THE JOURNAL OF THE AAPA VOLUME 8 ISSUE 4 2018 IN THIS ISSUE
Peer-Reviewed 1 CE Quiz & Peer-Reviewed Manuscript: New Malignant Transformation of Childhood Malignant Transformation of Burn Wound with Metastasis: A Case CE Article Report Childhood Burn Wound with 3 Letter from the Editor Metastasis: A Case Report N. Dominic Alessio, PA(ASCP)CM 6 CE Quiz & Peer-Reviewed Manuscript: Breast Cancer Metastasis to the Colon Detroit Medical Center, Detroit, MI Presenting After Fifteen Years Fellow members were given the opportunity to apply for a travel grant to attend an upcoming Fall Conference or Spring Meeting of 8 Peer-Reviewed Manuscript: their choice. Fellows were required to write a manuscript, and the Aurora Diagnostics Pathologists’ Assistant four winning entries received a grant valued at up to $1800 (full week Breast Specimen Handling Best Practice Guideline registration + $1000 to help cover travel expenses). Congratulations, Dominic, on your winning submission! 11 44th Annual Continuing Education Conference Recap Abstract 12 44th Annual Continuing Education Marjolin’s ulcer is a rare and aggressive form of cutaneous squamous cell carcinoma Conference Photos (SCC) which forms through malignant transformation of chronically irritated previous injury, such as incompletely healed burns, ulcers, and other wounds. Although similar in 17 8th Annual Spring Meeting microscopic morphology, Marjolin’s ulcer is unique from other cutaneous SCCs in many other significant characteristics. The carcinoma often appears decades after the initial 18 Board of Trustees Chair’s Report trauma, but once present it follows a rapid course of growth and metastasis. In the current case study, a male in his mid-30s with history of extensive burns as a child presented 21 Gross Photo Unknown to the Emergency Department complaining of a large, open wound on his lower back. Biopsy of the primary lesion showed moderately to poorly differentiated squamous cell 22 Town Hall Meeting Recap carcinoma, prompting wide local excision. Subsequent radiology and biopsy showed positive metastasis to the right ventricle of the heart, with concern for metastasis to 23 Legislative Update the left lung and left axillary lymph nodes. The following article presents a rare and unique case, while advocating for complete submission of skin resection margins on 24 Book Review: Human Errors large specimens even in the context of multiple negative intraoperative diagnoses. A Panorama of Our Glitches, From Pointless to Broken Genes Key words: Marjolin’s ulcer, squamous cell carcinoma, burn scar, skin excision 25 Calendar Introduction and Brief Review of Literature 26 Member Spotlight One of the rarest and most aggressive forms of squamous cell carcinoma 27 Gross Photo Tutorial (SCC) of the skin is found in malignant transformation of a site of previous 27 Institutional PA Program Members trauma, a condition often nicknamed “Marjolin’s ulcer” after a French physician 28 Sustaining Members who first described the condition in the early 19th century. However, this presentation represents only a small subsection of a much broader condition. While cutaneous SCC as a category is quite common, especially in older and light-skinned individuals, the predominant cause is exposure to ultraviolet (UV) light.1 The high-energy UV light rays cause DNA damage and subsequent mutations in the well-known tumor suppressor TP53.
Transformation continued on page 4 > Gross Photo Unknown, see page 21 AAPA EXECUTIVE DIRECTOR Michelle L. Sok, CAE [email protected]
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JOURNAL SUBMISSIONS The AAPA encourages any AAPA member or interested party to John Eckman Thomas Reilly Jana Sovereign Lindsay McCarley Shannon McWilliams BOT Chair, Vice Chair/Secretary, Chief Financial Trustee Trustee contribute articles, updates, Executive Council Executive Council Officer, Administration Committee Education photos or upcoming event Executive Council Oversight Committee Oversight announcements for the quarterly edition of The Cutting Edge. In particular, articles related to the field of pathology are welcomed. Articles and photos may be submitted electronically. (Note: photo files must be a minimum Beth Obertino-Norwood Steven Rath Ryan Schniederjan Dennis Strenk of 300 dpi resolution.) Trustee Trustee Trustee Trustee Education Committee Membership Committee MarComm Committee MarComm Committee Oversight Oversight Oversight Oversight
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Page 2 THE CUTTING EDGE THE JOURNAL OF THE AAPA The Cutting Edge Journal is published Letter from the Editor
by the American Association Beth Felicelli, PA(ASCP)CM of Pathologists’ Assistants Editor-in-Chief [email protected] Cutting Edge Journal Staff Beth Felicelli works at Western Editor-in-Chief: Beth Felicelli Michigan Pathology Associates in Assistant Editor: Minda Koval Holland, MI. She has been a member of the AAPA since 1997, and recently Book Review: Chet Sloski became Managing Editor of The Cutting Edge. She serves CE Quiz: Nea Moyer as the Print Communication Subcommittee Chair for the Karah Jones MarComm Committee. Gross Photo Tutorial: Emily Paull Acheson This issue features a recap of the 2018 fall conference AAPA Committee & Subcommittee Chairs in New Orleans as well as information on the upcoming 2019 spring meeting in Phoenix. Both the fall conference Administration: Karen Ron and the spring meeting are great ways to earn continuing Vice Chair: Chevanne Scordinsky education credits, network with others in our field, meet old Governing Documents: Chevanne Scordinsky friends, and make new ones. I highly recommend attending Nominations/Elections: Karen Ron these events and although I could not be in New Orleans, I enjoyed living vicariously through the photographs and stories! Education: Jennifer Perez Vice Chair: Megan Pickard We are featuring a CE article from one of our recent Beyond the Bench: April Reineke recipients of the Board of Trustees Award, Dominic Allesio. CE Content Generation: Nea Moyer This interesting article about a malignant transformation Meetings: Heather Manternach of a burn wound was the 2018 Fellow Conference Travel Becky Stankowski Grant Neoplastic case winner. Our second CE article is Study Materials: Matt Guerin the 2018 Student Non-Delegate Conference Travel Grant winner, Samantha Etters, with a case study of a breast cancer metastasizing to the colon. Our third article is a Marketing/Communications: Charlene Gettings timely feature on the proper handling of breast cases, by Vice Chair: Joel Wichmann James Barry and Angeline Dowell. Ad Sales: Janelle Fabian Advocacy: Open All three featured articles are informative and great reads. Communication - Electronic: Open Each case study was something I have never come across Communication - Print: Beth Felicelli in my 20+ years at the bench. I always enjoy reading about Marketing - External: Open cases I’ve never seen and it’s a great opportunity to learn Marketing - Internal: Annie Schniederjan something new. Media: Ryan Schniederjan Larry Marquis was presented the Lifetime Achievement Award in New Orleans this fall. Thank you, Larry, for all you Membership: Roseann Vitale have done for the AAPA! See page 13 for more information Vice Chair: Dominic Alessio on Larry’s achievements. Recruitment: Tara Shea-Leandro Retention: James Romnes Specialty Groups: Coy Wagoner Student Committee: Sabrina Innes Kristina Scharer-Zielinski AAPA Core Values: Student Delegate Program: Brittin Cavanagh Surveys: Derek Deutsch Quality Patient Care: Volunteer Management: Open The AAPA ensures quality patient care is an integral component to the environment and endeavors of the Association. Operations Dir. of Professional Development: Connie Thorpe Education: Dir. of Professional Outreach: Jon Wagner The AAPA provides educational opportunities that support patient Technical Support: Ryan Schniederjan care and promote the advancement of professional competencies.
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PATHASSIST.ORG Page 3 Transformation invasion, lymphatic spread and wide outflow tract mass measuring nearly 3 cm metastasis.4 As with most conditions, early in greatest dimension, protruding into the > Continued from cover diagnosis and treatment leads to improved right ventricle. Initial CT scans additionally In addition, the HRAS gene can undergo prognosis; however, this goal presents a showed a small (0.3 cm) but suspicious activating mutation—increasing cell particular challenge considering the long- nodule within the left lung. Approximately division and survival—and Notch receptors term nature of the malignancy and the six weeks after the initial surgery, the can experience loss-of-function mutations, fact that such chronic lesions tend to be patient underwent transcatheter heart affecting the normal differentiation of painless. Marjolin’s ulcer generally presents biopsy, which was diagnosed as metastatic 1 squamous epithelium. Lesions are as a large, irregular, ulcerated wound with squamous cell carcinoma. Cytologic generally well-defined and plaque-like, with an excavated center and fungating borders, evaluation of pleural fluid aspiration was ulceration present only in advanced cases. and often produces a foul-smelling exudate. negative for malignant cells, but follow-up These common forms of SCC tend to be Wide excision of the primary lesion— CT scans showed an enlarged left axillary completely treatable by local excision and including amputation of limbs—is the only lymph node which had grown from 0.6 cm rarely metastasize to lymph nodes or other treatment which has demonstrated efficacy to 2 cm in four weeks, as well as noting that organs. to date. Systemic treatments such as the pulmonary nodule mentioned earlier chemotherapy have been used with patients had more than doubled in size (to 0.7 cm) However, while still a cutaneous SCC, suffering from widespread metastasis, over the same time period. At the time of Marjolin’s ulcer is distinct from standard but many such cases have a prognosis of this writing, no further surgical treatment cases in nearly every one of the only 2-3 years.4 On the other hand, if the had been planned. characteristics described above. Neither lesion can be completely excised with clear age nor skin pigmentation are associated margins, patients recover well. Pathology with risk or prognosis. Exposure to sunlight is generally irrelevant in cases of Marjolin’s Patient History The primary wide local excision received ulcer; instead, the cause is traumatic in in the pathology gross room measured nature, with malignancies most commonly A male in his mid-30s presented to the 24 cm in diameter, and the specimen was forming at old burn scars but also on Emergency Department with a large, predominantly occupied by a centrally- poorly-healed wounds of various sorts such open lower back wound. The patient had ulcerated, tan to red, nodular, firm and as pressure, venous stasis, or diabetic 2,3 a history of extensive burns to his back friable mass which was raised a maximum ulcers. According to available literature, and lower extremities as a child, which he of 2 cm above the skin surface (Fig. 1). On from 1-2% of burn scars undergo malignant reported had healed by adulthood. Surgery the deep aspect, the excision extended to transformation but these represent 4,5 had been performed on his left axilla to the underlying muscular and fascial tissue, <0.5% of all skin cancers. Interestingly, correct range of motion restriction due to with a maximum depth of 4 cm. For the sake rather than DNA damage due to UV rays, severe scarring, with contracture release of consistency, the anatomic orientation the pathophysiology