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PubMedDate not supplied

[Intraoperative extemporaneous examination of the parathyroid gland: what is the role of the pathologist in parathyroid pathology?].

Hyperparathyroidism (HPT), once considered a rare disease, is nowadays observed and diagnosed more frequently. Consequently, surgical treatment of HPT is often performed with good therapeutic results. The success of parathyroid surgery depends mainly on the accuracy of histopathologic diagnosis through intraoperative examination of frozen tissue specimens. Yet, parathyroid gland pathology is very complex and some of its topics even controversial. Terminology and clinico-pathological concepts in this field are constantly changing and even basic characteristics such as weight, stromal fat content and "normal " histologic patterns of these glands are still actively discussed. The pathologist must often determine, merely by studying a small bioptic specimen, not only the parathyroidal (or non-parathyroidal) origin of the examined tissue, but also the histological "normal" or "abnormality" of the tissue. In carrying out his work the experienced pathologist takes on an important task and responsibility in distinguishing between normal, early hyperplastic (asymmetric), hyperplastic or adenomatous parathyroid glands. New diagnostic technical approaches (such as Electron Microscopy, intracellular fat morphometric evaluation, parenchymal cell mass study by density gradient, etc.) enhance the possibility of reaching a reliable pathologic diagnosis, but they do not solve all the present problems and sometimes can even lead the pathologist astray. Presently the diagnosis and treatment of primary HPT should be considered an open and current problem inasmuch as definite criteria to be followed in distinguishing between normal or single enlarged glands microscopically are still lacking. Neither the degree of accuracy of intraoperative frozen section examination during parathyroid surgery nor the possibility of misleading observations in such a study has been fully evaluated. A close cooperation between the pathologist and head and neck surgeon is of utmost importance to assure the best therapeutical results obtainable from parathyroid surgery in HPT.

Adenoma↗

PubMed1991

The pathologist's workstation. Issues and an early prototype.

The role of a pathologist demands the efficient collection, processing and communication of information. Although computerization has been readily adopted in the laboratory to help with specimen processing, educational programs and technological tools for the pathologist's own information handling are at the inception stage. Many pathologists feel their role as a consultant would be enhanced by easy-to-use microcomputer information tools linked to their laboratory databases. This article provides an overview of emerging computer science trends and reviews areas in which a workstation is likely to be useful to the pathologist. A currently operational project embodying some of these concepts is described.

Clinical Laboratory Information Systems↗

PubMed1989

The role of speech language pathologists in the management of dysphagia, 1989.

Speech-language pathologists involved in the management of patients with dysphagia provide services that include evaluation, diagnosis, and rehabilitation. Dysphagia is a swallowing disorder that may be due to various neurological, structural, and cognitive deficits. While dysphagia can afflict any age group, it most often presents among the elderly. Rehabilitation efforts by the speech-language pathologist are undertaken after a medical diagnosis and referral have been made. The dysphagia evaluation begins with a bedside examination that is sometimes followed by a video-fluoroscopic study. The information obtained by the evaluation results in a feeding recommendation by the speech-language pathologist that includes appropriate diet level, amount of intake per swallow, positioning and other facilitating techniques, and swallowing exercises. Patients who are motivated, moderately alert, and have some degree of deglutition are appropriate candidates for dysphagia therapy. Elements of the therapy program can include thermal stimulation to heighten the sensitivity of the swallowing reflex, exercises to improve oromotor control, training in laryngeal adduction and compensatory swallowing techniques, positioning, and dietary modifications. Significant improvement in the swallowing disorder of appropriately selected patients cna be obtained in a rehabilitation program with properly trained and experienced speech-language pathologists.

Deglutition Disorders↗

PubMed1989

[Views of pathologists and clinicians on autopsy].

The study was performed using questionnaires which were filled in by 114 pathologists and 210 clinicians. The pathologists considered the major attractive professional motivations to be the elucidation of clinical aspects and possibility to be engaged in biopsy diagnosis, the most unattractive thing was a small salary. The clinicians supported the view that an autopsy was obligatory, the ratio of supporters to ++nonsupporters among clinicians and pathologists being 2.5:1 and 1:1, respectively. The average expected autopsy cost is 50 levs, but its real one is 84 levs. The overload of dissectors decreases the quality of autopsies and requires the revision of their performance rates. Pathologists's specialization, contact with clinicians, and labour safety are also discussed in the paper. It is only one half of the clinicians who are able to determine which disease is the major one. The death certificates that are filled in by a physician are insignificant (20% of errors are due to improper diagnosis of the major disease). The authors believe that it is high time to set up a national pathoanatomical record office equipped with computers.

