Goals and Objectives:

1. To provide a high-volume and active learning environment in which residents become competent
   diagnostic pathologists.
2. To educate residents in the knowledge, skills and attitudes needed for pathology practice.
3. To develop consultative, administrative, and managerial skills needed to convey a diagnosis to the clinician after interpretation of a biopsy or resection.

GENERAL SURGICAL PATHOLOGY ROTATIONS

The General Surgical Pathology service receives and evaluates approxi-mately 40,000 general surgical specimens. In addition, 15,000 obstetrical/gynecologic and perinatal surgical pathology specimens are proc-essed through the Women's and Perinatal Pathology service. These services together process over 6400 frozen sections per year with common facility in close proximity to the operating suite and receive over 9000 referral consultations per year. The Chief of Surgical Pathology is Dr. Christopher Fletcher. Dr. Vânia Nosé, is Associate Director of Surgical Pathology.

Residents play an active role in the frozen section room, examining tissues and then selecting and cutting tissue blocks, review-ing microscopic sections and assisting staff in formulating a diagnosis, which the resident usually communicates to the surgeon.

Detailed descriptions of the rotations in surgical pathology, methods for processing interpreting and reporting individual specimens, and the logistics of each of the various subdivisions of the service are provided in a detailed Surgical Pathology Manual, updated annually. Five residents are typically on the surgical pathology service at one time. The work is divided broadly into diagnostic biopsy specime-ns (quicks), therapeutic resection specimens (bigs), and slide consultations. General surgical pathology cases, including endocrine, mediastinal, pulmonary, urinary tract, male genital tract, bone and soft tissue specimens, are seen by the general surgical pathology resident rotating on surgical pathology and are signed out with the general staff. During first and second year 4-6 week rotations, hematopath-ology, renal, cytology, neuropathology, gynecologic, cardiac, GI, and dermatopathology cases are processed and reviewed by residents and signed out with the senior subspeci-alty pathologist. Beginning residents are trained in specimen dissection, frozen section and section preview, and supervised on a one-on-one basis by educated senior resident preceptors for approximately 3 weeks at the start of their first surgical pathology rotations. Senior residents, fellows and staff are readily available for consultation thereafter.

While on the Surgical Pathology service, a resident rotates between cutting in and signing out. Typically, a resident will cut in his/her specimens one afternoon, receive his/her slides back the next day, examine them that night and formulate a written diagnosis, and sign them out with the senior pathologist the following day. The opportunity to review slides and develop an independent diagnostic opinion prior to one-on-one sign-out with faculty is a key element of our training program. A resident rotating on the general surgical pathology service is quite busy; on a typical afternoon, a resident may process as many as 50 cases with the help of pathology assistants.

In the Frozen Section Laboratory, residents perform operating room consultations in order to become competent in frozen section diagnosis and in preparing frozen sections. A resident covers the Frozen Section Laboratory from 7:30 am to 5 pm. A senior staff member is in the laboratory from 8 am until 5 pm. Technicians are in the laboratory from 8:30 am to 5:00 pm weekdays and on an "on-call" basis from the main laboratory from 8 am until noon on Saturday. The laboratory processes approximately 30 specimens per day. The resident is responsible for the gross description, recording, and preparation of any special studies, and selection of samples for frozen sections or other special studies in consultation with the staff pathologist. The resident examines the slides with the staff member, formulates a diagnosis, and as he/she becomes more senior, communicates that diagnosis to the surgeon. Many specimens come to this laboratory for gross examination only and for evaluation of tissue allocation to research studies (according to IRB-approved protocols), in which the resident also participates. Residents on subspecialty rotations are responsible for all operating room consultations from 5 pm to 7:30 am on weekdays and residents on surgical pathology weekend duty provide frozen section coverage from 5 pm Friday through 7:30 am Monday.

Residents achieve a steep learning curve in surgical pathology. During preparation for sign-out, they have ready access to surgical pathology and subspecialty pathology texts in a specifically designated mini-library within the residents' review room. Teaching on the service is extensive. In addition to a one-on-one learning experience with staff at daily sign-out conferences, residents at-tend/participate actively in multiple conferences ranging from the interesting case conference held weekly to weekly dermatopathology and oncology conferences and an every other week bone conference. A slide conference held Tuesday at 1:00 pm is devoted specifically to specific surgical pathology topics and follows a systematic program through the year, and the Surgical Pathology Update each Friday at 1:00 pm is an overview presentation by a BWH or other faculty expert on a contemporary topic. Residents also participate in a variety of other surgical pathology-oriented conferences under the various subs-pecialties. Residents are encouraged to publish appropriate material encountered (or other clinical research projects involving archived specimens) duri-ng their time in surgical pathology with the help of senior staff.

