Core Competencies

1. Craniofacial Bone Pathology
2. Ear and Temporal Pathology
3. Laryngeal and Hypopharangeal Pathology
4. Neck Soft Tissue Pathology
5. Odontogenic Pathology
6. Oral Pathology
7. Oropharynx and Nasopharynx Pathology
8. Salivary Gland Pathology
9. Sinonasal Tract Pathology

Reactive

1. Recognize key radiologic findings as applied to diagnosis of reactive bony and cartilaginous lesions.
2. Recognize specific clinical, radiologic, or chemical features that point to metabolic bone disease.
3. Distinguish infectious reactive bony lesions from true benign fibro-osseous lesions.
4. Recognize osseous and cartilaginous metaplasia (chondrometaplasia) at various head and neck sites.
5. Recognize the clinical scenarios and features associated with gnathic osteonecrosis.
6. Recognize unique clinical, radiologic, and histologic findings associated with dentition related reactive bone Lesions.

Neoplastic - Benign

1. Recognize key radiologic findings as applied to diagnosis of benign bony and cartilaginous lesions.
2. Recognize unique clinical, radiologic, and histologic findings to classify benign fibro-osseous lesions and recognize specific subtypes within each category.
3. Recognize unique clinical and histologic findings in benign chondroid neoplasms of the jaw and craniofacial region.

Neoplastic - Malignant

1. Recognize key radiologic findings as applied to diagnosis of malignant bony and cartilaginous lesions.
2. Distinguish osteosarcoma from benign and reactive fibroosseous proliferative processes.
3. Recognize osteosarcoma and chondrosarcoma variants commonly seen in the jaw and craniofacial region.
4. Differentiate chordoma from chondrosarcoma from other matrix producing mimics.
5. Recognize and assess therapy related change in osteosarcoma, chondrosarcoma, and rhabdomyosarcoma (cytodifferentiation).
6. Distinguish true osteosarcoma and chondrosarcoma from sarcomatoid carcinoma/carcinosarcoma with matrix production arising from mucosa or salivary gland.
7. Differentiate between `round blue cell` malignancies of the bone.
8. Recognize metastases and hematolymphoid neoplasms to the jaw or craniofacial bones.

Ancillary Testing

1. Utilize immunohistochemical stains to distinguish between chordoma, chondrosarcoma, and other histologic mimics.
2. Utilize immunohistochemical stains and molecular markers delineating `round blue cell` malignancies of the bone.

Reporting and Communication

1. Employ published recommendations on reporting of bone and cartilaginous lesions.
2. Generate clear, concise, and accurate reports that effectively communicate jaw and craniofacial bone testing results and treatment implications to the patient`s health care team.
3. Clearly communicate critical/significant diagnoses requiring immediate action; appropriately indicate when there is going to be a delay in diagnosis and note these preliminary communications in the final report.
4. Accurately integrate results of ancillary testing into the final diagnosis and generate clear, concise, and accurate ancillary testing documentation.
5. Demonstrate willingness and ability to discuss current results and patient issues with clinicians and multidisciplinary health care teams.

Treatment Implications

1. Recognize the implications of intraoperative diagnosis in subsequent surgical management.
2. Recognize entities that may have a familial or genetic predisposition and may thus require further evaluation of both patient and family members.
3. Recognize the implications of diagnosis of bony and cartilaginous neoplasms that may require specific management approaches.
4. Convey the significance of a histologic variant of a bony or cartilaginous neoplasm that may require deviation from the standard clinical management of an entity.
5. Recognize the implications of specific immunohistochemical and molecular markers in targeted therapeutic approaches.

Radiologic Pathologic Correlation

1. Recognize the basic uses and limitations of various imaging modalities (ie, panoramic roetgenogram, computerized tomogram) in the diagnosis of craniofacial bone and cartilage lesions.
2. Recognize normal variations in jaw and craniofacial radiologic findings that may mimic a lesion.
3. Correlate histologic findings with radiologic features in jaw and craniofacial radiologic findings in benign and reactive processes.
4. Correlate radiologic lesional border and landmarks of involvement to assess malignant potential of a lesion.
5. Recognize varying radiologic patterns of lesional matrix deposition to arrive at a diagnosis.

Reactive

1. Diagnose commonly recognized reactive and proliferative ear and temporal bone lesions, with specific attention to mimics of malignancy; eg, accessory tragus, encephalocele, first branchial cleft anomaly, necrotizing otitis externa, otitis media, chondrodermatitis nodularis helicis, otic polyp, cystic chondromalacia, otosclerosis, gout, cholesteatoma, exostosis, keloid, Langerhans cell histiocytosis, malakoplakia, synovial chondromatosis
2. Identify the specific anatomic parts of the ear and temporal bone which may be uniquely affected by these disorders.
3. Distinguish between infectious, inflammatory, and reactive changes which may affect ear and temporal sites.
4. Relate the specific features which are specific to dermatologic disorders, as well as ear/temporal bone manifestations of systemic disorders.

Neoplastic - Benign

1. Diagnose commonly recognized benign neoplasms of the ear and temporal bone, eg, ceruminous adenoma, middle ear adenoma, paraganglioma, schwannoma, meningioma, angiolymphoid hyperplasia with eosinophilia, and endolymphatic sac tumor.
2. Correlate the histopathologic findings with otoscopic, imaging, and specific anatomic site of involvement.
3. Advise on when biopsy is indicated and when additional studies may be required to confirm a diagnosis.

Neoplastic - Malignant

1. Diagnose commonly recognized malignant neoplasms of the ear and temporal bone, eg, skin based tumor (atypical fibroxanthoma, squamous cell carcinoma, basal cell carcinoma, Merkel cell carcinoma, melanoma, dermatofibrosarcoma protuberans), ceruminous adenocarcinoma, rhabdomyosarcoma, and metastatic tumors.
2. Distinguish mimics of malignant neoplasms, benign neoplasms, and reactive lesions.
3. Interpret artifacts unique to the anatomic site with the histologic findings.
4. Apply standard World Health Organization histologic criteria for the initial classification of neoplasms.
5. Analyze pertinent immunohistochemical and histochemical tests to support a specific diagnosis.
6. Describe the differences in immunohistochemical staining that may occur in primary versus metastatic tumors.

Ancillary Testing

1. Recognize the limitations of small biopsies in making a definitive diagnosis.
2. Correlate the histologic findings with imaging and otoscopic findings to determine if the lesion is adequately sampled.

Specimen Handling

1. Appropriately select tissue for frozen section or additional studies, especially in limited biopsy samples.
2. Incorporate the clinical and imaging findings in specimen handling.
3. Determine appropriate tissue submission for histologic examination.
4. Ensure there is sufficient material for ancillary tests or additional testing (culture, electron microscopy, immunohistochemistry, flow cytometry, molecular testing).
5. Identify the pitfalls associated with crush artifact, especially when biopsies are small or limited.

Differential Diagnosis

1. Assess the lesion/tumor based on targeted and pertinent differential diagnosis.
2. Utilize imaging information to formulate differential diagnosis.
3. Demand the exact anatomic site be incorporated into the request or report to narrow the differential diagnosis.
4. Select pertinent ancillary tests to narrow a differential diagnosis down to the correct interpretation; limited material may force a triage of how to order ancillary testing.
5. Evaluate clinical and laboratory information in light of the histologic features.
6. Describe the limitations of subtyping or classification in small biopsy specimens.
7. Identify the range of morphologic patterns which may be seen in various ear/temporal bone neoplasms (middle ear adenoma, ceruminous adenoma specifically).

Radiologic Pathologic Correlation

1. Explain the importance of communication between pathologist, radiologist, and surgeon in evaluating specimens obtained from targeted areas.
2. Recognize the importance of radiographic information in ensuring optimal pathology interpretation.
3. Correlate the histopathologic findings with imaging and clinical findings.
4. Recommend a specific course of action to resolve discrepancies between pathology and imaging.

Reporting and Communication

1. Follow published recommendations for ear and temporal bone reporting and appropriate staging (including skin based primaries).
2. Demonstrate consistent use of terminology (World Health Organization) in reports.
3. Generate clear, accurate, and complete reports that effectively communicate results and treatment implications to the patient`s health care team.
4. Demonstrate willingness and ability to discuss current issues about ear and temporal bone tumors with clinicians and other members of the health care team.
5. Accurately integrate the results of all ancillary testing in the final diagnosis.
6. Clearly communicate critical values or diagnosis which may require immediate action; appropriately indicate when there is going to be a delay in diagnosis.

Treatment Implications

1. Explain the basic treatment alternatives for ear and temporal bone lesions and how pathology findings affect the choice.
2. Explain the pathologic factors that influence patient management and treatment options.
3. Demonstrate an understanding of how different treatment options will change outcome.
4. Define when to utilize pre-operative embolization or imaging to help guide ultimate management.

Reactive

1. Diagnose commonly recognized reactive and proliferative larynx/hypopharynx lesions, with specific attention to mimics of malignancy; eg, laryngocele, laryngeal cysts, laryngitis, vocal cord nodules and polyps, contact ulcer, tracheopathia osteoplastica, and reactive epithelial changes (keratosis, parakeratosis, hyperplasia, dyskeratosis).
2. Recognize specific anatomic sites of predilection for each lesion.
3. Distinguish between the types of laryngeal cysts.
4. Recognize the spectrum of changes seen in reactive epithelial lesions, including keratosis, parakeratosis, hyperplasia, pseudoepitheliomatous hyperplasia, and radiation changes.
5. Identify specific features of unique infectious agents (virus, fungi, bacteria).

Neoplastic - Benign

1. Diagnose commonly recognized benign neoplasms of the larynx/hypopharynx, with specific attention to mimics of malignancy; eg, squamous papilloma, granular cell tumor, amyloidoma, adult rhabdomyoma, paraganglioma, and salivary gland neoplasms.
2. Determine when to recommend a repeat biopsy due to processing or acquisition limitations.
3. Correlate the histopathologic findings with endoscopic or operative findings and patient symptoms.

Neoplastic - Malignant

1. Diagnose commonly recognized malignant neoplasms of the larynx/hypopharynx, eg, dysplasia (keratinizing and non-keratinizing), carcinoma in situ, squamous cell carcinoma and its variants (verrucous, spindle cell, basaloid, exophytic, and adenosquamous), neuroendocrine carcinoma, chondrosarcoma, and metastases.
2. Distinguish between mimics of carcinoma and reactive lesions.
3. Interpret artifacts in processing, frozen section, and fixation as they apply to diagnostic limitations.
4. Utilize ancillary techniques in a judicious and targeted fashion, as samples are usually limited and may be difficult to re-acquire.
5. Correlate potential treatment alterations (such as radiation therapy) with histologic findings.
6. Describe basic treatments for laryngeal/hypopharyngeal malignancies in order to appropriately select patients for specific therapies.

Ancillary Testing

1. Assess accompanying samples (such as radical neck dissections) to assure appropriate evaluation of disease stage.
2. Describe when each special/additional study should be used and how it will influence the diagnosis.
3. Develop a course of action to resolve potential discrepancies or spurious results which may influence diagnosis or additional testing.

Specimen Handling

1. Appropriately select tissue for frozen section or additional studies, especially in limited biopsy samples.
2. Limit unnecessary frozen sections so that the sample integrity can be maintained and artifacts limited.
3. Incorporate the clinical and imaging findings in specimen handling.
4. Determine appropriate tissue submission for histologic examination based on anatomy, margins, and tumor location.
5. Specifically address margin status and detect when margins are positive or close.
6. Describe the effects on tissue subjected to decalcifying agents and fixatives.
7. Ensure there is sufficient material for ancillary tests or additional testing (culture, electron microscopy, immunohistochemistry, flow cytometry, molecular testing).

Differential Diagnosis

1. Assess the lesion/tumor based on a pertinent differential diagnosis.
2. Select several diagnoses for the site and actively eliminate them.
3. Choose targeted ancillary tests to narrow a differential diagnosis down to the correct interpretation; limited material may force a specific order of incorporating special studies.
4. Evaluate clinical and laboratory information in light of the histologic features.
5. Determine exact anatomic site in all cases to specifically formulate a differential diagnosis.

Reporting and Communication

1. Follow published recommendations for larynx/hypopharynx reporting and appropriate staging.
2. Demonstrate consistent use of terminology (World Health Organization, etc) in reports.
3. Comply with standardized processing recommendations for laryngectomy specimen.
4. Generate clear, accurate, and complete reports that effectively communicate results and treatment implications to the patient`s health care team.
5. Discuss cases with treating physicians in pre-operative (preanalytic) stage to resolve potential conflicts or difficulties.
6. Demonstrate willingness and ability to discuss current issues about laryngeal/hypopharyngeal tumor with clinicians and other members of the health care team.
7. Accurately integrate the results of all ancillary testing in the final diagnosis.
8. Explain the impact of preanalytic variables on the final diagnosis and interpretation (ie, inappropriate frozen sections, insufficient tissue sampling, artifacts of tangential sectioning).
9. Clearly communicate critical values or diagnosis which may require immediate action; appropriately indicate when there is going to be a delay in diagnosis.

Treatment Implications

1. Recognize the importance of margins and assessment of tumor.
2. Incorporate treatment effects into specimen evaluation and diagnosis.
3. Describe the basic treatment alternatives for laryngeal/hypopharyngeal tumors and how pathology factors affect the choices.
4. Explain the pathologic factors that influence patient management and treatment options.
5. Demonstrate an understanding of how different treatment options will change outcome.
6. Recognize the need for additional testing after therapy and be able to recommend biopsy timing.

Reactive

1. Diagnose commonly recognized reactive and proliferative neck and soft tissue lesions, with specific attention to mimics of malignancy; eg, branchial cleft cyst, cervical thymic cyst, bronchogenic cyst, infectious diseases (within lymph nodes, such as cat scratch disease, bacillary angiomatosis, mycobacterial spindle cell pseudotumor), sarcoid, and nodular fasciitis.
2. Identify the specific anatomic compartments of the neck (lymph nodes, vessels and nerves, soft tissue) and which may be uniquely affected by these disorders.
3. Distinguish between infectious, inflammatory, and reactive changes which may affect these sites.
4. Incorporate the clinical findings and imaging results into determining the diagnosis.
5. Utilize fine needle aspiration, core biopsy, and open biopsy techniques in interpreting findings.
6. Describe the common pitfalls in diagnosis.

Neoplastic - Benign

1. Diagnose commonly recognized benign neoplasms of the neck and soft tissue lesions, with specific attention to mimics of malignancy; eg, paraganglioma, elastofibroma, perineurioma, lipoma (spindle cell and pleomorphic subtypes), lipoblastoma, hibernoma, nuchal-type fibroma, and lymphangioma.
2. Differentiate between various lipomatous tumors of the soft tissues of the neck.
3. Incorporate imaging findings and anatomic sites of involvement into the diagnosis.
4. Recognize key features to distinguish between benign and malignant tumors based on fine needle aspiration or core needle biopsies and excision/resection samples.
5. Utilize ancillary tests to assess the tumor.

Neoplastic - Malignant

1. Diagnose commonly recognized malignant neoplasms of neck and soft tissue, eg, metastatic tumors to lymph nodes (especially cystic squamous cell carcinoma), synovial sarcoma, chordoma, liposarcoma, fibrosarcoma, and angiosarcoma.
2. Distinguish between spindle cell carcinoma and mesenchymal primaries and how to separate them.
3. Utilize ancillary techniques to help narrow the differential diagnosis for metastatic disease, especially for cystic squamous cell carcinoma, among others.
4. Interpret artifacts in processing, frozen section, and fixation as they apply to diagnostic limitations.
5. Describe basic treatments for soft tissue malignancies in order to appropriately select patients for specific therapies.
6. Describe the significance of margin status as it applies to various malignancies in these sites.

Ancillary Testing

1. Assess accompanying samples to assure appropriate evaluation of disease stage.
2. Describe when each special/additional study should be used and how it will influence the diagnosis.
3. Develop a course of action to resolve potential discrepancies or spurious results which may influence diagnosis or additional testing.

Specimen Handling

1. Appropriately select tissue for culture, flow, or other ancillary studies, especially in limited biopsy samples (such as fine needle aspiration or core needle).
2. Incorporate the clinical and imaging findings in specimen handling.
3. Determine appropriate tissue submission for histologic examination based on anatomy, margins, and tumor location, especially for radical neck lymph node dissections.
4. Obtain orientation and anatomic landmarks from the surgeon before processing radical neck samples.

