Colorectal cancer pathology reporting: a regional audit.

AIMS: To audit the information content of pathology reports of colorectal cancer specimens in one National Health Service region. METHODS: All reports of colorectal cancer resection specimens from the 17 NHS histopathology laboratories in Wales during 1993 were evaluated against: (a) standards previously agreed as desirable by pathologists in Wales; and (b) standards considered to be the minimum required for informed patient management. RESULTS: 1242 reports were audited. There was notable variation in the performance of different laboratories and in the completeness of reporting of individual items of information. While many items were generally well reported, only 51.5% (640/ 1242) of rectal cancer reports contained a statement on the completeness of excision at the circumferential resection margin and only 30% (373/1242) of all reports stated the number of involved lymph nodes. All of the previously agreed items were contained in only 11.3% (140/1242) of reports on colonic tumours and 4.0% (40/1242) of reports on rectal tumours. Seventy eight per cent (969/1242) of colonic carcinoma reports and 46.6% (579/ 1242) of rectal carcinoma reports met the minimum standards. CONCLUSIONS: The informational content of many routine pathology reports on colorectal cancer resection specimens is inadequate for quality patient management, for ensuring a clinically effective cancer service through audit, and for cancer registration. Template proforma reporting using nationally agreed standards is recommended as a remedy for this, along with improved education, review of laboratory practices in the light of current knowledge, and further motivation of pathologists through their involvement in multidisciplinary cancer management teams.

The still video camera: a suitable and convenient method of demonstrating post mortem findings.

The post mortem demonstration continues to play an important role in medical education at both undergraduate and postgraduate levels. However, for a variety of reasons its format needs to be adaptable in order to maximize the educational benefit and increasingly to comply with legislation. We have developed a method of demonstration based upon a still video camera system which we have found is acceptable to our students and overcomes some of the problems associated with other formats. In this paper we describe the system itself, compare it with other systems, discuss its potential applications and present the results of a questionnaire-based survey of the first groups of medical students to be taught in this way. These results confirm that the technique is popular with students and that it appears to be a useful teaching modality worthy of further development.

Information on death certificates: cause for concern?

AIMS: To assess the frequency with which the cause of death on death certificates included the relevant details requested of certifying doctors, especially in deaths due to malignant disease, but also including certain other deaths where specific information would be expected to be included. METHODS: Consecutive series of certificates attributing death to malignancy, pneumonia, an acute cerebrovascular event, and renal failure were inspected and compared with the categories identified in the International Classification of Disease. Review of clinical notes and of laboratory data was used to determine the number of cases in which detailed histological diagnoses were available. RESULTS: A histological diagnosis was available in 79.1% of cases of deaths due to malignancy, but was recorded on only 23.6% of certificates. Haematologists performed best (69.6%) and general surgeons worst (2.8%). The sites of primary tumours were recorded in detail in only 23 of 89 cases of tumours of the large bowel (22/36), lung (1/35) and stomach (0/18). In cases of pneumonia the causative organism was recorded in only 4 of 330. In cases of an acute cerebrovascular event one of 70 was recorded as being due to haemorrhage. A distinction between cerebral or precerebral arterial occlusion (embolism/thrombosis) and cerebral haemorrhage was not recorded in any of the other cases. In cases of renal failure a cause was not recorded in 75 of 95. CONCLUSIONS: Despite consistent encouragement to record all relevant details on death certificates this study shows that doctors fail to do so in most cases. Such a failure diminishes information available to the Office of Population Censuses and Surveys, affecting mortality statistics and gives further cause for concern about standards of certification. Means by which the standard of certification might be improved are discussed, including screening of certificates by a medically qualified person prior to registration.

Phraseology in pathology reports. A comparative study of interpretation among pathologists and surgeons.

This questionnaire based study compared the interpretation, use and preferences, among pathologists and surgeons, of descriptive phrases found in surgical reports. The results show that there is a wide variation in individual interpretation of phrases in both groups. The frequency of usage of phrases by pathologists and preference for phrases by surgeons were also diverse. The adoption of a limited number of descriptive phrases that are mutually understood and acceptable for use by both pathologists and clinicians is recommended to avoid interpretive ambiguity in pathology reports.

Death certification: is correct formulation of cause of death related to seniority or experience?

