The American Journal of Surgical Pathology最新文献

{"title":"Hemangioblastoma-like Clear Cell Stromal Tumor of the Lung: A Clinicopathologic and Immunohistochemical Study of 5 Cases.","authors":"Kaleigh E Lindholm,&nbsp;Cesar A Moran","doi":"10.1097/PAS.0000000000001429","DOIUrl":"https://doi.org/10.1097/PAS.0000000000001429","url":null,"abstract":"<p><p>Five cases of an unusual primary benign stromal tumor designated as hemangioblastoma-like clear cell stromal tumor of the lung are presented. The patients are 4 women and 1 man between the ages of 39 and 52 years of age (average: 45.5 y). The patients presented with nonspecific symptoms of cough, chest pain, or dyspnea. None of the patients had any prior history of malignancy or tumor elsewhere. Diagnostic imaging showed the presence of an intrapulmonary tumor. Lobectomy was performed in all 5 patients. Grossly, the tumors were well-demarcated but not encapsulated with focal areas of hemorrhage without necrosis. Histologically, low power examination showed a cellular proliferation alternating with discrete dilated vessels reminiscent of a vascular neoplasm. Higher magnification showed medium-sized cells with clear cytoplasm arranged in sheets and cords. Mitotic activity and marked cellular atypia were not present. A wide panel of immunohistochemical studies was performed including epithelial, neural, muscle, vascular, and neuroendocrine markers, all of which showed negative staining. Tumor cells showed positive staining for vimentin. In 2 cases, fluorescence in situ hybridization for the solitary fibrous tumor was performed and was negative. Clinical follow-up in 3 patients showed no evidence of recurrence. The cases herein presented highlight an unusual benign stromal tumor of the lung, which needs to be considered in the differential diagnosis of tumors with a clear cell and vascular appearance.</p>","PeriodicalId":275221,"journal":{"name":"The American Journal of Surgical Pathology","volume":" ","pages":"771-775"},"PeriodicalIF":5.6,"publicationDate":"2020-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/PAS.0000000000001429","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"37522190","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Head and Neck Mesenchymal Neoplasms With GLI1 Gene Alterations: A Pathologic Entity With Distinct Histologic Features and Potential for Distant Metastasis.","authors":"Bin Xu,&nbsp;Koping Chang,&nbsp;Andrew L Folpe,&nbsp;Yu-Chien Kao,&nbsp;Shiuan-Li Wey,&nbsp;Hsuan-Ying Huang,&nbsp;Anthony J Gill,&nbsp;Lisa Rooper,&nbsp;Justin A Bishop,&nbsp;Brendan C Dickson,&nbsp;Jen-Chieh Lee,&nbsp;Cristina R Antonescu","doi":"10.1097/PAS.0000000000001439","DOIUrl":"https://doi.org/10.1097/PAS.0000000000001439","url":null,"abstract":"<p><p>Soft tissue tumors with GLI1 gene fusions or amplifications have been recently described as a unique pathologic entity with an established risk of malignancy. We herein expand these findings by investigating a cohort of 11 head and neck lesions with GLI1 alterations, including 8 from the tongue, for their clinicopathologic and molecular features. The tumors commonly affected males in their 30s (male:female ratio 2.7:1; range: 1 to 65). Tumors showed a multinodular growth pattern, nested architecture separated by a delicate, arborizing vascular network, monotonous round to ovoid nuclei, and clear cytoplasm. Tumor protrusion into vascular spaces was common. Genetic alterations were investigated by fluorescence in situ hybridization and/or targeted RNA sequencing. Seven tumors harbored GLI1 fusions with the following partners: ACTB (n=4), PTCH1 (n=2), or MALAT1 (n=1). The remaining 4 cases showed coamplifications of GLI1 with CDK4 and MDM2 genes. Tumors were commonly positive for S100 protein and CD56. CDK4, MDM2, and STAT6 were positive in GLI1-amplified tumors. Two of 6 patients with available follow-up (1 each with GLI1 amplification and PTCH1-GLI1 fusion) developed distant metastases. Both tumors showed a high mitotic index and tumor necrosis. The head and neck region, particularly tongue, is a common location for GLI1-related mesenchymal tumors. Although a morphologic overlap was noted with the previously reported \"pericytoma with t(7,12) translocation,\" often occurring in the tongue, our findings expand the original findings, to include a more variable immunophenotype, propensity for late distant metastases, and alternative mechanisms of GLI1 oncogenic activation, such as various GLI1 fusion partners or GLI1 coamplifications with MDM2 and CDK4 genes.