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Pⁿ Blog
The Pⁿ Blog is a forum for opinions, questions, controversies, and instructive discussions across the field of pathology and its relevant subspecialties.
Friday, May 03, 2013
Authorities are not Infallible
Virtually every organization in existence has one or more "authoritative" structures with variable power.  Pathology has many.  There are groups governing training, certification, quality, reporting formats, billing, continuing medical education, and on and on. 
 
On the diagnostic side of pathology a variety of subspecialty groups has been of value in establishing more uniform diagnostic and reporting guidelines for surgical pathology and cytopathology.  The World Heath Organization (WHO) conferences and resultant "Blue Books" have been generally useful in codifying tumor diagnosis on a worldwide level and the AJCC has been instrumental in setting staging criteria and, indirectly, report formatting for tumor diagnosis, at least in the United States.  But as potentially valuable as these and other "expert" groups can be in codifying our approach to pathology, they are composed of human beings and are not infallible... far from it.  Sometimes, in fact, they make decisions that seem downright bone headed. 
 
This shouldn't be totally surprising.  Lauren Ackerman used to describe a WHO tumor consensus meeting more or less as follows:
A bunch of variably capable, variably experienced individuals with very large egos come together from all over the world, each with their own agenda and little or no willingness to abandon their preconceptions.  They spend most of the day debating whose nomenclature should be adopted for this or that tumor until the dinner hour approaches, thoughts of food and drink intercede, and discussions rapidly degenerate into, "I'll vote for your tumor if you vote for mine.... and let's go to dinner!"  Amazingly, most of the time things work out reasonably well, but there are notable exceptions.  And blind trust in any authority is NEVER a good idea.
 
From my personal perspective the following is a very brief, off the top of my head list of what I believe are some recent (and not so recent) examples of muddy thinking by "authorities."  You may or may not agree.
 
1. The 2010 AJCC decision that a single immunohistochemically positive "malignant-appearing" cell in a sentinel lymph node for malignant melanoma constitutes "N1" disease.   I don't know where to start with this one.  Can you recognize a malignant nucleus when it's covered with brown/red chromogen?  Do these patients really have Stage III disease?  Wow!  Cure rates for Stage III melanoma are going to skyrocket.   ...and don't get me started on the value of sentinel lymph nodes for melanoma.  Where are the data?  At least once a week we review cases for our melanoma clinic in which S100-positive dendritic cells or intra-capsular nevus cells have been interpreted as metastases.  In some cases, it's unlikely the original lesion was anything more than an architecturally disordered nevus.  There's a LOT more that could be said on this point, but I'll save that for a later blog.
 
2. The ACS requirement that synoptic reports should be filled out on tumor resections that are devoid of any residual tumor.  Lots of words wasted to say, "no tumor seen."
 
3. The decision to relabel all pancreatic neuroendocrine carcinomas as "pancreatic endocrine tumors."  The word "tumor" doesn't even indicate that it's a neoplasm, let alone benign or malignant.
 
4. The 2002 WHO decision to rename uterine malignant mixed mullerian tumors as "carcinosarcomas."   They are sarcomatoid carcinomas, not sarcomas.
 
5. Multiple overly complex contrived systems for designating thymomas.
 
6. The decision by the WHO to retain the term "atypical carcinoid tumor" in pulmonary pathology.
 
...I'm sure you can think of more!  
(I could as well, but I'm already late with this blog!)
 
 
5/16/2013
Kaushik K. Dasgupta said:
Dear Prof, Couldn't agree more with you on all these points. Recently, I was appalled to see that my marks were deducted in an English External Quality Assurance Scheme for using the term triple MT instead of carcinosarcoma and this was detrimental/disparaging to my score. The retention of the term atypical carcinoid in pulmonary pathology is very unfortunate and many times I find it difficult to give the flair for the biology of these tumours to my lung MDT colleagues and that these would be grade 2 neurodocrine carcinomas if they happened to be in any other organs. So it is just happenstance! The so called alphanumeric compromise for thymic neoplasms is hardly a classification and the reason for not adopting Suster and Morans simplified yet biologically meaningful classification is purely probably political. Incidentally I am seeing Prof Moran within the next few hours!
About the Author

Stacey E. Mills, MD
Stacey E. Mills, MD, a graduate of University of Virginia (UVA) and the UVA Medical Center, has authored nearly 230 articles, 20+ books, atlases and monographs—including the renowned Sternberg's Diagnostic Surgical Pathology. He has been a practicing Professor and Staff Pathologist at UVA for 30+ years and is Director of Surgical Pathology and Cytopathology. His clinical specialty is general surgical pathology with emphasis on neoplasms and neoplasm-like lesions. Dr. Mills is also Editor-in-Chief of The American Journal of Surgical Pathology.