UR Medicine Central Labs and UR Medicine Labs have been providing essential, behind-the-scenes services for sites across the U.S. participating in a clinical trial for cancer immunotherapy.
An Elmira man was featured in the local news because he was the first person enrolled at the Wilmot Cancer Institute to participate in the national clinical study of CAR T-cell therapy, which uses a patient’s own immune system to fight cancer. The trial is limited to people with certain types of lymphoma who have not responded to conventional treatment, and who meet strict eligibility criteria.
UR Medicine labs first partnered with a pharmaceutical company in 2015 to adapt and validate as assay for the presence and quantity of CAR19 T-cells in a patient’s blood, based on an a model developed by the National Cancer Institute. Since then the UR labs team has worked to refine and validate the assay for large-scale implementation.
The immunotherapy trial is designed to manipulate the body’s built-in defense mechanisms to fight cancer. Regular antibodies can be effective in fighting infection but are not so useful in killing tumor cells. Research has shown that a certain type of lymphocytes (a disease-fighting category of white blood cells) called T lymphocytes can target and kill lymphoma cells.
These "T-cells" must first receive permission from the body to fight, however. The patient's T-cells are introduced to DNA that first incorporates itself into their genome to produce a new protein – a chimeric antigen receptor (CAR) – that activates each cell, giving it the ability to detect and bind to a lymphoma cell.
"You're bypassing a lot of the regulatory checks and balances that have prevented previous attempts to generate tumor-killing T-cells," said Dr. Dan Ryan, director of Central Labs. "If (the cells) don't become activated, they die off."
Bill Crowe and Paul Rothberg from the Molecular Diagnostics Laboratory are leaders of the group that expanded the NCI test. Central Labs closely monitors test results from participating patient treatment sites across the U.S., and a vast network of lab professionals completes a series of time-sensitive steps.
Staff at Ridgeland Road assembles and sends out testing kits to each treatment site. The blood samples are then received via mail by Specimen Logistics staff six days a week. Technologists at the Tissue Typing Lab at Strong Memorial Hospital, Lymphoma/Leukemia Tissue Bank (SMH), Hematology Lab and Microarray Lab (Ridgeland) are responsible for processing and freezing all of the peripheral blood mononuclear cell blood tubes (PBMCs) for storage.
Phil Rock is a lab technician at SMH whose duties include tracking frozen samples for the CAR T-cell trial. He says the number of samples has skyrocketed since the trial began, which is a positive sign for immunotherapy.
"I think this trial, and the fact that (Central Labs) is growing is great for the department," said Rock. "I enjoy it immensely because having a hand in it allows me to use things that I went to school for and I've been trained to do that previously had no application."
Top: Clinical tech specialist, Jonathan Hoffmann, treats PBMC samples in the Human Leukocyte Antigen (HLA) Laboratory at URMC. Middle: Dr. Dan Ryan, director of UR Medicine Central Labs, which coordinates participation in clinical trials. Bottom: UR Medicine Central Labs kit production coordinator Deidra Davis, left, and Morgan Devaney.
It’s 9:05 on a Wednesday morning and a group of apron-clad pathologists' assistants (PAs) are gathering for morning rounds.
This is a daily meeting during which the pathologists, PAs, and residents meet on the floor of the gross room at the University of Rochester Medical Center.
Raman Baldzizhar, a resident doing his Surgical Pathology rotation, reads the schedule aloud for the group. He states the age and gender of each patient along with their procedure and the name of the doctor doing the surgery.
Today’s agenda includes a prostate, a pancreas, a kidney, a spleen, esophagus, and two stomachs.
After hearing the schedule, the team decides how they’ll divide up the day's work. Moments later, a colleague walks through the door carrying a frozen section specimen. It's a dark brown piece of tissue that was removed just moments ago from a patient's thyroid.
The team has to move quickly: A frozen section specimen is sent for immediate analysis while a patient is in the operating room (OR) under anesthesia. A diagnosis must be made within 20 minutes, which will help the surgeon make a decision during the procedure.
For this procedure, the tissue is literally frozen in a chamber called a cryosat. Once frozen, it is cut into extremely thin slices. A section of the tissue is placed on a glass microscope slide and stained with dye. The pathologist will examine the tissue under a microscope, render a diagnosis and report the results to the surgeon in the OR.
