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ABSTRACT: Context.-High-resolution scanning technology provides an opportunity for pathologists to make diagnoses directly from whole slide images (WSIs), but few studies have attempted to validate the diagnoses so obtained. Objective.-To compare WSI versus microscope slide diagnoses of previously interpreted cases after a 1-year delayed re-review ("wash-out") period. Design.-An a priori power study estimated that 450 cases might be needed to demonstrate noninferiority, based on a null hypothesis: "The true difference in major discrepancies between WSI and microscope slide review is greater than 4%." Slides of consecutive cases interpreted by 2 pathologists 1 year prior were retrieved from files, and alternate cases were scanned at original magnification of ×20. Each pathologist reviewed his or her cases using either a microscope or imaging application. Independent pathologists identified and classified discrepancies; an independent statistician calculated major and minor discrepancy rates for both WSI and microscope slide review of the previously interpreted cases. Results.-The 607 cases reviewed reflected the subspecialty interests of the 2 pathologists. Study limitations include the lack of cytopathology, hematopathology, or lymphoid cases; the case mix was not enriched with difficult cases, and both pathologists had interpreted several hundred WSI cases before the study to minimize the learning curve. The major and minor discrepancy rates for WSI were 1.65% and 2.31%, whereas rates for microscope slide reviews were 0.99% and 4.93%. Conclusions.-Based on our assumptions and study design, diagnostic review by WSI was not inferior to microscope slide review (P < .001).
Archives of pathology & laboratory medicine 01/2013; · 2.58 Impact Factor
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Deepa T Patil,
John R Goldblum,
Lisa Rybicki,
Thomas P Plesec,
Joel E Mendelin,
Ana E Bennett,
Elias A Castilla, Walter H Henricks,
Lynn Schoenfield,
Marek Skacel,
Lisa M Yerian,
Thomas W Rice,
Mary P Bronner,
Erinn Downs-Kelly
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ABSTRACT: Distinguishing Barrett esophagus with high-grade dysplasia (BE-HGD) from intramucosal and submucosal adenocarcinomas on biopsies is challenging, yet important, in the choice of therapy. The current study evaluates preresection biopsies from patients who underwent esophagectomy for at least BE-HGD, to compare the recently published histologic categories by the University of Michigan (UM) and Cleveland Clinic (CC), correlate preresection and final resection diagnosis, and identify histologic features in biopsies that might be predictive of adenocarcinoma on esophagectomy. A total of 112 cases with a consensus biopsy diagnosis (agreement by ≥4 of 7 gastrointestinal pathologists) were statistically analyzed to identify histologic features that predicted adenocarcinoma on resection. Applying the UM criteria to the biopsy series showed excellent agreement with the CC system (κ=0.86) and significant correlation between preoperative and esophagectomy diagnoses (P<0.001). The likelihood of finding carcinoma on resection was significantly higher with the category of HGD with marked glandular distortion cannot exclude intramucosal adenocarcinoma [CC; odd ratio (OR), 2.8; P=0.046] or HGD suspicious for adenocarcinoma (UM; OR, 4.3; P=0.008), compared to HGD alone. The presence of "never-ending" glands (OR, 3.7; P=0.008), sheet-like growth (P<0.001), angulated glands (OR, 8.5; P<0.001), ≥3 dilated glands with intraluminal debris (OR, 2.6; P=0.05), and >1 focus of single-cell infiltration into the lamina propria (OR, 8.9; P<0.001) increased the odds of finding carcinoma on resection. The latter 2 variables remained independent predictors of adenocarcinoma in multivariable analysis. In conclusion, the CC and UM systems show excellent agreement and define histologic categories that can improve prediction of adenocarcinoma on resection.
The American journal of surgical pathology 11/2011; 36(1):134-41. · 4.06 Impact Factor
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Walter H Henricks
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ABSTRACT: Electronic health records (EHRs) have emerged as a major topic in health care and are central to the federal government's strategy for transforming healthcare delivery in the United States. Recent federal actions that aim to promote the use of EHRs promise to have significant implications for laboratories and for pathology practices. Under the HITECH (Health Information Technology Economic and Clinical Health) Act, an EHR incentive program has been established through which individual physicians and hospitals can qualify to receive incentive payments if they achieve "meaningful use" of "certified" EHR technology. The rule also establishes payment penalties in future years for eligible providers who have not met the requirements for meaningful use of EHRs. Meaningful use must be achieved using EHR technology that has been certified in accordance with functional and technical criteria that are set forth a regulation that parallels the meaningful use criteria in the incentive program. These actions and regulations are important to laboratories and pathologists for a number of reasons. Several of the criteria and requirements in the meaningful use rules and EHR certification criteria relate directly or indirectly to laboratory testing and laboratory information management, and future stage requirements are expected to impact the laboratory as well. Furthermore, as EHR uptake expands, there will be greater expectations for electronic interchange of laboratory information and laboratory information system (LIS)-EHR interfaces. Laboratories will need to be aware of the technical, operational, and business challenges that they may face as expectations for LIS-EHR increase. This paper reviews the important recent federal efforts aimed at accelerating EHR use, including the incentive program for EHR meaningful use, provider eligibility, and EHR certification criteria, from a perspective of their relevance for laboratories and pathology practices.
