Lab Soft News

Pathology Is Not Disintegrating in Canada!

Today's guest blog has been written by the very distinguished Canadian pathologist, Dr. Michael McNeely. Mike is currently the President of the Association for Pathology Informatics (API) and Past-President of the Canadian Association of Pathologists. He lives in Victoria, British Columbia, Canada.

No, Pathology in Canada is NOT “coming apart at the seams”.  Our country continues to enjoy exemplary clinical laboratory service. The situation is tight and, in certain instances, is dangerous.  Recent newsworthy events and an editorial in the CMAJ (see:  Canada's pathology) speak to two issues which I would like to clarify: (1) “lack of a national QA program” and (2) a shortage of laboratory professional staff.

Quality Assurance: This part of the report has caused some to believe that Canada does not use QA. This is clearly not correct. Although Canada has government-funded health care, each individual province is responsible for the administration and management of health care within its own jurisdiction. With some provincial variation, lab accreditation and mandatory QA has been standard across the country for 30+ years.  What has not been routinely available (until several recent notable projects were launched) has been scrutiny of the professional work of pathologists.  This has been compounded by situations where pathologists work alone. 

Professional Staffing: During the 1960s and early 70s, Canada was the beneficiary of an influx of highly trained pathologists from other countries (mainly the UK). This bolus took up the open positions but neutralized the need to develop a full stream of residents. Twenty-seven years ago (commenting on research conducted by the late Vern Waldorf), I wrote an editorial in the Canadian Association of Pathologists Newsletter (Vol 24: March 1982; p. 18) in which I stated “It is probable that retirement will produce a manpower shortage that will start in about five years and will reach crisis proportions around the year 2000.”  Since, the early 80s, medical school output was curtailed and pathology residencies not expanded to meet the declining requirements. Today, we are “holding on” but all groups are stretched thin and specific locations are inadequately serviced.

CAP Foundation's Futurescape Coming Up Soon

The CAP Foundation launched a conference called Futurescape of Pathology last June (see: CAP Foundation Futurescape Lectures Now Available). It served to fill a critical niche in the world of PLM (pathology and lab medicine) continuing education -- a forward-looking view about how these disciplines will evolve in the future. The various lectures stimulated me to post a number of notes including the following: The Future of Medicine and, Therefore, of Pathology and Lab Medicine. I also posted a critique of the conference written by a pathology resident who attended on the basis of a travel award; see: CAP Futurescape Conference: A Pathology Resident's Perspective.

The second conference in this series, entitled Transforming Pathology will be held on June 6-8, 2008, at the Westin O’Hare Hotel near the Chicago ariport. The speaker and topic lineup is once again excellent. The entire program can be viewed here. On-line registration is available. You can also register by fax (847-832-8324) or mail: Futurescape Conference, 325 Waukegan Road, Northfield, IL 60093. The conference is being held over the weekend to accommodate to the schedule of the busy pathologist. It's definitely worth attending.

Integration of Anatomic and Clinical Pathology

Although I have posted a number of previous notes about the potential merger of pathology and lab medicine with radiology, I strongly believe that such a change must be preceded by a much tighter integration of clinical pathology (CP) and anatomic pathology (AP). Part of the value of the proposed merger for radiologists will be the ready availability of a total view of disease based on both molecular diagnostics and morphologic observations coming from the pathologists.

As I have noted before, one of the key practice models for this future direction for CP and AP will be the practice of hematopathology in which both the morphologic characteristics of malignant cells as well as their biochemical nature are taken into consideration when arriving at a diagnosis (see: Reinventing Pathology: The Hematopathologist as a Model for the Pathologist of the Future). In addition, hematopatholgists frequently participate in the selection of therapy for patients because such choices are frequently based on their diagnoses and thought processes.

There is growing evidence that the practice of surgical pathology is now moving closer to clinical pathology. Evidence for this can be found in the lectures of Dr. Jeff Myers. He has emphasized the close collaboration of surgical pathologists with pathology informaticians to increase patient safety (see: Aligning Surgical Pathology & Aligning Surgical Pathology & Informatics to Promote Informatics to Promote Patient Safety). Research in tissue biomarkers will also help to convert surgical pathology to a more quantitative discipline (see: In-Vitro Biomarkers vs. In-Situ Biomarkers; Changing Strategies for Interrogating Tissue Samples: A Systems Pathology Primer).

