canaadian jtouhrnal ofolog y volume 4, issue 4 winter 2012 · 2020. 7. 6. · william boyd lecture...

Test Utilization and the Clinical Laboratory

William Boyd Lecture 2012: Going Viral

Canadian Journal of

Pathology

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Volume 4, Issue 4 • Winter 2012

t Utilization and the Clinical Laboratory

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VOLUME 4, ISSUE 4 2012

About the Cover

108

110

Editorial: Successful Test Utilization Management Initiatives in a Canadian CentreIrene Sadek, MD, MSC, FRCPC

Éditorial : Initiative fructueuse de gestion de l’utilisation des tests dans un établissement canadienIrene Sadek, MD, MSC, FRCPC

EDITOR-IN-CHIEFJ. Godfrey Heathcote, MA, MB BChir, PhD, FRCPC

EDITORIAL BOARDManon Auger, MD, FRCPC, Cytopathology;

Calvino Cheng, BSc, MD, FRCPC, Pathology Informatics and Quality Management;

Eleftherios Diamandis, BSc, MD, PhD, FRCPC, Medical Biochemistry; David K. Driman, MB ChB, FRCPC, Anatomical Pathology;

Todd F. Hatchette, BSc, MD, FRCPC, Medical Microbiology; Michael J. Shkrum, MD, FRCPC, Forensic Pathology;

Louis D. Wadsworth, MB ChB, FRCPath, FRCPC, Hematopathology

MANAGING EDITORSusan Harrison

COPY EDITOR Susan Harrison

PROOFREADERScott Bryant

ART DIRECTORAndrea Brierley, [email protected]

TR ANSL ATORMarie Dumont

SALE S AND CIRCUL ATION COORDINATORBrenda Robinson, [email protected]

ACCOUNTINGSusan McClung

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Canadian Journal of Pathology • Volume 4, Issue 4, 2012 Contents

Original Articles

For Instructions to Authors, please visit www.andrewjohnpublishing.com/CJP/instructionstoauthors.html

The cover image shows metastatic malignant melanoma in the subcapsular sinus of a sentinel lymph node.

123

CAP-ACP News

112 Message from the Nominating Committee

Practice Matters113 Test Utilization and the Clinical Laboratory

Dr. Curtis Hanson and Elizabeth Plumhoff

Mixed Encapsulated Papillary Carcinoma/Invasive Ductal Carcinoma of the Male Breast with Metastasis to Lymph NodeZhongchuan Will Chen, MDCM, Anna Marie Mulligan, MBBCh, Pauline Henry, MD, Vladimir Iakovlev, MD

A Case of Confused Identity: Which Cancer Does the Lymphatic Metastasis Belong To?Ali Cadili, BA, MSc, MD, Hanin Musbah, Kelly Dabbs, MSc, MD, FRCSC

Uterine Tumour Resembling Ovarian Sex-Cord Tumour with True Sex-Cord DifferentiationManjula Jain, MD, Neha Kawatra Madan, MD, Smita Singh, MD

Conflict and Resolution: William Boyd’s Appointment to the Department of Pathology of the Winnipeg General HospitalGuillermo Quinonez, MD, MS, MA, FRCPC William Boyd Lecture 2012: Going ViralRichard G. Hegele, MD, PhD, FRCPC

118

FOUNDING EDITORJagdish Butany, MBBS, MS, FRCPC

Book Review142 Biomarkers of Kidney Disease

Reviewed by Dawn L. MacLellan, MD, FRCSC

Professional Development/Employment OpportunitiesMcGill UniversityNorthern HealthKingston GeneralUniversity Health Network

122130141143

131

126

136

Canadian Journal of P athology 107Winter 2012

Winter 2012108 Canadian Journal of P athology

Competing interests: None declared

EDITORIAL

We read with interest the comprehensive and

informative article “Test Utilization and the Clinical

Laboratory,” reprinted in this issue of the Canadian Journal

of Pathology and authored by Dr. Curtis Hanson and Elizabeth

Plumhoff of Mayo Medical Laboratories.1 Test utilization

management is not a new concept to most laboratories.

However, now more than ever, appropriate utilization is an

essential component of laboratory operations. With an aging

population, the need for medical intervention and laboratory

tests has increased. In fact, laboratory workload rises by

around 5% every year, and the increasing cost and complexity

of tests necessitate an expansion of the laboratory budget.

Clinical laboratories are faced with a very difficult challenge

in accommodating this growing demand and complexity,

while maintaining the same budget or even absorbing budget

cuts because of shrinking health care funding in Canada.

The sustainability of our laboratory services is in part

dependant on appropriate laboratory utilization to provide

the patients with the right test at the right time and to

maintain quality services. Laboratory professionals are well

positioned to control test utilization, and there are many

points where a laboratory professional can intervene,

including physician education, test ordering guidelines, and

limiting access to certain groups of physicians.

In our experience at a large Canadian academic centre,

physician education about test indication and appropriateness

is most successful when the test-ordering guidelines are

enforced by the laboratory.2 The Canadian Diabetes

Association’s 2008 Clinical Practice Guidelines indicate that

HbA1C should be tested no more frequently than every

3 months.3 As might have been expected from previous

reports,4 physician education led to a negligible decrease in

testing. However, the introduction of a rule that the test is

cancelled by the laboratory if an HbA1C result was reported

in the laboratory information system in the previous 90 days

led to an 8% decrease in HbA1C testing. Surprisingly,

18 months after implementation of this rule, the laboratory

continues to receive inappropriate HbA1C requests, and the

cancellation rate remains the same. Ideally, we need to reach

a state where inappropriate testing is not ordered in the first

place to avoid sample collection and processing. To achieve

this will require a lot more education and dialogue with the

clinicians.

Over the past 2 years, 31 cancellation rules based on similar

principles have been implemented in our laboratories. For the

vast majority, between 1 and 8% of the tests subject to

utilization rules are cancelled. These rules result in the

cancellation of approximately 61,000 tests per year. The

estimated reagent costs of those cancelled tests are around

$160,000 annually, and the reduced workload has allowed

technologists to be redeployed to other areas of the laboratory

that are experiencing an appropriate increase in workload.

The laboratory remains flexible in implementing those

utilization rules. Physicians are able to request exemptions, if

warranted for clinical reasons, by indicating on the requisition

or calling the pathologist; but discussions with physicians are

taking place in an effort to curtail overuse of exemption

requests. We now include previous test results in the

cancellation comment to ensure that the physician is aware

of the latest test results. Hopefully, easier access to previous

results will decrease re-orders, which may occasionally be

necessary. One of the challenges the laboratory faces in this

process is that the procedure for cancelling tests is labour

intensive. Collaboration is ongoing with those in pathology

informatics to determine a more efficient process for

implementing rules and allowing for exceptions to be handled

by the laboratory information system instead of manually.

Our laboratory serves both academic and community

physicians; they have different practice patterns, which further

complicates test utilization management. Another approach

to controlling test utilization described in the Mayo article is

limiting test ordering to a certain group of physicians. In our

experience, limiting access to ordering HLA-B27 to certain

groups of specialists (ophthalmologists, rheumatologists, and

Successful Test Utilization Management Initiatives in a Canadian Centre


SADEK

orthopedic surgeons) resulted in a major decrease from 2,500

tests per year to a more appropriate 200 tests per year. Testing

has remained stable at the lower level for over 5 years.

Our successful initiatives underscore the importance and

usefulness of a test utilization management program in the

laboratory in our cost-conscious health care system. We have

found that utilization management has allowed savings of

several hundred thousands of dollars while maintaining high-

quality patient care. Utilization test management programs

will differ from one centre to another5,6 but have become a

mandatory component of a clinical laboratory. While other

test utilization initiatives – such as informing physician groups

of their test ordering patterns, and screening orders for

expensive tests and those that may need referral to another

laboratory (e.g., cytogenetic and molecular diagnostics) –

have been implemented in our laboratory, cancellation of

inappropriate, high-volume tests has resulted in the most

savings without affecting patient care.

Over the past years, our experience in utilization management

has grown. We have been able to stimulate physician groups

to question their ordering patterns. We aim to change the

ordering physician culture from that of a fisherman, casting

a wide net of test orders hoping to catch the right test, to that

of a hunter, ordering only the required tests.

Irene Sadek, MD, MSC, FRCPCHead, Division of Hematopathology Chair, Laboratory Utilization CommitteeDepartment of Pathology and Laboratory MedicineCapital District Health Authority, Halifax, Nova Scotia

References1. Hanson C, Plumhoff E. Test utilization and the clinical laboratory. Communiqué

2012;37(3):1–5.

2. McHugh J, Afghan R, O’Brien E, et al. Impact of the introduction of guidelines

on vitamin B12�testing. Clin Chem 2012;58(2):471–5.

3. Canadian Diabetes Association. 2008 Clinical Practice Guidelines. Toronto

(ON): The Association; 2008.

4. Axt-Adam P, van der Wouden JC, van der Does E. Influencing behavior of

physicians ordering laboratory tests: a literature study. Med Care

1993;31(9):784–94.

5. Kim JY, Dzik WH, Dighe AS, Lewandrowski KB. Utilization management in a

large urban academic medical center. Am J Clin Pathol 2011;135:108–18.

6. Bunting PS, Van Walraven C. Effect of a controlled feedback intervention on

laboratory test ordering by community physicians. Clin Chem

2004;50(2):321–6.

C’est avec grand intérêt que nous avons pris

connaissance de l’article exhaustif et instructif sur

l’utilisation des tests au laboratoire clinique (« Test

Utilization and the Clinical Laboratory »1) de Curtis Hanson

et Elizabeth Plumhoff des Laboratoires médicaux Mayo,

reproduit dans le présent numéro de Canadian Journal of

Pathology. La gestion de l’utilisation des tests n’a rien de

nouveau dans la plupart des laboratoires. Le sujet resurgit

avec d’autant plus d’actualité aujourd’hui que l’utilisation

appropriée des tests constitue à l’évidence un

incontournable dans les opérations du laboratoire. Au fil du

vieillissement de la population, les interventions médicales

et les tests de laboratoire se font de plus en plus nombreux.

De fait, la charge de travail au laboratoire grimpe de près de

5 % par an, et le coût et la complexité accrus des tests forcent

l’augmentation de l’enveloppe budgétaire du laboratoire. Le

laboratoire clinique affronte un dilemme de taille, celui de

satisfaire cette demande grandissante et de se perfectionner

pour composer avec l’aspect complexe des tests, tout en ne

débordant pas de son cadre budgétaire, toujours le même,

voire en faisant avec des compressions en raison du

financement à la baisse des soins de santé au Canada.

La viabilité de nos services de laboratoire relève notamment

de l’utilisation appropriée des tests afin d’offrir au patient le

test judicieux au moment opportun et de maintenir la

qualité des services. Les professionnels du domaine sont tout

à fait en mesure de contrôler l’utilisation des tests et ils

peuvent intervenir à maints égards, en participant à

l’éducation des médecins, en établissant des lignes directrices

sur la prescription des tests ou en limitant la prescription

des tests à certains groupes de médecins, par exemple.

Notre expérience à un grand établissement universitaire

canadien nous révèle que l’éducation médicale à propos des

indications et du caractère approprié des tests est efficace

lorsque le laboratoire est responsable de la mise en

application des lignes directrices sur la prescription des

tests2. Dans ses Lignes directrices de pratique clinique 2008,

l’Association canadienne du diabète recommande le dosage

de l’hémoglobine glyquée (HbA1c) tous les trois mois, pas

plus fréquemment3. Comme l’illustre la documentation4,

l’éducation médicale ne s’accompagne que d’une baisse

négligeable de la prescription. En revanche, l’application

d’une règle selon laquelle le laboratoire annulera le test si

son système d’information renferme le résultat du dosage

de l’HbA1c pour ce patient dans les 90 jours se traduit par

une diminution de 8 % des tests de dosage de l’hémoglobine

glyquée. Curieusement, le laboratoire reçoit toujours des

ordonnances de dosage de l’HbA1c inappropriées 18 mois

après l’entrée en vigueur de la règle, et le taux d’annulation

demeure le même. En théorie, le résultat escompté est celui

voulant que la prescription inappropriée cesse afin d’éviter

le prélèvement et son traitement. Pour y parvenir, il nous

faudra accentuer les initiatives d’éducation médicale et le

dialogue avec les cliniciens.

Dans les deux dernières années, nos laboratoires ont instauré

31 règles d’annulation fondées sur le même principe général.

Le taux d’annulation de la grande majorité des tests qui font

l’objet de ces règles va de 1 % à 8 %. Autrement dit, les règles

ont conduit à l’annulation de près de 61 000 tests par an. Le

coût estimatif des réactifs qui auraient été utilisés pour ces

tests s’élève à 160 000 $ environ chaque année, et la baisse

de la charge de travail a permis aux technologues de se

consacrer à d’autres tâches dont le volume s’accroît à juste

titre.

À noter que le laboratoire fait preuve de souplesse dans

l’application de ces règles d’utilisation. Le médecin a le loisir

de demander une exemption, justifiée par un motif clinique,

en l’indiquant sur l’ordonnance ou en communiquant avec

le pathologiste; mais, de concert avec les médecins, nous

nous efforçons de trouver des moyens de prévenir la

surutilisation de la demande d’exemption. Pour être certains

que le médecin connaît les résultats des derniers tests de son

patient, nous les indiquons dans l’avis d’annulation.

Espérons que cette mesure de diffusion accrue des résultats

amène une diminution des ordonnances du même test, ce

qui peut être nécessaire parfois, nous en convenons. L’un des


Conflits d’intérêts : aucun

ÉDITORIAL

Initiative fructueuse de gestion de l’utilisationdes tests dans un établissement canadien


SADEK

défis que pose cette façon de faire vient de ce que la

procédure d’annulation nécessite une main-d’œuvre

importante. Nous nous penchons sur cette question avec des

spécialistes de l’informatique en pathologie afin de

déterminer un mode d’application des règles plus efficient

et de traitement des exceptions par le système d’information

du laboratoire, plutôt qu’à la main.

