SURGICAL PATHOLOGY

Subspecialty of anatomical pathology concerned with the study and the diagnosis of disease, based on observable cellular and tissue changes in specimens removed from living patients.

Doctors practicing this specialty: 4

N. Peter Libbey, MD - ADMINISTRATIVE OFFICE: Roger Williams Medical Center, Department of Pathology, 825 Chalkstone Avenue, RI Providence, RI 02908; Phone: 401-456-2162, Fax: 401-456-2131
Paul Ferbend, DO - CLINICAL PRACTICE: Roger Williams Medical Center, Department of Pathology, 825 Chalkstone Avenue, Providence, RI 02908; Phone: 401-456-2162, Fax: 401-456-2131
Jila Khorsand, MD - CLINICAL PRACTICE: Roger Williams Medical Center, Department of Pathology, 825 Chalkstone Avenue, Providence, RI 02908; Phone: 401-456-2162, Fax: 401-456-2131

SATELLITE PRACTICE LOCATION: 25 Wells Street, Westerly, RI 02891; Phone: 401-596-6000, Fax: 401-348-3714 - ADMINISTRATIVE OFFICE: Roger Williams Medical Center, Department of Pathology, 825 Chalkstone Avenue, Providence, RI 02908; Phone: 401-456-2162, Fax: 401-456-2131
Nicola Kouttab, PhD - ADMINISTRATIVE OFFICE: Roger Williams Medical Center, Department of Pathology, 825 Chalkstone Avenue, Providence, RI 02908; Phone: 401-456-2162, Fax: 401-456-2131

MOST RECENT PUBLICATIONS RELATED TO THIS SPECIALTY

1: Arch Pathol Lab Med. 2010 Jul;134(7):969-74. 

Adequacy of surgical pathology reporting of cancer: a College of American
Pathologists Q-Probes study of 86 institutions.

Idowu MO, Bekeris LG, Raab S, Ruby SG, Nakhleh RE.

Department of Pathology, Virginia Commonwealth University Health System,
Richmond, VA 23298, USA. midowu@mcvh-vcu.edu

CONTEXT: Inclusion of all scientifically validated elements in surgical
pathology cancer reports is needed for optimal patient care. OBJECTIVE: To
evaluate the frequency with which surgical pathology cancer reports contain all
the scientifically validated elements required by the American College of
Surgery (ACS) Commission on Cancer (CoC), the extent to which checklists are
used, and the effects that the use of checklists have on the completeness of
cancer reports. DESIGN: Participants in the College of American Pathologists
voluntary Q-Probes program reviewed 25 consecutive surgical pathology reports to
include cancer reports from breast, colon, rectum, and prostate cancer
specimens. For each report, the type and total number of missing required
elements, deemed essential by the ACS CoC, was recorded. RESULTS: A total of
2125 cancer reports were reviewed in 86 institutions; 68.8% of all surgical
pathology cancer reports included all the required elements. Institutions in
which checklists were routinely used reported all required elements at a higher
rate than those that did not use checklists (88% versus 34%), and institutions
that had a system in place to track errors also reported all required elements
at a higher rate when compared to those that did not have such a system in place
(88% versus 68%). The missing mandated elements, common to cancer reports of all
tumor types, were extent of invasion and status of the resection margin.
CONCLUSIONS: This study demonstrates that about 30% of cancer reports do not
have all the scientifically validated elements required by the ACS CoC.
Pathology departments in which checklists are not routinely used have a
substantially lower rate of reports that include all the required elements.

Publication Types:
    Evaluation Studies

PMID: 20586623 [PubMed - indexed for MEDLINE]

2: Am J Clin Pathol. 2010 Jun;133(6):836-41. 

The development and testing of a laboratory information system-driven tool for
pre-sign-out quality assurance of random surgical pathology reports.

Owens SR, Dhir R, Yousem SA, Kelly SM, Piccoli A, Wiehagen L, Lassige K, Parwani
AV.

Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh,
PA, USA.

We describe the development and testing of a novel pre-sign-out quality
assurance tool for case diagnoses that allows for the random review of a
percentage of cases by a second pathologist before case verification and release
of the final report. The tool incorporates the ability to record and report
levels of diagnostic disagreement, reviewers' comments, and steps taken to
resolve any discrepancies identified. It is expandable to allow for the review
of any percentage of cases in any number of subspecialty or general pathology
"benches" and provides a prospective instrument for preventing some serious
errors from occurring, thereby potentially affecting patient care in addition to
identifying and documenting more general process issues. It can also be used to
augment other more conventional methods of quality control such as frozen
section/final diagnosis correlation, conference review, and case review before
interdisciplinary clinicopathologic sessions. There has been no significant
delay in case turnaround time since implementation. Further assessment of the
tool's function after full departmental application is underway.

PMID: 20472840 [PubMed - indexed for MEDLINE]

3: Arch Pathol Lab Med. 2010 May;134(5):740-3. 

Surgical pathology case reviews before sign-out: a College of American
Pathologists Q-Probes study of 45 laboratories.

Nakhleh RE, Bekeris LG, Souers RJ, Meier FA, Tworek JA.

Department of Pathology, Mayo Clinic Florida, Jacksonville, FL 32224, USA.
nakhlehroauf@mayo.edu

CONTEXT: To avoid errors many surgical pathology services mandate review of a
case by a second pathologist before reports are released (signed out).
OBJECTIVE: To study the extent and characteristics of such review. DESIGN:
Participants retrospectively examined up to 400 cases to identify a maximum of
30 cases reviewed by at least one additional pathologist before sign-out. For
each case, participants documented the organ system, primary disease type,
number of additional pathologists consulted, and the reason for case review. The
main outcome measure was the fraction of surgical pathology cases that underwent
second pathologist review before sign-out. RESULTS: From 45 laboratories,
examination of 18 032 surgical pathology cases yielded 1183 (6.6%) cases that
had been reviewed before sign-out. The median laboratory reviewed 8.2% of cases.
Three-fifths of reviews focused on 4 organ systems: gastrointestinal (20.5%),
breast (16.0%), skin (12.7%), and female genital tract (10.0%). Malignant
neoplasm far exceeded all other categories of disease in reviewed cases (45.3%).
Cases were reviewed by one additional pathologist 78% of the time. Two dominant
reasons for case review emerged: difficult diagnosis (46.2%) and audit required
by departmental policy (43.0%). Most laboratories (71%) had departmental
policies regarding review of cases. These laboratories reviewed cases about 33%
more often than laboratories without policies (9.6% versus 6.5%). CONCLUSIONS:
Review of selected surgical pathology cases before sign-out is widely accepted
with 71% of participant laboratories following policies to this effect. About 1
case in 15 (6.6%) were reviewed with the median laboratory of participants
reviewing about 1 in 12 (8.2%).

PMID: 20441505 [PubMed - indexed for MEDLINE]

4: Arch Pathol Lab Med. 2010 May;134(5):728-34. 

