Integrating Molecular Information Into Your Anatomic Pathology Practice

- (techno music) - This is Lab Medicine Rounds, a curate podcast for physicians, laboratory professionals, and students. I'm your host, Justin Kreuter, the Bow Tie Bandit of blood, a transfusion medicine pathologist at Mayo Clinic. Today, we're rounding with Dr. Jorge Torres-Mora, assistant Professor of Laboratory Medicine Pathology at Mayo Clinic. Dr. Torres-Mora is an anatomic pathologist and program director of the Bone and Soft Tissue Pathology Fellowship at Mayo Clinic.

Thanks for joining us today. - Hey, thank you very much, Justin. Thank you for inviting me. This is, I feel honored, and I think it's a very relevant, very current hot topic in molecular in pathology. I'm happy to be here and hopefully I can help to spread a little bit more of awareness on this discipline. - Yeah! I think that's exactly what we're going for. Is this kind of blending on how do we think about anatomic pathology,

but then also all this molecular information, maybe you can kick us off with why is molecular information important for you in your practice to integrate anatomic pathology? - Oh, sure, definitely. That is a great question. Of course, nowadays, with all these molecular advances, the field of pathology is completely different to what it was only, let's say a decade ago, right?

So many new discoveries, so many new technologies and we are doing a good job incorporating them into the clinical practice. So, molecular pathology is important for me as a pathologist, as a diagnostician for several reasons. But I would say three important things. One is Diagnosis, which is what I do. That's my main job. I diagnose what a tumor is, et cetera, is it benign, malignant, what's the type, what lineage.

The other important thing that is a little bit more helpful for the clinician is therapeutic and prognostication, right? I can tell you a little bit about more of every one of those reasons, diagnostic, for instance, we are lucky nowadays to have one extra layer of verification for our diagnosis. In the past, it was okay, unusual two more, not very specific, or it doesn't fit in a specific box, so I don't know what it is, I think it's this.

Other people, other experts would say, "I think it's the other thing." Other expert would say a different thing. Now a day, we have an extra layer of information that we can incorporate. We can do a molecular technique and we can tell us, "Oh, you know what, "this has a specific fusion. "Oh, pathologist one, two or three has the right answer." This fusion is diagnostic for such a such specific entity. So that's one reason, more accuracy in diagnosis.

Second reason is, you know, we are discovering nowadays that what we thought the normal morphologic spectrum of some tumors is actually wider than we initially believe, right? We see that for instance, recently, we have seen a couple of cases I give you one example of many, Extraskeletal Myxoid Chondrosarcoma, very classic malignant tumor, but with a protractive clinical course.

Nowadays we are seeing cases that, look High-grade spindle cell sarcomas, and then you look at it, and you wouldn't think this are Extraskeletal Myxoid Chondrosarcomas until you do the molecular and you find the characteristic fusion or characteristic gene rearrangement, and you say, "Oh! Wait a minute, "let me go back to that slide."

And then just sure enough in retrospective you go back and look at those little foci in between the high grade tumors, that look like classic Extraskeletal Myxoid Chondrosarcoma, right? So, is very important for us to expand in you know, the spectrum, the two spectrum of tumors. Another layer of verification in further expand our knowledge about tumors. The other reason, you know, recently one of the best example is more round blue cell tumors.

Ewing sarcoma, one of the most common small cell sarcomas in kids, if not the most. In the past, everything was Ewing sarcoma or Ewing-like sarcoma, right? Nowadays, with the all these availability of molecular techniques, we are seeing that, the tumor that in the past we used to call Ewing-like sarcomas are actually a very heterogeneous group of tumors that have different molecular iterations, different prognosis, different response to treatment, and it's not just a single entity.

So that's very useful for the clinicians, for the parents to know what what to expect, this tumor is gonna respond to you in therapy or not, et cetera, for a variety of reasons. And lately, therapeutic is so important, with all these precision targeted treatment for a variety of tumors. I can tell you many of them, but one of the most successful stories we heard of lately in Trachomas, right? One of those, tissue agnostic treatment, right?

