Chapter 01: Neuropathology and MD Anderson's Neuropathology Services

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Chapter 01: Neuropathology and MD Anderson's Neuropathology Services

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Description

Dr. Bruner begins the first chapter with a brief overview of her field and clinical service. Few patients know what a neuropathologist does (even physicians can be unclear on the role). Dr. Bruner defines neuropathology and explains the neuropathologist's activities and contributions to a patient's diagnosis and care. She also describes the organization of MD Anderson's neuropathology services, noting its strengths, some of the analyses performed (including a rapidly developing area of immunohistochemistry testing and gene-sequencing), and the methods of its accreditation.

Identifier

BrunerJM_01_20120604_C01

Publication Date

6-4-2012

City

Houston, Texas

Topics Covered

The Interview Subject's Story - Personal Background; Overview; Definitions, Explanations, Translations; The Researcher; The Clinician; Institutional Processes; Devices, Drugs, Procedures; Institutional Mission and Values; Devices, Drugs, Procedures

Transcript

Tacey Ann Rosolowski, PhD:

So we’re starting, and I’m Tacey Ann Rosolowski interviewing Dr. Janet M. Bruner at the University of Texas MD Anderson Cancer Center in Houston, Texas. This interview is being conducted for the “Making Cancer History® Voices” Oral History Project run by the Historical Resources Center at MD Anderson. Dr. Bruner is a diagnostic neuropathologist. She joined the faculty of MD Anderson in 1984. She was Chair of Pathology for twelve years and has been Deputy Head of Pathology and Laboratory Medicine since 1998. Do I have those dates all correct?

Janet M. Bruner, MD:

Right.

Tacey Ann Rosolowski, PhD:

Okay. And this I probably will need help with. She holds the Ferenc and Phyllis Gyorkey Chair for Research and Education in Pathology.

Janet M. Bruner, MD:

Right.

Tacey Ann Rosolowski, PhD:

Since 1994, she has also held a joint appointment as a professor in the Department of Neuro-Oncology. This interview is taking place in Dr. Bruner’s office in the Department of Pathology on MD Anderson’s main campus. This is the first of two planned interview sessions, and today is June 4, 2012. The time is two minutes after 2:00. So thank you very much for taking the time.

Janet M. Bruner, MD:

Thank you.  

Tacey Ann Rosolowski, PhD:

And as I mentioned earlier, I wanted to start off by asking you for an overview of diagnostic neuropathology because I was in reading some of your background materials that you educated me that patients—that your role is really key—and all diagnostician’s roles are really key to patient care, but most patients don’t even know that individuals like you are working behind the scenes. So if you could, tell me what diagnostic neuropathology is as a field and how it contributes to a patient’s treatment and care.

Janet M. Bruner, MD:

Well, I think all of the pathologists really feel very strongly that patient treatment starts with the diagnosis—that unless you have the correct diagnosis or the most complete diagnosis, you can’t—you don’t know how to treat a patient. Neuropathology is really the specialty of pathology that deals with the brain, and diagnostic neuropathology obviously deals with making the correct assessment of what’s wrong with the patient’s brain. Here at MD Anderson, we deal mostly with tumors, so we receive biopsies from surgery that are done by neurosurgeons, brain biopsies of patients who have some problem with the brain, or some mass that’s been discovered. It’s our job to look at those with a microscope, assess them in every way that we know how through our professional eyes, and come up with a correct, complete diagnosis so that the neuro-oncologist and/or the neurosurgeon knows how to treat those patients going forward.

Tacey Ann Rosolowski, PhD:

Now what would be a timeline? I mean, could there be a scenario when the sample is taken and in the midst of surgery you’re actually doing a diagnostic look? Maybe you could give me a little bit of a sense of—

Janet M. Bruner, MD:

Yeah. That’s actually very common here at MD Anderson in all specialties, but it seems particularly so in brain. Our surgeons need to know the type of tumor and how malignant it is because that’s going to tell them what they need to do during surgery at the moment. So we are on call. There are four of us here at MD Anderson who do diagnostic neuropathology. One of us is on call whenever there’s a neurosurgeon in surgery. When they call and say, “I have a specimen ready,” we physically go to the area that is adjacent to surgery that we have for pathology, we freeze the tissue in order to make it hard so we can cut very thin slices, and then the slices are cut. They’re put on a slide, they’re stained, and we use a microscope to look at those slices of tissue. We can interpret that—not 100 percent, but we can get now an eighty percent, eighty-five percent, ninety percent idea of what’s going on in that patient’s brain at the time and give immediate feedback to the surgeon. Our goal is to do that within less than twenty minutes.

