Goals and Objectives:

1. To provide exposure to the heterogeneity, variability, and natural history of human cytogenetic disorders and the theo-retical and practical basis of diagnostic molecular biology through reading, observation and hands-on participation.
2. To appreciate the heterogeneity, variability, and natural history of human cytogenetic, genetic and neoplastic disorders amenable to scrutiny using techniques of molecular biology.
3. To understand the range of cytoge-netic and molecular laboratory methods used in establishing a diagnosis, and in risk assessment.
4. To appreciate the importance of the family and medical histories, physical examination, correlation with other data, and communica-tion with clinicians.
5. To understand issues of quality assurance, risk management, and cost effectiveness as they relate to cytogenetics and molecu-lar pathology.

Cytogenetics is taught principally in two ways:

1. During an 8 week period, which for AP residents is combined with the Cytol-ogy/Molecular Biology rotation, residents attend a weekly 1.5 hour working case conference, during which all abnormal cases are fully discussed. This case conference reviews patient history, pathology findings, ancillary test results (including ultrasound, etc.), cytogenetic test results, impact on diagnosis, and genetic counseling implications. Karyotypes are distributed and fully discussed, along with discussion of the rationale for choosing specific staining techniques, use of FISH probes, and unanswered questions. Interpretive skills of the laboratory results are acquired by attendance at the aforemen-tioned case review conferences and by three individualized one hour tutorials covering clinical cytogenetics (Frederick Bieber), FISH (Stana Weremowicz), and Cancer Cytoge-netics (Jonathan Fletcher). These tutorials include discussion of laboratory techniques, microscopy and imaging technology, review of selected patient folders, and review of karyotypes on instructive cases. These teaching sessions also include discussion of correlation with pathology gross and microscopic findings, other laboratory testing, and cost-effectiveness. Ethical and legal issues including genetic privacy are also addressed. Independent reading and review of a binder of reading materials and instructive abnormal karyotypes with their reports and accompanying pathology reports provides another mechanism for the residents to understand the importance of clinical cytogenetics in modern pathology.
2. Cytogenetic studies and test results are correlated with anatomic and clinical pathology data on an ongoing basis throughout the residency education. The residents select tissues from tumors and from autopsy cases to be sent for cytogenetic testing, and the cytogenetic test results become part of their formal reports or as addenda. During the rotation in the Women's and Perinatal Division, the residents perform the fetal autopsies on many malformed fetuses with known or suspected chromosome anomalies. These matters are discussed as part of the review and sign out of each case. With regard to Clinical Pathology, serum screening (for amniotic fluid AFP, uE3, and hCG) identifies pregnan-cies at-risk for aneuploidy, and the laboratory provides follow-up on these cases. Residents can attend genetic counseling sessions during which patients are counseled regarding abnormal pathology and cytogenetic findings. As many of our residents have prior backgrounds in genetics and molecular biology, some arrange special projects using FISH methods. At least several residents each year do extended research experiences with Dr. Jonathan Fletcher, usually on projects related to solid tumor cytogenetics, on an individual basis depending upon their own particular interests.

A formal fellowship in Clinical Cytogenetics is available in the laboratory. This is a two-year program, accredited by the American Board of Medical Genetics, which requires one year of full time work in the clinical laboratory and one year of research. Fellows in this program participate actively in all components of the laboratory activities, including cell culture, cell harvest and slide preparation, microscopic analysis of metaphase and interphase cells, utilization of FISH techniques, CAP proficiency testing, case review and sign out and teaching at conferences.

The Molecular Pathology rotation is also integrated with the Cytology rotation (10 hrs over 2 months) and exposes the resident to the theoretical and practical fundamentals of applied molecular biology.

The Molecular Diagnostic Laboratory (Dr. Janina Longtine, Clinical Director) performs about 1000 tests annually, and pioneers new techniques in this area. Although a specific rotation in this laboratory is assigned for residents in the 1st 2 years. Molecular Pathology is integrated throughout the resident's training as we believe it is a critical component in today's practice. This rotation is integrated with the Cytology rotation (10 hrs over 2 months) and exposes the resident to the theoretical and practical fundamentals of applied molecular biology. The laboratory tests center on neoplasia by assessing clonality through antigen receptor rearrange-ments or by identifying specific chromosomal translocations at the molecular level. In addition, tests for genetic mutations associated with risk of thrombophilia are also a major focus of the laboratory. The techniques employed include Southern blot hybridization and the polymerase chain reaction. Specimens processed in the laboratory include blood, bone marrow and tissue biopsies. Examples of specific tests done include: a) Southern blot analysis of immunoglobulin or T cell receptor genes for B or T cell clonality and/or for clonal EBV; b) RT-PCR for bcr-abl mRNA (t(9;22)); c) Invader (cleavase based) assays for Factor V Leiden and Prothrombin 20210A point mutation; and d) PCR analysis of immunoglobulin or T cell receptor genes for B or T cell clonality.

As a result of the considerable experience many of our residents have from prior research which utilized molecular biology techniques and concepts, there is considerable latitude in formulating a meaningful rotation. Residents who need exposure observe and/or perform a Southern blot hybridization and polymerase chain reaction assay. Interpretative skills of the laboratory results are acquired through tutorial sessions with the professional staff which address the specific technical issues and interpretive pitfalls inherent in each of the assays. In addition, the residents participate in the weekly laboratory sign-out where the correlation of these tests with other clinical and pathologic data is stressed as well as the related issues of quality assurance and cost-effectiveness. The residents are encouraged to independently review the results prior to the sign-out sessions. The wording of the resultant interpretive reports is discussed with the resident at this session and the report written by the senior pathologist. The residents are provided with a packet of pertinent literature for independent readings. Electives for those wishing further experience and full time fellow-ships approved by the American Board of Medical Genetics are available and have been pursued successfully by residents.

The professional staff associated with the Cytogenetics Laboratory are: Cynthia Morton, Ph.D., Frederick Bieber, Ph.D., Mary Sandstrom, Ph.D., Stanislawa Weremowi-cz, Ph.D., and Jonathan Fletcher, M.D., Those associated with the Diagnostic Molecular Biology Laboratory are Janina Longtine, M.D., Ph.D., and Frank Kuo, M.D., Ph.D., M.D., Jeffrey Kutok, M.D., Ph.D., Neal Lindeman, M.D.