MHH  Hematopathology

Category:                    core rotation

Training level:             introductory to advanced (the first month is taken within the initial
                                    eight months of residency training)

Length of rotation:      3 months, taken in 1-month increments

Location:                     MHH hematology lab, 1st floor Robertson

Rotation director:        Andy Nguyen, M.D.

 

Resident Duties

Working hours:  The resident is expected to be on duty from 8am to 5pm.

 

Service duties:  After the morning conference, the resident reviews all pending materials (bone marrow aspirate/biopsy, peripheral blood, body fluid, coagulation, flow cytometry) and prepares a draft for interpretation using all laboratory and clinical data including those from CERNER LIS and EMR.  Cases with complete data are signed out with the attending.  Note that if bone marrow procedures are scheduled, the sign-out schedule will be changed accordingly.  Different residents will be assigned different tasks depending on level of training.

 

The attending will edit and release reports while the resident reviews unknowns (taken from study sets) if time permits (unknowns may not be given on a very busy day).  The resident meets with the attending at 1pm or 2pm (depending on bone marrow slide availability) to review bone marrow aspirates obtained in the morning & other pending cases, and also to review the unknowns.  The resident meets with the attending at 3pm or 4pm (depending on coagulation data availability) to sign out coagulation cases. 

Note that the resident needs to check on all pending cases in the laboratory (hemepath, coagulation cases) throughout the day and to prepare drafts for the reports before signing out with the attending.

 

Lymph node cases that are referred from Surgical Pathology and UT-Outreach Laboratory for consultation are also reviewed and signed out with the attending in the Hematology Laboratory.

 

Typically, two pathology residents are on the rotation each month.  The resident will also work with other trainees on the rotation (one or two MDACC hematology-oncology fellow/month, 1-3 fourth-year medical students/month, 4-5 MDACC hemepath fellows/year, 2 TMH hemepath fellows/year).

 

After hours/weekends:  Residents take night and weekend call per the global DPALM CP call schedule.

 

Conferences:  Residents are required to participate in 8am UTHMS teaching conferences, 3pm CP conferences, and the once-monthly CAP lab management audio conference, unless prohibited from doing so by urgent service duties.  Selected cases will be chosen for presentation by the resident in the 3pm CP Conferences.  Hematopathology journal articles of interest are also selected and presented once a month in one of the Wednesday 3pm CP Conferences.  Residents are expected to critically appraise the article and assess its contribution to the existing literature.  Selected cases are also presented by the residents in the Texas Medical Center Wide Hematopathology Conferences.

 

Goals and Objectives of Rotation

A breakdown according to the six ACGME competencies is listed within the section “Goals and Objectives for Rotations Incorporating Hematopathology”.

 

The resident is to acquire knowledge for the practice of hematopathology and coagulation.  The resident is expected to acquire skills in procuring hematopoietic tissues, examining hematopoietic specimens/coagulation results, and rendering diagnoses, recommending further diagnostic studies and assisting in treatment decisions.  To accomplish this, the resident must acquire expertise in:

 

Hematopathology:

1        Evaluate the patient's clinical history and physical findings.

2        Perform bone marrow biopsies and aspirations

3        Prepare bone marrow specimens of high quality for examination.

4        Examine hematopathology specimens (peripheral blood smear, bone marrow aspirate and biopsy, lymph node), render diagnosis using additional techniques as needed, and give appropriate recommendations to the primary physician.

5        Skills in interpreting special studies: flow cytometry, immunoperoxidase stains.

6        Knowledge about treatments for various hematologic disorders.

7        Work closely with other consulting physicians to assist the primary physician in each patient's care.

8        Utilize nonscheduled time for review of case materials (hemepath study sets) filed in the Hematology sign-out room, as well as other tutorial materials.

9        Read hematology procedure manuals to be familiar with testing methodology and interpretation of hematology tests.

10    Quality control program in hematology.

 

Clinical microscopy:

1        Urinalysis (chemical and physiochemical tests; microscopy of urine sediment).

2        Pleural and peritoneal fluid/cerebrospinal fluid/synovial fluid.

 

Coagulation:

1        Read coagulation procedure manuals to learn methods of performing the tests for investigating patients with coagulation and platelet disorders.

2        Investigation of hemostatic disorders, using information obtained from laboratory tests and clinical information obtained directly from medical records or by consulting with patients' primary physicians.

3        Knowledge of clotting factors/inhibitors, their physicochemical properties, and their relationship to the rational use of blood components and other blood derivatives in coagulopathy.

