Evidence-based medicine, medical decision analysis, and pathology

Histologic Findings in Surgical Pathology Specimens From Individuals Taking Feminizing Hormone Therapy for the Purpose of Gender Transition: A Systematic Scoping Review

CONTEXT.—

Transgender women experience health disparities in all areas of medicine. Within surgical pathology, knowledge gaps relating to the concepts of transgender care exist. Medical transition for transgender women and transfeminine persons may involve hormone therapy and/or surgery to feminize the body. Understanding the common histologic changes in specimens from feminizing surgeries, as well as other specimens from patients on feminizing hormone therapy, will aid surgical pathologists in providing better care to this unique patient population.

OBJECTIVE.—

To summarize histologic findings in surgical pathology specimens from transgender women taking feminizing hormones.

DATA SOURCES.—

A systematic review of the OVID Medline and PubMed databases was performed to identify all studies describing histologic findings in surgical pathology specimens from transgender women from 1946 to 2019.

CONCLUSIONS.—

Much of the literature to date describing histologic findings in transgender women comes from the examination of genitourinary specimens removed during feminizing surgeries. Common benign changes associated with feminizing hormone therapy include the development of acini and lobules in the breast, testicular tubular changes, and squamous metaplasia of the prostate and urethra. Neoplastic cases include breast adenocarcinoma and fibroepithelial lesions, testicular germ cell tumors, prostatic adenocarcinoma, anal squamous cell carcinoma, pituitary adenomas, and meningiomas. Additional studies assessing the findings in other organ systems as well as population-based studies assessing rates of neoplasia are needed. However, future research relies on engagement within the surgical pathology community as well as collaboration with clinicians and patients to achieve optimal results.

Can artificial intelligence overtake human intelligence on the bumpy road towards glioma therapy?

Gliomas are one of the most devastating primary brain tumors which impose significant management challenges to the clinicians. The aggressive behaviour of gliomas is mainly attributed to their rapid proliferation, unravelled genomics and the blood-brain barrier which protects the tumor cells from chemotherapeutic regimens. Suspects of brain tumors are usually assessed by magnetic resonance imaging and computed tomography. These images allow surgeons to decide on the tumor grading, intra-operative pathology, feasibility of surgery, and treatment planning. All these data are compiled manually by physicians, wherein it takes time for the validation of results and concluding the treatment modality. In this context, the arrival of artificial intelligence in this era of personalized medicine, has proven promising performance in the diagnosis and management of gliomas. Starting from grading prediction till outcome evaluation, artificial intelligence-based forefronts have revolutionized oncological research. Interestingly, this approach has also been able to precisely differentiate tumor lesion from healthy tissues. However, till date, their utility in neuro-oncological field remains limited due to the issues pertaining to their reliability and transparency. Hence, to shed novel insights on the "clinical utility of this novel approach on glioma management" and to reveal "the black-boxes that have to be solved for fruitful application of artificial intelligence in neuro-oncology research", we provide in this review, a succinct description of the potential gear of artificial intelligence-based avenues in glioma treatment and the barriers that impede their rapid implementation in neuro-oncology.

Pathologists should probably forget about kappa. Percent agreement, diagnostic specificity and related metrics provide more clinically applicable measures of interobserver variability

Kappa statistics have been widely used in the pathology literature to compare interobserver diagnostic variability (IOV) among different pathologists but there has been limited discussion about the clinical significance of kappa scores. Five representative and recent pathology papers were queried using clinically relevant specific questions to learn how IOV was evaluated and how the clinical applicability of results was interpreted. The papers supported our anecdotal impression that pathologists usually assess IOV using Cohen's or Fleiss' kappa statistics and interpret the results using some variation of the scale proposed by Landis and Koch. The papers did not cite or propose specific guidelines to comment on the clinical applicability of results. The solutions proposed to decrease IOV included the development of better diagnostic criteria and additional educational efforts, but the possibility that the entities themselves represented a continuum of morphologic findings rather than distinct diagnostic categories was not considered in any of the studies. A dataset from a previous study of IOV reported by Thunnissen et al. was recalculated to estimate percent agreement among 19 international lung pathologists for the diagnosis of 74 challenging lung neuroendocrine neoplasms. Kappa scores and diagnostic sensitivity, specificity, positive and negative predictive values were calculated using the majority consensus diagnosis for each case as the gold reference diagnosis for that case. Diagnostic specificity estimates among multiple pathologists were > 90%, although kappa scores were considerably more variable. We explain why kappa scores are of limited clinical applicability in pathology and propose the use of positive and negative percent agreement and diagnostic specificity against a gold reference diagnosis to evaluate IOV among two and multiple raters, respectively.

Prognosis in pathology: Are we "prognosticating" or only establishing correlations between independent variables and survival? A study with various analytics cautions about the overinterpretation of statistical results

Survival data from 225 patients with resected pulmonary typical carcinoids were analyzed with Kaplan-Meier statistics (K-M) and "deep learning" methods to illustrate the difference between establishing "correlations" and "prognostications". Cases were stratified into G1 and G2 classes using a ≤5% Ki-67% cut-point. Overall survival, number of patients at risk and 95% confidence intervals (CI) were estimated for the two classes. Seven neural network models (NN) were developed with GMDH Shell 3.8.2 and Statgraphics Centurion 18.1 software, using variable prior probabilities and different numbers of training vs testing cases. The NNs used age, sex, and pTNM, G1 and G2 as input neurons and "alive" and "dead" as output neurons. Areas under the curve (AUC) and other performance measures were evaluated for all models. Log-rank test showed a significant difference in overall survival between G1 and G2 (p < 0.001). However, 95% CI estimates showed considerable variability in survival at different time intervals. Including the number of patients at risk at different time intervals showed that most G2 patients had been censored by 100 weeks. The NN models provided variable "prognostications", with AUC ranging from 0.5 to 1 and variability in the sensitivity, specificity, and other performance measures. The results illustrate the limitations of survival statistics and NNs in predicting the prognosis of individual patients. The need for pathologists not to overinterpret the finding of significant correlations as "prognostic" or "predictive" for individual patients is discussed.

