Surgical Pathology and Cytopathology

Surgical Pathology Overview

Ten pathologists provide general and subspecialty surgical pathology services including renal pathology and neuropathology. Subspecialty interests and expertise encompass breast, lung, head and neck, gynecologic, genitourinary, liver, gastrointestinal, and bone and soft tissue pathology.

Two Pathologist’s Assistants, one administrative assistant, and three laboratory assistants comprise the staff. Technical work is performed by TriCore Histology, a large laboratory division of TriCore Reference Laboratories (TRL) that provides basic and advanced histology services for both the UNM School of Medicine, Department of Pathology and Presbyterian Hospital’s Pathology Associates of Albuquerque.

Pathology residents collaboratively work with faculty and staff from the initial stage of frozen section progressing to gross dissection and culminating in microscopic review and diagnosis. Trainees are vital participants in the clinical work of the Division.

Surgical Pathology Highlights

Surgical Pathology Services Provided:

• Evaluation of Surgical Resections and Performance of Intra-operative Consultations: These are performed on specimens from patients undergoing surgery at the main operating rooms at UNMH, the Barbara and Bill Richardson Pavilion, the UNM ambulatory care center (Outpatient Surgery and Imaging Services; OSIS), and Sandoval Regional Medical Center.
• Clinical Biopsy Diagnosis: A large volume of clinical biopsies is reviewed, and these are obtained from UNM or TriCore affiliated outpatient clinics. These primarily consist of gastrointestinal, endometrial, and cervical biopsies. Subspecialty boarded dermatopathologists (located at TRL) evaluate all skin biopsies.
• Consultations: The surgical pathologists offer consultation services to pathologists practicing at other New Mexico hospitals and some other regional hospitals.
• Review of Outside Cases for Patients Treated at UNM HSC: UNM pathologists review tissue specimens from patients coming for treatment at UNM Health Sciences Center (including the UNM Cancer Center) who have had prior surgery elsewhere.

Surgical Pathology Volume of Cases: The total number of surgical cases received in 2016 is approximately 19,000. That does not include consults or cytology specimens.

Surgical Pathology Additional Services:

• Protocol Support: Numerous Cancer Center patients are enrolled in clinical and research trials. For several hundred of these patients annually, the Surgical Pathology Division works with Cancer Center coordinators to appropriately triage specimens and select and release tissues as specified per protocol.
• Tissue Banking: The Department of Pathology and UNM Cancer Center jointly support a human biospecimen repository (the UNM Human Tissue Repository; UNM HTR). The main collection of specimens derives from residual tumor and normal tissues remaining after surgical excisions have been sampled for diagnostic and therapeutic purposes. Hundreds of specimens are collected yearly in cooperation with pathologists, staff, and trainees, following Human Research Review Committee requirements.
• Resident, Fellow and Medical Student Education: Pathology residents and fellows preview cases before signout with pathology faculty. They are trained by experienced pathologist’s assistants in gross dissection techniques. Education comprises a mix of one on one teaching, unknown case conferences, lectures and group slide sessions. Residents from other Departments are also taught by pathologists, typically in the format of group slide review, lectures and clinical case review conferences.

Surgical Pathology Methodology:

• General Approach: Even in the 21st century, much of the diagnostic work of surgical pathology is accomplished through evaluation of standard hematoxylin and eosin stained sections. More complex cases require immunohistochemical assessment. TriCore Reference Laboratories provides a broad array of antibodies with new antibodies introduced regularly. For a few cases, cytogenetic FISH or karyotyping or molecular support is sought. Most such assays are performed in the Cytogenetics and Molecular Pathology Laboratories at TriCore Reference Laboratory.
• Importance of Clinician-Pathologist Relationship: Pathologists easily are able to access medical charts and radiology findings through PowerChart and PACs services (electronic medical records and electronic imaging databases, respectively). However, for some patients, it is integral to the appropriate practice of surgical pathology that the pathologists directly communicate with clinicians. This is accomplished both on a case-by-case basis and through consistent participation in multiple subspecialty tumor boards.
• Most commonly, the surgical pathologists engage with surgeons to confirm the orientation of gross specimens and in real-time examination of frozen sections. Pathologists form part of the health care team at tumor boards to discuss specific patients and patient issues.
• Tumor Boards: Currently, the tumor boards for which surgical pathologists provide staffing (with vital pathology resident and fellow participation) include the following: Adult General Tumor Board, Breast Tumor Board, ENT Tumor Board, GastroIntestinal (GI) Clinicopathologic Conference, Gynecology (GYN)-Colposcopy Conference, Gyn-Oncology Tumor Board, Pediatric Tumor Board, Renal Biopsy Conference, and Sarcoma Tumor Board. These conferences are significant learning opportunities for residents and fellows.

