Head And Neck Pathology
Neoplastic Pulmonary Pathology
- Staging of Lung Cancer
- Subclassification of non-small cell carcinoma
- Diagnosis of sarcomatoid carcinoma and its subtypes
- Classification of Adeno
- Assessment of Invasion
- Interpretation of small biopsies of the lung (eg, core needle biopsies, trans/endobronchial, bronchial biopsy, etc)
- Small Cell and Differential
Staging of Lung Cancer
- Describe how size of tumor affects staging and recognize the impact of fixation, fibrosis, and adjacent airspace organization on tumor size
- Identify pleural invasion using current published criteria, utilize elastic tissue staining when appropriate, and understand how pleural invasion affects staging
- Differentiate intrapulmonary metastases from synchronous primaries using various methodologies (eg, Martini-Melamed, comprehensive histologic assessment)
- Recognize importance of pleural and pericardial effusion in tumor staging and appraise need for histochemical or immunohistochemical testing as indicated
- Differentiate tumor staging based on invasion of important landmark structures (eg, chest wall, large vessels, mainstem bronchus, adjacent lobe)
- Define how the extent of postobstructive pneumonia impacts staging
- Interpret how accurate staging guides treatment options for surgery, chemotherapy, or radiotherapy
Subclassification of non-small cell carcinoma
- Describe how classification may determine treatment options (eg,chemotherapy regimen)
- Recognize subclasses which may benefit from molecular testing
- Apply standard WHO histologic criteria for initial classification of neoplasms
- Analyze pertinent immunohistochemical and histochemical tests to support a specific phenotype when histologic criteria are incomplete
- State the limitations of immunohistochemical staining in classification
- Diagnose large cell carcinoma when appropriate
Diagnosis of sarcomatoid carcinoma and its subtypes
- Define pleomorphic (Sarcomatoid) carcinoma using current WHO criteria
- Recognize spindle and giant cell carcinomas
- Define and recognize carcinosarcoma (sarcomatoid carcinoma with heterologous differentiation)
- Recognize the utility and limitations of keratin staining in this subset of tumors
Classification of Adeno
- Describe and apply the new IASLC/ATS/ERS classification of lung adenocarcinomas
- Define lepidic growth and understand the definition of adenocarcinoma in situ
- Contrast lepidic growth with various patterns of invasive growth (see also assessment of invasion section)
- Identify histologic features which distinguish lepidic growth from papillary and micropapillary growth
- Describe the significance of micropapillary growth as it relates to tumor prognosis
- Explain the updated definition of mucinous adenocarcinoma of the lung and how it relates to the former classification of mucinous bronchioloalveolar carcinoma
- Describe the definitions and criteria for mucinous carcinoma, colloid carcinoma and enteric adenocarcinoma
- Explain the significance of histologic subtypes of adenocarcinoma in regard to the potential presence of molecular abnormalities (i.e., patterns which tend to have EGFR mutations, patterns which tend to have KRAS mutations, patterns which tend to have EML4-ALK mutations)
- Describe the importance of molecular abnormalities in regard to selection of chemotherapeutic agents
Assessment of Invasion
- Discuss radiographic features which correlate with invasive versus non-invasive disease
- Recognize the typical appearances of vascular and lymphatic invasion and apply characteristic histochemical and immunohistochemical stains to support findings when indicated
- Recognize the typical appearances of visceral pleural invasion and apply elastic stains when indicated
- Recognize the typical appearances of parietal pleura, chest wall invasion and elastic stains to support findings when indicated
- Describe the likely progression of many adenocarcinomas from in situ to collapse to invasion
- Summarize the importance of size of invasive focus in minimally invasive adenocarcinomas
- Recognize patterns of growth which indicate an invasive tumor (eg, solid, papillary)
- Differentiate desmoplastic reaction as an indicator of invasion
- Explain the role and limitations of immunostains in distinguishing between adenocarcinoma and squamous cell carcinoma of the lung
- Explain the role and limitations of immunostains most commonly used to support a primary pulmonary origin for an adenocarcinoma (TTF-1, Napsin-A)
- Describe the differences in immunohistochemcial staining that may occur in primary pulmonary mucinous adenocarcinomas in comparison to pulmonary tumors with non-mucinous morphology
- Identify the pitfalls associated with cdx-2 in regard to pulmonary mucinous adenocarcinomas and the concept of pulmonary carcinoma with "enteric" differentiation
- Identify the range of primary pulmonary neoplasms which may show positive staining for neuroendocrine markers (chromogranin, synaptophysin, CD56)
- Identify known mimics of pulmonary non-small cell carcinoma, including common metastatic lesions and interpret appropriate immunohistochemical panels for evaluating primary versus metastatic tumors in the lung