Emerging MRI Techniques to Redefine Treatment Response in Patients With Glioblastoma

Glioblastoma is the most common and most malignant primary brain tumor. Despite aggressive multimodal treatment, its prognosis remains poor. Even with continuous developments in MRI, which has provided us with newer insights into the diagnosis and understanding of tumor biology, response assessment in the posttherapy setting remains challenging. We believe that the integration of additional information from advanced neuroimaging techniques can further improve the diagnostic accuracy of conventional MRI. In this article, we review the utility of advanced neuroimaging techniques such as diffusion-weighted imaging, diffusion tensor imaging, perfusion-weighted imaging, proton magnetic resonance spectroscopy, and chemical exchange saturation transfer in characterizing and evaluating treatment response in patients with glioblastoma. We will also discuss the existing challenges and limitations of using these techniques in clinical settings and possible solutions to avoiding pitfalls in study design, data acquisition, and analysis for future studies. LEVEL OF EVIDENCE: 2 TECHNICAL EFFICACY STAGE: 3 J. Magn. Reson. Imaging 2020;52:978-997.

Localized malignant mesothelioma, an unusual and poorly characterized neoplasm of serosal origin: best current evidence from the literature and the International Mesothelioma Panel

Localized malignant mesotheliomas (LMM) is an uncommon and poorly recognized neoplasm. Its pathologic diagnosis is often surprising in patients with serosal/subserosal based localized tumors that are clinically suspicious for metastatic lesions or primary sarcomas. Once a tumor is diagnosed as "mesothelioma", LMM is often mistaken for diffuse malignant mesothelioma (DMM). Best currently available evidence about LMM was collected from the literature and cases diagnosed by members of the International Mesothelioma Panel (IMP). One hundred and one (101) LMM have been reported in the English literature. Patients had localized tumors with identical histopathologic features to DMM. Patients ranged in age from 6 to 82 years; 75% were men. Most (82%) of the tumors were intrathoracic. Others presented as intrahepatic, mesenteric, gastric, pancreatic, umbilical, splenic, and abdominal wall lesions. Tumors varied in size from 0.6 to 15 cm. Most patients underwent surgical resection and/or chemotherapy or radiation therapy. Median survival in a subset of patients was 29 months. Seventy two additional LMM from IMP institutions ranged in age from 28 to 95 years; 58.3% were men. Sixty tumors (83.3%) were intrathoracic, others presented in intraabdominal sites. Tumors varied in size from 1.2 to 19 cm. Median survival for 51 cases was 134 months. Best evidence was used to formulate guidelines for the diagnosis of LMM. It is important to distinguish LMM from DMM as their treatment and prognosis is different. A multidisciplinary approach is needed for the diagnosis of LMM as it shows identical histopathology and immunophenotype to DMM.

Pathology in the era of "Personalized Medicine": The need to learn how to integrate multivariate immunohistochemical and "omics" data with clinicopathologic information in a clinically relevant way"

"Personalized medicine" has been proposed as a new paradigm for patient care that, based on the integration of genomics and other "omics" data with clinical and other multidisciplinary information, promises early disease detection, improved outcomes and reduced side effects to therapies. Pathologists have become important participants in this new approach as the guardians of tissues and experts in the performance of molecular and other laboratory tests. Large amounts of new laboratory data in multiple neoplasms and other entities are being reported but there has been limited discussion about how best to evaluate the clinical significance of this information and how to integrate it into currently available diagnostic and therapeutic modalities. This article introduces a variety of epistemological problems presented by the "personalized medicine" paradigm and briefly discusses various topics that will be evaluated in further detail in future articles of this new series on Evidence-Based Pathology.

Artificial Intelligence in the Management of Glioma: Era of Personalized Medicine

Purpose: Artificial intelligence (AI) has accelerated novel discoveries across multiple disciplines including medicine. Clinical medicine suffers from a lack of AI-based applications, potentially due to lack of awareness of AI methodology. Future collaboration between computer scientists and clinicians is critical to maximize the benefits of transformative technology in this field for patients. To illustrate, we describe AI-based advances in the diagnosis and management of gliomas, the most common primary central nervous system (CNS) malignancy.

Methods: Presented is a succinct description of foundational concepts of AI approaches and their relevance to clinical medicine, geared toward clinicians without computer science backgrounds. We also review novel AI approaches in the diagnosis and management of glioma.

Results: Novel AI approaches in gliomas have been developed to predict the grading and genomics from imaging, automate the diagnosis from histopathology, and provide insight into prognosis.

Conclusion: Novel AI approaches offer acceptable performance in gliomas. Further investigation is necessary to improve the methodology and determine the full clinical utility of these novel approaches.

The Use of LPC and Wavelet Transform for Influenza Disease Modeling

In this paper, we investigated the modeling of the pathological features of the influenza disease on the human speech. The presented work is novel research based on a real database and a new combination of previously used methods, discrete wavelet transform (DWT) and linear prediction coding (LPC). Three verification system experiments, Normal/Influenza, Smokers/Influenza, and Normal/Smokers, were studied. For testing the proposed pathological system, several classification scores were calculated for the recorded database, from which we can see that the proposed method achieved very high scores, particularly for the Normal with Influenza verification system. The performance of the proposed system was also compared with other published recognition systems. The experiments of these schemes show that the proposed method is superior.