Attitude↗

PubMed1982

The interstitial lung diseases: a pathologist's view.

The accurate diagnosis of the interstitial lung diseases requires that the pathologic features, whether they be derived from routine light microscopy, bronchoalveolar lavage material, ultrastructural or immunologic studies, be interpreted in the light of the clinical, roentgenographic, and physiologic presentations. The clinician must ensure that representative tissue is sampled and that the pertinent clinical data are supplied to the pathologist. Furthermore, the clinician should gain some appreciation of the pathologic changes commonly encountered. Such knowledge facilitates clinicopathologic correlations. The pathologist must ensure that the sampled tissue is handled in the most appropriate and efficient manner in order to realize the greatest diagnostic yield. In addition, the pathologist must convey to the clinician his confidence in the diagnosis as to whether the observed pathologic changes are diagnostically specific or nonspecific, in light of the clinical data. The diagnosis of interstitial disease in the immunocompromised patient entails even more intensive efforts, which must be accomplished in a very limited period of time. Only the close cooperation between clinician and pathologist can ensure diagnostic success.

Biopsy↗

PubMed1995

The biopsy. The pathologist's point of view.

The science of medicine is constantly evolving. Surgical pathology must respond to these changes. For example, incisional biopsies once taken during an open surgical procedure are now being replaced by FNA biopsies performed on the outpatient. Pathologists are being asked to diagnose lesions on smaller pieces of tissue and fewer cells. Advances in molecular biology are allowing diseases to be examined at the molecular level. The pathologist is now asked to integrate this molecular data into his or her diagnostic process (e.g., lymphomas). The impact on the pathologist of the increased complexity imposed on examination of tissues cannot be overstated. Despite these difficulties, diagnosis always comes down to the integration of the morphologic features with the clinical findings. As such, the diagnosis will always depend on close teamwork between the surgeon and the pathologist.

Biopsy↗

PubMed1995

The importance of communication between the pathologist and the clinician in caring for patients receiving gynecologic treatment.

These cases clearly illustrate the importance of communication between the pathologist and gynecologist or gynecologic oncologist to deliver optimal patient care. It is not only important for the pathologist and gynecologist to review the pathologic diagnosis before implementing treatment plans, it is also imperative that the gynecologist provide the pathologist with a thorough history. As part of this communication process, the pathologist conveys abnormalities of histology as well as uncertainties, such as that which occurred in the mucinous cystadenocarcinoma case. By maintaining open communication, the patient receiving gynecologic treatment will receive the best possible care.

Adult↗

PubMed1995

Economic tools for the pathologist.

Whether or not it is generally accepted by medical care personnel within the hospital or the laboratory, the laboratory is a business within a hospital. If the laboratory is free-standing, with a corporate ownership, then a laboratory is a business by itself. Even if it is a part of a nonprofit organization (more than two thirds of American hospitals are nonprofit), a laboratory must be able to generate more gains (profits, assets, contribution margin) than losses (liabilities, costs). With the growing volume and complexity of laboratory tests in the United States, the onerous surge of regulatory restrictions, decreasing capital, decreasing physician's reimbursement, increasing salary and operating costs, it is now time for the pathologist to add new tools to his/her customary "tools of the trade," such as surgical knives, microtomes, analyzers, and microscopes. These new tools are the economic tools of cost analysis, productivity analysis, ratio analysis, utilization review, and capital asset analysis. The pathologist of the future must not only provide patient care diagnostic expertise, but must also be a successful manager of human, fiscal, and operational resources to survive in an economic environment that demands knowledge of the principles of successful laboratory management. In addition to a general review of economic and financial "tools," this article describes techniques that have been developed during the past several years by the Laboratory Fiscal Management Committee of the College of American Pathologists that analyze, condense, and interpret general macro-indicators of laboratory cost and operational functions. These indicators are generic and can be quickly understood and utilized by every pathologist practicing in a private, commercial, or public laboratory setting.

Humans↗

PubMed1995

Will pathologists play as important a role in the future as they have in the past against the challenge of infectious diseases.