Laboratory compliance with the American Society of Clinical Oncology/college of
American Pathologists guidelines for human epidermal growth factor receptor 2
testing: a College of American Pathologists survey of 757 laboratories.

Nakhleh RE, Grimm EE, Idowu MO, Souers RJ, Fitzgibbons PL.

Department of Pathology, Mayo Clinic Florida, Jacksonville, FL 32224, USA.
Nakhleh.roauf@mayo.edu

CONTEXT: To ensure quality human epidermal growth receptor 2 (HER2) testing in
breast cancer, the American Society of Clinical Oncology/College of American
Pathologists guidelines were introduced with expected compliance by 2008.
OBJECTIVE: To assess the effect these guidelines have had on pathology
laboratories and their ability to address key components. DESIGN: In late 2008,
a survey was distributed with the HER2 immunohistochemistry (IHC) proficiency
testing program. It included questions regarding pathology practice
characteristics and assay validation using fluorescence in situ hybridization or
another IHC laboratory assay and assessed pathologist HER2 scoring competency.
RESULTS: Of the 907 surveys sent, 757 (83.5%) were returned. The median
laboratory accessioned 15 000 cases and performed 190 HER2 tests annually.
Quantitative computer image analysis was used by 33% of laboratories. In-house
fluorescence in situ hybridization was performed in 23% of laboratories, and 60%
of laboratories addressed the 6- to 48-hour tissue fixation requirement by
embedding tissue on the weekend. HER2 testing was performed on the initial
biopsy in 40%, on the resection specimen in 6%, and on either in 56% of
laboratories. Testing was validated with only fluorescence in situ hybridization
in 47% of laboratories, whereas 10% of laboratories used another IHC assay only;
13% used both assays, and 12% and 15% of laboratories had not validated their
assays or chose "not applicable" on the survey question, respectively. The 90%
concordance rate with fluorescence in situ hybridization results was achieved by
88% of laboratories for IHC-negative findings and by 81% of laboratories for
IHC-positive cases. The 90% concordance rate for laboratories using another IHC
assay was achieved by 80% for negative findings and 75% for positive cases.
About 91% of laboratories had a pathologist competency assessment program.
CONCLUSIONS: This survey demonstrates the extent and characteristics of HER2
testing. Although some American Society of Clinical Oncology/College of American
Pathologists guidelines have been implemented, gaps remain in validation of HER2
IHC testing.

PMID: 20441503 [PubMed - indexed for MEDLINE]

5: Bull NYU Hosp Jt Dis. 2010;68(1):18-21. 

Utility of pathologic evaluation following removal of explanted orthopaedic
internal fixation hardware.

Davidovitch RI, Temkin S, Weinstein BS, Singh JR, Egol KA.

New York University School of Medicine, NY, USA.

This report questions the cost and effectiveness of routinely sending explanted
hardware to pathology for evaluation. Forty-six consecutive patients who had
symptomatic hardware removed were enrolled in this study. Pathology reports
following hardware removal were obtained, and charts were reviewed for these
patients. The pathology department was contacted for related departmental
procedure codes, and hospital billing records were obtained regarding the cost
of the procedure. In all cases, the pathology reports gave the gross diagnosis
of "hardware" and the gross description included the measurements of the
internal fixation hardware removed. In no case did the report alter the plan of
the attending physician. The healthcare system may benefit by subspecialty
review of the current practice of sending internal fixation devices to pathology
for evaluation. We recommend a single radiographic view along with proper
documentation in the postoperative report to confirm the removal of internal
fixation hardware in lieu of pathologic evaluation.

Publication Types:
    Evaluation Studies

PMID: 20345357 [PubMed - indexed for MEDLINE]

6: Afr J Med Med Sci. 2009 Jun;38 Suppl 2:81-8. 

Diagnostic oncology: role of the pathologist in surgical oncology--a review
article.

Mandong BM.

Department of Pathology/Haematology, University of Jos, PMB 2084 Jos, Nigeria.
mafala2004@yahoo.com

The practice of surgical oncology requires a multidisciplinary approach
involving the pathologist, surgeon, clinicians and other workers. The task of a
pathologist is to provide adequate, and accurate diagnosis sufficient for the
clinician to take decision for patient management. In the tropics, the practice
of pathology is seriously challenged by infrastructural decay and in most cases
clinicians rely on their clinical skills for management of cancer patients. With
tremendous advance in the field of oncology, the diagnosis of cancers involve
the understanding of biological behaviour of the cancer. The details of type and
origin of the tumour, its differentiation, level of invasion, the number of
lymph node(s) with and without metastasis, the presence or absence of receptors
for hormones, activity of enzymes, ploidy, frequency of mitosis and percentage
of cells in the S-phase may all be relevant in the pathological assessment of
neoplastic tissue. The use of molecular biology has also enhanced our
understanding of the neoplastic process. Examples include the use of nucleic
acid probes with or without amplification, polymerase chain reaction to detect
expression of specific tumour genes or gene mutations, but these have not yet
become standard practice in this environment. The review is aimed at
highlighting the role of the pathologist in the management of cancer.

Publication Types:
    Review

PMID: 20229744 [PubMed - indexed for MEDLINE]

7: Ann Diagn Pathol. 2010 Apr;14(2):100-6. 

Sectionable cassette for embedding automation in surgical pathology.

Dimenstein IB.

Loyola University Medical Center (Ret.), Maywood, Ill 60153, USA.

Embedding automation can be a step ahead in histology processing development.
Among advantages in replacing time-consuming manual embedding, the possibility
of the final specimen orientation by the grossing person is very attractive for
surgical pathology. There is not yet a satisfactory technological solution for 2
main problems in the design of a sectionable cassette for biopsy specimens and
small specimens: maintaining the orientation of the sample at the end of
grossing and substitute fine skill manual alignment of the sample at the surface
of the block for microtomy. The technical note presents attempts to solve these
problems in the design of sectionable cassette. The latest sectionable cassettes
by Sakura Finetek for shave and core biopsy specimens are discussed in detail.
Copyright 2010. Published by Elsevier Inc.

PMID: 20227015 [PubMed - indexed for MEDLINE]

8: J Cataract Refract Surg. 2010 Feb;36(2):222-9. 

Assessment of toric intraocular lens alignment by a refractive power/corneal
analyzer system and slitlamp observation.

Carey PJ, Leccisotti A, McGilligan VE, Goodall EA, Moore CB.