of Marjolin’s ulcer and skin grafting. However, some years markers were translated into clock-face progresses through multiple diverse and following this operation, the patient noticed designations, and the margins were inked simultaneous processes, many of which are a small (less than 2 cm) wound on his left such that the 12:00 to 6:00 (medial) edge, still areas of active research. One significant lower back, which progressively increased 6:00 to 12:00 (lateral) edge and deep aspect mechanism involves the chronic irritation in size and depth, up to 30 cm in diameter. were represented in three different colors. present in old, unhealed and possibly The patient had been avoiding healthcare After orientation and inking, the entire infected wounds—the epithelial cells are due to insurance issues, but eventually peripheral margin was circumferentially being damaged and regenerated at a much presented to the emergency department shaved and submitted en face (Fig. 2). The higher rate than usual, releasing high levels following weight loss of 15 lb over the central area of the wound was sampled in of necrotic toxins and providing exponentially 4 previous two months. relationship to all relevant points, including more opportunities for mutations to arise. the attached muscle, fascia, unremarkable Other studies have shown that chronic Hospital Course skin, greatest height of growth and point of scar tissue lacks the usual immunological deepest gross invasion. components of healthy dermis, including Initial physical examination of the patient Langerhans cells and lymphatics, providing revealed a warm, pink area across the Microscopic examination revealed invasive, an uncontrolled site in which malignant left back measuring approximately 30 moderately- to poorly-differentiated cells can grow unchallenged. Finally, x 30 cm, including a large eroding and squamous cell carcinoma (Fig. 3) with significant differences in gene expression fungating mass which released purulent an invasion depth of 3.6 cm into the deep have been noted between cells sampled discharge with a foul smell upon palpation. subcutaneous tissue, resulting in an from Marjolin’s ulcer compared to other Samples were taken from six different 6 anatomic “Clark level” designation of V cutaneous SCC. For example, heightened locations around the periphery and (out of maximum V) (Fig. 4). Microscopy extracellular matrix turnover and epithelial- center of the wound, all of which came of the heart biopsy showed myocardium to-mesenchymal transformation have back positive for invasive squamous cell infiltrated by highly malignant neoplastic been traced to the drastically increased carcinoma. The patient was then referred cells, with pleomorphism, high nuclear to metastatic potential of these cells. to surgery for wide excision of the mass. cytoplasmic ratio, abundant eosinophilic Although four frozen sections were sent cytoplasm, and hyperchromatic nuclei. These unique etiological characteristics intraoperatively—each of which was The surrounding stroma was reactive and contribute to Marjolin’s ulcer having a negative for carcinoma—the final specimen showed desmoplastic reaction typically particularly aggressive course, although showed focally positive margins along one seen surrounding neoplastic growth. the disease can be latent for decades edge, prompting a full lateral re-excision six Immunohistochemical stains of the heart following the initial trauma. In fact, the time days later. Following the surgical course, biopsy were positive for AE1/AE3 (a elapsed between injury and presentation concern for post-operative thrombosis cytokeratin combination characteristic of malignancy has been reported to be as called for a transthoracic echocardiogram, of epithelial lineage) and negative for long as 74 years, with an average between which showed an unexpected mass within myogenin (which is expressed in muscular 35-38 years.2,5,7 Once carcinoma develops, the right ventricle. MRI was ordered, which differentiation), strongly suggesting there is high risk for deep and rapid local confirmed an intramural right ventricular malignant squamous cell metastasis.8,9 No
Page 4 THE CUTTING EDGE THE JOURNAL OF THE AAPA Fig. 1: Gross photograph of local skin excision specimen Fig. 2: Diagram used in pathology to demonstrate location and plane of sections. prior to sectioning. lymph nodes had been biopsied at the time and a much more optimistic prognosis. the margin, the positive foci would almost of this writing. Finally, aside from the mere interest in such surely have been missed. Thankfully, proper an unusual case presentation, the technical grossing technique and careful examination Discussion aspect of the grossing process in pathology by a dermatopathologist provided an deserves note because of its significant accurate final diagnosis allowing for re- The case discussed above is relevant implications on diagnosis and subsequent excision of the margin. Complete removal across a broad range of healthcare treatment. This case provides an excellent of the primary tumor was confirmed by disciplines. For the patient, education example of the importance of shaving and shaving the new margin and submitting it on this rare but aggressive complication submitting the entire peripheral margin, entirely. n of a decades-old wound could prompt a even on large skin resections and in the sooner hospital presentation and avoid the context of multiple negative intraoperative Peer Review Notes: Manuscript received June devastating diagnosis of top-stage cancer diagnoses. Had the pathologists’ assistant 2018. Reviewed July 2018. Accepted for publication with widespread metastasis at such a only shaved representative segments of August 2018. young age. For example, had these risks been discussed more thoroughly with the patient following his previous skin graft Transformation References: operation, he may not have waited until 1. Kumar V, Abbas A, Aster J. Robbins Basic Pathology. 9th Get a jump on the new the wound had grown from 2 cm to 30 cm ed. Philadelphia, PA: Elsevier Saunders; 2013:863-864. before seeking medical attention. On the 2. Oruc M, Kankaya Y, Sungur N, et al. Clinicopathological year, renew your AAPA clinical side, heightened awareness of the evaluation of Marjolin ulcers over two decades. Kaohsiung J Med Sci. 2017;33(7):327-333. doi: 10.1016/j. membership for 2019! risks associated with Marjolin’s ulcer could kjms.2017.04.008. lead to better follow-up, earlier detection 3. Cavaliere R, Mercado DM, Mani M. Squamous cell carcinoma from Marjolin’s ulcer of the foot in a diabetic patient: Member Benefits: Case study. J Foot Ankle Surg. 2018;S1067-2516(17)30653- 1. doi: 10.1053/j.jfas.2017.11.016. [Epub ahead of print] n Free CE opportunities
4. Bazalinski D, Przybek-Mita J, Baranska B, Wiech n Quarterly Journal P. Marjolin’s ulcer in chronic wounds - review of available n Grossing Guidelines Access literature. Contemp Oncol (Pozn). 2017;21(3):197-202. doi: 10.5114/wo.2017.70109. n Job Hotline and Salary Surveys
5. Copcu E. Marjolin’s ulcer: a preventable complication n Scholarship and travel grant of burns? Plast Reconstr Surg. 2009;124(1):156-164. doi: opportunities 10.1097/PRS.0b013e3181a8082e. n Discounts on events and 6. Sinha S, Su S, Workentine M, et al. Transcriptional analysis reveals evidence of chronically impeded ECM merchandise turnover and epithelium-to-mesenchyme transition in scar tissue giving rise to Marjolin’s ulcer. J Burn Care Res. n AAPA CE credits automatically Fig. 3: Squamous cell carcinoma from border of mass. 2017;38(1):14-22. doi: 10.1097/BCR.0000000000000432. transfer directly to the ASCP 7. Liu Z, Zhou Y, Zhang P, et al. Analysis of clinical characteristics of 187 patients with Marjolin’s ulcers. Zhonghua Shao Shang Za Zhi. 2016;32(5):293- To renew 298. doi: 10.3760/cma.j.issn.1009-2587.2016.05.009. Log in to your profile on 8. Pernick N. Cytokeratin AE1 / AE3. PathologyOutlines. pathassist.org com. http://www.pathologyoutlines.com/topic/stainsae1ae3. html. Published July 2013. Updated March 2018. Accessed June 27, 2018.
9. Pernick N. Myogenin. PathologyOutlines.com. http:// www.pathologyoutlines.com/topic/stainsmyogenin.html. Published June 2005. Updated November 2015. Accessed June 27, 2018.
Fig. 4: Tumor invasion into deep subcutaneous tissue and skeletal muscle.
PATHASSIST.ORG Page 5 Peer-Reviewed New Breast Cancer Metastasis to the Colon CE Article Presenting After Fifteen Years Samantha Etters, Wayne State University
Second year student members (non-Delegate) were given the opportunity to apply for a travel grant to attend an upcoming Fall Conference or Spring Meeting of their choice. Students were required to write a manuscript, and the winning entry received a grant valued at up to $1600 (full week registration + $1000 to help cover travel expenses). Congratulations, Samantha, on your winning submission!
Abstract time. The tumor was 3.5 cm in greatest amount of purulent fluid and thickened loops dimension. The cancer was diagnosed of small bowel, as well as a large portion The case presented is that of a female as moderately differentiated invasive of omentum and stool. The ascending in her late 70s with a history of invasive ductal carcinoma, estrogen receptor (ER) colon and hepatic flexure were constricted, ductal carcinoma, diagnosed in 2002. positive, progesterone receptor (PR) completely blocking the area extending to Fifteen years later, she was found to have weakly positive, and HER2/neu negative. the transverse colon. A right hemicolectomy metastases to the stomach and to the Following treatment with chemotherapy and repair of the left side Spigelian hernia colon, both rare sites of spread from breast and antihormonal therapy, she had been was performed. cancer. The metastasis to the colon is of periodically monitored and had no evidence particular note here as it was received as of recurrence. Pathological Findings a surgical specimen and evaluated by a pathologists’ assistant. Histologically, the In late 2017, fifteen years after the original Upon gross examination of the surgical cell morphology was compared between breast cancer diagnosis, the patient specimens, the pathologists’ assistant the primary breast cancer and colon presented to the emergency department noted 15 cm of the ascending colon metastasis and found to be strikingly similar. with nausea, vomiting, and inability to wall was narrowed and thickened with Further discussed are related case reports keep down food or liquid. Endoscopy congested mucosa imparting a cobblestone and analyses in the literature of such breast revealed a gastric outlet obstruction. A appearance, giving the gross impression of cancer metastases to the gastrointestinal biopsy of the antrum was positive for Crohn’s disease or another inflammatory tract and their characteristics. Although rare, cancer, determined to be metastases of colitis (Fig. 1, 2). The cecum was dilated the possibility of gastrointestinal metastasis her previous ductal breast cancer by use and the mucosa flattened. The hernia sac in a patient with a history of breast cancer of immunohistochemistry comparison. was remarkable for a nodule containing should always be considered when Computed tomography (CT) scans exudate upon sectioning. Appropriate diagnosing or grossing a gastrointestinal revealed marked abnormal thickening of sections including the cobblestoned areas, lesion. the pylorus and dilation of the stomach, but no other indications of metastasis. A Keywords: ductal carcinoma of breast, palliative bypass with gastrojejunostomy breast cancer metastasis, gastrointestinal was performed followed by a chemotherapy metastasis, metastasis to colon regimen.