</p>","PeriodicalId":275221,"journal":{"name":"The American Journal of Surgical Pathology","volume":" ","pages":"729-737"},"PeriodicalIF":5.6,"publicationDate":"2020-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/PAS.0000000000001439","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"37540976","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Characterization of Novel Injectable Lifting Agents Used in Colonic Polyp Removal: An Emerging Amyloid Mimic.","authors":"Maryam K Pezhouh,&nbsp;Lawrence J Burgart,&nbsp;Kenrry Chiu,&nbsp;David A Cohen,&nbsp;Danielle A Hutchings,&nbsp;Schuyler O Sanderson,&nbsp;Maryam Shirazi,&nbsp;Peter P Stanich,&nbsp;Christopher J VandenBussche,&nbsp;Lysandra Voltaggio,&nbsp;Ellen D Willhoit,&nbsp;Yue Xue,&nbsp;Christina A Arnold","doi":"10.1097/PAS.0000000000001435","DOIUrl":"https://doi.org/10.1097/PAS.0000000000001435","url":null,"abstract":"<p><p>Colon polypectomy can require an injection of a submucosal lifting agent to fully visualize and completely remove the polyp. To the best of our knowledge, this is the largest morphologic series on the novel lifting agents Eleview and Orise. The study consisted of 1 polypectomy and 8 colon resections from 9 patients: 6 women, 3 men (mean age=64 y); Orise=6, Eleview=3; the median time interval between injection and resection=16 weeks. Pathologic diagnoses of the polyps included tubular adenoma (n=4), tubulovillous adenoma (n=4), and sessile serrated adenoma/polyp (n=1). We report that a histologically processed Orise aliquot from the manufacturer showed similar histology to that seen in the specimens from patients with confirmed Orise injection. The morphology of the agents in the patient specimens changed with time status postinjection: immediate resection of the lifting agent showed basophilic, amorphous, and bubbly-extracellular material with prominent hemorrhage, and resection ∼3 months after lifting agent injection showed prominent hyalinized, pink-amorphous ribbons and globules with a foreign body giant cell reaction and fibrosis. The epicenter of the lifting agents was in the submucosa, and the agents were neither refractile nor polarizable. Because of the morphologic overlap with amyloid, 5 cases were stained with Congo Red, and all cases were negative. In conclusion, awareness of the morphology of these new lifting agents is important for accurate diagnosis and to avoid the diagnostic pitfall of amyloid. These lesions can be definitively distinguished from amyloid by their nonreactivity on a Congo Red and familiarity with their characteristic clinicopathologic presentation.</p>","PeriodicalId":275221,"journal":{"name":"The American Journal of Surgical Pathology","volume":" ","pages":"793-798"},"PeriodicalIF":5.6,"publicationDate":"2020-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/PAS.0000000000001435","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"37540979","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Brown Bowel Syndrome: A Multi-institutional Case Series.","authors":"Christina A Arnold,&nbsp;Allen P Burke,&nbsp;Edward Calomeni,&nbsp;Romana C Mayer,&nbsp;Arvind Rishi,&nbsp;Aatur D Singhi,&nbsp;Kristen Stashek,&nbsp;Lysandra Voltaggio,&nbsp;Rashmi Tondon","doi":"10.1097/PAS.0000000000001443","DOIUrl":"https://doi.org/10.1097/PAS.0000000000001443","url":null,"abstract":"<p><p>Brown bowel syndrome (BBS) is a rare condition associated with vitamin E deficiency and defined by prominent lipofuscin deposition in the muscularis propria. Eight unique cases of BBS were identified: 5 men and 3 women (mean age=58.6 y). Pertinent comorbidities included bariatric surgery=2, malnourishment=2, Crohn=2, cystic fibrosis=1, alcohol and cocaine abuse=1, and prior small bowel resections=1. Presenting symptoms included abdominal pain=3, bleeding=1, nausea and vomiting=1, and nonresponsiveness=1. Imaging studies were often abnormal: thickened bowel wall=3 (1 with a mass), small bowel