Notre laboratoire est à la disposition de médecins des

milieux universitaire et communautaire; ils n’ont pas le

même mode de pratique, ce qui complique la gestion de

l’utilisation des tests. L’article des laboratoires Mayo propose

une autre façon de contrôler l’utilisation des tests, soit de

limiter la prescription des tests à certains groupes de

médecins. Nous avons choisi de limiter la possibilité de

prescrire le test HLA-B27, de ne l'offrir qu'à des spécialistes,

plus précisément les ophtalmologistes, les rhumatologues et

les chirurgiens orthopédistes. Nous avons observé une baisse

spectaculaire du nombre de tests, qui était auparavant de

2 500 par an et qui en est rendu à 200 par an, une situation

qui correspond mieux aux indications appropriées. En plus

de cinq ans, ce nombre n’a d’ailleurs pratiquement pas

bougé.

Nos initiatives fructueuses viennent souligner l’importance

et l’utilité d’un programme de gestion de l’utilisation des

tests au laboratoire dans un système de santé soucieux des

coûts. Nous constatons les retombées d’un tel programme

qui ne compromet en rien la qualité des soins de santé, à

savoir des économies de plusieurs centaines de dollars. Le

programme de gestion de l’utilisation ne sera pas le même

d’un établissement à un autre5,6, mais il constitue désormais

un passage obligé pour le laboratoire clinique. Nous avons

entrepris d’autres initiatives ayant trait à l’utilisation des

tests, qu’il s’agisse d’examiner avec les médecins leurs

tendances de prescription des tests, d’analyser le bien-fondé

des ordonnances de tests onéreux ou la nécessité d’aiguiller

des tests à un autre laboratoire (diagnostic cytogénétique ou

moléculaire, par exemple), mais il n’en demeure pas moins

que l’annulation de tests inappropriés de volume élevé se

traduit par les plus grandes économies sans nuire à la qualité

des soins.

Au fil des ans, notre expérience dans la gestion de

l’utilisation s’est approfondie. Nous avons incité des groupes

de médecins à remettre en question leur mode de

prescription. Nous nous employons à changer la culture de

prescription des médecins, à les convaincre d’abandonner la

pratique du pêcheur qui lance à la volée un vaste filet dans

l’espoir d’attraper tout ce qui passe au profit de celle du

chasseur qui vise juste en prescrivant les tests appropriés et

nécessaires.

Irene Sadek, M.D., MSC, FRCPCChef, Division d’hématopathologie Présidente, Comité de l’utilisation des services de laboratoireService de pathologie et de biologie médicaleCapital District Health Authority, Halifax (Nouvelle-Écosse)

Références 1. Hanson C, Plumhoff E. Test utilization and the clinical laboratory.

Communiqué 2012;37(3):1–5.

2. McHugh J, Afghan R, O’Brien E, et al. Impact of the introduction of guidelines

on vitamin B12 testing. Clin Chem 2012;58(2):471–5.

3. Association canadienne du diabète. Lignes directrices de pratique

clinique 2008 pour la prévention et le traitement du diabète au Canada.

Canadian Journal of Diabetes, septembre 2008, vol. 32, suppl. 1.

4. Axt-Adam P, van der Wouden JC, van der Does E. Influencing behavior of

physicians ordering laboratory tests: a literature study. Med Care

1993;31(9):784–94.

5. Kim JY, Dzik WH, Dighe AS, Lewandrowski KB. Utilization management in a

large urban academic medical center. Am J Clin Pathol 2011;135:108–18.

6. Bunting PS, Van Walraven C. Effect of a controlled feedback intervention on

laboratory test ordering by community physicians. Clin Chem

2004;50(2):321–6.


Dear CAP-ACP Members,

The Nominating Committee proposes the following Slate of

Officers for June 2013; the only new nominations are for

vice-president and members-at-large.

Executive:

• President – Martin Trotter

• Vice-president – Victor Tron

• Past president – Vina Alexopoulou

• Secretary treasurer – Brian Cummings

• Continuing professional development chair – Jason

Ford

• Annual meeting chair – Avrum Gotlieb

• Resource development chair – Alan Spatz

• Website editor – Tadaki Hiruki

• Journal editor-in-chief (ex-officio) – Godfrey

Heathcote

• Patient safety and quality assurance chair (ex-officio)

– Laurette Geldenhuys

• Member-at-large – Marciano Reis

• Member-at-large – Julianne Klein

Other:

• Membership chair – Bernard Tetu

If you would like to make an alternative nomination for the

positions of vice-president or member-at-large, please submit

your nomination to [email protected].

The nomination

• must be signed by five qualified ordinary members,

with membership dues paid;

• must be agreed to by the proposed nominee, who must

be a qualified ordinary member; and

• must be received at least 30 days prior to the Annual

General Meeting.

Laurette GeldenhuysPast PresidentChair, Nominating Committee

Message from the Nominating CommitteeCAP-ACP NEWS


This article has been reprinted from Mayo Medical Laboratories Communiqué, 2012, Volume 37, Number 3, by permissionof the Mayo Foundation for Medical Education and Research. All rights reserved.

Dr. Curtis Hanson and Elizabeth Plumhoff

ABSTRACTThe clinical laboratory has an important and expanding role in ensuring that laboratory tests

are appropriately utilized in clinical practice. Laboratories are discovering that they are well

positioned to provide medical guidance and direction for clinicians who are trying to maneuver

their way through the increasingly complex world of laboratory testing.

RÉSUMÉ Le rôle du laboratoire clinique dans l’utilisation appropriée des tests de laboratoire dans la

pratique clinique prend de l’ampleur. Le laboratoire constate de fait qu’il est en mesure de baliser

la prescription des tests, d’offrir un encadrement sur ce plan aux cliniciens qui s’efforcent de

trouver leur chemin dans l’univers de plus en plus complexe des analyses de laboratoire.

PRACTICE MATTERS

Test Utilization and the Clinical Laboratory

BackgroundThe clinical laboratory has an important and expanding role

in ensuring that laboratory tests are appropriately utilized in

clinical practice. Laboratories are discovering that they are

well positioned to provide medical guidance and direction

for clinicians who are trying to maneuver their way through

the increasingly complex world of laboratory testing,

including genetic-driven diagnostics and therapeutics. There

are literally thousands of laboratory tests that clinicians

might request as they evaluate a particular patient, but it is

difficult, if not impossible, for any one individual to be

proficient in all areas of medicine. Because of the number

and the complexity of these tests, physicians are realizing that

they have gaps in their knowledge and understanding of

these assays. In addition to providing guidance to clinicians,

test utilization efforts may also be driven by financial realities

as laboratories try to rein in laboratory costs or in response

to payer programs and policies that reduce payments to

providers. Whatever the underlying reasons, the clinical

laboratory needs to take the lead in developing a successful

test utilization initiative.

So, why the sudden interest and enthusiasm for test

utilization? Health care costs in the United States are thought

to approach $2.5 trillion per year, and laboratory and

pathology testing accounts for $60 billion or about 4% of

total health care costs. However, that percentage is increasing

rapidly, with some experts estimating that laboratory costs

are skyrocketing at a 15% to 25% annual increase. Molecular

and genetic assays are driving this escalation, as the explosion

of genomic knowledge has led to novel genetic assays for

almost any common, or even rare, disease process. This

financial burden will clearly become a focus for payers and

health care providers alike. It will be impossible to ignore the

realities associated with laboratory costs and the need for

defining appropriate test utilization.

Test Utilization DefinedTest utilization should be defined as a strategy for

performing appropriate laboratory and pathology testing

with the goal of providing high-quality, cost-effective patient

care. A test utilization program must be focused on patient

care, ultimately leading to a more efficient and cost-effective

laboratory diagnostic approach to answer the clinical

questions being asked. A test utilization initiative cannot be

driven as a pure cost-control process. If the primary motive

is financially instead of patient care driven, then any


TEST UTILIZATION AND THE CLINICAL LABORATORY

utilization program will either be short-lived or ineffective

in its outcome. High-quality medical practice must be the

driving force if a test utilization program is to be successful.

Mayo Clinic has defined the clinical value equation as: Value

= Quality/Cost with quality defined as Outcomes + Service

+ Safety. Clinical value increases when quality (ie, outcomes,

service, and safety) is improved and cost is decreased.

This is as relevant for the laboratory as it is for a clinical

practice. No matter how we define test utilization, the

clinical laboratory needs to understand the critical role it

must play in our changing health care environment.

The Clinical Laboratory’s RoleLaboratory professionals need to be fully engaged with the

clinical practice in any test utilization process. It is not easy

and requires interactions with clinical colleagues that may

not always be comfortable. We need to be able to question

test requests that come from our clinical colleagues, suggest

appropriate tests to answer the clinical question being asked,

and cancel test orders when they are inappropriate for the

question at hand. Laboratorians must become comfortable

and confident in these interactions. Our clinical colleagues

have few incentives to order fewer tests, and they certainly

are not being trained with that intent in mind. So it becomes

the laboratory’s responsibility to identify utilization issues,

implement a program that will achieve more effective

laboratory testing, and establish processes from the

beginning to the end of the testing cycle that lead to a

successful laboratory test utilization program.

Test Utilization Control Process The biggest questions that laboratories usually encounter

when trying to develop a test utilization program are simple:

“How do we do it?” and “Where do we start?” That we have

these very basic questions emphasizes that no simple

answers exist. A successful solution requires a multipronged

approach that must involve the clinician, the laboratory, and

clinically engaged pathologists and laboratory directors. The

key is to understand how the clinical laboratory test cycle

works, the roadblocks that invariably exist, and how the

laboratory can integrate into these processes and overcome

the roadblocks.

A utilization control process actually starts when the

clinician begins to consider what tests are needed to evaluate

his or her patient—whether for diagnosis, follow-up,

therapeutics, or exclusion of disease. Appropriate ordering

depends on the clinician having the correct core knowledge

to make that decision. The laboratory enters the process

early on as it provides that clinician with the tools to order

the correct test. A test-ordering process often varies. The

process for ordering clinical tests may be designed to make

it easy for the physician to request any and all tests, or it may

include prerequisites, requirements, or permissions that the

clinician must fulfill prior to placing that order.

After the test order or specimen is received in the laboratory,

the laboratory professional can play a more active role in the

test decision process. Clinical laboratories are beginning to

explore how to use algorithms, test guidelines, and test

formularies to put appropriate medical and utilization

reviews in place. Instead of taking the easier and passive role,

“if the doctor orders it, we do it,” clinical laboratories are

beginning to explore how to use algorithms, test guidelines,

and test formularies to put appropriate medical and

utilization reviews in place.

An overall test utilization control process might look

something like this:

1. Important test information (clinical indications, overall

value of that test, test indications, etc) that is readily

available is the first step for the laboratory engaging the

clinician in a test utilization effort. This information

should be available in an easy electronic format—

whether it is linked to the electronic medical record, the

electronic ordering system, other available electronic

tools, or via smart phone applications. If that is not

possible, a current laboratory test catalog may

substitute. Electronic information is preferable as it is

current and accurately represents recent changes.

2. Algorithms and test-ordering guidelines are the next

step necessary to guide the clinician through a

utilization process (Figure 1). While they are a small

Value=(Outcomes, Safety, Service)

Quality

Cost


HANSON AND PLUMHOFF

piece of the puzzle, testing algorithms and guidelines are

essential tools in guiding both the clinician and

laboratory toward appropriate test selection. The success

of test-ordering algorithms and guidelines, however,

depends on the clinician making the effort to seek out

that information, and a busy clinician may lack the time

or willingness to do so. It may be necessary to actively

engage the clinician in discussions surrounding the use

of algorithms using educational tools such as recorded

videos, Grand Round presentations, publications, etc.

3. Other tools are available to assist in a utilization process.

Some laboratories have implemented a test formulary

patterned after the pharmaceutical model. The

laboratory test formulary is used to limit access to

certain tests and often requires authorization from a

pathologist, subspecialist, or laboratory committee

before a particular test can be ordered. Laboratories may

use a tiered approach, with some tests available to all

physicians, some complex tests available to only a

subspecialty group of physicians, and other complex

tests requiring written justification and committee

authorization. Another approach that has been used to

control test utilization is mandating that some tests can

only be ordered after discussion with the laboratory

pathologist. Whatever the process, test formulary

restrictions may be driven by cost and reimbursement

issues, known situations of test misutilization, or

whether the test is performed in-house versus sent to a

reference laboratory. Regardless of the underlying

rationale, a test formulary by itself will have little

impact, but appropriate test utilization requires active

engagement with the clinical practice by the laboratory

to ensure that the most effective testing strategy is being

used to answer the clinical question.

4. Sometimes it may be necessary to use a “send and hold”

process where a test may be sent to a testing laboratory

(or even held within the ordering laboratory), but

testing is not performed by the receiving laboratory

until the sender notifies the receiving laboratory to

perform or cancel the test. This strategy is utilized when

an initial laboratory result is required to determine the

need for the follow-up test, but delaying the shipment

could impact specimen integrity. In this manner, the

specimen is available for testing as soon as the initial

result is released. For example, it is very appropriate that

flow cytometry, molecular-based studies, and

cytogenetic studies in hematologic disease be held until

the bone marrow aspirate and biopsy are reviewed by

the pathologist or until the initial round of testing is

complete. A decision can then be made regarding if or

what subsequent testing is necessary.

5. Reports must be clear and should integrate all the

findings associated with an episode of care.

Unfortunately, laboratory information systems do not

always effectively transmit the intended information to

the clinician. Laboratory reports are often just lists of

results with no or minimal correlative interpretation.

This can make it difficult, if not impossible, for the

clinician to get the information he or she needs. The

pathologist in particular needs to be engaged in this

process to ensure that the reporting system is working

as intended.

6. Finally, auditing results is a critical step in the utilization

process. The laboratory generates a tremendous amount

of data. When analyzed, these data can tell you how a

test is being used, whether the intended outcome of a

utilization process is being achieved, and where

problems exist. The audit process can also identify

which guidelines are not working as planned or need

modifications or revisions.