Introduction Three months later, the patient returned to the emergency department complaining Reports of breast cancer metastasizing to of abdominal pain, nausea, and vomiting the gastrointestinal tract are quite rare, and that had been worsening over the past even rarer to have occurred in the colon. few days. She also had worsening Most often, breast cancer metastasizes to abdominal distension and reported no the lymph nodes, bone, lungs, liver, and bowel movements for the past four days. Fig. 1: Wall of colon specimen showing cobblestone brain. The case presented here is that of A CT scan revealed the cecum was dilated arrangement of metastatic tumor (previously sectioned). a patient with a history of invasive ductal to greater than 12 cm, a large left lower breast cancer metastasizing fifteen years quadrant abdominal wall hernia, and a right later to the colon, and is significant for inguinal hernia containing multiple loops several unusual findings in its presentation of small bowel. The patient was admitted and pattern of metastasis when compared and exploratory surgery was recommended to the literature. by the surgeon, as a colonoscopy was unable to be performed. It was theorized Case Presentation by physicians that a loop of colon may be trapped within the hernia, causing the cecal A Caucasian woman now in her late 70s distension. had a diagnosis of breast cancer in 2002 and underwent a left modified radical The surgery revealed several remarkable mastectomy and axillary node dissection, findings. The cecum was very distended 6/14 of which were positive, but no and believed to be perforated within the Fig. 2: Cobblestoned portion of colon wall cut to reveal other metastases were identified at the hernia. The hernia sac contained a large infiltration of the lesion into the mucosal layers.
Page 6 THE CUTTING EDGE THE JOURNAL OF THE AAPA dilated cecum, unremarkable mucosa, and attached appendix were submitted for histological examination.
Microscopically, the cobblestoned portion coincided with diffusely infiltrating and poorly differentiated carcinoma resembling linitis plastica. Neoplastic cells with signet- ring forms involved the mucosa and bowel wall and invaded into the pericolic tissue and serosal surface. There was also evidence of neoplastic cells in grossly uninvolved portions, including the dilated cecum. Two pericolic lymph nodes found around the cobblestoned portion and the nodule in the hernia sac were positive for metastatic carcinoma. Fig. 3: Comparison of primary invasive ductal breast cancer (A) and colon metastasis taken from cobblestoned area Immunohistochemistry staining determined (B), low magnification (H&E). the tumor to be ER positive and PR negative. HER2/neu testing was not performed. Slides from the patient’s previously diagnosed breast cancer were obtained from the original treating hospital and compared with the metastatic tumor, which showed the two to have similar histological features, though the colon metastasis was diffuse and poorly differentiated in comparison (Fig. 3, 4). The final diagnosis was metastatic breast carcinoma, diffusely involving the right colon.
The patient tolerated the procedure well and after recovery was discharged and continued to be treated in outpatient care. Two months later, she was admitted to the emergency department with worsening renal function and elected to undergo Fig. 4: Comparison of primary invasive ductal breast cancer (A) and colon metastasis taken from cobblestoned area supportive care. As of the submission (B), high magnification (H&E). of this manuscript, the patient had been transferred to a hospice facility. metastases at autopsy than were clinically for either a gastrointestinal primary cancer detected in surgical cases.2 or other inflammatory disease. There have Discussion been two published reports of metastasis to Despite being the most common type the colon specifically mistaken for Crohn’s This case is noteworthy for demonstrating of invasive breast carcinoma, ductal disease based on clinical, surgical, and/ several rarities in regard to breast cancer carcinoma is less likely to metastasize or radiographic findings.4,5 Complicating metastases, all of which raise important to the gastrointestinal tract than lobular a proper diagnosis is the variety and non- diagnostic challenges for health care carcinoma. In published reports, lobular specificity of gastrointestinal symptoms, providers to consider. First, reports of breast breast carcinoma is the most often typically including nausea, vomiting, cancer metastasizing to the gastrointestinal reported type implicated in gastrointestinal diarrhea, and intestinal pain.1 Many of these tract are rare, and even more rare to have metastasis from the breast, though reasons symptoms also coincide with side effects of occurred in the colon. Most often, breast for this have not yet been explored.1 A treatment, further obscuring the diagnosis. cancer metastasizes to the lymph nodes, study comparing metastatic patterns of bone, lungs, liver, and brain. In a five-year lobular and ductal breast carcinoma found Microscopically, most reports note a retrospective study at one institution, of gastrointestinal metastases in 4.5% of signet-ring cell pattern of morphology in 980 patients diagnosed with breast cancer patients with lobular diagnoses and only in gastrointestinal metastases, regardless of only five (0.5%) had metastatic disease to 0.2% of ductal.3 whether the original breast cancer was ductal the gastrointestinal tract.1 The same study or lobular.2 In one of the reported cases of found in their case analysis and in a review The gross and microscopic characteristics metastasis simulating Crohn’s disease, of literature that the stomach was the most of the presented case do coincide with the morphology also showed signet-ring common site of gastrointestinal metastasis published reports. The appearance cell configuration.5 In the presented case, from breast cancer (60% of cases), while of breast cancer metastases to the the receptor status changed from ER/PR the colon was indicated in 11% of cases. It gastrointestinal tract have been found to positive in the primary tumor to ER positive, is likely that the incidence of gastrointestinal be variable; one study revealed a range PR negative in the metastatic tumor. While metastasis from breast cancer may be of presentations, from diffuse thickening in most cases immunohistochemistry higher due to clinically undetected cases, of the walls mimicking linitis plastica to results match between the original breast as evidenced by a study comparing surgical large obstructive ulcerated masses.2 Any of cancer and metastasis, there have been cases with autopsy results that found over these presentations may cause diagnostic twice as many incidences of gastrointestinal difficulty, as the metastasis may be mistaken > Breast Cancer continued on page 20
PATHASSIST.ORG Page 7 Peer-Reviewed Aurora Diagnostics Pathologists’ Assistant Breast Specimen Handling Best Practice Guideline James L. Barry, MHS, PA(ASCP)CM and Angeline Dowell, MS, PA(ASCP)CM Aurora Diagnostics Pathologists’ Assistant Working Group Members are encouraged to submit articles for The Cutting Edge. An upload link can be found on the Publications page of the website. Earn 5 CMP points for authoring journal articles for peer-reviewed publications. Published articles are also eligible for the annual Journal Award with cash prizes!
Introduction: Results: Once the breast specimen is received in the grossing room, the way it is handled A group of Aurora Diagnostics’ Pathologists’ Lab vigilance, location of surgical center, is determined by the type of specimen. Assistants have come together to form courier schedules, radiographic delays, cold Needle localization specimens and partial Aurora Diagnostics Pathologists’ Assistant ischemic time (CIT), proper fixative, and mastectomies can be received with or Working Group (PA-WG). The goal was to fixative volumes all play critical roles and without the use of a wire in place, anatomic create a uniform approach to the handling challenges in the effort in abiding to CAP- orientation, metallic localization devices, of all breast specimens in an effort to ASCO guidelines. Lab staff management and an accompanying radiograph. Before optimize breast protocol standards and of daily surgical schedules accounting the specimen is cut, a prior biopsy report maximize current breast predictive factor for each breast surgical case, proactive should be obtained and the specimen (BPF) test results. communication for late or weekend cases, correlated anatomically, if possible, to a and immediate communication for breast radiograph. A standard inking protocol Initial core biopsies may not represent specimens not received during the expected should be used for consistency. Optimal appropriate subtypes throughout the entirety time are factors affecting optimal breast slice thickness for these specimens is of the tumor due to tumor heterogeneity. specimen handling. Remote surgical sites 3-4 mm and laid out sequentially for Additional findings and specimens not play a challenging, but not an impossible examination. A specimen slice diagram meeting the ASCO-CAP adequate fixation role when it comes to abiding to CAP- template is also helpful in documenting and cold ischemic time guidelines are ASCO guidelines. There must be an open the tissue selection in correlation with the also encountered. For these reasons, line of communication between the sites section code; this ensures better accuracy new breast predictive factor testing will be and couriers. This is extremely important and minimizes the amount of additional performed on these varying specimens when it comes to scheduling of weekend sections to be submitted when incidental which did not meet CAP-ASCO guidelines. and late cases. The couriers should be findings are discovered. See Fig. 4. Optimal breast protocol standards are scheduled in order to minimize transit time Mastectomy specimens should be inked, essential to determine the correct course of to the lab. The tissue should be x-rayed sectioned into 1-1.5 cm slices (kept intact therapy for breast cancer patients. prior to being placed in a minimum of 1:10 as much as possible), and placed in an ratio (tissue: 10% NBF). Guidelines suggest appropriate amount of 10% NBF within Breast cancer biomarkers (ER, PR, and that 10% NBF (neutral buffered formalin) is the one hour guideline ensuring adequate HER2) can identify patients who may be the only acceptable fixative. Cold ischemic fixation of the tumor and additional surfaces eligible for targeted therapy. The HER2 time (CIT) is the time frame from which the for possible breast predictive factor testing. oncogene is over expressed in 15 to 20% of specimen was excised from the patient and invasive breast cancers and is associated the time the specimen is placed in formalin. Discussion: with aggressive disease and increased A process that minimizes CIT should be risk of metastasis. Factors involved in utilized. An intraoperative x-ray device and Biomarkers such as estrogen receptor (ER), specimen collection, whether from needle immediate interpretation is the route to the progesterone receptor (PR), and HER2 are core biopsies or large resections, and the shortest CIT. Transport to a nearby radiology important in determining prognosis and handling/processing of breast tissue in department and immediate placement in therapy for a particular patient. According to histopathology can greatly affect scoring formalin is also an acceptable practice in our findings, these markers are affected by and interpretation of biomarker testing, minimizing the CIT of the specimen. The the method and length of fixation. For this possibly causing discordant biomarker cold ischemic time should be documented, reason, fixative must penetrate the tumor rates and denying patients beneficial at minimum, on the specimen requisition. within the one-hour time limit to have optimal treatment options. The time the specimen is placed in 10% ER, PR and HER2 results. It is important at NBF should also be documented by the Methods: the time of grossing to be aware of these Operating Room, Radiology, or Pathology issues, and to educate staff on the best The PA-WG focused on and evaluated staff; contingent on who placed the tissue practices for handling breast specimens. three areas that affect biomarker outcomes: in 10% NBF. This time should abide by the The understanding of the ER/PR/HER2/ pre-analytical, gross room procedures, and CAP-ASCO guidelines of less than one TNBC (triple negative breast cancer) communication/education. These were hour and can be documented as follows: receptor rates for all of the outpatient determined to be the factors affecting clinicians and all of the hospital labs that cold ischemic time (CIT), handling of the Specimen Excised from Patient at: ______feed into the main laboratory is paramount specimen once received in histopathology, (refer to SEER data below to compare Specimen Placed in 10% NBF at: ______and effectively communicating and national benchmark data to local data). The educating other departments/providers in Pathologists and Pathologists’ Assistants proper specimen submission. See Fig. 1, 2, & 3. are at the forefront of communication with
Page 8 THE CUTTING EDGE THE JOURNAL OF THE AAPA Fig. 1: Demonstrates the increased incidence of Negative ER receptor biomarker in specimens with a CIT of Fig. 4: Sample Breast Slice Orientation Guide template greater than one hour. that can be utilized in documenting tissue selection in correlation with the gross description section code.
