Exploring Academic Soft Tissue and Sarcoma Pathology

Session 180

Dr. Jose Mantilla is an academic doctor who originally wanted to be a psychiatrist but eventually ended up in pathology. We discuss patient interactions and more!

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[02:10] Interest in Sarcoma and Soft Tissue Pathology

Jose initially wanted to be a psychiatrist, which only lasted for one semester. Then when they had the histology course, specifically three semesters of it, he was just drawn into it and realized it was what he wanted to do for the rest of his life. So he made up his mind early on in his first year of medical school.

A big part of his decision is knowing that he is a visually-oriented person. He had planned his rotations and his goals. In his sixth year of medical school, they would do a real internship where they rotate in everything as if you were doing a transitional year. Then in the second half, they would get six months of elective time. Then he did three months in pathology and another three months in clinical genetics.

Jose also had a mentor in the pathology department who was really into bone pathology and did a bit of everything. And he considers his mentor as the one who convinced him the most about it. When he started residency, he wanted to do either bone and soft tissue, or hematopathology, which both share things in common.

After residency, he did a fellowship in general surgical pathology, and then a year of bone and soft tissue pathology.

[04:36] Not Enough Demand for Bone and Soft Tissue Pathology

'It's hard to practice bone and soft tissue pathology alone even in a large academic center, I still do have neck and thoracic pathology.'Click To Tweet

Sarcomas are 1% or less of human cancers. And the amount of benign lesions is not that common either. So if you’re practicing bone and soft tissue pathology, you have to practice in a large academic center that has the orthopedic oncologist and multidisciplinary teams to practice it. But there are many places where you can do it. And when you do it, you want to do something else unless you have a gigantic console service.

With sarcoma about 1% of human cancers, there are hundreds of different types of sarcomas. They all look very different. They all behave very differently. You have sarcomas that are very indolent where you can just excise them, they won’t metastasize and they will behave well. And you have sarcomas that are dead sentences that respond very poorly to therapy.

New emerging round cell sarcomas just have a dismal prognosis versus lower grade sarcomas or benign things that may resemble sarcomas.

So it makes a big difference in how to classify them. Sometimes, there is some overlap. But they have a lot of immunohistochemical and molecular tools. They also do a lot of amateur radiology. Jose believes what they do makes a big difference in how patients get treated and how they’re going to do in the long term.

[07:30] Traits that Lead to Becoming a Good Bone and Soft Tissue Pathologist

First, you have to pay a lot of attention to detail. You have to be both detail-oriented and visually oriented, as long as in any area of anatomic pathology, you have to read a lot. Jose says he has never stopped reading to stay up to date.

Especially in the realm of sarcomas, they always come up with new classifications, new genetic tools, and they describe new sarcoma types all the time.

'You always have to stay up to date.'Click To Tweet

Jose also emphasizes the need to work closely with colleagues. They show each other cases all the time and try to do consensus conferences nearly every day. So it helps to have a good team to work with.

[08:38] The Biggest Misconceptions Around Sarcoma and Soft Tissue Pathology

It’s a major misconception that all sarcomas are terrible. Any kind of cancer is bad obviously. But what they do makes a huge difference as they’re able to find things that respond a lot better to treatment and there are targeted therapies.

“People often think well, sarcoma is bad news, no matter what. That's not necessarily true.”Click To Tweet

Another misconception is that they receive something and they’re some kind of magical black box. Jose explains there’s a lot of subjectivity in what they do.

That being said, they cannot work in a vacuum. They need as much information as possible. For instance, every time they sign up for bone tumors, they look at imaging and they work closely. And sometimes, unfortunately, the bigger the mass, the smaller the biopsy, and people don’t seem to understand that.

So for all future primary care doctors, and even sub-specialists, out there – treat your pathologists nicely and give them as much information as possible because there’s no such thing as too much the issue.

[11:02] Patient Interaction

Jose says there is very little patient interaction in his specialty. Sometimes, patients call his office to ask questions about their diagnosis. But some patients in rural areas don’t necessarily have access to them or call their team. So most of their interactions are with other physicians.

[11:55] The Training Path

To go down this path, you either do three years of residency if you want to do anatomic pathology only. Or you do four years if you do anatomic pathology and clinical pathology combined. Then afterward, bone and soft tissue pathology fellowships are one year.

So at a minimum, it would be four years of training. Jose did two fellowships which ranged from four to six years.

[12:22] Typical Day

Jose has a very flexible schedule. He would usually walk in later in the morning. And when on service, he would go over cases with residents. He looks at the in-house biopsies first, works them up, and orders immunohistochemical stains. Then he looks at the large risk resections.

They usually have the residents get split between biopsies and large resections. And that takes most of his morning through early afternoon. After which, he reviews console cases with the fellows in their institution.

The fellows’ responsibilities usually guide the residents and review slide reviews and call consults from the outside. Some days, he’s on frozen sections, either from 8 am to 12:35 pm while trying to sign out cases.

They also have their sarcoma tumor board up to 40 extremities on Tuesdays and one for visceral sarcomas on Wednesdays. He also covers thoracic and head and neck boards which usually take an hour here and there.

A tumor board is a meeting with surgeons, radiologists, radiation oncology, medical oncology, and these cost complex cases between all the specialties where they try to set up a plan for treatment or additional study. So it’s a very close multidisciplinary work.

