Prevalence of adverse pathology features in grade group 2 prostatectomy specimens with syn- or metachronous metastatic disease.

BACKGROUND: To validate the importance of recently established adverse histopathology features (cribriform pattern and intraductal carcinoma) as contra-indication for deferred treatment of Gleason score 7 (3 + 4) (grade group [GG] 2) prostate cancer, we investigated their frequency in GG2 radical prostatectomies with syn- or metachronous metastatic disease. METHODS: GG2 prostatectomy specimens of patients with concomitant lymph node metastasis or distant metastasis at follow-up were identified in a clinical database of a tertiary care center and their pathology was reviewed for pathological stage, lymphovascular invasion, Gleason grade 4 subpatterns, presence of tertiary grade 5, and ductal adenocarcinoma histology. A control group of 99 GG2 prostatectomy specimens who had no metastatic disease (controls) was reviewed for the same adverse pathological features. RESULTS: Of 1860 GG2 prostatectomy specimens (operated between 2002 and 2020), 45 (2.4%) had concurrent regional lymph node metastases or distant metastases at follow-up. Pathological stage distribution of cases and controls was 24% and 79% pT2, 42% and 15% pT3a, 33% and 6.1% pT3b -T4, respectively (p < 0.001). Eleven of 45 cases (24%) had ≤10% Gleason grade 4 component. Cribriform pattern or intraductal carcinoma was present in 84% of cases versus 34% of controls (p < 0.001), tertiary grade 5 in 16% of cases versus 5% controls (p = 0.05) and ductal adenocarcinoma in 16% of cases versus 2% of controls (p = 0.004). Among the seven cases without cribriform or intraductal carcinoma, two displayed ductal adenocarcinoma features. CONCLUSIONS: Well-established unfavorable histopathologic features (intraductal and cribriform pattern carcinoma, ductal adenocarcinoma) are represented in about 90% of GG2 prostate cancers with local or distant metastatic disease and are much less common (38%) in those without metastatic disease. Strikingly, about 25% of GG2 prostatectomy cases with metastatic disease had an organ-confined disease and/or a small percentage of Gleason grade 4 pattern. This further emphasizes the relative importance of these adverse histopathological features (cribriform, intraductal, and ductal adenocarcinoma) rather than percentage Gleason grade 4 as contra-indicator of deferred treatment for patients with GG2 prostate cancer.

Combined hepatocellular-cholangiocarcinoma and its mimickers: Diagnostic pitfalls in surgical pathology.

BACKGROUND: The diagnosis of combined hepatocellular-cholangiocarcinoma (cHCC-CCA) requires histomorphological detection of both hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (iCCA). However, these primary liver cancers (PLCs) have a wide variety of microscopic appearances resulting in difficulties and uncertainties in cHCC-CCA's diagnosis. This study aims to perform a clinicopathologic analysis on the diagnosis of PLCs at a tertiary referral hospital in Thailand using traditional morphologic studies. METHODS: A 5-year retrospective analysis of pathologically diagnosed PLCs was conducted. Pathological features and clinical characteristics of cHCC-CCA and other PLCs with the histopathologic resemblance to cHCC-CCA were studied. The pathological diagnosis was rendered based on histomorphological context rather than immunoreactivity. A literature review containing diagnostic pitfalls of cHCC-CCA was carried out. RESULTS: PLCs from a total of 295 patients were retrieved, and cHCC-CCA accounted for 1.4% (n = 4) of the malignancies. Histomorphological evaluation is the most reliable diagnostic modality for cHCC-CCA. Extremely uncommon variants of iCCA (i.e., mucinous iCCA and adenosquamous iCCA) and iCCA arising with hepatocellular nodular lesions (i.e., iCCA with nodular regenerative hyperplasia (NRH), and iCCA in cirrhosis) could have a histomorphologic resemblance to that of cHCC-CCA. CONCLUSIONS: Although there has been an exceedingly high incidence of iCCA in Thailand, such a commonness is not valid for cHCC-CCA in our series. Rare forms of iCCA could have a morphologic resemblance to that of cHCC-CCA. Regardless of the differentiation and immunophenotype, iCCA without a distinct HCC component should never be diagnosed as cHCC-CCA.

Audit in surgical histopathology at a tertiary healthcare center: Study of preanalytical and analytical phase.

