How do we help pathologists find pathology?

Dan C. Martin, MDProfessor, Department of Obstetrics and Gynecology

Divisional Director of Minimally Invasive SurgeryDivisional Director Reproductive EndocrinologyDirector Minimally Invasive Surgery Fellowship

Faculty Senator, University of Tennessee Health Science CenterMemphis, Tennessee.

March 27-29, 2014Atlanta, Georgia

Learning Objectives

At the end of this presentation, participants should be able to:• Be aware of STARD criteria• Understand the use of select STARD

criteria in clinical care• Clarify a signal-noise ratio• Review available staining techniques.• Communicate better with pathologists

Conflict of Interest• None

Confirmation at a Research Level

STARD

Standards for Reporting of Diagnostic Accuracy

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

Confirmation at a Research Level• The protocol needs to be a fixed in order to be compatible with STARD.

The protocol in yellow below may not be compatible with STARD• Surgeon Experience Clarified• No Expectation of Appearance vs. Specified Appearances

“Absence of Normal Appearance” vs. “Appearance of Endometriosis”• Biopsy Techniques (biopsy forceps, nmicro-scissors, trim large specimens,

micro-point monopolar electrosurgery knife, 5000+ w/cm2 CO2 LASER)• Additional punctures and equipment for additional control• Adequate Number of Biopsies • Signal to Noise Ratio (trim specimens)• Tagging the Specimen Location• Marking the Specimen Side• Notations on Pathology Request (i.e. 1 mm lesion, 19+ from 1986, other?)• Uniform Specimen Size in Container• Cell Block• Transferring the Specimen to Container and then to Cassette• Processing by the Surgeon• Communications with the Cutters• Communications with the Pathologist• Re-cutting Specimens• Histologic Criteria (Batt 1989)• Infectious disease cultures, NNA, DDA, titers, etc. in pain studies• Routine or selective use of iron stains (hemosiderin, other iron forms and steroid pigment)• Routine or selective use of trichrome staining for collagen and muscle• Require a Histology Description Compatible with Surgical Findings.

A 1 mm lesion requires histology compatible with a 1 mm lesion.• Reviewing Slides.

Confirmation at a Combined Research / Clinical Level

• No Expectation of Appearance or that any appearance is endometriosis• Biopsy Techniques (biopsy forceps, scissors, knife)• Adequate Number of Biopsies • Signal to Noise Ratio (trim specimens)• Tagging the Specimen Location• Notations on Pathology Request (i.e. 1 mm lesion, 19+ from 1986,

other?)• Uniform Specimen Size in Container• Cell Block• Transferring the Specimen to Container and then to Cassette• Communications with the Cutters and Pathologists• Selective use of iron stains (hemosiderin, other iron forms and steroid

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

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

Confirmation at a Clinical Level

• No expectation that any appearance is endometriosis

• Tag small lesions on large specimens

• Signal to noise ratio

• Notations on pathology request (i.e. 1 mm lesion)

• Selective use of iron stains for iron forms

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

What do we know?

Non-Specific Lesions

These are non-specific lesions unless pathology is specific.

Non-Specific LesionsSmall clear and small white lesions- Endometriosis- Endosalpingiosis- Psammoma Bodies- Lymphoid Aggregates- Non-specific Inclusions - Mesothelial Proliferation

If on a Fallopian tube, add- Walthard Rest

With clusters, add- Low Malignant Potential Tumor

If there are solid nodules, add- Metastatic Cancer

Grades of Certainty• Grade 1: Possible residua of resorbed endometriosis,

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

• Grade 2: Consistent with endometriosis, i.e., hemosiderin, characteristic glands, OR stroma.

• Grade 3: Definite endometriosis, i.e., characteristic glands AND stroma with hemosiderin.

• Grade 4: Grade III with structures conveying and organoid pattern, i.e., glandular-stromal layer overlying well developed smooth muscle layer

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

What is Classical?

• Obliterated Pouch of Douglas• Powder Burn • Clear, Red, and/or White?

Classical 1860 – 1920Batt Grades 3 and 4

Futh 1903 Lockyer 1918

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

Iron Stain

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

Classical 2005Batt Grade 1 Endometriosis, Precursor or Facilitator

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

Batt, et al. 1989; Marsh and Laufer 2005: Cabana et al. 2010

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Inflammatory InductionFacilitator for Retrograde FlowCoincidenceAnother “Watch this space” story

LeftOvary Uterosacral

Ligament

Broad Ligament

Look-a-Like Lesions

Uterus

Signal – Noise Ratio

Tag large lesions.