multiple departments and outlying hospitals. The role of the Pathologists’ Assistant in conveying information is to communicate with multiple sources including the Tumor Registrar, Nurse Navigator, Pathologist, Lab Manager, and Tumor Board to capture receptor rate data and demographics for the local lab. Correlating receptor rates for the local lab to the national benchmark rates aids in identifying discrepancies. When discrepancies are identified, consider the local demographics for a possible explanation of the differences. Furthermore, consider demographics for each site to include age, ethnicity, hormone receptor (HR) status, etc. If the local demographics do not support the difference, re-evaluate the pre-analytics as a solution. Tracking Fig. 2: Compares a fraction of ER+ breast cases from 0 to greater than 100 minutes showing a 1.6% decrease of the receptor rates and providing feedback ER+ with a CIT of 0-60 minutes; 6.6% decrease in fraction of ER+ breast cases in comparing those with a CIT of to the multi-disciplinary team frequently 40-60 minutes with those at 60-80 CIT; and a significant decrease of 14.9% in those exceeding a CIT of greater ensures the quality of practice methods. than 100 minutes. Systematic and long-term collection of the data allows assessment of trends over time. For example, assessing data over a three- to five-year period, and re-assessing at yearly increments can identify potential problems, and comparisons among data sets. See Fig. 5 on page 10.
The universal education of staff handling breast specimens at each site is multi- faceted and should include updating requisition forms, education of the importance of cold ischemia time, and providing guidance to all staff engaged with the breast specimen. When updating requisition forms, ensure that the importance of cold ischemia time is understood and times are logged.Depending on site and IT limitations, there may be up to seven time stamps to include:
Fig. 3: Demonstrates an example of a non-refrigerated breast case. The tumor was strongly positive for estrogen 1. Time out of body receptor (similarly to core biopsy) at 0.5 h of delayed fixation (a) but demonstrated significant reduction at 3 h (b), 2. Time in Radiology 24 h (c), and 48 h (d). All photomicrographs were taken at 200X. 3. Time in formalin
PATHASSIST.ORG Page 9 4. Time specimen is prepped 5. Time specimen is grossed 6. Start of processor 7. Duration of fixation 6-72 hours
If changes cannot be added to the requisition forms due to IT or SOP limitations, consider including the time the specimen is removed from the body as part of each specimen source. For example, the specimen site can be listed as “Left Breast at 1:00, placed in formalin at 9:30 am”. This update would be preceded by the education of staff handling the breast specimen before arrival to the Pathology Lab. Proactive communication will enhance the importance of Cold Ischemic Time. The guidance on Cold Ischemic Time provided by the Pathologists’ Assistant includes, but is not limited to, OR Staff, Surgeons, Fig. 5: US incidence of breast cancer subtypes by joint hormone receptor (HR) and HER2 status. Radiology, Lab Staff, Courier Staff, Remote Sites, and the Multi-Disciplinary Team. increased error rates that result from breast Aurora Diagnostics that will allow for future Use the Director of Surgical Services and surgeries scheduled on Fridays, weekends, cooperation and problem-solving, benefiting Tumor Board as a platform to disseminate and after normal hours. Beyond the OR, our individual pathology groups. n information to the OR staff, Surgeons, lab staff and couriers can be trained to Peer Review Notes: Manuscript received January and Pathologists. Educational meetings identify errors and reduce processing 2018. Reviewed February 2018. Accepted for should continue at six-month intervals to time. Lab personnel staff can be trained to publication April 2018. accommodate staff rotations and changes. double check specimen container size and Also, consider adding a Quality Assurance formalin volume before transporting breast Aurora Acknowledgements: (QA) flag to identify any areas for practice specimens. For courier staff, emphasize improvement and patient safety. For We thank the following colleagues for direct editing, the importance of reducing transport time. supervision, and valued insights, whose expertise greatly example, the most logical flag would be There should be a consistent, available assisted with the collaboration of this research article: added to the Pathology LIS to aggregate Jesse Hicks MBA, PA(ASCP)CM, Scott Whittington, MHS, means of communication between the PA(ASCP)CM, Nicole Flanigan, PA, Rachelle Kanas, data for monthly, yearly, and long-term remote surgical site and the pathology lab. PA(ASCP)CM, Katrina Fryar, PA(ASCP)CM, Walliang Rosene, QA data reports. Other flags may include PA(ASCP)CM. stickers added to requisition forms, etc. Conclusion: Special thank you to:
Joshua Kish, MD, (FCAP), (FASCP), Jennifer Kish, MHS, Remote sites can be a challenge when In creating this guideline to support the PA(ASCP)CM, Mike Walsh, M.D., and Anne Horstmann, PhD. handling breast specimens in a universal Pathology Executive Council (PEC) References: manner, especially sites that are not staffed Breast Biopsy General Recommendation with PAs or Pathologists. Figures 1 & 2: David G. Hicks, MD. University of Rochester, (ADXPB-31), the PA-WG has been able Surgical Pathology Unit. to identify challenges and hindrances to Methods to ensure the proper Figure 3: Isil Z Yildiz-Aktas, David J Dabbs, and Rohit ensuring accurate biomarker outcomes Bhargava: The effect of cold ischemic time on the implementation of breast specimen relating to proper specimen collection, immunohistochemical evaluation of estrogen receptor, handling include requesting specialized progesterone receptor, and HER2 expression in invasive handling, grossing, and processing. Various breast carcinoma. Modern Pathology (2012), 1–8. personnel, specimen inking by the surgeon, institutional and workplace methodologies and designated responsible OR team Figure 4: James L. Barry PA(ASCP)CM. Hallmark Health have provided beneficial solutions that System, Inc. Department of Pathology, Hallmark Pathology members. For days when a breast case is have been shared amongst the PA-WG. Inc. scheduled at a remote site, a Pathologist An added bonus of forming this PA-WG for Figure 5: US Incidence of Breast Cancer Subtypes Defined or Pathologists’ Assistant can be requested this breast specimen handling best practice by Joint Hormone Receptor and HER2 Status. Howlader, N to staff the lab, ensuring copacetic guideline is the creation of a connected et al. J Natl Cancer Inst. 2014: Vol. 106, Issue 5; 1-8. management of the breast procedure. network of Pathologists’ Assistants within Providing sterile ink for surgeons to orient and slice breast specimens immediately after removal from the patient is an Win a Travel Grant to Attend an Upcoming Meeting! alternative to arranging a PA on location. In addition, designating a surgical team Fellows Apply Between Oct. 1, 2018 - Jan. 1, 2019 staff member to be responsible for Cold Ischemia Time documentation allows Submit a manuscript in one of two categories: for continual accurate documentation. Another option for ensuring correct Cold - Neoplastic Cases Ischemia Time is to treat every breast case - Non-Neoplastic Cases as an Intraoperative Consultation with a Pathologist to guarantee every breast The winning submission in each category will receive a travel grant valued at up specimen is inked, sliced, and exposed to $1,800 to attend an upcoming Fall Conference or Spring Meeting. to formalin within the recommended one- Visit pathassist.org/scholarships for more information, hour window. Pathologists and PAs can including rules and regulations to submit your manuscript, plus FAQs and past winners. make the process of breast handling more efficient by educating the surgeons on the
Page 10 THE CUTTING EDGE THE JOURNAL OF THE AAPA 44th Annual Continuing Education Conference Recap New Orleans, LA September 23 - 28, 2018 Heather Manternach, PA(ASCP)CM Fall Conference Chair
Another great fall conference is in the all who participated and to Lauren Polli, our registering to be a donor. If you didn’t have books! As I say goodbye to New Orleans great master of ceremonies! a chance to register while you were in New and the 44th Annual Continuing Education Orleans, or if you weren’t able to attend but Conference, I look back and think how On Tuesday, we had over 30 attendees still want to sign up, go to Join.BetheMatch. fast the week went and realize that this dine together with Dinner with Strangers. org/aapa to begin the process. Signing up conference continues to amaze me. Where I feel we need to change the name to is simple and easy. After the fundraising, else can you find 19 lectures, 4 poster Dinner with Future Friends – it’s always a and with the generous match up to $1000 by sessions, and 3 discussion groups all great opportunity to get to know new PAs. the AAPA Board of Trustees, we raised over dedicated to PA-specific education? The Tuesday we also had the Golf Classic. $2,300 for Be the Match®. Thank you to all speakers were top-notch and presented After a short down pour, the golfers were who participated and supported the cause. timely and pertinent information for at it again – having fun and enjoying New Each year we will pair with an organization pathologists’ assistants. We gained tools Orleans. All skill levels are welcome at the to help give back as an association. If you and information that we can use daily. The golf classic – no experience required! have any organizations that you would like poster sessions provided great insight to suggest, please let me know. We would into ongoing research, case studies and The Happy Hour Fun Run/Walk took place love to support an organization that is near topics that we see throughout our PA on Thursday afternoon. Thank you to all and dear to one of our members. career. The discussion groups continued the dedicated runners and walkers who Thank you for helping us “Get Jazzed in our conversations focused around relevant braved the rain. It was so great to see so New Orleans”. I hope you were able to topics including management, resident many people--runners and nonrunners--at meet new PAs and reconnect with friends, education, and grossing tips and AJCC the happy hour. Please plan on joining us share ideas with colleagues, and to learn updates. It seems like an hour just wasn’t next year – it’s a great time! from our great speakers. We are continually enough to cover all the discussions, so look looking for ways to improve the conference for expanded discussion groups next year. and to provide our members with the best PA-specific conference. We want to make I want to acknowledge and give kudos this your preferred conference! to our fellow PAs who lectured at the fall conference: Brad Skilton, Sarah Garner, See you next year at the Hyatt Regency Alejandra Meza, Andrew McLoughlin, and for the 45th Annual Continuing Education Steve Taylor. Thank you for sharing your Conference in the windy city…Chicago! n expertise with us. I learned so much from our fellow PAs, and I encourage all PAs to Heather Manternach, PA(ASCP)CM works at consider presenting a lecture at a future Wisconsin Diagnostic Laboratories as a PA spring meeting or fall conference. in Milwaukee, WI. She has been a member For our social cause this year, we worked of AAPA since 1998, and has served as the If you were not able to make it to the fall with Be the Match®. Not only did we support AAPA Conference Committee Food and conference, I highly recommend listening to Be the Match® financially through the T-shirt Beverage Subcommittee Chair from 2000- the lecture given by TJ Figueroa. His talk sales, mask donations, and raffle tickets, 2013, and as the Fall Conference Chair was truly inspirational and reinforces the we also were able to support them by since 2014. high level of work we perform in the name of patient care. We should never forget that all specimens are connected to a patient.
