BETA - What is the role of a pathologist (the behind-the-scenes expert) in myeloma patient care?

You may not meet them face to face, but pathologists play a key role in your care. These highly trained doctors specialize in studying blood, bone marrow, and tissue samples to help diagnose and track diseases like multiple myeloma. Their detailed analysis gives your medical team the critical information they need to understand your specific case and create the best treatment plan for you. In this Health Tree University lesson, you'll get a closer look at how pathologists support your myeloma journey and why their work is so important to getting the right diagnosis and care. What is a pathologist? 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 like the COVID microbiology, molecular pathology. 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 work up like flow cytometry, cytogenomics. Hematopathology bridges several fields within pathology. A person that looks at myeloma most commonly are hematopathologists. We have other subspecialty pathologists, dermatopathologists looking at the skin for amyloid nodules. Renal, the kidney pathologist, they look at them and they have subspecialty training. And then just diabetic renal disease or hypertensive renal. So there's this whole other world even within pathology and within myeloma that I don't think people may be aware or understand. What is the role of the pathologist on the myeloma team? Actually the doctor is the face of a huge team behind him or her. We present the data that we collect from multiple teams. Let's take an example, multiple myeloma patient. We start by drawing blood. We look at the M spike, the M protein, and this M component is measured by the pathologist. So while your doctor is presenting this data, your doctor is not actually reading the M spike itself. More importantly, and the same thing goes for radiology. If I order a PET scan, yes we can look at the images together, but the professional reading, the correct accurate reading comes from a radiologist. So you could already have a sense. We have the doctor, the hematologist, we have the radiologist, we have the pathologist, we have the nursing team. They draw blood, they actually give the chemotherapy. We have to remember the pharmacy team. They will calculate the doses, they will mix the drugs. Any step that goes wrong in this process, things will work basically. So while the doctor tend to get the credit for the work, but it's all a huge team behind the doctor. Let's go back to the pathologist, which is an important person in the team. The pathologist truly directs us where to go. After the bone marrow biopsy, the reading comes from the pathologist to make sure, one, we have multiple myeloma, the diagnosis is accurate, we don't have other cancers with myeloma. This requires very well experienced pathologists. Let's say for example, a patient has MPN with myeloma, MDS with myeloma. Those things could be happening, especially that myeloma population is older than other cancers population. So that gives us accurate readings where we can give a good treatment that fits the patient. Nowadays for multiple myeloma specifically, we get more important role for pathology, which is reading or identifying patients with MRD-negative disease. This field is only growing. I don't know if you recently, the FDA allowed us to use it for clinical trials. Actually I've been using this for my clinical trial that got allowed, we got the kit to proceed from the FDA since 2019. So we've been doing it for small trials, but now we got more approvals even for bigger trials. I think MRD-negativity is a hot topic. Pathologists will look at data, for example here at the Levine Cancer Institute, we analyze about 10 million cells on average for each patient. So you look how huge the data is and how the pathologist reading is very important. A lot of patients will have zero cancer cells in it. And the goal is truly to have less than 10 cancer cells in those 10 million cells. That is a very important role and that affects the way we treat the patients directly. I believe without a good strong pathology department, the hematologist cannot treat patients well. Beside MRD testing, what other testing does a pathologist do? There is another role they do that's been around forever, which is looking at the FISH results for multiple myeloma, as well as the conventional cytogenetics. Keeping in mind that plasma cells are difficult to grow in the lab and it's very difficult to get their conventional cytogenetics. And that's why you feel like always hematobathologist is very helpful. This hematobathologist means a pathologist person that works for hematology. And some centers will even have pathologists that works only for multiple myeloma. So that's very important. That helps a lot. Allow us to get more accurate, timely data to analyze it. There's another method, but that's mostly a send out test for the genes where we can depth of the genetic component of myeloma through NGS testing. This has not made it to the standard of care yet, but it's done by pathology as well. And I truly believe that once we get more information and know how to use it in the clinic, it will get more and more application. I remember from my previous work, we used to use it every day. It did not make it to the standard of care yet, but looking at the depth of the genetics and pathology is very helpful with that. I'm pretty sure it will be important in the future. You work closely with the clinical team. Some places have very simple templates. Others want more detail. So here, 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. These are plasma cell markers on immunohistochemistry, so it sort of highlights those plasma cells in the bone marrow. CD138, 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, they get worked up for karyotype, FISH, next-gen sequencing, MRD, depending on the stage at which it's biopsied. How do you communicate with the myeloma team? Here, every Wednesday, we have a myeloma tumor board. They present cases, 815. There's up to two to three, four cases. And we discuss the clinical history, radiology, or nuclear medicine that present the bony or organ abnormalities by radiology. And pathology presents images of the biopsy, the smear, the peripheral blood, the flow cytometry. And then molecular presents the cytogenomics and FISH aberrations, next-gen sequencing aberrations. Then they discuss, OK, further workup or additional workup. These are all discussed at these tumor boards. We're having issues with this therapy. We want to try this therapy. So the latest is, oh, can you add BCO2? So we can add venetoclax, BCMA, before and after CAR T cell therapy, additional immune markers, T cells, cytotoxic T cells. We kind of add that to our workup if that's what they're worried. Or even if they're worried about myeloid neoplasm, MDS workup. Join HealthTreeCure Hub. You can connect your medical records and view all of them here in one place. You can also track your disease, find treatment options, clinical trials, and side-effect solution.