Breast Pathology

Goals and Objectives

 

Level: PGY-1, PGY-2, PGY-3, PGY-4 and PGY-5

In the CBD cohort, junior residents are considered to be PGY-1 and PGY-2; senior residents are considered to be PGY-3 and PGY-4.  PGY-5 CBD residents are also considered to be senior residents and within the CBD curriculum. The goal is to allow for independence in the form of independent sign out, intraoperative consultations and supervision of junior residents and Pathologist Assistants.

For surgical sign out in Anatomical Pathology residency training, there is no separation of cases based on complexity.  Due to the nature of Anatomical Pathology (all cases are ultimately reviewed and finalized by a supervising staff), a resident in any training level can review the glass slides and write up a preliminary report on any surgical pathology case.

  • Ordering of any ancillary studies (histochemical stains, immunohistochemical stains, molecular testing) will initially be done under staff supervision for junior residents.  This is done in order to conserve tissue and prevent tissue waste that may limit the staff pathologist's ability to render a diagnosis. 
    • Based on the resident's experience and abilities they will eventually be permitted to order additional ancillary stains for straightforward, routine cases without consulting the staff pathologist.
    • Regardless of training level, any challenging case for which the resident is unsure of cell lineage or is unable to formulate a differential diagnosis that would be resolved by ancillary testing, the resident must consult the staff pathologist before ordering any ancillary stains.
    • It is expected that senior residents, including PGY-5 residents, would be able to initiate a preliminary panel of ancillary studies for routine cases.  This is ultimately at the discretion of their supervising staff.
  • Grossing of routine specimens can be handled by a resident at any training level.  Complex specimens, which for bone and soft tissue pathology include forequarter or hindquarter amputation for tumour, en bloc retroperitoneal sarcoma resections and segment bone resections for sarcoma, or other specimens, should be done by residents that are able to demonstrate a complete understanding of the anatomical and imaging findings as well as the surgical procedure.  Junior residents must obtain staff approval or be supervised by a senior resident for a complex specimen.  Majority of extremity and trunk wall soft tissue resections are considered to be routine (simple) surgical specimens.

It is expected that the first bone and soft tissue pathology rotation by a junior resident will result in the mastery of normal histology, knowledge of the various surgical procedures encountered and the ability to diagnose common entities. 

It is also expected that the junior residents will review the gross report and correct any typographical errors, assess the completeness of the grossing and correctly report the specimen site, laterality and procedure in the diagnostic section of the surgical pathology report.

Subsequent bone and soft tissue pathology rotations by senior residents will be built upon the above foundation and include the ability to formulate reasonable differential diagnoses as well as to work up challenging cases.  A senior resident should be able to produce a draft surgical pathology report that includes the elements listed above, along with the appropriate diagnosis, completion of a synoptic report (if indicated) and an appropriately completed microscopic description and/or comment field.  This draft report should also be free of typographical errors. The supervising staff pathologist is expected to provide an appropriate volume of cases for review based on the PGY-1 and PGY-2 resident’s level of training in these areas with the understanding that greater responsibility and workload will be taken on in PGY-3.

Additionally, while junior residents are expected to attend all interdisciplinary rounds, they are not expected to present cases while a more senior resident is on service. If there is no senior resident on service, the junior resident will be responsible for obtaining slides of appropriate cases and working with the staff pathologist in order to present cases which are appropriate for their level of training.

Staff pathologists are required to be present at all interdisciplinary rounds during which a resident is presenting, particularly for junior residents.

Senior residents are expected to independently prepare for and present cases at interdisciplinary MSK rounds, and, with staff pathologist supervision and guidance, answer questions and take part in discussion during said rounds.

The PGY-5 year is one of senior leadership and the resident should be able to assume responsibility for organizing the service and supervising junior residents and students. The resident should have mastery of the information contained in standard texts and be prompt in using the literature to solve specific problems. The resident will be responsible for presentations at conferences and for teaching junior residents and students on a routine basis. The PGY-5 should begin to have an understanding of the role of the practitioner in an integrated health care delivery system and to be aware of the issues in health care management facing patients and physicians. 

Based on the Royal College guidelines and recommendations, following the completion of their surgical pathology rotations and EPAs, CBD residents should be ready for independent sign out.

