Overcoming Educational Challenges and Impact of COVID-19 in a Pathology Residency Program.

Our program in is a 4-year combined anatomic pathology (AP) and clinical pathology (CP) program located in New Hampshire. Prior to the novel coronavirus (COVID-19) pandemic, double-headed sign-outs and multi-headed scope didactic conferences took place daily. On the autopsy service, cases were performed in-house under attending supervision, and forensic cases were performed at the off-site Office of the Medical Examiner. In CP, residents engaged in weekly didactic CP lectures and engaged in in-person resident-attending discussions, laboratory rounds, and direct patient contact on a daily basis. Institutional Universal Guidelines from the Emergency Order from New Hampshire were imposed at the beginning of the pandemic. These included exposure mitigation and employee screening strategies. Changes to resident rotations and didactic sessions, strategies to maintain resident wellness, and the program director perspectives are described. Amid the pandemic, digital pathology, teleconferencing platforms, and social media became important resources for pathology education. Digital platforms allowed groups of people to communicate and watch live presentations while social distancing. In AP, whole slide imaging allowed both attendings and residents to scan slides for personal learning, slide conferences, and didactic learning sessions. Following these measures, we supported the clinical needs of our medical center and learning needs of our residents while enacting social distancing and prevention guidelines early in the pandemic. Although the full impact of COVID-19 on pathology residency programs is still unknown, we incorporated new facets of communication technologies. These were immensely helpful in maintaining social distancing and helping to reduce the spread of disease.

Rapid EGFR mutation testing in lung cancer tissue samples using a fully automated system and single-use cartridge.

INTRODUCTION: Activating mutations in the tyrosine kinase domain of the epidermal growth factor receptor (EGFR) gene in non-small cell lung cancer (NSCLC) patients predicts response to EGFR tyrosine kinase inhibitors (TKIs). The Idylla™ system (Biocartis, Mechelen, Belgium) is a fully integrated, cartridge-based platform that provides automated sample processing and real-time PCR-based mutation detection in a single-use cartridge. This study evaluated the Idylla™ EGFR Mutation Assay cartridges against next-generation sequencing (NGS) using formalin fixed, paraffin embedded (FFPE) lung cancer tissue samples. METHODS: Thirty-four FFPE lung adenocarcinoma tissue samples were tested on the Idylla™ system. 21 had at least one mutation in EGFR and 13 had no EGFR mutation as determined by NGS analysis using the Ion AmpliSeq 50-gene Cancer Hotspot Panel v2 (Thermo Fisher Scientific). One 10 â€‹µm FFPE tissue section was used for each Idylla™ test and all cases met the Idylla™ minimum tumor content requirement (≥10%). RESULTS: Idylla™ results were in complete agreement with those obtained by NGS for EGFR mutations targeted by the Idylla™. NGS identified two additional EGFR mutations that are not targeted by the Idylla™ in two samples (E709V and V774M). No EGFR mutations were detected by the Idylla™ in samples determined by NGS as having wild-type EGFR. CONCLUSION: The fully automated Idylla™ system offers rapid and reliable testing for clinically actionable mutations in EGFR directly from FFPE tissue sections. Its simplicity and ease of use compared to other available molecular techniques make it suitable for routine clinical use in a variety of settings.

An Examination of Advocacy Education in Residency Training.

CONTEXT.­: Pathology-related advocacy is best when performed directly by pathologists. Practicing advocacy is included in the Milestones 2.0 and should be introduced during residency training. OBJECTIVE.­: To understand advocacy education in residency training we surveyed pathologists to ask what training they had in residency, what resources were available, and what experiences were most impressionable. DESIGN.­: Two types of inquiry were performed. First, a survey to program graduates asking about leadership and advocacy activities during training and about leadership and advocacy activities since graduation. Secondly, focused email and telephone inquiries were made to 12 pathologists-4 in practice for more than 20 years, 4 within the first 10 years of practice, and to 4 PGY4 (postgraduate year 4) residents-asking what training and experiences were available to them, and how they became motivated to become active in practice. RESULTS.­: Our results showed that resources available outside of the home program have changed through the years and more national resident groups are available that were not available in the past. These groups may educate trainees in leadership and advocacy. Internally, opportunities to shadow faculty at interdepartmental leadership meetings, as well as selection of the chief resident, are enduring tools for honing these skills. CONCLUSIONS.­: Teaching advocacy in training is important and part of the Accreditation Council for Graduate Medical Education core requirements as well as a level 5 Milestone. Education may require a balance of internal and external resources since different programs may offer different opportunities. Shadowing during real advocacy events was the most impressionable experience.