Not only did we have a week packed full of great lectures, educational poster sessions, and pertinent discussion groups, but don’t forget the fun, networking activities. The conference kicked off on Sunday evening with the Masquerade Welcome Party. We were able to see new and old friends, classmates, and colleagues. In addition to the great New Orleans-themed food, we were treated to a masquerade contest. The Mark your calendars! AAPA 45th Annual Continuing Education Conference contestants truly outdid themselves with will be held August 25 - 30, 2019 at the Hyatt Regency in Chicago, IL. their masks and costumes. Thank you to Information will soon be available on the AAPA website.
PATHASSIST.ORG Page 11 Conference t-shirts were sold to support Be The Match®, this year’s social cause AAPA 44th Annual Continuing Education Conference Photos New Orleans, LA, September 23 - 28, 2018
Welcome Party: Connecting with old friends and new colleagues
Ansley Bradley, PA(ASCP)CM winner of the decorated mask contest
A special thank you to Steve Suvalsky, PA(ASCP)CM and Michelle Johnson, PA(ASCP)CM for taking the conference photos.
Page 12 THE CUTTING EDGE THE JOURNAL OF THE AAPA 2018 Lifetime Achievement Award Presented to Laurence G. Marquis, MHS, PA(ASCP)CM With gratitude and deep appreciation for your many years of outstanding service and unwavering commitment to our association and our profession. Leading always by example, you shared with all of us the values of honor, integrity, and friendship.
1981-Quinnipiac University program grad 1981-present, AAPA Fellow Member
1995-present, Golf Tournament 2000-2002, Conference Chair 2003-2004, President-Elect 2005-2006, President 2007-2013, Board of Trustees Member 2014-present, Nominations Subcommittee Larry Marquis and Tisa Lawless, MHS, Additional roles included contract PA(ASCP)CM in “jail” at the 2017 Larry Marquis, PA(ASCP)CM Lifetime negotiations, policy & procedure review, Fall CE Conference raising money for Achievement Award winner conference site inspector Living Beyond Breast Cancer.
2018 Board of Trustee’s Award Presented to: Brittin Cavanagh, PA(ASCP)CM & N. Dominic Alessio, PA(ASCP)CM
Thank you to Brittin Cavanagh and Dominic Alessio for their dedication and commitment to our association as the founding Student Committee leaders! Recognizing that students represent the future of our organization, Brittin and Dominic have encouraged students to value membership and inspire them to actively participate in our association. Congratulations!
Brittin and Dominic are recent graduates and have been instrumental in developing, and were the driving force, behind the creation of the AAPA Student Committee. They have both moved through the progression of student officer, graduate CM officer, and now have rotated off the Brittin Cavanagh, PA(ASCP) , (center right) who recently relocated to New Zealand, and Dominic CM committee. Alessio, PA(ASCP) , (center left) who received one of the most recent Fellow travel grants, were both in attendance at the Fall Conference and received their awards in person presented by BOT Chair John Eckman, MHS, PA(ASCP)CM, (far left) and Membership Committee Chair, Roseann Vitale, Currently Brittin oversees the Student PA(ASCP)CM, (far right). Committee under the umbrella of Membership, and Dominic is the Membership Committee Vice Chair.
PATHASSIST.ORG Page 13 Delegates and students who participated in the Student Roundtable. Students & Poster Sessions
Poster Session, Shane Ferraro, PA(ASCP)CM. Poster Session, Lou Mendes-Kramer, Poster Session, Cathleen Paschal, student PA(ASCP)CM, Wayne State program director, from Rosalind Franklin University. with presenter WSU student Jamie Maurice. Lectures & Workshops
Heather Manternach, PA(ASCP)CM with keynote Chevanne Scordinsky, PA(ASCP)CM with Speaker Jerad M. Gardner, MD. speaker Steven Kroft, MD. speaker Andrew McLoughlin, PA(ASCP)CM.
Keynote speaker David Grignon, MD with Speaker Fred Rodriguez, MD. Conference attendees waiting for the lecture to Connie Thorpe, PA(ASCP)CM. begin.
Page 14 THE CUTTING EDGE THE JOURNAL OF THE AAPA Heather Manternach, PA(ASCP)CM with a Faxitron representative. Paul Degennaro, PA(ASCP)CM with Kubtec representatives. Thank you Platinum Sponsors: Faxitron, Kubtec, Merrick & Mopec
Larry Marquis, PA(ASCP)CM with Merrick representatives. Mopec representative demonstrates new products during Exhibitors Happy Hour. Fun Run/Walk
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AAPA 8th Annual Spring Meeting Phoenix, AZ April 8 - 10, 2019
Becky Stankowski, PA(ASCP)CM Spring Meeting Chair
Consider joining us for the 8th Annual n Colorectal Carcinomas: Updates and Spring Meeting, April 8 - April 10, 2019, Practical Approach to Common at the Embassy Suites by Hilton Phoenix Dilemmas Scottsdale. Registration includes 15 n The Renal Transplant Biopsy After lectures, breakfast all three days, lunch Hours on Monday and Tuesday, and the Monday evening reception. This smaller meeting is The Embassy Suites by Hilton Phoenix limited to 125 attendees and offers great Scottsdale is located on the edge of networking opportunities. The condensed Stonecreek Golf Club, with beautiful views format of the Spring Meeting is a wonderful of the surrounding mountains. Spend option for those who may like to attend the time on the driving range, putting green, The AAPA larger Fall Conference but are not able jogging track, or in the hotel’s outdoor pool. Macroscopic Examination Take the hotel’s complimentary shuttle to due to budgeting or scheduling matters. Guidelines: As always, Embassy Suites offers a locations within a one-mile radius, including Utilization of the complimentary full, hot breakfast and nightly Paradise Valley Mall, Picture Show movie reception, including snacks and drinks for theater, and Theatre Artists Studio (live CAP Cancer Protocols at all hotel guests, making it a great value for theater). Sixty dining options are available the Surgical attendees who travel with their family. within 1.5 miles of the hotel, ranging from Gross Bench chain favorites like In-N-Out Burger and (Grossing Guidelines), The lecture topics include medical ethics, Z’Tejas Southwestern Grill to local eateries Second Edition macroscopic examination and staging of like the Salty Sow, OHSO Brewery, The cancer cases, and a case study told from Covenant, and Oink Cafe. If you have free the perspective of a Pathologists’ Assistant time to explore the nearby mountains and who was also the patient. Here is a sample desert, many tour companies pick up right of some of the other great lectures planned at the Embassy Suites. If you prefer renting for this meeting: a car for your sightseeing, the hotel offers free parking in their lot. n Current Diagnosis and Staging of Lung Cancer We hope to see you at the Spring Meeting. n Pathology of Heart and Lung Space is limited, so register early. n Transplantation CM n The Handling of Nephrectomy Becky Stankowski, PA(ASCP) works as Specimens: Tips, Tricks, and Future a PA at Wisconsin Diagnostic Laboratories Directions in Milwaukee, WI. She has been a member n Pediatric Lymph Node Pathology of AAPA since 2009, and has served n Common Pediatric Brain Tumors: as a member of the AAPA Conference A resource for the Committee from 2010-2013, and as the A Primer macroscopic n Gestational Hypertension followed by Spring Conference Chair since 2014. Pulmonary Hypertension in Infant - examination of A Case Study cancer specimens. Board of Trustees 2019-2021 Election Results Produced and maintained
John, Charlene and Roseann will by pathologists’ begin their term effective January assistants to support 1, 2019, with this being John’s second consecutive 3-year term. laboratory personnel. Nominations for the next round of Board seats opening (2020-2022) will be accepted during the month John Eckman Charlene Gettings Roseann Vitale, of March 2019. pathassist.org MHS, PA(ASCP)CM MS, PA(ASCP)CM PA(ASCP)CM
PATHASSIST.ORG Page 17 Board of Trustees Chair’s Report
John Eckman, MHS, PA(ASCP)CM [email protected]
The Board of Trustees (BOT) includes nine pleased to have seen a number of items have meaningful interactions with larger board members plus six adjuncts to the completed, including revision of our organizations. The initial work on the board, which include a legislative adjunct profession’s Scope of Practice; release of Grossing Guidelines led the AAPA to become and representatives to the APATP, the the Inspection Readiness Kit; completion of a member organization of the American ASCP BOC, NAACLS, the AJCC, and the the 2nd edition of the Grossing Guidelines; Joint Committee on Cancer (AJCC). Jon Commission on Cancer. Three members the ASCP’s acceptance of our proposal to Wagner, Director of Professional of the BOT make up the Executive add continuing education credits related Outreach, serves as our representative. Council, comprised of the BOT Chair, Vice to cancer care, increasing the number of AJCC membership is comprised of many Chair/Secretary and the Chief Financial credits required for credential maintenance distinguished cancer care organizations. Officer. Together, we all work very closely by 15 advanced AP credits and one ethics The AAPA is a small organization among with Executive Director Michelle Sok to credit for each three year period; and many large and prestigious organizations. implement and develop the Association’s submission of a formal response to the CMS Jon has recruited expert speakers from the mission and vision. regarding the change in rules that will allow AJCC for our conferences, and they come nurses to perform high complexity testing in away better informed about who we are All of the Adjunct members are appointed the laboratory along with a template for our and what we do, and are impressed with by the BOT for one-year terms. Each BOT members to submit a response. (The AAPA our members, the association, and our member position is elected by a vote of was the only organization that took a strong profession. the membership for a three-year term. stance in support of pathologists’ assistants Board member terms are limited to two regarding this rule change.) Connie Thorpe, At the AJCC meetings Jon attends, he is consecutive three-year terms. Director of Professional Development, was able to build personal relationships with instrumental in accomplishing many of high level members of the AJCC and the Three members have been elected to the these items. The board so appreciates all CAP. While some of these interactions BOT for the 2019-2021 term; they are new that Connie does. consist of discussing our profession, our board members Charlene Gettings and qualifications, and how we contribute to Roseann Vitale, along with myself. I am This year the BOT made a new effort to patient care in pathology; other interactions grateful to have been elected to serve my engage the membership by holding quarterly include aligning the AAPA and its members second term on the BOT, and appreciate town hall meetings. We sought to bring with opportunities to collaborate on a larger the confidence that the board has in me back an element of the business meeting scale. Jon recently met with Dr. Carolyn to serve as BOT Chair. I look forward to by having a presentation and discussion Compton, Precision Core Editorial Chair, welcoming two new board members, and with members about what endeavors the AJCC. Dr. Compton was a speaker at our working to guide the BOT as we continue board was working on or considering. conference a couple years ago and is very our work in directing and providing oversight