As cancer is becoming more complex, they have better treatment options. They have genetic findings that can guide treatment so it’s becoming more individualized. And every patient’s cancer can be treated differently or studied differently. So it makes sense to meet as a team. And this causes cases to try to view the patients the best care they can.

[15:20] Competitiveness in Matching

Jose describes matching as a buyer’s market having very few fellowship training programs. They all know each other and it’s a very small world. So everyone interested ends up in a good fellowship. There’s not a proper match. It’s a more informal process. So it’s generally very low-key.

They have are patients getting oncologic resection for complicated tumors. So the surgeon needs to make sure tumors are completely excised. They get representative sections of the margins they’re concerned about so they can give an estimate or a rapid evaluation or whether a boiler to margin is involved or not.

Brush biopsies are usually more commonly transplant biopsies when they cover general surgical pathology calls. And the most common is transplant rejections.

[17:15] Life Outside of the Hospital and Remote Work

Jose says he has a lot of flexibility. With COVID-19, they use a skylight scanner, a technology where they can scan slides and look at them from home. Jose does this sometimes when doesn’t have a call. And if there’s a residency on-site, they can scan and he could look at them remotely. He says it’s not the same as having the glass slide in your hands. But it’s convenient.

He also volunteered for a program facilitated by the ASCP (American Society of Clinical Pathology) where they review cases from Africa and they look at slides from Uganda. Sometimes, it’s consults of challenging sarcoma cases. And he finds it fascinating to see something across the planet straight from your computer.

“It doesn't feel the same as a glass slide, but you can make a diagnosis.”Click To Tweet

[19:54] Overcoming Bias Against Osteopathy and Message to Primary Care Physicians

Jose doesn’t think there’s any bias several of their residents are DOs. Sometimes, he even jokes about how to do OMT on pathology.

Jose also wishes to tell the future primary care doctors that to prevent frustrations on both sides, they need to understand that tissue doesn’t make it straight from the patient into a glass slide in seconds because it needs to be processed.

'Tissue doesn't make it straight from the patient into a glass slide in seconds – it takes processing.'Click To Tweet

Processing entails the tissue going into formalin to fix proteins. As the tissue rots, it gets dehydrated and the water gets replaced by paraffin through a series of processes. And from that paraffin, the tissue is removed, dehydrated, then stained and cleared so light can go through it.

So that whole process is complex and it takes about eight hours on average. You can speed it up, but it does affect quality. So it’s not productive when you just take a biopsy and call pathology half an hour later asking for results. It takes time to process tissues.

If something’s easy, they can look at it and make a diagnosis in seconds. But some cases are difficult, so they need to think about them. They need to order additional stains and show them around to their colleagues. And so, sometimes if you have to compromise fast or accurately, Jose would always pick accurate.

[23:50] Other Specialties They Work the Closest With

Jose says they work the closest with orthopedic oncology, oncologic surgery for the abdominal surgical cases, medical oncology, and radiology. Essentially, they all work together.

[24:19] What He Wished He Knew Before Entering the Field

When he was a medical student, Jose says he used to think they were also a black box. But he should have known better back then. That being said, he has no regrets about it. It’s part of knowing better.

He then emphasizes the importance of knowing every other specialty of medicine too if you’re going to pathology. Especially if you’re doing a subspecialty that deals with rare diseases, you need to know some radiology as well as some surgery and some internal medicine.

You need to know a bit of everything. Therefore, you shouldn’t blow off all the other specialties because there’s a lot to learn from them.

'It's important to know every other specialty of medicine too if you're going to pathology.'Click To Tweet

[25:37] The Most and Least Liked Things

Jose likes that he’s able to see really interesting diseases and that they work with a nice group. They have a really good collegial environment so it’s very satisfying to make some diagnoses.

And he also finds it to be very satisfying to be able to tell someone that their lesion is benign, especially when they initially thought they had a very aggressive one.

Jose also enjoys the teaching aspect of his job, as well as doing clinical research.

On the flip side, what he likes the least is the administrative issues and burdens, although this goes with every single specialty.

He often fights with insurance companies with molecular testing. They have a really interesting platform based on RT PCR. And they use it to take fusion genes. And about a third of sarcoma entities have some fusion genes that help them diagnose them and drive their behavior.

And then they have this platform that runs something like 100 genes for RT PCR. It gives you an exact fusion gene, regardless of the partner. And so, you can detect a lot of new fusions on top of the ones you know. And getting insurance to approve that test is a nightmare every single time.

[28:21] Major Changes in the Future

Jose thinks the impact of technology on their field is more positive than anything. It might take a lot of the hideous parts of their job away, like scanning lymph nodes. The same was said about molecular as people thought that you could sequence every single tumor to give you a diagnosis, which turned out not to be true. But it’s a really useful tool.

And the same is going to happen with machine learning where they will be able to have computers telling them things that will make their lives easier.

[30:04] Final Words of Wisdom

If you’re interested in going into pathology, it’s good to learn what they do and how the specialty works. Unfortunately, medical school curricula have been getting shorter and shorter on histology and anatomy.

It’s always nice to get a rotation. If you’re interested in rotating pathology, it will make you competitive considering they’re a very small world. So they tend to know each other all over the academic pathology world.