In my past blog notes and in the interest of being all inclusive, I have found myself using the awkward phrase pathology and laboratory medicine to refer to the field. This is truly a mouthful but I can't come up with the better name for the more closely merged CP-AP unit that I am discussing here. Therefore, I have decided to refer to it in the future as PLM. I know that change is merely cosmetic but having a more manageable name will be useful. If and when PLM merges with radiology, this problem will go away. We can then refer to the merged entity as diagnostic medicine.

Fantastic 1819 Anatomic Illustrations by Kyoto Physician Yasukazu Minagaki

The Tohoku University Library in Japan provides an online display of the painfully-real Kaibo Zonshinzu anatomy scrolls created in 1819 by Kyoto-area physician Yasukazu Minagaki. The style of these medical drawings is markedly different than the more sanitized approach favored in Western countries (see: Kaibo Zonshinzu Anatomy Scrolls Online).

More details about the these Japanese anatomic drawings are supplied at the Pink Tentacle (see: Kaibo Zonshinzu anatomy scrolls (1819):

Unlike European anatomical drawings of the time, which tended to depict the corpse as a living thing devoid of pain (and often in some sort of Greek pose), these realistic illustrations show blood and other fluids leaking from subjects with ghastly facial expressions. The fact that the bodies used in scientific autopsies in Edo-period Japan generally belonged to heinous criminals executed by decapitation adds to the grisly nature of the illustrations.

These works of medicine and art from 1819 are worth a look and somewhat shocking even for physicians who may have been trained using Gray's Anatomy, now available on-line. The online display of the drawings requires you to click the "left arrow" to navigate through the scroll.

Operational Issue Relating to Endo-Microscopy: Some Early Speculation

In a previous note (see: Progress in Diagnoses with Endo-Microscopy), I discuss some of the evolving science and technology underlying endo-microscopy. Using this technique, a probe is inserted into suspicious lesions discovered during colonoscopy. This probe functions as a confocal microscope and provides a detailed examination of the lesion at the cellular level. After reading this note, Bev MD posted the following comment:

As a pathologist, I would have a few questions about the sensitivity/specificity of this technique. How would it label cells that we consider "dysplastic' for instance? What would be its false negative rate, risking nonremoval of a cancerous polyp that has invaded by the time of a re-exam? Given the relative ease of resecting most polyps, I can't see much benefit except for saving the pathologist's bill, given that the endoscopist would now charge more using this technique, plus a polyp excision charge for ones deemed "malignant". Or am I missing something?

All good questions but perhaps somewhat premature given that this technology is still in the research stage and therefore has not entered into standard clinical practice. However and as I speculated in my note, the major potential and obvious advantage of endo-microscopy is its  ability to determine real-time whether borderline lesions are benign or malignant. It would then be possible to resect malignant and dysplastic lesions during the procedure or immediately afterward with a surgical procedure.

I can't help drawing an analogy between this new approach and fine-needle aspiration (FNA) of "lumps and bumps" in the breast, thyroid, and lung lesions. The cells aspirated from the lesion are immediately examined by a cytopathologist and the patient is spared a traumatic surgical procedure for purposes of diagnosis. In the case of endoscopy, recent news (see: Flat Colon Lesions Identified And Removed Using Colonoscopy) suggests that the diagnosis of gross lesions in the colon may be more challenging than previously thought. Here is an excerpt from the article:

A study released this week from researchers at the Veterans Affairs Palo Alto Healthcare System in California shows that non-polypoid colorectal neoplasms or flat colon lesions, are more common in Americans than previously thought and may have a greater association with cancer compared to polypoid neoplasms or the more commonly diagnosed colorectal polyp.

So where does all of this leave us, admittedly at an early stage in the development of the endo-microscopy? Here are some of my early ideas:

• Research on endo-microscopy will undoubtedly continue, perhaps resulting in an extension of the diagnostic capabilities of colonoscopy and with the added ability to determine, perhaps with certainty, the diagnosis of colonic lesions real-time.
• It is quite possible, following the example of FNA, that the microscopic diagnosis during endoscopy will be turfed to pathologists who will participate in the procedure. Given that the majority of colonoscopies reveal no suspicious lesions at all, it could make perfect sense for pathologists to provide such support.
• Pathologists are now commonly joining gastroenterology groups to diagnose the tissue samples obtained during various procedures such as endoscopy. If endo-microcopy eventually takes hold, the technology may act as an incentive for more gastroenterology groups to recruit their own pathologists.

