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July 2002
TNM residual tumor classification revisited
The TNM classification includes several modifiers that are useful
for categorizing disease status at various points during a cancer
patient's course. Prognosis is strongly influenced by the completeness
of tumor removal at the time of cancer-directed surgery or disease
remission after nonsurgical treatment with curative intent. These
parameters define the relative success of definitive treatment and
can be codified by the residual tumor (R) classification, an additional
subclassification within the TNM system. Despite the importance of
residual tumor status in designing clinical management after treatment,
misinterpretation and inconsistent application of the R classification
frequently occur and diminish or abrogate its clinical utility. The
authors analyzed the relevant literature regarding the use and prognostic
importance of the R classification. They discussed the prognostic
importance of the R classification for different kinds of tumors,
described the problems that arise in using the R classification, and
addressed special issues regarding the use of the R classification.
The R classification is a strong indicator of prognosis and aids in
comparing treatment results if applied in a consistent manner. Uniform
use and interpretation of this classification are essential for standardizing
post-treatment data collection.
Wittekind C, Comptom CC, Greene FL, et al. TNM
residual tumor classification revisited. Cancer. 2002;94:2511-2519.
Reprints: Dr. Christian Wittekind, Institute of Pathology, University Clinic
of Leipzig, Liebigsraße 26, D-04103 Leipzig, Germany; wittc@medizin.uni-leipzig.de
Use of forceps biopsy versus polypectomy for removing gastric polyps
The authors conducted a prospective multi-institutional study in Germany
to determine whether an adequate histologic diagnosis of gastric polyps
can be obtained on the basis of forceps biopsy, taking into account
complications observed during polypectomy, particularly bleeding.
A total of 194 patients with 222 gastric polyps (>5 mm) that
could be removed endoscopically underwent forceps biopsy and complete
polypectomy. Patients with fundic gland polyps and polyposis syndrome
were excluded. Specimens were evaluated by primary and reference pathologists,
and the complication rate of gastric polypectomy was determined. Of
the 222 polyps, histological examination of the polypectomy specimens
revealed tumor-like lesions in 77 percent (10 percent focal foveolar
hyperplasia, 59 percent hyperplastic polyps, four percent inflammatory
fibroid polyps, four percent other polyps) and neoplasia in 19 percent
(10 percent tubular adenoma, two percent tubulovillous adenoma, one
percent high-grade intraepithelial neoplasia, six percent adenocarcinoma).
When biopsy results were compared, complete agreement was found in
55.8 percent of cases, and it was possible to clinically differentiate
between tumor-like lesions and neoplasia in an additional 34.7 percent.
Relevant differences, however, were found by the reference pathologist
in 2.7 percent of cases, the most common reason being failure of biopsy
to reveal foci of carcinoma in hyperplastic polyps. Bleeding was observed
after polypectomy in 16 patients (7.2 percent) and was managed conservatively
in 15 of them. The authors recommended that an experienced endoscopist
remove all epithelial gastric polyps larger than 5 mm after thorough
individualized risk-benefit analysis.
Muehldorfer SM, Stolte M, Martus P, et al. Diagnostic
accuracy of forceps biopsy versus polypectomy for gastric polyps:
a prospective multicentre study. Gut. 2002;50:465-470.
Correspondence: C. Ell, Dept. of Medicine II, Dr. Horst-Schmidt-Kliniken, Ludwig-Erhard-Str 100, 65199 Wiesbaden, Germany
Storing and distributing pathology digital images using Web-based systems
Health care providers have expressed increasing interest in incorporating
digital images of gross pathology specimens and photomicrographs into
routine pathology reports. The authors describe the technical and
logistical challenges involved in integrating the various components
necessary for developing a system for integrated Web-based viewing,
storage, and distribution of digital images in a large health care
system. The authors used an Oracle version 8.1.6 database to store,
index, and deploy pathology digital photomicrographs via their intranet.
The database allows images to be retrieved using patient demographics
or SNOMED (Systematized Nomenclature of Medicine) code information.
The intranet is located in a large health care system and is accessible
from multiple computers located within the medical center and at distant
private physician offices. The images can be viewed using any of the
health care system's workstations that have authorized access to the
intranet via a standard browser or browser software. The images can
be printed on paper or transferred to film using a digital film recorder.
Digital images can also be displayed at pathology conferences using
a wireless local area network and secure remote technologies. The
authors concluded that standardizing technologies and adopting a Web
interface for all computer systems allow a large medical center to
distribute digital images from a pathology database to a potentially
large group of users in multiple locations throughout the institution.
Marchevsky AM, Dulbandzhyan R, et al. Storage
and distribution of pathology digital images using integrated Web-based
viewing systems. Arch Pathol Lab Med. 2002;126: 533-539.
Reprints: Dr. Alberto M. Marchevsky, Dept. of Pathology, Cedars-Sinai Medical
Center, 8700 Beverly Blvd., Los Angeles, CA 90048; alberto.marchevsky@cshs.org
Cytohistologic correlation as a pathology tool
The use of cytohistologic discrepancies to investigate and reduce
error seldom is studied. The authors, however, classified all gynecologic
discrepancies (n=283; 0.87 percent and 7.37 percent of all cytologic
and histologic cases, respectively) and non-gynecologic discrepancies
(n=146; 2.26 percent and 0.44 percent of all cytologic and histologic
cases, respectively) as sampling or interpretive over 26 months. They
evaluated specimen type and pathologist discrepancy percentages, effect
of discrepancies on patient outcome, and interobserver agreement of
discrepancies. Discrepancies were interpretive in 67 percent and 34
percent of gynecologic and nongynecologic cases, respectively. Statistically
significant associations were seen between individual pathologists
and discrepancy percentages. Breast (1.2 percent) and bronchial (0.8
percent) cytologic diagnoses had the highest discrepancy percentages.
The kappa scores ranged from 0.02 to 0.45 for pairwise agreement of
discrepant cases. Of nongynecologic interpretive discrepancies available
for review, 63 percent and 14 percent were of no significance or minor
clinical significance, respectively. The authors concluded that cytohistologic
correlation is a useful tool to monitor performance and identify specimen
types prone to error.
Clary KM, Silverman JF, Liu Y, et al. Cytohistologic
discrepancies: a means to improve pathology practice and patient outcomes.
Am J Clin Pathol. 2002;117:567-573.
Reprints: Dr. K.M. Clary, Dept. of Pathology and Lab Medicine, Allegheny General
Hospital, 320 E. North Ave., Pittsburgh, PA 15212
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