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THE JOURNAL OF THE AAPA VOLUME 8 ISSUE 4 2018 IN THIS ISSUE

Transformation continued on page 4 >

Abstract

Marjolin’s ulcer is a rare and aggressive form of cutaneous squamous cell carcinoma (SCC) which forms through malignant transformation of chronically irritated previous injury, such as incompletely healed burns, ulcers, and other wounds. Although similar in microscopic morphology, Marjolin’s ulcer is unique from other cutaneous SCCs in many other significant characteristics. The carcinoma often appears decades after the initial trauma, but once present it follows a rapid course of growth and metastasis. In the current case study, a male in his mid-30s with history of extensive burns as a child presented to the Emergency Department complaining of a large, open wound on his lower back. Biopsy of the primary lesion showed moderately to poorly differentiated squamous cell carcinoma, prompting wide local excision. Subsequent radiology and biopsy showed positive metastasis to the right ventricle of the heart, with concern for metastasis to the left lung and left axillary lymph nodes. The following article presents a rare and unique case, while advocating for complete submission of skin resection margins on large specimens even in the context of multiple negative intraoperative diagnoses.

Key words: Marjolin’s ulcer, squamous cell carcinoma, burn scar, skin excision

Introduction and Brief Review of Literature

NewCE Article

Peer-Reviewed

N. Dominic Alessio, PA(ASCP)CM

Detroit Medical Center, Detroit, MIFellow members were given the opportunity to apply for a travel grant to attend an upcoming Fall Conference or Spring Meeting of their choice. Fellows were required to write a manuscript, and the four winning entries received a grant valued at up to $1800 (full week registration + $1000 to help cover travel expenses). Congratulations, Dominic, on your winning submission!

Malignant Transformation of Childhood Burn Wound with Metastasis: A Case Report

1 CE Quiz & Peer-Reviewed Manuscript: Malignant Transformation of Childhood Burn Wound with Metastasis: A Case Report

3 Letter from the Editor 6 CE Quiz & Peer-Reviewed Manuscript: Breast Cancer Metastasis to the Colon Presenting After Fifteen Years

8 Peer-Reviewed Manuscript: Aurora Diagnostics Pathologists’ Assistant Breast Specimen Handling Best Practice Guideline

11 44th Annual Continuing Education Conference Recap

12 44th Annual Continuing Education Conference Photos 17 8th Annual Spring Meeting 18 Board of Trustees Chair’s Report

21 Gross Photo Unknown

22 Town Hall Meeting Recap

23 Legislative Update

24 Book Review: Human Errors A Panorama of Our Glitches, From Pointless to Broken Genes 25 Calendar

26 Member Spotlight

27 Gross Photo Tutorial

27 Institutional PA Program Members

28 Sustaining Members

Gross Photo Unknown, see page 21

One of the rarest and most aggressive forms of squamous cell carcinoma (SCC) of the skin is found in malignant transformation of a site of previous trauma, a condition often nicknamed “Marjolin’s ulcer” after a French physician who first described the condition in the early 19th century. However, this presentation represents only a small subsection of a much broader condition. While cutaneous SCC as a category is quite common, especially in older and light-skinned individuals, the predominant cause is exposure to ultraviolet (UV) light.1 The high-energy UV light rays cause DNA damage and subsequent mutations in the well-known tumor suppressor TP53.

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JOURNAL SUBMISSIONSThe AAPA encourages any AAPA member or interested party to contribute articles, updates, photos or upcoming event announcements for the quarterly edition of The Cutting Edge. In particular, articles related to the field of pathology are welcomed. Articles and photos may be submitted electronically. (Note: photo files must be a minimum of 300 dpi resolution.)

Use the upload link on the AAPA website or send your contributions directly to [email protected]. All submitted material is edited for content and clarity. Research articles and case reports are subjected to a peer review process. Please see the AAPA website for complete submission details.

JOURNAL DEADLINESIssue 1: January 1 Issue 2: April 1Issue 3: July 1 Issue 4: October 1

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THE CUTTING EDGE THE JOURNAL OF THE AAPA

Beth Felicelli, PA(ASCP)CM

[email protected]

Beth Felicelli works at Western Michigan Pathology Associates in Holland, MI. She has been a member of the AAPA since 1997, and recently became Managing Editor of The Cutting Edge. She serves as the Print Communication Subcommittee Chair for the MarComm Committee.

The Cutting Edge Journal is published by the American Association of Pathologists’ Assistants

Cutting Edge Journal Staff

Editor-in-Chief: Beth Felicelli Assistant Editor: Minda Koval Book Review: Chet Sloski CE Quiz: Nea Moyer Karah Jones Gross Photo Tutorial: Emily Paull Acheson

AAPA Committee & Subcommittee Chairs

Administration: Karen Ron Vice Chair: Chevanne Scordinsky Governing Documents: Chevanne Scordinsky Nominations/Elections: Karen Ron

Education: Jennifer Perez Vice Chair: Megan Pickard Beyond the Bench: April Reineke CE Content Generation: Nea Moyer Meetings: Heather Manternach Becky Stankowski Study Materials: Matt Guerin

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Operations Dir. of Professional Development: Connie Thorpe Dir. of Professional Outreach: Jon Wagner Technical Support: Ryan Schniederjan

Letter from the Editor

This issue features a recap of the 2018 fall conference in New Orleans as well as information on the upcoming 2019 spring meeting in Phoenix. Both the fall conference and the spring meeting are great ways to earn continuing education credits, network with others in our field, meet old friends, and make new ones. I highly recommend attending these events and although I could not be in New Orleans, I enjoyed living vicariously through the photographs and stories!

We are featuring a CE article from one of our recent recipients of the Board of Trustees Award, Dominic Allesio. This interesting article about a malignant transformation of a burn wound was the 2018 Fellow Conference Travel Grant Neoplastic case winner. Our second CE article is the 2018 Student Non-Delegate Conference Travel Grant winner, Samantha Etters, with a case study of a breast cancer metastasizing to the colon. Our third article is a timely feature on the proper handling of breast cases, by James Barry and Angeline Dowell.

All three featured articles are informative and great reads. Each case study was something I have never come across in my 20+ years at the bench. I always enjoy reading about cases I’ve never seen and it’s a great opportunity to learn something new.

Larry Marquis was presented the Lifetime Achievement Award in New Orleans this fall. Thank you, Larry, for all you have done for the AAPA! See page 13 for more information on Larry’s achievements.

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outside organizations whose purposes are synergistic with the Association.

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Transformation> Continued from coverIn addition, the HRAS gene can undergo activating mutation—increasing cell division and survival—and Notch receptors can experience loss-of-function mutations, affecting the normal differentiation of squamous epithelium.1 Lesions are generally well-defined and plaque-like, with ulceration present only in advanced cases. These common forms of SCC tend to be completely treatable by local excision and rarely metastasize to lymph nodes or other organs.

However, while still a cutaneous SCC, Marjolin’s ulcer is distinct from standard cases in nearly every one of the characteristics described above. Neither age nor skin pigmentation are associated with risk or prognosis. Exposure to sunlight is generally irrelevant in cases of Marjolin’s ulcer; instead, the cause is traumatic in nature, with malignancies most commonly forming at old burn scars but also on poorly-healed wounds of various sorts such as pressure, venous stasis, or diabetic ulcers.2,3 According to available literature, from 1-2% of burn scars undergo malignant transformation but these represent <0.5% of all skin cancers.4,5 Interestingly, rather than DNA damage due to UV rays, the pathophysiology of Marjolin’s ulcer progresses through multiple diverse and simultaneous processes, many of which are still areas of active research. One significant mechanism involves the chronic irritation present in old, unhealed and possibly infected wounds—the epithelial cells are being damaged and regenerated at a much higher rate than usual, releasing high levels of necrotic toxins and providing exponentially more opportunities for mutations to arise.4 Other studies have shown that chronic scar tissue lacks the usual immunological components of healthy dermis, including Langerhans cells and lymphatics, providing an uncontrolled site in which malignant cells can grow unchallenged. Finally, significant differences in gene expression have been noted between cells sampled from Marjolin’s ulcer compared to other cutaneous SCC.6 For example, heightened extracellular matrix turnover and epithelial-to-mesenchymal transformation have been traced to the drastically increased metastatic potential of these cells.

These unique etiological characteristics contribute to Marjolin’s ulcer having a particularly aggressive course, although the disease can be latent for decades following the initial trauma. In fact, the time elapsed between injury and presentation of malignancy has been reported to be as long as 74 years, with an average between 35-38 years.2,5,7 Once carcinoma develops, there is high risk for deep and rapid local

invasion, lymphatic spread and wide metastasis.4 As with most conditions, early diagnosis and treatment leads to improved prognosis; however, this goal presents a particular challenge considering the long-term nature of the malignancy and the fact that such chronic lesions tend to be painless. Marjolin’s ulcer generally presents as a large, irregular, ulcerated wound with an excavated center and fungating borders, and often produces a foul-smelling exudate. Wide excision of the primary lesion—including amputation of limbs—is the only treatment which has demonstrated efficacy to date. Systemic treatments such as chemotherapy have been used with patients suffering from widespread metastasis, but many such cases have a prognosis of only 2-3 years.4 On the other hand, if the lesion can be completely excised with clear margins, patients recover well.

Patient History

A male in his mid-30s presented to the Emergency Department with a large, open lower back wound. The patient had a history of extensive burns to his back and lower extremities as a child, which he reported had healed by adulthood. Surgery had been performed on his left axilla to correct range of motion restriction due to severe scarring, with contracture release and skin grafting. However, some years following this operation, the patient noticed a small (less than 2 cm) wound on his left lower back, which progressively increased in size and depth, up to 30 cm in diameter. The patient had been avoiding healthcare due to insurance issues, but eventually presented to the emergency department following weight loss of 15 lb over the previous two months.

