Cut it Out … No, Really, I Need Margins

Hello everyone! Back again with another post about that interesting space between my experiences working in laboratory medicine as an MLS and my current path through medical school toward a career in pathology. Last month, I discussed how the new 5th generation cardiac enzyme assays are evolving and reaffirming the relationships between lab data and clinical decision making. This month, as I adjust to a very different circadian rhythm, I’d like to talk about some topics in my surgery rotation as they relate to surgical pathology and the lab.

Just to summarize, besides epidemiological research and public health initiatives I’ve written about here on this blog, I had several years of lab work before medical school. In my experience, I have seen the gamut of required steps for pathology specimens peri/post-operatively. Everything from placenta, bone, blood, marrow, skin, brain, lung, GI, to any other organ system’s tissue is processed, blocked, stained and examined on glass by pathologists who write reports for their clinical colleagues.  Often, we in the lab receive phone calls from providers inquiring about turn-around times and results as they  follow-up on their patients and cases. In Chicago, I was able to see and train in a great trauma center at Northwestern, community hospitals like Swedish Covenant and Weiss Memorial, and an academic hospital centers like Rush and UIC. What I learned there is just how much really depends on those pathology reports. Cytology, diagnostic immunohistochemistry, morphology, margins, and gross analysis all contribute to a final diagnosis. After an extended observership at UAB Medical Center, I was fortunate to see first-hand the critical process involved in signing out dermatology consults, examining gross pathology, and even frozen neuropathology specimens. Sitting with attendings in the OR and frozen rooms deciding between glioblastoma multiforme, lymphoma, or something benign (read: defer to permanent slide diagnosis later) was fascinating. Meanwhile, I’m now a month into formal surgical rotations at Bronx-Care Hospital in NY and I get to see the other side of the pathology report.

The Relationships Between Surgeons and Pathologists are Critical

Many surgical interventions and procedures require resection of known or suspected pathologic tissue. Whether it’s malignancy, benign growth, obstruction, adhesion, or otherwise mechanically compromising tissue, many patients require a surgeon to remove the entity in question. And, while the difficulty of these excisions and resections may vary depending on location, cases rely heavily on the pathologist-surgeon collaboration. Virtually all neoplasms are diagnosed through anatomic pathology assessment under a microscope. Fine needle aspirates, pap smears, bone marrow biopsies, and countless other tissues must go through pathology before being finalized. This interdisciplinary collaboration between the surgical team and the pathology team is, of course, by nature acutely critical. In proper circumstances, open cases in the operating room are consulted to a pathologist STAT. The effective communication between the pathologist and surgeon awaiting the intraoperative consultation is key to effectively treating their shared patient. Sometimes operating rooms will have live microscopic image-casting, sometimes there is an intercom system, sometimes its solely based on electronic forms in the EHR, and sometimes pathologists need to go into the surgical field to examine the resection intraoperatively in person. However it happens, this is a very important relationship that patients might not be aware of.

The Point of View Between Surgical Pathology and Clinical Surgeons Are Different

So this sounds like a perfect match, right? Surgeons and pathologists living in harmony? Unfortunately, harmony isn’t part of regular onboarding at many institutions so, as with any staff, there are different scopes and sometimes this can be a challenge. Getting a frozen notification as a pathologist is a serious task. They are emergent and must be addressed immediately and diagnoses are made with serious gravity, often consulting with other pathologists. This is also, however, a singular teaching moment as every frozen section is different and pathologists use these learning opportunities to teach their residents and medical students. In the interests of accurate diagnoses, educational value, and appropriate response to the OR, pathologists take measures to ensure success. For example, frozen specimens will be received, a history and presentation of the patient is discussed, the specimen is partitioned for frozen section (STAT), permanent section, and further studies (routine). So, for the pathologist it’s all about accuracy, reliability, and what they can confidently report. The surgeon has a different point of view: they are operating with a specific physical goal in mind by either resecting a tumor, or isolating good margins from a known malignancy, or ensuring the tissue being removed is correct/adequate for its therapeutic purpose. Fun fact: surgical pathology was a field originally developed by surgeons! There are things a pathologist only knows, and there are things a surgeon only knows—but when working together, the overlap of medical knowledge increases the coverage of care for their shared patients’ outcomes.