CONTEXT: An audit aims to verify conformance to required processes, assess their implementation, and define the targets of quality control. AIMS: To evaluate preanalytic and analytic phases of surgical histopathology in a tertiary healthcare center. SETTING AND DESIGN: An observational retrospective and prospective study over 3 months each of year 2013 and 2014. MATERIALS AND METHODS: Biopsy, small resections, large organ resections, bone marrow aspirate/biopsy (BMA/BMB), and frozen section samples received in surgical histopathology were categorized as I to V, respectively. A manual audit was done for preanalytical phase (adequacy of clinical information and grossing adequacy) and analytical phase [turnaround time (TAT) and tissue section quality]. STATISTICAL ANALYSIS: Qualitative data was assessed by Chi-Square test. Quantitative data was assessed using One-Way Analysis of Variance. RESULTS: Among 3179 total cases, category I to V had 1558 (49%), 1099 (34.6%), 342 (10.8%), 124 (3.8%), and 56 (1.8%) cases, respectively. Category I had shortest TAT but maximum number of inadequately sent specimens and recuts. Category III had maximum cases with inadequate clinical history, grossing errors, additional sections, and longest TAT. Category IV had maximum cases with poor quality sections. Category V had maximum cases with inadequate demographic details and clinical investigations. BMB (114, 91.9%) was more useful than BMA for diagnosis. Mean TAT for fixed tissues and frozen tissues was 3.6 ± 1.8 days and 26.6 ± 11.2 min, respectively. CONCLUSIONS: Total 25% of annual workload was studied by an observational, manual audit. Quality indicators were achieved as per international norms despite limited resources. Remedial actions were suggested for technicians, clinicians, and pathologists to minimize errors.

Correlation of anal cytology with follow-up histology and Human Papillomavirus genotyping: A 10-year experience from an academic medical center.

BACKGROUND: Anal cytology (AC) is accepted as a practical screening modality for anal cancer. However, studies suggest that AC and anal biopsy dysplasia correlation is less robust than in cervicovaginal specimens. The current study goals were to look at our institutional experience in a subset of ACs and correlate with surgical pathology (SP), as well as evaluate their Human Papillomavirus (HPV) status. METHODS: 377 ACs from 169 patients (151 males and 18 females) from 2008 to 2017 were included. HPV genotyping (n = 47) and SP within one year of AC (n = 58) were reviewed. RESULTS: AC/SP was discrepant in 22 cases (37.9%), with a tendency towards AC underestimating the degree of dysplasia. Specifically, any abnormality on AC was 93.8% sensitive for detecting high-grade dysplasia (HGD). However, when requiring a high-grade AC diagnosis, the sensitivity decreases to 12.5%. "Other high-risk HPV" was the most common genotype (57.4%). When considered with all AC with a high-grade diagnosis, co-testing with HPV improved the sensitivity for HGD to 56.3%. Sensitivity improved further to 87.5% when only considering cases with both AC and HPV testing, and were high-risk HPV positive. Furthermore, following review and consensus diagnosis, 8 cases changed from "Discrepant" to "Agreed", reducing the discrepancy rate to 24.1%. Remaining discrepancies were explained by sampling error. CONCLUSION: Given the enhanced sensitivity of AC and HPV testing together, and sampling error seen with AC leading to underestimating dysplasia, we recommend AC and HPV co-testing, as well as describing confounding factors in AC reports and obtaining consensus opinion in equivocal cases.

Practice Paradigms Before and After Introduction of the Diagnosis-Noninvasive Follicular Thyroid Neoplasm with Papillary-Like Nuclear Features (NIFTP): an Institutional Experience.

The recently adopted terminology of "Noninvasive follicular thyroid neoplasm with papillary-like nuclear features" (NIFTP) reflects the indolent behavior of these tumors. In contrast to conventional papillary thyroid carcinomas, NIFTP can be managed conservatively. The purpose of this study was to investigate changes in surgical and pathologic practice patterns at our institution since the introduction of the NIFTP diagnosis in 2016. A retrospective analysis of all thyroid specimens received in our laboratory between January 2015 and April 2017 was performed. The final cohort consisted of 1508 thyroidectomy specimens from 1508 patients (1153 (76.5%) women and 355 (23.5%) men), of which 1011 (67%) were total thyroidectomies and 497 (33%) were partial thyroidectomies. There were 558 (69.2%) total thyroidectomies and 248 (30.8%) partial thyroidectomies performed prior to introduction of the NIFTP diagnosis and 453 (64.5%) and 249 (35.5%) total and partial thyroidectomies, respectively, after the change in nomenclature. Within a year following the initial use of this diagnosis, 67 NIFTP cases were identified (9.5% of all thyroidectomies), whereas compared with the year preceding it, malignant diagnoses decreased from 54.5 (439) to 44.6% (313), and the benign category remained unchanged from 44.5 (367) to 45.9% (322). For the entirely submitted 67 NIFTP cases, the mean number of blocks submitted was 14.7 (0.98 blocks/g); for malignant lesions 17.7 (0.92 blocks/g); and for benign lesions 16.6 (0.75 blocks/g). The results of our study suggest that NIFTP are encountered in almost 10% of thyroidectomies at our institution with expected shifts in cytology and surgical pathology diagnoses as a result of the change in nomenclature. During this time period, significant shifts towards less aggressive surgical management were not observed. All 67 NIFTP nodules were submitted entirely with no significant difference in the number of cassettes submitted for NIFTP nodules as compared with follicular variant papillary thyroid carcinoma (PTC), classic variant PTC, or follicular adenoma.