These town hall meetings are held via supportive of pathologists’ assistants. Dr. to the association’s committees. webinar and also live at our spring meeting Compton is organizing a national “precision and fall conference. Topics have included: core pre-analytic molecular summit” and The BOT attended our annual working 1. Limited International membership, 2. The is attempting to bring together all of those weekend meetings with Michelle Sok in upcoming increase in credits required for the who are “players” in the pre-analytic phase Minneapolis, Minnesota in November. This ASCP Credential Maintenance Program, 3. of specimen handling and processing. She is an intensive three-day meeting where the Licensure of Pathologists’ Assistants, and is including CAP and other physician and board reviews the activity of the association 4. Advocacy: How the AAPA advocates hospital associations in the meeting. The over the past year, and lays out our strategic for our members and how you can meeting is to occur in Washington DC plan for the next one-, three-, and five-year advocate for yourself and the profession. to facilitate CDC, NIH, CMS, and other periods. In doing so, the BOT considers If you missed our Town Hall meetings, a governmental agencies involvement. The the AAPA mission, vision, and core recording of each webinar is available on agenda she is crafting revolves around the values of quality patient care, education, the AAPA website www.pathassist.org . appropriate management of specimens to advocacy, and collaboration. Part of the The BOT also uses member feedback ensure validation of molecular studies. She board’s strategic planning includes review from our surveys to select topics for each sees the AAPA and pathologists’ assistants of member surveys, and using the most Town Hall meeting. The preparation to as major contributors in the discussion. common issues and concerns raised by present each topic and the discussion the membership to guide our plan. While during the town hall are very valuable in Jon was also able to speak with Dr. being able to accomplish all within the guiding the board as we move forward. Samantha Spencer, Director of Structured strategic plan is challenging, this past Reporting at CAP, along with others. He year has been very productive. A sound The Board of Trustees is very excited about reports that the CAP Cancer Committee strategic plan is essential, but executing what is happening with our professional recently asked that the AAPA add a synoptic such a plan is what counts. The BOT is outreach as it has been a long process to section of grossing elements for each tumor
Page 18 THE CUTTING EDGE THE JOURNAL OF THE AAPA group in our Grossing Guidelines that off in expanding our reach and elevating committee chair to the board, serving as could be used similarly to the pathologists’ our profession. Vice Chair, Chair, and CFO. Throughout synoptic checklist. It is very significant that her time on the BOT, Jana reminded us the CAP requested the AAPA to create As we close out 2018, BOT members Jana of the high standards we must maintain something of clinical relevance, and Sovereign and Steve Rath have served as members of the board and as an something that could become a required two consecutive terms and will depart the association. n reporting element in the future. board. We thank them for their time and service. John Eckman is a PA at Penrose Hospital in As a result of our membership in the AJCC, Colorado Springs. He has been a member of the AAPA was invited and encouraged Steve Rath was appointed to the BOT in the AAPA since 1992 and is currently serving to become a member organization of the 2014 to complete the term of another board as the Chair of the Board of Trustees and is Commission on Cancer (CoC) in 2018. member who had stepped down. Steve was the GYN Section Author on the Grossing Erika Paulsen is our representative and then elected to serve a 3-year term from Guidelines. John has served on the BOT new adjunct to the board. The CoC is an 2016-2018. Steve brought his perspective since 2016, and had previously served as the arm of the American College of Surgeons as an experienced PA and as a manager to Website Committee Chair for 10 years. and is the credentialing body for cancer the board, and provided valuable insight as centers across the nation. As Erika begins a BOT member and during his oversight of attending CoC meetings and has the the education and membership committees. opportunity to represent pathologists’ Prior to joining the board, Steve served as 2018 Fall Conference CE assistants and our association, others in the Legislative Committee Chair. the CoC will understand our expertise in Lectures Now Available pathology and our role in cancer care. In Jana Sovereign was elected to serve two the future, PAs may have the opportunity to terms on the BOT spanning 2013-2018. Watch the conference lectures be involved in the process of accreditation Prior to joining the BOT, Jana served as at your own pace. of cancer centers on some level. Conference Committee Chair beginning in 2003. She served a total of 12 years in that The more organizations and high-level role, including a dual role as Conference Passing a CE quiz will be individuals that the AAPA interacts with Committee chair and BOT member for required to earn credit for each and demonstrates the expertise and the 2 years. During this time, Jana attended important role pathologists’ assistants have numerous conference site visits and played recorded lecture. in patient care and cancer care, the more a key role in selecting conference locations. we expand our network of support and In 2007, Jana was the recipient of the CE Store: pathassist.org recognition as a profession. All of this work BOT Award. She brought her thoughtful and these interactions are definitely paying insight and considerable experience as a
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PATHASSIST.ORG Page 19 Breast Cancer years prior. Had the history been available, and when combined with histological the colon specimen may have been grossed comparison of the primary breast tumor, > Continued from page 7 differently. First, guidelines for breast accurate diagnosis was made. Despite reported cases with a change in receptor cancer grossing would have been followed, the rarity of this event, this case as well as status, especially in poorly differentiated including ensuring proper fixation time of the handful of published literature have in cancers that tend to lose the tissue-specific the specimen. Believing the specimen to be common the goal to bring the possibility of gene expression apparent in the primary affected by an inflammatory process rather colon and other gastrointestinal metastases tumor.6 than a tumor, a thorough search for lymph from breast cancer closer to the forefront of nodes was not performed, another change providers’ minds. n The time elapsed between the original that would have been made if the history Peer Review Notes: Manuscript received May breast cancer diagnoses and discovery of or possibility of cancer was known. The 2018. Reviewed July 2018. Accepted for publication gastrointestinal metastasis is also long in specimen may also have been sampled August 2018. this case at 15 years; however, lengthier differently, perhaps by sampling more of time spans have been recorded. Metastases the grossly unaffected areas, rather than Breast Cancer References: from breast cancer occur within the first five taking the majority of samples from the 1. Ambroggi M, Stroppa EM, Mordenti P, et al. Metastatic years following the diagnosis of early stage cobblestoned portion. Overall, the grossing breast cancer to the gastrointestinal tract: report of five disease about 75% of the time.7 In the case procedure did not affect the outcome of this cases and review of the literature. Int J Breast Cancer. 2012;2012:439023. doi: 10.1155/2012/439023. of gastrointestinal metastasis, analyses of case, as it was still able to be diagnosed published reports have discovered median properly with no additional sampling 2. Washington K, McDonagh D. Secondary tumors of time intervals between 4-7 years, but required. the gastrointestinal tract: surgical pathologic findings and comparison with autopsy survey. Mod Pathol. 1995;8(4):427- there have been cases of gastrointestinal 433. metastasis reported up to 30 years later.7 In In conclusion, this case brings up two the aforementioned five-year retrospective important points for providers. First is the 3. Borst MJ, Ingold JA. Metastatic patterns of invasive lobular versus invasive ductal carcinoma of the breast. study, the range of time between breast potential for breast cancer to metastasize Surgery. 1993;114(4):637-642. cancer diagnosis and discovery of to the gastrointestinal tract, no matter how metastasis to the gastrointestinal tract was rare it is believed to be, nor the span of time 4. Weisberg A. Metastatic adenocarcinoma of the breast masquerading as Crohn’s disease of the colon. Am J Proctol between 0 (found at initial diagnosis) and since the original diagnosis. In any patient Gastroenterol Colon Rectal Surg. 1982;33(5):10-21. 22 years.1 Unfortunately, the diagnosis of with a history of breast cancer presenting with gastrointestinal lesions discovered 5. Koos L, Field RE. Metastatic carcinoma of breast gastrointestinal metastasis from cancer of simulating Crohn’s disease. Int Surg. 1980;65(4):359-362. any kind is followed by a poor prognosis, surgically or radiographically, the possibility with most patients surviving no more than of metastasis should be considered. 6. Paiva C, Garcia J, Silva C, Araujo A, Araujo A, Santos 2 Second, this case stresses the importance MD. Single jejunum metastasis from breast cancer arising a year. twelve years after the initial treatment. Case Rep Oncol Med. of the pathologists’ assistant to be 2016;2016. http://dx.doi.org/10.1155/2016/8594652. The patient’s previous history of breast provided with patient history so appropriate cancer was not provided to the pathologists’ sections are taken. In the presented case, 7. Wiisanen JM, Kaur JS. Gastrointestinal metastases from breast cancer, a comprehensive review. Breast J. assistant before grossing the specimen, as immunohistochemistry was ordered so the 2015;21(5):572-573. doi:10.1111/tbj.12464. it was diagnosed at a different hospital 15 origin of the colon tumor was discerned, Conduct Your Workspace with the
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Page 20 THE CUTTING EDGE THE JOURNAL OF THE AAPA Gross Photo Unknown
Quiz Case:
41-year-old G1P0 female with no significant medical history and an uncomplicated pregnancy thus far. She presented at her 34-week prenatal check-up with a distended abdomen and associated pain. Ultrasound showed polyhydramnios and a 6.4 cm hypoechoic mass located near the umbilical cord insertion site.
Quiz:
1. This is the most common tumor of the placenta. A. Hematoma B. Chorangioma C. Amnion nodosum D. Choriocarcinoma
2. When grossing placentas, it is important to measure and record: A. The number of any lesions that are present B. The sizes of any lesions that are present C. The approximate percentage of the total cut surface a lesion(s) occupies/occupy for clinical significance D. All of the above
3. True or False: Chorangioma has malignant potential.
Answers found on page 27
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PATHASSIST.ORG Page 21 npictured left to right AAPA Town Hall Meeting - Sept. 24 Recap
Inspection Readiness Kit Available Now
Newly Updated!
