Gynecologic Pathology

Goals and Objectives

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

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

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

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

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

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

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

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

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

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

A senior resident (PGY3 or PGY4) is expected to complete an end-of-rotation presentation for the one of their senior gynecologic pathology rotations.

Both PGY-2 and PGY-3 residents are expected to complete end of rotation slide exams.

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

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

Medical Expert

  • Demonstrate a working knowledge of the anatomy, histology and embryology of the female genitourinary tract including ovary, fallopian tube, uterus, cervix, vulva, placenta (EPA: F#2)
  • Demonstrate skill in the gross dissection of common large resection specimens from the female reproductive tract including hysterectomy, oophorectomy, vulvar resection, with particular attention to staging information (EPAs: TTD# 1A, F#1, C#2, C#3).
  • Demonstrate proficiency in interpretation of common biopsy specimens including cervix and endometrium (including cervical intraepithelial neoplasia, glandular lesions, endometrial metaplasias, hyperplasia, carcinomas, inflammatory/infectious diseases) (EPAs: TTD# 1A, F#1, C#4, C#5).
  • Demonstrate ability to deal with difficult gross specimens i.e. occult tumors, post neoadjuvant specimens, poorly oriented specimens (EPAs: C#2, C#3)
  • Demonstrate proficiency in the interpretation of endometrial, ovarian and other gynecologic tract biopsies, and knowledge of lesions that cannot be adequately assessed in a limited biopsy sample (EPAs: F#2, C#4, C#5, TTP#1)
  • Acquire proficiency in the morphologic diagnosis, immunohistochemical work-up and staging of the spectrum of ovarian tumors (germ cell, surface-epithelial, sex-cord- stromal and others) (EPAs: F#2, C#4, C#5, TTP#1).
  • Acquire proficiency in the morphologic diagnosis, immunohistochemical work-up and staging of the spectrum of gestational trophoblastic disease and related lesions (EPAs: F#2, C#4, C#5, TTP#1).
  • Acquire proficiency in the morphologic diagnosis, immunohistochemical work-up and staging of the spectrum of uterine mesenchymal tumors (EPAs: F#2, C#4, C#5, TTP#1).
  • Acquire proficiency in the morphologic diagnosis, immunohistochemical work-up and staging of the spectrum of surface-peritoneal lesions (EPAs: F#2, C#4, C#5, TTP#1).
  • Acquire proficiency to prepare well-organized, comprehensive reports that convey the appropriate staging and prognostic information in common gynecologic oncology specimens including ovary, fallopian tube, uterus, cervix, vulva (EPAs: F#2, C#4, C#5, TTP#1).
  • Acquire knowledge of the spectrum of gynecologic disease and tumours and the associated risk implications (EPAs: F#2, C#4, C#5, TTP#1)
  • Acquire knowledge in the use and interpretation of immunohistochemistry pertinent to gynecologic pathology, including MMR immunohistochemistry (EPAs:  C#10, TTP#1)

Communicator/Collaborator

  • Obtain a relevant clinical history, including relevant laboratory and imaging results and interpreting this information in light of the clinical information and providing a summary to the supervising staff pathologist (EPA: TTD#2)
  • Demonstrate the ability to function at a junior staff pathologist level at gynecologic oncology tumor rounds by previewing cases to be presented, appropriately choosing histology slides to present, presenting the pertinent pathological features, and responding to questions regarding the cases (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)
  • Demonstrate the ability to teach aspects of gynecologic pathology at teaching sessions including gross rounds, gynecologic pathology seminars and other teaching sessions. (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)
  • Gain an understanding of clinical aspects of gynecologic disease, the management of ovarian, endometrial, cervical and vulvar cancer, and stromal uterine tumors. (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)

Manager

  • Understand the importance of quality control and quality assurance measures for immunohistochemical markers used in the diagnosis of gynecological lesions including preanalytical, analytical and postanalytical variables (EPAs: F#1, F#2, C#15, TTP#3)
  • Understand the value of proficiency testing for immunohistochemistry (EPAs: C#15, TTP#3).