Routine Pathologic Evaluation of Plastic Surgery Specimens: Are We Wasting Time and Money?

BACKGROUND: Recent health care changes have encouraged efforts to decrease costs. In plastic surgery, an area of potential cost savings includes appropriate use of pathologic examination. Specimens are frequently sent because of hospital policy, insurance request, or habit, even when clinically unnecessary. This is an area where evidence-based guidelines are lacking and significant cost-savings can be achieved. METHODS: All specimen submitted for pathologic examination at two hospitals between January and December of 2015 were queried for tissue expanders, breast implants, fat, skin, abdominal pannus, implant capsule, hardware, rib, bone, cartilage, scar, and keloid. Specimens not related to plastic surgery procedures were excluded. Pathologic diagnosis and cost data were obtained. RESULTS: A total of 759 specimens were identified. Of these, 161 were sent with a specific request for gross examination only. There were no clinically significant findings in any of the specimens. There was one incidental finding of a seborrheic keratosis on breast skin. The total amount billed in 2015 was $430,095. CONCLUSIONS: The infrequency of clinically significant pathologic examination results does not support routine pathologic examination of all plastic surgery specimens. Instead, the authors justify select submission only when there is clinical suspicion or medical history that warrants evaluation. By eliminating unnecessary histologic or macroscopic examination, significant cost savings may be achieved.

Utility of Additional Tissue Sections in Surgical Pathology.

BACKGROUND: To avoid diagnostic errors such as missed diagnosis and errors in staging tumors due to inadequate tissue sampling, pathologists submit additional sections (AS). OBJECTIVE: This study assessed frequency, diagnostic yield, distribution, and cost of AS. METHOD: Among 1542 AS cases, we calculated mean AS per case; fraction of AS that altered diagnosis or stage; AS variation by tissue, malignant versus benign lesions, presence or absence of neoadjuvant therapy, mass, margin, lymph nodes, or other source, resident versus pathologist assistant (PA) dissector; and AS cost per case. RESULTS: Overall 9.2 ± 8.8 AS were collected per case. In only 3.8% (58/1542) of cases AS altered diagnosis or stage. Urinary bladder cases provoked the most AS: 19.5 ± 15.1 per case. Significantly more AS came from malignant versus benign lesions (10.8 ± 9.7 vs 7.6 ± 7.5, P = <.0001) and from specimens treated with neoadjuvant therapy versus malignant lesions not so treated (12.3 ± 9.4 vs 10.3 ± 9.8, P = .02). Lymph nodes were sampled more heavily compared with mass, margin, and other sites combined (11.8 ± 11.4 vs 8.9 ± 8.4, P = .003), but in 78.4% (1209/1542) of cases, AS were from mass. Of diagnosis or stage altering AS cases, two thirds (38/58) were from masses, one fifth (11/58) from lymph nodes, a 10th (6/58) from margins, and a 20th (3/58) from other specimen sites. Resident versus pathologist assistant dissection caused no significant AS difference. AS contributed 40% cost per case. CONCLUSIONS: AS per case ranged widely; their diagnostic yield was low; they were highest in urinary bladder specimens, in malignant and particularly neoadjuvant-treated lesions. Although lymph nodes were most heavily sampled, most AS were from masses. Resident dissection did not increase AS and cost of AS was high.

Routine pathologic examination of tonsillectomy specimens: A 10-year experience at a tertiary care children's hospital.

