Highlights in Pathology - Quality and patient safety (April 2021)
Dr. Tra Truong - Sunnybrook Health Science Centre
1. Margin-positive Pancreatic Ductal Adenocarcinoma during Pancreaticoduodenectomy: additional resection does not improve survival.
Zheng, R., Nauheim, D., Bassig, J. et al. Ann Surg Oncol 28, 1552–1562 (2021). https://doi.org/10.1245/s10434-020-09000-9
Intraoperative frozen section analysis is routinely performed on surgically resected margins by surgeons to identify microscopically positive margins and take additional tissue as needed, to achieve a margin-negative resection. The impact of resecting positive margins during pancreaticoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDA) on improving overall survival (OS) however remains debated.
Zheng, R et al assessed the effect of margin status on 5 year OS of 501 patients with PDA who underwent PD from 2006 to 2015 at Thomas Jefferson University Hospital. Pancreatic neck, bile duct, and uncinate frozen section margins were assessed before and after resection of positive margins.
The study found that any positive PD margins are associated with reduced overall survival and resection of additional margins does not seem to improve OS, particularly with concurrently unresectable positive uncinate margins. Adjuvant chemotherapy, on the other hand, improves OS with positive margins, with or without resection.
2. Frozen section diagnosis of borderline ovarian tumors with suspicious features of invasive cancer is a devil's dilemma for the surgeon: a systematic review and meta-analysis.
De Decker K, Jaroch KH, Edens MA, Bart J, Kooreman LFS, Kruitwagen RFPM, Nijman HW, Kruse AJ. Acta Obstet Gynecol Scand. 2021 Feb 4. doi: 10.1111/aogs.14105. PMID: 33539545.
Frozen section (FS) diagnoses of borderline ovarian tumors are not always straightforward, and a frozen section diagnosis reported as "at least borderline" or similar descriptions presents surgeons with the dilemma of whether or not to perform a full surgical staging procedure.
De Decker K et al addressed this issue by performing a large-scale systematic review of the literature about the prevalence of straightforward borderline and "at least borderline" FS diagnoses, as well as proportion of patients with a final diagnosis of invasive carcinoma.
Meta-analysis from a total of 921 women in 8 selected qualified studies found that women diagnosed with "at least borderline" FS diagnoses have a higher chance of having a final diagnosis of carcinoma compared to those with a straightforward borderline FS diagnosis (41.0% vs 9.7%).
The author suggests that especially in the serous subtype, with preoperative consent, full staging during initial surgery might be considered in “at least borderline” FS cases to prevent a second surgical procedure.
3. The current state of communication of urgent and significant, unexpected diagnoses in anatomic pathology: results of an association of directors of anatomic and surgical pathology survey
Paul N. Staats, Vinita Parkash, Christopher N. Otis, Poonam Sharma, Olga Ioffe, Erika R Bracamonte. Arch Pathol Lab Med 1 September 2020; 144 (9): 1067–1074. doi: https://doi.org/10.5858/arpa.2019-0436-OA
Communication of critical values to providers has been proposed for anatomical pathology (AP) just over a decade ago. Since the issue of a consensus statement by the College of American Pathologists (CAP) and Association of Directors of Anatomic and Surgical Pathology (ADASP) in 2012, no Multi-Institutional study of communication policies for critical values has been reported since then.
This study by CAP and ADASP surveys the policies of AP laboratories regarding the communication of critical values using a 14-question electronic survey tool (Table 1).
Responses received from 38 institutions institute the following consensus from > 75% of the responders (Table2)
Policies for communication of critical/urgent/significant, unexpected results in anatomic pathology are the standard of care.
Diagnoses most commonly considered “Critical/Urgent” are new/unexpected malignancies and discrepancies between intraoperative consultation and permanent section diagnoses.
A direct phone call to the responsible provider is the most common acceptable means of communication
The most common time frame for reporting “Critical/Urgent” diagnoses is the same day.
Most laboratories document the date, time, and person to whom the result was communicated in the final or addendum report.
4. Revised reporting (issuing addenda and amendments) in pathology: reality and best practices.
Amy Spiczka, MS, SCT, MB, HTL (ASCP)CM, Liz Waibel, MPH, Edna Garcia, MPH, Iman Kundu, MPH, Melissa Kelly, PhD, Ali Brown, MD, FASCP. American Journal of Clinical Pathology, 2020;, aqaa146, https://doi.org/10.1093/ajcp/aqaa146
Revisions to diagnostic pathology reports in the form of addenda and amendments are necessary for pathology laboratories and practices in a variety of circumstances. The American Society for Clinical Pathology (ASCP) conducted a study to address the challenges of revised reporting in the areas of anatomic pathology, surgical pathology, cytopathology, and hematopathology.
The study uses an online revised reporting survey to conduct an opinion poll from national wide pathologists, pathology residents, pathology fellows, pathology managers, and laboratory directors. The survey questions and corresponding response rates are summarized in Figures 1-13 and Table 1.
The results from this survey demonstrate a significant variation in standards for creating, issuing, and tracking quality indicators related to addenda and amendments. The author suggests that these findings provide opportunities to improve patient safety associated with accurate pathology reporting and further the development of optimal pathology revised reporting guidelines.
See also our Clinical Laboratory Services section, where the Quality Council is implementing projects to improve patient care.