Automatic disease stage classification of glioblastoma multiforme histopathological images using deep convolutional neural network

In the field of computational histopathology, computer-assisted diagnosis systems are important in obtaining patient-specific diagnosis for various diseases and help precision medicine. Therefore, many studies on automatic analysis methods for digital pathology images have been reported. In this work, we discuss an automatic feature extraction and disease stage classification method for glioblastoma multiforme (GBM) histopathological images. In this paper, we use deep convolutional neural networks (Deep CNNs) to acquire feature descriptors and a classification scheme simultaneously. Further, comparisons with other popular CNNs objectively as well as quantitatively in this challenging classification problem is undertaken. The experiments using Glioma images from The Cancer Genome Atlas shows that we obtain 96.5 % average classification accuracy for our network and for higher cross validation folds other networks perform similarly with a higher accuracy of 98.0 % . Deep CNNs could extract significant features from the GBM histopathology images with high accuracy. Overall, the disease stage classification of GBM from histopathological images with deep CNNs is very promising and with the availability of large scale histopathological image data the deep CNNs are well suited in tackling this challenging problem.

Circulating full-length cytokeratin 18 for predicting prognosis of hepatitis B virus-related acute-on-chronic liver failure patients with lamivudine treatment

AIM

The predictive value of circulating full-length cytokeratin 18 (M65) on prognosis of hepatitis B virus-related liver failure is still not well investigated. The aim of this study was to reveal the association between serum M65 levels and outcomes of hepatitis B virus-related acute-on-chronic liver failure, and to further clarify clinical significance of M65 in lamivudine treatment.

METHODS

Ninety-six patients with hepatitis B virus-related acute-on-chronic liver failure were recruited between January 2011 and December 2013, and 52 of them received lamivudine treatment. Blood were obtained from participants at admission, and M65 were determined by enzyme-linked immunosorbent assay. Other necessary data were collected from medical records.

RESULTS

The liver failure patients were divided into high and low level groups according to the serum M65 levels. After 24-week follow up, survival incidences were significantly higher in the low level group than that in the high level group (odds ratio [OR] = 0.3, 95% confidence interval = 0.1-0.7). In addition, the survival incidences and albumin levels improved in the patients with lamivudine treatment compared with the patients without lamivudine treatment in the low level group (OR = 5.4, 95% CI = 1.1-26.0 and OR = 4.2, 95% CI = 1.3-13.2). A similar improvement was not observed in the high level group.

CONCLUSION

The study suggested that the circulating M65 may serve as a relatively independent prognostic parameter for liver failure. If prospectively validated in further studies, M65 measurement may also be a useful method for optimizing antiviral therapy.

[Principles of evidence-based medicine in dentistry and Maxillo-facial surgery]

Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.

Evidence-based pathology: systematic literature reviews as the basis for guidelines and best practices

CONTEXT

Evidence-based medicine has been proposed as a new paradigm for the identification and evaluation of medical information. Best available evidence or data are identified and used as the basis for the diagnosis and treatment of individual patients. Evidence-based pathology has adapted basic evidence-based medicine concepts to the specific needs of pathology and laboratory medicine.

OBJECTIVES

To briefly review the history and basic concepts of evidence-based medicine and evidence-based pathology, describe how to perform and interpret systematic reviews, and discuss how to integrate best evidence into guidelines.

DATA SOURCES

PubMed (National Library of Medicine, Washington, DC) and Web of Science (Thompson Reuters, New York, New York) were used.

CONCLUSIONS

Evidence-based pathology provides methodology to evaluate the quality of information published in pathology journals and apply it to the diagnosis of tissue samples and other tests from individual patients. Information is gathered through the use of systematic reviews, using a method that is less biased and more comprehensive than ad hoc literature searches. Published data are classified into evidence levels to provide readers with a quick impression about the quality and probable clinical validity of available information. Best available evidence is combined with personal experience for the formulation of evidence-based, rather than opinion-based, guidelines that address specific practice needs.

Quality and safety aspects in histopathology laboratory

Histopathology is an art of analyzing and interpreting the shapes, sizes and architectural patterns of cells and tissues within a given specific clinical background and a science by which the image is placed in the context of knowledge of pathobiology, to arrive at an accurate diagnosis. To function effectively and safely, all the procedures and activities of histopathology laboratory should be evaluated and monitored accurately. In histopathology laboratory, the concept of quality control is applicable to pre-analytical, analytical and post-analytical activities. Ensuring safety of working personnel as well as environment is also highly important. Safety issues that may come up in a histopathology lab are primarily those related to potentially hazardous chemicals, biohazardous materials, accidents linked to the equipment and instrumentation employed and general risks from electrical and fire hazards. This article discusses quality management system which can ensure quality performance in histopathology laboratory. The hazards in pathology laboratories and practical safety measures aimed at controlling the dangers are also discussed with the objective of promoting safety consciousness and the practice of laboratory safety.

Patterns in Immunohistochemical Usage in Extended Core Prostate Biopsies: Comparisons Among Genitourinary Pathologists and Nongenitourinary Pathologists

Context.—Immunohistochemical (IHC) stains have known utility in prostate biopsies and are widely used to augment routine staining in difficult cases. Patterns in IHC utilization and differences based on pathologist training and experience is understudied in the peer-reviewed literature.

Objectives.—To compare the rates of IHC usage between specialized (genitourinary; [GU]) and nonspecialized (non-GU) pathologists in extended core prostate biopsies (ECPBs) and the effects of diagnosis; and in cancer cases Gleason grade, disease extent, and perineural invasion on the rate.

Design.—Consecutive ECPBs from 2009–2011 were identified and billing data were used to determine the number of biopsies and IHC stains per case. Diagnoses were mapped and in cancer cases, Gleason grade, extent of disease, and perineural invasion were recorded. Pathologists were classified as GU or non-GU on the basis of training and experience.