OBJECTIVE: To review histopathologic diagnoses from tonsillectomy specimens and determine whether routine pathologic exam is necessary. METHODS: Pathology reports of patients undergoing tonsillectomy from 2005 to 2014 at our pediatric tertiary care hospital were reviewed. Histopathologic diagnoses were recorded with special attention to identification of malignancy. RESULTS: A total of 8807 paired tonsil specimens were sent to pathology over a 10-year course. Gross analysis was performed on all. Microscopic histopathologic analysis was performed on 612 (6.95%) specimens with all but one demonstrating strictly reactive lymphoid hyperplasia. The single specimen (0.16%) demonstrated follicular hyperplasia with focal necrotizing granulomatous lymphadenitis without organisms identified on special staining. The surgeon requested pathologic diagnosis to rule out lymphoma in 4 of 8087 (0.05%) of the specimens. No malignancies were identified. The approximate charges for gross examination of a paired tonsillectomy specimen and microscopic examination were $136.10 and $294.54, respectively. Over the 10 year period of the study, total charges were estimated at $1,115,340 (gross) and $180,258 (microscopic). DISCUSSION: Microscopic analysis of tonsil specimens is unlikely to identify abnormal pathology that changes patient management. This study suggests that neither gross nor microscopic pathologic examination of tonsillectomy specimens is necessary on a routine basis. Histologic analysis of tonsils should be requested only on a case by case basis when clinical suspicion for malignancy is high. Avoiding routine pathologic exam of tonsils may be cost effective and medically safe.

Emergency laparotomy in infants born at <26 weeks gestation: a neonatal network-based cohort study of frequency, surgical pathology and outcomes.

OBJECTIVE: Identify the proportion of infants born at <26 completed weeks' gestation who require emergency laparotomy, and review the surgical pathology, incidence of subsequent surgical procedures and outcome. DESIGN: Retrospective cohort review. SETTING: Tertiary neonatal surgical unit. PATIENTS: All infants born at <26 weeks' gestation in a neonatal network over an 8-year period. RESULTS: Of 381 infants, laparotomy was indicated in 61 (16%) and performed in 57. Surgical pathology encountered included spontaneous intestinal perforation (SIP) (28), necrotising enterocolitis (NEC) (14), volvulus without malrotation (1), strangulated inguinal hernia (1), milk curd obstruction (4), NEC stricture (1) and meconium obstruction of prematurity (2). No intestinal pathology was found in six. Four infants with indications for laparotomy and severe comorbidity had intensive care withdrawn without surgery. The most frequent procedure performed was resection with primary anastomosis. Nine infants (16%) required more than one laparotomy. Of the 16 infants who had stoma formation, eight had closure before discharge. Fifteen infants required surgical patent ductus arteriosus ligation following laparotomy, and 17 had laser therapy for retinopathy of prematurity. Overall 42 infants with indication for laparotomy (69%) survived to discharge. CONCLUSIONS: Nearly one in six infants born at <26 weeks required emergency laparotomy. The most frequent pathology encountered was SIP (49%), followed by NEC (25%). Over one-quarter required subsequent gastrointestinal surgery, with many also requiring cardiothoracic and ophthalmic procedures. These data are important for those caring for extremely preterm infants, the provision of information to parents and organisation of neonatal services.

Machine learning classification of surgical pathology reports and chunk recognition for information extraction noise reduction.

BACKGROUND AND AIMS: Machine learning techniques for the text mining of cancer-related clinical documents have not been sufficiently explored. Here some techniques are presented for the pre-processing of free-text breast cancer pathology reports, with the aim of facilitating the extraction of information relevant to cancer staging. MATERIALS AND METHODS: The first technique was implemented using the freely available software RapidMiner to classify the reports according to their general layout: 'semi-structured' and 'unstructured'. The second technique was developed using the open source language engineering framework GATE and aimed at the prediction of chunks of the report text containing information pertaining to the cancer morphology, the tumour size, its hormone receptor status and the number of positive nodes. The classifiers were trained and tested respectively on sets of 635 and 163 manually classified or annotated reports, from the Northern Ireland Cancer Registry. RESULTS: The best result of 99.4% accuracy - which included only one semi-structured report predicted as unstructured - was produced by the layout classifier with the k nearest algorithm, using the binary term occurrence word vector type with stopword filter and pruning. For chunk recognition, the best results were found using the PAUM algorithm with the same parameters for all cases, except for the prediction of chunks containing cancer morphology. For semi-structured reports the performance ranged from 0.97 to 0.94 and from 0.92 to 0.83 in precision and recall, while for unstructured reports performance ranged from 0.91 to 0.64 and from 0.68 to 0.41 in precision and recall. Poor results were found when the classifier was trained on semi-structured reports but tested on unstructured. CONCLUSIONS: These results show that it is possible and beneficial to predict the layout of reports and that the accuracy of prediction of which segments of a report may contain certain information is sensitive to the report layout and the type of information sought.

