January 2005
Curriculum Content and Evaluation
of Resident Competency in Anatomic Pathology
A Proposal
Association of Directors of Anatomic and Surgical Pathology*
* This document was
prepared by an ADASP Working Group composed of James L. Connolly, MD,
Christopher D.M. Fletcher, MD, FRCPath, W. Jack Frable, MD, Margaret M. Grimes, MD, Jon H. Ritter, MD (ad
hoc member), and Mark R. Wick, MD (chair).
DOI: 10.1309/8GFXK5MJ5GCNUW5Q
New program requirements
promulgated by the Accreditation Council for Graduate Medical Education
(ACGME) in the United States necessitate the development of a defined
educational program (curriculum) for trainees in all medical specialties,
focused on 6 main areas of competency: patient care, medical knowledge,
practice-based learning and improvement, interpersonal and communication
skills, professionalism, and systems-based practice (see http://www.acgme.org/outcome). In parallel with
any such curriculum, training programs are required to develop a detailed
set of performance measures to evaluate each resident's competence in
these 6 areas. These new requirements are being implemented and, going
forward, residency training programs are being inspected and assessed for
accreditation according to these guidelines by the various residency review committees (RRCs) in each specialty area.
In anatomic pathology, as in
most specialties, the largest and most detailed elements of such a
curriculum are devoted to patient care and medical knowledge. Because
these elements are taught very largely by anatomic and surgical
pathologists, the Association of Directors of Anatomic and Surgical
Pathology (ADASP) formed a working group in 2002, the role of which was to
develop an "idealized" but flexible curriculum (with associated measures
of competence) in anatomic pathology. This document represents the result
of these efforts.
The curriculum (and simple
guidelines for competency assessment) that follow have been shared with
the RRC for Pathology. The RRC has had the opportunity to review this
curriculum, and that supervisory body encourages its dissemination,
believing that it will serve as a valuable and comprehensive template for
many anatomic pathology training programs. In particular, the RRC for
Pathology believes that this curriculum should be especially valuable to
residency directors as they respond to the recent general competency
initiatives of the ACGME (Steven P. Nestler, PhD, and C. Bruce Alexander, MD,
personal communication, August 2003). ADASP developed this document with
the hope that individual programs will be able to use and modify it to
serve local needs, recognizing that there is great heterogeneity in the
size, scope, and organization of existing pathology residency programs in
the
Basic Learning Objectives
1. Gain knowledge and technical skills to recognize,
interpret, and explain pathologic processes in the clinical practice of
anatomic pathology
2. Effectively communicate pathologic findings to
colleagues and provide consultative information regarding patient
management
3. Effectively direct and manage the pathology
laboratory in all regards
Basic Programmatic Expectations
of Residents
1. Develop an understanding of basic pathologic
processes
2. Acquire skills needed to interpret laboratory data
and make clinicopathologic
correlations
3. Communicate effectively and share expertise with
peers and colleagues
4. Develop investigative skills to better understand pathologic processes as they apply to both individual patients and the general patient population
5. Acquire knowledge and experience in laboratory
direction and management
6. Assume leadership roles in education of other
physicians and allied health professionals
Specific Skills That Apply to
All Areas of Anatomic Pathology
1. Ability to obtain pertinent information from the
patient's clinical record
2. Demonstrate knowledge of information that is
necessary to provide adequate clinical history on submission forms for
anatomic pathology specimens
3. Demonstrate knowledge of the general principles
and terminology for processing anatomic pathology specimens, including
patient identification, gross examination, and dissection
4. Ability to dissect tissues in such a way as to
preserve important pathologic findings and fix them so they may be used
for clinicopathologic
correlation as well as teaching
5. Ability to select correct pieces of tissue for
sectioning and preservation and maintenance and identification of tissue
orientation during processing
6. Ability to list common stains used for microscopic
sections, as well as their indications and the expected results for
various tissue types
7. Ability to enumerate the elements of satisfactory
histologic sections and
stains and identify the possible reasons for unsatisfactory preparations
8. Ability to select correct fixatives for special
histologic preparations
9. Demonstrate knowledge of the specimens that
commonly require special handling (eg, flow cytometry, microbiologic cultures, recovery of
crystals, electron microscopy, immunohistology)
10. Ability to select an appropriate piece of tissue
for frozen section and to cut and stain the section satisfactorily
11. Ability to collect and preserve appropriate
tissues and fluids for immunofluorescence and flow cytometric studies
12. Ability to select and submit tissue appropriately
for electron microscopy
13. Ability to take suitable gross and microscopic
photographs using both film-based and digital cameras
14. Proficiency in performing special hematologic studies, including
touch preparations, cytocentrifuged preparations, and blood smears
15. Proficiency in initiating routine microbiologic
studies, including appropriate cultures, smears, and stains, and involving
knowledge of methods of collection and preservation, if needed
16. Demonstrate familiarity with the detailed
organization, equipment, and techniques of the histology laboratory,
including tissue processing, tissue embedding, preparation and staining of glass slides,
information that histotechnologists must have to process tissue
properly, and orientation of specimens
17. Ability to present cases at conferences with clarity, completeness, and high-quality illustrations and to reach reasonable interpretative conclusions
18. Demonstrate knowledge of precautions to be taken against infections and other hazards in the handling of fresh tissue during intraoperative consultations
19. Demonstrate knowledge of the appropriate storage
and disposal of tissues and fixatives and the proper "banking" of human
tissues
20. Demonstrate knowledge of the common pathogens
that can be transmitted to laboratory personnel in pathology, as well as
basic safety precautions to be taken in the anatomic pathology laboratory,
including universal precautions against infectious agents and the role of
the pathologist in institutional infection control
21. Know current regulations emanating from the
Health Insurance Portability and Accountability Act regarding protection
of patient confidentiality; demonstrate knowledge of how such rules impact
the pathology laboratory, and means for their implementation in the
handling of human tissues for diagnostic work and research.
