Lymphoma Pathology

Goals and Objectives

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

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

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

  • Ordering of any ancillary studies (histochemical stains, immunohistochemical stains, molecular testing) will initially be done under staff supervision for junior residents.  This is done in order to conserve tissue and prevent tissue waste that may limit the staff pathologist's ability to render a diagnosis. 
    • Based on the resident's experience and abilities they will eventually be permitted to order additional ancillary stains for straightforward, routine cases without consulting the staff pathologist.
    • Regardless of training level, any challenging case for which the resident is unsure of cell lineage or is unable to formulate a differential diagnosis that would be resolved by ancillary testing, the resident must consult the staff pathologist before ordering any ancillary stains.
    • It is expected that senior residents, including PGY-5 residents, would be able to initiate a preliminary panel of ancillary studies for routine cases.  This is ultimately at the discretion of their supervising staff.
  • Grossing of routine LN biopsies (core or excisional) can be handled by a resident at any training level.  By the end of the residents first lymphoma block, mastery of lymphoma protocol and proper tissue allocation is expected. 

It is expected that the first lymphoma pathology rotation by a junior resident will result in the mastery of normal histology 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 lymphoma 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-2 resident’s level of training in these areas with the understanding that greater responsibility and workload will be taken on in PGY-3.

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

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

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

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

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

Medical Expert/Clinical Decision-Maker

General Requirements

  • Demonstrate diagnostic skills for accurate pathological diagnosis in of lymphoproliferative disorders in a variety of organs (EPAs: F#2, C#4, C#5, C#6, TTP#1).
  • Access and apply relevant information to clinical practice (EPAs: TTD#2, C#13).
  • Demonstrate effective consultation services with respect to patient care, education and legal opinions (EPAs: C#18).

Specific Requirements

  • Demonstrate knowledge of normal anatomy, physiology and immunology of the lymphatic/immune system (EPA: F#2).
  • Demonstrate understanding of the general principles of embryologic development and the most common variations of normal lymph nodes, spleen, thymus and bone marrow (EPA: F#2).
  • Demonstrate a superior and detailed knowledge of the normal gross and light microscopic appearance of lymph nodes, spleen and other lymphoid tissues (EPAs: C#2, C#3, C#4, C#5).
  • Understand the basic principles of cell biology, immunology and pathogenesis, and the changes that occur in specific lymphomas (EPAs: F#2, C#4, C#5).
  • Be familiar with the CD classification of lymphocyte antigens and their application to immunophenotyping of lymphoproliferative disorders (EPAs:  F#1, F#2, C#10, C#15, TTP#1, TTP#3).
  • Understand the principles of immunohistochemical diagnosis in malignant and inflammatory conditions (EPAs:  F#1, F#2, C#10, C#15, TTP#1, TTP#3).
  • Understand the principles of tissue processing and the use of different fixatives in the laboratory (EPAs:  F#1, F#2, C#10, C#15, TTP#1, TTP#3).
  • Demonstrate an in-depth knowledge of the appropriate processing and sampling of biopsy specimens for suspected lymphoma (EPAs: TTD# 1A, F#1, C#2, C#3).
  • Understand the principles of nucleic acid-based molecular biology techniques and be familiar with their application to diagnosis in lymphoma diagnosis, especially the role of PCR and Southern blotting in gene rearrangement, lineage and specific translocation studies (EPAs:  F#1, F#2, C#10, C#15, TTP#1, TTP#3).
  • Understand the overall approach to examining a lymphoid organ microscopically, formulating a differential diagnosis based on histologic features and proceeding with the selection of confirmatory immunophenotyping (EPAs: F#2, C#4, C#5, TTP#1).
  • Be familiar with the WHO classification of lymphoproliferative disorders and their clinical significance (EPAs: F#2, C#4, C#5, TTP#1).
  • Understand the diagnostic pitfalls in interpreting biopsy tissues, including sample size, fixation problems, etc (EPAs: F#2, C#4, C#5, TTP#1).
  • Demonstrate ability to take satisfactory gross and microscopic photographs of lymphoid tissues, including digital presentations of individual cases for teaching purposes (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).

Communicator

General Requirements

  • 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 lymphoma tumor rounds by reviewing cases, presenting the cases at rounds and responding to questions regarding the cases (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)
  • Demonstrate the ability to teach aspects of lymphoproliferative disorders at multidisciplinary rounds and teaching sessions (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)
  • Gain an understanding of clinical aspects of lymphoproliferative disease, particularly in lymphoma tumor board (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)
  • Establish effective relationships with consulting physicians and surgeons (EPA: TTP#5, TTP#6).

Specific Requirements

  • Assist in the continuing education of physicians and other members of the hospital staff by participating in educational rounds/clinical review forums such as surgical pathology rounds (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Act as a consultant to clinical colleagues on the interpretation and relevance of pathological findings, with particular regard to their significance in the management of the patient (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Understand the information pathology should provide in a given clinical situation and be able to communicate it effectively in an oral and written form (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).

Collaborator

General Requirements

  • Consult effectively with other physicians and health care professionals (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Contribute effectively to other interdisciplinary team activities (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).

Specific Requirements

  • Utilize experience in clinical medicine and surgery to achieve a sound understanding of the effects of disease and the role of pathology in its management (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)
  • Demonstrate the ability to advise on the appropriateness of obtaining histologic specimens and following examination of these, to advise on further appropriate investigations (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)

Manager

General Requirements

  • Utilize resources effectively to balance patient care, learning needs, and outside activities (EPA: C#17, TTP#4).
  • Utilize the resources of the anatomical pathology laboratory to make an accurate and timely diagnosis (EPAs: C#1, C#9, C#10 C#18, TTP#5)
  • Work effectively and efficiently in a health care organization (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Utilize information technology to optimize patient care, life-long learning and other activities (EPA: C#17, TTP#4).

