Lung Pathology

February 07, 2022

Information

February 6, 2022

Yale Cancer Center

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00:00Funding for Yale Cancer Answers is
00:02provided by Smilow Cancer Hospital.
00:07Welcome to Yale Cancer Answers with
00:09your host doctor Anees Chagpar.
00:11Yale Cancer Answers features the
00:13latest information on cancer care by
00:15welcoming oncologists and specialists
00:17who are on the forefront of the
00:19battle to fight cancer. This week,
00:21it's a conversation about lung cancer
00:23pathology with Doctor Robert Homer.
00:25Doctor Homer is a professor of pathology
00:27and director of thoracic pathology
00:29at the Yale School of Medicine,
00:31where Doctor Chagpar is a
00:33professor of surgical oncology.
00:36Doctor Homer, maybe we can start
00:37off by you telling us a little bit
00:39about yourself and what exactly you do.
00:41So I've come to New Haven in 1979 to
00:45be part of the Yale MD PhD program.
00:47I did a PhD in Immunology,
00:50did a residency in anatomic pathology,
00:52and then subsequently I sort of
00:54risen to the ranks eventually
00:56become a professor in 2009,
00:58so anatomic pathology is an area
01:00that I not sure a lot of people in
01:03the community are familiar with.
01:05It is a branch of medicine.
01:07So pathologists are those people
01:09who've gone to medical school.
01:11We have medical training,
01:13but we've then specialized really
01:15in looking more on the diagnostic
01:18end rather than on, you know,
01:20the the immediate clinical care of patients.
01:2311 way to say it is that we
01:24care so much about our patients.
01:26We want to make sure everybody
01:28has the right diagnosis.
01:30In my particular case,
01:31the area of pathology that I'm in,
01:33which is which is pathology,
01:35is a very broad field,
01:36but the area which I specialize in
01:39predominantly involves looking at
01:41histologic sections of lung tissue.
01:44In order to understand what's
01:46going on with the patient.
01:48We do review radiographs.
01:50I look at X rays,
01:52CT scans and PET scans and other
01:56radiologic imaging routinely.
01:57I look at other clinical information
02:00that's available in patients,
02:01but at the end of the day,
02:03the particular skills that I bring is
02:07understanding the histopathology of
02:09variety of diseases involving the lung,
02:11in particular lung cancer,
02:12but not only lung cancer.
02:15So you know, we've talked on
02:17this show previously about.
02:19About lung cancer and the
02:21fact that almost universally,
02:23for most cancers.
02:26Nearly everything starts with the
02:28pathologist everything starts with
02:29the biopsy so can you tell us a
02:32little bit about the different
02:34kinds of biopsy there are the The
02:37Advantages and disadvantages and how
02:39that impacts you as a pathologist.
02:42I think that's a great question,
02:44so it is certainly true that for
02:46some tumors there are variety
02:48of ways of getting a diagnosis,
02:50but for lung cancer,
02:52particular, as you say,
02:53histopathology really is.
02:55Still is a central element of
02:58the diagnostic process.
03:00The kinds of biopsies when could
03:02obtain range from getting a what's
03:05called a cytology or a smear of cells,
03:09and those cells can be obtained
03:10in a number of different ways.
03:12If a patient happens to have a what's thought
03:15to be a possible metastasis in another site,
03:18you could put a needle in,
03:21maybe even through the skin,
03:22like into a lymph node around the
03:24neck or or under the arms and
03:27just obtain a smear and aspirate.
03:29Just put a needle in.
03:31With a syringe on it,
03:32put a little suction on it at
03:34get a few cells into the Chamber
03:37and then smooth them onto a slide
03:39and stained and looked at it.
03:41Historically,
03:41that was really the major way in
03:43which a lot of lung cancer diagnosis
03:46were made and there was a very
03:48simple classification that that we
03:50used what's called non small cell
03:52and small cell carcinoma and by and
03:55large that very simple technique
03:57of just putting smear cells on
03:59the slide was adequate for that.