Basic Schedule of Rotations: Anatomic Pathology
(Note: Skill level I is attached
to items for which training will begin immediately on entering the
anatomic pathology education track; skill level II denotes material that
typically is covered at a more advanced level of training in the residency
program.)
1. Anatomic pathology, 4-6 months (core program);
includes autopsy and forensic pathology and may be combined with surgical
pathology training: skill level I
2. Anatomic pathology, 4-6 months (additional
rotation): skill level II (same content as core program)
3. Surgical pathology I (18-24 months) (may include
subspecialty pathology areas): skill level I
4. Surgical pathology, advanced (part of total time
in surgical pathology): skill level II
5. Cytopathology (3-6 months): skill level I
6. Neuropathology (1-2 months) (may be combined with
surgical and autopsy pathology): skill level I
7. Immunohistochemistry and electron microscopy
(usually incorporated into other rotations): skill level I
8. Molecular diagnostics and cytogenetics (usually incorporated into other
rotations): skill level I
9. Laboratory management (incorporated into other
rotations): skill level I
Recommended Rotations and Learning Objectives
Anatomic Pathology, 4-6 Months
Includes autopsy and forensics and may be combined
with surgical pathology training.
Skill Level I
Demonstrate competency in basic skills in anatomic
pathology
Demonstrate competent autopsy prosection using routine techniques,
completing gross examination in a period of 3 hours for uncomplicated
cases or 4 hours for complicated ones
Show the ability to correctly describe common abnormalities of diseased organs by gross and microscopic examination, including congenital, degenerative, inflammatory, neoplastic, and autoimmune disorders
Demonstrate an ability to compose a provisional
anatomic diagnostic report of autopsy findings within 24 hours of
completing the postmortem examination
Demonstrate an ability to compose a final autopsy
report according to an approved format and within 30 days of completing
the postmortem examination, including accurate and complete anatomic
diagnoses, thorough gross and microscopic descriptions, and pertinent
clinicopathologic
correlations and mechanistic interpretations
Anatomic Pathology, Advanced
(4-6 Months)
See previous section for description.
Skill Level II Independently perform at least 1
adult and 1 pediatric autopsy (with the possible assistance of dieners and/or pathology
assistants), demonstrating the following:
1. Familiarity with the laws regarding permission for
autopsy and the classification of the autopsies requiring medicolegal status
2. Knowledge of modified autopsy techniques such as
Rokitansky-style organ
removal, other en bloc dissections, needle biopsies, aspiration of joint
fluid, and procurement of spinal fluid
3. Ability to remove the brain and spinal cord
without causing injury to either structure
4. Ability to remove the eyes, the epiglottis and
tongue, and the inner and middle ears and to examine leg veins, bones, and
joints
5. Ability to identify the cases for which blood
samples and vitreous eye fluid are required for biochemical tests and to
collect those samples in the proper manner
6. Ability to describe the circumstances in which
specimens (fluids or tissues) should be kept for toxicologic studies and knowledge of how to do
so
7. Ability to assist Autopsy I residents in the
achievement of basic skills in anatomic pathology (see above)
8. Ability to take selective autopsy call in support
of Autopsy I residents
Surgical Pathology I (18-24
Months)
May include subspecialty pathology.
Skill Level I
Demonstrate proficiency in basic anatomic pathology
skills
Demonstrate knowledge of the standards (Joint
Commission on Accreditation of Healthcare Organizations [JCAHO];
Demonstrate knowledge of the common and basic
elements of the surgical pathology report, including the following:
1. Identifiers (patient and institution)
2. Input from the responsible pathologist
3. Input from the responsible clinician
4. Necessary dates and times that must be in the
report
5. Necessary clinical information
6. Documentation of the specimens that were submitted
7. Thorough and accurate gross description
8. Determination of when a microscopic description
and/or interpretation is
necessary and provision of such information
Demonstrate competency in selecting representative
tissue samples for intraoperative frozen sections, preparing the
same, and staining the sections
Be able to evaluate margins of tumor resection
specimens using frozen sections and touch preparations
Know the procedures for the reporting of untoward
incidents in the laboratory
Demonstrate knowledge of the basic recommendations
and requirements (JCAHO, CAP, regional legal requirements) pertaining to
retention of pathology specimens and records
Demonstrate knowledge of the basic principles of
informatics in anatomic pathology and ability to effectively utilize the
local computer network
Demonstrate knowledge of Web-based or
organization-related (eg,
CAP, ASCP,
Surgical Pathology, Advanced
Part
of the recommended total of 24 months in surgical
pathology.