Journal of pathology informatics. 01/2011; 2:7.
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ABSTRACT: The vast advancements in telecommunications and converting medical information to a digital format have increased the number of applications within telemedicine. Telepathology, in simplest terms, is the practice of formally rendering a pathologic diagnosis based upon examination of an image rather than of a glass slide through traditional microscopy. The use of telepathology for clinical patient care has so far been limited to relatively few large academic institutions. Although a number of challenges remain, there is increasing demand for the use of information technology in pathology as a whole owing to the expansion of health care networks and the opportunity to enhance the quality of service delivered to patients. The software used to acquire, display, and manage digital images for clinical patient care may be subject to national and federal regulations just as is any other electronic information system. Despite the barriers, telepathology systems possess the capability to help manage pathology cases on a global scale, improve laboratory workload distribution, increase standardization of practice and enable new classes of ancillary studies to facilitate diagnosis and education even in the most remote parts of the earth.
Advances in anatomic pathology 03/2010; 17(2):130-49. · 3.22 Impact Factor
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Erinn Downs-Kelly,
Joel E Mendelin,
Ana E Bennett,
Elias Castilla, Walter H Henricks,
Lynn Schoenfield,
Marek Skacel,
Lisa Yerian,
Thomas W Rice,
Lisa A Rybicki,
Mary P Bronner,
John R Goldblum
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ABSTRACT: Grading Barrett's dysplasia at the lower end of the metaplasia-dysplasia spectrum (negative, indefinite, and low-grade dysplasia) suffers from poor interobserver agreement, even among gastrointestinal pathologists. Data evaluating interobserver agreement in Barrett's mucosal biopsies with changes at the upper end of the dysplasia spectrum (high-grade dysplasia, intramucosal, and submucosal adenocarcinoma) have not been published. The accurate categorization of pretreatment biopsies drives therapeutic decision making, but if the diagnostic distinction between cancer and high-grade dysplasia in Barrett's biopsies is inconsistent, then the use of these diagnoses to make management decisions is suspect. To this end, our aim was to assess interobserver reproducibility among a group of gastrointestinal pathologists in the interpretation of preresection biopsies.
All study pathologists agreed upon the histologic criteria distinguishing four diagnostic categories, including high-grade dysplasia; high-grade dysplasia with marked distortion of glandular architecture, cannot exclude intramucosal adenocarcinoma; intramucosal adenocarcinoma; and submucosally invasive adenocarcinoma. The histologic criteria were used to independently review preresection biopsies from 163 consecutive Barrett's esophagus patients with at least high-grade dysplasia who ultimately underwent esophagectomy. Reviewers recorded the specific histologic criteria used to categorize each case and Kappa statistics were calculated to assess interobserver agreement.
Using kappa statistics, the overall agreement was only fair (kappa= 0.30). Agreement for high-grade dysplasia was moderate (kappa= 0.47), while agreement for high-grade dysplasia with marked architectural distortion, cannot exclude intramucosal adenocarcinoma and intramucosal adenocarcinoma were only fair (kappa= 0.21 and 0.30, respectively) and agreement for submucosal adenocarcinoma was poor (kappa= 0.14).
The overall poor interobserver reproducibility among gastrointestinal pathologists who see a high volume of Barrett's cases calls into question treatment regimens based on the assumption that high-grade dysplasia, intramucosal adenocarcinoma, and submucosal adenocarcinoma can reliably be distinguished in biopsy specimens.
The American Journal of Gastroenterology 08/2008; 103(9):2333-40; quiz 2341. · 7.28 Impact Factor
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ABSTRACT: Laboratory informatics is the application of computers and information systems to information management in the pathology laboratory. Effective information management is crucial to the success of pathologists and laboratorians. Informatics has become one of the key pillars of pathology, and the requirement for skilled informaticists in the laboratory has quickly grown. This article provides a wide-ranging review of pertinent aspects of laboratory informatics, and deals with important technical and management processes. Topics covered include personal computing, networks, databases, fundamentals and advanced functions of the laboratory information system, interfaces and standards, digital imaging, coding, hospital information systems and electronic medical records.
