Ambiguous report in anatomic pathology; a southwestern Nigeria experience

Background: Ambiguity in anatomic pathology reports is common, with terms like “suspicious for,” “indefinite for,” and “see text” used to express diagnostic uncertainty. Objective: The study assessed the frequency of use of ambiguous terms in anatomic pathology reports in our hospital. Methods: The retrospective cross- sectional study involved 125 cases of surgical pathology results with ambiguous terminology in Bowen University Teaching Hospital, Ogbomoso, from January 2012 to December 2020. The patients’ sociodemographic data, years of experience of the pathologists, adequacy of biopsy samples, and cases with terms such as “non-representative”, ‘’see description’’ ‘’see text’’, and ‘’inadequate for opinion’’ were retrieved. All cytology reports, surgical pathology reports with standard diagnoses and reports with incomplete biodata were excluded. Results: There was a male predominance 69 (55.2%) in the studied sample population. A greater proportion (36.8%) of the samples population were of the elderly group About 2.36% of the surgical samples reports were ambiguous. The ambiguous terms “See text (49.6%) and see description (28%)” were more common in the reports Out of the total number of samples studied, 111 (88.80%) of the samples were considered as being adequate and, 14 (11.20%) was inadequate. Most of the specimens that were considered as inadequate were from tru-cut and small biopsies.There was no significant gender difference in the samples reported as inadequate, (p=0.6780.). All the pathologists used ambiguous terms and, there was no significant difference in the use of ambiguous terms between the inexperienced and experienced pathologists (p=0.108). Conclusion: Ambiguous reports in anatomic pathology were common and were used by all categories of pathologists. These have become ways of avoiding specific diagnosis in cases that are uncertain thereby reducing errors and possible attendant litigations. Re-training programmes for pathologists should be encouraged with provision of high tech ancillary investigations for practicing pathologists to minimize the frequency of ambiguous reports and their attendant negative impact on the management of patients and research.