Results.—A total of 618 ECPBs were included in the study. Genitourinary pathologists ordered significantly fewer IHC tests per case and per biopsy than non-GU pathologists. The rate of ordering was most disparate for biopsies of cancerous and benign lesions. For biopsies of cancerous lesions, high-grade cancer, bilateral disease, and perineural invasion decreased the rate of ordering in both groups. In cancer cases, GU pathologists ordered significantly fewer stain tests for highest Gleason grade of 3 + 3 = 6, for patients with focal disease and for patients with multiple positive bilateral cores. The effect of the various predictors on IHC ordering rates was similar in both groups.

Conclusions.—Genitourinary pathologists ordered significantly fewer IHC stain tests than non-GU pathologists in ECPBs. Guidelines to define when IHC workup is necessary and not necessary may be helpful to guide workups.

Gradient field microscopy for label-free diagnosis of human biopsies [Invited]

We introduce a label-free method for detecting high-grade prostatic intraepithelial neoplasia (HGPIN) in unstained biopsies. We image this condition based on the identification of basal cells in biopsies that otherwise would resemble prostate cancer by unassisted histologic examination. Gradient field microscopy (GFM) is used as a label-free imaging method which increases the contrast of a transparent sample by taking the first-order phase derivative that is very sensitive to rapid refractive index changes. GFM is able to image the basal cell layers in HGPIN biopsies because of their rapid refractive index changes at the periphery of small glandular structures.

Evidence-Based Principles in Pathology: Existing Problem Areas and the Development of “Quality” Practice Patterns

Context.—Contrary to the intuitive impressions of many pathologists, several areas exist in laboratory medicine where evidence-based medicine (EBM) principles are not applied. These include aspects of both anatomic and clinical pathology. Some non-EBM practices are perpetuated by clinical “consumers” of laboratory services because of inadequate education, habit, or overreliance on empirical factors. Other faulty procedures are driven by pathologists themselves.

Objectives.—To consider (1) several selected problem areas representing non-EBM practices in laboratory medicine; such examples include ideas and techniques that concern metastatic malignancies, “targeted” oncologic therapy, general laboratory testing and data utilization, evaluation of selected coagulation defects, administration of blood products, and analysis of hepatic iron-overload syndromes; and (2) EBM principles as methods for remediation of deficiencies in hospital pathology, and implements for the construction of “quality” practices in our specialty.

Data Sources.—Current English literature relating to evidence-based principles in pathology and laboratory medicine, as well as the authors' experience.

Conclusions.—Evidence-based medicine holds the promise of optimizing laboratory services to produce “quality” practices in pathology. It will also be a key to restraining the overall cost of health care.

Evidence-based pathology: umbilical cord coiling

The generation of a pathology test result must be based on criteria that are proven to be acceptably reproducible and clinically relevant to be evidence-based. This review de-constructs the umbilical cord coiling index to illustrate how it can stray from being evidence-based. Publications related to umbilical cord coiling were retrieved and analysed with regard to how the umbilical coiling index was calculated, abnormal coiling was defined and reference ranges were constructed. Errors and other influences that can occur with the measurement of the length of the umbilical cord or of the number of coils can compromise the generation of the coiling index. Definitions of abnormal coiling are not consistent in the literature. Reference ranges defining hypocoiling or hypercoiling have not taken those potential errors or the possible effect of gestational age into account. Even the way numerical test results in anatomical pathology are generated, as illustrated by the umbilical coiling index, warrants a critical analysis into its evidence base to ensure that they are reproducible or free from errors.

The pathology informatics curriculum wiki: Harnessing the power of user-generated content

BACKGROUND

The need for informatics training as part of pathology training has never been so critical, but pathology informatics is a wide and complex field and very few programs currently have the resources to provide comprehensive educational pathology informatics experiences to their residents. In this article, we present the "pathology informatics curriculum wiki", an open, on-line wiki that indexes the pathology informatics content in a larger public wiki, Wikipedia, (and other online content) and organizes it into educational modules based on the 2003 standard curriculum approved by the Association for Pathology Informatics (API).

METHODS AND RESULTS

In addition to implementing the curriculum wiki at http://pathinformatics.wikispaces.com, we have evaluated pathology informatics content in Wikipedia. Of the 199 non-duplicate terms in the API curriculum, 90% have at least one associated Wikipedia article. Furthermore, evaluation of articles on a five-point Likert scale showed high scores for comprehensiveness (4.05), quality (4.08), currency (4.18), and utility for the beginner (3.85) and advanced (3.93) learners. These results are compelling and support the thesis that Wikipedia articles can be used as the foundation for a basic curriculum in pathology informatics.

CONCLUSIONS

The pathology informatics community now has the infrastructure needed to collaboratively and openly create, maintain and distribute the pathology informatics content worldwide (Wikipedia) and also the environment (the curriculum wiki) to draw upon its own resources to index and organize this content as a sustainable basic pathology informatics educational resource. The remaining challenges are numerous, but largest by far will be to convince the pathologists to take the time and effort required to build pathology informatics content in Wikipedia and to index and organize this content for education in the curriculum wiki.

Health care systems in Sweden and China: Legal and formal organisational aspects

BACKGROUND

Sharing knowledge and experience internationally can provide valuable information, and comparative research can make an important contribution to knowledge about health care and cost-effective use of resources. Descriptions of the organisation of health care in different countries can be found, but no studies have specifically compared the legal and formal organisational systems in Sweden and China.

AIM

To describe and compare health care in Sweden and China with regard to legislation, organisation, and finance.

METHODS

Literature reviews were carried out in Sweden and China to identify literature published from 1985 to 2008 using the same keywords. References in recent studies were scrutinized, national legislation and regulations and government reports were searched, and textbooks were searched manually.

