Few think about the other specialist doctor, a skilled pathologist working in the background to help the surgeon make the right decisions, often saving the patient from a second operation or futile surgery.

Using the latest equipment, operated by a highly skilled pathologist; a tissue sample is immediately frozen, sliced very thinly, stained and examined under a microscope to provide a diagnosis to the surgery team within minutes for on-the-spot action.

In cancer operations, in-theatre pathologists help surgeons determine everything from a specific diagnosis to whether they have removed all of the tumour. To the naked eye, a tumour can often look like normal body tissue. In these cases, the surgeon will cut out a small piece of tissue for the pathologist to examine.

Pathologists play an especially vital role in brain surgery. Sometimes tests before the operation cannot distinguish whether a lesion is a tumour or an infection requiring vastly different treatment. between a cancerous tumour, a benign tumour or a lesion caused by an infection.

During these operations, the surgeon will take a small sample and hand it to the pathologist who will hurry to an onsite lab to perform a mini operation on the tissue and examine it while the surgical team awaits a diagnosis. What the pathologist finds will determine whether to cut out the tumour, or to transfer the patient to a medical ward for antibiotics.

The pathologist can also tell if all the cancer has been removed, and only healthy tissue left behind; known as having negative margins.

“Without pathologists working alongside surgical teams, sometimes patients might have to go back for secondary surgery if not all the cancer had been removed,” says Dr John Ciciulla, an Anatomical Pathologist at Melbourne Pathology.

“Every time a patient goes under an anaesthetic there is a risk. We can help the surgeon perform in one surgery what may have otherwise been done in a second operation.”

“In some cases, a second operation might damage the delicate reconstructive work surgeons have performed on a patient’s face after the removal of a tumour,” he says.

“It is always better to get the tumour out on the first go and that is one of the key reasons to have a pathologist working with the surgeon.”

For other head and neck cancers pathologists are vital to ensure the tumour is correctly identified and removed. For example, tumours located in the parathyroid gland in the side of the neck. The gland is buried within the lymph nodes which can look almost identical. To a surgeon’s naked eye, it is difficult to tell the difference between the parathyroid gland and the lymph nodes, so a pathologist can examine the tissue the surgeon has removed to ensure the tumour is not left behind.

After the operation the pathologist can perform a more detailed examination of tissue inside the lab to get more information about the exact type of cancer the patient has, and this in-depth information allows treating doctors to develop the best strategy for that patient.

“There are more than 20 different subtypes of tumours in most body tissues. For example, breast cancer is not one disease. It is the pathologist who informs the oncologist exactly what they are dealing with so they can decide what treatment it will respond to,” says Dr Ciciulla.

“Each type of cancer is treated in a specific way which has an important impact on the patient’s prognosis. Although not seen by the patient, the pathologist plays a vital role in the patient outcome.”

The post Under the knife and under the microscope; how pathologists help surgeons first appeared on Know Pathology Know Healthcare.

The post What does an Anatomical Pathologist do? first appeared on Know Pathology Know Healthcare.

We asked Dr Mikkaela McCormack, an Anatomical Pathologist in one of Victoria’s busiest labs, what led her into Anatomical Pathology and why she loves her job.

What made you decide to become an Anatomical Pathologist?

I first developed an interest in forensic pathology in high school, fuelled by my need to know the ‘whys’ of everything, combined with a strong scientific curiosity, a compulsion to problem solve, and a desire to help people.

I studied medicine and law at university, and after completing my final year elective at the Victorian Institute of Forensic Medicine I set my sights on specialising in forensic pathology.

I’d heard the best grounding for becoming a great forensic pathologist was being a good anatomical pathologist, so I made this my goal.  As I trained in both however, I realised that what had really enamoured me with pathology was the opportunity to give answers to questions in an engaging and intellectually interesting way.  Anatomical pathology allowed me to do this in a more wide-ranging fashion and working with living patients meant I could potentially have a positive impact on their lives.

What does a typical day look like for you?

On any given day I will ‘see’ 30 to 80 patients – well, I will see their tissue specimens under my microscope! I analyse their slides and provide their referring doctors with written reports outlining my diagnosis.

Most can be given answers based on simple histology sections, but many will require additional testing of antibodies, special staining techniques or increasingly, genetic testing that I will also need to interpret.