Hospital Course

Initial physical examination of the patient revealed a warm, pink area across the left back measuring approximately 30 x 30 cm, including a large eroding and fungating mass which released purulent discharge with a foul smell upon palpation. Samples were taken from six different locations around the periphery and center of the wound, all of which came back positive for invasive squamous cell carcinoma. The patient was then referred to surgery for wide excision of the mass. Although four frozen sections were sent intraoperatively—each of which was negative for carcinoma—the final specimen showed focally positive margins along one edge, prompting a full lateral re-excision six days later. Following the surgical course, concern for post-operative thrombosis called for a transthoracic echocardiogram, which showed an unexpected mass within the right ventricle. MRI was ordered, which confirmed an intramural right ventricular

outflow tract mass measuring nearly 3 cm in greatest dimension, protruding into the right ventricle. Initial CT scans additionally showed a small (0.3 cm) but suspicious nodule within the left lung. Approximately six weeks after the initial surgery, the patient underwent transcatheter heart biopsy, which was diagnosed as metastatic squamous cell carcinoma. Cytologic evaluation of pleural fluid aspiration was negative for malignant cells, but follow-up CT scans showed an enlarged left axillary lymph node which had grown from 0.6 cm to 2 cm in four weeks, as well as noting that the pulmonary nodule mentioned earlier had more than doubled in size (to 0.7 cm) over the same time period. At the time of this writing, no further surgical treatment had been planned.

Pathology

The primary wide local excision received in the pathology gross room measured 24 cm in diameter, and the specimen was predominantly occupied by a centrally-ulcerated, tan to red, nodular, firm and friable mass which was raised a maximum of 2 cm above the skin surface (Fig. 1). On the deep aspect, the excision extended to the underlying muscular and fascial tissue, with a maximum depth of 4 cm. For the sake of consistency, the anatomic orientation markers were translated into clock-face designations, and the margins were inked such that the 12:00 to 6:00 (medial) edge, 6:00 to 12:00 (lateral) edge and deep aspect were represented in three different colors. After orientation and inking, the entire peripheral margin was circumferentially shaved and submitted en face (Fig. 2). The central area of the wound was sampled in relationship to all relevant points, including the attached muscle, fascia, unremarkable skin, greatest height of growth and point of deepest gross invasion.

Microscopic examination revealed invasive, moderately- to poorly-differentiated squamous cell carcinoma (Fig. 3) with an invasion depth of 3.6 cm into the deep subcutaneous tissue, resulting in an anatomic “Clark level” designation of V (out of maximum V) (Fig. 4). Microscopy of the heart biopsy showed myocardium infiltrated by highly malignant neoplastic cells, with pleomorphism, high nuclear to cytoplasmic ratio, abundant eosinophilic cytoplasm, and hyperchromatic nuclei. The surrounding stroma was reactive and showed desmoplastic reaction typically seen surrounding neoplastic growth. Immunohistochemical stains of the heart biopsy were positive for AE1/AE3 (a cytokeratin combination characteristic of epithelial lineage) and negative for myogenin (which is expressed in muscular differentiation), strongly suggesting malignant squamous cell metastasis.8,9 No


lymph nodes had been biopsied at the time of this writing.

Discussion

The case discussed above is relevant across a broad range of healthcare disciplines. For the patient, education on this rare but aggressive complication of a decades-old wound could prompt a sooner hospital presentation and avoid the devastating diagnosis of top-stage cancer with widespread metastasis at such a young age. For example, had these risks been discussed more thoroughly with the patient following his previous skin graft operation, he may not have waited until the wound had grown from 2 cm to 30 cm before seeking medical attention. On the clinical side, heightened awareness of the risks associated with Marjolin’s ulcer could lead to better follow-up, earlier detection

Transformation References:1. Kumar V, Abbas A, Aster J. Robbins Basic Pathology. 9th ed. Philadelphia, PA: Elsevier Saunders; 2013:863-864.

2. Oruc M, Kankaya Y, Sungur N, et al. Clinicopathological evaluation of Marjolin ulcers over two decades. Kaohsiung J Med Sci. 2017;33(7):327-333. doi: 10.1016/j.kjms.2017.04.008.

3. Cavaliere R, Mercado DM, Mani M. Squamous cell carcinoma from Marjolin’s ulcer of the foot in a diabetic patient: Case study. J Foot Ankle Surg. 2018;S1067-2516(17)30653-1. doi: 10.1053/j.jfas.2017.11.016. [Epub ahead of print]

4. Bazalinski D, Przybek-Mita J, Baranska B, Wiech P. Marjolin’s ulcer in chronic wounds - review of available literature. Contemp Oncol (Pozn). 2017;21(3):197-202. doi: 10.5114/wo.2017.70109.

5. Copcu E. Marjolin’s ulcer: a preventable complication of burns? Plast Reconstr Surg. 2009;124(1):156-164. doi: 10.1097/PRS.0b013e3181a8082e.

6. Sinha S, Su S, Workentine M, et al. Transcriptional analysis reveals evidence of chronically impeded ECM turnover and epithelium-to-mesenchyme transition in scar tissue giving rise to Marjolin’s ulcer. J Burn Care Res. 2017;38(1):14-22. doi: 10.1097/BCR.0000000000000432.

7. Liu Z, Zhou Y, Zhang P, et al. Analysis of clinical characteristics of 187 patients with Marjolin’s ulcers. Zhonghua Shao Shang Za Zhi. 2016;32(5):293-298. doi: 10.3760/cma.j.issn.1009-2587.2016.05.009.

8. Pernick N. Cytokeratin AE1 / AE3. PathologyOutlines.com. http://www.pathologyoutlines.com/topic/stainsae1ae3.html. Published July 2013. Updated March 2018. Accessed June 27, 2018.

9. Pernick N. Myogenin. PathologyOutlines.com. http://www.pathologyoutlines.com/topic/stainsmyogenin.html. Published June 2005. Updated November 2015. Accessed June 27, 2018.

Peer Review Notes: Manuscript received June 2018. Reviewed July 2018. Accepted for publication August 2018.

and a much more optimistic prognosis. Finally, aside from the mere interest in such an unusual case presentation, the technical aspect of the grossing process in pathology deserves note because of its significant implications on diagnosis and subsequent treatment. This case provides an excellent example of the importance of shaving and submitting the entire peripheral margin, even on large skin resections and in the context of multiple negative intraoperative diagnoses. Had the pathologists’ assistant only shaved representative segments of

Fig. 1: Gross photograph of local skin excision specimen prior to sectioning.

Fig. 2: Diagram used in pathology to demonstrate location and plane of sections.

Fig. 3: Squamous cell carcinoma from border of mass.

Fig. 4: Tumor invasion into deep subcutaneous tissue and skeletal muscle.

the margin, the positive foci would almost surely have been missed. Thankfully, proper grossing technique and careful examination by a dermatopathologist provided an accurate final diagnosis allowing for re-excision of the margin. Complete removal of the primary tumor was confirmed by shaving the new margin and submitting it entirely. n

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Abstract

The case presented is that of a female in her late 70s with a history of invasive ductal carcinoma, diagnosed in 2002. Fifteen years later, she was found to have metastases to the stomach and to the colon, both rare sites of spread from breast cancer. The metastasis to the colon is of particular note here as it was received as a surgical specimen and evaluated by a pathologists’ assistant. Histologically, the cell morphology was compared between the primary breast cancer and colon metastasis and found to be strikingly similar. Further discussed are related case reports and analyses in the literature of such breast cancer metastases to the gastrointestinal tract and their characteristics. Although rare, the possibility of gastrointestinal metastasis in a patient with a history of breast cancer should always be considered when diagnosing or grossing a gastrointestinal lesion.

Keywords: ductal carcinoma of breast, breast cancer metastasis, gastrointestinal metastasis, metastasis to colon

Introduction

Reports of breast cancer metastasizing to the gastrointestinal tract are quite rare, and even rarer to have occurred in the colon. Most often, breast cancer metastasizes to the lymph nodes, bone, lungs, liver, and brain. The case presented here is that of a patient with a history of invasive ductal breast cancer metastasizing fifteen years later to the colon, and is significant for several unusual findings in its presentation and pattern of metastasis when compared to the literature.

Case Presentation

A Caucasian woman now in her late 70s had a diagnosis of breast cancer in 2002 and underwent a left modified radical mastectomy and axillary node dissection, 6/14 of which were positive, but no other metastases were identified at the

time. The tumor was 3.5 cm in greatest dimension. The cancer was diagnosed as moderately differentiated invasive ductal carcinoma, estrogen receptor (ER) positive, progesterone receptor (PR) weakly positive, and HER2/neu negative. Following treatment with chemotherapy and antihormonal therapy, she had been periodically monitored and had no evidence of recurrence.

In late 2017, fifteen years after the original breast cancer diagnosis, the patient presented to the emergency department with nausea, vomiting, and inability to keep down food or liquid. Endoscopy revealed a gastric outlet obstruction. A biopsy of the antrum was positive for cancer, determined to be metastases of her previous ductal breast cancer by use of immunohistochemistry comparison. Computed tomography (CT) scans revealed marked abnormal thickening of the pylorus and dilation of the stomach, but no other indications of metastasis. A palliative bypass with gastrojejunostomy was performed followed by a chemotherapy regimen.

Three months later, the patient returned to the emergency department complaining of abdominal pain, nausea, and vomiting that had been worsening over the past few days. She also had worsening abdominal distension and reported no bowel movements for the past four days. A CT scan revealed the cecum was dilated to greater than 12 cm, a large left lower quadrant abdominal wall hernia, and a right inguinal hernia containing multiple loops of small bowel. The patient was admitted and exploratory surgery was recommended by the surgeon, as a colonoscopy was unable to be performed. It was theorized by physicians that a loop of colon may be trapped within the hernia, causing the cecal distension.

The surgery revealed several remarkable findings. The cecum was very distended and believed to be perforated within the hernia. The hernia sac contained a large

amount of purulent fluid and thickened loops of small bowel, as well as a large portion of omentum and stool. The ascending colon and hepatic flexure were constricted, completely blocking the area extending to the transverse colon. A right hemicolectomy and repair of the left side Spigelian hernia was performed.

Pathological Findings

Upon gross examination of the surgical specimens, the pathologists’ assistant noted 15 cm of the ascending colon wall was narrowed and thickened with congested mucosa imparting a cobblestone appearance, giving the gross impression of Crohn’s disease or another inflammatory colitis (Fig. 1, 2). The cecum was dilated and the mucosa flattened. The hernia sac was remarkable for a nodule containing exudate upon sectioning. Appropriate sections including the cobblestoned areas,

Breast Cancer Metastasis to the Colon Presenting After Fifteen YearsSamantha Etters, Wayne State University

NewCE Article

Peer-Reviewed

Fig. 2: Cobblestoned portion of colon wall cut to reveal infiltration of the lesion into the mucosal layers.

Fig. 1: Wall of colon specimen showing cobblestone arrangement of metastatic tumor (previously sectioned).

