April 2007
ANATOMIC PATHOLOGY
Tissue preparation for MOHS frozen sections: a comparison of
three techniques
Accurate, efficient frozen section analysis is important for tumor control. A few studies address the technical issues. More are needed, especially as new technologies become available. The objective of this study is to compare the efficiency of three techniques of flattening tissue for microscopically oriented histologic surgery (MOHS): conventional frozen sectioning, Cryocup, and CryoHist. Conventional chuck/heat sink-frozen section preparation were compared with Cryocup™ and CryoHist to determine the most efficient technique to examine 100% of the surgical margin of 4-cm diameter, full thickness, fresh autopsy cylinders of anterior abdominal skin, which were marked on their deep and peripheral margins. The specimens were frozen sectioned at 5 μm until all the marking dye was gone from the deep surface, and 95% of the perimeter epidermis could be seen. The conventional chuck required an average of 304 micrometers to clear the deep margin and four fifths did not contain 95% of the epidermal margin. The Cryocup required an average of 284 μm to examine the deep margin and 95% of the epidermal margin. The CryoHist required an average of 104 μm to examine the deep margin and 95% of the epidermal border. The new techniques improve the efficiency and presumably the accuracy of tumor margin analysis.
Virchows Archiv,
10.1007/s00428-007-0380-0,
Benign Endometrial Hyperplasia Sequence
and Endometrial Intraepithelial Neoplasia
Mutter GL, Zaino RJ, Baak JP et al.
Endometrial "hyperplasia," as currently diagnosed, includes the changes caused by an abnormal hormonal state and those caused by a separate category of monoclonal premalignant disease. The appearance of the disease in these 2 functional categories is discontinuous, permitting more specific diagnosis of the condition using the terms "benign endometrial hyperplasia" and "endometrial intraepithelial neoplasia" (EIN), respectively. Benign endometrial hyperplasia involves the entire endometrial compartment and, with protracted estrogen exposure, shows the progressive development of cysts, remodeled glands, vascular thrombi, and stromal microinfarcts. They are best construed as a sequence of changes whereby the appearance at any single time point is uniquely dependent on the preceding combination and the duration of hormonal exposures. In contrast, the premalignant clone of an EIN lesion is characteristically offset from the background endometrium by its altered cytology and crowded architecture. The use of an internal standard for cytology assessment, combined with the distinctive topography of a clonal process, enables the diagnosis of EIN lesions with a long-term cancer risk 45-fold greater than that of their benign endometrial hyperplasia counterparts. The resolution of hormonal and premalignant subsets of traditional "endometrial hyperplasias" is possible using redefined diagnostic criteria, enabling patient therapy to be appropriately matched with the underlying disease mechanisms.
Int J Gynecol Pathol. 2007 Apr;26(2):103-114
Difficulties in assessing the depth of myometrial invasion in endometrial carcinoma
Ali A, Black D, Soslow RA.
The depth of myometrial invasion (DMI) is one of the
most important prognostic indicators and determinants of therapy in endometrial
cancer. There are well-documented problems in recognizing DMI. We examined 100
previously diagnosed endometrioid endometrial
carcinomas in hysterectomy specimens, reassessed DMI, and explored
morphological features that complicated appraisal of myometrial
invasion. The DMI was different from the original measurement in 29% of cases.
Twelve percent of all cases (40% of cases with measurement discrepancies)
involved differences in the assignment of invasion categories (noninvasive,
</=50% myometrial invasion, and >50% myometrial invasion). Nearly all endometrial cancers
originally diagnosed as invasive were considered noninvasive on review. We
examined whether the distribution of stromal metaplasia, noninvasive patterns (exophytic
tumors, irregular endomyometrial junctions, and adenomyosis), and myometrial
invasion patterns were different in cases with and without measurement
discrepancies. Irregular endomyometrial junctions, exophytic tumors, and adenomyosis
tended to coexist and were more common in the cases with DMI discrepancies.
Although there seemed to be a relationship between smooth muscle metaplasia and exophytic tumors,
it did not appear that smooth muscle metaplasia was
significantly more common in cases with measurement difficulties. However,
cases with extensive smooth muscle metaplasia posed
problems with assessment of myometrial invasion.
Patterns of myometrial invasion other than the
conventional destructive pattern were sufficiently uncommon as to not impact on
DMI measurement in large numbers of cases. Measuring the DMI is usually
uncomplicated, but additional scrutiny should be paid to cases involving exophytic tumors, irregular endomyometrial
junctions, adenomyosis, and extensive stromal smooth muscle metaplasia.
