I Had a Blast

Hi again everyone!

Welcome back. Last month I talked about a colleague of mine, a fellow student who’s pursuing a career in pathology. The month before that I wrote a bit about Just Culture and how those of us in laboratory medicine ought to act as leaders for patient advocacy—especially when it comes to putting the needs of patients first. And in the spirit of progressing career timelines and fortuitous transitions, this month I want to talk about a place where Just Culture is tangible, where “patient come first” is a mission statement, and where I just spent the last month rotating in their Department of Laboratory Medicine and Pathology: The Mayo Clinic.

Image 1. Commemorative statue of the Mayo brothers in a park in front of the main building of the downtown campus at Mayo Clinic in Rochester, MN.

Before I go any further, if you haven’t seen the PBS Ken Burns’ documentary, I highly suggest you do; it’s fantastic. There are also a few excellent books on the hospital’s history and vision here and here. But back to the rotation: I can’t express how lucky I feel having spent time there or convey how much of a privilege it was to see pathology in a uniquely Mayo way. What I can do is try to talk a little bit about my experience and what that translates to regarding a culture of advocacy and collaboration; and I’ll share a case conference I presented on my last day in a topic I find fascinating.

Image 2. Ken Burns presents The Mayo Clinic: Faith, Hope, and Science on PBS, which aired September 2018.

Mission, Vision, and Values

As with any hospital, academic center, clinic, etc., you’re always going to have a driving philosophy that anchors the values of that particular institution. Some of my experiences in larger academic centers tout their strides at the forefront of medicine and translational research, others advertise that they treat the whole person body and spirit. Community hospitals sometimes lean into their integral part of, well, their communities as a center for trust and health. Sometimes institutions have specific populations to cater to or work intensely with industry and boast strong contributions to medical science. At the Mayo Clinic you’d be hard pressed to miss the message (in various forms) that “The Patients Come First”—in fact that line from many years ago comes from Dr. William Mayo delivering a commencement speech at a Rush Medical College graduation. (I was so happy to see so many Chicago-Mayo Clinic connections!)

Image 3. Dr. W. Mayo articulated the concept of patients’ “needs come first” in a graduation speech at Rush Medical College in Chicago on June 15, 1910.

It becomes very obvious that this culture of advocacy permeates into the daily proceedings there. The hospital makes a strong point to celebrate outreach, education, and research; and clinicians are given a cultivated environment in which to flex muscles of compassion for patient outcomes. It makes you a better clinician, and I argue, person. Everyone at this hospital has a voice and a seat at the table. I was continuously encouraged to interact with staff, clinicians, residents, fellows, and patients and contribute what I thought would benefit patient care. A unique perspective as a visiting medical student with previous MLS experience was both noted and celebrated.

Leadership in Pathology

In many of my pieces on this blog, I frequently discuss how we should champion active roles in testing stewardship, policy advocacy, and promoting positive patient outcomes. Granted, when you find yourself in larger, resource-rich, tertiary academic centers you can really push the envelope for progress. But generally, those of us on the ‘scopes operate in this margin between clinical medicine and translational research. Where does our leadership come in? What does it look like? I think it comes in the form of prolific contributions to societal guidelines and interdisciplinary work. Nowhere have I seen this more than my month in Rochester.

So many of their residents contributed abstracts and presentations at this year’s USCAP conference, some winning awards. The academic cycle of producing something great requires strong support from your home institution and that’s exactly what I saw. Not only were folks supported for their trips to conferences per usual, they were celebrated—hallway handshakes, accolades at morning conference, discussions post-meeting, and social media shares. Which, by the way, social media is now a leadership staple. You can’t go far in the present day without utilizing technology both inside and out of your practice. The Pathologist recently celebrated their first #TwitterPathAward for residents like Dr. Tiffany Graham at UAB for contributions to medical education and advocacy in pathology. Mayo clinicians, including residents, consultants, pathologist’s assistants, and more share case studies, educational material, and cutting-edge pathology news in terabytes! I now find myself increasingly active on social media representing pathology and interests within our field.

Image 4. A spring 2015 issue of The Pathologist discussed the increasing presence of pathology in social media and the trends of utilization for medical laboratorians abound.

Side note: I’ve followed a number of these social media pages about cases in pathology for a while, and when I was fortunate enough to be part of ASCP’s Top 40 Under Forty 2017, I connected with lots of awesome laboratorians. Some of which I got to meet this month! Including a fellow blogger on this site, some celebrated path assistants, and a prolific parasite-discussing clinical microbiologist.

Case Conference

So, my presentation was intense! I’ve given plenty of case reports and conference discussions before, but this was an opportunity for me to explore quite a rare case in genetics and connect it with my interests in hematopathology. This was a case of a patient with Li-Fraumeni Syndrome (LFS) who developed therapy-related Acute Myeloid Leukemia. It’s not a current case and has since been signed-out and closed, but I’ll only be talking about the pathologic entities involved.

Image 5. Remember that power of social media I mentioned earlier? Well, what better way to share information for other medical students interested in pathology and interested in visiting Mayo Clinic! Having my presentation grab an honorable mention amidst their productive and busy residents was great! #path2path #hemepath #lablogatory

Essentially, this patient was found to have Li-Fraumeni after the second manifestation of an acute sarcoma—the first being osteosarcoma in her teenage years and the second breast cancer in her 30s. Both cancer diagnoses were treated accordingly, and this patient was going through routine work-up for anemia before being referred to the Mayo Clinic. By the time the patient reached there, the clinical investigation included a battery of testing for causes of anemia—all within normal limits—so a bone marrow examination was performed which revealed a significant, though not acute (<20% blasts), myelodysplastic process. A follow-up in-house bone marrow collection revealed hypercellular marrow, now in acute myeloid proliferation, with abnormal myeloid cell maturation and very complex cytogenetics. She had a very complex karyotype and several detectable mutations which were consistent with the WHO’s classification and description of therapy-related myeloid neoplasm as a sequale to the treatments she received for her prior cancers. In the setting of a patient with LFS, it is almost impossible to avoid malignancy. The following slides are a (very abridged) summary taken from my presentation of this patient’s case:

Figure 1. Official LFS and AML discussion. As mentioned, this is the case of a patient with a history of osteosarcoma and breast carcinoma, both treated, now presenting status-post initial work-up for evaluating possible causes for anemia. Ultimately, when reaching a bone marrow examination, certain myelodysplastic features were discovered, referring this case for close investigation and expanding the differential to include various hematologic malignancies.
Figure 2. This bone marrow biopsy was evaluated at an outside institution and was reported to this patient’s case at Mayo Clinic. Note the presence of myeloid lineage blasts cells in the peripheral blood (PB) and bone marrow (BM) evaluations, however, at less than 20% this would not immediately indicate any acute myeloid crisis. There is a definitive left-shift in maturity with myeloid dysplasia.
Figure 3. This bone marrow evaluation was done about a month after the previous reported one. Note the significant increase in myeloid blasts present in both peripheral and bone marrow specimens. This time, there was significant dysplasia noted in multiple lineages as well as particular changes in granulocytic lines including left-shift and pseudo Pelger-Huet cells present. This diagnosis was upgraded from myeloid dysplasia to acute myeloid leukemia in the setting of myelodysplasia. The blast count has now crossed the 20% threshold and there are marked changes to morphology in several cell lines. Hypercellularity and cytogenetic testing were also highly contributory in this diagnosis. Not included in this slide but CD34+ cells that previously expressed CD15, CD33, and CD38 were now negative for those three markers. This indicates decrease in maturity and a poorer prognostic and clinical assessment of this malignancy.
Figure 4. A peripheral blood smear at the time of the second bone marrow specimen. In almost every field photographed, there were myeloid blast cells present. No Auer rods were seen, but many blasts had granules. There was left shift, and some immature granulocytes were present. Erythroid immaturity was demonstrated with morphology and circulating nucleated RBCs. Abnormalities in granulocytic lineages were present with hypogranular neutrophils and pseudo Pelger-Huet morphology.
Figure 5. At nearly any age, this bone marrow needle core biopsy on H&E stain would qualify as hypercellular. At low to medium power this is clearly evident. At higher powers, note the presence of predominantly immature granulocytes (with very few, if any, mature PMNs) as well as numerous blasts—on H&E blasts appear differently, but appreciate the increased number of cells with active nuclei, condensing chromatin, and prominent nucleoli.
Figure 6. Back to traditional hematology staining, you can still appreciate this bone marrow aspirate’s hypercellularity. There is a labeled megakaryocyte (which appears slightly abnormal) to scale against the numerous, immature and left-shifted granulocytes which overrun the fields. Myeloid blasts are seen in high numbers, with granules and prominent nucleoli. Increased levels of mitotic activity, abundant (and some abnormal) myeloid precursors, and a highly proliferative picture is appreciated.
Figure 7. Li-Fraumeni Syndrome (LFS) is a rare genetic predisposition to soft-tissue sarcomas. It is a germline mutation of either TP53 or CHECK2, more often the former. The mutation usually has an autosomal dominant inheritance pattern and has very high penetrance, more so in females (possibly due to the fact that the most common presentation of tumor formation in LFS is breast cancer). Note that this patient had a clinical history significant for both breast carcinoma and osteosarcoma which were treated with chemotherapy and radiation.
Figure 8a. Patients with LFS often have a germline mutation in p53, a very significant tumor suppressor gene, which is implicated in a wide host of cellular functions. Located on the short arm of Chromosome 17, when mutated this gene affects a myriad of pathways including cell senescence, growth cycle response, proliferation, DNA damage repair from mutations, epigenetic, or exogenous causes, and programmed cell death. If this downstream protection against severe DNA compromise is lost, this becomes a highly pre-cancerous environment for Knudsen’s “second hit” to negatively affect cells and ultimately lead to a vast array of malignancies.
Figure 8b. I mean just look! P53 is a serious player in cell survival and DNA damage recovery. It is the archetype example of a tumor suppressor gene and is implicated in an ever-growing number of cell survival and growth cycle pathways—of course a loss of p53 function would set the stage for high-risk.
Figure 9a. The World Health Organization (WHO) and its updated guidelines for diagnosing and addressing hematologic malignancies now includes a lot of new data regarding the molecular biology of cancer. Its applications to diagnostics in hematopathology are growing daily. In these guidelines, the WHO classify AML into seven general categories. For reasons relating to her clinical history of cancers and treatment, as well as the timeline she presented with, t-MN or therapy-related myeloid neoplasm would be an appropriate diagnosis.
Figure 9b. The American Society of Hematology (ASH) and the College of American Pathologists (CAP) co-wrote guidelines for the diagnosis of AML and published a number of recommendations in The Hematologist in 2017-2018. Essentially, proper laboratory test utilization and incorporation with significant clinical history is crucial. Staying organized and operating within WHO guidelines for hematologic malignancy diagnosis is just as important. The ASH/CAP guidelines tell diagnosticians to think about several key questions when approaching AML which further underscores the values of consistency, efficiency, and appropriate utilization.
Figure 10a. The reason for establishing a diagnosis of therapy-related AML is a significant one. The use of Topoisomerase II inhibitors, alkylating agents, antimetabolites, and radiation therapy all affect the genetic components relating to this particular leukemia. To correlate further, the patient had a 5q deletion, a complex karyotype, a history of receiving all treatments related to this entity, and a presentation of myelodysplasia which rapidly progressed to AML.
Figure 10b. LFS can cause leukemia on its own, AML can present as a hematologic malignancy on its own too; but this patient’s clinical history and treatment history lean the diagnosis away from de novo cancer to a myeloid process in response to a latent treatment effect.

Why All of This Matters

There are two main reasons why all of this is important enough to discuss in a case conference. First, as clinicians from the bench to the bedside we should all strive to talk through the toughest diagnoses and share with each other what best practices, lessons, and goals we can reach together. In the setting of Li-Fraumeni Syndrome it becomes critical to evaluate new onset (especially myeloid) neoplasms. TP53 mutations are associated with the lowest survival rates in acute myeloid leukemia, which has its own diagnostic and prognostic classifications set forth by the World Health Organization. Furthermore, understanding appropriate patient history, clinical information, and what appropriate lab investigation means is crucial. It not only keeps the needs and interests of the patient first, but also translates to the proper utilization of resources for the best results in the best timelines. Potential future implications of concurrent ongoing work in hematopathology and molecular genetics may yield therapeutic and diagnostic benefits we are not yet aware of—we must constantly include updates as we practice.

