Properly Interpreting Specimens for Diagnosis

03/18/2015

Once again, there is an article on the front page of the NY Times, which I feel mandates some commentary by me. And once again, I have gone back to the original article, which appears in the current issue of JAMA (Journal of the American Medical Association) rather than just the NY Times rendition and summary of it.

The article is entitled “Diagnostic Concordance Among Pathologists Interpreting Breast Biopsy Specimens.” In the first place, you should all feel very comfortable and confident that there was almost 100% concordance for those patients who had actual breast cancer. In other words, this is a relatively straightforward diagnosis and something that is not often misinterpreted by community pathologists. The area where there was less good coordination was in precancerous lesions. I believe this is why it is so important for all pathology specimens to be interpreted by experts.

Certainly, in my area, that of gynecology, I have purposely always used the NYU Laboratory for pathology. These are not only experts but people who train pathologists to go out into the community and perform pathologic evaluations, in general. Some of you have experienced the following scenario, which happens all too often:

• A patient will bring her young daughter in who has had a markedly abnormal Pap smear done elsewhere. She has been told that she needs a LEEP procedure, which is somewhat destructive in that it removes a portion of the cervix.
• This would triple her risk of preterm birth and incompetent cervix when she does decide to have children.
• It is appropriate to do such a procedure for high-grade abnormal Pap smears.
• The first thing I do is request the slides and bring them to the head of GYN Pathology here at NYU and look at them with him over a two-headed microscope. Probably four out of five times over the years that I have done this (and it seems to happen only a couple of times a year), he will end up showing me the area that this other pathologist thought was highly abnormal and is able to downgrade this to mildly abnormal or just atypical, thus allowing the young patient who hasn’t had her children yet to avoid any surgical intervention. Most physicians do not have pathology specimens re-reviewed, especially when these are sent to large commercial labs like Quest or National Health Laboratories. This is especially important if one is going to undertake a serious surgical procedure (like a total mastectomy or a LEEP of the cervix) for a “precancerous” lesion.

The final advice is something I often give to you when I see you in person, which is that your mammography (and therefore, breast biopsies and the pathologists that then look at them) should be done by facilities that are of the highest caliber and quality

Dr Steven R. Goldstein is an Obgyn in Manhattan for all gynecological needs.