Turnaround Time Goals:

• Routine, non-complex cases are signed out Day 3 of a three-day cycle (Day 1: resident grosses specimens, Day 2: resident reviews cases and signs out "24 hour turn around" cases with faculty member, Day 3: resident signs out remaining cases with the assigned faculty member).
• A few cases (about 5%) are reviewed the same day of receipt ("STAT" small biopsies) or the next day ("24 hour turn around"). Clinicians must request these specimens as "STAT" or "RUSH". For adequate processing, stat specimens may not exceed small biopsy size and must be submitted before 10:00 AM.

Cytopathology Overview

Nine pathologists provide cytopathology coverage at the University Hospital. Five of the individual Pathologists have subspecialty certification and training in cytopathology. Importantly, all eight cytopathologists also practice surgical pathology. The UNM Division of Anatomic Pathology believes the dual practice of these specialties enhances the diagnostic ability of the pathologist who can draw on skills in cytomorphology for surgical specimens and architectural and immunohistochemistry knowledge for cytology cases.

The cytology staff includes specimen processing technicians and histotechnologists located at TriCore Reference Laboratories.

Pathology residents and a cytopathology fellow collaborate with the cytopathologists and staff in performing adequacy checks and fine-needle aspiration biopsies and reviewing the microscopic features of all cases.

Cytopathology Highlights

• The UNM cytopathologists provide review of monolayer cervical/vaginal samples, traditional Pap smears, non-gynecological samples including endoscopic guided GI and lung/mediastinal aspiration biopsies and also perform fine needle aspiration biopsies and adequacy checks of interventional acquired specimens in the CT and MRI suites. Ancillary services include the provision of resident teaching and fellow teaching (there is a dedicated cytopathology fellow). Some education is also provided to residents and fellows of other departments who perform fine needle aspiration biopsies (such as ENT and endocrine residents and fellows).
• The division conducts its own Fine Needle Aspiration Clinic located at UNMH. Patients are referred for FNA from clinicians in other departments. The clinic also utilizes ultrasound imaging for selected aspiration procedures.

Cytopathology Methodology

• Cases are generally signed out by thorough review of Papanicolaou, Dif Quik and hematoxylin and eosin-stained smears, monolayers and cell blocks. In some circumstances, cells blocks are prepared. A broad array of immunocytochemical stains is available for use. As desirable, more cellular samples can be karyotyped, cultured for organisms, or assessed by Fluorescent In Situ Hybridization (FISH) and Polymerase Chain Reaction (PCR).
• Cervicovaginal specimens are also diagnostically triaged by automatic image analysis.
• As in surgical pathology, the pathologists have easy access to PowerChart (UNM's electronic medical record database) and radiology reports to facilitate a more accurate diagnosis. However, especially in cytopathology, there is real-time interaction with radiologists and clinicians on a case-by-case basis. Cytology results are often also discussed with health care teams at subspecialty tumor boards

Contact Information:

Surgical Pathologists and Subspecialty Interests/Expertise

Shweta Agarwal, M.D.
Head and neck pathology
Assistant Professor
(505) 272-0995
shagarwal@salud.unm.edu

Joshua Hanson, M.D.
Surgical Pathology, Gastrointestinal and Hepatic Pathology
Assistant Professor
(505) 272-1643
JAHanson@salud.unm.edu

Nancy Joste, M.D.
Division Director
Professor
(505) 272-5407
NJoste@salud.unm.edu

David Martin, M.D.
GI/Liver expertise
Assistant Professor
DAMartin@salud.unm.edu

Samuel Reynolds, M.D.
Assistant Professor
(505) 272-4746
SReynolds@salud.unm.edu

Karen SantaCruz, M.D.
Neuropathology
Associate Professor
(505) 272-5001
KSantaCruz@salud.unm.edu

Jain Zhou, M.D.
Gynecology and Genitourinary expertise
Assistant Professor
(505) 272-7572
JaZhou@salud.unm.edu