Colonoscopy Demonstrating a Live Ascaris lumbricoides Roundworm

This is a link for pathologists who don't like to go to the movies but will certainly like this one. Click on the "view video" link at the NEJM web site to see a live Ascaris lumbricoides roundworm viewed through a colonoscope. The video is a supplement to the following article: Jang MK and Lee KS. Ascariasis. N Engl J Med 2008;358:e16. I hate to spoil the ending of the flick for you, but the critter gets snared with a loop.

Progress in Diagnoses with Endo-Microscopy

Image from Wikipedia

I have a special interest in emerging technologies that may ultimately compete with histopathology in diagnosing pathologic lesions from tissue samples. I have posted a number of notes about molecular imaging but never any about endo-microscopy. A recent article about this topic caught my attention (see: Endo-microscopy Technique Shows Promise for Early Colon CA Diagnosis) and below is an excerpt from it, with boldface emphasis mine. Shown on the right is an image of a flexible endoscope.

...we [previously} profiled an endo-microscopy system from Paris-based Mauna Kea Technologies...[T]his company's main product, the Cellvizio fibered confocal microscopy system, allows a "practitioner to insert one of the miniprobes (only 300 um to 2.8 mm in diameter) into a conventional endoscope and record microscopic level movies of the tissue as fast as 12 frames/sec." The latest news is that Stanford University scientists tested the system in a small study, to evaluate the detection of early stages of colon cancer, and they were quite pleased with the results....The [scientists] found a short protein that sticks to colon cells in the early stages of cancer. Before screening a person, they spray that short protein attached to a fluorescent beacon into the colon. The protein then gloms on to any cancerous cells and creates an easily visible fluorescent patch. They then used a miniaturized microscope called Cellvizio GI, developed by Paris-based Mauna Kea Technologies..., to peer inside the colon and look for those telltale spots. Not only did the researchers see fluorescent patches, they could make out the individual cancerous cells.....In the initial trial with 15 patients, the technique detected 82 percent of the polyps that were considered cancerous by a pathologist.

Endomicroscopy, alternatively referred to as in-vivo microscopy, is defined in the following way: a newly developed endoscopic modality, which allows in vivo microscopy of the mucosal layer in about 1000-times magnification with subcellular resolution during ongoing gastrointestinal endoscopy. As noted above, the technique can be supplemented by a ligand protein + fluorescent label to enhance the ability to detect malignant transformation of colonic polyps real-time during GI endoscopy.

It's interesting that researchers are now combining the techniques of endomicroscopy with a fluorescent-labeled ligand to identify malignant transformation of polyps. In essence, the technique is being transformed into a type of molecular imaging managed by a gastroenterologist rather than a radiologist. However, in this former case, there is a human observer of the gross lesion supplemented by microscopic observation using a built-in confocal microscope. From the patient's perspective, the advantages of in-vivo real-time microscopy is that the malignant lesion(s) can be immediately detected and resected.

Unelievable! -- A Replica of a Beating, Bleeding Heart

To "entertain" everyone at its 2008 Gala in New York, the American Heart Association displayed this artwork representing a beating, bleeding heart by Billy Chasen, an installation that's not meant for the squeamish but that all pathologists will certainly appreciate.

Additional Discussion About Reinventing the Autopsy

In a recent post (see: Reinventing the Autopsy: CT Imaging as a Routine Part of the Procedure), I suggested that this may be the right time to begin to reinvent the autopsy. In particular, I believe that a whole-body CT scan should be a mandatory first step in all such procedures. At the beginning of this note, I cited Dr. Jared Schwartz as the individual who had stimulated my interest in integrating imaging techniques such as the CT scan into the standard autopsy. He has posted a comment to this note which I copy below with boldface emphasis mine:

Bruce you are correct I have been preaching to pathologists, pathology educators and hospital leaders of the potential value of reinvigorating the autopsy using modern technologic tools. Imaging combined with fine needle aspiration and the promise of molecular diagnostics could result in a minimally invasive autopsy or no autopsy in the traditional sense in some cases. Lets not forget other tools such as laparoscopy. High resolution CT imaging for autopsy is occurring at a few research/military facilities in a few countries. Unfortunately i have not been able yet to convince our health system to be an alpha site for this procedure. We need to continue to try and educate healthcare leaders that a modern autopsy using all the tools available would without doubt renew the autopsy as an important part of improving the quality of health care. BUT unless a financial model can be developed to show the savings through improved outcomes few hospitals will invest in the research needed to demonstrate whether our belief of imaging improving the autopsy and autopsy rates is correct. I am an optimist and thus convinced that soon a few brave institutions will step forward.