Análise da casuística das afecções cirúrgicas observadas na Clínica Cirúrgica de Pequenos Animais da FMVZ-USP no período de 1988 a 2007 / Casuistic analysis of surgical diseases in the Small Animal Surgery Sector of FMVZ-USP from 1988 to 2007

A patologia cirúrgica veterinária apresenta moléstias de diversas naturezas que acometem cada vez mais frequentemente os cães e os gatos. Mesmo assim, poucos levantamentos são encontrados a respeito da casuística das ditas afecções cirúrgicas em pequenos animais, principalmente com dados obtidos na realidade do Brasil. O presente trabalho descreve e analisa a frequência de afecções cirúrgicas, na Clínica Cirúrgica de Pequenos Animais da Faculdade de Medicina Veterinária e Zootecnia da Universidade de São Paulo, no período de 1988 a 2007, classificando-as em oito grupos: cárdio-respiratório, digestório, distrofias, genito-urinário, hematopoiético, locomotor, paratopias e pele e anexos. Foram avaliados um total de 18.585 casos cirúrgicos. Foi observado que a espécie canina apresentou número de afecções e procedimentos até seis vezes maior do que os registros em felinos, sendo que as afecções locomotoras apresentaram maior índice de ocorrência tanto em cães como em gatos, constituindo a amostra mais representativa atendida. As afecções associadas ao aparelho genito-urinário apresentaram a segunda maior frequência, principalmente por conta de urolitíases oriundas de hábitos alimentares. Paratopias, afecções do sistema digestório e de pele e anexos foram observadas em frequências próximas em ambas as espécies. Já as distrofias, afecções hematológicas e cardiorespiratórias foram pouco frequentes tanto em cães como em gatos. A média anual de casos submetidos a intervenções cirúrgicas (801,5) demonstra a realidade dos atendimentos cirúrgicos, bem como a caracterização das principais moléstias atendidas e submetidas à intervenção cirúrgica na rotina médica veterinária da cidade de São Paulo e da Grande São Paulo, Brasil.

Veterinary surgical pathology presents a long list of diseases that more often affect dogs and cats each day. Little information has been obtained from literature about surgical effects in dogs and cats. The present study describes and analyzes the frequency of surgical effects served in the Small Animal Surgery Service, Faculty of Veterinary Medicine, University of São Paulo, from 1988 to 2007, classifying the finds in eight categories: cardiorespiratory apparatus, digestor apparatus, dystrophies, genitourinary apparatus, hematopoietic system, locomotor apparatus, paratopies and skin and annexes components. We evaluated a total of 18.585 surgical cases and observed that the number of canine diseases and presented procedures was more than six times the number of records in cats, and locomotor diseases show a higher rate of occurrence in both dogs and cats, constituting the most representative sample found. The diseases associated with genitourinary showed the second highest frequency, mainly due to urolithiasis derived from new eating habits. Paratopies, disorders of the digestive system and skin and appendages were observed on nearby frequencies in both species. The dystrophies, cardiorespiratory and hematological disorders were infrequent both in dogs and in cats. The annual mean of cases (801.5) is adequate to characterize the routine as well as the most common surgical diseases seen in the São Paulo State and São Paulo City.

Turnaround time for large or complex specimens in surgical pathology: a College of American Pathologists Q-Probes study of 56 institutions.

CONTEXT: Turnaround time (TAT) for large or complex surgical pathology specimens is an indicator of efficiency in anatomic pathology and may affect coordination of patient care. OBJECTIVE: To establish benchmarks for TAT and to identify practice characteristics that may influence TAT. DESIGN: Participants in a 2012 Q-Probes quality improvement program of the College of American Pathologists retrospectively reviewed all surgical pathology cases from the prior 6 months to identify up to 50 cases coded as Current Procedural Terminology (CPT) code 88307 (excluding biopsies) or 88309. Participants reported the times and dates of accessioning and final sign-out. RESULTS: A total of 56 institutions reported on 2763 large or complex cases, which included 70% with CPT code 88307 and 30% with CPT code 88309. Cases requiring special handling comprised 51.5%, and 48.5% were routine. Among all institutions the median TAT was 2.72 calendar days (10th-90th percentile range, 6.23-1.22 days). Longer TAT occurred in governmental institutions (median, 6.06 versus 2.13 days; P < .001) and in institutions that mandate overnight fixation for some specimen types (median, 3.83 versus 2.07 days; P = .03). Longer TAT was associated with CPT code 88309 (median, 3.99 versus 2.82 days; P < .001), special handling (median, 4.13 versus 1.94 days; P < .001), frozen section (median, 3.38 versus 2.92 days; P < .001), radical cancer resection (P < .001), and malignant cases (P < .001). Turnaround time was not significantly affected by either pathology training programs or routine weekend sign-out. CONCLUSIONS: This study provides benchmark data for TAT in large or complex surgical pathology specimens. Turnaround time was good overall, but the range among participating institutions was wide.