Int J Gynecol Pathol. 2007 Apr;26(2):115-23.
Biliary intraepithelial neoplasia: an international interobserver
agreement study and proposal for diagnostic criteria
Zen Y, Adsay NV, Bardadin K, Colombari
R, Y et al
Cholangiocarcinoma of
the intrahepatic and extrahepatic
bile ducts develops through a multistep histopathologic sequence. Premalignant
or non-invasive neoplastic lesions of bile ducts have
been historically called biliary dysplasia
or atypical biliary epithelium. To this date, no
standard terminology or classification system has been offered for these
lesions. In 2005, a conceptual framework and diagnostic criteria for biliary intraepithelial neoplasia
(BilIN) were proposed using the livers of patients
with hepatolithiasis. We report herein an
international interobserver agreement study on the
diagnosis of biliary non-invasive neoplastic
lesions with the goal to obtain a consensus on the terminology and grading.
Seventeen pathologists from the
Mod Pathol. 2007 Apr 13;
doi:10.1038/modpathol.3800788, [Epub ahead of print]
Adenocarcinomas of the distal
esophagus and "gastric cardia" are
predominantly esophageal carcinomas
Chandrasoma P, Wickramasinghe
K, Ma Y, Demeester T.
BACKGROUND: Adenocarcinoma of the distal esophagus
and gastric cardia are defined by the relationship of
its epicenter to the gastro-esophageal junction, which is presently defined as
the end of the tubular esophagus. We have recently suggested that the true
gastro-esophageal junction is best defined by the proximal limit of gastric oxyntic mucosa. AIM: To reclassify adenocarcinomas
of this region by the relationship of the tumor to the proximal limit of
gastric oxyntic mucosa.
METHODS: Seventy-four patients who had esophago-gastrectomy for adenocarcinomas in this region were classified as adenocarcinoma of distal esophagus (38 patients) and gastric cardia (36 patients) by present criteria. The epithelial type at the epicenter and distal edge of these tumors was assessed. RESULTS: The epicenter of the tumor in 64 patients with noncircumferential tumors had squamous (5 cases), cardiac (21 cases), oxynto-cardiac (4 cases), and intestinal (Barrett-type) (34 cases) epithelia. None had gastric oxyntic mucosa. Of the 10 patients with circumferential tumors, 7 had cardiac or oxynto-cardiac epithelium at the distal tumor edge.
CONCLUSIONS: If the gastro-esophageal junction is defined histologically as the proximal limit of oxyntic mucosa, 71/74 patients would be classified as adenocarcinoma of the distal esophagus. The other 3 patients were questionable as to gastric or esophageal origin. We suggest that this reclassification based on the proposed new definition of the gastro-esophageal junction provides an explanation for the epidemiologic relationship that exists between adenocarcinoma of the "gastric cardia" and gastro-esophageal reflux disease.
Am J Surg Pathol. 2007 Apr;31(4):569-75.
Review Article
The cause of sarcoidosis:
the Centurial enigma solved
Dennis
K. Heffner
I am an experienced pathologist (4 decades), and I can now confidently perceive the cause of sarcoidosis. I can see clearly now because of 2 things: (1) modern evidence indicating a genetic-based immune dysregulation as an essential predisposing causal cofactor and (2) a century of accumulated pathology observations relevant to the point. The first factor helps explain numerous environmental, clinical, and research uncertainties, contradictions, and puzzles. The second factor, not readily available to clinicians, allows me to perceive the answer. The argument: (1) although most pathologists are vague in their conception of a “granuloma,” the discerning pathologist realizes that a “true,” well-formed epithelioid granuloma has only a very limited number of possible causes; (2) these causes do not include autoimmune diseases nor “self-perpetuating” granulomas to a “cleared” infectious agent; (3) the only feasible 2 causes are an infection or a reaction to a foreign particulate; (4) the only possible infections are ones where the infectious agent can be seen under the microscope; (5) experienced infectious disease pathologists do not see a microorganism (after a century of looking); (6) foreign particulates are therefore the cause (the only feasible cause remaining). This is not a new speculation; what I contribute that is new are pathology perceptions that confirm it beyond speculation. The reason the particles are not seen microscopically is that they are nanoparticles (less than a micrometer in largest dimension); larger particles are cleared from the lung efficiently by mucociliary transport. Direct evidence for this nanoparticulate theory is abundant. A recent case I studied has some compelling details. The nanoparticle theory should be accepted and acted upon, guiding further research, and there are risk-free measures that probably could benefit patients now.