Experiential Teaching Paradigms: Adapting the Medical Education Literature to Academic Pathology Practice.

The medical education literature has presented many experiential teaching paradigms to help faculty teach more effectively in busy clinical settings. Three prominent teaching models are The Aunt Minnie model, the SNAPPS model, and the One-Minute Preceptor. Teaching paradigms can help faculty to develop into effective teachers. Each of these models can be adapted to a busy academic pathology practice. The Aunt Minnie model is effective in cases with high pattern recognition, such as repetitive trays of biopsies. The SNAPPS model is learner directed and is easily adapted for an advanced learner with complex cases requiring ancillary testing. The One-Minute Preceptor method is effective for teachers with groups of learners, such as multiheaded scope sessions.

Educational Case: Aspiration Pneumonia.

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.1.

Synchronous Pulmonary Adenofibroma and Solitary Fibrous Tumor: Case Report and Review of the Literature.

Pulmonary adenofibroma (PAF) is a rare neoplasm that may be related to solitary fibrous tumor (SFT). A subset of PAFs harbor the NAB2-STAT6 fusion that is typical of SFT, but a significant proportion do not. Their distinction is clinically important as SFTs can potentially have an aggressive clinical course, while there has been no report of a PAF behaving in a malignant fashion. We report a case of a 60-year-old male who developed a SFT and PAF in the same lung. The SFT harbored a NAB2-STAT6 fusion, while the PAF did not have any identifiable fusion. This case represents the first instance of a single patient with both of these tumors occurring simultaneously in the same lung.

Light scattering measured with spatial frequency domain imaging can predict stromal versus epithelial proportions in surgically resected breast tissue.

This study aims to determine if light scatter parameters measured with spatial frequency domain imaging (SFDI) can accurately predict stromal, epithelial, and adipose fractions in freshly resected, unstained human breast specimens. An explicit model was developed to predict stromal, epithelial, and adipose fractions as a function of light scattering parameters, which was validated against a quantitative analysis of digitized histology slides for N = 31 specimens using leave-one-out cross-fold validation. Specimen mean stromal, epithelial, and adipose volume fractions predicted from light scattering parameters strongly correlated with those calculated from digitized histology slides (r = 0.90, 0.77, and 0.91, respectively, p-value <1 × 10 - 6). Additionally, the ratio of predicted epithelium to stroma classified malignant specimens with a sensitivity and specificity of 90% and 81%, respectively, and also classified all pixels in malignant lesions with 63% and 79%, at a threshold of 1. All specimens and pixels were classified as malignant, benign, or fat with 84% and 75% accuracy, respectively. These findings demonstrate how light scattering parameters acquired with SFDI can be used to accurately predict and spatially map stromal, epithelial, and adipose proportions in fresh unstained, human breast tissue, and suggest that these estimations could provide diagnostic value.

A 49-Year-Old Woman With Right Apical Thoracic Mass.

A 49-year-old woman with a medical history of essential hypertension presented to the ED with severe pain in the left superior chest and dull aching pain in the upper flank, lasting for the last 2 days.

A Patient-Specific 3D-Printed Form Accurately Transfers Supine MRI-Derived Tumor Localization Information to Guide Breast-Conserving Surgery.

BACKGROUND: Wire-localized excision of nonpalpable breast cancer is imprecise, resulting in positive margins 25-30% of the time. METHODS: Patients underwent preoperative supine magnetic resonance imaging (MRI). A radiologist outlined the tumor edges on consecutive images, creating a three-dimensional (3D) view of its location. Using 3D printing, a bra-like plastic form (the Breast Cancer Locator [BCL]) was fabricated, with features that allowed a surgeon to (1) mark the edges of the tumor on the breast surface; (2) inject blue dye into the breast 1 cm from the tumor edges; and (3) place a wire in the tumor at the time of surgery. RESULTS: Nineteen patients with palpable cancers underwent partial mastectomy after placement of surgical cues using patient-specific BCLs. The cues were in place in <5 min and no adverse events occurred. The BCL accurately localized 18/19 cancers. In the 18 accurately localized cases, all 68 blue-dye injections were outside of the tumor edges. Median distance from the blue-dye center to the pathologic tumor edge was 1.4 cm, while distance from the blue dye to the tumor edge was <5 mm in 4% of injections, 0.5-2.0 cm in 72% of injections, and >2 cm in 24% of injections. Median distance from the tumor center to the BCL-localized wire and to the clip placed at the time of diagnosis was similar (0.49 vs. 0.73 cm) on specimen mammograms. CONCLUSIONS: Information on breast cancer location and shape derived from a supine MRI can be transferred safely and accurately to patients in the operating room using a 3D-printed form.