Retrospective blinded review of interpretational diagnostic discrepancies in surgical pathology: 18 years of experience at a tertiary care facility.

We evaluated our quality assurance (QA) methods and QA consensus conference model for assessing the rate of interpretational diagnostic errors and trend of errors. Using monthly QA reports from review of frozen section- permanent section correlation and amended reports, all cases with interpretational diagnostic errors were identified. Retrospective blinded review of study cases were independently performed by all staff pathologist and subsequently discussed in QA conference sessions. 277 (.07%) interpretational errors were identified from 1993-2010. Errors with patient consequences comprised 15% of all errors, 4% of which were major errors. More than half (57%) of the errors were identified on review of frozen section- permanent section correlation and accounted for 64 % of all errors with patient consequence and 45% of major errors. Comparison of errors between two equally divided time periods (1993-2001 and 2002-2010) showed significant error reduction (p< 0.05). 64% of all errors, 61% of errors with patient consequence and 73% of major errors were a consequence of incorrect interpretation of the biologic behavior of the neoplasm. To conclude, we propose this quality assurance model as an effective tool for assessing interpretational errors, particularly those with significant patient consequences, enhancing participation of pathologists and reducing errors.

Communicating diagnostic uncertainty in surgical pathology reports: disparities between sender and receiver.

Surgical pathologists use a variety of phrases to communicate varying degrees of diagnostic certainty which have the potential to be interpreted differently than intended. This study sought to: (1) assess the setting, varieties and frequency of use of phrases of diagnostic uncertainty in the diagnostic line of surgical pathology reports, (2) evaluate use of uncertainty expressions by experience and gender, (3) determine how these phrases are interpreted by clinicians and pathologists, and (4) assess solutions to this communication problem. We evaluated 1500 surgical pathology reports to determine frequency of use of uncertainty terms, identified those most commonly used, and looked for variations in usage rates on the basis of case type, experience and gender. We surveyed 76 physicians at tumor boards who were asked to assign a percentage of certainty to diagnoses containing expressions of uncertainty. We found expressions of uncertainty in 35% of diagnostic reports, with no statistically significant difference in usage based on age or gender. We found wide variation in the percentage of certainty clinicians assigned to the phrases studied. We conclude that non-standardized language used in the communication of diagnostic uncertainty is a significant source of miscommunication, both amongst pathologists and between pathologists and clinicians.

[Consultation in breast surgical pathology: interobserver diagnostic variability of atypical intraductal proliferative lesions]. / Consultoria em patologia cirúrgica mamária: variabilidade interobservador no diagnóstico de lesões proliferativas intraductais atípicas.

PURPOSE: To evaluate the agreement about the histopathological diagnosis of intraductal proliferative breast lesions between general pathologists and a specialist in breast pathology. METHODS: This was an observational, cross-sectional study of 209 lesions received in consultation at the Breast Pathology Laboratory of the School of Medicine, Federal University of Minas Gerais, from 2007 to 2011, comparing the original diagnosis and the review. We included only cases with a formal request for review and cases in which the original diagnosis or reviewer's diagnosis showed proliferative lesions, pure ductal carcinoma in situ, ductal carcinoma in situ associated with microinvasion or associated with invasive carcinoma. The kappa index and percent concordance were used in the statistical analyses. RESULTS: A moderate agreement was observed between the original histopathological diagnosis and the second opinion (kappa=0.5; percentual concordance=83%). After the review, the diagnosis of malignancy was confirmed in 140/163 cases (86%) and the diagnosis of benign lesions was confirmed in 34/46 cases (74%). Regarding specific diagnosis, we observed moderate agreement between the original diagnosis and the reviewer's diagnosis (136/209 cases; kappa=0.5; percent concordance=65%). The highest disagreement was observed in cases of ductal carcinoma in situ with microinvasion (6/6 cases; 100%). Important discordance was observed in cases of atypical ductal hyperplasia (16/30 cases; 53%) and ductal carcinoma in situ (25/75 cases; 33%). Regarding the histological grade of ductal carcinoma in situ, we observed good agreement between the original diagnosis and the review (29/39 cases; kappa=0.6, percent agreement=74%). CONCLUSION: Our data confirm that intraductal proliferative breast lesions, especially atypical ductal hyperplasia, ductal carcinoma in situ and ductal carcinoma in situ with microinvasion show relevant discrepancies in the histopathological diagnoses, which may induce errors in therapeutic decisions.

