Anatomic Pathology Laboratory Information System Research Articles

Abstract P1-02-10: Breast tumor measurement after neoadjuvant chemotherapy using the 8th edition of the American Joint Committee on cancer staging system: Impact on estimates of tumor size and discrepancies with residual cancer burden class

Abstract Background: In the 8th Edition of the American Joint Committee on Cancer Staging System (yAJCC) for breast cancer after neoadjuvant chemotherapy (NAC), tumor size is based on the largest focus of residual tumor, excluding treatment-related fibrosis. The goal of this study was to assess the impact of strict adherence to yAJCC criteria on residual breast tumor size and discrepancies between yAJCC stage and Residual Cancer Burden (RCB) class. Design: Breast cancer resections after NAC from 2016-2020 were identified in the Anatomic Pathology laboratory information system. Stage IV, pT4b, pT4d, pCR, neoadjuvant endocrine therapy alone and no response to NAC were exclusion criteria. Tumor size, ypT category and focality were reassessed using current yAJCC criteria and compared to the original reports. A median of 29 slides per case were reviewed (range, 9-113). Results: A total of 189 cases met inclusion criteria, including 58 (31%) TNBCs, 50 (26%) HER2+ and 81 (43%) hormone receptor-positive/HER2-negative (HR+/HER2-). The reassessed tumor size and ypT category differed from the original report in 113 (60%) and 107 (57%) cases, respectively. In all of these cases the tumor size or ypT category was smaller/lower on review. The 107 cases with lower ypT categories included 41% of TNBCs, 62% of HER2+ and 64% of HR+/HER2- (p=0.02) In the original report, 36 (19%) cases were classified as multifocal versus 131 (69%) after review (p=0.00001). yAJCC staging based on the reassessed ypT categories differed from the original report in 38 (20%) cases (all down-staged). There were 77/189 (41%) cases with yAJCC/RCB Class discrepancies in the original reports versus 95/189 (50%) after slide review (p=0.08). The yAJCC/RCB discrepant cases in the original reports included 47% of TNBCs, 38% of HER2+ and 38% of HR+/HER2- versus 47% of TNBCs, 48% of HER2+ and 54% of HR+/HER2- after review (p=0.62). The higher proportion of discrepancies among HR+/HER2- after review did not reach statistical significance (p=0.06). Conclusions: Strict adherence to 8th Ed. yAJCC criteria for measurement of the residual breast tumor after NAC resulted in smaller tumor size, lower ypT category, lower yAJCC stage and more tumors classified as multifocal. Changes in ypT category occurred more often among HER2+ and HR+/HER2- than TNBC. There was no significant change in the frequency of yAJCC/RCB discrepancies. Citation Format: Dawn Harter, Siobhan M O'Connor, Johann D Hertel, Benjamin C Calhoun. Breast tumor measurement after neoadjuvant chemotherapy using the 8th edition of the American Joint Committee on cancer staging system: Impact on estimates of tumor size and discrepancies with residual cancer burden class [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P1-02-10.

Research Highlights

Research Highlights

Process Variation Detection using Missing Data in a Multihospital Community Practice Anatomic Pathology Laboratory

Objectives: Barcode-driven workflows reduce patient identification errors. Missing process timestamp data frequently confound our health system’s pending lists and appear as actions left undone. Anecdotally, it was noted that missing data could be found when there is procedure noncompliance. This project was developed to determine if missing timestamp data in the histology barcode drive workflow correlated with other process variations, procedure noncompliance, or is an indicator of workflows needing focus for improvement projects. Materials and Methods: Data extracts of timestamp data from January 1, 2018, to December 15, 2018 for the major histology process steps were analyzed for missing data. Case level analysis to determine the presence or absence of expected barcoding events was performed on 1031 surgical pathology cases to determine the cause of the missing data and determine if additional data variations or procedure noncompliance events were present. The data variations were classified according to a scheme defined in the study. Results: Of 70,085, there were 7218 cases (10.3%) with missing process timestamp data. Missing histology process step data was associated with other additional data variations in case-level deep dives (P < 0.0001). Of the cases missing timestamp data in the initial review, 18.4% of the cases had no identifiable cause for the missing data (all expected events took place in the case-level deep dive). Conclusions: Operationally, valuable information can be obtained by reviewing the types and causes of missing data in the anatomic pathology laboratory information system, but only in conjunction with user input and feedback.

