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

Improving Interdisciplinary Communication and Pathology Reporting for Head and Neck Cancer Resections: 3D Visualizations and Margin Reconciliation

PURPOSE

Surgical pathology reports play an integral role in postoperative management of head and neck cancer patients. Pathology reports of complex head and neck resections must convey critical information to all involved clinicians. Previously, we demonstrated the utility of 3D specimen and defect scanning for communicating margin status and documenting the location of supplemental margins. We introduce a newly designed permanent pathology report which improves documentation of intraoperative margin mapping and extent of corresponding supplemental margins harvested.

METHODS

We test the hypothesis that gaps in understanding exist for head and neck resection pathology reports across providers. A cross-sectional exploratory study using human-centered design was implemented to evaluate the existing permanent pathology report with respect to understanding margin status. Pathologists, surgeons, radiation oncologists, and medical oncologists from United States-based medical institutions were surveyed. The results supported a redesign of our surgical pathology template, incorporating 3D specimen / defect scans and annotated radiographic images indicating the location of inadequate margins requiring supplemental margins, or indicating frankly positive margins discovered on permanent section.

RESULTS

Forty-seven physicians completed our survey. Analyzing surgical pathology reports, 28/47 (60%) respondents reported confusion whether re-excised supplemental margins reflected clear margins, 20/47 (43%) reported uncertainty regarding final margin status, and 20/47 (43%) reported the need for clarity regarding the extent of supplemental margins harvested intraoperatively. From this feedback, we designed a new pathology report template; 61 permanent pathology reports were compiled with this new template over a 12-month period.

CONCLUSION

Feedback from survey respondents led to a redesigned permanent pathology report that offers detailed visual anatomic information regarding intraoperative margin findings and exact location/size of harvested supplemental margins. This newly designed report reconciles frozen and permanent section results and includes annotated radiographic images such that clinicians can discern precise actions taken by surgeons to address inadequate margins, as well as to understand the location of areas of concern that may influence adjuvant radiation planning.

Mesothelioma in the pleura, pericardium and peritoneum: Recommendations from the International Collaboration on Cancer Reporting (ICCR)

AIMS

Mesothelioma is a rare malignancy of the serosal membranes that is commonly related to exposure to asbestos. Despite extensive research and clinical trials, prognosis to date remains poor. Consistent, comprehensive and reproducible pathology reporting form the basis of all future interventions for an individual patient, but also ensures that meaningful data are collected to identify predictive and prognostic markers.

METHODS AND RESULTS

This article details the International Collaboration on Cancer Reporting (ICCR) process and the development of the international consensus mesothelioma reporting data set. It describes the 'core' and 'non-core' elements to be included in pathology reports for mesothelioma of all sites, inclusive of clinical, macroscopic, microscopic and ancillary testing considerations. An international expert panel consisting of pathologists and a medical oncologist produced a set of data items for biopsy and resection specimens based on a critical review and discussion of current evidence, and in light of the changes in the 2021 WHO Classification of Tumours. The commentary focuses particularly upon new entities such as mesothelioma in situ and provides background on relevant and essential ancillary testing as well as implementation of the new requirement for tumour grading.

CONCLUSION

We recommend widespread and consistent implementation of this data set, which will facilitate accurate reporting and enhance the consistency of data collection, improve the comparison of epidemiological data, support retrospective research and ultimately help to improve clinical outcomes. To this end, all data sets are freely available worldwide on the ICCR website (www.iccr-cancer.org/data-sets).

The Significance of Unsampled Microscopic Thyroid Carcinomas in Multinodular Goiter

Thorough gross examination and appropriate sampling of the thyroidectomy specimens are fundamental to the diagnosis and clinical risk management of patients. This study aims to investigate the frequency and clinical significance of initially unsampled microscopic thyroid carcinomas in total thyroidectomy specimens with presumed benign multinodular thyroid disease. Seventy-two total thyroidectomy specimens belonging to multinodular goiter patients were randomly selected and included in this prospectively designed study. Inclusion criteria were set as no suspicion of malignancy before surgery as well as lack of intra-parenchymal primary thyroid carcinoma after histopathological evaluation of slides generated from initial sampling. Subsequently, the remaining thyroidectomy specimens were submitted for microscopic examination and sign-outs were finalized following the microscopic examination of the entire thyroid tissue. Microcarcinomas, with a maximum diameter of 3.5 mm, were detected in 29 cases (40.2%) after the whole gland sampling. Although most of these tumors were low-risk papillary microcarcinomas confined to the thyroid, one specimen also showed a medullary microcarcinoma measuring 1.5 mm. Three had micrometastatic nodal disease. There was no local recurrence or distant metastatic disease during the follow-up (mean 51.4 months). This study further supports microscopic carcinomas, including papillary microcarcinoma, and medullary microcarcinoma might stay hidden in thyroidectomy specimens. Increased glandular weight, male gender, and advanced age were significant risk factors in the detection of microcarcinomas in this series. While each multinodular thyroidectomy specimen is unique, we recommend dynamic extensive sampling (rather than bare-minimum approach) strategy based on careful gross and initial histologic examination findings as well as by taking into consideration risk factors.

Survey of medical malpractice cases and settlements with pathology or laboratory standard of care issues

Medicolegal liability is an issue of concern for all physicians, including pathologists. Identification of the key clinical issues that tend to lead to medical malpractice litigation, as well as the settlement values for such claims, can be useful for prospective risk management. This review analyzes medical malpractice claims filed in state and federal courts as published in legal databases. Additionally, this review also analyzes the reported settlement values for such claims.

Specimen Identification Errors in Breast Biopsies: Age Matters. Report of Two Near-Miss Events and Review of the Literature

The consequences of patient identification errors due to specimen mislabeling can be deleterious. We describe two near-miss events involving mislabeled breast specimens from two patients who sought treatment at our institution. In both cases, microscopic review of the slides identified inconsistencies between the histologic findings and patient age, unveiling specimen identification errors. By correlating the clinical information with the microscopic findings, we identified mistakes that had occurred at the time of specimen accessioning at the original laboratories. In both cases, thanks to a timely reassignment of the specimens, the patients suffered no harm. These cases highlight the importance of routine clinical and pathologic correlation as a critical component of quality assurance and patient safety. A review of possible specimen identification errors in the anatomic pathology setting is presented.

Dataset for Reporting of Malignant Mesothelioma of the Pleura or Peritoneum: Recommendations From the International Collaboration on Cancer Reporting (ICCR)

CONTEXT

-The International Collaboration on Cancer Reporting is a not-for-profit organization formed by the Royal Colleges of Pathologists of Australasia and the United Kingdom; the College of American Pathologists; the Canadian Association of Pathologists-Association Canadienne des Pathologists, in association with the Canadian Partnership Against Cancer; and the European Society of Pathology. Its goal is to produce common, internationally agreed upon, evidence-based datasets for use throughout the world.

OBJECTIVE

-To describe a dataset developed by the Expert Panel of the International Collaboration on Cancer Reporting for reporting malignant mesothelioma of both the pleura and peritoneum. The dataset is composed of "required" (mandatory) and "recommended" (nonmandatory) elements.

DESIGN

-Based on a review of the most recent evidence and supported by explanatory commentary.

RESULTS

-Eight required elements and 7 recommended elements were agreed upon by the Expert Panel to represent the essential information for reporting malignant mesothelioma of the pleura and peritoneum.

CONCLUSIONS

-In time, the widespread use of an internationally agreed upon, structured, pathology dataset for mesothelioma will lead not only to improved patient management but also provide valuable data for research and international benchmarks.