How do we help pathologists find pathology? Dan C. Martin, MD - - PowerPoint PPT Presentation

▶
how do we help pathologists find pathology
SMART_READER_LITE
LIVE PREVIEW

How do we help pathologists find pathology? Dan C. Martin, MD - - PowerPoint PPT Presentation

Jul 11, 2023 476 likes •908 views

How do we help pathologists find pathology? Dan C. Martin, MD Professor, Department of Obstetrics and Gynecology Divisional Director of Minimally Invasive Surgery Divisional Director Reproductive Endocrinology Director Minimally Invasive

slide-1
SLIDE 1

How do we help pathologists find pathology?

Dan C. Martin, MD

Professor, Department of Obstetrics and Gynecology Divisional Director of Minimally Invasive Surgery Divisional Director Reproductive Endocrinology Director Minimally Invasive Surgery Fellowship Faculty Senator, University of Tennessee Health Science Center Memphis, Tennessee.

slide-2
SLIDE 2

March 27-29, 2014

Atlanta, Georgia

slide-3
SLIDE 3

Learning Objectives

At the end of this presentation, participants should be able to:

  • Be aware of STARD criteria
  • Understand the use of select STARD

criteria in clinical care

  • Clarify a signal-noise ratio
  • Review available staining techniques.
  • Communicate better with pathologists
slide-4
SLIDE 4

Conflict of Interest

  • None
slide-5
SLIDE 5

Confirmation at a Research Level STARD

Standards for Reporting of Diagnostic Accuracy

Bossuyt PM, Reitsma JB, Bruns DE, et al. Towards Complete and Accurate Reporting of Studies of Diagnostic Accuracy: The STARD Initiative Clinical Chemistry 49:1, 1–6 (2003)

slide-6
SLIDE 6

Confirmation at a Research Level

  • The protocol needs to be a fixed in order to be compatible with STARD.

The protocol in yellow below may not be compatible with STARD

  • Surgeon Experience Clarified
  • No Expectation of Appearance vs. Specified Appearances

“Absence of Normal Appearance” vs. “Appearance of Endometriosis”

  • Biopsy Techniques (biopsy forceps, nmicro-scissors, trim large specimens,

micro-point monopolar electrosurgery knife, 5000+ w/cm2 CO2 LASER)

  • Additional punctures and equipment for additional control
  • Adequate Number of Biopsies
  • Signal to Noise Ratio (trim specimens)
  • Tagging the Specimen Location
  • Marking the Specimen Side
  • Notations on Pathology Request (i.e. 1 mm lesion, 19+ from 1986, other?)
  • Uniform Specimen Size in Container
  • Cell Block
  • Transferring the Specimen to Container and then to Cassette
  • Processing by the Surgeon
  • Communications with the Cutters
  • Communications with the Pathologist
  • Re-cutting Specimens
  • Histologic Criteria (Batt 1989)
  • Infectious disease cultures, NNA, DDA, titers, etc. in pain studies
  • Routine or selective use of iron stains (hemosiderin, other iron forms and steroid pigment)
  • Routine or selective use of trichrome staining for collagen and muscle
  • Require a Histology Description Compatible with Surgical Findings.

A 1 mm lesion requires histology compatible with a 1 mm lesion.

  • Reviewing Slides.
slide-7
SLIDE 7

Confirmation at a Combined Research / Clinical Level

  • No Expectation of Appearance or that any appearance is endometriosis
  • Biopsy Techniques (biopsy forceps, scissors, knife)
  • Adequate Number of Biopsies
  • Signal to Noise Ratio (trim specimens)
  • Tagging the Specimen Location
  • Notations on Pathology Request (i.e. 1 mm lesion, 19+ from 1986,
  • ther?)
  • Uniform Specimen Size in Container
  • Cell Block
  • Transferring the Specimen to Container and then to Cassette
  • Communications with the Cutters and Pathologists
  • Selective use of iron stains (hemosiderin, other iron forms and steroid

pigment)

  • Selective use of trichrome staining for collagen and muscle
  • Reviewing Slides.
  • Require a Histology Description Compatible with Surgical Findings.

