Surgical pathology refers to the study of tissue samples obtained by various surgical means, including core needle biopsies, skin punch and shave biopsies, open biopsies, video-assisted and laparoscopic biopsies and surgical resection specimens.
The proper handling, processing and evaluations of surgical samples constitutes the core of the activities rendered by the majority of pathologists in the United States. Our program utilizes a subspecialty-based system for the training of residents in the various sub-disciplines in surgical pathology. Duties in surgical pathology include learning to properly gross and describe specimens, microscopic interpretation and diagnosis, and reporting of findings and proper communication with the clinicians regarding the results. The residents acquire graduated responsibilities as they advance in seniority. A practical slide-based exam is given at the end of each block of rotations to assess the progress and identify areas of weakness.
A year-long lecture series in surgical pathology is given by the faculty twice a week. These didactic conferences are principally organized along a glass slide-based format, whereby faculty members review a set of glass slides on well-defined topics that cover the entire gamut of organ systems in surgical pathology. Such sessions take place at a multi-headed microscope. The objective of this lecture series is to ensure that all residents in the program are exposed to classical examples of all the major entities and conditions in surgical pathology and have had the opportunity to review an actual glass slide of all such conditions by the time they complete their residency.
The department also houses a large teaching slide collection in the resident’s room that is categorized by organ-systems and contains a generous sampling of classical examples of common entities as well as examples of rare entities and unusual cases for the use of the residents. A multi-headed microscope with capacity for ten viewers and with a live video monitor is available in the resident’s room for group review of slides by the residents.
The histology lab in surgical pathology counts with four (4) modern grossing stations equipped with automated voice-recognition dictation equipment, computer terminals and digital cameras for macrophotography.
Frozen sections are carried out in our new frozen section suite, which has state-of-the-art equipment, and is conveniently located next to the operating rooms (ORs) and rapid response lab. Communication with the ORs is done through a sophisticated two-way video conferencing system, which allows the pathologist to converse directly with the surgeon via a monitor and to display images from the microscope to explain any problem issues.
All surgical pathology specimens are signed out with faculty. Independence is initially achieved in the gross evaluation of specimens and choice of sections to be submitted for histologic analysis.
Every fourth day residents are assigned to “grossing” (i.e., description, cutting, sampling) of specimens. Grossing of specimens is based on a “selective grossing” philosophy, whereby residents are assigned specimens based on their level of experience and skill, and the amount and complexity of specimens is gradually increased as the residents advance in their rotations. Residents are expected to have grossed a certain minimum number of cases for all major organ systems by the time they have completed their surgical pathology rotations.
The first year resident is initially guided in the gross evaluation of specimens by surgical pathology faculty, senior pathology residents, dedicated pathology assistants, and the online surgical pathology Grossing Manual, which provides detailed step-by-step instructions for the grossing of all specimens. As experience is gained, the resident is encouraged to complete the gross evaluation and tissue selection independently, with the surgical pathology staff providing a more general supervisory role.
After a specimen has been accessioned and subsequently “grossed” by a resident or pathologist assistant, a secretary transcribes the gross dictations. The resident reviews the paperwork and slides and formulates a preliminary diagnosis, correlating the histologic features with the submitted clinical information, laboratory studies, radiology reports, and additional clinical information provided by the submitting physician and/or resident. This information is combined into a preliminary document that incorporates all relevant elements necessary for a comprehensive surgical pathology report. This preliminary report is then reviewed with the surgical pathology faculty.
Gradually, the resident is also expected to independently initiate the triaging of specimens for special studies (e.g. molecular studies, cytogenetics, electron microscopy, hormone receptor studies, flow cytometry, special stains, etc.) that complete the pathologic evaluation. The final reports are electronically signed out by the surgical pathology attendings, and copies are sent to attending physicians and medical records.
Intraoperative consultation by means of frozen section diagnosis is a critical and integral part of the role a pathologist plays in the health care team. Rotating in the frozen section suite is designed to provide the resident with ample exposure to the variety and different levels of complexity of specimens that are processed using this technique.
Residents in the first through fourth years of Anatomic Pathology training participate in intraoperative frozen section consultations. All frozen section intraoperative consultations are the primary responsibility of the frozen section (FS) resident. These are evaluated under the direct supervision of an attending surgical pathologist who is assigned to the Frozen service on a rotational basis. Frozen sections are done by residents in combination with activities during the Surgical Pathology block rotations and is also available as a separate one-block elective rotation.
