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July 2002

TNM residual tumor classification revisited
The TNM classification includes several modifiers that are useful for categorizing disease status at various points during a cancer patient's course. Prognosis is strongly influenced by the completeness of tumor removal at the time of cancer-directed surgery or disease remission after nonsurgical treatment with curative intent. These parameters define the relative success of definitive treatment and can be codified by the residual tumor (R) classification, an additional subclassification within the TNM system. Despite the importance of residual tumor status in designing clinical management after treatment, misinterpretation and inconsistent application of the R classification frequently occur and diminish or abrogate its clinical utility. The authors analyzed the relevant literature regarding the use and prognostic importance of the R classification. They discussed the prognostic importance of the R classification for different kinds of tumors, described the problems that arise in using the R classification, and addressed special issues regarding the use of the R classification. The R classification is a strong indicator of prognosis and aids in comparing treatment results if applied in a consistent manner. Uniform use and interpretation of this classification are essential for standardizing post-treatment data collection.

Wittekind C, Comptom CC, Greene FL, et al. TNM residual tumor classification revisited. Cancer. 2002;94:2511-2519.

Reprints: Dr. Christian Wittekind, Institute of Pathology, University Clinic of Leipzig, Liebigsra├če 26, D-04103 Leipzig, Germany; wittc@medizin.uni-leipzig.de

Use of forceps biopsy versus polypectomy for removing gastric polyps
The authors conducted a prospective multi-institutional study in Germany to determine whether an adequate histologic diagnosis of gastric polyps can be obtained on the basis of forceps biopsy, taking into account complications observed during polypectomy, particularly bleeding. A total of 194 patients with 222 gastric polyps (>5 mm) that could be removed endoscopically underwent forceps biopsy and complete polypectomy. Patients with fundic gland polyps and polyposis syndrome were excluded. Specimens were evaluated by primary and reference pathologists, and the complication rate of gastric polypectomy was determined. Of the 222 polyps, histological examination of the polypectomy specimens revealed tumor-like lesions in 77 percent (10 percent focal foveolar hyperplasia, 59 percent hyperplastic polyps, four percent inflammatory fibroid polyps, four percent other polyps) and neoplasia in 19 percent (10 percent tubular adenoma, two percent tubulovillous adenoma, one percent high-grade intraepithelial neoplasia, six percent adenocarcinoma). When biopsy results were compared, complete agreement was found in 55.8 percent of cases, and it was possible to clinically differentiate between tumor-like lesions and neoplasia in an additional 34.7 percent. Relevant differences, however, were found by the reference pathologist in 2.7 percent of cases, the most common reason being failure of biopsy to reveal foci of carcinoma in hyperplastic polyps. Bleeding was observed after polypectomy in 16 patients (7.2 percent) and was managed conservatively in 15 of them. The authors recommended that an experienced endoscopist remove all epithelial gastric polyps larger than 5 mm after thorough individualized risk-benefit analysis.

Muehldorfer SM, Stolte M, Martus P, et al. Diagnostic accuracy of forceps biopsy versus polypectomy for gastric polyps: a prospective multicentre study. Gut. 2002;50:465-470.

Correspondence: C. Ell, Dept. of Medicine II, Dr. Horst-Schmidt-Kliniken, Ludwig-Erhard-Str 100, 65199 Wiesbaden, Germany

Storing and distributing pathology digital images using Web-based systems
Health care providers have expressed increasing interest in incorporating digital images of gross pathology specimens and photomicrographs into routine pathology reports. The authors describe the technical and logistical challenges involved in integrating the various components necessary for developing a system for integrated Web-based viewing, storage, and distribution of digital images in a large health care system. The authors used an Oracle version 8.1.6 database to store, index, and deploy pathology digital photomicrographs via their intranet. The database allows images to be retrieved using patient demographics or SNOMED (Systematized Nomenclature of Medicine) code information. The intranet is located in a large health care system and is accessible from multiple computers located within the medical center and at distant private physician offices. The images can be viewed using any of the health care system's workstations that have authorized access to the intranet via a standard browser or browser software. The images can be printed on paper or transferred to film using a digital film recorder. Digital images can also be displayed at pathology conferences using a wireless local area network and secure remote technologies. The authors concluded that standardizing technologies and adopting a Web interface for all computer systems allow a large medical center to distribute digital images from a pathology database to a potentially large group of users in multiple locations throughout the institution.

Marchevsky AM, Dulbandzhyan R, et al. Storage and distribution of pathology digital images using integrated Web-based viewing systems. Arch Pathol Lab Med. 2002;126: 533-539.

Reprints: Dr. Alberto M. Marchevsky, Dept. of Pathology, Cedars-Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA 90048; alberto.marchevsky@cshs.org

Cytohistologic correlation as a pathology tool
The use of cytohistologic discrepancies to investigate and reduce error seldom is studied. The authors, however, classified all gynecologic discrepancies (n=283; 0.87 percent and 7.37 percent of all cytologic and histologic cases, respectively) and non-gynecologic discrepancies (n=146; 2.26 percent and 0.44 percent of all cytologic and histologic cases, respectively) as sampling or interpretive over 26 months. They evaluated specimen type and pathologist discrepancy percentages, effect of discrepancies on patient outcome, and interobserver agreement of discrepancies. Discrepancies were interpretive in 67 percent and 34 percent of gynecologic and nongynecologic cases, respectively. Statistically significant associations were seen between individual pathologists and discrepancy percentages. Breast (1.2 percent) and bronchial (0.8 percent) cytologic diagnoses had the highest discrepancy percentages. The kappa scores ranged from 0.02 to 0.45 for pairwise agreement of discrepant cases. Of nongynecologic interpretive discrepancies available for review, 63 percent and 14 percent were of no significance or minor clinical significance, respectively. The authors concluded that cytohistologic correlation is a useful tool to monitor performance and identify specimen types prone to error.

Clary KM, Silverman JF, Liu Y, et al. Cytohistologic discrepancies: a means to improve pathology practice and patient outcomes. Am J Clin Pathol. 2002;117:567-573.

Reprints: Dr. K.M. Clary, Dept. of Pathology and Lab Medicine, Allegheny General Hospital, 320 E. North Ave., Pittsburgh, PA 15212