Int J Gynecol Pathol. 2022 Jan 1;41(1):20-27. doi: 10.1097/PGP.0000000000000761.
In the United Kingdom, endometrial biopsy reports traditionally consist of a morphologic description followed by a conclusion. Recently published consensus guidelines for reporting benign endometrial biopsies advocate the use of standardized terminology. In this project we aimed to assess the acceptability and benefits of this simplified "diagnosis only" format for reporting non-neoplastic endometrial biopsies. Two consultants reported consecutive endometrial biopsies using 1 of 3 possible formats: (i) diagnosis only, (ii) diagnosis plus an accompanying comment, and (iii) the traditional descriptive format. Service users were asked to provide feedback on this approach via an anonymized online survey. The reproducibility of this system was assessed on a set of 53 endometrial biopsies among consultants and senior histopathology trainees. Of 370 consecutive benign endometrial biopsies, 245 (66%) were reported as diagnosis only, 101 (27%) as diagnosis plus a brief comment, and 24 (7%) as diagnosis following a morphologic description. Of the 43 survey respondents (28 gynecologists, 11 pathologists, and 4 clinical nurse specialists), 40 (93%) preferred a diagnosis only, with 3 (7%) being against/uncertain about a diagnosis only report. Among 3 histopathology consultants and 4 senior trainees there was majority agreement on the reporting format in 53/53 (100%) and 52/53 (98%) biopsies. In summary, we found that reporting benign specimens within standardized, well-understood diagnostic categories is an acceptable alternative to traditional descriptive reporting, with the latter reserved for the minority of cases that do not fit into specific categories. This revised approach has the potential to improve reporting uniformity and reproducibility.
在英国，子宫内膜活检报告传统上由形态描述组成，后面跟着一个结论。最近发布的良性子宫内膜活检报告共识指南提倡使用标准化术语。在这个项目中，我们旨在评估这种简化的“仅诊断”格式用于报告非肿瘤性子宫内膜活检的可接受性和益处。两位顾问使用以下 3 种可能的格式之一报告连续的子宫内膜活检：（i）仅诊断，（ii）诊断加附带评论，和（iii）传统描述性格式。通过匿名在线调查，服务使用者对这种方法提供了反馈。在顾问和高级组织病理学学员中，对 53 个子宫内膜活检进行了该系统的重现性评估。在 370 例连续良性子宫内膜活检中，245 例（66%）仅报告为诊断，101 例（27%）为诊断加简短评论，24 例（7%）为形态描述后诊断。在 43 名调查受访者（28 名妇科医生、11 名病理学家和 4 名临床护士专家）中，40 名（93%）更喜欢仅诊断报告，3 名（7%）表示反对/不确定仅诊断报告。在 3 名组织病理学顾问和 4 名高级学员中，53/53 （100%）和 52/53 （98%）活检的报告格式达成了多数共识。总之，我们发现，在标准化、易于理解的诊断类别中报告良性标本是传统描述性报告的一种可接受的替代方法，后者仅保留用于少数不符合特定类别的病例。这种修订后的方法有可能提高报告的一致性和重现性。