Since the recognition less than 120 years ago that organisms visible only microscopically are capable of causing human diseases, pathologists have played a major role in identifying and characterizing the etiologic infectious agents and in elucidating the pathogenic mechanisms. In face of the opportunities and challenges presented by molecular technology, AIDS and other emerging infections, and the evolution of health care systems, it is worthwhile to question whether the field of pathology will continue in the future to make major contributions in the field of infectious diseases. The AIDS epidemic has awakened pathologists to the need to reemphasize infectious diseases in diagnostic anatomic and clinical pathology, basic and applied research, and medical and scientific education. The knowledge and skills of pathologists are uniquely critical to the achievement of efficient advances in infectious diseases, and will remain so provided that pathologists embrace molecular science and apply it as a principal component in their methodologic and conceptual armamentarium.

Forecasting↗

PubMed1996

Consistencies and controversies in the application of the International Society for Heart and Lung Transplantation working formulation for heart transplant biopsy specimens. Rapamycin Cardiac Rejection Treatment Trial Pathologists.

BACKGROUND: The International Society for Heart and Lung Transplantation (ISHLT) working formulation was proposed in 1990 to promote standardization in the interpretation of endomyocardial biopsy specimens obtained after heart transplantation, especially in the setting of multicenter clinical trials and for publication purposes. METHODS: To assess uniformity in interpretation, 16 pathologists experienced in posttransplant endomyocardial biopsy specimen interpretation each read independently, in randomized order, an identical series of 23 biopsy specimens representing all ISHLT grades of rejection (n = 12) and other posttransplant biopsy findings (n = 11). The pathologists represented heart transplantation centers participating in the Rapamycin Treatment Trial for Grades 2 and 3A Rejection. The index diagnosis in each case was determined by two pathology consultants who had concurred blindly on 22 of 23 (96%) biopsy specimen evaluations on their first independent reading. Discrepancies that would not affect clinical response (for example grades 0 versus 1A, 1A versus 1B, 3A versus 3B, 3B versus 4) were considered minor; those that could alter therapy were considered major. RESULTS: The 16 trial pathologists were in exact agreement with the index diagnosis in 17 (mean) +/- 3 biopsy specimens (range 10 to 22) and 20 (mean) +/- 2 biopsy specimens (range 16 to 22) if minor discrepancies were excluded. Of 368 diagnoses rendered, 265 agreed exactly with the index diagnosis and 103 differed, of which 50 were minor discrepancies. The 53 major discrepancies included grades 1A/B versus 2, 22 discrepancies; 2 versus 3A, 11; Quilty B versus 2/3A, 10; biopsy site versus 3A, 2; ischemic injury versus 3A/B, 2; Toxoplasma versus 3A, 2; posttransplantation lymphoproliferative disorder versus 3B/4, 3; and Quilty B versus posttransplantation lymphoproliferative disorder, 1. Interobserver agreement assessed by weighted kappa values was 0.67. CONCLUSIONS: First, there was agreement among the trial pathologists and the index diagnosis (excluding minor discrepancies) in 85% of biopsy specimen interpretations. Second, of 53 major discrepancies, 43 (81%) involved grades 1A/B versus 2, 2 versus 3A, and Quilty B versus 2/3A. Third, in 54% of instances in which biopsy findings other than rejection were misdiagnosed as rejection grades, the grade was sufficiently high to have adverse treatment implications. Fourth, the ISHLT working formulation provides for a high degree of diagnostic consistency among experienced observers, and concordance could be further enhanced by clarification of criteria for grade 2 rejection and Quilty B lesions.

Biopsy↗

PubMed1998

"No pictures from summer vacation": portrayals of pathologists in the printed media.

Public perceptions of pathologists can be shaped by individuals' direct contacts with these medical specialists, as well as by portrayals of them in the media. Few lay people, whether healthy or ill, have direct professional interaction with pathologists. Accordingly, media portrayals can assume great importance in shaping public views of pathologists and their profession. This report discusses how pathologists and the specialty of pathology are depicted in newspaper articles.

Forensic Medicine↗

PubMed1998

Consistency achieved by 23 European pathologists in categorizing ductal carcinoma in situ of the breast using five classifications. European Commission Working Group on Breast Screening Pathology.