Differential Diagnosis

1. Recognize the many anatomic compartments and different tissue types within the neck which can be used to narrow the focus of diagnosis.
2. Incorporate pertinent and selected ancillary testing into the diagnosis, especially in metastatic tumors or spindle cell lesions of the neck.
3. Utilize imaging, clinical, and laboratory information to formulate differential diagnosis.
4. Obtain the exact anatomic site to narrow the differential diagnosis.
5. Describe the limitations of subtyping or classification in small or limited biopsy specimens.

Radiologic Pathologic Correlation

1. Describe the importance of communication between pathologist, radiologist, and surgeon in evaluating specimens obtained from targeted areas.
2. Recognize the importance of radiographic information in ensuring optimal pathology interpretation.
3. Correlate the histopathologic findings with imaging and clinical findings.
4. Recommend a specific course of action to resolve discrepancies between pathology and imaging.

Reporting and Communication

1. Follow published recommendations for reporting and appropriate staging of specific tumor types of the neck.
2. Demonstrate consistent use of terminology (World Health Organization) in reports.
3. Generate clear, accurate, and complete reports that effectively communicate results and treatment implications to the patient`s health care team.
4. Accurately integrate the results of all ancillary testing in the final diagnosis.
5. Clearly communicate critical values or diagnosis which may require immediate action; appropriately indicate when there is going to be a delay in diagnosis.

Treatment Implications

1. Recognize the importance of ancillary testing and how it may apply to patient management and outcome.
2. Describe the effect neoadjuvant or adjuvant therapy may have on specimen evaluation.
3. Explain any pathologic factors which may influence patient therapy or outcome.
4. Define the basic treatment options for each disorder in the neck and know how to incorporate these factors into diagnosis.

Reactive

1. Diagnose common inflammatory processes that occur in the jaws related to teeth, eg, radicular (periapical) cyst and periapical inflammation.
2. Distinguish between mimics of inflammatory cysts and inflamed developmental cysts.

Neoplastic - Benign

1. Diagnose commonly recognized benign odontogenic cysts and tumors, eg, dentigerous cyst keratocystic odontogenic tumor (odontogenic keratocyst), glandular odontogenic cyst, calcifying cystic odontogenic tumor, calcifying epithelial odontogenic tumor, squamous odontogenic tumor, and odontoma.
2. Diagnose commonly recognized non-ameloblastoma, benign tumors of odontogenic epithelium, eg, odontoma, adenomatoid odontogenic tumor, and calcifiying epithelial odontogenic tumor.
3. Recognize the morphologic variants of ameloblastoma, eg, plexiform, follicular, unicystic, acanthomatous, and peripheral.
4. Distinguish hyperplastic dental follicle from odontogenic neoplasms, eg, odontogenic myxoma and odontogenic fibroma.
5. Correlate the pathologic findings to the clinical and radiographic findings.
6. Determine when to apply special stain and/or immunohistochemical stains for diagnosis.
7. Recommend a course of action when the pathologic findings do not correlate with the radiographic and/or clinical findings.

Neoplastic - Malignant

1. Recognize the histopathologic features of malignant odontgenic tumors, eg, ameloblastic carcinoma, ameloblastic fibrosarcoma, intraosseous mucoepidermoid carcinoma, and clear cell odontogenic carcinoma.
2. Define the difference between malignant ameloblastoma and ameloblastic carcinoma.
3. Distinguish metastases to the jaws, eg, renal cell carcinoma and prostate carcinoma.
4. Determine when to apply immunohistochemical and/or special stains for diagnosis.

Ancillary Testing

1. Recognize the limitations of special stains and immunohistochemical stains when evaluating odontogenic neoplasms.
2. Recognize the effects of decalcification of tissue morphology.

Reporting and Communication

1. Generate clear, accurate, and complete reports that effectively communicate results and treatment implications for the patient`s health care team.
2. Demonstrate willingness to discuss pathologic findings with the multidisciplinary health care team relating to rare odontogenic neoplasms.
3. Accurately integrate results of ancillary testing into the final diagnosis.
4. Report on radiographic correlation if applicable.
5. Employ consistent use of terminology (World Health Organization) in generating reports.

Treatment Implications

1. Explain the clinical significance of multiple keratocystic odontogenic tumors on patient management.
2. Communicate how different treatment options will affect patient outcome.

Radiologic Pathologic Correlation

1. Explain the importance of evaluating radiographs when diagnosing and differentiating odontogenic neoplasms.
2. Correlate the histopathologic features with the imaging and clinical findings.
3. Recommend a specific course of action to resolve discrepancies between pathology and imaging

Reactive

1. Diagnose common reactive processes that occur in the soft tissue of the oral cavity, eg, mucocele/ranula, chronic sialoadenitis, fibroma, pyogenic granuloma, benign migratory glossitis (geographic tongue), oral lymphoepithelial cyst, and pseudoepitheliomatous hyperplasia.
2. Diagnose the clinical presentation of necrotizing sialometaplasia and differentiate from mucoepidermoid carcinoma and/or squamous cell carcinoma.
3. Distinguish morphologic mimics of squamous cell carcinoma, eg, pseudoepitheliomatous hyperplasia associated with reactive or infectious (fungal) agent.
4. Distinguish morphologic mimics of hematopoietic malignancy, eg, traumatic ulcerative granuloma with stromal eosinophilia.

Neoplastic - Benign

1. Diagnose common benign growths of oral cavity mucosa including peripheral ossifying fibroma, peripheral giant cell granuloma, congenital epulis, granular cell tumor, verruxiform xanthoma, schwannoma, and neurofibroma.
2. Distinguish pigmented lesions such as melanotic macule and melanoacanthoma from other clinically pigmented lesions including amalgam tattoo.
3. Distinguish morphologic mimics of squamous cell carcinoma, eg, pseudoepitheliomatous hyperplasia associated with a granular cell tumor, squamous metaplasia in sialadenitis.
4. Recognize general features of oral epithelial dysplasia and distinguish between mild, moderate, and severe dysplasia using World Health Organization guidelines.
5. Recognize oral immune-mediated vesiculobullous disorders including lichen planus, mucous membrane pemphigoid, and pemphigus vulgaris.
6. Recognize morphologic mimics of oral lichen planus such as lichenoid drug reactions and "lichenoid" dysplasia.
7. Recognize the morphologic pattern of atypical verrucous epithelial hyperplasia and understand the clinical setting and relevance of proliferative verrucous leukoplakia.

Neoplastic - Malignant

1. Differentiate squamous cell carcinoma from known mimics, eg, pseudoepitheliomatous hyperplasia, therapeutic changes, necrotizing sialometaplasia, and granulomatous diseases.
2. Recognize the limitations of small oral biopsies in diagnosis of malignancy.
3. Recognize the significance of invasive or in situ carcinoma at the margins within the context of a specific case.
4. Report the distance of invasive or in situ carcinoma from the tissue border.
5. Identify the variants of squamous cell carcinoma.
6. Recognize the morphologic findings of radiation therapy and/or chemotherapy on tissue specimens.
7. Recognize the need to correlate the histopathology and clinical features to diagnose verrucous carcinoma.
8. Distinguish Kaposi Sarcoma from morphologic mimics, eg, angiosarcoma and pyogenic granuloma.
9. Distinguish metastases to the oral mucosa from primary malignancies, eg, lung, renal, breast, and prostate cancer.
10. Determine when to apply immunohistochemical and/or staining for diagnosis.
11. Correlate the pathologic findings to the clinical and radiographic findings.
12. Recommend a course of action when the pathologic findings do not correlate with imaging studies.

Ancillary Testing

1. Describe when high risk HPV testing of oropharyngeal cancer is recommended.
2. Recognize the uses and limitations of ancillary testing.
3. Explain the role of direct and indirect immunofluorescence in vesiculobullous diseases.
4. Recognize the effects of decalcification on tissue specimens.
5. Competency Area: Reporting and Communication.
6. Follow published recommended guidelines (AJCC) for oral squamous cell carcinoma for reporting and staging.
7. Accurately integrate results of ancillary testing (immunohistochemistry, in situ hybridization) into the final diagnosis.
8. Generate clear, accurate, and complete reports that effectively communicate results and treatment implications for the patient`s health care team.
9. Demonstrate willingness to discuss pathologic findings with the multidisciplinary health care team relating to oral squamous cell carcinoma.
10. Apply the new AJCC staging classification for primary oral melanoma.
11. Recommend additional testing (immunofluorescence) in vesiculbullous diseases to ensure proper patient treatment.

Treatment Implications

1. Explain the pathologic factors that influence re-excision in oral dysplasia.
2. Correlate accurate staging with treatment options for surgery, chemotherapy, or radiation therapy.

Reactive

1. Interpret imaging modalities as applied to diagnosis of reactive oropharyngeal and nasopharyngeal lesions.
2. Recognize distinct infectious and inflammatory processes that can involve the oropharynx and nasopharynx.
3. Recognize various developmental cysts and abnormalities that can involve the oropharynx and nasopharynx.

Neoplastic - Benign

1. Interpret imaging modalities as applied to diagnosis of benign oropharyngeal and nasopharyngeal lesions.
2. Distinguish between benign and malignant papillary epithelial proliferations.
3. Recognize benign mesenchymal and salivary gland neoplasms that can involve the oropharynx and nasopharynx.

Neoplastic - Malignant

1. Interpret imaging modalities as applied to diagnosis and staging of malignant neoplasms of the oropharynx and nasopharynx.
2. Distinguish between keratinizing and non-keratinizing oropharyngeal squamous cell carcinomas.
3. Classify nasopharyngeal carcinoma according to World Health Organization 2005 subtypes.
4. Recognize the morphologic spectrum of nasopharyngeal carcinoma post treatment.
5. Distinguish hematolymphoid neoplasms from reactive lymphoid hyperplasia in the oropharynx and nasopharynx.
6. Recognize metastases to the oropharynx and nasopharynx.

Ancillary Testing

1. Utilize immunohistochemical stains to delineate mucosal derived oropharyngeal and nasopharyngeal carcinomas from salivary type, hematolymphoid, and neuroendocrine type malignancies.
2. Interpret immunohistochemical, in-situ hybridization, and PCR findings to define human papilloma virus driven oropharyngeal carcinomas.
3. Recognize pitfalls and limitations of various methodologies for the detection of human papilloma virus DNA or RNA.
4. Interpret immunohistochemical, in-situ hybridization, and PCR findings to define Epstein Barr virus driven nasopharyngeal carcinomas.

Reporting and Communication

1. Employ published recommendations on reporting of oropharyngeal and nasopharyngeal lesions.
2. Generate clear, concise, and accurate reports that effectively communicate oropharyngeal and nasopharyngeal testing results and treatment implications to the patient`s health care team.
3. Clearly communicate critical/significant diagnoses requiring immediate action; appropriately indicate when there is going to be a delay in diagnosis and note these preliminary communications in the final report.
4. Accurately integrate results of ancillary testing into the final diagnosis and generate clear, concise, and accurate ancillary testing documentation.

5. Demonstrate willingness and ability to discuss current results and patient issues with clinicians and multidisciplinary health care teams.

Treatment Implications

1. Recognize the implications of intraoperative diagnosis in subsequent surgical management.
2. Recognize the implications of distinguishing between human papilloma virus driven and non-human papilloma virus driven oropharyngeal carcinomas.
3. Recognize the implications of distinguishing between Epstein-Barr virus and non-Epstein-Barr virus driven nasopharyngeal carcinomas.
4. Recognize the implications of specific immunohistochemical and molecular markers in targeted therapeutic approaches.

Reactive

1. Recognize key radiologic findings as applied to the diagnosis of reactive conditions of the salivary gland.
2. Recognize reactive findings on fine needle aspirates and other preparations.
3. Recognize characteristic morphologic features of infectious and autoimmune salivary gland lesions.
4. Distinguish post-therapy related reactive changes and pseudotumoral salivary gland lesions from true neoplasms.
5. Correlate histologic features with clinical, microbial, and/or serologic findings to further classify reactive salivary gland lesions.
6. Interpret lip biopsies for the diagnosis of Sjogren syndrome and other autoimmune conditions.

Neoplastic - Benign

1. Recognize key radiologic findings as applied to the diagnosis of benign conditions of the salivary gland.
2. Interpret findings on salivary gland core and incisional biopsies and recognize the limitations and contraindications of this technique.
3. Recognize cytologic features and pitfalls in the diagnosis of benign salivary gland neoplasms on fine needle aspirates and other preparations.
4. Classify benign salivary gland neoplasms based on distribution and morphologic features of tumor cell types and stromal characteristics.
5. Recognize common histologic variants or metaplastic changes in each benign salivary gland tumor category.

Neoplastic - Malignant

1. Recognize key radiologic findings as applied to the diagnosis and stage of malignant conditions of the salivary gland.
2. Interpret findings on salivary gland core and incisional biopsies and recognize the limitations and contraindications of this technique.
3. Recognize cytologic features and pitfalls in the diagnosis of malignant salivary gland neoplasms on fine needle aspirates and other preparations.
4. Classify malignant salivary gland neoplasms based on distribution and morphologic features of tumor cell types and stromal characteristics.
5. Recognize common histologic variants or metaplastic changes in each malignant salivary gland tumor category.
6. Apply grading schemes for malignant salivary gland tumors when appropriate.
7. Recognize co-existing benign precursor lesions in salivary gland malignancies.
8. Distinguish primary salivary gland malignancies from metastases.

Ancillary Testing

1. Apply histochemical tests to distinguish between different salivary gland lesions.
2. Utilize immunohistochemical stains to define tumor cell phenotype for the diagnosis of salivary gland tumors.
3. Utilize immunohistochemical biomarkers for treatment and prognosis of salivary gland tumors.
4. Interpret molecular studies for diagnostic translocations in salivary gland tumors.
5. Interpret molecular studies for biomarkers used in the treatment and prognosis of salivary gland tumors.

Reporting and Communication

1. Employ published recommendations on reporting of salivary gland lesions.
2. Generate clear, concise, and accurate reports that effectively communicate salivary gland testing results and treatment implications to the patient`s health care team.
3. Clearly communicate critical/significant diagnoses requiring immediate action; appropriately indicate when there is going to be a delay in diagnosis and note these preliminary communications in the final report.
4. Accurately integrate results of ancillary testing into the final diagnosis and generate clear, concise, and accurate ancillary testing documentation.
5. Demonstrate willingness and ability to discuss current results and patient issues with clinicians and multidisciplinary health care teams.

Treatment Implications

1. Recognize the implications of intraoperative diagnosis in subsequent surgical management.
2. Recognize the implications of diagnosis of salivary gland neoplasms that may require specific management approaches.
3. Convey the significance of a histologic variant of a salivary gland neoplasm that may require deviation from the standard clinical management of an entity.
4. Recognize the implications of specific immunohistochemical and molecular markers in targeted therapeutic approaches.

Reactive

1. Recognize key radiologic findings as applied to diagnosis of reactive sinonasal tract disease.
2. Classify various types of chronic rhinosinusitis.
3. Distinguish between non-invasive (allergic) and invasive fungal sinusitis and recognize that the later often constitutes a medical emergency.
4. Categorize the various midfacial (granulomatous) destructive diseases.
5. Recognize developmental and hamartomatous entities in the sinonasal tract.

Neoplastic - Benign

1. Interpret imaging modalities as applied to diagnosis of benign sinonasal tract neoplasms.
2. Categorize each type of schneiderian type papilloma and delineate these from non-schneiderian papillary epithelial neoplasms.
3. Recognize benign salivary and mesenchymal neoplasms involving the sinonasal tract.
4. Recognize ectopic benign central nervous system tumors that can arise in the sinonasal tract.

Neoplastic - Malignant

1. Interpret imaging modalities as applied to diagnosis and staging of malignant neoplasms of the sinonasal tract.
2. Delineate olfactory neuroblastoma from other `blue cell tumors` and undifferentiated neoplasms of the sinonasal tract.
3. Apply Hyams grading scheme to olfactory neuroblastomas.
4. Classify primary sinonasal adenocarcinomas into intestinal and non-intestinal types.
5. Recognize the morphologic spectrum of primary mucosal melanomas.
6. Recognize metastases to the sinonasal tract.

