Pediatric and Perinatal Pathology
Goals and Objectives
During training, each Resident will master the following skills:
- Understand the specific roles of Pediatric Pathology in the clinical practice of specific subspecialties.
- Understand appropriate manners of communication with parents and treating physicians.
- Learn to read and understand pediatric intensive care unit and pediatric hospital charts.
- Appreciate the three major roles of the perinatal pathologist: immediate diagnosis for the care and treatment of the mother and infant, determination of the primary and secondary causes of perinatal morbidity and mortality, and genetic counseling and prediction of recurrence risk.
- Read and understand obstetric and neonatal intensive care unit hospital charts.
- Learn appropriate forms of communication with parents and treating physicians.
Have a working familiarity with the etiology, diagnosis, and treatment of:
- Pediatric tumors: "Small, round blue cell tumors" - neuroblastoma, primitive neuroectodermal tumor, intrabdominal desmoplastic round cell tumor; Renal tumors- Wilms' tumor, mesoblastic nephroma, others; Pediatric bone and soft tissue tumors- rhabdomyosarcoma, osteosarcoma, others; Germ cell tumors- yolk sac carcinoma, teratoma, Liver tumors- hepatoblastoma, hepatocellular carcinoma, others; Lymphomas including Hodgkin's disease; Childhood leukemias, pediatric brain tumors, histiocytic disorders-Langerhans cell histiocytosis, Rosai- Dorfman disease, others.
- Gastrointestinal diseases: including reflex esophagitis, Hirschsprung's disease, neonatal necrotizing enterocolitis, malabsorption syndromes, inflammatory bowel disease, infectious colitis, allergic disorders.
- Genitourinary diseases: reflux uropathy, undescended testes, herniorrhaphies.
- Hepatobiliary tract diseases: infantile cholestasis, autoimmune and drug induced hepatitis, others.
- Metabolic diseases: glycogen storage diseases, Wilson's disease, Niemann Pick, Gaucher, tyrosinemia, galactosemia, urea cycle enzyme deficiencies, fatty acid oxidation defects.
- Infections: pediatric AIDS, lymphadenitis, osteomyelitis, H. Pylori, infections of immunocompromised host.
- Immunologic disorders: AIDS, congenital immunodeficiency, autoimmune disease, asthma and allergy.
- Transplant Pathology (liver, heart, bone marrow, kidney, lung): rejection, vascular problems, associated conditions.
- Renal diseases: nephrotic syndrome, other glomerular diseases, cystic disease.
- Endocrine conditions: congenital adrenal hyperplasia, hyperinsulinemia, thyroid disease, calcium and bone disorders, intersex disorders.
- Pediatric forensic pathology: sudden infant death syndrome, child abuse, child neglect.
- Diseases of Pregnancy: gestational trophoblastic disease, spontaneous abortion, ectopic pregnancy, intrauterine fetal death, preterm birth, fetal growth restriction, preeclampsia, acute and chronic abruption, perinatal asphyxia, congenital infections (toxoplasmosis, rubella, cytomegalovirus, herpes, syphilis), chorioamnionitis.
- Chromosomal Abnormalities: trisomies 13, 18, 21, monosomy X, triploidy.
- Major Congenital Malformations hypoplastic left heart:, ventricular septal defect, atrial septal defect, tetralogy of Fallot, truncus arteriosus, anomalous pulmonary venous return, endocardial cushion defects, patent ductus arteriosus, coarctation of aorta, Eisenmenger's syndrome, neural tube defects, hydrocephalus, Potter's syndrome, osteochondrodysplasias.
- Conditions of neonatal period: neonatal/hypoxic-ischemic encephalopathy, intraventricular hemorrhage, newborn respiratory conditions, iatrogenic lesions, neonatal necrotizing enterocolitis, early onset neonatal sepsis, complications of prematurity.
Practice Based Learning and Improvement
Acquire and master the following skills:
- Surgical gross room techniques for the evaluation of tumor resections, explant organs, organs removed for non-neoplastic disease, skin specimens, bone specimens, open lung biopsies, endomyocardial biopsies, rectal suction biopsies.