Interpretation of small biopsies of the lung (eg, core needle biopsies,
trans/endobronchial, bronchial biopsy, etc)
- Identify the common methods of obtaining biopsies and the use of each (eg, transbronchial biopsy, endobronchial biopsy, percutaneous CT guided biopsy, endobronchial ultrasound-guided biopsy, electromagnetic navigation)
- Recognize the limitations of small lung biopsies in diagnosis of malignancy
- Determine the inability to rule out invasion in small biopsies showing BAC/AIS
- Differentiate carcinoma from known mimics (eg, sclerosing hemangioma, acute lung injury, carcinoid tumor, granulomatous disease)
- Evaluate small biopsies for triage for molecular studies and immunohistochemical staining
- Correlate histologic findings with radiographic imaging to determine if lesion is adequately sampled
Small Cell and Differential
- Define the major categories of pulmonary neuroendocrine carcinomas (typical carcinoid atypical carcinoid, large cell neuroendocrine carcinoma, small cell carcinoma) using WHO criteria
- Differentiate typical carcinoid (TC) from atypical carcinoid (AC)
- Differentiate TC and AC from the high grade neuroendocrine carcinomas
- Explain the concepts of carcinoid tumorlets, multiple carcinoid tumorlets and diffuse neuroendocrine cell hyperplasia (DIPNECH) and their clinical significance
- Identify the pitfalls associated with crush artifact, especially in small biopsy specimens
- Explain the utility and limitations of proliferation markers in the role of classifying pulmonary neuroendocrine carcinomas
- Describe the limitations of subtyping carcinoid tumors in small biopsy specimens
- Identify the range of morphologic patterns which may be encountered in carcinoid tumors
- Discriminate carcinoid tumors from other histologic mimics (adenoid cystic carcinoma, sclerosing hemangioma)
- Describe the significance of TTF-1 staining in carcinoid tumors in contrast to small cell carcinoma
- Identify the histologic features which distinguish small cell carcinoma from large cell neuroendocrine carcinoma
- Describe the limitations of diagnosing LCNEC on a small biopsy
- Discriminate the high grade neuroendocrine carcinomas from other histologic mimics (poorly differentiated and/or basaloid squamous carcinoma, basaloid carcinoma, PNET, lymphoma)
- Quality Management
- Specimen Handling
- IHC Techniques
- Reporting and Communication
- Implement external proficiency testing when required
- Employ appropriate methods for pathologist competency assessment
- Apply controls appropriately (eg, internal, external, reagent, and tissue)
- Distinguish between batch and on-slide controls
- Ensure that controls react as expected before issuing reports on patient specimens
- Differentiate between antibodies designated for research use only, analyte specific reagents, and reagents designated for in vitro diagnostic (IVD) use
- Comply with statutory limitations on use of reagents (including frozen aliquots)
- Maintain proper equipment operation and documentation
- Establish procedures to minimize cold ischemia time
- Identify the impacts of inadequate and prolonged fixation on test results
- Establish procedures to ensure appropriate fixation
- Recognize potential limitations of alternative fixatives and decalcification on IHC test results
- Recognize the potential impact of improper handling of unstained tissue sections on IHC test results
- Determine specimen adequacy for IHC testing of cytology samples
- Recognize how differences in fixation and processing methods between laboratories may affect test results
- Explain the basic principles of immunohistochemistry
- Recognize differences between primary antibody types (ie, mouse vs. rabbit; monoclonal vs. polyclonal)
- Recognize the utility of antigen retrieval, including heat-induced epitope retrieval or protease treatment
- Recognize differences in antigen detection systems, chromogenic reporter molecules, and potential need for blocking steps (eg, biotin-based)
- Differentiate between initial assay validation/verification and ongoing assay assessment
- Identify conditions requiring assay revalidation
- Implement a new immunohistochemistry test in your laboratory including selection of primary antibody, determination of initial antibody titer and test characteristics (eg, antigen retrieval, antibody dilution, incubation time and temperature), assay validation/verification, and ongoing monitoring of performance
- Differentiate between diagnostic and predictive immunohistochemistry tests and their clinical implications
- Recognize the importance of positive and negative internal controls when selecting blocks for analysis
- Interpret lineage marker results in the context of histologic and clinical evaluation
- Identify appropriate antibody panels that are effective in distinguishing cell types (eg, adenocarcinoma vs mesothelioma; squamous carcinoma vs adenocarcinoma; carcinoma of unknown origin)
- Determine the significance of immunolocalization (nuclear, cytoplasmic, or membranous staining) when interpreting IHC stains
- Recognize common artifacts including endogenous pigment (hemosiderin, melanin, biotin), edge effect, necrosis, etc.
