Aberrant neurofilament protein and synaptophysin expression in malignant melanoma of the nasal cavity

Sir: Paranoia abounds when a ‘new’ technology is identified that may replace a job traditionally performed by humans, rendering those individuals redundant. Will the use of magnetic resonance imaging (MRI) and other similar imaging technologies replace the need for full invasive autopsies of all types, thus finally confining the autopsy to the memoirs of retired pathologists? The paper by Roberts et al. would suggest that this is not the case, although we wish to draw to the attention of your readers a number of observations that this paper has prompted. The authors are correct in stating that this is the first study of non-suspicious sudden adult deaths to assess the use of MRI in establishing the cause of death. However, this is not the case for forensic or paediatric autopsies, or for the post mortem examination of head and neck structures. Thali et al. published a highly illustrated series of 40 forensic cases in which they compared the findings of both multislice computed tomography (MSCT) and MRI with full invasive examination, illustrating the wider application of these technologies in autopsy practice. Rather than restricting their study to the question of the cause of death, the authors also explored the use of MSCT and MRI for the assessment of trauma (soft tissue, skeletal and visceral), vital reaction and forensic reconstruction. The article highlighted how these technologies can both supplement and enhance the autopsy examination and, in 55%, could have replaced autopsy examination altogether. Other studies have also highlighted the potential use of MSCT for the identification of an unknown individual, one of the principal questions of the coroner’s remit (who, where, when and how). We routinely use a variety of imaging techniques, including plain X-ray, fluoroscopy, MSCT and MRI, the latter being reserved for paediatric cases and the former three used depending on the questions posed. These days, for adults, the use of MSCT has now almost entirely replaced the use of plain X-rays as, with one hour’s notice, we have access to the hospital CT scanner, 24 h per day, 7 days per week. The on-call radiographers are trained in the use of the technology and the bodies need not be removed from the sealed body bags, thus providing advantages over traditional forms of radiography. As in the abovementioned papers, a full-body trauma scan can be undertaken in a matter of minutes with more detailed reconstruction scans undertaken for areas of interest, the cost of the radiological examination being much less than that quoted by Roberts et al. The forensic pathologist is present during the examination to review the scans and discuss the findings, although, to date, a radiologist continues to report the films formally. The autopsies are then performed immediately after the imaging. Has the MSCT or MRI replaced the need for an autopsy—in our opinion, no. The commonest cause of adult death in the UK, according to the paper by Roberts, can still not be diagnosed with sufficient accuracy to replace the neccessity for an autopsy. If stenosis of the coronary arteries is identified on the images, is this necessarily the cause of death? Even supplementing the image with a clinical history and an external examination of the body may still not adequately remove the need for an autopsy. The MRI cannot diagnose inborn errors of metabolism, conductive abnormality or toxicological deaths. In fact, with regard to the latter possibility, the identification of coronary artery atheroma on a scan following the nonsuspicious death of an elderly adult, could actually lead to a misdiagnosis. However, we agree that these techniques have a significant role in modern autopsy practice, including the identification of cause of death, such as traumatic brain injury or disseminated cancer, or the revealing of an unexpected finding which may or may not be related to the ultimate cause of death, e.g. packets of drugs within the gastrointestinal tract of a drug ‘mule’ (Figure 1). Imaging may identify the location of a projectile within the body (Figure 2) and, using reconstruction, show the path of the passage through the body soft tissues. Finally, it may answer a specific question, for example, is there a cardiac air embolus in a person who has suffered neck trauma (Figure 3). As Roberts et al. mention, the images can be stored in an electronic format for review at a later date or use in court long after the body has been disposed of. Is it necessary, therefore, to continue to a full formal examination? The answer is no; however, the courts at present still request full examinations for evidence. In the future this may not always be the case. Secondary pathology or post mortem changes are also often revealed during these imaging examinations. By being present during the imaging the pathologist can discuss the case, especially where there is diagnostic