The effect of using templates on the information included in histology reports on specimens of uterine cervix taken by loop excision of transformation zone (LETZ)

I should again like to congratulate Dr Al-Nafussi and her colleagues for providing us with an interesting and stimulating paper¹ and to take the opportunity to add some comments of my own. Following earlier correspondence in the journal,^2,3 I have sought to develop a system of standardised phrases that are used in reporting the features listed in the paper by Reid et al.¹ Secretarial or medical staff can enter a short code of up to 35 letters, which is expanded electronically to produce a phrase or sentence in coherent English. In this department, we use the Telepath system, which allows more than one such code to be used in any given report. Snomed codes are linked to the codes and automatically included in the departmental database. Furthermore, it is possible to recover reports in which a given standardised phrase or sentence has been used. This allows us to identify the proportion of cases with specific findings such as involved specimen edges, traumatised squamocolumnar junctions, or the presence of endocervical epithelium or squamous epithelium at the end of the endocervical canal. Because these are quality features that are to some extent under the control of the colposcopist or surgeon, it is envisaged that we can then provide feedback on the adequacy of specimens deriving from particular clinics to the responsible consultants.

Finally, in addition to the ectocervical and endocervical edges we routinely comment upon the presence of CIN (cervical intraepithelial abnormality) at the deep lateral edge. This is the edge that runs between the superior, endocervical edge of the specimen to the lateral, ectocervical edge of the specimen. Although this is composed of cervical stroma with variable degrees of cautery artefact, we regard this involvement as being important because there is the potential of residual disease being covered in the re-epithelialisation process, so that it will not be detected on colposcopy or cytological surveillance. Residual disease, if undetected, has been suggested as a cause of later invasive cervical carcinoma in patients treated for CIN.^4,5