'To use words wrongly and indefinitely is not merely an error in itself: it also creates an evil in the soul.'
Socrates.
Contents
Introduction
On first consideration the act of describing a histopathology specimen should seem to be a simple task: merely say what you see in front of you. However, when first confronted with a specimen the need to describe the specimen using technical terms, deployed in formal language while ensuring that all essential observations are made, can add a surprising level of complexity to the task. This can be compounded by the fact that although spoken language is being used the action is actually one of dictating words that are intended to be read.
A person's use of spoken and written language can differ considerably. The latter tends to be more formal and grammatically orthodox. Being able to speak in a way that will read well when seen in print is not a skill that many people will have practised before starting their training in specimen dissection and it can be interesting to discover that what sounded perfectly reasonable when heard does not come across well when read.
As with various aspects of specimen dissection practice is the key, coupled with feedback on the product of the activity but there are some general observations that may help.
Polonius's Advice
This above all to thine own self be true
Polonius to Laertes, Hamlet Act One Scene Three by William Shakespeare
In the same speech, Polonius also cautions his son 'neither a borrower nor a lender be' so Shakespeare was in good form with sagaciuous life advice at this point. To thine own self be true applies to histopathology descriptions, be they of macroscopy or microscopy. Different people have different styles and different ways of doing things. Requirements of precision and the inclusion of essential data will impact on the content of those descriptions but ultimately each pathologist will need to find a style which is natural to them.
Over the course of training this may involve encountering approaches that the trainee likes and incorporates into his or her style but also meeting techniques that do not fit well and deciding to eschew those in their own future practice.
Adopting somebody else's style wholesale can be unnatural and contrived but perhaps worse is for the trainer to impose on the trainee a style that is merely one of many valid alternatives as if that style was a sole, fundamental truth.
Grammatically Correct Language
Years ago histopathology reports had to be created on a manual typewriter and synchronous copies made using carbon paper. Even for a skilled typist this was a fraught process because error correction required manual erasure of the mistake (on the top copy and the underlying carbon copies) then realigning the typewriter to retype over the erased region. That laborious task was if the typist was lucky. Some errors might require the entire page to be retyped from the beginning.
Faced with such a Herculean endeavour it perhaps inevitable that histopathology reports tended to brevity and the use of short sentence fragments. The fewer characters that were employed the less was the chance for typographical errors.
For example a macroscopic description might have read 'Skin ellipse 25x15x4mm. Lesion 5mm. AE(2).'
The full version could be
'The specimen comprises an unorientated ellipse of skin that measures 25x15mm to a depth of 4mm. On the surface of the ellipse is a flat pigmented lesion that measures 5mm and is 6mm from the peripheral margin and 4mm from the closer tip. Serially sliced and all embedded.
'A1) Tips
'A2) Centre'
Modern word processors and the use of quickcodes that allow chunks of text to be generated by only a few keystrokes facilitate reports which employ complete sentences. Back in the days of manual typing the effort needed to produce such reports may have been prohibitive. Hence, sentence fragment reporting arose and the method was passed on and inherited by younger generations.
Do not underestimate the depth of opinion that can exist regarding how macroscopic reports should be constructed. Advocates of the brief, sentence fragment approach are common but it is crucial to remember that given the advantages in typing afforded by modern technology it is difficult to support an argument that criticises descriptions which use complete, grammatically correct sentences. Any word which is essential to make the sentence grammatically correct should not be classed as 'unnecessary' or 'verbose'.
Nevertheless, the sentence fragment approach, especially for the opening gambit of a description, is common and the reader may find it fits their own natural style.
Measurements
Specimens in histopathology require measurement to give an indication of their size.
Length
The default base unit that is employed is length. The units employed to measure length in histopathology macroscopic descriptions are typically millimetres. Using millimetres avoids errors that can occur with misplaced or omitted decimal points if centimetres of metres are adopted. It is easy to dictate 'point five centimetres' but if this is typed as .5cm it simple for the decimal point to be overlooked (if typed in the first place).
