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PubMed1998

Arthur Purdy Stout (1885-1967), a pioneer of surgical pathology: a survey of his Notes on the Education of an "Oncological" Surgical Pathologist.

Arthur Purdy Stout (1885-1967) started his medical career as a surgical intern and house surgeon at institutions that were to join the Columbia-Presbyterian Medical Center. With virtualy no formal training in pathology and little supervision, he was given the opportunity to work in a laboratory of surgical pathology. He focused his attention on neoplasms and tumor-like conditions, and authored Human Cancer in 1932. This book was organized according to topography of lesions and set a model for the Atlas of Tumor Pathology project. In addition to his many articles and slide seminars, Stout embarked during his "postretirement" years, with the help of residents and fellows, on a systematic study of soft tissue tumors in children. In 1950, he also began his Notes on the Education of an "Oncological" Surgical Pathologist. This manuscript of 427 typewritten pages offers candid details on his development as a surgical pathologist from rather primitive and chaotic beginnings, and on the post-World War II rise of surgical pathology. Notes provides interesting glimpses of his rapidly changing world, particularly of New York, the College of Physicians and Surgeons of Columbia University, and other pathologists. It also portrays an individual absorbed by his work and intent on leaving behind the legacy of a pioneer in the field of surgical pathology.

Academic Medical Centers↗
PubMed2000

A pathological view of disease.

This paper is a response to Christopher Boorse's recent defense of his Biostatistical Theory (BST) of health and disease. Boorse maintains that his concept of theoretical health and disease reflects the "considered usage of pathologists." I argue that pathologists do not use "disease" in the purely theoretical way that is required by the BST. Pathology does not draw a sharp distinction between theoretical and practical aspects of medicine. Pathology does not even need a theoretical concept of disease. Its focus is not theoretical, but practical; pathology's goal is to contribute to the healing of patients. Pathology, even experimental pathology, is not value-free. Not only "disease" but also such terms as "nerve" and "organ" are laden with conceptual values.

Biometry↗
PubMed2002

The utility and cost effectiveness of voice recognition technology in surgical pathology.

Voice recognition (VR) technology in computer systems converts speech directly into electronic text. In pathology, VR holds promise to improve efficiency and to reduce transcription delays and costs. We investigated the utility and cost effectiveness of targeted VR deployment in surgical pathology. A VR system was deployed for entry of gross descriptions of biopsies and of low to moderate complexity specimens and for entry of final reports for specimens not requiring microscopic analysis. Templates for VR were developed for all reports. Free-text speech entry was used to enter information not covered by templates. Voice converted to text by VR crossed over an interface into the anatomic pathology laboratory information system. Tallies were kept of whether individual specimens were entered by VR or by conventional dictation. A computer program was written to analyze the number of lines of text entered through VR. Cost savings were calculated based on per-line transcription costs from an outside agency. Over 18 months, gross descriptions for an average of 5617 specimens per month were entered via VR, corresponding to 70% of all gross specimens processed by the laboratory. A mean of 106 gross-only final reports per month was entered through VR. VR facilitated same-day processing of specimens received after the previous day processing cutoff time (average 35 specimens per day). VR generated an average of 23,864 lines of text per month, translating to $2625 savings per month. Estimated payback period for VRT as implemented is 1.9 years. The use of VR for gross descriptions of biopsies and low to moderate complexity specimens and for gross-only final reports in surgical pathology facilitates data entry, reduces transcription costs, and contributes to improved turnaround time. Development of templates is important to successful implementation of VR in surgical pathology.

Cost-Benefit Analysis↗
PubMed2007

Technology insight: will systems pathology replace the pathologist?

By using systems pathology, it might be possible to provide a predictive, personalized therapeutic recommendation for patients with prostate cancer. Systems pathology integrates quantitative data and information from many sources to generate a reliable prediction of the expected natural course of the disease and response to different therapeutic options. In other words, through the integration of relatively large data sets and the use of knowledge engineering, systems pathology aims at predicting the future behavior of tumors and their interaction with the host. In this Review, we introduce the methods used in systems pathology and summarize a recent study providing the first evidence of a concept for this strategy. The results show that systems pathology can provide a personalized prediction of the risk of recurrence after prostatectomy for cancer.