Ancillary Testing

1. Incorporate histochemical, immunohistochemical, and serologic findings to classify midfacial destructive diseases.
2. Utilize immunohistochemical stains, in-situ hybridization, and PCR findings to delineate between `round blue cell` and undifferentiated tumors of the sinonasal tract.
3. Utilize immunohistochemical stains to classify sinonasal adenocarcinomas into intestinal, nonintestinal, and salivary types.

Reporting and Communication

1. Employ published recommendations on reporting of sinonasal tract lesions.
2. Generate clear, concise, and accurate reports that effectively communicate salivary gland testing results and treatment implications to the patient`s health care team.
3. Clearly communicate critical/significant diagnoses requiring immediate action; appropriately indicate when there is going to be a delay in diagnosis and note these preliminary communications in the final report.
4. Accurately integrate results of ancillary testing into the final diagnosis and generate clear, concise, and accurate ancillary testing documentation.
5. Demonstrate willingness and ability to discuss current results and patient issues with clinicians and multidisciplinary health care teams.

Treatment Implications

1. Recognize the implications of intraoperative diagnosis in subsequent surgical management.
2. Recognize the implications of delineating non-infectious (allergic) fungal sinusitis from invasive fungal sinusitis.
3. Recognize the implications of distinguishing between the various midfacial destructive diseases.
4. Recognize the implications of distinguishing between the various `round blue cell`/undifferentiated tumors of the sinonasal tract.
5. Recognize the implications of specific immunohistochemical and molecular markers in targeted therapeutic approaches.

1. Adrenal and Paraganglioma Pathology
2. Inherited Endocrine Disease/Tumor Syndromes
3. Neuroendocrine Tumor Pathology
4. Parathyroid Pathology
5. Pathology of Diabetes
6. Pituitary Pathology
7. Thyroid Pathology

Clinicopathologic Correlation 

1. Diagnose adrenal cortical hyperfunction and hypofunction and recognize the morphologic features of adrenal pheochromocytoma and paraganglioma, including features distinguishing these from other disease entities.
2. Recognize radiologic features of adrenal lesions.
3. Competency Area: Chemical Pathology.
4. Implement biochemical tests for adrenal cortical tumors, pheochromocytoma, and paraganglioma.
5. Interpret biochemical tests for adrenal cortical tumors, pheochromocytoma, and paraganglioma.

Cytology

1. Diagnose adrenal lesions from cytologic aspirates.
2. Distinguish adrenal lesions and paragangliomas from other diseases.

Morphology

1. Recognize adrenal lesions, adrenal cortical tumors, pheochromocytoma, and paragangliomas.
2. Diagnose adrenal lesions, adrenal cortical tumors, pheochromocytoma, and paragangliomas.

Ancillary Studies

1. Apply histochemistry tests in adrenal lesions and paragangliomas.
2. Utilize appropriate immunohistochemistry tests for adrenal tumors and paragangliomas.
3. Interpret electron microscopic characteristics of adrenal cortical and medullary tumors and paragangliomas.
4. Assess the molecular genetics of distinct endocrine syndromes causing adrenal diseases and paragangliomas.
5. Interpret molecular markers for diagnosis, treatment, and prognosis of adrenal tumors and paragangliomas.

Treatment Implications

1. Correlate morphological findings of these tumors with the molecular findings to best identify treatment options.
2. Recognize treatment implications of the diagnosis of adrenal lesions and paragangliomas.

Reporting and Communication

1. Follow published recommendations for reporting adrenal disorders and paragangliomas.
2. Comply with synoptic reporting guidelines for adrenal cortical carcinoma.
3. Generate clear, concise, and accurate reports that effectively communicate adrenal testing results and treatment implications to the patient`s health care team.
4. Accurately integrate results of ancillary testing into the final diagnosis, and generate clear, concise, and accurate ancillary testing documentation.
5. Clearly communicate critical/significant diagnoses requiring immediate action; appropriately indicate when there is going to be a delay in diagnosis and note these preliminary communications in the final report.
6. Demonstrate willingness and ability to discuss current results and patient issues with clinicians and multidisciplinary health care teams.

Clinicopathologic Correlation

1. Recognize endocrine autoimmune diseases and polyendocrine autoimmune syndromes.
2. Identify familial endocrine tumor syndromes.

Chemical Pathology

1. Implement testing for hormone-secreting tumors, testing for selective or generalized hormonal insufficiencies, and serology for autoimmune endocrine disorders.
2. Interpret testing for hormone-secreting tumors, testing for selective or generalized hormonal insufficiencies, and serology for common autoimmune endocrine disorders.

Morphology

1. Recognize unique features that distinguish familial endocrine tumor syndromes, and recognize associated diseases.
2. Recognize features that predict familial endocrine autoimmune diseases and polyendocrine autoimmune syndromes.

Ancillary Studies

1. Assess the molecular genetics of distinct inherited endocrine diseases and familial tumor syndromes.
2. Utilize the appropriate immunohistochemistry tests in inherited endocrine disease/tumor syndromes.

Treatment Implications

1. Recognize critical laboratory results for inherited endocrine disease/tumor syndromes for clinicians` immediate knowledge.
2. Recognize treatment implications of diagnosis of familial endocrinopathies and familial tumor syndromes to patient and family.

Reporting and Communication

1. Follow published recommendations for reporting of familial endocrine disorders and familial tumor syndromes.
2. Comply with reporting guidelines for reporting of familial endocrine disorders.
3. Generate clear, concise, and accurate reports that effectively communicate testing results and implications of familial endocrinopathies and tumor syndromes to the patient`s health care team.
4. Clearly communicate critical/significant diagnoses requiring immediate action; appropriately indicate when there is going to be a delay in diagnosis and note these preliminary communications in the final report.
5. Accurately integrate results of ancillary testing into the final diagnosis, and generate clear, concise, and accurate ancillary testing documentation.
6. Demonstrate willingness and ability to discuss current results and patient issues with clinicians and multidisciplinary health care teams.

Chemical Pathology

1. Employ biochemical markers for neuroendocrine lesions and tumors.
2. Correlate biochemical findings with clinical features in patients with neuroendocrine lesions and tumors.

Clinicopathologic Correlation

1. Interpret radiologic features of neuroendocrine tumors.
2. Correlate morphologic and immunohistochemical features with clinical findings of neuroendocrine tumors.

Cytology

1. Recognize neuroendocrine tissues and lesions in cytology aspirates.
2. Classify neuroendocrine tissues and lesions in cytology aspirates.

Morphology

1. Diagnose neuroendocrine tumors and precursor lesions in diverse tissues.
2. Subclassify neuroendocrine tumors and precursor lesions in diverse tissues.

Ancillary Studies

1. Apply histochemistry tests in neuroendocrine diseases to best understand clinical and pathological correlation.
2. Interpret appropriate immunohistochemistry tests in neuroendocrine tumors.
3. Recognize electron microscopic characteristics of neuroendocrine tumors.
4. Determine the molecular genetics of distinct neuroendocrine diseases and familial syndromes.
5. Interpret molecular markers for diagnosis, treatment, and prognosis of neuroendocrine tumors.

Treatment Implications

1. Recognize critical neuroendocrine laboratory results and immediately communicate to clinicians.
2. Recognize treatment implications of neuroendocrine tumors.

Reporting and Communication

1. Follow published recommendations for classification, reporting, staging, and grading of neuroendocrine tumors.
2. Comply with synoptic reporting guidelines for neuroendocrine tumors in various sites.
3. Generate clear, concise, and accurate reports that effectively communicate testing results and treatment implications to the neuroendocrine tumor patient`s health care team.
4. Clearly communicate critical/significant diagnoses requiring immediate action.
5. Appropriately indicate when there is going to be a delay in diagnosis and note these preliminary communications in the final report.
6. Accurately integrate results of ancillary testing into the final diagnosis, and generate clear, concise, and accurate ancillary testing documentation.
7. Demonstrate willingness and ability to discuss current results and patient issues with clinicians and multidisciplinary health care teams.

Chemical Pathology

1. Implement testing methods for calcium/PTH abnormalities.
2. Interpret testing methods for calcium/PTH abnormalities.

Clinicopathologic Correlation

1. Interpret imaging modalities applied in parathyroid lesions.
2. Correlate the imaging findings (especially radiolabelled scintigraphic studies) with clinical findings.

Cytology

1. Recognize parathyroid tissue in cytologic aspirates.
2. Distinguish parathyroid lesions from other diseases.

Morphology

1. Distinguish diverse parathyroid lesions.
2. Diagnose a diverse array of parathyroid lesions.

Ancillary Studies

1. Apply histochemistry tests in parathyroid diseases for diagnosis, prognostic indicators, and for treatment.
2. Utilize appropriate immunohistochemistry tests in parathyroid lesions.
3. Interpret electron microscopic characteristics of parathyroid tumors.
4. Assess the molecular genetics of distinct parathyroid diseases and familial syndromes.
5. Interpret molecular markers for diagnosis, treatment, and prognosis of parathyroid tumors.

Treatment Implications

1. Recognize implications of intraoperative diagnosis and intraoperative PTH assay.
2. Recognize the implications of diagnosis of parathyroid neoplasms such as adenoma, atypical adenoma, and carcinoma that may require specific management approaches.

Reporting and Communication

1. Follow published recommendations on reporting of parathyroid lesions.
2. Generate clear, concise, and accurate reports that effectively communicate parathyroid testing results and treatment implications to the patient`s health care team.
3. Clearly communicate critical/significant diagnoses requiring immediate action; appropriately indicate when there is going to be a delay in diagnosis and note these preliminary communications in the final report.
4. Accurately integrate results of ancillary testing into the final diagnosis, and generate clear, concise, and accurate ancillary testing documentation.
5. Demonstrate willingness and ability to discuss current results and patient issues with clinicians and multidisciplinary health care teams.

Clinicopathologic Correlation

1. Distinguish the various types of diabetes mellitus including possible complications.
2. Recognize the specific findings with emphasis on diabetic changes in diverse organs.

Chemical Pathology

1. Implement testing methods for diabetes, eg, Glucose - random, Glucose - fasting, Glucose tolerance test - oral, Hemoglobin A1C, Point-of-care glucose.
2. Interpret testing methods for diabetes.

Morphology

1. Distinguish the various manifestations and complications of diabetes mellitus.
2. Recognize pathological changes associated with diabetes mellitus.

Treatment Implications

1. Recognize critical diabetic results and immediately communicate to clinicians.
2. Recognize treatment implications for diabetes mellitus.

Reporting and Communication

1. Follow published recommendations in pathology reporting formatting.
2. Comply with reporting surgical pathology guidelines for a clear diagnosis.
3. Generate clear, concise, and accurate reports that effectively communicate diabetes testing results and treatment implications to the patient`s health care team.
4. Clearly communicate critical/significant diagnoses requiring immediate action; appropriately indicate when there is going to be a delay in diagnosis and note these preliminary communications in the final report.
5. Accurately integrate results of ancillary testing into the final diagnosis, and generate clear, concise, and accurate ancillary testing documentation.
6. Demonstrate willingness and ability to discuss current results and patient issues with clinicians and multidisciplinary health care teams.

Clinicopathologic Correlation

1. Recognize clinical and biochemical features of pituitary tumors, pituitary hyperfunction and hypofunction, including features distinguishing these from other tumors.
2. Recognize radiologic features of diverse pituitary lesions.

Chemical Pathology

1. Implement dynamic testing for hormone-secreting pituitary tumors, testing for selective or generalized pituitary gland failure.
2. Interpret dynamic testing for hormone-secreting pituitary tumors, testing for selective or generalized pituitary gland failure.

Morphology

1. Recognize pituitary adenomas and nonneoplastic pituitary diseases.
2. Subclassify pituitary adenomas and nonneoplastic pituitary diseases.

Ancillary Studies

1. Utilize appropriate histochemistry tests in pituitary diseases.
2. Interpret appropriate immunohistochemistry tests in pituitary lesions.
3. Interpret electron microscopic characteristics of pituitary tumors.
4. Assess the molecular genetics of distinct pituitary diseases and familial syndromes.
5. Apply molecular markers for diagnosis, treatment, and prognosis of pituitary tumors.
6. Interpret molecular markers for diagnosis, treatment, and prognosis of pituitary tumors.

Treatment Implications

1. Recognize critical pituitary laboratory results and immediately communicate to clinicians.
2. Recognize treatment implications of pituitary lesions.

Quality Assurance

1. Identify antibody specificities and cross reactivities that impact pituitary tumor classification.
2. Correlate clinical, morphological, and radiological findings with pathology reporting.

Reporting and Communication

1. Follow published recommendations for use of ancillary studies in pituitary pathology.
2. Comply with synoptic reporting guidelines for pituitary tumors.
3. Generate clear, concise, and accurate reports that effectively communicate pituitary testing results and treatment implications to the patient`s health care team.
4. Clearly communicate critical/significant diagnoses requiring immediate action; appropriately indicate when there is going to be a delay in diagnosis and note these preliminary communications in the final report.
5. Accurately integrate results of ancillary testing into the final diagnosis, and generate clear, concise, and accurate ancillary testing documentation.
6. Demonstrate willingness and ability to discuss current results and patient issues with clinicians and multidisciplinary health care teams.

Chemical Pathology

1. Interpret thyroid chemistry, serology panels, and ultrasensitive TSH.
2. Correlate chemical findings to morphologic and molecular features.

Clinicopathologic Correlation

1. Identify thyroid pathology by fine needle aspiration and cytology interpretation.
2. Create integrated pathology report with chemical, morphologic, molecular findings and include comment about treatment implications.
3. Recognize morphologic characteristics of diverse thyroid lesions.
4. Correlate imaging findings with clinical, biochemical, and morphologic features of thyroid lesions.

Ancillary Studies

1. Apply histochemistry tests in thyroid diseases for diagnosis, prognostic indicators, and for treatment.
2. Utilize appropriate immunohistochemistry tests in thyroid lesions.
3. Interpret electron microscopic characteristics of thyroid tumors.
4. Assess the molecular genetics of distinct thyroid diseases and familial syndromes.

Reporting and Communication

1. Classify cytology lesions following NCI Thyroid Fine Needle Aspiration Guidelines.
2. Comply with CAP synoptic reporting guidelines for thyroid cancers.
3. Generate clear, concise, and accurate reports that effectively communicate thyroid testing results and treatment implications to the patient`s health care team.
4. Clearly communicate critical/significant diagnoses requiring immediate action; appropriately indicate when there is going to be a delay in diagnosis and note these preliminary communications in the final report.
5. Accurately integrate results of ancillary testing into the final diagnosis, and generate clear, concise, and accurate ancillary testing documentation.
6. Demonstrate willingness and ability to discuss current results and patient issues with clinicians and multidisciplinary health care teams.

Disease Type

Disease Types

1. Recognize the anatomic alterations and structural elements, such as types of epithelial lining and tissues, seen in developmental abnormalities and acquired deformations of the esophagus.
2. Identify common fungal and viral infections, such as Candida, herpes simplex, cytomegalovirus, and less commonly encountered pathogens such as tuberculosis and syphilis.
3. Diagnose specific forms of esophagitis, such as eosinophilic esophagitis and reflux esophagitis, by histologic features and correlation with clinical findings.
4. Recognize other inflammatory conditions affecting the esophagus, such as Crohn’s disease and sarcoidosis, and iatrogenic and traumatic injuries such as medication-induced ulcers.
5. Differentiate tumor-like conditions of the esophagus, such as diverticula, webs, xanthoma, and idiopathic muscular hypertrophy, from malignancies.
6. Diagnose carcinomas of the esophagus and their associated pre-invasive lesions, such as identifying Barrett’s Esophagus and classifying associated glandular dysplasia, and recognizing squamous cell carcinoma and associated changes of the squamous dysplasia-carcinoma sequence.
7. Diagnose and apply appropriate grading and staging schemes to non-epithelial neoplasms that occur in the esophagus.
8. Diagnose and classify esophageal polyps, such as squamous papilloma, heterotopias, and inflammatory and hyperplastic polyps.
9. Identify the etiology and histologic features of vascular disorders of the esophagus.
10. Recognize the histologic changes and clinical symptoms that may be seen in systemic diseases, such as amyloidosis, systemic sclerosis, polymyositis, and dermatomyositis.

