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OP(Oral Pathologist)inion matters
Oral Oncology 48 (2012) e47–e48
Contents lists available at SciVerse ScienceDirect
Oral Oncology journal homepage: www.elsevier.com/locate/oraloncology
Letter to the Editor OP(Oral Pathologist)inion matters
Introduction Specific sites in the oral and maxillofacial complex can be particularly problematic posing one of the greatest diagnostic challenges for physician pathologists (PPs). The medical school curricula and pathology residencies often do not deal extensively with diseases of the oral cavity and maxillofacial area, specifically the odontogenic tumors and cysts. Hence, the expertise of the oral and maxillofacial pathologists (OPs) in dealing with the nature, identification and management of these problematic cases may prove invaluable in assisting the PPs. There are limited reports in the English medical literature on the major disagreements in the head and neck region pathologies which vary from 7%1 to 11.4%2. Jones et al.3 reported major disagreements in 16.3% cases, wherein nine cases initially diagnosed as malignant by PPs were changed to benign in the second opinion report. Furthermore, seven cases submitted with a benign diagnosis were changed to malignant. The impact of these major disagreements is of great consequence, as they will significantly influence the nature and extent of the surgery, chemotherapy or radiotherapy and long-term follow-up. It is an established fact that cancer mortality can be reduced if lesions are detected, diagnosed and treated at an early stage.4 Moreover, after incisional biopsy the malignant lesions proliferate rapidly and subsequently the chances for regional and distant metastasis increase. In such situations, immediate diagnosis after incisional biopsy is necessary to avoid professional diagnostic delay related complications. The practice of sending biopsies to the PPs and then getting second opinion from the OPs can cause professional diagnostic delay.5 In India, from approximately 136 dental colleges, about 430 new OPs are graduating every year. Indian Association of Oral and Maxillofacial Pathologists has approximately 1300 members including students and life members. Looking at this scenario, there is a significant number of OPs available in India. But, there is a dire need to increase the awareness of oral pathology as a specialty branch. Since the ultimate aim is patient’s benefit to improve the quality of life and prognosis, all efforts should be directed towards early and accurate diagnosis of the disease. With this view in mind, following recommendations are suggested. 1. Efforts should be made to create awareness among PPs about the importance of second opinion from OPs. This can be done by discussing this issue at pathology conferences and workshops. 2. To resolve the issue of disagreement in the diagnosis, the pathology laboratories should be audited or peer reviewed by experienced OPs for oral biopsies on regular basis.
1368-8375/$ - see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.oraloncology.2012.07.014
3. As oral biopsies comprise a very minor portion of the total biopsies, all community based government and private hospitals should have an OP as visiting or on-call consultant on their panel. 4. Young OPs should be encouraged to do freelance practice or work at hospital level so that they can make themselves available for second opinion. 5. Second opinion related delay in diagnosis, especially in oral cancer and other malignancies can be avoided by sending oral biopsies by general dental practitioners, oral surgeons and even general surgeons directly to OPs. This can eventually encourage the budding OPs to practice oral pathology thereby increasing their availability.
Another common practice by surgeons in developing countries which leads to confusion is sending of multiple bits of biopsy to different pathologists. This becomes a potential source of diagnostic disagreement as the representative lesional tissue is not received by every pathologist. Such practices should be discouraged for the benefit of the patient. In conclusion, the major disagreements in diagnosis would have a significant impact on preoperative evaluation; alter the nature and extent of therapy and long-term follow-up. The head and neck should be considered as a high risk diagnostic area and second opinions should be made mandatory for problematic cases. Although it has been found that 98% of the PPs were aware of the specialty of oral pathology and 92% perceived a need for it,6 these results cannot be generalized especially so in developing countries. Thus, the role of OPs is vital to avoid jeopardizing the diagnosis and management of the patient.
References 1. Westra WH, Kronz JD, Eisele DW. The impact of second opinion surgical pathology on the practice of head and neck surgery: a decade experience at a large referral hospital. Head Neck 2002;24:684–93. 2. Manion E, Cohen MB, Weydert J. Mandatory second opinion in surgical pathology referral material: clinical consequences of major disagreements. Am J Surg Pathol 2008;32:732–7. 3. Jones K, Jordan RC. Patterns of second-opinion diagnosis in oral and maxillofacial pathology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:865–9. 4. Sarode SC, Sarode GS, Karmarkar S. Early detection of oral cancer: detector lies within. Oral Oncol 2012;48:193–4. 5. Allison P, Locker D, Feine JS. The role of diagnostic delays in the prognosis of oral cancer: a review of the literature. Oral Oncol 1998;34:161–70. 6. Barrett AW, Speight PM. Use of oral pathology services by general histopathologists and their attitudes to training of oral pathologists. J Clin Pathol 1996;49:565–9.
e48
Letter to the Editor / Oral Oncology 48 (2012) e47–e48
⇑
Sachin Chakradhar Sarode Gargi Sachin Sarode 1 Swarada Karmarkar 2 Ketaki Kalele Department of Oral and Maxillofacial Pathology, Dr. D.Y. Patil Dental College and Hospital, Dr. D.Y. Patil Vidyapeeth, Sant-Tukaram Nagar, Pimpri, Pune 411 018, Maharashtra, India * Corresponding author. Tel.: +91 9922491465. E-mail addresses: [email protected] (S.C. Sarode), gargi14@ gmail.com (G.S. Sarode), [email protected] (S. Karmarkar) Available online 15 August 2012
1 2
Tel.: +91 9823871462. Tel.: +91 9890048796.