Brisbane North Eye Centre, 708 Gympie Road, Chermside, Queensland 4032,
Australia. careyoptical@hotmail.com

PURPOSE: To assess the validity of an internal optical path difference map of a
refractive power/corneal analyzer system in determining the alignment of toric
intraocular lenses (IOLs). SETTINGS: Private practices, Spring Hill, Brisbane,
and Chermside, Australia. METHODS: This retrospective study comprised patients
with more than 1.5 diopters of preexisting corneal astigmatism who had
phacoemulsification and AcrySof toric IOL implantation. Preoperatively, the
surgical eye was marked at the slitlamp microscope using a 4-point technique.
The desired IOL orientation was marked with a Mendez marker based on the steep
corneal axis. The toric IOL axis was measured 3 weeks postoperatively by
rotating the slitlamp beam to align with the IOL axis indicator marks and using
the Internal OPD Map on the Nidek OPD-Scan system. Uncorrected (UDVA) and
corrected (CDVA) distance visual acuities, residual refractive sphere, and
residual keratometric and refractive cylinders were also measured at 3 weeks.
RESULTS: Postoperatively, the mean UDVA was 0.17 logMAR +/- 0.18 (SD) and the
mean CDVA, -0.01 +/- 0.12 logMAR; 88.2% of eyes had a UDVA of 0.3 or better, and
no eye lost lines of visual acuity. There was an 82.33% reduction in defocus
equivalent and a 64.62% reduction in refractive cylinder. The mean IOL
misalignment measured by slitlamp was 2.55 +/- 2.76 degrees and by the internal
map, 2.65 +/- 1.98 degrees. The correlation between the 2 methods was highly
significant (r = 0.99, P<.001). CONCLUSIONS: Both refractive power/corneal
analyzer system and slitlamp observation were reliable and predictable methods
of assessing IOL alignment. The 4-point preoperative marking technique yielded
clinically acceptable, accurate toric IOL alignment. Copyright  2010 ASCRS and
ESCRS. Published by Elsevier Inc. All rights reserved.

Publication Types:
    Validation Studies

PMID: 20152601 [PubMed - indexed for MEDLINE]

9: Int J Clin Exp Pathol. 2009 Nov 25;3(2):169-76. 

Immunohistochemistry in diagnostic surgical pathology: contributions of protein
life-cycle, use of evidence-based methods and data normalization on
interpretation of immunohistochemical stains.

Idikio HA.

Department of Pathology and Laboratory Medicine, University of Alberta,
Edmonton, Alberta T6G 2B7, Canada. hidikio@ualberta.ca

Immunohistochemical (IHC) staining of formalin-fixed and paraffin-embedded
tissues (FFPE) is widely used in diagnostic surgical pathology. All anatomical
and surgical pathologists use IHC to confirm cancer cell type and possible
origin of metastatic cancer of unknown primary site. What kinds of improvements
in IHC are needed to boost and strengthen the use of IHC in future diagnostic
pathology practice? The aim of this perspective is to suggest that continuing
reliance on immunohistochemistry in cancer diagnosis, search and validation of
biomarkers for predictive and prognostic studies and utility in cancer treatment
selection means that minimum IHC data sets including "normalization methods" for
IHC scoring, use of relative protein expression levels, use of protein
functional pathways and modifications and protein cell type specificity may be
needed when markers are proposed for use in diagnostic pathology. Furthermore
evidence based methods (EBM), minimum criteria for diagnostic accuracy (STARD),
will help in selecting antibodies for use in diagnostic pathology. In the near
future, quantitative methods of proteomics, quantitative real-time polymerase
chain reaction (qRT-PCR) and the use of high-throughput genomics for diagnosis
and predictive decisions may become preferred tools in medicine.

Publication Types:
    Review

PMID: 20126585 [PubMed - indexed for MEDLINE]

10: Am J Clin Pathol. 2010 Jan;133(1):156-9. 

Experience with voice recognition in surgical pathology at a large academic
multi-institutional center.

Kang HP, Sirintrapun SJ, Nestler RJ, Parwani AV.

Department of Pathology and Laboratory Medicine, Roswell Park Cancer Institute,
Buffalo, NY, USA.

There are few reports of institutional use of voice recognition technology in
clinical practice. We describe our experience with voice recognition-integrated
synoptic-like dictation, associating templates with key spoken phrases, that we
have used in gross examination of common specimens and as a major component of
our workflow since 2001. The primary application is VoiceOver Enterprise
(Voicebrook, Lake Success, NY), which uses Dragon NaturallySpeaking Medical
Edition (Nuance Communications, Burlington, MA) as its speech engine. This
integrates with the anatomic pathology laboratory information system (APLIS) and
other applications, such as Microsoft Office (Microsoft, Redmond, WA). The
largest user group, pathology assistants, mainly dictates biopsy reports,
numbering approximately 210,000 specimens since 2001. The technology has been
useful in our anatomic pathology workflow and provided a good return on
investment, including marked improvements in turnaround time, results
standardization, error reduction, and cost savings. The most helpful features of
the software are templating, the seamless integration with APLIS, and the voice
command creation tools.

PMID: 20023272 [PubMed - indexed for MEDLINE]

11: Arch Pathol Lab Med. 2009 Dec;133(12):1949-53. 

Whole-slide imaging digital pathology as a platform for teleconsultation: a
pilot study using paired subspecialist correlations.

Wilbur DC, Madi K, Colvin RB, Duncan LM, Faquin WC, Ferry JA, Frosch MP, Houser
SL, Kradin RL, Lauwers GY, Louis DN, Mark EJ, Mino-Kenudson M, Misdraji J,
Nielsen GP, Pitman MB, Rosenberg AE, Smith RN, Sohani AR, Stone JR, Tambouret
RH, Wu CL, Young RH, Zembowicz A, Klietmann W.

Department of Pathology, James Homer Wright Pathology Laboratories,
Massachusetts General Hospital, and the Department of Pathology, Harvard Medical
School, Boston, MA 02114, USA. dwilbur@partners.org

CONTEXT: -Whole-slide imaging technology offers promise for rapid,
Internet-based telepathology consultations between institutions. Before
implementation, technical issues, pathologist adaptability, and morphologic
pitfalls must be well characterized. OBJECTIVE: -To determine whether
interpretation of whole-slide images differed from glass-slide interpretation in
difficult surgical pathology cases. DESIGN: -Diagnostically challenging
pathology slides from a variety of anatomic sites from an outside laboratory
were scanned into whole digital format. Digital and glass slides were
independently diagnosed by 2 subspecialty pathologists. Reference, digital, and
glass-slide interpretations were compared. Operator comments on technical issues
were gathered. RESULTS: -Fifty-three case pairs were analyzed. There was
agreement among digital, glass, and reference diagnoses in 45 cases (85%) and
between digital and glass diagnoses in 48 (91%) cases. There were 5 digital
cases (9%) discordant with both reference and glass diagnoses. Further review of
each of these cases indicated an incorrect digital whole-slide interpretation.
Neoplastic cases showed better correlation (93%) than did cases of nonneoplastic
disease (88%). Comments on discordant cases related to digital whole technology
focused on issues such as fine resolution and navigating ability at high
magnification. CONCLUSIONS: -Overall concordance between digital whole-slide and
standard glass-slide interpretations was good at 91%. Adjustments in technology,
case selection, and technology familiarization should improve performance,
making digital whole-slide review feasible for broader telepathology
subspecialty consultation applications.

