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Jung-Soo Pyo 11 Articles
Current status of cytopathology practice in Korea: impact of the coronavirus pandemic on cytopathology practice
Soon Auck Hong, Haeyoen Jung, Sung Sun Kim, Min-Sun Jin, Jung-Soo Pyo, Ji Yun Jeong, Younghee Choi, Gyungyub Gong, Yosep Chong
J Pathol Transl Med. 2022;56(6):361-369.   Published online October 27, 2022
DOI: https://doi.org/10.4132/jptm.2022.09.21
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  • 3 Web of Science
  • 2 Crossref
AbstractAbstract PDFSupplementary Material
Background
The Continuous Quality Improvement program for cytopathology in 2020 was completed during the coronavirus pandemic. In this study, we report the result of the quality improvement program.
Methods
Data related to cytopathology practice from each institute were collected and processed at the web-based portal. The proficiency test was conducted using glass slides and whole-slide images (WSIs). Evaluation of the adequacy of gynecology (GYN) slides from each institution and submission of case glass slides and WSIs for the next quality improvement program were performed.
Results
A total of 214 institutions participated in the annual cytopathology survey in 2020. The number of entire cytopathology specimens was 8,220,650, a reduction of 19.0% from the 10,111,755 specimens evaluated in 2019. Notably, the number of respiratory cytopathology specimens, including sputum and bronchial washing/ brushing significantly decreased by 86.9% from 2019, which could be attributed to the global pandemic of coronavirus disease. The ratio of cases with atypical squamous cells to squamous intraepithelial lesions was 4.10. All participating institutions passed the proficiency test and the evaluation of adequacy of GYN slides.
Conclusions
Through the Continuous Quality Improvement program, the effect of coronavirus disease 2019 pandemic, manifesting with a reduction in the number of cytologic examinations, especially in respiratory-related specimen has been identified. The Continuous Quality Improvement Program of the Korean Society for Cytopathology can serve as the gold standard to evaluate the current status of cytopathology practice in Korea.

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  • A stepwise approach to fine needle aspiration cytology of lymph nodes
    Yosep Chong, Gyeongsin Park, Hee Jeong Cha, Hyun-Jung Kim, Chang Suk Kang, Jamshid Abdul-Ghafar, Seung-Sook Lee
    Journal of Pathology and Translational Medicine.2023; 57(4): 196.     CrossRef
  • Diagnostic proficiency test using digital cytopathology and comparative assessment of whole slide images of cytologic samples for quality assurance program in Korea
    Yosep Chong, Soon Auck Hong, Hoon Kyu Oh, Soo Jin Jung, Bo-Sung Kim, Ji Yun Jeong, Ho-Chang Lee, Gyungyub Gong
    Journal of Pathology and Translational Medicine.2023; 57(5): 251.     CrossRef
Current status of cytopathology practices in Korea: annual report on the Continuous Quality Improvement program of the Korean Society for Cytopathology for 2018
Yosep Chong, Haeyoen Jung, Jung-Soo Pyo, Soon Won Hong, Hoon Kyu Oh
J Pathol Transl Med. 2020;54(4):318-331.   Published online April 15, 2020
DOI: https://doi.org/10.4132/jptm.2020.02.26
  • 4,484 View
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  • 4 Web of Science
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AbstractAbstract PDFSupplementary Material
Background
The Korean Society for Cytopathology has conducted the Continuous Quality Improvement program for cytopathology laboratories in Korea since 1995. In 2018 as part of the program, an annual survey of cytologic data was administered to determine the current status of cytopathology practices in Korea. Methods: A questionnaire was administered to 211 cytopathology laboratories. Individual laboratories submitted their annual statistics regarding cytopathology practices, diagnoses of gynecologic samples, inadequacy rates, and gynecologic cytology-histology correlation review (CHCR) data for 2018. In addition, proficiency tests and sample adequacy assessments were conducted using five consequent gynecologic slides. Results: Over 10 million cytologic exams were performed in 2018, and this number has almost tripled since this survey was first conducted in 2004 (compounded annual growth rate of 7.2%). The number of non-gynecologic samples has increased gradually over time and comprised 24% of all exams. The overall unsatisfactory rate was 0.14%. The ratio of the cases with atypical squamous cells to squamous intraepithelial lesions accounted for up to 4.24. The major discrepancy rate of the CHCR in gynecologic samples was 0.52%. In the proficiency test, the major discrepancy rate was approximately 1%. In the sample adequacy assessment, a discrepancy was observed in 0.1% of cases. Conclusions: This study represents the current status of cytopathology practices in Korea, illustrating the importance of the Continuous Quality Improvement program for increasing the accuracy and credibility of cytopathologic exams as well as developing national cancer exam guidelines and government projects on the prevention and treatment of cancer.