Where Can the Laboratory Influence Test Utilization?At several points along the test-ordering continuum

laboratories can influence and change the ordering process.

Preanalytic: Clinician Test Ordering1. Modify test order requisition forms, whether electronic

or paper, and keep them current. Remove obsolete tests

and limit the inclusion of esoteric tests on the general

requisition. Establish a process to destroy old forms,

remembering to remove hard copies from outlying

areas.

2. Organize tests by disease state or by ordering patterns,

rather than the more typical alphabetical approach.

3. Review and minimize the process where tests are

bundled together for ease of physician ordering.


TEST UTILIZATION AND THE CLINICAL LABORATORY

12/11

Reactive: regardless of S/CO ratio*

HCPCR/60707 Hepatitis C VirusAntibody Screen with Re�ex to HCV RNA by PCR, SerumReactive antibody screen automatically re�exes to PCR

Type of Patient Abnormal liver enzyme levels with or without symptoms Recipient of blood or blood products prior to 1991 Hemophiliac Injection drug user

HCVQU/83142 Hepatitis C Virus (HCV) RNA Detection and Quanti�cation by Real-Time Reverse Transcription PCR, Serum

Additional testing is recommended to rule-out recovery from recent acute hepatitis C or ongoing (chronic) HCV infection with intermittent viremia.

Repeat PCR testing in 1 to 3 months, if clinically indicated.

Active HCV infection follow-up and treatment decisions depend on patient risk group.

Type of Patient Acute hepatitis Immunocompromised

Any viral load

Antibody result

Go to HCV Treatment Algorithm

STOPThis result and a reactive antibody screen suggest a false-reactive screen.

Indeterminate or unreadable

Negative Positive

STOPRepeat testing is recommended in 1 to 2 months.

STOPResolved (past) HCV infection

Negative Any viral load

Active HCV infection

Possible resolved/ past infection. Repeat HCVQU/83142 in 1 to 3 months.

Hepatitis C Virus (HCV) RNA Detection and Quanti�cation by Real Time ReverseTranscription PCR (RT-PCR), Serum

This result and a reactive antibody screen suggest either a false-reactive screen or a resolved (past) infection.

Recommend testing with RIBA/80181 Hepatitis C Virus Antibody Con�rmation, Serum to distinguish between these 2 conditions.

* S/CO ratio = signal-to-cutoff ratio

Negative Any viral load

Negative

Recommended Approach to the Diagnosis of Hepatitis C

© Mayo Foundation for Medical Education and Research (MFMER). All rights reserved. MAYO, Mayo Medical Laboratories and the triple-shield Mayo logo are trademarks and/or service marks of MFMER.

Figure 1. This is an example of an algorithm that was developed by Mayo Clinic Department of Laboratory Medicine and Pathology,Division of Clinical Microbiology and Mayo Medical Laboratories to guide the diagnosis of hepatitis C. Algorithms are available onlineat www.mayomedicallaboratories.com


HANSON AND PLUMHOFF

4. Review standing orders and how they are used in the

clinical practice.

5. Establish a process to review any new tests that are

requested.

6. Include necessary educational material – algorithms,

practice guidelines, publications, etc – to help close the

knowledge gap.

Laboratory Processing1. Establish an approval and cancel process for certain

tests. If it is a low-volume test, this process can be

undertaken by knowledgeable individuals and reviewed

manually. For higher-volume tests, an information

system-based process and intervention may need to be

developed.

2. Review those tests the laboratory sends to reference

laboratory partners using a test formulary-like or a

utilization review process. Some requests may need

laboratory director approval before processing.

PostanalyticLaboratory reports may not be easy to read or understand,

leaving the clinician with more questions than answers.

While there will be differences in format and presentation,

all laboratory reports must contain certain elements as

mandated by the Clinical Laboratory Improvement

Amendments (CLIA). The report may also need to contain

additional items not specifically required, but that can assist

the clinician in the interpretation of laboratory test results.

ConclusionTest utilization management is not a new concept to most

laboratories, but few have taken the steps necessary to truly

initiate a utilization control process. Every laboratory needs

to design its own strategy for test utilization and find what

best fits the structure and culture of its institution.

Laboratory professionals can position themselves as

utilization experts who can assist clinicians with test

ordering and ultimately improve the quality and efficiency

of patient care. The task is not easy. Conversations with

clinical colleagues to gain information, cancel a test, or

suggest ordering a different test can be uncomfortable, but

these interactions are necessary to build a successful

laboratory utilization program that leads to high-quality,

cost-effective patient care.


Mixed Encapsulated Papillary Carcinoma/Invasive Ductal Carcinoma of the Male Breast

with Metastasis to Lymph Node

Zhongchuan Will Chen, MDCM, and Pauline Henry, MD, are members of the Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario. Anna Marie Mulligan, MBBCh, and Vladimir Iakovlev, MD, are membersof the Department of Laboratory Medicine and the Li Ka Shing Knowledge Institute, St. Michael’s Hospital, University ofToronto. Correspondence may be directed to [email protected] article has been peer reviewed.Competing interests: None declared

Zhongchuan Will Chen, MDCM, Anna Marie Mulligan, MBBCh, Pauline Henry, MD, Vladimir Iakovlev, MD

ABSTRACTEncapsulated papillary carcinoma (EPC) of the breast is a controversial entity with features and

behaviour overlapping between ductal carcinoma in situ and invasive carcinoma. At present,

its metastatic potential is not clearly understood. The authors report the novel case of an EPC

in a man with nodal metastasis.

This 61-year-old man underwent total mastectomy with axillary dissection. The specimen

contained an EPC with an area of conventional invasive ductal carcinoma (IDC) at the

periphery. One of eight lymph nodes in the axillary dissection contained a metastasis. Of note,

the metastasis consisted mainly of a tumour with an encapsulated architecture replacing the

node and with capsular penetration; there was also a focus of IDC, recapitulating the primary

tumour.

The encapsulated component of EPC may have the ability to metastasize concurrently with the

invasive component. This case is remarkable due to the previously unreported finding of a

mixed EPC/IDC metastasizing to a lymph node in a male.

RÉSUMÉ Le carcinome papillaire encapsulé du sein est une entité controversée dont les caractéristiques

et l’évolution rappellent celles du carcinome canalaire in situ pour certaines et celles du

carcinome invasif pour d’autres. Son potentiel métastatique demeure largement méconnu

encore. Les auteurs examinent le cas inédit d’un homme présentant un carcinome papillaire

encapsulé avec métastase ganglionnaire.

L’homme de 61 ans a subi une mastectomie totale accompagnée d’un évidement ganglionnaire

axillaire. À l’analyse histologique, on dénote un carcinome papillaire encapsulé ainsi qu’une

zone caractéristique d’un carcinome canalaire invasif en périphérie. Une métastase s’est logée

dans l’un des huit ganglions excisés à l’évidement ganglionnaire. À souligner que la métastase

en question est formée principalement d’une tumeur d’architecture encapsulée qui se substitue

au ganglion et qu’il y a pénétration de la capsule; on observe également un foyer de carcinome

canalaire invasif à l’image de la tumeur primitive. La composante encapsulée du carcinome

peut métastaser en même temps que la composante invasive. Ce cas est remarquable en ce qu’il

est le premier cas rapporté chez un homme d’une tumeur mixte disséminée dans un ganglion

lymphatique, où cohabitent un carcinome papillaire encapsulé et un carcinome invasif.

ORIGINAL ARTICLE


CHEN ET AL.

Encapsulated papillary carcinoma (EPC) of the breast is

an unusual neoplasm characterized by a circumscribed

expansile mass consisting of an arborizing network of

papillae covered by malignant epithelial cells. The papillae

are frequently compact, forming cribriform and solid areas;

however, fibrovascular cores, albeit sometimes

inconspicuous, are retained. A fibrous rim typically

surrounds the tumour, and morphological evidence of

stromal invasion is lacking. Despite the morphological

impression of an in situ process, myoepithelial cells are

typically absent from the periphery of the lesion, leading

certain authors to postulate that EPC is an indolent form of

invasive carcinoma.1,2 On the other hand, others have

proposed that EPC is a variant of ductal carcinoma in situ

since type IV collagen can be identified around the

periphery of the tumour.3 As is the case for all breast cancers,

it is rarer in men, with fewer than 50 cases reported in the

literature to date. We describe the first case in a man of a

mixed EPC/invasive ductal carcinoma (IDC) with metastasis

to a lymph node in which the metastatic deposit had the

same architectural pattern as the primary, containing

predominantly the encapsulated and focally the IDC

component.

Case ReportA previously healthy 61-year-old man presented with a self-

identified left breast mass. A needle-core biopsy was

performed, and the lesion was diagnosed as EPC with IDC,

of no special type (NST). He subsequently underwent a total

mastectomy with axillary dissection, which, on pathological

examination, revealed EPC with IDC and metastasis to one

of eight lymph nodes. The patient received adjuvant

chemotherapy on the FEC-D protocol (5-fluorouracil,

epirubicin, and cyclophosphamide followed by docetaxel).

He was then started on tamoxifen and completed 5 weeks

of adjuvant radiation therapy, with no evidence of recurrent

or metastatic disease 18 months after surgery.

Materials and MethodsThe surgical specimen was fixed in 10% neutral buffered

formalin. Paraffin-embedded tissue sections of 4 µm were

cut and stained with hematoxylin and eosin.

Immunohistochemistry was also performed on these

sections according to established protocols on a Ventana

Benchmark XT automated stainer (Ventana Medical

Systems, Tucson, Arizona). The antibodies used included

p63 (clone BC4A4, Biocare Medical, Concord, California),

smooth muscle myosin heavy chain (clone SMMS1,

BioGenex, Fremont, California), estrogen receptor (ER)

(clone SP1, Ventana Medical Systems), progesterone

receptor (PR) (clone 1E2, Ventana Medical Systems), and

HER2 (clone A0485, Dako, Carpinteria, California; and

clone 4B5, Ventana Medical Systems). Fluorescent in situ

hybridization for HER2 (PathVysion HER-2 DNA probe kit,

Abbott [www.abbottmolecular.com]) was also performed

on paraffin sections according to standard protocols.

ResultsGross examination of the surgical specimen showed a 2.2 ×

2.2 × 1.6 cm retro-areolar, well-circumscribed, solid mass

with an eccentric cystic area containing serosanguineous

fluid. Microscopic examination revealed the mass to consist

of a dilated, cystic space containing a compact papillary

growth with fibrovascular cores, surrounded by a thick

fibrous capsule (Figure 1). Immunostaining for

myoepithelial cells with antibodies to p63 and smooth

muscle myosin–heavy chain (SMM-HC) was negative at the

periphery of the tumour (Figure 2). The findings were in

keeping with a diagnosis of EPC. At one edge of the

encapsulated component, there were several foci showing

histological evidence of stromal invasion. The invasive

component was an IDC-NST (see Figure 1). The largest

dimension of the EPC was 2.2 cm, and the IDC extended 1.7

cm along the EPC edge. In the axillary dissection, eight

lymph nodes were identified, the largest of which harbored

a 2.4 cm metastasis with extranodal extension (Figure 3).

Interestingly, this metastasis recapitulated the EPC pattern

of the primary tumour and almost completely replaced the

node. Focally, there was penetration of the nodal capsule by

the EPC as well as by an area of IDC-NST (see Figure 3).

The invasive components at the primary and metastatic sites

also had similar morphology and histological grade: no

tubular differentiation, moderate nuclear pleomorphism,

and low mitotic counts. A final diagnosis of IDC-NST (1.7

cm, Nottingham grade II/III) arising on a background of

EPC was made. Lymphovascular invasion was not identified


MIXED EPC/IDC OF THE MALE BREAST WITH METASTASIS

and all margins were negative. Immunoreactivity for ER was

100% and for PR 80% in both the primary tumour and

metastasis. HER2 immunostaining was equivocal (2+), and

testing by fluorescence in situ hybridization showed non-

amplification in both the primary tumour and metastasis.

Of note, both EPC and IDC components at the primary and

metastatic sites showed equivalent staining for ER, PR, and

HER2.

DiscussionEPC usually presents as a subareolar mass with nipple

discharge in elderly women, but has been reported to occur

in men. In the largest series to date of 917 EPCs from the

California Cancer Registry, the median age was 69.5 years

and only 32 cases (3.5%) involved males.4 EPC is typically

considered an indolent tumour with a prognosis similar to

ductal carcinoma in situ (DCIS) despite the absence of a

myoepithelial cell layer. In the same series of 917 EPCs, the

relative cumulative survival for EPC compared with age-

Figure 1. Encapsulated papillary carcinoma with cystic spacescontaining compact papillary proliferations with fibrovascularcores and surrounded by a thick fibrous capsule (thick arrows); afocus of invasive ductal carcinoma, no special type is present atthe periphery (double arrows). (Hematoxylin and eosin)

Figure 2. Smooth muscle myosin–heavy chain immunostaininghighlights the absence of myoepithelial cells around theencapsulated (thick arrows) and invasive (double arrows)components, while blood vessels and a normal duct on the left ofthe image serve as internal controls. Note the vascular networkwithin the encapsulated papillary carcinoma component.(Immunoperoxidase)

Figure 3. A, The lymph node metastasis recapitulates thehistopathology of the primary encapsulated papillary carcinoma(EPC). B and C, The node is extensively replaced by an almostexclusively EPC component with foci of invasive carcinoma at theperiphery. Note the penetration of the nodal capsule by theencapsulated component at two sites. D, A focus of invasive ductalcarcinoma of no special type is seen between them. (Hematoxylinand eosin)

C A

B

D


CHEN ET AL.

matched controls was 97.3% after 5 years and 95.6% after

10 years. In addition, only 39 of 917 cases (4.3%) showed

direct extension into adjacent tissue or metastasis to lymph

nodes, illustrating the tumour’s low propensity for

metastasis.4 Similarly, a recent series containing 208 cases of

EPCs described clinicopathological findings consistent with

previous studies.5

Histologically, EPC consists of dilated ducts or spaces

occupied by a proliferation of neoplastic cells supported by

fibrovascular cores, or papillae. Myoepithelial cells are

typically not present within or at the periphery of the

tumour. EPC must be differentiated from other papillary

lesions of the breast, including benign papilloma and

papillary DCIS. The main distinguishing feature between

DCIS and EPC is the absence, or presence, of myoepithelial

cells around the periphery of the tumour, which are absent

from EPC and present in papillary DCIS. EPC can be

distinguished from papilloma by the preservation of

myoepithelial cells in the fibrovascular cores and the absence

of a neoplastic epithelial component in the latter.

