Clinicians are from Mars and pathologists are from Venus

Modifying phrases in veterinary pathology diagnostic reports: The veterinary professionals' perception on the diagnostic confidence

Pathologists use modifying phrases (MPs) to express diagnostic confidence (DC) in the diagnosis when essential features of a lesion are lacking. Although commonly used, a standardized application and shared definitions of MPs are not recognized, resulting in a discretional use in veterinary pathology reports. Through an anonymous online survey, this study explored how different groups (veterinary pathologists, general practitioners, specialists of other specialties, residents, and students) perceive selected MPs used in veterinary pathology reports, evaluated their impact on the clinical decision, and provided a possible indication on their use. Participants (n = 753) responded from various continents. The highest DC was generally perceived for the term "diagnostic of," in all groups. "Compatible with," "indicative of," and "consistent with" were also generally perceived with high DC. The DC was lower for the other MPs ("suggestive of," "suspicious for," and "cannot rule out"). MPs perceived as having the highest DC were more often interpreted as definitive diagnoses, while those with lower DC were more likely perceived as suggestions to perform additional diagnostic tests. Pathology reports may benefit from using the comment section to further clarify the level of certainty of the diagnosis. Limitations in the data's representativeness arise from the non-probabilistic sampling and a predominance of a single nation's participants. Despite this, our study provides valuable insights into the perception and clinical impact of MPs, providing a foundation for discussions aimed in standardizing their use in veterinary pathology reports. Adopting consistent and uniform MPs could improve communication between pathologists and clinicians and patient care.

From classroom to clinic: evaluating a clinical pathology course to strengthen pathology report literacy of medical interns

BACKGROUND

Pathology reports serve as the primary communication tool between pathologists and clinicians, directly influencing clinical decision-making and treatment strategies. Despite their critical role, medical students may struggle with interpreting these reports, which can lead to miscommunication and potential diagnostic errors. This study investigated the impact of incorporating a clinical pathology course into the routine medical curriculum to enhance medical students' understanding of pathology reports and their satisfaction with the course.

METHODS

This cross-sectional study involved 92 medical students in their internship phase, who were divided into two groups: those who had completed the clinical pathology course and those who had not. The participants were provided with two pathology reports (covering malignant and benign gastrointestinal diseases) and a self-administered questionnaire consisting of 24 items. The data were analyzed via the chi-square test to assess significant differences between groups.

RESULTS

Medical interns who completed the course demonstrated significantly higher rates of moderate interpretation scores (80.43% vs. 63.04%) and lower rates of weak scores (6.53% vs. 32.61%) compared to those who did not participate (p = 0.001). Interns who passed the clinical pathology course had a significantly greater mean number of correct answers for interpreting malignant cases reports (p = 0.04), although no significant difference was found for benign cases reports (p = 0.93). Most interns who completed the course reported that it helped improve their interpretation skills, although some felt that the perceived benefits were limited. Additionally, the study identified key challenges students still faced when interpreting pathology reports including difficulties with pathology report terminology, understanding cancer staging abbreviations, and applying basic pathology concepts in clinical context.

CONCLUSIONS

Our findings suggest that clinical pathology courses can improve medical students' understanding of pathology reports, particularly in cases of cancer, but improvements in course content and teaching methods are needed. This research offers valuable insights into improving medical education.

Development of a Scoring Rubric Assessing Medical Students' Explanations of Pathology Reports

CONTEXT.—

With increasing availability of immediate patient access to pathology reports, it is imperative that all physicians be equipped to discuss pathology reports with their patients. No validated measures exist to assess how pathology report findings are communicated during patient encounters.

OBJECTIVE.—

To pilot a scoring rubric evaluating medical students' communication of pathology reports to standardized patients.

DESIGN.—

The rubric was iteratively developed using the Pathology Competencies for Medical Education and Accreditation Council for Graduate Medical Education pathology residency milestones. After a brief training program, third- and fourth-year medical students completed 2 standardized patient encounters, presenting simulated benign and malignant pathology reports. Encounters were video recorded and scored by 2 pathologists to calculate overall and item-specific interrater reliability.

RESULTS.—

All students recognized the need for pathology report teaching, which was lacking in their medical curriculum. Interrater agreement was high for malignant report scores (intraclass correlation coefficient, 0.65) but negligible for benign reports (intraclass correlation coefficient, 0). On malignant reports, most items demonstrated good interrater agreement, except for discussing the block (cassette) summary, explaining the purpose of the pathology report, and acknowledging uncertainty. Participating students (N = 9) felt the training was valuable given their limited prior exposure to pathology reports.

CONCLUSIONS.—

This pilot study demonstrates the feasibility of using a structured rubric to assess the communication of pathology reports to patients. Our findings also provide a scalable example of training on pathology report communication, which can be incorporated in the undergraduate medical curriculum to equip more physicians to facilitate patients' understanding of their pathology reports.

Visual pathology reports for improved collaboration at multidisciplinary head and neck tumor board

PURPOSE

Multidisciplinary tumor boards (TB) are the standard for discussing complex head and neck cancer cases. During TB, imaging and microscopic pathology is reviewed, but there is typically no visualization of the resected cancer.

METHODS

A pilot study was conducted to investigate the utility of visual pathology reports at weekly TB for 10 consecutive weeks. Faculty-level participants completed a pre-survey and post-survey to assess understanding of resected cancer specimens.

RESULTS

Providers (n = 25) across seven medical specialties completed pre-survey and post-survey. Following intervention, providers reported significant improvement in understanding of anatomic orientation of the specimen and sites of margin sampling (mean 47.4-96.1, p < 0.001), ability to locate the site of a positive margin (mean 69.5-91.1, p < 0.001), and confidence in treatment plans created (mean 69.5-89.2, p < 0.001) with the addition of visual pathology reports.

CONCLUSIONS

Visual pathology reports improve provider understanding of resected cancer specimens at multidisciplinary TB.

3D Scanning of Surgical Specimens to Improve Communication Between Surgeon and Pathologist: A Head and Neck Pilot Study

Background/Objectives Successful surgical outcomes in head and neck cancer depend on the accurate identification of resection margins. Effective communication between surgeons and pathologists is critical, but is often jeopardised by challenges in sampling and orienting anatomically complex specimens. This pilot study aims to evaluate the use of 3D scanning of surgical specimens as a tool to improve communication and optimise the pathology sampling process. Methods Two structured light 3D scanners, Cronos Dual and Optor Lab, were used to acquire 3D models of anatomical specimens in both preclinical (cadaver specimens) and clinical contexts (fresh surgical specimens). Surgical margins and critical points were annotated on the digital models. Acquisition quality, operating times and subjective feedback from surgeons and pathologists were evaluated. Results The Optor Lab scanner demonstrated superior image quality, shorter processing times and a more user-friendly interface than the Cronos Dual. Key challenges identified included specimen geometry, surface reflectivity and tissue stability. Feedback from both surgeons and pathologists was positive, highlighting the potential of 3D models to improve the surgical-pathology workflow. Conclusions 3D scanning of surgical specimens provides accurate, detailed digital models that can significantly enhance communication between surgeons and pathologists. This technology shows promise in improving pathological staging and clinical decision making, with further studies required to validate its integration into routine practice.

