Reimagining Pathology Reporting for Head and Neck Cancer Resections: 3D Visualizations and Margin Reconciliation

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Joseph, Vivian Su, Ricardo J. Ramirez, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4139597/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Purpose Surgical pathology reports play an integral role in postoperative management of head and neck cancer patients. Pathology reports of complex head and neck resections must convey critical information to all involved clinicians. Previously, we demonstrated the utility of 3D specimen and defect scanning for communicating margin status and documenting the location of supplemental margins. We introduce a newly-designed permanent pathology report which improves documentation of intraoperative margin mapping and extent of corresponding supplemental margins harvested. Methods A cross-sectional study using human-centered design was implemented to evaluate the existing permanent pathology report with respect to understanding margin status. Pathologists, surgeons, radiation oncologists, and medical oncologists from United States-based medical institutions were surveyed. The results supported a redesign of our surgical pathology template, incorporating 3D specimen / defect scans and annotated radiographic images indicating location of inadequate margins requiring supplemental margins, or indicating frankly positive margins discovered on permanent section. Results Forty-seven physicians completed our survey. Analyzing surgical pathology reports, 28/47 (60%) respondents reported confusion whether re-excised supplemental margins reflected clear margins, 20/47 (43%) reported uncertainty regarding final margin status, and 20/47 (43%) reported the need for clarity regarding the extent of supplemental margins harvested intraoperatively. From this feedback, 61 permanent pathology reports were compiled using newly-designed reporting templates over a 12 month period. Conclusion Feedback from survey respondents led to a redesigned permanent pathology report that offers detailed visual anatomic information regarding intraoperative margin findings and exact location/size of harvested supplemental margins. This reimagined report reconciles frozen and permanent section results and includes annotated radiographic images such that clinicians can discern precise actions taken by surgeons to address inadequate margins. human centered design surgical pathology report frozen section multimedia report 3D scanning Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction The pathology report follows cancer patients throughout their journey from treatment, to surveillance, and survivorship. It is a road map for radiation oncologists who determine the need for radiation boosts and where these boosts should be administered. This road map also aids radiologists in interpreting post-treatment surveillance scans. Producing accurate, timely, and clear surgical pathology reports is integral to effective postoperative management of head and neck surgical oncology patients and for informed radiographic surveillance. It is apparent, however, that surgical pathology reports have fallen short of effectively conveying relevant and sufficient information to providers [ 1 – 3 ]. A study by Powsner et al. (2000) assessed surgeons’ understanding of surgical pathology reports for specimens of varying complexity [ 4 ]. Test scores revealed that surgeons misinterpreted pathology reports 30% of the time. Thus, surgeons and pathologists have a significant communication gap [ 4 ]. Furthermore, surgical pathology reports have been largely stagnant over the past several decades and an understanding of their clarity and value to downstream caregivers has not been explored. Three-dimensional (3D) specimen scanning has pushed the boundaries of intraoperative communication by enabling visualization of the resection specimen and conveyance of critical margin status information [ 5 – 11 ]. We have now transcended the limitations inherent in purely written narrative by using 3D virtual representations of resection specimens and surgical defects . This has transformed intraoperative communication regarding the exact locations of inadequate margins [ 5 ]. Close margins refer to a distance of < 5 mm from invasive carcinoma; positive margins refers to “cut-through”. To simplify communication, we refer to either close and/or positive margins as “ at-risk ”, as either category requires a surgical response. Larger resection specimens, by their nature, invite a greater risk of failing to convey important anatomical details. We have addressed this by videoconferencing from the frozen section laboratory into the operating room and showing 3D representations of the resection specimens generated prior to dissection and histologic margin mapping. The 3D specimen representations are annotated with the location of all histologically sampled margins and the pathology results. 3D scanning of the surgical defect allows surgeons to accurately document the locations and breadth of supplemental margins that address margins at-risk [ 12 ]. Our previously published “frozen section timeout form” connects these two processes and transparently documents that the intraoperative margin status has been discussed, understood, and addressed [ 13 ]. Importantly, this form allows for visualization of the margins at-risk, correlated with the supplemental margins harvested based on initial results. It links the actionable pathologic findings from specimen analysis with the downstream supplemental actions and margin results, and clearly documents the important intraoperative steps taken. We surveyed multidisciplinary stakeholders to determine how to improve resection margin reporting and identified a unique opportunity for enhancing reporting of complex head and neck cancer resections. We provide enhanced visuospatial documentation of the resection specimen, surgical defect, and final surgical margin status by generating mixed-media pathology reports that include screen shots from digitally annotated 3D resection specimen and defect models [ 5 , 12 , 13 ]. Given the above advances in intraoperative communication on margin surveillance, it is clear that there is room for innovation in permanent surgical pathology reporting. Our enhanced reporting facilitates more precise design of adjuvant radiotherapy fields and improved radiographic surveillance. Including precise surgeon-annotated preoperative radiographic images into a pathology report may seem unusual, but it is the perfect home for this valuable information, which informs the radiation oncologist of the extent of surgery and highlights locations of intraoperative margin challenges. This annotated preoperative radiograph (CT, MRI, PET CT) can be mapped to postoperative scans and used for treatment planning and surveillance. Methods Study Design This cross-sectional study used human-centered design (HCD), a quality improvement (QI) initiative commonly implemented to design products that best address the needs of end-users [ 14 ]. Three key phases of HCD - Understand, Explore, and Materialize ( Fig. 1 ) - were leveraged to implement our proposed permanent pathology report. Beginning with the Understand phase, we identified the target audience of physicians who most often use surgical pathology reports, including head and neck surgeons, pathologists, radiation and medical oncologists. In accordance with the principles of HCD, particularly user-centeredness, we surveyed the needs of these representative groups to define the problem at-hand. Participants and Data Collection A 9-item survey was distributed electronically across several United States based medical institutions to acquire feedback from key stakeholders using convenience sampling methodology [ 15 ]. We recruited a diverse sample of providers from various geographic locations, health system sizes, specialties, and backgrounds. We distributed our questionnaire-based survey to experts in the aforementioned fields, and these initial stakeholders then distributed the survey amongst their colleagues—using snowball sampling to add participants at their respective institutions. The online questionnaire-based survey was designed using SurveyMonkey® ( Momentive, SurveyMonkey.com) to assess the strengths and shortcomings of the existing permanent pathology report used at participants' own institutions. A crucial aspect of the HCD framework involves incorporating open-ended survey questions, which are included in Appendix 1 . Data Analysis Two independent reviewers analyzed survey results and manually identified themes expressed by stakeholders. Data was analyzed through Mural® ( Tactivos, Inc., San Francisco, CA ), a collaborative visualization tool which highlights key themes and the underlying relationships between themes, subthemes, and stakeholders. Based on the survey results, a novel surgical pathology report template was designed and implemented by the Departments of Pathology and Otolaryngology - Head and Neck Surgery at Mount Sinai West Hospital between January 31, 2023 and October 20, 2023. We improved upon the electronic “frozen section timeout” form described by Kapustin et al. (2023) by undergoing iterative brainstorming and prototyping sessions to incorporate new features based on stakeholder feedback [ 13 ]. This study was approved by the Institutional Review Board of the Icahn School of Medicine at Mount Sinai (STUDY-23-01174). Results Explore Phase: Survey Findings Forty-seven physicians completed our survey. Survey response rate cannot be reported because the total number of survey recipients are unknown due to snowball sampling methods. The respondents consisted of 10 (21%) medical oncologists, 13 (28%) radiation oncologists, 9 (19%) pathologists, and 15 (32%) head and neck surgeons. Most respondents were between 11–20 years from completion of residency or fellowship training and were affiliated with an academic practice (91%). There were 11 national institutions involved; the majority of respondents were associated with the University Hospital Cleveland Medical Center (24%), Moffitt Cancer Center (15%), and Massachusetts General Hospital (13%) ( Table 1 ) . Table 1 Respondent Institutions Institution Number of Respondents (%) University Hospital Cleveland Medical Center (OH) 11 24% Moffitt Cancer Center (FL) 7 15% Massachusetts General Hospital (MA) 6 13% University of Virginia Health (VA) 5 11% Memorial Sloan Kettering Cancer Center (NY) 5 11% Mount Sinai Health System (NY) 4 9% Keck Medicine of the University of Southern California (CA) 2 4% University of Washington Medicine (WA) 2 4% Fox Chase Cancer Center at Temple University Hospital (PA) 2 4% Valley Health (NJ) 1 2% University of Michigan Health (MI) 1 2% Total 46* 100% * One respondent out of our total 47 respondents did not identify their home institution. The following major gaps in current surgical pathology reports were identified: lack of clarity regarding “whether the supplemental margins harvested reflect clear margins for the entire specimen” (n = 28); “final