The AAPA held its fourth Town Hall Multiple examples were provided of Meeting Live! at the New Orleans Fall AAPA fellow members serving as Conference on September 24, 2018. adjuncts or committee members for other Members who were not in attendance associations including NAACLS, ASCP, were invited to call in via GoToWebinar. CAP, AJCC, and the CoC. Lauren Polli (center) was the onsite moderator, and the panel of presenters, When asked what the association has on pictured left to right, consisted of Board the horizon for its advocacy efforts, Jana of Trustees (BOT) Adjunct - ASCP highlighted some future projects including BOC Mike Sovocool, BOT CFO Jana a task force to examine the possibility Sovereign, BOT Chair John Eckman, of PAs expanding into forensics, the BOT Adjunct - APATP Mary Dydo, development of a credentialing kit, MarComm Committee Chair Charlene global humanitarian opportunities, and Gettings, and BOT Adjunct - CoC Erika professional promotional videos. Next, Paulsen. BOT member and Technical the panel talked about how to advocate Support Ryan Schniederjan is not for yourself as a PA including community pictured. The topic for the final Town Hall outreach, speaking opportunities, and of 2018 was Advocacy: How the AAPA promotion of Pathologists’ Assistant advocates for our members and how Day. The panel gave examples of Has your laboratory director YOU can advocate for yourself. tools available for advocacy and ways members could get more involved in requested checklists for advocacy. macroscopic specimen The presentation began with John examination supervision pointing out that advocacy is one of the Before opening the floor to questions, AAPA’s core values and then reviewing the Town Hall wrapped up with panel templates or competency the historical timeline of advocacy members giving personal examples assessment for milestones within the association’s of ways they have advocated for pathologists’ assistants? history. Some of the association’s themselves, given students the tools to most recent accomplishments were advocate for themselves, and promoted highlighted including the revised Scope the profession. We would love to hear of Practice, the Grossing Guidelines, the from you on this subject! Please go to The AAPA has Inspection Readiness Kit, and the AAPA pathassist.org to replay the recording, PR exhibit booth travels. In addition, and continue the conversation on the a solution! the benefits of advocacy in the area of new Advocacy forum on our website. professional outreach were discussed. Your input is very important to the AAPA. n Designed to assist in achieving a successful CAP Inspection Upcoming Town Hall Meeting Dates by providing templates and useful tools for To be held in conjunction with the pathologists’ assistant 2019 Spring Meeting and Fall Conference personnel management.
Join while attending or remotely through GoToWebinar. Details will follow closer to the meeting date. pathassist.org
Page 22 THE CUTTING EDGE THE JOURNAL OF THE AAPA Legislative Update
Elizabeth “Liz” Rizzo, PA(ASCP)CM Board of Trustees Legislative Adjunct
In my last article for The Cutting Edge, job and were grandfathered in and eligible The most important take home message I talked about regulatory agencies which to sit for the ASCP certification exam is this: Please notify the AAPA if you hear govern laboratory medicine, specifically prior to 2011). of any state licensure talk in your state. anatomic pathology, and how they impact Please do not move forward on your own 2. Passage of the ASCP certification exam. our practice as PAs. This article will address by contacting your representatives prior to an equally complex issue for our profession, 3. Participation in the credential formulating a clear plan with the AAPA and i.e. licensing. In June 2018, the AAPA hosted maintenance program. AAPA leadership. If the pathology group a Town Hall on this topic for our members. or facility you work in has questioned your Much of the information presented in that Although the question of a national license credentials because you don’t hold a Town Hall will be recapped here. has been asked, traditionally licensing is license, please let the AAPA know of this a state responsibility. Some providers and so we can address each situation as it First, some definitions of commonly nurses share reciprocity of licensure across arises. n used terms and concepts, specifically state lines, but this is an agreement between certification, credentialing, and licensure. the states and not profession specific. Liz Rizzo is a PA at Dartmouth-Hitchcock Medical Center. She previously served as Certification is a formal process that Currently, West Virginia, Nevada, and AAPA Vice President 1995-1996. Liz has validates a person’s qualifications in a field. New York require licensure for PAs. These presented safety lectures in the past and has This voluntary process assures people licenses vary in cost ($25-$200 annually) interests in Lean/Six Sigma processes. meet a minimum educational standard, and specificity to our profession. Licensure usually pass a certification exam, and is also being discussed in Louisiana and require ongoing continuing education for California as well. each certification cycle. The ASCP is our certifying agency. Congratulations to the Credentialing is performed by a third party (your hospital, employer, laboratory) 2018 Journal Award Winners! with authoritative power and is proof of qualification and competency. This non- government authority verifies a baseline of Editor in Chief of The Cutting Edge, Beth Felicelli, and Assistant Editor competency in a given field. We often see Minda Koval have selected the top three journal articles to receive cash prizes. All this with physicians as well as mid-level articles published in The Cutting Edge September 1, 2017 to August 31, 2018 are providers. eligible.
Licensure is a state’s grant of legal authority to practice a profession within a The winning articles are as follows: scope of practice. The state defines the scope of practice and passing a certification n 1st place with a $1,000 prize: examination is generally required. Clear Cell Renal Cell Carcinoma with Solitary Synchronous Metastasis to the Contralateral Adrenal Gland, Lori Stewart, Issue 1, 2018. While certification and credentialing both address qualifications, it is licensure that n 2nd place with a $750 prize: is the “law-of-the-land” and clearly defines New Insight into Endometrioid Borderline Ovarian Tumor, a profession, including who is allowed to Bing Miller, PA(ASCP)CM, Issue 1, 2018. perform the tasks in the scope of practice. n 3rd place with a $500 prize: The AAPA supports state licensure specific A General Overview of Tissue Submission Guidelines for Zika Virus Testing, to pathologists’ assistants when legislation Kimberly Green, MHS, PA(ASCP)CM, Issue 3, 2017. is created that is based on our scope of practice, is not unnecessarily burdensome Would you like to win cash for writing an article? Members are highly encouraged to to pathologists’ assistants or their employers, and includes: submit articles to The Cutting Edge, or better yet, join our newly formed staff writers team! Writing an article is a great way to get involved, get published, and earn 5 CMP 1. Graduation from a NAACLS accredited points for authoring a journal article for a peer-reviewed publication. training program (or were trained on-the-
PATHASSIST.ORG Page 23 Book Review Human Errors A Panorama of Our Glitches, From Pointless Bones To Broken Genes Written by Nathan H. Lents Review by Chet Sloski, PA(ASCP)CM
Molded by millions of years of evolution, as the RLN exit the spinal cord a little below you might think the human body is a fine- the shoulder blade. The left RLN then loops tuned machine; a Lamborghini, if you will. under the aorta and travels back up to the But in his new book, Human Errors, a neck, where it reaches the larynx. Lents Panorama of our Glitches, from Pointless tells us that the RLN is more than three Bones to Broken Genes, author Nathan times longer than it has to be. Is there a H. Lents informs us that our bodies are functional reason for this circuitous route? the leg bones to help with the strain. The a clumsy hodgepodge of adaptations No. In fact, the superior laryngeal nerve that consequence was that human legs became and maladaptations. Your body is not a also innervates the larynx, travels the exact straightened so that the bones, rather than Lamborghini; it’s a 1970 Ford Fairlane. route that we would predict. the muscles, could bear most of the impact.
Lents puts our errors or flaws into three So why does the RLN travel this long road? The straight-leg arrangement works fine for categories. The first category deals with The answer according to Lents is in our routine walking and running. But for those aspects of our design that evolved in an evolutionary history. This nerve originated sudden shifts in direction or momentum, the ecosystem different from the present one. in ancient fish, and all modern vertebrates knees must bear the force of this intense An example would be our tendency to easily have it. In fish, the nerve connects the strain. Sometimes the ACL is not strong gain weight and our frustration at losing it. brain to the gills, which were the precursor enough to hold the leg bones together as This setup would have made sense in the of the larynx. In fish, the nerve makes they twist or pull away from each other, Pleistocene savannas of Central Africa the short trip from the spinal cord to the and the ACL tears. This is a problem for where food could be scarce. But today gills in a predictable route. Along the athletes, as anyone who plays fantasy it leads to what Lents calls mismatch way, however, it weaves through some of football knows. diseases; obesity, atherosclerosis, and type the major vessels that exit the fish heart, 2 diabetes. the equivalent of the branching aortas of In the chapter titled, Pointless Bones and mammals. During the course of vertebrate Other Anatomical Errors, Lents says that The second category consists of flaws of evolution, the heart began to move farther humans have way too many bones. Sure, incomplete adaptation. An example would back as the body form took on a distinct we have examples of superbly designed be the human knee which is the product of chest and neck. From fish to amphibians joints in our bodies; the shoulder and hip a redesign that took place as our ancestors to reptiles to mammals, the heart inched joints for example. But not so the wrist and shifted form a quadrupedal posture to farther and farther away from the brain. The ankle. There are eight wrist bones that Lents bipedal terrestrial posture. RLN should not have been affected by the says look like a pile of rocks. They don’t do changing position of the heart except for the anything individually and the flexibility of The third category includes those human fact that it was intertwined with the vessels. the wrist joint is restricted by them. The defects that are due to nothing more than The RLN got stuck and was forced to grow ankle contains seven bones, most of them the limits of evolution; meaning that our into a large loop structure in order to travel pointless. The bones do not move relative bodies can only advance through the tiniest from the brain to the neck. The result is to one another and they would function changes, which occur randomly and rarely. that the RLN forms a long, unnecessary better as a single, fused structure. There loop in the neck and upper chest. And would also be less of a chance of a sprain. Now, for some examples of our all tetrapod vertebrates are stuck with No engineer would design the wrist and maladaptations. Take the recurrent the same anatomical arrangement. One ankle in such a haphazard way. laryngeal nerve or RLN. The axons found in wonders what the length of the RLN of, say, the RLN originate near the top of the brain an ostrich would be. (Answer: a meter.) In the chapter titled, Our Needy Diet, Lents and connect to the muscles of the larynx. asks why humans have such a fastidious You would think that axons that commence On to the knee. The ACL is vulnerable to diet compared with other mammals. in the brain and end in the upper throat tearing in humans because our upright, Vitamins A, B, C, D as well as nine of the would travel a short distance: through bipedal posture forces it to bear more strain amino acids are essentials that we must the spinal cord, into the throat, and to the than it is designed to. In quadrupeds, the include in our diets. So how come cows can larynx. The whole thing could be just a few strain of running and jumping is spread survive on…grass? How about dogs? Most centimeters long. among four limbs, and the limb muscles dog food is nothing more than meat and absorb the most of it. But once our rice. The answer is that our human bodies But the axons of the RLN are packaged ancestors transitioned to bipedalism, the fail to make many of the things that other with the vagus nerve. It travels down the strain was spread over two legs instead animals do. More specifically: our bodies spinal cord all the way to the upper chest. of four. This was too much for the muscles have lost the ability to make many of the From there, the sub-bundle of axons known by themselves, so our bodies drafted things that other animals do.