Histological evidence of stromal invasion may be seen with

EPC and should be distinguished from pseudo-invasion in

which neoplastic epithelium becomes entrapped within the

fibrous capsule. Invasive carcinoma should be clearly located

beyond the fibrous capsule and should show features of

infiltrative malignancy: stromal infiltration with possible

desmoplasia, cytological atypia, and mitoses. When stromal

invasion occurs in this setting, it is typically an invasive

ductal carcinoma of no special type; it is extremely rare for

the invasive component to be an invasive papillary

carcinoma. When an invasive carcinoma is present in

association with EPC, the current convention is that only

the unequivocally invasive component should be used to

determine the size of tumour for staging.1 If there is no

invasive component, the size of the EPC should not be used

to determine the T stage, and a comment on the indolent

nature and prognosis of EPC should be provided to the

clinician in order to avoid overtreatment of the patient.1

To our knowledge, this report is the first of EPC/IDC with

lymph node metastasis in a male. To date, there are seven

literature reports of EPC with clearly documented lymph

node sampling in males, but none had lymph node

involvement.6–12 The metastatic potential of pure EPC in

women has been documented and is presumed to be very

low, but exact numbers have not been defined. It is believed

that some metastases from EPC actually represent

metastases from an occult invasive stromal component

missed as a result of inadequate sampling, or mechanical

transport of tumour to a lymph node.13 Nevertheless, one

case report described two patients with adequately sampled

EPCs without stromal invasion that developed lymph node

micrometastases.14 In both patients, the micrometastases

showed morphological features similar to the primary EPCs

and had no features suggesting mechanical transport, such

as the presence of foreign body giant cells, altered red blood

cells, lymphocytes, or hemosiderin-laden macrophages

adjacent to the transported epithelium.14 In our case, the

lymph node metastasis consisted predominantly of tumour

with morphological features identical to the breast EPC as

well as showing a minor, invasive component with features

of the primary IDC-NST. The most plausible explanation

for this is that the EPC component of the primary tumour

has metastatic potential distinct from the IDC component.

Alternatively, the possibility of mechanical transport to a

lymph node during needle biopsy of the primary tumour

exists. However, the lack of histological evidence of

mechanical transport and the requirement that the

transported epithelium grew to be bigger than the primary

in the 1-month interval between biopsy and mastectomy

render this hypothesis less likely. A third explanation could

include the development of an EPC with subsequent stromal

invasion arising in an epithelial rest within the lymph node.

The fact that both the breast and lymph node tumours

showed identical morphology makes this scenario unlikely.

If further studies can definitively demonstrate that EPC

indeed has metastatic potential independent of a coexisting

IDC component, then the current convention of not

including the size of the EPC component in the T stage may

need to be reconsidered. Perhaps a separate T stage category

could be devised for EPC and other tumours with uncertain

malignant potential. Such a category could reflect the

prognosis of these tumours, which is significantly better

than that of IDC.

This previously undescribed case of mixed EPC-IDC with

lymph node metastasis reiterating the primary mixed

pattern in a man provides further insight into the biology


MIXED EPC/IDC OF THE MALEBREAST WITH METASTASIS

and behaviour of this peculiar tumour. Since the metastasis

contained not only the IDC component but also the EPC

component of the primary, it suggests that EPC itself may

have metastatic potential and supports the view that this

entity occupies an intermediate position in a spectrum of

disease from in situ to invasive carcinoma.2

References1. Collins LC, Schnitt SJ. Papillary lesions of the breast: selected diagnostic and

management issues. Histopathology 2008;52(1):20–9.

2. Hill CB, Yeh IT. Myoepithelial cell staining patterns of papillary breast lesions:

from intraductal papillomas to invasive papillary carcinomas. Am J Clin Pathol

2005;123(1):36–44.

3. Esposito NN, Dabbs DJ, Bhargava R. Are encapsulated papillary carcinomas

of the breast in situ or invasive? A basement membrane study of 27 cases. Am

J Clin Pathol 2009;131(2):228–42.

4. Grabowski J, Salzstein SL, Sadler GR, Blair S. Intracystic papillary carcinoma:

a review of 917 cases. Cancer 2008;113(5):916–20.

5. Rakha EA, Gandhi N, Climent F, et al. Encapsulated papillary carcinoma of

the breast: an invasive tumor with excellent prognosis. Am J Surg Pathol

2011;35(8):1093–103.

6. Brahmi SA, El M’rabet FZ, Akesbi Y, et al. Intracystic papillary carcinoma

associated with ductal carcinoma in situ in a male breast: a case report. Cases

J 2009;2:7260.

7. De Cicco C, Baio SM, Veronesi P, et al. Sentinel node biopsy in male breast

cancer. Nucl Med Commun 2004;25(2):139–43.

8. Dragoumis DM, Tsiftsoglou AP. Intracystic papillary carcinoma associated

with ductal carcinoma in situ in a male breast. J Postgrad Med 2008;54(1):39–

40.

9. Hussain A, Sweeney KJ, Salman R, et al. Intracystic papillary carcinoma of the

male breast: a case report and review of the literature. Ir J Med Sci 2012

Sep;181(3):329–31. Epub 2009 Jul 9.

10. Imoto S, Hasebe T. Intracystic papillary carcinoma of the breast in male: case

report and review of the Japanese literature. Jpn J Clin Oncol 1998;28(8):517–

20.

11. Romics L Jr., O’Brien ME, Relihan N, et al. Intracystic papillary carcinoma in

a male as a rare presentation of breast cancer: a case report and literature

review. J Med Case Reports 2009;3:13.

12. Yoshida M, Mouri Y, Yamamoto S, et al. Intracystic invasive papillary

carcinoma of the male breast with analyses of loss of heterozygosity on

chromosome 16q. Breast Cancer 2010;17(2):146–50.

13. Carter BA, Jensen RA, Simpson JF, Page DL. Benign transport of breast

epithelium into axillary lymph nodes after biopsy. Am J Clin Pathol

2000;113(2):259–65.

14. Mulligan AM, O’Malley FP. Metastatic potential of encapsulated (intracystic)

papillary carcinoma of the breast: a report of 2 cases with axillary lymph node

micrometastases. Int J Surg Pathol 2007;15(2):143–7.

DISPLAY CLASSIFIED

Cytopathology Review CourseApril 27 – 30, 2013

Montréal, Québec, Canada

Course Director: Dr. Manon Auger

For further information

contact:

Email: [email protected]

McGill University Health Centre

Continuing Education Office

Tel: (514) 934-8253

Fax: (514) 934-1779

www.muhc-cme.mcgill.ca


A Case of Confused Identity: Which CancerDoes the Lymphatic Metastasis Belong To?

Ali Cadili, BA, MSc, MD, and Kelly Dabbs, MSc, MD, FRCSC, are members of the Department of Surgery, Misericordia Hos-pital and University of Alberta, in Edmonton, Alberta. Hanin Musbah is a student at the University of Alberta. Correspondence may be directed to [email protected] article has been peer reviewed.Competing interests: None declared

Ali Cadili, BA, MSc, MD, Hanin Musbah, Kelly Dabbs, MSc, MD, FRCSC

ABSTRACTA 64-year-old woman developed a malignant melanoma of the upper arm, and metastatic

melanoma was confirmed in one sentinel axillary node by immunohistochemistry. She

underwent further axillary node dissection, and metastatic tumour was identified in six of 14

nodes. Immunohistochemistry was not performed at that time. Two years later, a screening

mammogram revealed a lesion that was proven to be a primary breast carcinoma on needle

core biopsy; the patient underwent simple mastectomy. Pathological review of the lymph nodes

from the axillary dissection indicated that they contained metastatic breast carcinoma and not,

as had been assumed, metastatic melanoma. The patient’s prognosis was upgraded.

RÉSUMÉ Une femme de 64 ans présente un mélanome malin au bras; l’immunohistochimie révèle la

présence d’une métastase dans un ganglion axillaire sentinelle. La patiente subit un évidement

ganglionnaire axillaire, et l’analyse détecte une tumeur métastatique dans 6 des 14 ganglions

prélevés. Il n’y a pas eu d’analyse immunohistochimique à ce moment-là. Deux ans plus tard,

une mammographie de dépistage décèle une lésion qui s’avère un carcinome du sein primitif

à la biopsie par aspiration; la patiente subit une mastectomie simple. L’examen pathologique

des ganglions lymphatiques excisés à l’évidement axillaire indique la présence de métastases

d’un carcinome du sein, non pas du mélanome comme on l’a supposé d’abord. Le pronostic a

été modifié en conséquence.

ORIGINAL ARTICLE

Case ReportA 64-year-old woman presented to her family physician with

a changing mole on the upper outer aspect of her left arm.

An excisional biopsy was performed, and it revealed

malignant melanoma. The Breslow thickness was 5 mm,

Clark level IV, and there was no evidence of ulceration. The

patient was referred to a surgeon for a wide excision of the

biopsy area and a sentinel lymph node (SLN) biopsy. The

SLN biopsy result revealed that one node was positive for

tumour cells expressing HMB-45 and MART1, consistent

with metastatic melanoma (Figure 1). Several clusters of

melanoma cells were identified by immunohistochemistry

in the positive node, the largest of which measured 5 mm in

greatest diameter. The patient thereafter underwent a

completion lymph node dissection (CLND) of the left axilla,

and six positive lymph nodes, out of 14 lymph nodes

examined, were identified. In accordance with the hospital’s

protocol for handling CLND specimens following positive

SLN results, the nodes were not examined with

immunohistochemistry. Based on these results, the patient


A CASE OF CONFUSED IDENTITY

was prescribed a 1-year course of adjuvant interferon

treatment. The interferon treatment was halted after 8

months because of worsening syncopal episodes thought to

be the result of intolerance.

Two years after the initial melanoma diagnosis, the patient

was referred back to the surgeon because of an abnormal

result on screening mammography. This showed changes in

the left breast suspicious for cancer, which had not been

present on her last mammogram 2 years previously. The

patient reported no specific symptoms other than a slightly

indrawn nipple present for the past few years. Her family

history included breast cancer in one maternal aunt

diagnosed in old age. The patient reached menarche at the

age of 13 years, had her first pregnancy at the age of 31,

breastfed two term infants, and reported prior use of oral

contraceptives for a total of 4 years. She had reached

menopause at the age of 52 and had no history of radiation

or other risk factors for breast cancer. The patient’s medical

history was notable for hypertension (controlled for years

with hydrochlorothiazide) and hypothyroidism, for which

the patient was on medication. Her only previous surgery

was a hysterectomy (without oophorectomy) for

leiomyomas.

An ultrasonography of the left breast confirmed the lesion

and a subsequent ultrasound-guided core-needle biopsy

revealed infiltrating carcinoma. A metastatic workup,

including blood tests, chest radiography, computed

tomography of the abdomen, and a bone scan, did not reveal

any metastatic spread. The patient underwent a simple

mastectomy with no lymph node sampling, given the prior

left axillary lymph node dissection. Pathological

examination of the mastectomy specimen revealed

multifocal, invasive pleomorphic lobular carcinoma, with

the largest lesion measuring 4.1 cm in greatest dimension.

In addition, pleomorphic lobular carcinoma in situ was also

identified within the specimen. The carcinoma showed

Figure 1. Malignant melanoma cells in a sentinel lymph node.(Hematoxylin and eosin; insets, immunoperoxidase)

Figure 2. Metastatic lobular carcinoma in an axillary lymph node.(Immunoperoxidase; inset, hematoxylin and eosin)

Figure 3. Lobular carcinoma of breast in an axillary lymph node.(Hematoxylin and eosin)


CADILI ET AL.

lymphovascular and perineural invasion and expressed both

estrogen and progesterone receptors. The HER2/Neu status

was negative and, of note, one intramammary lymph node

was identified as harboring metastatic carcinoma. All

margins were clear of carcinoma, the closest margin being

the deep margin that was 4 mm away from tumour.

Given the patient’s history of melanoma with nodal

dissection on the same side as the breast carcinoma, a full

pathological review of the previously excised axillary lymph

nodes was undertaken. The review concluded that the six

positive lymph nodes in the axillary node dissection

exhibited a pattern of metastasis that was characteristic of

lobular carcinoma but unusual for metastatic melanoma.

The positive nodes were strongly positive for cytokeratin 7

on immunohistochemistry and negative for HMB-45 and

MART1 (Figures 2 and 3). The axillary nodes also exhibited

widespread extranodal extension. Based on these findings,

the patient was put on adjuvant chemotherapy. She

completed three cycles of docetaxel and cyclophosphamide

therapy and, at the time of this writing, was set to undergo

three cycles of FEC (5-fluorouracil, epirubicin,

cyclophosphamide) treatment.

DiscussionThat the sentinel lymph node was positive for melanoma

metastasis was confirmed by immunohistochemistry.

However, the cancer identified in the subsequent axillary

lymph node dissection actually represented metastasis from

an occult primary breast carcinoma rather than the

melanoma. The standard procedure for dealing with a

CLND specimen following a positive SLN does not involve

detailed immunohistochemistry, since it is assumed that any

cancer found is of the same type as that in the SLN. In this

particular case, had immunohistochemical staining been

carried out on the CLND specimen, the metastatic cancer

would most likely have been identified as originating from

a breast primary. This would not have altered the decision

to put the patient on a course of adjuvant interferon therapy;

the characteristics of the primary melanoma, as well as the

positive SLN, are sufficient to warrant this course of action.