Like the clinicians can treat locally advance or metastatic NTRK-rearranged tumors, regardless of what we see on the light. They're trying to get rid of us in a way but (laughs). Hopefully, it doesn't happen in my lifetime. But it's one of those things that, we tell them, listen this tumor has an NTRK1 rearrangement.

They can treat it with NTRK inhibitors and the patient can respond wonderfully. And it's just one story of many others. I think we are in the earliest stages. But I hope in the near future, these stories become more and more and more frequent and everybody can have a very specific tailored treatment to specific tumor, specific person.

- Yeah, I like how you're highlighting how this is really made and really continues to reinvent pathology really in the tip of the sphere, for what's the accurate diagnosis, therapeutic, we should use. What kind of prognostic information, you've really articulated that. Something else in your answer that I just wanted to pull out here and maybe ask a follow up question. You're talking about, this is something that, in the last 10 years really has been a revolution.

And so something I'm interested in, because, interested in how do we learn new information? I imagine that, could say, well, you know, there's a lot of molecular information thats come out new. But I'm certainly here focused on my morphology or something But, how did you recognize that molecular information was really a critical competency for you to develop as an anatomic pathologist? Cause' this has happened during your career so far. - Yes, exactly.

And I can tell you, even, like I said, at 10 years ago I was in a different hospital. A very big cancer center, doing my fellowship there. And we didn't even have the availability of fees for MDM2 for well different cell liposarcomas, which nowadays is almost unthinkable, not to have it, right. So yes, my career has been developed along the new discovery. So I have seen this evolution along my relatively short career. It is very important. So how do I recognize it?

Well, it's kind of impossible not to in the place we work, right. We work with so many different teams and colleagues that are always up to date trying to find what's the best for the patient what's out there, what's new? And then, that's very important, they call me, "Hey, listen." The oncologist, for instance, they tell me, what about this, you know Imatinib for genes, is this Gene's KIT mutation or not? It's just a example of many. So that make me, oh, let me look into that.

Let me see what's out there. What can we do to to tell you this particular tumor has a KIT mutation or not? Then I go and ask my molecular colleagues, right? I don't do molecular. I'm not part of that select group of smart people. I just do whatever they come up with. But every time I have a question, I go ask them, "Hey listen, what do I have? "I wanna prove this tumor has a KIT mutation. "What do I do?" So they tell me, okay, go do the Genes paneling on a test

you know, mutation for the exon, so and so. We gonna test for PD for alpha. We gonna test for SDHV, et cetera. So, first of all, going back to your question, the other colleagues always push you especially here at Mayo Clinic to be at the advance in the front age of the most recent advances, right? The other thing, my all pathology colleagues who that do similar things that I do there is always communication sharing of cases. And I learn from them, right?

The most senior colleagues they all also from the more juniors, that we exchange information and we share cases and stories, like it'll have a similar case and I did this, and I contacted this and this. I have this new paper. I went to this course, et cetera. So is a group effort where you have to be always alert and try to be up to date, to see what's out there. - I see.

And so, I like that you're highlighting colleagues both within your team, as well as outside and as I hear you, sorting to pick up, what are people interested in? What are the oncologist talking about? That's been a driver, as well as conversations,

it sounds like, during your pathology conferences with them. Do you find yourself going to different sessions than when you go to conferences? Are you specifically kind of paying attention to ones that have a molecular thread through them? - No! Well, first of all, we go to interdisciplinary conferences here. That are more focused on what I do, right? The Bone soft tissue with my colleagues, the interdisciplinary groups, orthopedic oncologists, right?