Second, this was an opportunity to share insights into the diagnosis and discussion of AML that came from my clinical experiences before rotating there. I previously mentioned the demonstrated value of including clinical viewpoints for the benefit of patient care outcomes, so appropriately I incorporated these topics into this case conference and included the following points to consider:

  • Hematologic premetastatic niches

When I was in graduate school at Rush University in Chicago, I did some research in hematopoietic responses to various therapies in the context of proliferation and understanding mobilization for transplant and engraftment. In this work, I became familiar with the concept of a reactive stroma and a “pre-metastatic niche.” There are small microenvironments in which hematopoietic, mesenchymal, and endothelial cell lines in the bone marrow thrive and develop which are full of cytokines and cell-cell interactions. My work focused on mobilizing all three lines with a CXCR4 target, but the concept holds true when considering germline and somatic mutability. In effect, those cells with pre-malignant mutations can cluster and affect the environment of other cells maturing in the same setting. The same way invasive cells can break through barriers to metastasize and spread past their in situ conditions, the same mobilizing spread can grow from pre-metastatic clusters. This, again, opens the discussion for treatment targets in future LFS and/or AML patients as molecular pathology expands.

  • Acute Myeloid Leukemia and Myeloid Sarcoma

In a recently published paper in Histopathology, I was part of a team at the UAB hospital’s department of pathology which discussed their experience with patients diagnosed with myeloid sarcomas (MS). The point was to look for correlations with MS to connect the entity with age, sex, location of tumor, AML status, genetics, etc. Ultimately, what became the highest predictor of disease was a complex karyotype, consistent with other concurrent literature. With respect to this patient, what if there was another soft tissue (or other location) sarcoma alongside her myelodysplastic picture. What if she had a low blast count, or hypocellular bone marrow, or necrosis/fibrosis, or had received G-CSF? Would AML with myeloid sarcoma be considered in this diagnostic setting, would myeloid sarcoma be something to worry about in her future or in her clinical history as a misdiagnosis? The take-home message would be to pay close attention to patient clinical history and stay both focused on the current diagnostic work-up but also open enough to avoid pitfalls in diagnostic challenges.

  • Misdiagnosis in clinical settings

In a case report from 2017 I discussed a patient who had bilateral lung nodules several years after being treated for breast carcinoma. It was initially thought to be relapse but was later correctly diagnosed as de novo peripheral T-cell lymphoma (PTCL). This could have very well been the same clinical scenario, with a different cell lineage. The lesson gleaned here is the same as those ASH/CAP guidelines: stay organized, consistent, and purposeful with your testing and investigation. What came down to a few immunohistochemical markers in this PTCL case could make all the difference in another case. Missing the clinical history and specific genetic mutations present in this LFS/AML patient could have led to a diagnosis of a myelodysplasia related AML instead of a therapy-related one, especially in the setting of such a severe germline pre-disposition.

  • Future plans for this patient

I thought it was ultimately important to discuss the patient’s future plans with the audience. In pathology we often sign-off after we sign-out. So, in order to make sure we emphasize the patient’s best interests moving forward from a poor prognostic diagnosis, we discussed her enrollment in a trial aimed at improving bone marrow donor matching based on HLA and KIR combination typing. This a relatively new and promising concept in the literature which I hold high hopes for.

If anything, this was something I learned last month: in order for you to call the quality of care the highest possible, you have to uphold many standards, both clinical and non-clinical. Clinically we all have to share with each other the latest and greatest in modern literature and advances in interdisciplinary or translational research. Aside from this, however, we have to keep each other human and connected to our patients. I never like to hear the stereotypes in pathology that place us in lab medicine miles away from patient care; instead, we do things every day that impact our patients’ lives greatly. And when we keep ourselves connected to that fact, like the philosophy at the Mayo Clinic, then we can boast our quality of care—from small community hospital to academic trauma center. Because its not the size of the lens on the scope, it’s the vast scope of impact we look through in a lens of compassion.

There you have it. That’s my month at Mayo and a case conference in a nutshell. It was a fantastic experience and I have to say it—I had a blast!

Thanks for reading, I’ll see you next time!

And have a Happy Lab Week 2019!

–Constantine E. Kanakis MSc, MLS (ASCP)CM graduated from Loyola University Chicago with a BS in Molecular Biology and Bioethics and then Rush University with an MS in Medical Laboratory Science. He is currently a medical student actively involved in public health and laboratory medicine, conducting clinicals at Bronx-Care Hospital Center in New York City.

Surgical Pathology Case Study: A 63 Year Old Male with a ~60 Year Recurring Neck Mass

Case History

A 63 year old man presented with a long standing history of a recurring pleomorphic adenoma of the parotid gland. As a child, the patient had radiotherapy to the bilateral parotid glands for parotid swelling. He then developed a left parotid mass ~15 years later and underwent parotidectomy. After another recurrence ~15 years after the initial parotidectomy, he underwent a second resection of multiple masses in the preauricular region. The patient then developed a recurrence ~20 years after the second resection and underwent neutron beam therapy. The patient tolerated the treatment well noting mild dry mouth, which is persistent, and left ear pain, but otherwise has no major long-term sequelae from the treatment. Eighteen years after the neutron beam therapy, the patient developed a left submandibular mass. A subsequent biopsy of the mass revealed a pleomorphic adenoma.  Enlarged left and right submental and submandibular nodes were noted, with biopsies performed at an outside hospital of these nodes demonstrating metastatic poorly differentiated carcinoma within three lymph nodes. It was noted on this pathology report that the histological features, in light of the history, could represent a carcinoma ex pleomorphic adenoma. A CT scan of the head and neck revealed a large multiloculated, cystic, rim-enhancing mass within the left parotid gland, as well as large enhancing lymph nodes within the right anterior and posterior cervical triangle and the right submandibular space, the largest of which measured 2.1 cm. A PET scan showed increased activity within the right neck. Upon meeting with otolaryngology, a 4.0 x 7.0 cm lobular, non-fixed left parotid mass, and two level 1B right sided nodes, were palpated. Based on the patient’s history, physical exam, and prior biopsy results, it was decided to proceed with a parotidectomy and bilateral neck dissection. 