Publication Types:
    Research Support, Non-U.S. Gov't

PMID: 19961250 [PubMed - indexed for MEDLINE]

12: Arch Pathol Lab Med. 2009 Nov;133(11):1841-9. 

Standards to support information systems integration in anatomic pathology.

Daniel C, Garcia Rojo M, Bourquard K, Henin D, Schrader T, Della Mea V,
Gilbertson J, Beckwith BA.

ADICAP; INSERM, UMR_S 872 eq20 and Universite Paris Descartes, Paris, France.
christel.daniel@spim.jussieu.fr

CONTEXT: Integrating anatomic pathology information- text and images-into
electronic health care records is a key challenge for enhancing clinical
information exchange between anatomic pathologists and clinicians. The aim of
the Integrating the Healthcare Enterprise (IHE) international initiative is
precisely to ensure interoperability of clinical information systems by using
existing widespread industry standards such as Digital Imaging and Communication
in Medicine (DICOM) and Health Level Seven (HL7). OBJECTIVE: To define
standard-based informatics transactions to integrate anatomic pathology
information to the Healthcare Enterprise. DESIGN: We used the methodology of the
IHE initiative. Working groups from IHE, HL7, and DICOM, with special interest
in anatomic pathology, defined consensual technical solutions to provide
end-users with improved access to consistent information across multiple
information systems. RESULTS: The IHE anatomic pathology technical framework
describes a first integration profile, "Anatomic Pathology Workflow," dedicated
to the diagnostic process including basic image acquisition and reporting
solutions. This integration profile relies on 10 transactions based on HL7 or
DICOM standards. A common specimen model was defined to consistently identify
and describe specimens in both HL7 and DICOM transactions. CONCLUSION: The IHE
anatomic pathology working group has defined standard-based informatics
transactions to support the basic diagnostic workflow in anatomic pathology
laboratories. In further stages, the technical framework will be completed to
manage whole-slide images and semantically rich structured reports in the
diagnostic workflow and to integrate systems used for patient care and those
used for research activities (such as tissue bank databases or tissue
microarrayers).

Publication Types:
    Research Support, Non-U.S. Gov't

PMID: 19886721 [PubMed - indexed for MEDLINE]

13: Adv Anat Pathol. 2009 Nov;16(6):418-23. 

Core components of a comprehensive quality assurance program in anatomic
pathology.

Nakhleh RE.

Department of Pathology, Mayo Clinic Florida, Jacksonville, 32224, USA.
Nakhleh.raouf@mayo.edu

In this article the core components of a comprehensive quality assurance and
improvement plan are outlined. Quality anatomic pathology work comes with focus
on accurate, timely, and complete reports. A commitment to continuous quality
improvement and a systems approach with a persistent effort helps to achieve
this end. Departments should have a quality assurance and improvement plan that
includes a risk assessment of real and potential problems facing the laboratory.
The plan should also list the individuals responsible for carrying out the
program with adequate resources, a defined timetable, and annual assessment for
progress and future directions. Quality assurance monitors should address
regulatory requirements and be organized by laboratory division (surgical
pathology, cytology, etc) as well as 5 segments (preanalytic, analytic,
postanalytic phases of the test cycle, turn-around-time, and customer
satisfaction). Quality assurance data can also be used to evaluate individual
pathologists using multiple parameters with peer group comparison.

PMID: 19851132 [PubMed - indexed for MEDLINE]

14: Am J Clin Pathol. 2009 Nov;132(5):658-65. 

The Bethesda System For Reporting Thyroid Cytopathology.

Cibas ES, Ali SZ; NCI Thyroid FNA State of the Science Conference.

Dept of Pathology, Brigham and Women's Hospital, Boston, MA 02115, USA.

To address terminology and other issues related to thyroid fine-needle
aspiration (FNA), the National Cancer Institute (NCI) hosted the NCI Thyroid FNA
State of the Science Conference. The conclusions regarding terminology and
morphologic criteria from the NCI meeting led to the Bethesda Thyroid Atlas
Project and form the framework for The Bethesda System for Reporting Thyroid
Cytopathology (TBSRTC). For clarity of communication, TBSRTC recommends that
each report begin with 1 of 6 general diagnostic categories. The project
participants hope that the adoption of this flexible framework will facilitate
communication among cytopathologists, endocrinologists, surgeons, radiologists,
and other health care providers; facilitate cytologic-histologic correlation for
thyroid diseases; facilitate research into the epidemiology, molecular biology,
pathology, and diagnosis of thyroid diseases; and allow easy and reliable
sharing of data from different laboratories for national and international
collaborative studies.

Publication Types:
    Consensus Development Conference, NIH
    Review

PMID: 19846805 [PubMed - indexed for MEDLINE]

15: Ugeskr Laeger. 2009 Aug 24;171(35):2453-8. 

[Lymph node identification in colorectal cancer specimens cases]

[Article in Danish]

Schmidt MB, Engel UH, Mogensen AM, Bulow S, Petersen LN, Holck S; Danish
Colorectal Cancer Group.

Patologiafdelingen, Hvidovre Hospital, DK-2650 Hvidovre.

Colorectal carcinoma is one of the most prevalent malignancies in Western
countries. Lymph node status is a significant prognosticator. The chance of
identifying node-positivity is positively correlated with the number of lymph
nodes (LN) identified. The present paper discusses various variables that may
influence the detection of LNs, including patient- as well as surgeon- and
pathologist-related issues. The pathologist-related variable most probably
shapes the yield the most. Introduction of guidelines focusing on the most
appropriate technique may secure better and more consistent results, and the
pathologist's commitment is crucial in this respect.

Publication Types:
    English Abstract
    Review

PMID: 19732529 [PubMed - indexed for MEDLINE]

16: Histopathology. 2009 Sep;55(3):294-300. 

Virtual reality Powerwall versus conventional microscope for viewing pathology
slides: an experimental comparison.

Treanor D, Jordan-Owers N, Hodrien J, Wood J, Quirke P, Ruddle RA.

Pathology and Tumour Biology, Leeds Institute of Molecular Medicine, University
of Leeds, Leeds LS9 7TF, UK. darrentreanor@nhs.net

AIMS: Virtual slides could replace the conventional microscope. However, it can
take 60% longer to make a diagnosis with a virtual slide, due to the small
display size and inadequate user interface of current systems. The aim was to
create and test a virtual reality (VR) microscope using a Powerwall (a
high-resolution array of 28 computer screens) for viewing virtual slides more
efficiently. METHODS AND RESULTS: A controlled user experiment was performed to
compare the Powerwall with the microscope for four types of task: (i) a simple
diagnosis, (ii) a decision about a lymph node, (iii) finding small objects, (iv)
scoring a tissue microarray. User behaviour was recorded by video and
questionnaire. Time taken to perform all four tasks and diagnostic confidence
were similar using the Powerwall and conventional microscope. CONCLUSIONS: After
just a few minutes' familiarization, a VR Powerwall allowed tasks to be
performed as quickly and confidently as a microscope. Behavioural data indicated
how histopathologists should be trained to make the best use of the large
display provided by the VR microscope. Together with the potential for further
improvements in the design of the VR microscope, future virtual slide systems
could out-perform conventional microscopes in histopathological diagnosis.