margin status” (n = 20); and the “extent of supplemental margins harvested intraoperatively” (n = 20) ( Table 2 ) . Thematic content analysis led to the emergence of three areas of improvement for current pathology reports ( Fig. 2 ) : 1) Ambiguousfinal margin status, 2) Ambiguous anatomic relationships, 3) Lack of relevance to downstream clinical management. Table 2 Gaps identified in the current surgical pathology report. Participants were instructed to select all that apply. Answer Choice Frequency Unclear whether the supplemental margins harvested reflect clear margins for the entire specimen 28 Extent of supplemental margins harvested intraoperatively 20 Final margin status 20 Location of supplemental margins harvested intraoperatively 15 Initial specimen margins 10 None 9 Other (please specify) 7 Information gaps were a more common complaint among radiation and medical oncologists (14/23 or 61%) compared with surgeons and pathologists (4/24 or 16%). Radiation and medical oncologists acknowledged that current pathology reports are difficult to navigate and critical information is not easily accessible. On the contrary, surgeons and pathologists reported finding permanent surgical pathology reports easy to navigate and that they were able to efficiently access critical information. Overall, 28/47 (60%) of respondents reported uncertainty regarding whether re-excised supplemental margins reflected clear margins for the entire specimen, and 20/47 (43%) reported uncertainty regarding the final margin status at the conclusion of the case. Lastly, 20/47 (43%) reported the need for greater clarity regarding the extent of supplemental margins harvested intraoperatively. Using thematic content analysis, key themes emerged from responses to the “ideation” survey question including recommendations for more visualizations in pathology reports, improvement in clarity of reported margin status, and workflow improvement regarding intraoperative surgeon/pathologist communication. With respect to visualization, several respondents requested gross images of the resection specimen and surgical defect, 3D modeling, clearly marked correlations between specimen and defect, and margin details within the pathology report. Appendix 2 lists specific recommendations from survey responses corresponding to these key themes. Explore Phase: Prototyping A “reimagined” pathology report template was designed to address the three areas of improvement identified from survey responses: lack of clarity regarding 1) final margin status, 2) extent of supplemental margins harvested intraoperatively, and 3) whether the harvested supplemental margins reflected final clear margin status. Screenshots from the pathologist-annotated 3D specimen models are embedded into the template demonstrating the location of histologically sampled margins. Screenshots from the surgeon-annotated 3D surgical defect scans are also embedded into the template, and document the location and the breadth of harvested supplemental margins. The surgeon also annotates preoperative CT, MRI, and/or PET-CT scans immediately after surgery, mapping 1) the extent of tumor resection and 2) regions with margins at-risk that required supplemental margins. Annotations of both the defect scan and preoperative radiographs also convey information from the final pathologic analysis that supersedes the frozen section analysis, if there is a discrepancy. We believe that embedding these surgeon-annotated preoperative scans are particularly valuable for radiation oncologists and radiologists, as these providers need precise anatomic information. Lastly, to focus attention to the initial margins at-risk and harvested supplemental margins, we embed a “Final Margin Reconciliation” table at the end of the report, which clearly communicates the final margin status. Fig.s 3–5 illustrate these novel components of the “Reimagined Pathology Report” in the context of the entire pathology report shown as thumbnails on the top of the illustrations. Other standard reporting elements, such as the frozen section results and the CAP synoptic report, are contained within the complete report and not illustrated here. These images and table are added as an addendum, after the final margin status is known. They can be directly viewed in the Powerpath environment. At this time, the images do not migrate downstream into the electronic health record environment (EPIC). The pathology report refers clinicians to the Powerpath environment for viewing with the following comment: “When reviewing this report in EPIC, please click Results Report in the upper left screen. This allows you to view the report as published in Powerpath. Scroll down to view embedded images.” Alternatively, the pathology report can refer to an addendum uploaded to the media section of EPIC. All of the elements of the final pathology report can be printed and sent to clinicians outside of the immediate institution where the surgery was performed. Materialize Phase: Testing and Implementing Throughout the testing phase, pathologists completed newly designed pathology report templates during frozen section analysis and updated them with the final results. After interacting with our template, pathologists provided feedback in short feedback sessions. Feedback was overwhelmingly positive, with one participant stating, “having supplemental margins drawn in intraoperatively is priceless.” Overall, 61 permanent pathology reports were compiled using our novel permanent pathology report template over a 12-month period. Table 3 summarizes the ablative procedures performed. Table 3 Sixty-one procedures for which permanent surgical pathology reports were compiled. Procedure Number Palatomaxillectomy 12 Glossectomy 11 Total laryngopharyngectomy 9 Composite resection of mandible, tongue, and floor of mouth 7 Mandibulectomy 7 Total parotidectomy 3 Retromolar Trigone 3 Soft tissue oral cavity resection 2 Upper lip resection 2 Soft tissue oropharyngeal resection via lip split 1 Radical parotidectomy, mandibulectomy, and skull base resection 1 Rhinoplasty with septal repair 1 Subfascial tumor of soft tissue of neck 1 Scalp Resection 1 Legends Screen shots of two views of the 3D resection specimen model. “ B” shows the mucosal aspect of the palate. Rotating the specimen (A) allows for better documentation and easier discussion of the regions sampled. Annotations (1 through 10) reflect locations where margins were histologically sampled. The seven unique asterisks, demonstrated on two views, represent margins at-risk. The defect scan ( C ) demonstrates where supplemental margins were harvested and annotated with frozen section numbers, (see G ). To present the anatomic information holistically, radiographic images follow. Preoperative radiograph D is annotated to depict the extent of resection performed. Preoperative radiographs E and F are annotated to map back to the depict margins at-risk. Discussion Analysis using HCD framework pinpointed three specific areas for improvement of current surgical pathology reporting: 1) final margin status, 2) ambiguous anatomic relationships, and 3) lack of relevance to downstream clinicians. Our multidisciplinary approach enabled the development of an improved pathology report that enhances clarity of final margin status and reconciles the extent and location of supplemental margins. HCD methodology is not standardized, and the three phases ( Understand , Explore , and Materialize) may use slightly different terminology across institutions. During the Understand phase, researchers gather as much information as possible about the target population and problem at-hand. During the Explore phase, researchers work with end-users to brainstorm effective solutions to solve identified problems. Finally, during the Materialize phase, the prototype is placed into practice, followed by end-user feedback, improved prototypes based on feedback, and retesting of those prototypes. Several medical institutions have invoked HCD in their research programs and medical education curricula [ 14 , 16 ]. Additionally, HCD methodology has been increasingly used in medicine to provide creative solutions—such as a triage tool for the pediatric emergency departments [ 17 ]—that improve patient care. We invoked these methods to co-design an effective surgical pathology report that addresses gaps identified by the downstream providers who regularly rely on pathology reports. This project is uniquely positioned for HCD methodology because of the collaboration that the permanent pathology report invokes between surgeons, pathologists, oncologists, and other clinicians involved in the postoperative care of cancer patients. It is not surprising that there was a divide between surgeons/pathologists and medical/radiation oncologists with respect to satisfaction with current pathology reporting. Surgeons and pathologists are intimately involved in the activities in the operating room and frozen section lab. However, the reimagined pathology report allows even pathologists to understand how well supplemental margins actually address margins at-risk by identifying the exact location and the breadth of supplemental margins harvested. This allows the pathologist to confidently report on the final margin status. Previously, it was not possible to bridge this essential information gap relying solely on the labeling of supplemental margins. The surgical pathology report is integral to the complex multidisciplinary management of postoperative oncology patients. Ideally, it should present findings in a manner that is easily understood by all. A systematic review by Mossanen et al. (2014) assessed 25 articles on the impact of pathology report formatting on clarity of communication. Their review highlighted the need for better organization within the report, permitting succinct understanding of results and effective interactions between pathologists and clinicians [ 18 ]. The pathology report also plays a pivotal role in holding surgeons and pathologists accountable, and significantly impacts surgical liability [ 1 ]. A well-defined, comprehensive documentation system can reduce human error and ultimately improve patient care. We have previously described our workflow for 3D specimen scanning [ 5 , 12 , 13 ]. The complexity of large head and neck resections render them difficult to document, either by drawing or descriptions. A surgeon needing to understand the location of margins at-risk might have to walk to the frozen laboratory, only to find a dissected specimen bearing no resemblance to the one that was resected. Videoconferencing the margin mapping results using the specimen representations streamlines this process, avoids surgeon down-time, and decreases frustrations for both surgeon and pathologist. The optical scans are produced in the frozen laboratory prior to specimen dissection. After specimen scanning, the pathologist works on the actual resection specimen, identifying margin planes, inking them, and dissecting in the usual manner. Perpendicular scalpel cuts are produced through all margin planes, to visually identify