- Use appropriate scoring criteria for predictive markers
- Determine when to reject or repeat a test
- Identify common technical causes of staining problems, such as high background, uneven/weak staining, unexpected negative, failure of positive controls, or unexpected (false) positive staining
- Explain the potential role of quantitative image analysis in improving interpretation consistency
Reporting and Communication
- Generate clear and complete reports that effectively communicate test results and diagnostic implications
- Integrate IHC test results with the overall diagnostic assessment and other ancillary studies as appropriate
- Ensure that reports clearly communicate the clinical significance of IHC staining results when lack of (or negative reactivity) denotes an abnormal result
- Include all required information in predictive factor test reports
- Recognize when to incorporate the analyte specific reagents (ASR) disclaimer in reports
- Specimen Grossing
- Frozen Section Preparation/Interpretation
- Microscopic Interpretation of Excisional Specimens
- Microscopic Interpretation of Punch/Shave Biopsy Specimens
- Sentinel Lymph Node Assessment
- Clinical/Pathological Correlation
- Immunofluorescence Interpretation
- Reporting and Communication
- Understand the importance of appropriate margin sampling to ensure a complete pathological report can be generated
- Understand how to accurately and concisely gross oriented and unoriented excisions from different body sites
- Recognize the different techniques for grossing large and small specimens and the advantages and disadvantages of each for interpretation and laboratory work load
- Understand the rationale for special processing of punch biopsies for alopecia versus punch biopsies for other purposes
- Understand the method for processing sentinel lymph nodes with appropriate sectioning
Frozen Section Preparation/Interpretation
- Understand the different surgical procedures that may require frozen section assessment and how specimen margins may be submitted by the surgeon
- Understand the process of Mohs surgery and how margins are assessed and the specimen is submitted
- Know appropriate indications and contraindications for frozen section assessment of inflammatory and neoplastic lesions of the skin
- Recognize the limitations of frozen section margin assessment and technical issues that may be encountered
- Determine how best to sample margins from a specimen
- Appropriately interpret the frozen section and be able to communicate the diagnosis and any relevant additional information to the surgeon
- Correlate frozen section material with permanent sections, and demonstrate an ability to resolve and handle frozen section discrepancies
Microscopic Interpretation of Excisional Specimens
- Recognize normal skin structures and their variation by site and patient age
- Understand how margins have been sampled from the excisional specimen and provide appropriate information to the clinician
- Identify and report incidental findings in excisional specimens including effects from prior treatments/interventions
- Correctly diagnose common neoplastic conditions, including but not limited to basal cell carcinoma, squamous cell carcinoma, melanoma, vascular tumours, lymphoproliferative disorders and spindle cell neoplasms, and differentiate these from non-neoplastic mimics.
- Perform appropriate work-up for challenging lesions such as spindle cell lesions, pigmented lesions, poorly differentiated tumors, and cutaneous metastases
- Correctly interpret ancillary studies such as special stains and immunohistochemistry
- Correlate findings with results of prior biopsies/excisional specimens, and resolve any discrepancies which may arise
Microscopic Interpretation of Punch/Shave Biopsy Specimens
- Understand the limitations of punch biopsy and in which situations a punch biopsy would be preferred over a shave biopsy
- Explain the value of deeper sections and know indications for ordering them.