Rather, that determination would have triggered a diligent

search for the occult breast primary carcinoma which, in

turn, would have resulted in earlier treatment of that cancer.

The revised assessment actually places the patient in an

improved risk/survival category. Had the lymph node

metastases represented metastatic melanoma, as originally

thought, the patient would have had a stage IIIC melanoma.1

The estimated 5-year survival rate for patients with stage

IIIC melanoma has been found to range from 24 to 29%.2,3

On the other hand, the estimated 5-year survival for our

patient with a stage IIB breast cancer is 76%.4With this new

information, the patient has been re-classified as having

stage IIIA melanoma, which carries a survival of up to

70%.2,3

References1. American Joint Committee on Cancer. Melanoma of the skin. In: AJCC Cancer

Staging Manual, 6th edition. New York: Springer; 2002: 209–20.

2. Ries LAG, Eisner MP, Kosary CL, et al., eds. SEER Cancer Statistics Review,

1975–2000. Bethesda (MD): National Cancer Institute; 2003: Tables XVI-1-9.

3. Balch CM, HSoong SJ, Gershenwald JE, et al. Prognostic factors analysis of

17,600 melanoma patients: validation of the American Joint Committee on

Cancer melanoma staging system. J Clin Oncol 2001;19(16):3622–34.

4. Woodward WA, Strom EA, Tucker SL, et al. Changes in the 2003 American

Joint Committee on Cancer staging for breast cancer dramatically affect stage-

specific survival. J Clin Oncol 2003;21(17):3244–48.


Uterine Tumour Resembling Ovarian Sex-CordTumour with True Sex-Cord Differentiation

Manjula Jain, MD, Neha Kawatra Madan, MD, Smita Singh, MD, are members of the Department of Pathology with LadyHardinge Medical College, in New Delhi, India. Correspondence may be directed to [email protected]. This article has been peer reviewed.Competing interests: None declared

Manjula Jain, MD, Neha Kawatra Madan, MD, Smita Singh, MD

ABSTRACTUterine tumours are diagnosed in the majority of cases using light microscopy. In some cases,

extensive immunohistochemical analysis is needed to properly categorize these tumours. The

authors present a rare case in a 50-year-old woman who had a submucosal polypoid growth in

the uterine fundus that showed a circumscribed tumour arranged in sheets and nests of small

oval to plump spindle cells. In places, tumour cells were more round to cuboidal, arranged in

tubules, anastomosing cords, and trabeculae. Immunohistochemically, the cells showed diffuse

and strong cytoplasmic positivity for calretinin, CD99, and vimentin and diffuse nuclear

positivity for progesterone receptor. Focal positivity for cytokeratin and estrogen receptor and

focal weak positivity for inhibin and CD10 were noted, whereas epithelial membrane antigen,

carcinoembryonic antigen, smooth muscle actin, and desmin were not expressed. The findings

provided strong evidence of true sex-cord differentiation. The final diagnosis was uterine

tumour resembling ovarian sex-cord tumour (with true sex-cord differentiation), infiltrating

less than half of the myometrium.

RÉSUMÉ Habituellement, l’examen au microscope optique est suffisant pour déterminer la nature de la

tumeur utérine. Dans certains cas, l’analyse immunohistochimique approfondie est nécessaire

pour classer la tumeur avec précision. Les auteurs examinent le cas rare d’une femme de 50 ans

présentant une croissance polypoïde sous-muqueuse dans le fonds de l’utérus; il s’agit d’une

tumeur circonscrite déployée en plages et en nids de petites cellules fusiformes ovales ou

ventrues. Par endroits, les cellules tumorales sont plutôt rondes ou cubiques, formant des

tubules, des filons anastomosés ou des trabécules. L’analyse immunohistochimique révèle la

présence cytoplasmique diffuse et intense de calrétinine, de CD99 et de vimentine, et de

récepteurs de la progestérone dans le noyau. Il indique également la présence localisée de

cytokératine et de récepteurs oestrogéniques et la faible présence localisée d’inhibine et de CD10,

alors qu’il n’y a pas d’expression de l’antigène de la membrane épithéliale, de l’antigène

carcinoembryonnaire, d’actine du muscle lisse ni de desmine. Les constatations pointent avec

insistance dans la direction d’une véritable différenciation des cordons sexuels. Le diagnostic

définitif est celui d’une tumeur utérine à l’allure d’une tumeur ovarienne des cordons sexuels

(différenciation des cordons sexuels sans équivoque) se propageant à moins de la moitié du

myomètre.

ORIGINAL ARTICLE


JAIN ET AL.

UTROSCT refers to a uterine tumour resembling an ovarian

sex-cord tumour, the true nature of which remains unclear.

Some authors believe that they are of epithelial nature, others

suggest that they have a myoid phenotype or are of

endometrial stromal origin, and still others conclude that the

immunophenotype is consistent with true sex-cord

differentiation.1,2

The term UTROSCT was first used by Morehead and Bowman

in 1945. Clement and Scully performed a detailed evaluation

of 14 such cases in 1976 and divided them into two groups

based on the predominance of the stromal or epithelial

component. Endometrial stromal tumours with minor sex-

cord-like elements (ESTSCLE) were put into group 1, and

uterine tumours resembling ovarian sex-cord tumour

(UTROSCT) with predominance of the sex-cord-like

component were put into group 2.3 We present a case of

UTROSCT in a 50-year-old woman.

Case ReportA 50-year-old woman with a G4, P3, A1 obstetrical history was

admitted to the gynecology ward with complaints of bleeding

per vaginam and lower abdominal pain of 1 month’s duration.

On pelvic examination, the uterus was found to be the size it

would be at 12 week’s pregnancy, retroverted, and mobile, and

no adnexal mass was palpable. Pelvic ultrasonography showed

an echogenic polypoid intracavitary uterine mass measuring

4 × 3 × 3 cm, suggesting the presence of a myoma. Both ovaries

appeared normal. Results of a cervical Papanicolaou smear

were unremarkable. A preoperative diagnosis of uterine

myoma was made, and a vaginal hysterectomy was performed.

The gross specimen consisted of the uterus with the cervix but

without adnexa. The endometrial cavity was expanded and

occupied by a submucosal polypoid growth measuring 3.5 ×

2.5 × 2 cm, arising from the fundus. On section, the polyp

appeared well circumscribed, soft, and grey-white with focal

yellow-tan areas (Figure 1). The cervix was unremarkable.

Sections from the polypoidal mass showed a circumscribed

submucosal tumour predominantly arranged in sheets and

nests, containing numerous small arterioles and extending into

the superficial myometrium (Figure 2A and B). Tumour cells

were small, oval to plump, and spindled, exhibiting mild

anisocytosis with a moderate amount of eosinophilic

cytoplasm, round to oval nuclei, fine granular chromatin, and

inconspicuous nucleoli. In places, the tumour cells were

arranged in tubules, anastomosing cords, and trabeculae (see

Figure 2C and D). In these areas, the cells appeared more

round to cuboidal and showed mild nuclear atypia. Mitotic

activity was low, with zero to two mitotic figures per high-

power field. There were no areas of hemorrhage or necrosis,

and no lymphovascular invasion was noted.

At this stage, a differential diagnosis of ESTSCLE, UTROSCT,

and low-grade endometrial adenocarcinoma with spindled

stroma and focal sex-cord-like structures was considered.

Immunohistochemistry was subsequently performed with a

panel of markers including cytokeratin (CK), epithelial

membrane antigen (EMA), carcinoembryonic antigen (CEA),

estrogen receptor (ER), progesterone receptor (PR), CD10,

vimentin, calretinin, inhibin, CD99, smooth muscle actin, and

desmin. The cells showed diffuse and strong cytoplasmic

positivity for calretinin, CD99, and vimentin, suggesting sex-

cord differentiation, and diffuse nuclear positivity for PR

(Figure 3). Focal positivity for CK and ER and focal weak

positivity for inhibin and CD10 were also noted (Figure 4),

whereas EMA, CEA, smooth muscle actin, and desmin were

not expressed, thus ruling out ESTSCLE and endometrial

adenocarcinoma with spindled stroma and focal sex-cord-like

structures.

The final diagnosis was UTROSCT, infiltrating less than half

Figure 1. Gross specimen showing a submucosal polypoid growththat is soft and grey-white, with focal yellow-tan areas.


UTERINE TUMOUR RESEMBLING OVARIAN SEX-CORD TUMOUR

of the myometrial wall. The patient was closely

followed up for 6 months. No postoperative

complications or recurrence was noted.

DiscussionUTROSCTs are an unusual group of uterine

tumours that exhibit ovarian sex-cord-like

epithelial structures. They are placed in the

miscellaneous category in the recent World Health

Organization classification of tumours of the

uterine corpus.4 Clinically, UTROSCTs

predominate in middle-aged women, with an

average age at presentation of 50 years. The main

presenting features include abnormal vaginal

bleeding and lower abdominal pain, sometimes

with a palpable uterine mass. Preoperative

diagnosis of these tumours is difficult as they are

rare, and no specific signs are seen on imaging

studies. No serum marker has yet been found for

these mysterious neoplasms.

Grossly, the majority of UTROSCTs are

circumscribed solid intramural masses.

Sometimes, they are polypoidal and submucosal,

as in our case. The cut surface is soft and yellow-

tan, unlike the firm and whorled pattern of a

leiomyoma. They show a diverse histology with a

variety of stromal and epithelial patterns

resembling ovarian sex-cord tumours.

Occasionally, diffuse sheets of uniform cells

resembling a granulosa cell tumour may be seen.

The tumour cells show mild atypia, and mitoses

are scanty.

The histogenesis of UTROSCT has been a matter

of controversy. Czernobilsky has stated that they

most likely arise from pluripotent mesenchymal

cells that express a predominant immuno-

phenotype of sex-cord tumours.5 Variable

positivity for a number of immunohistochemical

markers has been shown by various workers.2,6,7

Three studies have all demonstrated that

UTROSCT is a polyphenotypic neoplasm

expressing markers of epithelial, sex-cord, and

endometrial stromal differentiation.2,6,7 They

Figure 2. A, Circumscribed tumour predominantly arranged in sheets and nests,permeating into the superficial myometrium. B, Tumour tissue showingnumerous small arterioles. C and D, Round to cuboidal cells arranged in tubules,anastomosing cords, and trabeculae. (Hematoxylin and eosin)

A

C D

B

A

C D

B

Figure 3. Tumour cells showing diffuse and strong cytoplasmic positivity forcalretinin (A), CD99 (B), and vimentin (C) and diffuse nuclear positivity forprogesterone receptor (D). (Immunoperoxidase)


JAIN ET AL.

concluded that the most reliable immuno-

histochemical markers in UTROSCT are

calretinin, inhibin, CD99, and melan-A. They also

remarked that positivity for calretinin and for at

least one of the other three markers is highly

suggestive of UTROSCT. Although the staining

pattern of UTROSCT does not indicate any single

path of differentiation, it seems to be unique and

can be useful in differentiating it from other more

common tumours.

The differential diagnosis includes ESTSCLE,

endometrial adenocarcinoma with spindled

stroma and sertoliform sex-cord-like areas,

leiomyoma with epithelioid features, and

metastasis of ovarian Sertoli-Leydig cell tumour

(Table 1). ESTSCLE contains areas of conventional

endometrial stromal sarcoma composed of small

spindle cells and numerous arterioles, in addition

to focal sex-cord-like areas. It shows diffuse

positivity for ER, PR, and, most importantly,

CD10. It may show focal positivity for one of the

sex-cord markers, mostly calretinin, but it is never

strong and diffuse, as seen in our case. Endometrial

adenocarcinoma with sex-cord-like areas shows

strong immunoreactivity for CK, EMA, and CEA

but usually lacks positivity for the sex-cord

markers. Leiomyomas, especially the epithelioid

variant, may show sex-cord-like structures but lack

positivity for sex-cord markers. Metastatic ovarian

Sertoli-Leydig cell tumour can be differentiated on

the basis of the clinical picture, finding a primary

in the ovary, and expression of the sex-cord

markers (inhibin, calretinin, WT1, and melan-A).

UTROSCTs were initially considered benign;

however, occasional cases have shown malignant

transformation.8 Recurrences have been reported

in 15% of cases 2–12 years after hysterectomy. It is

currently suggested that UTROSCTs should be

considered neoplasms of uncertain malignant

potential. Vaginal hysterectomy is usually

performed for small tumours, whereas radical

surgery is undertaken for larger ones. These

tumours are extremely rare. Their clinical,

A

C D

B

Figure 4. Tumour cells showing focal positivity for CK (A) and estrogen receptor(B) and focal weak positivity for inhibin (C) and CD10 (D). (Immunoperoxidase)

Table 1. Comparison of Immunophenotype of the Various Differential Diagnoses

Endometrial Leiomyoma Adenocarcinoma with with Sertoliform Epithelioid

UTROSCT ESTSCLE Sex-Cord-Like Areas FeaturesCalretinin + ER + CK + SMA +Inhibin + PR + EMA + Desmin +CD99 + CD10 + CEA + Vimentin +Melan-A + Inhibin +/-CD56 + CD99 +/-Vimentin +ER +/-PR +/- �CD10 +/-�CK +/-�

CEA = carcinoembryonic antigen; CK = cytokeratin; EMA = epithelial membrane antigen; ER = estro-gen receptor; ESTSCLE = endometrial stromal tumours with minor sex-cord-like elements; PR = prog-esterone receptor; SMA = smooth muscle actin; UTROSCT = uterine tumour resembling an ovariansex-cord tumour.

DISPLAY CLASSIFIED

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UTERINE TUMOUR RESEMBLING OVARIAN SEX-CORD TUMOUR

pathological, and immunohistochemical features are

extremely varied. Thus, there is no standard approach to such

cases.