Medical Expert

  • Demonstrate skill and knowledge in the handling and interpretation of bone and soft tissue biopsies for frozen section (EPA: C#13)
  • Demonstrate understanding of the importance of integrating clinical, imaging and histological information for the interpretation of bone and soft tissue biopsies/excisions/resections and frozen sections (EPAs: TTD#2, C#13)
  • Demonstrate skill and knowledge in handling fresh soft tissue specimens (biopsies, excisions and resections), triage tissue (Electron Microscopy, Molecular, Flow, Cytogenetics, Histology), and in the orientation, inking, gross description, and sampling of bone and soft tissue tumours (EPAs: TTD# 1A, F#1, C#2, C#3)
  • Understand the importance of grossing with respect to the important information that ultimately determines tumor grade and stage (EPAs: TTD# 1A, F#1, C#2, C#3).
  • Demonstrate a working knowledge of the anatomy and histology of the bone, joints and soft tissue structures (EPA: F#2).
  • Demonstrate skill in the gross dissection and sampling of routine (simple) bone, joints and soft tissue structures and lesions (EPAs: TTD# 1A, F#1, C#2, C#3).
  • Demonstrate ability to dissect and sample difficult gross specimens i.e. forequarter or hindquarter amputation for tumour, en bloc retroperitoneal sarcoma resections and segment bone resections for sarcoma (EPAs: C#2, C#3)
  • Demonstrate proficiency in the interpretation of soft tissue and bone and understand the limitations in classifying lesions on limited samples (EPAs: F#2, C#4, C#5, TTP#1).
  • Acquire proficiency in the interpretation of sarcoma excisions/resections and ability to prepare accurate comprehensive reports (EPAs: F#2, C#4, C#5, TTP#1).
  • Acquire knowledge of the gross dissection and sampling of benign bone and soft tissue lesions, including joint replacements, and amputations from peripheral vascular disease (EPAs: TTD# 1A, F#1, C#2, C#3).
  • Acquire knowledge of the important molecular and cytogenetic characteristics of soft tissue sarcomas (EPAs: C#9, TTP#1).
  • Acquire knowledge in the use and interpretation of immunohistochemistry pertinent to soft tissue tumors and bone tumors (primary and secondary) (EPAs:  C#10, TTP#1).
  • Acquire knowledge in the use and availability of molecular testing on paraffin and fresh tissue (FISH and NGS) for diagnosing soft tissue tumors (EPAs: C#9, TTP#1).
  • Acquire knowledge of the characteristics of electron microscopic findings in some soft tissue tumors (EPAs:  C#10, TTP#1).

Communicator/Collaborator

  • Obtain a relevant clinical history, including relevant laboratory and imaging results and interpreting this information in light of the clinical information and providing a summary to the supervising staff pathologist (EPA: TTD#2)
  • Demonstrate the ability to function at a junior staff pathologist level at MSK multidisciplinary tumor rounds by reviewing cases, presenting the cases at rounds and responding to questions regarding the cases (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)
  • Demonstrate the ability to teach aspects of bone and soft tissue pathology at multidisciplinary rounds and teaching sessions (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)
  • Gain an understanding of clinical aspects of bone and soft tissue sarcomas, particularly surgical and clinical oncological management of bone and soft tissue sarcomas (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)

Manager

  • Understand the importance of quality control and quality assurance measures for immunohistochemistry including preanalytical, analytical and postanalytical variables (EPAs: F#1, F#2, C#15, TTP#3).
  • Understand the value of proficiency testing for immunohistochemistry (EPAs: C#15, TTP#3).
  • Understand the impact of prolonged fixation and decalcification of tissue for immunohistochemistry (EPAs: F#1, F#2, C#15, TTP#3).

Health Advocate/Professional

  • Understand the importance of turn-around time for diagnostic bone and soft tissue biopsies and lesions, but also understand that the complexity of the lesion may result in delayed reporting due to the need for ancillary tests (EPA: TTD#1B).
  • Understand the importance of communication with clinical colleagues when there is a delay due to case complexity (EPA: TTD#1B).
  • Know when to appropriately consult an expert in bone and soft tissue pathology (EPAs: C#5, TTP#1).
  • Demonstrate an increasing ability to handle more of the clinical workload of the staff pathologist.  It is expected that PGY4 and PGY5 residents are able to handle the full clinical workload of the staff pathologist each day on service (EPAs: TTP#1, TTP#5, TTP#6)

Scholar

  • Consider conducting a research project or case report based on bone and soft tissue pathology material (EPAs: C#16, C#17, TTP#4)
  • Review the pertinent literature relating to advances in bone and soft tissue pathology (i.e. molecular testing, classification of tumors, treatment options, prognostic factors) (EPAs: C#9, C#10, C#15, C#16, TTP#4)

Instructional Tools

The resident will meet with the Bone and Soft Tissue subspecialty Lead and go over this document and the overall aspects of the rotation the day before the rotation starts.