- Understand issues involving orientation of small specimens and be able to suggest a means to correct sub-optimal sectioning
- Correctly recognize inflammatory patterns (spongiotic, psoriasiform, perivascular inflammation, interface, granulomatous, panniculitis, etc.)
- Correctly diagnose common inflammatory conditions including, but not limited to, psoriasis, lichen simplex chronicus/prurigo nodule, patterns favouring drug reaction including AGEP and fixed drug reaction, dermal hypersensitivity reaction, erythema multiforme/toxic epidermal necrolysis, lichen planus, neutrophilic dermatoses
- Interpret melanocytic lesions and appropriately communicate to the clinician if re-excision of a lesion is recommended
- Recognize artifacts in small biopsies such as hemorrhage, pinch artifact, displacement of epidermis
Sentinel Lymph Node Assessment
- Explain the role of sentinel lymph node biopsy in cutaneous malignancies
- Ensure that sentinel lymph nodes are appropriately evaluated
- Explain the utility of ancillary assessment of sentinel lymph nodes (eg, immunohistochemistry) and discuss potential pitfalls in interpretation
- Classify sentinel lymph node findings following AJCC criteria
- Interpret the clinical history provided on the requisition and understand the clinical appearance based upon the differential diagnosis provided
- Understand the importance of clinical information in Dermatopathology and explain how histologically similar entities may have different clinical appearances and vice versa
- Explain the importance of clear communication between the Dermatologist and Pathologist in order to obtain the most appropriate diagnosis
- Understand the implications of a diagnosis on clinical management of a patient for both inflammatory and neoplastic conditions
- Explain the situations in which a biopsy for immunofluorescence would be appropriate and know that Michel's medium is required
- Explain the technique of direct immunofluorescence and which antigens are being targeted in different disease states
- Interpret direct immunofluorescence slides and understand the artifacts that may be encountered
- Describe the immunofluorescence staining patterns of common immunobullous and vasculitic disorders and their corresponding histologic findings
Reporting and Communication
- Follow published recommendations for reporting common tumours and appropriate staging
- Generate clear, accurate and complete reports that effectively communicate results and treatment implications to the patient`s health care team
- Demonstrate willingness and ability to discuss issues related to site of biopsy and challenges encountered during interpretation
- Explain which critical results require immediate communication to the treating physician
- Openly accept feedback from clinicians regarding differential diagnoses rendered, report content and clarity of reporting
- Appropriately utilize terminology of Dermatology and Dermatopathology
- Collaborate with dermatologists, surgeons, medical and radiation oncologists in multidisciplinary conferences and other tumour boards to optimize patient care
Be able to select the appropriate material for clinical trials and molecular testing, and understand that these requests must be handled expeditiously.
- Demonstrate Integrity
- Participate in Life-long Learning
- Serve Others
- Develop Others
- Influence Outcomes
- Advance the Field
- Think Strategically
- Solve Problems
- Achieve Goals
- Lead Change
Leadership is a learned skill, the evolution and expression of which depends upon an individual's personality, professional opportunities, practice environment, and other personal traits. As with all skills, leadership abilities develop through time and use, even beyond the end of residency.