04:01And we still use things along those lines.
04:04It might involve, as I said,
04:07putting a needle into the skin into
04:09some very superficial part of the body.
04:11Like I said,
04:12a lymph node or a lymph node
04:14under the armor around the neck.
04:16But it might also involve a medical
04:19procedure where they put a bronchoscope
04:22down the patient into the lungs and
04:24just do a washing where you put in fluid,
04:26and then you aspirate the fluid
04:28out and then again he is take that
04:30fluid and you smear it on his slide.
04:32Or if you have fluid around the lungs
04:33that might take some of that fluid,
04:35and again smeared on a slide,
04:37those are all ways in which, again,
04:39you can use the vast majority
04:41of cases can make a diagnosis,
04:43as one might imagine,
04:44the sensitivity of that is going
04:47to depend on a lot of factors,
04:49the amount of tissue obtained,
04:51the kind of tumor it is,
04:52if it is in fact the tumor,
04:54what else is going on with the patient,
04:57and so those are all you know historically,
04:59that sort of the classic ways
05:01which we did it.
05:02More recently,
05:03I have to say that the we're much more.
05:07We get more information out of what's
05:10called the histopathology of tumors,
05:12whereas if you take that same smell,
05:14cell smear and then you can
05:17prepare it such that you could
05:19make a pallet of cells you make,
05:20take those cells, use pin them down,
05:23you make a collection of cells.
05:25You then actually can take a fix.
05:28Those cells in a fixative in process
05:30them as if they were regular.
05:32Tissue biopsy and then two sections of it.
05:35And then you'll have cells that
05:37you can actually look at in a
05:39diff slightly different way.
05:40The advantage of that method
05:41is a couple of things.
05:43One is you can start looking
05:45at so-called immunostains.
05:47That is, we take antibodies
05:50against cellular components.
05:52We apply them to the tissue,
05:53stain to the tissue section,
05:55and then we sort of see which
05:57elements of the cells are present
06:00and different cells will be
06:01able to stay in a different.
06:02The different patterns in a large
06:04part of my job has to do with
06:06understanding the exact patterns
06:08from different kinds of stains.
06:09They're used again,
06:10they have different degrees of sensitivity.
06:13That is, you know,
06:14are they true positive if it stains,
06:16or if it's negative,
06:17is that really a negative?
06:18And how you know?
06:19And that's a large part of my job,
06:21has to understanding just how good
06:24that processes and understanding it.
06:26In addition to staining again,
06:29these kind of small samples where you
06:31take a smear and you can make a cell
06:33so called cell block out of them.
06:35You can also do biopsies of various types.
06:38One biopsy technique is to again to take a.
06:43Bronchoscope,
06:43which goes into the patient's lungs,
06:46and the bronchoscopies would then
06:47maneuver it down into the lungs,
06:49where he then takes a small piece of tissue.
06:52Using a biopsy forceps and there's
06:54a variety of tissues they can get.
06:56This way they can get some
06:58lung tissue itself,
06:59but they also they're extremely good
07:02at getting using that technique to
07:04get lymph nodes within the chest,
07:06which gives you a sense of whether
07:08the tumor has spread or not
07:09spread to adjacent lymph nodes.
07:11And this is critical for understanding
07:14a therapeutic approaches.
07:15Alternatively,
07:16sometimes the tumor or this deletion
07:19of the suspicious lesion is in the very
07:22periphery of the lung near the chest wall,
07:25and sometimes you'll then have a
07:27go to CT scan and then you can have
07:30someone who can put a needle through
07:32the skin into the lung that way,
07:34so and then of course,
07:35people who have unfortunately more
07:37advanced disease where they might have
07:40a lesion somewhere in the liver or in bones,
07:43those can be biopsied again by.
07:45Usually by CT scan or by under ultrasound
07:48guidance and obtain piece of tissue,
07:50which then again is submitted
07:52for routine Histology.