Critical diagnoses in cytopathology: Experience at a large medical center

Critical values have been well established and accepted in laboratory medicine, but to the authors' knowledge are less well accepted in anatomic pathology. Herein, the authors used a reporting process whereby reports with critical diagnoses were coded to ensure that the patient's clinical team was promptly notified electronically of this finding. The aim of the current study was to determine whether this coding mechanism was used appropriately for critical cytopathology diagnoses in the study health care system. A retrospective review of the University of Pittsburgh Medical Center anatomic pathology laboratory information system was performed to identify cytopathology reports in which a critical diagnosis code (MedTrak notification/CoPath Tissue Code TC66; TC66) was used from 2011 through 2016. TC66-coded cytopathology reports between 2015 and 2016 were reviewed further to determine whether this code was used appropriately. A total of 1687 TC66-coded cytopathology reports were identified. Between 2015 and 2016, a total of 30 of 46 reports (65%) from academic hospitals and 46 of 441 reports (10%) from community hospitals met the critical diagnoses criteria outlined by institutional policy. The remaining TC66-coded cases were predominantly for new diagnoses of malignancy in patients clinically suspected of having cancer. Use of a code for critical cytopathology diagnoses was found to be occurring increasingly at the study health care system. Pathologists at the academic and community hospitals in the study institution used this code somewhat differently, reflecting the need to satisfy communication with clinicians in different practice settings. Nevertheless, the authors' experiences with using a code for critical diagnoses not only ensured timely patient care but also proposed a model that could be used by other medical specialties to enhance communication and improve quality of care. Cancer Cytopathol 2017;125:726-30. © 2017 American Cancer Society.

Overinterpretation is common in pathological diagnosis of appendix cancer during patient referral for oncologic care.

ContextLow-grade appendiceal mucinous neoplasm (LAMN) and appendiceal adenocarcinoma are known to cause the majority of pseudomyxoma peritonei (PMP, i.e. mucinous ascites); however, recognition and proper classification of these neoplasms can be difficult despite established diagnostic criteria.ObjectiveTo determine the pathological diagnostic concordance for appendix neoplasia and related lesions during patient referral to an academic medical center specialized in treating patients with PMP.DesignThe anatomic pathology laboratory information system was searched to identify cases over a two-year period containing appendix specimens with mucinous neoplasia evaluated by an outside pathology group and by in-house slide review at a single large academic medical center during patient referral.Results161 cases containing appendix specimens were identified over this period. Forty-six of 161 cases (28.6%) contained appendiceal primary neoplasia or lesions. Of these, the originating pathologist diagnosed 23 cases (50%) as adenocarcinoma and 23 cases (50%) as LAMN; however, the reference pathologist diagnosed 29 cases (63.0%) as LAMN, 13 cases (28.3%) as adenocarcinoma, and 4 cases (8.7%) as ruptured simple mucocele. Importantly, for cases in which the originating pathologist rendered a diagnosis of adenocarcinoma, the reference pathologist rendered a diagnosis of adenocarcinoma (56.5%, 13 of 23), LAMN (39.1%, 9 of 23), or simple mucocele (4.3%, 1 of 23). The overall diagnostic concordance rate for these major classifications was 71.7% (33 of 46) with an unweighted observed kappa value of 0.48 (95% CI, 0.27–0.69), consistent with moderate interobserver agreement. All of the observed discordance (28.3%) for major classifications could be attributed to over-interpretation. In addition, the majority of LAMN cases (65.5%) had potential diagnostic deficiencies including over-interpretation as adenocarcinoma and lacking or discordant risk stratification (i.e. documentation of extra-appendiceal neoplastic epithelium).ConclusionsAppendiceal mucinous lesions remain a difficult area for appropriate pathological classification with substantial discordance due to over-interpretation in this study. The findings highlight the critical need for recognition and application of diagnostic criteria regarding these tumors. Recently published consensus guidelines and a checklist provided herein may help facilitate improvement of diagnostic concordance and thereby reduce over-interpretation and potential overtreatment. Further studies are needed to determine the extent of this phenomenon and its potential clinical impact.