Histopathology specimens are three dimensional objects and should have their size measured in three perpendicular planes. Ellipses of skin that measure 30x25mm to a depth of 15mm and 30x10mm to a depth of 3mm are two quite different specimens but if each is described only as 'an ellipse of skin that measures up to 30mm' this distinction will be lost.
Most lesions that are found in three dimensional specimens also should be measured in three dimensions (preferably parallel to those of the host specimen). The main exception is a flat abnormality that is seen on the surface of a skin specimen.
Having measured the lesion its distance from the nearest margin(s) should be stated if the specimen is intended as an excision. For some specimens there may be only one relevant margin while others may have several.
Weight
Despite length being the first choice parameter to record the size of the specimen it is not the only possibility. The weight of the specimen is an often overlooked alternative.
The weight is most useful for small specimens that are composed of multiple small pieces, such as prostate chippings. Such a collection of multiple pieces can be aggregated into a variety of forms each of which would have different dimensions. While descriptions along the lines of '... a collection of pieces of tissue which together measure x*y*z mm' are prudent it is sensible to add the weight. The weight of the specimen is constant and cannot be deformed in the way that length can.
The weight is also mandatory for specimens such as parathyroid glands, breast wide local excisions and breast reductions.
In general, consider stating the weight as well as the linear measurements either for specimens which are composed of lots of smaller pieces or for specimens which have an irregular shape that could generate quite different sets of measurements depending on which three planes were chosen.
A before and after opening weight may also be helpful for cystic specimens. The difference in the weight indicates the portion of the specimen that was contributed by the cyst contents.
Specimens sent because of haemorrhage, for example as placental abruptions and ruptured spleens, should also be weighed in order to gauge the volume of blood lost. On occasion this can involve weighing just blood clot itself. This data can have important medicolegal implications.
Words
Histopathology is a scientific discipline and as such is rich in terminology. While it might be an interesting philosophical debate to consider whether there is any real difference between the phrases 'a knobbly grey wodge' and 'a bosselated nodular piece of grey tissue' it is the latter that would be expected to be seen in a macroscopic description.
Allowing for the embracement of terminology, the words used to describe the specimen should convey pertinent information about the specimen and any abnormalities it contains. The diagnostic information that can be obtained from the macroscopic description is easily overlooked but in some instances may be integral to the final diagnosis that is made.
A detailed enumeration of the various terms that can be used will not be attempted here but in general the following aspects of a specimen / abnormality should be borne in mind when describing it.
- Size
- Shape
- Contour
- Colour
- Regular or irregular
- Homogenous or heterogenous
- Effect on the host organ (for example stricturing of the lumen)
Also bear in mind that many specimens have an outer surface, a middle and an inner surface or hilum.
Templates
Datasets and template reports abound in histopathology and threaten to turn histopathologists into uniform clones. Such transformation into a
Stepford Pathologist should be resisted but the utility of templates should not be dimissed in the same act.
After various rounds of practice in specimen dissection each pathologist is likely to find themselves settling on a form of words that they use for a given sort of specimen. This template exists in the mind of the individual and is in effect a program that they execute when confronted with a particular type of specimen. In other words: this is an orientated skin ellipse therefore I do this. A skeleton report exists in the pathologist's memory and the process of cutting up the specimen allows them to fill in the variables in that report. For example.
The specimen comprises an (insert orientated or unorientated) ellipse of skin that measures length*width mm to a depth of depth mm. On the surface of the ellipse is a insert description of the lesion here that measures length*width if not flat add by a height of measurement mm. The lesion is measurement mm from the peripheral margin and insert measurement mm from the nearer pole. Serially sliced and all embedded.
A1) Tips
A2-Amax) Centre
The process is akin to executing a learned motor skill such as juggling or riding a bicycle. The core of the activity is discharged automatically leaving the pathologist free to focus on the nuances of the case rather than having to divert concentration on what to do next.