Specific Requirements

  • Demonstrate knowledge of the methods of quality control in the laboratory as it relates to flow cytometry and immunohistochemistry of lymphoproliferative disorders (EPAs: C#15, TTP#3).

Health Advocate

General Requirements

  • Identify the important determinants of lymphoma pathogenesis and diagnosis (EPAs: C#4, C#5, TTP#1).
  • Identify factors that may need to be relayed for discussion to the consultants in regards to modifiable risk factors for the patient and their family (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).

Specific Requirements

  • As members of an interdisciplinary team of professionals responsible for individual and population in health care, the surgical pathologist will endeavour to help informing the public about issues surrounding the diagnosis of lymphomas and risk factors for their development. (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).

Scholar

General Requirements

  • Develop, implement and monitor a personal continuing education strategy for continuing medical education in lymphoma pathology (EPA: C#17, TTP#4).
  • Critically appraise sources of medical information and recognize the current best sources for lymphoma research reporting (EPAs: C#9, C#10, C#15, C#16, TTP#4)
  • Facilitate learning of patients, house staff/students and other health professionals by attending and presenting at rounds at various venues (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Contribute to development of new knowledge (EPAs: C#16, C#17, TTP#4).

Specific Requirements

  • There should be consideration of completing a small research project or case report dealing with lymphoma pathology.  This should be discussed with the rotation supervisor at the beginning of the elective and the project could be presented at any one of a number of forums ranging from lymphoma rounds to national meetings (EPAs: C#16, C#17, TTP#4).

Professional

General Requirements

  • Deliver highest quality care with integrity, honesty and compassion.
  • Exhibit appropriate personal and interpersonal professional behaviours.
  • Practice medicine ethically consistent with obligations of a physician.
  • Demonstrate the knowledge, skills and attitudes relating to gender, culture, and ethnicity pertinent to anatomical pathology.

Specific Requirements

  • Act as an appropriate role model for students and others (EPAs: TTP#2, TTP#6).
  • Demonstrate a professional attitude to colleagues, as well as to other laboratory staff (EPAs: TTP#2, TTP#6).
  • Have an appreciation of the crucial role of the anatomical pathologist in providing quality patient care. This will include knowledge of individual professional limitations and the necessity of seeking appropriate second opinions (EPAs: C#5, TTP#1 TTP#6)
  • 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)

Instructional Tools

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

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

  • All levels (PGY-2 to PGY-5):
    • Mastery of tissue allocation in the setting of lymphoma protocol is expected.
    • As most specimens encountered will consist of either excisional or core biopsy, there are no mandatory grossing requirements for lymphoma block rotations.

Microscopy

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

Rounds

  • PGY-2 level: Resident is expected to attend and depending on their skill level, may be asked to present at interdisciplinary rounds (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

  • Final evaluation to be completed by the lymphoma pathologists encountered during the rotation. The lymphoma section head evaluation will include results of the:
    • End of rotation test: includes components of a slide test, written test (short answer questions) and/or oral examination
  • Mid-rotation evaluation to be completed by the Lymphoma section head with input from other lymphoma pathologists.
  • Expectations will be graded according to the level of training

Recommended Reading

  • “Lymphoma Path Rotation 101” powerpoint presentation (provided by Dr. A. Paliga)
  • All chapters pertaining to hematolymphoid organs/tissue and lymphoma pathology in Sternberg’s Diagnostic Surgical pathology
  • WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues
  • All chapters pertaining to hematolymphoid organs/tissue and lymphoma pathology in Robbins and Cotran - Pathologic Basis of Disease
  • CAP protocols for all hematolymphoid malignancies

 

 Lymphoma Cheat Sheet

Large B cell Lymphoma

Image result for high grade b cell lymphoma

 

IHC panel:

CD20, Pax5, +/-CD19, CD3, CD5, CD10, Bcl6, Mum1, Bcl2, c-myc, Ki67, Cyclin D1, CD30, EBV

B cell markers: CD20, Pax5, +/-CD19

T cell marker: CD3

R/o blastic mantle: CD5, Cyclin D1

Make sure no dendritic network: CD21

Hans algorithm: CD10, Bcl6, Mum1

Screen for Double Hit Lymphoma: Bcl2, c-myc

Proliferation: Ki67

Eligible for Brentuximab: CD30

Associated with immune-disregulation: EBV

If evaluating for Gray zone (DLBCL vs cHL): add CD79, CD15, CD45, CD43

If blastic morphology: TdT

 

Small B cell lymphoma panel

Establish architecture: CD20/CD3/CD21

R/o FL: Bcl2/Bcl6/CD10

R/o Mantle: CD5/Cyclin D1

Prove marginal: CD43, Kappa/lambda ISH

 

T cell panel

CD2, CD3, CD5, CD7, CD4, CD8, TiA-1; never sign out on a core! Get flow and clonality and clinical

 

Myeloma panel

CD138, Kappa/lambda, Cyclin D1, CD19, CD45, CD117, CD56

 

CD45 negative hematolymphoid prolif?

CD30 (r/o cHL, ALCL)

CD43 (r/o myeloid sarcoma, T cell lymphoma, plasma cell neoplasm)

Kappa/lambda ish (anaplastic myeloma)

Consider for myeloid sarcoma: Myeloperoxidase, CD68, CD163, muramidase/lysozyme

 

Please refer to this website for additional information regarding the CanMEDS roles.

 

Updated April, 2022

 

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