Humans↗
PubMed1990

Description of laryngeal pathologies in children evaluated by otolaryngologists.

The purpose of this investigation was to describe the occurrence of laryngeal pathologies and their distribution across age, sex, and race in a pediatric sample. Data were collected on 731 patients seeking evaluation or treatment at a children's hospital otolaryngology clinic. The most frequent laryngeal pathologies were subglottic stenosis, vocal nodules, laryngomalacia, and vocal fold paralysis. For the total sample, laryngeal pathologies were significantly more common to males than females. Laryngeal pathologies were most common in the youngest patients. The distribution of pathologies within each race was similar to that found throughout the total sample. Comparisons with similar investigations are made. Implications for management are discussed.

Adolescent↗
PubMed2003

Improvement in quality of colorectal cancer pathology reporting with a standardized proforma--a comparative study.

BACKGROUND: Histopathological evaluation is a critical component in the management of patients with colorectal cancer (CRC). It is the single most powerful prognostic indicator in CRC and determines if adjuvant chemotherapy is indicated. The aim of this study was to assess if the introduction of a comprehensive standardized pathology proforma improved the quality of histopathology reporting. METHODS: A standardized pathology proforma, based on the 1996 minimum dataset for colorectal histopathology reporting, was introduced in our pathology department in 1998. Pathology reports for all colonic resection specimens for 1996 (n = 85) and 2000 (n = 86) were identified, retrieved and entered on to database. Comparison was made with the minimum dataset published in the 1996 guidelines for the management of colorectal cancer. RESULTS: Demographic details were complete in all cases. Clinical data was incomplete in 57 (67%) patients in 1996 and 63 (73%) in 2000 (ns; chi2). There were 24 (28%) (7 Abdomino-perineal resections (APER)) and 40 (47%) (17 APER's) rectal specimens for 1996 and 2000, respectively. The presence or absence of pathological background abnormalities were commented on in 18 (21%) reports in 1996 and 80 (93%) reports in 2000 (P < 0.01; Fishers exact test (Fisher)). Histological differentiation was commented on in 73 (86%) and 86 (100%) in 1996 and 2000, respectively (P < 0.01; Fisher). Dukes' stage was stated in 33 (39%) reports in 1996 and 86 (100%) in 2000 (P < 0.01; Fisher) but Dukes' stage was calculable in 84 (99%) in 1996 and 86 reports (100%) for 2000 (ns; Fisher). The apical node was commented on in 34 (40%) reports in 1996 and 85 (99%) reports in 2000 (P < 0.01; Fisher). The median (IQR) number of nodes assessed in 1996 was 8 (5-12) compared to 12 (8-17) in 2000 (P < 0.001; Mann-Whitney (MW)). Complete resection was mentioned in 74 (87%) reports in 1996 and 86 (100%) in 2000 (P < 0.01; Fisher). Regarding rectal specimens, the circumferential resection margin (CRM) was commented on in 19 of 24 specimens in 1996 and 38 of 40 specimens in 2000 (ns; Fisher). Relationship to the peritoneal reflection was commented on in 1 (1%) rectal specimen in 1996 and 30 (35%) in 2000 (P < 0.001; Fisher). CONCLUSION: The introduction of a standardized proforma for reporting CRC resection specimens improves the quality of histopathological reporting. This aids decision-making regarding adjuvant chemotherapy or radiotherapy and further surveillance.

Colorectal Neoplasms↗
PubMed2005

Strategies for laboratory cost containment and for pathologist shortage: centralised pathology laboratories with microwave-stimulated histoprocessing and telepathology.