where histological margin sampling is needed. As the tissue blocks are being cut and frozen slides are produced, the pathologist annotates the location of sampled margins onto the virtual specimen representation. Following videoconferencing to describe the margin results, the surgeon annotates 3D defect scans to document location and size of harvested supplemental margins. We have previously demonstrated that 3D defect scans are superior to standard conventional defect photography, as the defect scans are rotated in space to optimize documentation of supplemental margins [ 12 ]. The current literature has yet to address the relationship between pathologists, surgeons and medical and radiation oncologists, and their collaborative quest to deliver vital surgical / pathology information via surgical pathology reporting. We call attention to the pressing need for a more integrated approach among providers, reducing informational silos and increasing understanding of interdisciplinary perspectives. Designing a surgical pathology report that can effectively convey visual anatomic information helps to bridge the communication gap between specialties and promotes a more collaborative approach to patient care. Embedding screen shots selected from 3D specimen and defect models enhance the reader’s ability to appreciate visuospatial information about the locations of margins at-risk, and the harvesting of supplemental margins. This enables downstream clinicians to better participate in shared decision-making processes. With respect to the final margin status, the established final pathology reporting is flawed and fraught with vagaries regarding the labeling process for harvested supplemental margins [ 19 ]. The specimen label may bear little resemblance to the anatomic location of a known margin at-risk. The pathologist may be unable to confirm that a specific supplemental margin actually addresses a particular margin at-risk. Indeed, the difficulty in returning to exact regions at-risk is discussed by Maxwell and colleagues with respect to low-stage oral cancer patients requiring supplemental margins [ 20 ]. They compared outcomes for 3 groups of patients; Group 1 : patients with en-bloc resections and negative specimen-driven margins; Group 2 : patients with inadequate preliminary specimen-driven margins requiring supplemental margins; Group 3 : patients with surgeon sampled margins taken only from the surgical defect. Not surprisingly, the margin status for Group 3 patients did not correlate with outcome, and these patients had the worst local control. These data support resection specimen-driven margin assessment over defect only margin sampling. The Kaplan-Meier curves also demonstrated a trend (p = 0.06) for worst local recurrence for Group 2 compared with Group 1 . One possible explanation is the lack of accuracy when returning to the surgical defect to harvest additional supplemental margins . Another explanation may be with the distribution of worst pattern of invasion, not assessed in these groups. Group 1 may have been skewed towards nonaggressive pattern of invasion, which is more amenable to resection with negative margins, as compared to Group 2, which might have contained more patients with aggressive pattern of invasion, which is more likely to be associated with incomplete resection, and inherently poorer prognosis [ 21 ]. Our approach provides precise anatomical context for margin locations and offers a comprehensive analysis of their status, description, and visualization, which further improves comprehensibility of surgical interventions. Radiation oncologists play an important role in a patient’s postoperative care, which includes planning target volume, dosing boosts, and limiting toxicity to adjacent structures [ 22 ]. We believe that our redesigned pathology report offers downstream providers a better understanding of important anatomic details. Embedding preoperative radiographs into final pathology reports, with the surgeon’s annotations for overall resection contours, and at-risk regions, which required supplemental margins, will help stakeholders to correlate intraoperative findings with postoperative radiographs. Our preliminary survey highlights the difficulties for downstream physicians to understand the precise locations of supplemental margins, especially if several rounds of supplemental margin harvesting are required. Visuospatial annotations of at-risk margins onto the 3D specimen models and harvested supplemental margins onto the 3D defect models provide an excellent means for transmitting information. The importance of embedded annotated radiographs becomes very clear when considering the radiation oncologist’s perspective. The radiation oncologist must embark on an electronic health record treasure hunt , synthesizing data from pathology reports, operative notes, and imaging, to understand where difficulties in tumor clearance were encountered, and what additional tissues were harvested to attain negative margins. These anatomic regions at risk may receive radiation dose boosts. Usually, radiation oncologists might discuss margin status with surgeons several weeks postoperatively, when a surgeon’s memory is murkier. We hope that our redesigned reports will obviate the need for those postoperative discussions. The embedded radiographic details convey 3D landmarks and becomes a vital link from the specimen and defect scans to the overall postoperative reconstruction. This is extremely important as complex surgical resections often require complex reconstructions that include bone and soft tissue taken from other parts of the body. Annotation of defect scans and preoperative radiographs provides a direct link to areas at-risk in postoperative / pre-adjuvant therapy scans. Limitations Response and selection bias were study limitations. Survey responses were limited to only US-based medical institutions and a small sample of physicians. Future work should expand the sample size of included stakeholders from more varied institutional types to further guide development. In this study, we present the best-case scenario of a workflow between head and neck surgeons, pathologists, designated space, equipment, and technical research staff located in the frozen section laboratory and operating room. We recognize that the additional time, effort, and personnel may seem daunting to surgeons and pathologists in other institutions attempting to emulate this process. However, one cannot contest the additional value and inherent beauty of this approach in delivering more detailed information on pathology findings and the actions taken, which sets the stage for more precise postoperative management and surveillance. In our effort to establish a new gold standard of information transfer , we anticipate that future streamlining of this process will reduce the time required to achieve the desired end. Another limitation lies in the inherent challenges of using intraoral 3D scanning to accurately capture complex anatomical areas in smaller defect regions such as the base of the tongue, tonsils, hard and soft palate, oropharynx, and hypopharynx [ 5 ]. We are currently developing a library of “stock” 3D defect models to use when necessary. Conclusion The fundamental goal of designing a new pathology report is to provide downstream members of a patient’s care team with a more detailed record of intraoperative margin findings and information as to where supplemental margins were harvested. This information previously resided in the domain of intraoperative conversations between surgeon and pathologist, which often were not documented or easily retrieved from the electronic health record. Toward that end, our reimagined head and neck pathology report offers visuospatial documentation of at-risk margins based on a 3D resection specimen model and the precise location and breadth of harvested supplemental margins annotated on a 3D surgical defect model. At-risk margins that persist following the completion of surgery can also be identified both on the defect scan as well as the corresponding imaging studies. In addition, our prototype enables reconciliation of frozen section and permanent section results and visualization of annotated radiographic images that correlate to at-risk regions of the defect. We believe that these modifications empower downstream clinicians to understand the intraoperative pathology findings and subsequent actions taken by surgeons. This information potentially guides future clinical decisions. It is an invaluable adjunct for radiologists entrusted with interpreting surveillance imaging. It is important to note that this more detailed pathologic report is not intended to replace the standard CAP protocol for pathologic reporting, but rather to add more precise anatomic information in the form of an addendum to that widely accepted postoperative document. Declarations Acknowledgements We would like to acknowledge the Duke University–NC State University Design Thinking collaboration, particularly David Ming, Richard Chung, and Tsai Lu Liu, for introducing our team members to HCD methodology and to its research applications in the field of medicine. Funding This study was not supported by any funding. The authors declare that they have no conflict of interest. Ethics Approval This article does not contain any studies with human participants or animals performed by any of the authors. This study was approved by the Institutional Review Board of the Icahn School of Medicine at Mount Sinai (STUDY-23-01174). For this type of study informed consent is not required. This study has obtained IRB approval from Icahn School of Medicine at Mount Sinai and the need for informed consent was waived. For this type of study consent for publication is not required. Availability of data and materials Not Applicable Compliance with Ethical Standards This study was not supported by any funding. The authors declare that they have no conflict of interest. This article does not contain any studies with human participants or animals performed by any of the authors. This study was approved by the Institutional Review Board of the Icahn School of Medicine at Mount Sinai (STUDY-23-01174). For this type of study informed consent is not required. This study has obtained IRB approval from Icahn School of Medicine at Mount Sinai and the need for informed consent was waived. For this type of study consent for publication is not required. References Wick MR. Medicolegal liability in surgical pathology: a consideration of underlying causes and selected pertinent concepts, (in eng). Semin Diagn Pathol. May 2007;24(2):89–97. 10.1053/j.semdp.2007.03.003 . Mirham L, Hanna J, Yousef GM. Addressing the Diagnostic Miscommunication in Pathology, (in eng). 