Georgia Association of Pathology

GAP News March 2021

Welcome from the At some point, maybe today, perhaps tomorrow, or theoretically even later this year, take a few minutes president to talk to another pathologist about the GAP. That’s it. Your task is one person (although perhaps you could Welcome to the Georgia coordinate with other GAP members to not all gang up Association of Pathology on the same person). You don’t even have to tell them newsletter, and welcome how awesome we are here at GAP – just let them to 2021! In spite of an know that we exist, and that we’d love to have them inauspicious start, I continue join us. to have high hopes for this year. I’m excited to begin Goal #2 is to continue the (frankly) unbelievable my tenure as president, work that Dr. Lara Harik has done with the Education and I thought it would be Committee. Dr. Harik has put together some fitting to provide a “state of fantastic educational programs, including (just in the society” update before the past six months!) a virtual session in August in listing my goals for the coming year. 2020 focusing on challenging cases in surgical and hematopathology, our annual meeting on November As we start 2021, our organization has upwards 7, and a series of webinars, most recently on January of 87 members across the state of Georgia (out of 21 on clinical toxicology. She has great ideas for the a total of around 400 Georgian pathologists). We coming year, and we’d like to expand our educational operate on a shoestring budget – in 2019 we ended offerings. These types of programs are essential to the year with $0.00 in the bank. In 2020, the figure increasing the value of a GAP membership. was closer to $700. Our expenses are the fee we pay our management company (without whom none I briefly considered having a third goal, because of this would be possible) and the costs associated human beings seem to like groups of three, but I’ve with providing our members news and education. decided against it. That’s not to say that we won’t be Our biggest source of revenue, and our biggest working on multiple other initiatives (because we will expense, is our annual meeting. Our officers and be). In fact, if you have something you’d like us to board members are all volunteers, and all of us address, just send me a message. My email is dean. are passionate about supporting the practice of [email protected], and my cell phone is 404-313- pathology - which is, of course, the greatest of the 8587. medical professions. Warm regards, and Happy New Year! So where do we go from here? The GAP exists to serve the needs of our members, but our members Dean Joelson, MD make up a relatively small percentage of the total number of pathologists in our state. My first goal of P.S. Please check your spam folders for our emails the year, therefore, is to expand our membership. and put us on your “trusted” list. We have all been And in that regard, I have a task for each of you. vaccinated and will transmit no viruses. Ha! Get it?

Page 1 Advocacy Case Update Presentation

Unlike last year, when the GAP advocated for Presented by and obtained concessions beneficial to Georgia pathologists in the balance billing legislation Melad N. Dababneh that Governor Kemp signed in July, this year Pathology Resident, PGY-2 promises to be a quieter one for pathologists at the Georgia capitol. The GAP has endorsed Lara R. Harik, MD just one bill so far in this legislative session – Assistant Professor of Pathology House Bill 93. The bill would eliminate state certification of laboratories. The legislation Emory University School of Medicine was proposed by the Department of Public Health, as the Department recognized that state Multiple-choice question: certification is redundant, in most cases simply copying CLIA/CAP regulations. An informal Which of the following is FALSE regarding the likely diagnosis: GAP poll of laboratory directors confirmed the Department’s assertion, and, therefore, the GAP A. This lesion is benign. supports the elimination of this unnecessary certification. B. The lesion is associated with infertility.

On the national front, the GAP continues to C. Use of immunohistochemical studies is not often necessary. monitor the progress of the $1.9 trillion COVID relief package that is working its way through D. Presence of siderophages is required for morphological Congress. This legislation has several items of diagnosis. interest to pathologists (adapted from the CAP website): E. It is associated with higher risk for developing malignancies.

• $50 billion to expand testing across the United States. • $35 billion, with 20% set aside for rural hospitals, to replenish the Provider Relief Fund. • $30 billion for the Disaster Relief Fund used for boosting personal protective equipment, laboratory supplies, and reimbursement to state and local governments for emergency response. • $20 billion for a federal government vaccination campaign. • Additional investment in virus surveillance, sequencing, and analytics.

In addition, GAP leadership continues to engage with members of the state legislature and the Medical Association of Georgia (MAG). Dr. Joelson attended the virtual Physician’s Day at the capitol with state representatives References on February 17, and Drs. Fries and Joelson are both members of the MAG Council on Saliba, Christian et al. “Abdominal Wall Endometriosis: A Case Legislation, where we represent the interests of Report.” Cureus vol. 11,2 e4061. 13 Feb. 2019, doi:10.7759/ Georgian pathologists. cureus.4061

If any of our members has any issues they Agarwal, Neha, and Arulselvi Subramanian. “Endometriosis would like the GAP to address with the State - morphology, clinical presentations and molecular pathol- Legislature or with MAG, please don’t hesitate ogy.” Journal of laboratory physicians vol. 2,1 (2010): 1-9. to contact us. doi:10.4103/0974-2727.66699

See page 4 for the correct answer.

Page 2 GAP Virtual Pathology Presentations in 2021

Lara Harik, MD Emory University [email protected]

We hope you enjoyed the GAP Virtual Pathology July 15, 2021 presentations which took place over the spring, summer Faisal Saeed, MD and fall of 2020. We have more presentations planned Updates in HPV-related for the year 2021. The presentations usually take place neoplasia in head and neck on Thursdays at noon EST USA, virtually via zoom. The link is emailed to you a week before the presentation, as well as the day of the presentation. If you have not received these emails, please check your spam folder.