The increased detection of ductal carcinoma in situ (DCIS) by mammographic screening, the greater use of breast-conserving surgery, and the recognition that certain histological subtypes are associated with a greater risk of local recurrence has led to the formulation of several new classifications of DCIS in recent years. There are, however, no data concerning the degree of consistency with which these schemes can be applied by reasonable numbers of pathologists. Thirty-three cases of DCIS were thus examined by a working group of 23 European pathologists who categorized them using five recently published classifications: (1) that of the European Pathologists' Working Group based on differentiation (a combination of nuclear grade and cell polarization) with categories of poorly, intermediately, and well differentiated; (2) one based entirely on nuclear grade with categories of high, intermediate, and low, currently in use in the UK national and EC-funded breast screening programs; (3) the same classification in which only two categories, high nuclear grade and other, were used; (4) the Van Nuys system in which lesions are divided into high grade, non-high grade with necrosis and non-high grade without necrosis; and (5) a two-category classification based entirely on the presence or absence of comedo necrosis. Of the three systems with three categories, Van Nuys gave the highest overall kappa statistic of 0.42. Others gave similar values of 0.37 and 0.35 showing that assessing cell polarization in addition to nuclear grade neither improves nor worsens consistency. In all three systems, the middle category was associated with the lowest value for kappa. Of the two systems with two categories, that based on nuclear grade gave the highest overall kappa of 0.46 and that based on comedo necrosis the lowest of 0.34. The most robust histological features were thus high- and low-grade nuclei and necrosis as long as the latter did not involve the recognition of a comedo growth pattern. These values probably represent the maximum achievable, at least by reasonable numbers of pathologists in everyday practice. They are better than those previously reported for classification based entirely on architecture, but further improvement is needed.

Breast Neoplasms↗

PubMed1992

Cutaneous T-cell lymphoma. Evaluation of pretreatment skin biopsy specimens by a panel of pathologists.

BACKGROUND AND DESIGN: Cutaneous T-cell lymphoma (CTCL) frequently presents a difficult diagnostic challenge for the clinician and pathologist. To assess the diagnostic validity of conventional histopathologic findings in CTCL, pretreatment skin biopsy specimens were scored prospectively and independently by a panel of five to seven dermatopathologists and pathologists. Scores were compared with disease outcome. Repeatability of these scores was examined among observers and for the same observer. The study population consisted of 165 subjects, initially referred for suspected mycosis fungoides or Sézary syndrome. Ninety-two patients determined to have CTCL have been followed up for 6.3 +/- 3.5 years (mean +/- SD) and are categorized according to disease outcome: 22 are in complete remission, 35 are in partial remission, three have progressive lymphoma, 15 died of disease, 13 died of other causes, and four were unavailable for follow-up. Seventy-three patients determined not to have CTCL have been followed up for 5.3 +/- 3.2 years without subsequent clinicopathologic evidence of CTCL. These longitudinal data allowed comparisons of the clinical course with the original histologic interpretations. RESULTS: Data showed that the histologic scores rendered by the pathology panel did not correlate with stage of disease and were not an accurate predictor of clinical outcome, because the histologic ratings did not discriminate between patients who eventually had complete remission and those with either progressive lymphoma or who have died of disease. The results also substantiate the low inherent reliability of histopathologic findings in CTCL. Large differences existed among pathologists in scoring the study populations and repeated reading of selected cases by the same panel member resulted in a change of diagnosis 15% of the time. Among the histologic features evaluated, only the presence of mitoses in the infiltrating cells showed a trend toward an unfavorable outcome. CONCLUSION: Pathologic diagnosis in the CTCL disease spectrum should be interpreted with caution and then only in conjunction with the clinical evaluation. As expected, the use of an average value from a panel of readers added a component of stability to the histologic interpretation.

Biopsy↗

PubMed1976

Common errors made by pathologists in the diagnosis of bone tumors.

The pathologist must obtain X-rays before attempting to make a diagnosis in a bone tumor. Errors are made with both benign and malignant lesions associated with calluses. Infection may stimulate a malignant bone tumor radiographically and pathologically. Secondary aneurysmal bone cyst may dominate the radiographic and pathologic findings and obscure the primary diagnosis. Osteoblastomas are becoming increasingly difficult to diagnose. The question of whether such an entity can become malignant has not been resolved. Cartilagenous tumors are often difficult to diagnose and the pathologist must not only rely on histologic findings, but in particular pay attention to the radiographic pattern which is often diagnostic. Accuracy of diagnosis in Ewing's sarcoma is essential because the treatment now can result in a cure rate of almost 40%. Certain lesions such as lymphoma or osteosarcoma can mimic this tumor. To re-emphasize the problem, the pathologist must have all the clinical information before attempting a diagnosis of a bone tumor and without the pertinent X-ray, errors are almost inevitable.