RESULTS

The health care systems in Sweden and China show dissimilarities in legislation, organisation, and finance. In Sweden there is one national law concerning health care while in China the law includes the "Hygienic Common Law" and the "Fundamental Health Law" which is under development. There is a tendency towards market-orientated solutions in both countries. Sweden has a well-developed primary health care system while the primary health care system in China is still under development and relies predominantly on hospital-based care concentrated in cities.

CONCLUSION

Despite dissimilarities in health care systems, Sweden and China have similar basic assumptions, i.e. to combine managerial-organisational efficiency with the humanitarian-egalitarian goals of health care, and both strive to provide better care for all.

Interobserver diagnostic variability at "moderate" agreement levels could significantly change the prognostic estimates of clinicopathologic studies: evaluation of the problem using evidence from patients with diffuse lung disease

Does interobserver diagnostic variability (IODV) influence the accuracy of prognostic estimates of clinicopathologic studies? "Best evidence" from usual interstitial pneumonia (UIP) and nonspecific interstitial pneumonia (NSIP) patients was used to investigate the effects of IODV. Systematic literature review identified studies of UIP and NSIP providing "best evidence." Survival proportions from studies were compared using chi(2) and meta-analysis. Interobserver diagnostic variability was simulated in the data arbitrarily at 5% to 30% intervals. The various "diagnoses" were evaluated with kappa, and chi(2) statistics were used to evaluate the interobserver agreement and compare survival proportions. The survival proportions for UIP and NSIP patients in 7 retrospective level III studies ranged from 11% to 58% and 39% to 100%, respectively. Analysis of simulation results with kappa and chi(2) statistics showed that IODV greater than 10% resulted in significantly different survival proportion estimations. Interobserver diagnostic variability at moderate agreement levels significantly influences prognostic estimates. Evaluation and minimization of IODV in future clinicopathologic studies are indicated.

Evidence-based evaluation of the risks of malignancy predicted by thyroid fine-needle aspiration biopsies

A National Cancer Institute (NCI) "Thyroid Fine-Needle Aspiration (FNA) State of the Science Conference" recently proposed standardized nomenclature and "risks of malignancies" associated with various diagnostic categories. We evaluated the evidence levels of the data used by NCI to predict malignancy risks and whether those estimates had clinical validity in our patient population.Eight hundred seventy-nine patients underwent thyroid FNA during 2006. FNA diagnoses were translated into NCI diagnostic categories, and 2-year follow-up retrospective information was obtained. Four percentages of malignancies were calculated for each diagnostic category using follow-up information from FNA, thyroidectomy, both, and all patients as denominators. 95% confidence intervals (CI) were estimated for all proportions, and results were analyzed with chi-square statistics. "Relative risk" calculations were performed using the percentage of malignancies in the entire population under study as a denominator.Most of the studies cited by the NCI provided incomplete and variable level III evidence based mainly on surgical follow-up. Among our patients, the percentages of malignancies calculated with follow-up data from all patients as the denominator were similar to the "risk estimates" proposed by the NCI, but estimates based on surgical follow-up overestimated the probability of thyroid malignancy for patients with FNA diagnosis of "benign" and "follicular lesions of undetermined significance" (FLUS). Relative risk and 95% CI calculations suggested that the NCI classification could be simplified into three categories: "benign," "FLUS + neoplasm," and "suspicious + malignant."

Overview of laboratory data tools available in a single electronic medical record

BACKGROUND

Laboratory data account for the bulk of data stored in any given electronic medical record (EMR). To best serve the user, electronic laboratory data needs to be flexible and customizable. Our aim was to determine the various ways in which laboratory data get utilized by clinicians in our health system's EMR.

METHOD

All electronic menus, tabs, flowsheets, notes and subsections within the EMR (Millennium v2007.13, Cerner Corporation, Kansas City, MO, US) were explored to determine how clinicians utilize discrete laboratory data.

RESULTS

LABORATORY DATA IN THE EMR WERE UTILIZED BY CLINICIANS IN FIVE DISTINCT WAYS: within flowsheets, their personal inbox (EMR messaging), with decision support tools, in the health maintenance tool, and when incorporating laboratory data into their clinical notes and letters.

CONCLUSIONS

Flexible electronic laboratory data in the EMR hava many advantages. Users can view, sort, pool, and appropriately route laboratory information to better support trend analyses, clinical decision making, and clinical charting. Laboratory data in the EMR can also be utilized to develop clinical decision support tools. Pathologists need to participate in the creation of these EMR tools in order to better support the appropriate utilization of laboratory information in the EMR.

Diagnosis of Metastatic Neoplasms: A Clinicopathologic and Morphologic Approach

Context.—The diagnosis of the site of origin of metastatic neoplasms often poses a challenge to practicing pathologists. A variety of immunohistochemical and molecular tests have been proposed for the identification of tumor site of origin, but these methods are no substitute for careful attention to the pathologic features of tumors and their correlation with imaging findings and other clinical data. The current trend in anatomic pathology is to overly rely on immunohistochemical and molecular tests to identify the site of origin of metastatic neoplasms, but this “shotgun approach” is often costly and can result in contradictory and even erroneous conclusions about the site of origin of a metastatic neoplasm.

Objective.—To describe the use of a systematic approach to the evaluation of metastatic neoplasms.

Data Sources.—Literature review and personal experience.

Conclusions.—A systematic approach can frequently help to narrow down differential diagnoses for a patient to a few likely tumor sites of origin that can be confirmed or excluded with the use of selected immunohistochemistry and/or molecular tests. This approach involves the qualitative evaluation of the “pretest and posttest probabilities” of various diagnoses before the immunohistochemical and molecular tests are ordered. Pretest probabilities are qualitatively estimated for each individual by taking into consideration the patient's age, sex, clinical history, imaging findings, and location of the metastases. This estimate is further narrowed by qualitatively evaluating, through careful observation of a variety of gross pathology and histopathologic features, the posttest probabilities of the most likely tumor sites of origin. Multiple examples of the use of this systematic approach for the evaluation of metastatic lesions are discussed.

