Surgical Pathology Rotations
Head and Neck Pathology
Head and neck pathology involves the study of disease conditions developing over a broad anatomic region including the oral cavity, larynx, nasal cavity, paranasal sinuses, jaw, facial bones, neck, eyes, ears and salivary glands. Therefore, this is a specialty that requires a thorough understanding of the wide range of benign and malignant pathologic entities that can involve a variety of tissues, including skin, mucosal surfaces, bone, teeth, cartilage, soft tissues, salivary glands, lymphoid tissue, nervous tissue and eyes. Over 1600 cases of head & neck pathology are accessioned on average each year. Residents are expected to learn how to handle the entire range of specimens pertaining to this subspecialty, including complex laryngectomy specimens, oncologic specimens from the oral cavity and radical neck dissections. A head & neck tumor board conference takes place weekly with the head and neck surgeons and oncologists, during which residents are expected to present cases and discuss issues pertaining to the pathology and staging of the lesions. Signout of cases is generally done at a multiheaded microscope, and select cases are shared at the daily Peer Review Conference to ensure that all residents in the program get the opportunity to review all interesting or unusual cases.
Pulmonary (Thoracic) Pathology
Thoracic pathology involves the study of specimens removed from the thoracic cavity for diagnostic or therapeutic purposes, including lung, pleura and mediastinum. This includes endoscopic and percutaneous core biopsies of the lung and pleura, video-assisted thoracoscopic surgery (VATS) specimens, wedge biopsies of the lung, and resection specimens of lung, pleura, diaphragm, mediastinal masses and extrapleural pneumonectomies. The residents are expected to gain proficiency in the grossing of all such specimens under the supervision and with the assistance of their mentors, and to develop a clear understanding of the criteria and elements involved in making a correct diagnosis for these conditions. Approximately 700 specimens related to thoracic pathology are processed in our lab per year. Residents rotating through this service also participate in interdepartmental specialty conferences with clinical and surgical departments and are responsible for presenting cases at these interdepartmental meetings.
Gastrointestinal and Liver Pathology
The division of gastrointestinal and liver pathology is the busiest service in surgical pathology and handles approximately 8,000 cases per year. The hospital has a busy GI and liver service and a high volume of endoscopic biopsies are processed yearly through our lab. The division is also in charge of reviewing all major resection specimens for inflammatory bowel/Crohn’s disease as well as a large variety of cancer resection specimens involving the entire GI tract, liver and pancreas. A busy liver transplantation service also provides ample experience in liver transplant pathology. Residents are expected to attain proficiency in the handling of the gross specimens pertaining to these cases as well as to learn the criteria for histopathologic diagnosis of the various conditions that affect the GI tract and liver. Residents participate in various interdisciplinary conferences with clinicians, gastroenterologists, surgeons and radiologists in which difficult and problem cases are discussed.
Gynecological pathology involves the study of the female reproductive system, including uterus and cervix, uterine adnexa, vulva and ovaries. The signout of placental pathology is shared with members of Children’s Hospital pathology department, and is also part of the GYN Pathology rotation experience. Conditions spanning the spectrum of benign, precancerous and malignant are represented, including cervical dysplasias, endometrial polyps and hyperplasia, and the whole spectrum of cancers of the uterus, ovaries and adnexa. Over 5,000 cases corresponding to GYN pathology are accessioned through our lab per year. The residents are expected to learn how to properly handle the grossing of complex gynecologic specimens, and are expected to participate in the GYN tumor board and other interdisciplinary conferences in the specialty.
The breast pathology service handles approximately 1,500 cases per year, and is involved in the interpretation of breast core biopsies, lumpectomies, quadrantectomies and mastectomies in patients suffering from breast cancer and other conditions. The division participates in a weekly multidisciplinary breast tumor board in which all cases are reviewed and the relevant medical information is discussed. Residents are expected to assist in the preparation of cases for the tumor board and actively participate in it. The residents are also expected to learn how to handle and adequately process breast resection and biopsy specimens to provide the complete prognostic information required for guiding the treatment of the patient. Interesting and difficult cases are regularly shared at the daily Peer Review Conference to allow all residents in the program to benefit from the learning experience.
The division of urologic pathology is responsible for the processing and interpretation of all specimens related to the urinary tract, including urethra, ureters, prostate, bladder, kidneys, and male reproductive system. Significant areas include prostate and kidney cancer, as well as testicular neoplasms. Approximately 1,200 cases of urologic pathology are accessioned through our lab per year. Resident duties include grossing of the specimens under supervision by more experienced personnel and signout of cases with the attending physician. The residents are also expected to participate in the various interdepartmental tumor conferences and assist in the discussion and presentation of cases for consultation with the clinicians and oncologists. Interesting or problem cases are shared at the daily Peer Review Conference to ensure that all residents obtain exposure to all the interesting teaching cases seen by the division all year long.
