Biopsies grim future

[WEBB PINKERTON]

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http://www.darkdaily.com/new-pathol...ur-at-the-bedside-with-96-accuracy-60911#more-


Sure looks like a lot of companies are wanting to eliminate our jobs. I've lost tract of all the devices in development to eliminate biopsies. Better make your money while you can and retire young. That is my goal.

 

[pathstudent]

Sounds like pie on the sky. Will they be ae to grade the tumor. They'll still need tissue for ancillary tests.

 

[Whiskeyjack]

Recently attended a grand rounds of a (if not the) top GI pathologist in the US. He is convinced that examination of Esophageal biopsies for aneuploidy is much more effective than histological evaluation in predicting CA risk. He went as far as to suggest that inconsistencies in HE evaluation may in fact be downright dangerous.

 

[raider]

Read the pdf. The study is a joke. Any average pathologist reading this lame excuse of an article will find out the authors have no clue about what a "pathology diagnosis" constitutes. They maybe able to convince a few oncologists because some of those people are as clueless as these clowns from MIT. I remember tearing one of these oncologists a newone when he mentioned the nonsense " tumor origin" BS molecular test. While reading the article, I actually felt sorry for the author's woeful knowledge of what constitutes "real world diagnosis". The GI person mentioned above seems to have had a frontal lobotomy or maybe presenile dementia. I love it when clueless people who fancy themselves experts, talk nonsense with conviction. It is hilarious and a riot. Actually more funny are the *****s who take them seriously.

While we are at it lets get rid of oncologists too, just feed data in a machine and let nurses follow the algorithms and give the medicine, since obviously it's sooooooooo simple.

Yeah sure one day we are going to colonize Mars and maybe do other ****, but not in my lifetime.

Ps. Ofcourse this isn't a criticism against your post WB. I enjoy your posts and they are very informative. Keep up the great work.

 

[yaah]

Tests like this are mainly useful if you already know the diagnosis. Perhaps someday that will change, but not yet. Using molecular studies for Barrett's patients I guess is a possible test, but doubtful that it would replace biopsy, it would merely supplement it.

Everything in medicine, and every type of physician, is POTENTIALLY replaceable by some cool technology or advancement. Pathology will not be the first. Personally, I think molecular testing will start to encroach in certain areas - it already is in some places like pap smears (HPV) and urine (FISH) but these tests don't really replace anything. My wager is that the first places we will see molecular tests replacing biopsy are in cytology - possibly in thyroid. Put the FNA material directly into the molecular test as a screen for specific abnormalities. But even if that works perfectly, if you get a negative test how do you even know it's lesional tissue?

IF computers and diagnostic algorithms are going to replace pathologists, they are probably going to replace radiologists first because the studies are orders of magnitude less complex to a computer (there is just a lot less data). And that isn't close to happening.

 

[raider]

Tests like this are mainly useful if you already know the diagnosis. Perhaps someday that will change, but not yet. Using molecular studies for Barrett's patients I guess is a possible test, but doubtful that it would replace biopsy, it would merely supplement it.

Everything in medicine, and every type of physician, is POTENTIALLY replaceable by some cool technology or advancement. Pathology will not be the first. Personally, I think molecular testing will start to encroach in certain areas - it already is in some places like pap smears (HPV) and urine (FISH) but these tests don't really replace anything. My wager is that the first places we will see molecular tests replacing biopsy are in cytology - possibly in thyroid. Put the FNA material directly into the molecular test as a screen for specific abnormalities. But even if that works perfectly, if you get a negative test how do you even know it's lesional tissue?

IF computers and diagnostic algorithms are going to replace pathologists, they are probably going to replace radiologists first because the studies are orders of magnitude less complex to a computer (there is just a lot less data). And that isn't close to happening.

I agree wholeheartedly with Yaah. Ask yourself has flow cytometry or molecular diagnostics effected heme biopsies? Theoretically, flow is all that is needed in the vast majority of cases.All you need are a few cells and lo and behold run the flow and get the diagnosis. But what about all the Hodgekins and DLBCLs you are going to miss (not to mention the unexpected metastases). Any half decent diagnostician knows that making a diagnosis is not looking at one piece of datum. Diseases are treacherous, they present themselves under different guises and we have at best a very limited understanding of most at present. The more knowledge, experience and pieces of info you have the more accurate your diagnosis will be. Shortcuts (single tests), when one has little understanding of the disease process, will undoubtedly be "disastrous" in a good percentage of cases (as anyone who has has any experience with IHC will tell you). There is no substitute for the trained and experienced mind. And there is no easy way to it. It takes intelligence and a lifetime of learning. And even then expect to be "proven wrong" in a certain number of cases. It is just the nature of the beast we are trying our best to recognize.