Routine Digital Pathology Workflow: The Catania Experience

Introduction: Successful implementation of whole slide imaging (WSI) for routine clinical practice has been accomplished in only a few pathology laboratories worldwide. We report the transition to an effective and complete digital surgical pathology workflow in the pathology laboratory at Cannizzaro Hospital in Catania, Italy. Methods: All (100%) permanent histopathology glass slides were digitized at ×20 using Aperio AT2 scanners. Compatible stain and scanning slide racks were employed to streamline operations. eSlide Manager software was bidirectionally interfaced with the anatomic pathology laboratory information system. Virtual slide trays connected to the two-dimensional (2D) barcode tracking system allowed pathologists to confirm that they were correctly assigned slides and that all tissues on these glass slides were scanned. Results: Over 115,000 glass slides were digitized with a scan fail rate of around 1%. Drying glass slides before scanning minimized them sticking to scanner racks. Implementation required introduction of a 2D barcode tracking system and modification of histology workflow processes. Conclusion: Our experience indicates that effective adoption of WSI for primary diagnostic use was more dependent on optimizing preimaging variables and integration with the laboratory information system than on information technology infrastructure and ensuring pathologist buy-in. Implementation of digital pathology for routine practice not only leveraged the benefits of digital imaging but also creates an opportunity for establishing standardization ofworkflow processes in the pathology laboratory.

Critical Diagnoses in Cytopathology: Experience at a Large Medical Center

BACKGROUND Critical values have been well established and accepted in laboratory medicine, but to the authors' knowledge are less well accepted in anatomic pathology. Herein, the authors used a reporting process whereby reports with critical diagnoses were coded to ensure that the patient's clinical team was promptly notified electronically of this finding. The aim of the current study was to determine whether this coding mechanism was used appropriately for critical cytopathology diagnoses in the study health care system. METHODS A retrospective review of the University of Pittsburgh Medical Center anatomic pathology laboratory information system was performed to identify cytopathology reports in which a critical diagnosis code (MedTrak notification/CoPath Tissue Code TC66; TC66) was used from 2011 through 2016. TC66-coded cytopathology reports between 2015 and 2016 were reviewed further to determine whether this code was used appropriately. RESULTS A total of 1687 TC66-coded cytopathology reports were identified. Between 2015 and 2016, a total of 30 of 46 reports (65%) from academic hospitals and 46 of 441 reports (10%) from community hospitals met the critical diagnoses criteria outlined by institutional policy. The remaining TC66-coded cases were predominantly for new diagnoses of malignancy in patients clinically suspected of having cancer. CONCLUSIONS Use of a code for critical cytopathology diagnoses was found to be occurring increasingly at the study health care system. Pathologists at the academic and community hospitals in the study institution used this code somewhat differently, reflecting the need to satisfy communication with clinicians in different practice settings. Nevertheless, the authors' experiences with using a code for critical diagnoses not only ensured timely patient care but also proposed a model that could be used by other medical specialties to enhance communication and improve quality of care. Cancer Cytopathol 2017. © 2017 American Cancer Society.