Specimen Handling

1. Manage or oversee gross examination of endoscopic mucosal and submucosal resection specimens to optimize histologic examination and assure appropriate evaluation of margins.
2. Implement a process for gross (macroscopic) examination and sectioning of esophageal resection specimens for carcinoma, with or without preoperative neoadjuvant treatment, to ensure inclusion of all relevant staging and prognostic information.
3. Request additional tissue when technical artifact and/or limited sampling hamper diagnosis.
4. Evaluate frozen sections of gastric specimens for identification of lesions and margin status.
5. Communicate with gastroenterologists to implement ways to improve or optimize quality of tissue samples obtained for histologic evaluation, such as orientation of pinch biopsy specimens in the endoscopy suite or implementation of more complete biopsy protocols.
6. Employ the optimal biopsy and fixation strategy for endoscopic work-up of bullous disorders of the esophagus.
7. Employ optimal collection techniques and transport media selection for flow cytometry work-up of possible hematolymphoid disorders.
8. Recommend appropriate fixatives for routine histology versus special handling, such as electron microscopy.

Differential Diagnosis

1. Identify and quantitate increased intraepithelial eosinophils, and interpret this finding in context of an appropriate differential diagnosis, such as eosinophilic esophagitis versus reflux esophagitis.
2. Classify esophageal adenocarcinoma versus gastric adenocarcinoma for purposes of AJCC staging.
3. Generate a differential diagnosis for granulomatous disease in the esophagus, utilizing special stains in the work-up as indicated.
4. Generate a differential diagnosis for uncommon neoplasms of the esophagus, such as small cell carcinoma and spindle cell carcinoma.
5. Distinguish primary esophageal tumors from non-esophageal malignancies, such as metastatic melanoma or lung cancer.
6. Diagnose non-epithelial neoplasms of the esophagus, distinguishing GIST from leiomyoma and other mimics.
7. Apply differential diagnostic considerations for iatrogenic and traumatic lesions, such as those due to medications, radiation, corrosive substance ingestion, and mechanical injury.
8. Distinguish between benign and malignant inflammatory infiltrates.
9. Distinguish between reactive epithelial changes, low-grade dysplasia, high-grade dysplasia, and intramucosal adenocarcinoma in Barrett’s esophagus and know when to apply the indefinite for dysplasia category.

Clinical Implications

1. Recognize the long-term sequelae of inflammatory esophageal conditions, including reflux esophagitis and achalasia.
2. Communicate the assessment of HER2 status in esophageal adenocarcinoma, with recognition of the impact of findings on clinical treatment options.
3. Recognize the clinical implication of diagnosis of Barrett’s esophagus and associated dysplasia and its impact on surveillance and treatment.
4. Compare the definition of Barrett’s esophagus used in North America (Canada and US) with that used in Japan and UK.
5. Ensure accurate TNM staging of esophageal carcinoma and understand the clinical use of such information.
6. Recognize the different clinical implications of a diagnosis of reflux esophagitis and eosinophilic esophagitis.

Reporting and Communication

1. Generate accurate, clear, and concise reports that communicate results and therapeutic implications with the patient’s healthcare team.
2. Employ synoptic reporting for esophageal carcinomas and gastrointestinal stromal tumors (eg, CAP cancer protocols) utilizing World Health Organization (WHO) terminology, as appropriate.
3. Perform TNM staging of esophageal carcinomas and gastrointestinal stromal tumors according to the guidelines specified in the current edition of the AJCC TNM Cancer Staging Manual.
4. Utilize current WHO (or other international accepted terminology) to classify and grade esophageal cancer.
5. Integrate results of ancillary testing into the final diagnosis.
6. Communicate significant or unexpected findings and anticipated delays in diagnosis, and document these preliminary communications in the final report.
7. Demonstrate willingness, accessibility, and ability to discuss results with a multidisciplinary healthcare team, including participation in appropriate conferences and tumor boards.
8. Apply appropriate terminology for tumor regression after neoadjuvant therapy.
9. Apply accepted terminology when reporting cases of Barrett’s esophagus and associated dysplasia.
10. Follow the appropriate ethical protocol to communicate hereditable syndromes.
11. Consult (other) subspecialty experts as appropriate on problematic cases.
12. Ensure that patient confidentiality is maintained while communicating and reporting patient results to the provider.

Procedures

1. Employ an optimal biopsy and fixation strategy for endoscopic work-up of bullous disorders of the esophagus.
2. Employ a strategy for gross examination and sectioning of esophageal resection specimens for carcinoma with or without neoadjuvant treatment.
3. Utilize the American College of Gastroenterology guidelines for examining specimens from patients with Barrett’s neoplasia.
4. Apply algorithms for HER2 testing in esophageal adenocarcinoma, utilizing immunohistochemistry and fluorescence in situ hybridization as recommended by standard-setting organizations such as the National Comprehensive Cancer Network (NCCN) or FDA.
5. Recommend appropriate molecular testing methods for GI stromal tumors.

Ancillary Studies

1. Apply appropriate special histological stains (eg, PAS, methenamine silver stain) for detection of fungi in esophageal specimens.
2. Recognize the clinical settings that suggest the need for special studies for viral pathogens and utilize the appropriate special methods for their detection.
3. Employ an appropriate panel of immunohistochemical studies to assist in the diagnosis of nonepithelial neoplasms, poorly differentiated carcinomas, and metastatic tumors to the esophagus.
4. Score immunohistochemical studies for HER2 performed on an esophageal adenocarcinoma according to site-specific guidelines, and recommend cases that need HER2 fluorescence in situ hybridization studies.
5. Employ special mucin stains that may be used in detecting Barrett’s esophagus, when appropriate.
6. Communicate results of HER2 FISH studies in esophageal adenocarcinoma, including HER2/CEP17 ratio and absolute HER2 number.
7. Determine appropriate positive and negative controls for each histochemical and immunohistochemical stain employed in the laboratory.
8. List the immunofluorescent (IF) stains indicated in the differential diagnosis of bullous lesions of the esophagus and the media indicated for collecting/holding biopsies for IF.

Clinical Indications for Testing

1. Determine microsatellite instability (MSI) status of all colorectal cancers.
2. for RAS (KRAS/NRAS) mutation in stage IV colorectal cancer and recommend testing for BRAF mutation if RAS is not mutated.
3. Determine the presence/absence of HER2 overexpression/amplification in advanced or metastatic gastric or gastro-esophageal junction cancer.
4. Recommend testing for mutations in the KIT and PDGFRA genes in advanced or metastatic gastrointestinal stromal tumors when tyrosine kinase inhibitors are considered.

Specimen Handling

1. Recognize the need for established laboratory procedures/protocols for handling tissue and specimen for potential future nucleic acid or other ancillary testing.
2. Ensure that samples are processed correctly, avoiding decalcification and under/over fixation, so that reliable and accurate diagnosis and test results can be obtained.
3. Recognize the importance of blocks selection with sufficient tumor cells based on limits of detection (the minimal percentage of neoplastic cells that are present in a sample) for DNA-based molecular tests and ensure that they are voided of any extraneous/floater tissue.
4. Identify an area(s) of the sample for macrodissection/microdissection that will allow you to obtain a sufficient percentage of tumor cells for molecular testing if further dissection is required.
5. Provide an estimate of the percentage of neoplastic cells present in the tissue section or selected area used for testing.
6. Ensure that a normal tissue/blood sample is submitted with the tumor sample for MSI testing.
7. Ensure that sufficient tumor tissue is tested for HER2 overexpression/amplification in gastric or gastroesophageal junction cancer due to tumor heterogeneity.
8. Recognition of the importance of using 10% neutral buffered formalin for HER2 studies.

Testing Methods

1. Utilize immunohistochemistry (IHC) or MSI testing by PCR or both to screen for MSI-high colorectal cancers.
2. Recognize that both IHC and MSI testing by PCR have a 5%-10% false-negative rate, identify common pitfalls of each, and repeat or recommend alternative testing when necessary.
3. Recognize the need for additional testing (testing for BRAF V600E mutation and/or hypermethylation of MLH1 promoter) for MSI-high colorectal cancers to differentiate Lynch Syndrome-related colorectal cancer from sporadic MSI-high tumor.
4. Recognize the several test methods that can be employed for detecting RAS or BRAF mutations, including Sanger sequencing, pyrosequencing, allele-specific PCR, PCR and single-base extension, next generation sequencing, and immunohistochemistry for BRAF mutation.
5. Recognize advantages and disadvantages of the different methods for detecting RAS or BRAF.
6. Employ techniques such as Sanger sequencing with/without combination of restriction enzyme digestion of PCR product to detect KIT/PDGRFA mutations in gastrointestinal stromal tumors.
7. Detect HER2 protein overexpression by IHC and HER2 gene amplification by fluorescence in situ hybridization (FISH) in gastric and gastro-esophageal cancers.
8. Recognize the differences in HER2 overexpression between breast and gastric/gastro-esophageal junction cancers.
9. Recognize the differences in HER2 expression between biopsy and resection specimen in gastric/gastroesophageal junction cancers.

Clinical Implications

1. Recognize clinical implications of MSI testing, such as prognosis, prediction of response to 5-FU and irinotecan therapy, detection of Lynch Syndrome, and impact on family members who will require screening.
2. Identify RAS(KRAS/NRAS)-wild type (and possibly BRAF-wild type) stage IV colorectal cancers that respond to cetuximab or panitumumab.
3. Understand that the presence or absence of mutations in specific regions of the KIT and PDGFRA genes are correlated with response or resistance to certain tyrosine kinase inhibitors.
4. Recognize that patients with a HER-2 positive (3+ immunohistochemical staining or FISH+) advanced gastric or gastro-esophageal junction cancer may benefit from treatment with trastuzumab, a recombinant humanized IgG1 monoclonal anti-HER2 antibody.

Reporting and Communication

1. Specify the genes, loci, or mutation types tested and the method used to analyze the sample and its limitations.
2. Integrate the test results with clinical history, morphologic findings, and results of other ancillary studies, and establish algorithm to recommend appropriate follow- up testing if necessary.
3. Provide accurate, clear and concise interpretation of the result(s) obtained and incorporate any relevant, up to date advice including the potential use of targeted therapy in mutation positive tumors.
4. Demonstrate willingness, accessibility, and the ability to discuss results with the patient`s healthcare team.
5. Follow appropriate ethical protocols to communicate heritable syndromes and recognize the national, state and local regulatory and/or ethical requirements for consent, ordering and performance of genetic testing.

Disease Types

1. Diagnose gastritis, including H. pylori gastritis and special forms of gastritis such as lymphocytic, collagenous, eosinophilic gastritis, and atrophic gastritis due to autoimmune gastritis.
2. Diagnose other inflammatory disorders of the stomach such as reactive gastropathy, involvement of the stomach by inflammatory bowel disease, and systemic disorders such as sarcoidosis.
3. Distinguish vascular disorders of the stomach, including gastric antral vascular ectasia, portal hypertensive gastropathy, and Dielafoy`s lesion using morphologic, endoscopic, and clinical findings.
4. Identify histologic findings of gastric ulcers and medication-related injuries, including iron, NSAIDs, Kayexalate, and correlate with etiology.
5. Differentiate tumor-like lesions of the stomach (such as gastritis cystica profunda, pancreatic rest, and foveolar hyperplasia) from malignancies.
6. Diagnose epithelial neoplasms of the stomach and identify changes of the metaplasia-dysplasia-carcinoma sequence.
7. Diagnose mesenchymal neoplasms of the stomach and apply appropriate grading and staging schemes to gastrointestinal stromal tumors arising in the stomach.
8. Distinguish between primary gastric carcinoma and histologic mimics (metastatic tumors, pseudosignet ring cell change, etc.).
9. Diagnose and classify common lymphoid neoplasms involving the stomach such as follicular lymphoma, MALT and mantle zone lymphoma and know when to consult or refer other suspicious lymphoid lesions.
10. Recognize the controversy surrounding the distinction of intestinal metaplasia of the distal esophagus and the gastric cardia.
11. Classify and distinguish from malignant lesions all gastric polyps including fundic gland polyp, hyperplastic polyp, hamartomatous polyp, and inflammatory fibroid polyp.
12. Classify and grade neuroendocrine proliferations and tumors.

Specimen Handling

1. Employ optimal collection strategy and media selection for flow cytometry analysis of possible hematolymphoid disorders.
2. Recommend appropriate fixatives for routine histology versus techniques requiring special processing, such as for electron microscopy.
3. Manage or oversee gross examination of endoscopic mucosal and submucosal resection specimens to optimize histologic examination and assure appropriate evaluation of margins.
4. Implement a strategy for gross examination and sectioning of gastric resection specimens for carcinoma, with or without preoperative neoadjuvant treatment, to ensure inclusion of all relevant staging and prognostic information.
5. Request additional tissue when technical artifact and/or limited sampling hamper diagnosis.
6. 6Communicate with gastroenterologists to implement ways to improve or optimize quality of tissue samples obtained for histologic evaluation, such as orientation of pinch biopsy specimens in the endoscopy suite or implementation of more complete biopsy protocols.
7. Evaluate frozen sections of gastric specimens for identification of lesions and margin status.

Testing Methods

1. Recommend appropriate molecular testing methods for gastrointestinal stromal tumors.
2. Recognize utility of cultures in gastric specimens.
3. Recognize the role of fine needle aspiration in endoscopic ultrasound-guided diagnosis of submucosal lesions.
4. Apply algorithms for HER2 testing in gastric adenocarcinoma, utilizing immunohistochemistry and fluorescence in situ hybridization as recommended by standard-setting organizations such as the National Comprehensive Cancer Network (NCCN) or FDA.

Ancillary Studies

1. Apply appropriate histochemical or immunochemical stains for detection of Helicobacter pylori organisms in gastric specimens.
2. Recognize the clinical settings that might indicate a need for special studies for viral, fungal, and non-H. pylori bacterial pathogens, and utilize the appropriate special methods for their detection.
3. Use appropriate special studies (gastrin or other immunohistochemical stains) to assist in the diagnosis of atrophic gastritis, neuroendocrine cell hyperplasia, and intestinal metaplasia.
4. Employ an appropriate panel of immunohistochemical studies to assist in the diagnosis of nonepithelial neoplasms, poorly differentiated carcinomas, and metastatic tumors to the stomach.
5. Score immunohistochemical studies for HER2 performed on a gastric carcinoma according to sitespecific guidelines, and recommend cases that need HER2 fluorescence in situ hybridization studies (FISH).
6. Evaluate and interpret the results of HER2 FISH studies in gastric adenocarcinoma, including HER2/CEP17 ratio and absolute HER2 number.
7. Employ a panel of immunohistochemical studies to evaluate lymphoid lesions and diagnose/classify the most commonly encountered lymphoid neoplasms.
8. Determine appropriate positive and negative controls for each histochemical and immunohistochemical stain employed in the laboratory.
9. Grade neuroendocrine tumors using mitotic rate or Ki67 immunohistochemistry according to current guidelines.

Differential Diagnosis

1. Classify chronic gastritis and its variants, including lymphocytic gastritis, collagenous gastritis, and eosinophilic gastritis, using accepted grading schemes such as the updated Sydney system, when appropriate.
2. Diagnose non-epithelial neoplasms of the stomach, distinguishing GIST (gastrointestinal stromal tumors) from schwannoma and other mimics.
3. Distinguish inflammatory bowel disease involving the stomach from other inflammatory conditions.
4. Generate a differential diagnosis for granulomatous gastritis.
5. Evaluate the range of findings in graft versus host disease, with generation of an appropriate differential diagnosis based on histologic and clinical findings.
6. Classify gastric adenocarcinoma versus gastroesophageal junction adenocarcinoma and esophageal adenocarcinoma for purposes of AJCC staging.
7. Distinguish between ultra-short segment Barrett`s esophagus and intestinal metaplasia of the stomach.
8. Generate a differential diagnosis of medication-induced injury in the stomach.
9. Distinguish between vascular lesions of the stomach using clinical, endoscopic and histologic findings.
10. Use clinical, laboratory, and histologic findings to distinguish eosinophilic gastroenteritis from other inflammatory conditions involving the stomach.
11. Distinguish gastric neoplasia versus its mimics (dysplasia from reactive change, signet ring cells from pseudo-signet ring cells).
12. Distinguish between and classify neuroendocrine cell hyperplasia, dysplasia, and neoplasia according to accepted criteria.
13. Distinguish between hyperplastic, fundic gland, hamartomatous, and less common gastric polyps.
14. Distinguish between benign and malignant inflammatory infiltrates.

