How high-tech approach may reshape the autopsy

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Dr. Nolte

What remains unclear is when, exactly, advanced imaging can serve as a useful additive to traditional forensic autopsy and when it can be used alone to answer the critical medicolegal questions at hand. That is what Kurt B. Nolte, MD, and his colleagues are trying to find out. Dr. Nolte is director of the Radiology-Pathology Center for Forensic Imaging at the University of New Mexico School of Medicine. The university also is home to New Mexico’s centralized medical examiner’s office.

With the help of a three-year, nearly $900,000 grant from the U.S. Department of Justice, the New Mexico team is conducting a double-blinded trial to determine the effectiveness of CT scans in assessing four kinds of cases that account for about one-third of New Mexico forensic autopsies: blunt-force injuries, firearm injuries, pediatric trauma, and drug poisonings.

Nearly 1,000 cases are being examined in the following way, Dr. Nolte says: “The pathologists do the autopsy without knowing the CT findings, and the radiologists read the CT scans without knowing the autopsy findings.” The autopsy and radiologic findings are coded and compared using the Abbreviated Injury Scale, and the radiologists and pathologists involved will then see how concordant or discordant their findings are.

“It’s a complex process, but ultimately it gives us a full picture of what CT’s good at, and what autopsy’s good at,” says Dr. Nolte, who also is executive vice president of the National Association of Medical Examiners. He hopes to report the first findings from the study at NAME’s annual meeting in September.

“A lot of early studies looked at autopsy as the gold standard, but it’s clear that autopsy is not the gold standard,” Dr. Nolte says. “We’re looking at the gold standard as being a combination of CT and autopsy. There’s stuff that CT finds that autopsy doesn’t, and stuff that autopsy finds that CT doesn’t.”

The New Mexico team also is researching the use of MRI in the medical examiner’s office. The cost of acquiring the advanced imaging equipment has been shared by the state and the university. Dr. Nolte acknowledges that even slam-dunk findings to show that postmortem advanced imaging is useful and catches things missed in traditional autopsy will not necessarily speed the way toward widespread adoption of the virtual approach in forensic pathology.

“Forensic pathology and medical examiners’ offices are not among the most well funded of health care organizations,” Dr. Nolte says. “The question is how do medical examiners garner scanners in the future, and clearly that’s going to require a combination of pressure from the courts, from attorneys, from families, and perhaps federal funding.”

A blue-ribbon panel of 37 scientists, lawyers, forensics experts—including three pathologists—held its first meeting in February and could provide the impetus for more federal dollars flowing into forensic pathology. This panel—the National Commission on Forensic Science—is a joint venture of the Justice Department and the Commerce Department’s National Institute of Standards and Technology, and was sparked by a 2009 National Research Council report that found big gaps in the quality of U.S. forensics (“Strengthening Forensic Science in the United States: A Path Forward”). Meanwhile, a bill introduced by Sen. Jay Rockefeller (D-W.Va.) calls for more federal funding for forensic science research.

Even as federal officials seem eager to explore the potential for advanced imaging to remake the autopsy, some pathologists argue for proceeding with caution.

Dr. Graham

“I don’t see the United States—across the board—just saying, ‘OK, you know, instead of doing an autopsy we’re going to replace the autopsy with imaging. I don’t think it’s going to happen, and I don’t think it should happen,” says Michael A. Graham, MD, chair of the CAP’s Forensic Pathology Committee and professor of pathology at Saint Louis University School of Medicine.

“Imaging isn’t perfect, and it doesn’t answer a lot of the questions we’re asked to answer. Even with imaging, we have to do invasive things. If there’s evidence of an infection, we have to go in after it in order to assess its features and identify the causative organism,” Dr. Graham adds. “We have to go in after projectiles and other evidence. Important timing or aging issues can currently only be resolved using microscopy. It’s not like you can completely say you’re not going to autopsy anybody and just going to use all that money for MRIs. But if you look at it as yet another tool to help answer the questions we need to answer—that puts it in a little bit better perspective.”

Dr. Miller

The CAP’s policy, last revised in 2012, appears to leave ample room for advanced imaging as one of many methods used in the autopsy process. The policy defines the autopsy to include “examination of the decedent by one or more of several modalities including (but not limited to) surgical techniques, dissection, imaging, microscopy, and/or laboratory analysis.”

Dylan V. Miller, MD, chair of the CAP’s Autopsy Committee, says virtual autopsy could be a great help in mass-casualty events and can be a suitable replacement for invasive autopsy in cases such as when it can confirm suspected subarachnoid hemorrhage. The virtual approach alone “will never replace the diagnostic information obtained from a complete autopsy,” adds Dr. Miller, director of the autopsy service at Intermountain Medical Center.

Whatever the potential role of advanced imaging and robot-assisted tissue sampling in autopsy may be, experts agree it is unlikely to become widely implemented overnight.

“Things move slowly in the autopsy world,” Dr. Miller says. [hr]

Kevin B. O’Reilly is CAP TODAY senior editor.