Diagnosis

Received in the Surgical Pathology laboratory is a soft tissue mass resection from the area of the left parotid gland measuring 9.0 x 6.0 x 4.2 cm. The specimen is oriented by a single long stitch designating the superior aspect, and a double long stitch designating the lateral aspect (Figure 1). The specimen is entirely inked black, and then bisected to reveal multiple discrete, white-tan, partially cystic masses ranging in size from 0.2-4.0 cm in greatest dimension and measuring 7.0 x 3.5 x 3.0 cm in aggregate dimension (Figure 2). The largest mass is partially cystic with the cystic component measuring 1.2 cm in greatest dimension. This largest mass abuts the anterior, medial and lateral margins. The remaining tumor deposits are located:

– 1.2 cm from the inferior margin

– 0.4 cm from the superior margin

– 0.9 cm from the posterior margin

No gross salivary gland tissue is identified. The remainder of the specimen consists of unremarkable yellow adipose tissue and red-brown skeletal muscle. The specimen is submitted as follows.

Cassette 1:   superior margin

Cassette 2:   representative sections of anterior margin

Cassette 3:   anterior superior margin

Cassette 4:   anterior inferior margin

Cassette 5:   posterior margin

Cassette 6-9:   representative sections of mass with approach to lateral margin

Cassette 10:   representative sections of mass with approach to medial margin

Cassette 11:   mass in relation to surrounding skeletal muscle

Cassette12-15:   representative sections of mass

On microscopy, the specimen contains nests of tumor cells ranging in size from 0.2 to 4.0 cm within a dense fibrous matrix. Although these deposits may represent lymph node metastases, no residual lymphoid tissue is present. The tumor is represented by residual pleomorphic adenoma and numerous soft tissue deposits of pleomorphic adenoma (Figure 3). Admixed are broad areas of high grade carcinoma with necrosis (Figure 4). Most regions show adenocarcinoma, although a rare focus of squamous differentiation is also present. The lateral margin is positive for carcinoma, and a pleomorphic adenoma component approaches within 0.1 cm of the medial margin. The anterior, posterior, inferior, and superior margins are all free of tumor. No salivary gland tissue is identified.

In addition, eleven frozen sections are submitted from various areas surrounding the mass, with five of the eleven frozen sections demonstrating tumor deposits. A right neck dissection is performed with following results:

Level IB: 2 of 3 positive (largest deposit: 1.8 cm)

Level II and III: 1 of 14 positive, Level II (1.9cm)

Level IV: 1 of 8 positive (2.0 cm)

Based on these results, the specimen was signed out as carcinoma ex-pleomorphic adenoma, and designated as pT4aN2cMx

Figure 3. 2x photomicrograph showing a classic appearing pleomorphic adenoma with satellite nodules along the periphery

Discussion

Carcinoma ex pleomorphic adenoma (CXPA) is a carcinoma that arises in a primary (de novo) or recurrent benign pleomorphic adenoma (PA). While a PA is the most common salivary gland tumor, accounting for approximately 80% of all benign salivary gland tumors, a CXPA is quite uncommon, accounting for only 3.6% of all salivary gland tumors. CXPA is predominantly found in the sixth to eighth decades of life, with a slight predilection for females. CXPA arises most commonly in the salivary glands, in particular the parotid and the submandibular glands. CXPA can also arise in the minor salivary glands in the oral cavity, although these tumors tend to be smaller than their counterparts in the parotid and submandibular gland. There have also been cases of CXPA in the breast, lacrimal gland, trachea, and nasal cavity.

Clinically, CXPA presents as a firm, asymptomatic mass that can go undetected for years since they are not generally invasive. When the patient does experience any symptoms, with pain being the most common, it is usually due to the mass extending to adjacent structures. If the mass was to involve the facial nerve, paresis or palsy can occur. Other signs and symptoms include skin ulceration, mass enlargement, skin fixation, lymphadenopathy, dental pain, and dysphagia. The onset of symptoms can range anywhere from 1 month up to 60 years (such as with this case), with a mean onset of 9 years. Half of patients will have a painless mass for less than 1 year. Since these symptoms are similar to those of a benign PA, it’s important that the treating physician be aware of the possibility of a CXPA, especially considering the rarity of the cancer.

Grossly, CXPA appears as a firm, ill-defined tumor, and can vary greatly depending on the predominant component. If the PA is the predominant component, the mass may appear gray-blue and translucent, and it could be possible to grossly differentiate between the PA areas and the CXPA areas. If the malignant component predominates, then the mass may contain cystic, hemorrhagic and necrotic areas.

Microscopically, CXPA is defined as having a mixture of a benign PA, admixed with carcinomatous components. Zbaren et al, in an analysis of 19 CXPA cases, found 21% of the tumors were composed of less than 33% carcinoma, 37% of the tumors were composed of 33-66% carcinoma, and 42% of the tumors were composed of greater than 66% carcinoma. Most often, the malignant component is adenocarcinoma, but can also include adenoid cystic carcinoma, mucoepidermoid carcinoma, salivary duct carcinoma, and other less common variations. In cases where the entire tumor is replaced by carcinoma, the diagnosis of CXPA will be based on the presence of a PA on the previous biopsy. Conversely, you could also have a tumor that is predominately composed of a PA, with sparse areas of malignant transformation, such as nuclear pleomorphism, atypical mitotic figures, hemorrhage and necrosis. The likelihood of malignant transformation increases with the length of the PA being present, from 1.5% at 5 years, up to 10% after 15 years.

CXPA can be further sub-divided into four categories based on the extent of invasion of the carcinomatous component outside the capsule: in-situ, non-invasive, minimally invasive, and invasive carcinoma.

#1) In-situ carcinoma occurs when nuclear pleomorphism and atypical mitotic figures are found within the epithelial cells, but do not extend out beyond the border of the myoepithelial cells (Figure 5).

#2) Non-invasive CXPA, which can include in-situ carcinoma, is maintained within the fibrous capsule of the PA, but extends beyond the confines of the myoepithelial cells. Non-invasive CXPA may begin to show malignant transformation, but will overall behave like a benign PA.