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  • Diagnostic proficiency test using digital cytopathology and comparative assessment of whole slide images of cytologic samples for quality assurance program in Korea
    Yosep Chong, Soon Auck Hong, Hoon Kyu Oh, Soo Jin Jung, Bo-Sung Kim, Ji Yun Jeong, Ho-Chang Lee, Gyungyub Gong
    Journal of Pathology and Translational Medicine.2023; 57(5): 251.     CrossRef
  • Recent Application of Artificial Intelligence in Non-Gynecological Cancer Cytopathology: A Systematic Review
    Nishant Thakur, Mohammad Rizwan Alam, Jamshid Abdul-Ghafar, Yosep Chong
    Cancers.2022; 14(14): 3529.     CrossRef
  • Re-Increasing Trends in Thyroid Cancer Incidence after a Short Period of Decrease in Korea: Reigniting the Debate on Ultrasound Screening
    Chan Kwon Jung, Ja Seong Bae, Young Joo Park
    Endocrinology and Metabolism.2022; 37(5): 816.     CrossRef
  • Current status of cytopathology practice in Korea: impact of the coronavirus pandemic on cytopathology practice
    Soon Auck Hong, Haeyoen Jung, Sung Sun Kim, Min-Sun Jin, Jung-Soo Pyo, Ji Yun Jeong, Younghee Choi, Gyungyub Gong, Yosep Chong
    Journal of Pathology and Translational Medicine.2022; 56(6): 361.     CrossRef
Analysis of PAX8 immunohistochemistry in lung cancers: a meta-analysis
Jae Han Jeong, Nae Yu Kim, Jung-Soo Pyo
J Pathol Transl Med. 2020;54(4):300-309.   Published online July 10, 2020
DOI: https://doi.org/10.4132/jptm.2020.06.08
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  • 4 Web of Science
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AbstractAbstract PDF
Background
In this meta-analysis, we aimed to evaluate the PAX8 immunohistochemical expressions in primary lung cancers and metastatic cancers to the lung.
Methods
We identified and reviewed relevant articles from the PubMed databases. Ultimately, 18 articles were included in this meta-analysis. PAX8 expression rates were analyzed and compared between primary and metastatic lung cancers.
Results
The PAX8 expression rate in primary lung cancers was 0.042 (95% confidence interval [CI], 0.025 to 0.071). PAX8 expression rates of small cell (0.129; 95% CI, 0.022 to 0.496) and non-small cell carcinomas of the lung (0.037; 95% CI, 0.022 to 0.061) were significantly different (p=.049 in a meta-regression test). However, the PAX8 expression rates of adenocarcinoma (0.013; 95% CI, 0.006 to 0.031) and squamous cell carcinoma (0.040; 95% CI, 0.016 to 0.097) were not significantly different. PAX8 expression rates of metastatic carcinomas to the lung varied, ranging from 1.8% to 94.9%. Metastatic carcinomas from the lung to other organs had a PAX8 expression rate of 6.3%. The PAX8 expression rates of metastatic carcinomas from the female genital organs, kidneys, and thyroid gland to the lung were higher than those of other metastatic carcinomas.
Conclusions
Primary lung cancers had a low PAX8 expression rate regardless of tumor subtype. However, the PAX8 expression rates of metastatic carcinomas from the female genital organs, kidneys, and thyroid were significantly higher than those of primary lung cancers.