07:53Finally,
07:54not very commonly,
07:55but occasionally we'll have cases
07:58where there might be a surgical
08:00intervention where you're really
08:02not sure what the lesion is.
08:05And it might be small.
08:06It might be difficult to obtain
08:08and the one way you're absolutely
08:10certain to obtain the tissue that's
08:12diagnostic is to surgically resect it
08:15even without a specific diagnosis,
08:17because if you go through the
08:18appropriate work up from there,
08:19clinicians who really think,
08:21look,
08:21we really think this is probably a cancer,
08:23and the only way we can know for sure,
08:25it's really take it out
08:27and really show the entire
08:29thing to a pathologist.
08:30Problem one of the problems
08:33in lung pathology is that.
08:35Lung cancers or lung tumors commonly
08:37have areas where there's lot of
08:39scarring and a lot of inflammation,
08:40and if you get a biopsy,
08:41which only shows that you're
08:43never completely sure that you
08:45haven't missed an actual cancer.
08:48And so again, with the appropriate work
08:50up and with really careful thinking
08:52and with discussion with the patient,
08:54you might go ahead and actually
08:56surgically remove a nodule entirely
08:59and then send it to a pathology.
09:02At that point,
09:03there's really two choices.
09:04You can either send it to what's
09:07called the frozen section area,
09:08where we have people who are stand by,
09:11you know all the time and we'll
09:13take those and get make a rapid
09:15section out of that and you can
09:17do that by literally freezing the
09:19tissue and then cutting sections
09:21on specially equipped machines
09:23called cry items which can make
09:25sections which the pathologist can
09:27look at within a few minutes of the
09:30specimen arriving in pathology.
09:31Pathologist looks at that and
09:33very quickly makes a decision.
09:35Is this look like a cancer or does
09:38this look like something else?
09:40And those are you know those though.
09:42That kind of analysis is extremely accurate.
09:45I just recently looked at our jails,
09:48institutions experience and,
09:50you know,
09:51in almost all cases it's not perfect.
09:52There are certainly examples where
09:54it's not completely accurate,
09:56but by and large it's a very,
09:58very accurate technique and you can tell
10:01immediately whether it is in fact a cancer.
10:03Alternatively,
10:04sometimes people will simply
10:05take that tissue and submit it
10:07for so-called permanent section,
10:09whereas.
10:09Where we process it as we would any other
10:13specimen where we fix it in fixative,
10:16we then section it.
10:17We then submit it for routine astrology
10:19and that usually takes overnight
10:21if the tissue is small enough,
10:22we might be able to do it the same day,
10:24but usually we do it overnight.
10:26And again we look at it the next day.
10:28And in all these cases again,
10:30we're very commonly would be using.
10:32As I said,
10:33these stains that we can use to
10:34highlight specific molecular
10:35features of the tumor or to
10:37understand exactly what it is and
10:39characterize it a little bit.
10:40Better.
10:42So there are a whole variety,
10:44as you alluded to,
10:46of types of biopsies and types of
10:48techniques of looking at the these
10:51tissues to come to a diagnosis.
10:53I think a few questions come to mind.
10:56The first is when you're
10:58looking at these tiny cells.
11:01You know when you talked about
11:03putting a needle into something
11:04and aspirating a few cells.
11:06I'm sure that people wonder how
11:08easy is it for you to tell that.
11:11Is a cancer cell versus not a cancer
11:14cell or a non small cell cancer cell
11:17versus a small cell cancer cell?
11:20How?
11:20How sure are you when you make that
11:23diagnosis of the diagnosis that you make,
11:26especially when it's just a few cells.
11:31I think I agree that this is
11:32really part of the training.
11:34I think we've all you know,
11:35one of the things that pathology
11:37involves is really a lot of
11:40a lot of hands-on experience.
11:41That's number one number two.