Annals of
Diagnostic Pathology Volume
11, Issue 2, April 2007, Pages 142-152
CYTOPATHOLOGY
Role of fine
needle aspiration and frozen section in determining the extent of thyroidectomy
Akhtar S, Awan
MS.
The routine use of fine needle aspiration (FNA) and frozen section (FS) in the
management of a thyroid nodule is controversial and needs to be evaluated on an
institution to institution basis. Authors aim was to determine the role of FNA
and FS in determining the extent of thyroidectomy.
Authors performed a comparative study of FNA and FS examination of all patients
presenting with nodular thyroid disease between September 2002 and December
2005. Data were collected on a proforma by reviewing
FNA, FS and histopathological reports. Data were
analyzed on SPSS 11. Sensitivity, specificity, accuracy, positive predictive
value and negative predictive values were calculated. We included 44 patients
with preoperative FNA, intraoperative FS examination
and final histopathology reports available. Authors excluded patients with
local invasion and distant metastases. Final histopathological
report was taken as gold standard. FNA reported 8 benign, 7 papillary
carcinoma, 22 follicular neoplasm, 1 medullary and 6
suspicious lesions. On final pathology there were 16 benign and 28 malignant
cases. Thus a total of 20 carcinomas were missed by FNA. When routine FS was
done, a total of ten patients who had malignancy were missed. Both FNA and FS
have high specificity for diagnosis of thyroid cancer but lacked sensitivity at
our institution. This is mainly because of high false negative results.
Eur Arch Otorhinolaryngol. 2007 Apr
13; [Epub ahead of print]
CLINICAL
PATHOLOGY
DGNews
PSA Doubling Predicts Prostate Cancer Recurrence
The study, published in the April issue of Mayo Clinic Proceedings, concludes that patients with a PSA doubling time of less than three months after therapy are at imminent risk of death from prostate cancer. Patients with a doubling time of three to 12 months are at a significant risk for the development of systematic disease and cancer-specific death.
According to the authors, the new findings should prompt physicians whose patients have doubling times of less than one year to treat them with systematic therapies. Patients with PSA doubling times of one to 10 years are more likely to have a local rather than systematic recurrence, and patients with a PSA doubling time of greater than 10 years are at a low risk of recurrence.
SOURCE: Mayo
Clinic
HbA1c as a screening tool for
detection of Type 2 diabetes: a systematic review
C. M. Bennett, M. Guo and S. C. Dharmage
Aim: To assess the validity of glycated haemoglobin A1c (HbA1c) as a screening tool for early detection of Type 2 diabetes.
Methods: Systematic review of primary cross-sectional studies of the accuracy of HbA1c for the detection of Type 2 diabetes using the oral glucose tolerance test as the reference standard and fasting plasma glucose as a comparison.
Results: Nine studies met the inclusion criteria. At certain cut-off points, HbA1c has slightly lower sensitivity than fasting plasma glucose (FPG) in detecting diabetes, but slightly higher specificity. For HbA1c at a Diabetes Control and Complications Trial and UK Prospective Diabetes Study comparable cut-off point of ≥ 6.1%, the sensitivity ranged from 78 to 81% and specificity 79 to 84%. For FPG at a cut-off point of ≥ 6.1 mmol/l, the sensitivity ranged from 48 to 64% and specificity from 94 to 98%. Both HbA1c and FPG have low sensitivity for the detection of impaired glucose tolerance (around 50%).
Conclusions: HbA1c and FPG are equally effective screening tools for the detection of Type 2 diabetes. The HbA1c cut-off point of > 6.1% was the recommended optimum cut-off point for HbA1c in most reviewed studies; however, there is an argument for population-specific cut-off points as optimum cut-offs vary by ethnic group, age, gender and population prevalence of diabetes. Previous studies have demonstrated that HbA1c has less intra-individual variation and better predicts both micro- and macrovascular complications. Although the current cost of HbA1c is higher than FPG, the additional benefits in predicting costly preventable clinical complications may make this a cost-effective choice.