This is interspersed with various other responsibilities including guiding trainees on dissecting and sampling specimens, discussing difficult cases with colleagues (good pathologists are collaborative pathologists), attending multidisciplinary cancer meetings on complex patients, speaking with general practitioners, medical specialists and occasionally patients regarding their results, and working with clinical and academic colleagues on research projects.

I am also involved in business strategy, innovation and marketing for our organisation, which further fuels my enthusiasm for the profession.

What makes your job satisfying?

My work provides me with an endless and wide-ranging supply of questions to answer and problems to solve, to help patients from all walks of life.

I often think of myself as a medical detective; I find and decipher the clues within patients’ specimens and I use my knowledge and experience to solve the mystery of what pathological process was occurring in that tissue.

My answers need to be of the highest standard and dependability as they will direct other medical specialists in how to manage and treat those patients; they can be the difference between life and death.  This motivates my practice as a pathologist, and the knowledge that what I do positively affects people’s lives in a meaningful way is what makes my work satisfying – even if most of them aren’t aware of my existence!

Our specialty is in a constant state of fast-paced change, as we learn more about diseases thanks to scientific and technological advances. This requires constant learning and improving across multiple medical specialist areas. I also get to work collaboratively with other specialties, research institutions and industries to drive research, innovation, scientific discovery and the delivery of up to date and accessible medicine.

This is all incredibly exciting and makes it very easy to remain engaged in my career!

What are the most common conditions and samples that you deal with?

The nature of anatomical pathology means I work across multiple body systems, so on any given day I may diagnose a range of benign and neoplastic diseases within almost any organ, including breast, skin, lung, liver, bone, lymph node, gastrointestinal system or gynaecological system.

It is also important however, to foster a greater level of expertise within a smaller number of sub-speciality areas.  I am our laboratory’s main breast pathologist; I am involved in the daily diagnosis and management of benign and malignant breast disease and I also participate in multi-institutional breast cancer research.  My other areas of interest are in skin (neoplastic, inflammatory skin conditions and alopecia), urology (most commonly prostate specimens), and gastrointestinal and thyroid pathology.

What is the most unusual diagnosis you have made since working in pathology?

As a trainee, I examined a set of lungs from a young transplant patient suffering from a rare condition called lymphangioleiomyomatosis (LAM lung disease), which causes muscle cells in the lungs to multiply abnormally. This results in the formation of many large cysts, which can rupture and cause serious complications. The lungs also contained several small nodules, and when I examined them they showed features of a second disease, angiomyolipoma (AML).

These two diseases are classically found in patients with a genetic condition called tuberous sclerosis, but AML almost always occurs in the kidney. At that time the phenomenon of these small tumours also occurring in the lungs had not even been described in the literature.

What is your most memorable moment working in pathology?

Undertaking my first autopsy would have to be the moment in my career that holds the most meaning for me.  It is in some ways the most intimate and intrusive procedure we perform in medicine, and I felt the gravity and respect that comes with that. Whilst I don’t perform autopsies these days, I think that was the moment I first understood what it truly meant to be a pathologist.

What advice would you give to students or young people considering pathology careers?

Pathology is a slightly mysterious area of medicine, including for medical students and other doctors. The only way to know if you’d be interested in a career in pathology is to spend time within real pathology laboratories – meet the pathologists, scientists and support staff, ask them for honest answers to hundreds of questions about working in the laboratory. Observe, experience and get involved in the tasks that are part of the job. Then ask yourself if you could do those things for at least the next 5-10 years!

The post “I often think of myself as a medical detective” – Dr Mikkaela McCormack on her role as an Anatomical Pathologist first appeared on Know Pathology Know Healthcare.

Anatomical Pathologists make diagnoses of skin cancer  – much of their work involves analysing biopsies for melanoma and determining suitable treatment.

We spoke to three anatomical pathologists to get their insights on skin cancer and sun safety.

Dr Penny Yarrow

As an Anatomical Pathologist and a mother of two, Dr Penny Yarrow has spent many years teaching the value of Slip, Slop, Slap.

“With kids, I think it’s crucial to set good examples at a young age. I have a daughter and a son who have been taught to wear hats and sunscreen since they were toddlers. They are both very wary of sun burn as a result.”

Throughout her career, Penny has diagnosed thousands of skin cancers and melanomas in people of all ages.

”Skin cancer isn’t just a threat to older adults, it is a multi-generational health issue, affecting grandparents, parents and even teenagers. Much of the sun damage to our skin that causes skin cancers in later life occurs during our teenage years so it’s essential that we teach our kids to be sun smart throughout childhood and adolescence.”