Visual pathology reports for communication of final margin status in laryngeal cancer surgery

Background

Positive margins are frequently observed in total laryngectomy (TL) specimens. Effective communication of margin sampling sites and final margin status between surgeons and pathologists is crucial. In this study, we evaluate the utility of multimedia visual pathology reports to facilitate interdisciplinary discussion of margin status in laryngeal cancer surgery.

Methods

Ex vivo laryngeal cancer surgical specimens were three-dimensional (3D) scanned before standard of care pathological analysis. Using computer-aided design software, the 3D model was annotated to reflect inking, sectioning, and margin sampling sites, generating a visual pathology report. These reports were distributed to head and neck surgeons and pathologists postoperatively.

Results

Fifteen laryngeal cancer surgical specimens were 3D scanned and virtually annotated from January 2022 to December 2023. Most specimens (73.3%) were squamous cell carcinomas (SCCs). Among the cases, 26.7% had final positive surgical margins, whereas 13.3% had close margins, defined as <5 mm. The visual pathology report demonstrated sites of close or positive margins on the 3D specimens and was used to facilitate postoperative communication between surgeons and pathologists in 85.7% of these cases. Visual pathology reports were presented in multidisciplinary tumor board discussions (20%), email correspondences (13.3%), and teleconferences (6.7%), and were referenced in the final written pathology reports (26.7%).

Conclusions

3D scanning and virtual annotation of laryngeal cancer specimens for the creation of visual pathology reports is an innovative approach for postoperative pathology documentation, margin analysis, and surgeon-pathologist communication.

Digital mapping of resected cancer specimens: The visual pathology report

Background

The current standard-of-care pathology report relies only on lengthy written text descriptions without a visual representation of the resected cancer specimen. This study demonstrates the feasibility of incorporating virtual, three-dimensional (3D) visual pathology reports to improve communication of final pathology reporting.

Materials and methods

Surgical specimens are 3D scanned and virtually mapped alongside the pathology team to replicate grossing. The 3D specimen maps are incorporated into a hybrid visual pathology report which displays the resected specimen and sampled margins alongside gross measurements, tumor characteristics, and microscopic diagnoses.

Results

Visual pathology reports were created for 10 head and neck cancer cases. Each report concisely communicated information from the final pathology report in a single page and contained significantly fewer words (293.4 words) than standard written pathology reports (850.1 words, p < 0.01).

Conclusions

We establish the feasibility of a novel visual pathology report that includes an annotated visual model of the resected cancer specimen in place of lengthy written text of standard of care head and neck cancer pathology reports.

Seeing the random forest through the decision trees. Supporting learning health systems from histopathology with machine learning models: Challenges and opportunities

This paper discusses some overlooked challenges faced when working with machine learning models for histopathology and presents a novel opportunity to support "Learning Health Systems" with them. Initially, the authors elaborate on these challenges after separating them according to their mitigation strategies: those that need innovative approaches, time, or future technological capabilities and those that require a conceptual reappraisal from a critical perspective. Then, a novel opportunity to support "Learning Health Systems" by integrating hidden information extracted by ML models from digitalized histopathology slides with other healthcare big data is presented.

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.

Enhancing the Diagnostic Accuracy of Placental Pathology by Using the Amsterdam Consensus Criteria

Background and objective Standardizing placental pathology diagnoses is crucial for improving diagnostic accuracy and clinical communication. The Amsterdam Consensus Criteria were developed to address inconsistencies in diagnosing significant placental pathologies. This study aimed to assess the application and effectiveness of the Amsterdam Consensus Criteria in diagnosing placental pathologies, with a focus on improving the reliability and precision of placental pathology reports. Methods A retrospective review of 100 consecutively archived placental pathology samples was performed at a tertiary care hospital. These samples, gathered from January through December 2021, were reassessed according to the Amsterdam criteria. The revised diagnoses were then compared with the original descriptive diagnoses. Results Significant changes were noted in all principal diagnoses, including maternal vascular malperfusion (MVM), fetal vascular malperfusion (FVM), chronic villitis of unknown etiology (VUE), and acute chorioamnionitis (ACA). This evaluation led to a recategorization of several cases. Frequently, parenchymal infarcts were reported without adequate information to ascertain their association with MVM. Additionally, there was a noticeable lack of understanding of FVM and VUE among pathologists. ACA was the condition most consistently documented. However, detailed grading and staging were often not included. Conclusions Our findings emphasize the need to use standardized diagnostic criteria, such as the Amsterdam criteria, to enhance diagnostic accuracy and facilitate communication between pathologists and clinicians. This will ultimately lead to improved patient care outcomes. It also underlines the necessity of continuous education and calibration for pathologists to mitigate interobserver variability. There is a demand to modify these criteria to ensure universal applicability and relevance in various clinical settings.

Reproducibility of the Paris System in Urine Cytology by Third-Year Pathology Residents

INTRODUCTION

Standardized basic morphology and the algorithmic approach make the Paris System (TPS) for Reporting Urinary Cytology understandable and applicable. This study examined how well the TPS categories are understood by pathology residents and how well these criteria are enabling them reaching accurate diagnosis.

MATERIALS/METHODS

A hundred consecutive cases representing all categories were selected. Authors reevaluated slides using TPS regardless of their original diagnosis. In the next step, the TPS was explained to four residents and trained them by five optimal urine cytology samples from each category. Then they were asked to diagnose the selected slides according to the TPS. The diagnoses were compared to authors. The agreement was assessed using kappa. Discordant diagnoses were classified as high and low impact based on potential on clinical practice.

RESULTS

The sensitivity of authors was 62.8%, and residents' were 24-31.8%. The specificity of authors was 98.8%, and residents' were 82.3-92.8%. Reproducibility of TPS was 40-46%. Kappa values were below 0.40 except for one resident. The highest rate of concordance was for negative for high-grade urothelial carcinoma (NHGUC): authors assigned 38 NHGUC (35 biopsy-proven benign cases). Twenty to twenty-six of them were assigned as NHGUC by residents. While authors assigned 42 cases as suspicious for high-grade urothelial carcinoma (SHGUC) or high-grade urothelial carcinoma (HGUC) (35 biopsy-proven malignant cases), residents assigned 22-29 of them. Discordant diagnosis with high clinical implication was 56-63%.

CONCLUSION

Diagnostic accuracy rates of junior pathology residents using the TPS were unsatisfactory. The best agreement was observed in NHGUC and HGUC categories. Combining HGUC and SHGUC doubled the sensitivity of residents.

"Clinicians Are From Mars and Pathologists Are From Venus" Revisited: Synoptic Reports Improve Clinician Comprehension of Pathology Reports in Inflammatory Bowel Disease

CONTEXT.—

A prior study in this journal, "Clinicians Are from Mars and Pathologists Are From Venus," demonstrated that clinicians can erroneously interpret pathology reports up to 30% of the time. After noticing reporting heterogeneity in the setting of inflammatory bowel disease (IBD), we speculated that a standardized synoptic report could improve gastroenterologist comprehension.

OBJECTIVE.—

To investigate the effect of a synoptic table on gastroenterologist comprehension of IBD pathology reports.