Signal – Noise Ratio

2.5 cm

Uterus

Ovary3 mm 2 mm 1 mm 0.5 mm

Utero-sacral ligament

Signal – Noise Ratio

1 mm

10 mm

Signal – Noise Ratio

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

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

Signal – Noise Ratio

1 mm

2 mm

Diagnosis and Confirmation

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

• Diagnosis using white light – No confirmationChronic pelvic pain. Ling, 1999

• Diagnosis using white light vs. 5-ALA induced fluorescenceConfirmation by histologyComparison of illumination. Buchweitz, 2004

• Diagnosis using white light - Confirmation by histologyChronic pelvic pain. Jenkins, 2008

• Diagnosed at laparoscopy - No confirmationGene polymorphisms . Sundqvist, 2010

• Endometriosis was self-reported - No confirmationGene polymorphisms . Near, 2010

Positivity – Single Study

Cases100 500

100

90

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40

30

20

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200 300 400

Perc

ent P

ositi

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● Pardanini 1998

Walters 2001

Mettler 2003

Pardanini 1998

Pardanini 1998

Confirmation at a Research Level99% in last 69 of 495 cases over 60 months (8.2 per month by one physician)Year 1982 1983 1984 1985 1986.1 1986.2Cumulative Number 97 188 279 376 426 495

of Patients by One GynPositive for Endo 62% 50% 91% 93% 96% 99%

when ExcisedMartin 1987, Stripling 1988, Martin 1990

42% to 76% range by 3 physicians doing 11 to 22 cases.Pardanani, Barbieri 1998 (Harvard, Boston)

45% PPV in 44 cases over 20 months (2.2 per month by ?? physicians)Walter, Magrina, et al. 2001 (Mayo Clinic, Phoenix, Arizona)

61% of lesions in first 46 cases over 34 months (1.4 per month by ?? physicians)68% of lesions in next 56 cases over 36 months (1.6 per month by ?? physicians)Stratton 2003, Stegmann 2005 (NIH Bethesda clinical group)

87% in research conditions, 56% in clinical use. Buchweitz 2003, Luebeck, Germany

88% in 72 clinical cases over 7 months (10.3 cases per month by one physician)Webb, Martin et al. in preparation

Positivity – Time Intervals

Cumulative Cases

100 500

100

90

80

70

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40

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200 300 400

Perc

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Martin 1987, Stripling 1988, Martin 1989, Martin 1990

Stratton 2002, Stegmann 2008●●

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Dulumba 2012

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Positivity – Research v Clinical100

90

80

70

60

50

40

30

20

10

Perc

ent

Posi

tive

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ClinicalResearch

Stripling 1988, Martin 1990

Webb, Martin 2005

Buchweitz 2003

Buchweitz, 2003

Psammoma Bodies, Ovary, Endosalpingiosis,LMPT and Metastatic Cancer

Psammoma Bodies

EndosalpingiosisRemnant Ovary

Uterus

Metastatic Breast Cancer

Bladder

Low Malignant Potential Tumor

Conclusions

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

histology as a criteria.

SLIDES FOR Q&A

Marsh 2005

Endometriosis After Inflammation

Endometriosis After Inflammation

• Induction• Damage predisposing

to implantation• Coincidence

Marsh 760

Diagnosis of PathologyEndo X Melbourne 2008

“We are still looking for peer reviewed, published articles abstracted in PubMed that show a statistically significant difference in outcomes (pain, tenderness, fertility, change in appearance or other outcomes) of surgery or medical therapy based on histology that is positive (glands and stroma) as compared with histology that is negative for endometriosis. There is a $100 reward to a researcher who first gives or sends those type articles to me.”

$200

Until the end of the 10:50 break tomorrow, this is $200 for you.

You can phone as many friends as needed.

After the 10:50 break, the $100 offer is still available for anyone.

$200

$200 a for peer reviewed, published articles abstracted in PubMed that shows a statistically significant difference in outcomes (pain, tenderness, fertility, change in appearance or other outcomes) of surgery or medical therapy based on histology that is positive (glands and stroma) as compared with histology that is negative for endometriosis.

$100 to the first to give me this after 10:50 tomorrow if I do not get it before then.

Todd Jenkins 2008

BCPs in 93 and Lupron in 17 of 104(?) patients• Chronic pelvic pain• 88 (84%) of 104 patients had endometriosis• Endometriosis diagnosed laparoscopically in:

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

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

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