Tropical medicine rounds
A retrospective audit of skin biopsies done in a tertiary care center in India Pradeep Balasubramanian, MD, Laxmisha Chandrashekar, MD, DNB, Devinder Mohan Thappa, MD, DHA, FAMS, FIMSA, Telanseri Jayakar Jaisankar, MD, Munisamy Malathi, MD, DNB, Rajesh Nachiappa Ganesh, MD, DNB, and Nidhi Singh, MD
Department of Dermatology & STD, JIPMER, Pondicherry, India Correspondence Laxmisha Chandrashekar, MD, DNB Department of Dermatology & STD JIPMER Danvantri Nagar Post Pondicherry-06 India E-mail: [email protected]
Abstract Background Skin biopsies are an invaluable tool in the diagnostic armamentarium of a dermatologist and have several factors that determine outcome. Objectives The aim of this study was to retrospectively assess the quality of data included in the pathology request forms and reports and to assess the level of clinicopathological correlation in the reported biopsy specimens. Methods We retrospectively analyzed 3006 histopathology request forms and reports of skin, mucosal, and nail biopsies to assess the quality of data included in them and assessed the level of clinicopathological correlation in these biopsies. Two hundred discordant histopathology slides were randomly reviewed by a pathologist in the presence
Conflicts of interest: None.
of a dermatologist to analyze the causes for discordance. Results The pathological diagnosis was concordant with clinical diagnosis in 1798 (59.8%) biopsies, partially concordant in 228 (7.6%) biopsies, and discordant in 929 (30.9%) biopsies. In a clinicopathologically concordant category, the duration for reporting the biopsies was significantly shorter, and the definitive pathologist’s diagnosis was frequently mentioned. Of the 200 discordant slides reviewed randomly by a pathologist in the presence of a dermatologist, 7.5% slides afterward turned out to be consistent and 15% partially consistent with the diseases in doubt. Conclusion Several deficits were identified that need to be rectified to improve the diagnostic accuracy of skin biopsy. A portion of discordant slides showing features compatible with the disease when reviewed by a pathologist and dermatologist together emphasizes the importance of a joint review by both in doubtful cases.
Introduction An audit is a quality improvement process that seeks to improve the quality of existing healthcare facilities through a systematic review of care against explicit criteria and implementation of changes for its betterment.1 Skin biopsy remains the gold standard diagnostic procedure in dermatology, but several factors determine the outcome. The histopathology request form is the crucial link between the treating dermatologist and the pathologist. Pathologists need adequate clinical information to interpret subtle histopathological features. Similarly, the clinician needs a good histopathology report to arrive at an appropriate diagnosis;2 hence, we undertook this retrospective study to assess the quality of data included in the histopathology request forms and reports and to evaluate the level of clinicopathological correlation. In addition, we attempted to analyze the cause for discordance ª 2015 The International Society of Dermatology
by reviewing a few randomly selected discordant slides. To the best of our knowledge, this is the second study in English literature to assess the clinicopathological correlation of all categories of skin disorders and probably the first study to analyze the cause for the clinicopathological discordance in skin biopsies after reviewing the discordant slides. Material and methods A retrospective audit of histopathology request forms and their corresponding reports of skin, mucosal, and nail biopsies done over a period of three years (January 2009–December 2011) in the Department of Dermatology was undertaken after approval by the Institutional Review Board and Ethics Committee. Histopathology request forms, reports, and slides in the Pathology Department and biopsy records in the Dermatology Department were reviewed. Demographic details, information International Journal of Dermatology 2015, 54, 939–943
939
940
Tropical medicine rounds
Balasubramanian et al.
Audit of skin biopsies
provided in histopathology request forms and reports, time taken for reporting, and level of clinicopathological correlation were analyzed. Level of clinicopathological correlation was graded as concordant (pathologist’s diagnosis essentially/ substantially identical with the clinical diagnosis), minor discordance (pathologist’s diagnosis has one or more minor differences from the clinical diagnosis), and discordant (pathologist’s diagnosis substantially different from the clinical diagnosis). The data were analyzed using IBM SPSS statistics version 20 for Windows. All categorical and quantitative variables were presented as frequencies and percentages and were compared by chi-squared test for trend. All statistical analysis was carried out for two-tailed significance, and P < 0.05 was considered significant.