DESIGN.—

We recruited gastroenterology fellows and faculty to participate in this study. All participants were given 6 pathology reports and asked if the following were present: active inflammation, chronic inflammation, IBD, and dysplasia. Participants were also asked to rate their confidence. After a 6-week washout period, the same questionnaire was distributed with a synoptic report. We performed paired t-tests to compare the mean accuracy and confidence scores between the preintervention and postintervention responses.

RESULTS.—

A total of 39 physicians participated: 9 fellows and 30 faculty. Mean accuracy scores were higher after the intervention (0.81 versus 0.86; P < .001). Mean confidence was also higher after intervention, but this was not statistically significant (3.91 versus 3.98; P = .24).

CONCLUSIONS.—

The improvement in accuracy scores after intervention confirms that clinician comprehension improved with the synoptic table. A synoptic report may provide a standardized way of communicating diagnostic information to clinicians in the setting of IBD and potentially other inflammatory conditions.

Video Documentation in Thyroidectomy and an Evaluation of Operative Notes

Introduction Accurate and detailed documentation of surgical operation notes is crucial for post-operative care, research and academic purposes, and medico-legal clarity. Several studies have shown their defiency and inaccuracy sometimes, and some methods have been proposed to make them more objective. This study aimed to evaluate the completeness of thyroidectomy operative notes in a tertiary center and to assess the adequacy of video documentation by comparing it to the corresponding operative notes. Methods A retrospective review of thyroidectomy operative notes from 2010 to 2020 at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, was performed to ensure completeness. Subsequently, 15 thyroidectomies were video recorded, and their notes were compared to the corresponding written operative notes. The completeness score was calculated based on an item list that included items that had to be included in an operative note. An independent samples t-test was used to compare the completeness score means between the two groups. One-way analysis of variance was used to compare the completeness score means between two or more groups. Result A total of 385 thyroidectomy-operative notes were retrospectively reviewed. The completeness scores ranged between 6% and 89% for the various items that had to be documented, with a mean of 54.47%. The mean score of the video-documented operative record was 83.86%±12.84%, which was significantly higher than the corresponding written operative notes (47.53%±18.06%) (p <0.001). Conclusion Video documentation showed significant improvement compared to the corresponding written and retrospective operative notes. Video recording can also be a valuable tool when teaching anatomy and surgical skills and conducting research.

Pathology skills lab: use of macroscopic tumor models in pathology teaching

BACKGROUND

The shortage of pathologists in Germany, coupled with an aging workforce, requires innovative approaches to attract medical students to the field. Medical education must address different learning styles to ensure that all students are successful.

METHODS

The pilot project "Practical Pathology" aims to enhance students' understanding of pathology by providing hands-on experience in macroscopic gross analysis through the use of tumor dummies built from scratch.

RESULTS

An evaluation survey, completed by 63 participating students provided positive feedback on the course methodology, its relevance to understanding the pathology workflow, and its improvement over traditional teaching methods. The majority of students recognized the importance of hands-on training in medical education. Students with previous work experience rated the impact of the course on knowledge acquisition even more positively.

CONCLUSION

The course improved students' understanding of pathological processes and potential sources of clinical-pathological misunderstanding. An increase in motivation for a potential career in the field of pathology was observed in a minority of students, although this exceeded the percentage of pathologists in the total medical workforce.

Preferences of clinical pathologists for probability-modifying terms describing cytologic sample evaluations: A survey study

BACKGROUND

A recent study identified 7 probability ranges used by clinical pathologists and associated qualitative terms used in cytology reports. Clinicians and clinical pathologists agreed that limiting the number of terms could help enhance communication between clinical pathologists and clinicians. However, the preferred terms for each range remain undetermined.

OBJECTIVE

We sought to determine a single term for each probability range that could be adopted by the global veterinary clinical pathology community.

METHOD

Clinical pathologists responded to a survey invitation distributed via the specialty listserv. Clinical pathologists were asked to rank previously identified terms for each probability range from "most preferred" to "least preferred." An alternative term could be proposed if they preferred a term not included in the question. The preferences were summed by rank. Where first choice ranks were within 20% of each other, the 1st and 2nd choices were added. The term with the highest counts was chosen to represent the probability range.

RESULTS

The highest-ranking terms corresponding to the probability ranges of 0%-20%, 20%-50%, 50%-65%, 65%-75%, 75%-85%, 85%-95%, and 95%-100% were "no evidence for," "cannot rule out," "possible," "suspicious for," "most likely," "most consistent with," and no modifier, respectively.

CONCLUSIONS

We have sampled clinical pathologists across the globe to rank terms in cytology reports associated with previously identified probability ranges to identify single qualitative terms for which there was the most agreement between clinicians and clinical pathologists. Our study provides the foundation for standardizing and limiting probability-modifying terms to improve communication with clinicians.

Laboratory Test Names Matter: A Survey on What Works and What Doesn't Work for Orders and Results

CONTEXT.—

Health care providers were surveyed to determine their ability to correctly decipher laboratory test names and their preferences for laboratory test names and result displays.

OBJECTIVE.—

To confirm principles for laboratory test nomenclature and display and to compare and contrast the abilities and preferences of different provider groups for laboratory test names.

DESIGN.—

Health care providers across different specialties and perspectives completed a survey of 38 questions, which included participant demographics, real-life examples of poorly named laboratory orders that they were asked to decipher, an assessment of vitamin D test name knowledge, their preferences for ideal names for tests, and their preferred display for test results. Participants were grouped and compared by profession, level of training, and the presence or absence of specialization in informatics and/or laboratory medicine.

RESULTS.—

Participants struggled with poorly named tests, especially with less commonly ordered tests. Participants' knowledge of vitamin D analyte names was poor and consistent with prior published studies. The most commonly selected ideal names correlated positively with the percentage of the authors' previously developed naming rules (R = 0.54, P < .001). There was strong consensus across groups for the best result display.

CONCLUSIONS.—

Poorly named laboratory tests are a significant source of provider confusion, and tests that are named according to the authors' naming rules as outlined in this article have the potential to improve test ordering and correct interpretation of results. Consensus among provider groups indicates that a single yet clear naming strategy for laboratory tests is achievable.

One procedure-one report: the Re-Imagine Cytopathology Task Force position paper on small tissue biopsy triage in anatomic pathology

INTRODUCTION

Endoscopic biopsy procedures increasingly generate multiple tissue samples from multiple sites, and frequently retrieve concurrent cytologic specimens and small core needle biopsies. There is currently lack of consensus in subspecialized practices as to whether cytopathologists or surgical pathologists should review such samples, and whether the pathology findings should be reported together or separately.

MATERIALS AND METHODS

In December 2021, the American Society of Cytopathology convened the Re-Imagine Cytopathology Task Force to examine various workflows that would facilitate unified pathology reporting of concurrently obtained biopsies and improve clinical care.

RESULTS AND CONCLUSIONS

This position paper summarizes the key points and highlights the advantages, challenges, and resources available to support the implementation of such workflows that result in "one procedure-one report".

Intraoperative Communications Between Pathologists and Surgeons: Do We Understand Each Other?

CONTEXT.—

Clear communication between pathologists and surgeons during intraoperative consultations is critical for optimal patient care.

OBJECTIVE.—

To examine the concordance of intraoperative diagnoses recorded in pathology reports to surgeon-dictated operative notes and assess the impact of an intervention on the discrepancy rates.

