what every pathologist wants the gi nurse to know (and how

© 2008 Caris Diagnostics, Inc. All rights reserved.

What Every Pathologist Wants the GI

Nurse to Know

(and how you can help us help you)

Jonathan N. Glickman MD PhD

Director, GI Pathology, Caris Diagnostics, Newton, MA

Associate Professor of Pathology, Harvard Medical School


OUTLINE

• Introduction

• Overview of Anatomic Pathology Workflow

Procedures (i.e., what do pathologists do anyway?)

• Pathologist- Clinical Group Interactions

• Clinical and Endoscopic Information- the More the

Better!

• Sample Pathology Cases


A little about myself…..• Washington University Medical

School, MD PhD 1995

• Brigham and Women’s Hospital

(BWH)

– Pathology residency

– GI pathology fellowship

• Staff pathologist, BWH and

Children’s Hospital

• Associate Professor of Pathology,

Harvard Medical School

• Director of GI Pathology, Caris

Diagnostics, Newton, MA

http://aboutabride.files.wordpress.com/2008/09/st-louis-arch-address.jpg

http://images.google.com/imgres?imgurl=http://automationsolutionsinc.com/images/project%2520pics/09.jpeg&imgrefurl=http://www.automationsolutionsinc.com/SITE_Public/hospitals.aspx&usg=__wrf-lADIUWF-nz7CQYjc6wBSnJQ=&h=256&w=384&sz=22&hl=en&start=3&um=1&tbnid=owrg9jkijnH1rM:&tbnh=82&tbnw=123&prev=/images%3Fq%3Dbrigham%2Band%2Bwomens%2Bhospital%26hl%3Den%26rlz%3D1T4GGLL_enUS312US312%26um%3D1


Caris Pathology – Who are we?

• Three closely collaborating full-service laboratories (Irving, TX;

Newton, MA; Phoenix, AZ)

• 16 GI pathology fellowship-trained physicians

• 13 additional pathologists with GI expertise and fellowship

training in surgical pathology, cytopathology, or

hematopathology.

• Over 20 institutions represented:University of Washington, Baylor College of Medicine, Beth Israel Deaconess Medical Center, Brigham and

Women’s Hospital, Cleveland Clinic, Dallas VA Medical School, Duke University, Georgetown University, Harvard

Medical School, Indiana University, Johns Hopkins University, Mayo Clinic, M.D. Anderson Cancer Center,

Memorial Sloan-Kettering Cancer Center, University of Cincinnati, University of Iowa, University of Kansas,

University of Kentucky, University of Michigan, University of Nebraska Medical Center, University of Pittsburgh,

University of Southern California, University of Texas


Pathology Practice

• Two basic venues for anatomic pathology practices

– Hospital based

– Non-hospital based (private lab/outpatient)

• Key differences

– Pathologist activities

– Types of specimens

– Nature of pathologist-clinician interactions

– Access to clinical and endoscopic information


Anatomic Pathology Laboratory- Workflow

1. Receipt and Accessioning

- Patient identification

- Documentation of clinical history and endoscopic

findings

2. Gross examination and description of tissue

3. Tissue processing and embedding in paraffin

4. Sectioning/slide preparation and staining

5. Microscopic examination of slides

6. Preparation and release of pathology report


Accessioning• Review received

paperwork

• Verify that

specimens received

match paperwork

• Verify patient info

• Correlate with pre-

accessioned cases

• Log into

information system


Gross Description and Tissue Submission

• Trained Pathology

Assistant

• Review of paperwork,

submitted clinical

information

• Dictation

• Tissue sectioning (if

necessary)

• Placement in cassettes


Tissue Processing/Embedding/Sectioning• Good tissue processing and

sectioning is paramount to a good consultation report

• Proper processing

– Additional fixation in formalin

– Progressive dehydration to allow paraffin permeation

• Tissue is embedded in paraffin blocks

• Paraffin saturation enables thin sections

– Acts a support medium

• Sectioned at 4-6 microns onto glass slides

• Technique matters!


Slide preparation and staining• Taken through

deparaffinization,

rehydration, and drying

steps

• Once rehydrated, slides are

stained


Tissue Sectioning


Microscopic examination• Integration of all

supplied information

• Formulation of

diagnosis


Quality Control

• Patient identification errors

• Accurate clinical information

• Specimen loss

• Specimen mix-up


Specimen labeling

• Please label clearly!

• Printed labels are

even better!


What should a good GI biopsy pathology report

do?


Final Diagnosis

• A summary medical interpretation based on the gross

and microscopic findings

• Incorporates supplied clinical history and endoscopic

information, results of prior pathology, etc.

• Standard terminology

– Classification systems

– Necessary for clear communication

• Must state all pertinent positive and negative findings

relevant to diagnosis


Comment

• A narrative prominently placed in the pathology consultation

report that addresses clinical/pathologic correlations, pertinent

supportive evidence, prognostic information, references

• Answer the clinical question posed to the best of our ability

– Place histologic findings in clinical and endoscopic context

• Differential diagnosis, with preference if appropriate.

• Sufficient information to make meaningful treatment decisions

– Polyps- margins, high grade dysplasia

– Need for more tissue?


An Informative Pathology Report

• Differentiates normal from abnormal

– Willing to call a biopsy normal!

