Laboratory of Pathology - Staff

1. Patient Care
   1. Technical Skills
      The resident will review the cases submitted to the Hematopathology Section of the Laboratory of Pathology. Formulate lists of immunohistochemical stains, and molecular studies if appropriate. Review all data from ancillary studies submitted with the case and present the case to the attending.
      
      
   2. Clinical Consultation
      The resident will provide appropriate consultation to the requesting physicians. Consultation may include providing a diagnosis, discussing the implications of a diagnosis in the management of the patient.
      
      
2. Medical Knowledge
   1. Fund of Medical Knowledge
      The resident will acquire knowledge of morphology and immunophenotype of normal lymph node, spleen, bone marrow and peripheral blood. Learn to recognize some of the more common neoplastic and non-neoplastic disorders of the hematopoietic system and know the immun0phenotype and genotypic characteristics.
      
      
   2. Application of Medical Knowledge in the Practice of Hematopathology
      The resident will learn the clinical aspects of these disorders, apply his/her knowledge of the diagnostic, prognostic and general therapeutic features of common hematopoietic disorders, construct a differential diagnosis and establish a definitive diagnosis.
   3. Practice-based Learning and Improvement

Evidence-Based Practice
The resident will learn to make effective use of conferences, lectures and reading of the medical literature to inform his/her daily practice of hematopathology and to acquire tools to achieve effective differential diagnosis. The resident must evaluate critically the quality of research studies.

Use of Information Technology
The resident will learn to use a variety of information technologies to inform and improve the daily routine of pathology, including electronic search of medicalliterature databases, web-based information resources and other computer-based resources (CD, DVD etc.)

Interpersonal and Communications Skills

Communication Skills
The resident will communicate effectively and courteously with health care professionals, laboratory staff members, administrators, patients and any other individual in the course of his/her practice. These communications will include verbal and written formats. The resident must learn to communicate in a clear, concise and accurate manner. Discuss problem cases and sensitive issues with other clinicians and patients if necessary.

Present with clarity at conferences.

Teamwork

The resident will learn to work as an effective member of the health care team in his/her daily practice. The resident must be responsible, facilitate the tasks of other team members and be cooperative in his/her interactions. (Other team members may include: technologists, transcriptionists, secretaries, other residents, fellows, attending pathologists, clinicians, referring physicians and others).

Professionalism

Courtesy and Collegiality
The resident must learn to treat health care professionals, administrators, patients and others courteously and respectfully. The resident must learn to be collegial in all interactions with other member of the health care team.

Professional Responsibility
The resident must learn to take his/her various professional responsibilities seriously and act accordingly. The resident must learn to be reliable, punctual, to have an ethical behavior and be sensitive to issues of diversity.

System-Based Practice

The Health Care System and the Role of Pathology
The resident must acquire knowledge of practice and health care delivery systems and an awareness of the role of pathology in the larger context of health care system. Learn to utilize basic aspects of resources available in the health system.

General Laboratory Administration

The resident will develop an understanding of the general administrative aspects of pathology practice. The resident will learn to understand and apply the principles of quality control, quality assurance, and continuous quality improvement. The resident will develop a working knowledge of laboratory staffing, laboratory instrumentation, workflow, turnaround time management, safety, customer service, regulatory accreditation, budget and billing practice.

3. Overview

The philosophy and underlying guiding principle of the training program in Hematopathology is to provide broad and in-depth exposure to the subject matter of hematopathology, with an emphasis on clinical correlation, relationships to disease mechanisms, and exposure to investigational opportunities. The resident should become fully grounded in the laboratory techniques, observational and descriptive analysis procedures, and communication skills required to gain the maximum information prior to rendering a diagnosis. Each case or patient under study should be viewed in the context of (1) the individual patient's clinical course, (2) strong personal interactions with the clinicians caring for the patient, and (3) the general relevance to disease pathophysiology and investigational questions.

The Hematopathology rotation is based in the Laboratory of Pathology (LP), National Cancer Institute (NCI). This unit is the sole facility providing laboratory services in anatomic pathology at the National Institutes of Health (NIH) Clinical Center. The patient population of the NIH is diverse, and includes patients with lymphoma, leukemia, multiple myeloma, bone marrow transplantation, autoimmune disorders, primary and secondary immune deficiency disorders, immunotherapy, and gene therapy. The Hematopathology Section also provides consultative services to the extramural community, both nationally and internationally. Each case is evaluated using morphologic, immunophenotypic, and molecular approaches, as indicated by the clinical situation. Each year approximately 1700 cases are received in consultation, with more than 2000 lymphoid lesions evaluated on an annual basis. The resident is fully integrated into the diagnostic service. He/she reviews the case independently, formulates a provisional diagnosis, reviews the case with the staff hematopathologist, reviews and interprets adjunctive special studies, and prepares a final diagnostic report. The service rotation is supplemented by weekly conferences (Hematopathology Journal Club, Molecular Diagnostic Conference, Hematological Malignancies Conference).

