High Def Scope to assess polyps (Disruptive technology)

[WEBB PINKERTON]

More disruptive technology in the news...

http://www.eurekalert.org/pub_releases/2014-12/mc-mcp121614.php

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[LADoc00]

Bwhahahahahaha 95% accurate. So 1 in 20 cases, the technology under-assesses carcinoma and the patient dies....

One word: Morcellator.

this crap will never see the light of day in most places. One bad outcome in the WSJ and every small town attorney will be slapping up billboards all across America. Perhaps this is research is being Dark Funded by the ABP/CAP/ASCP Black Ops style. Maybe the plan is to have us make a windfall amount in the all the malpractice suits...fascinating. SUPER Disruptive technology WEBB! But Disruptive like a Taliban suicide vest filled with C4 for the gastros.

No, Im afraid these shields will quite operational by the time your friends arrive..

 

[Sulfinator]

You all are just fantastic.

 

[WEBB PINKERTON]

Hell, when bundled payments come you will wish they do ANYTHING to assess polyps..My fear is that shot callers will tell docs to throw em in the trash and their salaries will be tied to NOT USING the laboratory as much as possible.

I better change my avitar picture because of those North Korean hackers. It's just a matter of time before they see Team America World Police. America, f*ck yeah!

 

[LADoc00]

FREE WITH EVERY GI SCOPE! NOW FROM OLYMPUS!!


I would love a "national movement" to throw specimens in the trash without histologic examination.

The legal consultation fees I would get would be LEGEN......wait for it....DARY.


as I said: Super Disruptive Technology.

 

[Sulfinator]

Yep, fantastic.

 

[Alteran]

Lawyer: Is it standard of care to assess the malignant potential of a GI polyp by endoscopic camera viewing alone?

GI Doc: Yes (because I have a fancy endoscope with cool optics that I get to surcharge the patient for beyond what a normal endoscopy would bill for).

Lawyer: So, do you believe standard of care was rendered when Ms. Smith's 4 cm polyp was snared and tossed away into the trash without a pathologic evaluation because you said it was "not malignant" by endoscopy? And if so, how do you explain a malignant perforation of bowel at that site 2 years later with biopsy proven liver and lung metastasis by colorectal adenocarcinoma?

GI Doc: .....

 

[pathstudent]

I disagree

Lawyer: Is it standard of care to assess the malignant potential of a GI polyp by endoscopic camera viewing alone?

GI Doc: Yes (because I have a fancy endoscope with cool optics that I get to surcharge the patient for beyond what a normal endoscopy would bill for).

Lawyer: So, do you believe standard of care was rendered when Ms. Smith's 4 cm polyp was snared and tossed away into the trash without a pathologic evaluation because you said it was "not malignant" by endoscopy? And if so, how do you explain a malignant perforation of bowel at that site 2 years later with biopsy proven liver and lung metastasis by colorectal adenocarcinoma?

GI Doc: .....

I disagree with your premise. I can't see any endoscopist discarding a 4 cm polyp.

I agree with that article that says that polyps under 5mm are extraordinarily uncommonly to be malignant.

I have never seen a 2mm carcinoma of the colon. Maybe one in a million are. But we as a society might just to have to let those go.

 

[Alteran]

I disagree


I disagree with your premise. I can't see any endoscopist discarding a 4 cm polyp.

I agree with that article that says that polyps under 5mm are extraordinarily uncommonly to be malignant.

I have never seen a 2mm carcinoma of the colon. Maybe one in a million are. But we as a society might just to have to let those go.

I have seen a patient transplanted for an angioimmunoblastic T-cell lymphoma solely off of a lymph node FNA flow cytometry finding...as in that was the only workup she had prior to being transplanted. This one among other really unwise medical decisions I have personally seen, I believe that incredibly stupid things will be done if 1) peer reviewed articles with "good data" say its okay even if contrary to common sense and 2) an extra buck can be made or saved.

 

[pathstudent]

Where the heck was that done? I hope they had the sense to try steroids, cyclosporine, or CHOP first. I can't imagine classifying any T-cell lymphoma based on flow. Other than CLL, I can't think of many B-cell lymphomas that you can purely classify off flow.

Incredible.

 

[cmz]

Where the heck was that done? I hope they had the sense to try steroids, cyclosporine, or CHOP first. I can't imagine classifying any T-cell lymphoma based on flow. Other than CLL, I can't think of many B-cell lymphomas that you can purely classify off flow.

Incredible.