These clowns take 40 or so intra-abdominal malignancies (I think they were like two benign cases) run their BS panel of like four markers (HER2, EGFR etc.) and proclaim how their test is going to change AP. Only, lay people (like those writing the dark report or whatever)and maybe some clown docs believe in this "bogus" hype. This is the same population that is fed (and fantastically believes) the bogus hype about how the new onco drug (which has improved survival by 2 weeks in 15% of the population and costs a fortune) is a "miracle" cure. Be a good doc , do not be a clown.

PS. Again, WP this is definitely not directed at you. I understand where you are coming from. I like your posts. This is for the residents etc. who might think they can stop working hard because disease diagnosis is a simple process requiring a "proteomics/genomics blender" that churns out diagnosis. Work hard at being a good diagnostician. Star trek diagnosis (along with interplanetary travel and making hybrid babies with "hot" aliens) will not happen in your lifetime.

 

[Torsed]

I'm with Raider on this one. Some nabob saying this method works in 96% of maligancies in a fairly small sample size is absurd, I wonder how many decades until this passes FDA clearance? What about the other 4% of malignancies that were not detected? No comment on those? What is this comment in the story with protein contamination in the lab, thats a hoot, were not forensics investigators in a shady massage parlor, typical Ph.D. ballyhoo. Not sure what to make of the comments about the if maybe most prominent GI pathologist in the world saying aneuploidy is better than histology. Not sure if that would have helped with the metastatic melanoma that I had in a GI biopsy the other day....

Again, as someone mentioned what about grade and stage? So you can say there is malignancy there? Who really cares, thats what we have radiology for, they suggest every differential in the book, but we all know everyone harrasses the lab for the real answers. I'll try to take the advice and make my money while I'm young.

 

[Whiskeyjack]

He(GI Guy) was actually referring to biopsies screening for BE. I'm assuming that the endoscopist can differentiate btw BE and a suspicious GI nodule.

 

[pathstudent]

He(GI Guy) was actually referring to biopsies screening for BE. I'm assuming that the endoscopist can differentiate btw BE and a suspicious GI nodule.

As far as I can tell all patients that complain of heartburn/abdominal paihenry an upper gi as part of the work up with biopsies of the duodenum, stomach and ge junction. 19 out of 20 times it shows normal esophagus, normal stomach or normal stomach-esophagus with or without a little inflammation. Maybe 1 out of 20 times it shows metaplasia with at most 1 out of ten of those showing dysplasia and probably less than 1 out of 10 of those showing high grade dysplasia. So widespread fish/molecular studies on distal esophagus biopsies to screen for esophageal cancer would be *****ic unless you were the maker of such a test or on their dole which this unnamed expert could be. Maybe it would be useful in patients with established dysplasia. Remember the point of all this is to have a surgery before adenocarcimoma develops. Saying you are going to surgery solely based on a karyotype is extremely irrational.

Now in an exfoliative cytology specimen like urine it is more helpful. But still I have never seen a patient go to cystectomy solely based on urovision.

 

[Whiskeyjack]

Sigh........pathstudent you really should go find out how BE is diagnosed as I cant be bothered to explain it here.. I mean I was pretty specific in my response...I said BE screening (hint: in most parts of the world it is an endoscopic NOT histologic dx). And the aneuploidy is not by FISH/cytogenetics its by flow. As for waiting for index dysplasia cases, sampling issues as well as interobserver inconsistencies complicate H&E evaluation so if indeed the molecular studies have a greater sensitivity why all the hoolah. What is best for the patient right?
I'm a pathologist and I dont want to be without a job but this kneejerk response of vapidly denying genomic advances in a misguided attempt to cement our continuing relevance makes us look silly.
Be like Aniken.....embrace the dark side...much power will you have.

P.S Unnamed expert is one Dr. Robert Odze. Knowing the guy I'm certain he wont be shy about defending his "*****ic" as you put it suggestions.

 

[pathstudent]

Sigh........pathstudent you really should go find out how BE is diagnosed as I cant be bothered to explain it here.. I mean I was pretty specific in my response...I said BE screening (hint: in most parts of the world it is an endoscopic NOT histologic dx). And the aneuploidy is not by FISH/cytogenetics its by flow. As for waiting for index dysplasia cases, sampling issues as well as interobserver inconsistencies complicate H&E evaluation so if indeed the molecular studies have a greater sensitivity why all the hoolah. What is best for the patient right?
I'm a pathologist and I dont want to be without a job but this kneejerk response of vapidly denying genomic advances in a misguided attempt to cement our continuing relevance makes us look silly.
Be like Aniken.....embrace the dark side...much power will you have.

P.S Unnamed expert is one Dr. Robert Odze. Knowing the guy I'm certain he wont be shy about defending his "*****ic" as you put it suggestions.