Digital pathology and anatomic pathology laboratory information system integration to support digital pathology sign-out

Background: The adoption of digital pathology offers benefits over labor-intensive, time-consuming, and error-prone manual processes. However, because most workflow and laboratory transactions are centered around the anatomical pathology laboratory information system (APLIS), adoption of digital pathology ideally requires integration with the APLIS. A digital pathology system (DPS) integrated with the APLIS was recently implemented at our institution for diagnostic use. We demonstrate how such integration supports digital workflow to sign-out anatomical pathology cases. Methods: Workflow begins when pathology cases get accessioned into the APLIS (CoPathPlus). Glass slides from these cases are then digitized (Omnyx VLI20 scanner) and automatically uploaded into the DPS (Omnyx® Integrated Digital Pathology (IDP) software v. 1.3). The APLIS transmits case data to the DPS via a publishing web service. The DPS associates scanned images with the correct case using barcode labels on slides and information received from the APLIS. When pathologists remotely open a case in the DPS, additional information (e.g. gross pathology details, prior cases) gets retrieved from the APLIS through a query web service. Results: Following validation of this integration, pathologists at our institution have signed out more than 1000 surgical pathology cases in a production environment. Integration between the APLIS and DPS enabled pathologists to review digital slides while simultaneously having access to pertinent case metadata. The introduction of a digital workflow eliminated costly manual tasks involving matching of glass slides and avoided delays waiting for glass slides to be delivered. Conclusion: Integrating the DPS and APLIS were instrumental for successfully implementing a digital solution at our institution for pathology sign-out. The integration streamlined our digital sign-out workflow, diminished the potential for human error related to matching slides, and improved the sign-out experience for pathologists.

Signet-ring Cells in Pleural and Peritoneal Effusions Identified on Wright Stains – A Diagnostic Pitfall

s S17 Materials and Methods: Pathology reports of BAL (bronchoalveolar lavage) specimens were obtained by searching for “Pneumocystis” in our present Anatomic Pathology Laboratory Information System (PowerPath) from January 2006 to December 2013. Pneumocystis positivity was determined by Grocott’s methenamine silver (GMS) stain results. Immune status history was identified from the pathology reports. Fisher’s exact test was used to compare PJP in HIV positive and non-HIV patients between 2006-2009 and 2010-2013. Results: A total of 2877 cases were reviewed. Ninety-eight patients, with variable immune status, were diagnosed with PJP. Of the 98 positive cases, 34 cases were HIV positive and 64 cases were in non-HIV immunocompromised patients, with hematologic malignancy, chemotherapy, bone marrow and solid organ transplant or viremia. PJP positivity in patients with transplant and malignancies (mostly hematologic) has increased from 11% of total patients in 2006-2010 to 33% in 2011, 42% in 2012 and 80% in 2013 (Table 1). A significant increase in non-HIV PJP patients in 20102013 is observed when compared to those in 2006-2009 (pZ 0.03). Conclusions: There is a significant increase in the incidence of PJP in nonHIV immunocompromised patients and a decrease of PJP in HIV patients. These results reflect the clinical improvement due to anti-retroviral therapy and primary prophylaxis. These results support the possible utility of rapid GMS testing in the non-HIV immunocompromised population, suggesting the indication for early prophylaxis against pneumocystis in this demographic, warranting further studies.

Incidence of Pneumocystis in HIV and Non-HIV Immunocompromised Patients

s S17 Materials and Methods: Pathology reports of BAL (bronchoalveolar lavage) specimens were obtained by searching for “Pneumocystis” in our present Anatomic Pathology Laboratory Information System (PowerPath) from January 2006 to December 2013. Pneumocystis positivity was determined by Grocott’s methenamine silver (GMS) stain results. Immune status history was identified from the pathology reports. Fisher’s exact test was used to compare PJP in HIV positive and non-HIV patients between 2006-2009 and 2010-2013. Results: A total of 2877 cases were reviewed. Ninety-eight patients, with variable immune status, were diagnosed with PJP. Of the 98 positive cases, 34 cases were HIV positive and 64 cases were in non-HIV immunocompromised patients, with hematologic malignancy, chemotherapy, bone marrow and solid organ transplant or viremia. PJP positivity in patients with transplant and malignancies (mostly hematologic) has increased from 11% of total patients in 2006-2010 to 33% in 2011, 42% in 2012 and 80% in 2013 (Table 1). A significant increase in non-HIV PJP patients in 20102013 is observed when compared to those in 2006-2009 (pZ 0.03). Conclusions: There is a significant increase in the incidence of PJP in nonHIV immunocompromised patients and a decrease of PJP in HIV patients. These results reflect the clinical improvement due to anti-retroviral therapy and primary prophylaxis. These results support the possible utility of rapid GMS testing in the non-HIV immunocompromised population, suggesting the indication for early prophylaxis against pneumocystis in this demographic, warranting further studies.