DESIGN.—

Discrepancies between the intended communication by pathologists and the interpretation by surgeons were characterized as minor with no crucial clinical impact, and major with the potential of altering patient management. After analysis, a corrective intervention was implemented with education, information sharing, and a change in protocol, and a comparative analysis was conducted.

RESULTS.—

We examined 223 surgical cases with 578 intraoperative consultations. In 23% (51) of the cases, the intraoperative diagnosis was not recorded in the operative reports. We found minor discrepancies in 34% (59) and major discrepancies in 2% (3) of the remaining cases. Deferrals accounted for 24% (14 of 59) of the minor and 33% (1 of 3) of the major discrepancies. Among the discrepant cases, 56% (35 of 62) were multipart cases, including all major discrepancies. Following intervention, no major discrepancies were found in 101 cases with 186 intraoperative interpretations. The cases with no operative documentation reports decreased from 23% to 16% (16 of 101). Minor discrepancies were found in 11% (9 of 85) of the cases, indicating significant improvement (P < .001).

CONCLUSIONS.—

Intraoperative diagnoses can be miscommunicated and/or misinterpreted, possibly impacting intraoperative management, particularly in multipart cases and those involving deferrals. This study highlights the importance of auditing intraoperative communications and addressing the findings through a local intervention.

Awareness of Placental Pathologic Examination Criteria and Utilization of Pathology Reports among Obstetricians

Background and Objectives: Several studies have reported a low rate of pathological examination of the placentas and a poor utilization of pathology reports. We assessed Saudi obstetricians’ awareness and utilization of the placental pathological examination guidelines of the College of American Pathologists (CAP) and evaluated their understanding of the reports. Materials and Methods: An anonymous survey was distributed to obstetricians registered in the Saudi Commission of Health Specialties database. We examined the association between the participants’ level of training or practice as well as their institution type with the surveyed elements. Results: Of 292 respondents, 34.2% were aware of the CAP guidelines. Most of them were practicing in government hospitals. Moreover, 18.2% of them routinely sent the placenta for pathological examination, and approximately 70.5% routinely reviewed the pathology reports and understood the nomenclature used; these percentages were significantly higher among university hospital practitioners. The residents were the least aware of the CAP guidelines and the least likely to review and understand the pathology reports. Regardless of the CAP guidelines awareness, the most common indication for placental pathologic examination was fetal anomalies, followed by medicolegal reasons and infections. Conclusions: Placental pathologic examination appeared uniformly underutilized in Saudi Arabia. Obstetricians are required to generate awareness of the need to comply with the CAP guidelines and to improve the understanding and utilization of pathology reports.

Patient-facing communication for cytopathologists: A framework for disclosing diagnostic error

Medical errors are a major source of harm to patients. Regulatory bodies mandate and patient safety experts advocate the disclosure of medical errors to patients to promote transparency and to create accountability for improving health care processes. Although pathologists regularly report errors-either to pathology or clinical colleagues or via internal safety reporting systems-few pathologists directly disclose those errors to patients. Yet many pathologists are interested in participating in the direct disclosure of medical errors to patients and may even be mandated to do so. When surveyed on why they do not directly disclose errors to patients, pathologists commonly cite a lack of confidence and a lack of training. Another barrier cited is the lack of a preexisting relationship between the pathologist and the patient. With respect to this last barrier, cytopathologists have a distinct advantage over surgical or clinical pathologists, as many cytopathologists regularly interact with and develop a rapport with patients when they are performing fine-needle aspiration (FNA) procedures. To improve the safety culture in pathology, direct error disclosure practices must be developed, supported, and strengthened. It is critical for cytopathologists to be comfortable with disclosing errors to patients. Being comfortable with disclosing an error, however, requires training, practice, and advance reflection. Using a practical, case-based format centered around FNA examples, this article addresses how to disclose a medical error to a patient. It provides a framework, heuristic principles, and structured conversation systems and talking points to guide the inexperienced pathologist to find his or her voice in a challenging disclosure conversation.

Design considerations for a hierarchical semantic compositional framework for medical natural language understanding

Medical natural language processing (NLP) systems are a key enabling technology for transforming Big Data from clinical report repositories to information used to support disease models and validate intervention methods. However, current medical NLP systems fall considerably short when faced with the task of logically interpreting clinical text. In this paper, we describe a framework inspired by mechanisms of human cognition in an attempt to jump the NLP performance curve. The design centers on a hierarchical semantic compositional model (HSCM), which provides an internal substrate for guiding the interpretation process. The paper describes insights from four key cognitive aspects: semantic memory, semantic composition, semantic activation, and hierarchical predictive coding. We discuss the design of a generative semantic model and an associated semantic parser used to transform a free-text sentence into a logical representation of its meaning. The paper discusses supportive and antagonistic arguments for the key features of the architecture as a long-term foundational framework.

A manifesto on explainability for artificial intelligence in medicine

The rapid increase of interest in, and use of, artificial intelligence (AI) in computer applications has raised a parallel concern about its ability (or lack thereof) to provide understandable, or explainable, output to users. This concern is especially legitimate in biomedical contexts, where patient safety is of paramount importance. This position paper brings together seven researchers working in the field with different roles and perspectives, to explore in depth the concept of explainable AI, or XAI, offering a functional definition and conceptual framework or model that can be used when considering XAI. This is followed by a series of desiderata for attaining explainability in AI, each of which touches upon a key domain in biomedicine.

Real-time intraoperative surgical telepathology using confocal laser endomicroscopy

OBJECTIVE

Communication between neurosurgeons and pathologists is mandatory for intraoperative decision-making and optimization of resection, especially for invasive masses. Handheld confocal laser endomicroscopy (CLE) technology provides in vivo intraoperative visualization of tissue histoarchitecture at cellular resolution. The authors evaluated the feasibility of using an innovative surgical telepathology software platform (TSP) to establish real-time, on-the-fly remote communication between the neurosurgeon using CLE and the pathologist.

METHODS

CLE and a TSP were integrated into the surgical workflow for 11 patients with brain masses (6 patients with gliomas, 3 with other primary tumors, 1 with metastasis, and 1 with reactive brain tissue). Neurosurgeons used CLE to generate video-flow images of the operative field that were displayed on monitors in the operating room. The pathologist simultaneously viewed video-flow CLE imaging using a digital tablet and communicated with the surgeon while physically located outside the operating room (1 pathologist was in another state, 4 were at home, and 6 were elsewhere in the hospital). Interpretations of the still CLE images and video-flow CLE imaging were compared with the findings on the corresponding frozen and permanent H&E histology sections.

RESULTS

Overall, 24 optical biopsies were acquired with mean ± SD 2 ± 1 optical biopsies per case. The mean duration of CLE system use was 1 ± 0.3 minutes/case and 0.25 ± 0.23 seconds/optical biopsy. The first image with identifiable histopathological features was acquired within 6 ± 0.1 seconds. Frozen sections were processed within 23 ± 2.8 minutes, which was significantly longer than CLE usage (p < 0.001). Video-flow CLE was used to correctly interpret tissue histoarchitecture in 96% of optical biopsies, which was substantially higher than the accuracy of using still CLE images (63%) (p = 0.005).