Challenges of the "omics" future and pathology informatics systems: are we--pathologists, clinicians, and consumers--ready?

The health care system is extremely complex and it is currently undergoing a massive transformation with rapid advances in technology. Pathology services have been leading the technology adaptation process and will continue to evolve rapidly with the introduction of "omics" technology. Future pathology informatics systems (PIS) will need to meet the needs of pathologists, clinicians, organizations, community services as well as the expectations of patients, especially given the complexity of "omics" technology. Technology advances, however, often progress at a pace faster than socio-cultural adaptation. A major question therefore arises, "Are we ready?" This article explores the socio-cultural-technical issues and provides a conceptual framework for future discussion about socio-cultural integration in the use of technology to provide a seamless delivery of patient-centered care. It discusses system requirements of future PIS in the context of rapid evolution of medical care. Finally, this article proposes some strategies for the design and implementation of future PIS to achieve socio-cultural-technical harmony in the "omics" era.

Unison or cacophony: postgraduate training in pathology in Europe

With the free movement of people in the European Union, medical mobility has increased significantly. This is notably the case for disciplines for which shortage of well-trained staff has occurred. Pathology is among those specialties and effectively the discipline is confronted with a striking increase in mobility among trainees and qualified specialists. The presumption underlying unlimited mobility is that the competencies of the medical specialists in the European countries are more or less equal, including significant similarities in the postgraduate training programs. In order to assess whether reality corresponds with this presumption, we conducted a survey of the content and practice requirements of the curricula in the EU and affiliated countries. The results indicate a striking heterogeneity in the training program content and practice requirements. To name a few elements: duration of the training program varied between 4 and 6 years; the number of autopsies required varied between none at all and 300; the number of biopsies required varied between none at all and 15,000. We conclude that harmonization of training outcomes in Europe is a goal that needs to be pursued. This will be difficult to reach through harmonization of training programs, as these are co-determined by political, cultural, and administrative factors, difficult to influence. Harmonization might be attained by defining the general and specific competencies at the end of training and subsequent testing them through a test to which all trainees in Europe are subjected.

Evidence-Based Pathology and the Pathologic Evaluation of Thymomas: Transcapsular Invasion Is Not a Significant Prognostic Feature

Context.—Evaluation of transcapsular invasion is currently considered very important in the pathologic examination of thymomas. However, recent studies have questioned the prognostic value of stratifying thymoma patients into stage I and II disease. Evidence-based pathology promotes the use of systematic reviews of literature and meta-analysis of data to synthesize the results of multiple publications.

Objective.—To analyze the data in the literature regarding the prognostic importance of transcapsular invasion in thymoma stage I and II.

Design.—A systematic review of the English literature was carried out for “thymoma,” “stage,” and “prognoses.” Case reports, case series with fewer than 10 cases, and studies with follow-up periods shorter than 5 years were excluded. Twenty-one retrospective publications reporting the experience with 2451 thymomas were selected for review, including 1419 stage I and 1032 stage II patients. Meta-analysis was performed, and possible publication bias was studied with funnel plots of precision and various statistics.

Results.—Meta-analysis yielded no significant differences in disease-free or overall survival rates in stage I and II thymoma patients. Funnel plots of precision and statistical tests such as the Egger regression intercept test showed no significant publication bias.

Conclusions.—The lack of significant differences in the prognosis of patients with stages I and II thymoma suggests that evaluation of transcapsular invasion is of no clinical value in tumors that lack invasion of neighboring organs or the pleura. The data regarding the prognosis of stage II thymoma patients is somewhat heterogenous, with only some individuals having been treated with radiation therapy, suggesting the need for future randomized controlled trials.

Evidence-based Guidelines for the Utilization of Immunostains in Diagnostic Pathology: Pulmonary Adenocarcinoma Versus Mesothelioma

There are no firmly established guidelines for the use of antibodies in immunohistology as individual tests or panels. Practicing pathologists must rely on information available in individual publications, review articles, books, and internet-based databases to develop diagnostic immunohistochemical algorithms for their individual practices. In contrast, other medical specialties have crafted many evidence-based practice guidelines (EBG) that are widely used; these have helped to augment standardization and cost effectiveness. In particular, the use of several "epithelial" and "mesothelial" antibodies has been proposed to distinguish epithelioid malignant mesothelioma from metastatic pulmonary adenocarcinoma. Other authors have previously done systematic literature reviews of this subject up through 2004 and integrated the results of 88 publications into summarized test-performance values for 15 preselected immunohistochemical markers. The results suggested that 7 tests provide optimal sensitivity and specificity (MOC-31, BG8, CEA, TTF-1, CK5/6, WT-1, and HBME-1), but they provide no guidance for integration of such data into EBG. Odds ratios (ORs) were employed to compare the effectiveness of any single test, and chosen combinations thereof, in the differential diagnosis of malignant mesothelioma and metastatic pulmonary adenocarcinoma. Surprisingly, selected single immunostains or antibody pairs yielded ORs (varying from 96.34 to 1233.19) that were equal or better in efficacy when compared with more comprehensive panels. These results support the potential value of systematic reviews, meta-analysis, and OR calculations for development of EBG in diagnostic immunohistology.

Pathogen profiling for disease management and surveillance

The usefulness of rapid pathogen genotyping is widely recognized, but its effective interpretation and application requires integration into clinical and public health decision-making. How can pathogen genotyping data best be translated to inform disease management and surveillance? Pathogen profiling integrates microbial genomics data into communicable disease control by consolidating phenotypic identity-based methods with DNA microarrays, proteomics, metabolomics and sequence-based typing. Sharing data on pathogen profiles should facilitate our understanding of transmission patterns and the dynamics of epidemics.

Original research in pathology: judgment, or evidence-based medicine?

