Diagnostic Theory in

Chemical Pathology

Prof Ching-wan Lam

Chemical Pathology
Department of Pathology
The University of Hong Kong
 Objectives
• To introduce the principles of evidence-based
chemical pathology in modern medicine.

• To discuss the key concepts such as diagnostic

accuracy, sensitivity, specificity, predictive
values, precision, uncertainty of measurement,
pre-analytical variables and biological
variations of chemical pathology tests, Bayes’
theorem and receiver operating characteristic
curve analysis.
• As a medical doctor, you are
required to make diagnosis.
• Does the patient have disease?
• What can the test result tell me?
• There are two types of tests:
– 1. Screening tests
– 2. Diagnostic/Confirmatory tests
– Some tests can serve dual functions.
 Chemical Pathology Tests
• Screening
– To identify risk factors for disease (e.g. cholesterol for CAD)
– To detect occult disease in asymptomatic persons (e.g. FOBT in
colon cancer)

• Diagnosis
– To establish or exclude the presence of disease in symptomatic
persons (e.g. amylase in acute pancreatitis)
– To assist in developing a differential diagnosis (e.g. insulin in
hypoglycemia)
– To determine the stage / activity of disease (e.g. ABG in asthma)

• Other uses of laboratory tests:

– To evaluate the disease severity (e.g. RFT and GFR)
– To estimate the prognosis (e.g. NT-proBNP in heart failure)
– To monitor the disease course (progression, stability, or
resolution) (e.g. HBA1c in diabetes mellitus)
– To detect disease recurrence (e.g. tumor markers)
– To select drugs and adjust therapy (e.g. pharmacogenetics and
therapeutic drug monitoring)

Nicoll D. Pocket Guide to Diagnostic Tests

 To Test or Not to Test
• One should weigh the potential
benefits against the potential costs
and disadvantages
• Some tests may cause patients
discomfort and stress
• Some tests may even be risky
– e.g. Chorionic villous sampling for
prenatal testing (1 in 100 risk of
abortion)
• Any positive result will trigger further
follow-up and more investigations
• Affect patients and family members for
hereditary diseases
• False positives lead to wrong diagnosis,
unnecessary investigations, treatment,
anxiety, even harm
 Diagnostic tests

• The fundamentals of
Evidence-Based Medicine

TEST
RESULTS
 True Positives
those who tested positive for a condition do have the disease

Test + Test -

Disease +

Disease -
 False Positives
those who tested positive for a condition actually do not have the disease

Test + Test -

Disease +

Disease -
 True Negatives
those who tested negative for a condition and do not have the disease

Test + Test -

Disease +

Disease -
 False Negatives
those who tested negative for a condition, yet do have the disease
Test + Test -

Disease +

Disease -
Fill in the blanks (TP / TN / FP / FN)
Test + Test -

Disease +

Disease -
Positive and Negative Predictive Values
• In clinical practice, we use a test to decide
whether the patient has disease or not.
• So, only the test result is known.
• What proportion of tested individuals
with positive results are truly abnormal?
• What proportion of tested individuals
with negative results are truly normal?
 Positive Predictive Value
Test + Test -

Disease + TP

Disease - FP

PPV =
TP/(TP+FP)

PPV =true positive (TP)/all positive (TP+FP)

 Negative Predictive Value
Test + Test -

Disease + FN

Disease - TN

NPV
=TN/(TN+FN)

NPV = true negative (TN)s/all negative (TN+FN)

 Sensitivity and Specificity
• An approach to quantifying the
diagnostic ability of the test
• Sensitivity is the proportion of true
positives that are correctly
identified by the test.
• Specificity is the proportion of true
negatives that are correctly
identified by the test.
Hypothetical distribution of test results for
healthy and diseased individuals

Nicoll D. Pocket Guide to Diagnostic Tests

 Sensitivity

a
No. of subjects tested

Test Positive

Normal Disease

Test results
 Sensitivity
No. of subjects tested

Test Positive

Normal Disease

Test results
 Sensitivity
No. of subjects tested

Test Positive

Normal Disease

Test results
 Sensitivity
No. of subjects tested

Test Positive

Normal Disease

Test results
 Sensitivity
No. of subjects tested

Test Positive

Normal Disease

Test results
Sensitivity and Screening Test
• A test with high sensitivity gives good
_______ predictive values
• To pick up as many as positive cases
• Useful to exclude a diagnosis
• Render few false negatives
• Probably include some false positives
• Require confirmation by specific tests
• e.g.
– Prostate specific antigen for Ca prostate
– Fecal occult blood for colorectal cancers
 Sensitivity: Pick up Positive Cases
Test + Test -