Filamentous fungal carbon catabolite repression supports metabolic plasticity and stress responses essential for disease progression.

Aspergillus fumigatus is responsible for a disproportionate number of invasive mycosis cases relative to other common filamentous fungi. While many fungal factors critical for infection establishment are known, genes essential for disease persistence and progression are ill defined. We propose that fungal factors that promote navigation of the rapidly changing nutrient and structural landscape characteristic of disease progression represent untapped clinically relevant therapeutic targets. To this end, we find that A. fumigatus requires a carbon catabolite repression (CCR) mediated genetic network to support in vivo fungal fitness and disease progression. While CCR as mediated by the transcriptional repressor CreA is not required for pulmonary infection establishment, loss of CCR inhibits fungal metabolic plasticity and the ability to thrive in the dynamic infection microenvironment. Our results suggest a model whereby CCR in an environmental filamentous fungus is dispensable for initiation of pulmonary infection but essential for infection maintenance and disease progression. Conceptually, we argue these data provide a foundation for additional studies on fungal factors required to support fungal fitness and disease progression and term such genes and factors, DPFs (disease progression factors).

Does pTis exist in HPV-driven tonsillar carcinomas? An ultrastructural review and examination of two cases.

Many tonsillar tumors present clinically as cervical nodal metastases and the primary tumor is often difficult to find. HPV-driven tonsillar carcinoma begins in the reticulated crypt epithelium, possibly through viral integration. The basement membrane is not complete in the reticulated crypt epithelium, which may enhance the immune function. We examined the reticulated crypt epithelium in a normal case and five neoplastic tonsils with cervical metastasis as the presenting symptom to further investigate whether tonsil carcinoma in-situ exists. Our results suggest that in-situ carcinoma may need to be excluded from the future staging for human papilloma virus associated tonsillar tumors.

Clinical Genotyping of Non-Small Cell Lung Cancers Using Targeted Next-Generation Sequencing: Utility of Identifying Rare and Co-mutations in Oncogenic Driver Genes.

Detection of somatic mutations in non-small cell lung cancers (NSCLCs), especially adenocarcinomas, is important for directing patient care when targeted therapy is available. Here, we present our experience with genotyping NSCLC using the Ion Torrent Personal Genome Machine (PGM) and the AmpliSeq Cancer Hotspot Panel v2. We tested 453 NSCLC samples from 407 individual patients using the 50 gene AmpliSeq Cancer Hotspot Panel v2 from May 2013 to July 2015. Using 10 ng of DNA, up to 11 samples were simultaneously sequenced on the Ion Torrent PGM (316 and 318 chips). We identified variants with the Ion Torrent Variant Caller Plugin, and Golden Helix's SVS software was used for annotation and prediction of the significance of the variants. Three hundred ninety-eight samples were successfully sequenced (12.1% failure rate). In all, 633 variants in 41 genes were detected with a median of 2 (range of 0 to 7) variants per sample. Mutations detected in BRAF, EGFR, ERBB2, KRAS, NRAS, and PIK3CA were considered potentially actionable and were identified in 237 samples, most commonly in KRAS (37.9%), EGFR (11.1%), BRAF (4.8%), and PIK3CA (4.3%). In our patient population, all mutations in EGFR, KRAS, and BRAF were mutually exclusive. The Ion Torrent Ampliseq technology can be utilized on small biopsy and cytology specimens, requires very little input DNA, and can be applied in clinical laboratories for genotyping of NSCLC. This targeted next-generation sequencing approach allows for detection of common and also rare mutations that are clinically actionable in multiple patients simultaneously.

The potential utility of re-mining results of somatic mutation testing: KRAS status in lung adenocarcinoma.