Diabetic
Medicine,Volume 24 Issue 4 Page 333 - April 2007
BOTTOM LINE
Education in pathology
The
autopsy as a performance measure and teaching tool
Richard E. Horowitz, Wesley Y. Naritoku
Summary
A survey of pathology training programs about current operations and attitudes revealed that the autopsy is underused in medical student and pathology resident teaching, is inadequately reported, often does not have a dedicated faculty, is not championed by pathologists or clinicians, is not valued as a performance measure, and is barely used as a resource for medical research. The autopsy can be reestablished as a teaching tool and performance measure, but this will require that the autopsy be recognized as a credible and valuable medical procedure. The autopsy must then be funded; and new sources of both volume and funding, such as incorporating autopsies into payment schedules, into clinical trials, and in pay-for-performance initiatives, must be solicited. Once there is reimbursement for autopsies, pathologists, clinicians, and health care administrators will embrace the autopsy as a new source of revenue and as a valid measure of physician, hospital, and health system performance. Pathologists and the pathology specialty societies must take the lead in the reestablishment of the autopsy and must, at the same time, encourage innovations such as centralization, greater use of Pathology Assistants, and application of molecular techniques. New tools for using the autopsy in medical student teaching should be embraced, and the role of the autopsy in pathology residency programs must be reevaluated.
Response
The
questionnaire was sent to pathology training programs via the Pathology Training
Program Directors Section of the Association of Pathology Chairs (PRODS) list
serve; and 35 responses were received, an approximately 25% response rate
(Appendix B). The responses came from training programs in 18 different states
(
Medical students—survey results and comments
Most of the students have only minimal exposure to the autopsy during medical school. The 20% of students who take pathology electives in the responding programs see an average of 8 autopsies. The others see on the average only one and 20% see none at all. Even when students do attend an autopsy, they hardly ever see the microscopic slides; and except those in the pathology elective, none of the students sees the Final Autopsy Diagnosis. Most students do attend conferences, Clinical Pathological Conferences (CPC), or organ recitals using autopsy materials; and almost all of the pathology faculty felt that the autopsy had value in medical student education. However, none commented on what that value might be.
A major impediment in using the autopsy for medical student teaching is simple logistics. Ideally, a student would attend the autopsy of a patient he or she knows and has examined; but the scheduling of the autopsy, finding the student, freeing him or her from other rotations or classes, and getting the enthusiastic encouragement from the clinical faculty are not easy. There are some innovative approaches being used to utilize the autopsy in medical student teaching; one is the “reverse CPC,” where students are taken through an entire autopsy or shown relevant organs and asked to reconstruct the patient's history, physical examination, laboratory findings, and imaging studies. An example is the students being shown a lung with lobar pneumonia—they hold it in their hands and appreciate the nonaerated, solidified parenchyma and then can “feel” why the patient was short of breath, why there was dullness on percussion, why the white blood cell count was elevated, and why the chest x-ray film showed opacification. Another unique approach to autopsy teaching is to shift it to the fourth year. When first or second year medical students attend autopsies either in a hospital or especially in a medical examiner's facility, they more often have a demonstration of luridness or blood and guts sensationalism rather than an educational experience in anatomical pathology. The fourth year student has the necessary clinical background to appreciate the value of the autopsy in clinical-pathological correlation and in assessing the accuracy of diagnoses and efficacy of treatment.
Pathology residents—survey results and comments
Almost 80% of pathology faculty members that responded to the survey felt that there should be a requirement for residents to perform a minimum number of autopsies. The average suggested was 53, with a range from 25 to 100. Several programs are unable to meet the current Accreditation Council for Graduate Medical Education (ACGME) Pathology Program Requirements and the ABP requirement of 50 autopsies and must send their residents to other institutions where the supervision and educational value may be questionable. The Pathology Residency Review Committee (RRC) has recently recommended changes in the autopsy requirements, one of which would allow 2 residents to “share” their required 50 autopsies. Several respondents proposed an assessment of competency, possibly with a “final exam” autopsy at the end of a rotation, instead of an absolute numerical requirement. Some 85% of responding programs require the residents to demonstrate the Association of Directors of Anatomic and Surgical Pathology (ADASP) autopsy skill levels. A few were not familiar with those requirements or questioned their legitimacy. In programs where forensic cases are a significant part of the autopsy volume, the ADASP skills may not be applicable. The RRC has expressed concern when pathology residency programs use forensic cases to fulfill the 50 required autopsies because of, among other things, the lack of histologic preparations; however, the RRC has also recommended that histologic examination of grossly normal organs in forensic cases would not necessarily be mandated but should be “appropriate to the case.”
