Evolving imaging technology could begin to replace some traditional autopsy methodologies and encourage an increase in the number of autopsies performed
New imaging technology may give pathologists in the United Kingdom a new way to perform non-invasive autopsies. It is another example of how long-standing clinical practices can be transformed by the capabilities of newly developed technologies.
Leading experts within the field of post-mortem cross-sectional imaging in Britain have recommended that England’s National Health Service (NHS) introduce alternative techniques for performing non-invasive autopsies. A review of current procedures in the NHS system showed that alternative autopsy methodologies offer important advantages. In some circumstances, the non-invasive approach could replace traditional autopsy methods.
Pathologist Conducted the Review of the New Technology
Pathologists at the Department of Health’s Post Mortem, Forensic and Disaster Imaging Group (PMFDI), NHS Implementation Sub-Group (ISG) conducted a review of current autopsy procedures, according to a press release published by EurekAlert. Following the review, the ISG issued a report detailing the recommendations.
“There are important religious, cultural and humanitarian benefits offered by non-invasive autopsies,” observed Guy N. Rutty, M.D., Chief Forensic Pathologist to the East Midlands Forensic Pathology Unit (EMFPU) at the University of Leicester. Rutty, who chaired the sub-group that prepared the report, said “It is recognized that there is no longer the need to undertake invasive autopsy examinations in certain types of death.”
In England, pathologists working at the National Health Service Implementation Sub-Group, a part of the Department of Health’s Post Mortem, Forensic and Disaster Imaging Group, recently issued a report recommending that England adopt non-invasive, imaging-based autopsy techniques. A pathologist from the University of Leicester’s East Midlands Forensic Pathology Unit chaired the group. (photo copyright University of Leicester.)
The group’s key recommendation was that it is realistic to introduce non-invasive autopsy procedures as an alternative to the current invasive approach.
Reversing the Decline in Numbers of Autopsies
In previous e-briefings, Dark Daily has reported the medical community’s concerns about the declining numbers of autopsies. In the U.S., the American Medical Association (AMA) joined the U.S. pathology profession in pointing out the negative impact of reduced numbers of autopsies on medicine and public health. (See Dark Daily, “American Medical Association and PBS Both Join Pathology Profession in Publicizing Why Declining Autopsy Rates May Hurt Quality of Healthcare”, March 14, 2012.)
Russian pathologists have warned their politicians that the declining use of autopsies could result in the country losing the ability to accurately determine cause of death, and thus a better understanding of the health of its people. (See Dark Daily, “‘Death’ of Pathology in Russia Lamented by Nation’s Leading Pathologists”, April 29, 2011.)
For the British medical system, the ISG report confirmed the significant value of autopsy data. “Establishing a pathological cause of death…has importance that is much more than the personal value and medical significance of a person’s Death Certificate to their immediate family,” the authors stated. “These statistics are key in healthcare planning, allocation of resources, policy development, health and injury research, and many other areas of public interest and importance. Therefore, the accurate determination and recording of the cause of death is not just desirable, it is essential.”
New Technologies Will Help Pathologists Conducting Autopsies
Technological advances have made imaging increasingly applicable in autopsy investigation. Minimally invasive computed tomography (CT) and magnetic resonance imaging (MRI) can be used to examine tissue post-mortem. For example, during the Iraq war, U.S. military pathologists began using increased-intensity imaging radiation for post-mortem tissue examination. This approach produces much more detail in the resulting images.
In the United Kingdom, Rutty’s EMFPU group pioneered research relating to the use of CT in the investigation of sudden cardiac death. They also used the non-invasive approach in cases of mass fatality investigations.
New Autopsy Program Would Combine Radiology and Pathology Services
The ISG report recommended introducing non-invasive autopsy as a single, integrated service through 30 mortuary-based imaging centers in England. This would involve both radiology and pathology professionals. They also recommended a national teaching and training program, along with sub-specialty recognition for all professionals involved in the proposed service.
Additional funding for research to establish a medical evidence base for developing the service and technology involved was another recommendation. This would support expansion of the types of deaths amenable to non-invasive imaging autopsy techniques.
“The current demand by the general public for a non-invasive autopsy service is expected to grow,” Rutty noted in the press release.
Pathologists and clinical laboratory managers can expect that medical systems in other countries are likely to consider adoption of non-invasive autopsy techniques as the technology to support this approach continues to improve.
—Pamela Scherer McLeod
Related Information
NHS should replace traditional autopsies with non-invasive alternative
“‘Death’ of Pathology in Russia Lamented by Nation’s Leading Pathologists”
American pathologists should not rush to embrace this UK report suggesting that traditional autopsies be replaced with a “non-invasive alternative.” Professor Guy Rutty, who chaired the group making this recommendation is a renowned forensic pathologist and the conclusions of the commission may well be appropriate as a less costly approach for the forensic autopsy. Unfortunately, currently existing non-invasive technology does not, and may not ever, satisfy all the purposes of the hospital autopsy and may not actually satisfy the needs of the forensic autopsy: a 2012 report in Lancet (Roberts ISD et al: Post-mortem imaging as an alternative to autopsy in the diagnosis of adult deaths: a validation study. Lancet 2012;379(9811):136-142), indicated that “common causes of sudden death are frequently missed on CT and MRI and, unless these weaknesses are addressed, systematic errors in mortality statistics would result if imaging were to replace conventional autopsy.” In a study with similar results (Wichmann D et al: Virtual autopsy as an alternative to traditional medical autopsy in the intensive care unit: a prospective cohort study. Ann Int Med 2012;156:123-130) ‘virtual autopsy’ missed the main diagnoses in 9 of 72 cardiac and 12 of 30 cancer cases. Further, the well-performed autopsy serves purposes at least as important as determining the cause of death which will not be served by non-invasive methods and which are too numerous to mention in this brief response (see: Hill RB, Anderson RE: The uses and value of autopsy in medical education as seen by pathology educators. Acad Med 1991;66:97-100). The autopsy remains the ‘gold standard’ in being able to identify whatever lesions are present, including precursor lesions. A complete autopsy, behind identifying cause of death, is necessary to understand the multi-organ factors that contributed to the patients illness, including to recognize the effects, both positive and negative, of surgical and/or medical therapies. The complete autopsy remains the most effective way to teach new pathologists about the nuances of gross interpretation and about the preparation of tissues for histopathology, skills in serious decline as the number of autopsies performed diminishes. The autopsy serves surviving friends and family by making the grieving period shorter and easier (Beckwith JB: The value of the pediatric postmortem examination. Pediatr Clin North Am 1989;36:29-36, Leblanc TW et al: Autopsy and grief: a case of transformative postmortem examination. J Palliat Med 2012;15:251-3).
The biggest problem for the hospital autopsy, as indicated by the continuing declining rate of utilization, is not the incursion by new technologies but rather the abandonment of this still valuable procedure by pathologists who are increasingly occupied with other important tasks and who, also increasingly, have little understanding of or interest in the autopsy.