I don't think a flow report would ever have stated "Angioimmunoblastic T-cell lymphoma" as their main diagnostic line. Perhaps, "Immunophenotypically aberrant CD10(+) T-cell population..." and giving "angioimmunoblastic T-cell lymphoma" as something high on their differential. I bet there is more to this story than that... they would have at least looked at a PET scan (hey, they already have a proper node to excise!), performed a bone marrow, etc before starting something that aggressive. Perhaps this is a recurrence in a patient with a known diagnosis and there is outside material that you're not aware of?

I would hope that the pathologist looking at the FNA of the LN along with the flow report would be somewhat soft and ask for an excisional biopsy before making such a diagnosis. At the end of the day, that's all on the oncologist anyway... they should know that flow is just an ancillary test and there's a limit to what you can do with an FNA specimen of this caliber (even if you had a cell block in this case). Suffice it to say, I would never diagnose AITL without staining the heck out of it.

As a side note, "CLL" isn't always straight forward via flow. In fact, the only diagnosis I could ever plainly make on flow has been B acute lymphoblastic leukemia.

 

[pathstudent]

How about "often times you can diagnose CLL purely based on flow."?

 

[cmz]

How about "often times you can diagnose CLL purely based on flow."?

"consistent with CLL/SLL" Purely academic, but how often would a CD5(+) B-cell monotypic population with dim CD20, dim surface light chain, etc be something NOT CLL/SLL? I don't know that answer myself... maybe never?

 

[Tissue issue]

I disagree


I disagree with your premise. I can't see any endoscopist discarding a 4 cm polyp.

I agree with that article that says that polyps under 5mm are extraordinarily uncommonly to be malignant.

I have never seen a 2mm carcinoma of the colon. Maybe one in a million are. But we as a society might just to have to let those go.

I've seen several 2mm carcinoids in the past few months alone.......... I'm sure many of us have.

 

[yaah]

Yeah I put this on twitter but given like 16,000,000 colonoscopies annually a 4-5% error rate is a HUGE number of potential errors. 96% sensitive sounds great except when you think about how many individuals that means.

Left unsaid of course is whether this high def scope costs more and results in higher charges. And also, are they going to increase the surveillance rate to the typical "adenoma" follow up any time they see any polyp? That would increase charges too.

I don't think in its current form this will have a huge impact. Maybe the technology will improve in the years to come though, no doubt it will. Eventually scopes will probably be able to do on site molecular analysis and classify the polyps immediately.

 

[Animus]

This sounds like the same sky is falling mentality that went along with, immunostains will eventually replace H and E, said long ago. Then it was molecular will eventually replace H and E and immunostains, that has been said for years, how has that worked out? In fact imo molecular has only continued to further confuse morphology and immunos and lead to a greater need for such things in combination.

 

[WEBB PINKERTON]

Another device in the news....

Ignore technology all you want but some of these will be reducing the number of biopsies dramatically. Pathology better be going "interventional".

http://www.businesswire.com/news/ho...sers-Sound-Waves-Deeper-Melanoma#.VHT9e-Z0ypo

 

[royal blue]

Technology like this is still at the gimmick phase, and will probably be so for decades. The most it can hope to be is a supplement, not a replacement. Isn't the whole rubrik based on the correlation of endoscopic with pathologic? Just because the endoscopic exam might improve, doesn't make the pathologic portion any less definitive or vital. The complete uplifting of histology is highly unlikely.

And as someone said before, it takes just one case...

 

[yaah]

Technology is definitely going to reduce biopsies in some areas. But bear in mind that technology is also going to increase biopsies in other areas - by seeing things that traditional methods did not see, for example. Where it evens out is anyone's guess. I don't think anyone doubts that as the years go by there will be fewer traditional biopsies followed by morphologic diagnosis, but the real questions are when and to what extent.

 

[icpshootyz]

Another device in the news....

Ignore technology all you want but some of these will be reducing the number of biopsies dramatically. Pathology better be going "interventional".

http://www.businesswire.com/news/ho...sers-Sound-Waves-Deeper-Melanoma#.VHT9e-Z0ypo

I don't see this changing things one bit. Most skin biopsies are not done for melanoma at all, certainly not presumed melanoma. As a dermpath I would say way less than 1% of my biopsies are for actual suspected melanoma. The vast majority are benign moles (including dysplastic), NSMCs, SKs, warts, rashes, and other non-melanoma diagnoses. Not to mention this device can in no way differentiate between melanoma in situ arising within a compound nevus, nor invasive melanoma that comprises only a portion of a compound nevus. Not to mention deep penetrating nevi, clonal nevi, cellular blue nevi, etc. I really don't see this tool providing any real use for dermatologists. The wise ones would still wait for the histopathologic diagnosis will full prognostic staging before doing any further surgery or treatment.

 

[royal blue]

What about amelanotic melanoma, that wouldn't produce melanin to absorb these "signals"?