The imposition of laboratory cost containment, often from external forces, dictates the necessity to develop strategies to meet laboratory cost savings. In addition, the national and worldwide shortage of anatomical pathologists makes it imperative to examine our current practice and laboratory set-ups. Some of the strategies employed in other areas of pathology and laboratory medicine include improvements in staff productivity and the adoption of technological developments that reduce manual intervention. However, such opportunities in anatomical pathology are few and far between. Centralisation has been an effective approach in bringing economies of scale, the adoption of 'best practices' and the consolidation of pathologists, but this has not been possible in anatomical pathology because conventional histoprocessing takes a minimum of 14 hours and clinical turnaround time requirements necessitate that the laboratory and pathologist be in proximity and on site. While centralisation of laboratories for clinical chemistry, haematology and even microbiology has been successful in Australia and other countries, the essential requirements for anatomical pathology laboratories are different. In addition to efficient synchronised courier networks, a method of ultra-rapid tissue processing and some expedient system of returning the prepared tissue sections to the remote laboratory are essential to maintain the turnaround times mandatory for optimal clinical management. The advent of microwave-stimulated tissue processing that can be completed in 30-60 minutes and the immediate availability of compressed digital images of entire tissue sections via telepathology completes the final components of the equation necessary for making centralised anatomical pathology laboratories a reality.

Histocytological Preparation Techniques↗
PubMed2000

Prevalence of inter-institutional anatomic pathology slide review: a survey of current practice.

Multiple studies have demonstrated discrepancy rates between original and review histopathologic diagnoses of up to 30% with a mean of approximately 10%. In view of these rates of discrepancy, several authorities, including the Association of Directors of Anatomic and Surgical Pathology, have recommended in-house review of all outside materials before commencement of therapy. We used a mail survey to determine the degree of compliance with these recommendations among pathology groups in the United States. Mail surveys were sent to six randomly selected hospitals from each state (300 total). The survey included demographic questions, including surgical pathology caseload, size of hospital (beds), and type of hospital (community-general, non-academic-tertiary care, or academic-tertiary care). The survey asked whether the hospital required review of all outside slides before the performance of surgery. If not, was such a policy encouraged but not required. The survey also asked whether in-house review of outside cases had disclosed any significant differences in pathologic diagnoses. Finally, the survey questioned whether any discrepancies between an internal and external surgical pathology diagnosis had been discovered following radical surgery. One hundred twenty-six usable responses were obtained. Fifty-five of these were from hospitals self-described as community-general, seven were from hospitals describing themselves as non-academic-tertiary care, and the remaining 61 hospitals described themselves as academic-tertiary care institutions. Sixty-three institutions stated they had a requirement for in-house review of outside material, with 46 of 61 academic-tertiary centers having such a requirement. Thirty-seven of 55 community-general hospitals did not require in-house review of outside material before surgery could be performed. One hundred ten of the 126 institutions returning surveys either encouraged or required review of outside material. Ninety-five institutions reported that they had at least one outside case in which their diagnosis was significantly discordant with that rendered by the referring pathologist. Sixty (48%) of the 126 institutions reported at least one case in which a discrepancy was found between the outside biopsy diagnosis and the internal diagnosis rendered on material obtained by radical surgery. Approximately half of all responding institutions have a requirement for in-house review of outside material prior to surgery. A majority of institutions requiring such review have found discrepancies between the in-house diagnoses and those rendered by referring laboratories.

Diagnostic Errors↗
PubMed2003

Digital imaging applications in anatomic pathology.

Digital imaging has progressed at a rapid rate and is likely to eventually replace chemical photography in most areas of professional and amateur digital image acquisition. In pathology, digital microscopy has implications beyond that of taking a photograph. The arguments for adopting this new medium are compelling, and given similar developments in other areas of pathology and radiologic imaging, acceptance of the digital medium should be viewed as a component of the technological evolution of the laboratory. A digital image may be stored, replicated, catalogued, employed for educational purposes, transmitted for further interpretation (telepathology), analyzed for salient features (medical vision/image analysis), or form part of a wider digital healthcare strategy. Despite advances in digital camera technology, good image acquisition still requires good microscope optics and the correct calibration of all system components, something which many neglect. The future of digital imaging in pathology is very promising and new applications in the fields of automated quantification and interpretation are likely to have profound long-term influence on the practice of anatomic pathology. This paper discusses the state of the art of digital imaging in anatomic pathology.