Tacey Ann Rosolowski, PhD:

Wow.

Janet M. Bruner, MD:

Then the surgeon can decide what to do—either stop surgery at that point if they don’t feel additional surgery is going to be beneficial or proceed to take out more of the tumor or more of the tissue, and we then process it on a more extended schedule. Usually we have a diagnosis available within a couple of days—a much more complete diagnosis. Sometimes we need to do additional studies in order to tell them more, so sometimes those take an additional one or two days also, and those are studies that can’t be done on the frozen basis. They take a little bit longer.

Tacey Ann Rosolowski, PhD:

So you would collaborate. Are these studies that you would do here in-house in Pathology or do you—?

Janet M. Bruner, MD:

Yes, they’re studies we would do here. We have several different types of laboratories in Pathology that are capable of doing different diagnostic tests on tissue, and we send the tissue to whichever area we know does the test that we need. We really have a very complete diagnostic repertoire here that we really don’t need to send out too much. There are a few diagnostic tests now that are patented so that we cannot do them here. They have to be done at a different laboratory, and those we send out. But just about everything else we try to do in-house.

Tacey Ann Rosolowski, PhD:

And what are those—what are the areas in which you do the testing? You said there were four areas.

Janet M. Bruner, MD:

No, there are many.

Tacey Ann Rosolowski, PhD:

Okay.

Janet M. Bruner, MD:

We do routine histology stains. We do immunohistochemistry. We do some fluorescence in situ hybridization, which we call FISH. We do—we can do electron microscopy although now—we used to do that here. Now we send it to St. Luke’s because it’s very expensive equipment to maintain, and our need is just not that great right now. What else do we do? We do other molecular diagnostic procedures, even gene sequencing on some of the tissue if it’s necessary, and all that can be done here just in various areas of Pathology or of MD Anderson.

Tacey Ann Rosolowski, PhD:

Where is this—is there a ranking system for pathology laboratories? I’m wondering if—where MD Anderson sits in terms of its ranking in efficiency and accuracy if there’s something of that kind of standard that’s established.

Janet M. Bruner, MD:

Yeah, there are standards that are established. We are accredited by the College of American Pathologists, and our laboratory is fully accredited. Now, it’s not really a ranking system. I can’t tell you whether we rank first or fifth or twentieth, but really any hospital laboratory in the United States who’s going to be examining patient tissue needs to have this type of accreditation, so we take it very seriously. We’re accredited every two years. They come and actually send people to inspect us. It’s like—people hear of the Joint Commission for Hospital Accreditation, the JCAHO, that the hospital undergoes every two or three years, but JCAHO doesn’t pay much attention to pathology and labs because most of the pathology and lab people are accredited by the College of American Pathologists and they take that—they have what’s called “deemed status.” So they take the—the JCAHO takes the CAP’s word that they are inspecting us in a very strict manner.

Tacey Ann Rosolowski, PhD:

And as Deputy Head of this department, what’s your satisfaction level with its performance? Where do you feel you’re very strong? Where do you feel maybe there are some areas that need to be improved?

Janet M. Bruner, MD:

Actually, I’m the Deputy Head of the Division so the Division of Pathology and Laboratory—

Tacey Ann Rosolowski, PhD:

And Laboratory?

Janet M. Bruner, MD:

Right, and I think we’re pretty strong in almost all areas. I know we have a particularly strong transfusion service and blood bank. It’s just—we transfuse a lot of blood. We have our own donor services, which is really a good thing. One thing that we are developing now much more strenuously, if you will, is the molecular diagnostic and gene sequencing of tumors and tissues. That is a very rapidly developing area—the Human Genome Project and gene sequences—and we really are, I think, doing a great job. I actually think we’re pretty far out at near the head of the field, but I don’t think that’s recognized sufficiently at MD Anderson. It’s like you’re never a prophet in your own land, and I think that we’re doing a lot here in all areas that we just—we don’t respect each other enough. I think we look outside and we see, “Oh, those guys are doing this,” but we don’t realize that they’re way back behind the pack in a lot of other areas. I think we are really at the forefront in our molecular diagnostic testing particularly in—but we need to go further and faster, and we are. That’s one that thing we’re developing a lot. We do a tremendous amount of immunohistochemistry testing on tissues, and that’s specifically for Pathology. Our panel of antibodies that we run for those tests is well over 300 antibodies, and it’s huge compared with other places. And I think we can get just about any test in that area that we feel we need to have done. It seems like we can get it. Our technologists are very anxious to keep up at the forefront of the field, and so they tend to push us along, too.

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Chapter 01: Neuropathology and MD Anderson's Neuropathology Services

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