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Observer Variation in the Application of the Pheochromocytoma of the Adrenal Gland Scaled Score

Wu, David MD, PhD*; Tischler, Arthur S. MD; Lloyd, Ricardo V. MD; DeLellis, Ronald A. MD§; de Krijger, Ronald MD; van Nederveen, Francien MD, PhD; Nosé, Vânia MD, PhD*

The American Journal of Surgical Pathology: April 2009 - Volume 33 - Issue 4 - p 599-608
doi: 10.1097/PAS.0b013e318190d12e
Original Articles

Morphologic determination of the malignant potential of adrenal pheochromocytoma is a challenging problem in surgical pathology. A multiparameter Pheochromocytoma of the Adrenal Gland Scaled Score (PASS) was recently developed based on a comprehensive study of a single institutional cohort of 100 cases. Assignment of a PASS was proposed to be useful for identifying pheochromocytomas with potential to metastasize, which defines malignancy according to the current World Health Organization terminology. A PASS is derived by evaluating multiple morphologic parameters to obtain a scaled score based on the summed weighted importance of each. Despite the proposal of this system several years ago, few studies have since examined its robustness and, in particular, the potential for observer variation inherent in the interpretation and assessment of these morphologic criteria. We further examined the utility of PASS by reviewing an independent single institutional cohort of adrenal pheochromocytomas as evaluated by 5 multi-institutional pathologists with at least 10 years experience in endocrine pathology. We found significant interobserver and intraobserver variation in assignment of PASS with variable interpretation of the underlying components. We consequently suggest that PASS requires further refinement and validation. We cannot currently recommend its use for clinical prognostication.

*Department of Pathology, Brigham and Women's Hospital

Tufts Medical Center, Boston, MA

Departments of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN

§Department of Pathology and Laboratory Medicine, Brown Medical School, Providence, RI

Department of Pathology, Josephine Nefkens Institute, Erasmus MC, Rotterdam, The Netherlands

Supported by intradepartmental funding from the Department of Pathology, Brigham and Women's Hospital, Boston, MA to Dr Vânia Nosé.

Correspondence: Vânia Nosé, MD, PhD, Department of Pathology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115 (e-mail:

Ronald de Krijger and Francien van Nederveen have contributed equally to this report.

© 2009 Lippincott Williams & Wilkins, Inc.