Citations

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  • Prognostic value of PAX8 in small cell lung cancer
    Fengyun Tao, Hangyan Zhu, Jiayun Xu, Yanan Guo, Xin Wang, Lei Shao, Deng Pan, Guosheng Li, Rong Fang
    Heliyon.2024; 10(7): e28251.     CrossRef
  • Cystic primary squamous cell carcinoma of the thyroid
    Sakurako Harada‐Kagitani, Yusuke Kouchi, Yoshiki Shinomiya, Takuto Hiramoto, Tomoyuki Arai, Toyoyuki Hanazawa, Kiyotaka Onodera, Kaito Nakama, Takanori Aihara, Masayuki Ota, Jun‐Ichiro Ikeda, Takashi Kishimoto
    Pathology International.2024;[Epub]     CrossRef
  • Immunocytochemistry of effusions: Processing and commonly used immunomarkers
    Vinod B. Shidham, Beata Janikowski
    Cytojournal.2022; 19: 6.     CrossRef
  • Significance analysis of PAX8 expression in endometrial carcinoma
    Shan Hu, Hua Gan, Fengmei Yang
    Medicine.2022; 101(42): e31159.     CrossRef
Response to Comment on “Prognostic Role of Claudin-1 Immunohistochemistry in Malignant Solid Tumors: A Meta-Analysis”
Jung-Soo Pyo, Nae Yu Kim, Won Jin Cho
J Pathol Transl Med. 2019;53(6):412-414.   Published online November 1, 2019
DOI: https://doi.org/10.4132/jptm.2019.09.27
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  • 60 Download
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Prognostic Role of Claudin-1 Immunohistochemistry in Malignant Solid Tumors: A Meta-Analysis
Jung-Soo Pyo, Nae Yu Kim, Won Jin Cho
J Pathol Transl Med. 2019;53(3):173-179.   Published online March 5, 2019
DOI: https://doi.org/10.4132/jptm.2019.02.03
  • 5,945 View
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  • 5 Web of Science
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AbstractAbstract PDF
Background
Although the correlation between low claudin-1 expression and worse prognosis has been reported, details on the prognostic implications of claudin-1 expression in various malignant tumors remain unclear. The present study aimed to elucidate the prognostic roles of claudin- 1 immunohistochemistry (IHC) in various malignant tumors through a meta-analysis.
Methods
The study included 2,792 patients from 22 eligible studies for assessment of the correlation between claudin-1 expression and survival rate in various malignant tumors. A subgroup analysis based on the specific tumor and evaluation criteria of claudin-1 IHC was conducted.
Results
Low claudin-1 expression was significantly correlated with worse overall survival (OS) (hazard ratio [HR], 1.851; 95% confidence interval [CI], 1.506 to 2.274) and disease-free survival (DFS) (HR, 2.028; 95% CI, 1.313 to 3.134) compared to high claudin-1 expression. Breast, colorectal, esophageal, gallbladder, head and neck, and lung cancers, but not cervical, liver or stomach cancers, were significantly correlated with worse OS. Breast, colorectal, esophageal, and thyroid cancers with low claudin-1 expression were associated with poorer DFS. In the lower cut-off subgroup (< 25.0%) with respect to claudin-1 IHC, low claudin-1 expression was significantly correlated with worse OS and DFS.
Conclusions
Taken together, low claudin-1 IHC expression is significantly correlated with worse survival in various malignant tumors. More detailed criteria for claudin-1 IHC expression in various malignant tumors are needed for application in daily practice.

