Are amended surgical pathology reports getting to the correct responsible care provider?

OBJECTIVES: Amended reports (AmRs) need to follow patients to treating physicians, to avoid erroneous management based on the original diagnosis. This study was undertaken to determine if AmRs followed the patient appropriately. METHODS: AmRs with diagnostic changes and discrepancies between ordering and treating physicians were tracked. Chart reviews, electronic medical report (EMR) reviews, and interviews were conducted to establish receipt of the AmR by the correct physician. RESULTS: Seven of 60 AmRs had discrepancies between the ordering and treating physicians, all with malignant diagnoses. The AmR was present in the treating physician's chart in only one case. Ordering physicians indicated that AmRs were not forwarded to treating physicians when corrected results arrived after patient referral, under the assumption that the new physician was automatically forwarded pathology updates. No harm was documented in any of our cases. In one case with a significant amendment, the correct information was entered in the patient chart based on a tumor board discussion. A review of two electronic health record systems uncovered significant shortcomings in each delivery system. CONCLUSIONS: AmRs fail to follow the patient's chain of referrals to the correct care provider, and EMR systems lack the functionality to address this failure and alert clinical teams of amendments.

Nodular histiocytic aggregates in the endometrium: a report of 7 cases.

Nodular aggregates of nonfoamy histiocytes in the endometrium are uncommon. We describe herein the clinical and pathologic characteristics of 7 additional cases in endometrial biopsies or curettages. The patients ranged in age from 48 to 72 years, and the most common presenting symptom was abnormal uterine bleeding. Five of seven patients had undergone prior endometrial sampling (including 1 who had undergone 3 endometrial biopsies over the preceding 5 yr for follow-up of abnormal uterine bleeding). In 2 cases, an endometrial polyp was present in the same sample, and an additional 2 were found to have endometrial polyps on subsequent biopsies that were performed within 4 months of original samplings. The lesions, which ranged in size from 1 to 8 mm, were composed of monomorphic cells with abundant pink eosinophilic cytoplasm with a vaguely nodular arrangement. Two cases showed focally high mitotic activity with up to 4 mitoses per high-power field. Patient outcomes were unremarkable, which affirms the benign nature of the proliferation. Several features of this lesion, including mitotic activity, focal necrosis, and tight aggregation of cells, may raise the possibility of a neoplastic proliferation. This differential diagnosis can be readily resolved by awareness of the lesion and immunohistochemical analyses. Possible pathogenetic considerations are discussed, but these nodules represent, in our opinion, reaction to necrotic tissue in the endometrial cavity, possibly related to prior procedure.

Addenda in pathology reports: trends and their implications.

Addenda are typically used to report results of additional studies that are delayed relative to histopathologic studies. However, the frequency and pattern of use of addenda have not been previously reported. We studied the dynamics of addenda creation within the same month at 5-year intervals during a 15-year period at our institution. The number of addenda and type and impact of information communicated in addenda were assessed in the month of July in 1993, 1998, 2003, and 2008, and the possible role of addenda in quality improvement was evaluated. Cases with addenda increased from 0.9% in 1993 to 8.6% in 2008. In 5.6% of addenda, there was information that might have been better reported in an amendment, suggesting that criteria for amendments need to be universally implemented. Charting trends and types of addenda offered opportunities for quality improvement by identifying weaknesses in the workflow organization of the laboratory.

Histopathologic outcomes and clinical correlations for high-risk patients screened with anal cytology.

OBJECTIVE: Anal cytologic testing is being increasingly used as a preventive screening test in high-risk populations. We document anal cytology results, correlating HIV test results, and histopathologic follow-up outcomes from a large integrated health system which recently implemented anal screening. STUDY DESIGN: Anal Pap tests between May 2007 and August 2009 were studied and correlated with HIV test histories and follow-up histopathologic diagnoses. RESULTS: 688 anal cytologic tests were identified with 7.4% reported as unsatisfactory; 72% of anal cytologic tests were abnormal; 91% of patients were HIV positive. The HIV-positive rate and likelihood of high viral load were both significantly greater among patients with abnormal anal cytology than among patients with negative anal cytology, but did not vary significantly among patients with different categories of abnormal anal cytology. For 459 patients with abnormal anal cytology, 198 had anal biopsies. For patients with abnormal anal cytology findings of ASC-US (atypical squamous cells of undetermined significance), LSIL (low-grade squamous intraepithelial neoplasia), ASC-H (atypical squamous cells, cannot exclude high-grade squamous lesion), and HSIL (high-grade squamous intraepithelial neoplasia), histopathologic intraepithelial neoplasia (AIN)2/3 or 2/3+ diagnoses were established in 46.5, 56.6, 65, and 80.8%, respectively. CONCLUSIONS: Patients with any level of abnormal anal cytology result are at significant risk of the presence of histopathologically verifiable high-grade anal intraepithelial lesions. More specific markers for identifying patients at highest risk of progression to invasive anal carcinoma are needed.