Second year student members (non-Delegate) were given the opportunity to apply for a travel grant to attend an upcoming Fall Conference or Spring Meeting of their choice. Students were required to write a manuscript, and the winning entry received a grant valued at up to $1600 (full week registration + $1000 to help cover travel expenses). Congratulations, Samantha, on your winning submission!


dilated cecum, unremarkable mucosa, and attached appendix were submitted for histological examination.

Microscopically, the cobblestoned portion coincided with diffusely infiltrating and poorly differentiated carcinoma resembling linitis plastica. Neoplastic cells with signet-ring forms involved the mucosa and bowel wall and invaded into the pericolic tissue and serosal surface. There was also evidence of neoplastic cells in grossly uninvolved portions, including the dilated cecum. Two pericolic lymph nodes found around the cobblestoned portion and the nodule in the hernia sac were positive for metastatic carcinoma.

Immunohistochemistry staining determined the tumor to be ER positive and PR negative. HER2/neu testing was not performed. Slides from the patient’s previously diagnosed breast cancer were obtained from the original treating hospital and compared with the metastatic tumor, which showed the two to have similar histological features, though the colon metastasis was diffuse and poorly differentiated in comparison (Fig. 3, 4). The final diagnosis was metastatic breast carcinoma, diffusely involving the right colon.

The patient tolerated the procedure well and after recovery was discharged and continued to be treated in outpatient care. Two months later, she was admitted to the emergency department with worsening renal function and elected to undergo supportive care. As of the submission of this manuscript, the patient had been transferred to a hospice facility.

Discussion

This case is noteworthy for demonstrating several rarities in regard to breast cancer metastases, all of which raise important diagnostic challenges for health care providers to consider. First, reports of breast cancer metastasizing to the gastrointestinal tract are rare, and even more rare to have occurred in the colon. Most often, breast cancer metastasizes to the lymph nodes, bone, lungs, liver, and brain. In a five-year retrospective study at one institution, of 980 patients diagnosed with breast cancer only five (0.5%) had metastatic disease to the gastrointestinal tract.1 The same study found in their case analysis and in a review of literature that the stomach was the most common site of gastrointestinal metastasis from breast cancer (60% of cases), while the colon was indicated in 11% of cases. It is likely that the incidence of gastrointestinal metastasis from breast cancer may be higher due to clinically undetected cases, as evidenced by a study comparing surgical cases with autopsy results that found over twice as many incidences of gastrointestinal

metastases at autopsy than were clinically detected in surgical cases.2

Despite being the most common type of invasive breast carcinoma, ductal carcinoma is less likely to metastasize to the gastrointestinal tract than lobular carcinoma. In published reports, lobular breast carcinoma is the most often reported type implicated in gastrointestinal metastasis from the breast, though reasons for this have not yet been explored.1 A study comparing metastatic patterns of lobular and ductal breast carcinoma found gastrointestinal metastases in 4.5% of patients with lobular diagnoses and only in 0.2% of ductal.3

The gross and microscopic characteristics of the presented case do coincide with published reports. The appearance of breast cancer metastases to the gastrointestinal tract have been found to be variable; one study revealed a range of presentations, from diffuse thickening of the walls mimicking linitis plastica to large obstructive ulcerated masses.2 Any of these presentations may cause diagnostic difficulty, as the metastasis may be mistaken

for either a gastrointestinal primary cancer or other inflammatory disease. There have been two published reports of metastasis to the colon specifically mistaken for Crohn’s disease based on clinical, surgical, and/or radiographic findings.4,5 Complicating a proper diagnosis is the variety and non-specificity of gastrointestinal symptoms, typically including nausea, vomiting, diarrhea, and intestinal pain.1 Many of these symptoms also coincide with side effects of treatment, further obscuring the diagnosis.

Microscopically, most reports note a signet-ring cell pattern of morphology in gastrointestinal metastases, regardless of whether the original breast cancer was ductal or lobular.2 In one of the reported cases of metastasis simulating Crohn’s disease, the morphology also showed signet-ring cell configuration.5 In the presented case, the receptor status changed from ER/PR positive in the primary tumor to ER positive, PR negative in the metastatic tumor. While in most cases immunohistochemistry results match between the original breast cancer and metastasis, there have been

> Breast Cancer continued on page 20

Fig. 4: Comparison of primary invasive ductal breast cancer (A) and colon metastasis taken from cobblestoned area (B), high magnification (H&E).

Fig. 3: Comparison of primary invasive ductal breast cancer (A) and colon metastasis taken from cobblestoned area (B), low magnification (H&E).

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Introduction:

A group of Aurora Diagnostics’ Pathologists’ Assistants have come together to form Aurora Diagnostics Pathologists’ Assistant Working Group (PA-WG). The goal was to create a uniform approach to the handling of all breast specimens in an effort to optimize breast protocol standards and maximize current breast predictive factor (BPF) test results.

Initial core biopsies may not represent appropriate subtypes throughout the entirety of the tumor due to tumor heterogeneity. Additional findings and specimens not meeting the ASCO-CAP adequate fixation and cold ischemic time guidelines are also encountered. For these reasons, new breast predictive factor testing will be performed on these varying specimens which did not meet CAP-ASCO guidelines. Optimal breast protocol standards are essential to determine the correct course of therapy for breast cancer patients.

Breast cancer biomarkers (ER, PR, and HER2) can identify patients who may be eligible for targeted therapy. The HER2 oncogene is over expressed in 15 to 20% of invasive breast cancers and is associated with aggressive disease and increased risk of metastasis. Factors involved in specimen collection, whether from needle core biopsies or large resections, and the handling/processing of breast tissue in histopathology can greatly affect scoring and interpretation of biomarker testing, possibly causing discordant biomarker rates and denying patients beneficial treatment options.

Methods:

The PA-WG focused on and evaluated three areas that affect biomarker outcomes: pre-analytical, gross room procedures, and communication/education. These were determined to be the factors affecting cold ischemic time (CIT), handling of the specimen once received in histopathology, and effectively communicating and educating other departments/providers in proper specimen submission.

Results:

Lab vigilance, location of surgical center, courier schedules, radiographic delays, cold ischemic time (CIT), proper fixative, and fixative volumes all play critical roles and challenges in the effort in abiding to CAP-ASCO guidelines. Lab staff management of daily surgical schedules accounting for each breast surgical case, proactive communication for late or weekend cases, and immediate communication for breast specimens not received during the expected time are factors affecting optimal breast specimen handling. Remote surgical sites play a challenging, but not an impossible role when it comes to abiding to CAP-ASCO guidelines. There must be an open line of communication between the sites and couriers. This is extremely important when it comes to scheduling of weekend and late cases. The couriers should be scheduled in order to minimize transit time to the lab. The tissue should be x-rayed prior to being placed in a minimum of 1:10 ratio (tissue: 10% NBF). Guidelines suggest that 10% NBF (neutral buffered formalin) is the only acceptable fixative. Cold ischemic time (CIT) is the time frame from which the specimen was excised from the patient and the time the specimen is placed in formalin. A process that minimizes CIT should be utilized. An intraoperative x-ray device and immediate interpretation is the route to the shortest CIT. Transport to a nearby radiology department and immediate placement in formalin is also an acceptable practice in minimizing the CIT of the specimen. The cold ischemic time should be documented, at minimum, on the specimen requisition.The time the specimen is placed in 10% NBF should also be documented by the Operating Room, Radiology, or Pathology staff; contingent on who placed the tissue in 10% NBF. This time should abide by the CAP-ASCO guidelines of less than one hour and can be documented as follows:

Specimen Excised from Patient at: ______

Specimen Placed in 10% NBF at: ______

See Fig. 1, 2, & 3.

James L. Barry, MHS, PA(ASCP)CM and Angeline Dowell, MS, PA(ASCP)CM Aurora Diagnostics Pathologists’ Assistant Working Group

Peer-Reviewed

Aurora Diagnostics Pathologists’ Assistant Breast Specimen Handling Best Practice Guideline

Members are encouraged to submit articles for The Cutting Edge. An upload link can be found on the Publications page of the website. Earn 5 CMP points for authoring journal articles for peer-reviewed publications. Published articles are also eligible for the annual Journal Award with cash prizes!

Once the breast specimen is received in the grossing room, the way it is handled is determined by the type of specimen.Needle localization specimens and partial mastectomies can be received with or without the use of a wire in place, anatomic orientation, metallic localization devices, and an accompanying radiograph. Before the specimen is cut, a prior biopsy report should be obtained and the specimen correlated anatomically, if possible, to a radiograph. A standard inking protocol should be used for consistency. Optimal slice thickness for these specimens is 3-4 mm and laid out sequentially for examination. A specimen slice diagram template is also helpful in documenting the tissue selection in correlation with the section code; this ensures better accuracy and minimizes the amount of additional sections to be submitted when incidental findings are discovered. See Fig. 4. Mastectomy specimens should be inked, sectioned into 1-1.5 cm slices (kept intact as much as possible), and placed in an appropriate amount of 10% NBF within the one hour guideline ensuring adequate fixation of the tumor and additional surfaces for possible breast predictive factor testing.

Discussion:

Biomarkers such as estrogen receptor (ER), progesterone receptor (PR), and HER2 are important in determining prognosis and therapy for a particular patient. According to our findings, these markers are affected by the method and length of fixation. For this reason, fixative must penetrate the tumor within the one-hour time limit to have optimal ER, PR and HER2 results. It is important at the time of grossing to be aware of these issues, and to educate staff on the best practices for handling breast specimens. The understanding of the ER/PR/HER2/TNBC (triple negative breast cancer) receptor rates for all of the outpatient clinicians and all of the hospital labs that feed into the main laboratory is paramount (refer to SEER data below to compare national benchmark data to local data). The Pathologists and Pathologists’ Assistants are at the forefront of communication with


Fig. 1: Demonstrates the increased incidence of Negative ER receptor biomarker in specimens with a CIT of greater than one hour.

Fig. 2: Compares a fraction of ER+ breast cases from 0 to greater than 100 minutes showing a 1.6% decrease of ER+ with a CIT of 0-60 minutes; 6.6% decrease in fraction of ER+ breast cases in comparing those with a CIT of 40-60 minutes with those at 60-80 CIT; and a significant decrease of 14.9% in those exceeding a CIT of greater than 100 minutes.

Fig. 3: Demonstrates an example of a non-refrigerated breast case. The tumor was strongly positive for estrogen receptor (similarly to core biopsy) at 0.5 h of delayed fixation (a) but demonstrated significant reduction at 3 h (b), 24 h (c), and 48 h (d). All photomicrographs were taken at 200X.