A 1 mm lesion requires histology compatible with a 1 mm lesion.

slide-8
SLIDE 8

Confirmation at a Clinical Level

  • No expectation that any appearance is endometriosis
  • Tag small lesions on large specimens
  • Signal to noise ratio
  • Notations on pathology request (i.e. 1 mm lesion)
  • Selective use of iron stains for iron forms
  • A 1 mm lesion requires histology compatible with

a 1 mm lesion.

slide-9
SLIDE 9

What do we know?

slide-10
SLIDE 10

Non-Specific Lesions

These are non-specific lesions unless pathology is specific.

slide-11
SLIDE 11

Non-Specific Lesions

Small clear and small white lesions

  • Endometriosis
  • Endosalpingiosis
  • Psammoma Bodies
  • Lymphoid Aggregates
  • Non-specific Inclusions
  • Mesothelial Proliferation

If on a Fallopian tube, add

  • Walthard Rest

With clusters, add

  • Low Malignant Potential Tumor

If there are solid nodules, add

  • Metastatic Cancer
slide-12
SLIDE 12

Grades of Certainty

  • Grade 1: Possible residua of resorbed endometriosis,

i.e., hemosiderin, calcium, nerve, blood vessels and smooth muscle.

  • Grade 2: Consistent with endometriosis, i.e.,

hemosiderin, characteristic glands, OR stroma.

  • Grade 3: Definite endometriosis, i.e., characteristic

glands AND stroma with hemosiderin.

  • Grade 4: Grade III with structures conveying and
  • rganoid pattern, i.e., glandular-stromal layer overlying

well developed smooth muscle layer

Batt RE et.al. A case-series -- peritoneal pockets and endometriosis: rudimentary duplications of the Müllerian system. Adolesc Pediatr Gynecol. 1989: 2:47-56

slide-13
SLIDE 13

What is Classical?

  • Obliterated Pouch of Douglas
  • Powder Burn
  • Clear, Red, and/or White?
slide-14
SLIDE 14

Classical 1860 – 1920 Batt Grades 3 and 4

Futh 1903 Lockyer 1918

slide-15
SLIDE 15

Classical 1960 - 2000 Batt Grade 2, 3, or 4

slide-16
SLIDE 16

Iron Stain

Iron staining of the peritoneum may aid in clarifying the brown appearance of the peritoneum.

slide-17
SLIDE 17

Classical 2005

Batt Grade 1 Endometriosis, Precursor or Facilitator

Batt Grade 1: possible residua of resorbed endometriosis, i.e., hemosiderin, calcium, nerve, blood vessels, and smooth muscle.

Batt, et al. 1989; Marsh and Laufer 2005: Cabana et al. 2010 ===================== Inflammatory Induction Facilitator for Retrograde Flow Coincidence Another “Watch this space” story

Left Ovary Uterosacral Ligament Broad Ligament

slide-18
SLIDE 18

Look-a-Like Lesions

Uterus

slide-19
SLIDE 19

Signal – Noise Ratio

Tag large lesions.

slide-20
SLIDE 20

Signal – Noise Ratio

2.5 cm Uterus Ovary 3 mm 2 mm 1 mm 0.5 mm Utero-sacral ligament

slide-21
SLIDE 21

Signal – Noise Ratio

1 mm 10 mm

slide-22
SLIDE 22

Signal – Noise Ratio

  • 1 cm specimen with 1 mm lesion

– Linear is 1 mm signal with 9 mm noise (1:9) – Volumetric is 1 mm2 in 78.5 mm2 (πr2) (1:77.5)

  • 2 mm specimen with 1 mm lesion

– Linear is 1 mm signal with 1 mm noise (1:2) – Volumetric is 1 mm2 in 3.14 mm2 (πr2) (1:2.14)

slide-23
SLIDE 23

Signal – Noise Ratio

1 mm 2 mm

slide-24
SLIDE 24

Diagnosis and Confirmation

  • Diagnosis dark lesions using white light – No confirmation
  • Infertility. Marcoux, 1997
  • Diagnosis using white light – No confirmation

Chronic pelvic pain. Ling, 1999

  • Diagnosis using white light vs. 5-ALA induced fluorescence

Confirmation by histology

Comparison of illumination. Buchweitz, 2004

  • Diagnosis using white light - Confirmation by histology

Chronic pelvic pain. Jenkins, 2008

  • Diagnosed at laparoscopy - No confirmation

Gene polymorphisms . Sundqvist, 2010

  • Endometriosis was self-reported - No confirmation

Gene polymorphisms . Near, 2010

slide-25
SLIDE 25

Positivity – Single Study

Cases

100 500

100 90 80 70 60 50 40 30 20 10

200 300 400

Percent Positive

  • Pardanini 1998

Walters 2001 Mettler 2003 Pardanini 1998 Pardanini 1998

slide-26
SLIDE 26

Confirmation at a Research Level

99% in last 69 of 495 cases over 60 months (8.2 per month by one physician)