#3) Minimally invasive CXPA is defined as <1.5 mm extension into the extracapsular tissue, with a mix of benign PA components and carcinomatous components.

#4) Invasive CXPA is defined as a > 1.5 mm extension into the extracapsular tissue, and will begin to demonstrate more carcinomatous components, such as hemorrhage and necrosis.

As the carcinomatous areas begin to increase in prevalence, the PA nodules will begin to be composed of hyalinized tissue with sparse, scattered ductal structures, and the malignant cells will begin to decrease in size as they move away from the site of origin. Perineural and vascular invasion can be easily identified as the tumor extends into the neighboring tissue (Figure 6).

The development of CXPA has been shown to follow a multi-step model of carcinogenesis with a loss of heterozygosity at chromosomal arms 8q, followed by 12q, and finally 17p. Both PA and CXPA demonstrate the same loss of heterozygosity, however, the carcinomatous components exhibit a slightly higher loss of heterozygosity at 8q, and a significantly higher loss of heterozygosity at 12q and 17q. The early alterations of the chromosomal arm 8q in a PA often involves PLAG1 and MYC, with the malignant transformation of the PA to a CXPA being associated with the 12q genes HMGA2 and MDM2.

Treatment for CXPA involves surgery, radiotherapy and chemotherapy, with a parotidectomy being the most common procedure performed. If a benign PA had originally been resected, but residual remnants of the PA were left behind, then satellite PA nodules will arise in its place (Figure 3). If in-situ, non-invasive or minimally invasive carcinoma is suspected in the superficial lobe of the parotid gland, than a superficial parotidectomy can be performed. Invasive carcinoma will result in a total parotidectomy, with every attempt made to try and preserve the facial nerve. If metastasis is suspected to the cervical lymph nodes, a neck dissection may also be performed. Reconstructive surgery following the removal of the tumor may be necessary, depending on where the tumor was resected from. Other treatment options currently being considered include a combination therapy of trastuzumab and capecitabine, as well as the possibility of a WT1 peptide based immunotherapy.

Figure 5. 40x microphotograph demonstrating an in-situ carcinoma confined within the myoepithelial cells
Figure 6. 10x photomicrograph of carcinoma at the lateral margin with areas of perineural invasion

References

  1. Antony J, Gopalan V, Smith RA, Lam AK. Carcinoma ex pleomorphic adenoma: a comprehensive review of clinical, pathological and molecular data. Head Neck Pathol. 2011;6(1):1–9. doi:10.1007/s12105-011-0281-z
  2. Chooback N, Shen Y, Jones M, et al. Carcinoma ex pleomorphic adenoma: case report and options for systemic therapy. Curr Oncol. 2017;24(3):e251–e254. doi:10.3747/co.24.3588
  3. Di Palma S. Carcinoma ex pleomorphic adenoma, with particular emphasis on early lesions. Head Neck Pathol. 2013;7 Suppl 1(Suppl 1):S68–S76. doi:10.1007/s12105-013-0454-z
  4. Handra-Luca A. Malignant mixed tumor. Pathology Outlines. http://www.pathologyoutlines.com/topic/salivaryglandsmalignantmixedtumor.html. Revised March 21, 2019. Accessed April 5, 2019.

-Cory Nash is a board certified Pathologists’ Assistant, specializing in surgical and gross pathology. He currently works as a Pathologists’ Assistant at the University of Chicago Medical Center. His job involves the macroscopic examination, dissection and tissue submission of surgical specimens, ranging from biopsies to multi-organ resections. Cory has a special interest in head and neck pathology, as well as bone and soft tissue pathology. Cory can be followed on twitter at @iplaywithorgans.

Proficiency Testing (PT) Part 2: Investigating Failures

Last month we discussed the rules and requirements for how to properly perform proficiency testing (PT) within your laboratory. In part 2 of this 3-part series we’ll review the rules associated with evaluating your results, and how to investigate any unsuccessful surveys. Still to come in part 3 we will look into how to utilize your PT results to monitor for trends and shifts in your values.

The rules:

  • Performance Review: Laboratories must initiate and document a review of their PT performance evaluations within 2 weeks of notification that results are available. This includes a review of both graded and non-graded/educational analytes and events as well.

Key things to note: Even though educational samples are not formally graded, you should still verify the accuracy of your results, with appropriate follow-up for any failures. CAP specifically requires you to evaluate these educational challenges as well. Whether the sample is graded or not does not change the fact that you had an incorrect result.

  • Unsatisfactory Performance: For any unsatisfactory results, you are required to perform a root cause analysis to determine why (see below for guidance). This also includes any clerical errors – you need to evaluate your process and find ways to prevent these simple errors from happening again. If they are happening with PT samples, it is possible they are happening with patient samples as well.
  • Cessation of Patient Testing: Unsatisfactory events indicate that there was a problem with that particular survey; whereas unsuccessful events indicate there has been a pattern of unsatisfactory events/samples and a larger problem exists. If a pattern of poor performance is detected, you may be asked by your local state department of health to cease all testing for a particular analyte.

Key things to note: This also applies to clerical errors. Even if there was no technical problem with the accuracy of your results, failure to submit results on time or clerical errors made while submitting can also have severe impacts on your ability to continue offering that test.

  • Remedial Action: If you’ve been notified by your PT provider or state DOH to cease testing, there are extensive steps that must be completed to prove that the problem was correctly identified and corrected. You must also identify where samples will be referred to for tests you are unable to perform in-house.

Key things to note: If testing has been removed from your laboratory, you will be required to demonstrate successful performance in 2 consecutive PT survey events for the analyte(s) in question before being granted permission to resume patient testing. This can cause significant delays and financial impact for your organization.

Root Cause Analysis: Investigate to determine who, what, why, when, and how the event occurred. Be sure to evaluate all phases of testing to ensure you identify all potential causes.