Skill Level II
Demonstrate knowledge of the common situations
requiring expedited processing of a pathology specimen and those that do
not
Demonstrate knowledge of the common indications for
an intraoperative
consultation
Demonstrate proficiency in interpreting and
reporting frozen sections within 15 minutes of receiving a specimen for
that purpose in the pathology laboratory
Demonstrate the ability to effectively construct a
complex surgical pathology report
Demonstrate knowledge of the common grading and
staging systems applied to malignant neoplasms
Be able to properly prepare synoptic surgical
pathology reports for common malignancies
Demonstrate the ability to dictate necessary
amendments and/or addenda for surgical pathology reports
Demonstrate knowledge of how and when to obtain external consultations in anatomic pathology and document the results appropriately
Demonstrate the steps for preparation of
consultation reports on outside slides and/or paraffin blocks and
transmittal of those reports to responsible clinicians and/or referring
pathologists
Demonstrate the techniques for preparing intraoperative cytology smears
Enumerate the indications and the limitations
pertaining to intraoperative frozen section examinations
Demonstrate an ability to manage workflow in the
gross room, assist junior residents with gross dissection, provide
accurate gross descriptions of routine and complex specimens, use the
local anatomic pathology laboratory information system, and practice
safety in the pathology laboratory
Demonstrate knowledge of available procedures for
locating a missing specimen and resolving questions of specimen identity
Be able to independently report the histopathologic aspects of
routine and complex cases, including cases prepared by junior residents
and/or pathology assistants, with attention to organization of diagnostic
format, development of differential diagnosis, and ordering of necessary
special stains and other ancillary techniques
Demonstrate knowledge of quality control pertaining
to histologic sections and
special stains, including troubleshooting of mistakes in accessioning and
labeling and misidentification of specimens
Demonstrate proficiency in digital imaging
techniques
Review consultation slides on referral cases with
attention to pertinent clinical information, requests for additional
slides or blocks if needed, and formatting of the final consultative
report
Demonstrate an ability to organize, perform, and
analyze a quality control review project in surgical pathology for
presentation to faculty
Neuropathology (1-2 Months)
May be combined with surgical and autopsy pathology.
Skill Level I
Demonstrate knowledge of basic anatomy of the brain
and spinal cord
Demonstrate knowledge of basic gross description of
the normal brain
Demonstrate knowledge of the routine sections to be
taken for gross and microscopic examination of the brain and spinal cord
Demonstrate diagnostic knowledge of the common
brain tumors
Demonstrate knowledge of the common special stains
used in neuropathology
Demonstrate knowledge of basic muscle pathology and
common enzyme histochemical
stains used in muscle biopsy interpretation
Demonstrate understanding of the common
neurodegenerative diseases
Cytopathology I (3
Months Minimum)
(Note: These recommendations are modified, with
permission, from those of the American Society of Cytopathology Taskforce on Residency Training
in Cytopathology.)
Skill Level I
Includes skills necessary to move from novice to
advanced beginner; from basic acquaintance with cytopathology to readiness for independent
learning in that discipline.
Be able to verify that cytopathology requisitions are completed
correctly
Demonstrate familiarity with the methods of
collection, cytopreparatory
processing, and turnaround times for common cytopathology specimens, to be able to answer
clinicians' questions concerning expected results from the cytopathology laboratory
Demonstrate knowledge of the current Bethesda
System terminology for reporting on gynecologic cytopathology specimens and of the principles
and application of human papillomavirus probe analysis
Demonstrate knowledge of the elements of adequacy
and the current laboratory reporting system (such as negative,
inflammatory/reactive, atypical/suspicious, neoplastic or malignant) for fine-needle
aspiration (FNA) biopsy and exfoliative nongynecologic cytopathology specimens from the various
commonly sampled body sites
Demonstrate knowledge of the cytopathologic features of normal, reactive,
infectious, dysplastic, and
neoplastic conditions as
seen in common cytopathology specimens
Demonstrate knowledge of how common cyto-pathology specimens are
screened
Demonstrate knowledge of how to evaluate common
cytopathology specimens
comprehensively
Cytopathology II
(Advanced, Part of the Recommended Minimum 3 Months of Cytopathology)
(Note: These recommendations are modified, with
permission, from those of the American Society of Cytopathology Taskforce on Residency Training
in Cytopathology.)
Skill Level II
Includes skills necessary to move from advanced
beginner to practitioner; from independent learning of cytopathology to readiness for the competent
practice of cytopathology.