Pathology is both a medical specialty and an investigative scientific discipline, concerned with understanding the essential nature of human disease. Ultimately, pathology is accountable as well, as measured by the accuracy of our diagnoses and the resultant patient care outcomes. As such, we must consider the evidence base underlying our practices. Within the realm of Laboratory Medicine, extensive attention has been given to testing accuracy and precision. Critical examination of the evidence base supporting the clinical use of specific laboratory tests or technologies is a separate endeavor, to which specific attention must be given. In the case of anatomic pathology and more specifically surgical pathology, the expertise required to render a diagnosis is derived foremost from experience, both personal and literature-based. In the first instance, knowledge of the linkage between one's own diagnoses and individual patient outcomes is required, to validate the role of one's own interpretations in the clinical course of patients. Experience comes from seeing this linkage first hand, from which hopefully comes wisdom and, ultimately, good clinical judgment. In the second instance, reading the literature and learning from experts is required. Only a minority of the relevant literature is published in pathology journals to which one may subscribe. A substantial portion of major papers relevant to the practice of anatomic pathology are published in collateral clinical specialty journals devoted to specific disease areas or organs. Active effort is therefore required to seek out the literature beyond the domain of pathology journals. In examining the published literature, the essential question then becomes: Does the practice of anatomic pathology fulfill the tenets of 'evidence-based medicine' (EBM)? If the pinnacle of EBM is 'systematic review of randomized clinical trials, with or without meta-analysis', then anatomic pathology falls far short. Our published literature is largely observational in nature, with reports of case series (with or without statistical analysis) constituting the majority of our 'evidence base'. Moreover, anatomic pathology is subject to 'interobserver variation', and potentially to 'error'. Taken further, individual interpretation of tissue samples is not an objective endeavor, and it is not easy to fulfill the role of a 'gold standard'. Both for rendering of an overall interpretation, and for providing the semi-quantitative and quantitative numerical 'scores' which support evidence-based clinical treatment algorithms, the Pathologist has to exercise a high level of interpretive judgment. Nevertheless, the contribution of anatomic pathology to 'EBM' is remarkably strong. To the extent that our judgmental interpretations become data, our tissue interpretations become the arbiters of patient care management decisions. In a more global sense, we support highly successful cancer screening programs, and play critical roles in the multidisciplinary management of complex patients. The true error is for the clinical practitioners of 'EBM' to forget the contribution to the supporting evidence base of the physicians that are Anatomic Pathologists. Finally, the academic productivity of pathology faculty who operate in the clinical realm must be considered. A survey of six North American academic pathology departments reveals that 26% of all papers published in 2005 came from 'unfunded' clinical faculty. While it is likely that their academic productivity is lower than that of 'funded' research faculty, the contribution of clinical faculty to the knowledge base for the practice of modern medicine, and to the academic reputation of the department, must not be overlooked. The ability of clinical faculty in academic departments of pathology to pursue original scholarship must be supported if our specialty is to retain its preeminence as an investigative scientific discipline in the age of EBM.

What is quality in surgical pathology?

Quality in surgical pathology may be defined as accurate, timely, and complete reports. Achieving quality requires substantial investment in the basic structure and in the people who undertake surgical pathology. Quality assurance and improvement works best when it is woven into the systems of surgical pathology with well informed, well trained, and knowledgeable staff.

Evidence-based interpretation of liver biopsies

'Evidence based medicine' is a paradigm introduced in the 1990s in which collection of clinical data in a reproducible and unbiased way is intended to guide clinical decision-making. This paradigm has been promulgated across the spectrum of medicine, but with more limited critical analysis in the realm of pathology. The 'evidence base' in support of our practices in Anatomic Pathology is a critical issue, given the key role that such diagnoses play in patient management decisions. The question is, 'On what basis are diagnostic opinions rendered in Anatomic Pathology?' The operative question becomes, 'What is the published literature that supports our anatomic pathology interpretations?' This second question was applied to the published literature in Hepatopathology, by identifying the 'citation classics' of this discipline. Specifically, the top 150 most-cited liver pathology articles were analyzed for: authorship; journal of publication; type of publication; and year of publication. Results are as follows. First, it is indeed true that the preeminent hepatopathologists of the age are the most cited authors in the 'top 150'. Second, the most cited articles in hepatopathology are not published in the pathology literature, but are instead published in much higher impact clinical journals. Third, the pathology of viral hepatitis is demonstrated to be extraordinarily well-grounded in 'evidence based medicine'. Much of the remainder of the hepatopathology literature falls into a 'narrative based' paradigm, which is the rigorous reporting of case experience without statistical clinical outcomes validation. Finally, the years of publication reflect, on the one hand, a vigorous recent literature in the pharmaceutical treatment of viral hepatitis, and on the other, a broadly distributed set of 'narrative' articles from the 1960s, 1970s, 1980s, and 1990s. In conclusion, the discipline of hepatopathology appears to be well-grounded in 'evidence based medicine' in the realm of viral hepatitis. The remainder of our discipline rests predominantly upon the time-honored identification of disease process through the publication of narrative case series.

dbZach: A MIAME-compliant toxicogenomic supportive relational database

Quantitative risk assessment and the elucidation of mechanisms of toxicity requires computational infrastructure and innovative analysis approaches that systematically consider available data at all levels of biological organization. dbZach (http://dbzach.fst.msu.edu) is a modular relational database with associated data insertion, retrieval, and mining tools that manages traditional toxicology and complementary toxicogenomic data to facilitate comprehensive data integration, analysis, and sharing. It consists of four Core Subsystems (i.e., Clones, Genes, Sample Annotation, and Protocols), four Experimental Subsystems (i.e., Microarray, Affymetrix, Real-Time PCR, and Toxicology), and three Computational Subsystems (i.e., Gene Regulation, Pathways, Orthology) that comply with the Minimum Information About a Microarray Experiment (MIAME) standard. It is capable of including emerging technologies and other model systems, including ecologically relevant species. dbZach represents an enterprise toxicogenomic data management system which facilitates data integration and analysis, and reduces uncertainties in the continuum from initial exposure to toxicity while facilitating more comprehensive elucidations of mechanisms of toxicity and supporting mechanistically-based quantitative risk assessment.