Chronic hypertrophic vulvar herpes simulating neoplasia.

We present a case of a 40-year-old woman with a history of human immunodeficiency virus infection and a nodular, hyperkeratotic 3.5-cm vulvar mass that increased in size over a 2-month period. Histopathologic examination of the excised mass was diagnostic of chronic hypertrophic vulvar herpes simulating neoplasia. Hypertrophic vulvar herpes presents a diagnostic challenge for both pathologists and clinicians because of its unusual clinicopathologic features that mimic neoplasia and its rarity. There is therefore the need for the correct diagnosis of this entity, so that appropriate therapy can be given. The pertinent literature is reviewed and discussed.

Characterization of high-grade ductal carcinoma in situ with and without regressive changes: diagnostic and biologic implications.

Regressive changes (RC) have been described in malignant melanoma, carcinomas of the prostate and cervix. The presence of RC in these neoplasms may signify some degree of host response to tumor and seems to be a sign of poor prognosis for some neoplasms. RC in breast cancer is vaguely defined in the older literature. We have observed periodically similar RC in a subset of high-grade ductal carcinoma in situ (HGDCIS) in breast specimens. The aim of our study is to demonstrate how to recognize RC in the diagnostic setting and an attempt to understand the biologic behavior in this subset of HGDCIS cases. Fifty-nine cases of HG-DCIS (35 cases with RC and 24 cases without RC) were included. We defined RC in our study as demonstrating thick periductal fibrosis, dense lymphocytic infiltrate, and a thin rim of intact neoplastic cells. A short panel of immunomarkers to study this entity included myoepithelial markers. Reduced expression of myoepithelial markers (p63 and smooth muscle heavy chain myosin) were seen more frequently in the HGDCIS group with RC than without RC cases. Invasion as well as metastatic disease was seen in association with HGDCIS with RC nearly 4 times as often. It is also critically important to recognize HGDCIS-RC for diagnostic purposes, as the differential diagnosis of RC includes, benign associations such as papilloma, fibrocystic changes and periductal mastitis. HGDCIS-RC may also be a sign of an aggressive phenotype than other HGDCIS subtypes. Further outcome studies are necessary to determine if it has a clinical impact akin to other tumors with RC.

WT1 immunoreactivity in breast carcinoma: selective expression in pure and mixed mucinous subtypes.

Current literature suggests that strong WT1 expression in a carcinoma of unknown origin virtually excludes a breast primary. Our previous pilot study on WT1 expression in breast carcinomas has shown WT1 expression in approximately 10% of carcinomas that show mixed micropapillary and mucinous morphology (Mod Pathol 2007;20(Suppl 2):38A). To definitively assess as to what subtype of breast carcinoma might express WT1 protein, we examined 153 cases of invasive breast carcinomas. These consisted of 63 consecutive carcinomas (contained 1 mucinous tumor), 20 cases with micropapillary morphology (12 pure and 8 mixed), 6 micropapillary 'mimics' (ductal no special type carcinomas with retraction artifacts), 33 pure mucinous carcinomas and 31 mixed mucinous carcinomas (mucinous mixed with other morphologic types). Overall, WT1 expression was identified in 33 carcinomas, that is, 22 of 34 (65%) pure mucinous carcinomas and in 11 of 33 (33%) mixed mucinous carcinomas. The non-mucinous component in these 11 mixed mucinous carcinomas was either a ductal no special type carcinoma (8 cases) or a micropapillary component (3 cases). WT1 expression level was similar in both the mucinous and the non-mucinous components. The degree of WT1 expression was generally weak to moderate (>90% cases) and rarely strong (<10% cases). None of the breast carcinoma subtype unassociated with mucinous component showed WT1 expression.

