William J. Frable

A Multi-Institutional Survey of Critical Diagnoses (Critical Values) in Surgical Pathology and Cytology

Critical values (CVs) are well established in clinical pathology, and an analogous concept has recently been suggested in anatomic pathology, with the terminology of critical values, or, alternatively, critical diagnoses (CDs). To better identify anatomic pathology CVs, a survey was sent to 225 members of the Association of Directors of Anatomic and Surgical Pathology (ADASP) for grading 17 possible surgical pathology and 18 possible cytology CVs. There were 73 responses for surgical pathology and 57 for cytology. The majority of the respondents believed in the concept of CVs in anatomic pathology. There was good agreement concerning most of the possible CVs, although there were differences of opinion for some diagnoses. Several additional CVs were suggested, and there was discussion of the best terminology for CVs, degree of urgency, and appropriate notification documentation. A few respondents expressed concern about medicolegal implications. Based on the results of this survey, an ADASP committee has developed national guidelines for CDs (CVs) in surgical pathology and cytology.

Soft part sarcomas revisited. Review and comparison of a second series

Our experience with 117 cases of soft part sarcomas, diagnosed from January 1950‐December 1965, is reviewed and compared to similar reported reviews. Cases diagnosed from the first 9 years of the study were compared to those diagnosed in the last 7 years to see if there were differences in survival rates. Aside from fibrosarcoma, which showed improved survival figures for the latter period, no statistical contrast between the two groups was noted. Ninety per cent of the malignancies were comprised of, in order of frequency, fibrosarcoma (including dermatofibrosarcoma protuberans), rhabdomyosarcoma, liposarcoma, Kaposis sarcoma, and leiomyosarcoma. Excluding the miscellaneous tumors, the lowest survival rates were seen in the rhabdomyosarcoma and leiomyosarcoma groups. Although there are indications from the study of a more aggressive approach in recent years toward the treatment of sarcomas of soft parts, the survival rates for most of these tumors continue to be poor, and consideration of new modes of treatment is urged.

Screening for endometrial cancer

T he success of the Papanicolaou (Pap) smear in significantly reducing the mortality from cervical cancer in developed countries is well known. For more than 50 years, it has appeared to be a natural extension that some type of cytology examination might be suitable for screening for endometrial cancer, which is now the most commonly diagnosed cancer of the female genital tract. However, the landscape is littered with devices that have failed to make screening for endometrial cancer feasible. Some were offered simply as a direct sampling procedure of the endometrium that would be less painful and costly than either dilatation and curettage or the Pipelle biopsy device and, in the case of the latter, would be an outpatient clinic or office procedure. Although on occasion endometrial cells are recognized in cervical cytology samples, it is relatively rare that they represent significant endometrial disease, either atypical complex endometrial hyperplasia or endometrial cancer, in a totally asymptomatic woman. Thus, no comprehensive screening program for endometrial cancer has been mounted to date. The Bethesda System for reporting the results of conventional cervical cytology, either direct smears or liquid–based preparations, has also addressed the issue of the reporting of endometrial cells found in cytology samples in women aged 40 years. In the revised Bethesda terminology after the 1991 Conference, cytologically benign endometrial cells appearing in postmenopausal women were classified as an epithelial cell abnormality. This appeared to cause excessive further investigation, with a very low yield of significant endometrial pathology. After the 2001 Bethesda Conference, a category termed ‘‘other’’ was created for reporting benign endometrial cells in women aged 40 years, with atypical endometrial cells reported as an epithelial cell abnormality. Recent evidence suggests that even this terminology leads to excessive investigation with little or no benefit from the detection of significant endometrial disease. The question also remains as to the criteria for atypical endometrial cells. It is further noted in the Bethesda System 2001 that cervical cytology is unreliable for the detection of endometrial lesions and should not be used to evaluate causes of suspected endometrial abnormalities. There are an additional 63 lines of explanatory notes that include sample reports and educational notes (optional for the report) regarding the presence of benign endometrial cells. See referenced original article on pages 228–35, this issue.

Leopold G. Koss (1920–2012): A multi‐author tribute

I first learned of Dr. Koss during my cytotechnology training at Memorial Sloan-Kettering Cancer Center. His text was required reading and I appreciated the way he was able to make complicated topics understandable. He was a great teacher. I first met Dr. Koss when I came to work in his department in 1986 as assistant supervisor. I think he saw me initially as someone to do errands for him. As time went by, he began to see me more as an assistant, taking me with him when he gave workshops. This afforded me a glimpse of the groupies that would flock to him to have him sign their copies of his book and by extension to me with, “What’s it like working for DR. KOSS?” Having the opportunity staying late in the evenings chatting in his office listening to Mozart, afforded a more personal view of him. He was in a sense, developing into my cytology grandfather. Close, but still at a distance. Eventually, we began to collaborate. He, the master of 5 languages, would sometimes give me manuscripts to proof read and edit. I felt inadequate to the task but did my best. I doubt he appreciated my viewpoints, but it would trigger discussion of the fine points of the article. When I decided to leave in 1996, he tried to talk me into staying but understood the opportunity ahead of me. I will remember him as the kind gentleman who took me under his wing and taught me a few things about cytology and life. Rest in Peace, Dr. Koss (Fig. 1).