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Brandwein-Gensler M et al. Feb., Oral squamous cell carcinoma: histologic risk assessment, but not margin status, is strongly predictive of local disease-free and overall survival, (in eng), Am J Surg Pathol , vol. 29, no. 2, pp. 167 – 78, 2005, 10.1097/01.pas.0000149687.90710.21 . Boero IJ et al. Importance of Radiation Oncologist Experience Among Patients With Head-and-Neck Cancer Treated With Intensity-Modulated Radiation Therapy, (in eng), J Clin Oncol , vol. 34, no. 7, pp. 684 – 90, Mar 1 2016, 10.1200/jco.2015.63.9898 . Additional Declarations No competing interests reported. Supplementary Files Appendixs.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 07 Apr, 2024 Reviews received at journal 01 Apr, 2024 Reviewers agreed at journal 22 Mar, 2024 Reviewers invited by journal 22 Mar, 2024 Editor assigned by journal 22 Mar, 2024 Submission checks completed at journal 22 Mar, 2024 First submitted to journal 20 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4139597","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":282850958,"identity":"a5baaf65-7b9a-402a-a781-fe4e3e10ba12","order_by":0,"name":"Jun Yun","email":"","orcid":"","institution":"Thyroid, Head and Neck Cancer (THANC) Foundation","correspondingAuthor":false,"prefix":"","firstName":"Jun","middleName":"","lastName":"Yun","suffix":""},{"id":282850959,"identity":"8ba756e2-45e1-4897-be24-c08150089ecf","order_by":1,"name":"Danielle Kapustin","email":"","orcid":"","institution":"Thyroid, Head and Neck Cancer (THANC) Foundation","correspondingAuthor":false,"prefix":"","firstName":"Danielle","middleName":"","lastName":"Kapustin","suffix":""},{"id":282850960,"identity":"44e3aa09-34f1-4ee4-9447-d7c85c381293","order_by":2,"name":"Justin K. Joseph","email":"data:image/png;base64,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","orcid":"","institution":"Thyroid, Head and Neck Cancer (THANC) Foundation","correspondingAuthor":true,"prefix":"","firstName":"Justin","middleName":"K.","lastName":"Joseph","suffix":""},{"id":282850961,"identity":"56950f85-9ead-4a13-9276-c5192ac8560f","order_by":3,"name":"Vivian Su","email":"","orcid":"","institution":"Thyroid, Head and Neck Cancer (THANC) Foundation","correspondingAuthor":false,"prefix":"","firstName":"Vivian","middleName":"","lastName":"Su","suffix":""},{"id":282850962,"identity":"9eeb4b86-045e-41eb-a5ea-8cc20d870332","order_by":4,"name":"Ricardo J. Ramirez","email":"","orcid":"","institution":"Thyroid, Head and Neck Cancer (THANC) Foundation","correspondingAuthor":false,"prefix":"","firstName":"Ricardo","middleName":"J.","lastName":"Ramirez","suffix":""},{"id":282850963,"identity":"d8e6c3e3-c3ac-4e65-a269-5369a8106fa4","order_by":5,"name":"Mohemmed N. Khan","email":"","orcid":"","institution":"Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai","correspondingAuthor":false,"prefix":"","firstName":"Mohemmed","middleName":"N.","lastName":"Khan","suffix":""},{"id":282850964,"identity":"f264a7de-a0a0-4ef3-883e-a59850a093f1","order_by":6,"name":"Raymond Chai","email":"","orcid":"","institution":"Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai","correspondingAuthor":false,"prefix":"","firstName":"Raymond","middleName":"","lastName":"Chai","suffix":""},{"id":282850965,"identity":"620b3d68-93fc-4d1c-aceb-47aa2f2b70a7","order_by":7,"name":"Michael Karasick","email":"","orcid":"","institution":"Thyroid, Head and Neck Cancer (THANC) Foundation","correspondingAuthor":false,"prefix":"","firstName":"Michael","middleName":"","lastName":"Karasick","suffix":""},{"id":282850966,"identity":"85d30e07-935b-4717-9d68-6aaf6f64996f","order_by":8,"name":"Christina Wiedmer","email":"","orcid":"","institution":"Department of Pathology, Icahn School of Medicine at Mount Sinai","correspondingAuthor":false,"prefix":"","firstName":"Christina","middleName":"","lastName":"Wiedmer","suffix":""},{"id":282850967,"identity":"b0184dd1-0ca4-41f4-b116-1e252aeac862","order_by":9,"name":"Margaret Brandwein-Weber","email":"","orcid":"","institution":"Department of Pathology, Icahn School of Medicine at Mount Sinai","correspondingAuthor":false,"prefix":"","firstName":"Margaret","middleName":"","lastName":"Brandwein-Weber","suffix":""},{"id":282850970,"identity":"0ea21e20-b0e4-4a3b-babb-555a2c9b6a9e","order_by":10,"name":"Mark L. Urken","email":"","orcid":"","institution":"Thyroid, Head and Neck Cancer (THANC) Foundation","correspondingAuthor":false,"prefix":"","firstName":"Mark","middleName":"L.","lastName":"Urken","suffix":""}],"badges":[],"createdAt":"2024-03-20 21:44:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4139597/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4139597/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53669411,"identity":"21a6252b-5403-4c21-9faf-8e761389f8d2","added_by":"auto","created_at":"2024-03-28 17:36:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1093789,"visible":true,"origin":"","legend":"\u003cp\u003eAn overview of human-centered design (HCD) methodology and component phases, demonstrating the iterative and cyclic nature of this framework.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4139597/v1/2cad03a780fdd955b3c8da9c.png"},{"id":53669409,"identity":"074c171d-a06e-4153-9fec-78282b74ef6d","added_by":"auto","created_at":"2024-03-28 17:36:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":870956,"visible":true,"origin":"","legend":"\u003cp\u003eThree\u003cstrong\u003e \u003c/strong\u003ekey areas of improvement resulting from Thematic Content Analysis using Mural®. The emerging themes and examples of “pain points” are: 1) \u003cstrong\u003eComprehension of Final Margin Status\u003c/strong\u003e (primary vs supplemental margin status, final margin status unavailable, confusion when margin is positive on permanent, but separately submitted margins are negative, difficult finding data on margin status). 2) \u003cstrong\u003eAmbiguous anatomic relationships\u003c/strong\u003e (lack of correlation with intraoperative findings, no documentation of communication between surgeons and pathologists, lack of visualizations, difficult to identify true surgical margin, exact location of margins at risk lacking) 3) \u003cstrong\u003eLack of relevance to downstream clinical management (\u003c/strong\u003ereport too detailed, information not relevant for downstream providers and clinical decision-making).\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4139597/v1/6e3319d7e87778ed3ef5fc68.png"},{"id":53669412,"identity":"d0b15318-0726-4d4f-8943-b8c99d1e6b8d","added_by":"auto","created_at":"2024-03-28 17:36:20","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":11903802,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA:\u003c/strong\u003e The Reimagined Pathology Report, Example 1 – Palatectomy.\u003c/p\u003e\n\u003cp\u003eScreen shots of two views of the 3D resection specimen model. “\u003cstrong\u003eB” \u003c/strong\u003eshows the mucosal aspect of the palate. Rotating the specimen \u003cstrong\u003e(A) \u003c/strong\u003eallows for better\u003cstrong\u003e \u003c/strong\u003edocumentation and easier discussion of the regions sampled. Annotations (1 through 10) reflect locations where margins were histologically sampled. The seven unique asterisks, demonstrated on two views, represent margins\u003cstrong\u003e \u003c/strong\u003eat-risk. The defect scan (\u003cstrong\u003eC\u003c/strong\u003e) demonstrates where supplemental margins were harvested and annotated with frozen section numbers, (see \u003cstrong\u003eG\u003c/strong\u003e). To present the anatomic information holistically, radiographic images follow. Preoperative radiograph \u003cstrong\u003eD \u003c/strong\u003eis annotated to depict the extent of resection performed. Preoperativeradiographs \u003cstrong\u003eE \u003c/strong\u003eand\u003cstrong\u003e F \u003c/strong\u003eare annotated to map back to the depict margins at-risk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB:\u003c/strong\u003e This is the final margin reconciliation table\u003cstrong\u003e (G)\u003c/strong\u003e. To improve data presentation, this table is limited to a line-by-line accounting of the seven margins at-risk (left, red) plus the corresponding supplemental margins (right green). Downstream users can grasp at a glance that all margins at-risk (7 line items) were adequately addressed. Note that the number of supplemental margins need not equal the number of margins at risk. The keystone of margin reconciliation is the discussion between surgeon and pathologist (frozen section time out) and the agreement that all margins at risk were addressed. This allows the pathologist to confidently report on the final margin status\u003c/p\u003e\n\u003cp\u003eThe data associated with \u003cem\u003e\u003cstrong\u003eall\u003c/strong\u003e\u003c/em\u003e of the sampled margins plus other negative supplemental margins, are presented elsewhere in the report, and are not illustrated here. The thumbnails (top) represent the usual Word-based elements of the pathology report. This multimedia report is issued as an addendum following the CAP synoptic.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4139597/v1/08d7b0e9e18436110b019185.png"},{"id":53669413,"identity":"6ad60dac-9973-4af6-98ef-1e2d5210306d","added_by":"auto","created_at":"2024-03-28 17:36:20","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":11655246,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA:\u003c/strong\u003e The Reimagined Pathology Report, Example 2 - Retromolar trigone, mandibulectomy.\u003c/p\u003e\n\u003cp\u003eScreen shots of the 3D resection specimen model representing buccal (A) and lingual (B) aspects of right hemimandible. Annotations (1 through 9) reflect locations where margins were histologically sampled. The asterisks represent two margins at-risk. The defect scan (\u003cstrong\u003eC\u003c/strong\u003e) reflects where two supplemental margins were harvested and is annotated with the frozen section numbers (Buccal deep FS 1279, and floor of mouth FS 1285). Preoperative radiograph \u003cstrong\u003eD\u003c/strong\u003e shows the extent of resection. Radiograph\u003cstrong\u003e E\u003c/strong\u003e maps back to the soft tissue margins at-risk.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB:\u003c/strong\u003e The final margin reconciliation table\u003cstrong\u003e (F) \u003c/strong\u003econtains line-by-line accounting of margins at-risk (left, red) and corresponding supplemental margins (right green). It is important to reiterate that defect and radiograph annotations are performed by the surgeon either during or immediate after surgery. These data provide the radiation oncologist an accurate reflection of the location and extent of supplemental margins harvested., which is important for treatment planning. At a glance, one can see here that both margins at risk were successfully addressed. As with Fig. 3, the comprehensive margin data is located elsewhere in the report. The thumbnails (top) represent the usual Word-based elements of the pathology report. This multimedia report is added as an addendum following the CAP synoptic.