Consultoria em patologia cirúrgica mamária: variabilidade interobservador no diagnóstico de lesões proliferativas intraductais atípicas / Consultation in breast surgical pathology: interobserver diagnostic variability of atypical intraductal proliferative lesions

OBJETIVO: Avaliar a concordância nos diagnósticos histopatológicos de lesões mamárias proliferativas intraductais entre patologistas gerais e especialistas em patologia mamária. MÉTODOS: Trata-se de estudo observacional e transversal, com análise de 209 lesões encaminhadas ao Laboratório de Patologia Mamária da Faculdade de Medicina da Universidade Federal de Minas Gerais para consultoria, no período de 2007 a 2011, comparando os diagnósticos originais com os após a revisão. Foram incluídos apenas os casos com solicitação formal de revisão e que apresentavam diagnóstico histopatológico no laudo original ou de revisão de lesões proliferativas, carcinoma ductal in situ puro, carcinoma ductal in situ com microinvasão ou associado a carcinoma invasor. A concordância percentual e o índice kappa foram utilizados para a análise estatística. RESULTADOS: Observamos moderada concordância nos diagnósticos originais de benignidade ou malignidade versus os diagnósticos de revisão (kappa=0,5; concordância percentual=83%). Após a revisão, o diagnóstico de malignidade foi confirmado em 140/163 casos (86%) e o diagnóstico de benignidade foi confirmado em 34/46 casos (74%). Quanto aos diagnósticos específicos, observamos concordância moderada entre o laudo original e de revisão (136/209 casos; kappa=0,5; concordância percentual=65%). A maior discordância foi observada nos casos de carcinoma ductal in situ com microinvasão (6/6 casos; 100%). Grande discordância foi observada nos casos de hiperplasia ductal atípica (16/30 casos; 53%) e carcinoma ductal in situ (25/75 casos; 33%). Em relação ao grau histológico do carcinoma ductal in situ, observou-se boa concordância entre os laudos originais e de revisão (29/39 casos; kappa=0,6; concordância percentual=74%). CONCLUSÃO: Nossos dados confirmam que as lesões mamárias proliferativas intraductais, em especial as hiperplasias ductais atípicas, o carcinoma ductal in situ e o carcinoma ductal in situ com microinvasão apresentam relevantes discordâncias nos diagnósticos histopatológicos, que podem induzir o clínico a erros nas decisões terapêuticas.

PURPOSE: To evaluate the agreement about the histopathological diagnosis of intraductal proliferative breast lesions between general pathologists and a specialist in breast pathology. METHODS: This was an observational, cross-sectional study of 209 lesions received in consultation at the Breast Pathology Laboratory of the School of Medicine, Federal University of Minas Gerais, from 2007 to 2011, comparing the original diagnosis and the review. We included only cases with a formal request for review and cases in which the original diagnosis or reviewer's diagnosis showed proliferative lesions, pure ductal carcinoma in situ, ductal carcinoma in situ associated with microinvasion or associated with invasive carcinoma. The kappa index and percent concordance were used in the statistical analyses. RESULTS: A moderate agreement was observed between the original histopathological diagnosis and the second opinion (kappa=0.5; percentual concordance=83%). After the review, the diagnosis of malignancy was confirmed in 140/163 cases (86%) and the diagnosis of benign lesions was confirmed in 34/46 cases (74%). Regarding specific diagnosis, we observed moderate agreement between the original diagnosis and the reviewer's diagnosis (136/209 cases; kappa=0.5; percent concordance=65%). The highest disagreement was observed in cases of ductal carcinoma in situ with microinvasion (6/6 cases; 100%). Important discordance was observed in cases of atypical ductal hyperplasia (16/30 cases; 53%) and ductal carcinoma in situ (25/75 cases; 33%). Regarding the histological grade of ductal carcinoma in situ, we observed good agreement between the original diagnosis and the review (29/39 cases; kappa=0.6, percent agreement=74%). CONCLUSION: Our data confirm that intraductal proliferative breast lesions, especially atypical ductal hyperplasia, ductal carcinoma in situ and ductal carcinoma in situ with microinvasion show relevant discrepancies in the histopathological diagnoses, which may induce errors in therapeutic decisions.

Confocal microscopy with strip mosaicing for rapid imaging over large areas of excised tissue.

Confocal mosaicing microscopy is a developing technology platform for imaging tumor margins directly in freshly excised tissue, without the processing required for conventional pathology. Previously, mosaicing on 12-×-12 mm² of excised skin tissue from Mohs surgery and detection of basal cell carcinoma margins was demonstrated in 9 min. Last year, we reported the feasibility of a faster approach called "strip mosaicing," which was demonstrated on a 10-×-10 mm² of tissue in 3 min. Here we describe further advances in instrumentation, software, and speed. A mechanism was also developed to flatten tissue in order to enable consistent and repeatable acquisition of images over large areas. We demonstrate mosaicing on 10-×-10 mm² of skin tissue with 1-µm lateral resolution in 90 s. A 2.5-×-3.5 cm² piece of breast tissue was scanned with 0.8-µm lateral resolution in 13 min. Rapid mosaicing of confocal images on large areas of fresh tissue potentially offers a means to perform pathology at the bedside. Imaging of tumor margins with strip mosaicing confocal microscopy may serve as an adjunct to conventional (frozen or fixed) pathology for guiding surgery.