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Image 1. A pathologist processes a frozen specimen on a cryostat machine. A summary of frozen sections from JAMA, 2005;294(24):3200. doi:10.1001/jama.294.24.3200

The Cold Truth About Frozen Sections

Frozen specimens aren’t perfect. In these specimens, tissue gets stiffened by freezing instead of routine paraffin embedding, and because of that a frozen section could be distorted by folds, tears, and other artifacts that might appear because of mechanical manipulation during processing. Frozen samples also leave artifacts where water would crystallize and freeze, but one of the caveats regarding artifacts in frozen sections is that FAT DOES NOT FREEZE. Instead, specimens that have large fat content (i.e. brain tissue) have to be examined carefully to not confuse findings with inflammation or other pathologic processes. Ultimately, it takes numerous cases to properly hone the skills required to confidently diagnose from frozen section. While they might not be perfect, it is a critical tool used between the surgical and pathology teams. Challenges in this handoff process relate to proper use of this surgical tool. For instance, if a frozen is called for and the surgery is closed by the time a pathology report is filed, then (assuming there were no serious delays) this may have been an inappropriate specimen decision. Furthermore, specimens must be discussed prior to receipt for appropriateness and clinical relevance. Fatty lipomas aren’t going to go to frozen section, they shouldn’t be ordered. A thyroid lobectomy? That’s a better utilization of resources and tools.

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Image 2. A demonstration of water-related crystal formation causing distortion and artifact (LEFT) on frozen section of muscle tissue, compared to normal (RIGHT). From Northwestern, source: http://www.feinberg.northwestern.edu/research/docs/cores/mhpl/tissuefreezing.pdf

Ultimately, with proper training and experience a pathologist can effectively use the frozen section as a useful clinical tool to improve patient outcomes. Surgeons operating in the best interests of their patients, should strive to create a functional and successful communication between both services. My experiences in NY with surgeons of various kinds reveals a common truth among them: pathology is a critical player in surgical interventions, and without margins, diagnostic stains, and other work-ups, those interventions would be much more difficult and risky.

Thanks again! See you next time!

Bonus: for more content specifically detailing some of the cellular morphologies and cytology I discussed above, please check out I Heart Pathology, a compendium website my friend and colleague at UAB, Dr. Tiffany Graham, manages. It’s meant for other pathology residents to review and refresh on material and it’s updated as often as possible. Check out the link here: https://www.iheartpathology.net/

 

 

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–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.

Moving Forward One (Baby) Step at a Time

As this summer passes quickly by, I find myself, once again, anticipating the fall Annual Meeting of ASCP. Deadlines are fast approaching as I pull together my own power point presentation, review the schedule for sessions to moderate as well as those I wish to attend on my own time.

Many of you are involved in the planning process for the Annual Meeting and understand the deliberation and organization that this entails. The plethora of educational proposals is vast, submitted by numerous respected individuals and teams. Given the back-drop of this immense undertaking, I must say that I was thrilled this year to be a part of the discussion for the newly -created Hot Topics in Clinical Pathology. This has been a long-awaited moment for me and many of my cronies who have felt for quite a long time that the focus on Surgical Pathology at the Annual Meeting has essentially pushed aside the importance of Clinical Pathology and Laboratory Medicine as a vital part of everyday pathology practice.

With the creation of the “Hot Topics” track, we at least begin to see a small, but significant move forward. Clinical Laboratory Scientists clearly identify their work and the laboratory as primary contributors to patient care. Pathologists should begin to embrace this concept more fervently. The fields of Microbiology, Coagulation, Hematology, Transfusion Medicine, Serology, Chemistry (and a multitude of other areas) are expanding rapidly and are the KEY to understanding, diagnosing, monitoring and treatment of disease. Our clinical laboratories support and enhance our Surgical Pathology practices as well and the sooner pathologists regain the interest and care for these areas within our expertise, the better off our patients will be (and yes…they are OUR patients too!)

Hats off to the Annual Meeting Planning Committee for taking this bold step (although a “baby” one) toward bringing Clinical Pathology back into the fold. I hope to see this agenda pushed forward and expanded, not just at the Annual Meeting, but also in our other educational offerings. We are, by the way, the American Society for Clinical Pathology!

Our clinical laboratories and clinical pathologists are not the departments or doctors of the lesser god! Hope to see you in Tampa, in attendance at the Hot Topics sessions!

 

Burns

-Dr. Burns was a private practice pathologist, and Medical Director for the Jewish Hospital Healthcare System in Louisville, KY. for 20 years. She has practiced both surgical and clinical pathology and has been an Assistant Clinical Professor at the University of Louisville. She is currently available for consulting in Patient Blood Management and Transfusion Medicine. You can reach her at cburnspbm@gmail.com.

PGY-1: First Month

So, as another July 1st has come and passed, neophyte first years have begun their training in pathology residency training programs across the country. Many will begin with either a bootcamp-style orientation and/or an introduction to surgical pathology. Although I do have a PGY-1 friend who started with a CP rotation (and not an intro one at that).