obstruction=2, and edematous and dilated bowel wall=2. Most specimens were surgical resections (n=7, autopsy=1): extended right colectomy=2, small bowel only=5 (terminal ileum=3, jejunum=2). Two specimens were grossly described as mahogany, and 1 case contained a perforation. Histologic sections of all cases showed finely granular, brown cytoplasmic pigment in smooth muscle cells on hematoxylin and eosin. This pigment was most conspicuous in the muscularis propria (small bowel>colon), and it was not identified in the mucosa. The pigment was reactive with Fontana-Masson, carbol lipofuscin, Periodic acid-Schiff, and Periodic acid-Schiff with diastase, and electron microscopy was compatible with lipofuscin. The mean clinical follow-up was 208 weeks: 1 patient died of complications of encephalitis, the others were alive and well. BBS is important to recognize because it is linked with malnutrition, specifically vitamin E deficiency, and it can (rarely) clinically simulate malignancy. The diagnosis is based on the identification of the lipofuscin pigment in the cytoplasm of smooth muscle cells, which is most easily seen in the muscularis propria of the small bowel.</p>","PeriodicalId":275221,"journal":{"name":"The American Journal of Surgical Pathology","volume":" ","pages":"834-837"},"PeriodicalIF":5.6,"publicationDate":"2020-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/PAS.0000000000001443","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"37582445","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Prognostic Value of Myogenic Differentiation in Dedifferentiated Liposarcoma.","authors":"Pawel Kurzawa,&nbsp;John T Mullen,&nbsp;Yen-Lin Chen,&nbsp;Sarah E Johnstone,&nbsp;Vikram Deshpande,&nbsp;Ivan Chebib,&nbsp;G P Nielsen","doi":"10.1097/PAS.0000000000001436","DOIUrl":"https://doi.org/10.1097/PAS.0000000000001436","url":null,"abstract":"<p><p>Myogenic differentiation (MD) has been claimed to be a poor prognostic factor in dedifferentiated liposarcoma (DDLPS). To validate this, the prognostic significance of MD in a uniformly treated cohort of DDLPS was assessed. A cohort of patients that have been uniformly treated at one institution for DDLPS of the retroperitoneum and pelvis were stained with smooth muscle actin (SMA) and desmin and semiquantitatively scored for staining focality and strength. Clinical and survival data was collected, and the prognostic significance of MD was evaluated. A total of 50 patients with uniformly treated DDLPS were evaluated. SMA (P=0.052) and a combined score of MD (SMA+desmin) showed a statistically significant decrease in 5-year disease-free survival (P=0.002) in univariate analysis and in multivariate testing combined MD trended toward significance (P=0.052). Combined MD was associated with a decreased OS in multivariate analysis (P=0.004). In a uniformly treated cohort of DDLPS stained for myogenic markers, a combined myogenic score was associated with poor overall survival in multivariate analysis. However, the difference in groups was slight and the clinical application is limited.</p>","PeriodicalId":275221,"journal":{"name":"The American Journal of Surgical Pathology","volume":" ","pages":"799-804"},"PeriodicalIF":5.6,"publicationDate":"2020-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/PAS.0000000000001436","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"37582446","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Prevalence of Partial Hydatidiform Mole in Products of Conception From Gestations With Fetal Triploidy Merits Reflex Genotype Testing Independent of the Morphologic Appearance of the Chorionic Villi.","authors":"Lucy M Han,&nbsp;James P Grenert,&nbsp;Arun P Wiita,&nbsp;Molly Quinn,&nbsp;Victor Y Fujimoto,&nbsp;Joseph T Rabban","doi":"10.1097/PAS.0000000000001466","DOIUrl":"https://doi.org/10.1097/PAS.0000000000001466","url":null,"abstract":"&lt;p&gt;&lt;p&gt;Diagnosis of first-trimester partial mole is challenging as the key morphologic features may not be well-developed and may overlap with those of a nonmolar gestation harboring a cytogenetic disorder or degenerative changes. Genotype testing has emerged as the reference tool to distinguish partial mole (diandric triploid genotype) from its