Semantic analysis of SNOMED CT for a post-coordinated database of histopathology findings.
OBJECTIVE
This research investigated the use of SNOMED CT to represent diagnostic tissue morphologies and notable tissue architectures typically found within a pathologist's microscopic examination report to identify gaps in expressivity of SNOMED CT for use in anatomic pathology.


METHODS
24 breast biopsy cases were reviewed by two board certified surgical pathologists who independently described the diagnostically important tissue architectures and diagnostic morphologies observed by microscopic examination. In addition, diagnostic comments and details were extracted from the original diagnostic pathology report. 95 unique clinical statements were extracted from 13 malignant and 11 benign breast needle biopsy cases.


RESULTS
75% of the inventoried diagnostic terms and statements could be represented by valid SNOMED CT expressions. The expressions included one pre-coordinated expression and 73 post-coordinated expressions. No valid SNOMED CT expressions could be identified or developed to unambiguously assert the meaning of 21 statements (ie, 25% of inventoried clinical statements). Evaluation of the findings indicated that SNOMED CT lacked sufficient definitional expressions or the SNOMED CT concept model prohibited use of certain defined concepts needed to describe the numerous, diagnostically important tissue architectures and morphologic changes found within a surgical pathology microscopic examination.


CONCLUSIONS
Because information gathered during microscopic histopathology examination provides the basis of pathology diagnoses, additional concept definitions for tissue morphometries and modifications to the SNOMED CT concept model are needed and suggested to represent detailed histopathologic findings in computable fashion for purposes of patient information exchange and research.


BACKGROUND
UNMC Institutional Review Board ID# 342-11-EP.
Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska, USA.
Walter S
WS
Campbell
Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA.
James R
JR
Campbell
Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska, USA.
William W
WW
West
Department of Emergency Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA.
James C
JC
McClay
Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska, USA.
Steven H
SH
Hinrichs
D001940:Breast / Q000473:pathology*; D016208:Databases, Factual; D006801:Humans; D010340:Pathology, Surgical; D012660:Semantics; D039061:Systematized Nomenclature of Medicine
Anatomic Pathology; Histology Reporting; Pathology Reporting; Snomed CT; Whole Slide Imaging