Publication Types:
    Comparative Study
    Evaluation Studies
    Research Support, Non-U.S. Gov't

PMID: 19723144 [PubMed - indexed for MEDLINE]

17: Arch Pathol Lab Med. 2009 Sep;133(9):1468-71. 

Circulating tumor cells from well-differentiated lung adenocarcinoma retain
cytomorphologic features of primary tumor type.

Marrinucci D, Bethel K, Luttgen M, Bruce RH, Nieva J, Kuhn P.

Department of Cell Biology, The Scripps Research Institute, La Jolla, CA 92037,
USA.

The detailed cytomorphologic appearance of circulating tumor cells (CTCs) in
cancer patients is not well described, despite publication of multiple methods
for enumerating these cells. In this case study, we present the cytomorphology
of CTCs obtained from the blood of a woman with stage IIIB well-differentiated
lung adenocarcinoma. Four years after she was diagnosed with her disease, 67
CTCs were identified in a blood sample using an immunofluorescent staining
protocol and then subsequently stained with Wright-Giemsa. The cytomorphology of
the CTCs was compared with the original tissue biopsy from 4 years prior. We
found that CTCs and cells from the original biopsy had strikingly similar
morphologic features, including large size in comparison to white blood cells
and low nuclear to cytoplasmic ratios with voluminous cytoplasm. Careful
cytomorphologic evaluation of CTCs will provide insights about the metastatic
significance of these cells, which could yield widespread implications for the
diagnosis, treatment, and management of cancer.

Publication Types:
    Case Reports
    Research Support, N.I.H., Extramural

PMID: 19722757 [PubMed - indexed for MEDLINE]

18: Arch Pathol Lab Med. 2009 Sep;133(9):1375-8. 

Significant and unexpected, and critical diagnoses in surgical pathology: a
College of American Pathologists' survey of 1130 laboratories.

Nakhleh RE, Souers R, Brown RW.

Department of Pathology, Mayo Clinic Florida, Jacksonville, FL 32224, USA.
Nakhleh.roauf@mayo.edu

CONTEXT: The Joint Commission and the College of American Pathologists have
emphasized improved communication as a strategy to improve patient safety and
reduce errors. OBJECTIVE: To determine current policies and practices concerning
critical and/or significant and unexpected results in anatomic pathology.
DESIGN: A survey was distributed with the 2007 D mailing of the Performance
Improvement Program slides. The survey included questions that determined
laboratory size, practice setting, and anatomic pathology critical and/or
significant and unexpected result policies and practices. RESULTS: Surveys from
1130 laboratories were received. A total of 75% had a written policy regarding
anatomic pathology critical and/or significant and unexpected results; 25% did
not. A total of 30% of laboratories with written policies stated that their
policies included guidelines but did not include specific examples. A total of
33% listed 5 or fewer specific examples, 18% listed more than 5 examples, and
19% stated that they had a specifically defined list of significant and
unexpected and/or critical diagnoses. The conditions that were listed included
malignancies (48% of all laboratories), findings not expected by the clinical
history (45%), life-threatening infections (45%), no chorionic villi in products
of conception (37%), inflammatory or immunologic processes (19%), and organ
rejection (14%). Laboratories with a higher median number of accessioned
surgical and cytology cases and independent laboratories tended to have policies
with more than 5 specific examples or precise lists of must-call diagnoses (P <
.001). CONCLUSIONS: This survey illustrates current anatomic pathology policies
and practices with respect to critical and significant and unexpected results.

PMID: 19722742 [PubMed - indexed for MEDLINE]

19: Malays J Pathol. 2009 Jun;31(1):11-6. 

Historical development of the renal histopathology services in Malaysia.

Looi LM, Cheah PL.

Department of Pathology, Faculty of Medicine, University of Malaya, Kuala
Lumpur, Malaysia. looilm@ummc.edu.my

Western-style medicine was introduced to Malaya by the Portuguese, Dutch and
British between the 1500s and 1800s. Although the earliest pathology
laboratories were developed within hospitals towards the end of the 19th
Century, histopathology emerged much later than the biochemistry and
bacteriology services. The University Departments of Pathology were the pioneers
of the renal histopathology diagnostic services. The Department of Pathology,
University of Malaya (UM) received its first renal biopsy on 19 May 1968.
Hospital Universiti Kebangsaan Malaysia (HUKM) and Hospital Universiti Sains
Malaysia (HUSM) started their services in 1979 and 1987 respectively. It is
notable that the early services in these University centres caterred for both
the university hospitals and the Ministry of Health (MOH) until the mid-1990s
when MOH began to develop its own services, pivoted on renal pathologists
trained through Fellowship programmes. Currently, key centres in the MOH are
Kuala Lumpur Hospital, Sultanah Aminah Hospital Johor Bahru and Malacca
Hospital. With the inclusion of renal biopsy interpretation in the Master of
Pathology programmes, basic renal histopathology services became widely
available throughout the country from 2000. This subsequently filtered out to
the private sector as more histopathologists embraced private practice. There is
now active continuing professional development in renal histopathology through
clinicopathological dicussions, seminars and workshops. Renal research on
amyloid nephropathy, minimal change disease, IgA nephropathy, fibrillary
glomerulonephritis, lupus nephritis and microwave technology have provided an
insight into the patterns of renal pathology and changing criteria for biopsy.
More recently, there has been increasing involvement of renal teams in clinical
trials, particularly for lupus nephritis and renal transplant modulation.

Publication Types:
    Historical Article

PMID: 19694308 [PubMed - indexed for MEDLINE]

20: Am J Surg Pathol. 2009 Oct;33(10):1547-53. 

Lymph node retrieval in rectal cancer is dependent on many factors--the role of
the tumor, the patient, the surgeon, the radiotherapist, and the pathologist.

Mekenkamp LJ, van Krieken JH, Marijnen CA, van de Velde CJ, Nagtegaal ID;
Pathology Review Committee and the Co-operative Clinical Investigators.

Department of Pathology, Radboud University Nijmegen Medical Centre, The
Netherlands.