In all programs, the residents' gross autopsy findings, provisional autopsy diagnosis, causes of death, microscopic description, and final diagnosis are reviewed by faculty. However, there is some variation in the use of the autopsy as a teaching and learning tool. About 80% of the programs require the residents to write a clinical-pathological correlative summary, and similar numbers of programs have the residents participate in CPCs and Mortality conferences.
Emblematic of the entire “problem” of the autopsy is that only 40% of training programs responding to our survey have a dedicated autopsy faculty with no other service responsibilities. Pressure from research, teaching duties, and surgical pathology always take precedence. So who does the teaching on the autopsy service? Very often, it is the Pathology Assistant (PA) or the third or fourth year resident teaching and supervising the new first year resident. More importantly, who assesses the competence of the residents and what criteria are used? Unfortunately, we do not have an answer.
Only 60% of queried programs present autopsies at departmental conferences. This seems a tragic waste of pathological material. Several respondents described the various teaching or conference uses of autopsy material including classical “organ recital” of gross organs from the autopsies performed during the previous week, followed by microscopic review of those same cases. A new law in the state of Massachusetts has put an end to this practice, as it requires that all organs be returned to the body, unless it is necessary to retain the organ to determine a diagnosis or if the organ requires prolonged fixation. Small pieces of tissue may be retained for histologic examination; however, it is now illegal in the state of Massachusetts to retain organs for the purposes of an organ recital. Use of digital gross and microscopic photographs for weekly autopsy reviews and retention of digital images on the hospital information system open a great opportunity for innovative conferencing methods. However, the program director from one program in Massachusetts who uses digital photography in PowerPoint presentations at clinicopathological correlation conferences reports that the clinicians complain that “this is just not the same as being able to touch and feel the gross organs.”
Clinical residents—survey results and comments
In the past, both medical and surgical residents spent 6 to 12 months performing autopsies, usually early in their training. As time demands of the clinical residencies increased, the time spent on autopsies declined so that now clinical residents rotate on the autopsy service in only a minority of training program. The survey respondents indicated that clinical residents or attendings regularly attend autopsies in only 30% of programs; in the remaining programs, clinicians rarely or never attend autopsies, even when they are called—it is understandable that in today's hectic medical centers there are simply too many things to do, and going to the autopsy room is not a high enough priority nor is it one of the more aesthetically pleasing aspects of a physician's day. At the program that has the highest autopsy rate in the country, however, “we frequently see multiple members of the clinical team come to see the autopsy, including residents/fellows, nurses, and attendings.”
The predominant comment from program directors was that clinical interaction is still too infrequent. There were comments such as “Not getting the clinicians involved in the autopsy to show the value of the autopsy to them, is one of our primary failings at our institution” or “We believe that the increasingly low rate of autopsies at our institution is, to a significant degree, a reflection of the lack of interest in the autopsy by the leadership of the Department of Medicine.” Many clinicians still believe that autopsies can lead to litigation. When questioned why they have not requested an autopsy, interns have replied that they were instructed by their senior residents not to order an autopsy because the autopsy may disclose something that will result in a lawsuit. Another respondent, however, stated that “Surgery residents attend autopsies, because their Chair insists on it. Others attend occasionally.” One program concentrated its efforts on the medical intensive care unit (MICU): “We have started a twice/month conference with the MICU team (almost half of our autopsies come from the MICU service) and this has been working well.”
More than 80% of programs offer autopsy conferences for clinicians and participate in clinical conferences presumably using autopsy materials or findings. But the number of Morbidity and Mortality (M & M) conferences to which pathologists are invited has declined significantly over the past several years.
Autopsy reporting—survey results and comments
Almost all responding programs issue monthly, quarterly, or annual reports of autopsy volume, autopsy rate, and turnaround times; however, fewer than 40% of programs issue reports of autopsy findings, that is, causes of death, types of malignancy, or unusual diseases. Very few respondents made any comments about autopsy reporting. Clearly, prompt reporting is important and improves clinicians' perception of the value of autopsy; and in those jurisdictions where the attending physician is responsible for completing the death certificate, the availability of the Provisional Autopsy Diagnosis (PAD) immediately after completion of the autopsy is critical. Sending digital images of the case on the day of the autopsy is now possible with digital gross photographs and a sophisticated hospital information system.
Other innovations in reporting might be considered; one program produces clinically relevant, pathophysiology-based reports and diagnoses, rather than laundry lists of anatomical findings. Another sends reports not only to the Division of Anatomic Pathology but also to the hospital's M & M Conferences.