We have every Thursday morning, we have a joint conference with other services, radiology, oncologists, radiation, oncologists, et cetera. We all get together. And they present cases and at the end, they give a very nice little summary what's out in the literature and we all get to pitch in. If somebody has a question for a specific discipline, specific specialty, somebody answers. And that's how you learn from your colleagues.

And now from, also the outside conferences, I don't go to a specific molecular. I try to go mostly virtual. Morphology in general, because I do a lot of general surgical pathology. And there is a little bit of everything morphology,

immunohistochemistry, molecular in every single one of them. So basically you put everything together, and then you integrate and adopt what your colleagues need and why you think it is important. - I see. And so what do you think for our audience, right? which is a mix of students, clinicians, laboratory professionals. How do you recommend that we all kind of continue to embrace new opportunities in clinical practice?

- Well, I guess the most important thing Justin is to create a channels of communication with your colleagues, with the other teams. If you don't create those channels of communication, you're going to get cut off of the the most cutting edge technology. What do your colleagues need from you? You're gonna be stuck in the past. So most important thing is create relationships. Communicate with them. What do you want from me? What do you need?

We sometimes, I try to ask my colleagues, "Hey, what do you need? And my report, is this enough for you? Do you want me to do any specific tests that is gonna help you?" Sometimes, not every molecular test is helpful for them. So we have to be aware that not to waste resources, right? So it's a constant communication. But I would would say that the communication with your clinical colleagues and your own interest to keep yourself up to date. What's out in the literature

to what are your other leading hospitals doing, is very important. Of course, very important to keep in mind that you are here. The main reason are the patients and the better you do your job, the most the patients are gonna benefit, and is gonna give you more satisfaction and fulfillment. That's why we are here. - You know, I'm kinda struck by how you're talking about setting up these channels of communication. I'm curious, how has this changed or has it changed since you started practice?

We're talking about how molecular has kind of come down the pike and really been something new that's added onto your practice, is this importance of channels of communication. How has it changed in recent years do you think? - Well, I think it may be just my imagination, but I think, in the past, at least when I was a fellow resident, a lot of times it's like the pathologist just tell them what it is.

And then the clinician decides what to do, because you just tell them the diagnosis and just a diagnosis and you don't offer a too much more information, right? Of course, prognostication is always important, and the morphology is enough to prognosticate case sometimes But nowadays there are so many things that as a pathologist we can offer. Like I said, therapeutic implications, new entities that in the past we didn't know about. And we are starting to create new classifications, new schemes.

So, I think the pathologists nowadays have way more to offer not only diagnostic, again therapeutic and prognostication even more than in the past. - Wow! So it sounds like that communication has always been a constant. But has gotten more complex in recent years. - Exactly, way more complex. And that's a good point. You're right, hitting the nail right there, because there is so complexes that were so much information out there. So many new discoveries every day, that is hard to keep up.

Now, you have to work with your colleagues to filter what's important, what's clinical significant. What's gonna help the patient, basically through signal, what is background noise, right? So for that, you cannot do it by yourself. You need the help of your colleagues and a good team effort. - Wow! That's been wonderful. So, we've been rounding with Dr. Torres-Mora.

Thank you for taking the time to talk about molecular in anatomic pathology, and really on this theme of talking about complexity and communication. - Awesome! It had been my pleasure and I'm available, you guys have my contact information. If anybody has any interest, will be my pleasure to talk about it. - Thank you.

And If you or audience would like to hear more on this topic be sure to register for the Virtual Surgical Pathology Symposium 2022, where our very own Dr. Torres-Mora will be presenting cases on Bone soft tissue. This conference is being held on May 13th. So, check the show notes for the link to register. (techno music) To all of our listeners, Thank you for joining us today. We invite you to share your thoughts and suggestions by email.

Please direct any suggestions to [email protected] and reference this podcast. If you've enjoyed Lab Medicine Rounds podcast, please subscribe until our next rounds together. We encourage you to continue to connect lab medicine and the clinical practice through insightful conversations. (techno music continues) (techno music fades)