  • Pre-Examination:
    • Human Resources – evaluate the training and competency records for staff involved in the handling and testing of samples.
    • Facilities – reagent inventory control & storage temperatures, equipment maintenance and function checks
    • Standard Operating Procedures (SOPs) – staff compliance with written policies, bench excerpts are current and valid, document version control up to date
    • Specimen –test requisition/order entry (was the correct test code ordered/performed?), labeling (were aliquot/pour off tubes properly labeled?), transport (was appropriate temperature requirements maintained until testing performed), quality (was there visible deterioration with the sample prior to testing or cracked/damaged tubes received?), quantity (was the original sample spilled or leaking causing an incomplete aspiration of sample by your instrument?)
  • Examination:
    • Method Validations – were instruments current with calibration requirements, any bias noted during instrument correlation studies, values being reported within the verified AMR
    • Environmental Controls – temperatures/humidity within tolerance limits, for light sensitive studies (bilirubin) was there excessive exposure of the samples to light prior to testing, excessive vibrations occurring that may have affected results (nearby construction or a running centrifuge on a shared work bench)
    • Quality Control – did QC pass on the day of testing, was QC trending or shifts noted that month
    • Analytical Records (worksheets) – were sample results transcribed correctly between the analyzer and worksheet, between the worksheet and LIS
    • Instrument Errors – were any corrective actions or problems noted for the days before, during, or immediately after testing of PT occurred
    • Testing Delay, Testing Errors – were samples prepared and not tested immediately leaving them exposed to light or air which may affect results (blood gas samples), any errors or problems noted during testing that may have caused a delay or affected accuracy of results
  • Post-Examination:
    • Data & Results Review – check for clerical errors, was data trasmitted correctly from the instrument into LIS, was data entered correctly on your PT provider entry submission forms
    • Verification of Transmission – did your results correctly upload to the PT provider website, was there an error or failure with submission
    • Review of LIS – are your autoverification rules set up correctly, is the autoverification validation current with no known issues
    • Patient Impact – perhaps the most important step to take when reviewing PT failures, you need to determine what impact your failure had on your patient results. Depending upon the identified root cause and how different your values were from the intended response, this can potentially pose a severe impact on your patient values tested at the same time as the PT samples.

Involve your medical director to determine if the discrepancy in results is clinically significant. Perform a patient look-back to review patient values for the same analyte with the failure during the time period in question. Evaluate the bias that was present, and if deemed to be clinically significant then corrected patient reports will need to be issued with a letter from the medical director explaining why. If it was decided that the discrepancy is not clinically significant, document this in writing and keep on record with your complete investigation response.

Corrective Actions/Preventative Actions – use the following set of questions to help guide you in ensuring that the problem identified during your root cause analysis will not occur again:

  • What changes to policies, procedures, and/or processes will you implement to ensure there will not be a repeat of this problem?
  • Do any processes need to be simplified or standardized?
  • Is additional training or competency assessment needed? If so, identify specific team members to be trained, and who will be accountable for performing and documenting this training.
  • Is additional supervisory oversight needed for a particular area or step?
  • Are current staffing levels adequate to handle testing volumes?
  • Would revision or additional verification of the LIS rules address or prevent this problem?
  • How can the communication between laboratory, nursing, and medical staff be improved to reduce errors in the future?

Continuous Process Improvement – after identifying the true root cause(s) for the failure and implementing corrective/preventative actions, you need to evaluate the effectiveness of those improvements. Have they been sustained? Are they working to correct the original problem? Have you created new problems by changing the previous process?

  • Quality Management Meetings – if necessary, increase the frequency of these meetings during the evaluation period for timely feedback to management and staff
  • Implement internal audits and quality indicators to check for potential issues
  • Access the specimen transport conditions to ensure they meet test requirements
  • Evaluate and monitor your turnaround time metrics to track problem specimens and impact of testing delays
  • If necessary, increase the frequency when QC is performed or calibration frequency if stability issues are identified

Performing a thorough root cause analysis for any failures will allow you to implement appropriate corrective actions that will address the true issues. Having a robust quality management program will help ensure these issues are identified and corrected in a timely manner, and reduce the potential for the dreaded Cessation of Patient Testing letter from your local DOH.

Coming up in the final installment of this series on PT testing, we’ll review all of the quality indicators and data that can be found in your PT evaluation reports to help ensure you’re on track for accurate patient values.

-Kyle Nevins, MS, MLS(ASCP)CM is one of ASCP’s 2018 Top 5 in the 40 Under Forty recognition program. She has worked in the medical laboratory profession for over 18 years. In her current position, she transitions between performing laboratory audits across the entire Northwell Health System on Long Island, NY, consulting for at-risk laboratories outside of Northwell Health, bringing laboratories up to regulatory standards, and acting as supervisor and mentor in labs with management gaps.

The System

Outside the city of New Bern, in Craven County, North Carolina, there is a particular system for residents to dispose of their garbage. Locals must go to the nearest participating gas station and purchase stickers which cost about $2.00 each. These stickers must be placed on each bag of garbage generated in the household, otherwise they will not be picked up during the weekly trash collection. In order to save money, a group of widows has formed a club in which members scout out the open dumpsters in town (usually behind stores or gas stations). Then they call and let group members know where they can covertly dump their trash for free that week.

This story may seem funny, but for the most part, it is true. I have no doubt this also occurs in other parts of the country where the system for trash collection is similar. Why do people behave this way? Are they purposely trying to circumvent the trash collection system in place or is the system just not easy for locals to utilize? If you’re having difficulty getting people to change safety behaviors (like PPE compliance) in your laboratory, you might need to determine that for the systems you have in place and ask similar questions.

In one laboratory the manager struggles with staff who work part of the day in a clean office and another part in the lab itself. When the employees go into the lab for brief periods, they often fail to don their PPE. Upon further investigation, you would learn that staff are not allowed to keep their lab coats on their chairs and that all PPE is kept in one lab store room located on the opposite side away from the offices. The system is set up to reinforce PPE non-compliance.

In another lab the manager placed a permanently-mounted counter face shield in the chemistry department so that staff would be forced to use it when popping specimen caps. Staff loaded instrument racks behind the shield, but when they carried the racks over to the analyzers, their faces were not protected from splashing. Exposures continued to occur. Here the system is at play again. A face shield was put in place to change behaviors, but it was only a partial solution. In order to protect staff fully here, they would need goggles or a face shield that can be worn. Offer light-weight reusable or disposable face protection that staff can use easily. Be sure to give them a say in whatever option is chosen.

