Good communication between clinician and pathologist is essential for optimal patient care and management of colorectal polyps and carcinoma. General principles of communication include making sure that the pathologist as well as the endoscopist has all the information needed to make an accurate diagnosis and that the pathologist communicate the diagnosis back to the endoscopist in a clear and timely fashion. In recent years, the increasing complexity of the classification of colorectal polyps and carcinomas has added to the need for clear communication pathways between clinician and pathologist. The first part of this article is devoted to a brief outline of general communication issues; the second is discussion of current concepts in colorectal polyps and carcinomas.

Communication begins with, but should not be restricted to, the pathology requisition form that should always list the source of the specimen, including the specific location in the colon, the clinical differential diagnosis, and any special requests. A description of the endoscopic findings and procedure (eg, biopsy vs polypectomy) as well as the outcome of the procedure (ie, complete vs incomplete excision of a lesion) is essential and is easily accomplished by sending a copy of the endoscopy report to pathology with the specimen. If there are findings that an endoscopist specifically wants to have addressed, this should be stated on the requisition. Family history may be relevant in cases of colorectal polyps or carcinomas, in particular if there is a possibility of Lynch syndrome for which additional work-up of the carcinoma for absence of mismatch repair (MMR) enzymes may be useful for deciding on proper therapy of the lesion (discussed later).

All pathology reports should specifically mention the site of the biopsy. If a specific site is not submitted with the specimen, that should be stated in the report. There should be a gross description of the specimen that includes, for biopsy specimens, the number and approximate size of fragments in the container and, for polypectomy specimens, a specific description indicating if the polyp was intact or fragmented and, if fragmented, how many fragments were present. If multiple polyps are submitted in one container, they should be handled individually by submitting in separate blocks for processing or by inking the different polyp fragments different colors. If a resection line of a polyp can be grossly identified, the margin should be inked and the polyp sectioned through that margin. In some cases, with a large number of biopsy fragments, an accurate count may not be possible but an estimate should be made. One importance of fragment counts, particularly if how many biopsies were taken is stated in the endoscopy report, is that it allows confirmation that all of the submitted tissue was included in the block and slide and that no tissue was lost. Alternatively, occasionally there are more pieces of tissue on the slide than were counted in the container. This most often occurs because tissue fragments stick together in the container and are miscounted as one when there are really two fragments present, but occasionally this indicates tissue cross-contamination from another patient’s material. This becomes important if one of the fragments shows disparate histologic features. In laboratories processing many different types of tissue, the contaminating tissue likely is of a different organ than the gastrointestinal (GI) tract and is readily identifiable as not belonging to the case; however, in laboratories processing only GI cases, such easy identification is often not possible. This can lead to potentially disastrous consequences. I have seen cases of cross-contamination of malignant tissue into a GI biopsy that is otherwise benign, potentially leading to misdiagnosis and unnecessary surgery. Although it is impossible to prevent all cross-contamination, proper procedure in the pathology laboratory should make this rare. Cross-contamination is a situation, however, in which proper communication can be helpful. Oftentimes in these cases, the worrisome findings are present in only one of multiple biopsies and seem out of context if the pathologist knows the clinical situation and endoscopic findings. The mistaken findings may not correlate with the endoscopic findings. In cases where there seems to be a discrepancy between the clinical findings and the results of the biopsy, careful attention to number of fragments and rapid communication between clinician and pathologist may prevent an unfortunate outcome.

Other essential elements of the pathology report should include a statement of adequacy of the biopsy, a diagnosis, and recommendations for further evaluation in cases of nondiagnostic specimens for which the pathologist thinks that the biopsy may not be adequate. Biopsy of a mass lesion that consists only of superficial ulcer debris, for example, may lead to a suggestion for rebiopsy if the index of suspicion for malignancy is high. In cases of neoplastic colorectal polyps, the report should include a specific diagnosis, including elements considered indicative of advanced neoplasia and if the polyp contains a carcinoma; then, if possible, there should be a statement regarding adequacy of excision of the lesion based on risk factors (described later). In many cases of polypectomy, a statement regarding adequacy of excision cannot be made because the polyp is removed in a piecemeal fashion or because of suboptimal orientation of the specimen. Therefore, for most adenomas without malignancy, adequacy of excision is best determined by an endoscopist. Essential elements of a pathology report for a polyp or carcinoma specimen are summarized in Box 1 .

Ideally all pathology departments should have a critical diagnosis call list (ie, a list of diagnoses for which the responsible clinician should be called with the diagnosis) rather than just relying on the pathology report to convey the results. This list typically includes conditions requiring immediate clinical attention (for example, opportunistic infections in immunocompromsed patients), conditions requiring rapid follow-up, or conditions that might not be expected based on the clinical history or endoscopic findings. For example, the finding of carcinoma in a biopsy taken from a small erosion that was not considered suspicious for carcinoma, is best discussed directly with an endoscopist, as are carcinomas arising in polypectomy specimens. The critical diagnosis list cannot be standardized for all laboratories but is best developed jointly between the gastroenterologist and pathologist because there are some things that certain gastroenterologists might want immediate notification of whereas others might not. If a critical diagnosis call list is developed, it is crucial for all pathologists in the servicing pathology group to always abide by the list, because with such a list, the presumption is that these diagnoses will be called, and if they are not, there may well be a presumption that all is fine. A typical critical diagnosis call list is shown in Box 2 .

Box 2

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