Clinics in Laboratory Medicine 01/2008; 27(4):823-43, vii. · 1.97 Impact Factor
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ABSTRACT: To be successful in tomorrow's health care environment, to make the most appropriate decisions for their laboratories, to optimize training and continuing medical education opportunities, and to advance pathology as a professional specialty, pathologists must possess basic informatics knowledge and proficiency. Traditional areas of anatomic and clinical pathology residency training employ learning objectives, knowledge expectations, and skill sets, but such items have not been as well developed or widely implemented for pathology informatics training.
We present a proposal that defines a standard and specific set of learning (knowledge) objectives and skill set (proficiency) expectations for resident training in pathology informatics.
The proposal includes a comprehensive and detailed set of knowledge applications and proficiencies that will assist residency programs in developing basic pathology informatics training for residents. The content of the proposal is based on and compiled from existing successful pathology informatics training programs. Learning objectives include those related to general and enterprise computing as well as objectives related specifically to pathology informatics. Skill set expectations include the ability to use software that facilitates and adds value to the work of pathologists, including the use of a laboratory information system and of productivity software and other tools. Other topics include guidelines for evaluating residents' informatics competency, suggestions regarding curriculum structure and implementation, and recommendations for residents' computing infrastructure.
This proposal provides a foundation for building effective and standard curricula for residency training in pathology informatics. These curricula will be able to meet increasing expectations and needs for pathologists to contribute to clinical information management.
Archives of pathology & laboratory medicine 09/2003; 127(8):1009-18. · 2.58 Impact Factor
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ABSTRACT: Laboratory analyses may generate multiple data types that may reside in disparate systems, and combining data into a report often requires laborious, error-prone methods. Kidney stone analysis, which includes biochemical composition analysis and gross feature documentation, is an example of such a situation. We developed the kidney stone reporting system (KISS) that integrates patient and specimen information from the laboratory information system, digital images of stones, and analytic instrument data into a concise report for the ordering clinicians. The database management environment facilitates archival and retrieval capabilities. Implementation of the system has reduced the number of manual steps necessary to produce a report and has saved approximately 30 technologist hours per week. Transcription errors have been virtually eliminated. The KISS represents an innovative use of standard tools to integrate text, image, and graphic data from disparate systems into an integrated laboratory report, without the need for expensive interfaces.
American Journal of Clinical Pathology 09/2002; 118(2):179-83. · 2.60 Impact Factor
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ABSTRACT: Information management is crucial in pathology, and previous reports have stressed the needfor improved informatics training in pathology residency programs. We surveyed 150 US programs to assess informatics training with respect to types of training, proficiency expectations, and computing infrastructure. Seventy-two programs (48.0%) responded. Of the respondents, 67 (93%) reported offering informatics training; of these, 52 (78%) required it. Most programs integrated informatics into another rotation, usually management. In 37 programs (55%), the amount of informatics training has increased during the last 3 to 5 years. The most common instructional methods were hands-on training and self-study; 61 programs (91%) used multiple methods. In all but 2 programs, computers were designated for residents; 9 programs offered individual computers to residents. All programs provided productivity software. These data suggest progress in informatics training but that considerable room for improvement exists. Our data also document for the first time detailed computing resources available to residents.
American Journal of Clinical Pathology 09/2002; 118(2):172-8. · 2.60 Impact Factor
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ABSTRACT: Voice recognition (VR) technology in computer systems converts speech directly into electronic text. In pathology, VR holds promise to improve efficiency and to reduce transcription delays and costs. We investigated the utility and cost effectiveness of targeted VR deployment in surgical pathology. A VR system was deployed for entry of gross descriptions of biopsies and of low to moderate complexity specimens and for entry of final reports for specimens not requiring microscopic analysis. Templates for VR were developed for all reports. Free-text speech entry was used to enter information not covered by templates. Voice converted to text by VR crossed over an interface into the anatomic pathology laboratory information system. Tallies were kept of whether individual specimens were entered by VR or by conventional dictation. A computer program was written to analyze the number of lines of text entered through VR. Cost savings were calculated based on per-line transcription costs from an outside agency. Over 18 months, gross descriptions for an average of 5617 specimens per month were entered via VR, corresponding to 70% of all gross specimens processed by the laboratory. A mean of 106 gross-only final reports per month was entered through VR. VR facilitated same-day processing of specimens received after the previous day processing cutoff time (average 35 specimens per day). VR generated an average of 23,864 lines of text per month, translating to $2625 savings per month. Estimated payback period for VRT as implemented is 1.9 years. The use of VR for gross descriptions of biopsies and low to moderate complexity specimens and for gross-only final reports in surgical pathology facilitates data entry, reduces transcription costs, and contributes to improved turnaround time. Development of templates is important to successful implementation of VR in surgical pathology.