Clinical Implications

1. Recognize the long-term sequelae and natural history of Helicobacter pylori gastritis, including ulcerations, atrophy, and neoplasia.
2. Ensure accurate assessment of risk for progressive disease in GIST(gastrointestinal stromal tumor).
3. Estimate risk of developing adenocarcinoma in association with intestinal metaplasia.
4. Recognize the clinical impact of endoscopic mucosal resection findings.
5. Incorporate knowledge of clinical/etiologic setting in assessing the risk of progression for gastric neuroendocrine tumors.
6. Ensure adequate lymph node retrieval in gastric adenocarcinoma resection specimens, taking into account the type of lymph node dissection performed.
7. Ensure accurate TNM staging of gastric adenocarcinoma to guide adjuvant therapy.
8. Communicate assessment of HER2 status in gastric adenocarcinoma, with recognition of impact of findings on clinical treatment options.

Reporting and Communication

1. Generate accurate, clear, and concise reports that effectively communicate results and therapeutic implications to the patient`s healthcare team.
2. Employ synoptic reporting for gastric adenocarcinomas, neuroendocrine neoplasms, and gastrointestinal stromal tumors (eg, CAP Cancer Protocols).
3. Perform TNM staging of gastric adenocarcinomas, neuroendocrine neoplasms, and gastrointestinal stromal tumors according to the guidelines specified in the current edition of the AJCC (American Joint Committee on Cancer) TNM Cancer Staging Manual.
4. Utilize current World Health Organization (WHO) (or other internationally accepted terminology) to classify and grade gastric cancer, including carcinomas and well-differentiated neuroendocrine tumors.
5. Use recommended terminology to describe the histologic findings in biopsies from the distal esophagus, gastroesophageal junction, and gastric cardia.
6. Integrate results of ancillary testing into the final diagnosis.
7. Communicate significant or unexpected findings and anticipated delays in diagnosis, and document these preliminary communications in the final report.
8. Demonstrate willingness, accessibility, and ability to discuss results with a multidisciplinary healthcare team, including participation in appropriate conferences and tumor boards.
9. Apply appropriate terminology for tumor regression after neoadjuvant therapy.
10. Follow appropriate ethical protocols to communicate heritable syndromes.
11. Consult (other) subspecialty experts as appropriate on problematic cases.

Disease Types

1. Recognize the clinical symptoms, endoscopic and histological findings for vascular abnormalities of the small intestine (eg, Angiodysplasia, arteriovenous malformation, Dieulafoy’s abnormality, infarcts, ischemia).
2. Identify the symptoms, causes, and histologic findings of primary and secondary neuromuscular disorders.
3. Recognize the histologic, gross/endoscopic, and microscopic appearance of the small intestine mucosa in fungal, viral, mycobacterial, parasitic and helminthic infections (eg, CMV, giardiasis adenovirus, Cytomegalovirus and adenovirus, Whipple disease).
4. Recognize clinical and histologic features to suggest immunodeficiencies and autoimmune enteropathy.
5. Recognize clinical, endoscopic, and histologic features to suggest peptic injury.
6. Recognize features of drug-induced injury to the small intestine (ie, NSAIDs, mycophenolate).
7. Define the clinical, serologic, and histologic features that can be seen in, along with possible complications of celiac disease.
8. Identify the common clinical presentation and histologic changes of erosive/ ulcerating disease.
9. Recognize histologic features of graft-versus-host disease.
10. Recognize histologic features of acute cellular and antibody mediated rejection in small bowel allografts.
11. Identify the histologic features of the types of neoplastic and nonneoplastic polyps that can occur in the small intestine.
12. Discuss the epidemiology and the clinical, radiological, and endoscopic findings that may suggest a nonepithelial neoplasm (eg, granular cell tumor, leiomyoma, GIST, lymphangioma, lymphoma, melanoma, lipoma, hemangioma, Kaposi sarcoma, sarcoma, Schwannoma).
13. Recognize features of a neuroendocrine neoplasm and recommend appropriate supportive stains, if needed.
14. Identify the features of small intestinal involvement by chronic inflammatory bowel disease (Crohn’s disease).
15. Discuss the common sites of heterotopia involving the small intestine and setting in which it may be encountered.

Specimen Handling

1. Employ the optimal biopsy and fixation strategy for endoscopic work-up of celiac sprue.
2. Manage endoscopic mucosal and submucosal resection specimens appropriately for histologic examination, including evaluation of margins.
3. Examine grossly and section small intestinal and ampullary resection specimens appropriately for accurate diagnosis, grading, and staging of neoplasms with or without preoperative neoadjuvant treatment.
4. Perform gross examinations of small intestinal resection specimens with non- neoplastic diseases, (ie, idiopathic inflammatory bowel disease, infarct/ischemia, and trauma) and section them appropriately to document the extent and severity of the pathological process.
5. Recognize situations in which special specimen processing may be necessary (eg, electron microscopy for suspected microvillous inclusion disease, frozen/fresh tissue for enzyme analysis).

Testing Methods

1. Recommend serologic testing for antibodies, when appropriate, based on clinical- pathologic correlative questions.
2. Utilize cytogenetics for the work-up of mesenchymal neoplasms of the small intestine.
3. Employ special histochemical stains, immunohistochemical stains, and other tests (electron microscopy) to confirm a diagnosis of microvillus inclusion disease.
4. Use immunohistochemical or histochemical stains to increase detection of mast cells.
5. Use immunohistochemical staining menus and flow cytometry for the diagnosis and classification of hematolymphoid neoplasms.
6. Utilize stains assessing the cell cycle (such as Ki67) to appropriately grade neuroendocrine neoplasms.
7. Utilize immunohistochemical staining menus to differentiate primary from secondary tumors involving the small intestine.
8. Employ special histologic and immunohistochemical stains to detect bacterial, mycobacterial, fungal, viral, and parasitic infectious agents.
9. Use special histologic stains for the diagnosis of amyloidosis.

Differential Diagnosis

1. Identify common artifacts that may be seen in small intestinal biopsies and the diseases they may mimic.
2. Differentiate true invasion in epithelial tumors from its histologic mimics.
3. Use differential diagnostic considerations to diagnose vascular abnormalities in the small intestine.
4. Apply differential diagnostic considerations for erosive/ulcerative injury to diagnose appropriately.
5. List the differential diagnostic considerations for increased intraepithelial lymphocytes (eg, Celiac, Crohn’s disease, bacterial overgrowth, drug effect, collagenous and lymphocytic colitis).
6. List the differential diagnostic considerations for increased mucosal eosinophils.
7. List the differential diagnostic considerations for malabsorption/steatorrhea.
8. Outline the range of findings and the differential diagnostic considerations that can be seen with graft-versus host disease of the small intestine.
9. Describe the range of findings and differential diagnostic considerations for diagnosing acute cellular and antibody mediated rejection in small intestinal allografts.
10. Provide a differential diagnosis for small intestinal crypt apoptosis.
11. List the differential diagnostic considerations for granulomas in the small intestine.
12. Identify and assess severity of villous blunting (mild, moderate and marked).
13. Identify intraepithelial lymphocytosis and provide a differential diagnosis for cases with these findings.
14. Provide a differential diagnosis for subepithelial mesenchymal or spindle-cell neoplasms of the small intestine.
15. Provide a differential diagnosis for epithelial/epithelioid neoplasms of the small intestine.
16. Compare the changes in histology expected in acute, chronic intermittent, and healed ischemic damage.
17. Report the differential diagnoses associated with foveolar metaplasia with or without activity at different anatomic sites.

Treatment Implications

1. Recognize long-term sequelae following corrosive injury, radiation changes, thermal burns, and ulcers from medication effect and due to chemotherapy.
2. Recommend genetic testing and or genetic counseling based on rendered diagnoses, as appropriate.
3. Recognize the risk of synchronous and metachronous tumors in patients in whom a hamartomatous polyp is identified.
4. Recognize the treatment implications of the mutation status of gastrointestinal stromal tumors.
5. Recognize syndromic associations with neuroendocrine neoplasms of the small bowel.

Reporting and Communication

1. Suggest to the gastroenterologist additional clinical features that may need to be considered in the work-up of a disorder.
2. Utilize the accepted terminology for reporting UICC/ AJCC TNM staging of malignant neoplasms, as appropriate.
3. Recognize critical results necessitating immediate contact with clinicians (eg, infection in an immunocompromised host, GVHD, small bowel transplant rejection, new/unsuspected diagnosis of malignancy).
4. Provide appropriate comments and recommendations for cases in which findings are not specific, but rather which raise a differential diagnosis that requires additional testing or work-up.
5. Define a process for implementing the appropriate timing of reporting results.
6. Provide the appropriate histologic grade for cases of small intestinal transplant rejection.
7. Provide grading information for neuroendocrine neoplasms using accepted classification schemata.

Disease Types

1. Recognize the features of invasive carcinoma in endoscopic biopsies, polypectomies, and resection specimens.
2. Recognize the endoscopic and histological findings for the various patterns of chronic inflammatory bowel disease (ie, Crohn’s disease, ulcerative colitis, indeterminate colitis, and fulminant colitis).
3. Identify the common clinical presentation and spectrum of histologic changes of microscopic colitis (lymphocytic and collagenous colitis).
4. Identify the common clinical presentation and histologic features of pseudomembranes in biopsy and resection specimens.
5. Identify the clinical setting and histologic findings that suggest mucosal prolapsed.
6. Recognize the spectrum of morphologic changes that occur in drug-induced colonic injury (ie, NSAIDs).
7. Recognize histologic features of graft-versus-host disease.
8. Recognize the epidemiology and gross/microscopic changes in the large bowel caused by commonly encountered infectious agents (ie, viral such as CMV and adenovirus, mycobacterial, cryptosporidium, spirochetes, bacterial, protozoal, and helminthic organisms).
9. Recognize the clinical symptoms, endoscopic, histological findings, and common complications of diverticular disease.
10. Identify the histologic features of the types of polyps that can occur in the large intestine.
11. Describe the morphologic features of epithelial tumors/polyps that suggest inherited syndromes with and without associated increased cancer risk.
12. Recognize non-epithelial neoplasms (ie, endometriosis, granular cell tumor, leiomyoma, GIST, lymphangioma, lymphoma, melanoma, lipoma, hemangioma, Kaposi sarcoma, sarcoma, and Schwannoma).
13. Recognize features of neuroendocrine neoplasms.
14. Identify the histologic features that suggest ischemia.

Specimen Handling

1. Manage endoscopic mucosal, submucosal, and transanal resection specimens appropriately for histologic examination, including evaluation of margins.
2. Examine grossly and section large intestinal resection specimens appropriately from all anatomic sites for accurate diagnosis, grading, and staging for epithelial and non-epithelial neoplasms, with or without neoadjuvant treatment.
3. Describe assessment of the mesorectal envelope in rectal cancers (incomplete, nearly complete, complete.
4. Perform gross examinations of large intestinal resection specimens with non- neoplastic diseases, including idiopathic inflammatory bowel disease, infarct/ischemia, diverticular disease, and trauma, and section them appropriately to document the extent and severity of the pathological process.
5. Describe appropriate specimen handling in cases of suspected hematolymphoid neoplasia involving the large intestine.
6. Describe strategies for managing technical limitations in specimens (ie, histologic/processing artifact, inadequate tissue).

Testing Methods

1. Use immunohistochemical staining menus for the classification and diagnosis of primary and metastatic epithelial, non-epithelial, hematolymphoid neoplasms involving the large intestine.
2. Utilize immunohistochemical stains to assist in diagnosis and grading of neuroendocrine neoplasms.
3. Use an immunohistochemical approach to diagnose a mesenchymal neoplasm of the large intestine.
4. Use special histological and immunohistochemical stains to detect microorganisms in large intestinal specimens.
5. Recommend flow cytometry appropriately in cases in which clinical and endoscopic features suggest a possible hematolymphoid neoplasm.
6. Interpret the results of Masson staining for use in the diagnosis of collagenous colitis.
7. immunohistochemical stains for DNA mismatch repair proteins.
8. Correlate the results of molecular analyses for BRAF/KRAS mutations in primary/metastatic colorectal carcinoma with the impact on adjuvant therapy and prognosis.
9. Correlate the site of c-KIT mutations in GISTs with their neo-/adjuvant therapy implications.

Differential Diagnosis

1. Differentiate the clinical, endoscopic, gross, and microscopic features of ulcerative colitis, Crohn’s disease, and acute self-limited colitis.
2. Differentiate dysplasia in the setting of inflammatory disease from reactive epithelial changes.
3. List the differential diagnostic considerations for bloody diarrhea, non-bloody diarrhea, and constipation in light of the clinical scenario.
4. Outline the differential diagnostic considerations for increased intraepithelial and lamina propria eosinophils.
5. Generate a differential diagnosis for large intestinal crypt epithelial apoptosis.
6. List the differential diagnostic considerations for granulomas and their mimics in the large intestine.
7. Differentiate the clinical, endoscopic, gross, and microscopic features of epithelial lesions (ie, polyps and tumors).
8. Generate a differential diagnosis non-epithelial spindle cell and epithelioid neoplasms of the large intestine.
9. Compare the changes in histology expected in acute versus chronic intermittent or healed ischemic damage.
10. Differentiate the etiologies of pseudomembranes based on clinical, gross, and microscopic findings.
11. Identify common artifacts that may be seen in large intestinal biopsies and the diseases they may mimic.

Treatment Implications

1. Recognize sequelae following corrosive injury, radiation changes, medication effect, and chemotherapy.
2. Recognize the potential treatment implications of identifying dysplasia in colons affected by inflammatory bowel disease.
3. Report the salient features of invasive carcinomas arising within polyps necessary to guide further treatment.
4. Compare inherited tumor syndromes involving the colon and recognize the risk of developing synchronous and metachronous neoplasms in other organs.
5. Recognize the clinical, endoscopic and histologic features of advanced adenomas and the screening implications.
6. Utilize histologic criteria to stratify the risk of a gastrointestinal stromal tumor’s aggressive behavior.

Reporting and Communication

1. Recognize critical results necessitating immediate contact with clinicians (eg, infection in an immunocompromised host, high-risk infections, GVHD, new/unsuspected diagnosis, suspected perforation).
2. Provide appropriate comments and recommendations for cases in which findings are not specific, but rather which raise a differential diagnosis that requires additional testing or work-up.
3. Complete synoptic reports for colorectal neoplasms, as appropriate.
4. Utilize the accepted terminology for reporting the AJCC TNM staging of malignant neoplasms, as appropriate.
5. Use appropriate terminology to describe neuroendocrine neoplasms
6. 6. Integrate the results of ancillary studies (ie, molecular) into a report for a colorectal neoplasm.

1. Perinatal Pathology

2. Placental Pathology

3. Gastrointestinal

4. Liver Pathology

5. Pulmonary Pathology

Specimen Handling (include stillbirths)

1. Confirm identity of the infant utilizing autopsy consent form and body identification tags/bands
2. Determine autopsy consent restrictions as recorded on the consent form and adhere to those restrictions or if the scope of the permission is uncertain obtain clarification from the responsible clinician
3. Review appropriate clinical charts prior to performing an autopsy
4. Perform routine specimen radiographs as clinically appropriate
5. Photograph autopsy specimens adequately to document the external, internal and radiographic findings
6. Perform internal examination utilizing standard dissection techniques and a systematic format
7. Record relevant weights and measurements using a standard reference table of normal ranges
8. Examine the brain, meninges and pituitary if included in autopsy consent
9. Fix brain prior to cutting and sampling if allowed by autopsy consent
10. Select appropriate tissue samples from major organs for microscopy and stock storage.