As advanced residents attain increasing responsibility as they progress and gain competence through the program, they:

1. Sign out frozen sections with staff supervision.
2. Sign out of quicks/-bigs surgical specimens with staff supervision.
3. Serve as preceptor as a second/third year resident training first year residents in procedures and gross and microscopic pathology.
4. Represent the department by presenting and discussing cases in conferences with the departments of Radiology, Medicine, Oncology, Hematology, Surgery and others.
5. Give seminars/lectures/reports of studies performed to pathology residents and staff.

Functioning as consultants to other physicians, residents respond to calls from clinicians, provide results of early readings, and give final diagnoses. Over 9000 diagnostic consultations in anatomic pathology are handled annually, including 6000 institutional consultations on patients referred to either Brigham and Women's Hospital or Dana-Farber Cancer Institute for treatment or second opinion and 2500 consultations directed to individual faculty. There is considerable resident (and fellow) involvement in consultations.

Fellowships formally exist and are occupied each year in hematopathology, neuropathology, cytopathology, women's and perinatal patholog-y, dermatopathology. Fellowships are also offered in soft tissue pathology, and renal, cardiac, pulmonary, breast, GI, and genitourinary pathology. Straight AP residents usually take these fellowships in year 3 or 4 and those doing AP/CP in year 5. For a period of 3-12 months, fellows have greater responsibility and independence in terms of working up cases and interacting with clinicians, supervised by a faculty member. Fellows play a key role in the orientation, training and supervision of residents, thereby gaining an additional form of graduated responsibility. Care is taken, however, that fellow-s augment but do not interfere with the learning opportunities of residents.

Surgical Immunopathology

Immunopathology exposure is longitudinal, as immunopathological techniques are used routinely in surgical pathology and in most of the subspecialties: (a) Immunohisto-chemical studies are requested by residents following consultation with the senior staff. The slides from these studies are then reviewed with the residents in regard to interpretation of the markers, their diagnostic applicability in a given case, and their incorporation into the case signout. (b) For hemato-pathology cases, residents are provided with the cryostat and paraffin sections studies on lymphoid tissues, bone marrows, and other hematologic specimens. In some cases, flow cytometry studies are also available. The residents are responsible for interpretation of this material and incorporation of the findings in the case signout. The routine sections and the immunophenoty-pic studies are then reviewed with the senior staff in preparation of the final report. (c) During rotations in dermatopathology, residents are instructed in the interpretation of immunofluorescent studies as they relate to the evaluation of bullous diseases, connective tissue diseases, vasculitis and other disorders. Residents are also instructed in the use of

immunoperoxi-dase studies in the assessment of leukemic or lymphomatous skin infiltrates and in the evaluation of various neoplasms. (d) In renal pathology, residents learn to interpret immunofluorescent studies of renal biopsies to determine sites of reactivity and patterns of deposition of immunoglobu-lins, complement, fibrinogen, and albumin, as they relate to various diseases, e.g., glomerulo-pathies, collagen diseases, coagulopathies, vasculitides, and other disorders. The residents are further instructed in the correlation of these studies with histologic features and electron microscopy, as well as the clinical findings, in order to arrive at a final interpretation of the renal biopsy. (e) In cytology, immunohistochemical studies are performed on cytocentrifuge preparations, cytologic smears, and/or cell blocks in evaluation of possible lymphomatous processes and assessment of specific tumor types. Residents are provided with this material and are instructed in incorporation of these studies in the final signout.

Electron Microscopy

An active diagnostic electron microscopy (EM) service, handling 600 cases per year, is established in the Department. The two major categories of specimen handled are renal biopsies (under the supervision of Dr. Helmut Rennke) and unusual tumors (under the supervision of Dr. Christopher Fletcher), the latter consisting principally of poorly differentiated neoplasms identified at frozen section, soft tissue tumors and pleural tumors, especially mesothelioma. An additional and increasing third group consists of nerve, muscle and brain biopsies, mainly for non-neoplastic disorders. The purpose and role of electron microscopy (as well as the appropriate manner to handle specimens for ultrastructural analysis) is explained to residents early in their training and is described in the Manual of Surgical Pathology. The majority of EM cases are signed out by Drs. Rennke or Fletcher, except for pleural lesions which are reported by Dr. Joseph Corson. Neuropathology cases are signed out by the attending faculty member on that service, having first been scoped by the neuropathology fellow. An attempt is always made to show, discuss and explain the EM findings with the relevant resident or fellow handling the case and the EM photomicrographs are also made available to the regular attending who is handling the case so that the results may be discussed at final signout of the entire specimen.

In addition, aside from any EM component in organ-specific lectures or seminars, occasional teaching (or surgical pathology) conferences are devoted to the use of electron microscopy and its interpretation. Residents who show a particular interest are taught and encouraged to take part in the routine electron microscopy (including viewing, photographing and writing the report for cases). Several residents have also incorporated an EM component in their research projects.