Fig. 4: Sample Breast Slice Orientation Guide template that can be utilized in documenting tissue selection in correlation with the gross description section code.

multiple departments and outlying hospitals. The role of the Pathologists’ Assistant in conveying information is to communicate with multiple sources including the Tumor Registrar, Nurse Navigator, Pathologist, Lab Manager, and Tumor Board to capture receptor rate data and demographics for the local lab. Correlating receptor rates for the local lab to the national benchmark rates aids in identifying discrepancies.When discrepancies are identified, consider the local demographics for a possible explanation of the differences. Furthermore, consider demographics for each site to include age, ethnicity, hormone receptor (HR) status, etc. If the local demographics do not support the difference, re-evaluate the pre-analytics as a solution. Tracking the receptor rates and providing feedback to the multi-disciplinary team frequently ensures the quality of practice methods. Systematic and long-term collection of the data allows assessment of trends over time. For example, assessing data over a three- to five-year period, and re-assessing at yearly increments can identify potential problems, and comparisons among data sets. See Fig. 5 on page 10.

The universal education of staff handling breast specimens at each site is multi-faceted and should include updating requisition forms, education of the importance of cold ischemia time, and providing guidance to all staff engaged with the breast specimen. When updating requisition forms, ensure that the importance of cold ischemia time is understood and times are logged.Depending on site and IT limitations, there may be up to seven time stamps to include:

1. Time out of body 2. Time in Radiology 3. Time in formalin

PATHASSIST.ORG

Fig. 5: US incidence of breast cancer subtypes by joint hormone receptor (HR) and HER2 status.

4. Time specimen is prepped 5. Time specimen is grossed 6. Start of processor 7. Duration of fixation 6-72 hours

If changes cannot be added to the requisition forms due to IT or SOP limitations, consider including the time the specimen is removed from the body as part of each specimen source. For example, the specimen site can be listed as “Left Breast at 1:00, placed in formalin at 9:30 am”. This update would be preceded by the education of staff handling the breast specimen before arrival to the Pathology Lab. Proactive communication will enhance the importance of Cold Ischemic Time. The guidance on Cold Ischemic Time provided by the Pathologists’ Assistant includes, but is not limited to, OR Staff, Surgeons, Radiology, Lab Staff, Courier Staff, Remote Sites, and the Multi-Disciplinary Team. Use the Director of Surgical Services and Tumor Board as a platform to disseminate information to the OR staff, Surgeons, and Pathologists. Educational meetings should continue at six-month intervals to accommodate staff rotations and changes. Also, consider adding a Quality Assurance (QA) flag to identify any areas for practice improvement and patient safety. For example, the most logical flag would be added to the Pathology LIS to aggregate data for monthly, yearly, and long-term QA data reports. Other flags may include stickers added to requisition forms, etc.

Remote sites can be a challenge when handling breast specimens in a universal manner, especially sites that are not staffed with PAs or Pathologists.

Methods to ensure the proper implementation of breast specimen handling include requesting specialized personnel, specimen inking by the surgeon, and designated responsible OR team members. For days when a breast case is scheduled at a remote site, a Pathologist or Pathologists’ Assistant can be requested to staff the lab, ensuring copacetic management of the breast procedure. Providing sterile ink for surgeons to orient and slice breast specimens immediately after removal from the patient is an alternative to arranging a PA on location. In addition, designating a surgical team staff member to be responsible for Cold Ischemia Time documentation allows for continual accurate documentation. Another option for ensuring correct Cold Ischemia Time is to treat every breast case as an Intraoperative Consultation with a Pathologist to guarantee every breast specimen is inked, sliced, and exposed to formalin within the recommended one-hour window. Pathologists and PAs can make the process of breast handling more efficient by educating the surgeons on the

Aurora Acknowledgements:

We thank the following colleagues for direct editing, supervision, and valued insights, whose expertise greatly assisted with the collaboration of this research article: Jesse Hicks MBA, PA(ASCP)CM, Scott Whittington, MHS, PA(ASCP)CM, Nicole Flanigan, PA, Rachelle Kanas, PA(ASCP)CM, Katrina Fryar, PA(ASCP)CM, Walliang Rosene, PA(ASCP)CM.

Special thank you to:

Joshua Kish, MD, (FCAP), (FASCP), Jennifer Kish, MHS, PA(ASCP)CM, Mike Walsh, M.D., and Anne Horstmann, PhD.

References:

Figures 1 & 2: David G. Hicks, MD. University of Rochester, Surgical Pathology Unit.

Figure 3: Isil Z Yildiz-Aktas, David J Dabbs, and Rohit Bhargava: The effect of cold ischemic time on the immunohistochemical evaluation of estrogen receptor, progesterone receptor, and HER2 expression in invasive breast carcinoma. Modern Pathology (2012), 1–8.

Figure 4: James L. Barry PA(ASCP)CM. Hallmark Health System, Inc. Department of Pathology, Hallmark Pathology Inc.

Figure 5: US Incidence of Breast Cancer Subtypes Defined by Joint Hormone Receptor and HER2 Status. Howlader, N et al. J Natl Cancer Inst. 2014: Vol. 106, Issue 5; 1-8.

Peer Review Notes: Manuscript received January 2018. Reviewed February 2018. Accepted for publication April 2018.

increased error rates that result from breast surgeries scheduled on Fridays, weekends, and after normal hours. Beyond the OR, lab staff and couriers can be trained to identify errors and reduce processing time. Lab personnel staff can be trained to double check specimen container size and formalin volume before transporting breast specimens. For courier staff, emphasize the importance of reducing transport time.There should be a consistent, available means of communication between the remote surgical site and the pathology lab.

Conclusion:

In creating this guideline to support the Pathology Executive Council (PEC) Breast Biopsy General Recommendation (ADXPB-31), the PA-WG has been able to identify challenges and hindrances to ensuring accurate biomarker outcomes relating to proper specimen collection, handling, grossing, and processing. Various institutional and workplace methodologies have provided beneficial solutions that have been shared amongst the PA-WG. An added bonus of forming this PA-WG for this breast specimen handling best practice guideline is the creation of a connected network of Pathologists’ Assistants within

Aurora Diagnostics that will allow for future cooperation and problem-solving, benefiting our individual pathology groups. n

Submit a manuscript in one of two categories: - Neoplastic Cases - Non-Neoplastic Cases

The winning submission in each category will receive a travel grant valued at up to $1,800 to attend an upcoming Fall Conference or Spring Meeting.

Visit pathassist.org/scholarships for more information, including rules and regulations to submit your manuscript, plus FAQs and past winners.

Win a Travel Grant to Attend an Upcoming Meeting!Fellows Apply Between Oct. 1, 2018 - Jan. 1, 2019


Heather Manternach, PA(ASCP)CM

Fall Conference Chair

44th Annual Continuing Education Conference RecapNew Orleans, LASeptember 23 - 28, 2018

Mark your calendars! AAPA 45th Annual Continuing Education Conference will be held August 25 - 30, 2019 at the Hyatt Regency in Chicago, IL.

Information will soon be available on the AAPA website.

PATHASSIST.ORG

registering to be a donor. If you didn’t have a chance to register while you were in New Orleans, or if you weren’t able to attend but still want to sign up, go to Join.BetheMatch.org/aapa to begin the process. Signing up is simple and easy. After the fundraising, and with the generous match up to $1000 by the AAPA Board of Trustees, we raised over $2,300 for Be the Match®. Thank you to all who participated and supported the cause. Each year we will pair with an organization to help give back as an association. If you have any organizations that you would like to suggest, please let me know. We would love to support an organization that is near and dear to one of our members.

Thank you for helping us “Get Jazzed in New Orleans”. I hope you were able to meet new PAs and reconnect with friends, share ideas with colleagues, and to learn from our great speakers. We are continually looking for ways to improve the conference and to provide our members with the best PA-specific conference. We want to make this your preferred conference!

See you next year at the Hyatt Regency for the 45th Annual Continuing Education Conference in the windy city…Chicago! n Heather Manternach, PA(ASCP)CM works at Wisconsin Diagnostic Laboratories as a PA in Milwaukee, WI. She has been a member of AAPA since 1998, and has served as the AAPA Conference Committee Food and Beverage Subcommittee Chair from 2000-2013, and as the Fall Conference Chair since 2014.

all who participated and to Lauren Polli, our great master of ceremonies!

On Tuesday, we had over 30 attendees dine together with Dinner with Strangers. I feel we need to change the name to Dinner with Future Friends – it’s always a great opportunity to get to know new PAs. Tuesday we also had the Golf Classic. After a short down pour, the golfers were at it again – having fun and enjoying New Orleans. All skill levels are welcome at the golf classic – no experience required!

The Happy Hour Fun Run/Walk took place on Thursday afternoon. Thank you to all the dedicated runners and walkers who braved the rain. It was so great to see so many people--runners and nonrunners--at the happy hour. Please plan on joining us next year – it’s a great time!

For our social cause this year, we worked with Be the Match®. Not only did we support Be the Match® financially through the T-shirt sales, mask donations, and raffle tickets, we also were able to support them by

Another great fall conference is in the books! As I say goodbye to New Orleans and the 44th Annual Continuing Education Conference, I look back and think how fast the week went and realize that this conference continues to amaze me. Where else can you find 19 lectures, 4 poster sessions, and 3 discussion groups all dedicated to PA-specific education? The speakers were top-notch and presented timely and pertinent information for pathologists’ assistants. We gained tools and information that we can use daily. The poster sessions provided great insight into ongoing research, case studies and topics that we see throughout our PA career. The discussion groups continued our conversations focused around relevant topics including management, resident education, and grossing tips and AJCC updates. It seems like an hour just wasn’t enough to cover all the discussions, so look for expanded discussion groups next year.

I want to acknowledge and give kudos to our fellow PAs who lectured at the fall conference: Brad Skilton, Sarah Garner, Alejandra Meza, Andrew McLoughlin, and Steve Taylor. Thank you for sharing your expertise with us. I learned so much from our fellow PAs, and I encourage all PAs to consider presenting a lecture at a future spring meeting or fall conference.

If you were not able to make it to the fall conference, I highly recommend listening to the lecture given by TJ Figueroa. His talk was truly inspirational and reinforces the high level of work we perform in the name of patient care. We should never forget that all specimens are connected to a patient. Not only did we have a week packed full of great lectures, educational poster sessions, and pertinent discussion groups, but don’t forget the fun, networking activities. The conference kicked off on Sunday evening with the Masquerade Welcome Party. We were able to see new and old friends, classmates, and colleagues. In addition to the great New Orleans-themed food, we were treated to a masquerade contest. The contestants truly outdid themselves with their masks and costumes. Thank you to

Welcome Party: Connecting with old friends and new colleagues

A special thank you to Steve Suvalsky, PA(ASCP)CM and Michelle Johnson, PA(ASCP)CM for taking the conference photos.