Disease + TP FN Sensitivity =
TP/TP+FN

Disease -

Sensitivity = number of patients with positive test

total number of patients
Specificity = Negative Sensitivity

Test Positive

Normal Disease
 Specificity: Pick up Negative Cases
Test + Test -

Disease +

Specificity =
Disease -
FP TN TN/(TN+FP)

Specificity = number of patients without disease with normal result

total number of patients without disease
Specificity and Confirmatory Test

• Highly specific test

• Some tests are both sensitive and
specific
 Bayes’ theorem
Probability of A&B = (Probability of A) times (Probability of B given A)
P(A&B) = P(A)P(B|A) = P(B)P(A|B)

www.astro.ucla.edu/~wright/statistics/
 Bayes’ theorem and PPV
P(A/B) = [P(B/A)P(A)]/P(B)

D+ = disease positive
D- = disease negative
T+ = test positive
T- = test negative

PPV = P(D+/T+)
[P(T+/D+)P(D+)]
=
P(T+)

True positive (TP)

= All positive (TP+FP)

[(sensitivity)(prevalence)]
= P(T+)
 Bayes’ theorem and PPV
Since P(T+)
= P(T+/D-)P(D-) + P(T+/D+)P(D+)

PPV
[(sensitivity)(prevalence)]
=
[(1- specificity)(1- prevalence) +(sensitivity)(prevalence)]
 Q: What condition(s) can
give you a PPV of 1?

• ____________________________
• ____________________________
 Bayes’ theorem and NPV
• NPV = P(D-/T-)
[P(T-/D-)P(D-)]
=
P(T-)
True negatives (TN)
=
All negatives (TN+FN)

[(specificity)(1-prevalence)]
=
P(T-)

• Since P(T-) = P(T-/D+)P(D+)+P(T-/D-)P(D-)

[(specificity)(1-prevalence)]
NPV = [(1-sensitivity)(prevalence)+(specificity)(1-prevalence)]
 Q: What condition(s) can
give you a NPV of 1?

• ____________________________
• ____________________________
 The Story of Phantom hCG
• Multiple publications on misdiagnosed
gestational trophoblastic disease

Sigi et al Lancet 2000; 355: 712

Receiver Operating Characteristic Curve

• The performance of two different tests can be

compared by plotting the sensitivity and
(1-specificity) of each test at various cutoff
values.
• The resulting ROC curve shows which test is
better.
• Better the test if the ROC curve lies above and
to the left of the inferior test curve
• Better the test, larger the area under curve
 Receiver Operating Characteristic Curve

Optimal point

Example of
ROC curves for
prostate-specific
antigen (PSA)
and prostatic
acid phosphatase
(PAP) in the
diagnosis of
prostate cancer

http://www.accessmedicine.com/popup.aspx?aID=22032&print=yes_chapter
 • In 1912
• Autosomal recessive
• Neurological deficits
• psychiatric disorders
• Cirrhosis of the liver
• Progressive
• Invariably fatal

DR. SAMUEL WILSON

(1878-1937)
 Wilson’s disease (WD)

• Commonest inheritable liver disorder in Hong Kong

• Defective copper excretion leading to systemic copper
accumulation and organ damage
• Early diagnosis enables effective treatment with promising
prognosis
• Traditionally, diagnosis by two out of three:
1. Neurological deficits
2. Kayser-Fleischer rings
3. Serum Ceruloplasmin (Cp) < 0.20 g/L
Mak et al. Clin Chem 2009
 Results (5)

0.14 g/L

Mak et al. Clin Chem 2009

Optimal Cutoffs

Mak et al. Clin Chem 2009

Likelihood Ratio

Nicoll D. Pocket Guide to Diagnostic Tests

 Likelihood ratio
• How useful is a test of sensitivity
50% and specificity 50%?

• LR+ =

• LR- =
 Likelihood ratio
• What condition(s) of a test will
give a LR+ / LR- of one?
• ___________________________
• ___________________________
Results (5)

Mak et al. Clin Chem 2009

Conceptual Clarification
 Conceptual Clarification

• 100 % Sensitivity = no ____

• 100 % Specificity = no ____
• 80% Sensitivity = 20% ____
• 80% Specificity = 20% ____