Grossing (EPAs: F1, C2, C3, TTP#2)

  • PGY1 and PGY2 level:
    • Grossing in your bone and soft tissue pathology will not be scheduled and will occur throughout your rotation in the afternoon when more grossing benches are available.
    • A junior resident should gross the following specimens during their first bone and soft tissue pathology rotation:
      • At least 2 hip fractures
      • At least 2 osteoarthritis gross only specimens
      • At least 5 simple soft tissue lesions of the appendicular skeleton or trunk wall.  These specimens may include lipomas (conventional, spindle lipomas, etc), nerve sheath tumours (ie. Schwannoma), palmar fibromatosis, ganglion cysts.
      • At least 2 bone curettage specimens
      • At least 2 soft tissue biopsies
        • Considering separating cores into several blocks to ensure adequate tissue for ancillary studies.
    • A junior resident may also gross larger and/or complex sarcoma specimens (as listed below) with staff approval.  This is encouraged as sarcoma specimens are rare and the opportunity to gross these specimens may not be available during future rotations.
  • PGY3 and PGY4 level:
    • Grossing in your bone and soft tissue pathology will not be scheduled and will occur throughout your rotation in the afternoon when more grossing benches are available.
    • By their end of their senior bone and soft tissue pathology rotation, it is expected that the senior resident will gross:
      • One en block retroperitoneal sarcoma
      • One to two appendicular or trunk wall soft tissue sarcomas
    • If available during their rotation, it is expected that the senior resident will gross any forequarter or hindquarter amputation for sarcoma, bone resection for sarcoma with mapping and any other complex sarcoma resection.
  • Senior residents, including PGY5 residents, are expected to supervise and teach junior trainees in the gross room (EPA: TTP#2)
  • Resident will complete a “grossing log” (shared filed created by the gross room director). The resident will review the slides of the case that he/she grossed and review it with the attending pathologist assigned to the case. The attending will review the gross description and sign the log sheet.

Microscopy

  • The resident will contact the attending pathologist that they are scheduled to sign cases with, the day before in order to arrange time of sign out and distribute cases
  • Retrieve pertinent clinical and radiologic information from the electronic medical records system (EPA: TTD #2)
  • Review all of the slides, recognize normal histology and areas with lesional pathology.  Be able to adequately describe the lesional areas (EPAs: C#4, C#5)
  • Provide a diagnosis or a differential diagnosis of the identified lesion (EPAs: C#4, C#5, TTP#1)
  • Based on the differential diagnosis, be able to provide an ancillary testing panel to work through the proposed differential diagnosis (EPAs: C#5, C#10, TTP#1)
  • Be able to select the correct slide for ordering ancillary testing (EPAs: C#5, C#9, C#10, TTP#1)

FISH for MDM2 amplification and NGS sarcoma fusion panel

  • Learn how to recognize microscopic features that are suggestive of a translocation sarcoma (EPAs: C#4, C#5, C#10, C#15)
  • Learn indicators for ordering FISH for MDM2 amplification in lipomatous tumours (EPAs: C#5, C#9)
  • Learn how to interpret FISH in potential sarcomas (EPAs: C#5, C#9, C#15)

Rounds

  • PGY1 and 2 level: Resident is expected to attend and depending on their skill level, may be asked to present at interdisciplinary rounds (on Fridays at 12:00 pm) (EPAs: C#14, C#18)
  • PGY 3-5: Resident is expected to attend interdisciplinary and consensus conferences and present the cases. This implies reviewing the cases with the pathologist in charge beforehand and organizing the presentation in the appropriate format (EPAs: C#14, C#18, TTP#1, TTP#2, TTP#5, TTP#6)

Evaluation

  • The resident will be given an evaluation based on the objectives and PGY level milestones.

Recommended Reading

  • Most recent edition of Enzinger and Weiss, "Soft Tissue Tumors"
  • Most recent edition of Bullough, Orthopaedic Pathology
  • CAP protocols for bone and soft tissue resections
  • WHO Classification of Tumours: Soft Tissue and Bone Tumours.
  • All chapters covering bone and soft tissue lesions/processes in Robbins and Cotran, Pathologic Basis of Disease

 

 

Updated April, 2022

 

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