- Pathology plays a key role in patient diagnosis, treatment decisions, and outcomes through tissue examination and ancillary studies. - A pathologist's report provides the diagnosis, prognostic/predictive factors, and assists physicians. New technologies have improved characterization. - Errors can occur so quality assurance like second reviews are important. A case was discussed where a diagnosis changed from invasive cancer to benign through further review, avoiding unnecessary mastectomy.

1. Pathology and
How to
Understand it
FLASCO Rapid Integration
Training
May 19, 2017
Westin, FL
Shahla Masood, M.D.
Professor and Chair
Department of Pathology and Laboratory Medicine
University of Florida College of Medicine-Jacksonville
Medical Director, UF Health Breast Center
Chief of Pathology and Laboratory Medicine
UF Health Jacksonville

2. Pathology
The Plan
o To provide an overview of the
contributions of pathologists in patient
care, research, and education

3. Pathology
The Definition
o Pathology is the study of diseases and
the changes they cause
o A pathology report is the story of
human illness

4. Pathology
o Studies fluids, tissue, and other material from the
body
o Provides diagnostic/prognostic/predictive
information
o Assists physicians in making treatment decisions
and follow-up care
o Performs minimally invasive sampling procedures
such as fine needle aspiration biopsy
o Participates in research
o Participates in medical education
o Performs autopsies
What does a Pathologist Do?

5. Pathology
o Anatomic Pathologist: studies tissue samples
o Clinical Pathologist: studies non-tissue
samples such as:
 Blood
 Urine
 Bodily fluids
Different Types of Pathologists

6. Pathology
Sub-specialties in Pathology
o Forensic Pathology: studies the causes of
death in post-mortem autopsies
 Focus of several TV shows
• Quincy, M.E.
• CSI (Crime Scene Investigation)
• Crossing Jordan
• Cold Case

7. Pathology
o Cytopathology
o Hematopathology
o Head & Neck Pathology
o Surgical Pathology
o Breast Pathology
o Gynecological Pathology
o Gastrointestinal Pathology
o Molecular Pathology
o …and many more!
Sub-Specialties in Pathology

8. The Changing Role of Pathologists
The Way It Was:
o Pathology diagnosis was based on:
 Gross examination
 Light microscopy
o The most common diagnosis was:
 Undifferentiated malignant neoplasm

9. The Changing Role of Pathologists
The Pattern
o The emergence of new technologies
o Molecular characterization of tumors
o Stratification of patients for therapy based
on tumor characteristics
o A paradigm shift in patient outcome

10. The Changing Role of Pathologists
The Way it is Now:
o Establish a diagnosis
o Classify a neoplasm
o Differentiate between a primary versus a
metastatic tumor
o Predict the response to therapy
o Provide the prognosis
o Compose a comprehensive pathology report

11. Pathology Report
o Diagnostic Information
o Prognostic/Predictive Information

12. Pathology
Diagnosis
o Characterization of the lesion
o Benign versus malignant
o Distinction between primary versus
metastasis
o Assessment of metastatic tumors of
unknown primary origin

13. Pathology
Ancillary Studies
o Special stains
o Microbiology studies
o Electron microscopy
o Flow Cytometry
o Immunocytochemistry
o Fluorescent in situ hybridization
o Molecular testing
o Tissue microarray technology
o Morphometry
o Others

14. Pathology Diagnosis
Microbiology Studies
Tuberculous Granulomatous Inflammation

15. Ancillary Studies: Flow Cytometry
B-Cell Lymphoma
Pathology Diagnosis

16. Ancillary Studies: Flow Cytometry
T-Cell Lymphoma
Pathology Diagnosis

17. o Pertinent clinical history of any primary
malignancy
o Review of the morphologic feature of primary
malignancy
o The use of appropriate ancillary studies
Ancillary Studies: Metastasis versus
Primary Carcinoma
Pathology Diagnosis

18. Pathology Diagnosis
Ancillary Studies: Immunocytochemistry
High Grade Sarcoma

19. Metastatic carcinoma of the colon to breast
Pathology Diagnosis
Ancillary Studies: Special Stain and EM Study

20. Ancillary Studies: Immunocytochemistry
Metastatic malignant melanoma to breast
Pathology Diagnosis

21. Prognosis: Treatment Planning
o Tumor size
o Tumor type
o Histologic grading
o Lympho-vascular invasion
o Lymph node status
o Status of surgical margins
The Role of Pathologists

22. Prediction of Response to Therapy
o Assessment of the status of expression of
estrogen and progesterone
 Endocrine therapy
o Assessment of the pattern of expression of
HER-2/neu oncogene
 Herceptin therapy
o Assessment of others/new genetic molecular
pathway
 Molecular/adjuvant chemotherapy
The Role of Pathologists

23. The Role of Pathologists
The Significance of Accurate
Prognostic/Predictive Testing
o Selection of those patients who will most likely
benefit from systemic therapy
o Offering personalized medicine with greater
safety and effectiveness
o Providing affordable and cost-effective care