Adolescent↗

PubMed1982

Disagreement of histopathological diagnosis of different pathologists in ovarian tumors-with some theoretical considerations.

Microscopical sections of forty-nine ovarian tumors have been assessed as benign, borderline or malignant by four different pathologists, who were unaware of the FIGO stage and clinical follow-up of each patient and each others' diagnosis. There was absolute agreement in 37 cases (75.5%), and disagreement in 12 cases (24.5%). The majority of the disagreements involved borderline-malignant differences. If one of the pathologists did disagree with the other three (in 9 cases, or 18%), there is no correlation between disagreement and histopathological experience. In three cases (6.5%) two pathologists did disagree with the other two. It is concluded that in pathology, objective reproducible and if possible, quantitative techniques should be used instead of subjective grading methods. The probability of the diagnosis should be expressed in a numerical way.

Diagnosis, Differential↗

PubMed2000

The pathologist's role in sentinel lymph node evaluation.

Patients with high-risk (thick, deeply invasive) primary melanoma were, in the past, managed by wide local excision and elective node dissection or wide local excision alone, with subsequent lymphadenectomy if the regional nodes developed clinically detectable metastases. We recently developed a more logical approach called selective lymph node dissection. To be effective, this requires close collaboration of surgeons, pathologists, and nuclear medicine physicians. The draining lymph node basin is identified preoperatively by lymphoscintigraphy. During surgery, a marker dye (isosulfan blue) and radioactive technetium labeled albumin are injected intradermally around the primary melanoma and the afferent lymphatics are followed up to the first lymph nodes of the ipsilateral regional nodal basin. The surgeon excises the blue-colored and maximally radioactive sentinel nodes and the pathologist critically evaluates these for the presence of a metastatic tumor. If the sentinel nodes are tumor free, no further nodal dissection is undertaken; if a tumor is present, a complete dissection of the nodal basin is performed. We have examined 1,119 sentinel lymph nodes from 669 patients treated by selective lymph node dissection. We identified melanoma cells in sentinel nodes from 126 patients (17.8%). A single node contained tumors in 67% of patients, 2 nodes were positive in 25%, and the remaining 12% of patients had three tumor-containing nodes. Melanoma cells were dispersed singly or in variably sized groups, usually in the peripheral nodal sinus. In around 40% of patients, immunohistochemistry is required to identify minute numbers of tumor cells. With experience, pathologists identify tumors in hematoxylin and eosin (H&E) preparations in an increasing proportion of lymph nodes. Tumor cells are more frequent in the sentinel nodes of patients with primary tumors of deeper Clark level and greater Breslow thickness. Tumor cells must be discriminated from capsular nevus cells, interdigitating dendritic leukocytes, macrophages, and intranodal neural tissues.

Humans↗

PubMed2000

Her Majesty's coroners and home office forensic pathologists perception of the nurses' role in the coroner's enquiry.

A study was performed to elicit the perceived role of the registered nurse in the coroner's enquiry from Her Majesty's coroners and Home Office forensic pathologists viewpoint. A qualitative small sample study of unstructured interviews was performed followed by a quantitative and qualitative survey of all 134 coroners and 44 forensic pathologists practising in England and Wales. 72 (53.5%) coroners and 26 (59.1%) forensic pathologists finally participated in the study of which 51% perceived that there was a role for the nurse in the coroner's enquiry. Roles identified included: actual i. e. keeping records, being conversant with nursing policies and "knowing" ("Knowing" means having knowledge about coroners' enquiries); potential i.e. resource provider, communicator, supporter, presencing, evidence giver and stewardship; and future i. e. certifying the fact of death and being an expert witness. Possible action by the registered nurse to embrace the outcome of this study is put forward.

Attitude of Health Personnel↗

PubMed1980

The general pathologist's role in forensic medicine: the Massachusetts scene.

The Commonwealth of Massachusetts medicolegal system is discussed. The current situation necessitates active participation by general pathologists. The rudimentary skills needed in forensic pathology are delineated. It is emphasized that since medicolegal cases are nationally increasing and since recent comprehensive studies confirm the present shortage of full time forensic pathologists, it is imperative that general pathologists become more involved.

Autopsy↗