Muhammad Ashraf Sharif

Second opinion and discrepancy in the diagnosis of soft tissue lesions at surgical pathology

OBJECTIVE To determine the frequency and magnitude of discrepancies in the surgical pathological diagnosis of soft tissue lesions on review and second opinion in a histopathology center. STUDY DESIGN Cross-sectional, observational. PLACE AND DURATION OF STUDY Department of Histopathology, Armed Forces Institute of Pathology, Rawalpindi, from April 2006 to May 2007. MATERIALS AND METHODS All the cases of soft tissue as well as bone lesions, irrespective of age and gender, which were referred for second opinion or review after being reported elsewhere, were included in the study. A panel of antibodies of soft tissue, epithelial and lymphoid markers was applied according to the requirements of each case. The cases were categorized as category A where there was concurrence between initial diagnosis and diagnosis at review. Category B included cases where there was disagreement in the specific diagnostic entity as per WHO classifications without therapeutic implications. Category C was cases where the category of benign or malignant diagnosis remained the same but there was disagreement in the specific diagnosis with definite therapeutic implications. Category D had diagnosis of benign changed to malignant while category E had cases where diagnosis of malignancy was changed to a benign lesion. RESULTS During the study period, 34 cases of soft tissue lesions were received for review and second opinion. The mean age of the patients was 39 22 years and immunohistochemistry was performed in 21 (62%) of 34 cases. Concurrence between the review and initial diagnosis was seen in 18 (53%) cases (category A). Discrepancy in the diagnosis at review and initial consultation was seen in 16 (47%) cases. There were four (11.8%) cases that were placed in category B as the diagnosis of benign and malignant remained the same but the specific diagnostic entity was changed. Category C included eight (23.5%) cases where the review diagnosis changed the therapeutic modality despite the benign or malignant category remaining unchanged. All the cases in this category required immunohistochemistry as diagnosis of metastatic carcinoma was changed to sarcoma in two cases and diagnosis of sarcoma was changed to carcinoma in three cases. There was only one (2.9%) case in category D where a benign diagnosis was changed to malignant on review and three (8.8%) cases reported as malignant had a revised diagnosis of benign lesion, placing them in category E. CONCLUSION In the absence of a quality assurance regulatory body to monitor and overlook the professional competence of practicing surgical pathologists, a mandatory review and second opinion should be undertaken whenever a major therapeutic endeavor is to be undertaken, regardless of the cost for the ultimate benefit of the patient.

Clinico-pathological profile and outcome of inhalational burns

OBJECTIVE To determine clinico-pathological profile and outcome of inhalational burns in a specialized burns treatment unit. STUDY DESIGN Case-series. PLACE AND DURATION OF STUDY The Department of Plastic Surgery and Burns Centre Unit, Combined Military Hospital, Kharian Cantonment in March 2005. METHODOLOGY Patients of inhalational burns were included and evacuated within 30 hours of accident to the specialized burns centre after immediate resuscitation. Total Body Surface Area (TBSA) involved in burns was calculated. Complete blood count and renal profile along with serum albumin and total proteins was obtained. Portable chest radiographs and bronchoscopic examination was conducted. Escarotomies were carried and wounds were covered with split thickness skin grafts. Ventilatory support was used as needed. Comparison of the clinico-pathological profile of surviving and fatal cases was done for significance using t-test. RESULTS There were 19 patients of inhalational burns, 8 (42%) of whom expired. The mean percentage of TBSA in 11 surviving patients was 50+/-10.87 and 70+/-15.46 in fatal cases. The mean haemoglobin (Hb) on admission was 15.8+/-1.6 g/dL and after fluid resuscitation it became 11.4+/-1.5 g/dL. The mean Total Leucocyte Count (TLC) in surviving patients was 9.6+/-6.1 x 10(9)/L and 1.5+/-2.3 x 10(9)/L in fatal cases (p=0.001). The mean platelet count of surviving patients was 205+/-63 x 10(12)/L while in fatal cases was 58+/-48 x 10(12)/L (p=0.05). The serum urea levels in surviving patients was 4.3+/-2 mmol/L while in fatal cases was 8.6+/-0.9 mmol/L (p=0.05). The serum creatinine levels were 98.2+/-16.5 micromol/L in the survivor group and 249.5+/-76 micromol/L in the mortality group (p=0.05). The serum total protein in surviving patients was 63+/-8 g/dL while in mortality cases it was 57+/-7 g/L. Serum albumin in the survivor group was 36.7+/-5 g/L and 35+/-4 g/L in fatal cases. Significant in Hb, protein and albumin levels. All the expired patients had acute respiratory distress syndrome while acute renal failure with multi-organ failure co-existed in 6 patients. CONCLUSION Inhalational burns injury cases multi-system injury with high mortality. Body area involvement, total leucocyte count, platelet count, serum area and serum creatinine are important indicators of survival.