- Honesty with others and self
- Demonstrate through actions a commitment to principles and community over personal gain
- Establish credibility by consistently achieving results and being recognized as competent
- Follow-through on commitments
- Address sensitive issues with objectivity and respect for others
- Maintain composure and lead during difficult times
- Model appropriate behaviour and set a positive example for colleagues, learners, and other health care workers
Participate in Life-long Learning
- Assess personal strengths and weaknesses and make improvements (eg, reflect on and learn from failures; ask for and accept constructive feedback from others)
- Strive for innovation and excellence in area of expertise or responsibility
- Participate actively in ongoing professional development (eg, CME and non-CME; independent study
- and research; seek a mentor)
- Serve the goals of the organization and effectively manage its resources
- Encourage and demonstrate openness to others ideas
- Share successes and give credit where credit is due
- Ensure that those they lead have the resources, equipment and organizational support to successfully do their work
- Establish clear expectations and give feedback on performance
- Identify and promote new responsibilities, project opportunities, or education for others
- Empower others to take ownership for their work and project activities
- Inspire and motivate others to meet organizational goals and to do their best work
- Foster long term growth and career development in others through mentoring
- Effectively organize committees or groups to accomplish initiatives
- Persuade others through information, logic and effective communication rather than by authority and/or intimidation
- Communicate own point of view with confidence and effectively manage resistance
- Become involved in key organizational groups to ensure that laboratory concerns are represented
Advance the Field
- See oneself as a physician actively involved in the patient care team
- Promote the current and future value of the laboratory and laboratory professionals to internal and external audiences
- Look for new opportunities for the profession and new ways in which pathologists can serve patients
- Understand the vision, mission and critical success factors of the department in the context of the larger organization/ institution
- Ensure that tactics and decisions are aligned with the organization`s mission and goals
- Be aware of trends and innovations in the field of pathology and use this knowledge to guide long-term planning efforts
- Identify key stakeholders who are influential in laboratory related decisions
- Recognize when to engage and address problems and issues
- Participate in problem-solving discussions when appropriate and provide input on resolutions
- Seek out alternative points of view and/or additional information to resolve issues when appropriate
- Understand how to assess and interpret data (or ask for assistance) in order to make data-driven decisions
- Make decisions when appropriate, even in ambiguous and/or time-sensitive situations
- Establish goals, timelines and metrics to measure project outcomes based on the analysis of data and stakeholder input
- Complete tasks in a timely fashion despite competing demands
- Achieve goals as measured by objective criteria (eg, turnaround times, review rates)
- Delegate tasks effectively and hold others accountable for their actions.
- Promote necessary change even when it is difficult or not desired
- Help others to move in another direction by effectively communicating the reasons and benefits of change
- Provide input to implementation plans for change initiatives
- Lead change initiatives that involve the laboratory
Hospital and Forensic Autopsy
Primary Competencies: Hospital Autopsy
At the completion of the three-month block in hospital autopsy in PGY1, residents should be able to:
- Understand the indications for a hospital autopsy.
- Demonstrate familiarity with the EORLA hospital autopsy manual.
- Know all the parts of a complete hospital autopsy report (preliminary and final).
- Understand the concept of “informed consent” and who can provide consent for a hospital autopsy.
- Draft a complete adult postmortem examination report with appropriate full description at the gross and microscopic levels, and interpret the findings in the context of the clinical history.
- Formulate a cogent cause of death statement according to the World Health Organization (WHO) death certificate format.
- Present autopsy findings in a concise and relevant manner at rounds.
- Complete an appropriate clinical synopsis that summarizes the hospital patient’s medical history, course in hospital and outstanding clinical issues (if any), and communicate with clinical staff for clarification if required.
- Health Advocate
- Recognize the importance of adhering to existing legislation pertaining to human tissue and remains (Coroner’s Act, Human Tissue gift Act, Morgue Act and Public Hospital Act).
- Apply the principles of Universal Precautions
- Demonstrate safe techniques for high-risk autopsies, including viral hepatitis, HIV, tuberculosis and Creutzfeld-Jakob disease.
- Medical Expert
- Perform a systematic review of medical records and the consent form, and appropriately plan the approach to the autopsy.
- Successfully eviscerate the internal organs using both the Virchow and the Letulle methods.
- Properly separate the organs of the thoraco-abdominal organ block, weigh and dissect the organs
- Appropriately sample and block tissues from the major organs.
- Recognize normal and abnormal findings at the macro- and microscopic level.
- Understand the difference between cause, manner and mechanism of death.
- Perform dissections to demonstrate the presence of pneumothorax, pulmonary embolism, deep vein thrombosis and air embolism.
- Know the clinical, gross and microscopic findings of common pathologic conditions at autopsy (e.g. ruptured berry aneurysm, infective endocarditis, subacute myocardial infarct, diabetic nephropathy, etc.).
- Know when it is appropriate to take extra specimens at autopsy (e.g. for bacterial culture or molecular studies), and to do so successfully.