KRAS mutant non-small cell lung cancers (NSCLCs) vary in clinical outcome depending on which specific KRAS mutation is present. Shorter progression free survival has been associated with KRAS variants G12C and G12V. Cell lines with these variants depend to a greater extent on the RAS/RAF/MEK/ERK signaling pathway and become more susceptible to MEK inhibition. Because different KRAS mutations may lead to altered drug sensitivity, we aimed to determine specific KRAS mutation status in a NSCLC patient cohort at our institution. A total of 502 NSCLC samples were screened for somatic mutations using the 50 gene AmpliSeq™ Cancer Hotspot Panel v2 (CHPv2). However only samples positive for variants in the KRAS gene were included in this study. Variants identified in the KRAS genes were curated using publicly available databases. The overall mutation rate in the KRAS gene was 32.7% (164/502). The most common KRAS mutations were G12C (41%), G12V (19%), and G12D (14%) along with less frequent variants. After re-mining our sequencing data, we found that more than a half of our KRAS mutant NSCLC patients could potentially benefit from the addition of a MEK inhibitor such as selumetinib to standard chemotherapeutic agents. Due to mutated KRAS, these patients will likely fail traditional anti-EGFR therapies but be eligible for newer combination therapies.

Examination of the Residency Interview Process for Academic Pathology Departments: How to Make the Most of a Resource-Heavy Process.

Annual resident recruitment is a complex undertaking that requires many departmental resources of faculty time and effort and in many cases financial investment for meals and lodging. The applicants represent the future of the profession as well as the providers of patient care in the respective training programs. Although we understand the importance of this process, as we become more and more distracted by financial, administrative, and academic duties, the demands of recruitment have not decreased and continue annually. In an attempt to find the best practices for the improvement in our methods of recruitment, a review of the literature on the employment interviews with a specific eye to pathology residency relevant information was conducted. This article reviews some of the factors proven to be important to the applicants as well as an examination of the structure of the interview and the postinterview applicant evaluation process.

MCM2/TOP2A (ProExC) immunohistochemistry as a predictive marker in head and neck mucosal biopsies.

Mucosal biopsies from the head and neck are often small and poorly oriented, which impedes diagnostic interpretation, especially in patients with a history of cancer, being monitored for recurrence. A cocktail of antibodies targeted against DNA topoisomerase IIA and mini-chromosome maintenance protein 2 (MCM2/TOP2A, ProExC), markers of aberrant S-phase induction, have been used with success as a diagnostic adjunct in the evaluation of squamous dysplasia of the uterine cervix. We tested the utility in head and neck biopsies to see if ProExC could be used to discriminate reactive/inflammatory from true pre-neoplasia. Sixty-four archival biopsies were selected from patients who presented to the surgeon with an indication for biopsy to "rule out" dysplasia. Histologically, all biopsies showed nonspecific atypia that was difficult to discriminate from dysplasia. Twenty-three of the patients progressed to squamous carcinoma and the rest remained benign over five years follow-up. Cases stained with ProExC by IHC methods showed a significant pattern of expression (p=0.026). The staining was greatest in patients without a history of prior head and neck cancer but was not significant. Our results show that ProExC, used in conjunction with the H&E slide, can enhance the predictive power of a mucosal biopsy in a cohort of patients.

Spatial and temporal distributions of lung cancer histopathology in the state of Maine.

Maine has among the highest rates of lung cancer in the United States (US). Maine serves as a geographical representation of US rural communities, and their associated health disparities. As the key risks of tobacco use decrease and radon abatement increases, previously obscured environmental exposures may measurably contribute to the attributable risk fraction of lung cancer. To generate hypotheses of novel environmental exposures associated with lung cancer, we investigated if there was non-random spatial distribution of lung cancer in Maine. Case data (n = 14,038) between 1995 and 2006 were obtained from the Maine Cancer Registry. Population data were obtained from the 2000 US Census. We assessed the spatial distribution of lung cancers among white cases by histopathology subtype [non-small cell lung carcinoma (NSCLC): adenocarcinoma (n = 3680), squamous cell (n = 2801) and large cell (n = 1195); and small cell lung carcinoma (SCLC) (n = 1994)], using spatial scan statistic, assuming a discrete Poisson distribution adjusted for age and population density. Because of time-dependent trends in lung cancer differential diagnostic criteria, we repeated our analyses, limiting it to 2002-2006. While SCLC rates were equivalent across the state, we identified discrete regions with elevated rates of adenocarcinoma among females and squamous cell carcinoma among males. Independent of gender, the most striking geospatial observation was elevated large cell lung cancer specifically in one of the poorest counties in the US. A selective spatial distribution of large cell lung cancer has not been previously reported. More research is needed to identify factors inducing large cell carcinoma pathology, and to determine if in rural communities health disparities are associated with increased risk for this diagnosis.