Ancillary Studies (include skeletal dysplasias, metabolic disease, stillbirths)

1. Specify optimal sampling sites and tissue handling requirements for cytogenetic testing
2. Describe the importance of autopsy radiologic evaluation of fetuses and neonates with known or suspected skeletal dysplasias, growth anomalies or congenital anomalies
3. Determine when to request a Kleihauer-Betke test or equivalent to look for fetal maternal hemorrhage in cases of stillbirth or unexplained neonatal death with neonatal anemia
4. Communicate to clinicians the importance of thorough placental examination in cases of unexplained stillbirth or perinatal death
5. Determine when it is appropriate to perform a metabolic autopsy including the timing and handling of required tissue samples
6. Determine ancillary tissue sampling appropriate for autopsy investigation of neonatal hydrops fetalis
7. Select appropriate samples for microbiologic studies for evaluation of possible intrauterine or perinatal infection

Reporting and Communication

1. Prepare a well-organized, thorough provisional autopsy report within 2 working days including at least principal findings
2. Perform appropriate literature searches to support pathologic findings with citation of references in the autopsy report as appropriate
3. Communicate results to clinicians and quality assurance committees and families, as appropriate
4. Communicate discrepancies between prenatal/premortem diagnoses and autopsy findings to relevant clinicians
5. Generate a clear, concise final autopsy report that integrates clinical history, gross and microscopic findings, placental review, ancillary testing and clinicopathologic correlations

Complications of Prematurity (include NEC, BPD, and IVH)

1. Identify the major organ systems that are affected by prematurity
2. Identify the gross and histologic features of the bowel in necrotizing enterocolitis
3. Identify the gross and histologic features of bronchopulmonary dysplasia
4. Distinguish the phases of lung development in order to evaluate for pulmonary hypoplasia
5. Diagnose diffuse lung disease in children following current classifications where applicable
6. Classify the severity of intraventricular hemorrhage and correlate with the clinical history and imaging findings

Chromosomal Abnormalities (include common aneuploidies)

1. Select the samples in a fetal or perinatal autopsy that are most likely to promote growth in culture for a successful cytogenetic analysis
2. Recognize the pertinent phenotypic features associated with the three commonest autosomal trisomies seen at autopsy (the "surviving" trisomies, 21, 18, and 13)
3. Identify the pertinent phenotypic features associated with monosomy X/Turner syndrome
4. Outline the major clinical and pathologic features of selected syndromes associated with partial aneuploidy
5. Summarize the cytogenetics, molecular genetics, and clinical features of chromosomal instability syndromes
6. Identify the pertinent clinical features, major congenital malformations and methodologies to diagnose velocardiofacial/DiGeorge syndrome and other microscopic chromosomal anomalies
7. Identify the pertinent phenotypic features in the most common pediatric imprinting disorders, namely,
8. Beckwith-Wiedemann, Prader-Willi, and Angelman syndromes

Infectious and Inflammatory Conditions (include stillbirths)

1. Identify the major congenital immunodeficiencies that are associated with an increased risk of sepsis and their characteristic associated infectious agents to guide the microbiology diagnostic workup
2. Recognize the spectrum of adverse fetal outcomes that can complicate intrauterine infections with TORCH agents according to the particular organism and the timing of the insult
3. Recognize particular clinical scenarios that should initiate an infectious disease workup in a perinatal or infant autopsy
4. Outline a procedure for the autopsy evaluation of stillborn fetuses, neonates, or infants with suspected infectious causes of death, incorporating appropriate ancillary studies
5. Identify the major etiologic microbial agents responsible for early- and late-onset neonatal sepsis
6. Identify the potential fetal and newborn complications associated with maternal Group B Streptococcus colonization/infection
7. Outline the major clinical, gross pathologic, and diagnostic laboratory features in fetal and neonatal syphilis
8. Define the criteria for HIV infection in infants and children

Developmental Defects (include multiples, stillbirths)

1. Specify the process (steps) involved in the diagnostic workup of a hydropic fetus (immune and nonimmune hydrops fetalis)
2. Distinguish between syndrome, sequence, malformation, deformation, using particular examples likely to be encountered in a perinatal autopsy (eg, Potter/oligohydramnios sequence vs. Meckel syndrome)
3. Identify the salient features of the major teratogenic disruptions, namely, embryopathies induced by thalidomide, folic acid antagonists and derivatives, valproic acid, warfarin, isoretinoin, alcohol (fetal alcohol syndrome), and diphenylhydantoin
4. Identify the major fetal anomalies associated with maternal diabetes
5. Identify the spectrum of fetal defects associated with the amnion rupture disruption sequence (ADAM complex)
6. Recognition of postmortem/in utero changes and distinguish them from true pathologic alterations

Specimen Handling

1. Utilize a systematic approach in the gross examination of the placenta
2. Identify lesions on the fetal and maternal surfaces and within the parenchyma
3. Identify defects in membranous insertion
4. Demonstrate how to examine an umbilical cord and its salient features including the site of insertion, number of vessels, length, etc
5. Demonstrate appropriate sectioning techniques and tissue to submit for microscopic examination of both singleton and multiple gestation placentas
6. Photograph specimens adequately to document the gross appearance and lesions of the placenta

Ancillary Studies

1. Identify the particular indications that warrant the use of ancillary testing in the differential diagnosis of complete and partial hydatidiform moles and hydropic abortuses, in particular, ploidy analysis and immunohistochemistry analysis for p57KIP2
2. Identify when and how to obtain samples for cytogenetic (chromosomal) analysis from the placenta
3. Perform the procedure for obtaining samples for microbial culture from the placenta in cases of suspected amniotic fluid infection or infectious villitis
4. Recognize the rationale for obtaining both embryonic (fetal) and placental tissue for cytogenetic analysis in cases of suspected confined placental mosaicism (CPM)
5. Utilize appropriate immunohistochemical profiles in the differential diagnosis of diseases of extravillous trophoblast, namely, placental site nodule, exaggerated placental site, placental site trophoblastic tumor, and epithelioid trophoblastic tumor
6. Identify the pathologic findings within the placenta that would lead the pathologist to suggest a thrombophilia workup to the clinician.

Reporting and Communication

1. Communicate critical pathology results in a timely fashion (eg, placentas from babies in NICU, cases of acute chorioamnionitis, infectious villitis)
2. Develop a mechanism to communicate clear, accurate and complete placental pathology results and clinical implications to the newborn`s and mother`s clinical team
3. Demonstrate willingness and ability to discuss current results and patient issues with clinicians, ultrasonographers, multidisciplinary health care teams and, if needed, expert consultants and patients
4. Utilize a standardized placental pathology reporting format derived from published sources

Disorders of placental development (include tumors)

1. Distinguish between circumvallate and circummarginate membrane insertion
2. Recognize abnormalities of the umbilical cord including umbilical cord length, coiling index, insertion site, true and false knots, and umbilical vessel number
3. Diagnose disorders of placental implantation such as placenta accreta/increta/percreta, superficial implantation and exaggerated placentation
4. Diagnose abnormal villous development including distal villous hypoplasia and villous immaturity
5. Identify disorders of fetal vascular development including chorangiosis, chorangioma, and chorangiomatosis
6. Recognize placental changes seen in metabolic storage disease, chromosomal abnormalities, and mesenchymal dysplasia
7. Diagnose placental metastases from maternal malignancies
8. Recognize postmortem in utero changes in the placenta and distinguish them from true pathologic alterations
9. Classify benign tumors in the placenta, including chorangioma, leiomyoma, heterotopic liver, and heterotopic adrenal
10. Recognize morphologic changes in the placenta that could be associated with later development of cerebral palsy
11. Distinguish between placentas with accessory lobes, multilobation and monochorionic multiple gestation

Infectious and Inflammatory Conditions

1. Grade and stage acute chorioamnionitis
2. Identify the patterns of fetal acute inflammatory response (eg, acute funisitis and chorionic vasculitis)
3. Identify the patterns of villitis caused by organisms such as Listeria, E. coli, and TORCH organisms
4. Diagnose non-infectious inflammatory lesions including villitis of unknown etiology, chronic histiocytic intervillositis, lymphoplasmacytic deciduitis, and eosinophilic/T-cell chorionic vasculitis
5. Inform the appropriate public health authority of placental infections due to reportable microorganisms

Circulatory Disorders of Maternal and Fetal Vasculature

1. Specify compartments of the placenta that contain maternal versus fetal blood
2. Identify histologic features of maternal decidual vasculopathy
3. Identify histologic features of fetal thrombotic vasculopathy
4. Correlate clinical history with signs of abnormal maternal and fetal blood flow in the placenta
5. Identify gross and histologic features that correlate with clinical abruption and retained placenta
6. Correlate the presence of intravillous circulating fetal normoblasts during the first, second and third trimesters with clinical relevance

Multiples

1. Determine placentation type (chorionicity) of a multiple placenta
2. Identify abnormal cord insertions
3. Examine all monochorionic twin placentas for vascular anastomoses by performing a gross examination and including injection technique for demonstrating artery-to-vein (A-V) anastomoses when appropriate
4. Recognize the placental changes seen in twin-twin transfusion syndrome
5. Detect the placental changes seen in twin-reversed arterial perfusion (TRAP) sequence
6. Identify fetal remnants in cases of intragestational loss or selective fetal reduction
7. Recognize sites of prenatal laser ablation therapy

Specimen Handling/Ancillary Studies

1. Ensure correct specimen identity by secure patient identification, specimen labeling, completion of requisition form, etc, according to local laboratory practice
2. Review clinical and radiologic information before specimen grossing for large and/or complex specimens, when appropriate
3. Take photographs of non-biopsy resection specimens, when appropriate
4. Evaluate adequacy and proper orientation of the histologic sections of GI specimens
5. Ensure appropriate collection and handling of specimens for additional studies as needed
6. Recognize the utility of frozen sections performed during surgical procedures for Hirschsprung Disease
7. Utilize appropriate histochemical and immunohistochemical stains

Reporting and Communication

1. Generate accurate, clear, and concise reports (including synoptic reports, when appropriate) that effectively communicate results and therapeutic implications to the patient`s health care team
2. Integrate results of ancillary testing into the final diagnosis
3. Communicate significant and unexpected findings and anticipated delays in diagnosis, and document these preliminary communications (with date, time, and the name of the person to whom findings were reported) in the final report
4. Demonstrate willingness and ability to discuss results with the multidisciplinary health care team

Developmental Anatomy and Anomalies

1. Review the major anatomic aspects of embryologic development of the gastrointestinal tract and clinically relevant molecular details involved in the pathogenesis of common congenital anomalies
2. Recognize the disorders more commonly associated with specific gastrointestinal malformations (eg, stenoses, atresias)
3. Recognize cystic and tubular duplications
4. Describe the spectrum of omphalomesenteric remnants, including Meckel's diverticulum
5. Recognize abnormalities of gastrointestinal rotation and fixation
6. Recognize common heterotopias of the GI tract
7. Recognize the histopathologic features and clinical presentation of intussusception
8. Competency Area: Esophageal Disorders
9. Recognize the clinical features and histopathologic changes in gastroesophageal reflux in children
10. Relate the endoscopic and histopathologic features and the role of special stains in making the diagnosis of Barrett esophagus in children
11. Identify the pathologic changes, clinical features, and commonly associated conditions of eosinophilic (allergic) esophagitis
12. Specify the elements to include in a pathologic report when evaluating a case for eosinophilic esophagitis
13. Contrast the pathologic changes of eosinophilic esophagitis with the changes of reflux esophagitis and recognize the challenges in discriminating the two conditions
14. Distinguish between the common types of infectious esophagitis in children and relate the pathologic features and ancillary stains helpful in diagnosing them
15. Recognize the most common pathologic findings in systemic diseases involving the esophagus, including inflammatory bowel disease, connective tissue diseases, and immunodeficiency

Gastropathies

1. Recognize the endoscopic and morphologic features of Helicobacter gastritis in children and relate the most common ancillary tests for diagnosis, the post-therapy pathologic changes, and the potential complications
2. Recognize the etiologies and pathologic changes of reactive and chemical gastropathies in children
3. Contrast the etiologic agents, pathologic changes, and clinical outcome of Menetrier disease in children and adults
4. Recognize the most common pathologic findings in systemic diseases involving the stomach in children, including inflammatory bowel disease, eosinophilic disorders, and autoimmune disorders

Enteropathies Associated with Diarrhea and Malabsorption

1. Recognize the value and limitations of the intestinal biopsy in the evaluation of diarrhea and malabsorption in the pediatric age group
2. Recognize the major histologic features in intestinal biopsies of disorders of epithelial differentiation such as microvillous inclusion disease, enteroendocrine cell deficiency, and tufting enteropathy
3. Review the clinicopathologic features of celiac disease, including serologic diagnosis, immunologic workup, associated disorders, and differential diagnosis
4. Recognize the major categories of eosinophilic GI disorders and their differential diagnoses
5. Identify the characteristic histologic features of the major primary immunodeficiency disorders in intestinal biopsies
6. Recognize the primary and secondary causes of intestinal lymphangiectasia

7. Recognize the histologic features of common small and large bowel infectious causes of diarrhea such as giardiasis and amebiasis

Immunodeficiencies

1. Review the clinicopathologic features of autoimmune enteropathy, including serologic diagnosis, immunology workup, associated systemic conditions, and histologic and immunohistochemical features
2. Identify the primary immunodeficiency disorders with prominent gastrointestinal manifestations
3. Recognize the clinicopathologic features of gastrointestinal manifestations of primary B-lymphocytes disorders, including X-linked agammaglobulinemia, common variable immunodeficiency, and IgA deficiency
4. Recognize the clinicopathologic features of gastrointestinal manifestations of primary T-lymphocyte defects, including DiGeorge syndrome, ataxia telangiectasia, Wiskott-Aldrich syndrome, and X-linked hyper-IgM syndrome
5. Review the clinicopathologic features of gastrointestinal manifestations of severe combined immunodeficiency and its variants
6. Review the clinicopathologic features of gastrointestinal manifestations of chronic granulomatous disease, leukocyte adhesion deficiency, and autoimmune polyglandular syndrome
7. Review the clinicopathologic features of HIV enteropathy
8. Recognize the histology, ultrastructural features, microbiologic diagnosis, and molecular diagnosis of gastrointestinal infections common in immunocompromised patients, including bacteria
9. (Mycobacterium avium complex, Mycobacterium tuberculosis, Spirochetosis), parasitic
10. (Cryptosporidium, Isospora belli, Microsporidium, Toxoplasma), fungal, and viral infections

Enterocolitis\Colitis

1. Recognize artifacts produced by bowel preparations and biopsy procedures and distinguish them from disease
2. Recognize the histologic features and complications of acute appendicitis and the changes in interval appendectomy specimens
3. Recognize the histologic features of infectious (self-limited) colitis and distinguish them from chronic inflammatory bowel disease
4. Outline the differential diagnosis of granulomatous colitis in the pediatric age group
5. Recognize the histologic features of pouchitis and diversion colitis
6. Recognize the histologic features of medication-induced abnormalities
7. Recognize the histologic features of vasculitides affecting the colon such as HSP (Henoch–Schönlein purpura) and HUS (hemolytic uremic syndrome)
8. Recognize the histopathologic features and clinical presentation of NEC (necrotizing enterocolitis) and solitary intestinal perforation of prematurity

Intestinal Motor Disorders

1. Define the diagnostic criteria for Hirschsprung Disease, including histopathologic criteria for biopsy adequacy
2. Recognize the utility of calretinin and acetylcholinesterase stains in the diagnosis of Hirschsprung Disease
3. Recognize the features of the transition zone between aganglionic and normal bowel segments and how to identify them in intraoperative frozen sections
4. Recognize the histologic changes, including cellular inclusions, which are seen in cytologic enteric neuropathies
5. Recognize the primary and secondary enteric myopathies that may present with intestinal pseudoobstruction

Polyps and Tumors

1. Recognize the clinical, gross and microscopic features of a juvenile polyp, including when and how to diagnose a juvenile polyposis syndrome
2. Relate the clinical, morphologic, and genetic characteristics of major hamartomatous polyposis syndromes in children, including Peutz-Jeghers, Cowden, Bannayan-Riley-Ruvalcaba, and Proteus
3. Recognize the pathologic features and significance of adenomatous polyps in the gastrointestinal tract of children
4. Relate the clinical, genetic, and pathologic findings of familial adenomatous polyposis and its variants (Gardner and Turcot syndromes)
5. Relate the clinical and pathologic features of inflammatory, hyperplastic, and lymphoid polyps in children
6. Identify the subtypes of colorectal carcinoma seen in children and genetic syndromes associated with them
7. Discriminate between the most common types of stromal tumors of the gastrointestinal tract, including their morphologic features and immunohistochemical profiles
8. Recognize the histopathologic features of ganglioneuromatous polyps and associated syndromes
9. Recognize the types, clinical presentation, and pathologic findings of lymphoproliferative disorders seen in the gastrointestinal tract of children
10. Recognize gastrointestinal neuroendocrine tumors and their management implications in children
11. Recognize common benign masses such as lymphatic malformations and vascular tumor

