnecessary surgeries and maximises the detection of malignant cases diagnosed as FN/SFN.

Incidental findings of thyroid tissue in cervical lymph nodes: old controversy not yet resolved?

The clinical significance of papillary or follicular thyroid tissue incidentally discovered in cervical lymph nodes during pathological assessment of neck dissections for non-thyroid cancers of the upper aero-digestive tract is critically reviewed. Special emphasis is given to controversies over normal-looking, nodal, thyroid follicles. Arguments for and against the benign nature of these follicles are considered together with processes that could be involved in their formation. The admittedly limited evidence suggests that benign, thyroid follicular inclusions rarely occur in cervical lymph nodes. Histological criteria that could be helpful in recognizing the inclusions, which include assessing their extent in conjunction with the size of the node, are discussed. Finally, an algorithm based on collaboration between specialists, correlating histological findings with imaging and loco-regional control of the upper aero-digestive tract cancer, is suggested for the management of patients with incidentally discovered, nodal thyroid tissue.

Does a multidisciplinary team approach in a tertiary referral centre impact on the initial management of head and neck cancer?

OBJECTIVES

A multi-disciplinary team (MDT) is essential in the management of cancer. Head and neck cancer (HNC) is a rare, complex and heterogeneous group of malignancies for which different treatment options are available. However, the potential impact of MDT on the management of HNC has been only poorly evaluated to date. This study evaluates the impact of MDT on the management of HNC in a tertiary centre.

METHODS

We retrospectively analysed records of HNC patients referred to a MDT evaluation at the Istituto Nazionale Tumori of Milan, Italy, from May 2007 to January 2012. All cases were reviewed by a MDT consisting of a head and neck surgeon, a radiation oncologist, and a medical oncologist.

RESULTS

Data from 781 HNC patients were analysed. Approximately 70% of patients were referred to our Institution for a second opinion consultation. Following MDT evaluation, new staging examinations were requested in 49% of patients, and treatment plan was modified in 10%.

CONCLUSIONS

A MDT approach in a tertiary referral hospital leads to staging refinement of disease or changes in treatment plan in about 60% of patients.

Salivary mucoepidermoid carcinoma revisited

Clinicopathological features, prognosis and therapeutic strategies for mucoepidermoid carcinoma originating in salivary and salivary-type glands of the head and neck are reviewed. We emphasise histopathological aspects, appraise the value of histochemistry, electron microscopy, immunohistochemistry and cytophotometry, and discuss histogenesis and characteristic gene translocations. We additionally consider possible diagnostic difficulties, problems related to histological grading and accuracy of existing literature, and areas of controversy or uncertainty which may benefit from further investigations.