Ansley Bradley, PA(ASCP)CM winner of the decorated mask contest

AAPA 44th Annual Continuing Education Conference Photos New Orleans, LA, September 23 - 28, 2018

Conference t-shirts were sold to support Be The Match®, this year’s social cause


2018 Board of Trustee’s AwardPresented to:Brittin Cavanagh, PA(ASCP)CM & N. Dominic Alessio, PA(ASCP)CM

Thank you to Brittin Cavanagh andDominic Alessio for their dedicationand commitment to our association asthe founding Student Committee leaders!Recognizing that students representthe future of our organization, Brittin and Dominic have encouraged students to value membership and inspire them to actively participate in our association. Congratulations!

Brittin and Dominic are recent graduates and have been instrumental in developing, and were the driving force, behind the creation of the AAPA Student Committee. They have both moved through the progression of student officer, graduate officer, and now have rotated off the committee.

Currently Brittin oversees the Student Committee under the umbrella of Membership, and Dominic is the Membership Committee Vice Chair.

2018 Lifetime Achievement AwardPresented to Laurence G. Marquis, MHS, PA(ASCP)CM

With gratitude and deep appreciation for your many years of outstanding service and unwavering commitment to our association and our profession. Leading always by example, you shared with all of us the values of honor, integrity, and friendship.

Brittin Cavanagh, PA(ASCP)CM, (center right) who recently relocated to New Zealand, and Dominic Alessio, PA(ASCP)CM, (center left) who received one of the most recent Fellow travel grants, were both in attendance at the Fall Conference and received their awards in person presented by BOT Chair John Eckman, MHS, PA(ASCP)CM, (far left) and Membership Committee Chair, Roseann Vitale, PA(ASCP)CM, (far right).

Larry Marquis, PA(ASCP)CM Lifetime Achievement Award winner

Larry Marquis and Tisa Lawless, MHS, PA(ASCP)CM in “jail” at the 2017

Fall CE Conference raising money for Living Beyond Breast Cancer.

1981-Quinnipiac University program grad1981-present, AAPA Fellow Member 1995-present, Golf Tournament2000-2002, Conference Chair2003-2004, President-Elect2005-2006, President2007-2013, Board of Trustees Member2014-present, Nominations Subcommittee

Additional roles included contract negotiations, policy & procedure review, conference site inspector

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Students & Poster Sessions

Lectures & Workshops

Poster Session, Shane Ferraro, PA(ASCP)CM. Poster Session, Lou Mendes-Kramer, PA(ASCP)CM, Wayne State program director, with presenter WSU student Jamie Maurice.

Chevanne Scordinsky, PA(ASCP)CM with speaker Andrew McLoughlin, PA(ASCP)CM.

Heather Manternach, PA(ASCP)CM with keynote speaker Steven Kroft, MD.

Speaker Jerad M. Gardner, MD.

Keynote speaker David Grignon, MD with Connie Thorpe, PA(ASCP)CM.

Delegates and students who participated in the Student Roundtable.

Poster Session, Cathleen Paschal, student from Rosalind Franklin University.

Speaker Fred Rodriguez, MD. Conference attendees waiting for the lecture to begin.


Larry Marquis, PA(ASCP)CM with Merrick representatives.

Thank you Platinum Sponsors: Faxitron, Kubtec, Merrick & Mopec

Fun Run/Walk

Golf Outing

Heather Manternach, PA(ASCP)CM with a Faxitron representative.

Mopec representative demonstrates new products during Exhibitors Happy Hour.

Paul Degennaro, PA(ASCP)CM with Kubtec representatives.

PATHASSIST.ORG

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Becky Stankowski, PA(ASCP)CM

Spring Meeting Chair

AAPA 8th Annual Spring Meeting Phoenix, AZ April 8 - 10, 2019

Board of Trustees 2019-2021 Election Results

John Eckman MHS, PA(ASCP)CM

Charlene Gettings MS, PA(ASCP)CM

Roseann Vitale, PA(ASCP)CM

John, Charlene and Roseann will begin their term effective January 1, 2019, with this being John’s second consecutive 3-year term. Nominations for the next round of Board seats opening (2020-2022) will be accepted during the month of March 2019.

Registration Opens: December 10

PATHASSIST.ORG

Consider joining us for the 8th Annual Spring Meeting, April 8 - April 10, 2019, at the Embassy Suites by Hilton Phoenix Scottsdale. Registration includes 15 lectures, breakfast all three days, lunch on Monday and Tuesday, and the Monday evening reception. This smaller meeting is limited to 125 attendees and offers great networking opportunities. The condensed format of the Spring Meeting is a wonderful option for those who may like to attend the larger Fall Conference but are not able due to budgeting or scheduling matters. As always, Embassy Suites offers a complimentary full, hot breakfast and nightly reception, including snacks and drinks for all hotel guests, making it a great value for attendees who travel with their family.

The lecture topics include medical ethics, macroscopic examination and staging of cancer cases, and a case study told from the perspective of a Pathologists’ Assistant who was also the patient. Here is a sample of some of the other great lectures planned for this meeting:

n Current Diagnosis and Staging of Lung Cancern Pathology of Heart and Lung Transplantationn The Handling of Nephrectomy Specimens: Tips, Tricks, and Future Directionsn Pediatric Lymph Node Pathologyn Common Pediatric Brain Tumors: A Primern Gestational Hypertension followed by Pulmonary Hypertension in Infant - A Case Study

n Colorectal Carcinomas: Updates and Practical Approach to Common Dilemmasn The Renal Transplant Biopsy After Hours

The Embassy Suites by Hilton Phoenix Scottsdale is located on the edge of Stonecreek Golf Club, with beautiful views of the surrounding mountains. Spend time on the driving range, putting green, jogging track, or in the hotel’s outdoor pool. Take the hotel’s complimentary shuttle to locations within a one-mile radius, including Paradise Valley Mall, Picture Show movie theater, and Theatre Artists Studio (live theater). Sixty dining options are available within 1.5 miles of the hotel, ranging from chain favorites like In-N-Out Burger and Z’Tejas Southwestern Grill to local eateries like the Salty Sow, OHSO Brewery, The Covenant, and Oink Cafe. If you have free time to explore the nearby mountains and desert, many tour companies pick up right at the Embassy Suites. If you prefer renting a car for your sightseeing, the hotel offers free parking in their lot.

We hope to see you at the Spring Meeting. Space is limited, so register early. n

Becky Stankowski, PA(ASCP)CM works as a PA at Wisconsin Diagnostic Laboratories in Milwaukee, WI. She has been a member of AAPA since 2009, and has served as a member of the AAPA Conference Committee from 2010-2013, and as the Spring Conference Chair since 2014.

pathassist.org

A resource for the macroscopic

examination of cancer specimens.

Produced and maintained by pathologists’

assistants to support laboratory personnel.

The AAPA Macroscopic Examination

Guidelines: Utilization of the

CAP Cancer Protocols at the Surgical Gross Bench

(Grossing Guidelines), Second Edition

have meaningful interactions with larger organizations. The initial work on the Grossing Guidelines led the AAPA to become a member organization of the American Joint Committee on Cancer (AJCC). Jon Wagner, Director of Professional Outreach, serves as our representative. AJCC membership is comprised of many distinguished cancer care organizations. The AAPA is a small organization among many large and prestigious organizations. Jon has recruited expert speakers from the AJCC for our conferences, and they come away better informed about who we are and what we do, and are impressed with our members, the association, and our profession. At the AJCC meetings Jon attends, he is able to build personal relationships with high level members of the AJCC and the CAP. While some of these interactions consist of discussing our profession, our qualifications, and how we contribute to patient care in pathology; other interactions include aligning the AAPA and its members with opportunities to collaborate on a larger scale. Jon recently met with Dr. Carolyn Compton, Precision Core Editorial Chair, AJCC. Dr. Compton was a speaker at our conference a couple years ago and is very supportive of pathologists’ assistants. Dr. Compton is organizing a national “precision core pre-analytic molecular summit” and is attempting to bring together all of those who are “players” in the pre-analytic phase of specimen handling and processing. She is including CAP and other physician and hospital associations in the meeting. The meeting is to occur in Washington DC to facilitate CDC, NIH, CMS, and other governmental agencies involvement. The agenda she is crafting revolves around the appropriate management of specimens to ensure validation of molecular studies. She sees the AAPA and pathologists’ assistants as major contributors in the discussion.

Jon was also able to speak with Dr. Samantha Spencer, Director of Structured Reporting at CAP, along with others. He reports that the CAP Cancer Committee recently asked that the AAPA add a synoptic section of grossing elements for each tumor

John Eckman, MHS, PA(ASCP)CM

[email protected]

Board of Trustees Chair’s Report

The Board of Trustees (BOT) includes nine board members plus six adjuncts to the board, which include a legislative adjunct and representatives to the APATP, the ASCP BOC, NAACLS, the AJCC, and the Commission on Cancer. Three members of the BOT make up the Executive Council, comprised of the BOT Chair, Vice Chair/Secretary and the Chief Financial Officer. Together, we all work very closely with Executive Director Michelle Sok to implement and develop the Association’s mission and vision.

All of the Adjunct members are appointed by the BOT for one-year terms. Each BOT member position is elected by a vote of the membership for a three-year term. Board member terms are limited to two consecutive three-year terms.

Three members have been elected to the BOT for the 2019-2021 term; they are new board members Charlene Gettings and Roseann Vitale, along with myself. I am grateful to have been elected to serve my second term on the BOT, and appreciate the confidence that the board has in me to serve as BOT Chair. I look forward to welcoming two new board members, and working to guide the BOT as we continue our work in directing and providing oversight to the association’s committees.