11:43We are very sensitive to the notion
11:45that we don't want to, you know,
11:47call something a cancer that's not cancer,
11:49and so again, as part of the training,
11:51we learn very carefully that there's a
11:53minimum number of cells you really need
11:55in order to make a specific diagnosis.
11:57And there's no, you know,
11:59magic number in terms of
12:00exactly how many cells that is.
12:02But I you know one cell is
12:04certainly not going to be enough.
12:06And you know, is 100 cells necessary?
12:08We certainly get down into,
12:10maybe, you know, 100 cells,
12:12or maybe in some cases fewer.
12:14But largely we're very sensitive for
12:16the notion we really want to see a
12:18population of cells that are really
12:20clearly represent a malignancy.
12:22And the other thing we do is particularly
12:25on the smaller samples we commonly, you know,
12:28pathologists will commonly show things we,
12:29each other.
12:30We're totally, you know,
12:32there's no sense of you know, ego involved.
12:34We show each other things.
12:36What do you think?
12:36What do you think?
12:37Is this enough and we generally anything
12:39where there's even a marginal call.
12:42We show things to each other and
12:44we document that we've shown it to
12:46somebody else who agrees with us.
12:48So that's really sort of
12:49intrinsically baked into our process,
12:51and I think that the you know,
12:52if you actually were to go
12:54and look at the literature.
12:55You'd say that the based on you
12:59know if summaries people have done
13:00this in pathology extensively,
13:02whereas you ask and you go back and
13:03you look at other peoples diagnosis.
13:05How often are you correct and you know,
13:08I can't say everything is perfect.
13:10There's nothing in life which
13:11is completely perfect.
13:12But by and large it's extremely good.
13:15And so I think that you know if
13:17there is really any doubt you know
13:18patients can always ask for to
13:20send it to another institution.
13:21I don't recall a case at Yale
13:23where you know we've had a change
13:25diagnosis along this line, certainly.
13:27People can have other opinions
13:30exactly how to classify a tumor,
13:32but by and large we are very
13:34careful to try to prevent anything
13:36where that's really an issue.
13:39Terrific,
13:40well we're going to learn a lot
13:41more about lung cancer pathology
13:43right after we take a short
13:45break for a medical minute.
13:47Please stay tuned to learn more about
13:49lung cancer pathology with my guest
13:51Doctor Robert Homer.
13:53Funding for Yale Cancer Answers
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15:02yalecancercenter.org you're listening
15:03to Connecticut Public Radio.
15:07Welcome back to Yale Cancer Answers.
15:09This is doctor Anees Chagpar
15:10and I'm joined tonight
15:12by my guest doctor Robert Homer.
15:14We're learning more about lung
15:16cancer pathology and Doctor Homer,
15:18right before the break you were
15:20talking about the fact that
15:21there's a lot of training that
15:23goes into being a pathologist,
15:24and that's really important because.
15:27You know you really need to be able
15:29to recognize the difference between
15:31a cancer cell and a non cancer cell
15:33when making that diagnosis and when
15:37you have questions or concerns,
15:40do you have enough of a sample or
15:42it's kind of a borderline call?
15:45There's really no issue in terms
15:47of seeking another opinion and
15:50you as pathologists do that a lot.
15:53You'll show that to other pathologists.
15:55So one question that people who
15:57are listening might.
15:58Ask is you know, should patients,
16:03when given a lung cancer diagnosis,
16:06seek a second opinion with
16:08regards to their pathology?
16:12At another institution,
16:13if they're not sure, and because,
16:16how can a patient really be sure,
16:19aside from the fact that most of
16:20us have a lot of confidence in the
16:22institutions that we frequent?
16:25I, I think that anytime if there
16:28is a patient really unsure,
16:30you know I'm you know.
16:31I sort of think about this in medicine.
16:33I think this is sort of a general
16:35question about any medical advice.
16:37So pathology report is is medical advice.
16:40I think that if you see an oncologist and
16:42aren't sure about their advice you give,
16:44you should be free to seek another opinion.