4        Quality control program in hemostasis.

 

Graduated responsibilities by level of training:

Month 1: (a) learn the routine activities, (b) with help from senior residents and the attending, learn to complete interpretation drafts for clinical reports to be input into CERNER LIS, (c) complete reading topics for month 1 (see core curriculum)

 

Month 2: (a) help junior residents to review clinical cases and to complete interpretation drafts, (b) complete reading topics for month 2 (see core curriculum)

 

Month 3: (a) acting as attending to render preliminary diagnosis and to help junior residents to complete interpretation drafts, (b) work with the attending on laboratory issues such as QC/QA,  correlation studies, (c) complete reading  topics for month 3 (see core curriculum)

 

Teaching Staff

Andy Nguyen, M.D.; and other hematopathology faculty

 

Core Curriculum

 

(A) Self-study materials:

      Reading materials are available for

   -Malignant hematopathology:        http://www.uth.tmc.edu/pathology/faculty/pages/nguyen-nghia/WHO-Review/List.htm

         -Benign hematopathology:            http://www.uth.tmc.edu/pathology/faculty/pages/nguyen-nghia/Heme-Review/List.htm

 

Residents on hemepath rotation need to read the following topics (arranged month-by-month)

 

Reading Topics for Month 1 (indicated with * in list of topics shown in web pages above)

 

Benign Hematopathology

•           Peripheral Blood Examination 

•           Microcytic Hypochromic Anemia 

•           Megaloblastic Anemia  

•           Infectious Agents in Peripheral Blood Examination 

•           Autoimmune Hemolytic Anemia

            Bone Marrow and Spleen Examination

•           Flow Cytometry 

•           Thromboelastograph 

•           Coagulation Essentials 

•           Urine Crystals and Joint Fluid Crystals 

 

Malignant Hematopathology

•           Chronic Myelogenous Leukemia  

•           Acute Myeloid Leukemia with Recurrent Cytogenetic Abnormalities  

•           Precursor B Neoplasm  

•           Precursor T Neoplasm  

•           Introduction, Chronic Lymphocytic Leukemia, Small Lymphocytic Lymphoma 

•           Introduction to Lymph Node Pathology  

 

 

Reading Topics for Month 2 (indicated with ** in list of topics shown in web pages above)

 

Benign Hematopathology

·         Benign Lymph Node Pathology  

 

Malignant Hematopathology

•           Polycethemia Vera, Essential Thrombocythemia   

•           Chronic Idiopathic Myelofibrosis, Myeloproliferative Disorders-unclassified  

•           Chronic Myelomonocytic Leukemia, Atypical Chronic Myelogenous Leukemia   

•           Myelodysplastic Syndromes   

•           Acute Myeloid Leukemia, not otherwise categorized (M0, M1, M2, M4, M5, M6, M7)   

•           Hairy Cell leukemia   

•           Plasma Cell Myeloma, Plasmacytoma   

•           Extranodal Marginal Zone B-Cell Lymphoma (MALT)   

•           Nodal Marginal Zone B-Cell Lymphoma, Follicular Lymphoma, Mantle Cell Lymphoma   

•           Diffuse Large B Cell Lymphoma   

•           Burkitt Lymphoma/leukemia   

•           Peripheral T-cell Lymphoma-unspecified, Hepatosplenic T-cell Lymphoma, Extranodal NK/T-cell Lymphoma-Nasal Type   

•           Hodgkin Lymphoma   

 

 

Reading Topics for Month 3 (indicated with *** in list of topics shown in web pages above)

 

Benign Hematopathology

•           Flow Cytometry Cases    

•           QC and Method Evaluation   

 

Malignant Hematopathology

•           T-cell Large Granular Lymphocytic Leukemia, Aggressive NK-cell Leukemia    

•           Adult T-cell leukemia/Lymphoma    

•           Mycosis Fungoides / Sezary Syndrome    

•           Angioimmunoblastic T-cell Lymphoma     

•           Anaplastic Large Cell Lymphoma    

•           Post-transplant Lymphoproliferative Disorders   

•           Mastocytosis   

 

 

 

(B) Coagulation elective:

This elective is offered twice a year (in combination with Hematopathology rotation) for residents to obtain further training in coagulation.  Trainees are exposed to principles of instrumentation, testing methodologies and interpretation.  Daily conference is held to cover key topics and a series of case studies involving various coagulation disorders.