Dr Nick Musgrave

Nick Musgrave has experienced skin cancer both in the lab and in his personal life.

”I’ve had more skin cancers than the average Anatomical Pathologist! Being fair skinned and growing up in Queensland has its consequences and it’s taught me that prevention is critical.”

Nick is a strong advocate for skin checks, particularly for those with a genetic predisposition to skin cancer.

”Anyone with lots of freckles and moles or with a family history of skin cancer should get a professional skin check once per year. In Queensland, 2 out of 3 people will have skin cancer before the age of 70 so it’s important to be aware of your risk.”

While the statistics are concerning, Nick is encouraged by advances in pathology which have helped improve treatment of melanoma.

“Thanks to BRAF mutation testing, we can identify a patient’s genetic blueprint and guide targeted therapy for melanoma.

Genetic testing has had a dramatic improvement on the prognosis for patients who have melanoma that’s already spread. With advances in genetic testing, the hope is that melanoma will become more of a chronic disease than a fatal one.”

Dr David Clift

When David Clift was growing up in the 1950s, people had less knowledge of sun safety.

“It was very common for people to get plenty of sunburns, peeling and even blistering burns so it is no surprise that melanoma rates have doubled in the last 20 years and we are seeing 80% of all melanomas on 50+ year old Australians, who grew up not using sunscreen”, he says.

David has noticed that a greater public awareness of skin cancer has helped to improve patient outcomes.

“During the summer months in the lab, we see a much larger volume of skin cancer cases. People are showing more skin and noticing new moles that were never there before. Rather than ignoring it, they’re going to their doctor and getting treatment early and that can save their life.”

A keen sailor, David is always careful to protect himself on the water.

”Skin cancer is very common on the neck and ears so I always wear a hat with a legionnaire scarf to protect those areas.”

The post How do anatomical pathologists protect themselves in the sun? first appeared on Know Pathology Know Healthcare.

In anatomical pathology, digital microscopy is the conversion of glass microscope slides into image files called “digital slides” using a high-quality scanning machine – the pathology equivalent to computer-based x-rays.

Once digitised, the slide images can be used by the pathologist as an alternative to conventional microscopy for histological (tissue-based) diagnosis. They can also be analysed by computer algorithms to automate the counting of cells highlighted by special stains.

With digital slides, pathologists can directly access image files and view the same case at the same time – from anywhere in the world. This means additional opinions can be readily obtained without the need to ship fragile glass slides from site to site. In complex cases, multiple care teams can collaborate across sites without the delays involved in transporting materials, and this can potentially improve the efficiency of diagnosis and treatment planning. The technology can be particularly beneficial to pathologists operating in remote and isolated environments.

Digitised slides are being increasingly used as teaching aids for medical students and pathology trainees, for quality assurance purposes, and even for examination purposes, ensuring all candidates have access to exactly the same slide images.

Currently the storage of glass slides is a major logistic burden for laboratories, as labs in Australia are required to keep slides for a minimum of 10 years for adults (or until age 25 for children). The ability to review a case is necessary in case a disease recurs. In future, it is possible that retention of high quality digital images may be a substitute for the storage of glass slides.

Finally, the digitisation of clinical data creates new opportunities. Using digital microscopy to count and analyse cells has been shown to be at least as accurate as manual counting by a pathologist and can potentially save time. Computer files can be analysed, shared, archived and compared in ways physical slides cannot. This means larger data sets and potentially new insights provided by emerging technology, which may not have been possible with glass slides.

So are the machines taking over? Not quite. Digital microscopy does not remove the necessity for a highly skilled pathologist to oversee the analysis of slides and interpret accompanying data, particularly in complex cases. It does, however, take some of the manual labour and logistic complexity out of the process – meaning pathology professionals can focus on what really counts – a quick, accurate diagnosis for their patient.

The potential benefits of digital pathology are obvious, but they are difficult to monetise. This is maybe the biggest barrier for anatomical pathology labs considering going digital. The investment in new equipment and training needs to be justified – and without hard numbers, that can be difficult. But as the pathology sector is put under increasing pressure to produce more results in shorter time frames, more and more Australian laboratories are making the leap.

The post Digital pathology: enabling accurate diagnosis at a distance first appeared on Know Pathology Know Healthcare.