Burroughs S H, Biffin A H, Pye J K, Williams G T
Department of Pathology, University of Wales College of Medicine, Cardiff, UK.
J Clin Pathol. 1999 Jun;52(6):435-9. doi: 10.1136/jcp.52.6.435.
To audit the information content of pathology reports of oesophageal and gastric cancer resection specimens in Wales.
All such reports from the 16 NHS histopathology laboratories in Wales in a one year period were evaluated for their information content. Two standards were used: (1) best practice reporting, and (2) a minimum dataset required for informed patient management that included clear statements on histological tumour type, depth of tumour invasion, lymph node involvement, and completeness of excision.
282 reports were audited. Minimum standards were achieved in 77% of gastric resections (156/203) and 53% of oesophageal resections (42/79). All laboratories achieved minimum standards in some gastric cancer reports (range 50-100%); three laboratories did not achieve minimum standards in any oesophageal cancer reports (range 0-100%). Best practice reporting was achieved in only 20% of gastric and 18% of oesophageal cancer reports. Failure to include an explicit statement on completeness of excision or involvement of the oesophageal circumferential resection margin were the most frequent causes of inadequate reporting. Most other data items were generally well reported, but apparent inadvertent omission of just one item was noted in many of the substandard reports.
This audit shows the need to improve the information content of pathology reports in gastric and oesophageal cancer. The widespread implementation of template proforma reporting is proposed as the most effective way of achieving this. Multidisciplinary meetings of clinicians involved in cancer management should provide a forum for greater communication between pathologists and surgeons, and help to maintain standards of pathological practice.
审核威尔士地区食管癌和胃癌切除标本病理报告的信息内容。
对威尔士地区16家国民健康服务体系（NHS）组织病理学实验室在一年时间内出具的所有此类报告的信息内容进行评估。采用了两项标准：（1）最佳实践报告；（2）患者知情管理所需的最小数据集，其中包括关于组织学肿瘤类型、肿瘤浸润深度、淋巴结受累情况以及切除完整性的明确表述。
共审核了282份报告。77%的胃癌切除术（156/203）和53%的食管癌切除术（42/79）达到了最低标准。所有实验室在部分胃癌报告中达到了最低标准（范围为50%-100%）；三家实验室在任何食管癌报告中均未达到最低标准（范围为0%-100%）。仅有20%的胃癌报告和18%的食管癌报告达到了最佳实践报告标准。未明确提及切除完整性或食管环周切缘受累情况是报告不充分的最常见原因。大多数其他数据项通常报告良好，但在许多不合格报告中都发现明显无意遗漏了一项内容。
本次审核表明需要提高胃癌和食管癌病理报告的信息内容。建议广泛采用模板形式报告作为实现这一目标的最有效方法。参与癌症管理的临床医生多学科会议应为病理学家和外科医生之间加强沟通提供一个平台，并有助于维持病理实践标准。