Let me qualify my comment. I think screening for intestinal metaplasia by flow or FISH is most likely *****ic. Like I said 19 out of 20 biopsies where GI docs write "rule out barrett's" are negative. So instead of doing a $2000 flow study to show that it is negative, I propose sticking with a $40 H&E pathologists interpretation. Does Dr. Odze have data that doing flow on a screening biopsies would reduce mortality from adenocarcinoma or reduce healthcare spending while maintaining a similar mortality or some other benefit? Otherwise what's the point?

I am not denying genomic advances. I am denying vapidly embracing technology for technology's sake. If it makes a difference and doesn't dramatically increase healthcare expenses for at a most marginal benefit, I am all for it.

 

[Whiskeyjack]

Let me qualify my comment. I think screening for intestinal metaplasia by flow or FISH is most likely *****ic. Like I said 19 out of 20 biopsies where GI docs write "rule out barrett's" are negative. So instead of doing a $2000 flow study to show that it is negative, I propose sticking with a $40 H&E pathologists interpretation. Does Dr. Odze have data that doing flow on a screening biopsies would reduce mortality from adenocarcinoma or reduce healthcare spending while maintaining a similar mortality or some other benefit? Otherwise what's the point?

I am not denying genomic advances. I am denying vapidly embracing technology for technology's sake. If it makes a difference and doesn't dramatically increase healthcare expenses for at a most marginal benefit, I am all for it.

He has a paper in the AJG which you should read (http://www.nature.com/ajg/journal/v104/n10/full/ajg2009390a.html). You will find that he (with empiric support) takes issue with our current understanding and approach to the dx of intestinal metaplasia in the first place. So forgive me for not taking your 19/20 neg results at face value. If we can more accurately and objectively determine risk of CA with flow rather than subjectively through morphologically equivocal features I beleive that it could have a significant impact (fiscally and morbidity) on how often pt's present for f/u re biopsy for BE and progression to dysplasia evaluations. Read the paper and we can again share opinions. As a balance you might also like to read the letter responses to the article which are also insightful.

 

[raider]

He has a paper in the AJG which you should read (http://www.nature.com/ajg/journal/v104/n10/full/ajg2009390a.html). You will find that he (with empiric support) takes issue with our current understanding and approach to the dx of intestinal metaplasia in the first place. So forgive me for not taking your 19/20 neg results at face value. If we can more accurately and objectively determine risk of CA with flow rather than subjectively through morphologically equivocal features I beleive that it could have a significant impact (fiscally and morbidity) on how often pt's present for f/u re biopsy for BE and progression to dysplasia evaluations. Read the paper and we can again share opinions. As a balance you might also like to read the letter responses to the article which are also insightful.

Dude where do you practice? I love these theoretical i.e. extremely impractical suggestions that sometimes emanate from people who fancy themselves experts (WTF is that actually? you work for a low salary at some brand name place that gives it to you 24/7 and if you are sucker enough to stick long enough you become an expert????? you may have an IQ of like 70 but hey you work at Harvard or Hopkins or whatever so you must be right). The world of "genomic advances" as you call it is rife with graves of "the newest and most important advance". I cannot recall how many times people have got excited only to realize after having wasted enough money that they were STUPID to begin with , as an example consider the subclassification of DLBCL by the much touted study (if I am not wrong they were like a hundred so called experts aka *****s on that paper) into GC and nonGC. For sometime, a few more idiots joined the bandwagon and did unnecessary immunostains. Well everyone knows the rest of the story. The same BS is going on with breast cancer , all the basal crap. Do not underestimate disease. Nothing can replace the trained mind. Look at all testing with a critical eye. There are no shortcuts. And predicting time to cancer progression based on aneuploidy by flow? Laughable (if you still do not get why this is beyond hilarious to me, google "aneuploidy+normal+ benign"), these experts must have *****s for their audiences. Next time challenge them and show the audience how stupid their idea actually is. You will be doing everyone a favor.

Molecular testing has a place in diagnosis. It is called ancillary testing. I am sure when IHC came along some geniuses thought it was the end of the anatomic pathologist. Just stain the slide, let the computer detect the brown and viola you have the diagnosis. Go ahead try that and kill some poor patient.

What is tissue morphology. It is the ultimate expression of disease at a moment in time. What is needed is not some fancy test, but rather the trained eye and the sharp AND CRITICAL mind to glean "clinically relevant" info and make reasonable predictions. Go on develop those skills and when all the molecular tests have failed, I promise they will come looking for you for help. I say this from personal experience and any half decent diagnostician will know what I am talking about.

Ps. For the sake of the GI pathologists patients I hope you misunderstood what he was trying to say. I bet what he was trying to say was that in "a very limited subset of patients" (not all patients) it may be worthwhile to consider "aneuploidy by flow" in addition to biopsies to establish screening interval.