The BOT attended our annual working weekend meetings with Michelle Sok in Minneapolis, Minnesota in November. This is an intensive three-day meeting where the board reviews the activity of the association over the past year, and lays out our strategic plan for the next one-, three-, and five-year periods. In doing so, the BOT considers the AAPA mission, vision, and core values of quality patient care, education, advocacy, and collaboration. Part of the board’s strategic planning includes review of member surveys, and using the most common issues and concerns raised by the membership to guide our plan. While being able to accomplish all within the strategic plan is challenging, this past year has been very productive. A sound strategic plan is essential, but executing such a plan is what counts. The BOT is

pleased to have seen a number of items completed, including revision of our profession’s Scope of Practice; release of the Inspection Readiness Kit; completion of the 2nd edition of the Grossing Guidelines; the ASCP’s acceptance of our proposal to add continuing education credits related to cancer care, increasing the number of credits required for credential maintenance by 15 advanced AP credits and one ethics credit for each three year period; and submission of a formal response to the CMS regarding the change in rules that will allow nurses to perform high complexity testing in the laboratory along with a template for our members to submit a response. (The AAPA was the only organization that took a strong stance in support of pathologists’ assistants regarding this rule change.) Connie Thorpe, Director of Professional Development, was instrumental in accomplishing many of these items. The board so appreciates all that Connie does.

This year the BOT made a new effort to engage the membership by holding quarterly town hall meetings. We sought to bring back an element of the business meeting by having a presentation and discussion with members about what endeavors the board was working on or considering. These town hall meetings are held via webinar and also live at our spring meeting and fall conference. Topics have included: 1. Limited International membership, 2. The upcoming increase in credits required for the ASCP Credential Maintenance Program, 3. Licensure of Pathologists’ Assistants, and 4. Advocacy: How the AAPA advocates for our members and how you can advocate for yourself and the profession. If you missed our Town Hall meetings, a recording of each webinar is available on the AAPA website www.pathassist.org . The BOT also uses member feedback from our surveys to select topics for each Town Hall meeting. The preparation to present each topic and the discussion during the town hall are very valuable in guiding the board as we move forward.

The Board of Trustees is very excited about what is happening with our professional outreach as it has been a long process to


group in our Grossing Guidelines that could be used similarly to the pathologists’ synoptic checklist. It is very significant that the CAP requested the AAPA to create something of clinical relevance, and something that could become a required reporting element in the future.

As a result of our membership in the AJCC, the AAPA was invited and encouraged to become a member organization of the Commission on Cancer (CoC) in 2018. Erika Paulsen is our representative and new adjunct to the board. The CoC is an arm of the American College of Surgeons and is the credentialing body for cancer centers across the nation. As Erika begins attending CoC meetings and has the opportunity to represent pathologists’ assistants and our association, others in the CoC will understand our expertise in pathology and our role in cancer care. In the future, PAs may have the opportunity to be involved in the process of accreditation of cancer centers on some level.

The more organizations and high-level individuals that the AAPA interacts with and demonstrates the expertise and the important role pathologists’ assistants have in patient care and cancer care, the more we expand our network of support and recognition as a profession. All of this work and these interactions are definitely paying

off in expanding our reach and elevating our profession.

As we close out 2018, BOT members Jana Sovereign and Steve Rath have served two consecutive terms and will depart the board. We thank them for their time and service.

Steve Rath was appointed to the BOT in 2014 to complete the term of another board member who had stepped down. Steve was then elected to serve a 3-year term from 2016-2018. Steve brought his perspective as an experienced PA and as a manager to the board, and provided valuable insight as a BOT member and during his oversight of the education and membership committees. Prior to joining the board, Steve served as the Legislative Committee Chair.

Jana Sovereign was elected to serve two terms on the BOT spanning 2013-2018. Prior to joining the BOT, Jana served as Conference Committee Chair beginning in 2003. She served a total of 12 years in that role, including a dual role as Conference Committee chair and BOT member for 2 years. During this time, Jana attended numerous conference site visits and played a key role in selecting conference locations. In 2007, Jana was the recipient of the BOT Award. She brought her thoughtful insight and considerable experience as a

committee chair to the board, serving as Vice Chair, Chair, and CFO. Throughout her time on the BOT, Jana reminded us of the high standards we must maintain as members of the board and as an association. n

John Eckman is a PA at Penrose Hospital in Colorado Springs. He has been a member of the AAPA since 1992 and is currently serving as the Chair of the Board of Trustees and is the GYN Section Author on the Grossing Guidelines. John has served on the BOT since 2016, and had previously served as the Website Committee Chair for 10 years.

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PATHASSIST.ORG

reported cases with a change in receptor status, especially in poorly differentiated cancers that tend to lose the tissue-specific gene expression apparent in the primary tumor.6

The time elapsed between the original breast cancer diagnoses and discovery of gastrointestinal metastasis is also long in this case at 15 years; however, lengthier time spans have been recorded. Metastases from breast cancer occur within the first five years following the diagnosis of early stage disease about 75% of the time.7 In the case of gastrointestinal metastasis, analyses of published reports have discovered median time intervals between 4-7 years, but there have been cases of gastrointestinal metastasis reported up to 30 years later.7 In the aforementioned five-year retrospective study, the range of time between breast cancer diagnosis and discovery of metastasis to the gastrointestinal tract was between 0 (found at initial diagnosis) and 22 years.1 Unfortunately, the diagnosis of gastrointestinal metastasis from cancer of any kind is followed by a poor prognosis, with most patients surviving no more than a year.2

The patient’s previous history of breast cancer was not provided to the pathologists’ assistant before grossing the specimen, as it was diagnosed at a different hospital 15

years prior. Had the history been available, the colon specimen may have been grossed differently. First, guidelines for breast cancer grossing would have been followed, including ensuring proper fixation time of the specimen. Believing the specimen to be affected by an inflammatory process rather than a tumor, a thorough search for lymph nodes was not performed, another change that would have been made if the history or possibility of cancer was known. The specimen may also have been sampled differently, perhaps by sampling more of the grossly unaffected areas, rather than taking the majority of samples from the cobblestoned portion. Overall, the grossing procedure did not affect the outcome of this case, as it was still able to be diagnosed properly with no additional sampling required.

In conclusion, this case brings up two important points for providers. First is the potential for breast cancer to metastasize to the gastrointestinal tract, no matter how rare it is believed to be, nor the span of time since the original diagnosis. In any patient with a history of breast cancer presenting with gastrointestinal lesions discovered surgically or radiographically, the possibility of metastasis should be considered. Second, this case stresses the importance of the pathologists’ assistant to be provided with patient history so appropriate sections are taken. In the presented case, immunohistochemistry was ordered so the origin of the colon tumor was discerned,

Peer Review Notes: Manuscript received May 2018. Reviewed July 2018. Accepted for publication August 2018.

Breast Cancer> Continued from page 7

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and when combined with histological comparison of the primary breast tumor, accurate diagnosis was made. Despite the rarity of this event, this case as well as the handful of published literature have in common the goal to bring the possibility of colon and other gastrointestinal metastases from breast cancer closer to the forefront of providers’ minds. n

Breast Cancer References:1. Ambroggi M, Stroppa EM, Mordenti P, et al. Metastatic breast cancer to the gastrointestinal tract: report of five cases and review of the literature. Int J Breast Cancer. 2012;2012:439023. doi: 10.1155/2012/439023.

2. Washington K, McDonagh D. Secondary tumors of the gastrointestinal tract: surgical pathologic findings and comparison with autopsy survey. Mod Pathol. 1995;8(4):427-433.

3. Borst MJ, Ingold JA. Metastatic patterns of invasive lobular versus invasive ductal carcinoma of the breast. Surgery. 1993;114(4):637-642.

4. Weisberg A. Metastatic adenocarcinoma of the breast masquerading as Crohn’s disease of the colon. Am J Proctol Gastroenterol Colon Rectal Surg. 1982;33(5):10-21.

5. Koos L, Field RE. Metastatic carcinoma of breast simulating Crohn’s disease. Int Surg. 1980;65(4):359-362.

6. Paiva C, Garcia J, Silva C, Araujo A, Araujo A, Santos MD. Single jejunum metastasis from breast cancer arising twelve years after the initial treatment. Case Rep Oncol Med. 2016;2016. http://dx.doi.org/10.1155/2016/8594652.

7. Wiisanen JM, Kaur JS. Gastrointestinal metastases from breast cancer, a comprehensive review. Breast J. 2015;21(5):572-573. doi:10.1111/tbj.12464.


Quiz Case: 41-year-old G1P0 female with no significant medical history and an uncomplicated pregnancy thus far. She presented at her 34-week prenatal check-up with a distended abdomen and associated pain. Ultrasound showed polyhydramnios and a 6.4 cm hypoechoic mass located near the umbilical cord insertion site.

Gross Photo Unknown

Quiz: 1. This is the most common tumor of the placenta.

A. Hematoma B. Chorangioma C. Amnion nodosum D. Choriocarcinoma

2. When grossing placentas, it is important to measure and record:

A. The number of any lesions that are present B. The sizes of any lesions that are present C. The approximate percentage of the total cut surface a lesion(s) occupies/occupy for clinical significance D. All of the above

3. True or False: Chorangioma has malignant potential. Answers found on page 27

There are many volunteer opportunities available to help further the PA profession. Where can you help?

n Peer-review n Tech Savvy n Writing n Conference Planning n Marketing n Staff Exhibit Booth n Communication n Conference Speaker

Learn more at: pathassist.org/Volunteer

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npictured left to right

The AAPA held its fourth Town Hall Meeting Live! at the New Orleans Fall Conference on September 24, 2018. Members who were not in attendance were invited to call in via GoToWebinar. Lauren Polli (center) was the onsite moderator, and the panel of presenters, pictured left to right, consisted of Board of Trustees (BOT) Adjunct - ASCP BOC Mike Sovocool, BOT CFO Jana Sovereign, BOT Chair John Eckman, BOT Adjunct - APATP Mary Dydo, MarComm Committee Chair Charlene Gettings, and BOT Adjunct - CoC Erika Paulsen. BOT member and Technical Support Ryan Schniederjan is not pictured. The topic for the final Town Hall of 2018 was Advocacy: How the AAPA advocates for our members and how YOU can advocate for yourself.

The presentation began with John pointing out that advocacy is one of the AAPA’s core values and then reviewing the historical timeline of advocacy milestones within the association’s history. Some of the association’s most recent accomplishments were highlighted including the revised Scope of Practice, the Grossing Guidelines, the Inspection Readiness Kit, and the AAPA PR exhibit booth travels. In addition, the benefits of advocacy in the area of professional outreach were discussed.

Multiple examples were provided of AAPA fellow members serving as adjuncts or committee members for other associations including NAACLS, ASCP, CAP, AJCC, and the CoC.

When asked what the association has on the horizon for its advocacy efforts, Jana highlighted some future projects including a task force to examine the possibility of PAs expanding into forensics, the development of a credentialing kit, global humanitarian opportunities, and professional promotional videos. Next, the panel talked about how to advocate for yourself as a PA including community outreach, speaking opportunities, and promotion of Pathologists’ Assistant Day. The panel gave examples of tools available for advocacy and ways members could get more involved in advocacy.