CONCLUSIONS

When CLE is employed in tandem with a TSP, neurosurgeons and pathologists can view and interpret CLE images remotely and in real time without the need to biopsy tissue. A TSP allowed neurosurgeons to receive real-time feedback on the optically interrogated tissue microstructure, thereby improving cross-functional communication and intraoperative decision-making and resulting in significant workflow advantages over the use of frozen section analysis.

Anatomy of a Cyberattack: Part 1: Managing an Anatomic Pathology Laboratory During 25 Days of Downtime

OBJECTIVES

Our institution was affected by a multi-institution, systemwide cyberattack that led to a complete shutdown of major patient care, operational, and communication systems. The attack affected our electronic health record (EHR) system, including all department-specific modules, the laboratory information system (LIS), pharmacy, scheduling, billing and coding, imaging software, internet access, and payroll. Downtime for the EHR lasted 25 days, while other systems were nonfunctional for more than 40 days, causing disruptions to patient care and significantly affecting our laboratories. As more institutions transition to network EHR systems, laboratories are increasingly vulnerable to cyberattack. This article focuses on the approaches we developed in the anatomic pathology (AP) laboratory to continue operations, consequences of the prolonged downtime, and strategies for the future.

METHODS

Our AP laboratory developed manual processes for surgical and cytopathology processing, redeployed staff, and used resources within the department and of nearby facilities to regain and maintain operations.

RESULTS

During the downtime, our AP laboratory processed 1,362 surgical pathology and consult cases as well as 299 cytology specimens and outsourced 1,308 surgical pathology and 1,250 cytology cases.

CONCLUSIONS

Our laboratory successfully transitioned to downtime processes during a 25-day complete network outage. The crisis allowed for innovative approaches in managing resources.

Using Explainable Machine Learning to Explore the Impact of Synoptic Reporting on Prostate Cancer

Machine learning (ML) models have proven to be an attractive alternative to traditional statistical methods in oncology. However, they are often regarded as black boxes, hindering their adoption for answering real-life clinical questions. In this paper, we show a practical application of explainable machine learning (XML). Specifically, we explored the effect that synoptic reporting (SR; i.e., reports where data elements are presented as discrete data items) in Pathology has on the survival of a population of 14,878 Dutch prostate cancer patients. We compared the performance of a Cox Proportional Hazards model (CPH) against that of an eXtreme Gradient Boosting model (XGB) in predicting patient ranked survival. We found that the XGB model (c-index = 0.67) performed significantly better than the CPH (c-index = 0.58). Moreover, we used Shapley Additive Explanations (SHAP) values to generate a quantitative mathematical representation of how features—including usage of SR—contributed to the models’ output. The XGB model in combination with SHAP visualizations revealed interesting interaction effects between SR and the rest of the most important features. These results hint that SR has a moderate positive impact on predicted patient survival. Moreover, adding an explainability layer to predictive ML models can open their black box, making them more accessible and easier to understand by the user. This can make XML-based techniques appealing alternatives to the classical methods used in oncological research and in health care in general.

Innovative Synoptic Reporting With Seven-Point Sampling Protocol to Improve Detection Rate of Microvascular Invasion in Hepatocellular Carcinoma

Pathological MVI diagnosis could help to determine the prognosis and need for adjuvant therapy in hepatocellular carcinoma (HCC). However, narrative reporting (NR) would miss relevant clinical information and non-standardized sampling would underestimate MVI detection. Our objective was to explore the impact of innovative synoptic reporting (SR) and seven-point sampling (SPRING) protocol on microvascular invasion (MVI) rate and patient outcomes. In retrospective cohort, we extracted MVI status from NR in three centers and re-reviewed specimen sections by SR recommended by the College of American Pathologists (CAP) in our center. In prospective cohort, our center implemented the SPRING protocol, and external centers remained traditional pathological examination. MVI rate was compared between our center and external centers in both cohorts. Recurrence-free survival (RFS) before and after implementation was calculated by Kaplan-Meier method and compared by the log-rank test. In retrospective study, we found there was no significant difference in MVI rate between our center and external centers [10.3% (115/1112) vs. 12.4% (35/282), P=0.316]. In our center, SR recommended by CAP improved the MVI detection rate from 10.3 to 38.6% (P<0.001). In prospective study, the MVI rate in our center under SPRING was significantly higher than external centers (53.2 vs. 17%, P<0.001). RFS of MVI (−) patients improved after SPRING in our center (P=0.010), but it remained unchanged in MVI (+) patients (P=0.200). We conclude that the SR recommended by CAP could help to improve MVI detection rate. Our SPRING protocol could help to further improve the MVI rate and optimize prognostic stratification for HCC patients.

Communicating Certainty in Pathology Reports: Interpretation Differences Among Staff Pathologists, Clinicians, and Residents in a Multicenter Study

CONTEXT.—

Pathology reports are the main modality in which results are communicated to other physicians. For various reasons, the diagnosis may be qualified on a spectrum of uncertainty.

OBJECTIVE.—

To examine how communication of uncertainty is an unexamined source of possible medical error. No study to our knowledge has examined pathology reports across multiple institutions. This study seeks to identify commonly used phrases of diagnostic uncertainty and their interpreted meanings by surgical pathologists and clinicians.

DESIGN.—

Anonymous surveys were completed at 3 major US academic institutions by 18 practicing staff pathologists, 12 pathology residents, 53 staff clinicians, and 50 resident/allied health professional clinicians at 5 standard tumor boards. All participants rated percentage certainty associated with 7 diagnostic terms. Pathologists answered 2 questions related to the ability to clarify a diagnosis using a comment and comfort wording pathology reports. Clinicians answered questions on how often they read a pathology report comment, if they found the comment helpful, and how comfortable they were in reading pathology reports.

RESULTS.—

A wide range in percentage certainty was found for each of the 7 diagnostic phrases. Both staff and resident clinicians and residents showed wide variability in interpreting the phrases. Twenty-five of 50 staff clinicians (52%) were very comfortable reading a pathology report, whereas only 4 of 53 resident clinicians (8%) were very comfortable reading a pathology report. Twenty-four of 53 staff clinicians (63%) reported always reading the comment, yet only 20 of 53 (27%) always found the comment helpful. The phrases "diagnostic of" and "consistent with" had the strongest agreement in meaning. The weakest agreement was between "suspicious for" and "compatible with."

CONCLUSIONS.—

Efforts to standardize diagnostic terms may improve communication.

Practice of Placenta Submission for Histopathological Examination, Experience of a Teaching/Tertiary Care Hospital in Saudi Arabia

Objectives

The aim of this study is to determine the appropriateness of histopathologic examination of the placenta at King Abdulaziz University Hospital (KAUH), Jeddah, based on the guidelines of the College of American Pathologists (CAP).

Methods

It is a retrospective review of obstetric and pathologic records for all deliveries at KAUH, between January 1, 2017, and April 30, 2019. The placentae were assessed for eligibility to undergo pathologic examination. Furthermore, examined and non-examined placentae meeting the CAP criteria were compared based on their actual indications.

Results

There were 8,929 deliveries, of which 1,444 (16.2%) placentae met the CAP guidelines. A total of 583/1,444 placentae (40.4%; 95% confidence interval [CI] = 37.8-43) were sent for pathologic examination. Of the 7,485 placentae that did not require submission for pathological examination, as determined by the pathologist, 7,456 (99.6%; 95% CI = 99.4-99.7) were not submitted appropriately. The labor and delivery staff were more likely to submit placentae with fetal/neonatal indications rather than those with maternal indications for examination, which was statistically significant (odds ratio = 6.5; 95% CI = 5.08-8.30).

