Hematopathology Fellow Responsibilities
The specific fellowship rotations are described below. Fellows also have time to pursue their research projects that may be with faculty in the Division, elsewhere in the Department or elsewhere in the School of Medicine. After their first six months, fellows also participate in the on call schedule (with faculty back-up). Fellows are also active participants in the varied teaching activities of the Division and are expected to be an important resource for residents and faculty in the Pathology Department as well as for clinical fellows and faculty.
SPECIFIC ROTATIONS
1. Adult bone marrow sign-out
(Hematopathology Faculty, bone marrow technologists)
Adult bone marrow sign-out at the UPMC involves assembling the relevant slides and ancillary data, an initial review including the performance of a peripheral blood and marrow differential by the fellow and bone marrow technologist and then a final sign-out with a staff hematopathologist. A preliminary review of marrow smears is also performed within two hours of their receipt. Diagnoses include an interpretation of all ancillary data such as any cytochemical stains or flow cytometric immunophenotypic
studies. Interpretation of studies which have a longer turn around time are expected to be included in addenda to the original report. Initially the fellow reviews cases and then signs them out with a staff hematopathologist while later, with permission of the staff, they are given increasing responsibilities (all slides are reviewed by a hematopathologist). Competencies in signing out marrows and associated phenotypic and genotypic studies is one of the areas stressed in this fellowship. The
fellow is also responsible for being available to review peripheral blood and marrow aspirate smears and marrow biopsies with students, house officers and staff from other departments. The fellow is also expected to perform about ten marrow aspirates and biopsies in the hematology/bone marrow transplant division.
Goals and Objectives
- Learn normal and abnormal blood cell morphology.
- Learn basic approach to bone marrow aspirate, biopsy and particle preparation interpretation.
- Become familiar with the use of ancillary studies in the diagnosis of bone marrow examinations-cytochemical stains, immunophenotypic studies, genotypic studies, and cytogenetic studies.
- Develop a basic understanding of the more common neoplastic and non-neoplastic disorders which involve the marrow: acute and chronic leukemias, myelodysplasias, myeloproliferative disorders, anemias, thrombocytopenias, leukopenias, thrombocytosis, leukocytosis, infections (including HIV), and metastatic neoplasms. Be able
to diagnose cases of the above and understand their biology.
- As year progresses, be able to sign-out bone marrows as independently as current regulations allow and after faculty feels fellow is ready for this increased responsibility.
- Learn to perform marrow aspirates and biopsies.
2. Adult lymph node (and related solid tissue hematopathology) Sign Out
(Drs. Swerdlow, Contis).
The hematopathology division is responsible for the gross processing and final signout of most diagnostic lymph node biopsies (and related solid tissue hematopathology). Residents and the fellow are responsible for handling and triaging the gross specimen, reviewing all histologic material and gathering the ancillary data such as the flow cytometric immunophenotypic findings. Depending on the experience of the fellow, they may at this point, order additional ancillary studies such as immunohistologic stains.
After interpreting everything, the case including the ancillary studies will be signed out with the faculty hematopathologist. Addenda will be issued for ancillary studies such as genotypic studies completed after case has been signed out. This part of the fellowship will include review of any solid tissue hematopathology consults or any consults specifically sent to the faculty on this service. This functional approach to diagnostic lymph node pathology is another area, which is stressed in the fellowship.
Goals and Objectives:
- Learn the use of a multiparameter approach to diagnostic lymph node pathology. (morphology, flow cytometry and immunohistologic phenotypic studies, genotypic studies)
- Learn to diagnose reactive lymphadenopathies, Hodgkin's lymphomas, the non- Hodgkin's lymphomas and other hemopathologic disorders seen in tissue biopsies
- Understand the pathobiology of the above disorders.
- Develop more independence in the work up of lymph node biopsies and serve as an intradepartmental resource.
3. Flow Cytometry
(Hematopathology faculty; flow cytometry technologists).
While most of the interpretive teaching and indications for testing will occur during marrow and lymph node sign out, a more limited period of time will be spent in the laboratory learning some of the technical aspects involved in these studies.
Goals and Objectives
- Understand sample preparation, basic flow cytometry, quality control, gating on specific cell populations, determination of positive versus negative staining and methods of data presentation.