Demonstrate knowledge of the application of
ancillary techniques including image analysis, immunocytochemistry, flow cytometry, cytogenetics, electron microscopy, and
molecular studies (fluorescence in situ hybridization [FISH]; polymerase
chain reaction [PCR])
Demonstrate knowledge of how to rapidly evaluate
common FNA biopsy specimens, including determination of specimen adequacy
and the need for ancillary techniques, and the appropriate collection of
materials for such techniques
Demonstrate knowledge of the content of training
materials on correct performance of FNA biopsies
Demonstrate working familiarity with the
instruments and materials needed to perform FNA biopsies
Demonstrate correct performance of FNA, including
preparation of smears and collection of diagnostic materials with proper
handling for ancillary techniques, on appropriate specimens at the
surgical pathology gross cutting area
Demonstrate competency under supervision of staff
cytopathologists in the
performance of clinical superficial FNA biopsy, appropriately taking
history, correctly obtaining informed consent, competently examining the
lesion to be biopsied,
preparing the patient and biopsy instruments, physically procuring the
specimen, and preparing and staining the smears, with preliminary
interpretation of the smears and appropriate aftercare of the patient
Demonstrate knowledge of how to clearly, concisely,
and completely compose a cytopathology report for specimens from
various commonly sampled body sites based on the final diagnostic findings
and of how to appropriately recommend clinical follow-up
Demonstrate familiarity with the principles of
automated screening for gynecologic cytopathology specimens
Demonstrate knowledge of how to perform quality
assurance, including the correlation of gynecologic and nongynecologic cytopathology with surgical pathology, both in
aggregate for quality assurance purposes and on a case-by-case basis for
diagnostic purposes
Demonstrate knowledge of how to apply concepts of
quality control, quality improvement, risk management, and regulatory
compliance, including correct coding, as these pertain to the practice of
cytopathology
Immunohistochemistry and
Electron Microscopy (Usually Incorporated Into Autopsy/Surgical
Pathology/Cytopathology)
Skill Level I
Demonstrate knowledge of the procedures for
submitting specimens for electron microscopy
Demonstrate general knowledge of preparation of
tissue specimens for electron microscopy and, optionally, participate in
that preparation
Demonstrate knowledge of common ultrastructural features in diseases that
routinely require electron microscopy and, optionally, learn to operate a
diagnostic electron microscope
Demonstrate knowledge of basic principles of immunohistochemistry
Demonstrate knowledge of appropriate collection,
fixation, and preparation of tissue samples for immunohistochemistry and, optionally, perform
the actual procedures used in the immunohistochemistry laboratory
Demonstrate knowledge of the interpretation of
positive and negative immunohistochemical results and artifacts
Demonstrate an ability to select proper antibody
panels for the differential diagnosis of neoplastic diseases
Demonstrate a knowledge of prognostic factors that are
detectable by immunohistochemical studies of paraffin
sections
Molecular Diagnostics and Cytogenetics (Usually
Incorporated Into Other Rotations)
Skill Level I
Learn the fundamentals of molecular biology and
cytogenetics as they relate
to the diagnosis of disease, including infectious (eg, viral, fungal, mycobacterial), hereditary (eg, hemochromatosis, fragile X syndrome, cystic
fibrosis, factor VLeiden
mutations), neoplastic
(eg, familial adenomatous polyposis, hereditary breast/ovarian
carcinoma, hereditary nonpolyposis colon cancer, soft tissue
sarcomas), and hematolymphoid disorders (eg, T- and B-cell lymphoproliferations, myeloid leukemias, myelodysplasias), and to identity testing
Appreciate the heterogeneity, complexity, and
natural history of neoplastic and nonneoplastic disorders that are commonly
studied by molecular biologic and cytogenetic techniques
Understand the range of methods routinely used for
clinical diagnosis in the molecular pathology and cytogenetics laboratories
Understand issues of quality control, quality
improvement, risk, cost-effectiveness, and laboratory management as they
specifically relate to molecular pathology and cytogenetics
Be able to search the scientific literature to
critically assess the development of new tests in molecular pathology and
cytogenetics
Observe and, optionally, independently perform
tests in clinical molecular pathology, including Southern blotting
analysis, the PCR, reverse transcriptase (RT)-PCR, karyotyping, and fluorescence in situ
hybridization
Communicate with requesting physicians to advise
them on the appropriate use of molecular diagnostic and cytogenetic methods
Review and interpret molecular pathologic and cytogenetic results and prepare
reports of the same in concert with attending pathologists
Laboratory Management in
Anatomic Pathology (Usually Incorporated Into All Rotations)
Skill Level I
Demonstrate the ability to properly assign
International Classification of Diseases, Ninth Revision (ICD-9) codes to
all specimens in anatomic pathology and submit appropriate forms for
billing pertaining to those specimens
Understand federal and state regulations with
special application to anatomic pathology and the general requirements for
"compliance" in the reporting of professional activities for billing
purposes
Demonstrate a familiarity with standards set forth
by the CAP and JCAHO for laboratory certification in anatomic pathology
and participate in at least 1 internal ("mock") inspection of the
institutional anatomic pathology laboratory
Understand the principles applying to evaluation of
the cost-effectiveness of laboratory procedures and activities in anatomic
pathology
Show a working knowledge of the basic principles of
quality assurance, quality control, continuous quality improvement, and
outcomes analysis as they apply to anatomic pathology
Demonstrate knowledge of how to utilize
risk-management resources in cases involving medicolegal liability
Understand the basic legal aspects of medical
malpractice lawsuits and the potential roles of pathologists as defendants
and consultants in such actions
Competencies in Pathology
The ACGME currently requires
that training programs in pathology enable residents to develop
competencies in the broad areas described in the following sections.
General Comments on Competencies
Residents must develop
competencies in the 6 following areas to the level expected of a new
practitioner. Toward this end, each program must define the specific
knowledge, skills, and attitudes that are required and provide educational
experiences as needed in order for their residents to develop the desired
competencies. The program must create and reinforce the concept of
lifelong learning.