Contents lists available at SciVerse ScienceDirect
Oral Oncology journal homepage: www.elsevier.com/locate/oraloncology
Letter to the Editor OP(Oral Pathologist)inion matters
Introduction Specific sites in the oral and maxillofacial complex can be particularly problematic posing one of the greatest diagnostic challenges for physician pathologists (PPs). The medical school curricula and pathology residencies often do not deal extensively with diseases of the oral cavity and maxillofacial area, specifically the odontogenic tumors and cysts. Hence, the expertise of the oral and maxillofacial pathologists (OPs) in dealing with the nature, identification and management of these problematic cases may prove invaluable in assisting the PPs. There are limited reports in the English medical literature on the major disagreements in the head and neck region pathologies which vary from 7%1 to 11.4%2. Jones et al.3 reported major disagreements in 16.3% cases, wherein nine cases initially diagnosed as malignant by PPs were changed to benign in the second opinion report. Furthermore, seven cases submitted with a benign diagnosis were changed to malignant. The impact of these major disagreements is of great consequence, as they will significantly influence the nature and extent of the surgery, chemotherapy or radiotherapy and long-term follow-up. It is an established fact that cancer mortality can be reduced if lesions are detected, diagnosed and treated at an early stage.4 Moreover, after incisional biopsy the malignant lesions proliferate rapidly and subsequently the chances for regional and distant metastasis increase. In such situations, immediate diagnosis after incisional biopsy is necessary to avoid professional diagnostic delay related complications. The practice of sending biopsies to the PPs and then getting second opinion from the OPs can cause professional diagnostic delay.5 In India, from approximately 136 dental colleges, about 430 new OPs are graduating every year. Indian Association of Oral and Maxillofacial Pathologists has approximately 1300 members including students and life members. Looking at this scenario, there is a significant number of OPs available in India. But, there is a dire need to increase the awareness of oral pathology as a specialty branch. Since the ultimate aim is patient’s benefit to improve the quality of life and prognosis, all efforts should be directed towards early and accurate diagnosis of the disease. With this view in mind, following recommendations are suggested. 1. Efforts should be made to create awareness among PPs about the importance of second opinion from OPs. This can be done by discussing this issue at pathology conferences and workshops. 2. To resolve the issue of disagreement in the diagnosis, the pathology laboratories should be audited or peer reviewed by experienced OPs for oral biopsies on regular basis.
1368-8375/$ - see front matter Ó 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.oraloncology.2012.07.014
3. As oral biopsies comprise a very minor portion of the total biopsies, all community based government and private hospitals should have an OP as visiting or on-call consultant on their panel. 4. Young OPs should be encouraged to do freelance practice or work at hospital level so that they can make themselves available for second opinion. 5. Second opinion related delay in diagnosis, especially in oral cancer and other malignancies can be avoided by sending oral biopsies by general dental practitioners, oral surgeons and even general surgeons directly to OPs. This can eventually encourage the budding OPs to practice oral pathology thereby increasing their availability.
Another common practice by surgeons in developing countries which leads to confusion is sending of multiple bits of biopsy to different pathologists. This becomes a potential source of diagnostic disagreement as the representative lesional tissue is not received by every pathologist. Such practices should be discouraged for the benefit of the patient. In conclusion, the major disagreements in diagnosis would have a significant impact on preoperative evaluation; alter the nature and extent of therapy and long-term follow-up. The head and neck should be considered as a high risk diagnostic area and second opinions should be made mandatory for problematic cases. Although it has been found that 98% of the PPs were aware of the specialty of oral pathology and 92% perceived a need for it,6 these results cannot be generalized especially so in developing countries. Thus, the role of OPs is vital to avoid jeopardizing the diagnosis and management of the patient.
References 1. Westra WH, Kronz JD, Eisele DW. The impact of second opinion surgical pathology on the practice of head and neck surgery: a decade experience at a large referral hospital. Head Neck 2002;24:684–93. 2. Manion E, Cohen MB, Weydert J. Mandatory second opinion in surgical pathology referral material: clinical consequences of major disagreements. Am J Surg Pathol 2008;32:732–7. 3. Jones K, Jordan RC. Patterns of second-opinion diagnosis in oral and maxillofacial pathology. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:865–9. 4. Sarode SC, Sarode GS, Karmarkar S. Early detection of oral cancer: detector lies within. Oral Oncol 2012;48:193–4. 5. Allison P, Locker D, Feine JS. The role of diagnostic delays in the prognosis of oral cancer: a review of the literature. Oral Oncol 1998;34:161–70. 6. Barrett AW, Speight PM. Use of oral pathology services by general histopathologists and their attitudes to training of oral pathologists. J Clin Pathol 1996;49:565–9.
e48
Letter to the Editor / Oral Oncology 48 (2012) e47–e48
⇑
Sachin Chakradhar Sarode Gargi Sachin Sarode 1 Swarada Karmarkar 2 Ketaki Kalele Department of Oral and Maxillofacial Pathology, Dr. D.Y. Patil Dental College and Hospital, Dr. D.Y. Patil Vidyapeeth, Sant-Tukaram Nagar, Pimpri, Pune 411 018, Maharashtra, India * Corresponding author. Tel.: +91 9922491465. E-mail addresses: [email protected] (S.C. Sarode), gargi14@ gmail.com (G.S. Sarode), [email protected] (S. Karmarkar) Available online 15 August 2012
1 2
Tel.: +91 9823871462. Tel.: +91 9890048796.