More extensive studies must be performed on these tumours

in future. Recent studies have shown that UTROSCTs lack the

JAZF1–JJAZ1 translocation suggesting that this tumour may

be distinct from other endometrial stromal tumours, including

ECTSCLE, at least 50% of which show this translocation.9

References1. McCluggage WG. Uterine tumors resembling ovarian sex-cord tumors:

immunohistochemical evidence for true sex-cord differentiation. Histopathology

1999;34:375–6.

2. de Leval L, Lim GS, Waltregny D, Oliva E. Diverse phenotypic profile of uterine

tumors resembling ovarian sex cord tumors: an immunohistochemical study of

12 cases. Am J Surg Pathol 2010;34(12):1749–61.

3. Clement PB, Scully RE. Uterine tumors resembling ovarian sex-cord tumors. A

clinicopathologic analysis of fourteen cases. Am J Clin Pathol 1976;66:512.

4. Nogales F, Tavassoli FA. Tumours of the uterine corpus. In: Tavassoli FA, Devilee

P, eds. Pathology and Genetics of Tumours of the Breast and Female Genital

Organs. Lyon, France: IARC Press; 2003:217–57.

5. Czernobilsky B. Uterine tumors resembling ovarian sex-cord tumors: an update.

Int J Gynecol Pathol 2008;27:229–35.

6. Irving JA, Carinelli S, Prat J. Uterine tumors resembling ovarian sex-cord tumors

are polyphenotypic neoplasms with true sex-cord differentiation. Mod Pathol

2006;19:17–24.

7. Hurrell DP, McCluggage WG. Uterine tumour resembling ovarian sex cord

tumour is an immunohistochemically polyphenotypic neoplasm which exhibits

coexpression of epithelial, myoid and sex cord markers. J Clin Pathol

2007;60(10):1148–54.

8. Biermann K, Heukamp LC, Büttner R, Zhou H. Uterine tumor resembling an

ovarian sex cord tumor associated with metastasis. Int J Gynecol Pathol

2008;27:58–60.

9. Staats PN, Garcia JJ, Dias-Santagata DC, et al. Uterine tumors resembling ovarian

sex cord tumors (UTROSCT) lack the JAZF1-JJAZ1 translocation frequently seen

in endometrial stromal tumors. Am J Surg Pathol 2009;33(8):1206–12.


Conflict and Resolution: William Boyd’s Appointment to the Department of Pathology

of the Winnipeg General Hospital

Guillermo Quinonez, MD, MS, MA, FRCPC, is with the Department of Pathology, University of Manitoba, Winnipeg, Manitoba,and the Department of Social Medicine, University of North Carolina, Chapel Hill, North Carolina; he also has an office inAncaster, Ontario. Correspondence can be directed to [email protected] article has been peer reviewed.Competing interests: None declared

Guillermo Quinonez, MD, MS, MA, FRCPC

ABSTRACTThe appointment of William Boyd as professor at the University of Manitoba in 1915 illustrates

the conflict that exists between two visions of pathology: the view that the main responsibility

of a pathologist lies in research and teaching, with patient care as an ancillary activity; and the

opposing view that the main activities of a pathologist should be patient centred, with teaching

and research as only ancillary activities. The dean of medicine, Harvey H. Chown, supported

the former, while the practising physicians at the Winnipeg General Hospital supported the

latter. A comprehensive explanation for the dean’s reasons for the appointment has not been

specifically addressed in the literature. This essay describes the events and concludes that,

although Boyd became the leading pathologist in English Canada, Chown’s vision succeeded

only partially because Boyd excelled in teaching but not in basic science research.

RÉSUMÉLa nomination de William Boyd à un poste de professeur à l’Université du Manitoba en 1915

illustre le conflit entre deux visions opposées de la pathologie : celle voulant que les principales

fonctions du pathologiste relèvent de la recherche et de l’enseignement, la prestation de services

destinés au patient étant une tâche accessoire, l’autre selon laquelle les principales activités du

pathologiste sont centrées sur le patient, tandis que l’enseignement et la recherche ne sont que

des tâches secondaires. S’affrontent alors deux camps, les tenants de la première vision avec à

leur tête Harvey H. Chown, doyen de la faculté de médecine, à l’origine de la nomination de

William Boyd, et les adeptes de la seconde, les médecins exerçant à l’Hôpital général de

Winnipeg. La documentation ne s’étend pas vraiment sur les motifs du doyen. L’article passe

en revue cette période en examinant ces deux écoles de pensée et se conclut par le constat

voulant que, bien que William Boyd soit devenu la figure de proue en pathologie dans le Canada

anglais, la vision de M. Chown ne se soit pas concrétisée tout à fait, car son protégé a excellé en

enseignement, mais pas en recherche fondamentale.

ORIGINAL ARTICLE


CONFLICT AND RESOLUTION: WILLIAM BOYD’S APPOINTMENT TO WGH

Conflict between clinicians and basic science scientists

has been a driving force in the development of

pathology in certain periods of the specialty’s history.1–3

Conflict resulting from a struggle between distinct views of

the specialty was illustrated in 1914 with the appointment of

William Boyd as professor of pathology and bacteriology at

the University of Manitoba and as director of the laboratories

of the Winnipeg General Hospital (WGH). Hoogstraten, in

a presentation given to the Manitoba Medicine History

Club,4 and Carr, in a biography of Boyd,5 have amply

documented the event. Both authors presented an objective

narrative but, while Carr was sympathetic to Boyd,

Hoogstraten, a clinician, was not. The conflict resulted from

two perspectives: the view that the main responsibility of a

pathologist lies in research and teaching, with patient care as

an ancillary activity, and the perspective that the main

activities of a pathologist should be patient-centred, with

teaching and research as only ancillary activities. The conflict

was clearly expressed in Boyd’s appointment made by the

dean of the Manitoba Medical College, Harvey Havelock

Chown. A comprehensive explanation of the events demands

additional research on the contextual conditions that were

evolving at the Manitoba Medical College and the WGH in

those years, which influenced the dean’s decision.

AntecedentsThe root of the conflict can be understood in terms of the

inadequate conditions of medical education in North

America at the beginning of the 20th century, the same

period in which Chown was dean. The conditions in

Winnipeg were no different from those in the United States.

To address the problem, in 1902 the American Medical

Association (AMA) appointed the AMA Council on Medical

Education, which in 1905 set the minimum standards for

medical education: 4 years of high school for admission, a 4-

year medical course, and satisfactory performance in a state

licensing examination. Based on medical school inspections

in the United States, the council also categorized the

institutions as classes A, B, and C. Around the same time, the

Carnegie Foundation for the Advancement of Teaching was

created (1906). Both organizations joined forces, and

Abraham Flexner from the Carnegie Foundation and Nathan

P. Colwell from AMA inspected American and Canadian

medical schools. The basis for their report, a bulletin

published in 1910, was the Johns Hopkins educational model

that included full-time staff, laboratories, and hospital

facilities.6 The model responded to a new vision of medicine

closer to the German one and distinct from the French model

of clinical-pathological correlation based on the autopsy. The

new approach introduced experiment and laboratory into

the everyday practice of medicine and considered medical

education a university function. The Carnegie Foundation

was ready to provide monetary subsidies for schools’

infrastructure, for fostering relationships between medical

schools and hospitals, and for establishing salaried

professorships.7

Flexner’s report on the Manitoba Medical College and the

WGH was satisfactory.6 Flexner visited Winnipeg in May of

1909 and reported that the Medical College had 115 students

and a teaching staff of 41. The only source of income for the

college was students’ fees, which amounted to $14,000 per

year. Using this criterion alone, the Medical College was a

proprietary school. When referring to pathology, Flexner

mentioned that the University of Manitoba competently gave

instruction in that subject and that there was a well-kept

collection of several hundred wet specimens. He stated that

the hospital was “excellent.” The school faculty formed the

staff of the wards, and the relationship between both

institutions was “admirable.” Students worked at the

hospital’s installations. He categorized the college not as A,

B, or C (he never used this system), but grouped it with

Kingston, below the University of Toronto and McGill but

above Laval and Halifax.6

Dean Chown was a leader, and he therefore made difficult

decisions. In spite of Flexner’s comments about the situation

in Winnipeg, he had to have known the real conditions of the

college in relation to the direction that medical education

was taking in North America. He knew that he had to

reinforce the basic sciences as part of the medical school

curriculum, since that was the future. Chown followed the

general recommendations given by Flexner in his report and

took the initiative of creating basic science departments

directed by full-time university professors. The decision was

understandable, and the action not completely unexpected,

for an individual with a somewhat authoritarian personality,

according to his son.8 These were Dean Chown’s realities.


QUINONEZ

The AppointmentA notification in the Manitoba Medical College Annual

Announcement for the session 1914–1915 heralded the

beginning of William Boyd’s tenure. It read, “The University

has decided to appoint a Professor of Pathology, who will

devote his whole time to this department. As the various

hospitals furnish abundant material for the study of

Pathology, this will give every opportunity for research as well

as for didactic work.” The notification indicated that a

decision to appoint a professor of pathology and

bacteriology, who will do research and teach, had been taken

by the authorities. The decision was made in a faculty

meeting in May 1913.4,5 However, a determining factor was

that in the same year the college had been rated as class B by

AMA, in part due to inadequate physical facilities and only a

few full-time professors.9 This event likely precipitated the

decision. The notice, interestingly, brought attention to the

fact that WGH was not the only focus and that the future

professor would control the pathological material generated

in all Winnipeg hospitals. In practice, however, WGH became

the only institution under the proposed structure. Future

events resulting from this decision highlighted the first-ever

conflict in determining the vision for the role of a

department of pathology in a university-affiliated hospital in

Winnipeg.

As an Edinburgh-trained surgeon and a citizen of the

Empire, Dean Chown looked to Great Britain for recruits to

create the basic science faculty. The first one was R.J. Evatt, a

graduate from Durham, England, who became full-time

professor of anatomy. Alexander Gibson, a graduate from

Edinburgh, eventually replaced him in 1913.9 The next

recruit was William Boyd. It became evident that Sidney J.S.

Peirce, the director of the laboratories and a practitioner at

WGH, did not fit Chown’s vision. On June 9, 1914, Gibson,

a classmate and close friend of Boyd who had arrived in

Winnipeg 6 months earlier, wrote to Boyd inviting and

encouraging him to apply for the professorship.4,5 Even Boyd

himself, in a presentation in Winnipeg years later, cited

Gibson’s intervention as the reason for his appointment. On

August 18, 2 months later, Dean Chown reported to the

faculty on the negotiations and, on September 11, 1914, he

reported that the university had appointed William Boyd as

professor of pathology and bacteriology.

Consequences of the AppointmentBoyd’s appointment was met with the expected negative

reactions. In the faculty meeting on October 8, 1915, it was

revealed that Peirce had presented his resignation as lecturer

in pathology. Peirce was the recognized pathologist at WGH

and at the provincial level. Before becoming director of the

laboratories, he had spent 1 year of training with Gordon

Bell, the first professor of pathology and bacteriology and the

founder of the department, and 2 more years at the Mayo

Clinic with Louis B. Wilson, one of the leading pathologists

and medical educators in the United States. Furthermore,

Director Peirce had spent one winter with Professor Aschoff

in Germany. He had also published several papers in

bacteriology and pathology, and had done an excellent job

directing the department. His autopsies were well written

with the scientific language of a trained pathologist. It is only

natural to conclude that the resignation was the result of his

frustration at not being appointed professor. The response

to his resignation by the faculty council was to appoint a

committee to consult with Peirce and the hospital

administration about the work and the pathological material,

but it did not deal with the issue of his resignation. However,

the result was that Peirce withdrew his resignation and

continued working in the hospital and at the college.4,5

The outcome of Boyd’s appointment also had consequences

for the dean. Chown resigned as dean in November 1915, the

month following Peirce’s resignation, but was convinced to

withdraw his resignation in December.4 There is no record

of the reasons for this sudden and unexpected action.

However, the negative reaction by the medical staff of the

hospital, of which Chown was a member and a successful

surgeon, is the most likely explanation. Peirce was also a

member of the staff and worked closely with clinicians as a

consultant. This conclusion about the dean’s resignation is

supported by events in the following years. Peirce’s daily

autopsy presentations were well attended, but the same

cannot be said of Boyd’s. At the beginning of Boyd’s tenure,

no one attended his autopsies except, occasionally, Chown.

Peirce was clearly a popular figure at the hospital.

The plan to restructure pathology as one of the fundamental

basic sciences continued to be implemented by Chown and

the authorities of the college. In January 1916, a committee

formed by Chown, Boyd, and Prowse (the future dean of


CONFLICT AND RESOLUTION: WILLIAM BOYD’S APPOINTMENT TO WGH

medicine) was appointed to integrate the Department of

Pathology of WGH with that of the college under the control

of the professor of pathology. In another meeting of the

faculty council a month later, a motion addressing the same

issue was introduced.4 The motion also recognized that,

before Boyd’s arrival, the departments of pathology in both

institutions were separate entities. The motion was

elaborated in more detail in a memo attached to the faculty

council minutes and dated March 10, 1916. In it, both

departments were amalgamated under the authority of the

professor of pathology (i.e., Boyd), and the responsibilities

of the hospital and the college were clearly spelled out.4

The Ensuing YearsThe impact of the Flexner report in the United States is very

well known.7 But, what was the impact of the decisions taken

by the faculty council under Chown’s leadership that

followed Flexner’s philosophy? In the first 3 years of Boyd’s

tenure, the department became consolidated. As part of the

support given by the hospital administration, the

department was moved to new facilities, new equipment was

added, and the budget was increased.10 It is clear that the

hospital’s board of directors had agreed to the takeover of

the department by the Medical College since, by this time,

the board had three members representing the university.11

It is also curious to find that in the 1917 annual report, in

the same paragraph in which Boyd praises the use of the

laboratory facilities for teaching by Peirce and emphasizes

the need for close collaboration between the hospital and

the college, he added, “When the normal conditions of peace

again prevail it is intended to develop this aspect of the

work.”10

Teaching pathology to undergraduate students was

expanded by increasing hours of instruction and by

separately identifying the teaching of clinical pathology. This

distribution followed the Hopkins model but, curiously, also

followed the Edinburgh curriculum.5 Pathology and

histology were also segregated from bacteriology. Pathology

was divided into general pathology and special (anatomical)

pathology. In the Faculty of Medicine’s Annual

Announcement of 1917–1918, information on an

anatomical and pathological museum under the direction

of Professors Gibson and Boyd appeared for the first time.