Lymph node status is the strongest prognostic factor for survival in colorectal
cancer. There are several guidelines concerning the minimum numbers of lymph
nodes that need to be examined to make reliable staging possible, but there is
no consensus in the available literature. In this study, we determine in
patients with rectal cancer factors that relate to the number of lymph nodes
found and the presence of lymph node metastasis. In addition, the number of
examined lymph nodes was correlated with prognosis. A total of 1227 patients
were selected from a multicenter prospective randomized trial investigating the
value of neoadjuvant radiotherapy. The median number of examined lymph nodes in
all patients was 7.0. The number of retrieved lymph nodes in patients with node
metastasis was significantly higher than in node negative patients. After
neoadjuvant radiotherapy fewer lymph nodes were retrieved (6.9 vs. 8.5;
P<0.0001). Variations in lymph node yield between pathology laboratories and
individual pathologists were striking. The following patient and tumor
characteristics are associated with a significant lower lymph node retrieval:
age over 60 years, overweight, small size, and low invasion depth of the tumor,
poor differentiation grade, and absence of a lymphoid reaction. Node negative
patients in whom seven or less lymph nodes were examined had a lower recurrence
free interval than patients in whom at least 8 lymph nodes were examined (17.0%
vs. 10.7%, P=0.016). We conclude that in pathology laboratories a median of at
least 8 lymph nodes need to be examined in rectal cancer specimens, but that
higher numbers are desirable and achievable in most cases, even after
preoperative radiotherapy.

PMID: 19661781 [PubMed - indexed for MEDLINE]

21: Arch Pathol Lab Med. 2009 Aug;133(8):1256-61. 

Introduction of the 7th edition eyelid carcinoma classification system from the
American Joint Committee on Cancer-International Union Against Cancer staging
manual.

Ainbinder DJ, Esmaeli B, Groo SC, Finger PT, Brooks JP.

Department of Ophthalmology, Madigan Army Medical Center, MCHJ-SOU, Tacoma, WA
98431, USA. darryl.ainbinder@amedd.army.mil

CONTEXT: The American Joint Committee on Cancer (AJCC) and the International
Union Against Cancer commissioned the Ophthalmic Oncology Task Force to modify
and update the ophthalmic chapters of the 7th edition of the AJCC Cancer Staging
Manual. OBJECTIVE: To review the existing eyelid carcinoma chapter in the 6th
edition of the AJCC Cancer Staging Manual for its clinical and research utility
and to seek evidence-based revisions with the strongest medical foundation to
use in updating the anatomically based TNM cancer staging system manual. DATA
SOURCES: The 4-year Ophthalmic Oncology Task Force consisted of 45 tumor
specialists from 10 countries and an extensive internal and external peer review
process. The 10-member Carcinoma of the Eyelid team included a diverse group of
international authors. The group included extensive representation by
clinicians, pathologists, surgeons, radiation therapists, and cancer registrars,
all with advanced, ophthalmic cancer-related areas of subspecialty. Data sources
included the above expertise applying a worldwide medical literature search,
with no discrimination based on language, country of origin, discipline source,
specialty source, or surgical practice. CONCLUSIONS: Revisions were made to the
TNM classification in areas with the strongest basis in evidence and practical
effect. Lymph node staging data were expanded markedly to reflect its
significant prognostic value. T3 and T4 were redefined and stage groupings were
added that applied current understanding in tumor biology, respected
site-specific risk factors, and provided greater correlation with the common
language of the overall AJCC Cancer Staging Manual. Evidence-based biomarkers
and data-field modifiers were included to capture additional pathologically and
clinically substantiated prognostic factors.

PMID: 19653721 [PubMed - indexed for MEDLINE]

22: Arch Pathol Lab Med. 2009 Jul;133(7):1135-8. 

Frozen section and the surgical pathologist: a point of view.

Taxy JB.

Section of Surgical Pathology, Department of Pathology, University of Chicago,
Chicago, Illinois 60637, USA. Jerome.taxy@uchospitals.edu

Frozen section is a prominent point of intersection between surgeons and
pathologists. It is regarded as the most definitive--but not the sole--form of
intraoperative consultation. Its role in tissue triage, diagnosis, and
intraoperative management should not be misconstrued as a shortcut to a
definitive diagnosis. Although the pathologist remains in control of the tissue
disposition, frozen sections are ideally requested and executed as a
collaborative effort. Frivolous requests with no direct consequences for the
conduct of a given procedure should not be honored. Frozen section plays a
material role in resident education and may be the last vestige of general
surgical pathology in an era of organ system specialization. Frozen section will
retain its relevance only in the context of broad clinical knowledge by the
pathologist and judicious utilization by the surgeon, both in the ultimate
service of the patient.

PMID: 19642740 [PubMed - indexed for MEDLINE]

23: Arch Pathol Lab Med. 2009 Jul;133(7):1026-32. 

Recent developments in the pathology of renal tumors: morphology and molecular
characteristics of select entities.

Yan BC, Mackinnon AC, Al-Ahmadie HA.

Department of Pathology, University of Chicago, Chicago, Illinois, USA.

CONTEXT: Renal cell carcinoma is a heterogeneous group of tumors with distinct
histopathologic features, molecular characteristics, and clinical outcome. These
tumors can be sporadic as well as familial or associated with syndromes. The
genetic abnormalities underlying these syndromes have been identified and were
subsequently found in corresponding sporadic renal tumors. OBJECTIVE: To review
the recent molecular and genetic advancements relating to sporadic and familial
renal carcinomas as well as those related to Xp11.2 translocation-associated
renal cell carcinoma and renal medullary carcinoma. DATA SOURCES: Literature
review, personal experience, and material from the University of Chicago.
CONCLUSIONS: Molecular genetic diagnostic techniques will continue to introduce
new biomarkers that will aid in the differential diagnosis of difficult cases.
The identification of specific signaling pathways that are defective in certain
renal tumors also makes possible the development of new therapies that
selectively target the aberrant activity of the defective proteins.

Publication Types:
    Review

PMID: 19642729 [PubMed - indexed for MEDLINE]

24: Vet Clin Pathol. 2009 Sep;38(3):281-7. Epub 2009 Jul 9. 

Guidelines for resident training in veterinary clinical pathology. III:
cytopathology and surgical pathology.

Kidney BA, Dial SM, Christopher MM.

Department of Veterinary Pathology, Western College of Veterinary Medicine,
University of Saskatchewan, Saskatoon, SK, Canada. beverly.kidney@usask.ca

The Education Committee of the American Society for Veterinary Clinical
Pathology has identified a need for improved structure and guidance of training
residents in clinical pathology. This article is the third in a series of
articles that address this need. The goals of this article are to describe
learning objectives and competencies in knowledge, abilities, and skills in
cytopathology and surgical pathology (CSP); provide options and ideas for
training activities; and identify resources in veterinary CSP for faculty,
training program coordinators, and residents. Guidelines were developed in
consultation with Education Committee members and peer experts and with
evaluation of the literature. The primary objectives of training in CSP are: (1)
to develop a thorough, extensive, and relevant knowledge base of biomedical and
clinical sciences applicable to the practice of CSP in domestic animals,
laboratory animals, and other nondomestic animal species; (2) to be able to
reason, think critically, investigate, use scientific evidence, and communicate
effectively when making diagnoses and consulting and to improve and advance the
practice of pathology; and (3) to acquire selected technical skills used in CSP
and pathology laboratory management. These guidelines define expected
competencies that will help ensure proficiency, leadership, and the advancement
of knowledge in veterinary CSP and will provide a useful framework for didactic
and clinical activities in resident-training programs.

