The Daily Sign-Out

Imaging tumors in the future

Baohong Yuan and Joshua Rychak have written an interesting review in the February 2013 American Journal of Pathology that outlines emerging techniques based on ultrasound to obtain functional and molecular imaging of tumors.  Apart from being fascinating reading, this article underscores how the disciplines of radiology and pathology may merge at certain points sometime in the future.  Abstract:

Tumor functional and molecular imaging has significantly contributed to cancer preclinical research and clinical applications. Among typical imaging modalities, ultrasonic and optical techniques are two commonly used methods; both share several common features such as cost efficiency, absence of ionizing radiation, relatively inexpensive contrast agents, and comparable maximum-imaging depth. Ultrasonic and optical techniques are also complementary in imaging resolution, molecular sensitivity, and imaging space (vascular and extravascular). The marriage between ultrasonic and optical techniques takes advantages of both techniques. This review introduces tumor functional and molecular imaging using microbubble-based ultrasound and ultrasound-mediated optical imaging techniques. (Am J Pathol 2013, 182: 305e311; http://dx.doi.org/10.1016/j.ajpath.2012.07.036)

 

If you have a chance, I highly recommend checking this one out!

General Surgical Pathologist is Dead

Excellent post from Digital Pathology Blog on the demise of the general surgical pathologist! It's amazing (and worrisome) that this happened so quickly in our field.

What happens to those "orphan" areas that don't really have a subspecialty training or certification or lack sufficient volume-even in some training centers--to "pay for" a full-time subspecialist? Head and neck, neuropathology, cardiac pathology for example? I propose that the general decline in autopsies (providing exposure to general pathology), lack of recognition and reimbursement for clinical pathology (and autopsies), and GI/urology usurpation of pathology practices have contributed mightily to this trend and almost singularly focuses resident training and practice on surgical pathology. I fear "molecular pathology" (and something unique, separate or distinctive from plain-ol' surgical pathology) will only exacerbate this trend. I could see there being molecular pathologists that are uncomfortable signing out surgical pathology--even within a subspecialty.

Kudos to Dr. Kaplan for broaching this subject! This is a complex issue that I'm not sure is even on the radar screens of our representative pathology societies.

Dr. R2D2--Computerized pathologist?

Meet C-Path, the iJobPlodd version of the 21st century pathologist.

The December 3rd-9th, 2011issue of The Economist has an article in this "Technology Quarterly" section entitled, "Indolent or Aggressive: A computerised pathologist that can outperform its human counterparts could transform the field of cancer diagnosis."  Actually, this a is review/interview on an article (abstract) published on 9 November 2011 in Science Translational Medicine by Daphne Koller and colleagues from Stanford.

Unfortunately, it appears that the author of The Economist article failed to consult a practising pathologist to get some context for this study.  Here's an example:

LOOKING for needles in haystacks is boring. But computers do not get bored. Contracting out to machines the tedious business of assessing the dangerousness of cancer cells in histological microscope slides ought thus to be an obvious thing to do. Cervical-cancer smear tests aside, however, such electronic intrusions into the pathology laboratory are limited. Grading cancer cells into “indolent” and “aggressive”, and hazarding an opinion about whether they spell a treatable condition or an untreatable one, has remained the realm of the human expert.

Perhaps I'm being a bit sensitive, but I don't consider looking at a patient's slides "tedious business" and resent this characterization of my practice of medical care!  According to this logic, perhaps patients would be better served having computers undertake the "tedious business' of taking a history or pelvic exams or listening to the heart.  In brief, this is a cutting-edge research article--not a roadmap for radically changing pathology practice in general (or even for the narrow application for breast cancer) .  As an example, it looks only at breast cancer tissue microarrays--not real clinical specimens.

I absolutely do not wish to take away from this article, however.  It is brilliant!  As I re-read it, apart from being green with envy (imagining how great it would be to do this with my own pet, non-small cell lung cancer!), I am picking up more and more fine points of trying to do this kind of work.  Here are my two main points which make this worth recommending:

1. The image features to be measured were not predetermined by a pathologist: the system made a very large set of measurements of the epithelial and stromal components--and their relationships--of the tumor and then the program determined which of these were related to survival outcomes.
2. The confirmation of the crucial role of the stroma in tumor outcome.

The bottom line, after reading this article (which I highly encourage anyone interested in digital pathology or anyone planning on practicing anatomic pathology in the next 20+ years to do), is that pathologists can be reassured of having a "job."  But--the article points to how our job might be significantly impacted by digital imaging and robust image analysis (ahem!--without regarding to FDA, CAP, payment, etc., i.e. the real drivers for adoption and implementation of these technologies).