Patient Care
Residents must demonstrate a
satisfactory level of diagnostic competence and the ability to provide
appropriate and effective consultation in the context of pathology
services.
Medical Knowledge
Residents must demonstrate
knowledge about established and evolving biomedical, clinical, and cognate
(eg, epidemiologic and
social-behavioral) sciences and the application of this knowledge to
pathology.
Practice-Based Learning and Improvement
Residents must be able to
demonstrate the ability to investigate and evaluate their diagnostic and
consultative practices, appraise and assimilate scientific evidence, and
improve their patient care practices.
Interpersonal and Communication Skills
Residents must be able to
demonstrate interpersonal and communication skills that result in
effective information exchange and teaming with other health care
providers, patients, and patients' families.
Professionalism
Residents must demonstrate a
commitment to carrying out professional responsibilities, adherence to
ethical principles, and sensitivity to a diverse patient population.
Systems-Based Practice
Residents must demonstrate an awareness of and
responsiveness to the larger context and system of health care and the
ability to call on system resources to provide pathology services that are
of optimal value.
Although principal
responsibility for ensuring this process lies with pathology residency
program directors and their department chairs, the ADASP seeks to set
standards in anatomic pathology that are applicable principally to the
area of patient care (and, to a lesser extent, medical knowledge).
Observations on Competencies in
Pathology
The curriculum and associated
competencies proposed by the ADASP relate principally to "core" (nonelective) training in anatomic
pathology. The ADASP does not seek, at the current time, to define
competencies for advanced training in specific subspecialty areas with
dedicated fellowships and board examinations (eg, hematopathology, dermatopathology).
Because individual residency
programs show marked variation in the sequence and duration of individual
rotations, the ADASP believes that it is not practicable to define
competencies that are specific for year 1 or year 2 of training. Instead,
certain competencies are simply described as "more advanced." The ADASP
also believes that it is neither realistic nor desirable to specify
certain diagnoses or defined numbers of cases of a given type as elements
of competency. All ACGME-accredited training programs are already required
to provide a caseload that is both high enough and varied enough to ensure
broad training. Undue emphasis on specific diagnoses or number of cases
underestimates the continuous and experiential nature of learning anatomic
pathology.
In defining competencies in
anatomic pathology, the ADASP seeks to delineate specific and critical
areas in the training process, without attempting to provide excessive
detail or complexity. Attempts to microdefine competencies could hinder
programmatic individuality, would likely be impractical, and would render
assessment of competency more difficult. In this regard, it is also
unfeasible to define specific standards in any quantitative way, and,
therefore, the ADASP endorses the style of competency assessment favored
by ACGME (using descriptors such as novice-level, competent, and
expert-level).
The ADASP recommends that each
of the competencies be assessed as follows: novice, advanced beginner,
competent, proficient, expert.
Basic Principles
Knowledge of JCAHO and CAP standards and
requirements for specimen submission
Knowledge of JCAHO and CAP standards regarding
occupational hazards and infection control
Tissue fixation (including commonly used special
fixatives)
Tissue processing
Embedding, orientation
Section preparation, levels, and so on
Use of special stains, immunohistology, electron microscopy, cytogenetics, and so forth
Storage and disposal of specimens and hazardous
chemicals
Basic computer skills in anatomic pathology
Gross Examination
Specimen identification
Anatomically correct dissection
Accurate dictated description
Specimen photography (when appropriate)
Taking appropriate blocks for microscopic
examination
Proper examination of margins (when appropriate)
Special handling of common specimens (eg, culture, electron microscopy,
cytogenetics, bone marrow)
Microscopic Examination
Basic
Accurate morphologic description
Reasonable diagnosis and differential diagnosis
Basic elements of information required in all
reports
Preparation of written report
Prepared and organized for sign-out with senior
resident
Correlation with frozen section findings
More Advanced
Formulate an accurate diagnosis or recognize need
for consultation
Selection of special stains/immunohistochemical studies (when appropriate)
Interpretation of immunostains (and associated artifacts)
Knowledge and use of grading systems
Use of synoptic reports (as appropriate)
Amended reports and addenda
Proper handling of consultation cases
Photomicroscopy
Intraoperative
Frozen Sections and Smears
Basic
Role of intraoperative diagnosis; appropriate
indications
Tissue sampling for intraoperative diagnosis
Cut and stain frozen section (within 10 minutes)
Precautions for handling fresh tissue or other
specimens for intraoperative diagnosis
More Advanced
Preparation and staining of smears
Interpretation of frozen sections and smears
Understanding limitations of intraoperative diagnosis
Communication and dialogue with treating physician
Autopsy
Role of autopsy and indications for autopsy
Understanding of autopsy permission and assignment
of medicolegal status
Adequately perform an autopsy (in less than 4
hours)
Distinguish natural from unnatural death
Cytopathology
The following competency objectives are modified,
with permission, from those of the American Society of Cytopathology Taskforce on Residency Training
in Cytopathology.
