Chapter 09: The Neuropathology Lab in Detail

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Chapter 09: The Neuropathology Lab in Detail

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Next Dr. Bruner details the work of the neuropathology lab, which handles 70-80 thousand cases per year and processes over 1000 tissue blocks (tissue set in paraffin blocks for slicing) per day. She describes the measures taken to insure the accuracy and efficiency of the diagnoses, including the bar-coding of anything related to a sample to prevent mix-ups. The mechanization of various instruments (e.g. for staining slides) has aided in the service's speed. The laboratory also scans slides sent by other services, increasing the repository of examples that diagnosticians can use for reference. Dr. Bruner closes this section with interesting reflections on whether pathologists will eventually examine only digital images. She notes differences between the pathology image and images in radiology, and concludes that, for now, pathology is "an analog specialty in a digital world."

Identifier

BrunerJM_01_20120604_C09

Publication Date

6-4-2012

City

Houston, Texas

Topics Covered

The University of Texas MD Anderson Cancer Center - An Institutional Unit; Overview; Definitions, Explanations, Translations; The Researcher; The Clinician; The Administrator; Institutional Processes; Devices, Drugs, Procedures; Professional Practice; The Professional at Work; Patients, Treatment, Survivors

Transcript

Tacey Ann Rosolowski, PhD:

And I do want to get there. Do you mind if I ask you just a couple of other lab-related things?

Janet M. Bruner, MD:

Sure.

Tacey Ann Rosolowski, PhD:

And then we’ll turn to that. Okay. I was wondering some real technical things, like now in the pathology lab, how many cases per day does the laboratory handle?

Janet M. Bruner, MD:

The lab—I can’t tell you how many cases per day. We have about—

Tacey Ann Rosolowski, PhD:

Whatever unit—I’m just trying to get a sense of the volume of work.

Janet M. Bruner, MD:

Right. We have about 70,000 or 80,000 cases a year, and about half of those are cases from outside. We do a tremendous amount of reviewing cases from outside, because we review the slides of every patient who comes here. If you have a diagnosis outside somewhere else, we’re going to review those slides before you’re treated here, and it’s for not only the patient’s protection but also our doctors because we don’t want them treating something that doesn’t exist.

Tacey Ann Rosolowski, PhD:

On the basis of a bad diagnosis.

Janet M. Bruner, MD:

Right. Right. And we do have that. We’ve had cases where the patient really had an infection in the brain, and some pathologist outside called it a tumor, and they had radiation therapy to the brain for an infection. It doesn’t help it. An antibiotic would’ve been much better. That’s really a sad thing. So it’s not only the difference between benign tumor and malignant tumor or a different type of malignant tumor but things like an infection that’s misdiagnosed or some other inflammatory condition—an arthritis type of thing that’s diagnosed as a tumor.

Tacey Ann Rosolowski, PhD:

How frequently do you find that?

Janet M. Bruner, MD:

We’ve done a study in brain, and it’s about eight percent to ten percent.

Tacey Ann Rosolowski, PhD:

Really?

Janet M. Bruner, MD:

Which doesn’t sound very high until you realize it’s one out of ten people, and if you’re that one person it’s critical.

Tacey Ann Rosolowski, PhD:

Absolutely.

Janet M. Bruner, MD:

It’s critical. That’s the number of cases per year that we see. Our laboratory processes here over 1000 tissue blocks a day, and a tissue block is what we make the slide from. It’s a piece of paraffin wax with tissue inside it, and it’s where the slide is cut from. The significance of that is if you think about 1000 tissue blocks a day and about 250 working days in a year, that’s a quarter of a million tissue blocks in a year. That’s huge, and we have to store those! We have to store them in a controlled climate condition. We actually store them at a warehouse offsite.

Tacey Ann Rosolowski, PhD:

Oh, do you?

Janet M. Bruner, MD:

We hire Iron Mountain. MD Anderson has a contract with Iron Mountain so they not only store documents—

Tacey Ann Rosolowski, PhD:

Is that “Iron Mountain”?

Janet M. Bruner, MD:

Iron Mountain.

Tacey Ann Rosolowski, PhD:

Iron Mountain.

Janet M. Bruner, MD:

I-R-O-N. It’s a very well-known document control—document storage, but they also store other things.

Tacey Ann Rosolowski, PhD:

Interesting. Well, I was going to ask you what you felt ensured that the pathology laboratory operates accurately and efficiently, and you’re starting to answer that question. So what else goes into that—ensuring a really high quality of diagnosis and speed?