- Autopsy techniques for older child with particular reference to congenital heart disease, malignancy, metabolic disease, infection.
- Autopsy techniques for fetuses (fragmented or intact), stillbirths, and neonatal deaths with or without congenital anomalies.
- Normal Histology: fetal, neonatal.
- Interpretation of pediatric clinical pathology tests including, metabolic disease screens, hemoglobin electrophoresis, flow cytometry of leukemia-lymphoma, cytogenetics of congenital anomalies and pediatric tumors, granulocyte function studies, pediatric blood transfusion.
- Interpretation of perinatal clinical pathology tests: amniotic fluid chemistry, Kleihauer-Betke test, maternal-fetal antibody testing, serology of infection and autoimmune disorders, blood gas interpretation.
- Gross and microscopic examination: spontaneous abortion and gestational trophoblastic disease, fetuses and newborns third-trimester placenta
- Patient Presentations: Prepare and present interdepartmental conferences, Prepare and present Pathology Grand Rounds.
- Research: Identify areas of potential investigation, Formulate methods appropriate to carry out a potential research project.
Interpersonal and Communication Skills:
- Acquire a clinically relevant patient history from the treating physician.
- Compose a pertinent autopsy discussion clearly stating the primary and underlying causes of death.
- Present pediatric tumors and other cases at clinical management and M & M conferences.
- Discuss the diagnosis and interpretation of perinatal and pediatric surgical pathology, autopsy, and frozen section cases with the treating physician.
- Appreciate the role of ancillary staff: pathology assistants, histology, transcription.
- Respond in a timely manner to all clinical questions.
- Triage and prioritize cases that you are responsible for.
- Render and communicate diagnoses in a precise, unambiguous, and clinically responsive manner.
- Admit, rectify, and learn from mistakes.
Systems Based Practice:
- Use hospital information system to gather patient data.
- Master all aspects of the Anatomic and Clinical Pathology information systems.
- Use computers to access information from online databases.
Training in pediatric and perinatal pathology takes place throughout the AP curriculum, which is spread over years 1, 3, and 4. Residents receive specific pediatric and perinatal pathology instruction in each of the three components which make up the AP core. The total pediatric and perinatal pathology experience encompasses approximately 62 weeks of the 144 week AP curriculum.
Surgical Pathology and Frozen Sections: residents gross and signout pediatric and perinatal specimens one of every two days spent on this rotation. Pediatric and perinatal specimens consist of 15-20% of all surgical accessions at our hospital. Residents participate in the preparation and analysis of all pediatric intraoperative consultations (approximately 5-10/ week).
Residents are encouraged to become involved in the ongoing clinical and basic research projects of the pediatric and perinatal pathology staff and their collaborators from both the clinical and basic science departments of the hospital and medical school. Dedicated time may be devoted to projects during the third and fourth-year electives block.
Duties and Responsibilities of Residents by Year
Perinatal and Pediatric Autopsy Pathology
Residents are initially trained by being paired with an experienced Resident, then assume independence for their own cases. Residents assume graded responsibility, first as apprentices, then as practitioners, and then as teachers and supervisors.
Are encouraged to concentrate upon technical skills, and to collaboratively sign their cases with the Attending Pathologists. Residents should be aware that pediatric and perinatal autopsy procedures differ in many ways from those used for adult autopsies. Special concerns, procedures and differential diagnoses differ with the age of the patient. The first year Resident should develop an appropriate approach to the fetal, newborn and child categories.
Senior (PGY3,4) Residents
Are expected to bring autopsy cases for signout in essentially complete form, ready for approval by the Attending Pathologist. Autopsy techniques for patients of different ages should be mastered.
Perinatal and Pediatric Surgical Pathology and Intraoperative Consultations
The expectations for Residents training in pediatric surgical pathology are divided into four levels of experience.
First Year Residents, 1st 6 months:
- Demonstrate habits of punctuality and efficiency in the cutting and frozen section rooms.
- Read and understand the Pediatric Pathology Resident's Manual and relevant sections of the Surgical Pathology and Autopsy Manuals.
- Learn the location and contents of common sources of the major pediatric pathology textbooks and journals.
- Develop competence in reporting information to and receiving information from clinicians whether in person or by telephone.