PMID: 19619150 [PubMed - indexed for MEDLINE]

25: Hum Pathol. 2009 Aug;40(8):1082-91. Epub 2009 Jun 23. 

Virtual slide telepathology enables an innovative telehealth rapid breast care
clinic.

Lopez AM, Graham AR, Barker GP, Richter LC, Krupinski EA, Lian F, Grasso LL,
Miller A, Kreykes LN, Henderson JT, Bhattacharyya AK, Weinstein RS.

Department of Pathology, The University of Arizona College of Medicine, Tucson,
AZ 85724, USA.

An innovative telemedicine-enabled rapid breast care service is described that
bundles telemammography, telepathology, and teleoncology services into a single
day process. The service is called the UltraClinics Process. Because the core
services are at 4 different physical locations, a challenge has been to obtain
stat second opinion readouts on newly diagnosed breast cancer cases. To provide
same day quality assurance rereview of breast surgical pathology cases, a
DMetrix DX-40 ultrarapid virtual slide scanner (DMetrix Inc, Tucson, AZ) was
installed at the participating laboratory. Glass slides of breast cancer and
breast hyperplasia cases were scanned the same day the slides were produced by
the University Physicians Healthcare Hospital histology laboratory. Virtual
slide telepathology was used for stat quality assurance readouts at University
Medical Center, 6 miles away. There was complete concurrence with the primary
diagnosis in 139 (90.3%) of cases. There were 4 (2.3%) major discrepancies,
which would have resulted in a different therapy and 3 (1.9%) minor
discrepancies. Three cases (1.9%) were deferred for immunohistochemistry. In 2
cases (1.3%), the case was deferred for examination of the glass slides by the
reviewing pathologists at University Medical Center. We conclude that the
virtual slide telepathology quality assurance program found a small number of
significant diagnostic discrepancies. The virtual slide telepathology program
service increased the job satisfaction of subspecialty pathologists without
special training in breast pathology, assigned to cover the general surgical
pathology service at a small satellite university hospital.

PMID: 19552938 [PubMed - indexed for MEDLINE]

26: Hum Pathol. 2009 Aug;40(8):1057-69. Epub 2009 Jun 24. 

Overview of telepathology, virtual microscopy, and whole slide imaging:
prospects for the future.

Weinstein RS, Graham AR, Richter LC, Barker GP, Krupinski EA, Lopez AM, Erps KA,
Bhattacharyya AK, Yagi Y, Gilbertson JR.

Arizona Telemedicine Program, University of Arizona College of Medicine, Tucson,
AZ 85724, USA. ronaldw@u.arizona.edu

Telepathology, the practice of pathology at a long distance, has advanced
continuously since 1986. Today, fourth-generation telepathology systems,
so-called virtual slide telepathology systems, are being used for education
applications. Both conventional and innovative surgical pathology diagnostic
services are being designed and implemented as well. The technology has been
commercialized by more than 30 companies in Asia, the United States, and Europe.
Early adopters of telepathology have been laboratories with special challenges
in providing anatomic pathology services, ranging from the need to provide
anatomic pathology services at great distances to the use of the technology to
increase efficiency of services between hospitals less than a mile apart. As to
what often happens in medicine, early adopters of new technologies are
professionals who create model programs that are successful and then stimulate
the creation of infrastructure (ie, reimbursement, telecommunications,
information technologies, and so on) that forms the platforms for entry of
later, mainstream, adopters. The trend at medical schools, in the United States,
is to go entirely digital for their pathology courses, discarding their student
light microscopes, and building virtual slide laboratories. This may create a
generation of pathology trainees who prefer digital pathology imaging over the
traditional hands-on light microscopy. The creation of standards for virtual
slide telepathology is early in its development but accelerating. The field of
telepathology has now reached a tipping point at which major corporations now
investing in the technology will insist that standards be created for pathology
digital imaging as a value added business proposition. A key to success in
teleradiology, already a growth industry, has been the implementation of
standards for digital radiology imaging. Telepathology is already the enabling
technology for new, innovative laboratory services. Examples include STAT QA
surgical pathology second opinions at a distance and a telehealth-enabled rapid
breast care service. The innovative bundling of telemammography, telepathology,
and teleoncology services may represent a new paradigm in breast care that helps
address the serious issue of fragmentation of breast cancer care in the United
States and elsewhere. Legal and regulatory issues in telepathology are being
addressed and are regarded as a potential catalyst for the next wave of
telepathology advances, applications, and implementations.

Publication Types:
    Introductory Journal Article

PMID: 19552937 [PubMed - indexed for MEDLINE]

27: Hum Pathol. 2009 Aug;40(8):1122-8. Epub 2009 Jun 24. 

Competency assessment of residents in surgical pathology using virtual
microscopy.

Bruch LA, De Young BR, Kreiter CD, Haugen TH, Leaven TC, Dee FR.

Department of Pathology, Carver College of Medicine, The University of Iowa,
Iowa City, IA, USA.

Our goal was to develop an efficient and reliable performance-based virtual
slide competency examination in general surgical pathology that objectively
measures pathology resident's morphologic diagnostic skill. A Perl scripted
MySQL database was used to develop the test editor and test interface. Virtual
slides were created with the Aperio ScanScope. The examination consisted of 20
questions using 20 virtual slides. Slides were chosen to represent general
surgical pathology specimens from a variety of organ systems. The examination
was administered in a secure environment and was completed in 1 to 1 1/2 hours.
Examination reliability, as an indicator of the test's ability to discriminate
between trainee ability levels, was excellent (r = 0.84). The linear correlation
coefficient of virtual slide competency examination score versus months of
surgical pathology training was 0.83 (P = .0001). The learning curve was much
steeper early in training. Correlation of virtual slide competency examination
performance with resident's performance on the 64 item Resident In-Service
Examination surgical pathology subsection was 0.70. Correlation of virtual slide
competency examination performance with global end of rotation ratings was 0.28.
This pilot implementation demonstrates that it is possible to create a short,
reliable performance-based assessment tool for measuring morphologic diagnostic
skill using a virtual slide competency examination. Furthermore, the examination
as implemented in our program will be a valid measure of an individual
resident's progress in morphologic competency. Virtual slide technology and
computer accessibility have advanced to the point that the virtual slide
competency examination model implemented in our program could have applicability
across multiple residency programs.

Publication Types:
    Research Support, N.I.H., Extramural

PMID: 19552936 [PubMed - indexed for MEDLINE]

28: Hum Pathol. 2009 Aug;40(8):1092-9. Epub 2009 Jun 24. 

Robotic surgical telepathology between the Iron Mountain and Milwaukee
Department of Veterans Affairs Medical Centers: a 12-year experience.

Dunn BE, Choi H, Recla DL, Kerr SE, Wagenman BL.