Citations

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  • The Significance of Relative Claudin Expression in Odontogenic Tumors
    Ekarat Phattarataratip, Kraisorn Sappayatosok
    Head and Neck Pathology.2020; 14(2): 480.     CrossRef
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    Simon Kind, Franziska Büscheck, Doris Höflmayer, Claudia Hube-Magg, Martina Kluth, Maria Christina Tsourlakis, Stefan Steurer, Till S. Clauditz, Andreas M. Luebke, Eike Burandt, Waldemar Wilczak, Andrea Hinsch, David Dum, Sören Weidemann, Christoph Fraune
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    Camille M.H. Clément, Maika S. Deffieu, Cristina M. Dorobantu, Thomas F. Baumert, Nilda Vanesa Ayala‐Nunez, Yves Mély, Philippe Ronde, Raphael Gaudin
    Biology of the Cell.2020; 112(5): 140.     CrossRef
  • Comment on “Prognostic Role of Claudin-1 Immunohistochemistry in Malignant Solid Tumors: A Meta-Analysis”
    Bolin Wang, Yan Huang
    Journal of Pathology and Translational Medicine.2019; 53(6): 411.     CrossRef
Prognostic Role of Metastatic Lymph Node Ratio in Papillary Thyroid Carcinoma
Jung-Soo Pyo, Jin Hee Sohn, Kyungseek Chang
J Pathol Transl Med. 2018;52(5):331-338.   Published online August 30, 2018
DOI: https://doi.org/10.4132/jptm.2018.08.07
  • 6,152 View
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AbstractAbstract PDF
Background
The aim of this study is to elucidate the clinicopathological significances, including the prognostic role, of metastatic lymph node ratio (mLNR) and tumor deposit diameter in papillary thyroid carcinoma (PTC) through a retrospective review and meta-analysis.
Methods
We categorized the cases into high (≥ 0.44) and low mLNR (< 0.44) and investigated the correlations with clinicopathological parameters in 64 PTCs with neck level VI lymph node (LN) metastasis. In addition, meta-analysis of seven eligible studies was used to investigate the correlation between mLNR and survival.
Results
Among 64 PTCs with neck level VI LN metastasis, high mLNR was found in 34 PTCs (53.1%). High mLNR was significantly correlated with macrometastasis (tumor deposit diameter ≥ 0.2 cm), extracapsular spread, and number of metastatic LNs. Based on linear regression test, mLNR was significantly increased by the largest LN size but not the largest metastatic LN (mLN) size. High mLNR was not correlated with nuclear factor κB or cyclin D1 immunohistochemical expression, Ki-67 labeling index, or other pathological parameters of primary tumor. Based on meta-analysis, high mLNR significantly correlated with worse disease-free survival at the 5-year and 10-year follow-up (hazard ratio [HR], 4.866; 95% confidence interval [CI], 3.527 to 6.714 and HR, 5.769; 95% CI, 2.951 to 11.275, respectively).
Conclusions
Our data showed that high mLNR significantly correlated with worse survival, macrometastasis, and extracapsular spread of mLNs. Further cumulative studies for more detailed criteria of mLNR are needed before application in daily practice.

Citations

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  • Thyroglobulin expression, Ki-67 index, and lymph node ratio in the prognostic assessment of papillary thyroid cancer
    Helene Lindfors, Marie Karlsen, Ellinor Karlton, Jan Zedenius, Catharina Larsson, Catharina Ihre Lundgren, C. Christofer Juhlin, Ivan Shabo
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    Cancers.2023; 15(3): 943.     CrossRef
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    WenYi Wang, JiaJing Liu, XiaoFan Xu, LiQun Huo, XuLin Wang, Jun Gu
    Technology in Cancer Research & Treatment.2023; 22: 153303382311678.     CrossRef
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    Il Ku Kang, Joonseon Park, Ja Seong Bae, Jeong Soo Kim, Kwangsoon Kim
    Cancers.2023; 15(11): 2947.     CrossRef
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    Andreas Machens, Kerstin Lorenz, Frank Weber, Henning Dralle
    Head & Neck.2022; 44(12): 2717.     CrossRef
  • Value of Combining Clinical Factors, Conventional Ultrasound, and Contrast-Enhanced Ultrasound Features in Preoperative Prediction of Central Lymph Node Metastases of Different Sized Papillary Thyroid Carcinomas
    Yanfang Wang, Fang Nie, Guojuan Wang, Ting Liu, Tiantian Dong, Yamin Sun
    Cancer Management and Research.2021; Volume 13: 3403.     CrossRef
  • Atypical Histiocytoid Cells and Multinucleated Giant Cells in Fine-Needle Aspiration Cytology of the Thyroid Predict Lymph Node Metastasis of Papillary Thyroid Carcinoma
    Ji Eun Choi, Ja Seong Bae, Dong-Jun Lim, So Lyung Jung, Chan Kwon Jung
    Cancers.2019; 11(6): 816.     CrossRef
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    Zeming Liu, Sichao Chen, Yihui Huang, Di Hu, Min Wang, Wei Wei, Chao Zhang, Wen Zeng, Liang Guo
    Frontiers in Oncology.2019;[Epub]     CrossRef
  • Prognostic Implication of Metastatic Lymph Node Ratio in Colorectal Cancers: Comparison Depending on Tumor Location
    Jung-Soo Pyo, Young-Min Shin, Dong-Wook Kang
    Journal of Clinical Medicine.2019; 8(11): 1812.     CrossRef
Detection of Tumor Multifocality Is Important for Prediction of Tumor Recurrence in Papillary Thyroid Microcarcinoma: A Retrospective Study and Meta-Analysis
Jung-Soo Pyo, Jin Hee Sohn, Guhyun Kang
J Pathol Transl Med. 2016;50(4):278-286.   Published online June 6, 2016
DOI: https://doi.org/10.4132/jptm.2016.03.29
  • 9,514 View
  • 106 Download
  • 20 Web of Science
  • 22 Crossref
AbstractAbstract PDF
Background
The clinicopathological characteristics and conclusive treatment modality for multifocal papillary thyroid microcarcinoma (mPTMC) have not been fully established.
Methods
A retrospective study, systematic review, and meta-analysis were conducted to elucidate the clinicopathological significance of mPTMC. We investigated the multiplicity of 383 classical papillary thyroid microcarcinomas (PTMCs) and the clinicopathological significance of incidental mPTMCs. Correlation between tumor recurrence and multifocality in PTMCs was evaluated through a systematic review and meta-analysis.
Results
Tumor multifocality was identified in 103 of 383 PTMCs (26.9%). On linear regression analysis, primary tumor diameter was significantly correlated with tumor number (R2=0.014, p=.021) and supplemental tumor diameter (R2=0.117, p=.023). Of 103 mPTMCs, 61 (59.2%) were non-incidental, with tumor detected on preoperative ultrasonography, and 42 (40.8%) were diagnosed (incidental mPTMCs) on pathological examination. Lymph node metastasis and higher tumor stage were significantly correlated with tumor multifocality. However, there was no difference in nodal metastasis or tumor stage between incidental and non-incidental mPTMCs. On meta-analysis, tumor multifocality was significantly correlated with tumor recurrence in PTMCs (odds ratio, 2.002; 95% confidence interval, 1.475 to 2.719, p<.001).
Conclusions
Our results show that tumor multifocality in PTMC, regardless of manner of detection, is significantly correlated with aggressive tumor behavior.