24. The Role of Pathologists
Tissue Sampling:
Clinical/Research
o Fine needle aspiration biopsy
o Nipple aspiration fluid
cytology
o Ductal Lavage

25. Minimally Invasive Procedures
o Goals
 To eliminate the
need for open biopsy
in benign disease
 To provide a non-
surgical means to
diagnose breast
cancer
CORE
BIOPSY
FNA
BIOPSY VERSUS
The Role of Pathologists

26. FNA
Biopsy
Surgical
Specimen
Breast Cytopathology

27. Breast Cytopathology

28. Breast Cytopathology
Masood S, et al. Comparative cost-effectiveness of fine needle aspiration biopsy versus image-guided
biopsy, and open surgical biopsy, and open surgical biopsy in the evaluation of breast cancer in the era of
Affordable Care Act: A changing landscape. Diagn Cytopathol. 2015 Aug;43(8):605-12.
o Advantages of FNA Biopsy
 Providing a diagnosis when surgical biopsy
may not be available
• High acceptability
• Cost effectiveness

29. Ductal Lavage
(09/06/01)
Breast Cytopathology
Early Cancer Detection

30. DL: Papilloma
DL: Papilloma
Breast Cytopathology

31. Score 22
DL
AE 1/3
P63
Breast Cytopathology

32. Breast Cytopathology

33. What Does A
Pathologist Need to
Provide in an
Accurate Pathology
Report?

34. Effective Communication
o Type of the procedures
o Pertinent clinical history
 Age/Risk Factors
 The site and the size
 History of other malignancies
 History of chemo/radiation therapy
o Pertinent laboratory and imaging
findings
o Appropriate tissue orientation

35. Minimizing Errors in Pathology
Effective Communication
o Knowledge about the biology of the tumor
and the impact of the pathology report on the
follow-up treatment intervention and patient
outcome
o Inclusion of the appropriate scientific
references at the end of the report
o Following the current established pathology
reporting guidelines
o Participation in tumor conferences

36. Integration of Health Services
Survivorship
Nurse Navigator/
Coordinator
Pathology
Patient and
Physician
Education
Medical Oncology
Radiation
Therapy
Plastic and
Reconstructive
Surgery
Surgery
Data
Management
Psychosocial
Support
Research
Genetic
Counseling
Radiology

37. The Current
Challenges Associated
with the Practice of
Pathology

38. Current Issues in Pathology
o Diversity in tissue handling, processing and
reporting
o Insufficient evidence-based correlation
between morphology and patient outcome
o Significant interobserver variability in
diagnosis and test results
o Communication barriers among physicians
involved in patient care

39. Current Issues in Pathology
o There are no uniform guidelines to measure
the rate of diagnostic errors
o Fear of disclosure and medicolegal issues
limits the reporting of diagnostic errors
o There are many look-alikes in pathology that
can mimic cancer
o There is minimal standardization in pathology
and biomarker studies

40. Minimizing Errors in Pathology
Suggestions
o To establish quality assurance programs
 Consensus slide conference
 Mandatory second review of cancer cases
 Mandatory adherence to established guidelines
 Involvement in external quality assurance
programs
o To review the outside pathology slides and
reports before the initiation of cancer therapy
o To seek a second opinion

41. Minimizing Errors in Pathology
Why is a Second Opinion Important?
o The estimated rate of change in surgical
therapy following a second opinion is up to
7.5% of cases
o In 40% of cases additional prognostic
information may alter the outcome and the
course of additional therapy
Staradub et al: Annals of Surgical Oncology 9(10):982-987, 2002.

42. Minimizing Errors in Pathology
Multidisciplinary Case Review:
The Impact
Imaging Pathology
Interpretive
Change
45% 29%
Surgical
Management
Change
16% 9%
Newman EA, et al: Cancer 2006, 107:2346-2351.

43. The story of a patient

44. The Story
o A self-referred newly diagnosed breast cancer patient
was scheduled to undergo mastectomy and lymph node
dissection
o The patient was 32 years old with no risk factors and
discovered the mass when showering
o The breast mass was sampled by core needle biopsy
and was diagnosed as an invasive cancer
o A palpable lymph node was found and was assumed to
represent a lymph node metastasis
o The patient was advised to have mastectomy and
axillary dissection followed by chemotherapy

45. Biopsy Original Diagnosis
o Invasive moderately
differentiated ductal
carcinoma
o Low-grade ductal
carcinoma in Situ

46. Calponin
Review of the Biopsy at our Institution

47. Follow-up Excisional Biopsy

48. Consultant Reviews
o Diagnosis #1: Atypical apocrine
adenosis with sclerosis and
associated florid sclerosing adenosis
o Diagnosis #2: Low-grade apocrine
ductal carcinoma in Situ, with focal
sclerosis, periductal and radial,
involving multiples cores

49. Invasive Cancer  In Situ  Atypia Benign
The patient agreed to undergo close surveillance

50. New York Times Article: “Prone to
Error: Earliest Steps To Find Cancer”

51. The Story of the Patient
The Question
o Whose fault is it?
o Are we overdiagnosing
and overtreating
cancer?