Department of Pathology, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
Bruce.Dunn@va.gov

Since mid-1996, we have operated a diagnostic robotic telepathology (TP) system
at the Iron Mountain, MI, Department of Veterans Affairs Medical Center (VAMC)
from the Milwaukee, WI, VAMC, located some 220 miles away. No on-site
pathologist is present in Iron Mountain. Instead, an experienced, well-trained
pathologist assistant, under direction of pathologists located in Milwaukee, is
responsible for tissue grossing and sectioning. The pathologist assistant places
slides onto the stage of the robotic microscope, which is then controlled by
pathologists in Milwaukee. Each case read by TP is subsequently read by light
microscopy (LM) by the same pathologist. Three distinct phases of TP have been
recognized. Our experience during phase I (mid-1996 to early 1999) has been
published previously. During phase II (early 1999 to mid-2004), 1 of the 2
senior telepathologists in phase I retired, and 3 junior pathologists were
hired. During phase III (mid-2004 to June 2008), 2 new junior pathologists were
hired, and ASAP Imaging (Apollo Telemedicine, Inc., Falls Church, VA) was
implemented. The number of TP case opportunities in phases I, II, and III was
2200, 5841, and 3512, respectively, resulting in a total of 11 553. A total of
1834 cases were deferred to LM for a variety of reasons. The number of TP
diagnoses rendered in phases I, II, and III was 2144, 4636, and 2939,
respectively, resulting in a total of 9719. The major discordance rates in
phases I, II, and III were 0.33%, 0.45%, and 0.20%, respectively, with an
overall rate of 0.35%. Pathologist-specific discordance rates were not
significantly different and ranged from a low of 0.12% to a high of 0.77%,
whereas case deferral rates were significantly different (P < .0001) and ranged
from 2.5% to 28.7%. In general, no relationship between deferral rate and
discordance rate was noted. Iron Mountain clinicians have expressed great
satisfaction with the services provided by their off-site pathologist
colleagues.

PMID: 19552935 [PubMed - indexed for MEDLINE]

29: Hum Pathol. 2009 Aug;40(8):1129-36. Epub 2009 Jun 21. 

Virtual slide telepathology for an academic teaching hospital surgical pathology
quality assurance program.

Graham AR, Bhattacharyya AK, Scott KM, Lian F, Grasso LL, Richter LC, Carpenter
JB, Chiang S, Henderson JT, Lopez AM, Barker GP, Weinstein RS.

Department of Pathology, University of Arizona College of Medicine, Tucson, AZ
85724, USA.

Virtual slide telepathology is an important potential tool for providing
re-review of surgical pathology cases as part of a quality assurance program.
The University of Arizona pathology faculty has implemented a quality assurance
program between 2 university hospitals located 6 miles apart. The flagship
hospital, University Medical Center (UMC), in Tucson, AZ, handles approximately
20 000 surgical pathology specimens per year. University Physicians Healthcare
Hospital (UPHH) at Kino Campus has one tenth the volume of surgical pathology
cases. Whereas UMC is staffed by 10 surgical pathologists, UPHH is staffed daily
by a single part-time pathologist on a rotating basis. To provide same-day
quality assurance re-reviews of cases, a DMetrix DX-40 ultrarapid virtual slide
scanner (DMetrix, Inc, Tucson, AZ) was installed at the UPHH in 2005. Since
then, glass slides of new cases of cancer and other difficult cases have been
scanned the same day the slides are produced by the UPHH histology laboratory.
The pathologist at UPHH generates a provisional written report based on light
microscopic examination of the glass slides. At 2:00 pm each day, completed
cases from UPHH are re-reviewed by staff pathologists, pathology residents, and
medical students at the UMC using the DMetrix Iris virtual slide viewer. The
virtual slides are viewed on a 50-in plasma monitor. Results are communicated
with the UPHH laboratory by fax. We have analyzed the results of the first 329
consecutive quality assurance cases. There was complete concordance with the
original UPHH diagnosis in 302 (91.8%) cases. There were 5 (1.5%) major
discrepancies, which would have resulted in different therapy and/or management,
and 10 (3.0%) minor discrepancies. In 6 cases (1.8%), the diagnosis was deferred
for examination of the glass slides by the reviewing pathologists at UMC, and
the diagnosis of another 6 (1.8%) cases were deferred pending additional
testing, usually immunohistochemistry. Thus, the quality assurance program found
a small number of significant diagnostic discrepancies. We also found that
implementation of a virtual slide telepathology quality assurance service
improved the job satisfaction of academic subspecialty pathologists assigned to
cover on-site surgical pathology services at a small, affiliated university
hospital on a rotating part-time basis. These findings should be applicable to
some community hospital group practices as well.

PMID: 19540562 [PubMed - indexed for MEDLINE]

30: Hum Pathol. 2009 Aug;40(8):1070-81. Epub 2009 Jun 21. 

Primary frozen section diagnosis by robotic microscopy and virtual slide
telepathology: the University Health Network experience.

Evans AJ, Chetty R, Clarke BA, Croul S, Ghazarian DM, Kiehl TR, Perez Ordonez B,
Ilaalagan S, Asa SL.

Department of Pathology Laboratory Medicine Program, University Health Network,
Toronto, Ontario, Canada. andrew.evans@uhn.on.ca

Although telepathology (TP) has not been widely implemented for primary frozen
section diagnoses, interest in its use is growing as we move into an age of
increasing subspecialization and centralization of pathology services.
University Health Network is a 3-site academic institution in downtown Toronto.
The pathology department is consolidated at its Toronto General Hospital (TGH)
site. The Toronto Western Hospital (TWH), located 1 mile to west of TGH, has no
on-site pathologist, and generates 5 to 10 frozen section cases per week. More
than 95% of these frozen sections are submitted by neurosurgeons, in most cases
to confirm the presence of lesional tissue and establish a tissue diagnosis. In
2004, we implemented a robotic microscopy (RM) TP system to cover these frozen
sections. In 2006, we changed to a virtual slide (VS) TP system. Between
November 2004 and September 2006, 350 primary frozen section diagnoses were made
by RM. An additional 633 have been reported by VS TP since October 2006, giving
a total of 983 frozen sections from 790 patients. Of these cases, 88% have been
single specimens with total turnaround times averaging 19.98 and 15.68 minutes
per case by RM and VS TP, respectively (P < .0001). Pathologists required an
average of 9.65 minutes to review a slide by RM. This decreased 4-fold to 2.25
minutes after the change to VS TP (P < .00001). Diagnostic accuracy has been 98%
with both modalities, and our overall deferral rate has been 7.7%. Midcase
technical failure has occurred in 3 cases (0.3%) resulting in a delay, where a
pathologist went to TWH to report the frozen section. Discrepant cases have
typically involved minor interpretive errors related to tumor type. None of our
discrepant TP diagnoses has had clinical impact to date. We have found TP to be
reliable and accurate for frozen section diagnoses. In addition to its superior
speed and image quality, the VS approach readily facilitates consultation with
colleagues on difficult cases. As a result, there has been greater overall
pathologist satisfaction with VS TP.

Publication Types:
    Evaluation Studies

PMID: 19540554 [PubMed - indexed for MEDLINE]