- Learn how to perform a good frozen section and touch preparation.
Gross Room Skills
- Become competent at gross description of common specimens.
- Learn to section tissues thinly to allow adequate fixation.
- Learn to use the gross photography equipment.
- Learn to select, prepare and if necessary, fix tissues for various specialized laboratories, including cytogenetics, immunohistochemistry, flow cytometry and molecular diagnostics.
- Review and master normal histology.
- Become competent at microscopic description.
- Learn how to perform microscopic photography.
- Understand the use of common special stains
- Diagnose with relative confidence common placental and gastrointestinal lesions.
- Participate actively in teaching Medical Students during Pathology electives and in Medical School Pathology course (all 4 levels)
- Recognize cases that may add to the existing base of knowledge in Pediatric and Perinatal Pathology.
- Show evidence of reading at the textbook and review article level.
First Year Residents, 2nd 6 months
- Begin to recognize and seek to correct specific deficits in one's fund of knowledge.
- Know when to seek advice.
Gross Room Skills
- Take responsibility for the completeness of the information brought to signout including adequacy of histologic sampling, selection of special studies, and formulation of a working diagnosis.
- Be able concisely to describe and perform the technique for cutting in most major specimens as described in the various resident manuals specified above.
- Competently formulate a differential diagnosis for most lesions.
- Demonstrate ability to use journal literature to solve diagnostic problems.
- Develop diagnostic skill with more difficult specimens including pediatric tumors, pulmonary pathology, inflammatory bowel disease, common bone lesions, liver lesions unique to infants and children, and lymphoproliferative diseases.
- Participate actively in conferences
- Identify areas in need of investigation.
- Formulate methods that might be used to solve a research question.
- Discuss most topics at the textbook level and review journal article level.
Third Year Residents
- To improve diagnostic acumen.
- To troubleshoot difficult logistical problems.
- To oversee the performance of other Residents and students on service.
- To be a liaison between residents and faculty in case of problems/conflicts.
Gross Room Skills
- Able to gross in large specimens without direct supervision
- Able to help supervise junior Residents.
- Able to diagnose most cases and be aware of limitations
- Able to select appropriate areas for frozen sections
- Correctly interpret many frozen sections.
- To teach junior Residents both gross and microscopic pathology
- Become involved in the preparation of interdepartmental conferences.
- Prepare and present a case discussion for Pathology Grand Rounds.
- To become involved in studies with senior faculty members.
- Aware of controversies in diagnostic pathology.
- Read and integrate the latest literature into day to day practice.
Fourth Year Residents:
- Function essentially as a junior colleague of the faculty.
- Able to effectively supervise other Residents effectively acting as "Chief Resident" if needed.
Gross Room Skills
- Able to gross virtually any specimen with little supervision.
- Able to formulate a final diagnosis for most cases with limited supervision.
- Able to supervise frozen sections
- Able to interpret most frozen sections.
- Functions as a general resource for all junior Residents and rotating medical students.
- Research Skills
- Present original work at local and national meetings.
- Have acquired through reading a complete base of knowledge in Pediatric and Perinatal pathology.
- Able to help junior Residents organize work and avoid mistakes and delays in sign-out.
Resident Supervision and Evaluation
Each pediatric pathologist evaluates residents in the following manner:
Evaluation of Medical Knowledge and Practice Based Learning and Improvement occurs at the time of microscopic signout in Surgical Pathology, formulation of the Preliminary and Final Anatomic Diagnoses in Autopsy Pathology, and performance and interpretation of frozen sections at the time of Intraoperative Consultation.
Evidence of progress in utilizing a Systems Based Approach to Pathology Practice is assessed by review of the resident's handling of specimens, interaction with the clinical staff, and preparation of surgical and autopsy reports.
Formal on-line evaluations of each Resident (MyEvaluations.com system) addressing the following criteria: Patient Care, Medical Knowledge, Practice Based Learning and Improvement, Interpersonal and Communication Skills, Professionalism, System Based Practice, and Research and Scholarly Activities.
Each residents performance on the annual In Service examination is reviewed in detail
Critique and modify case presentations and research projects.