Results A total of 3006 histopathology request forms and their corresponding reports were reviewed. Of these, 51 reports were excluded in the analysis for clinicopathological correlation due to inadequacy of the biopsy sample. Two hundred discordant slides were randomly selected to be
reviewed by the pathologist and dermatologist to analyze the causes for discordance. Majority (2917, 97.04%) of the biopsies were performed for diagnostic purposes, and the remaining 89 (2.96%) biopsies were done for both diagnostic and therapeutic purposes. The biopsy technique was mentioned in only 15.7% of the request forms, and the most common technique used was elliptical incisional biopsy, followed by excisional and punch biopsy. The deficiencies observed in the request forms included the following: inadequate clinical history in 168 (5.6%) forms, inadequate examination findings in 406 (13.5%) forms, site of biopsy not mentioned in 506 (16.9%) forms. However, none of these deficiencies appeared to have affected the clinicopathological correlation (Table 1). The only deficiency observed in the histopathology reports was the absence of a detailed microscopic description in 872 (29%) reports. Special stains were used in 600 (20%) biopsies, immunohistochemistry was done in 31 (1.03%) biopsies, and direct immunofluorescence was done in 36 (1.2%) biopsies. The mean time taken for issuing the histopathology
Table 1 Distribution of the factors influencing clinicopathological correlation and their association with the level of clinicopathological correlation Biopsy report Factors influencing
Concordant, n (%)
Clinical history Mentioned 1690 Not mentioned 108 Examination findings Mentioned 1561 Not mentioned 237 Disease localization Mentioned 1675 Not mentioned 123 Number of differential diagnosis ≤2 1339 >2 459 Microscopic description Mentioned 1107 Not mentioned 691 Pathologist’s diagnosis Mentioned 1572 Not mentioned 226 Use of special stains/procedure Used 356 Not used 1442 Duration of reporting ≤1 week 1384 >1 week 414
Minor discordance, n (%)
Discordant, n (%)
Totala
P value
(60.5) (66.7)
219 (7.8) 9 (5.5)
884 (31.7) 45 (27.8)
2793 162
0.2565
(61.1) (59.4)
200 (7.8) 28 (7.0)
795 (31.1) 134 (33.6)
2556 399
0.5695
(61.0) (59.4)
215 (7.8) 13 (6.3)
858 (31.2) 71 (34.3)
2748 207
0.5357
(60.4) (62.3)
174 (7.8) 54 (7.3)
705 (31.8) 224 (30.4)
2218 737
0.6489
(52.9) (80.1)
198 (9.5) 30 (3.4)
787 (37.6) 142 (16.5)
2092 863
A retrospective audit of skin biopsies done in a tertiary care center in India Pradeep Balasubramanian, MD, Laxmisha Chandrashekar, MD, DNB, Devinder Mohan Thappa, MD, DHA, FAMS, FIMSA, Telanseri Jayakar Jaisankar, MD, Munisamy Malathi, MD, DNB, Rajesh Nachiappa Ganesh, MD, DNB, and Nidhi Singh, MD
Department of Dermatology & STD, JIPMER, Pondicherry, India Correspondence Laxmisha Chandrashekar, MD, DNB Department of Dermatology & STD JIPMER Danvantri Nagar Post Pondicherry-06 India E-mail: [email protected]
Abstract Background Skin biopsies are an invaluable tool in the diagnostic armamentarium of a dermatologist and have several factors that determine outcome. Objectives The aim of this study was to retrospectively assess the quality of data included in the pathology request forms and reports and to assess the level of clinicopathological correlation in the reported biopsy specimens. Methods We retrospectively analyzed 3006 histopathology request forms and reports of skin, mucosal, and nail biopsies to assess the quality of data included in them and assessed the level of clinicopathological correlation in these biopsies. Two hundred discordant histopathology slides were randomly reviewed by a pathologist in the presence
Conflicts of interest: None.
of a dermatologist to analyze the causes for discordance. Results The pathological diagnosis was concordant with clinical diagnosis in 1798 (59.8%) biopsies, partially concordant in 228 (7.6%) biopsies, and discordant in 929 (30.9%) biopsies. In a clinicopathologically concordant category, the duration for reporting the biopsies was significantly shorter, and the definitive pathologist’s diagnosis was frequently mentioned. Of the 200 discordant slides reviewed randomly by a pathologist in the presence of a dermatologist, 7.5% slides afterward turned out to be consistent and 15% partially consistent with the diseases in doubt. Conclusion Several deficits were identified that need to be rectified to improve the diagnostic accuracy of skin biopsy. A portion of discordant slides showing features compatible with the disease when reviewed by a pathologist and dermatologist together emphasizes the importance of a joint review by both in doubtful cases.