16:46If you seek a surgeon and get different
16:48advice you want and you're not happy
16:49with it or you're concerned and you
16:51want to make sure that you've seen it,
16:53you can get a second opinion.
16:54I don't think that.
16:55Salty diagnosis or any different?
16:56I think you would put it in the same
16:58category as any other medical opinion,
17:00and you know if there's really
17:02any any concern.
17:04I think that that's a fine thing to do.
17:07And so you know, I think one of the big
17:10distinctions is cancer versus no cancer,
17:13and one of the things that you
17:15mentioned before the break was that
17:18you're really very careful about
17:20calling cancer versus not cancer.
17:23And so tell us a little bit more about
17:25the nuances you mentioned that you
17:28know there's classifications in terms
17:30of small cell and non small cell.
17:33How do you make that distinction
17:36and why is it important?
17:37Or is it important to patients treatment?
17:41So the historical distinction between
17:43so-called small cell and non small
17:47cell carcinoma really goes back
17:49to the 1960s and 70s where it was
17:52understood that the vast majority of
17:54people with what's so called small
17:57cell carcinoma were most likely had
18:00a systemic disease on presentation,
18:02and they responded to certain types of
18:05chemotherapy that patients with so-called
18:07non small cell carcinoma did not.
18:09And that's really sort of become.
18:11Sort of a founding principle of the field
18:14of thoracic oncology for a long time.
18:18We certainly at the you know,
18:20back in the 60s to 70s we didn't
18:23have really any ancillary so called
18:25ancillary techniques like immunostains
18:27for molecular diagnostics and so
18:28that was really just based on the
18:30morphologic appearance of the cell.
18:32With a few relatively by
18:33our current standards,
18:34crude stains these days,
18:36it's really pretty clear that you
18:39can improve the reproducibility of
18:42the diagnosis by getting some stains.
18:45There is a one particular paper
18:47that I use routinely.
18:49But that's an international that
18:51show that international consensus of
18:52difficult cases cases that people
18:54agreed were not straightforward could
18:57be improved by using immunostains.
18:59And I also think that these days,
19:01with molecular diagnostics being
19:02as advanced as it is,
19:04there are very rare cases where
19:06that can be helped.
19:07It's clear that, again,
19:09so called small cell carcinoma has
19:11a very distinct molecular signature,
19:13whereas tumors of so called non
19:15small cell have a range of other
19:18signatures which really would not
19:19be expected to be seen in that.
19:21So I think that there is,
19:23you know,
19:24the basic diagnosis is certainly
19:26suggested by just routine Histology,
19:28and there's clearly cell,
19:30clearly tumors which are just not small cell.
19:32If you just look at it and say there's yeah,
19:34that's just not what it is,
19:36you know I don't really care about
19:37any of the other markers that are
19:39present and there's other tumors
19:40where you say you know I'm just
19:42not sure those are relatively.
19:44You know,
19:45maybe 5% of cases where people
19:47sort of have that thing.
19:48But of course you know at
19:50any larger Cancer Center.
19:51You know,
19:51like Yale or other large cancer centers,
19:53we see enough cancers that they they show up.
19:55You know, all the time.
19:58So we do have a sort of a,
20:00you know,
20:01a standard protocol for a for resolving that.
20:05In terms of non small cell carcinomas,
20:08we know that there is really two
20:11major subtypes within that admin,
20:13so called adenocarcinoma and
20:16squamous cell carcinoma.
20:18And there's excellent markers that
20:20distinguish those two things from each other.
20:22We know that there's a large
20:24percentage of those cases which
20:26might be surgically resectable.
20:27We also know that all of the you know,
20:29oncology protocols for patients
20:31who do not have resectable tumors.
20:35That's like the first thing,
20:36pretty much in all the protocols is to
20:39understand which of those two pathways it is.
20:41It's in pretty much all the
20:43molecular work up after that depends
20:45on that fundamental distinction,
20:46and a lot of the therapeutic.