Conclusion

While most of the examined placentae at KAUH met the CAP guidelines, there was a substantial under-submission of eligible placentae. Further studies are advised to reveal the reasons behind this underestimation so that correctional measures may be adopted, as placenta examination is a valuable tool to understand the risk factors and pathogenesis of deleterious maternal, neonatal, and fetal events.

Modifying phrases in surgical pathology reports: introduction of Standardized Scheme of Reporting Certainty in Pathology Reports (SSRC-Path)

Pathologists often incorporate modifying phrases in their diagnosis to imply varying levels of diagnostic certainty; however, what is implied by the pathologists is not equivalent with what is perceived by the referring physicians and patients. This discordance can have significant implications in management, safety, and cost. We intend to identify lack of consistency in interpretation of modifying phrases by comparing perceived level of certainty by pathologists and non-pathologists, and introduce a standard scheme for reporting uncertainty in pathology reports using the experience with imaging reporting and data systems. In this study, a list of 18 most commonly used modifying phrases in pathology reports was distributed among separate cohorts of pathologists (N = 17) and non-pathology clinicians (N = 225) as a questionnaire survey, and the participants were asked to assign a certainty level to each phrase. All the participants had practice privileges in Brown University-affiliated teaching hospitals. The survey was completed by 207 participants (17 pathologists, 190 non-pathologists). It reveals a significant discordance between the interpretations of the modifying phrases between the two cohorts, with significant variations in subgroups of non-pathology clinicians. Also there is disagreement between pathologists and other clinicians regarding the causes of miscommunication triggered by pathology reports. Pathologists and non-pathology clinicians should be mindful of the potential sources of misunderstanding of pathology reports and take necessary actions to prevent and clarify the uncertainties. Using a standard scheme for reporting uncertainty in pathology reports is recommended.

False positive cases in thyroid cytopathology - the experience of a single laboratory and a systematic review

INTRODUCTION

Fine needle aspiration (FNA) is fundamental in the pre-operative assessment of thyroid nodules. However, the shining success of thyroid FNA is occasionally eclipsed by false positive (FP) cytological diagnoses. We describe our experience regarding FP cytological diagnoses and present a literature review concerning FP rates.

MATERIALS AND METHODS

We retrospectively analyzed 2031 consecutive cytology reports. FP was defined as a case with "suspicious for malignancy" or "malignant" cytology, whose surgical follow-up failed to confirm the initial diagnosis of malignancy. We used the PubMed database for the literature review using specific search terms ("thyroid", "cytology", "false positive").

RESULTS

Out of 2031 FNA reports, 93 cases with "suspicious for malignancy" or "malignant" cytology underwent surgical excision. Histopathology did not confirm malignancy in 10 cases (0.6% FP rate). Nodules with FP cytology were significantly larger (P = 0.0024) than those with with TP (true positive) cytology. A review of 25 publications shows comparable results to ours with some slight differences. The majority of studies achieve a FP rate below 3%. Most FP cytological diagnoses turn out to be non-neoplastic lesions (nodular hyperplasia, adenomatous nodule, lymphocytic thyroiditis), which combined account for 80.5% of all histological diagnoses.

CONCLUSIONS

Thyroid nodules with FP cytology were larger than nodules with TP cytology. Most studies manage to adhere to the recommended FP rates, or values close to them, with some outliers. Nevertheless, the mean FP rate values are very close to the value recommended by The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC). The FP rate value depends on how one defines true negative cases, which can be either histologically proven benign cases, via a benign clinical course, or by assuming that cytologically benign cases remain as such.

Pathology reporting of pelvic exenteration specimens for locally recurrent rectal cancer

INTRODUCTION

Reporting of pelvic exenteration specimens for locally recurrent rectal cancer (LRRC) can be challenging for structured pathological analysis and currently, there is a lack of specific guidelines. The aim of this study was to assess the quality of pathology reporting in a cohort of patients who underwent pelvic exenteration for LRRC in a high-volume tertiary unit.

MATERIALS AND METHODS

In a retrospective analysis of histopathology reports of consecutive patients who underwent pelvic exenteration for LRRC from 1996 to 2018, the quality of pathology reporting was assessed using the Structure Reporting Protocol for Colorectal Cancer. The primary endpoint was the completeness of pathology reporting, secondary endpoints were the association between the reporting style (narrative versus synoptic), reporting period (the first half versus the second half), as well as the activity of the pathologists with the completeness of pathology reporting.

RESULTS

221 patients who underwent pelvic exenteration for LRRC were included into the study. There was a high variability in completeness of pathology reporting within the cohort, ranging from 9.5% to 100%. Notably, microscopic clearance was reported in only 92.4% of the reports. Overall, a significantly higher rate of completeness was observed in synoptic reports when compared to narrative reports and in more recent compared to earlier reports. There was no significant association between the activity of pathologists and the completeness of reporting.

CONCLUSIONS

This study shows a significant variability in the quality of reporting in pelvic exenteration for LRRC. The use of synoptic reporting clearly resulted in more complete reports.

Pathology Reporting in Neuroendocrine Neoplasms of the Digestive System: Everything You Always Wanted to Know but Were Too Afraid to Ask

During the 5th NIKE (Neuroendocrine tumors Innovation in Knowledge and Education) meeting, held in Naples, Italy, in May 2019, discussions centered on the understanding of pathology reports of gastroenetropancreactic neuroendocrine neoplasms. In particular, the main problem concerned the difficulty that clinicians experience in extrapolating relevant information from neuroendocrine tumor pathology reports. During the meeting, participants were asked to identify and rate issues which they have encountered, for which the input of an expert pathologist would have been appreciated. This article is a collection of the most rated questions and relative answers, focusing on three main topics: 1) morphology and classification; 2) Ki67 and grading; 3) immunohistochemistry. Patient management should be based on multidisciplinary decisions, taking into account clinical and pathology-related features with clear comprehension between all health care professionals. Indeed, pathologists require clinical details and laboratory findings when relevant, while clinicians require concise and standardized reports. In keeping with this last statement, the minimum requirements in pathology datasets are provided in this paper and should be a baseline for all neuroendocrine tumor professionals.

Terminology for melanocytic skin lesions and the MPATH-Dx classification schema: A survey of dermatopathologists

BACKGROUND

Diagnostic terms used in histopathology reports of cutaneous melanocytic lesions are not standardized. We describe dermatopathologists' views regarding diverse diagnostic terminology and the utility of the Melanocytic Pathology Assessment Tool and Hierarchy for Diagnosis (MPATH-Dx) for categorizing melanocytic lesions.

METHODS

July 2018-2019 survey of board-certified and/or fellowship-trained dermatopathologists with experience interpreting melanocytic lesions.

RESULTS

Among 160 participants, 99% reported witnessing different terminology being used for the same melanocytic lesion. Most viewed diverse terminology as confusing to primary care physicians (98%), frustrating to pathologists (83%), requiring more of their time as a consultant (64%), and providing necessary clinical information (52%). Most perceived that adoption of the MPATH-Dx would: improve communication with other pathologists and treating physicians (87%), generally be a change for the better (80%), improve patient care (79%), be acceptable to clinical colleagues (68%), save time in pathology report documentation (53%), and protect from malpractice (51%).