• Provides all pertinent positives/negatives

– H. pylori, granulomas, dysplasia

• Makes as specific a diagnosis as possible (etiologic/with attention to current disease classifications and terminology)

• Establishes a correlation between clinical and pathologic findings

• Doesn’t leave the clinician hanging!


The more information, the better!


Endoscopic findings may (and often do)

influence pathologic evaluation

• Availability of endoscopy report (even better, with images)

• Examples

– Polyp vs. flat mucosa

– Barrett's mucosa in esophagus

– Appearance of duodenum (normal vs. abnormal, for celiac

disease)

– Severity and distribution of colitis


Colonic polyps

Robbins & Cotran, 2005

Hyperplastic polyp

Adenoma


Polyp vs. flat mucosal biopsy• Polyp mimics

– Mucosal folds

– Submucosal

lesions

– Lymphoid

aggregates

• Deeper levels for

small lesions


“Polyp”- additional levels

• Small polyp identified endoscopically

• Tubular adenoma only on deeper levels

• Altered surveillance interval

Original

Deeper


50 year-old woman with a 1.2 cm polyp

in the right colon


Sessile serrated adenoma• Compared to hyperplastic

polyps:

– Larger

– Sessile

– Right sided

• Endoscopically subtle:

“thickened fold”

• Molecular abnormalities in

DNA mismatch repair:

“microsatellite instability”


Newer polyp entities• Many bland polyps previously thought to be hyperplastic

polyps are actually pre-malignant lesions.

• Histologic difference between:

• large hyperplastic polyps

• traumatized hyperplastic polyps

• mixed hyperplastic-adenomatous polyps

• “traditional” serrated adenomas

• sessile serrated adenomas

• sessile serrated adenomas with dysplasia or carcinoma


Polyp Margins

__Cold (forceps)__ ________Hot (snare)__________

Pedunculated Sessile


“Distal esophagus” biopsy• “Barrett’s mucosa”?

• “Squamocolumnar

mucosa with intestinal

metaplasia”?

• Comment: “If this biopsy is

derived from endoscopically

abnormal mucosa in the

tubular esophagus, then the

presence of intestinal

metaplasia fulfills the

American College of

Gastroenterology diagnostic

criteria of Barrett’s

esophagus.”


Barrett’s esophagus- additional levels

• Patient history of

heartburn

• “Tongues of

columnar mucosa”

• Intestinal metaplasia

only on deeper levels

• Patient now gets

appropriate

surveillance for

Barrett’s esophagus


Barrett’s esophagus – no dysplasia


Barrett’s esophagus – Low grade dysplasia Barrett’s esophagus – High grade dysplasia


Location of Biopsies

• GI tract disorders in which distribution of disease is key to

recognition

– IBD

– Esophagitis (reflux vs. eosinophilic)

– Barrett’s esophagus

– Atrophic gastritis

• Knowing the location of biopsy is a key part of pathologic

evaluation

• Avoid pooling biopsies in one jar!


Optimal/preferred endoscopic sampling

• IBD surveillance: Every 10 cm of involved colon, plus gross

lesions.

• Duodenum (for celiac): Multiple (at least 2-3 fragments)

• Stomach: Antrum and corpus

• Esophagus: Distal third and middle third (to exclude

eosinophilic esophagitis)

• Barrett’s esophagus: every 2 cm


Eosinophilic esophagitis


Diagnosis and classification of IBD

• Often not possible based on histologic examination alone.

• Clinical context is critical

• Distinction from mimics.

• Confounding effects of prior medical therapy, surgery.

• Prior of prior biopsies and/or resections may be helpful.


Crohn’s disease vs. UC

•Organ involvement

•Distribution

•Layers involved

•Microscopic


Subclassification of IBD

• Attempt to subclassify IBD

whenever possible

• Clinical and endoscopic

information always helpful

• Communication with

gastroenterologist

•

Sigmoid colon: “chronic colitis”


Recognition of histologic mimics; clinical

history can distinguish

• 74 year-old woman presented with rectal bleeding

• Colonoscopy revealed rectal erythema and mucosal granularity


H Ulcerative colitis

Patient G


Ulcerative colitis- key histologic features• Architectural distortion

– Branching

– Irregularity

– Crypt atrophy

• Lymphoplasmacytic

infiltrate

• Neutrophilic activity

Normal


Diagnosis

– Benign Anorectal Mucosa with Evidence of

Trauma/Prolapse


Some innocuous processes that can mimic

IBD

• Mimics:

• Prolapse changes

• Healing ulcers

• Anastomotic site changes

• Chronic medication effect (e.g. NSAIDs)

• Chronic ischemia

• Patient was not labeled with a chronic colitis/proctitis or

neoplasm

• Inappropriate treatment with immunosuppressive agents was

avoided


Diverticular disease associated colitis


Missed diagnoses• 18 year-old woman with a clinical history of “ulcerative

colitis”

• Patient presents with diarrhea


Our diagnosis

– Lymphocytic Colitis

– Patient avoids potent immunosuppressive therapy, and

does not require lifetime endoscopic surveillance


Conclusions

• Pathologic diagnosis does not occur in a vacuum

• High quality diagnosis (accurate and beneficial to patient care)

results from a team-oriented approach.

• The more we know, the better!


THANK YOU

what every pathologist wants the gi nurse to know (and how

Documents