Web-based synoptic reporting for cancer checklists

Background: The surgical pathology report remains the primary source for information to guide the treatment of patients with cancer. Failure to report critical elements in a cancer report is an increasing problem in pathology because of the heightened complexity of these reports and number of elements that are important for patient care. The American College of Surgeons Commission on Cancer (ACS-CoC) in concert with the College of American Pathologists (CAP) developed checklists that contain all of the scientifically validated data elements that are to be reported for cancer specimens. Most institutions do not as of yet have pathology information systems in which CAP checklists are embedded into the laboratory information system (LIS). Entering the required elements often requires extensive text editing, secretarial support and deletion of extraneous elements that can be an arduous task.Materials and Methods: We sought to develop a web-based system that was available throughout the workstations in our department and was capable of generating synoptic reports based on the CAP guidelines. The program was written in a manner that allowed automatic generation of the web-based checklists through a parsing algorithm.Results: Multiple web-based synoptic report generators have been developed to encompass required elements of cancer synoptic reports as required by the ACS-CoC/CAP. In addition, utilizing the same program, report generators for certain molecular tests (KRAS mutation) and FISH studies (UroVysiontm) have also been developed. The output of these reports can be cut-and-pasted into any text-based anatomic pathology LIS. In addition, the elements can be compiled in a database.Conclusions: We describe a simple method to automate the development of web-based synoptic reports that can be entered into the anatomic pathology LIS and database.

Experience With Voice Recognition in Surgical Pathology at a Large Academic Multi-Institutional Center

There are few reports of institutional use of voice recognition technology in clinical practice. We describe our experience with voice recognition-integrated synoptic-like dictation, associating templates with key spoken phrases, that we have used in gross examination of common specimens and as a major component of our workflow since 2001. The primary application is VoiceOver Enterprise (Voicebrook, Lake Success, NY), which uses Dragon NaturallySpeaking Medical Edition (Nuance Communications, Burlington, MA) as its speech engine. This integrates with the anatomic pathology laboratory information system (APLIS) and other applications, such as Microsoft Office (Microsoft, Redmond, WA). The largest user group, pathology assistants, mainly dictates biopsy reports, numbering approximately 210,000 specimens since 2001. The technology has been useful in our anatomic pathology workflow and provided a good return on investment, including marked improvements in turnaround time, results standardization, error reduction, and cost savings. The most helpful features of the software are templating, the seamless integration with APLIS, and the voice command creation tools.

Integration of Scanned Document Management With the Anatomic Pathology Laboratory Information System : Analysis of Benefits

Electronic document management systems (EDMSs) have the potential to improve the efficiency of anatomic pathology laboratories. We implemented a novel but simple EDMS for scanned documents as part of our laboratory information system (AP-LIS) and collected cost-benefit data with the intention of discerning the value of such a system in general and whether integration with the AP-LIS is advantageous. We found that the direct financial benefits are modest but the indirect and intangible benefits are large. Benefits of time savings and access to data particularly accrued to pathologists and residents (3.8 h/d saved for 26 pathologists and residents). Integrating the scanned document management system (SDMS) into the AP-LIS has major advantages in terms of workflow and overall simplicity. This simple, integrated SDMS is an excellent value in a practice like ours, and many of the benefits likely apply in other practice settings.

The Utility and Cost Effectiveness of Voice Recognition Technology in Surgical Pathology

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.