Rojiani, Amyn M.

Context.— The Goldman criteria are widely used to categorize diagnostic discrepancies in autopsy reports for hospital quality assurance. Despite their adoption, little is known about how consistently they are applied across institutions. Objective.— To evaluate the interrater reliability among academic pathologists applying the Goldman criteria to classify missed diagnoses in autopsy cases. Design.— Thirty autopsy cases from 2 academic hospitals were reviewed by 5 experienced autopsy pathologists. Each reviewer independently assigned Goldman classification scores (class I–IV) to missed diagnoses based on the original 1983 definitions. Consensus was defined as at least 60% agreement (≥3 of 5 raters). Fleiss κ and Gwet AC1 were calculated to assess interrater reliability. Results.— A total of 196 missed diagnoses were identified by at least 1 rater. Only 26% (51 of 196) achieved a consensus Goldman classification, and just 4% (8 of 196) had unanimous classification agreement. Most diagnoses (65%; 127 of 196) were not identified by at least 3 raters. Among consensus classification ratings, 49% (25 of 51) were class IV. Fleiss κ was 0.176 (slight agreement) while Gwet AC1 was 0.390 (fair agreement). Collapsing major (classes I–II) and minor (classes III–IV) categories modestly improved agreement. Conclusions.— Interrater agreement in applying the Goldman criteria is only fair to moderate, suggesting significant subjectivity in their application. As the criteria are used for institutional comparison and quality metrics, efforts to standardize definitions and provide reviewer training are warranted to improve reproducibility and utility.

Context.— After-death care can be complicated and time-consuming for clinical staff, and frustrating for bereaved families. Delays and errors can have damaging legal and reputational consequences for hospitals. Offices of Decedent Affairs (ODAs) have been proposed as a solution, and their potential benefits have been described in several single institution reports. The literature lacks a contemporary and comprehensive review of existing ODAs and their approaches. Objective.— To describe the process of establishing a new ODA and to provide a snapshot of the spectrum of structure, function, and impact of existing ODAs in the United States. Design.— A survey was administered to 11 established ODAs spread across the continental United States. Programs were identified through the College of American Pathologists Autopsy Committee and a Medical Autopsy Listserv. Results.— Eleven ODAs returned the survey, representing more than 190 cumulative years of experience in decedent care in the hospital setting (median, 10 years). There was a wide range in staffing (both staff size and background) as well as scope of services offered. The median ratio of hospital deaths to full-time equivalent (FTE) staffing was 360 deaths per FTE. Respondents reported that ODAs unburden clinical providers and facilitate decedent management. Some respondents reported a quicker turnover of hospital beds and shorter intervals between pronouncement of death and autopsy. ODAs increased autopsy rates when the autopsy services were part of the ODA. Conclusions.— This survey provides practical information for hospitals considering establishing a new ODA and useful benchmarks for existing ODA programs.

Context.— Decedent Affairs Offices and Programs can serve as an avenue to assist medical centers in facilitating efficient and comprehensive decedent management, despite a paucity of literature on their roles, establishment, and efficacy. Objective.— To characterize the motivations and rationales for establishing Decedent Affairs Offices. Design.— A survey was administered to 11 established Decedent Affairs Offices/Programs, identified through the College of American Pathologists Autopsy Committee and a Medical Autopsy Listserv. The questions comprehensively cover establishment, operations, and outcomes data available by institution. Results.— Survey respondents reported the rationale for starting their programs and the benefits such offices can have. Conclusions.— Decedent Affairs Offices and Programs provide a useful option to medical centers to navigate the increasingly complex task of comprehensive decedent management. The present survey helps to delineate the similarities and differences between these programs at 11 institutions, to aid nascent programs in their establishment and growth over time.

Abstract Context. —Brain metastases of adenocarcinoma of unknown primary pose a diagnostic dilemma to the surgical pathologist. Although the most common source in these cases is the lung, determining a primary source is difficult on routinely stained slides. Immunohistochemical stain panels including differential cytokeratins, hormone receptors, and breast-specific proteins are commonly used in these cases. Recently, attention has turned to tissue-specific transcription factors, such as thyroid transcription factor 1 (TTF-1) and Cdx2, in the appraisal of metastatic adenocarcinomas. Objective. —To characterize the previously unpublished immunohistochemical expression of the relatively new tissue-specific transcription factor Cdx2 in metastatic adenocarcinomas to the brain. Design. —We reviewed the surgical pathology files of the H. Lee Moffitt Cancer Center and Research Institute, Tampa, Fla, and retrieved 38 consecutive cases of metastatic adenocarcinoma (22 pulmonary, 10 breast, 6 gastrointestinal [2 esophagus/gastroesophageal junction, 4 colorectal]) to the brain with confirmation of the primary site by chart review and histologic evaluation. Sections were immunohistochemically stained with antibodies to TTF-1, Cdx2, and cytokeratins 7 and 20 by standard methods. Results. —Specificities and positive predictive values for Cdx2 and TTF-1 equaled 100% for metastatic gastrointestinal and pulmonary adenocarcinomas, respectively. The negative predictive value of Cdx2 was also very high at 97%. Conclusions. —Cdx2 is a specific and valuable tool for the surgical pathologist when faced with the common problem of metastatic adenocarcinoma of unknown primary. In conjunction with TTF-1, cytokeratin 7, and cytokeratin 20, Cdx2 can accurately differentiate the most common sources of metastatic adenocarcinoma to the brain.

Metastases to the brain may be the first presentation of systemic malignancy in 3–10% of new patients and thus pose a diagnostic challenge. While lung is the most common source, other frequent sites of origin include the GI tract and breast. The histologic appearance of metastatic adenocarcinoma often does not lend itself to identification of the primary source. In many cases immunohistochemical studies (IHC) to define these lesions may provide a reliable result, thus limiting the time and expense incurred by various clinical investigations. We have examined the IHC expression of cytokeratins 7 and 20, thyroid transcription factor ‐1 (TTF‐1) and the relatively new tissue specific transcription factor CDX2 in metastatic adenocarcinomas to the brain. 38 consecutive cases of metastatic adenocarcinoma (22 pulmonary, 10 breast, 6 gastrointestinal (2 esophagus/GE junction, 4 colorectal) to the brain were retrieved through a search of the surgical pathology files of the H. Lee Moffitt Cancer Center, Tampa, Florida. Confirmation of the primary site was obtained by chart review and histologic evaluation. Sections were immunohistochemically reacted with antibodies to TTF‐1, CDX2, and Cytokeratins 7 and 20 (CK7 and CK20) by standard methods. Specificities and positive predictive values for CDX2 and TTF‐1 equaled 100% for metastatic gastrointestinal and pulmonary adenocarcinomas, respectively. The negative predictive value of CDX2 was also very high at 97%. Our studies confirm that in conjunction with TTF‐1, CK7 and CK20, CDX2 can accurately differentiate the most common sources of metastatic adenocarcinoma from an unknown primary site to the brain.