January 2023

January 2023—Laura Esserman, MD, MBA, can still recall her Eureka moment. She had just seen a talk on residual cancer burden by pathologist W. Fraser Symmans, MB.ChB, a pioneer in the field. “When I saw Fraser present this,” says Dr. Esserman, director, University of California San Francisco Breast Care Center, “I knew immediately that MRI would work and that residual cancer burden would complement it. MRI was basically a snapshot of RCB over time. I realized that we had to institute RCB—we had to standardize our approach.” Until then, she and her colleagues across the I-SPY trial sites relied on individual pathologist assessment for each case. The pathologic complete response rate, or pCR, hovered at about 34 percent. That insight was soon followed by another. Intrigued by what she heard, Dr. Esserman and her pathologist colleagues from all the I-SPY sites traveled to MD Anderson, where Dr. Symmans helped develop the residual cancer burden system, for training.

January 2023—Guidelines for the diagnosis of von Willebrand disease, published in 2021, have raised questions about which von Willebrand factor activity assay laboratories should use.

January 2023—For the central microbiology laboratory serving Barnes-Jewish and four other hospitals in the St. Louis area, validating and implementing a new blood culture system and moving to a shorter incubation time came at a perfect time: right before the pandemic.

January 2023—Respiratory viruses were up in most states when Compass Group members met online Dec. 6 with CAP TODAY publisher Bob McGonnagle, and some were looking to centralize their now decentralized rapid molecular testing. At least one system had already done so. In California, a new law requires fentanyl screening be included in drug screens in all general acute-care hospital lab settings.

January 2023—Due out this spring is the CAP’s Color Atlas of Flow Cytometry. It consists of 71 cases and provides examples of the full range of hematolymphoid diseases that can be productively analyzed by flow cytometric immunophenotyping. Its editors are David Dorfman, MD, PhD, of Harvard Medical School and Brigham and Women’s Hospital; William Karlon, MD, PhD, of the University of California San Francisco Medical Center; and Michael Linden, MD, PhD, of M Health Fairview-University of Minnesota Medical Center. CAP TODAY recently asked Dr. Dorfman a few questions about the atlas. His answers to our questions and a sample case follow.

January 2023—The definition of “adequate” per the Merriam-Webster dictionary is “sufficient for a specific need.” In cytopathology, it is defined by the quantity and quality of the cellular material sampled. The final interpretation of a cytopathology report is almost universally preceded by an adequacy statement. While the essence of “adequacy” stays the same, its application varies depending on the specimen type and the site sampled. Furthermore, in the current era of personalized medicine, the definition of adequacy has expanded from “enough cells to make a morphologic diagnosis” to “enough cells to make a diagnosis and perform ancillary studies.”

January 2023—In recent years, a standardized classification system for the cytology of serous body cavities has been proposed. The system, known as the International System for Reporting Serous Fluid Cytopathology (ISRSFC), published by Ashish Chandra, et al.,1 in 2020, aims to enhance the reproducibility of cytologic diagnoses, thereby facilitating clearer communication with clinicians. The diagnostic categories are as follows: I. Non-Diagnostic; II. Negative for Malignancy; III. Atypia of Undetermined Significance; IV. Suspicious for Malignancy; V. Malignant. Each progressive diagnostic category from I through V carries with it an increasing risk of malignancy. This brief review article aims to highlight the salient points of each diagnostic category and includes discussion of recent publications and our own institutional experience.

January 2023—Automation and point-of-care, reflex, and viscoelastic testing were some of what came up when a group spoke with CAP TODAY publisher Bob McGonnagle in late November about hemostasis testing. Also tossed in: Results reporting to the EHR, which “can always be improved,” said Eric Salazar, MD, PhD, of University of Texas Health San Antonio. And D-dimer, one of the pandemic’s “health care heroes,” said Nichole Howard of Diagnostica Stago. Here’s what they said about all that and more.

January 2023—When I was newly elected into my officer role at the CAP in 2019, I had the opportunity to join a meeting of a committee under the umbrella of the Council on Accreditation. This was a committee whose work I knew little about but which I quickly grew to appreciate. In this committee I saw an extreme focus on operational processes and quality management structures. They wanted to prevent errors, not just fix them. This focus on process was different from the focus on blame that we often see in medicine. As I listened to Gaurav Sharma, MD, lead the CAP 15189 Committee, I knew I was among folks dedicated to pushing for ever-better care and quality for our patients and our laboratories.

January 2023—Borrelia burgdorferi is the leading cause of Lyme disease in the United States, with approximately 35,000 new cases reported to the CDC each year. The agency recommends a two-tiered approach to testing.

January 2023—Radioembolization therapy uses yttrium-90-impregnated resin or glass microspheres to selectively target hepatic lesions via transarterial radioembolization. Occasional cases of gastrointestinal (GI) tract injury secondary to nontargeted delivery of microspheres have been reported, but large descriptive pathology series are lacking.

January 2023—An international group of scientists and clinicians identified the molecular cause of a rare neurodevelopmental syndrome affecting children worldwide. This discovery was made possible through such publicly available online databases as MyGene2, GeneMatcher, and Matchmaker Exchange, which match genotypic profiles with phenotypic profiles of rare diseases.

January 2023—The acclaimed film composer John Powell said, “Communication works for those who work at it.” A sentiment to which Yonah Ziemba, MD, adhered when communicating data via charts, graphs, and tables during his pathology fellowship—benefiting himself and others.

January 2023 Q. I am updating our procedure for blood draw volume limits and using So You’re Going to Collect a Blood Specimen: An Introduction to Phlebotomy, 15th edition, by Frederick L. Kiechle, MD, PhD, as a guide. The chart in the manual lists volume limits for a single blood draw at 2 cc/kg. Other charts online list 2.5 cc/kg and a maximum milliliters per 30-day period that is twice the single blood draw (5 cc/kg). I am going to use 2 cc/kg and add a column for maximum milliliters in a 30-day period at 4 cc/kg. The phlebotomists are confused about whether a single blood draw means every day of the patient’s admission or if you would take the single blood draw and only allow the remainder of the 30-day limit. You could essentially draw the single blood draw volume limit on day one and the remainder on day two. Please clarify. Read answer. Q. An oncologist contacted the laboratory to ask if our standard estradiol immunoassay was appropriate to monitor her breast cancer patients who are on an aromatase inhibitor. What should I say? Read answer.

January 2023—The Association for Molecular Pathology last month released a report on somatic variant classification using 2017 standards and guidelines for interpreting and reporting such variants, which were a consensus recommendation of the AMP, CAP, and American Society of Clinical Oncology.

January 2023—The fourth edition of the International Organization for Standardization’s ISO 15189, Medical Laboratories—Requirements for Quality and Competence, was published at the end of 2022. This international standard, adopted as an accreditation standard by many countries around the world, applies principles of quality management to the clinical laboratory and has general requirements for competent performance of testing. In the United States, ISO 15189 has been implemented voluntarily by close to 100 laboratories as an adjunct to CLIA ’88 regulations or CAP accreditation.

January 2023—The CAP president’s column, “The visible pathologist” (CAP TODAY, November 2022), struck a chord that has been reverberating through our specialty for many years when a medical student who expressed an interest in pathology was asked, “Why don’t you want to be a real doctor?” You put it in terms of “disappearing” as judged by our role in the case of patients.