When specimens arrive for frozen section, residents examine the tissue, perform touch preps if indicated, select tissue to freeze, and orient the specimen for sectioning. Residents review slides with the FS attending, providing relevant history and previous material when available. Residents are responsible for ensuring that all diagnoses are properly recorded and transmitted to the appropriate OR.
The rotations in Surgical Pathology expose the resident to various organ systems and emphasize a broad exposure to the technical and basic interpretative aspects of surgical specimens.
Residents are responsible for each case assigned to them and, with supervision by a faculty member, initiate all studies necessary for the completion of a case, including utilization of all available ancillary studies, such as immunohistochemistry, electron microscopy and molecular techniques.
The ultimate goal for this area is to produce experienced, qualified Surgical Pathologists who will have a solid foundation on which to build their careers and who will appreciate the need for consultation.
Basic rotations consist of six 4-week blocks in the first year; advanced rotations consist of in-depth experiences in specific areas of surgical pathology during the second through fourth years. Residents are given graduated responsibilities as they progress through their training and, thus, the degree of direct staff supervision varies, and is directly tailored to each resident's competence level.
Head and neck pathology involves the study of disease conditions developing over a broad anatomic region including the oral cavity, larynx, nasal cavity, paranasal sinuses, jaw, facial bones, neck, eyes, ears and salivary glands. Therefore, this is a specialty that requires a thorough understanding of the wide range of benign and malignant pathologic entities that can involve a variety of tissues, including skin, mucosal surfaces, bone, teeth, cartilage, soft tissues, salivary glands, lymphoid tissue, nervous tissue and eyes.
On average, over 1,600 cases of head and neck pathology are accessioned each year. Residents are expected to learn how to handle the entire range of specimens pertaining to this subspecialty, including complex laryngectomy specimens, oncologic specimens from the oral cavity and radical neck dissections.
A head and neck tumor board conference takes place weekly with the head and neck surgeons and oncologists, during which residents are expected to present cases and discuss issues pertaining to the pathology and staging of the lesions. Signout of cases is generally done at a multi-headed microscope, and select cases are shared at the daily Peer Review Conference to ensure that all residents in the program get the opportunity to review all interesting or unusual cases.
Thoracic pathology involves the study of specimens removed from the thoracic cavity for diagnostic or therapeutic purposes, including lung, pleura and mediastinum. This includes endoscopic and percutaneous core biopsies of the lung and pleura, video-assisted thoracoscopic surgery (VATS) specimens, wedge biopsies of the lung, and resection specimens of lung, pleura, diaphragm, mediastinal masses and extrapleural pneumonectomies.
Residents are expected to gain proficiency in the grossing of all such specimens under the supervision and with the assistance of their mentors, and to develop a clear understanding of the criteria and elements involved in making a correct diagnosis for these conditions. Approximately 700 specimens related to thoracic pathology are processed in our lab per year.
Residents rotating through this service also participate in interdepartmental specialty conferences with clinical and surgical departments and are responsible for presenting cases at these interdepartmental meetings.
The division of gastrointestinal and liver pathology is the busiest service in surgical pathology and handles approximately 8,000 cases per year. The hospital has a busy GI and liver service and a high volume of endoscopic biopsies are processed yearly through our lab.
The division is also in charge of reviewing all major resection specimens for inflammatory bowel/Crohn’s disease as well as a large variety of cancer resection specimens involving the entire GI tract, liver and pancreas. A busy liver transplantation service also provides ample experience in liver transplant pathology.
Residents are expected to attain proficiency in the handling of the gross specimens pertaining to these cases as well as to learn the criteria for histopathologic diagnosis of the various conditions that affect the GI tract and liver. Residents participate in various interdisciplinary conferences with clinicians, gastroenterologists, surgeons and radiologists in which difficult and problem cases are discussed.
Gynecological pathology involves the study of the female reproductive system, including uterus and cervix, uterine adnexa, vulva and ovaries. The signout of placental pathology is shared with members of Children’s Hospital pathology department, and is also part of the GYN Pathology rotation experience. Over 5,000 cases corresponding to GYN pathology are accessioned through our lab per year.
