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November 2002
Pathologic algorithm for predicting lymph node metastasis in clinically localized prostate carcinoma
The risk of significant morbidity and mortality and the cost of pelvic
lymphadenectomy for patients with clinically localized prostate carcinoma
prompts attempts to develop a model to accurately assess the preoperative
lymph node status in such patients. The authors examined the validity
of a previously published algorithm based on the pathologic assessment
of the sextant biopsy specimen to assess the risk of lymph node metastasis
using data from their institution (n=443). The incidence of lymph
node metastasis was 44.4 percent in a high-risk group of patients
at the institution (> four of six biopsies with any Gleason
pattern four carcinoma), 20 percent in an intermediate-risk group
(> one of six biopsies with dominant Gleason pattern four,
excluding those classified as high risk), and 2.47 percent (10/404)
in a low-risk group (all others). The original algorithm, called the
Hamburg algorithm, proved to be a valid tool for predicting lymphatic
spread in this validation study of data from the authors' institution.
The authors concluded that the algorithm may serve as a tool to select
patients who do not need to undergo pelvic lymphadenectomy when they
undergo radical retropubic prostatectomy, thus reducing morbidity
and expense.
Haese A, Epstein JI, Huland H, et al. Validation
of a biopsy-based pathologic algorithm for predicting lymph node metastases
in patients with clinically localized prostate carcinoma. Cancer.
2002;95:1016-1021.
Reprints: Dr. A. Haese, James Buchanan Brady Urological Institute, The Johns
Hopkins University School of Medicine, 600 N. Wolfe St., Baltimore, MD 21287;
alexanderhaese@gmx.de
Do autopsies hamper the defense in medical malpractice suits?
To determine how autopsy information influences the outcome of medical
malpractice litigation, the authors studied state court records in
99 cases of medical malpractice adjudication from 1970 to the present.
The three largest groups defined by cause of death at autopsy were
acute pulmonary embolism, acute cardiovascular disease, and drug overdose/interaction.
Findings for defendant physicians outnumbered medical negligence in
the original trial proceedings by a 3:1 margin. The appellate courts
affirmed 51 acquittals and 19 findings of negligence and reversed
the original trial court decision for technical reasons in 29 cases.
The authors found no significant relationship between accuracy of
clinical diagnosis (using the autopsy standard) and outcome of a suit
charging medical negligence. Defendant physicians usually were exonerated,
even when a major discrepancy existed between the autopsy diagnosis
and clinical diagnosis and the unrecognized condition was deemed treatable.
Moreover, major diagnostic discrepancies were relatively uncommon
in suits in which a physician was found to be negligent. Conversely,
autopsy findings were helpful to defendant physicians in about 20
percent of cases. The authors believed their study confirmed that
a finding of medical negligence is based on standard-of-care issues
rather than accuracy of clinical diagnosis. Autopsy findings typically
are not the crux of a successful legal argument for either side in
a malpractice action. The authors concluded that fear of autopsy findings
has no rational basis and is an important obstacle to uninhibited
outcomes analysis.
Bove KE, Iery C, CAP Autopsy Committee. The role of the autopsy in medical malpractice cases, I: a review of 99 appeals court decisions. Arch Pathol Lab Med. 2002;126:1023-1031.
Reprints: Dr. Kevin E. Bove, Dept. of Pathology, Children’s Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH 45229; kevin.bove@uc.edu
Cytologic smears in the intraoperative evaluation of brain tumors
The authors performed a retrospective analysis of 4,172 patients undergoing
surgery at their medical center between 1985 and 1999. There were
3,541 intraoperative smears performed during open procedures and 631
during stereotactic biopsies. Complete correlation with the final
diagnosis was achieved in a mean of 89.8 percent (range, 83 to 93.7
percent per year). Diagnostic accuracy increased to 95 percent on
average (range, 91.5 to 96.7 percent per year) when cases of partial
correlation due primarily to grading deviations were included. The
most accurate intraoperative diagnoses were obtained in cases of meningioma
(97.9 percent), metastasis (96.3 percent), and glioblastoma (95.7
percent). A significant reduction in diagnostic accuracy was observed
in cases of oligodendroglioma (80.9 percent) and ependymoma (77.7
percent). In addition to diagnosis and grading, smear cytology provided
resection guidance in cases of well-delineated tumors. The authors
concluded that intraoperative smears in neurosurgery are easy to obtain,
inexpensive, and highly accurate. Intraoperative smears, as well as
stereotactic biopsy procedures, permit reliable intraoperative guidance
during lesion targeting and resection.
Roessler K, Dietrich W, Kitz K. High diagnostic accuracy of cytologic smears of central nervous system tumors: a 15-year
experience based on 4,172 patients. Acta Cytol. 2002;46:667-674.
Reprints: Dr. Karl Roessler, Dept. of Neurosurgery, University Hospital of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria;
karl.roessler@univie.ac.at
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