CONCLUSIONS

Most dermatopathologists view diverse terminology as contributing to miscommunication with clinicians and patients, adversely impacting patient care. They view the MPATH-Dx as a promising tool to standardize terminology and improve communication. The MPATH-Dx may be a useful supplement to conventional pathology reports. Further revision and refinement are necessary for widespread clinical use.

Should "suspicious for high-grade urothelial carcinoma" and "positive for high-grade urothelial carcinoma" remain separate categories?

BACKGROUND

The Paris System (TPS) for Reporting Urinary Cytology aims to standardize urine cytology reporting. Per TPS, the diagnosis of "suspicious for high-grade urothelial carcinoma (SHGUC)" is applied in cases that have few urothelial cells with severe atypia but are quantitatively insufficient for a diagnosis of "high-grade urothelial carcinoma (HGUC)." In our study, we compared the diagnostic accuracy and risk of malignancy (ROM) of these 2 categories to assess whether they could be combined in clinical practice to perhaps improve overall interobserver variability.

METHODS

All urine specimens with a diagnosis of either SHGUC or HGUC from January 2016 to July 2019 were retrieved from the pathology database of 2 large academic institutions. Only cases with follow-up biopsies within 6 months were included.

RESULTS

One hundred eighty-nine cases met the study criteria. Of these, 122 had a cytologic diagnosis of SHGUC, and 67 had a diagnosis of HGUC. Ninety-five (78%) cases from the SHGUC group and 64 (96%) cases from the HGUC group had biopsy-proven HGUC. The majority of cases with discordance had a history of treatment with either intravesical bacillus Calmette-Guérin or mitomycin. The difference in the rate of biopsy-proven HGUC between the SHGUC category and the HGUC category (95/122 vs 64/67, respectively) was statistically significant (P < .001).

CONCLUSIONS

The difference in ROM between SHGUC and HGUC was statistically significant in our study cohort. Intravesical chemotherapy was frequently observed in negative biopsy cases in both groups. Our preliminary findings suggest that the 2 TPS categories should remain separate.

Parallels Between Low-Risk Prostate Cancer and Thyroid Cancer: A Review

Importance

Across many countries, a rapid escalation of the incidence of thyroid cancer has been observed, a surge that nonetheless underestimates the true extent of the disease. Most thyroid cancers now diagnosed comprise small, low-risk cancers that are incidentally found and are unlikely to cause harm. In many ways, prostate cancer similarly harbors a well-behaved subclinical reservoir, a long natural history, and superlative outcomes that have made active surveillance the de facto guideline recommendation for low-risk disease. This review highlights the parallels and differences between prostate cancer and thyroid cancer regarding screening, diagnosis, risk stratification, and considerations for active surveillance.

Observations

Prostate cancer and thyroid cancer have undergone recalibrated, de-escalatory shifts to counter changing epidemiologic landscapes. The US Preventive Services Task Force has issued cautionary recommendations on screening via prostate-specific antigen testing or neck ultrasonography, while the thresholds to performing biopsy have increased. Comparable changes to cancer terminology and staging have also helped alleviate patient anxiety and minimize pressure for overtreatment. Long-term, randomized prospective clinical trials for prostate cancer have established active surveillance as a first-line treatment approach for properly stratified low-risk patients, while observational trials for thyroid cancer have also made strides in defining risk and eligibility for surgery. Caveats requiring deeper investigation include aggressive disease in older patients, underestimation of the extent of the disease, and patient-physician bias in shared decision making. For prostate cancer, survival may not improve and function will likely worsen after intervention; for thyroid cancer, patients are younger, surgery is safer, and the bar for surveillance will likely be higher.

Conclusions and Relevance

Despite similarities in biological indolence between low-risk prostate and thyroid malignant neoplasms, key distinctions in life expectancy and treatment sequelae may ultimately confer somewhat disparate management paradigms for the 2 diseases. Nevertheless, the experience forged by prostate cancer trials serves as a model for thyroid cancer management, potentially reshaping the perception of active surveillance into a credible, valuable treatment modality.

From Reactive Lymphadenopathy to Systemic Vasculitis, the Importance of Providing Sufficient Clinical Information to Optimize Pathological Interpretation, a Case Report

Introduction

Pathology must aim at a correct diagnosis, which is complete and useful for clinicians. However, in routine practice, there are multiple sources of errors in the pathology results, which have several impacts on the patient’s treatment and outcome.

Case presentation

Our patient is a 66 years old man, case of rheumatoid arthritis with lymphadenopathy due to vasculitis, which was underdiagnosed due to lack of complete clinical data during pathologic examination. Since the patient was extremely ill, and the workup was inconclusive, the pathology slides were sent to our center for consultation and molecular study to rule out lymphoma. The slide review was done with complete access to the patient’s history and status. In addition to reactive follicular hyperplasia, there was inter-follicular/paracortical plasma cell infiltration and remarkable leukocytoclastic vasculitis of small vessels.

Discussion

Most frequent errors in the laboratories are preanalytical, due to clinical failures (wrong clinical procedure, inappropriate ordering, erroneous, incomplete or misleading clinical information), and specimen transportation and delivery. Surgical pathology by its nature depends heavily on the input of clinicians and surgeons who are fully aware of patient condition.

Conclusion

This case clearly shows the importance of communication between the pathologist and clinicians and the impact on patient care. Clinicians should also provide complete clinical data for the pathologist. Full access to clinical information improves the pathologist’s ability to make an accurate diagnosis.

Pathology perspective on gynaecologic malignancy screening questions in electronic consultation

INTRODUCTION

The electronic consultation service, eConsult, is an asynchronous web-based platform for provider-to-provider consultation with specialists. This study described the utilization of eConsult by primary care providers to obtain specialist opinion in gynaecologic malignancy screening, with a specific focus on pathology-related inquiries.

METHODS

This is a cross-sectional retrospective review of eConsults submitted to obstetrics/gynaecology between September 2011 and December 2016. All questions pertaining to gynaecologic cancer screening and their pathologies were included. Each question was classified based on a pre-determined taxonomy. The mandatory primary care providers' exit surveys were analysed to determine eConsult's influence on patient care, primary care providers' referral patterns, primary care providers' satisfaction and educational value.

RESULTS

In total, 1,357 electronic consultations were submitted to the obstetrics and gynaecology service during the study period, of which 329 met inclusion criteria. Indications for a screening test based on patient risk factors made up 36% of consults pertaining to gynaecologic malignancy screening and 17% were inquiries about test intervals based on previous results. Primary care providers pointed out gaps in current screening guidelines. In total, 38% of primary care providers reported the eConsult service helped avoid a specialist referral, whereas 47% of primary care providers received new or additional courses of action. Pathology report interpretation accounted for 5% of eConsults and 6% of primary care providers wished for clarification of incidental pathology findings.

CONCLUSION

This study uncovered areas of uncertainty among primary care providers regarding gynaecologic cancer screening and gaps in current clinical guidelines. Furthermore, the role of pathology consultants in an eConsult platform is explored and may be extrapolated into practice.