Sometimes the system issues are not apparent until there is a safety event, and unfortunately, that can result in bigger problems. If your training program does not include regular fire safety training, a small fire situation may get out of hand quickly. Does your staff have experience handling a fire extinguisher? Would they easily be able to put out a fire? Do they know their evacuation routes and meeting places, and could they get there with ease? What about the lab emergency management plan? Have staff participated in a table-top drill so they have a basic understanding of how to respond during a chaotic disaster? These are examples of some safety systems that need to be in place to keep staff ready and safe at all times.

When people take shortcuts or find ways to circumvent the system, there is usually a pretty good reason, Often, it is the design of the system. In New Bern, elderly women can’t lift large heavy trash bags, so they use smaller bags. They don’t want to pay the same price for a garbage bag sticker that others are paying for big bags. There’s a problem with the system- and those ladies found a way around it. What problems do you see in your lab safety system? If you don’t know what they are, ask around. Staff will talk. It’s better to find out what the workarounds are now and to fix them before an injury or exposure occurs.

Dan Scungio, MT(ASCP), SLS, CQA (ASQ) has over 25 years experience as a certified medical technologist. Today he is the Laboratory Safety Officer for Sentara Healthcare, a system of seven hospitals and over 20 laboratories and draw sites in the Tidewater area of Virginia. He is also known as Dan the Lab Safety Man, a lab safety consultant, educator, and trainer.

A Pathologists’ Assistant Abroad

Jennison Hartong, MLS(ASCP)CM, PA(ASCP)CM, is a Pathologists’ Assistant who recently went to Ethiopia to teach grossing techniques. The editors of Lablogatory asked her a few questions about her experiences.

Lablogatory: How’d you get involved with ASCP’s Center for Global Health?

Jennison: Dr. Milner, Chief Medical Officer of ASCP, initially reached out to one of the pathologists at M.D. Anderson to inquire if any Pathologists’ Assistants (PAs) would be interested in attending a workshop in Nigeria. I reached out and expressed my interest in teaching grossing techniques rather than public speaking (not one of my strengths). Dr. Milner then told me about this opportunity in Ethiopia where pathologists were requesting advanced, gross training in lymph node dissections on breast and colon specimens. I immediately jumped at the opportunity to help in this way.

L: What were your motivations for going?

J: Whether with basic health needs or more complex areas like cancer treatments, I’ve always wanted to use my education and experience to help others and impact lives in areas around the world where certain aspects of healthcare may not be accessible. Before becoming a PA, I was a medical technologist and was always interested in working with Doctors Without Borders, however, I did not have the years of experience to apply. I decided to go to PA school and was disappointed to learn that Doctors Without Borders does not utilize PAs. I figured that dream would have to be accomplished another way, which was why I was so eager to work with the ASCP and their global health initiatives.

Another motivation for going on this trip was experiencing the work and organizational skills required for making a trip like this successful. I am currently finishing my second master’s degree in public health with a focus in health policy and management. I was very interested in learning everything I could about planning programs to help developing countries as well as being able to network with like-minded health professionals.

L: What did you hope to accomplish while you were there?

J: My main goal of this trip was to help advance Ethiopian residents and pathologists in certain grossing techniques. More specifically, I aimed to assist with lymph node dissections and, as it turned out, how to locate and sample the radial margin in colon cancer cases.  I also wanted to experience a different culture than my own, step out of my comfort zone and challenge myself as a PA by teaching others. At the end of this experience, I can say that this trip was definitely a life changing experience and one I am extremely grateful for.

Image 1. Jennison (black scrubs) training residents from St. Paul Hospital to locate radial margins on colorectal cancer cases.

L: What did you learn about lab medicine in Ethiopia?

J: During my week in Addis Ababa, I quickly realized that it was up to me to make this trip as successful as possible. Never before in my professional career were all the decisions up to me, and at first, it was slightly uncomfortable. I was worried I would come across as too bossy or even condescending. However, after meeting Eshetu Lemma, the ASCP local representative, along with the other participants and experiencing their kindness and eagerness to learn, I was newly determined to make this trip an absolutely positive experience for everyone. I made some changes to the training sessions and after the first day, the rest of the week ran smoothly. I learned a lot about how lab medicine is practiced in Ethiopia. I learned that, in the case of a power outage, you carefully set your blade down and wait it out. I learned that resources like aprons and sleeves are not thrown away unless completely used up. I learned that due to cassette shortages, tissue submission is done quite thoughtfully- more so than in the United States. I learned that the overwhelming majority of cancer cases are presented at stage 4 due to issues surrounding resources, fear, myths, and lack of cancer education. But most importantly, I learned that the labs in Addis Ababa, Ethiopia, are doing an amazing job with the resources they are given and are eager for opportunities to positively impact patient care.

L: Is what you learned there applicable to your work in the States?

J: I’ll take what I learned there and incorporate it into my work here in the States. I’ve gained confidence in my ability as a health professional and reignited my passion to help others.

To put it simply, this trip has been life changing. It has allowed me to experience and accomplish a lifelong dream for which I am forever grateful. I’m hopeful that my future holds more opportunities to serve other communities and help strengthen cancer programs in developing countries.

Image 2. View from St. Paul Hospital.

-Jennison Hartong, MLS(ASCP)CM, PA(ASCP)CM is a board certified Pathologists’ Assistant, specializing in surgical and gross pathology working mainly in oncology cases. Before attending graduate school, she worked as a Medical Laboratory Scientist (MLS) at Lurie Children’s Hospital of Chicago, Illinois. Upon graduating, Jennison started working at Memorial Sloan Kettering Cancer Center. In 2018, she relocated to Houston and currently works at M. D. Anderson Cancer Center in Houston, Texas. In May of 2019, Jennison will graduate with a second Master’s in public health with a focus in health policy and management from New York Medical College. She plans to use her extensive lab experience and newfound knowledge of public health to help bring basic healthcare to communities that would otherwise not have access to these necessities.