Demonstrate knowledge of the interpretation of
cytopathology specimens
from the various commonly sampled body sites, by examining cases prior to
sign-out and being prepared to provide diagnostic opinions, differential
diagnoses, and/or follow-up recommendations
Demonstrate capability in the performance of
superficial FNA biopsies in a clinical setting, with appropriate patient
care and diagnostic outcomes
Demonstrate ability to assist at the performance of
deep FNA biopsies in settings such as radiology and endoscopy, with appropriate determination of
specimen adequacy and the need for ancillary techniques and collection of
supplementary diagnostic materials for such techniques
Demonstrate knowledge of continuous quality
assurance and regulatory compliance methodologies as they apply to the
cytopathology laboratory,
for example, the Clinical Laboratory Improvement Amendments of 1988
Molecular Diagnostics and Cytogenetics
Role of these techniques in the diagnosis of neoplastic disease, particularly
hematolymphoid disorders
Role of these techniques in diagnosis of infectious
disease
Role of these techniques in diagnosis of more
frequent heritable disorders
Understand the principles and limitations of PCR,
RT-PCR, FISH, Southern blot analysis, and karyotyping
Understand critical issues of quality control in
using these techniques
Laboratory Management
Diagnostic coding and billing procedures
Basic federal law (including compliance) applicable
to pathology
Basic understanding of JCAHO and CAP standards for
laboratory certification
Cost-effective practice of pathology
Principles of quality assurance and improvement
Understanding of basic risk management issues
General Skills
Use of appropriate phraseology in reports
Appropriate communication with clinicians (or
patients/family as appropriate)
Timeliness, turnaround time, and indications to
rush cases
Resolution of diagnostic disagreement
Seeking internal and external consultation
Training more junior residents
Ability to make an independent case presentation
Am J Clin Pathol
Oral Squamous Cell Carcinoma: Histologic Risk Assessment, but Not Margin
Status, Is Strongly Predictive of Local Disease-free and Overall
Survival
Brandwein-Gensler
M, Teixeira MS, Lewis CM et
al
To analyze the impact of resection margin status and
histologic prognosticators
on local recurrence (LR) and overall survival (OS) for patients with oral
squamous cell carcinoma
(OSCC). This study was both retrospective and prospective in design.
Cohort 1 refers to the entire group of 292 patients with OSCC. The slides
from the earliest resection specimens from Cohort 1 were examined in an
exploratory manner for multiple parameters. Cohort 2 refers to a subset of
203 patients, who did not receive any neoadjuvant therapy and had outcome data.
Cohort 3 represents a subset of Cohort 2 (n = 168) wherein the histologic resection margin
status could be reconfirmed. Cohort 4 refers a subset of 85 patients with
tongue/floor of mouth tumors. Margin status was designated as follows:
group 1, clearance of >/=5 mm with intraoperative analysis, no need for
supplemental margins (n = 46); group 2, initial margins were measured as
<5 mm during intraoperative frozen section; supplemental
resection margins were negative on final pathology (n = 73); group 3, the
final pathology revealed resection margins <5 mm (n = 30); group 4, the
final pathology revealed frankly positive resection margins (n = 19). The
endpoints of LR and OS were queried with respect to T stage, tumor site,
margin status, and numerous histologic variables, by Cox regression and
Kaplan-Meier survival analyses. Tumor stage (T) was significantly
associated with LR (P = 0.028). Kaplan-Meier analysis for stage and for
intraoral site was
significantly associated with LR for T4 tumors. The increased likelihood
of LR was higher for T4 OSCC of the buccal mucosa (75%), sinopalate (50%), and gingiva (100%) compared with mobile tongue
(27%), and oropharynx (13%)
(P = 0.013). Margin status was not associated with LR or OS (Cohort 3).
This was so when all tumors were grouped together and when separate
analyses were performed by tumor stage and oral subsite. No significance was demonstrated when
margin status was examined for patients with similar treatment (surgery
alone or surgery with adjuvant RT). However, the administration of
adjuvant RT did significantly increase local disease-free survival (P =
0.0027 and P = 0.001 for T1 and T2 SCC, respectively). On exploratory
analyses of histologic
parameters, worst pattern of invasion was significantly associated with LR
(P = 0.015) and OS (P < 0.001). Perineural invasion involving large nerves
(>1 mm) was associated with LR (P = 0.005) and OS (P = 0.039). Limited
lymphocytic response was
also significantly associated with LR (P = 0.005) and OS (P = 0.001). When
used as covariates in a multivariate Cox regression model, worst pattern
of invasion, perineural
invasion, and lymphocytic
response were significant and independent predictors of both LR and OS,
even when adjusting for margin status. Thus, these factors were used to
generate our risk assessment. Authors risk assessment classified patients
into low-, intermediate-, or high-risk groups, with respect to LR (P =
0.0004) and OS (P < 0.0001). This classification retained significance
when examining patients with uniform treatment. In separate analyses for
each risk group, authors found that administration of adjuvant radiation
therapy is associated with increased local disease-free survival for
high-risk patients only (P = 0.0296) but not low-risk or intermediate-risk
patients. Resection margin status alone is not an independent predictor of
LR and cannot be the sole variable in the decision-making process
regarding adjuvant radiation therapy. Authors suggest that the
recommendation for adjuvant radiation therapy be based on, not only
traditional factors (inadequate margin, perineural invasion, bone invasion) but also
histologic risk assessment.
