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In January 2001, the Royal College of Pathologists’ bulletin published an article entitled “A recovery plan for histopathology”.1 Following this, the Royal College of Pathologists released the document “Histopathology of limited or no clinical value”.2 This document described specific areas in histopathology where the restriction of services would not deleteriously affect patient management and would increase the time available for other cases. We identified ovarian cyst aspirates as another specimen that does not appear to have clinical importance. We describe our partly successful attempts to decrease the number of specimens received in this department.
The risk of malignancy index (RMI) has been in clinical practice since 1990. The application of the RMI in clinical practice provides a rational basis for specialist referral of patients with ovarian cancer before diagnostic surgery.3 Table 1 shows details of the algorithm by which the RMI is calculated.
The finding of a simple cyst would give an RMI score of zero regardless of points gained in other areas.
To validate and quantify our impression that the cytological examination of ovarian cyst aspirates is a clinically unhelpful test, we initially reviewed all 56 cases received in our department over a one year period.
Twenty four of these were taken from patients undergoing fertility treatment, two were taken from patients at the time of caesarean section, and nine were taken from patients during surgery to remove the cyst in question. Fifteen were taken during a laparoscopic procedure, which was not otherwise described on the request form, and in six cases no information was given about the specimen. Table 2 shows the results of these cytology specimens.
Where no lining cells were identified, the caveat was added to the report that “therefore the exact histogenic origin of the cyst could not be determined”. In the nine cases where the ovarian cyst was removed and sent to the pathology department along with the contents of the cyst, seven of the aspirates showed no lining cells and two of the aspirates contained follicular cells.
Having shown that in 36 of the 47 aspirates sent without the ovary, no lining cells were identified, and therefore no diagnosis was made, we examined our database to see whether any further biopsies were taken from these patients. No further surgery was performed on these patients, including the patient with a dermoid cyst. Our findings are similar to those published by Higgins et al.4
We circulated the results in the department of reproductive medicine, summarising the above findings and asking for feedback. The feedback from the head of department was positive. However, some gynaecologists were unwilling to discontinue the practice and declined an offer from the pathologist who had performed the audit to come and discuss the results with them. We had hoped that by simply increasing awareness among clinicians of the unhelpfulness of the test, in relation to the RMI, that the numbers might naturally decrease. However, a repeat audit one year later showed that the numbers of specimens being sent, including those sent with the accompanying cyst, had actually increased.
Therefore, we again reported the audit findings to our clinical colleagues and have restricted the examination of cyst aspirates to those cases that do not accompany the cyst in question. Ideally, we would like to stop reporting these specimens completely, but this is not possible without support from our clinical colleagues.