The resident has integrated training in molecular diagnostics and in situ hybridization, both of which play a critical role in the evaluation of hematopathology cases. The resident learns the principles of molecular diagnostics, and reviews the primary gels and data from the molecular laboratory service. This information is integrated with other morphological and immunophenotypic data to arrive at a primary diagnosis. The resident prepares and dictates the Molecular Diagnostic Report, which is reviewed with the Chief of the Molecular Diagnostic Service. Similarly, in situ hybridization studies are reviewed and integrated into the Primary Surgical Pathology Report.

The Hematopathology Section of the Laboratory of Pathology performs research on the immunologic and molecular aspects of human hematologic diseases. The staff of the Hematopathology Section interface with the Clinical Services treating patients with hematologic malignancies, the Medicine Branch, the Radiation Therapy Branch, and the Pediatric Branch, DCS, NCI.

All hematopathology biopsies on in-house patients are handled and signed out by the in-house resident. Current NCI protocols require that fresh tissue be obtained for molecular and immunophenotypic studies. Since the vast majority of patients referred for NCI protocols already have an established diagnosis based on outside submitted slides, in many cases the repeat in-house biopsy is performed primarily for the purpose of obtaining fresh tissue for these studies. It is also desirable to obtain fresh tissue on recurrences to document alterations in the immunologic or molecular phenotype.

In the majority of cases routine lymph node biopsies will be delivered to the Hematopathology Section directly by the tissue procurement nurse. Tissue will be examined sterilely in a tissue culture hood and a representative portion of the tissue will be taken for special studies. Fresh imprints also may be prepared and stained with Wright Giemsa. Representative sections will be fixed in formalin by the Hematopathology staff. If large amounts of material are available, some of the tissue may be left fresh in saline and returned to the Surgical Pathology Blocking Room. The Hematopathology fellow or staff will fill out the Hematopathology Accession Form and return it with the fixed and fresh tissue to the Surgical Pathology Blocking Room. The staff will provide an adequate gross description of the specimen, as it was received, for the resident to use in his/her gross dictation. Information will also be provided as to how the specimen was handled, and what time it was placed in fixative. If tissue was taken for other special studies, such as electron microscopy, this information will also be provided to the resident. Please use the Gross Description Form? provided by the Hematopathology staff as your gross description, and document how the specimen was processed and divided based on the information provided. The Gross Description Form? should contain the description of the specimen as it was received by LP, not as it was received in the blocking room. If tissue was provided to other investigators outside LP, often according to protocol requirements, please include this information in your gross description. State the name of the investigator and/or the protocol specified.

Excellent fixation is necessary to obtain good cytological detail, an essential feature for accurate diagnosis. Sections should be no more than 2-3 mm in thickness to ensure satisfactory fixation. Formalin-fixed tissue is generally held overnight. Tissue is not fixed in B5 because it contains mercury, an environmental hazard. B5 also interferes with PCR.

In some cases the resident will receive the lymph node biopsy directly for frozen section. In such cases, please try to handle the specimen sterilely. The need for microbiological culture should also be considered and a sample sent to Microbiology, if indicated. Check with the surgeon to see if this has been obtained in the operating room (OR).

Touch preps should also be prepared and fixed in dip-quick, a modified Wright stain available in the Frozen Section Room. Touch preps are extremely useful in evaluating lymph node biopsies, and in some cases may obviate the need for a frozen section. In other cases they provide a useful and quick supplement to the frozen section.

If a frozen section is suggestive of lymphoma, page the hematopathology fellow to assist in processing the specimen. The remainder of the specimen should be sent to the Hematopathology Laboratory for division. Please remember that in some cases the primary reason for doing the biopsy is to obtain adequate tissue for special studies. The fellow and staff on service can be reached through the Hematopathology Section office, 496-0183.

The In Situ Hybridization Unit is a division of the Hematopathology Section of the Laboratory of Pathology, NCI. The In Situ Hybridization Service offers molecular diagnostic support to the Laboratory of Pathology, NCI. The In Situ Hybridization Unit provides the resident with practical experience using diagnostic and research tools that are applicable to biomedical research in cancer and other fields. The In Situ Hybridization Unit is responsible for clinical testing for Epstein Barr virus (EBV) viral sequences using the EBER RNA probe. Results of EBV in situ hybridization are reviewed by the resident, and these data are integrated into the surgical pathology or molecular diagnostic report. The resident also reviews test slides to determine the preservation of RNA in the clinical sample. In calendar year 2000, 386 clinical cases were studied by in situ hybridization.

On an elective basis, the resident may spend a full month in the In Situ Hybridization Unit. During this rotation, the resident receives training in: DNA/RNA purification, preparation of probes for in vitro transcription, labeling of probes, in situ hybridization procedures. The resident also actively participates in the screening and interpretation of the test materials, including evaluation of positive and negative controls. The resident also studies the research usage of in situ hybridization. The Director of the in situ service is responsible for the training of the resident.

4. Additional Information

Further information about the Laboratory of Pathology (LP) can be found on our public Web site.   This site contains the detailed Specimen Collection Guide and LP Staff Directory. The LP Web site is a useful supplement to this manual.