Education, Medical↗
PubMed2005

Effective strategy to guide pathology test ordering in surgical patients.

BACKGROUND: Ordering of pathology testing by junior medical staff is often a haphazard process with little regard to the appropriateness of test ordering. The aim of the present study was to reduce ordering of inappropriate pathology tests in surgical patients attending the pre-admission clinic (PAC) through the introduction of a protocol-based test ordering system and to create an environment where such improvement can be sustained. METHODS: This is a prospective study with a retrospective control group. Three cohorts of patients attending the PAC were included. Group I (n = 700) attended prior to the introduction of the test protocols (April-June 2002) and acted as a control group. Group II (n = 720) attended after the protocol introduction (April-June 2003), and group III (n = 763) attended during the subsequent 3-month period from July to August 2003. The study examined the numbers of patients in each group who were ordered any of eight standard pathology tests. The average number of tests per patient, and cost of tests per patient were also ascertained. RESULTS: Following the introduction of pathology test protocols, the ordering of all but one of the eight tests was statistically significantly reduced. In particular, ordering of coagulation studies was reduced from 22.5% to 13.8% and electrolytes, urea and creatinine from 65.2% to 48.25% of patients (both P < 0.0001). Average number of tests performed per patient declined from 2.48 to 1.88, representing a savings of 10.33 dollars per patient (a decrease from 42.22 dollars to 31.89 dollars) and a projected annualized cost saving in excess of 26,000 dollars. CONCLUSIONS: Provided that certain preliminary guidelines are followed, these protocols can reduce pathology test ordering in any pre-admission Service.

Clinical Protocols↗
PubMed2004

Perinatal pathology in the context of a clinical trial: attitudes of neonatologists and pathologists.

OBJECTIVE: To describe the attitudes of neonatologists to trial related perinatal postmortem examinations (PMs), in the light of declining perinatal PM rates and poor levels of participation in pathology studies. METHODS: A qualitative study was carried out, using semistructured interviews. Twenty six neonatologists from five UK neonatal units were interviewed; five UK perinatal pathologists also contributed to the study. The professionals involved were all linked to one or both of two neonatal trials. RESULTS: Pathologists expressed concern over the difficulties experienced in UK perinatal pathology and the impact on research of inadequate levels of samples. The interviews with neonatologists reveal discomfort over approaching bereaved parents for PMs, and a widespread concern that parents should not be further distressed or feel under pressure to consent. Although there was support for neonatal trials, the study highlights a view that PMs may be unnecessary if the cause of death seems apparent or when a baby was born prematurely, and a devaluation of PMs among some younger staff. Poor rates of participation in pathology studies may be accounted for by a notable sense of disconnection between trial interventions and pathology studies. CONCLUSIONS: Neonatologists were concerned to protect vulnerable parents and varied in whether they saw this as compatible with inclusion in trial related pathology studies. Dedicated research is needed to document and gain an understanding of the consent process and should examine the usefulness and impact of consent forms. It should assess whether professionals might benefit from training, to help parents to come to their decisions.

Adult↗
PubMed2005

Patients' perspective of pathology specimens. A prospective study.

AIM: To determine the degree of patients' interest in surgical pathology specimens. To assess the impact of patients' involvement in surgical pathology on their understanding of (and confidence in) the storage and use of pathology specimens. METHODS: Forty seven patients were invited to visit the pathology department and view their specimens postoperatively. Those who visited were asked to complete a questionnaire to assess the effect of the visit. RESULTS: Thirty three of the 47 patients wished to view their specimens, but only 14 actually made the visit. All those who visited indicated that it made them better able to understand the reason for surgery and tissue retention issues, and more likely to consent to the use of excess tissue for research. CONCLUSION: In general, patients are keen to know what happens to and what is wrong with the organs removed at surgery, and their involvement in surgical pathology can have positive and beneficial effects both for themselves and the profession.

Attitude to Health↗
PubMed1998

Internal quality assurance activities of a surgical pathology department in an Australian teaching hospital.