Performance measurement—survey results and comments
Only 65% of responding programs have an internal Quality Assurance (QA) system or an intradepartmental peer review process for autopsies, although a defined QA program is mandated by the College of American Pathologists (CAP) Anatomic Pathology Checklist (ANP .30000). Some programs are very vigilant; in one, the autopsy section head and the medical director of the hospital's QA program review all adult autopsies to identify discrepancies, possible trends, and quality improvement initiatives. In another program, a second attending pathologist reviews each autopsy before it is signed. This identifies grammatical errors, missed diagnoses (usually minor), and lack of clarity; it takes only about 15 minutes of someone's time, eliminates addendum reports, and achieves a greater uniformity of diagnostic terminology. But by and large, there is no significant quality control of autopsies.
External performance evaluation
Of the 35 programs responding, some two thirds categorize and report the number of autopsies that seem to validate, or to not validate, the clinical findings. And in most places, this information is incorporated into the institutional QA program; but rarely is there any feedback to the autopsy service. Less than half of the programs analyze discrepancies, that is, determine what happened, or did not happen, during the life of the patient that might have contributed to the discrepancy between the clinical diagnoses and the autopsy findings. Most do not collaborate with clinicians in the performance of such discrepancy analyses. And in almost no program is interrater reproducibility of discrepancy analyses assessed.
In one program, however, discrepancies are analyzed in detail by a committee within the Department of Internal Medicine, rather than by the Department of Pathology. In another, an interdisciplinary committee consisting of representatives from several specialties handles these analyses. At least one member of the committee reviews the autopsies, and any possible discrepancies are forwarded to the appropriate division director/department chair.
In more than 80% of the programs, significant discrepancies are communicated interdepartmentally; but it is not clear whether autopsy-detected discrepancies influenced patient care. About half of the respondents believe they do, 20% do not, and 20% do not know. Unfortunately, there have been virtually no published studies that might answer this question—but it must be remembered that absence of evidence is not evidence of absence.
Other than simply reporting apparent discrepancies, the autopsy is not prominent as a component of hospital QA, performance measurement, or improvement programs. In the few institutions where it has been used, it was the result of a concerted effort between multiple departments including pathology, administration, risk management, patient safety, and quality improvement and the various hospital services. In 2002, the Agency for Healthcare Research and Quality Evidence Report, “The Autopsy as an Outcome and Performance Measure”, emphasized the potential, but not yet actualized, value of the autopsy in the area of outcomes, performance measurement, and practice improvement. In the subsequent 4 years, there has been no surge of activity.
Research from the autopsy service—survey results and comments
An average of 2.3 articles were published from the surveyed autopsy services during the prior 2 years; the range was 0 to 10. Averages of 1.6 articles were done in collaboration with clinical services. It seems that often the autopsy service is a provider of specimens or materials, but the autopsy staff is not asked to collaborate. It seems that the autopsy as a source of research and publications is woefully underused in most training programs. Residency scheduling may also be a detriment. At one hospital, at least one case per month is found that would qualify for a resident's case report; but before the case is worked up, the literature searched, and the report written, the resident had been transferred to another section where the new demands on time precluded completion.
Technology/innovation
When autopsy credibility is established and volume increases, a critical reappraisal of the technique of the autopsy must be undertaken. The autopsy room can no longer be the museum of archaic techniques. We must expand from the knife, the sponge, and the hematoxylin and eosin slides to modern diagnostics and apply the entire spectrum of cytogenetic, genomic, and imaging technologies available for diagnosis.
As a first step, we need to reexamine the role of the pathologist in the autopsy room. The advent of the PA with formal education and certification by the American Society for Clinical Pathology Board of Registry introduces a new element to autopsy performance and autopsy training. PAs should do all of the evisceration, most of the dissection, much of the tissue sampling, and as in surgical pathology, much of the gross dictation. The resident in such venues learns what constitutes a “complete” autopsy and a correct dissection and proper sampling and is responsible for the PAD, the microscopic description, the Final Autopsy Diagnosis, and the clinical pathological correlation. We expect residents to know what constitutes an adequate surgical pathology slide, but we do not expect them to cut and stain their own slides; the same rationale should apply to autopsy performance. The utilization of PAs in exactly this way in the performance of autopsies is already underway in the community hospital setting.