The endocrine pathology division is responsible for processing and interpreting the surgical samples taken from endocrine organs, including the parathyroid glands, thyroid gland, adrenal glands, and the endocrine portion of other organs such as pancreas. This includes benign inflammatory or infectious conditions, hyperplastic processes, and benign and malignant neoplasms of the parathyroid glands, thyroid and adrenals. Approximately 500 cases of endocrine pathology cases are accessioned per year in the department. Residents are expected to attend and participate in the Endocrine Multidisciplinary Disposition Conference, where all aspects of these cases are discussed with a multidisciplinary team of surgeons, endocrinologists, radiologists and other specialists. Residents are expected to learn how to properly gross and handle the specimens under the supervision of more experienced personnel, and to sign out the cases with the appropriate faculty.
Soft Tissue and Bone Pathology
Soft tissue and bone (also known as musculoskeletal pathology) involves the study of all disease processes affecting bones, joints and soft tissue throughout the body. This includes benign and malignant disorders of bone and soft tissue, degenerative and inflammatory joint diseases, and soft tissue sarcomas. The hospital counts with one of the premiere musculoskeletal disorders team in the region and serves as the referral center for the majority of tumors of bone and soft tissue in the State of Wisconsin. Approximately 700 cases of bone and joint specimens and soft tissue tumors are accessioned through the system yearly. A weekly Musculoskeletal Tumor Board conference takes place and the residents are involved in the presentation and discussion of the pathology for the cases. The residents are expected to learn how to properly process complex musculoskeletal resection specimens and properly sample bone and soft tissue tumors for final histopathologic diagnosis and staging. Interesting or unusual cases are regularly shared at the daily Peer Review Conference to ensure that the residents enjoy continuous exposure to the discipline throughout the length of their training.
The dermatopathology division is responsible for the processing and interpretation of all skin biopsies submitted to the lab. Approximately 10,000 skin cases are processed through our lab yearly. The division supports an active outreach program in dermatopathology and services the needs of dermatologic surgeons, plastic surgeons and clinicians throughout the hospital as well as handling the skin biopsies from the Zablocki V.A. Medical Center. Residents are expected to learn how to properly handle shave and punch skin biopsies, how to orient and section resection specimens from skin tumors, and how to elaborate a proper differential diagnosis and reach a definitive diagnosis on histologic examination. The whole gamut of specialized ancillary tests applicable to dermatopathology are available in our department, including fluorescence microscopy, electron microscopy, immunohistochemistry, and a variety of molecular techniques pertinent to the study of skin conditions.
Intraoperative consultation by means of frozen section diagnosis is a critical and integral part of the role a pathologist plays in the health care team. The frozen section rotation in surgical pathology is designed to provide the resident with ample exposure to the variety and different levels of complexity of specimens that are processed using this technique. Approximately 3,500 frozen sections are performed in our laboratory per year. Frozen sections are carried out in our centralized frozen section suite, which counts with newly renovated, state-of-the-art equipment, and is conveniently located next to the tissue procurement station for our Tissue Bank. Communication with the ORs is done through a sophisticated two-way video conferencing system, which allows the pathologist to converse directly with the surgeon via a monitor and to display images from the microscope to explain any problem issues. Residents in the first through fourth years of Anatomic Pathology training participate in intra-operative frozen section consultations. During this rotation, all frozen section intra-operative consultations are the primary responsibility of the frozen section (FS) resident. These are evaluated under the direct supervision of an attending surgical pathologist who is assigned to the General/Frozen service on a weekly rotational basis. This rotation may be done by residents either in combination with the grossing activities during the Surgical Pathology three-month block rotation or as a separate one-month elective rotation. When specimens arrive for frozen section, residents should examine the tissue, perform touch preps if indicated, select tissue to freeze, and orient the specimen for sectioning. Residents should review slides with the FS attending, providing relevant history and previous material when available. Residents are responsible for ensuring that all diagnoses are properly recorded and transmitted to the appropriate OR. The FS resident and supervising FS staff discusses the rotation goals at the start of the rotation. During their rotation, FS residents receive ongoing input from FS faculty that culminates in a formal written or online evaluation in New Innovations. At the end of the rotation, the FS resident discusses his/her performance with the FS staff to see if the goals were met and what areas should be emphasized in future rotations. This process is crucial for monitoring the residents’ progress through their training, and identifying issues which need to be addressed in a timely fashion.