Pathophysiology Case Study: Misinterpretation in Pathology Practice

This case study delves into a real-world scenario encountered by a pathologist, highlighting the challenges of accurate diagnosis and effective communication in healthcare. The case revolves around a 53-year-old man presenting with a tongue mass, initially suspected to be cancerous. The pathologist's misinterpretation of the biopsy results, mistaking leukoplakia for squamous carcinoma, led to an incorrect diagnosis and inappropriate treatment. The study emphasizes the importance of precise reporting, clear communication among medical professionals, and the impact of diagnostic errors on patient outcomes. It further analyzes the contributing factors to the misdiagnosis, including the workload of pathologists and the need for continuous improvement in diagnostic proficiency. The study concludes by underscoring the significance of quality assurance programs and the role of the College of American Pathologists in promoting best practices within the field of pathology, ultimately aiming to reduce misinterpretations and improve patient care.

Running head: PATHOPHYSIOLOGY
Pathophysiology
Name of the student:
Name of the University:
Author’s note

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Summary of an interesting pathology case experienced by a pathologist:
The experience of pathologist in their field of practice has revealed that increase in
demand for pathology services and the need to improve turnaround time in clinical
management poses many challenges in pathology practices. The ordeal for pathologist also
increases with the increase in number of biopsies and the need to comply with guidelines for
cancer case reporting (Kamel, 2011). Similar challenges was also faced a pathologist when he
had to conduct the biopsy of the mass of the tongue of a 53 year old man. The old man came
to the clinician with a white patch and mass in the base of his tongue which showed up since
the past six months. Suspecting the diagnosis of cancer, the clinician ordered a biopsy test for
the patients. The pathologist conducted the biopsy test for the mass. He experienced dilemma
in reporting and conveying correct information of result as different groups of clinicians were
involved in handling the case. Poor communication between pathologist, oncologist and
surgeons resulted in misinterpretation of results and initiation of appropriate treatment for
patients.
The pathology report of the biomass of the tongue has revealed that normal histology
of the squamous mucosa was replaced with proliferation of the cell. The usual maturation
process was replaced with haphazard pattern and large vesicular nuclei. The main conclusion
that the pathologist made from the examination of the tongue biomass was diagnosis of
differentiated squamous carcinoma of the tongue. However, the diagnosis was not right
because the patient suffered from leukoplakia and tissue biopsy normally shows keratin build
up, however it is not always an indication of abnormal or cancerous cells. The risk of cancer
is high in such patients, but the tongues tissue had not become malignant (Van der Waal,
2015). The critical information of result was mistinterpreted and lack of detail in reporting
resulted in great disaster for patient. The pathology report should mainly have three key areas
including patient identification, reporting style and content and interpretation. The mistake

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done by pathologist came in erroneous critical information category as patient diagnosis was
misinterpreted (Cree et al., 2017). The reporting should have mentioned about moderate
detection and risk of squamous epithelial cells and main diagnosis of leukplakia. However,
the reporting about malignant cells resulted in the initiation of treatment for cancer and the
patient had to endure many sufferings during the process. Secondly, as group of clinicians
were involved in handling the case, poor communication between the team resulted in loss of
suffering and morbidity for patient. Lack of importance to quality assurance in pathology
testing and review of the diagnosis resulted in adverse outcome for patients.
Analysis of the case
The analysis of the case gave example about the error in misinterpretation in
pathology practice particularly in cancer cases. Although leukoplakia increased the risk of
cancer, however the keratin build up was wrongly interpreted as cancerous cells. The review
of recent research literature has shown that misinterpretation of squamous intraepithelial
lesion in a significant challenges in pathology practice and the research mainly pointed out
that high misinterpretation rate is mainly due to the differences in reporting responsibilities
and proficiency test grading criteria (Zhao et al., 2016). In the context of the case scenario, it
can be said that such mistake by pathologist occurred due to lack of test taking confidence
and compliance to quality reporting. The ultimate impact of such incidence was that patient
had to go through both emotional and physical suffering as the name of cancer itself is
associated with great distress in patients.
Hence, the main lesson that can be learnt from the review of case is that the
proficiency of the pathologist in the practice needs to be enhanced with greater focus on
providing test taking environment to pathologist. Often high demand of pathology service
and heavy workload is also the cause of misinterpretation. To curb the misinterpretation rate,

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continual involvement in Pathologist Laboratory Accreditation Program is necessary so that
pathologist develop confidence in pathological testing and they become accustomed to
issuing a final diagnosis that directs correct treatment option for patients (Ellis & Srigley,
2016. The College of American Pathologist programs is involved in educational efforts to
establish best practice to promote efficiency in the pathology field. The accreditation program
ensures that the laboratory practice is upto date and maintain gold standard in practice and
reporting (Wheeler, 2009).

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Reference
Cree, I. A., Deans, Z., Ligtenberg, M. J., Normanno, N., Edsjö, A., Rouleau, E., ... &
Dequeker, E. (2014). Guidance for laboratories performing molecular pathology for
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Ellis, D. W., & Srigley, J. (2016). Does standardised structured reporting contribute to quality
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Kamel, H. M. (2011). Trends and challenges in pathology practice: choices and
necessities. Sultan Qaboos University medical journal, 11(1), 38.
Van der Waal, I., 2015. Oral leukoplakia, the ongoing discussion on definition and
terminology. Medicina oral, patologia oral y cirugia bucal, 20(6), p.e685.
Wheeler, T. M. (2009). The role of CAP in standardisation of pathology practice, including
our laboratory accreditation program, predictive markers (HER2, ER, PR) and
pathology report standardisation. Pathology, 41, 1-2.
Zhao, C., Crothers, B. A., Ghofrani, M., Li, Z., Souers, R. J., Hussain, M., ... & College of
American Pathologists Cytopathology Committee. (2016). Misinterpretation rates of
high-grade squamous intraepithelial lesion in the College of American Pathologists
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& laboratory medicine, 140(11), 1221-1224.