If clinicians want to avoid the debilitation of adjuvant radiation
therapy, then a 5-mm margin standard may not be effective in the presence
of high-risk score.
Am J Surg Pathol. 29(2): 167-178, Feb.2005.
Early Vulvar Squamous Neoplasia: Advances in Classification,
Diagnosis, and Differential Diagnosis
Medeiros, Fabiola; Nascimento, Alessandra F; Crum, Christopher P
The recognition and
classification of preinvasive vulvar neoplasia are complicated by the facts that
(a) their respective carcinomas have a diverse (human papillomavirus [HPV]- and non-HPV-related)
pathogenesis; (b) not all vulvar squamous carcinomas are associated with
precursors with strictly defined morphologic features; (c) many carcinomas
have epithelial changes that are abnormal but lack sufficient nuclear
atypia to warrant
classification as an intraepithelial neoplasm; and (d) even lesions
associated with a common etiologic agent (HPV) present a diverse
morphologic spectrum. In this review, five categories of early vulvar neoplasia are defined, based on the available
literature, into (a) low-grade lesions with minimal cancer risk, (b)
high-grade lesions associated with HPV, (c) high-grade lesions associated
with other etiologies, (d) squamous atypias defined by abnormalities in
differentiation rather than abnormalities in nuclear morphology, and (d)
early carcinomas that do not exhibit conspicuous stromal invasion. The first three groups are
arranged into low- and high-grade intraepithelial lesions, the fourth into
intraepithelial atypias
that bear careful follow-up and attention to the co-existing squamous mucosa, and the fifth
into a category that, depending on the degree of cell differentiation, may
warrant local excision or lymph node dissection. Recognition of these five
categories is germane to proper management of women with squamous lesions of the
vulva.
Advances in Anatomic Pathology: Volume 12(1), 20-26 Jan.2005.
Virtual Microscopy
Applications in Diagnostic
Pathology
EDITORIAL
M Lundin, J Lundin and J Isola
In the
December 2004 issue of the Journal of Clinical
Pathology, authors describe an atlas
of breast histopathology, implemented with web based virtual microscopy. The article highlights the
advantages of virtual microscopy compared
with traditional methods for producing
educational material in histopathology. The described slide scanning and viewing technology will also
enable novel applications, such as large
scale quality assurance programmes, virtual slide seminars, and virtual slides as supplements to
scientific publications. In this
editorial, authors describe current and future applications of virtual microscopy, and we discuss how the
technology could be refined to allow even
further applications in diagnostic
pathology.
"Virtual slides archived on a network server can be
individually controlled and viewed by a
large number of simultaneous users"
The terms "virtual microscopy" and "telepathology" are often confused. Dynamic telepathology refers to remote robotic operation of a motorised microscope and real time transmission of the video image. In contrast, virtual microscopy is a form of static telepathology, where digital imaging technology is used to digitise, store, and view slides. A digital representation of an entire slide at the resolution of a high magnification objective is designated a "virtual slide". The application spectrum of dynamic telepathology is limited by its "live" nature and single user control, whereas virtual slides archived on a network server can be individually controlled and viewed by a large number of simultaneous users. This is the key to a wide range of potential applications of virtual microscopy, from production of educational material to integration into the hospital patient record system.
APPLICATIONS
Education
Educational material in pathology teaching has
traditionally been based on printed
micrographs and projection slides, and
buyers of modern textbooks now often receive a supplemental CD with digital images. Whether digital or
not, an ordinary micrograph is limited to
a preselected area and
magnification. In contrast, virtual
microscopy enables viewing of any part of
a specimen at any magnification. With annotations, selected important areas in a virtual slide can be
pinpointed, corresponding to micrographs
in printed textbooks. In addition, for pathologists in training, virtual slide atlases provide a
feasible way to view collections of very
rare diagnostic entities. "Quiz modes" and
other interactive functions, such as grading tutorials, are new and interesting educational tools.
Research
By providing virtual slides as supplements to
research articles in scientific journals,
results can be documented and thus verified
by other researchers in a way not currently possible with
ordinary printed micrographs. In molecular
pathology research, studies using tissue
microarrays could provide
the entire study material viewable as
supplemental web based virtual slides. Readers of case studies and studies describing new or
rare histopathological entities will benefit from the possibility of
viewing the virtual slides of the lesions
described. Thus, virtual microscopy responds
to increasing demands on openness and transparency in scientific reporting. Standard platforms for publishing
virtual slides online, ensuring future
access, would be valuable for authors,
journals, and the readers.
Live presentations
Didactic live presentations on diagnostic pathology are currently largely dependent on the use of conventional digital images embedded in PowerPoint presentations. With virtual microscopy, the presenter, with the use of a mouse, can navigate to any area within a slide on the projector screen and seamlessly change magnification. Interesting areas that have been annotated beforehand can instantly be displayed. The visual experience of the audience thus resembles that of viewing a glass slide using a multiheaded microscope or a microscope connected to a projector, but the number of participants can be much larger. When it comes to clinical meetings or slide seminars, it is also possible for the audience to view the virtual slides before the presentation. It is easy to foresee that this will be an integral part of future pathology congresses, where the paid registration fee not only includes the congress abstracts, but also opens access to the congress website, containing virtual slides of the cases to be presented in the lectures.