Gastric Cancer: A Multidisciplinary Approach

Maryam Zenali1*, Dmitriy Akselrod2, Eric Ganguly3, Eswar Tipirneni4 and Christopher J. Anker5*

1 Department of Pathology, 2 Department of Radiology, 3 Division of Gastroenterology, and 5 Division of Radiation Oncology, The University of Vermont Medical Center (UVMMC), Burlington, VT and 4 Department of Hematology Oncology, Central Vermont Medical Center (CVMC), The University Of Vermont Health Network, Adult Primary Care, Berlin, VT

*corresponding authors

A 57 year old woman with a personal and family history of breast cancer presented with early satiety and dysphagia for 5 months. Her abdominal computed tomography (CT) scan (Image 1 A) showed marked thickening of an apparently featureless gastric wall (A, blue arrows indicating the mucosal [rightward pointing] and serosal [leftward pointing] aspects of the gastric wall). Prominent gastrohepatic lymph nodes were noted as well. Her fluoroscopic upper GI study (Image1 B), following administration of barium and effervescent crystals (a double contrast effect to allow for mucosal evaluation), showed thickened rugal folds (B red arrow) and pooling of barium within an antral ulcer (B blue arrow). A subsequent CT scan (Image 1 C) after administration of intravenous and enteric contrast, confirmed marked diffuse gastric wall thickening (C blue arrows again indicating the mucosal [rightward pointing] and serosal [leftward pointing] aspects of the gastric wall) (Image 1, composite radiographs A-C).

The gastric body distended poorly with insufflation and demonstrated thickened, erythematous, edematous folds with erosions (Image 2, endoscopy image). On endoscopic ultrasound, the total thickness of the stomach was 12 mm with expanded wall layers in the proximal stomach to the antrum and a thickness of 3.5 mm in spared areas. Biopsies were obtained; the corresponding H&E and keratin stains are provided (Image 3, composite photomicrographs A-B).

Image 1. Composite radiographs.
Image 2. Endoscopy image.
Image 3. Composite photomicrographs.

Based on the original radiographic imaging that led to the biopsy, what are the differential diagnoses?

Working with Generation Y: How Other Generations Can Adapt

Generation Y is coming and they are coming in strong! It is fast becoming the world’s largest working generation and their impact on the workforce will become even clearer in the next few years. These digital natives find communication natural, in any shape or forms it comes. They prefer texting and instant messaging, but also appreciate face-to-face meetings and hand-written notes. They use social media for both personal and professional use and consider it essential to know how and where to access information. Instant gratification has become one of this generation’s key values, because they grew up with the world of information at their fingertips. They value professional development and feedback and they are at work to learn and grow.

When working with a Millennial the first step is to show them that you respect them and what they bring to the table. This generation has received more negative attention than other generations, but they have a tremendous amount to offer to the workplace (as do all the other generations). They value collaboration and learning opportunities, so they are typically quick to adjust when giving constructive feedback. Because of their collaborative approach, they value inclusion and Social Media to bring people together. They are well versed in finding information and can typically solve smaller technological issues without any help.

This generation is focused on having their work mean something, to have a purpose that is larger than simply getting a paycheck. They dislike long email and voicemails and anything that is a waste of paper. They appreciate flexibility and sending documents electronically. They experiences high academic pressures, so they are comfortable working in a fast-paced environment. They are comfortable multitasking and handling multiple projects simultaneously.

Millennials who work in larger organizations are on the brink of entering leadership positions. However, there are many self-starters who have had to learn leadership skills along the way. Because this generation values collaboration, leaders tend to encourage group work and giving people an acknowledgement for trying. They dislike people who are afraid or do not want to learn new technology and cynicism as they are a generally very positive generation.

When working with Millennials, note that they respond well to a participation work environment so ask for their input and suggestions. Be open about any processes, systems, and share information freely. Provide them with lots of feedback to help them learn and grow. Millennials respond well to a faster pace work environment, so do not try to slow them down. They dislike formality and stiffness, so allow flexibility whenever possible. For example, invite them to provide input for their own goals and do not hover over them. Give them multiple things to work on simultaneously so that they can go from project to project when their energy shifts. This generation is crucial to bring your organization to the next level, so mentor them, help them grow and develop and you get their dedication, passion, collaboration, and positivity in return.

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-Lotte Mulder earned her Master’s of Education from the Harvard Graduate School of Education in 2013, where she focused on Leadership and Group Development. She’s currently working toward a PhD in Organizational Leadership. At ASCP, Lotte designs and facilitates the ASCP Leadership Institute, an online leadership certificate program. She has also built ASCP’s first patient ambassador program, called Patient Champions, which leverages patient stories as they relate to the value of the lab.


What’s the purpose? That’s the question that most Gen Ys, or commonly known as Millennials, ask of their job. Why am I here? Can I make a difference in the world if I remain doing what I am doing?

The Baby Boomers worked because they felt an obligation to put in a hard day’s work whether they liked doing what they were doing or not. It was a job. The Generation Xers introduced a focus on work-life balance, which was not the case for the Baby Boomer. The Boomers never heard of the concept of “work-life balance” until their children, the Gen Xers, made it a job requirement and reality.

As for the Millennials, they need to really believe in their job and what they are doing. Millennials ask questions that the Boomers and Gen Xers wouldn’t think of asking. This is often misinterpreted as being lazy or looking for the easy way out. This is not the case. The Millennials took the best of their predecessors. Most Millennials have a good work ethic and they definitely look for balance. However, they’re also searching for a purpose.

My favorite story of a Millennial is centered on the importance of taking lunch at work. This topic surfaced from a Roundtable Discussion with laboratory professionals last October 2018, at the ASCP Annual Meeting in Baltimore. The actual topic for this Roundtable Discussion was “diversity.” However, that quickly changed when the nine people at the Roundtable focused on generational differences. This roundtable was rich in generational diversity. The table was comprised of Boomers, Gen Xers and Millennials. Boomers stated that they found it both necessary and easy to work through lunch. Why? It’s because they pride themselves in their incredible work ethic. The Boomers praised themselves for being better than “most Millennials” who often don’t and won’t work through lunch. Instead of that mindset, perhaps the better approach would be “What can we learn from Millennials in the work place?” That answer is “purpose and balance.”

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-Catherine Stakenas, MA, is the Senior Director of Organizational Leadership and Development and Performance Management at ASCP. She is certified in the use and interpretation of 28 self-assessment instruments and has designed and taught masters and doctoral level students.