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Accuracy of wording of pathology report (04HDC02992)

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(04HDC02992, 20 September 2005)

Pathologist ~ Lump ~ Ultrasound ~ Fine needle aspiration ~ Diagnosis ~ Consistent terminology in pathology reports ~ Presence of pathologist at multidisciplinary meetings

A 54-year-old woman attended her general practitioner complaining of a lump in her neck. The general practitioner prescribed antibiotics and arranged for an ultrasound scan (USS) and a USS-guided fine needle aspiration (FNA) to assist diagnosis.

A radiologist performed the scan, reporting "appearances are all consistent with metastatic squamous cell carcinoma … definitive cytology awaited". The radiologist performed an FNA, which was reported on the same day by the pathologist, as "the appearances are consistent with the clinical suggestion of metastatic squamous cell carcinoma". The woman underwent surgery, but in relation to all specimens taken from the neck surgery, no evidence of malignancy was found.

Subsequent to the pathologist's report, the FNA sample was accepted as indicating the likelihood of squamous cell carcinoma by the woman's clinicians. The FNA slides showed some changes that were "suggestive" of an underlying malignancy, but the FNA sample fell well short of being "consistent with" squamous cell carcinoma. It was held that the FNA should have been reported as inconclusive at most.

There is variation within New Zealand in the language that is used in pathology reports, and the pathologist's error was not a major one. His interpretation of the FNA was understandable given the circumstances of the abnormalities seen, and also the emphasis in the radiologist's request form. In all the circumstances it was held that the pathologist did not breach the Code.

This case highlights the importance of the use of consistent terminology by pathologists in their reports. Consistency of language used is necessary for consistent interpretation and appropriate treatment decisions. An independent pathologist should also be present at multidisciplinary meetings where treatment is planned on the basis of pathology reports.