nonmolar mimics. However, observer variation in defining the minimum threshold of how much morphologic alteration is required to trigger genotype testing may result in a subset of partial moles that go undetected. We hypothesized that the results of fetal aneuploidy testing performed for prenatal screening or evaluation of miscarriage may assist with triggering molecular testing in the evaluation of products of conception, specifically if fetal triploidy is detected. Gestations with fetal triploidy are either a partial mole (diandric triploidy) or are nonmolar (digynic triploidy). The aims of this study were to define the prevalence of partial mole in 20 products of conception specimens with known fetal triploidy by performing genotype testing and then to determine how well established morphologic criteria for partial mole correlate with the genotype results in this setting. Genotype testing demonstrated that 65% (13/20) were a partial mole and the remainder were nonmolar digynic triploid gestations. Most partial moles were under 9 weeks gestational age and, as expected, lacked classic well-developed morphologic features. Nearly a third (4/13) of the partial moles were originally interpreted as normal or nonmolar gestations with minimal abnormalities that did not merit molecular testing to exclude a partial mole. Even with the retrospective systematic morphologic review, only 23% (3/13) exhibited the combination of chorionic villous enlargement of ≥2.5 mm and cisterns, which has been previously established as the morphologic criteria with the highest predictive value for a molecularly defined partial mole. The other 77% exhibited focal, limited, variable degrees and extent of villous morphologic alterations. We conclude that, given the high prevalence of partial mole among products of conception with known fetal triploidy and the low prevalence of diagnostic morphologic findings in such specimens, reflex genotype testing should be performed in all such cases, regardless of whether or not the morphologic features are suspicious for a partial mole. This reflex testing strategy mitigates against the subjectivity of determining whether subtle villous abnormalities are significant enough to merit pursuing genotype testing. The success of this strategy depends on the clinician documenting the fetal triploidy result at the time of submitting the products of conception specimen and therefore clinician education is needed. Finally, it remains to be determined whether the risk for postmolar gestational trophoblastic disease is the same in diandric triploid gestations that exhibit classic morphologic features as in t","PeriodicalId":275221,"journal":{"name":"The American Journal of Surgical Pathology","volume":" ","pages":"849-858"},"PeriodicalIF":5.6,"publicationDate":"2020-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/PAS.0000000000001466","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"37765117","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical, Histologic, and Molecular Characteristics of Anaplastic Lymphoma Kinase-positive Primary Cutaneous Anaplastic Large Cell Lymphoma.","authors":"Rutger C Melchers,&nbsp;Rein Willemze,&nbsp;Merel van de Loo,&nbsp;Remco van Doorn,&nbsp;Patty M Jansen,&nbsp;Arjen H G Cleven,&nbsp;Nienke Solleveld,&nbsp;Marcel W Bekkenk,&nbsp;Marloes S van Kester,&nbsp;Gillis F H Diercks,&nbsp;Maarten H Vermeer,&nbsp;Koen D Quint","doi":"10.1097/PAS.0000000000001449","DOIUrl":"https://doi.org/10.1097/PAS.0000000000001449","url":null,"abstract":"<p><p>Unlike systemic anaplastic large cell lymphoma, the vast majority of primary cutaneous anaplastic large cell lymphomas (C-ALCL) do not carry translocations involving the ALK gene and do not express ALK. Expression of ALK protein therefore strongly suggests secondary cutaneous involvement of a systemic anaplastic large cell lymphoma. Recent studies described a small subgroup of ALK-positive C-ALCL, but information on frequency, prognosis, and translocation partners is virtually lacking. A total of 6/309 (2%) C-ALCL patients included in the Dutch registry for cutaneous lymphomas between 1993 and 2019 showed immunohistochemical ALK expression. Clinical and histopathologic characteristics, immunophenotype