Year

1982 1983 1984 1985 1986.1 1986.2

Cumulative Number

97 188 279 376 426 495

  • f Patients by One Gyn

Positive for Endo

62% 50% 91% 93% 96% 99%

when Excised

Martin 1987, Stripling 1988, Martin 1990

42% to 76% range by 3 physicians doing 11 to 22 cases. Pardanani, Barbieri 1998 (Harvard, Boston) 45% PPV in 44 cases over 20 months (2.2 per month by ?? physicians) Walter, Magrina, et al. 2001 (Mayo Clinic, Phoenix, Arizona) 61% of lesions in first 46 cases over 34 months (1.4 per month by ?? physicians) 68% of lesions in next 56 cases over 36 months (1.6 per month by ?? physicians) Stratton 2003, Stegmann 2005 (NIH Bethesda clinical group) 87% in research conditions, 56% in clinical use. Buchweitz 2003, Luebeck, Germany 88% in 72 clinical cases over 7 months (10.3 cases per month by one physician) Webb, Martin et al. in preparation

slide-27
SLIDE 27

Positivity – Time Intervals

Cumulative Cases

100 500

100 90 80 70 60 50 40 30 20 10

200 300 400

Percent Positive

  • Martin 1987, Stripling 1988, Martin 1989, Martin 1990

Stratton 2002, Stegmann 2008

  • Dulumba 2012
slide-28
SLIDE 28

Positivity – Research v Clinical

100 90 80 70 60 50 40 30 20 10

Percent Positive

  • Clinical

Research

Stripling 1988, Martin 1990 Webb, Martin 2005 Buchweitz 2003 Buchweitz, 2003

slide-29
SLIDE 29

Psammoma Bodies, Ovary, Endosalpingiosis, LMPT and Metastatic Cancer

Psammoma Bodies Endosalpingiosis Remnant Ovary

Uterus

Metastatic Breast Cancer

Bladder

Low Malignant Potential Tumor

slide-30
SLIDE 30

Conclusions

  • Biopsy can be useful.
  • Cancer can be missed.
  • Therapeutic research needs

histology as a criteria.

slide-31
SLIDE 31
slide-32
SLIDE 32
slide-33
SLIDE 33

SLIDES FOR Q&A

slide-34
SLIDE 34

Marsh 2005

slide-35
SLIDE 35

Endometriosis After Inflammation

slide-36
SLIDE 36

Endometriosis After Inflammation

  • Induction
  • Damage predisposing

to implantation

  • Coincidence
slide-37
SLIDE 37

Marsh 760

slide-38
SLIDE 38

Diagnosis of Pathology Endo X Melbourne 2008

“We are still looking for peer reviewed, published articles abstracted in PubMed that show a statistically significant difference in outcomes (pain, tenderness, fertility, change in appearance or other

  • utcomes) of surgery or medical therapy based on

histology that is positive (glands and stroma) as compared with histology that is negative for

  • endometriosis. There is a $100 reward to a

researcher who first gives or sends those type articles to me.”

slide-39
SLIDE 39

$200

Until the end of the 10:50 break tomorrow, this is $200 for you. You can phone as many friends as needed. After the 10:50 break, the $100 offer is still available for anyone.

slide-40
SLIDE 40

$200

$200 a for peer reviewed, published articles abstracted in PubMed that shows a statistically significant difference in outcomes (pain, tenderness, fertility, change in appearance or other outcomes) of surgery or medical therapy based on histology that is positive (glands and stroma) as compared with histology that is negative for endometriosis. $100 to the first to give me this after 10:50 tomorrow if I do not get it before then.

slide-41
SLIDE 41

Todd Jenkins 2008

BCPs in 93 and Lupron in 17 of 104(?) patients

  • Chronic pelvic pain
  • 88 (84%) of 104 patients had endometriosis
  • Endometriosis diagnosed laparoscopically in:

– 87% (41 of 47) with pain relief on BCPs or GnRH – 81% (46 of 57) with no pain relief on BCPs or GnRH

  • Endometriosis diagnosed histologically

– 67% (31 of 46) with pain relief on BCPs or GnRH – 68% (39 of 57) with no pain relief on BCPs or GnRH

Jenkins TR, Liu CY, White J. Does Response to Hormonal Therapy Predict Presence or Absence of Endometriosis? Journal of Minimally Invasive Gynecology (2008) 15, 82–86