I was fortunate to have a creative surgpath director who has an interest in different styles of medical education during my PGY-1. During the last two weeks of June, in addition to the general administrative orientation requirements, we had what we affectionately refer to as our “bootcamp.” First, we were taught proper blade/cutting technique with various food products (eg – potatoes, bratwurst) to get a feel for how to adjust our cutting technique for various specimen consistencies.

She was truly dedicated and personally went to a butcher in Chicago and picked up pig organ blocks three times for us during those two weeks. Then she and one of our two surgical fellows instructed us in the Rokitansky en bloc method of autopsy dissection after we had watched a narrated DVD that she had created from the previous year PGY-1 training sessions. We then would have to complete a fourth unsupervised pig block dissection and need to score at least a 75% in order to pass our autopsy competency exam. Those who did not pass, had to repeat the exam.

We also learned how to cut mock uteri and prostates since these are common specimens. She had molded and frozen ground turkey to simulate these organs and even added surprises like chick peas to represent leiomyomas. We practiced how to bivalve and cut the uteri for both endometrial and cervical cancers as well as how to gross prostates…although I did go through the whole year and never get one until I rotated in the fall of my second year at the VA where I got them almost daily.

Additionally, in order to learn how to cut frozen sections, we took ten sections from various organs from our pig blocks and embedded, cut, and stained frozen sections. This way we could understand how certain sections cut better than others (eg – fatty tissue is more difficult to cut), how to orient them, and how to cut them well without folding and unevenness. We were then graded on our sections for frozen section competency exam. For those who did not pass, they got some personal remediation at the cryostat with our assistant director of surgical pathology.

In the gross room, we had PAs who were good at teaching. We practiced dictating biopsies and placentas, grossing placentas, and grossing “smalls” like an appendix or gallbladder. Twice a week, we had multi-scope subspecialty sessions in dermpath, liver, renal, and neuropath since most of these types of specimens go to either our fellows or the subspecialty pathologists and our first years rarely saw them.

We initially started with a six-person, six-day schedule of frozens, grossing biopsies/smalls/bigs preview, grossing bigs, autopsy, peds path, and neuropath for 1.5 months. Our PAs usually gross our biopsies and benign smaller specimens. Then we were whittled down to a four-person, four-day schedule of frozens, preview, bigs, and autopsy with two of us taking “mandatory” vacations. The two residents that remained on SP after our five months of intro to SP were incorporate into our standard three-person, three-day schedule of frozen/grossing bigs, biopsy/smalls signout/bigs preview, and bigs signout.

At my new program, it is different because we don’t have surgpath fellows. Since we are a small program, each senior resident serves as a co-chief and one of their responsibilities is the training of the PGY-1 residents in surgpath during an initial one-month intro to SP rotation. Other senior residents on the surgpath rotation also help out with the teaching. They also give AM lectures on grossing topics in Lester’s Manual of Surgical Pathology and the specific nuances of the grossing preferences of our attendings.

As for me, I start off with a comprehensive CP rotation that combines working in both the chemistry and microbiology sections. As a PGY-1 here, they have 2 months of ‘Wet Lab’ or an intro to CP rotation. But since I am a PGY-3 transfer, I am a cross between a PGY-1 in terms of knowing how things are exactly done here and a senior resident. So this month for me combines intro to SP, Wet Lab, and the subsequent comp CP rotation that would come after Wet Lab. So, I get to gross a little (since things may be done differently here), learn about where and how things are done in the labs, and study more specialized CP topics. Since I came from a program where we rotate at four different hospitals for surgpath and can be self-directed in terms of CP, this works fine for me but still can be initially daunting in terms of trying to fit in do things the way they would like them done here.

So what do you think are the best ways to train PGY-1 residents most effectively? Should they start off with an intro to SP rotation and how should that be structured in terms of time, topic areas, and teaching of those topic areas? Or does it matter if they don’t do an intro to SP rotation and go straight into a CP rotation? And who should teach them how to gross? Let us know how things are done at your institution.

 

Chung

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

General Versus Subspecialty Surgical Pathology Sign-Out

I’m currently on a month of neuropathology/autopsy at our main academic center. After 2 months at a busy surgpath site with a 1-1.5 hour drive each way, it’s finally nice to be able to take a breather. Here, I’m responsible for any neuro frozen and grossing that doesn’t go to the SP resident, helping with the cutting of autopsy brains, and sign-out of neuropath cases. Since we don’t have a heavy neurosurgery service, this allows me more time to learn at my own pace and I feel that I’m able to retain more.