20:48Decisions are based on that as well.
20:49Not entirely,
20:50but largely.
20:51We have excellent markers that
20:53distinguish those two things these days,
20:55and all lung tumors that have
20:58enough tissue to evaluate would
21:01most likely get one of those,
21:02unless it's, again, histologically.
21:04You know, quite straightforward.
21:07And so that's really important because
21:09it it influences the type of treatment
21:12that that patients get. Is that right?
21:14It is it distinguished influences
21:16the treatment they get,
21:17but also to a certain extent the work up.
21:20If you have somebody with which seems
21:23to be a like a localized, there rarely.
21:25Again you have cases which are
21:27look like a localized small cell.
21:29The oncologist might try much harder to
21:32really convince himself or herself that
21:34that's really a truly localized tumor.
21:37Because the likelihood that
21:38they're probably missing something,
21:40so they might do a more extensive
21:41work up than they might otherwise.
21:44And it's also true that a lot of our
21:47patients have more than one tumor,
21:48unfortunately, and so a lot of lot
21:51of much of what I do, you know,
21:53is direct with fast conchology is a
21:55pathology or other is to really look at
21:57patients who have more than one tumor
21:59and really connect yourself that what
22:00you're seeing is which of those you know.
22:02Is this really a primary lung tumor,
22:04or is this really coming from somewhere else?
22:07And so understanding that distinction
22:09is important in order to help with
22:11that decision making process as well.
22:14You know you mentioned molecular
22:16diagnostics a few times and I want
22:18to dive a little bit more into that.
22:20It on this show.
22:22We've talked about personalized
22:24medicine and targeted therapies.
22:26The idea that these days pathologists,
22:30can you know, look at these tumors in
22:33a variety of ways to kind of unlock
22:36the genomic signatures of them,
22:38identify whether they express
22:40certain receptors or certain
22:42proteins that then are targetable.
22:45With certain drugs, how common is that done?
22:49It should, should patients be
22:51going to their medical oncologists,
22:53asking about you know whether they have
22:56a a BRAF mutation or a veg F mutation,
23:00or that kind of thing?
23:02Well, the good news is that there
23:04are quite a number of consensus
23:06statements on which tumors are
23:08really the appropriate ones to do.
23:10The mock their testing on their
23:12variety of professional societies,
23:13which include both pathology and oncology,
23:16which is really very, you know,
23:17very explicitly stated who should
23:20get this kind of profiling.
23:23So for example, as I mentioned,
23:25the distinction adenocarcinoma
23:26and squamous cell carcinoma is
23:29really critical and it's really
23:31quite clear that the guidelines.
23:32Or recommend that anyone with a
23:35nano carcinoma should absolutely
23:37have unlocked the profiling.
23:39That's really and at Yale.
23:40Let's say that 100% anyone with
23:43adequate tissue will have that done.
23:46I should also point out the fact
23:47that even though we like to think
23:49of this as a tissue based process,
23:51there's now also the options
23:54to get some of that molecular
23:56profiling done just by a blood test.
23:58It is not as sensitive as getting
24:00adequate piece of tissue, but if it's,
24:02you know if it detects it,
24:04appropriate genetic abnormality,
24:05then it can be.
24:08I think we're all pretty comfortable
24:10that we can rely on it.
24:11On the other hand, as I said,
24:13having an adequate piece of tissue to do
24:15that is still considered the gold standard.
24:18Patients with squamous cell carcinoma,
24:20unless with with relatively few exceptions,
24:24are not thought to benefit from sequencing.
24:27Again,
24:27there are few.
24:28There are a few exceptions and
24:30because there are a few exceptions,
24:31some oncologists do would like
24:33to see their lung cancers from
24:35these patients sequence as well.
24:37But that's a much,
24:39it's more of a very specific decision.