BREAST PATHOLOGY

Goals and Objectives:

1. To gain experience and expertise in difficult areas in breast pathology (ADH vs DCIS, DICS vs LCIS, sclerosing lesions vs invasive carcinoma, papillary lesions, etc.).
2. To be able to determine and accurately report prognostic/predictive factors in breast cancer and to understand how this information is used to guide patient management.
3. To be able to interpret ancillary studies (immunoperoxidase studies for ER, PR, and HER2/neu, FISH for HER2/neu).
4. To interpret image guided core needle biopsies and to be able to correlate the pathologic findings with the radiologic findings.
5. To become involved in projects to enhance the care of patients with breast cancer.

Residents will obtain extensive experience in interpreting breast lesions in excisions performed at BWH during the core rotations in surgical pathology.

The Breast Pathology Service signs out all breast pathology consultations (1400 cases per year), all core needle biopsies of the breast (1100 per year), and all immunoperoxidase studies on breast cancers. The service is also available for consultation for difficult breast lesions excised at BWH. Teaching sets are available in basic breast pathology, histologic types of breast cancer, hyperplasia/ADH/DCIS, core needle biopsy interpretation, inflammatory breast diseases, and stromal lesions of the breast.

The advanced resident/fellow has the following responsibilities:

1. Review and sign-out all breast pathology consultations, breast core needle biopsies, and all in-house consultations in collaboration with the breast pathology senior staff.
2. Present interesting current clinical cases (usually 2 to 30) to a multidisciplinary team (surgeons, medical oncologists, and radiation oncologists) once a week (Wednesday at 12:00). The cases are presented from glass slides via a microscope and projector.
3. Interpret and report immunoperoxidase studies on breast cancers.
4. Attend the monthly breast core needle pathology/radiology conference (Wednesday at 5:00). The cores with interesting findings from the prior month are reviewed with correlation with the radiologic findings.
5. Attendance at the weekly Wednesday morning (7:30 am) Breast Center conferences when the topic is of interest to pathologists.

CARDIOVASCULAR PATHOLOGY

Objective:

To gain familiarity with diagnostic considerations in cardiovascular surgical pathology and increase general knowledge of cardiac and vascular pathology.

The Cardiovascular Pathology Division provides support for an active cardiac transplant service through the interpretation of more than 800 endomyocardial biopsies and the evaluation of 25-30 explanted hearts per year. In addition, several hundred removed native and prosthetic valves, aortic segments and cardiac tumors are received as surgical specimens and approximately 50 autopsies involving primarily cardiac diseases are performed annually. Surgi-cal pathology specimens and autopsy hearts are received in consultation from other institutions and the Boston Medical Examiner's office.

To accomplish the goal, the resident will:

1. Preview and provide diag-noses for the rush endo-myo-cardial biopsies, at Tuesday, 12:30 pm and Friday, 11:30 am signout sessions with the cardiac transplant clinical team.
2. Sign out other cardiovascular surgical pathology with the designated senior cardiac pathologist.
3. Perform diagnostic evaluation of all cardiac valves, explanted hearts, and large vessels.

In addition, residents on an elective rotation dedicated to cardiovascular pathology will:

1. Review a brief teaching slide set of biopsy specimens with a staff member upon joining the rotation. Subsequently, review a formal teaching set of other cardiac and vascular pathology.
2. Review all cardiac and vascular pathology on the Autopsy Service arising during the period.
3. Review a notebook of key reprints.
4. Review specimens in the cardiac pathology museum collection in the autopsy room, as interested, and with coordinated staff review, as necessary.
5. Review and provide diagnoses for a self-assessment teaching slide set during the last week of the rotation, and review those with a cardiac pathology staff member.

Residents are closely supervised by Drs. Frederick Schoen (Director of Cardiac Pathology), Gayle Winters, Richard Mitchell, and James Stone. Research interests of the group include valvular, ischemic and myocardial pathology, substitute valves and other prosthetic devices, transplantation pathology and immunopathology. Opportunities exist for residents to elect additional advanced rotations in cardiovascular pathology, in order to pursue specific projects or develop areas of interest.

GASTROINTESTINAL, HEPATIC, AND PANCREATICOBILIARY PATHOLOGY

Goals and Objectives:

Experience in Gastrointestinal, Hepatic, and Pancreaticobiliary Pathology is obtained as a component of the core rotations in surgical pathology. Senior residents can select to participate on this service for periods ranging from 1-6 months (or longer periods of 1-3 years as fellows). As junior residents, experience with this service comes from "GI" signouts, since GI and liver biopsies represent a large component of specimens processed through the "quicks" bench. The objectives of this rotation are to develop competencies in:

1. Diagnosing GI, liver and pancreaticobiliary diseases by analysis of biopsy specimens and resection specimens and understanding the objectives and information to be obtained from analysis of biopsy specim-ens.
2. Interacting with clinicians and consolidating clinico-pathological data.
3. Stimulate interest in performing clinico-pathologic research related to GI, liver, or pancreaticobiliary diseases.