It indicated that there was already a museum in existence

(one developed by Peirce before Boyd’s arrival) and that it

had been reorganized. Specimens were now systematically

grouped and carefully classified and identified.

In the hospital’s annual reports, Boyd was listed as

“Pathologist” and “Director of Laboratories.” Peirce

appeared in the annual report of 1916, but in the next 2 years

his name did not show up again; he was mentioned only in

the corresponding reports of the department written by

Boyd and in the annual announcements of the college.

Peirce’s activities, as described by Boyd, were focused in the

areas of clinical (general) pathology and teaching. He

stopped performing autopsies except during Boyd’s

absences, did some clinical research, and taught medical

students at the hospital. It may be that Boyd’s intentions

were to assign clinical pathology to Peirce, keeping

anatomical pathology for himself. At the college, Peirce was

promoted from lecturer to associate professor.

One important event at the college was the discussion about

conversion of the college into the Faculty of Medicine of the

University of Manitoba. This change was an aspiration of

the faculty and became possible when the provincial

government passed the University of Manitoba Amendment

Act in 1917. It was in this year that Dean Chown resigned as

dean and as chief surgeon of WGH to become a member of

the new board of governors of the university.

Peirce left for Brandon, Manitoba, in March of 1918,

apparently with bitterness.12 When he departed, there was

no one who could teach clinical pathology. However, Peirce

left a legacy that cannot be easily ignored, and two of his

contributions are worthy of mention. One was the

transformation of the laboratories into a significant hospital

institution. The other was his effort in collecting and

preserving anatomical specimens that represented the

groundwork on which Boyd created the Pathology Museum,

one of his legacies to pathology. Boyd himself recognized

Peirce’s contributions when, in the departmental annual

report of 1918, he wrote, “It is unnecessary to remark that

the development of the Laboratory from its very beginning,

and of the Pathological work of the Hospital generally, is

entirely due to Dr. Peirce’s energy and scientific

attainments.” With Peirce gone, Boyd was now free to stamp

his vision on the department.


QUINONEZ

ConclusionDid Dean Chown make the right decision by selecting Boyd,

an external candidate, instead of Peirce, an internal one?

Chown’s position and action were determined by three

events. The first and essential reason was a consequence of

the Flexner report. Although the report itself had been kind

to the Medical College and to WGH, by its calling attention

to the conditions of medical education in North America,

Chown knew that, in reality, the Manitoba Medical College

was not an exception to Flexner’s criticisms. The institution

lacked strong basic sciences and full-time professors, one of

the main demands of the new vision introduced by Flexner.

A second and less important reason was Chown’s

background as a citizen of the British Empire and a surgeon

trained in Edinburgh. It was only natural that he looked there

for a candidate. Finally, a less important reason was the direct

influence of the anatomist Gibson, who originally referred

Boyd. Because the dean was evidently looking for

suggestions, he could not ignore the advice. These three

conditions together may explain Chown’s decision to appoint

Boyd over Peirce. Judging by the end results of the conflict,

we can only admit that Chown made the right decision. Boyd

became not only the leader of pathology in English Canada

but also brought fame to the department and, consequently,

to the Medical School. However, he only implemented the

teaching component of Chown’s vision since his contribution

to research was limited.13 The latter was perhaps not Boyd’s

flaw alone. Basic research was not on the agenda in Winnipeg

and most university hospitals in those years.14

This article is dedicated to Ian Carr, historian of Manitoba medicine.

References1. Foster WD. Pathology as a Profession in Great Britain and The Early History

of the Royal College of Pathologists. London: The Royal College of

Pathologists; n.d.

2. Rosai J, ed. Guiding the Surgeon’s Hand: The History of American Surgical

Pathology. Washington (DC): American Registry of Pathology; 1997.

3. Long ER. A History of American Pathology. Springfield (IL): Charles C.

Thomas Pub; 1962.

4. Hoogstraten J. Untitled presentation to the Manitoba Medicine History Club.

Winnipeg (MB): University of Manitoba, Neil John Maclean Health Sciences

Library Archives; 1987.

5. Carr I. William Boyd: Silver Tongue and Golden Pen. Toronto (ON):

Associated Medical Services & Fitzhenry & Whiteside; 1993.

6. Flexner A. Medical Education in the United States and Canada. A Report to

the Carnegie Foundation for the Advancement of Teaching (Bulletin Number

Four). New York: The Foundation; 1910.

7. Stevens R. American Medicine and the Public Interest. New Haven (CT): Yale

University Press; 1973.

8. Chown B. The story of the medical college. Univ Man Med J 1933;5:28–34.

9. Faculty of Medicine, University of Manitoba. Centennial Program. Winnipeg

(MB): The Faculty; 1983.

10. Winnipeg General Hospital. Department of Pathology: Annual Report.

Winnipeg (MB): The Hospital; 1917.

11. Winnipeg General Hospital. Department of Pathology: Annual Report.

Winnipeg (MB): The Hospital; 1916.

12. Bigelow WA. Forceps, Fin and Feather. Altona (MB): Friesen & Sons; 1969.

13. Carr I, Beamish RE. Manitoba Medicine: A Brief History. Winnipeg (MB): The

University of Manitoba Press; 1999.

14. Bowden D. Pathology 100, 1890–1990. Man Med 1990;60:55–7.


CAP-ACP William Boyd Lecture, 2012: Going Viral

Richard G. Hegele, MD, PhD, FRCPC, is a member of the Department of Laboratory Medicine and Pathobiology, Universityof Toronto, in Toronto, Ontario. Correspondence may be directed to [email protected] article was peer reviewed.Competing interests: Dr. Hegele has received payment as a consultant for Gilead Sciences, Inc.

Richard G. Hegele, MD, PhD, FRCPC

ABSTRACTFor a country that has a comparatively small population, Canada has a long-standing tradition

of internationally recognized excellence and leadership in pathology education and research.

In this presentation, the author reviews two areas of respiratory syncytial virus lung infection,

viral persistence and receptor discovery, to illustrate how pathologists have relevant expertise

that can be used to contribute to the creation of new knowledge and change paradigms about

disease etiology and pathogenesis, and to inform the design of innovative strategies for

treatment and prophylaxis.

RÉSUMÉ Pays dont la population est relativement peu nombreuse, le Canada jouit néanmoins depuis

longtemps d’une réputation mondiale d’excellence et de chef de file en éducation et en recherche

dans le domaine de la pathologie. L’auteur examine deux aspects de l’infection pulmonaire due

au virus respiratoire syncytial, la persistance virale et la découverte du récepteur, pour illustrer

l’expertise pertinente du pathologiste susceptible de contribuer à l’acquisition de nouvelles

connaissances, donc à la création d’un savoir nouveau, et à la transformation des paradigmes

au sujet de l’étiologie et de la pathogenèse de la maladie, et d’éclairer la conception de stratégies

thérapeutiques et prophylactiques novatrices.

ORIGINAL ARTICLE

It is a privilege to present the 2012 William Boyd Lecture

of the Canadian Association of Pathologists-Association

canadienne des pathologistes (CAP-ACP). William Boyd was

a pioneer of Canadian pathology, having emigrated from

Scotland to Winnipeg after having completed his training

and serving in the First World War. He was professor of

pathology at the University of Manitoba from 1915 to 1937

and at the University of Toronto from 1937 to 1951, and was

the inaugural professor of pathology of a brand new medical

school in Vancouver at the University of British Columbia

(UBC, 1951–1954). Professor Boyd published several

textbooks, including Surgical Pathology (1925; later called

Pathology for the Surgeon); Pathology of Internal Disease

(1931; later called Pathology for the Physician), Textbook of

Pathology (1932), and An Introduction to Medical Science

(1937). These books were extremely popular all over the

world, going through many editions and translation into

multiple foreign languages. Professor Boyd, of “silver tongue

and golden pen”1 was lauded for his “clarity, fine prose and

infectious enthusiasm for the subject matter.” Several

generations of medical students and physicians owe their

understanding of the causes and mechanisms of disease to

Dr. Boyd’s books and lectures, and one cannot underestimate

his influence on our country’s long-standing track record of

productivity and impact in pathology-related research and

practice. One little known fact about Dr. Boyd is that in


HEGELE

addition to being a pathologist, he was trained as a

neurologist and a psychiatrist and held a diploma in

psychiatry. It is tempting to speculate how this latter

credential could have given him an extra edge that enabled

him to leave such a profound legacy, in the face of having to

deal with the daily rigours and distractions of academic

leadership.

In some ways, my professional and scientific career

development can be traced to the memory of Dr. Boyd. It was

because of the William Boyd Lecture I attended in Winnipeg

in 1988, during my residency training, that I first met Dr.

James C. Hogg, professor of pathology at the University of

British Columbia (UBC). I knew of Dr. Hogg’s reputation as

an accomplished experimental lung pathologist and a

formidable presence on the world stage, recognized for his

many fundamental contributions to our understanding of

pulmonary structure-function relationships, particularly in

the context of obstructive lung diseases.2 Dr. Hogg delivered

the 1988 William Boyd Lecture when he was literally on his

way home to Vancouver after completing a sabbatical at the

University of Oxford. At Oxford he learned this “highfalutin”

technique called in situ hybridization3 and witnessed first-

hand early iterations of a new method called polymerase

chain reaction (PCR). As a result of this sabbatical

experience, Dr. Hogg almost single-handedly ushered in the

era of molecular biology to the study of lung disease. At the

coffee break following the Boyd lecture, I introduced myself

to Dr. Hogg and we talked at length about the implications

and exciting possibilities of applying molecular biological

approaches to the study of lung diseases. The next year, Dr.

Hogg became my PhD supervisor and introduced me to

respiratory viruses and asthma. I did my graduate degree in

experimental pathology, working in the UBC Pulmonary

Research Laboratory at St. Paul’s Hospital on the role of

respiratory syncytial virus (RSV) in the onset of pediatric

asthma. To this day, Dr. Hogg remains a dear colleague and

friend – we are even working on a paper together at this

moment. I owe great debt of gratitude to the CAP-ACP –

through the vehicle of the William Boyd Lecture – for

enabling me to have a chance encounter with Dr. Hogg and

literally change my life.

My presentation will focus on two major projects that

illustrate how I believe my background as an anatomical

pathologist proved invaluable to success. Firstly, I will review

work done while I was at UBC that defined a new paradigm

of RSV persistence in the lungs, and effects of persistent

infection on chronic airway inflammation, a hallmark of

asthma that has been recognized since Osler’s time.4

Secondly, I will recount the story of work done in Vancouver

and Toronto concerning our group’s discovery of nucleolin

as a cellular receptor to RSV, and share with you the feeling

of trepidation and excitement that came with delving into

the unknown. I will then close with a brief personal

perspective about how the expertise of pathologists can be

used in the creation of new knowledge concerning the causes

and mechanisms of disease.

Role of RSV in the Onset of Pediatric AsthmaAlthough relatively underappreciated in the area of surgical

pathology because it is not a common source of biopsy or

resection specimens, asthma is the most common chronic

disease in children and puts a huge burden on society, with

approximately 8–10% of the general population affected and

costs to the Canadian health care system of more than $1

billion annually.5,6 Asthma is a heterogeneous condition that

is defined by phenomena of reversible airflow obstruction,

airway hyper-responsiveness to bronchoconstrictor agents,

and chronic airway inflammation and remodelling.

Attempting to understand the pathobiology of asthma is

difficult owing to the heterogeneity of patients and the

potentially unrelated mechanisms producing the disease

phenotype. For this reason, investigators have focused on

particular subgroups of asthmatic patients so that any new

advances can be specifically targeted to these individuals. One

subgroup of asthmatic patients is those children whose onset

of disease occurs after an episode of RSV bronchiolitis, an

association first reported in the late 1950s.7 The mechanisms

of post-bronchiolitis asthma are not well understood,

although a relationship to a genetic predisposition to allergy

seems to be involved. In the absence of a safe, effective RSV

vaccine or good antiviral therapy, post-bronchiolitis asthma

will continue to be a problem for the foreseeable future.

Viral respiratory infections have traditionally been

considered to be of acute onset and of short clinical course,

characterized by the recovery of the infected patient with

clearance of the virus from the respiratory tract or, in


WILLIAM BOYD LECTURE, 2012: GOING VIRAL

unfortunate circumstances, by patient death.8When I began

my PhD studies with Dr. Hogg, after completion of my

anatomical pathology residency training, it was unknown

whether viruses could chronically persist9 in the lungs and

act to stimulate chronic airway inflammation. Given the

difficulties of testing the “working hypothesis” of RSV

persistence in the lungs of the natural hosts of RSV (humans,

primates, and cows),10 we elected to develop a small animal

model of experimental lung infection of guinea pigs with

human virus. The guinea pig was chosen because this species

was an established animal model of allergic sensitization and

airway hyper-responsiveness in the laboratory at St. Paul’s

Hospital.11 Sure enough, with the use of sensitive PCR-based

detection techniques for detection of RSV-associated nucleic

acid in guinea pig lung specimens, we documented RSV

persistence for as long as we studied the animals (for at least

60–100 days post-RSV inoculation) and noted virus-

associated airway inflammation with T cells and eosinophils,

airway hyper-responsiveness to inhalational acetylcholine

challenge,12–14 features of human asthma.15 This body of work

was very satisfying: RSV causes persistent lung infection and

is associated with structural and functional changes of

asthma, thus implicating a direct viral role in pathogenesis –

end of story.

