How important is histopathology in diagnosing an obvious gross pathological finding that was discovered during autopsy examination? Is it really necessary to always provide support of histopathology reports for diagnosing any pathology which can be opined on gross examination?
I cannot speak about autopsies, but at least when it is related to my field of work, oral pathology. Obviously the gross examination is very important, but even lesions that mimic completely benign inflamatory lesions can sometimes represent malignant lesions (a metastasis, for instance) microscopically, so ultimately the histopathology report is mandatory.
Usually you know what you are looking at grossly. Sometimes, you are surprised. As one of my colleagues always says, "that's why they make microscopes". If it's abnormal, I make a histologic slides of it.
It depends on the role of the autopsy that is being undertaken - is it merely to determine cause of death in a forensic setting, or to determine all relevant pathologies present?
As a pathologist, I am in the latter cohort, believing our duty of care extends to provide the family and referring clinician the most complete answer (within the limitations of the consent).
Complete autopsy examination entails assessing clinical, radiology, macroscopic and microscopic aspects, looking for primary (dominant) pathologies, determining how they relate to the terminal event, seeking underlying contributing factors to that pathology, and correlating with the observed clinical aspects. We also should be assessing concomitant unrelated pathology that may have caused later detriment to the patient.
In the case of tumour pathology, a macroscopic is rarely sufficient, and now in the era of genetics, paraffinized tissue may be useful for DNA archiving (within the limitation of autolysis). Other pathologies may give confusing macroscopic appearances (tumour mimics such as intestinal TB, perforated gastric ulcers, pulmonary fungal infections). Admittedly many pathologies, particularly cardiovascular ones, provide little further information histologically, and assessment is largely for excluding contributing factors (eg arteritis).
I remember being taught the addage "if you don't look, you will not find".
Autopsies that specifically target occult pathology (slicing the fixed thyroid and prostate) have quite high pick-up rates, though such examinations need to be age-appropriate. These "incidentals" may have relevance to family screening.
There is a significant diagnostic miss-rate for macroscopic-only autopsies, though this was often the result of them being performed by non-pathologists.
If resources are limited, histology should be targetted to the dominant pathology and determining possible contributing factors, but I would always be inclined to take some histology.
Like taking high-quality macroscopic photographs, histology sections provide documentation (that is reviewable), and in a forensic setting provides the higher level of proof that sometimes may be required.
Yes, It is absolutely important for any complete autopsy-more especially medico-legal cases though hospital autopsy same is applicable to be done. It helps to really ascertain the expert view about some lesions grossly. It is true over time the expert might feel some lesion could be made in the table but it pays him/her better to still subject such specimen/tissue to histopathology analysis for a true result. This is the yard stick of forensic and anatomical pathologist diagnosis in most cases.
Histopathology is the "gold standard" for the vast majority of diagnoses, because most of the diseases can be or are defined by miocroscopic features.
Therefore many diagnoses cannot be made with security without histopathology.
Even very experienced pathologists are often surprised, when comparing the macroscopic diagnosis with the histopathologic slides. An autopsy without histopathology is not following scientific standards and must in many cases be regarded as rather worthless or even misleading !
Prof Dr Konrtadin Metze, Department of Pathology, University of Campinas
gross examination usually give us very good information in reaching the diagnosis, as for example if the tumor has infiltrative margin or well circumscribed , in addition the size of tumor specially for soft tissue tumor has great significance
Both are complementary (gross morphology & histopathology), gross morphology provides about 50% of the diagnosis, this should be confirmed by histopatholgy. At the same time if you have a slide for microscopical evaluation you may ask for the gross morphology (size and shape of the lesion, colour, cut section findings, borders, abnormal material...etc). I agree with Prof Dr Konrtadin Metze that (An autopsy without histopathology is not following scientific standards).
The necessity of histopathological diagnosis of gross lesions depends on various factors. There are many diseases diagnosis of which do not require histopathology. Gross examination can be almost 90% confirmatory I.e. most of the skin diseases. Gross examination can direct you towards the right path of diagnosis. But histopathology confirms it. Not only that it also suggest whether further confirmatory diagnosis is needed or not. Thus histopathology saves time and cost by preventing the clinician and the patient from the advanced sophisticated diagnostic techniques so that proper treatment can be adapted in time in clinical cases. In case of autopsy, it is also helpful to determine or confirm the proper cause of death in time.
I strongly and always uphold the idea of all autopsy to be followed by histopathology diagnosis as is a tradition where i trained forensic medicine. Yes, a lot of lesions may be excluded virtually in gross at autopsy table or may even be in early stage appearing normal/undetermined-early myocardial infarction. Yes, as myocardium may appear grossly normal but on second thought taking a sample may be surprisinly showing features of early myocardic infarction which i have seen in most sudden deaths i have been privileage to have done autopsy-in avoidance of doubt. Since all clinicians looks forward to our result-i think there is an absolute need of doing the right thing notwithstanding ones experience over the years. Traditionally, doing a histopathological diagnosis gets one a strong scientific affirmation of the outcome of the autopsy both to colleagues and in any court of jurisdiction in terms of appearing as an expert witness.
Histological diagnosis may help in diagnosing microscopic metastasis in other organs apart from primary site, to confirm shock in adrenal specimens, seeing microthrombus in early DIC cases, in early AMI cases where the gross feature is not well appreciated in order to support the clinical diagnosis and cause of death
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