Specimen Handling/Ancillary Studies

1. Review clinical history, family history, clinical diagnoses, results of laboratory testing and any other information provided by the clinicians to formulate a differential diagnosis
2. Use the clinicopathologic differential diagnosis to guide processing of the sample and the selection of ancillary tests that will need to be performed
3. Define broad diagnostic categories (cholestasis, syndromic and nonsyndromic paucity, familial cholestatic syndromes, neonatal/infantile hepatitis, acute liver failure, chronic hepatitis, metabolic disorders) and establish a diagnostic algorithm using ancillary testing (light microscopy, electron microscopy, enzyme testing, molecular testing, other) to rule in/rule out given entities
4. Choose appropriate processing conditions (fixative, storage medium, storage temperature) to triage samples according to the testing algorithm suggested by the clinical presentation
5. Define major patterns of injury and their findings on light microscopy, electron microscopy, enzyme testing, and molecular testing
6. Formulate criteria for the selection of reference laboratories for the performance of ancillary testing of liver biopsy samples

Reporting and Communication

1. Integrate the clinical information, histology, ultrastructure, and biochemical and molecular findings to suggest a differential diagnosis or to formulate a specific diagnosis
2. Describe the clinicopathologic and ultrastructural features of entities leading to neonatal cholestasis
3. Review the different grading schemes for the activity and stage of chronic hepatitis and select the appropriate scheme to report in a given clinical situation
4. Use the components of NAFLD Activity Score (NAS) and Fibrosis Staging to report on the activity and stage of nonalcoholic steatohepatitis
5. Integrate the clinical and epidemiologic information with the histologic and ultrastructural features, and include the results of the ancillary tests (including genetic testing) and suggestions for further testing in your reports on metabolic disorders of the liver
6. Integrate the clinicopathologic features of acute liver failure and include a differential diagnosis, prognosis and recommendation for further testing of the patient and/or family (if appropriate) in your reports

Developmental Anatomy, Histology, and Congenital Anomalies of the Liver, Gallbladder, and Extrahepatic Biliary Tree

1. Review the embryologic development of the liver and biliary tree
2. Review the developmental structural anomalies of the liver, including situs anomalies
3. Recognize the histopathologic changes in the liver during fetal development and neonatal life
4. Review the developmental structural anomalies of the gallbladder and extrahepatic biliary tree
5. Recognize the histopathologic features of the liver in the various ciliopathies
6. Recognize the disorders associated with ductal plate malformation

Diseases of the Biliary Tree

1. Identify the major differential diagnosis of cholestasis in infancy and its clinical and laboratory evaluation
2. Recognize the histologic features of obstructive cholestasis in a liver biopsy and outline its differential diagnosis
3. Be familiar with the various clinical types of biliary atresia
4. Outline the causes of sclerosing cholangitis in childhood
5. Recognize the criteria for bile duct paucity in a liver biopsy and its differential diagnosis

Familial Hepatocellular Cholestatic Diseases

1. Recognize the differential diagnosis of high and low GGT-associated liver disease
2. Be familiar with the genetic basis of bile acid synthetic disorders and the different types of progressive familial intrahepatic cholestatic disorders
3. Be familiar with the use and pitfalls of immunohistochemistry in the investigation of cholestasis in a liver biopsy
4. Outline the differential diagnosis of unconjugated hyperbilirubinemia

Hepatitis and Liver Failure

1. Recognize the clinicopathologic features of congenital and neonatal hepatitis and define the histologic features that distinguish neonatal hepatitis from extrahepatic biliary obstruction
2. Identify the possible etiologies of congenital and neonatal hepatitis and the histologic and ultrastructural features that help to narrow down the differential diagnosis
3. Employ ancillary testing to rule in/out infectious, autoimmune, metabolic, and/or toxic etiologies
4. Identify the clinicopathologic features of chronic hepatitis and define histologic features that favor an infectious, autoimmune, drug-induced, metabolic, or other etiology
5. Formulate a differential diagnosis of the etiology of chronic hepatitis and rule them in/out by integrating the clinical, epidemiological, histological, ultrastructural features and the results of ancillary testing
6. Review the different grading/staging schemes for chronic hepatitis, and recognize the most appropriate to the clinical situation and clinician need/preference
7. Recognize the clinicopathologic features of acute liver failure, including the Pediatric ALF study group diagnostic criteria of acute liver failure
8. Identify possible etiologies of acute liver failure, according to the patient’s age and clinical history, and how to rule them in/out by integrating clinical, histologic, ultrastructural, biochemical, and genetic information

Metabolic Disorders

1. Recognize the histologic patterns of liver involvement by metabolic disorders in childhood
2. Identify the clinical, histologic, ultrastructural, biochemical, and molecular and genetic features of alpha-1 antitrypsin deficiency
3. Define the clinical, histologic, ultrastructural, biochemical, and molecular and genetic features of Wilson’s disease
4. Review the clinical, histologic, ultrastructural, biochemical, and molecular and genetic features of familial intrahepatic cholestasis, Allagile’s syndrome, bile acid synthesis defects, and other causes of neonatal cholestasis
5. Recognize the clinical, histologic, ultrastructural, biochemical, molecular and genetic features of the most common storage diseases affecting the liver in children: mucopolysaccharidoses, glycogen storage diseases, Niemann-Pick (type A, B ,C), and sphingolipidoses (Gaucher), and Wolman disease/cholesterol ester storage disease
6. Define the clinical, histologic, ultrastructural, biochemical, molecular and genetic features of the most common etiologies of liver steatosis in children: steatohepatitis of childhood, mitochondrial disorders including defects of beta oxidation, fructose intolerance, galactosemia, and urea cycle disorders
7. Recognize the risk of regenerative nodules, adenomas and hepatocellular carcinoma in metabolic diseases affecting the liver in children

Specimen Handling/Ancillary Studies

1. Evaluate clinical records, chest imaging studies, and communications with pediatric pulmonologists, neonatologists, and other treating physicians prior to handling and interpreting lung biopsy and lobectomy specimens
2. Triage wedge lung biopsies to maximize the diagnostic yield, including tissue collection for morphologic and ancillary studies (microbiology cultures, molecular testing, electron microscopy, and immunofluorescence study)
3. Recognize the potential indications for electron microscopy on pediatric lung biopsy specimens
4. Apply special specimen handling techniques to distinguish bronchial atresia from other congenital pulmonary airway malformations
5. Compare measured values to expected values for lung weight, lung/body weight ratio, and lung volume to evaluate for pulmonary hypoplasia and pulmonary hyperplasia during postmortem examination
6. Inflate wedge lung biopsy, lobectomy, pneumonectomy, and autopsy lung specimens for fixation prior to sectioning
7. Select tissue sections from pediatric lobar or explant lung specimens to optimize diagnosis of neoplastic and non-neoplastic disease and to allow staging of neoplasms
8. Select appropriate special stains in the diagnostic evaluation of diffuse lung disease in children, for example, PAS, trichrome/pentachrome, iron, oil red O (Bronchoalveolar Lavage (BAL) specimens), and bombesin

Developmental Anatomy and Histology

1. Apply the embryologic development of the respiratory tract to major malformations of the upper respiratory tract and lungs such as tracheoesophageal fistula and pulmonary agenesis
2. Correlate the histologic lung developmental stage with gestational age
3. Specify the relevant major molecular events of lung development
4. Correlate disorders associated with specific lower respiratory malformations (eg, agenesis, abnormal lobation, fistulas, and atresias) with major clinical syndromes and disorders
5. Evaluate lung histopathology of prematurity

Pulmonary Vascular Disease

1. Recognize the histopathology and molecular indicators of fetal and postnatal pulmonary vascular development
2. Identify the histologic and hemodynamic changes of pulmonary vascular tree at the transition period from intrauterine life to air-breathing
3. Specify the clinicopathologic features of neonatal lung disorders associated with pulmonary hypertension
4. Recognize disorders leading to pediatric pulmonary hypertension in childhood, including congenital heart disease
5. Review the genetics of familial pulmonary hypertension
6. Identify pulmonary vascular changes and lung findings associated with congenital heart disease
7. Recognize the conditions that lead to pulmonary lymphatic disorders
8. Competency Area: Congenital Anomalies and Cystic Lung Disorders
9. Relate the spectrum of pulmonary hyperplasia in the fetus/neonate to the level of fetal airway obstruction, including laryngeal atresia, solid or adenomatoid cystic adenomatoid malformation (Stocker type 3), and polyalveolar lobe
10. Identify the spectrum of gross and histologic features seen in bronchial atresia
11. Distinguish the pathologic features of the following bronchopulmonary abnormalities; eg, large cyst type congenital pulmonary airway malformation (CPAM), small cyst type CPAM, intralobar sequestration, extralobar sequestration, bronchogenic cyst, and congenital lobar overinflation
12. Recognize both the primary (eg, acinar dysplasia) and secondary causes (eg, congenital diaphragmatic hernia) of lung hypoplasia in the fetus/neonate
13. Identify the gross and histologic features of pulmonary hypoplasia, and recognize the clinical significance of these findings

Genetic Disorders

1. List the differential diagnosis of developmental and acquired lung diseases associated with Down syndrome (trisomy 21)
2. Identify the typical pulmonary manifestations of cystic fibrosis
3. Recognize normal ciliary movement, normal ciliary ultrastructure, and the pathologic features associated with primary ciliary dyskinesia
4. Distinguish the microscopic features of alveolar capillary dysplasia from other forms of neonatal pulmonary hypertension and developmental disorders of the lung
5. Recognize the clinical and microscopic phenotypes associated with TTF1 (NKX2-1) deficiency
6. List the genetic abnormalities associated with emphysema and lung cysts in children and young adults
7. Recommend appropriate molecular testing for known genetic disorders of the pediatric respiratory tract based on integration of clinical and pathologic findings

Diffuse Lung Disease

1. Diagnose diffuse lung disease in infants and young children utilizing the children’s interstitial lung disease (chILD) classification when applicable
2. Recognize the different phases of lung development in order to identify potential abnormalities in lung development (acinar dysplasia) and lung growth (pulmonary hypoplasia, chronic neonatal lung disease of prematurity)
3. Recognize alveolar simplification reflective of a lung growth abnormality and the common clinical settings in which it occurs
4. Recognize the characteristic histologic and ultrastructural features of pulmonary interstitial glycogenosis and evaluate for common comorbidities
5. Identify the criteria for diagnosing neuroendocrine cell hyperplasia of infancy including biopsy adequacy, bombesin immunohistochemical staining for assessing neuroendocrine cells, and correlation with the clinical history and radiographic appearance

Disorders of Surfactant Metabolism

1. Identify etiologies of primary and secondary pulmonary alveolar proteinosis
2. Recognize the histologic patterns associated with disorders of surfactant metabolism
3. Communicate a differential diagnosis of inherited disorders of surfactant metabolism based on the histopathologic findings and clinical history
4. Recognize the value and limitations of electron microscopy in evaluating for inherited disorders of surfactant metabolism
5. Comeptency Area: Tumors
6. Identify the gross and histologic features of pleuropulmonary blastoma (PPB), including types IR, I, II, and III.
7. Recognize the genetic implications (e.g. DICER-1) of a PPB diagnosis.
8. Differentiate low-grade cystic (Type I) PPB from non-neoplastic cystic lung lesions of the pediatric population, particularly blebs, bullae, and CPAMs.
9. Recognize the importance of adequate sampling in the diagnosis of Type I PPB
10. Recognize the spectrum of pathologic lesions associated with DICER-1 predisposition syndrome.
11. List the differential diagnosis of endobronchial tumors seen in children.

1. Identify where the conduction system is in the heart and how to excise it for cutting for referral
2. Develop knowledge of how to section the conduction system
3. Recognize the conduction system by microscopy
4. Know the normal aging changes and variations associated with the conduction system
5. Develop knowledge of the common systemic diseases affecting the conduction system
6. Develop knowledge of the common conduction system diseases, their clinical correlations and the genetic implications, if any

1. and Ischemic Heart Disease
2. Neoplasms and Pseudo tumours
3. Transplant Pathology
4. and Myocarditis
5. Heart Disease
6. Non-Atherosclerotic Vascular Disease
7. Disease
8. Conduction System

Disease Types

1. List the relative frequencies of the most common tumors involving the heart
2. Describe the most common benign primary cardiac tumors and describe their typical clinical presentations
3. Identify common malignant primary cardiac tumors

Differential Diagnosis

1. Generatea list of likely tumors based on the given cardiac chamber in which the tumor arises and whether it is intramural or growing into that chamber
2. Indicate which of the primary cardiac tumors are more likely to arise during childhood
3. List non-neoplastic processes that may clinically resemble cardiac neoplasms
4. Diagnose the most common primary atrial masses (myxoma, papillary fibroelastoma, mural thrombus) based on their histopathologic features
5. Diagnose the most common intramural cardiac masses by histopathology
6. Diagnose pericardial-based neoplasms on the basis of their characteristic histopathologic features
7. Recognize features indicating malignant potential in cardiac neoplasms

Ancillary Studies

1. Utilize immunohistochemistry and molecular ancillary testing to appropriately classify primary cardiac sarcomas and lymphomas
2. Employ immunohistochemistry to differentiate cardiac myxoma with hemorrhage from organizing thrombus

Treatment and Intervention Implications

1. List the genetic syndromes associated with cardiac myxomas, rhabdomyomas, and fibromas
2. Distinguish cardiac neoplasms with metastatic potential from benign tumors
3. Recognize potential complications (embolization, obstruction, arrhythmia, etc.) typically associated with specific cardiac neoplasms
4. Determine when surgical evaluation of margins is required for cardiac tumors

Disease Types

1. Identify the etiology, pathogenesis, and clinical features of acute cellular and antibody mediated rejection
2. Identify the etiology, pathogenesis, and clinical features of chronic rejection including transplant arteriopathy in explanted grafts at re-transplantation or autopsy
3. Recognize the histologic features of recurrent disease, especially amyloidosis and giant cell myocarditis in post-transplant endomyocardial biopsy samples

Specimen Handling

1. ecommend the preparation and handling necessary for a post-transplant endomyocardial biopsy sample including proper fixation and triage for special or ancillary studies when indicated
2. Establish the rationale for basic dissection approaches to explanted hearts as well as failed cardiac allografts

Differential Diagnosis

1. Recognize the light microscopic features of acute cellular and antibody mediated rejection
2. Identify the gross and histologic features of chronic rejection including transplant arteriopathy in explanted failed allografts at re-transplantation or autopsy
3. Describe the histologic features of recurrent disease, especially amyloid and giant cell myocarditis in post-transplant endomyocardial biopsy samples
4. Recognize the light microscopic features of acute ischemic (preservation) injury, healing and healed previous biopsy sites,  lymphocytic infiltrates (Quilty effect), infection secondary to cytomegalovirus (CMV), infection with toxoplasmosis, and post transplantation lymphoproliferative disorder (PTLD)

Reporting and Communication

1. Generate clear, concise and accurate reports that effectively communicate endomyocardial biopsy results and treatment implications to the patient`s health care team
2. Report the histologic findings from post-transplant endomyocardial biopsies utilizing the International Heart and Lung Transplantation (ISHLT) Grading scale for both cellular and antibody mediated rejection

Testing Methods

1. Recognize the light microscopic features of acute (cellular) and antibody mediated rejection
2. Recognize the gross and histologic features of chronic rejection including transplant arteriopathy in explanted failed allografts at re-transplantation or autopsy

Ancillary Studies

1. Recognize the pattern of positive immunohistochemical (IHC) or immunofluorescent (IF) staining for C4d or C3d in post-transplant endomyocardial biopsy specimens consistent with antibody mediated rejection
2. Recognize the pattern of positive staining with T cells (CD3), B cells (CD 20), Kappa and Lambda light chains and in situ hybridization for EBV (EBER) in post transplantation lymphoproliferative disorder (PTLD)

