Common Data Elements for Muscle Biopsy Reporting

Abstract

Context: There is no current standard among myopathologists for reporting muscle biopsy findings. The National Institute of Neurological Disorders and Stroke has recently launched a common data element (CDE) project to standardize neuromuscular data collected in clinical reports and to facilitate their use in research.

Objective: To develop a more-uniform, prospective reporting tool for muscle biopsies, incorporating the elements identified by the CDE project, in an effort to improve reporting and educational resources.

Design: The variation in current biopsy reporting practice was evaluated through a study of 51 muscle biopsy reports from self-reported diagnoses of genetically confirmed or undiagnosed muscle disease from the Congenital Muscle Disease International Registry. Two reviewers independently extracted data from deidentified reports and entered them into the revised CDE format to identify what was missing and whether or not information provided on the revised CDE report (complete/incomplete) could be successfully interpreted by a neuropathologist.

Results: Analysis of the data highlighted showed (1) inconsistent reporting of key clinical features from referring physicians, and (2) considerable variability in the reporting of pertinent positive and negative histologic findings by pathologists.

Conclusions: We propose a format for muscle-biopsy reporting that includes the elements in the CDE checklist and a brief narrative comment that interprets the data in support of a final interpretation. Such a format standardizes cataloging of pathologic findings across the spectrum of muscle diseases and serves emerging clinical care and research needs with the expansion of genetic-testing therapeutic trials.

Figure 1

Percentage of clinical findings included in the muscle-biopsy report.

Figure 2

Percentage of key pathologic findings reported. This reflects whether the finding was mentioned in the report, regardless of whether the finding was present or absent within the actual biopsy.

Figure 3

Range of diagnoses in reviewed reports. Note that the numbers reflect the original interpretations of the biopsy reports and do not reflect the degree to which specific elements were reported. The numbers of reports corresponding to each diagnosis are shown in parentheses (n=43 cases reviewed).