Before opening the floor to questions, the Town Hall wrapped up with panel members giving personal examples of ways they have advocated for themselves, given students the tools to advocate for themselves, and promoted the profession. We would love to hear from you on this subject! Please go to pathassist.org to replay the recording, and continue the conversation on the new Advocacy forum on our website. Your input is very important to the AAPA. n

Upcoming Town Hall Meeting DatesTo be held in conjunction with the

2019 Spring Meeting and Fall Conference Join while attending or remotely through GoToWebinar.

Details will follow closer to the meeting date.

AAPA Town Hall Meeting - Sept. 24 Recap

Inspection Readiness KitAvailable Now

Has your laboratory director requested checklists for macroscopic specimen

examination supervision templates or competency

assessment for pathologists’ assistants?

The AAPA has a solution!

Designed to assist in achieving a successful CAP Inspection by providing templates and

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pathassist.org

Newly Updated!


Elizabeth “Liz” Rizzo, PA(ASCP)CM

Board of Trustees Legislative Adjunct

Legislative Update

Congratulations to the 2018 Journal Award Winners!

Editor in Chief of The Cutting Edge, Beth Felicelli, and Assistant Editor Minda Koval have selected the top three journal articles to receive cash prizes. All articles published in The Cutting Edge September 1, 2017 to August 31, 2018 are eligible.

The winning articles are as follows:

n 1st place with a $1,000 prize: Clear Cell Renal Cell Carcinoma with Solitary Synchronous Metastasis to the Contralateral Adrenal Gland, Lori Stewart, Issue 1, 2018.

n 2nd place with a $750 prize: New Insight into Endometrioid Borderline Ovarian Tumor, Bing Miller, PA(ASCP)CM, Issue 1, 2018.

n 3rd place with a $500 prize: A General Overview of Tissue Submission Guidelines for Zika Virus Testing, Kimberly Green, MHS, PA(ASCP)CM, Issue 3, 2017.

Would you like to win cash for writing an article? Members are highly encouraged to submit articles to The Cutting Edge, or better yet, join our newly formed staff writers team! Writing an article is a great way to get involved, get published, and earn 5 CMP points for authoring a journal article for a peer-reviewed publication.

PATHASSIST.ORG

In my last article for The Cutting Edge, I talked about regulatory agencies which govern laboratory medicine, specifically anatomic pathology, and how they impact our practice as PAs. This article will address an equally complex issue for our profession, i.e. licensing. In June 2018, the AAPA hosted a Town Hall on this topic for our members. Much of the information presented in that Town Hall will be recapped here.

First, some definitions of commonly used terms and concepts, specifically certification, credentialing, and licensure.

Certification is a formal process that validates a person’s qualifications in a field. This voluntary process assures people meet a minimum educational standard, usually pass a certification exam, and require ongoing continuing education for each certification cycle. The ASCP is our certifying agency.

Credentialing is performed by a third party (your hospital, employer, laboratory) with authoritative power and is proof of qualification and competency. This non-government authority verifies a baseline of competency in a given field. We often see this with physicians as well as mid-level providers.

Licensure is a state’s grant of legal authority to practice a profession within a scope of practice. The state defines the scope of practice and passing a certification examination is generally required.

While certification and credentialing both address qualifications, it is licensure that is the “law-of-the-land” and clearly defines a profession, including who is allowed to perform the tasks in the scope of practice.

The AAPA supports state licensure specific to pathologists’ assistants when legislation is created that is based on our scope of practice, is not unnecessarily burdensome to pathologists’ assistants or their employers, and includes:

1. Graduation from a NAACLS accredited training program (or were trained on-the-

The most important take home message is this: Please notify the AAPA if you hear of any state licensure talk in your state. Please do not move forward on your own by contacting your representatives prior to formulating a clear plan with the AAPA and AAPA leadership. If the pathology group or facility you work in has questioned your credentials because you don’t hold a license, please let the AAPA know of this so we can address each situation as it arises. n

Liz Rizzo is a PA at Dartmouth-Hitchcock Medical Center. She previously served as AAPA Vice President 1995-1996. Liz has presented safety lectures in the past and has interests in Lean/Six Sigma processes.

job and were grandfathered in and eligible to sit for the ASCP certification exam prior to 2011).

2. Passage of the ASCP certification exam.

3. Participation in the credential maintenance program.

Although the question of a national license has been asked, traditionally licensing is a state responsibility. Some providers and nurses share reciprocity of licensure across state lines, but this is an agreement between the states and not profession specific.

Currently, West Virginia, Nevada, and New York require licensure for PAs. These licenses vary in cost ($25-$200 annually) and specificity to our profession. Licensure is also being discussed in Louisiana and California as well.

the leg bones to help with the strain. The consequence was that human legs became straightened so that the bones, rather than the muscles, could bear most of the impact.

The straight-leg arrangement works fine for routine walking and running. But for those sudden shifts in direction or momentum, the knees must bear the force of this intense strain. Sometimes the ACL is not strong enough to hold the leg bones together as they twist or pull away from each other, and the ACL tears. This is a problem for athletes, as anyone who plays fantasy football knows.

In the chapter titled, Pointless Bones and Other Anatomical Errors, Lents says that humans have way too many bones. Sure, we have examples of superbly designed joints in our bodies; the shoulder and hip joints for example. But not so the wrist and ankle. There are eight wrist bones that Lents says look like a pile of rocks. They don’t do anything individually and the flexibility of the wrist joint is restricted by them. The ankle contains seven bones, most of them pointless. The bones do not move relative to one another and they would function better as a single, fused structure. There would also be less of a chance of a sprain. No engineer would design the wrist and ankle in such a haphazard way.

In the chapter titled, Our Needy Diet, Lents asks why humans have such a fastidious diet compared with other mammals. Vitamins A, B, C, D as well as nine of the amino acids are essentials that we must include in our diets. So how come cows can survive on…grass? How about dogs? Most dog food is nothing more than meat and rice. The answer is that our human bodies fail to make many of the things that other animals do. More specifically: our bodies have lost the ability to make many of the things that other animals do.

Written by Nathan H. LentsReview by Chet Sloski, PA(ASCP)CM

Book Review

Human Errors A Panorama of Our Glitches, From Pointless Bones To Broken Genes

as the RLN exit the spinal cord a little below the shoulder blade. The left RLN then loops under the aorta and travels back up to the neck, where it reaches the larynx. Lents tells us that the RLN is more than three times longer than it has to be. Is there a functional reason for this circuitous route? No. In fact, the superior laryngeal nerve that also innervates the larynx, travels the exact route that we would predict.

So why does the RLN travel this long road? The answer according to Lents is in our evolutionary history. This nerve originated in ancient fish, and all modern vertebrates have it. In fish, the nerve connects the brain to the gills, which were the precursor of the larynx. In fish, the nerve makes the short trip from the spinal cord to the gills in a predictable route. Along the way, however, it weaves through some of the major vessels that exit the fish heart, the equivalent of the branching aortas of mammals. During the course of vertebrate evolution, the heart began to move farther back as the body form took on a distinct chest and neck. From fish to amphibians to reptiles to mammals, the heart inched farther and farther away from the brain. The RLN should not have been affected by the changing position of the heart except for the fact that it was intertwined with the vessels. The RLN got stuck and was forced to grow into a large loop structure in order to travel from the brain to the neck. The result is that the RLN forms a long, unnecessary loop in the neck and upper chest. And all tetrapod vertebrates are stuck with the same anatomical arrangement. One wonders what the length of the RLN of, say, an ostrich would be. (Answer: a meter.)

On to the knee. The ACL is vulnerable to tearing in humans because our upright, bipedal posture forces it to bear more strain than it is designed to. In quadrupeds, the strain of running and jumping is spread among four limbs, and the limb muscles absorb the most of it. But once our ancestors transitioned to bipedalism, the strain was spread over two legs instead of four. This was too much for the muscles by themselves, so our bodies drafted

Molded by millions of years of evolution, you might think the human body is a fine-tuned machine; a Lamborghini, if you will. But in his new book, Human Errors, a Panorama of our Glitches, from Pointless Bones to Broken Genes, author Nathan H. Lents informs us that our bodies are a clumsy hodgepodge of adaptations and maladaptations. Your body is not a Lamborghini; it’s a 1970 Ford Fairlane.

Lents puts our errors or flaws into three categories. The first category deals with aspects of our design that evolved in an ecosystem different from the present one. An example would be our tendency to easily gain weight and our frustration at losing it. This setup would have made sense in the Pleistocene savannas of Central Africa where food could be scarce. But today it leads to what Lents calls mismatch diseases; obesity, atherosclerosis, and type 2 diabetes.

The second category consists of flaws of incomplete adaptation. An example would be the human knee which is the product of a redesign that took place as our ancestors shifted form a quadrupedal posture to bipedal terrestrial posture.

The third category includes those human defects that are due to nothing more than the limits of evolution; meaning that our bodies can only advance through the tiniest changes, which occur randomly and rarely.

Now, for some examples of our maladaptations. Take the recurrent laryngeal nerve or RLN. The axons found in the RLN originate near the top of the brain and connect to the muscles of the larynx. You would think that axons that commence in the brain and end in the upper throat would travel a short distance: through the spinal cord, into the throat, and to the larynx. The whole thing could be just a few centimeters long.

But the axons of the RLN are packaged with the vagus nerve. It travels down the spinal cord all the way to the upper chest. From there, the sub-bundle of axons known


Take one example: scurvy. Vitamin C is essential, meaning we must get it from our diets. Lack of Vitamin C causes scurvy which can be fatal. Yet dogs don’t need to eat foods rich in Vitamin C. Turns out these animals make their own. Nearly all animals make their own Vitamin C, usually in their livers. Humans and other primates are nearly alone in the need for dietary Vitamin C. According to Lents, in our evolutionary past, human livers lost their ability to make Vitamin C.

Interestingly, humans still have all the necessary genes for Vitamin C synthesis, but one gene mutated and became nonfunctional. The gene, known as GULO, codes for an enzyme that is responsible in the manufacture of Vitamin C. Sometime in our evolutionary history there was a mutation in GULO that spread through the population. Our ancestors could no longer produce their own Vitamin C. This raises the question: why was the population not killed off due to scurvy?