Health Advocate/Professional

  • Understand the importance of turn-around time for diagnostic biopsies due to the high level of stress experienced by patients with symptomatic gynecologic disease and ovarian masses (EPA: TTD#1B)
  • Understand the implication of a diagnosis of cervical cancer and gestational and trophoblastic disease (EPAs: C#4, C#5, TTP#1).
  • Understand the physical and emotional difficulties related to aggressive ovarian cancer treatment (EPAs: C#4, C#5, TTP#1).
  • Know when to appropriately consult an expert in gynecologic pathology (EPAs: C#5, TTP#1)
  • Demonstrate an increasing ability to handle more of the clinical workload of the staff pathologist.  It is expected that PGY4 and PGY5 residents are able to handle the full clinical workload of the staff pathologist each day on service (EPAs: TTP#1, TTP#5, TTP#6)

Scholar

  • Consider conducting a case report, case series or more in-depth project on gynecologic pathology material (EPAs: C#16, C#17, TTP#4)
  • Review the pertinent recent literature regarding advances in ovarian, fallopian tube, uterine, cervical, vulvar and placental pathology including the molecular pathogenesis of these malignancies (EPAs: C#9, C#10, C#15, C#16, TTP#4).

Instructional Tools

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

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

  • PGY1 and PGY2 level:
    • For junior residents a grossing week is built into their rotation block.
    • The resident should gross at minimum the following specimen types during this grossing week:
      • At least 3 simple hysterectomies (not oncologic)
      • At least 3 cervical cone biopsies or LEEPs
      • At least 3 oophorectomies / salpingectomies (without uterus)
      • At least 3 endometrial biopsies
  • PGY3 and PGY4 level: Although no grossing week is built into their rotation block, an expectation of grossing remains.  By their end of their senior gynecologic pathology rotation, it is expected that the senior resident will gross:
    • Three hysterectomies (oncologic)
    • One radical hysterectomy
    • One vulvectomy or vaginectomy
    • One pelvic exenteration (if possible)
  • Senior residents, including PGY5 residents, are expected to supervise and teach junior trainees in the gross room (EPA: TTP#2)
  • Resident will complete a “grossing log” (shared filed created by the gross room director). The resident will review the slides of the case that he/she grossed and review it with the attending pathologist assigned to the case, if the slides are available before the end of the rotation. The attending will review the gross description and will complete the EPA (which may be initiated by the staff or the resident).

Microscopy

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

Prognostic Markers

  • Learn how to properly interpret routinely used gynecologic immunohistochemical markers including MMR immunohistochemistry (EPAs: C#4, C#5, C#10, C#15)
  • Learn indicators for molecular testing in gynecologic pathology (EPAs: C#5, C#9)
  • Learn how to interpret molecular tests in gynecologic pathology (EPAs: C#5, C#9, C#15)

Rounds

  • PGY1 and 2 level: Resident is expected to attend and depending on their skill level, may be asked to present at interdisciplinary rounds (on Wednesdays at 9:15 am) and the consensus conference (on Tuesday at 10:30 and Thursday at 9:30) (EPAs: C#14, C#18)
  • PGY 3-5: Resident is expected to attend interdisciplinary and consensus conferences and present the cases. This implies reviewing the cases with the pathologist in charge beforehand and organizing the presentation in the appropriate format (EPAs: C#14, C#18, TTP#1, TTP#2, TTP#5, TTP#6)

Evaluation

  • Presentation at the end of the rotation (PGY-3).The resident will choose a topic of interest. The presentation can be case based if the resident had an interesting or challenging case during the rotation that can serve as a starting point. The presentation should include review of the recent literature about the topic and cite specific references.
  • Mid-rotation evaluation to be completed by the gynecologic section head with input from other gynecologic pathologists.
  • Final evaluation to be completed by the gynecologic section head following evaluations completed by all gynecologic pathologists encountered during the rotation. The gynecologic section head evaluation will also include results of the:
    • Slide test (PGY-2 and PGY-3)
    • End of rotation presentation, if applicable (PGY-3)
  • Expectations will be graded according to the level of training

Recommended Reading

  • WHO, classification of tumours. Female Genital Tumours
  • Atlas of gynecologic surgical pathology, Clement, Young.
  • Blaustein’s Pathology of the female genital tract.
  • Robboy’s Pathology of the female reproductive tract
  • Gynecologic Pathology Marisa R. Nucci, Esther Olivia. A volume in the series of foundation in diagnostic pathology
  • Crum, Nucci et al. Diagnostic Gynecologic and Obstetric Pathology.
  • All Gyne chapters in Robbin’s and Cotran Pathologic Basis of Disease.

 

Updated April, 2022

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