Or was it? Nature has a way of being far more interesting than

any brilliant hypothesis one could ever conceive. Moving

from animal models to humans, we did a study in which

cores of human lung tissue and secretions from the lower

airways were tested for the presence of nucleic acid from

common respiratory viruses by using a PCR panel that we

developed.16,17 In contrast to the prevailing view that the

human lung is a sterile environment, at least in health,18,19

our results suggested that the lungs are actually a reservoir of

all sorts of pathogens. What made things particularly

confusing was the lack of an obvious relationship between

the presence of any given virus and a specific lung disease.

Undeterred, we decided to go back to the guinea pig model

and did a new series of experiments designed to compare the

effects of experimental RSV lung infection on airway

inflammation and airway hyper-responsiveness in two

different strains of guinea pig. One strain was genetically

predisposed toward developing allergy, and the other strain

was genetically resistant to becoming allergic. Given the

association between post-bronchiolitis asthma and allergy,

our working hypothesis was that RSV would persist in the

“allergy-susceptible” guinea pigs and be cleared by the

“allergy-resistant” strain, according to predictions of the Th1-

Th2 paradigm of CD4+ T lymphocytes.20 [Briefly, Th1

responses are involved in delayed-type hypersensivity

responses and are considered to be effective in antiviral

immunity, while Th2 responses are involved in allergic

responses and are less effective in antiviral immunity.]

Instead, what we found was that RSV persisted in the lungs

of all animals tested, regardless of their genetic predisposition

to allergy, but only the Th2-skewed, allergy-susceptible

guinea pigs developed RSV-associated airway inflammation

and hyper-responsiveness.21 The Th1-skewed, allergy-

resistant animals were spared the deleterious effects of RSV

on airway inflammation and lung function. We concluded

that the presence of virus within the lungs was by itself

insufficient to produce the structural and functional changes

of an asthmatic phenotype; instead, the host’s genetic

background for allergy appears to be important. These

findings emphasized the importance of virus-host

interactions in the genesis of a disease phenotype, not the

simple presence or absence of virus in lesional tissue.

Overall, I believe my background as a pathologist provided

me with important requisite knowledge and skills to apply

existing experimental techniques – and develop new ones –

to answer specific questions in a comprehensive, integrated

manner. As an epilogue to this body of work, the issue of

whether or not the lung is sterile has been resolved

definitively by the application of next-generation sequencing

technologies. The existence of a lung “microbiome” has now

been established unequivocally,22 and there is also emerging

evidence of a human lung “virome.”23,24 Overall, the concept

of the human lung being a sterile environment has been put

to rest once and for all. The new challenge is to understand

how this “garden” of microorganisms interacts with the host

to produce various disease phenotypes.

Discovery of a Cellular Receptor for RSV Continuing on the theme of virus-host interactions, our

group became interested in what can be considered as the

ultimate RSV-host interaction – namely, how the virus

interacts with the host cell surface to initiate infection. One


HEGELE

of the long-standing mysteries of RSV pathobiology is just

exactly what the virus binds to on the cell surface at the

beginning of infection, something that has perplexed even

experienced virologists for over half a century. All sorts of

candidate RSV receptors have been proposed over the years

since the discovery of RSV in 1956,25 but no candidate

molecule has fulfilled the functional criteria for a receptor,

that is, decreased cellular infection after the implementation

of interventions designed to decrease virus-receptor binding

and the converse situation whereby there is increased

infection of a resistant cell type after ectopic expression of

the candidate receptor molecule on the cell surface. Our

group sought to identify functional RSV receptors, the

rationale for pursuing this program of research being that

RSV receptors could provide new targets for the development

of novel antiviral prophylaxis and therapy, something much

needed in the field.

A courageous PhD student, Farnoosh Tayyari, went into this

area without any prior expertise in membrane biology. This

was probably a good thing, as neither she nor anyone else

working in the laboratory had any preconceived notion as to

what a receptor for RSV might be. We went back to first

principles and elected to chemically characterize the RSV

receptor(s). This approach consisted of pretreating cultured

cells with enzymes that digest the main components of the

cell surface (protein, lipid, carbohydrate) and seeing what

effects these enzyme treatments had on subsequent RSV

infection. Results showed that only protease digestion of the

cell surface resulted in decreased infection of cell cultures,

and this was seen in cells originating from various species,

including human, dog, and hamster. With this information,

a virus overlay protein binding assay (VOPBA) on protein

extracts from cell cultures was performed. VOPBA is a

technique similar to a Western blot, but for which the

infectious virus serves as the “primary antibody” and anti-

RSV antibody is the secondary antibody. Results of

numerous experiments reproducibly identified a signal of

molecular weight ~100 kDa, which on mass spectrometry

yielded nucleolin as a common “hit” among different RSV-

permissive cell types. This was not what any of us expected:

nucleolin was discovered and described as an intranuclear

molecule, and the idea of it being expressed on the cell

surface was puzzling. A literature search revealed that various

investigators have documented nucleolin expression on the

cell surface.26,27 We also showed that RSV could co-localize

with nucleolin on the cell surface using confocal microscopy

and antibody blocking approaches.

To validate nucleolin as a functional RSV receptor,

Dr. Tayyari and Dr. David Marchant, a post-doctoral fellow,

performed a large number of inhibition experiments

(blocking antibodies, competition with soluble nucleolin,

RNA interference of nucleolin expression), and results

showed significant decreases of RSV cellular infection

through these interventions. The issue of reconstitution,

whereby a resistant cell line becomes permissive to RSV via

ectopic expression of nucleolin, proved challenging. After

considerable detective work, Dr. Tayyari found that a type of

insect cell (Sf9) was reported as being RSV resistant.28

Dr. Marchant transfected the human nucleolin gene into Sf9

cells, and human nucleolin protein was expressed on the cell

surface. Nucleolin-transfected Sf9 cells were permissive to

RSV. This latter finding represented one of those “eureka

moments” that words cannot adequately express. Overall,

seeing the RSV signal in the nucleolin-transfected Sf9 cells

more than compensated for all of the challenges and

hardships we had experienced along the way.

While these were very impressive findings in a cell culture

dish, ultimate validation required confirmation of nucleolin

being a functional receptor for RSV in vivo. We established a

new collaboration with Dr. Theo Moraes at the Hospital for

Sick Children, in Toronto, whose laboratory had developed

a mouse model of experimental RSV lung infection. RNA

interference was used as a strategy to knockdown nucleolin

expression in the murine lung: this was an exciting time in

which my research associate, Peter Mastrangelo, worked with

Dr. Moraes, his technician Wenming Duan and David

Marchant, who came to Toronto from Vancouver expressly

to help set up in vivo experiments. RNA interference was

associated with decreased RSV infection of the murine lung,

thereby confirming nucleolin’s functional role in vivo. Our

paper on the discovery of nucleolin as a functional RSV

receptor was published last year.29 Our current work focuses

on understanding cell surface nucleolin expression in

different disease states, and testing compounds that can

interfere with RSV-nucleolin binding as potential agents for

prophylactic or therapeutic use.


WILLIAM BOYD LECTURE, 2012: GOING VIRAL

Overall, what enabled us to solve this 50+-year-old mystery?

I contend that a pathologist’s extensive knowledge of

phenotypes, high comfort level with using whatever

techniques are available to be directed at answering specific

questions, and going into the area without a preconceived

bias as to what the RSV receptor might be, proved crucial to

the success of this project.

ConclusionPathology is traditionally considered as a “bridge” specialty

between basic science and clinical care. As such, pathologists

can play a crucial role in working toward improving health

care by being involved in investigations of the causes and

mechanisms of disease. Pathologists can work in various roles

as principal investigators and collaborators: our expertise in

disease phenotyping at the tissue, cellular, and molecular

levels is arguably unmatched by any other discipline. I was

fortunate to have the opportunity to pursue investigative

pathology of viral lung disease just at the time that molecular

biological techniques were making their way into our arena.

It has been extremely gratifying to have the opportunity to

work with so many dedicated and talented individuals who

share a common goal to create new knowledge about disease

etiology and pathogenesis that has the potential to be

translated into improved health. In contrast to the era of

molecular biology as a dominant force for basic biomedical

research, in which I completed my scientific training, we now

live in an “-omics” and informatics age, where the ability to

interrogate biological systems comprehensively is

unprecedented in both breadth and depth. We have powerful

tools – and more are being developed – to be able to

understand the relationships of the various components

comprising a biological system. More than ever, we have the

ability to definitively determine which specific viral and host

factors are important to the development of airway

inflammation and hyper-responsiveness in the setting of

persistent RSV infection, and how to manufacture “designer”

molecules as novel RSV treatments. These things would be

been a pipedream only a few short years ago.

As a closing thought, in a previous issue of Canadian Journal

of Pathology, I wrote about the concept of “consilience,”

defined as a jumping or linking together of knowledge for

the purpose of forming new perspectives.30 In my opinion,

pathologists are particularly well placed to be leaders in

medical and scientific consilience, from a mindset that is

conducive to the effective management and integration of

large amounts of information obtained from different

sources. Our profession has a strong tradition of being able

to navigate through data and synthesize them to make sense

of the world around us, for the betterment of patients and

populations. Even with this expertise, we will need to

continually develop new skill sets to remain a relevant and

thriving discipline. Let us not forget how privileged we are

to have such opportunities before us: it is our obligation to

make the most of them, and in the process we have the

potential to derive considerable personal satisfaction and

fulfillment.

AcknowledgementsI have had the pleasure and privilege to work with many fine

individuals over the years. Special thanks to Drs. J. C. Hogg,

S. Hayashi, P. D. Pare, R. R. Schellenberg, A. Dakhama, A.

Bramley, N. Chan, V. Macek, T. Vitalis, T. Sutton, F. Tayyari,

D. Marchant, P. Mastrangelo, T. Moraes, W. Duan, M. A.

Khan, B. Wiggs and H.E. Manson.

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28. Osiowy C, Anderson R. Neutralization of respiratory syncytial virus after cell

attachment. J Virol 1995;69:1271–4.

29. Tayyari F, Marchant D, Moraes TJ, et al. Identification of nucleolin as a cellular

receptor for human respiratory syncytial virus. Nature Med 2011;17:1132–5.

30. Hegele RG. Post-graduate training in pathology and laboratory medicine: time

for a paradigm shift? Can J Pathol 2009;1:33–6.

The Department of Pathology and Molecular Medicine in the Queen’s University Faculty of Health Sciences and its affiliated teaching hospitals is recruiting an academic Forensic Pathologist. We are seeking someone with subspecialty training/expertise in forensic pathology. Expertise in another area, such as cardiac pathology or neuropathology or another area in anatomical pathology would be an asset. We are a very collegial department, with a strong culture of scholarship. The successful candidate would be the Director of the Kingston Regional Forensic Pathology Unit and Clinical Director of the Kingston General Hospital autopsy service and would be provided protected time to establish a research program. The applicant would also be expected to contribute to the department’s undergraduate, graduate and residency training programs in the area of forensic sciences. The compensation package is very competitive, and includes an attractive benefits package.

Candidates must be eligible for medical licensure in the province of Ontario and must hold postgraduate qualifications in Pathology, and, possess or be eligible to obtain certification in pathology from the Royal College of Physicians and Surgeons of Canada or the American Board of Specialities. This is an interna-tional search and the University invites applications from all qualified individuals. Appointment will be at the academic rank commensurate with experience.

Evaluation of applications will begin January 1, 2013 and will continue until the position is filled. Applicants should submit a letter of interest and a curriculum vita to: Victor A. Tron, Head, Department of Pathology and Molecular Medicine, Queen's University, Kingston, Ontario K7L 3N6 (Tel): (613) 533-2850; (Fax): (613) 533-2907; E-mail: [email protected] (electronic submission preferred). URL: www.path.queensu.ca

One of Canada’s leading universities, Queen’s has a long-standing reputation for academic excellence, research and a diverse and vibrant learning environment. With its strong tradition of public service, the University has helped to shape Canadian values and policies, educating notable political and cultural figures. Queen’s University is located on the shore of Lake Ontario, in the heart of historic Kingston, midpoint between Montreal, Toronto, and the nation’s capital.

Queen’s is committed to employment equity and diversity in the workplace and welcomes applications from women, visible minorities, Aboriginal people, persons with disabilities, and persons of any sexual orientation or gender identity. All qualified candidates are encouraged to apply; however, Canadian citizens and permanent residents will be given priority.

ACADEMIC FORENSIC PATHOLOGIST

QUEEN’S UNIVERSITY

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BOOK REVIEW

Biomarkers of Kidney Disease

Biomarkers of Kidney Disease is a thorough review of the

contemporary literature of biomarkers in renal disease. The

text focuses on potential biomarkers of kidney disease that can

be used for early diagnosis, assessment of severity, and long-term

prognosis. The book begins with a description of the

characteristics of an ideal biomarker in kidney disease, statistical

considerations of biomarker research, and comprehensive

chapters describing the role of metabolomics and proteomics in

the study of biological markers in kidney disease. The text then

proceeds to detailed descriptions of the current literature for

biomarkers in acute kidney injury, renal cancer, diabetic

nephropathy, glomerular disease, preeclampsia, and cystatin C

in renal disease.

The strength of the book lies in its early introductory chapters

focusing on taking biomarkers from the bench to the bedside.

The weakness of the text is that it is somewhat descriptive and

lacks figures other than tables listing identified biomarkers. The

field of biomarker research is rapidly evolving; nevertheless, this

comprehensive text provides an excellent introduction to the

topic based on the literature available at the time of publication.

This book would be valuable to clinicians with an interest in

renal disease and translational research in the field.

Dawn L. MacLellan, MD, FRCSCDepartments of Urology and PathologyDalhousie UniversityHalifax, Nova Scotia

Charles L. Edelstein, EditorAcademic Press, 2011ISBN: 978-0-12-375672-5426 pages

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canaadian jtouhrnal ofolog y volume 4, issue 4 winter 2012 · 2020. 7. 6. · william boyd lecture...

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