The Gastrointestinal Pathology Service handles approximately 20% of the specimens coming through the general surgical pathology service, actively interacts with the clinical Gastroenterolo-gists at the institution, participates in several academic GI and Liver confer-ences in the Harvard Medical area, and conducts a broad range of investigative and surgical pathology research activities.

The service is headed by Dr. Robert Odze, and typically involves 1-2 fellows. Residents and fellows are encouraged to participate in clinical GI, liver or pancreaticobiliary research projects which include surgical pathology research related to Barrett's esophagus and other GI inflammatory, metaplastic and neoplastic disorders, intestinal dysplasia, inflammatory bowel disease and gastrointestinal polyposis syndromes.

RENAL PATHOLOGY ROTATION

Goals and Objectives:

1. To review the pathological features of the most important and common renal disorders and acquire the ability to diagnose them.
2. To experience the nature and dynamics of an academic renal pathology serv-ice.
3. To learn essential principles of the ancillary techniques used in the evaluation of the renal biopsy.

Under the direction of Dr. Helmut Rennke, the resident will participate in all the daily activities of the renal pathology laboratory and will be involved with the renal staff pathologist in all the steps leading to the final diagnosis of all renal specimens submitted, including consults. These steps involve the examination of the fresh tissue obtained in the ultrasound suite, using the stereomicroscope, evaluation of the suitability of the tissue for structural analysis, dividing the tissue for immunofluorescence, light, and electron microscopy, reading the results, and reporting the findings. Self-teac-hi-ng material, consisting of sets of carefully selected illustrative cases, composed of slides, immunofluorescence microscopy illustrations, electron micrographs and clinical histories will be available. A pertinent list of reading material will be provided. Groups of cases will be discussed and reviewed on the multiheaded microscope.

During this period, the resident should also become familiar with the use of the immunofluorescen-ce and electron microscopy techniques used in the evaluation of renal biopsies, including processing of the tissue, operating the electron microscope, morphometric principles and the evaluation of the basement membrane thickness, calculation of final magnifications on micrographs, etc.

Conferences and other learning opportunities:

Renal Grand Rounds, Tuesday 8:00-9:30 am; one teaching case (often with pathology) is presented followed by a didactic talk (Renal Division).

Review of current cases with staff nephrologists, nephrology fellows, and house staff; every day at 4:00 pm at the multiheaded microscope (Pathology Department).

Journal Club of the Renal Division, Friday 8:30 am.

SOFT TISSUE PATHOLOGY

Goals and Objectives:

1. To develop and expand diagnostic skills in soft tissue and oncologic pathology.
2. To understand and experience the central role of close clinicopathologic collaboration in surgical oncology.
3. To undertake one or more research projects in the field of soft tissue neoplasia.

Experience in Soft Tissue Pathology is obtained as a component of the core rotations in surgical pathology. However, specialized training in the pathology of soft tissue tumors and related oncologic pathology as advanced rotations during the 3rd or 4th years of residency, comprisi-n-g periods of 3-6 months or a year or more may be done under the close supervision of Dr. Christopher Fletcher, Director of Surgical Pathology.

Aside from simple lipomas, in excess of 400 patients with soft tissue tumors are treated surgically at Brigham and Women's Hospital each year, including approximately 250 patients with sarcomas; there is also a joint Dana-Farber/Partners Soft Tissue Sarcoma Clinic treating 650 patients annually for which Dr. Fletcher reviews the pathology. In addition Dr. Fletcher has an international consult service for soft tissue tumor diagnosis and other oncologic pathology which receives approximately 2500 cases per year. Also available is an annotated teaching set of 350 soft tissue neoplasms, covering most of the diagnostic categories.

The responsibilities of an advanced resident include:

1. Coordinate of the handling of soft tissue tumor resection specimens generated at BWH, including participation in the orientation and cutting in of such specimens and the acquisition and suitable apportionment of fresh tissue for special studies (including EM and cytogenetic analysis), snap-freezing and any other pre-defined use.
2. Prepare (including log-in) and review a defined subset (1-2 days/-week) of Dr. Fletcher's consult cases as well as liaison with the SRSP in the handling and review of all institutional consults relating to the soft tissue pathology service.
3. Coordinate and prepare case materials for the Sarcoma Clinic Working Confer-ence held every Monday at 8:00 am in the Department of Pathology at BWH.
4. Attend the daily Soft Tissue Signout (4:30 pm).
5. Coordinate requests for special stains, immunohistochemistry and electron micros-copy generated by the soft tissue tumor service.