 

[Whiskeyjack]

Dude where do you practice? I love these theoretical i.e. extremely impractical suggestions that sometimes emanate from people who fancy themselves experts (WTF is that actually? you work for a low salary at some name brand place that gives it to you 24/7 and if you are sucker enough to stick long enough you become an expert?????). The world of "genomic advances" as you call it is rife with graves of "the newest and most important advance". I cannot recall how many times people have got excited only to realize after having wasted enough money that they were STUPID to begin with , as an example consider the subclassification of DLBCL by the much touted study (if I am not wrong they were like a hundred so called experts aka *****s on that paper) into GC and nonGC. For sometime, a few more idiots joined the bandwagon and did unnecessary immunostains. Well everyone knows the rest of the story. The same BS is going on with breast cancer , all the basal crap. Do not underestimate disease. Nothing can replace the trained mind. Look at all testing with a critical eye. There are no shortcuts. And predicting time to cancer progression based on aneuploidy by flow? Laughable, these experts must have *****s for their audiences. Next time challenge them and show the audience how stupid their idea actually is. You will be doing everyone a favor.

The thing is raider, I often think you do have some poignant concerns. However your delivery is usually wanting. I understand the use of hyperbole but chill out with the vitriol. You'll have a much bigger impact on us Type B's without it. If that is your intent.
No one is trying to take your cookie OK we're all just trying to make it taste better.😉

 

[raider]

The thing is raider, I often think you do have some poignant concerns. However your delivery is usually wanting. I understand the use of hyperbole but chill out with the vitriol. You'll have a much bigger impact on us Type B's without it. If that is your intent.
No one is trying to take your cookie OK we're all just trying to make it taste better.😉

Dude! I am not a mean person. The only reason why I get riled up is when I see a professional behaving like the lay public. It is one thing if the public is fed some nonsense and they take it hook,line and sinker and pay extra for it (I do feel sorry for them though), but a professional should always be critical . A professional is "the expert". Every practicing pathologist is the expert for the patient whose case they sign out. If I was mean to you, I apologize. That is never my intent. I just get carried away(I know it is a weakness, and I am working on it). Part of my response is logical, part emotional (I usually regret the emotional part but even achilles had his heel). Again, to all forum members my intent is never to hurt. If I did not think that the substantial majority of people on the path forum are awesome (from whom I learn some very interesting things), I would not waste my time here.

 

[KCShaw]

There's certainly a difference between something perhaps having potential, in certain circumstances, to have a markedly increased role, and quite another to jump from maybe some potential that could be explored in a research atmosphere to changing the way of life as we know it. History is far more full of ultimately empty declarations than accurate prophecies. Doesn't mean at least some of them don't deserve examination.

 

[Enkidu]

The other day in neuropathology slide conference we looked at a case where a patient had a prior diagnosis of GBM, which was treated with radiation and chemo. He had some neurological symptom about 6 months later and some lesion on MRI. The clinician wanted to know if it was a relapse of the GBM or something else.

When we examined the biopsy all we found was radiation necrosis with islands of residual tumor. The residual tumor was pretty sick looking. There was no relapse of the tumor.

I thought the case was pretty interesting, and it made me think that no molecular test or point-of-care test was going to diagnose this patient.

 

[scienceguy19]

Molecular test might pick up what tumor type it is from residual dna, but probably won't tell you that it's necrotic.

The other day in neuropathology slide conference we looked at a case where a patient had a prior diagnosis of GBM, which was treated with radiation and chemo. He had some neurological symptom about 6 months later and some lesion on MRI. The clinician wanted to know if it was a relapse of the GBM or something else.

When we examined the biopsy all we found was radiation necrosis with islands of residual tumor. The residual tumor was pretty sick looking. There was no relapse of the tumor.

I thought the case was pretty interesting, and it made me think that no molecular test or point-of-care test was going to diagnose this patient.

 

[yaah]

The other day in neuropathology slide conference we looked at a case where a patient had a prior diagnosis of GBM, which was treated with radiation and chemo. He had some neurological symptom about 6 months later and some lesion on MRI. The clinician wanted to know if it was a relapse of the GBM or something else.

When we examined the biopsy all we found was radiation necrosis with islands of residual tumor. The residual tumor was pretty sick looking. There was no relapse of the tumor.

I thought the case was pretty interesting, and it made me think that no molecular test or point-of-care test was going to diagnose this patient.

That's because currently the "diagnosis" is based on methods which don't include molecular tests. That could change.

Increasing molecular testing will require many many new studies to determine what the results actually mean. So much of what oncologists do and how prognosis and treatment are guided is based on current pathology practice. I think a lot of people presume there will be significant overlap between histology and molecular results, but there probably won't be. And no one is really going to know what results mean for a while, and how to relate them to histology findings.

 

[KCShaw]

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