Deoxyribonucleic acid content as an indicator of progression of squamous cell carcinogenesis in the esophagus: Comparative analysis on imprint-cytospin and tissue section preparation

BACKGROUND

The purpose of this study was to explore the potential use of image analysis on tissue sections preparation as a predictive marker of early malignant changes during squamous cell (SC) carcinogenesis in the esophagus. Results of DNA ploidy quantification on formalin-fixed, paraffin-embedded tissue using two different techniques were compared: imprint-cytospin and 6 microm thick tissue sections preparation.

METHODS

This retrospective study included 26 surgical specimens of squamous cell carcinoma (SCC) from patients who underwent surgery alone at the Department of Surgery in CHUV Hospital in Lausanne between January 1993 and December 2000. We analyzed 53 samples of healthy tissue, 43 tumors and 7 lymph node metastases.

RESULTS

Diploid DNA histogram patterns were observed in all histologically healthy tissues, either distant or proximal to the lesion. Aneuploidy was observed in 34 (79%) of 43 carcinomas, namely 24 (75%) of 32 early squamous cell carcinomas and 10 (91%) of 11 advanced carcinomas. DNA content was similar in the different tumor stages, whether patients presented with single or multiple synchronous tumors. All lymph node metastases had similar DNA content as their primary tumor.

CONCLUSIONS

Early malignant changes in the esophagus are associated with alteration in DNA content, and aneuploidy tends to correlate with progression of invasive SCC. A very good correlation between imprint-cytospin and tissue section analysis was observed. Although each method used here showed advantages and disadvantages; tissue sections preparation provided useful information on aberrant cell-cycle regulation and helped select the optimal treatment for the individual patient along with consideration of other clinical parameters.

Prognostic and predictive factors in prostate cancer: historical perspectives and recent international consensus initiatives

An understanding of prognosis in cancer medicine is important for patient care, research and cancer control programs. In prostate cancer, prognostic (predictive) factors are particularly important given the marked heterogeneity of this disease at clinical, morphologic and biomolecular levels. Clinical stage and histologic grade have historically played major roles in defining heterogeneity in prostate cancer. More recently, serum prostate-specific antigen measurement has assumed a significant prognostic role. Over the last two decades there has been an explosion of research into biomarkers, many of which have been purported to have prognostic significance. In this paper we present an overview of the various consensus initiatives that have transpired over the last dozen years. Criteria for evaluating prognostic factors and classifications of predictive factors have emerged that have proven useful and advanced our understanding of the biology of prostate cancer. The results of these consensus initiatives form a foundation on which the current international consultation on prognosis (prediction) in prostate cancer is built. Advances in our understanding of the new and promising prognostic factors will require a more rigorous evidence-based approach to the analysis of published studies. Furthermore, appropriate mathematical models for the analysis of the multiple factors that influence a prognostic system will have to be employed.

Evidence-based medicine in pathology: an introduction

Evidence-based medicine (EBM) is a school of thought that has spread rapidly through medicine in the past 2 decades and is eliciting an increasing interest in Anatomic Pathology and Laboratory Medicine. It has been defined as "the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients." The environmental factors that created a need for EBM and basic concepts of this discipline are reviewed. Methods for the accrual and critical appraisal of the validity of available evidence and its impact, applicability and usefulness in pathology practice are discussed. Basic concepts of bayesian data analysis with an emphasis on concepts such as prior and posterior probability and the use of "holdout" or "test" data are introduced. The future of EBM in pathology is discussed and potential applications of these concepts to pathology practice and research are proposed.

The application of special technologies in diagnostic anatomic pathology: is it consistent with the principles of evidence-based medicine?

Proponents of evidence-based medicine (EBM) have emphasized the need to consider the quality of different sources of medical information and have proposed various methods to integrate available "best evidence" into rules, guidelines and other diagnostic, therapeutic and prognostic models. The various factors that can affect the internal validity of studies in anatomic pathology, such as interobserver variability, use of retrospective rather than prospective data and others, are reviewed. The need for testing for the external validity of the results of anatomic pathology studies is introduced, using "test sets" of cases that have not been used to generate the classification or prognostic models. This methodology has been seldom used in anatomic pathology to validate the generalizability of various "entities," usefulness of diagnostic tests under different conditions and other information. Basic concepts of meta-analysis for research synthesis are introduced; these methods have been seldom used in anatomic pathology to integrate information from different studies using quantitative techniques rather than summary tables that merely list the results of various publications. The potential use of decision analysis and value of information analysis for the adoption of new tests is briefly discussed.

Evidence-based principles and practices in pathology: selected problem areas

Contrary to the intuitive impression of most pathologists, there are still many areas in laboratory medicine where evidence-based medicine (EBM) principles are not applied. These include aspects of both anatomic and clinical pathology. Some non-EBM practices are perpetuated by clinical "consumers" of laboratory services, because of inadequate education, habit, or over-reliance on empirical factors. Other faulty procedures are pathologist-driven, with similar underpinnings. This overview considers several exemplary problem areas representing non-EBM practices in the hospital laboratory. Such examples include ideas and techniques centering on metastatic malignancies, "targeted" oncological therapy, analysis of surgical margins in the excision of neoplasms, general laboratory testing and data utilization, evaluation of selected coagulation defects, administration of blood products, and analysis of hepatic iron-overload syndromes. The concepts illustrating departures from EBM are discussed for each of those topics.