and disease course were evaluated. Underlying ALK translocations were analyzed with anchored multiplex polymerase chain reaction-based targeted next-generation sequencing. Median age at diagnosis was 39 years (range: 16 to 53 y). All patients presented with a solitary lesion. Treatment with radiotherapy (n=5) or anthracycline-based chemotherapy (n=1) resulted in complete responses in all 6 patients. Three patients developed a relapse, of whom 2 extracutaneous. After a median follow-up of 41 months, 5 patients were alive without disease and 1 patient died of lymphoma. Immunohistochemically, 3 cases (50%) showed combined nuclear and cytoplasmic ALK expression with underlying NPM1-ALK fusions, while 3 cases (50%) showed solely cytoplasmic ALK expression with variant ALK fusion partners (TRAF1, ATIC, TPM3). ALK-positive C-ALCL is extremely uncommon, has a comparable favorable prognosis to ALK-negative C-ALCL, and should be treated in the same way with radiotherapy as first-line treatment.</p>","PeriodicalId":275221,"journal":{"name":"The American Journal of Surgical Pathology","volume":" ","pages":"776-781"},"PeriodicalIF":5.6,"publicationDate":"2020-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/PAS.0000000000001449","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"37939095","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Lung Transplantation for Bronchopulmonary Dysplasia in Adults: A Clinical and Pathologic Study of 3 Cases.","authors":"Natalia Liu,&nbsp;Oscar W Cummings,&nbsp;Amir Lagstein,&nbsp;Chadi A Hage,&nbsp;Kevin M Chan,&nbsp;Chen Zhang","doi":"10.1097/PAS.0000000000001438","DOIUrl":"https://doi.org/10.1097/PAS.0000000000001438","url":null,"abstract":"<p><p>Bronchopulmonary dysplasia (BPD) is usually seen in premature infants who require mechanical ventilation and oxygen therapy for acute respiratory distress. Although most patients wean from oxygen therapy by the ages of 2 to 3, rehospitalization for respiratory problems is common in these patients in adulthood. There have been few studies that document the long-term outcomes of BPD survivors and information about the pulmonary function and radiographic findings of adult BPD are limited. Data on pathologic features of adult BPD are scarce. Three adult patients who underwent recent lung transplantation for BPD from 2 institutions were identified. Clinical data including clinical presentation, chest radiographic images, pulmonary function tests, cardiac catheterization, and echocardiography were retrieved from the electronic medical records. Hematoxylin and eosin and selective elastic stained sections of the explant lungs were examined. CD31 immunohistochemical stain is performed on representative sections. All 3 cases had similar clinical and radiologic features including the history of prematurity and long-term mechanical ventilation after birth, hyperexpanded lungs with air trapping and mosaic attenuation on chest computed tomographic scan, severe obstructive changes on pulmonary function test, and pulmonary hypertension. Pathologic examination showed common features including enlarged and simplified alveoli, peribronchial, subpleural, and interlobular septal fibrosis, narrowing/obliteration of the small airways by elastosis and muscular hypertrophy, thickening of venous walls by fibromuscular hyperplasia, and bronchitis/bronchiolitis. Cholesterol granulomas were seen in 2 cases. The common pathologic findings in the lungs explain the clinical and radiologic findings. Future studies are warranted to further characterize the clinical and pathologic features of adult BPD to develop optimal management strategies for these patients.