Mycobacterium kansasii infection diagnosed by pleural fluid cytology: a case report.

BACKGROUND: Identification of disseminated nontuberculous Mycobacterium infection is a challenge, especially when it occurs in patients without a known cause of immunosuppression. Acid-fast organisms in the pleural fluid are rare and easily missed, especially when they occur in patients without a clinical suspicion of infection. The classical cytologic picture of tuberculous pleural fluid with lymphocytosis and paucity of mesothelial cells is not seen. CASE: A 57-year-old man presented with chronic neutrophilia of unknown etiology together with chest pain and bilateral pleural effusions. Pleural fluid cytology revealed organisms seen in the cytoplasm of numerous macrophages and neutrophils, creating a "negative image" on Diff-Quik smears. Acid-fast stains demonstrated intracellular acid-fast bacilli consistent with mycobacteria. Microbiologic studies with DNA probe technology resulted in identification of the mycobacterial organism as Mycobacterium kansasii. CONCLUSION: Nontuberculous Mycobacterium should be included in the differential diagnosis in patients with inflammatory, exudative pleural effusions.

Allelic loss of 3 different tumor suppressor gene loci in benign and malignant endothelial tumors of the head and neck.

CONTEXT: Angiosarcomas are rare malignancies that commonly arise in the head and neck. No definitive precursor lesion or etiological link between hemangiomas and angiosarcoma has been postulated. Evidence at the cell culture level suggests that loss of heterozygosity of 13q might be involved in tumorigenesis of endothelial cells. Although overexpression of p53 and WT-1 has been found in angiosarcoma, little is known about the molecular changes involved. OBJECTIVE: This study compared the molecular profile of angiosarcoma with that in some benign vascular lesions. DESIGN: Specimens from 6 cases of angiosarcoma, 5 of hemangioma, and 5 of granulation tissue were microdissected. DNA extraction and polymerase chain reaction amplification for 11 microsatellite markers on chromosomes 11p13, 13q14, and 17p13 (WT-1, RB, p53) were performed. Loss of heterozygosity of amplification products was assessed by capillary electrophoresis. Allelic loss and fractional allelic loss were calculated. RESULTS: The mean fractional allelic loss was 43% for angiosarcomas and 29% for hemangiomas. Eighty-three percent of angiosarcomas had allelic loss at 17p13, 66% at 13q14, and 50% at 11p13. Allelic loss was seen in 60% of hemangiomas at 13q14 and 17p13, but only in 20% at 11p13. Two cases of hemangioma and all the granulation tissue cases had no allelic losses. CONCLUSIONS: In our study, 11p13, 13q14, and 17p13 allelic losses were present in both hemangiomas and angiosarcomas. This supports the cell culture-based theories that tumorigenesis in endothelial cells likely involves these chromosomes and provides some insight into the potential pathogenesis of angiosarcomas and benign hemangiomas.

Human T-lymphotropic type-1 virus specific antibody detected in sera of HIV/AIDS patients in Ghana.

Serum samples from 124 acquired immunodeficiency syndrome (AIDS) hospitalized patients at the Fevers Unit, Korle-Bu Teaching Hospital, Accra, Ghana, were examined by the particle agglutination test for antibodies to human T-lymphotropic virus type 1 (HTLV-1) core proteins. The subjects included 84 males and 40 females, aged 16 to 54 years. Specific antibodies were detected in only 14 out of the 124 sera samples, giving an overall prevalence rate of 11.29%. The incidence was lower in males (5.95%; 5/84) than in females (22.50%; 9/40) (P<0.05). In both sexes, the age distribution of subjects positive for HTLV-1 antibodies ranged from 35 to 54 years. The prevalence rate reported herein is too low to suggest an association of HTLV-1 with AIDS, though it may indicate an opportunistic infection of AIDS patients by HTLV-1. Whether HTLV-1 is an underlying disease association or whether HTLV-1 plays some auxiliary role in the acquisition and progression of AIDS remains to be determined.