The Making of a WHO Book on Tumour Classificaton
The Making of a WHO Book on Tumour Classification
From Saturday January 12th, to Wednesday January 16th, 2002, an Editorial and Consensus Conference was held in Lyon, France, in the headquarters building of the International Agency for Research on Cancer (IARC), a research institute of the World Health Organization (WHO). The meeting was chaired by Drs Paul Kleihues, IARC Director and Leslie Sobin, Chief of the Division of Gastrointestinal Pathology at the A.F.I.P., Washington, in their capacity as Series Editors for the third Blue Book edition - the World Health Organization Classification of Tumours. This new book series is primarily for pathology and oncology communities world-wide. Therefore, each book needs to be based on a broad consensus of experts from many countries and regions. It is not the function of these books to present new and untested hypotheses. They are designed to be as concise as possible, to have relevant up to date references, and a generous number of high quality colour images that illustrate typical histopathological features of all tumour entities and their variants.
THE WORKING GROUP
At the heart of each book is a Working Group which is responsible for making recommendations for the WHO classification of human tumours. This time it consisted of 22 internationally recognised pathologists, geneticists and epidemiologists from 8 different countries.
A Plenary session.
Juan Rosai and Tanya Tavassoli chairing the Working Group discussing Precursor Lesions of Invasive Breast Carcinoma
Working Group discussing Precursor Lesions of Invasive Breast Carcinoma.
ANATOMY OF THE BOOKS
Working Group discussing Precursor Lesions of Invasive Breast Carcinoma.
Working Group on Invasive Breast Carcinoma.
Working Group on Benign and other Tumours of the Breast, selecting images to be presented at the Plenary Session for selecting images for the book.
PRE-INVASIVE BREAST CANCER
Since the publication of the second WHO edition on Breast Tumors in 1981, the biggest challenge in this field has resulted from imaging techniques which have allowed clinicians to identify and aspirate or biopsy small, non palpable lesions. This has led in some countries that can afford such tests, to the introduction of population screening with the objective of reducing mortality from breast cancer. As a result, pathologists are being presented with increased numbers of pre- invasive lesions which need to be histopathologically classified in a reproducible way, and assessed for their biological behaviour, in particular the risk of progression to invasive breast cancer.
DCIS vs. DIN
In several other organ sites, the shift in terminology has already occurred, e.g. cervix (CIN), prostate (PIN) and in the WHO classification of tumours of the G.I. tract, published in 2000. On the other hand, the current ductal intraepithelial neoplasia (DIN) classification was considered unacceptable by the participants, mainly because DIN 1 comprises lesions of vastly different biological behaviour. In particular, the designation of Ususal Ductal Hyperplasia (UDH) as DIN 1A was contested, on the basis that there is currently neither epidemiological nor genetic evidence indicating that UDH is a precursor of invasive breast cancer in a significant number of cases. There was general agreement that DCIS 2 and DCIS 3 largely correspond to DIN 2 and DIN 3, respectively. Because the pre-meeting e-mail correspondence on this topic was very lively, and sometimes heated, Juan Rosai from the National Cancer Institute in Milan, Italy, was asked to be Chairman and Facilitator - a task he performed very well. By the end of the second day, a basic consensus had been reached: (1) the DCIS classification remains the recommended terminology and will be used throughout the book; (2) in the histopathology section of pre-invasive breast cancer, a DIN classification that does not include UDH, will be presented as an alternative terminology. Despite this agreement, there was still quite a lot of controversy right up to the end of the meeting. The international community of pathologists, and all those involved in the management of cancer patients, will ultimately decide which classification is best suited to making evidence-based treatment decisions.
This was a very serious, but very lighthearted, boisterous, amusing and enjoyable session in which this group of experts who have been lecturing pathologists all around the world for many years, showed their best (and most prized) pictures. The session was conducted in the manner of an auction; another analogy would be the Roman Emperor adjudicating the result of gladiatorial combat in the Colosseum in Rome. "Do we accept or reject this photograph?" "Yes? No?", "Thumbs Up?, Thumbs Down?". Does the image illustrate the lesion it is supposed to? Is it in focus? Are the colours O.K.., if not, can they be corrected in Photoshop? "But Mr Chairman, colleagues, this is my most loved picture". "Objection over-ruled". "REJECT".
After each image selection session, the owners of the photographs joined Sibylle Soring and her colleagues of the Technical Support Team in the computer room, to dictate captions for the images. At the end of the conference, more than 700 images had been collected. They will now be reviewed by the technical editors to choose format and magnification, and examined by design experts to ensure they are technically acceptable.
METRO, FOOD, – AND CHAMPAGNE
Lyon is the second largest city in France and considered (particularly by les Lyonnais) the world capital of gourmets. The Metro connecting IARC and the town centre is driver-less and trains run every 3-5 minutes. It was amusing to see a group of highly intelligent people trying to work out how to buy a ticket. This was complicated by the fact that the new currency unit - the Euro - was less than two weeks old. Some of the machines would only take French francs, some only Euros, and one machine had "given up". Professional "conference facilitators" could never have dreamed up such a wonderful game to relax delegates and to get them talking and joking with each other. The slightly more structured social events were: drinks and finger food in Paul’s apartment overlooking the River Saone on the first evening; a dinner at the Brasserie Carnot the next evening; and, to celebrate the consensus, a champagne reception in the IARC cafeteria on the third evening.
IARC support staff for the meeting of authors for the WHO Tumour Pathology Series 3 Tumours of the Breast: Sybille Soring, Christine Yorian, Vojtek Bieurnat, Anike Revoire.
Sunil Lakhani (England), Maria Drijkoningen (Belgium) and Xavier Sastre-Garau (France). John Pettit in the background.
An uninvited "guest" to the conference was a virulent upper respiratory tract virus which caused great discomfort to a number of participants. On Wednesday the delegates returned to their normal places of work after a very busy and tiring four days of intense effort. They left the equally exhausted Support Staff at IARC to recover, and then to make the final preparations for publication of the fourth volume in the new series of WHO Tumor Classifications, to be published in September 2002.
The author is grateful to Dr Paul Kleihues for the invitation to report on this meeting for the information and interest of readers of the News Bulletin. Paul provided assistance with the information included in the article. His IARC staff were all extremely helpful in assisting the author to compile the information in the shortest possible time. Drs. Leslie Sobin and Rosemary Millis generously provided information and editorial guidance.
Election of International Officers of the IAP
Amsterdam Congress October 2002
The Chairman of the Nominating Committee of the IAP (Dr. Anna Kadar) invites nominations from individual members and from Divisions for the following offices which will be filled by election at the meeting of the International Council during the XXIV International Congress in Amsterdam, The Netherlands. President-Elect (2 year term, incumbent at the conclusion of his/her term becomes President) Vice Presidents (2 year term; however, a vice-president may succeed himself/herself in office without limitation). Africa - 2, Asia - 3, Australasia - 1, Europe - 3, N. America - 3, S. America - 2. In accordance with the Constitution, the duly elected persons will assume office one month after the end of the Amsterdam Congress.
All members of the IAP are entitled to submit names for consideration either directly or through Divisional Secretaries. Nominations need to be sent via the International Secretary:
Dr. Florabel G. Mullick,
Nominations need to arrive not later than September 5th, 2002.
Joint Meeting with the Pathological Society of Great Britain and Ireland.
Bristol, 1-4 July 2003.
Symposium on Lymphoreticular Disease
London, 28-29 November,
8 to 10 May, 2003.
Organized by the
Hellenic Division: www.mednet.gr/hsap
in Surgical Pathology
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