Not including CP rotations, I’ve always learned more, retained knowledge, and performed better on the subspecialty rotations that I’ve had – hematopathology, pediatric pathology, and now neuropathology. While I acknowledge that part of this is my own fault because when I’m on surgical pathology (we do general SP sign-outs), I read up pretty much only on my cases. I know that I need to preview them for sign-out so I read up on the SP diagnoses and differentials. But I often am not motivated to read up on general systems, so I can be real hot mess (and as one senior resident called me recently, “stupid”) during unknown conferences. In CP topics and those subspecialty areas I’ve had rotations in, I’m quite the opposite and tend to excel.

Yesterday, was the first time I’ve been at consensus conference since my first year. At the community and VA hospitals where I’ve spent most of my SP rotations during my second year, we didn’t have group consensus conferences. I remember last year thinking during consensus, “please don’t pick on me to answer a question” during the inevitable pimp sessions that evolved. But yesterday, besides the fellow, I was the only senior resident present. But I was less apprehensive and intimidated than I had been when I sat in the same place the year before. So even though I don’t consider myself a person who is good at SP, I was adequate enough and I must have learned something over the past year without realizing it.

Obviously, how we teach surgical pathology is restricted by the type of sign-out practiced at the institution we are at and this often is dictated by specimen volumes, faculty expertise, and the cultural philosophy dominant there. Even though I thought that I had taken this question into consideration when interviewing and ranking programs, I realize now that I didn’t have a complete grasp on how training styles and cultures really would affect me. Probably since I’m graduate school trained first and naturally think more like a scientist that focuses on one area and learning everything about that area, subspecialty sign-out works best for me.

Before starting residency, I had an intuition that this was true but thought that I would eventually adapt to a general sign-out format since that is how my institution practices. And I’ve adjusted, albeit maybe not progressed as quickly as my peers. It’s difficult to maintain all surgical pathology as subspecialty unless the volume is high enough and this usually means a large, well-known academic center if that’s what you need during your training. The majority of residents will end up in private practice and many often train at places where the sign-out is a more generalized one. So how do we match our learning needs with practice requirements at our training institutions with our eventual responsibilities as a pathologist in terms of sign-out? I can’t say that I have a solution for this conundrum but would welcome opinions on the topic. What works best to train our residents in surgical pathology?

 

Chung

Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.

The End of the Rotation

Since my program is on a monthly rotation schedule, last Thursday was the last day of my 2-month surgpath rotation at our busiest site, which is private practice at a community hospital that serves a more middle class and affluent patient population than our main academic hospital. So, it seems appropriate to finish my “Adventures in Grossing, Part I” post from 2 weeks ago now. As I think I mentioned in that previous post, my first day at this site (right after I just had gotten back from almost 10 hours of traveling due to layovers coming back from USCAP and getting a migraine during my flight to boot), was a disaster to say the very least.

I had made the mistake of jokingly saying to my rotation director that I was the most CP oriented of those in my year (I’m the last 2nd year to rotate at this site this year)…and he had mistakenly heard my statement as “I dislike surgpath and because of that probably wouldn’t work hard at this rotation.” We were reminiscing about it today as we had our face-to-face end of the rotation evaluation about how much has changed since that first day.

Communication is very important and sometimes that also entails knowing what not to say in a situation, especially if it can be misinterpreted. Luckily for me, after I had another talk with my rotation director, he was willing to ‘start fresh’ and see whether his initial impression of me held true. We did not work together again until the end of the month as I was assigned to other attendings during the interim. But by the time, we were assigned together again, he was “happy” with what he had heard about me from the other attendings.

As a first year, I had heard rumors about how hard this site and some of the attendings were…the stuff of legend so to speak. First years do not rotate at this site as we need to build up our grossing and time management skills to be able to adequately manage the higher volume of grossing at this site. We have a three-day schedule that includes two days allotted to finish grossing and a third intra-operative consultation day which includes frozen sections, sentinel node touch preps, and intra-op gross examination of specimens.

I still need to work on my grossing speed and time management skills but after two months of instruction and experience at this site, I do recognize that I have improved. It’s almost the end of my second year and I generally do fine with diagnoses at sign-out because they are either things I’ve seen before or things that I have some time to read about prior to sign-out. But when it comes to unknown conferences or my RISE surgical pathology scores for the past two years, I know that I am horribly deficient and need some work.

In two months, I will be transferring to a much smaller program in my home state for personal family reasons. My medical school friend will be one of the chiefs next year and one of their incoming first years is also from my medical school. Plus, they rotate mainly at one site and do 1-2 rotations/year at another site that is near where my parents live and where I went to medical school. So it will be different than my current program which has 27 residents that rotate at four sites. The culture also seems very different and I worry that I may be behind the curve in terms of my surgical pathology (SP) knowledge. I’m not worried about CP as my strengths and background are in CP.

So, I’ve been wondering…what are some good resources to learn SP and some good approaches to learn while busy on rotations? I still haven’t found a good solution to these questions yet.

 

Chung

Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.