Page 24 THE CUTTING EDGE THE JOURNAL OF THE AAPA Take one example: scurvy. Vitamin C is are born before they are ready. In a sense, essential, meaning we must get it from we are all born premature. our diets. Lack of Vitamin C causes scurvy AAPA Calendar which can be fatal. Yet dogs don’t need to And thanks to the Discovery Channel, we December 3 eat foods rich in Vitamin C. Turns out these all know that newborn mammals such as n CE Article Release animals make their own. Nearly all animals cows, giraffes, and horses hit the ground make their own Vitamin C, usually in their running—literally. Humans, however, need December 10 livers. Humans and other primates are much more time before they are self- n Spring Meeting Registration Opens nearly alone in the need for dietary Vitamin sufficient. (If you are a parent, you know C. According to Lents, in our evolutionary that age eighteen might be a little too December 28 past, human livers lost their ability to make optimistic.) n Annual CE Award Certificate Vitamin C. Submission Deadline So, in the 21st century, is evolution through January 1, 2019 Interestingly, humans still have all the natural selection still shaping us? Some n Journal Submission Deadline necessary genes for Vitamin C synthesis, scientists think that humans have escaped n but one gene mutated and became the forces of evolution. There may be some Fellow Conference Travel Grant nonfunctional. The gene, known as GULO, truth to that, at least compared to distant Deadline past generations. Today there is less codes for an enzyme that is responsible in January 2 the manufacture of Vitamin C. Sometime physical competition for food and mates. n CE Article Release in our evolutionary history there was a Medical advances let the sick survive to mutation in GULO that spread through the and beyond reproductive age, which is the January 15 population. Our ancestors could no longer only age evolution is interested in. Evolution n CE Article Release produce their own Vitamin C. This raises only “cares” that we live until we can pass the question: why was the population not down our genes. January 31 killed off due to scurvy? n Membership Renewal Due Lents says that while natural selection may Lents has a theory. Perhaps when this not be shaping us anymore, evolution is still February 1 mutation spread, our ancient forefathers, very much at work. Evolution simply refers n CE Article Release by chance, had enough Vitamin C in their to any genetic change in a species over n Membership Renewal Late diets. There must have been plenty of time. Natural selection, the phenomenon Fee Begins citrus fruits to eat. If so, there would have that picks winner and loser through their n Student General Educational been no consequences for losing the ability survival and reproduction, is just one way Scholarship Opens to produce your own Vitamin C. Scurvy that a species can evolve. There are other simply was not an issue. A version of this evolutionary forces. For example, if some March 1 Vitamin C hypothesis can, of course, be specific group of individuals reproduces n CE Article Release extended to the other essential vitamins more than other groups, that group will n BOT Nominations Open and micronutrients we need in today’s diet. contribute more to the gene pool of the next n Membership Suspension for generation. We know that this is happening Non-Renewals In the chapter titled, Homo sterilis, Lents tells because some groups are indeed n Fellow Conference Travel us why human reproduction is so inefficient. reproducing more than others. Birthrates Grant Opens We have flaws throughout almost the entire are low in developed countries as well as n Student Non-Delegate reproductive process, from the production in people with higher socioeconomic status Conference Travel Grant Opens of sperm and eggs to the survival of our with ready access to birth control. Those children. Many other mammals are better with a lower socioeconomic status tend to March 18-20 at reproduction and produce more offspring leave more offspring than do richer more n Exhibit Booth at USCAP, than humans do; think of cats. Many educated people. That could be considered National Harbor, MD humans suffer infertility problems and there a form of evolution too. Differential survival was a high infant mortality rate during our is not a major phenomenon, but differential March 31 ancestor’s rein which continues to this reproduction is. n BOT Nominations Due day in third world countries. Conversely, mothers dying in childbirth is unheard of in So, with all our glitches, foibles, and defects, April 1 chimpanzees, bonobos, gorillas, and all of should we be bummed out? I think not. If n CE Article Release you ask me, I think it’s our imperfections our other primate cousins. They seem to April 7-13 that make us perfect. n have perfected childbirth. n National Volunteer Week
Lents tells us that part of why humans are Chet Sloski, PA(ASCP)CM, works as a PA April 8-10 so out of step with other mammals when at North Coast Pathology in Oceanside, n AAPA 8th Annual Spring it comes to childbirth is because human CA. He has been a member of AAPA Meeting, Phoenix, AZ infants are born too early. This is due to our since 1993, and he has been reviewing large craniums and the females’ relatively books for The Cutting Edge since 2001. April 14 narrow hips. The rub is that human gestation n Pathologists’ Assistant Day time is similar to that of chimps and gorillas, even though our brains require more time April 15 and cognitive development in order to reach n CE Article Release their full potential. But the size of the female pelvis limits how large the fetus’s head can April 21-27 grow while in utero. The compromise is that n Lab Week the fetal gestation is cut short and babies
PATHASSIST.ORG Page 25 Member Spotlight
Minda Koval, MHS, PA(ASCP)CM Minda has been a PA for 19 years and works in Deleware
What’s you most memorable case? might help contribute to your work or personal life. Student General At Swedish Medical Center in Seattle, WA, I received what was thought to be a Educational Scholarship What’s your favorite hobby? dermoid cyst. While wading through the specimen looking for teeth or bone, Sorting and/or organizing anything while Apply between February 1 I was surprised to find a fetiform teratoma. watching movies I’ve already seen many, and May 1, 2019 The body was fairly well formed with 4 many times before. symmetrical appendages attached to the body. There was even a head but the facial How did you get into the PA profession? Call for Manuscripts on the features were nondescript. It has been the Happenstance and fate. I discovered Following Topic: only one I’ve ever seen. that my physical therapy major was a What technology will impact the huge mistake while volunteering during way Pathologists’ Assistants What’s your least favorite specimen to the summer. So, between semesters gross? perform their duties? I changed my major to biomed and Dermoid cysts prepared to transfer to a different college A winning paper will provide a for medical school. During a meeting well-researched literature review Where were you born and raised? with an advisor, she asked my thoughts and a discussion on its potential about pathology. Not knowing too much implications to PA practice. Springport, Michigan. It is a small, farming about the field at the time, but interested, village in central Michigan that is ironically she gave me a brief description and then Possible ideas include, but are nowhere near a spring, or a port. During suggested I go to my local hospital and the time that I lived there, the welcome not limited to, the following: shadow in pathology. Thanking her, I left n digital imaging/slide scanning sign read, “Population 701”. for my summer job, clocked into work, and my first customer was a woman in n automatic embedders Where did you go to high school? scrubs with a name badge that read, n surgical tools sensitive to cancer I went to Springport High school with ‘Pathology’. What were the chances? I n gene-specific personalized a graduating class of 55 students. The asked if I could shadow, she said sure, I medicine showed up, she showed me around and I school was partially connected to the n personalized cancer storage middle school (where my father was a thought it was fascinating. She offered me and vaccines teacher) and the elementary school (where a weekend position and I started working my mother still teaches). Some students as a pathology and morgue attendant. The Eligibility: would drive their tractors instead of their first specimen on my first day was a door Author must be a student cars. Yes, I’ve been taken to school by my handle. boyfriend on a tractor. I highly suggest it. member of the AAPA who will be in If you weren’t a PA, what other line of their second year of training as of What was your first job? work would you enjoy? the Fall Conference My first job was at our town library (yes, we I think I would enjoy being a tour guide at The manuscript must be the had a library) filing and sorting books. a museum or historical site, especially if it original work of the author was haunted. I think. n Favorite movie? Scholarship Details: Minda Koval, MHS, PA(ASCP)CM is a 1999 Sneakers, a 1992 computer caper with The winning entry will receive graduate of Quinnipiac College. She has a $2,500 scholarship toward Robert Redford, Dan Aykroyd, and Sidney served the AAPA in various forms including their education. Poitier. It’s a bit dated when they pull out volunteering on the Administrative Committee, the mammoth-sized, mobile phone and the Conference Committee, and as a Visit: work on the 8-bit computer, but it seems Newsletter Staff writer from 2007-2009. Minda like it’s just a matter of time before these currently is a peer-reviewer for submitted pathassist.org/scholarships items become back in style again. CE articles and recently became part of for more information, including the editorial team of The Cutting Edge as rules and regulations to Best advice you ever got? Assistant Editor. She resides with her family submit your manuscript, plus Never underestimate the knowledge of in Newark, DE. FAQs and past winners others. You never know how someone
Page 26 THE CUTTING EDGE THE JOURNAL OF THE AAPA Gross Photo Tutorial
Emily Paull Acheson, MHS, PA(ASCP)CM University of Arkansas for Medical Sciences
Discussion: mitotic activity, with both necrosis and solid areas. These may be fleshy and resemble A chorangioma is a non-neoplastic growth a sarcoma but have no malignant potential. and the most common tumor of the placenta Lesions greater than 4-5 cm, as in this despite having an incidence of 1%. They case, are associated with significant effects are considered a hamartoma-like or on the fetal hemodynamic and circulatory hyperplastic capillary lesion rather than a system leading to clinical complications true neoplasm. They arise from major stem such as polyhydramnios, toxemia, preterm villi and are mostly located on the chorionic labor, hydrops, and IUGR. Common risk plate or at the placental margin. Grossly, factors include increased maternal age, they are solid, congested, and red-brown, hypertension, multiple pregnancies, and resembling a blood clot. They may also living in higher altitudes. Chorangioma in a 41-year-old G1P0 female. have firm white areas indicating infarction. Treatments such as fetal transfusions Microscopically, they are composed of and laser coagulation exist; however, Quiz answers from page 21 numerous dilated vascular channels with interventions are risky with poor prognoses. 1. B. Chorangioma a mixture of endothelial cells, pericytes, The patient was able to carry the baby to and myofibroblastic stromal cells. The rare early term and delivered a healthy baby 2. D. All of the above atypical chorangioma may occur and is without complications via Cesarean at 37 3. False characterized by increased cellularity and weeks. n
AAPA Institutional Members NAACLS Accredited or Serious Applicant PA Training Programs
Drexel University Quinnipiac University University of Toledo College of Medicine Hamden, CT Toledo, OH Philadelphia, PA MHS Degree MSBS Degree MS Degree qu.edu utoledo.edu drexel.edu/medicine
Duke University Rosalind Franklin University of University of Western Ontario Durham, NC Medicine and Science Schulich School of Medicine & MHS Degree Chicago, IL Dentistry pathology.duke.edu MS Degree London, Ontario, Canada rosalindfranklin.edu MCISc Degree Eastern Virginia Medical School * schulich.uwo.ca/pathol/ Norfolk, VA University of Calgary MHS Degree Calgary, Alberta, Canada Wayne State University evms.edu MDPA Degree Eugene Applebaum College of * Serious Applicant ucalgary.ca Pharmacy and Health Sciences Detroit, MI Indiana University MS Degree Indianapolis, IN University of Maryland cphs.wayne.edu MS Degree School of Medicine medicine.iu.edu Baltimore, MD MS Degree West Virginia University Loma Linda University medschool.umaryland.edu School of Medicine Loma Linda, CA Morgantown, WV MHS Degree MHS Degree For more information on these programs, llu.edu select “Become a PA” from pathassist.org medicine.hsc.wvu.edu
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