- Take good quality macroscopic photographs of autopsy findings when indicated
- Demonstrate the ability to make satisfactory clinicopathologic correlations.
Primary Competencies: Forensic Pathology
At the completion of the one-month block in forensic pathology in PGY2, residents should be able to:
- Understand the structure of the death investigation system in Ontario and the role of the Forensic Pathologist within it.
- Understand what types of death are to be reported to the Coroner in Ontario (Section 10 of the Coroners Act of Ontario)
- Understand the indications for a medicolegal autopsy.
- Understand the differences between autopsies performed under next-of-kin consent and those performed under Coroner’s warrant.
- Understand the difference between cause, mechanism and manner of death.
- Understand the five steps of the medicolegal autopsy.
- Understand the circumstances in which an “external examination only” autopsy will be performed.
- Demonstrate familiarity with the Coroner’s Act of Ontario and the Ontario Forensic Pathology Service’s (OFPS) Practice Manual for Pathologists.
- Complete an adult postmortem examination report, following OFPS guidelines, on the above cases with appropriate full description at the gross and microscopic levels, and interpret the findings in the context of the clinical history
- Formulate a cogent cause of death statement according to the World Health Organization (WHO) death certificate format for these cases
- Health Advocate
- Medical Expert
- Understand the indications for toxicology testing and demonstrate the ability to collect the appropriate specimens.
- Recognize common postmortem changes and understand the pathophysiology behind them (eg. Livor mortis, rigor mortis).
- Know the different pathways of decomposition.
- Successfully eviscerate the internal organs including evisceration of the tongue, hyoid bone and laryngeal structures
- Complete a full postmortem examination including dissection of brain, heart, lungs, abdominal and pelvic organs, in the fresh (non-fixed) state
- Perform a complete postmortem examination on routine, non-trauma related cases such as:
- sudden natural deaths
- medico-legal autopsies on therapy related deaths (ie: hospital deaths with concerns regarding treatment where a Coroner has ordered an autopsy)
- deaths suspected to be from drug toxicity/overdose
Block #2 (PGY4)
At the completion of the one-month block in forensic pathology in PGY4, residents should be able to:
- Identify those cases where radiologic imaging of the body is required prior to the start of the autopsy.
- Demonstrate awareness of the need to consider and review the findings from the scene of death/discovery of a body.
- Complete requisition forms for all relevant ancillary tests, as required (e.g. toxicology, vitreous fluid biochemistry, microbiology).
- Complete an external examination postmortem examination report for a death from hanging case with appropriate full description of the evidence of injury and the summary of findings
- Complete an adult postmortem examination report on cases of sudden natural deaths and routine deaths due to trauma with appropriate full description at the gross and microscopic levels, as well as the evidence of injury when applicable, and interpret the findings in the context of the clinical history
- Appreciate the need to consider and procure the various relevant trace evidence samples from the body in criminally suspicious deaths at the very start of the autopsy.
- Ensure that satisfactory photographs of relevant external and internal findings (including injuries) are taken by either the resident, police or technical staff.
- Understand the role of an expert witness in the delivery of forensic pathology evidence in court.
- Health Advocate
- Identify those cases where retention of a whole organ(s) and subspecialty consultation (e.g neuropathology, cardiac pathology) is required, and have an understanding of the provincial guidelines and protocols regarding organ retention in autopsies performed under coroner's warrant.
- Know the indications for molecular testing in medicolegal autopsies, and understand the ethics of ordering genetic testing in such cases.
- Medical Expert
- Understand the various scientific and non-scientific methods of identifying bodies.
- Know the indications for special dissections in medicolegal autopsies (dry neck, musculocutaneous dissections of the torso and/or extremities, pelvic exenteration).
- Distinguish antemortem injuries from postmortem artifacts such as decomposition, insect activity and animal predation.
- Recognize and describe the various forms of blunt and sharp force injury.
- Recognize and describe the characteristic findings of gunshot wounds from handguns, high-velocity rifles and shotguns.
- Perform an external examination to an acceptable forensic standard.
- Perform a complete postmortem examination of :
- A sudden natural death
- A routine (i.e. non-criminally suspicious) traumatic death (e.g. motor vehicle collision, descent from height)
to an acceptable forensic standard.