The Classic Forensic Autopsy on the Verge of Being Obsolete

I posted a note on March 18, 2008, plus two follow-up notes, about what I then referred to as the catopsy, which I defined as a classic autopsy extended by the use of medical imaging techniques (see: Reinventing the Autopsy: CT Imaging as a Routine Part of the Procedure, Additional Discussion About Reinventing the Autopsy). At that time, I was unaware that the term virtopsy had already been used to refer to post-mortem imaging that was being performed in various centers. I subsequently published a note about the virtual-autopsy (i.e., virtopsy) (see: Introducing the Virtopsy, a Variant of the Catopsy Theme). My understanding at that time was that the virtopsy consisted of only the imaging component of an autopsy without histopathologic examination of tissue and was, therefore, an extension of the classic autopsy (see: Virtual Autopsy Offers Noninvasive Postmortem Exam).

At the 13th annual APIII conference held in Pittsburgh on October 19-23, I had the privilege of listening to lectures by three individuals who have been pivotal in the emergence of the virtopsy. They were Drs. Stephan Bolliger and Steffen Ross from the Institute for Forensic Medicine, Bern, Switzerland, and Colonel Angela Levy, Uniformed Services University of the Health Sciences, Bethesda, Maryland. These lectures (The Virtopsy Project: Novel Approaches in Post-Mortem Imaging, Drs. Bolliger and Ross; and The Virtual Autopsy and Postmortem Multi-Detector CT Imaging, Col. Levy) can be downloaded from the APIII 2008 web site (Wednesday, 22 October, 10:30 a.m. breakout session). Dr. Bolliger is a pathologist and Drs. Ross and Levy are radiologists. Caution: these two lectures are large PowerPoint files that download slowly but are worth the time and effort.

Having now observed the work being done by Drs. Bolliger, Ross, and Levy, I have personally come to the following conclusions about the virtopsy and the future of forensic pathology:

• The virtopsy now seems to be defined as a combination of classic autopsy techniques plus various imaging modalities. Dr. Ross is even performing post-mortem vascular imaging procedures using injected contrast material. However, the term virtopsy may be somewhat misleading because it refers to both a "real" autopsy and a "virtual" autopsy.
• Dr. Levy is focusing on the description and understanding of post-mortem artifacts as viewed by medical imaging techniques. Such knowledge, of course, is critical in the evolution of the virtopsy and extends the understanding of such artifacts that has been obtained over the years by pathologists.
• Because of the profound amount of new information that is now being added to the classic autopsy gross dissection techniques and microscopic observation of tissue, I personally believe that the forensic autopsy, as routinely performed in the U.S., is on the verge of being obsolete. I believe that most pathologists will come to the same conclusions after reviewing the two lectures referenced above.
• I urge all forensic pathologists to rapidly adopt the medical imaging techniques advocated and now demonstrated as practical by Drs. Bolliger, Ross, and Levy as soon as possible. This will enable a refinement of both standard and forensic autopsies techniques such that much more information can be obtained from the procedures and the information obtained can be better documented.
• Achieving broad adoption of the forensic virtopsy will be very challenging based on the following requirements of the virtopsy: (1) ready access to sophisticated medical imaging devices for most or even many of the procedures; and (2) ready availability of a forensic radiologist such as Dr. Ross to interpret the post-mortem images. Ultimately, I believe that the solution to this problem will be the cross-training of forensic pathologists in both pathology and radiology in order for them to interpret both gross/microscopic pathologic changes as well as the images produced by the various imaging modalities.
• I believe that early adoption of the forensic virtopsy in the better-funded medical examiner offices in urban centers will cause a medico-legal conundrum in other communities. The adoption process will begin to change the standard of practice for the forensic autopsy as interpreted by the courts. In those regions where the practice is not adopted, the defense bar may be able to challenge the validity of classic forensic autopsy findings as inadequate.

Comments

[Ajit Alles]

I think the classic autopsy will persist until costs of the virtual-autopsy are reduced. Medical examiners are hard pressed for funds as it is and I don't see this changing in the near future.