Modern Pathology 06/2002; 15(5):565-71. · 4.79 Impact Factor
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ABSTRACT: Histologic differential diagnosis of acinar cell carcinoma (ACC), mixed acinar-endocrine cell carcinoma (MAEC), and pancreatic endocrine tumors (PET) can be difficult but is important because of differences in their clinical behavior. This study investigates the utility of immunohistochemistry (IHC) in this differential diagnosis using immunohistochemical stains that are available in most laboratories. IHC was performed on paraffin-embedded tissue in ACC (n = 6), MAEC (n = 2), and PET (n = 13), using synaptophysin (SYN), chromogranin (CHR), chymotrypsin (CHY), and α-1-antitrypsin (AAT). Electron microscopy (EM) was performed in all cases to confirm the diagnosis. Long-term follow-up and death of disease (DOD) was known in all patients. The ACCs stained as follows: CHY (4/6), AAT (3/6), SYN (4/6); CHR was negative in all cases. Both cases of MAEC stained with CHY, AAT, and SYN (2/2); CHR was negative. PET stained as follows: SYN (13/13), CHR (8/13), CHY (4/13), AAT (5/13). In the ACC/MAEC group, six of eight patients were DOD at mean follow-up of 11 months. Among the PET, two of 16 patients were DOD at mean follow-up of 37 months. Considerable immunophenotypic overlap exists between ACC, MAEC, and PET. Consequently, one can neither confirm nor rule out a diagnosis of ACC or MAEC using generally available immunohistochemical stains alone. These findings support a role for EM in the evaluation of exocrine and endocrine pancreatic neoplasms.
Among the pancreatic neoplasms that are less frequently encountered than ductal adenocarcinoma, the most common are endocrine tumors (1). These benign or low-grade malignant tumors may be difficult to distinguish histologically from other unusual pancreatic neoplasms such as solid pseudopapillary tumor, pancreatoblastoma, acinar cell carcinoma, and mixed acinar-endocrine carcinoma. The widespread degenerative-hemorrhagic changes typical of solid pseudopapillary tumor and the squamoid nests seen in pancreatoblastoma are generally lacking in endocrine tumors and are helpful features in the recognition of these two rare entities (2–4). The differentiation of acinar cell carcinomas and mixed acinar-endocrine carcinomas from endocrine tumors can be much more difficult because their histologic and immunophenotypic features can be remarkably similar (5–7).
Acinar cell and mixed acinar-endocrine carcinomas may grow in solid or trabecular patterns, and typical acinar structures may be absent. Atypical cytologic features suggestive of this neoplasm, such as large nuclei with prominent nucleoli and abundant cytoplasm, can be limited to small areas within the tumor and may not be present in all cases. Conversely, endocrine tumors can often form pseudoglandular structures or display solid growth and thus may resemble acinar cell carcinomas (8,9).
Accurate distinction between acinar and endocrine tumors of the pancreas is important because their biological behavior and prognosis differ considerably. The majority of pancreatic endocrine tumors are benign, and even patients with malignant endocrine tumors usually survive for several years. In contrast, the reported median survival of patients diagnosed with acinar cell carcinoma is 18 months (10).
The existence of a true mixed acinar-endocrine carcinoma, although rare, can further complicate the differential diagnosis, because these tumors may have histologic features that overlap between acinar and endocrine neoplasms (11,12). Similar to acinar cell carcinoma, the reported median survival in the limited series of this tumor is rather poor (5).
Immunohistochemistry may be employed in an attempt to resolve the differential diagnosis of these lesions. Pancreatic endocrine tumors are classically described as staining positively with neuroendocrine markers such as chromogranin and synaptophysin, whereas acinar cell carcinomas reportedly stain positively for enzymatic markers such as trypsin and chymotrypsin (13).
A number of factors complicates the use of immunohistochemistry in this setting. First, chromogranin may be often negative in pancreatic endocrine tumors (6). Second, synaptophysin positivity has been described in acinar cell carcinomas (14). Third, the number of enzymatic stains necessary to display the exocrine nature of a tumor may include large number of markers that are not generally available, including trypsin, chymotrypsin, α-1-antitrypsin, butyrate esterase, lipase, and phospholipase A2. Finally, mixed acinar-endocrine carcinoma by its nature displays evidence of both endocrine and exocrine derivation, leading to difficulty in resolving the immunophenotype.
This study examines the immunohistochemical staining patterns of acinar, endocrine, and mixed acinar-endocrine neoplasms of the pancreas using commonly employed markers. By incorporating ultrastructural analysis as the gold standard, the aim of the study was to define the utility of a reasonable immunohistochemical panel and the role of electron microscopy in the workup and differential diagnosis of these uncommon pancreatic neoplasms.
Applied Immunohistochemistry 08/2000; 8(3):203-209. · 1.63 Impact Factor