Other advances in technology including the use of computer science, telepathology, digital imaging, and even the performance of virtual autopsies that use sophisticated radiological imaging and minimally invasive tissue removal should be investigated. An alternative approach is Rosai's proposal to restructure the autopsy (like a large surgical specimen) to focus on answering specific clinical questions with a quick turnaround time. Another approach, based on a “system analysis” that evaluated everything from the design of the consent form, an innovative method of rapidly perfusing the brain and resident scheduling, was able to shorten autopsy completion time at Creighton University School of Medicine from 57 days in 1992 to 5 days in 1994.
Not only technology but also organization and management of the autopsy need to be modernized. One way of addressing the volume problem is centralization. This would not necessarily provide data for an individual clinician or hospital, but might be invaluable for the health care system. Autopsies need to be centralized or regionalized in a single facility under the auspices of a medical school or medical examiner's office, thus freeing the community hospital and the community hospital pathologist of the chore, yet maintaining the teaching and research aspects of the autopsy. One university medical center has contracts with 23 community hospitals, both locally and up to 200 miles away. The community hospitals and their pathologists do not have to do autopsies, and the community hospitals do not need to invest in space and personnel; and these savings are passed on to the university as payment for performing the autopsy. The university thus gets sufficient numbers of autopsies for resident training, and the autopsies are done well by people who are interested in doing them. As its director told me, “it's a win, win, win!” With modern information systems, autopsy reporting is prompt and the distances are no problem.
Research
When all of the above recommendations are fulfilled, the autopsy will be funded, the volume will increase, the technology will be current, both clinicians and pathology chairs will be supportive, and a dedicated faculty will begin to use this remarkable resource for research and teaching.
However, a new and disturbing element in the use of the autopsy for research has been introduced recently by legislation in Massachusetts and California that limits or restricts the use of autopsy material in research and teaching. In addition, the requirement of highly specific informed consents and the intervention of institutional review boards into autopsy-based research may further limit the availability of autopsy materials for research.
Conclusion
The steady decline of autopsies, the collapse of autopsies as a teaching tool, the disregard of the autopsy as a performance measure, and the neglect of autopsies as a research resource can be ascribed to a loss of credibility and funding, with resultant erosion of support by pathologists, clinicians, and health care administrators.
In his
introduction to a 1990 symposium on the autopsy, Rolla B Hill, MD, cited the
autopsy as a professional obligation; he wrote, “… we have in large part
defined our professional integrity through our willingness to scrutinize error.
At its best, such self-criticism is … a healthy effort to improve future
medical care. If we are to look forward, truly forward, we must know our past.
The autopsy is the preeminent tool we have for such self-criticism. Because we
claim to be a profession—self-criticizing, self-regulating community, committed
to social good—the autopsy is a professional obligation. Nothing less than our
professional integrity requires the autopsy's revival”. If we accept this
premise, the pathology specialty societies must take the lead in reestablishing
the credibility of the autopsy, in demanding funding for the autopsy, in
recruiting champions, and in promoting innovation.
Appendix A: The survey
Number and rate of autopsies
performed during the last year
|
1. |
Number _____ 2. Rate _____ %. |
Medical students:
|
1. |
Do medical students attend
autopsies? Y/N |
|
2. |
Approximate number each student
attends during medical school? ____ |
|
3. |
Does the Pathology Course for
medical students include autopsy conferences, CPCs,
or organ recitals using autopsy materials? Y/N |
|
4. |
Does the autopsy have any value in
medical student teaching? Y/N |
|
5. |
Other thoughts? |
Pathology residents:
|
1. |
Are residents required to
demonstrate ADASP autopsy skill levels? Y/N |
|
2. |
Are the residents' gross autopsy,
PAD, COD, microscopic description, and Final Diagnosis reviewed by
faculty? Y/N |
|
3. |
Are residents required to write a
clinical pathological correlation? Y/N |
|
4. |
Are all autopsies presented at a
departmental conference? Y/N |
|
5. |
Do residents participate in CPCs or Mortality conferences? Y/N |