Immunohistochemistry validation procedures and practices: a College of American Pathologists survey of 727 laboratories.

CONTEXT: The immunohistochemistry (IHC) laboratory represents a dynamic area of surgical pathology with limited practice guidelines. Studies have shown significant interlaboratory variability in results. OBJECTIVE: To establish baseline parameters for IHC validation procedures and practice, and to assess their feasibility of implementation. DESIGN: In September 2010, a questionnaire was distributed by the College of American Pathologists. It was composed of 32 questions relating to nonpredictive assays as well as non-US Food and Drug Administration (non-FDA)-approved, predictive IHC assays other than human epidermal growth factor 2 (HER2/neu). RESULTS: For non-FDA approved, nonpredictive IHC assays, 68% of laboratories had a written validation procedure. Eighty-six percent of laboratories validated the most recently introduced nonpredictive antibody. Seventy-five percent used 21 or fewer total cases for the validation and 40% used weakly or focally positive cases. Forty-six percent of respondents had a written procedure for validation procedures for non-FDA approved, predictive marker IHC assays other than HER2/neu. Seventy-five percent of laboratories validated the most recently introduced predictive antibody other than HER2/neu. Fewer than half used 25 or more cases for the validation, and 47% used weakly or focally positive cases. CONCLUSION: Some laboratories have written validation procedures that appear to build upon HER2/neu testing guidelines. Some laboratories also manage to validate new antibodies according to those standards; however, many do not. There appears to be a need for further validation guideline development for nonpredictive and non-FDA approved predictive antibody IHC assays.

Rate of occult specimen provenance complications in routine clinical practice.

Occult specimen provenance complications (SPCs), which occur when there is an absence of any direct or indirect indication that a specimen switch or contamination may have occurred, constitute a significant patient safety and medical-legal problem because they can lead to misdiagnosis. However, the rate at which occult SPCs occur is unknown because, by definition, this category of errors is not identified by standard laboratory practices. In this study, we evaluated a data set comprising almost 13,000 prostate biopsies that were prospectively tested for specimen provenance errors as part of routine clinical practice. The frequency of occult type 1 errors (a complete transposition between patients) and type 2 errors (contamination of the patient's tissue with 1 or more unrelated patients) was 0.26% and 0.67%, respectively; every urology practice setting and surgical pathology laboratory type with a representative sample size experienced at least 1 type 1 and 1 type 2 error during the study period. Overall, the mean frequency of SPCs across practice settings was 0.22% for type 1 errors and 1.69% for type 2 errors. The type 1 rate showed no correlation with a surgical pathology laboratory setting or urologic practice group setting; the type 2 rate correlated solely with a surgical pathology laboratory setting. The occult SPC rate in this limited data set provides an estimate of the scope of the problem of potential misdiagnosis as a result of occult specimen provenance errors in routine clinical practice.

Observer agreement comparing the use of virtual slides with glass slides in the pathology review component of the POSH breast cancer cohort study.

AIMS: (1) To compare the use of scanned virtual slide images (virtual microscopy) with glass slides (conventional microscopy) in the assessment of morphological characteristics of breast cancers within the setting of the Prospective study of Outcomes in Sporadic versus Hereditary breast cancer (POSH), involving a cohort of women under 40 years of age, presenting with breast cancer. (2) To assess the acceptability to histopathologists of the use of virtual slide images. METHODS: 13 histopathologists from the UK and Australia participated in the POSH pathology review. The observers were asked to assess multiple morphological features such as tumour grade and type. Comparisons were made for a single observer using both virtual images and glass slides. Intra- and inter-observer variability was calculated using the κ statistic and a comparison was made between the use of each image modality. RESULTS: Diagnostic performance with virtual slides was comparable to conventional microscopic assessment, with the measurement of agreement best for vascular invasion, necrosis and the presence of a central scar (κ=0.37-0.78), and poor for more subjective parameters such as pleomorphism, stroma, the nature of the tumour border and the degree of lymphocytic infiltrate (κ=0.1). CONCLUSION: Virtual slides represent an acceptable methodology for central review of breast cancer histopathology and can circumvent the need for either travel to view material, or the potential problems of sending it by post.