Janet M. Bruner, MD:

Well, we have benchmarks that we have to adhere to as far as turnaround time for cases, so that’s where the speed comes from. It’s not to punish people that take an extra amount of time, but we do have a benchmark goal so that it can’t take you three weeks to sign out every case, because that just isn’t acceptable. We have a lot of checks. A lot of our work now in our labs is bar code driven. We had—

Tacey Ann Rosolowski, PhD:

What does—?

Janet M. Bruner, MD:

It means that every piece of physical property is bar coded. The container that the specimen comes in is bar coded the cassette that—I have a cassette around here I can show you. Yeah. Of course, this isn’t going to mean much to your listeners.

Tacey Ann Rosolowski, PhD:

Well this is—it’s a little tiny cassette tape?

Janet M. Bruner, MD:

No. It’s—

Tacey Ann Rosolowski, PhD:

Oh.

Janet M. Bruner, MD:

It’s a piece of plastic with paraffin wax.

Tacey Ann Rosolowski, PhD:

Oh, okay.

Janet M. Bruner, MD:

And this is the tissue.

Tacey Ann Rosolowski, PhD:

Yeah. Oh, I see.

Janet M. Bruner, MD:

And what we do—

Tacey Ann Rosolowski, PhD:

Embedded in the wax.

Janet M. Bruner, MD:

Right. Embed it in the wax as a support, and then the tissue is cut.

Tacey Ann Rosolowski, PhD:

Oh—

Janet M. Bruner, MD:

And see how similar that is?

Tacey Ann Rosolowski, PhD:

Yeah.

Janet M. Bruner, MD:

A thin section is cut. The wax is just a support to let us cut it as thin as possible.

Tacey Ann Rosolowski, PhD:

Right.

Janet M. Bruner, MD:

And this is cut at about four or five microns, and then it’s stained. The stainer is an autostainer, so every slice is supposed to be stained exactly the same. Now these are very old. These are from 1990, both of these.

Tacey Ann Rosolowski, PhD:

So they’re not bar coded.

Janet M. Bruner, MD:

They’re not bar coded. Right now, if you saw a cassette and a slide, the cassette has a bar code printed right there, and in order to print the slide that it goes on, there’s a bar code reader. The bar code reader then prints that same bar code on this slide so that I know it can never be mixed up. I only deal in the lab with one cassette at a time, one slide at a time, so there’s no tissue mix up. That’s a very critical issue with pathology. Obviously, if you have 1000 tissue blocks a day, you don’t want to be mixing up one slide with another block.

Tacey Ann Rosolowski, PhD:

Absolutely. Right.

Janet M. Bruner, MD:

So that’s one thing we do. We also—whenever we dictate—and we dictate a lot of the cases, and they’re transcribed by offsite transcriptionists. Whenever we dictate anything regarding a patient we also always have to dictate—we require two or three identifiers. We have a surgical pathology number that we assign, a patient name and patient medical record number, and most of us I think dictate all three things. Then whoever is transcribing that dictation, if they don’t hear what matches, or if when they type in the name of the case or the number of the case another name pops up, they stop, and they go back to the pathologist and say, “Are you sure? What were you dictating here?” So we have a lot of checks and balances, and most all of our labs now are bar code driven so that we have these critical things.

Tacey Ann Rosolowski, PhD:

When were those procedures instituted?

Janet M. Bruner, MD:

The bar coding actually has been fairly recently. It’s been about two or three years ago with parts of it and really only within the last year that we’ve been pretty fully bar coded. Before that, we would have—and even now—in addition to the bar code on the slide, we have the surgical pathology number and the patient last name. So there are multiple identifiers on a slide.

Tacey Ann Rosolowski, PhD:

I guess a related question I wanted to ask was how have various changes in technology been integrated into the diagnostic process and even altered it?

Janet M. Bruner, MD:

Yeah. That’s one, computers and dictation. We’re not using voice recognition yet in our lab. A lot of pathology labs are. We aren’t because we do have really good luck with our transcriptionists. That’s one thing. When I first started, we had a room where there were eight people sitting there typing all day, and of course we had typewriters. We didn’t even have computers, so that has been a tremendous advance. About—oh, gosh! I bet it’s been six or eight years ago, the transcriptionists—it was harder to get them, and the ones we had weren’t as productive as we liked, but they were talking about typing from home. So we said, “Okay, if you can meet these certain benchmarks for your typing, we’ll let you type from home, but you’ve got to earn it.” So we sent one or two of them home, and their productivity went way up. Finally, the last one we had on site who was one of our—very nice lady, but she was very distractible, and she loved to talked. It was terrible! She couldn’t make her benchmarks for typing. We said, “Okay, you’ve got to do this.” She wanted to go home, offsite. She finally did it. We sent her home. Her productivity soared at home. They just do so much better, and they enjoy it. They don’t have to fight the traffic. And what’s done it is a fast DSL or cable connection at home, and I think we do provide their computers, so they have a good computer at home. So computer—digital technology has just—is really what has advanced us. The other thing is mechanization of our instruments. We’ve really seen that help us a lot, both for consistency of product and also for speed, because we have now where we do these different staining procedures. We used to do that all by hand when I started. It was a totally manual procedure and now we have—I don’t know—a dozen instruments that handle slides. The technicians have to know how to do the procedure, because they have to program the instrument, which has a computer, but they don’t have to actually physically do it. It takes a lot of the routine out of their job and allows them to work faster. They’re much more productive. We could—never handle the workload today that we have with the number of people in the way we used to do it in the past, and it’s added consistency, that’s just wonderful.

Tacey Ann Rosolowski, PhD:

I’m wondering if there’s anything coming down the line with—whether the ability to produce and recognize visual imagery is really there in digital technologies. Is there anything where that can be used?

Janet M. Bruner, MD:

We are doing a lot of that. We’re doing—I won’t say as much as we can. We’re doing some of it. These outside cases that we review—people send in the glass slides. Well, it’s easy—we’ve talked about, “Wouldn’t it be great if they could scan the image, and then we could just look at the images?” But it would require all these small pathology labs out in the community to have scanners, high-resolution scanners for slides. Those are expensive. They’re $250,000 apiece. I don’t know if we’re ever going to get to a day when that happens, but what we do is when we have their slides in our hands—which we have to return to them because it’s a part of their permanent patient record—we have a scanner, so we scan those slides, and we attach them to our computer record on that patient. If we need to refer to that image or review that slide in the future, we’ve got the high-resolution image of it. That’s really been helpful for us. We’ve used that a lot. We often refer to that image if the patient has surgery here because the question here—you know—it’s MD Anderson. Does the patient have—is this a recurrence of their initial tumor, or is this a new cancer? By looking at that image and comparing, we can tell that, so it’s been very useful for us. It’s really helped us. I can think of several cases where somebody has said, “Can we compare that to the old slide?” and we look in the computer and—wow—it’s there. We don’t have to send away again, get their slides back. It saves us so much time, and the images are fine. They’re very good.

Tacey Ann Rosolowski, PhD:

Just out of curiosity, what kind of resolution do you scan them at?

Janet M. Bruner, MD:

We scan them at 20X which is—with a 10X eyepiece, it’s a 200 magnification.

Tacey Ann Rosolowski, PhD:

Oh, okay.

Janet M. Bruner, MD:

That seems to be sufficient. Most of the time when we look, our high power view is 40X. So it’s not quite as high as we might look on our microscope, but it usually is enough, usually is sufficient.

Tacey Ann Rosolowski, PhD:

And then it’s almost like a version of a tissue bank, too. You’ve got a huge bank—

Janet M. Bruner, MD:

Right. It is. It is—

Tacey Ann Rosolowski, PhD:

—images of tumors.

Janet M. Bruner, MD:

We talked about, “Is there ever going to be a time when the lab will produce a slide with a piece of stained tissue on it, and it will be immediately scanned, and the pathologists will only look at the image?” That day may come. I’m not quite as sure today—if you had asked me this three or four years ago I would’ve said we definitely are going to go there, but the technology doesn’t seem to be advancing quite as fast as I thought it would, improving. It’s a difference—Radiology does that. They have no more film now, but the difference is that the radiology image that is captured is a digital image. Their source image is digital because they’re working from MRI scans or CT scans, which is a digital image, whereas we have no digital image. Our source image is analog. We’ve—we say that we’re still—we’re an analog specialty in a digital world, and for the time being, I don’t see us being able to produce a source digital image. We have a physical piece of tissue that we have to deal with. I just don’t know when it’s going to—

Tacey Ann Rosolowski, PhD:

When that’s going to happen.

Janet M. Bruner, MD:

Tacey Ann Rosolowski, PhD:

Yeah. Interesting. Interesting. We have—let’s see. I’m looking at the time. It’s about twenty minutes of 4:00.

Janet M. Bruner, MD:

Okay.

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Chapter 09: The Neuropathology Lab in Detail

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