AIM: To assess the role of a quality assurance programme in improving the service provided by a surgical pathology department. METHODS: A continuous internal quality assurance study of the activities of an anatomical pathology department in an Australian teaching hospital was undertaken over a five year period. This addressed all steps involved in the production of a surgical pathology report. These were addressed in an open forum which included technical, scientific, clerical, and medical staff. Minor errors not needing immediate action were discussed and incorporated into laboratory practice. For major discrepancies with potential implications for patient management supplementary reports were issued and the relevant clinician informed of the outcome. RESULTS: Comprehensive peer review of 8.9% of the total workload of the department (3530 cases) and all the frozen sections (916 cases) over a period of five years, beginning in 1991, led to comments on some aspects of the original report by the reviewer in 19.6% of the cases. The great majority of the comments were minor, concerning issues related to the microscopic findings (4%), macroscopic description (3.1%), clerical aspects (3%), typographical errors (3%), coding errors (2.7%), technical errors including poor sections and incorrect labelling (1.7%), inadequate clinical history (1.2%), and incomplete or incomprehensible diagrams (0.9%). In two cases (0.05%) the original report did not state proximity of the tumour to surgical margins and in three of the frozen sections (0.3%) the original diagnosis was incorrect. However, in these cases the frozen section assessment did not alter the overall management of the cases. CONCLUSIONS: This study highlights the importance of a review system in detecting errors in surgical pathology reporting. Recognition of the fact that surgical pathology is not infallible has improved the end product. It has also minimised interobserver variability in the department, resulting in a uniform approach among the pathologists to macroscopic description, specimen sampling, special stains, and histological reporting.

Cryopreservation↗
PubMed2001

Molecular pathology of solid tumours: some practical suggestions for translating research into clinical practice.

"Molecular pathology" can be broadly defined as the use of genetic data, in addition to the standard pathological parameters, to optimise diagnosis and to indicate treatment and prognosis. The benefit to be gained from the exploitation of molecular techniques to provide additional information to aid patient management is potentially vast. Currently, molecular pathology is rarely used in clinical practice, although it is anticipated that it will eventually become a part of routine practice. However, incorporating molecular techniques into routine practice will not be straightforward because there are several issues to be resolved. Following on from a symposium held at the Royal College of Pathologists to discuss some of these issues, the establishment of a committee of molecular pathology is proposed to plan and coordinate the introduction of molecular pathology into routine clinical practice.

Congresses as Topic↗
PubMed1992

Clinical pathology in the National Toxicology Program.

The National Toxicology Program (NTP) developed a standard approach for clinical pathology investigations that was integrated into most toxicity studies designed and conducted after 1986. Protocols for these studies include specific hematology and clinical chemistry analyses at 3 selected time points in 13-wk studies. Requirements concerning the anesthetization of animals, collection and analysis of samples, and reporting of results have been established to control sources of variability within and between contract laboratories that perform these studies for the NTP. Laboratories must meet minimum standards to be approved for participation in the Program. Important areas of consideration for these laboratories to perform clinical pathology investigations include the facility, equipment, personnel, performance, and quality control procedures. Clinical pathology results from approximately 60 13-wk studies that have been conducted by the NTP in 7 laboratories since 1987 are being analyzed to generate a database of control values for the Fischer rat and B6C3F1 mouse and to identify sources of variability. Experimental data from these studies are being analyzed and correlated with histopathologic findings to evaluate the contribution of clinical pathology to the characterization of toxicity and to examine the appropriateness of the current approach. Efforts such as these will provide for the evolution and continued relevance of clinical pathology in toxicity testing.

Animals↗
PubMed2006

Differences in sentinel lymph node pathology protocols lead to differences in surgical strategy in breast cancer patients.