We looked at a series of death certificates completed by various grades of hospital clinicians, general practitioners (GPs) and pathologists. Specific error types were defined and identified in each group. In hospital it is still the pre-registration house officer who completes most of the death certificates. Senior hospital doctors make more errors than their juniors while GPs and pathologists make fewest errors. Even amongst pathologists 11% of certificates recorded no adequate underlying cause of death, 85.7% failed to record organisms identified and 76.7% failed to record the site or histological type of tumours. This agrees with other studies that show that inaccuracies in death certificates arise from inadequate formulation of cause of death and failure to record relevant information. It reveals that little heed has been paid to the recommendation in the joint report of the Royal College of Physicians and Pathologists that senior doctors should be more involved in certification--the frequency of errors in this group suggests that it might not, in any case, lead to a great improvement. The number or errors made by GPs and pathologists suggest that even practitioners with clinical experience and regular exposure to certification frequently make errors. The reasons for this are discussed and possible solutions proposed.

Quantitation of the renal arterial tree by fractal analysis.

To determine whether the renal arterial system has a fractal structure, the fractal dimension of renal angiograms from 52 necropsy cases was measured using an implementation of the box-counting method on an image analysis system. The method was validated using objects with known fractal dimensions. The method was accurate with errors of less than 1.5 per cent and reproducible with initial values within 1.2 per cent of the mean of ten sets of measurements (reliability coefficient 0.968, 95 per cent confidence limits 0.911-0.984). In the 36 satisfactory angiograms the mean fractal dimension was 1.61 (SD 0.06), which was significantly greater than the topological dimension of 1 (P < 0.0001), indicating that the renal arterial tree has a fractal structure. There was no significant relationship between age (P = 0.494), sex (P = 0.136), or systolic (P = 0.069) or diastolic (P = 0.990) blood pressure, but two congenitally abnormal kidneys (hypoplastic dysplasia and renal artery stenosis) had fractal dimensions at the lower end of the normal range (third percentile). Since the renal arterial tree has a fractal structure, Euclidean geometric measurements, such as area and boundary length, are invalid outside precisely defined conditions of magnification and resolution.

Inflammatory pseudotumour of the liver.

Inflammatory pseudotumours of the liver are uncommon, usually mistaken for malignant lesions and resected. This report describes the presentation of an inflammatory pseudotumour of the liver in a 28-year-old male which was demonstrated on C.T. scanning and diagnosed by percutaneous needle biopsy. This case was treated conservatively and spontaneously resolved within four months, emphasising the need to consider this lesion in the differential diagnosis of an intrahepatic mass.

General practitioners, skin lesions and the new contract.

We reviewed all skin lesions received in our laboratory from general practitioners (GPs) during a three-month period before the introduction of the new contract for GPs and during the same period a year later. For comparison we also reviewed skin lesions received from the general and plastic surgeons. Particular attention was paid to the completeness of excision. There was a significant increase in the number of skin lesions removed in general practice after the introduction of the new contract. Both benign and malignant lesions were more likely to be incompletely excised by GPs compared with surgeons. The GPs first noted to carry out minor surgery after the new contract came into force were less likely to have completely excised lesions than their more experienced colleagues. We suggest the future monitoring of lesions removed in general practice, possibly by the formation of a joint audit group.

Is the informational content of histopathological reports increasing?

Histopathology reports on 20 mastectomy and 20 colectomy specimens containing carcinomas were examined from the beginning of each decade for the period 1940-1990. The number of words and items of information in each report were recorded. There was a large (337%) increase in the number of words in reports of both types of specimens with a slightly smaller increase (273%) in the number of items of information. This increase may be due to clinician-led demand for more specific information or be related to the introduction of more detailed systems of pathological staging and prognostic assessment of breast and colonic tumours. The increase in data production and dissemination may not be reflected in workload measurement systems, such as Welcan, and must be considered when assessing the need for secretarial staff.

Should eye protection be worn when performing necropsies?

One hundred necropsies were performed by four junior pathologists wearing safety spectacles. The number of blood splashes on the spectacle surfaces were counted after each necropsy. Splashes were found after 22 necropsies (range 10-34%), with higher numbers being seen among the more junior grades of pathologist. This suggests that the use of safety spectacles should be considered by all pathologists performing necropsies.

Is there any justification for the routine examination of bowel resection margins in colorectal adenocarcinoma?

The proximal and distal bowel resection margins of 339 specimens of colorectal adenocarcinoma were examined for the presence of tumour. In only five cases was tumour found in a resection margin. In four of these cases macroscopic examination showed that the tumour extended to the resection margin. In the fifth case the tumour was present in the pericolic fat. These results and reported data on the intramural spread of colorectal cancer suggest that examination of bowel resection margins is unnecessary unless the tumour extends to within 2 cm of the resection margin. Examination of the deep radial margins of the tumour and slides to show other prognostic indicators would be a more effective use of histopathological resources.