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Communication



It is absolutely imperative for the pathology service to communicate effectively with radiologists and surgeons to ensure that appropriate and timely clinical care is delivered. This is not a glib statement - many of the errors that are made in medicine are due to poor communication and the breast service is no exception.



Examples of potential pitfalls in pre-operative reporting


Cytology


The C1/C2 boundary:


The dividing line between what is adequate or representative and what is not Important when cytology is used in diagnostic practice A decision between C1 & C2 is often made easier by discussion of the case with the Surgeon or Radiologist

The false negative C2:


This will usually occur in the context of a low grade carcinoma or a mucinous carcinoma
Read the request form, find out about the imaging and talk to the surgeon!!

The inappropriate C3:


Practitioners must feel able to express uncertainty - nevertheless the "suspicious" rate in cytology should be < 10%
Common areas for overcalling C3 (or worse) are fibroadenomas especially in women under 25 and gynaecomastia

The inappropriate C4:


Once again practitioner must feel free to express uncertainty. Most C4s in our experience turn out to be cancers. In the context of a radiologically or clinically appropriate lesion careful review of the cytology (especially with the assistance of a colleague) may allow the C4 to be revised to a C5 - BUT - beware fibroadenomas and apocrine changes.

The false positive C5:


Common causes are:



We will all continue to make these mistakes but their frequency can be reduced by good communication.

Please remember that it is just as important for pathology colleagues to communicate with each other as it is for them to communicate with surgeons and radiologists. It is essential in any pathology service that pathologists can feel free to share problems and therefore avoid mistakes.

The core biopsy




Screening


Assessment of calcs:

The reporting pathologist needs to be aware that he is in a diagnostic loop between the radiologist and the patient. Calcs are picked up on a mammogram, are then retrieved (more or less adequately) by the radiologist and then the pathologist reports the sections. It is the job of the pathologist to identify those calcs retrieved in the core (as seen on a specimen X ray, ideally), relate them to the histology and then discuss the findings to determine whether the mammographic abnormality is represented in the sections.

The areas of diagnostic difficulty are:



The boundary between B2 and B3


The usual problem here is drawing the line between usual type hyperplasias (B2) and atypical proliferations (B3). Columnar cell change often gives difficulty in this context and is often picked up at screening because of calcs.

The other common B3 diagnoses are for suspected
radial scars and apparently benign papillary lesions lesions.

The B3/B4 Boundary


In practice this is not much of a problem area. B3 and B4 will usually be followed by a diagnostic biopsy although a B4 call may encourage the surgeon to take a wider margin than for a B3 call. B4 should signal to the surgeon that there are very serious concerns about DCIS and may prompt a repeat core rather than a diagnostic biopsy so that definitive surgery can be planned. Most B4s will turn out to be DCIS +/- invasive cancer on excision. Once again communication with the surgeon and radiologist is vital so that the next step is the right step in the management of the case.

The B4/B5 boundary


This is a very difficult area of practice. It is essential that any core biopsy result is correlated with the radiology to ensure that the correct procedure follows. The following potential problems need to be kept in mind:

  1. An inappropriate diagnosis of DCIS can result in a mastectomy
  2. If there are benign and malignant calcs in sections SAY SO to avoid the misconception that ALL the calcs on a mammogram are malignant
  3. If you are not sure of your diagnosis show the sections to a colleague - don't allow yourself to be rushed or pressured
  4. Cut more levels - it is astonishing how a difficult case can get easier with more material to look at
  5. Immunohistochemistry for myoepithelial markers is helpful to distinguish ADH from DCIS

The Pathology Report & Communication


There is no substitute for verbal communication with the surgeon or radiologist about a case but this is not possible all the time. Furthermore if this route is overused it will simply clog this channel of communication.

    Communication in Breast Pathology

  1. The MDM - this should not just be reading the report but an interactive correlation of all the information available
  2. The Phone Call - use the phone - mobiles are great in this regard if your hospital allows them - consider texting
  3. The written report - see below


Pathology reports are required to deliver and record permanently key diagnostic and management information. Examples of reports are given in Specimen types and tissue handling

    Key points in the pathology report

  1. The FNA and core biopsy report need to be sufficiently clear to guide further management unambiguously
  2. If the pathology is equivocal say so and if possible reinforce by verbal discussion/MDM
  3. The non-cancer excision biopsy report needs to be reported so that there is no doubt about whether a patient needs to be followed up e.g. benign v atypical
  4. The cancer excision report (mastectomy or wide local excision) requires clear statements about grade, size etc, margins and nodes in addition to prognostic/management information e.g. ER, Her-2 status

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