Jared is absolutely correct that a new financial model is required if the catopsy, the reinvented autopsy that will include medical imaging, has any chance of being widely adopted. Let me put forward a couple of thoughts with regard to the development of this new financial model:

• I stated in my original note that tissues harvested at the time of catopsy would be submitted, whenever possible, to tissue biorepositories and that the revenue from these biorepositories would be used to offset some of the costs of the catopsy service. I do not know whether this financial model is feasible or how much additional revenue would be raised by pursuing this option.
• I believe that majority of catopsies would require little additional work beyond the initial performance of the CT scan and its rapid interpretation. Given that such a scan would cost what I would estimate to be one-quarter of the cost of a standard autopsy today, I believe that converting an autopsy to a catopsy service would actually result in a cost savings. However, catopsies may be in such demand that their numbers would increase. This increased workload would obviously increase the total cost of the proposed catopsy service.

Finally, I want to speak to Jared's last point which relates to the need to demonstrate to hospital executives that the conversion to a catopsy service (or even the current autopsy service, for that matter) will improve health outcomes in hospitals. My working hypothesis is that a catopsy will yield more useful feedback for physicians about their care of patients than the current autopsy. I further hypothesize that these physicians, in turn, will improve their modes of practice (i.e., improve health outcomes) on the basis of the reports that they receive following the procedure. In order to acquire data documenting any improved outcomes as a result of the conversion to a catopsy service, I would suggest adoption of the following procedure:

After receiving the catopsy report, the responsible physician will be asked, as part of the hospital QC program, to comment whether he/she will modify future treatment of patients in any way on the basis of information contained in the report. If the catopsy report documents findings that differ significantly from those recorded in the ante-mortem medical record, such a response will be considered mandatory.

Because these responses from physicians will be viewed as an important component of the total hospital QC program, they will be treated in a confidential and protected manner. They will thus be identical to other queries that are used to improve the quality of care and identify possible judgmental or procedural errors by physicians or nurses.

   

H&E Sections of Hot Dogs: Is This Kosher?

Everyone in anatomic pathology is familiar with various resident pranks including the introduction of H&E sections of hot dogs into the daily slide work. However, I was unaware that such pranks have sometimes resulted in journal publications. Justice has now triumphed with the appearance of the following article: Applying morphologic techniques to evaluate hotdogs: what is in the hotdogs we eat?. I must also comment that I found this article more instructive than many that appear in our journals. This gives me some hope for the future. Below is an excerpt from the article (boldface emphasis mine):

Americans consume billions of hotdogs per year resulting in more than a billion dollars in retail sales. Package labels typically list some type of meat as the primary ingredient. The purpose of this study is to assess the meat and water content of several hotdog brands to determine if the package labels are accurate. Eight brands of hotdogs were evaluated for water content by weight. A variety of routine techniques in surgical pathology including routine light microscopy with hematoxylin-eosin- stained sections, special staining, immunohistochemistry, and electron microscopy were used to assess for meat content and for other recognizable components. Package labels indicated that the top-listed ingredient in all 8 brands was meat; the second listed ingredient was water...and another type of meat ....Water comprised 44% to 69% ...of the total weight. Meat content determined by microscopic cross-section analysis ranged from 2.9% to 21.2% ....The cost per hotdog ($0.12-$0.42) roughly correlated with meat content....In conclusion, hotdog ingredient labels are misleading; most brands are more than 50% water by weight. The amount of meat (skeletal muscle) in most brands comprised less than 10% of the cross-sectional surface area. More expensive brands generally had more meat. All hotdogs contained other tissue types (bone and cartilage) not related to skeletal muscle; brain tissue was not present.

So what lessons can be learned from this article? First of all, it's a little shocking that meat was the top-listed ingredient in all brands but comprised as little as 2.9% of the wieners by microscopic cross-section analysis. To be fair to the hot dog manufacturers, the original weight of the actual "meat" ingredients may not accurately correlate with the cross-section analysis described. However, I think that the manufacturers should at least give us a small taste of the meat, bone, and cartilage extracted from the animal. However and In defense of the manufacturers, they have also resisted the temptation to throw a cow brain or two into the mix.

Secondly and in light of what we have learned from this article, restrain yourself if you have even a passing interest in watching C-SPAN when bored. To quote Otto von Bismarck: Laws are like sausages, it is better not to see them being made.