Multiple copies of
microscope slides
Applications requiring multiple copies of microscope slides are ideally suited to virtual microscopy. Interlaboratory comparisons of histopathological diagnoses have been conducted by preparing replicate sets of microscope glass slides and distributing them to the participating pathologists. When the specimen sample is small, such as a needle biopsy, this is not possible, and for cytological specimens there is often only a single diagnostic slide. Virtual microscopy allows each participant to view exactly the same tissue section, thus facilitating quality control programmes, even at a nationwide or international scale. Virtual microscopy could also be used for pathology board certification examinations, which are difficult to arrange if identical specimen sets are considered necessary.
ISSUES INVOLVED
A common feature of the applications discussed thus far is that virtual microscopy introduces a new level of functionality, not previously possible to accomplish. However, for further applications in diagnostic pathology, important issues to consider include image quality, slide navigation and viewing speed, depth of focus, storage costs, and scanning time.
The
atlas presented in this issue of JCP shows
that slides can be digitised with an image quality that would
satisfy most pathologists. However, the
image quality seen by the end user is ultimately
determined by the resolution and size of the computer screen. The quality of monitors has improved rapidly,
and one of the main improvements in the
next generation of computer operating
systems will be a shift from low resolution systems towards high resolution screen standards. With a large
monitor, more image information can then
be conveyed through a screen than is seen
in one high power field through the oculars. Because each monitor and graphics adapter displays the
image slightly differently, the
possibility of directly adjusting visual properties such as brightness and contrast of the virtual
slides is important, especially because
every pathologist has his own personal way
of fine-tuning the settings in the microscope.
"The depth of field in a virtual slide can be extended by capturing and layering multiple focal planes, and these can also be digitally merged"
Navigation by stage movement becomes almost a reflex action in pathologists, but getting accustomed to navigating a virtual slide with the mouse in combination with a overview window offers great advantages. Within a standard intranet of a pathology department, the viewing system described in this issue corresponds well to conventional microscopy in terms of viewing speed. There is no noticeable time delay when zooming in and out (switching objectives), and the specimen is automatically in focus. However, in a microscope, it is possible to adjust the focus continually by moving the zone of sharpness up and down the optical axis. This is important, because with a high quality objective, the depth of field is smaller than the thickness of most histological specimens. The depth of field in a virtual slide can be extended by capturing and layering multiple focal planes, and these can also be digitally merged. This technology will be important especially for viewing cytological specimens, which represent entire cells, unlike 25 m thick tissue sections.
The resolution and image quality of the atlas slides described in this issue of JCP were adjusted according to feedback from pathologists. This generated file sizes that only a few years ago would have resulted in massive storage costs. As a result of increasing capacity and falling prices of fast storage systems this is no longer a crucial issue, even if a department scanned every diagnostic slide produced in the laboratory. However, scanning with a x40 microscope objective was found necessary, leading to relatively long scanning times. Slide scanning with a x10 or x20 objective would be much faster, but the resulting image quality is clearly compromised. A promising technique to speed up scanning is parallel imaging using array microscope technology.
Most of the discussed problems have thus already been solved, and it seems clear that all technical obstacles will eventually be solved. As discussed, storage costs are already manageable, and obtaining the scanning equipment is a one-time cost. But although economically feasible, high quality digitisation of slides with current scanning systems is time consuming, so that its application in everyday diagnostic pathology cannot yet be recommended. Furthermore, the need for routine scanning of all diagnostic slides is still unclear. However, there is no doubt that a scanned copy of a slide would be valuable, because previous and current biopsies from the same patient could quickly be viewed, and slides would be readily available for meetings and consultations. It is likely that scanning of slides in pathology departments will begin with only the "interesting" slides being scanned as part of clinical meetings, consultations, and slide seminars. Regardless of whether all or only a part of all slides are scanned, it will be important that virtual slides are properly archived, together with complementary data, such as meeting protocols or seminar handouts, because these will constitute a valuable source of educational and reference material. There will gradually be a need to integrate the virtual slides into the hospital patient record system, thus creating a system corresponding to the highly successful picture archiving and communication systems in radiology departments.
THE FINAL OBSTACLE
The
perception of an image also involves a non-conscious part in the sequence leading to diagnosis. Whether
a pathologist used to conventional glass
slides can get the same perception from a
computer screen remains to be seen when all technical aspects are solved. Perhaps future
pathologists, who will get a considerable
part of their training from virtual slides, will
develop a different kind of "feeling" for screen viewing.
Perhaps there might be differences within
the slides, some being better visualised on a computer screen,
some using a microscope.
"The
feedback that we have received from pathologists shows that virtual microscopy should currently be
regarded as a useful complement to
conventional microscopy"
Already today virtual microscopy has a high potential for various tasks in pathology education, in clinical meeting activity, and in quality control. The feedback that authorse have received from pathologists shows that virtual microscopy should currently be regarded as a useful complement to conventional microscopy. The digital revolution in pathology will not be as swift and radical as in radiology. Instead, it will take place in a stepwise fashion, the pace and applications involved dictated by the needs of the pathologists, and paralleled by advances in microscope slide scanning and computer monitor technology.
Journal of Clinical Pathology 57:1250-1251 December 2004.