 

 Case studies:

      http://www.uth.tmc.edu/pathology/faculty/pages/nguyen-nghia/CoagCaseStudies/StudyList.htm

 

  1. vWD
  2. DIC
  3. Hemophilia A
  4. Vitamin K deficiency
  5. Thrombophilia, hereditary (FV Leiden, Factor II mutation, AT III def, etc)
  6. Heparin-associated antibody
  7. Platelet storage-pool disease

 

 Coagulation topics:

     http://www.uth.tmc.edu/pathology/faculty/pages/nguyen-nghia/Heme-Review/List.htm

1.      Coagulation Testing Principles

2.      Coagulation Essentials

3.      Coagulopathy In Surgery Patients

4.      Antiphospholipid Syndrome

5.      Thrombotic Thrombocytopenic Purpura

6.      Molecular Testing for Coagulation

7.      QC and Method Evaluation

 

 Coagulation unknowns:

   http://www.uth.tmc.edu/pathology/faculty/pages/nguyen-nghia/CoagUnknown/CoagCaseList.htm

  17 cases to be discussed together in group, facilitated by faculty

 

 

Reference Materials

 

Suggested Readings:

 

Kjeldberg C:  Practical Diagnosis of Hematologic Disorders.  American Society of Clinical Pathologists

 

World Health Organization Classification of Tumours:  Pathology and Genetics, Tumours of Haematopoietic and Lymphoid Tissue.  IARC Press, 2008

 

Jandl JH:  Blood: Textbook of Hematology.  Little Brown

 

Knowles D:  Neoplastic Hematopathology.  Williams & Wilkins

 

Foucar K:  Bone Marrow Pathology.  American Society of Clinical Pathologists

 

Kjeldberg C and Knight J:  Body Fluids.  American Society of Clinical Pathologists

 

Goodnight SH Jr and Hathaway WE:  Disorders of Hemostasis & Thrombosis: a Clinical Guide.  McGraw-Hill

 

Kottke-Marchant K (Ed): An Algorithmic Approach to Hemostasis Testing. CAP Press

 

Supplemental Learning Materials:

 

Hemepath study sets (14 sets):  approximately 1,400 microscopic slides (peripheral blood, bone marrow aspirate and biopsy, body fluids, lymph nodes) covering a wide spectrum of malignant and non-malignant disorders.  The study-set slides are also used as unknowns for didactic teaching.

 

Web-based Pathology Programs at University of Texas-Houston:  various self-study programs covering malignant hematopathology, non-malignant hematopathology, coagulation, flow cytometry, hemoglobin electrophoresis, and PowerPoint files of interesting Hemepath cases

http://HemePathReview.com

or

http://www.uth.tmc.edu/pathology/faculty/pages/nguyen-nghia/decision.html

 

Hematopathology Virtual Slide Box at University of Iowa:  virtual microscopy for 45 hemepath cases

http://www.path.uiowa.edu/cgi-bin-pub/vs/fpx_browse.cgi?cat=o_hemato&div=iowa

 

 

Hemepath Tutorial (University of Medicine & Dentistry of New Jersey):  tutorial with balanced combination of text and images

http://pleiad.umdnj.edu/hemepath/

 

Atlas of Genetics and Cytogenetics in Oncology and Haematology (Editor: Jean-Loup Huret, Genetics DIM, University Hospital, France)

http://www.infobiogen.fr/services/chromcancer/index.html

 

Syllabus of Human Hemoglobin Variants (Titus H.J. Huisman et al, published by The Sickle Cell Anemia Foundation, GA, USA)

http://globin.cse.psu.edu/globin/html/huisman/variants/

 

 

Additional Materials in Residents’ Manual

Goals and Objectives for Rotations Incorporating Hematopathology

 

Research opportunities

The resident will have opportunities during this rotation to get exposure to research in hematopathology and coagulation.  The scholastic activities will be greatly beneficial to the resident in future clinical practice as well as for credentials in applying for fellowship and job positions.  Clinical cases of pathologic interests seen during the rotation can be written up as case reports for presentation in local/national pathology meetings as well as for publication in pathology journals.  More elaborate research experience may be explored by talking to the hematopathology staff.  This may require extra amount of time to be taken as Clinical Pathology electives.  Research activities must not take priority over clinical activities during the 3-month core rotation.

 

Contact Information

Andy Nguyen, M.D.:  713-500-5337; pager 23699; Nghia.D.Nguyen@uth.tmc.edu

MHH Hematology Lab:  713-704-1693

Cy Ambalathumkal, Hematology Manager:  713-704-1662