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4139597/v1/0779ade1a46ae0fb80f81c27.png"},{"id":53669414,"identity":"71354b79-a068-4cff-a7c1-1261f883d0f7","added_by":"auto","created_at":"2024-03-28 17:36:20","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":10404578,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eA:\u003c/strong\u003e The Reimagined Pathology Report, Example 3 – Rhinectomy\u003c/p\u003e\n\u003cp\u003eFront and back views of the 3D resection specimen model (\u003cstrong\u003eA, B\u003c/strong\u003e). Annotations reflect locations of margins histologically sampled. The asterisks represent margins\u003cstrong\u003e \u003c/strong\u003eat-risk. The defect scan \u003cstrong\u003e(C) \u003c/strong\u003eshows where all supplemental margins were harvested. For clearer data presentation since many negative supplemental margins were also harvested, we only label those supplemental margins that addressed margins at risk, with the corresponding frozen section numbers (superior (FS 1831, FS 1832), lateral nasal (FS 1843), and left lateral subcutaneous (FS 1844). \u0026nbsp;Radiographic images show PET (\u003cstrong\u003eD\u003c/strong\u003e) and CT (\u003cstrong\u003eE\u003c/strong\u003e) with extent of resection. \u003cstrong\u003eF: \u003c/strong\u003eLeft lateral and left subcutaneous margins at risk mapped back to CT scan. \u003cstrong\u003eG:\u003c/strong\u003e Superior margin at risk mapped back to CT scan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB:\u003c/strong\u003e The final margin reconciliation table\u003cstrong\u003e (H) \u003c/strong\u003econtains line-by-line accounting of margins at-risk (left side table, red), and supplemental margins (right side table, green). The reader can grasp at a glance that the combination of intraoperative margin mapping plus final pathology sections revealed three margins at risk (superior nasal, FS 1829), (left nasal, A11), (left subcutaneous, FS 1830) that were addressed by four supplemental margins which were all negative. \u0026nbsp;The thumbnails (top) represent the usual Word-based elements of the pathology report. The illustrations are added as an addendum after the CAP synoptic.\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-4139597/v1/f8213b669599285fef5872e6.png"},{"id":53669943,"identity":"173fc90a-36a4-477f-b7e4-ed64b683248f","added_by":"auto","created_at":"2024-03-28 17:44:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2365911,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4139597/v1/558846fc-073e-410b-a358-e7c8f124f2a1.pdf"},{"id":53669939,"identity":"eed7c897-4248-4230-8fdb-33738592287b","added_by":"auto","created_at":"2024-03-28 17:44:19","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":17325,"visible":true,"origin":"","legend":"","description":"","filename":"Appendixs.docx","url":"https://assets-eu.researchsquare.com/files/rs-4139597/v1/64d9ffde0a911266ed1db800.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Reimagining Pathology Reporting for Head and Neck Cancer Resections: 3D Visualizations and Margin Reconciliation","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe pathology report follows cancer patients throughout their journey from treatment, to surveillance, and survivorship. It is a road map for radiation oncologists who determine the need for radiation boosts and where these boosts should be administered. This road map also aids radiologists in interpreting post-treatment surveillance scans. Producing accurate, timely, and clear surgical pathology reports is integral to effective postoperative management of head and neck surgical oncology patients and for informed radiographic surveillance.\u003c/p\u003e \u003cp\u003eIt is apparent, however, that surgical pathology reports have fallen short of effectively conveying relevant and sufficient information to providers [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A study by \u003cem\u003ePowsner et al. (2000)\u003c/em\u003e assessed surgeons\u0026rsquo; understanding of surgical pathology reports for specimens of varying complexity [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Test scores revealed that surgeons misinterpreted pathology reports 30% of the time. Thus, surgeons and pathologists have a significant communication gap [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Furthermore, surgical pathology reports have been largely stagnant over the past several decades and an understanding of their clarity and value to downstream caregivers has not been explored.\u003c/p\u003e \u003cp\u003eThree-dimensional (3D) specimen scanning has pushed the boundaries of intraoperative communication by enabling visualization of the resection specimen and conveyance of critical margin status information [\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9 CR10\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. We have now transcended the limitations inherent in purely written narrative by using \u003cb\u003e3D virtual representations\u003c/b\u003e of \u003cb\u003eresection specimens and surgical defects\u003c/b\u003e. This has transformed intraoperative communication regarding the exact locations of inadequate margins [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Close margins refer to a distance of \u0026lt;\u0026thinsp;5 mm from invasive carcinoma; positive margins refers to \u0026ldquo;cut-through\u0026rdquo;. To simplify communication, we refer to either close and/or positive margins as \u0026ldquo;\u003cb\u003eat-risk\u003c/b\u003e\u0026rdquo;, as either category requires a surgical response. Larger resection specimens, by their nature, invite a greater risk of failing to convey important anatomical details. We have addressed this by videoconferencing from the frozen section laboratory into the operating room and showing 3D representations of the resection specimens generated prior to dissection and histologic margin mapping. The 3D \u003cem\u003especimen\u003c/em\u003e representations are annotated with the location of all histologically sampled margins and the pathology results. 3D scanning of the surgical \u003cem\u003edefect\u003c/em\u003e allows surgeons to accurately document the locations and breadth of supplemental margins that address margins at-risk [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Our previously published \u0026ldquo;frozen section timeout form\u0026rdquo; connects these two processes and transparently documents that the intraoperative margin status has been discussed, understood, and addressed [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Importantly, this form allows for visualization of the margins at-risk, correlated with the supplemental margins harvested based on initial results. It links the actionable pathologic findings from specimen analysis with the downstream supplemental actions and margin results, and clearly documents the important intraoperative steps taken.\u003c/p\u003e \u003cp\u003eWe surveyed multidisciplinary stakeholders to determine how to improve resection margin reporting and identified a unique opportunity for enhancing reporting of complex head and neck cancer resections. We provide enhanced visuospatial documentation of the resection specimen, surgical defect, and final surgical margin status by generating mixed-media pathology reports that include screen shots from digitally annotated 3D resection specimen and defect models [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Given the above advances in intraoperative communication on margin surveillance, it is clear that there is room for innovation in permanent surgical pathology reporting.\u003c/p\u003e \u003cp\u003eOur enhanced reporting facilitates more precise design of adjuvant radiotherapy fields and improved radiographic surveillance. Including precise surgeon-annotated preoperative radiographic images into a pathology report may seem unusual, but it is the perfect home for this valuable information, which informs the radiation oncologist of the extent of surgery and highlights locations of intraoperative margin challenges. This annotated preoperative radiograph (CT, MRI, PET CT) can be mapped to postoperative scans and used for treatment planning and surveillance.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eThis cross-sectional study used human-centered design (HCD), a quality improvement (QI) initiative commonly implemented to design products that best address the needs of end-users [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Three key phases of HCD - \u003cem\u003eUnderstand, Explore, and Materialize\u003c/em\u003e \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e - were leveraged to implement our proposed permanent pathology report. Beginning with the \u003cem\u003eUnderstand\u003c/em\u003e phase, we identified the target audience of physicians who most often use surgical pathology reports, including head and neck surgeons, pathologists, radiation and medical oncologists. In accordance with the principles of HCD, particularly user-centeredness, we surveyed the needs of these representative groups to define the problem at-hand.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and Data Collection\u003c/h2\u003e \u003cp\u003eA 9-item survey was distributed electronically across several United States based medical institutions to acquire feedback from key stakeholders using convenience sampling methodology [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. We recruited a diverse sample of providers from various geographic locations, health system sizes, specialties, and backgrounds. We distributed our questionnaire-based survey to experts in the aforementioned fields, and these initial stakeholders then distributed the survey amongst their colleagues\u0026mdash;using snowball sampling to add participants at their respective institutions. The online questionnaire-based survey was designed using SurveyMonkey\u0026reg; (\u003cem\u003eMomentive, SurveyMonkey.com)\u003c/em\u003e to assess the strengths and shortcomings of the existing permanent pathology report used at participants' own institutions. A crucial aspect of the HCD framework involves incorporating open-ended survey questions, which are included in \u003cb\u003eAppendix 1\u003c/b\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eTwo independent reviewers analyzed survey results and manually identified themes expressed by stakeholders. Data was analyzed through Mural\u0026reg; (\u003cem\u003eTactivos, Inc., San Francisco, CA\u003c/em\u003e), a collaborative visualization tool which highlights key themes and the underlying relationships between themes, subthemes, and stakeholders. Based on the survey results, a novel surgical pathology report template was designed and implemented by the Departments of Pathology and Otolaryngology - Head and Neck Surgery at Mount Sinai West Hospital between January 31, 2023 and October 20, 2023. We improved upon the electronic \u0026ldquo;frozen section timeout\u0026rdquo; form described by \u003cem\u003eKapustin et al. (2023)\u003c/em\u003e by undergoing iterative brainstorming and prototyping sessions to incorporate new features based on stakeholder feedback [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This study was approved by the Institutional Review Board of the Icahn School of Medicine at Mount Sinai (STUDY-23-01174).