Disease Types

1. Discuss the etiology (embryologic basis), pathogenesis, and clinical features of cardiovascular shunts (eg, atrial septal defect (ASD), ventricular septal defect (VSD), atrioventricular septal defect, and patent ductus arteriosus (PDA))
2. Recognize the etiology, pathogenesis and clinical features of conotruncal anomalies, tetralogy of Fallot (TOF), pulmonary atresia with ventricular septal defect, double outlet right ventricle, persistent truncus arteriosus, complete transposition of the great arteries, and congenitally corrected transposition of the great arteries
3. Recognize the etiology, pathogenesis and clinical features of single functional ventricles (eg, tricuspid atresia, double inlet left ventricle, aortic atresia, hypoplastic left heart syndrome)
4. Recognize the etiology, pathogenesis and clinical features of cardiovascular obstructions (eg, aortic stenosis, pulmonary stenosis, coarctation of the aorta)
5. Recognize the etiology, pathogenesis and clinical features of additional anomalies (eg, anomalous pulmonary venous connection, Ebstein`s anomaly, coronary anomalies)
6. Distinguish morphologic features of diseases that cause cyanosis
7. Distinguish morphologic features of diseases that cause acyanotic congenital heart disease

Specimen Handling

1. Describe the importance of initial evaluation of pulmonary artery and vein connections, number of spleens and malrotations of the bowel as well as location of the liver
2. Confirm relative position of vena cavae, azygos, and hemiazygos veins, as well isomerism changes of atria and bronchi if anomalies in these areas exist
3. Describe the procedure for formalin fixation of the combined heart and lung block

Reporting and Communication

1. Generate concise reports utilizing the segmental approach for evaluation and description of anomalies and overall relationships
2. Document interventions including catheter-based, as well as open operative procedures
3. Describe status of interventions, as well as secondary effects of original disease, secondary effects of intervention and methods of failure if present

Clinicopathologic Correlation

1. Describe the gross morphologic features of cardiovascular shunts, conotruncal anomalies, single functional ventricles, and additional anomalies
2. Correlate the gross morphologic features of cardiovascular shunts, conotruncal anomalies, single functional ventricles, and additional anomalies with pre- treatment and post-treatment imaging findings when appropriate

Consequences and Complications

1. Describe the secondary cardiopulmonary effects of left to right shunts, right to left shunts, and obstructive lesions including, but not limited to, atrial hypertrophy and/or dilatation; ventricular hypertrophy and dilatation, fibrosis, focal, or regional myocardial injury; native or shunt vascular thrombosis
2. Describe the histologic changes, using the modified Heath-Edwards grading scale, of the pulmonary vasculature in patients with left to right shunts who develop pulmonary hypertension
3. Recommend genetic counseling to families with potential syndromic findings when appropriate
4. Evaluate the autopsy or explant specimen for gross and/or microscopic changes secondary to operative treatment or interventional (catheter-based) procedures (ie, residual shunts (ASD, VSD, PDA), residual subpulmonary stenosis (TOF), residual or recurrent coarctation, residual or regression of atrial or ventricular hypertrophy or dilatation, aortic aneurysm, dissection and rupture following coarctation repair, conduit stenosis and/or calcification of bioprosthetic valve, thrombosis and or neointimal hyperplasia within conduit or tube graft, or synthetic Blalock-Taussig shunt graft, partial dehiscence, mural thrombus formation or calcification of atrial or ventricular septal or interventricular closure patch or "clamshell" type device, infective endocarditis, pulmonary arteriovenous fistula, pulmonary vein stenosis, damage to sinus node or its artery, epicardial coronary arteries, ventricle, atrioventricular conduction tissue, status of pulmonary hypertensive vascular disease, evidence of extracardiac infection)

1. Identify where the conduction system is in the heart and how to excise it for cutting for referral
2. Develop knowledge of how to section the conduction system
3. Recognize the conduction system by microscopy
4. Know the normal aging changes and variations associated with the conduction system
5. Develop knowledge of the common systemic diseases affecting the conduction system
6. Develop knowledge of the common conduction system diseases, their clinical correlations and the genetic implications, if any

1. Specimen Handling
2. Patient Selection
3. Analytic Concerns
4. Test Prioritization
5. Test Interpretation
6. Reporting
7. Quality Assurance
8. Patient Management

1. Ensure effective communication between the medical or surgical oncologist, surgical pathologist and molecular pathologist to facilitate appropriate specimen collection including the types, quantities, and specimen handling requirements of samples that are needed at the time of diagnosis
2. Determine the most appropriate samples for chromosomal and molecular testing
3. Assess if the specimen is collected appropriately
4. Ensure that the specimen is adequate in quantity and quality for the necessary histologic and molecular testing, triaging the specimen as needed to achieve those goals
5. Ensure that the specimen is appropriately preserved for the anticipated testing, with appropriate documentation of specimen handling conditions
6. Establish policies and procedures to ensure specimens are of sufficient quantity and appropriately fixed to permit ancillary testing

1. Identify which neoplasms can be better classified with ancillary molecular testing
2. Assess the utility of molecular testing for determining treatment options for various neoplasms
3. Identify additional tests to narrow the differential diagnosis or assess prognosis
4. Determine whether the primary or metastatic tumor should be submitted for molecular testing
5. Recognize the indications for molecular testing so that patients who can potentially benefit from them will be treated appropriately

1. Recognize sources of analytical error for various molecular tests
2. Take steps to reduce the risk of analytical error
3. Ensure that the specimen contains lesional tissue when submitting snap frozen tissue for RT-PCR analysis or fresh tissue for conventional cytogenetic analysis
4. Ensure that lesional tissue is present
5. Identify the lesional tissue of interest on a corresponding H & E stained slide that is adjacent to the unstained slides submitted for in situ hybridization (ISH) molecular analysis so that the appropriate area may be dissected and the appropriate cells are scored for in situ assays
6. Consider the clinical and imaging studies when establishing the diagnosis for any bone or soft tissue tumor

1. Determine the need to allocate limited tissue appropriately for immunohistochemical and molecular testing to ensure optimal specimen utilization
2. Recognize the advantages and limitations of molecular testing as an adjunct to cytopathologic evaluation of cellular specimens
3. Recognize the advantages and limitations of molecular approaches commonly used in the assessment of mesenchymal neoplasms i. New cytogenetic and molecular variants continue to be discovered ii. Cytogenetic variant translocations occur as the result of rearrangement of one consistent gene with differing chromosomal translocation partners
4. Recognize that assays are frequently complementary and one approach may reveal the underlying abnormality when another approach has failed
5. Use clinicohistopathologic impression to determine what tests should be performed
6. Identify the three common genetic approaches used to identify tumor-specific abnormalities: (1) conventional cytogenetic; (2) molecular cytogenetic (in situ hybridization (ISH); (3) sequencing, and, (4) reverse transcription-polymerase chain reaction (RT-PCR) analyses

1. Interpret all molecular diagnostic test results together with available clinical and histopathological data
2. Interpret appropriate molecular test results in terms of the specific therapeutic options available for specific tumors (eg, KRAS and BRAF in colon cancer; KRAS and EGFR in NSCLC; BRAF in melanoma, etc.)
3. Assess the in situ hybridization (ISH) molecular findings in light of other clinical and histopathologic features
4. Recognize that molecular and cytogenetic variants may be such that designed primer sets will not be able to amplify the gene product resulting in a false- negative
5. Integrate the molecular results into the anatomic pathology report

1. When integrating molecular results into an anatomic pathologic report, include the recommended reporting elements
2. When referencing a freestanding molecular pathology report, ensure it is available to the oncologist
3. Utilize the standardized mutation nomenclature and standardized gene nomenclature (HUGO) when reporting molecular results

1. Ensure that all molecular tests have undergone adequate analytical validation
2. Ensure that all molecular tests are supported by appropriate clinical validation studies and that clinical utility is defined
3. Ensure that appropriate proficiency testing is in place for all molecular tests and that performance is being adequately monitored
4. Establish departmental (and interdisciplinary) protocols for the utilization of molecular tests for specific tumors and patient populations
5. Devise appropriate quality assurance monitors to demonstrate that protocols are being uniformly and consistently adhered to
6. Communicate with the clinicians and other pathologists (eg, submitting pathologist, and molecular pathologist)
7. Review report for proper use of conventions and formatting issues that are unique to molecular reports, including proper gene nomenclature
8. Maintain open lines of communication with the clinicians to discuss test results and interpretation as they become available

1. Recommend appropriate ancillary molecular and cytogenetic studies
2. Communicate information about corresponding therapies when using molecular oncology testing as a companion diagnostic test (ie, EGFR for erlotinib)
3. Recognize the clinical utility of monitoring minimal residual disease by molecular methods

1. Nucleic Acid Hybridization
2. Amplification of Nucleic Acids Using the Polymerase Chain Reaction
3. Mutation Detection Technologies
4. Interpretation of Sequence Variants
5. Real Time PCR
6. Reverse Transcription PCR (RT-PCR)
7. Array CGH (aCGH)

1. Discuss the roles of base pairing and hydrophobic base shielding in the formation of a duplex (double stranded) molecule from two single stranded nucleic acid molecules
2. Explain the role of complementary base pair association in determining the specificity of nucleic acid hybridizations
3. Understand the concept of melting temperature as it applies to nucleic acid hybridizations
4. Identify environmental conditions which can affect the strength and specificity of nucleic acid hybridizations as well as the melting temperature of the hybridized product
5. Competency Area: Amplification of Nucleic Acids Using the Polymerase Chain Reaction
6. Describe the three basic steps involved in a typical nucleic acid amplification carried out using the polymerase chain reaction
7. List the basic components (reagents) used in a polymerase chain reaction and identify those which have a significant effect on the target specificity of the amplification
8. Compare and contrast the appropriateness and potential limitations of each of the following sample types for analysis by polymerase chain reaction: 1) blood specimen with EDTA anticoagulant, 2) heparinized blood specimen, 3) fresh or frozen tissue sample, 4) formalin fixed paraffin embedded tissue sample.
9. Identify the most common inhibitors of the polymerase chain reaction encountered in a clinical laboratory setting
10. Explain the purpose of physically separating pre-amplification and post- amplification areas of laboratories which perform testing using the polymerase chain reaction
11. Understand the fundamental difference between target amplification (eg, the polymerase chain reaction) and signal amplification techniques for nucleic acid analyses
12. Competency Area: Mutation Detection Technologies
13. Describe the technique of allele specific polymerase chain reaction and explain the difference between this and a standard, non-allele specific polymerase chain reaction
14. Understand the basic biochemical processes underlying the Sanger method of DNA sequencing
15. Describe the limitations of Sanger sequencing for the detection of whole exon deletions and duplications
16. Describe the process of pyrosequencing and contrast this with the Sanger sequencing method in terms of the length of DNA sequence read in a single assay and the analytical detection limit for mutations or polymorphisms
17. Explain why there may be a different analytical level of detection required for the evaluation of somatic mutations in tumor tissue identified in a biopsy specimen versus mutations in the germline sequence of an individual

1. Distinguish between the terms mutation, polymorphism and sequence variant, both in terms of definitions and colloquial use
2. Describe each of the following types of mutations which may occur within a gene: 1) single nucleotide substitution, 2) nucleotide deletion, and 3) nucleotide insertion
3. Explain the functional effects of the following types of mutations on the protein product of a gene: 1) nonsense mutations, 2) missense mutations, and 3) frameshift mutations
4. Understand the possible effects on the protein product of splice site mutations

1. Understand the different chemistries utilized (DNA binding dyes vs. target specific probes) and the fluorescence detection technology used in real-time PCR
2. Compare the advantages of real-time PCR over end-point PCR, especially in terms of dynamic range and precision of quantification
3. Explain the importance of appropriate selection of internal controls for sample normalization
4. Recognize the different applications of real-time PCR in molecular diagnostics
5. Competency Area: Reverse Transcription PCR (RT-PCR)
6. Explain that the template used in RT-PCR (RNA) requires special handling to avoid degradation
7. Describe how genomic DNA contamination of template RNA poses special problems and the means of rectifying that
8. Describe the basic steps in RT-PCR (including reagents used, choice of primers and amplicon size) and understand the meaning of cDNA
9. Recognize that RT-PCR is often combined with real-time quantification in molecular diagnostics

1. Describe the basic principles of aCGH including differential labeling of normal and reference DNA and co-hybridization to the array
2. Identify the relation between array resolution and the twin parameters of target clone size and clone density
3. Recognize the applications of aCGH in detection of copy-number variations and loss of heterozygosity
4. Understand the concept of copy number polymorphisms
5. Recognize the chromosomal aberrations in which aCGH is not applicable (balanced translocations, inversions)

A. Breast Lesion Identification

B. Core Biopsy

C. Radiologic/Pathologic Correlation

D. Breast Conservation

E. Sentinel Lymph Node Assessment

F. Ancillary Studies

G. Treatment Implications

H. Reporting and Communication

1. Diagnose and understand the clinical significance of commonly recognized breast lesions, eg, epithelial proliferative lesions, columnar cell lesions (including flat epithelial atypia), papillary and fibroepithelial lesions, lobular neoplasia, special and no special type carcinomas, mimics of carcinoma and spindle cell proliferations.
2. Distinguish usual ductal hyperplasia from atypical ductal hyperplasia and low-grade ductal carcinoma in situ (DCIS).
3. Recognize and distinguish morphologic mimics of carcinoma in breast pathology.

1. Recognize the limitations of core biopsy in diagnosing some breast lesions and understand when lack of correlation between histologic and radiographic findings requires additional tissue for study.
2. Determine when to recommend excision based on core biopsy findings
3. Recognize in resection specimens the changes/artifacts associated with previous core biopsy, eg, squamous metaplasia, lesion disruption and epithelial displacement.
4. Ensure that tissue used for predictive factor testing is appropriate and that issues such as specimen adequacy, fixation and artifacts do not render testing unreliable.

1. Understand the importance of communication between pathologists and radiologists in evaluating specimens obtained with image guidance.
2. Recognize the importance of radiographic information (including reviewing specimen radiographs) in ensuring optimal pathologic evaluation.
3. Suggest additional steps when initial pathologic examination does not identify the targeted lesion (eg, mammographic evaluation of blocks).

1. Determine when re-excision is recommended following breast conservation surgery.
2. Determine appropriate tissue submission for histologic examination based on imaging and gross features.
3. Understand the significance of invasive or in situ carcinoma at or near margins within the context of a specific case.

1. Explain the role of sentinel lymph node biopsy in breast cancer.
2. Ensure that sentinel lymph nodes are appropriately evaluated.
3. Classify sentinel lymph node findings following AJCC criteria.
4. Understand the significance of macrometastases, micrometastasis as compared with isolated tumor cells.

1. Describe the requirements for specimen handling, appropriate fixation intervals and assay validation as recommended in the current ASCO/CAP HER2 and ER/PR testing guidelines.
2. Describe the scoring criteria for HER2 and hormone receptors as recommended in the current ASCO/CAP HER2 and ER/PgR testing guidelines.
3. Understand how decalcifying agents and fixatives other than buffered formalin can alter the results of IHC and ISH tests.
4. Address discrepancies between expected biomarker test results and morphologic findings.
5. Understand the role of internal and external controls in ensuring accurate predictive factor test results.
6. Understand the relationship between the molecular classification of breast cancer, morphologic features, immunohistochemical profile, tumor grade and predictive factor test results.
7. Understand the use and limitations of biomarker testing.
8. Describe how molecular profiling can be used to help refine the classification of breast cancer, assess prognosis, and predict response to therapy.
9. Understand how multiplex gene assay results can be impacted by specimen selection/histologic features (eg, DCIS, adjacent biopsy site, inflammation).

1. Recognize the importance of HER2 targeted therapy and appropriately select patients for its use.
2. Understand the effect of neoadjuvant therapy on specimen evaluation.
3. Understand appropriate patient selection criteria for using a multiplex gene assay for the purpose of informing treatment decisions.
4. Understand basic breast cancer treatment options as predicted by test results.
5. Explain the pathologic factors that influence post-surgical radiation therapy.
6. Describe how proliferation has been correlated with prognosis and response to chemotherapy for patients with invasive breast cancer.
7. Explain how multi-parameter gene/protein expression assays are used to determine prognosis and treatment of patients with breast cancer.