- Know indications for testing, taking into account cost effective medicine
4. Pediatric Hematopathology (Hematopathology faculty)
The object of this rotation is for fellows to become familiar with the most common aspects of pediatric hematopathology: laboratory use of automated instruments, reading bone marrow aspirates and biopsies, and peripheral blood. The fellow learns how to interpret results by integrating the information obtained by these methods with other information produced in the laboratories described above, such as flow cytometric results, molecular findings and immunocytochemistries. They also participate
in the Children's Hospital Tumor Board and in the general hematopathology conferences.
Goals and Objectives
- Learn the unique aspects of pediatric hematopathologic disorders in a fashion similar to that described above for the adult samples.
5. Molecular Diagnostic
(Dr. Jeffrey Kant and colleagues).
The molecular oncology rotation allows the fellow to become familiar with the basic molecular biologic techniques used in hematopathology. The laboratory is responsible for immunoglobulin and T cell receptor gene rearrangement studies as well as studies looking for specific translocations such as those involving the bcl-2 and bcl-abl genes. The fellow will become familiar with the professional functions associated with sample analysis including responsibility for correlating clinical history with laboratory requests to ensure proper clinical testing, selection of tests to be performed, review of test progress, interpretation and communication of preliminary results, interpretation and
reporting of final results in oral and written form, and review of quality assurance and proficiency testing results. The fellow is also welcome to attend other Division functions including the monthly staff CME conference and other educational conferences.
As of 2003, the rotation will be combined with the cytogenetics rotation and last 8 weeks. The first week will be all Molecular Diagnostics or Cytogenetics followed by a solid week of the other discipline. The next 6 weeks will be spent with mornings in Cytogenetics and afternoons in Molecular Diagnostics.
Specific activities and approaches:
[See Attached Checklist]
- Sample processing, methods of preparation Week 1 (and later if necessary)
- Observe individual assays All weeks
- Pre-review studies with resident and MDX fellow All weeks
- Take responsibility to enter data on at least ½ the cases Week 2 and Week 3
- Attend Wed AM Hemepath conf with resident to present MDX data as appropriate and requested All weeks
- Project - in consultation with staff All weeks
- Review basic concepts of molecular biology All weeks (? Piggyback with residents)
- Readings
- Scan all procedures in procedure manual
- Review interesting cases (initially will have to help us compile these)
- Bench experience (via projects)
- 'Case review' (Or library) projects - ideally in conjunction with interests/cases in hemepath.
Goals and objectives:
- Proper use of tests according to clinical circumstances
- Understand routine sample flow for molecular oncology specimens
- Understand different approaches to sample preparation of nucleic acid for blood, bone marrow, tissue and archival specimens
- Understand basic principles of all molecular oncology assays on hematopoietic samples
- Be able to interpret routine Southern blot, PCR, RT-PCR studies associated with hematopoietic samples received by the lab in the context of the overall case and create an appropriate report reflecting that synthesis
- Exposure to molecular assays associated with hypercoagulation
6. Cytogenetics
(Dr. U. Surti, Dr. S. Shekhter-Levin and Dr. S. Gollin).
This rotation allows the fellow to familiarize him or herself with the procedures carried out in the Cytogenetics laboratory, their application to clinical cases, and the roles of classical and molecular cytogenetics in clinical practice, specifically in hematology/ oncology/bone marrow transplantation. The majority of the specimens studied will be bloods and marrows from patients with leukemia or a myelodysplastic disorder.
As of 2003, the rotation will be combined with the Molecular Diagnostics rotation and last 8 weeks. The first week will be all Cytogenetics or Molecular Diagnostics followed by
a solid week of the other discipline. The next 6 weeks will be spent with mornings in Cytogenetics and afternoons in Molecular Diagnostics.
Specific responsibilities [See Checklist] are as follows:
- To review recent articles and text from the cytogenetics literature, to become familiar with the fields of genetics and cytogenetics, cytogenetic methods,
and applications to clinical medicine, particularly with regard to hematology/oncology/bone marrow transplantation.
- To read the laboratory procedure manual to understand the rationale and methods of procedure and the basic safety precautions practiced in the laboratory.
- To observe the basic laboratory procedures: cell culture initiation, harvest, banding, chromosome analysis, and karyotyping.
- To practice karyotyping and interpret the results of this effort in the form of a cytogenetics report.
- To scan G-banded slides in the microscope to compare the results of PHA-stimulated peripheral blood unstimulated blood and bone marrow cultures.
- To review the files of interesting cases to observe the longitudinal changes in karyotypes over the course of treatment and to see how various cytogenetic findings are interpreted.