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eExplore Phase: Survey Findings\u003c/h2\u003e \u003cp\u003eForty-seven physicians completed our survey. Survey response rate cannot be reported because the total number of survey recipients are unknown due to snowball sampling methods. The respondents consisted of 10 (21%) medical oncologists, 13 (28%) radiation oncologists, 9 (19%) pathologists, and 15 (32%) head and neck surgeons. Most respondents were between 11\u0026ndash;20 years from completion of residency or fellowship training and were affiliated with an academic practice (91%). There were 11 national institutions involved; the majority of respondents were associated with the University Hospital Cleveland Medical Center (24%), Moffitt Cancer Center (15%), and Massachusetts General Hospital (13%) \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRespondent Institutions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInstitution\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of Respondents\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity Hospital Cleveland Medical Center (OH)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMoffitt Cancer Center (FL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMassachusetts General Hospital (MA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity of Virginia Health (VA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMemorial Sloan Kettering Cancer Center (NY)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMount Sinai Health System (NY)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKeck Medicine of the University of Southern California (CA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity of Washington Medicine (WA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFox Chase Cancer Center at Temple University Hospital (PA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eValley Health (NJ)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity of Michigan Health (MI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e46*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e100%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cb\u003e*\u003c/b\u003eOne respondent out of our total 47 respondents did not identify their home institution.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe following major gaps in current surgical pathology reports were identified: lack of clarity regarding \u0026ldquo;whether the supplemental margins harvested reflect clear margins for the entire specimen\u0026rdquo; (n\u0026thinsp;=\u0026thinsp;28); \u0026ldquo;final margin status\u0026rdquo; (n\u0026thinsp;=\u0026thinsp;20); and the \u0026ldquo;extent of supplemental margins harvested intraoperatively\u0026rdquo; (n\u0026thinsp;=\u0026thinsp;20) \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e. Thematic content analysis led to the emergence of three areas of improvement for current pathology reports \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e: 1) Ambiguousfinal margin status, 2) Ambiguous anatomic relationships, 3) Lack of relevance to downstream clinical management.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGaps identified in the current surgical pathology report. Participants were instructed to select all that apply.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnswer Choice\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnclear whether the supplemental margins harvested reflect clear margins for the entire specimen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtent of supplemental margins harvested intraoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal margin status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation of supplemental margins harvested intraoperatively\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInitial specimen margins\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther (please specify)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eInformation gaps were a more common complaint among radiation and medical oncologists (14/23 or 61%) compared with surgeons and pathologists (4/24 or 16%). Radiation and medical oncologists acknowledged that current pathology reports are difficult to navigate and critical information is not easily accessible. On the contrary, surgeons and pathologists reported finding permanent surgical pathology reports easy to navigate and that they were able to efficiently access critical information. Overall, 28/47 (60%) of respondents reported uncertainty regarding whether re-excised supplemental margins reflected clear margins for the entire specimen, and 20/47 (43%) reported uncertainty regarding the final margin status at the conclusion of the case. Lastly, 20/47 (43%) reported the need for greater clarity regarding the extent of supplemental margins harvested intraoperatively.\u003c/p\u003e \u003cp\u003eUsing thematic content analysis, key themes emerged from responses to the \u0026ldquo;ideation\u0026rdquo; survey question including recommendations for more visualizations in pathology reports, improvement in clarity of reported margin status, and workflow improvement regarding intraoperative surgeon/pathologist communication. With respect to visualization, several respondents requested gross images of the resection specimen and surgical defect, 3D modeling, clearly marked correlations between specimen and defect, and margin details within the pathology report. \u003cb\u003eAppendix 2\u003c/b\u003e lists specific recommendations from survey responses corresponding to these key themes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eExplore Phase: Prototyping\u003c/h2\u003e \u003cp\u003eA \u0026ldquo;reimagined\u0026rdquo; pathology report template was designed to address the three areas of improvement identified from survey responses: lack of clarity regarding 1) final margin status, 2) extent of supplemental margins harvested intraoperatively, and 3) whether the harvested supplemental margins reflected final clear margin status. Screenshots from the pathologist-annotated 3D specimen models are embedded into the template demonstrating the location of histologically sampled margins. Screenshots from the surgeon-annotated 3D surgical defect scans are also embedded into the template, and document the location and the breadth of harvested supplemental margins. The surgeon also annotates preoperative CT, MRI, and/or PET-CT scans immediately after surgery, mapping 1) the extent of tumor resection and 2) regions with margins at-risk that required supplemental margins. Annotations of both the defect scan and preoperative radiographs also convey information from the final pathologic analysis that supersedes the frozen section analysis, if there is a discrepancy. We believe that embedding these surgeon-annotated preoperative scans are particularly valuable for radiation oncologists and radiologists, as these providers need precise anatomic information. Lastly, to focus attention to the initial margins at-risk and harvested supplemental margins, we embed a \u0026ldquo;Final Margin Reconciliation\u0026rdquo; table at the end of the report, which clearly communicates the final margin status.\u003c/p\u003e \u003cp\u003e \u003cb\u003eFig.s 3\u0026ndash;5\u003c/b\u003e illustrate these novel components of the \u0026ldquo;Reimagined Pathology Report\u0026rdquo; in the context of the entire pathology report shown as thumbnails on the top of the illustrations. Other standard reporting elements, such as the frozen section \u003cspan refid=\"Sec6\" class=\"InternalRef\"\u003eresults\u003c/span\u003e and the CAP synoptic report, are contained within the complete report and not illustrated here. These images and table are added as an addendum, after the final margin status is known. They can be directly viewed in the Powerpath environment. At this time, the images do not migrate downstream into the electronic health record environment (EPIC). The pathology report refers clinicians to the Powerpath environment for viewing with the following comment: \u003cem\u003e\u0026ldquo;When reviewing this report in EPIC, please click Results Report in the upper left screen. This allows you to view the report as published in Powerpath. Scroll down to view embedded images.\u0026rdquo;\u003c/em\u003e Alternatively, the pathology report can refer to an addendum uploaded to the media section of EPIC. All of the elements of the final pathology report can be printed and sent to clinicians outside of the immediate institution where the surgery was performed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eMaterialize Phase: Testing and Implementing\u003c/h2\u003e \u003cp\u003eThroughout the testing phase, pathologists completed newly designed pathology report templates during frozen section analysis and updated them with the final results. After interacting with our template, pathologists provided feedback in short feedback sessions. Feedback was overwhelmingly positive, with one participant stating, \u0026ldquo;having supplemental margins drawn in intraoperatively is priceless.\u0026rdquo; Overall, 61 permanent pathology reports were compiled using our novel permanent pathology report template over a 12-month period. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes the ablative procedures performed.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSixty-one procedures for which permanent surgical pathology reports were compiled.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcedure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePalatomaxillectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlossectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal laryngopharyngectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComposite resection of mandible, tongue, and floor of mouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMandibulectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal parotidectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetromolar Trigone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSoft tissue oral cavity resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUpper lip resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSoft tissue oropharyngeal resection via lip split\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadical parotidectomy, mandibulectomy, and skull base resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRhinoplasty with septal repair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubfascial tumor of soft tissue of neck\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScalp Resection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cb\u003eLegends\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eScreen shots of two views of the 3D resection specimen model. \u0026ldquo;\u003cb\u003eB\u0026rdquo;\u003c/b\u003e shows the mucosal aspect of the palate. Rotating the specimen \u003cb\u003e(A)\u003c/b\u003e allows for better documentation and easier discussion of the regions sampled. Annotations (1 through 10) reflect locations where margins were histologically sampled. The seven unique asterisks, demonstrated on two views, represent margins at-risk. The defect scan (\u003cb\u003eC\u003c/b\u003e) demonstrates where supplemental margins were harvested and annotated with frozen section numbers, (see \u003cb\u003eG\u003c/b\u003e). To present the anatomic information holistically, radiographic images follow. Preoperative radiograph \u003cb\u003eD\u003c/b\u003e is annotated to depict the extent of resection performed. Preoperative radiographs \u003cb\u003eE\u003c/b\u003e and \u003cb\u003eF\u003c/b\u003e are annotated to map back to the depict margins at-risk.