Pediatric and Placental Pathology Rotation (AP-1 and AP-2)

  • Dr. Brian West (Acting Pediatric Pathologist)

In the current temporary absence of a pediatric surgical pathologist, pediatric surgical specimens are handled by the individual sub-specialty teams at both the resident and attending levels, with the exception of placentas and fetuses less than 20 weeks of gestational age which are signed out by Dr. West. The resident on the pediatric service is also on the Neuropathology and Bone and Soft Tissue rotations, which is convenient as many of the pediatric cases are brain or bone tumors.

Resident responsibilities are similar to those on the other surgical pathology services, though modified by the interim arrangements (above). Many oncologic patients are enrolled in clinical trials, and residents should become familiar with molecular studies and participation with procedures of the national study groups (POG, NWTSG, etc.) for the array of neoplasms seen. Pediatric neoplasm, even those being handled by other subspecialties. The goals of this rotation are to become acquainted with the spectrum of material in this field and to be exposed to the critical role that molecular pathology plays in this particular area. Daily evaluation and supervision occurs in the gross room and at the time of signing out.

The experience in Pediatric surgical pathology complements the pediatric autopsy experience obtained during the Autopsy pathology rotations, building a strong exposure to pediatric and neonatal pathology.

Additional Resident Duties and Responsibilities

  • Attending and present intra- and interdepartmental conferences, such as monthly M&M perinatal and pediatric ICU sessions, weekly pediatric tumor board, monthly pediatric surgical pathology session, ad hoc pediatric pulmonary and pediatric cardiology sessions, etc. Most of these conferences (in particular those related to autopsy cases) require PowerPoint presentations, including gross and microscopic features of each case, ancillary test results, and clinicopathological correlations with with appropriate and updated literature support.

Additional Goals and Objectives for the Pediatric Pathology Rotation

Patient Care:

  • Becoming proficient in the standard techniques for the gross evaluation, dictation, and dissection of pediatric, perinatal, and placental specimens, paying particular attention to issues of diagnostic and prognostic significance. Pediatric specimens differ significantly from adult ones, and also among themselves, depending on the specific age group. Residents need to keep in mind that the key word in this rotation is DEVELOPMENT. Therefore, pediatric specimens are always uniquely characterized according to their age. Preservation of visceral relationships is essential in order to recognize deviations from the normal anatomy (vide infra re: malformations).
  • Knowing special techniques to dissect and submit sections for complex developmental disorders (including Hirschsprung disease, dysmorphic fetuses and abnormal placental vascular anastomoses) and pediatric tumors. Although most rules applicable to adult pathology are useful for pediatric specimens, there are specific needs to take into account. Extensive sectioning and special techniques are required to study certain developmental disorders and pediatric tumors. Frozen section analysis may also be required in some cases.
  • Recognizing when to submit specimens for special molecular techniques required in pediatric specimens (cytogenetics, flow cytometry, electron microscopy, molecular studies, tissue cultures and microbiology studies). Chromosomal and molecular genetic analyses are extremely important in the diagnosis and treatment of many pediatric neoplasms and other pediatric disorders. Chromosomopathies, detected by routine and high-resolution cytogenetic analysis, are frequently diagnostic and prognostically significant in pediatric oncology. Complete and partial moles require flow cytometry and/or molecular analysis, and the same may be true for other placental anomalies (e.g. confined placental mosaicism). Molecular studies for gene rearrangements and other genetic abnormalities (FISH, PCR-based studies, etc), are also frequently required in the analysis of solid tumors.
  • Looking up, prior to grossing and/or signout, any clinical terms, unusual syndromes, or abbreviations used on the requisition form. This is particularly important in pediatrics, since many relatively rare syndromes are part of our daily routine.
  • Reviewing and understanding, prior to grossing and/or signout, key points of the patient's clinical history that may be required for the appropriate interpretation of gross and/or microscopic findings. This may be done by utilizing any of the available electronic clinical information systems (i.e. Sunrise, Centricity, Synapse, etc.) and/or by contacting the clinician(s) in charge of the patient's care.
  • One particularly sensitive issue in pediatric pathology is the proper handling of fetuses. In Connecticut, examination of fetuses >20 weeks of gestation requires an autopsy request signed by a parent, and a death certificate. The autopsy examination is then performed at the morgue by one of the residents in the Autopsy Pathology rotation. The residents rotating in the Pediatric Pathology service need to familiarize themselves with the proper handling of fetuses algorithms, and should contact the Pediatric Pathology attending whenever necessary.

Medical Knowledge:

  • Understanding the clinical significance of the diagnoses being made, including implications for the subsequent treatment and prognosis. Genetic implications are extremely important in pediatric disease.
  • Understanding the basic principles of congenital/developmental diseases (malformations, deformations, sequences, field defects, dysmorphic syndromes, pediatric cancer-predisposition syndromes, and the like), pediatric tumors, inborn errors of metabolism, pediatric age-related infections, placental pathology, and disorders related to twining and multiple gestations.

Practice-Based Learning and Improvement:

  • Using online literature and online searching resources (such as Online Mendelian Inheritance in Man-OMIM) to identify recent advances in our understanding of the disease processes manifested in the cases

Interpersonal and Communication Skills:

  • When indicated, contacting the surgeons, radiologists, and/or other members of the clinical team and eliciting appropriate key information about the patient's medical history and specific questions to be addressed during evaluation of the specimen (e.g., imaging files in bone-related cases, etc.)
  • Always be aware of the increased sensitivity that parents may have in regards to their children's diseases. This sometimes introduces a high level of anxiety, and information needs to be delivered to clinicians promptly and efficiently. This approach should be kept at the level of individual communications with pediatric surgeons and all other pediatric specialists, as well as in interdepartmental conferences such as tumor board, and other sessions. The residents should not get in touch with family members of pediatric patients without previous consultation with the faculty member in charge of the case.

Systems-based Practice:

  • Be aware and able to make adequate use of the multi-institutional consortia that collaborate in gathering information and providing special techniques for tumor diagnosis and prognosis such as the Children's Oncology Group and its affiliates. This requires the ability to provide adequate information and appropriately collected samples, properly stored and transported to the specific centers involved.