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    E. V. Ryabchenko
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Core Needle Biopsy Is a More Conclusive Follow-up Method Than Repeat Fine Needle Aspiration for Thyroid Nodules with Initially Inconclusive Results: A Systematic Review and Meta-Analysis
Jung-Soo Pyo, Jin Hee Sohn, Guhyun Kang
J Pathol Transl Med. 2016;50(3):217-224.   Published online April 14, 2016
DOI: https://doi.org/10.4132/jptm.2016.02.15
  • 9,404 View
  • 108 Download
  • 15 Web of Science
  • 17 Crossref
AbstractAbstract PDF
Background
This study investigated the appropriate management of thyroid nodules with prior non-diagnostic or atypia of undetermined significance/follicular lesion of undetermined significance (AUS/FLUS) through a systematic review and meta-analysis.
Methods
This study included 4,235 thyroid nodules from 26 eligible studies. We investigated the conclusive rate of follow-up core needle biopsy (CNB) or repeat fine needle aspiration (rFNA) after initial fine needle aspiration (FNA) with non-diagnostic or AUS/FLUS results. A diagnostic test accuracy (DTA) review was performed to determine the diagnostic role of the follow-up CNB and to calculate the area under the curve (AUC) on the summary receiver operating characteristic (SROC) curve.
Results
The conclusive rates of follow-up CNB and rFNA after initial FNA were 0.879 (95% confidence interval [CI], 0.801 to 0.929) and 0.684 (95% CI, 0.627 to 0.736), respectively. In comparison of the odds ratios of CNB and rFNA, CNB had more frequent conclusive results than rFNA (odds ratio, 5.707; 95% CI, 2.530 to 12.875). Upon subgroup analysis, follow-up CNB showed a higher conclusive rate than rFNA in both initial non-diagnostic and AUS/FLUS subgroups. In DTA review of followup CNB, the pooled sensitivity and specificity were 0.94 (95% CI, 0.88 to 0.97) and 0.88 (95% CI, 0.84 to 0.91), respectively. The AUC for the SROC curve was 0.981, nearing 1.
Conclusions
Our results show that CNB has a higher conclusive rate than rFNA when the initial FNA produced inconclusive results. Further prospective studies with more detailed criteria are necessary before follow-up CNB can be applied in daily practice.