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAnalysis using HCD framework pinpointed three specific areas for improvement of current surgical pathology reporting: 1) final margin status, 2) ambiguous anatomic relationships, and 3) lack of relevance to downstream clinicians. Our multidisciplinary approach enabled the development of an improved pathology report that enhances clarity of final margin status and reconciles the extent and location of supplemental margins.\u003c/p\u003e \u003cp\u003eHCD methodology is not standardized, and the three phases (\u003cem\u003eUnderstand\u003c/em\u003e, \u003cem\u003eExplore\u003c/em\u003e, and \u003cem\u003eMaterialize)\u003c/em\u003e may use slightly different terminology across institutions. During the \u003cem\u003eUnderstand\u003c/em\u003e phase, researchers gather as much information as possible about the target population and problem at-hand. During the \u003cem\u003eExplore\u003c/em\u003e phase, researchers work with end-users to brainstorm effective solutions to solve identified problems. Finally, during the \u003cem\u003eMaterialize\u003c/em\u003e phase, the prototype is placed into practice, followed by end-user feedback, improved prototypes based on feedback, and retesting of those prototypes.\u003c/p\u003e \u003cp\u003eSeveral medical institutions have invoked HCD in their research programs and medical education curricula [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Additionally, HCD methodology has been increasingly used in medicine to provide creative solutions\u0026mdash;such as a triage tool for the pediatric emergency departments [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u0026mdash;that improve patient care. We invoked these methods to co-design an effective surgical pathology report that addresses gaps identified by the downstream providers who regularly rely on pathology reports. This project is uniquely positioned for HCD methodology because of the collaboration that the permanent pathology report invokes between surgeons, pathologists, oncologists, and other clinicians involved in the postoperative care of cancer patients.\u003c/p\u003e \u003cp\u003eIt is not surprising that there was a divide between surgeons/pathologists and medical/radiation oncologists with respect to satisfaction with current pathology reporting. Surgeons and pathologists are intimately involved in the activities in the operating room and frozen section lab. However, the reimagined pathology report allows even pathologists to understand how well supplemental margins actually address margins at-risk by identifying the exact location and the breadth of supplemental margins harvested. This allows the pathologist to confidently report on the final margin status. Previously, it was not possible to bridge this essential information gap relying solely on the labeling of supplemental margins.\u003c/p\u003e \u003cp\u003eThe surgical pathology report is integral to the complex multidisciplinary management of postoperative oncology patients. Ideally, it should present findings in a manner that is easily understood by all. A systematic review by \u003cem\u003eMossanen et al. (2014)\u003c/em\u003e assessed 25 articles on the impact of pathology report formatting on clarity of communication. Their review highlighted the need for better organization within the report, permitting succinct understanding of results and effective interactions between pathologists and clinicians [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The pathology report also plays a pivotal role in holding surgeons and pathologists accountable, and significantly impacts surgical liability [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. A well-defined, comprehensive documentation system can reduce human error and ultimately improve patient care.\u003c/p\u003e \u003cp\u003eWe have previously described our workflow for 3D specimen scanning [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The complexity of large head and neck resections render them difficult to document, either by drawing or descriptions. A surgeon needing to understand the location of margins at-risk might have to walk to the frozen laboratory, only to find a dissected specimen bearing no resemblance to the one that was resected. Videoconferencing the margin mapping results using the specimen representations streamlines this process, avoids surgeon down-time, and decreases frustrations for both surgeon and pathologist. The optical scans are produced in the frozen laboratory prior to specimen dissection. After specimen scanning, the pathologist works on the actual resection specimen, identifying margin planes, inking them, and dissecting in the usual manner. Perpendicular scalpel cuts are produced through all margin planes, to visually identify where histological margin sampling is needed. As the tissue blocks are being cut and frozen slides are produced, the pathologist annotates the location of sampled margins onto the virtual specimen representation. Following videoconferencing to describe the margin results, the surgeon annotates 3D defect scans to document location and size of harvested supplemental margins. We have previously demonstrated that 3D defect scans are superior to standard conventional defect photography, as the defect scans are rotated in space to optimize documentation of supplemental margins [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe current literature has yet to address the relationship between pathologists, surgeons and medical and radiation oncologists, and their collaborative quest to deliver vital surgical / pathology information via surgical pathology reporting. We call attention to the pressing need for a more integrated approach among providers, reducing informational silos and increasing understanding of interdisciplinary perspectives. Designing a surgical pathology report that can effectively convey visual anatomic information helps to bridge the communication gap between specialties and promotes a more collaborative approach to patient care. Embedding screen shots selected from 3D specimen and defect models enhance the reader\u0026rsquo;s ability to appreciate visuospatial information about the locations of margins at-risk, and the harvesting of supplemental margins. This enables downstream clinicians to better participate in shared decision-making processes.\u003c/p\u003e \u003cp\u003eWith respect to the final margin status, the established final pathology reporting is flawed and fraught with vagaries regarding the labeling process for harvested supplemental margins [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The specimen label may bear little resemblance to the anatomic location of a known margin at-risk. The pathologist may be unable to confirm that a specific supplemental margin actually addresses a particular margin at-risk. Indeed, the difficulty in returning to exact regions at-risk is discussed by Maxwell and colleagues with respect to low-stage oral cancer patients requiring supplemental margins [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. They compared outcomes for 3 groups of patients; \u003cb\u003eGroup 1\u003c/b\u003e: patients with en-bloc resections and negative specimen-driven margins; \u003cb\u003eGroup 2\u003c/b\u003e: patients with inadequate preliminary specimen-driven margins requiring supplemental margins; \u003cb\u003eGroup 3\u003c/b\u003e: patients with surgeon sampled margins taken only from the surgical defect. Not surprisingly, the margin status for \u003cb\u003eGroup 3\u003c/b\u003e patients did not correlate with outcome, and these patients had the worst local control. These data support resection specimen-driven margin assessment over defect only margin sampling. The Kaplan-Meier curves also demonstrated a trend (p\u0026thinsp;=\u0026thinsp;0.06) for worst local recurrence for \u003cb\u003eGroup 2\u003c/b\u003e compared with \u003cb\u003eGroup 1\u003c/b\u003e. \u003cb\u003eOne possible explanation is the lack of accuracy when returning to the surgical defect to harvest additional supplemental margins\u003c/b\u003e. Another explanation may be with the distribution of worst pattern of invasion, not assessed in these groups. Group 1 may have been skewed towards nonaggressive pattern of invasion, which is more amenable to resection with negative margins, as compared to Group 2, which might have contained more patients with aggressive pattern of invasion, which is more likely to be associated with incomplete resection, and inherently poorer prognosis [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Our approach provides precise anatomical context for margin locations and offers a comprehensive analysis of their status, description, and visualization, which further improves comprehensibility of surgical interventions.\u003c/p\u003e \u003cp\u003eRadiation oncologists play an important role in a patient\u0026rsquo;s postoperative care, which includes planning target volume, dosing boosts, and limiting toxicity to adjacent structures [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. We believe that our redesigned pathology report offers downstream providers a better understanding of important anatomic details. Embedding preoperative radiographs into final pathology reports, with the surgeon\u0026rsquo;s annotations for overall resection contours, and at-risk regions, which required supplemental margins, will help stakeholders to correlate intraoperative findings with postoperative radiographs. Our preliminary survey highlights the difficulties for downstream physicians to understand the precise locations of supplemental margins, especially if several rounds of supplemental margin harvesting are required. Visuospatial annotations of at-risk margins onto the 3D specimen models and harvested supplemental margins onto the 3D defect models provide an excellent means for transmitting information. The importance of embedded annotated radiographs becomes very clear when considering the radiation oncologist\u0026rsquo;s perspective. The radiation oncologist must embark on an \u003cb\u003eelectronic health record treasure hunt\u003c/b\u003e, synthesizing data from pathology reports, operative notes, and imaging, to understand where difficulties in tumor clearance were encountered, and what additional tissues were harvested to attain negative margins. These anatomic regions at risk may receive radiation dose boosts. Usually, radiation oncologists might discuss margin status with surgeons several weeks postoperatively, when a surgeon\u0026rsquo;s memory is murkier. We hope that our redesigned reports will obviate the need for those postoperative discussions. The embedded radiographic details convey 3D landmarks and becomes a vital link from the specimen and defect scans to the overall postoperative reconstruction. This is extremely important as complex surgical resections often require complex reconstructions that include bone and soft tissue taken from other parts of the body. Annotation of defect scans and preoperative radiographs provides a direct link to areas at-risk in postoperative / pre-adjuvant therapy scans.