We would love to hear from you regarding topics you would like to learn more about. Please email all suggestions for future topics to Dr. Lara Harik at Lara. [email protected]. September 23, 2021 Abdulwahab Ewaz, MD Please find below the planned schedule for 2021. We Practical Approach to Soft hope you will join us. Tissue Cytopathology

March 25, 2021 Abigail Goodman, MD Advances in Adult Neuropathology: Putting the c-IMPACT NOW updates into practice

November 18, 2021 Harold Cliff Sullivan, MD Blood Banking

May 20, 2021 Vaidehi Avadhani, MD Making sense of the non- neoplastic liver biopsy: simple tips for the general surgical pathologist

Page 3 Case Pathologist Presentation Quality Correct answer: Within the Piedmont healthcare system, we are currently engaged in a debate about how to design metrics to measure The correct answer is D. Presence of siderophages is a the quality of pathologists across our many entities. Simple, requirement for morphological diagnosis. right? I’m not sure why we’re having such a hard time. The answer is: it’s the percentage of time one’s diagnosis is Explanation of the correct answer: correct divided by the time it took to reach that diagnosis. The H&E histology shows the presence of benign glandular Except, well, some people don’t know what to do with the endometrial epithelium surrounded by endometrial stroma, percent/time units. It’s also possible that there isn’t a linear and embedded in a pink fibrotic background. The presence relationship between quality and either percentage or time. of two out of three of the following H&E findings; endometrial For example, if you take 24 hours to reach a conclusion, glands, endometrial stroma and hemosiderin-laden you’re an okay pathologist, but if you take 26 hours, you’re macrophages, is diagnostic of Endometriosis. Therefore the absolute worst – almost totally incompetent. At 25 hours, the presence of hemosiderin laden macrophages is not a people tolerate your presence in the doctor’s lounge, but they necessary criterion. Immunohistochemical stains are not begin to think you look a lot like that zombie coroner on the necessary to make the diagnosis. CW without the charm. “Joelson is probably pretty close to making a go for my brains. If he takes another hour with my Endometriosis is one of the subtypes of Mullerianosis, reports, I’m calling in Brad Pitt.” So maybe our equation is which also include endosalpingiosis (tubal epithelium) and actually closer to percentage correct divided by time squared. endocervicosis (endocervical type mucinous glands). It most Hey, I’m sure it took people a while to get used to saying commonly involves the ovaries and fallopian tubes, but can “meters per second squared” when referring to gravity. Give it be seen in more distant sites such as within the abdominal some time. wall. Its presence in the adnexae can cause adhesions which contribute to infertility in some cases. The presence Then we’ve got the whole accuracy thing. The bane of the of endometriosis is associated with an increased risk of private practice pathologist’s existence is that pathologist in developing endometrioid and clear cell carcinomas. the Yukon territory that the local clinician adores and who loves to disagree, marginally or not, with everything you say. Abdominal wall endometriosis – Brief Summary: You guys know the one. But who’s right? We could wait five years and see what happens to the patient, but, really, much Endometriosis is the presence of endometrial tissue of the time those disagreements don’t amount to anything outside its natural location (uterine cavity), most commonly significant clinically. Fundamentally, we get back to the simple implanted in ovaries, fallopian tube and uterine ligaments. It fact that a pathology report is a medical opinion. He’s entitled predominantly affects pre-menopausal women. Extrapelvic to an opinion, and so are you. People love to write papers endometriosis can be seen in the GI tract, pleura, urinary about how often breast pathologists come to blows over bladder and abdominal wall. It can also be seen within what’s atypical and what’s not. I’d like to see their accuracy lymphovascular spaces and this finding is of uncertain divided by time squared equations. It’s not an easy job. significance. So what’s a pathologist to do? If I’ve got a point to this article, Multiple theories are proposed to explain the well then I’m coming to it. And the point is: communicate. pathophysiology behind it, including direct transplantation, Communication introduces the “c” variable to our equation retrograde spread of endometrial cells during menses, (%*c/time2). Depending on the quality of your communication, lymphatic and vascular spread as well as metaplasia of c could equal something like, I dunno, like 1,000,000. If you peritoneal cells (coelomic metaplasia). are a slow pathologist, keeping the clinicians up-to-date on your progress can make a huge difference in improving your Abdominal endometriosis (or scar endometrioma) is rare equation. Here’s an even better tip: communicate with them and has been reported to occur after a history of pelvic about life. If they end up liking you, it almost doesn’t matter surgery. It is found in 0.03%-1.5% of women post cesarean what percentage or time squared equals. The c stretches section. It typically presents with a mass near or over the out to infinity. This last bit may be easier said than done, surgical scar with recurrent cyclic abdominal pain. Main depending on your degree of introspection and their degree differentials for it, based on location, would be suture of willingness to talk with someone they secretly suspect may granuloma and incisional hernia. want to eat their brains. But life is relationships, and there are few better professional relationships to cultivate than the ones On histologic sections, in addition to endometrial glands and with your clinicians. stroma, the presence of chronic hemorrhage evidenced by hemosiderin-laden macrophages can be helpful, but not a My gift to you (in case your administrators start poking around for quality metrics) is the elegance of %*c/time2 equation. Just necessary requirement. CD10 immunoreactivity is typically remember the importance of that c variable. Put in the effort. seen in the surrounding endometrial type stromal cells. Please. It’s worth it.

Dean Joelson, MD

Thanks for reading! We’ll next quarter for another edition of GAPNews! Page 4