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Constructing Comments in a Pathology Report: Advice for the Pathology

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Article  in  Archives of Pathology & Laboratory Medicine · October 2016

DOI: 10.5858/arpa.2016-0220-ED

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 Editorial
Constructing Comments in a Pathology Report
Advice for the Pathology Resident
Stephen M. Smith, MD; Martha Yearsley, MD
I n 1992, the Association of Directors of Anatomical and
Surgical Pathology released a brief guideline laying out
the basics of the pathology report.1 The term microscopic
description referred to ‘‘a description of the cytologic features
and the architectural arrangement of the cells in a histologic
section,’’ whereas a ‘‘comment’’ referred to ‘‘all other
pertinent information.’’ The guideline went on to note that
neither a microscopic description nor a comment need be a
part of every report, but should be added ‘‘whenever the
responsible pathologist considers that they are indicated.’’
We find that in training new pathologists, and in a review of
many pathology consults to our institution, the consider-
ation of both when and what to comment in pathology
reports remains a challenge. Here, we present general
advice to guide rising pathologists in crafting optimal
pathology comments.
WHY CREATE A COMMENT?
As pathologists, our communication with clinicians is
integral to coordinating proper patient care. Given that
hundreds of cases may be seen and signed out in a given
week, the effective writing of reports is essential to
providing this communication (and avoiding one’s tele-
phone from ringing incessantly). With this goal in mind,
comments are used when a diagnosis alone does not
sufficiently convey all prudent information.
TIPS FOR WRITING COMMENTS
Comments typically include relevant information that is not a
diagnosis. Such information may include pertinent clinical
history or test results, abnormal findings altering a typical
diagnosis, previous material/diagnoses on the patient, and a
differential diagnosis, if applicable. Further studies (eg,
special stains, cytogenetics) that are pending and/or may be
signed out in an addendum should be mentioned in a
Accepted for publication May 11, 2016.
From the Department of Pathology & Laboratory Medicine,
Wexner Medical Center at The Ohio State University, Columbus,
Ohio.
The authors have no relevant financial interest in the products or
companies described in this article.
doi: 10.5858/arpa.2016-0220-ED
Reprints: Martha Yearsley, MD, Department of Pathology &
Laboratory Medicine, The Wexner Medical Center at The Ohio State
University, 450 W 10th Ave, Columbus, OH 43210 (email: Martha.
Yearsley@osumc.edu).
Arch Pathol Lab Med—Vol 140, October 2016
comment, as it alerts clinicians to look for further
information.
Many systemic illnesses (eg, systemic lupus erythemato-
sus, sarcoidosis) and syndromic cases require clinical
evaluation of the patient for a definitive diagnosis to be
made. In these cases, clinical correlation should be
recommended with a suggestion of the clinical differential.
If it’s a definitive diagnosis, don’t write it in the comment.
Definitive diagnoses are reserved for the final diagnosis line
so as to draw the attention of the clinician and avoid
confusion. In the situation where the final diagnosis is
unclear (eg, a differential diagnosis list must be included, or
a possible diagnosis may be rendered, but not all diagnostic
criteria are met), a description of relevant histologic findings
and a reference to the comment should be written, with the
comment explaining the diagnostic possibilities and/or why
a definitive diagnosis cannot be made.
Rare diagnoses are not always well-known. Comments may,
in a polite way, be used to educate clinicians on atypical or
unexpected diagnoses. As pathologists, we are often aware
of entities that may not be on the forefront of a clinician’s
mind, which may be expounded upon in the comment, with
relevant references as necessary. In general, comments
should aim to give the clinician a direction for treatment.
A comment may be used to document where a case has been
shown and who has been notified. Intradepartmental consults
and external consults/expert opinions may be documented in
the comment. As the pathology report is a medicolegal
document, accuracy must be maintained in this regard. It is
unethical to document showing a case to a colleague without
actually showing said case; similarly, if a colleague disagrees
with a diagnosis, it is unethical to document that the case was
shown without also documenting that differing opinion.
Expert opinions or extradepartmental consults are often crafted
as verbatim addenda in lieu of a comment, for medicolegal
reasons. For similar causes, when a case is intimated to a
clinician, documentation should be made in the pathology
note, per the College of American Pathologists guidelines.2
Apply caution with treatment recommendations. As surgical
pathologists typically do not see the patient whose biopsy
specimen is before them, limits must be respected in
advising treatment to clinical colleagues. ‘‘Forcing the hand’’
of the surgeon is not always welcomed and should be
tempered by offering alternatives (eg, ‘‘close monitoring of
this lesion’’ in some cases). Personal conversations with the
clinician or raising such suggestions in a general discussion
forum (ie, tumor board) serve as a better alternative to
documenting a formal recommendation in writing.
Constructing Effective Pathology Report Comments—Smith & Yearsley 1023
 Use comments to correlate previous material and to address
premicroscopic issues. An abbreviated and relevant chronology
of a complex clinical history is often useful to future colleagues
who may need to refer to the material in your possession.
Moreover, as comparing samples to previous biopsy speci-
mens is good practice, documentation of such should be noted,
with any relevant differences or similarities expounded upon.
On occasion, sampling errors, storage/preservation errors,
grossing errors, or histologic errors may complicate a
microscopic diagnosis. In these contexts, it is vital not to
unreasonably overextend one’s diagnostic capabilities. At