Conditions spanning the spectrum of benign, precancerous and malignant are represented, including cervical dysplasias, endometrial polyps and hyperplasia, and the whole spectrum of cancers of the uterus, ovaries and adnexa.
Residents are expected to learn how to properly handle the grossing of complex gynecologic specimens, and are expected to participate in the GYN tumor board and other interdisciplinary conferences in the specialty.
The breast pathology service handles approximately 1,500 cases per year, and is involved in the interpretation of breast core biopsies, lumpectomies, quadrantectomies and mastectomies in patients suffering from breast cancer and other conditions.
The division participates in a weekly multidisciplinary breast tumor board in which all cases are reviewed and the relevant medical information is discussed. Residents are expected to assist in the preparation of cases for the tumor board and actively participate in it.
Residents are also expected to learn how to handle and adequately process breast resection and biopsy specimens to provide the complete prognostic information required for guiding the treatment of the patient. Interesting and difficult cases are regularly shared at the daily Peer Review Conference to allow all residents in the program to benefit from the learning experience.
The division of urologic pathology is responsible for the processing and interpretation of all specimens related to the urinary tract, including urethra, ureters, prostate, bladder, kidneys, and male reproductive system. Significant areas include prostate and kidney cancer, as well as testicular neoplasms. Approximately 1,200 cases of urologic pathology are accessioned through our lab per year.
Resident duties include grossing of the specimens under supervision by more experienced personnel and signout of cases with the attending physician.
Residents are also expected to participate in the various interdepartmental tumor conferences and assist in the discussion and presentation of cases for consultation with the clinicians and oncologists. Interesting or problem cases are shared at the daily Peer Review Conference to ensure that all residents obtain exposure to all the interesting teaching cases seen by the division all year long.
The endocrine pathology division is responsible for processing and interpreting the surgical samples taken from endocrine organs, including the parathyroid glands, thyroid gland, adrenal glands, and the endocrine portion of other organs such as pancreas. This includes benign inflammatory or infectious conditions, hyperplastic processes, and benign and malignant neoplasms of the parathyroid glands, thyroid and adrenals. Approximately 500 cases of endocrine pathology cases are accessioned per year in the department.
Residents are expected to attend and participate in the Endocrine Multidisciplinary Disposition Conference, where all aspects of these cases are discussed with a multidisciplinary team of surgeons, endocrinologists, radiologists and other specialists.
Residents are expected to learn how to properly gross and handle the specimens under the supervision of more experienced personnel, and to sign out the cases with the appropriate faculty.
Soft tissue and bone (also known as musculoskeletal pathology) involves the study of all disease processes affecting bones, joints and soft tissue throughout the body. This includes benign and malignant disorders of bone and soft tissue, degenerative and inflammatory joint diseases, and soft tissue sarcomas. The hospital counts with one of the premiere musculoskeletal disorders team in the region and serves as the referral center for the majority of tumors of bone and soft tissue in the State of Wisconsin. Approximately 700 cases of bone and joint specimens and soft tissue tumors are accessioned through the system yearly.
A weekly Musculoskeletal Tumor Board conference takes place and the residents are involved in the presentation and discussion of the pathology for the cases.
Residents are expected to learn how to properly process complex musculoskeletal resection specimens and properly sample bone and soft tissue tumors for final histopathologic diagnosis and staging. Interesting or unusual cases are regularly shared at the daily Peer Review Conference to ensure that the residents enjoy continuous exposure to the discipline throughout the length of their training.
The dermatopathology division is responsible for the processing and interpretation of all skin biopsies submitted to the lab. Approximately 10,000 skin cases are processed through our lab yearly. The division supports an active outreach program in dermatopathology and services the needs of dermatologic surgeons, plastic surgeons and clinicians throughout the hospital as well as handling the skin biopsies from the Zablocki VA Medical Center.
Residents are expected to learn how to properly handle shave and punch skin biopsies, how to orient and section resection specimens from skin tumors, and how to elaborate a proper differential diagnosis and reach a definitive diagnosis on histologic examination. The whole gamut of specialized ancillary tests applicable to dermatopathology are available in our department, including fluorescence microscopy, electron microscopy, immunohistochemistry, and a variety of molecular techniques pertinent to the study of skin conditions.