Lents has a theory. Perhaps when this mutation spread, our ancient forefathers, by chance, had enough Vitamin C in their diets. There must have been plenty of citrus fruits to eat. If so, there would have been no consequences for losing the ability to produce your own Vitamin C. Scurvy simply was not an issue. A version of this Vitamin C hypothesis can, of course, be extended to the other essential vitamins and micronutrients we need in today’s diet.

In the chapter titled, Homo sterilis, Lents tells us why human reproduction is so inefficient. We have flaws throughout almost the entire reproductive process, from the production of sperm and eggs to the survival of our children. Many other mammals are better at reproduction and produce more offspring than humans do; think of cats. Many humans suffer infertility problems and there was a high infant mortality rate during our ancestor’s rein which continues to this day in third world countries. Conversely, mothers dying in childbirth is unheard of in chimpanzees, bonobos, gorillas, and all of our other primate cousins. They seem to have perfected childbirth.

Lents tells us that part of why humans are so out of step with other mammals when it comes to childbirth is because human infants are born too early. This is due to our large craniums and the females’ relatively narrow hips. The rub is that human gestation time is similar to that of chimps and gorillas, even though our brains require more time and cognitive development in order to reach their full potential. But the size of the female pelvis limits how large the fetus’s head can grow while in utero. The compromise is that the fetal gestation is cut short and babies

are born before they are ready. In a sense, we are all born premature.

And thanks to the Discovery Channel, we all know that newborn mammals such as cows, giraffes, and horses hit the ground running—literally. Humans, however, need much more time before they are self-sufficient. (If you are a parent, you know that age eighteen might be a little too optimistic.)

So, in the 21st century, is evolution through natural selection still shaping us? Some scientists think that humans have escaped the forces of evolution. There may be some truth to that, at least compared to distant past generations. Today there is less physical competition for food and mates. Medical advances let the sick survive to and beyond reproductive age, which is the only age evolution is interested in. Evolution only “cares” that we live until we can pass down our genes.

Lents says that while natural selection may not be shaping us anymore, evolution is still very much at work. Evolution simply refers to any genetic change in a species over time. Natural selection, the phenomenon that picks winner and loser through their survival and reproduction, is just one way that a species can evolve. There are other evolutionary forces. For example, if some specific group of individuals reproduces more than other groups, that group will contribute more to the gene pool of the next generation. We know that this is happening because some groups are indeed reproducing more than others. Birthrates are low in developed countries as well as in people with higher socioeconomic status with ready access to birth control. Those with a lower socioeconomic status tend to leave more offspring than do richer more educated people. That could be considered a form of evolution too. Differential survival is not a major phenomenon, but differential reproduction is.

So, with all our glitches, foibles, and defects, should we be bummed out? I think not. If you ask me, I think it’s our imperfections that make us perfect. n

Chet Sloski, PA(ASCP)CM, works as a PA at North Coast Pathology in Oceanside, CA. He has been a member of AAPA since 1993, and he has been reviewing books for The Cutting Edge since 2001.

AAPA CalendarDecember 3 n CE Article Release

December 10 n Spring Meeting Registration Opens

December 28 n Annual CE Award Certificate Submission Deadline

January 1, 2019 n Journal Submission Deadline n Fellow Conference Travel Grant Deadline

January 2 n CE Article Release

January 15 n CE Article Release

January 31 n Membership Renewal Due

February 1 n CE Article Release n Membership Renewal Late Fee Begins n Student General Educational Scholarship Opens

March 1 n CE Article Release n BOT Nominations Open n Membership Suspension for Non-Renewals n Fellow Conference Travel Grant Opens n Student Non-Delegate Conference Travel Grant Opens March 18-20 n Exhibit Booth at USCAP, National Harbor, MD

March 31 n BOT Nominations Due

April 1 n CE Article Release

April 7-13 n National Volunteer Week

April 8-10 n AAPA 8th Annual Spring Meeting, Phoenix, AZ

April 14 n Pathologists’ Assistant Day

April 15 n CE Article Release

April 21-27 n Lab Week

PATHASSIST.ORG

Member Spotlight

Minda Koval, MHS, PA(ASCP)CM

Minda has been a PA for 19 years and works in Deleware

What’s you most memorable case?

At Swedish Medical Center in Seattle, WA, I received what was thought to be a dermoid cyst. While wading through the specimen looking for teeth or bone, I was surprised to find a fetiform teratoma. The body was fairly well formed with 4 symmetrical appendages attached to the body. There was even a head but the facial features were nondescript. It has been the only one I’ve ever seen.

What’s your least favorite specimen to gross?

Dermoid cysts

Where were you born and raised?

Springport, Michigan. It is a small, farming village in central Michigan that is ironically nowhere near a spring, or a port. During the time that I lived there, the welcome sign read, “Population 701”.

Where did you go to high school?

I went to Springport High school with a graduating class of 55 students. The school was partially connected to the middle school (where my father was a teacher) and the elementary school (where my mother still teaches). Some students would drive their tractors instead of their cars. Yes, I’ve been taken to school by my boyfriend on a tractor. I highly suggest it.

What was your first job?

My first job was at our town library (yes, we had a library) filing and sorting books.

Favorite movie?

Sneakers, a 1992 computer caper with Robert Redford, Dan Aykroyd, and Sidney Poitier. It’s a bit dated when they pull out the mammoth-sized, mobile phone and work on the 8-bit computer, but it seems like it’s just a matter of time before these items become back in style again. Best advice you ever got?

Never underestimate the knowledge of others. You never know how someone

might help contribute to your work or personal life.

What’s your favorite hobby?

Sorting and/or organizing anything while watching movies I’ve already seen many, many times before.

How did you get into the PA profession?

Happenstance and fate. I discovered that my physical therapy major was a huge mistake while volunteering during the summer. So, between semesters I changed my major to biomed and prepared to transfer to a different college for medical school. During a meeting with an advisor, she asked my thoughts about pathology. Not knowing too much about the field at the time, but interested, she gave me a brief description and then suggested I go to my local hospital and shadow in pathology. Thanking her, I left for my summer job, clocked into work, and my first customer was a woman in scrubs with a name badge that read, ‘Pathology’. What were the chances? I asked if I could shadow, she said sure, I showed up, she showed me around and I thought it was fascinating. She offered me a weekend position and I started working as a pathology and morgue attendant. The first specimen on my first day was a door handle. If you weren’t a PA, what other line of work would you enjoy?

I think I would enjoy being a tour guide at a museum or historical site, especially if it was haunted. I think. n

Minda Koval, MHS, PA(ASCP)CM is a 1999 graduate of Quinnipiac College. She has served the AAPA in various forms including volunteering on the Administrative Committee, the Conference Committee, and as a Newsletter Staff writer from 2007-2009. Minda currently is a peer-reviewer for submitted CE articles and recently became part of the editorial team of The Cutting Edge as Assistant Editor. She resides with her family in Newark, DE.

Student General Educational Scholarship

Apply between February 1 and May 1, 2019

Call for Manuscripts on the Following Topic:

What technology will impact the way Pathologists’ Assistants

perform their duties?

A winning paper will provide a well-researched literature review and a discussion on its potential

implications to PA practice.

Possible ideas include, but are not limited to, the following:

n digital imaging/slide scanning n automatic embedders n surgical tools sensitive to cancer n gene-specific personalized medicine n personalized cancer storage and vaccines

Eligibility:Author must be a student

member of the AAPA who will be in their second year of training as of

the Fall Conference

The manuscript must be the original work of the author

Scholarship Details:The winning entry will receive a $2,500 scholarship toward

their education.

Visit: pathassist.org/scholarships for more information, including

rules and regulations to submit your manuscript, plus

FAQs and past winners


AAPA Institutional Members NAACLS Accredited or Serious Applicant PA Training Programs

Discussion:

A chorangioma is a non-neoplastic growth and the most common tumor of the placenta despite having an incidence of 1%. They are considered a hamartoma-like or hyperplastic capillary lesion rather than a true neoplasm. They arise from major stem villi and are mostly located on the chorionic plate or at the placental margin. Grossly, they are solid, congested, and red-brown, resembling a blood clot. They may also have firm white areas indicating infarction.

Microscopically, they are composed of numerous dilated vascular channels with a mixture of endothelial cells, pericytes, and myofibroblastic stromal cells. The rare atypical chorangioma may occur and is characterized by increased cellularity and

Gross Photo Tutorial

Emily Paull Acheson, MHS, PA(ASCP)CM University of Arkansas for Medical Sciences

Quiz answers from page 21

1. B. Chorangioma 2. D. All of the above 3. False

mitotic activity, with both necrosis and solid areas. These may be fleshy and resemble a sarcoma but have no malignant potential. Lesions greater than 4-5 cm, as in this case, are associated with significant effects on the fetal hemodynamic and circulatory system leading to clinical complications such as polyhydramnios, toxemia, preterm labor, hydrops, and IUGR. Common risk factors include increased maternal age, hypertension, multiple pregnancies, and living in higher altitudes.

Treatments such as fetal transfusions and laser coagulation exist; however, interventions are risky with poor prognoses. The patient was able to carry the baby to early term and delivered a healthy baby without complications via Cesarean at 37 weeks. n

Chorangioma in a 41-year-old G1P0 female.

Quinnipiac UniversityHamden, CT MHS Degree qu.edu

Rosalind Franklin University of Medicine and ScienceChicago, ILMS Degreerosalindfranklin.edu

University of CalgaryCalgary, Alberta, Canada MDPA Degreeucalgary.ca

University of MarylandSchool of MedicineBaltimore, MD MS Degree medschool.umaryland.edu

University of Western Ontario Schulich School of Medicine & DentistryLondon, Ontario, Canada MCISc Degree schulich.uwo.ca/pathol/

Wayne State UniversityEugene Applebaum College of Pharmacy and Health SciencesDetroit, MI MS Degree cphs.wayne.edu

West Virginia UniversitySchool of MedicineMorgantown, WV MHS Degree medicine.hsc.wvu.edu

University of Toledo Toledo, OH MSBS Degree utoledo.edu

Drexel University College of MedicinePhiladelphia, PA MS Degree drexel.edu/medicine

Duke UniversityDurham, NC MHS Degreepathology.duke.edu

Indiana UniversityIndianapolis, IN MS Degree medicine.iu.edu

Loma Linda UniversityLoma Linda, CAMHS Degree llu.edu

Eastern Virginia Medical School *Norfolk, VAMHS Degree evms.edu* Serious Applicant

For more information on these programs, select “Become a PA” from pathassist.org

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AAPA Spring MeetingPhoenix, AZ

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