Citations

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  • Fine Needle Aspiration Cytology vs. Core Needle Biopsy for Thyroid Nodules: A Prospective, Experimental Study Using Surgical Specimen
    Hyuk Kwon, Jandee Lee, Soon Won Hong, Hyeong Ju Kwon, Jin Young Kwak, Jung Hyun Yoon
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MUC2 Expression Is Correlated with Tumor Differentiation and Inhibits Tumor Invasion in Gastric Carcinomas: A Systematic Review and Meta-analysis
Jung-Soo Pyo, Jin Hee Sohn, Guhyun Kang, Dong-Hoon Kim, Kyungeun Kim, In-Gu Do, Dong Hyun Kim
J Pathol Transl Med. 2015;49(3):249-256.   Published online May 15, 2015
DOI: https://doi.org/10.4132/jptm.2015.03.27
  • 7,514 View
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AbstractAbstract PDF
Background
While MUC2 is expressed in intestinal metaplasia and malignant lesions, the clinico-pathological significance of MUC2 expression is not fully elucidated in gastric carcinoma (GC). Methods: The present study investigated the correlation between MUC2 expression and clinico-pathological parameters in 167 human GCs. In addition, to confirm the clinicopathological significance of MUC2 expression, we performed a systematic review and meta-analysis in 1,832 GCs. Results: MUC2 expression was found in 58 of 167 GCs (34.7%). MUC2-expressing GC showed lower primary tumor (T), regional lymph node (N), and tumor node metastasis (TNM) stages compared with GCs without MUC2 expression (p=.001, p=.001, and p=.011, respectively). However, MUC2 expression was not correlated with Lauren’s classification and tumor differentiation. In meta-analysis, MUC2 expression was significantly correlated with differentiation and lower tumor stage (odds ratio [OR], 1.303; 95% confidence interval [CI], 1.020 to 1.664; p = .034 and OR, 1.352; 95% CI, 1.055 to 1.734; p = .017, respectively) but not with Lauren’s classification, pN stage, or pTNM stage. Conclusions: MUC2 expression was correlated with a lower tumor depth and lower lymph node metastasis in our study; the meta-analysis showed a correlation of MUC2 expression with tumor differentiation and lower tumor depth.

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Traumatic Bowel Perforation and Inguinal Hernia Masking a Mesenteric Calcifying Fibrous Tumor
Dong Hyun Kim, Kyueng-Whan Min, Dong-Hoon Kim, Seoung Wan Chae, Jin Hee Sohn, Jung-Soo Pyo, Sung-Im Do, Kyungeun Kim, Hyun Joo Lee
J Pathol Transl Med. 2015;49(3):267-269.   Published online May 15, 2015
DOI: https://doi.org/10.4132/jptm.2015.03.20
  • 7,215 View
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PDF

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    Angeliki Chorti, Theodossis S. Papavramidis, Antonios Michalopoulos
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Extranodal Follicular Dendritic Cell Sarcoma with Rapid Growth in Parapharynx: A Case Report
Jung-Soo Pyo, Guhyun Kang, Sung-Im Do, Seoung Wan Chae, Kyungeun Kim, Sang Hyuk Lee, Yoon-La Choi, Joon Hyuk Choi, Jin Hee Sohn, Dong-Hoon Kim
Korean J Pathol. 2012;46(3):306-310.   Published online June 22, 2012
DOI: https://doi.org/10.4132/KoreanJPathol.2012.46.3.306
  • 6,249 View
  • 39 Download
  • 9 Crossref
AbstractAbstract PDF

Follicular dendritic cell sarcoma (FDCS) is a rare malignancy arising from the antigen-presenting cells in the lymph node and extranodal tissue. We describe a 31-year-old male patient who presented with a swelling of the left parapharynx. The radiologic findings showed a 4.7×4.5×1.9 cm-sized, ill-defined mass in the left parapharyngeal space. A fine-needle aspiration cytology was performed and it showed scattered, irregular, cohesive clusters of tumor cells with a spindle-to-ovoid shape with irregular contours in a background of lymphocytes. Based on these findings, a diagnosis of spindle cell neoplasm was made. The surgically resected tumor was composed of elongated, ovoid or polygonal cells showing positive immunohistochemistry for CD21, CD23, and CD35. Postoperatively, the residual tumor was observed to undergo a rapidly growth. There is an overlap in the cytologic and histologic findings between FDCS of the parapharynx and other tumors. Pathologists should therefore be aware of its characteristics not only to provide an accurate diagnosis but also to recommend the appropriate clinical management.

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