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Brave New World: Pathology in 2020

Brave New World: Pathology in 2020. Dr. Clive Wells University College London. EWGBSP. Breast pathology 2020. With thanks to:-. Paul J van Diest Head, Department of Pathology University Medical Center Utrecht The Netherlands. No more sentinel nodes!.

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Brave New World: Pathology in 2020

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  1. Brave New World:Pathology in 2020 Dr. Clive Wells University College London EWGBSP

  2. Breast pathology 2020 With thanks to:- Paul J van Diest Head, Department of Pathology University Medical Center Utrecht The Netherlands

  3. No more sentinel nodes! • sentinel node procedure is for staging • in 2020 we can accurately stage based on • primary tumor features

  4. No more axillary lymph nodes! • wait-and-see policy for the axilla under • ultrasound follow up • or • radiotherapy of the axilla •  lymph node dissection only in case of recurrence

  5. No more resections! • non-invasive ablation therapy for smaller tumors • radio frequency ablation • highly focused ultrasound • laser induced thermal therapy • neoadjuvant chemotherapy for bigger tumors • adjuvant radiotherapy •  only (bigger) biopsies remain

  6. Extensive typing on biopsies! • Intermediate/high risk benign lesions • reliable markers that predict presence of DCIS or • invasive cancer •  resection, non-invasive ablation • reliable markers that predict progression to DCIS or • invasive cancer •  follow up strategy, resection, non-inv. ablation

  7. Extensive typing on biopsies! • DCIS • markers that predict presence of invasive cancer •  resection, non-invasive ablation • markers to guide • image guided surgery

  8. Extensive typing on biopsies! • Invasive cancer • markers that predict presence of DCIS •  resection, non-invasive ablation • markers to guide image • guided surgery

  9. Extensive typing on biopsies! • Invasive cancer • prognostic markers •  type of adjuvant therapy • predictive markers • type of neoadjuvant therapy • response monitoring by PET

  10. …. but not histological typing…. • … except for quality control! • typing will be overshadowed by biomarker typing • classical typing will merely serve as quality control Luminal A Basal Secretory Adenoid Cystic ER+ PR+HER2- ER- PR- HER2- translocation translocation

  11. Test to detect early breast lesions in nipple fluid • Nipple aspiration • intranasal oxytocin • vacuum • nipple fluid > 90% • 10 gene QM-MSP • (APC, BRCA1, BRCA2, CyclinD2, ERα, • E-Cad, HIN1, p16, RARβ, RASSF1A, TWIST)

  12. Test to detect breast cancer in blood • DCIS and invasive cancer? • methylation • same genes as in nipple fluid • microRNAs • circulating tumor cells • mutations?

  13. Ductoscopy • ductoscopy guided surgery • fluorescent markers • ductoscopic excisions • ductoscopic biopsies • fluorescent markers • (LIFE)

  14. Tissue processing 2020 • uniform protocols to avoid interlaboratory variation • during the day • fully automated (including embedding) • no more toxic chemicals • formaldehyde • xylene

  15. Immunohistochemistry 2020 • fully automated • uniform protocols • within 2 hours

  16. Molecular pathology 2020 • based on “whole” genome sequencing • set of 200 genes that matter • costs 2000 US $ • replaces • single gene mutation • amplification tests • translocation tests

  17. Whole genome sequencing 2020 • primary tumours and metastases • in search of treatable mutations with drugs • implies that molecular makeup is more important • than morphologic typing and origin • requires large pipeline of new targeted drugs • requires a huge setup of early clinical trials

  18. Digital pathology 2020 • all labs have a scanner and decent storage • digital consultation, remote revision, digital slide panels

  19. Digital pathology 2020 • all breast multidisciplinary meetings done digitally

  20. Digital pathology 2020 • enough bandwidth, processor speed and screen resolution to go wireless on PDA/iPad

  21. Digital pathology 2020 • image analysis guided immunoscoring

  22. Digital pathology 2020 • we use image analysis applications to find • mitoses • SN metastases mitoses SN metastases

  23. Breast pathology 2020 • no more histological grading

  24. Breast pathology 2020: no more grading… Markers of mitotic arrest - Therapeutic targets in cell cycle

  25. Breast pathology 2020 • uniform and sensible nomenclature •  no more “atypical” for lesions without atypia • good classification of apocrine lesions • precursor of high grade DCIS identified • more reproducible classification based on • immunohistochemical and molecular markers

  26. Breast pathology 2020 • web based image archive for matching rare cases • all labs have superspecialists in breast pathology • needed or just for consultation? • probably required • molecular breast pathology in all pathology labs • in developed countries (ISH, PCR)

  27. Breast pathology 2020 • What about microarrays? • no more microarrays for prognosis • Mammaprint • Oncotype Dx • no microarrays for molecular typing 2000 euro 3000 $

  28. What is stopping us? • Money for research to explore new areas • Bureaucracy to be overcome before use of tissue (especially UK) • Creating innovation only valued once a commercial market is visible • Salary scale for academics discourages the best people • Multicentre research needed but difficult to organise

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