Critical Diagnoses in Ophthalmic Pathology: Suspected Important Unanticipated Diagnoses in Surgically Removed Eyes

Aim

To describe the 5-year profile of anatomic critical diagnoses from an ophthalmic pathology laboratory and raise awareness of the challenges of establishing guidelines for these diagnoses.

Methods

Medical records of patients who had consecutively submitted surgically removed globes or eviscerated eyes from 1 October 2009 to 31 October 2014 were examined for a critical diagnosis, as defined by a verbal communication for a serious, unanticipated diagnosis.Important discordant anatomic and clinical diagnoses were reviewed to determine whether the anatomic finding was truly unanticipated.

Results

During the study period, 313 eyes were submitted to the laboratory as primary specimens. Twenty (6.4%) had critical (alert) diagnoses. Six of the 20 anatomic diagnoses (30%) were known or suspected prior to surgery but were not communicated on the pathology request form. Five diagnoses (25%) were not clinically suspect before surgery. In 9 cases (45%) medical-care providers were alerted to the critical findings but insufficient clinical information was provided about preoperative conditions.

Conclusions

The proportion of critical diagnoses among surgically removed eyes is small, but not inconsequential. Some "critical alerts" would be unnecessary if relevant clinical information was provided when the tissue is submitted to the laboratory. Laboratory guidelines for critical values in surgical pathology should be flexible since they need to anticipate the vicissitudes of clinical practice. Surgeons need to appreciate that relevant clinical information must be provided to pathologists because it can play a role in formulating anatomic diagnoses.

Synoptic reporting increases quality of upper gastrointestinal cancer pathology reports

Introduction

Traditionally, surgical pathology reports are narrative. These report types are prone to error and missing data; therefore, structured standardized reporting was introduced. However, the effect of synoptic reporting on the completeness of esophageal and gastric carcinoma pathology reports is not yet established.

Materials and methods

A population-based retrospective nationwide cohort study in the Netherlands was conducted over a period of 2012–2016, utilizing the Netherlands Cancer Registry for patient data and the nationwide network and registry of histology for pathology data.

Results

In total, 1148 narrative and 1311 synoptic pathology reports were included. Completeness was achieved in 56.4% of the narrative reports versus 97.0% of the synoptic reports (p < 0.01). Out of 21 standard items, 15 were significantly more frequently reported in synoptic reports.

Conclusion

Synoptic reporting improves surgical pathology reporting quality and should be implemented in standard patient care.

Electronic supplementary material

The online version of this article (10.1007/s00428-019-02586-w) contains supplementary material, which is available to authorized users.

Standardized terminology systems in cytopathology

There has been increasing pressure for systemization in cytopathology. Lack of uniformity in categorization, variation in opinion based regional practice, and technologic advancement have created an environment disposed toward creation of more consistent evidence-based approaches to diagnostic problems. This review provides an overview of the major standardized terminology systems in cytology, with historical perspectives and commentary on current uses of these systems. These systems now include gynecologic, thyroid, pancreaticobiliary, urinary, salivary gland, and breast cytology. We summarize major classification systems supported by national and international professional organizations, outlining the structure and goals of each system. Specific benefits and potential pitfalls in the implementation of each system are given. Finally, we address potential criticisms of standardized terminology systems and proposed future directions to continue the evolution of standardized terminology to improve clinical practice.

The Usefulness of Immunocytochemistry of CD56 in Determining Malignancy from Indeterminate Thyroid Fine-Needle Aspiration Cytology

BACKGROUND

Fine-needle aspiration cytology serves as a safe, economical tool in evaluating thyroid nodules. However, about 30% of the samples are categorized as indeterminate. Hence, many immunocytochemistry markers have been studied, but there has not been a single outstanding marker. We studied the efficacy of CD56 with human bone marrow endothelial cell marker-1 (HBME-1) in diagnosis in the Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) category III.

METHODS

We reviewed ThinPrep liquid-based cytology (LBC) samples with Papanicolaou stain from July 1 to December 31, 2016 (2,195 cases) and selected TBSRTC category III cases (n = 363). Twenty-six cases were histologically confirmed as benign (six cases, 23%) or malignant (20 cases, 77%); we stained 26 LBC slides with HBME-1 and CD56 through the cell transfer method. For evaluation of reactivity of immunocytochemistry, we chose atypical follicular cell clusters.

RESULTS

CD56 was not reactive in 18 of 20 cases (90%) of malignant nodules and showed cytoplasmic positivity in five of six cases (83%) of benign nodules. CD56 showed high sensitivity (90.0%) and relatively low specificity (83.3%) in detecting malignancy (p = .004). HBME-1 was reactive in 17 of 20 cases (85%) of malignant nodules and was not reactive in five of six cases (83%) of benign nodules. HBME-1 showed slightly lower sensitivity (85.0%) than CD56. The specificity in detecting malignancy by HBME-1 was similar to that of CD56 (83.3%, p = .008). CD56 and HBME-1 tests combined showed lower sensitivity (75.0% vs 90%) and higher specificity (93.8% vs 83.3%) in detecting malignancy compared to using CD56 alone.

CONCLUSIONS

Using CD56 alone showed relatively low specificity despite high sensitivity for detecting malignancy. Combining CD56 with HBME-1 could increase the specificity. Thus, we suggest that CD56 could be a useful preoperative marker for differential diagnosis of TBSRTC category III samples.

The structure and utility of the placental pathology report

The placenta is one of the most exciting organs. It is dynamic; its morphology and function continuously develop and adjust over its brief life span. It mediates the physiology of two distinct yet highly interconnected individuals. The pathology that develops in the placenta, and the adaptations the placenta undergoes to mitigate this pathology, may influence the later life health of the mother and baby (Circ Res, 116, 2015, 715; Hum Reprod Update, 17, 2011, 397; Nutr Rev 71, 2013, S88; Placenta, 36, 2015, S20). Pathological placenta examination may reveal macroscopic and microscopic patterns that provide valuable information to the obstetricians, neonatologists, and pediatricians caring for the family. The placenta often plays a key role in understanding adverse fetal outcomes such as hypoxic brain injury, cerebral palsy, fetal growth restriction, stillbirth, and neonatal death (Placenta, 35, 2014, 552; Placenta, 52, 2017, 58; Placenta, 30, 2009, 700; Obstet Gynecol, 114, 2009, 809; Clin Perinatol, 33, 2006, 503; Pediatr Dev Pathol, 11, 2008, 456; Arch Pathol Lab Med, 124, 2000, 1785). Moreover, it may help to understand the pathophysiology of pregnancy, improve management of subsequent pregnancies, and assist in medicolegal assessment. Placental pathologic examination may even provide evidence of susceptibility to adult-onset diseases such as diabetes (Pediatr Dev Pathol, 6, 2003, 54; Diabetes Metab, 36, 2010, 682; BJOG, 113, 2006, 1126; Int J Gynaecol Obstet, 104, 2009, S25; Zentralbl Gynakol, 97, 1975, 875). Pathologic examination of the placenta may thus be of tremendous value, particularly for those women experiencing an adverse pregnancy outcome. However, this potential utility may be entirely wasted, if the findings are not communicated in an effective manner to the appropriate clinicians. An optimized, readily understandable report of pathological findings is essential for clinical utility.