BACKGROUND: Internationally, there is no consensus on the pathology protocol to be used to examine the sentinel lymph node (SN). At present, therefore, various hospitals use different SN pathology protocols of which the effect has not been fully elucidated. We hypothesized that differences between hospitals in SN pathology protocols affect subsequent surgical treatment strategies. METHODS: Patients from four hospitals (A-D) were prospectively registered when they underwent an SN biopsy. In hospitals A, B, and C, three levels of the SN were examined pathologically, whereas in hospital D, at least seven additional levels were examined. In the absence of apparent metastases with hematoxylin and eosin examination, immunohistochemical examination was performed in all four hospitals. RESULTS: In total, 541 eligible patients were included. In hospital D, more patients were diagnosed with a positive SN (P < .001) as compared with hospitals A, B, and C, mainly because of increased detection of isolated tumor cells. This led to more completion axillary lymph node dissections in hospital D (66.3% of patients (P < .0001), compared with 29.0% in hospitals A, B, and C combined). Positive non-SNs were detected in 13.9% of patients in hospital D, compared with 9.7% in hospitals A, B, and C (P = .70). That is, in 52.4% of patients in hospital D, a negative completion axillary lymph node dissection was performed, compared with 19.3% of patients in hospitals A, B, and C combined. CONCLUSIONS: Differences in SN pathology protocols between hospitals do have a substantial effect on SN findings and subsequent surgical treatment strategies. Whether ultrastaging and, thus, additional surgery can offer better survival remains to be determined.

Adult↗
PubMedDate not supplied

A protocol for the handling of tissue obtained by operative lung biopsy: recommendations of the chILD pathology co-operative group.

This is the first of a series on pediatric pulmonary disease that will appear as Perspectives in Pediatric Pathology over the coming months. The series will include practical issues, such as this protocol for handling lung biopsies and another on bronchoalveolar lavage in childhood, as well as reviews of advances in various areas in pediatric pulmonary pathology. It has been 11 years since the last Perspectives on pulmonary disease. Much has happened since then in this area, and this collection will highlight some emerging and rapidly advancing areas in pediatric lung disease. These will include a review of molecular mechanisms of lung development, and another of mechanisms of pulmonary vascular development. The surfactant system and its disorders, as well as recent advances in the biology of the pulmonary neuroendocrine system and mechanisms of respiratory viral disease, will be addressed. Articles on pulmonary hypertension, pulmonary neoplasia, and pediatric lung transplantation, with their implications for the pediatric pathologist, are also planned. The contributors to this series are a diverse group with special interests and expertise in these areas. As Dr. William Thurlbeck noted in his foreword to the previous volume, Pulmonary Disease, volume 18 of Perspectives in Pediatric Pathology, pediatric pathology had been largely concerned with phenomenology, rather than with mechanisms, model systems, and experimental investigation. I think he would have been pleased to see the changes that have occurred over the past 10 years in pediatric lung biology and pathology in particular, because these were particularly favored interests of his later years.

Child↗
PubMed1999

Surgical pathology specimens for gross examination only and exempt from submission: a College of American Pathologists Q-Probes study of current policies in 413 institutions.

OBJECTIVE: To survey the scope of current written institutional policies for types of surgical pathology specimens exempt from submission to the laboratory and those that may be examined by gross inspection only. DESIGN AND SETTING: In the first quarter of 1997, a total of 413 voluntary participant institutions enrolled in the College of American Pathologists Q-Probes quality improvement program completed a checklist of 115 proffered specimens. Also included was a questionnaire defining demographic, practice, and reimbursement variables. MAIN OUTCOME MEASURES: The number and types of specimens exempt from submission and submitted for gross examination only based on written institutional policy rather than on unapproved actual practices. RESULTS: Most institutions had a written policy for types of specimens deemed exempt from submission to pathology (87.1 %) and for types of specimens subject to gross examination only (76.6%). There was a wide range of numbers of specimen types with a median number of 17 (range, 2-40) in the exempt category and 29 (range, 6-57) in the category of gross examination only. Significantly higher absolute counts of specimens exempt from submission to pathology were reported by institutions with a greater surgical pathology volume in 1996 and by nonteaching institutions. No aspect of practice was associated with numbers of specimens for gross examination only. CONCLUSIONS: This Q-Probes study creates a multi-institutional reference database of current practices to assist pathologists and clinical staff in the development of written guidelines pertaining to surgical pathology specimen submission exceptions and gross-only examinations.

Biopsy↗