Stanford Heme I/O and Surgical Pathology IPOX Rotation

The Heme Inside/Outside (I/O) service consists of the review of case material on patients seeking medical care at Stanford and LPCH hospitals from outside centers. All patients with a hematologic diagnosis, who come to our hospitals for treatment purposes or a second opinion, will first undergo review of their pathology by the hematopathology service. The mornings and early afternoons (until 2 pm) of this rotation are entirely dedicated to and reserved for the heme I/O service, and your biggest responsibility is to sign-out heme I/O cases during that time. The cases will be enriched for those dealing with lymph node pathology, but will also include hematopathology cases involving the spleen, bone marrow and other extranodal sites. The attending will help you triage cases as necessary. Generally, you will sign out your cases with the heme attending after morning conference. Following sign-out, you will complete your reports and communicate with clinicians and outside pathologists as necessary. As new heme I/O cases start to trickle in during the day, you are encouraged to preview and pre-dictate them as time permits. The hematopathology service has assembled slide-based pre- and post-tests that you will take at the beginning and end of the month and review with your attending. In addition, a vast collection of slide-based and digital teaching sets is available to supplement your hematopathology training during this rotation, so please inquire with your attending.

Heme I/O Rotation Faculty:

Dan Arber, MD
Susan Atwater, MD
Dita Gratzinger, MD, PhD
Yaso Natkunam, MD, PhD
Robert Ohgami, MD, PhD
Brent Tan, MD, PhD

The remainder of the afternoons on the service are dedicated to IPOX responsibilities.  You are the primary liaison for ordering additional immunohistochemical tests as well as important molecular tests, such as KRAS and MSI (microsatellite instability).  As Stanford hospital is busy and a lot of requests come in, this aspect of the rotation requires a great deal of organizational skills, and it’s very helpful to have an Excel spreadsheet tracking various pending tests and materials.  It is critical that blocks are forwarded to the molecular lab promptly, so as to enable timely patient care.  When the immunohistochemical stains come out around 2-3pm, you will preview them, render an interpretation, and then sign them out with your IPOX attending.  In addition, any new requests for molecular tests must be reviewed with the IPOX attending during signout.  After distributing the stained slides to the primary resident/fellow in charge of the case, you’ll have time to tie up loose ends and finish previewing and pre-dictating heme I/O cases for the following morning.  The HER2 FISH is read out by cytogenetics, and it is your responsibility to set up a time during the month to review these cases with Dana – this is a great opportunity to learn how to interpret HER2 FISH!  You should also contact the molecular fellow for MSI and KRAS mutation sign-out – these are less frequent and so should leave you time to meet your other responsibilities.  Both the cytogenetics and molecular labs are at Hillview.  There is a free Stanford shuttle that goes to/from Hillview and it is best to arrange visiting Hillview in the afternoons.  HOWEVER, if the cytogenetic or molecular sign-outs go late into the afternoon, DO NOT feel pressured to get back for your IPOX preview (just remember to communicate with your IPOX attending!).  The IPOX attendings can always proceed with the less interesting cases (negative sentinel lymph nodes) and hold the more instructive cases for you when you return.  This rotation is designed for your educational benefit and there is no educational value in ordering MSI, KRAS, and other molecular studies without learning how to interpret them!  Although you are not required to review all HER2, KRAS, and MSI cases during your month on this rotation, you should be sure to garner sufficient experience in positive/negative/equivocal cases to equip you with the necessary knowledge and competence to interpret these tests should you need to do so later in your career. You have no weekend responsibilities on this service.

Surgical Pathology Immunohistochemistry

Bob Rouse, M.D.
John Higgins, M.D.
Kristin Jensen, M.D.
Steven Long, M.D.
Teri Longacre, M.D.
Matt van de Rijn, M.D., Ph.D.
Erich Schwartz, M.D., Ph.D. 
Rob West, M.D. Ph.D.

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