- The fellows may culture and karyotype peripheral blood cells from himself/herself or another individual to practice the procedures they have learned.
- Didactically review cases with the Laboratory Director and/or Associate, Director during the process of sign out. The fellows are encouraged to present and or work on a case report for publication.
Goals and objectives:
- Learn the indications for cytogenetic testing in hematopathology.
- Be able to interpret cytogenetic reports.
- Know the cytogenetic abnormalities in the major hematopathologic disorders.
- Understand how the different types of cytogenetic tests used in hematopathology are performed and interpreted.
7. Clinical Laboratory Hematology and Special Hematology Laboratories
(Dr. S. Kaplan, Dr. L. Contis)
The general hematology (consolidated) laboratory performs CBCs, routine coagulation studies, urinalysis ,and body fluid counts and smear evaluations. The fellow will become acquainted with the following principles and practice of instrument functioning:
- Coulter Counter: how does the Coulter evaluate blood?, morning set up, troubleshooting, Q.C. procedures, instrument flags, and hands on time.
- MLA Coagulation equipment: morning set up, trouble shooting, Q.C. procedures, instrument flags, and hands on time.
- Urinalysis equipment including the Yellow Iris.
The fellow will also have experience in the preparation and staining of blood smears, review of abnormal results, review of abnormal body fluid results, quality control, quality assurance and proficiency surveys.
The Special Hematology Lab performs enzyme testing, hemoglobin electrophoresis at pH 8.6 and 6.8, osmotic fragility, autohemolysis, urine myoglobin screening tests, and cytochemical staining. The fellow will review and understand the methodology for all procedures, participate in assay procedures, review and interpret data, relate results to clinical data and determine if the test request was indicated, and how data was used.
Goals and Objectives:
- Increase general skills in hematopathologic morphology. (peripheral blood, urines)
- Understand automated hematology, urinalysis, and coagulation instrumentation and develop familiarity with special hematology tests.
- Understand how clinical laboratory testing is utilized in the evaluation and diagnosis of hematologic disorders.
- Develop understanding of how a large complex patient-oriented clinical laboratory facility is managed. This includes an appreciation of the scope of the testing, testing methodology and documentation of test accuracy.
- Specifically, learn the criteria and basis for non-neoplastic hematologic disorders that are diagnosed using general/special hematology laboratory testing.
- Know laboratory quality assurance and quality control procedures.
8. Coagulation (Dr. Franklin Bontempo)
The coagulation rotation for the Hematopathology Fellow is 4 weeks. It is based at the Boulevard of the Allies facility of the Central Blood Bank. The Fellow is provided with a study carrel and a syllabus of the best recent articles on coagulation. The Fellow also will be supplied with a series of sample coagulation profiles to aid in the demonstration of various abnormal coagulation patterns.
The Fellow obtains histories daily on all patients requiring interpretation of coagulation profiles. These patients are usually being evaluated for DIC, platelet dysfunction, abnormal pre-operative coagulation studies, possible lupus anticoagulants, recurrent thrombosis, generalized bleeding, von Willebrand's disease, hemophilia, other hereditary clotting factor deficiencies, or clotting inhibitors.
At the end of each day the Fellow presents the history and is given the opportunity to interpret, or to discuss, the patients' findings with the signout physicians, usually
Dr. Kiss (Director of Apheresis with major interest in platelets, 1 day per week), Dr. Ragni (Director of the Hemophilia Center with special interest in HIV infection in hemophiliacs, 1 day per week) and Dr. Bontempo (Director, Coagulation Laboratory, 3 days per week). For 1 week during the rotation the supervisor of the coagulation laboratory schedules the Fellow to observe the performance of various coagulation tests.
By the end of the rotation most fellows have become familiar with most clinical clotting problems and are able to interpret abnormal findings.
Ample opportunity for clinical research projects are available for interested fellows and their participation is welcomed and encouraged.
The Fellow will be required to do a 15-20 minute presentation on a coagulation topic of his/her choice.
Goals and Objectives:
- Become familiar with most clinical clotting problems and able to interpret abnormal findings.
- Become familiar with how clinical coagulation tests are performed.
Study of DNA content (Dr. L. Contis)
Dr. L. Contis reviews results of DNA content testing that our laboratory has sent out during the fellow's flow cytometry rotation, if possible and at other times.
Goals and Objectives:
- Become familiar with the preparation of specimens, interpretation and clinical significance of DNA content studies