|
6. |
Is there a dedicated autopsy
faculty with no other responsibilities? Y/N |
|
7. |
Should there be a required number
of autopsies? Y/N |
|
8. |
How many? ___ |
|
9. |
Other thoughts? |
Clinical residents:
|
1. |
Do any clinical residents rotate
on the autopsy service? Y/N |
|
2. |
Do clinical residents or attendings regularly attend autopsies? Y/N |
|
3. |
Does the service offer autopsy
conferences for clinicians? Y/N |
|
4. |
Does the service participate in
clinical M & M conferences? Y/N |
|
5. |
Other thoughts? |
Autopsy reports:
|
1. |
Does the service issue monthly,
quarterly, or annual reports of autopsy volume, autopsy rate, and turnaround
times? Y/N |
|
2. |
Does the service issue annual
reports of autopsy findings, for example, causes of death, types of
malignancy, unusual diseases? Y/N |
|
3. |
Other thoughts? |
Autopsy and performance measurement:
|
1. |
Does the service categorize the
number of autopsies that validate, or do not validate, the clinical findings
or cause of death? Y/N |
|
2. |
Does the service communicate such
findings to clinicians? Y/N |
|
3. |
Are the findings incorporated into
the institutional QA program? Y/N |
|
4. |
Does the service analyze the
causes for any discrepancies? Y/N |
|
5. |
Does the service collaborate with
clinicians in the performance of such discrepancy analyses? Y/N |
|
6. |
Is interrater
reproducibility of discrepancy analyses assessed? Y/N |
|
7. |
Are significant discrepancies
communicated interdepartmentally? Y/N |
|
8. |
Have autopsy-detected
discrepancies influenced patient care? Y/N |
|
9. |
Is there an intradepartmental peer
review of autopsies? Y/N |
|
10. |
Other thoughts? |
Research from the autopsy service:
|
1. |
How many primary autopsy articles
has the service published in the past 2 years? ___ |
|
2. |
How many articles done in
collaboration with clinical services have been published? ____ |
|
3. |
How many research projects are now
in progress on the autopsy service? ____ |
|
4. |
Other thoughts? |
Appendix B: Answers to survey
Number and percentage of autopsies
|
|
Total autopsies (excluding
coroner's cases) average per program: 156 (range, 10-479) |
|
|
Autopsy percentage average per
program: 16 (range, 1-70) |
Medical students:
|
1. |
Do medical students attend
autopsies?
|
||
|
2. |
Number of autopsies each attends
during medical school?
|
||
|
3. |
Does the Pathology Course for
medical students include autopsy conferences, CPCs,
or organ recitals using autopsy materials?
|
||
|
4. |
Does the autopsy have any value in
medical student teaching?
|
Pathology residents:
|
1. |
Are residents required to
demonstrate ADASP autopsy skill levels?
|
||
|
2. |
Are the residents' gross autopsy,
PAD, COD, microscopic description, and Final Diagnosis reviewed by faculty?
|
||
|
3. |
Are residents required to write a
clinical pathological correlation?
|
||
|
4. |
Are all autopsies presented at a
departmental conference?
|
||
|
5. |
Do residents participate in CPCs or Mortality conferences?
|
||
|
6. |
Is there a dedicated autopsy
faculty with no other responsibilities?
|
||
|
7. |
Should there be a required number
of autopsies?
|
||
|
8. |
How many?
|
Clinical residents:
|
1. |
Do any clinical residents rotate
on the autopsy service?
|
||
|
2. |
Do clinical residents or attendings regularly attend autopsies?
|
||
|
3. |
Does the service offer autopsy
conferences for clinicians?
|
||
|
4. |
Does the service participate in
clinical M & M conferences?
|
Autopsy reports:
|
1. |
Does the service issue monthly,
quarterly, or annual reports of autopsy volume, autopsy rate, and turnaround
times?
|
||
|
2. |
Does the service issue annual
reports of autopsy findings, for example, causes of death, types of
malignancy, unusual diseases?
|
Autopsy and performance measurement:
|
1. |
Does the service categorize the
number of autopsies that validate, or do not validate, the clinical findings
or cause of death?
|
||
|
2. |
Does the service communicate such
findings to clinicians?
|
||
|
3. |
Are the findings incorporated into
the institutional QA program?
|
||
|
4. |
Does the service analyze the
causes for any discrepancies?
|
||
|
5. |
Does the service collaborate with
clinicians in the performance of such discrepancy analyses?
|
||
|
6. |
Is interrater
reproducibility of discrepancy analyses assessed?
|
||
|
7. |
Are significant discrepancies
communicated interdepartmentally?
|
||
|
8. |
Have autopsy-detected
discrepancies influenced patient care?
|
||
|
9. |
Is there an intradepartmental peer
review of autopsies?
|
Research from the autopsy service:
|
1. |
How many primary autopsy articles
has the service published in the past 2 years?
|
|||
|
2. |
How many articles done in
collaboration with clinical services have been published?
|
|||
|
3. |
How many research projects are now
in progress on the autopsy service?
|
|||
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