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eResponse and selection bias were study limitations. Survey responses were limited to only US-based medical institutions and a small sample of physicians. Future work should expand the sample size of included stakeholders from more varied institutional types to further guide development. In this study, we present the \u003cb\u003ebest-case scenario\u003c/b\u003e of a workflow between head and neck surgeons, pathologists, designated space, equipment, and technical research staff located in the frozen section laboratory and operating room. We recognize that the additional time, effort, and personnel may seem daunting to surgeons and pathologists in other institutions attempting to emulate this process. However, one cannot contest the additional value and inherent beauty of this approach in delivering more detailed information on pathology findings and the actions taken, which sets the stage for more precise postoperative management and surveillance. In our effort to establish a \u003cb\u003enew gold standard of information transfer\u003c/b\u003e, we anticipate that future streamlining of this process will reduce the time required to achieve the desired end.\u003c/p\u003e \u003cp\u003eAnother limitation lies in the inherent challenges of using intraoral 3D scanning to accurately capture complex anatomical areas in smaller defect regions such as the base of the tongue, tonsils, hard and soft palate, oropharynx, and hypopharynx [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. We are currently developing a library of \u0026ldquo;stock\u0026rdquo; 3D defect models to use when necessary.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe fundamental goal of designing a new pathology report is to provide downstream members of a patient\u0026rsquo;s care team with a more detailed record of intraoperative margin findings and information as to where supplemental margins were harvested. \u003cb\u003eThis information previously resided in the domain of intraoperative conversations between surgeon and pathologist, which often were not documented or easily retrieved from the electronic health record.\u003c/b\u003e Toward that end, our reimagined head and neck pathology report offers visuospatial documentation of at-risk margins based on a 3D resection specimen model and the precise location and breadth of harvested supplemental margins annotated on a 3D surgical defect model. At-risk margins that persist following the completion of surgery can also be identified both on the defect scan as well as the corresponding imaging studies. In addition, our prototype enables reconciliation of frozen section and permanent section \u003cspan refid=\"Sec6\" class=\"InternalRef\"\u003eresults\u003c/span\u003e and visualization of annotated radiographic images that correlate to at-risk regions of the defect. We believe that these modifications empower downstream clinicians to understand the intraoperative pathology findings and subsequent actions taken by surgeons. This information potentially guides future clinical decisions. It is an invaluable adjunct for radiologists entrusted with interpreting surveillance imaging. It is important to note that this more detailed pathologic report is not intended to replace the standard CAP protocol for pathologic reporting, but rather to add more precise anatomic information in the form of an addendum to that widely accepted postoperative document.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to acknowledge the Duke University\u0026ndash;NC State University Design Thinking collaboration, particularly David Ming, Richard Chung, and Tsai Lu Liu, for introducing our team members to HCD methodology and to its research applications in the field of medicine.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not supported by any funding. The authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis article does not contain any studies with human participants or animals performed by any of the authors. This study was approved by the Institutional Review Board of the Icahn School of Medicine at Mount Sinai\u0026nbsp;(STUDY-23-01174).\u0026nbsp;For this type of study informed consent is not required. This study has obtained IRB approval from Icahn School of Medicine at Mount Sinai and the need for informed consent was waived.\u0026nbsp;For this type of study consent for publication is not required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompliance with Ethical Standards\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not supported by any funding. The authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003eThis article does not contain any studies with human participants or animals performed by any of the authors. This study was approved by the Institutional Review Board of the Icahn School of Medicine at Mount Sinai (STUDY-23-01174). For this type of study informed consent is not required. This study has obtained IRB approval from Icahn School of Medicine at Mount Sinai and the need for informed consent was waived. For this type of study consent for publication is not required.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWick MR. Medicolegal liability in surgical pathology: a consideration of underlying causes and selected pertinent concepts, (in eng). Semin Diagn Pathol. May 2007;24(2):89\u0026ndash;97. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1053/j.semdp.2007.03.003\u003c/span\u003e\u003cspan address=\"10.1053/j.semdp.2007.03.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMirham L, Hanna J, Yousef GM. Addressing the Diagnostic Miscommunication in Pathology, (in eng). 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Importance of Radiation Oncologist Experience Among Patients With Head-and-Neck Cancer Treated With Intensity-Modulated Radiation Therapy, (in eng), \u003cem\u003eJ Clin Oncol\u003c/em\u003e, vol. 34, no. 7, pp. 684\u0026thinsp;\u0026ndash;\u0026thinsp;90, Mar 1 2016, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1200/jco.2015.63.9898\u003c/span\u003e\u003cspan address=\"10.1200/jco.2015.63.9898\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"head-and-neck-pathology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Head and Neck Pathology](https://www.springer.com/journal/12105)","snPcode":"12105","submissionUrl":"https://submission.springernature.com/new-submission/12105/3","title":"Head and Neck Pathology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"human centered design, surgical pathology report, frozen section, multimedia report, 3D scanning","lastPublishedDoi":"10.21203/rs.3.rs-4139597/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4139597/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003ePurpose\u003c/b\u003e\u003c/p\u003e \u003cp\u003eSurgical pathology reports play an integral role in postoperative management of head and neck cancer patients. Pathology reports of complex head and neck resections must convey critical information to all involved clinicians. Previously, we demonstrated the utility of 3D specimen and defect scanning for communicating margin status and documenting the location of supplemental margins. We introduce a newly-designed permanent pathology report which improves documentation of intraoperative margin mapping and extent of corresponding supplemental margins harvested.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA cross-sectional study using human-centered design was implemented to evaluate the existing permanent pathology report with respect to understanding margin status. Pathologists, surgeons, radiation oncologists, and medical oncologists from United States-based medical institutions were surveyed. The results supported a redesign of our surgical pathology template, incorporating 3D specimen / defect scans and annotated radiographic images indicating location of inadequate margins requiring supplemental margins, or indicating frankly positive margins discovered on permanent section.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eForty-seven physicians completed our survey. Analyzing surgical pathology reports, 28/47 (60%) respondents reported confusion whether re-excised supplemental margins reflected clear margins, 20/47 (43%) reported uncertainty regarding final margin status, and 20/47 (43%) reported the need for clarity regarding the extent of supplemental margins harvested intraoperatively. From this feedback, 61 permanent pathology reports were compiled using newly-designed reporting templates over a 12 month period.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFeedback from survey respondents led to a redesigned permanent pathology report that offers detailed visual anatomic information regarding intraoperative margin findings and exact location/size of harvested supplemental margins. This reimagined report reconciles frozen and permanent section results and includes annotated radiographic images such that clinicians can discern precise actions taken by surgeons to address inadequate margins.\u003c/p\u003e","manuscriptTitle":"Reimagining Pathology Reporting for Head and Neck Cancer Resections: 3D Visualizations and Margin Reconciliation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-28 17:36:14","doi":"10.21203/rs.3.rs-4139597/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-04-07T09:56:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-01T18:14:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"0f7a439c-5771-4190-b883-5b01f7d84974","date":"2024-03-22T19:25:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-22T14:09:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-22T14:07:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-22T07:43:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"Head and Neck Pathology","date":"2024-03-20T21:39:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"head-and-neck-pathology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Head and Neck Pathology](https://www.springer.com/journal/12105)","snPcode":"12105","submissionUrl":"https://submission.springernature.com/new-submission/12105/3","title":"Head and Neck Pathology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"3880d9be-50ea-4a53-b0f1-6a786e50689f","owner":[],"postedDate":"March 28th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-08-02T14:29:47+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-28 17:36:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4139597","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4139597","identity":"rs-4139597","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}