Informatics and Autopsy Pathology

Why Should Clinical Autopsies Continue to Exist?

At some point in history, medicine was integrated with pathology, more precisely, with pathological anatomy [...].

Pulmonary tumor embolism: A retrospective study over a 30-year period

Background

Pulmonary tumor embolism (PTE) is difficult to detect before death, and it is unclear whether the discrepancy between antemortem clinical and postmortem diagnosis improves with the advance of the diagnostic technologies. In this study we determined the incidence of PTE and analyzed the discrepancy between antemortem clinical and postmortem diagnosis.

Methods

We performed a retrospective autopsy study on patients with the history of malignant solid tumors from 1990 to 2020 and reviewed all the slides of the patients with PTE. We also analyzed the discrepancies between antemortem clinical and postmortem diagnosis in 1999, 2009 and 2019 by using the Goldman criteria. Goldman category major 1 refers to cases in which an autopsy diagnosis was the direct cause of death and was not recognized clinically, but if it had been recognized, it may have changed treatment or prolonged survival.

Results

We found 20 (3%) cases with PTE out of the 658 autopsy cases with solid malignancies. Out of these 20 cases, urothelial carcinoma (30%, 6/20) and invasive ductal carcinoma of the breast (4/20, 20%) were the most common primary malignancies. Seven patients with shortness of breath died within 3–17 days (average 8.4±2.2 days) after onset of the symptoms. Pulmonary embolism was clinically suspected in seven out of twenty (35%, 7/20) patients before death, but only two patients (10, 2/20) were diagnosed by imaging studies before death. The rate of Goldman category major 1 was 13.2% (10/76) in 1999, 7.3% (4/55) in 2009 and 6.9% (8/116) in 2019. Although the rate of Goldman category major 1 appeared decreasing, the difference was not statistically significant. The autopsy rate was significantly higher in 2019 (8.4%, 116/1386) than in 2009 (4.4%, 55/1240).

Conclusions

The incidence of PTE is uncommon. Despite the advances of the radiological techniques, radiological imaging studies did not detect the majority of PTEs. The discrepancy between the antemortem clinical and the postmortem diagnosis has not improved significantly over the past 30 years, emphasizing the value of autopsy.

Changes in Clinical and Legal Autopsy Rates in Korea from 2001 to 2015

BACKGROUND

The autopsy is the medical examination of a deceased person that mainly provides information on the cause and manner of death. Two types are conducted in Korea: clinical and legal, depending on its purpose. Despite this procedure's importance, autopsy rates have been decreasing worldwide. The aim of this study was to determine the nationwide autopsy rate in Korea and compare it with that in other countries.

METHODS

We collected data of autopsies performed between 2001 and 2015 by searching previously published literature on autopsy statistics and by requesting data from the relevant institutions. We calculated the autopsy rate by using mortality data from Statistics Korea; furthermore, we investigated the type of autopsy performed by institution as well as by geographical region.

RESULTS

The total autopsy rate in Korea increased from 2.16% in 2001 to 2.60% in 2015. In terms of autopsy types, however, clinical autopsy rates decreased from 0.17% in 2001 to 0.03% in 2015, while legal autopsy rates increased from 1.99% to 2.57% during the same period. Moreover, the clinical autopsy rate tended to decrease throughout the period, while the legal autopsy rate fluctuated between 2001 and 2010 but steadily increased thereafter.

CONCLUSION

The autopsy rate in Korea is lower compared to that of the advanced countries. These findings implicate the need for nationwide policy to promote both clinical and legal autopsy, which remain crucial parts of medical science and public health.

Implementation of modern tools in autopsy practice-the way towards contemporary postmortal diagnostics

Medical, legal, and socioeconomic issues have contributed to the decline of autopsy rates. Pathology-related factors, however, with changing clinical duties on the one hand and decreasing interest and lack of substantial technical developments in this field on the other, may have contributed to this condition as well. We present our experience of a restructuring project that culminated in the introduction of a modernized postmortal diagnostic (PMD) unit: Workflows of PMD procedures and space organization were restructured according to LEAN management principles method. Classical autopsy suites were transformed into postmortal operating rooms. A PMD pathologist staff was designated to perform postmortal operative diagnostics (i.e., using laparotomy and thoracotomy approaches) with the intention of gradually replacing classical autopsy procedures. Postmortal minimal invasive diagnostics (PMID) using laparoscopy and thoracoscopy were successfully implemented with the expertise of clinical colleagues. Reorganization of workflow reduced turn-around times for PMD reports from a median of 33 days to 15 days. Short-term analysis revealed that this combined effort leads to a slight increase in the number of adult postmortal examinations 1 year after the introduction of this project. A change of culture in postmortal diagnostics may contribute to a better reputation of postmortal examinations from the perspective of clinicians, the general public, and affected relatives of the deceased. It may also serve to demonstrate that the pathology community is keen not only to preserve but also to further develop this valuable tool for medical quality control and education.

Report and Recommendations of the Association of Pathology Chairs' Autopsy Working Group

Autopsy has been a foundation of pathology training for many years, but hospital autopsy rates are notoriously low. At the 2014 meeting of the Association of Pathology Chairs, some pathologists suggested removing autopsy from the training curriculum of pathology residents to provide additional months for training in newer disciplines, such as molecular genetics and informatics. At the same time, the American Board of Pathology received complaints that newly hired pathologists recently certified in anatomic pathology are unable to perform an autopsy when called upon to do so. In response to a call to abolish autopsy from pathology training on the one hand and for more rigorous autopsy training on the other, the Association of Pathology Chairs formed the Autopsy Working Group to examine the role of autopsy in pathology residency training. After 2 years of research and deliberation, the Autopsy Working Group recommends the following:Autopsy should remain a component of anatomic pathology training.A training program must have an autopsy service director with defined responsibilities, including accountability to the program director to record every autopsy performed by every resident.Specific entrustable activities should be defined that a resident must master in order to be deemed competent in autopsy practice, as well as criteria for gaining the trust to perform the tasks without direct supervision.Technical standardization of autopsy performance and reporting must be improved.The current minimum number of 50 autopsies should not be reduced until the changes recommended above have been implemented.