</p>","PeriodicalId":275221,"journal":{"name":"The American Journal of Surgical Pathology","volume":" ","pages":"509-515"},"PeriodicalIF":5.6,"publicationDate":"2020-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/PAS.0000000000001438","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"37540978","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Uterine Cervical Sarcoma With a Novel RET-SPECC1L Fusion in an Adult: A Case Which Expands the Homology Between RET-rearranged and NTRK-rearranged Tumors.","authors":"Paul S Weisman,&nbsp;Morgan Altinok,&nbsp;Erica V Carballo,&nbsp;David M Kushner,&nbsp;Jessica J F Kram,&nbsp;Marc Ladanyi,&nbsp;Sarah Chiang,&nbsp;Darya Buehler,&nbsp;Elizabeth L Dickson Michelson","doi":"10.1097/PAS.0000000000001437","DOIUrl":"https://doi.org/10.1097/PAS.0000000000001437","url":null,"abstract":"","PeriodicalId":275221,"journal":{"name":"The American Journal of Surgical Pathology","volume":" ","pages":"567-570"},"PeriodicalIF":5.6,"publicationDate":"2020-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/PAS.0000000000001437","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"37526416","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Current Procedural Terminology Coding in an Academic Breast Pathology Service.","authors":"Emily S Reisenbichler,&nbsp;Andrea L Barbieri,&nbsp;Vinita Parkash","doi":"10.1097/PAS.0000000000001424","DOIUrl":"https://doi.org/10.1097/PAS.0000000000001424","url":null,"abstract":"To the Editor: We read with interest the article by Johnson et al1 positing that breast pathologists reviewed more slides than other subspecialty services and that therefore the valuation for breast pathology services needs to be increased. Although there is a sound basis for increasing the valuation of work on the breast service, and in pathology as a whole, the discussion the authors present is incomplete as it does not acknowledge the primary premise for subspecialization. The benefit of subspecialization is based on the concept of “gains in trade.” When 2 individuals perform different work, the greatest total work output is achieved by dividing work based on expertise. Using the equity of work as the primary principle for dividing work in large departments with subspecialty competencies imposes extremely high opportunity costs on both individuals and reduces the total productivity of the group. As an example (Table 1), assume that a breast pathologist can sign out 6 breast (B) cases in a day, but only 4 gastrointestinal (GI) cases; whereas the GI pathologist can sign out 10 GI cases in a day, but only 2 B cases. As Table 1 shows, dividing work based on subspecialty results in total productivity of 6 B+10 GI cases per day, while the equitable distribution of work results in a productivity of 4 B and 7 GI for the BGI group. This model, however, requires that each unit recognize the advantage to the whole and “share” in a mutually beneficial manner in the profits of this trade. This model provides no benefits in a system where each can do both jobs equally well. Equity in work is the better model in that circumstance (hence, the favored model for smaller, community practice setups). There are other downsides to the generalist model that are not pertinent to this discussion and are not presented here. Therefore, a primary characteristic of the subspecialization model is “different strokes for different folks.” Irrespective of the system of valuation of work, work will not divide equitably in this model. The only impact will be who is advantaged over the other. Therefore, a system that applies valuation based on a RVU model will favor the case-heavy specialties; while applying SVU (slide valuation unit) models will favor slideheavy specialties. Applying a valuation at an individual level to “equity” in work in a subspecialty-based model will simply result in one of the subspecialties feeling undervalued. Those disadvantaged by the SVU system, such as GI, may well argue that processing breast cases require more resources, that the higher valuation for hormone receptor studies relative to other immunohistochemical stains is unfair, and that high complexity GI frozen sections have workflow interruption costs that the SVU models do not consider. The most unsettling response could be from the Centers for Medicare and Medicaid Services (CMS), which has the herculean task of distributing finite dollars in a stressed health care environment. The result ma","PeriodicalId":275221,"journal":{"name":"The American Journal of Surgical Pathology","volume":" ","pages":"566"},"PeriodicalIF":5.6,"publicationDate":"2020-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1097/PAS.0000000000001424","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"37490914","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}