BETA - What is a pathologist?

What is a pathologist? A pathologist is a person who studies disease and there's anatomic pathology, clinical pathology. Now there's a bunch of subspecialty pathologists. In our department, molecular pathology is big. And so pathologists do a bunch of things. Anatomic pathologists focus on tissues and mainly tissues and microscopy. Then you have clinical pathologists who focus on laboratory practice, you know, like the COVID microbiology, molecular pathology. So I do hematopathology, which actually bridges both anatomic pathology, because we look at tissues, and clinical pathology, and even molecular pathology, because it involves blood. We do a lot of molecular testing, ancillary workup like flow cytometry, cytogenomics, hematopathology bridges, I think, you know, several fields within pathology. Then you do, after the four years, many people do subspecialty fellowship training. So a person that looks at myeloma most commonly are hematopathologists with subspecialty hematopathology training. And those range from two to three years, one to three years at academic programs. And these academic programs add on research training, so the longer the training, the more research time you have. The clinicians, when I first came here, you know, we had, we worked with, you work closely with the clinical team. Some places have, you know, very simple templates, others want more detail. So here, you know, our colleagues wanted the percent plasma cells on the biopsy, the percent cellularity of the biopsy, the percent plasma cells on the smear. Every biopsy that comes through, they want a panel of six stains, CD138. These are plasma cell markers on immunohistochemistry, so it's, it sort of highlights those plasma cells in the bone marrow. So 138, kappa, lambda to see if they're restricted or not, Congo red to rule out amyloid, reticulin, and iron. So every biopsy that comes through, we work it up for those markers. In addition, I think they get worked up for FISH or karyotype, FISH, next-gen sequencing, MRD, if, you know, depending on the stage at which it's biopsied. How do pathologists, geneticists, and clinicians work together? Every week, like here, every Wednesday, we have a myeloma tumor board. They present cases at 815, you know, now it's on Zoom. There's up to two to three, four cases. And we discuss the clinical history, pathology, there's radiology or nuclear medicine that present the bony abnormalities or organ abnormalities by radiology. And pathology presents images of the biopsy, the smear, the peripheral blood, the flow cytometry. And then molecular presents their, you know, the cytogenomics and FISH aberrations, next-gen sequencing aberrations. And there's a lot of trainees. So, you know, we have a residency program, fellowship program. So a lot of the trainees at all, you know, the clinical pathology and molecular, even radiology, it's presented by trainees and attendings also chime in and, you know, say, and then they discuss all the therapy options. Or, you know, they're concerned about some, you know, evolving myeloid neoplasm. And so then they discuss, okay, further workup or additional workup or, you know, so many, a lot of times now because I think myeloma, you know, they're doing a good job maybe with all these good therapies that now the issue is, you know, like clonal hematopoiesis or myeloid neoplasm, MDS, secondary MDS. Transplantation, right. So these are all discussed at these tumor boards. So, you know, it has because unless you like rotate in the clinic or they rotate in the lab, you know, it's like he says, you know, we know a lot, but we don't know a lot about each other. But yet we're all involved with the management of patients. And then, you know, they tell us, okay, they're having, you know, issues with this therapy. We want to try this therapy. So, you know, the latest is, oh, can you add BCO2, right? So we can add Venetoclax. Can we add MCO1 for, you know, some recent, I don't know the target. I don't know the drug for MCO1, BCMA, you know, after before and after car T. So therapy, additional immune markers, T cell cytotoxic T cells. We kind of add that to our workup if that's what there were, or even if they're worried about myeloid neoplasm, MDS workup, you know, do a follow up Marrow for to looking for, you know, a probe for myeloid neoplasm. So that's some of the later latest discussions. Yeah, absolutely. I mean, they have so many. I think myeloma program here is probably has one of the largest numbers of trials, entries with all the non-bi-specifics, you know, Dr. Chary, Dr. Jagannath. So we're involved, you know, and it has to be timely. That's the, you know, it's high volume, but and they want it quick, right? Because for trial entry, we have to respond very quickly. So we're in contact every day all the time, email, phone calls, tumor boards. Yeah, we're just accessible. How accurate is pathology in myeloma? How is it subjective? That's another lab within pathology. It's more, I think, an automated process, but it really depends on the way the assay is set up, the validation of the assay, and each lab can have their own reference levels. Unless all of that is standardized, right, it can have, you know, like the free light chains, the heavy chains, the M proteins. So you really need a good, you know, consistent assay or a different, you know, like a multimodality testing. So I think, you know, like low level like MGUS or something where they're trying to like MRD even, you know, these are you have to be, it's very sensitive. You're dealing with such low level disease. So, you know, Kappa lambda is restricted or not. Or, you know, so you have other modalities to test for the IHC. IHC can be, it's very subjective, you know, and you can have high background. So there's, you know, in situ hybridization, which is maybe a little cleaner. You have flow MRD, right? So all these and they test at, you know, all these different assays to make sure that what overall what you're seeing is consistent or fits. Is there anything else about the job of a pathologist myeloma patients should know? I mean, I think most people think pathologists maybe just, you know, doing autopsies in the basement or something. And we do, you know, people who have they want to study these cases more for myeloma. And I think, yeah, you know, the reputation or, you know, it's like we're hidden or we're like hidden figures. So we actually, you know, encourage like people to come to the lab. We can walk through with a specimen and sort of give you an eye. But it's also multifaceted now. There's so many parts of a pathologist or what, you know, what pathology is involved with in making a diagnosis in a person with myeloma. So and it's not just now bone, you know, you talk about kidney disease, right? So and so we have other subspecialty pathologists, dermatopathologists looking at the skin for amyloid nodules or some or Reno, the kidney pathologist. They look at and they have subspecialty training. So I don't sign off on these, but, you know, it's very long and involved. Reno pathology reports on the glomeruli. And then there's all this whole differential on not just myeloma associated disease, but, you know, amyloid that has so many different subtypes and and then just read, you know, diabetic Reno disease or hypertensive. So there's this whole other world, even within pathology and within myeloma that, you know, I don't think people may be aware or understand, but the more, you know, I mean, and it's interesting. You know, I trained at the NCI. My first job was at Sloan Kettering. And they have a high volume of cancer. But when you come to very, you know, like high volume myeloma center, I've never seen so much range of presentation and disease presentation. You know, even after 15 years at one high volume place, you know, the emphasis is very different. And what you see is a pathologist ranging from very early minute low level disease to just outright high grade bursting type disease versus at end stage autopsy. I mean, it's just unbelievable.