24:42That needs to be done individually,
24:44I think now and I should also point
24:46out the fact that from my perspective,
24:49even though we like to talk about
24:51Gnostics as being particularly important
24:53for specific therapeutic decisions,
24:55so do I have a mutation in a gene
24:58where there's a specific drug that
25:00targets that specific mutation,
25:01which is great when when we have have it.
25:05It's also true that from my perspective,
25:06sometimes that but profiling
25:08could be very useful to decide
25:10whether something is in fact a lung
25:12cancer or from somewhere else,
25:14or it's actually fairly common to have
25:16patients who have had a lung cancer
25:18to then have a second lung cancer.
25:20And sometimes we use it to
25:22distinguish whether is this really
25:23the same tumor which is record?
25:25Or is this really a new tumor?
25:27And at the again there may be
25:28therapeutic implications from that,
25:29depending on the specific
25:31patient circumstance.
25:34So it sounds like you know these decisions
25:36are are really critical and or can be.
25:41Now you mentioned that with Frozen section
25:44you can make a diagnosis in minutes,
25:48but in terms of getting all of the
25:51information you know small cell versus
25:54non small cell adeno versus squamous,
25:56the molecular profiling.
25:58How long does that take?
26:02So the add new versus squamous distinction
26:06so frequently that you know that
26:09depends on the specifics of the tumor.
26:11It's pretty common in a tumor which is so
26:14called well or moderately differentiated.
26:17That is still has histologic
26:19evidence that is producing these
26:21particular histologic features.
26:23You can tell it just at the
26:24time of frozen section would be
26:25pretty comfortable with that.
26:26There are other tumors where it's
26:29a very undifferentiated tumor.
26:30It really does not the Histology
26:31of the just looking at it doesn't
26:33really tell you very much.
26:34They needed a stains.
26:37No, it depends on you know
26:39that could be a day or two.
26:41Might be your students
26:42aren't terribly helpful.
26:43You might do a second round,
26:45so that might be a few days
26:48and then the molecular work,
26:50which includes one marker which helps
26:53determine how available you are or how
26:57effective immunotherapy is likely to be.
26:59With civil PDL.
27:00One stain that should be done
27:02within another few days or a week,
27:04and then they'll look up profiling.
27:05Again, should be done.
27:07There's again national standards
27:08that should be done within two weeks.
27:11So it can take up to two weeks to get,
27:14you know, kind of a thorough
27:16pathologic work up of your cancer
27:18is that is that about accurate?
27:20I think that for lung cancer,
27:21I think that's where we are the
27:23the peripheral blood testing.
27:25If it shows something,
27:26might be a few days before that,
27:28but it's not going to be.
27:29You know, it's not going
27:30to be just a few days,
27:31it might be 10 days instead of two weeks,
27:34but that seems to be where
27:35we are at the moment.
27:37The reason I bring it up is because you
27:39know when patients and people hear that.
27:42You can make a diagnosis in
27:44minutes with frozen section.
27:45They often will then go to their
27:47clinician saying why is it taking
27:50so long to get the pathology back.
27:52On my lung cancer can we
27:55get started with treatment?
27:57So I think that you've kind of
27:59elucidated why it takes so long
28:01and I personally have a maxim that
28:03says never rush the pathologist.
28:05Their opinion is too important.
28:08I appreciate that we all you know
28:11we want to get it right. We all.
28:12I think in pathology we're all
28:14really very aware that somebody
28:15is waiting for these diagnosis.
28:17You know we're not, you know, I,
28:20I always personally have a feeling that
28:22you know should you know should do it.
28:24You should be accurate,
28:25but you should also be fast and I think
28:27that that they're they're both important.
28:28You know nobody is going to cut corners.
28:30On the other hand,
28:31nobody wants to, just, you know.
28:34Slow walk this the diagnosis out the door
28:37yeah so in in our last minute or
28:40two maybe you can tell us what's on
28:43the horizon in thoracic pathology?
28:45What do we have to look forward to?
28:47That's a great question.
28:49I think one of the things going forward
28:52is really a better understanding of
28:54exactly how the immune system works.