times, a descriptive diagnosis with a comment expounding
upon the specimen’s histologic integrity, though undesir-
able, must suffice in lieu of a definitive diagnosis.
Finally, confirmation of or disagreement with a frozen
section diagnosis is requisite in the comment. One must
exercise caution in approaching this subject for obvious
medicolegal and collegial reasons. If disagreement with a
frozen section interpretation is noted, a carefully constructed
explanation for the disagreement should be noted in the
comment in addition to a telecommunication to the clinician.
REGARDING DICTION
Simple and plain language communicates more clearly.
Verbiage for a microscopic description differs from that of a
comment in that the audience for these sections is generally
different (with the notable exceptions of medical renal,
medical liver, and nonneoplastic skin biopsies, in which the
clinician is equally—if not more so—interested in the
microscopic findings). Thus, language used to address the
clinician in a comment should be free of pathology jargon
when possible. Brevity is often best: comments should be
concise and clearly convey only that information that is
relevant to the biopsy specimen at hand.
When composing a comment, consideration must be
given as to the degree of certainty to be conveyed. The use
of conditional terms (may, might, could) exudes uncertainty.
Many pathologists, by way of a legal safeguard, use this
language to allow for alternatives to a definitive diagnosis.
However, while such language may be obligatory in some
scenarios (eg, the nonspecific findings that lead to a
differential diagnosis and a descriptive final diagnosis), it
is hardly necessary or desirable in cases where a diagnosis is
certain. To the contrary, more definitive terms (is, consistent
with, and diagnostic of) are rigid and, as a general rule, are
best reserved for cases where a diagnostic consideration is
limited to a single entity. Care should be taken when using
these terms; they should not be used interchangeably.
ON ‘‘RECOMMENDING CLINICAL CORRELATION’’
The complex circuitry of many a pathologist’s brain in the
creation of pathology reports has, in many cases, reflexively
routed diagnoses through a small subcortical box en route to
signing out the report—a box requiring the addition of a
controversial phrase: ‘‘Clinical correlation is recommended’’
(CCIR). The question of whether a pathologist should
append this 4-word phrase is one of some depth; after all, is
not the function of the pathologist to clinically correlate the
specimen for evaluation? Indeed, pathology cannot be
practiced in a vacuum, devoid of clinical information, lest
the risk of diagnostic error become unacceptably high. So
who should clinically correlate, and when?
1024 Arch Pathol Lab Med—Vol 140, October 2016
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The answer to that question is the prudent pathologist. It
is our responsibility to obtain clinical information before
addressing the microscopy before us. In cases when no
history is available, an effort should likely be made to
contact the clinician, pending the diagnosis. If the case is
routine, which likely requires no history other than the
procedure indicated (eg, a vasectomy specimen showing a
complete cross-section of vas deferens without evidence of
significant inflammation or malignancy), clinical correlation
is unlikely to be useful and the case can be signed out absent
any such comment.
Some cases, however, cannot avoid CCIR. Tissues
exhibiting pathology with a nonspecific or undetermined
etiology warrant a comment (eg, a skin biopsy exhibiting
nonspecific dermal chronic inflammation). Often, it is
preferred practice to augment the presentation of the
differential diagnosis in these cases: ‘‘Based on the clinical
and histologic findings, a diagnosis of X is favored; however,
the differential diagnosis includes. . .’’ Yet again, the prudent
pathologist takes control and clinically correlates. Is CCIR
needed in this context? Certainly not, given that the prudent
clinician will then clinically correlate any pathologic findings
presented in a report, understanding that the pathologist
cannot be definitive.
Indeed, perhaps CCIR is best reserved as a statement for
saying ‘‘I cannot interpret these histologic findings without
directly examining the patient’’ or ‘‘I do not have enough
clinical information available to interpret the histologic
findings before me.’’ Most often, this scenario arises when
limited clinical history is available and nonspecific histologic
findings are seen that would require an exceptional degree
of assumption on the part of the examining pathologist to
definitively interpret. Great caution should be taken in
making such assumptions.
CONCLUSIONS
We have presented here advice that we hope the modern
pathology resident will find useful during training. We note
that one’s standing in the scientific community is built on
the words that are printed in the literature; similarly, one’s
standing among one’s clinical colleagues is constructed by
the reports one generates. Using relevant, clear, and concise
commentary while avoiding common mistakes, unnecessary
phrases, and typographic errors (indeed, among the greatest
inventions of the 20th century was the ability to check a
printed document electronically for spelling and grammat-
ical errors) not only prevents medical errors and potential
harm to a patient, but also is well within the prudent
pathologist’s interests of generating a true and reliable
report and sustaining an esteemed reputation.
The authors wish to thank Timothy B. Light, MD, Department of
Family Medicine, Wexner Medical Center at The Ohio State
University, for his thorough presubmission review of this manu-
script.
References
1. Rosai J, Bonfiglio TA, Corson JM, et al. Standardization of the surgical
pathology report. Mod Pathol. 1992;5(2):197–199.
2. Nakhleh RE, Myers JL, Allen TC, et al. Consensus statement on effective
communication of urgent diagnoses and significant, unexpected diagnoses in
surgical pathology and cytopathology from the College of American Pathologists
and Association of Directors of Anatomic and Surgical Pathology. Arch Pathol Lab
Med. 2012;136(2):148–154.
Constructing Effective Pathology Report Comments—Smith & Yearsley