Introduction An audit is a quality improvement process that seeks to improve the quality of existing healthcare facilities through a systematic review of care against explicit criteria and implementation of changes for its betterment.1 Skin biopsy remains the gold standard diagnostic procedure in dermatology, but several factors determine the outcome. The histopathology request form is the crucial link between the treating dermatologist and the pathologist. Pathologists need adequate clinical information to interpret subtle histopathological features. Similarly, the clinician needs a good histopathology report to arrive at an appropriate diagnosis;2 hence, we undertook this retrospective study to assess the quality of data included in the histopathology request forms and reports and to evaluate the level of clinicopathological correlation. In addition, we attempted to analyze the cause for discordance ª 2015 The International Society of Dermatology
by reviewing a few randomly selected discordant slides. To the best of our knowledge, this is the second study in English literature to assess the clinicopathological correlation of all categories of skin disorders and probably the first study to analyze the cause for the clinicopathological discordance in skin biopsies after reviewing the discordant slides. Material and methods A retrospective audit of histopathology request forms and their corresponding reports of skin, mucosal, and nail biopsies done over a period of three years (January 2009–December 2011) in the Department of Dermatology was undertaken after approval by the Institutional Review Board and Ethics Committee. Histopathology request forms, reports, and slides in the Pathology Department and biopsy records in the Dermatology Department were reviewed. Demographic details, information International Journal of Dermatology 2015, 54, 939–943
939
940
Tropical medicine rounds
Balasubramanian et al.
Audit of skin biopsies
provided in histopathology request forms and reports, time taken for reporting, and level of clinicopathological correlation were analyzed. Level of clinicopathological correlation was graded as concordant (pathologist’s diagnosis essentially/ substantially identical with the clinical diagnosis), minor discordance (pathologist’s diagnosis has one or more minor differences from the clinical diagnosis), and discordant (pathologist’s diagnosis substantially different from the clinical diagnosis). The data were analyzed using IBM SPSS statistics version 20 for Windows. All categorical and quantitative variables were presented as frequencies and percentages and were compared by chi-squared test for trend. All statistical analysis was carried out for two-tailed significance, and P < 0.05 was considered significant.
Results A total of 3006 histopathology request forms and their corresponding reports were reviewed. Of these, 51 reports were excluded in the analysis for clinicopathological correlation due to inadequacy of the biopsy sample. Two hundred discordant slides were randomly selected to be
reviewed by the pathologist and dermatologist to analyze the causes for discordance. Majority (2917, 97.04%) of the biopsies were performed for diagnostic purposes, and the remaining 89 (2.96%) biopsies were done for both diagnostic and therapeutic purposes. The biopsy technique was mentioned in only 15.7% of the request forms, and the most common technique used was elliptical incisional biopsy, followed by excisional and punch biopsy. The deficiencies observed in the request forms included the following: inadequate clinical history in 168 (5.6%) forms, inadequate examination findings in 406 (13.5%) forms, site of biopsy not mentioned in 506 (16.9%) forms. However, none of these deficiencies appeared to have affected the clinicopathological correlation (Table 1). The only deficiency observed in the histopathology reports was the absence of a detailed microscopic description in 872 (29%) reports. Special stains were used in 600 (20%) biopsies, immunohistochemistry was done in 31 (1.03%) biopsies, and direct immunofluorescence was done in 36 (1.2%) biopsies. The mean time taken for issuing the histopathology
Table 1 Distribution of the factors influencing clinicopathological correlation and their association with the level of clinicopathological correlation Biopsy report Factors influencing
Concordant, n (%)
Clinical history Mentioned 1690 Not mentioned 108 Examination findings Mentioned 1561 Not mentioned 237 Disease localization Mentioned 1675 Not mentioned 123 Number of differential diagnosis ≤2 1339 >2 459 Microscopic description Mentioned 1107 Not mentioned 691 Pathologist’s diagnosis Mentioned 1572 Not mentioned 226 Use of special stains/procedure Used 356 Not used 1442 Duration of reporting ≤1 week 1384 >1 week 414
Minor discordance, n (%)
Discordant, n (%)
Totala
P value
(60.5) (66.7)
219 (7.8) 9 (5.5)
884 (31.7) 45 (27.8)
2793 162
0.2565
(61.1) (59.4)
200 (7.8) 28 (7.0)
795 (31.1) 134 (33.6)
2556 399
0.5695
(61.0) (59.4)
215 (7.8) 13 (6.3)
858 (31.2) 71 (34.3)
2748 207
0.5357
(60.4) (62.3)
174 (7.8) 54 (7.3)
705 (31.8) 224 (30.4)
2218 737
0.6489
(52.9) (80.1)
198 (9.5) 30 (3.4)
787 (37.6) 142 (16.5)
2092 863