Each day, the PA team works against the clock; tissue specimens start to deteriorate soon after it is removed from the body and deprived of oxygen. For instance, breast tissue has a one-hour window before it must be submerged in formalin fixative to help preserve it.
The hospital’s Accessioning Unit is responsible for transporting specimens between the OR and the gross room. Technicians use an air-powered tube transport system similar to outdoor teller stations used at banks. Or, if the specimen is too large, it will be hand delivered to Surgical Pathology.
On this particular day, Dennis Dening, a PA, is examining a portion of tissue removed from a heart. I ask, What made you want to become a PA in the first place?
“I knew I wanted to do something medical, and I always enjoyed dissection,” he said, keeping his eyes fixed on the specimen.
Specimens come in all shapes and sizes. On average, the Surgical Pathology unit at URMC receives an average of nearly 500 specimens a day. They may be malignant or benign and can vary from small biopsies, such as an atypical mole removed by a dermatologist, or polyp removed during a colonoscopy. Other times, a specimen will be an entire breast or lung removed.
The PAs are responsible for dissecting and describing the specimens, in a process known as "grossing." A detailed gross examination includes information about the appearance of the specimen such as size, shape, color and consistency.
In cancer cases, the PA must identify the tumor and describe the relations of the tumor to the surrounding normal tissue. Once the gross description is completed the PA will determine what sections of the specimen will be examined microscopically by the pathologists.
Laurie Baxter was hired as URMC's first PA 21 years ago and now serves as the supervisor for a team of eight full-time PAs. During her time, has seen a lot of changes in the gross room as more people have shown interest in the profession.
"Once people come here to shadow and realize this is what they want to do," she said.
Since Baxter started her career, she's seen a greater number of students choose to go into the field. She has had four employees that started as biopsy technicians and returned to school to become PA's - and expects more will follow suit in the future.
Currently there are 10 PA training programs in North America with all but one culminating in a 2-year master's degree.
“This is a pretty satisfying job,” said Baxter. “Although we never come face to face with patients, PAs play a critical role in patient care. What we describe and submit for diagnosis directly impacts future treatment options for the patient."
In addition to grossing, PAs train residents and sometimes assist in autopsy procedures. The workflow in the gross room is steady, so the team must work together productively.
Biopsy specimens have the quickest turnaround time (one to two days) but larger specimens can be more work intensive and take several days to complete.
“Every specimen represents a patient," Baxter said. “We can't ever forget that."
And don’t be fooled by the term “gross.” The human body is amazing, after all, she tells me with a laugh.
"Who says it's gross?"
In photos (from top):
Dennis Dening, a PA, dissects a ventricular core (a heart tissue specimen).
Trista Skedel, a PA, checks dictation reports in the gross room at URMC.
A frozen tissue sample that will be cut, stained, and examined under a microscope by a pathologist.
Hilary Haefner, a PA, grosses a breast specimen.
Elizabeth Sharratt dissects a uterus at the grossing station in Surgical Pathology at URMC.
Vendors sell goods in the city of Cape Haitien, Haiti, which is the poorest nation in the Western Hemisphere.
Loralee McMahon was shocked as she asked a Haitian ob-gyn doctor and nurse how surgical specimens were used after an operation.
McMahon, 41, is the supervisor of Immunohistochemistry (IHC) in the Surgical Pathology division at the University of Rochester Medical Center.
In February, she took a solo trip to Haiti where she spent two weeks volunteering in the nation's two largest cities. Her task was to set up a full working histology lab at a hospital and train local lab technicians in IHC.
As she spoke with two women whom she was staying with in the city of Cape Haitien, McMahon was about to get a reality check.
"I said, I'm trying to train people in histology and it would be great if you guys could take the specimens to the lab. What are you doing with the specimens now?"
"We just throw them away," they responded.
Haiti is the poorest country in the Western Hemisphere and, with over 10 million people, the second most densely populated. Like most low income countries, the state of healthcare is bleak and options for cancer diagnosis and treatment are few.
Enter McMahon, who was first inspired to help after hearing Dr. Jennifer J. Griggs speak at URMC. Griggs is a medical oncologist based at the University of Michigan who previously completed a postdoctoral fellowship at UR.
Griggs took a one-year sabbatical to work with two schools with nursing programs in Haiti, which, like many low income nations, lacks the heath care infrastructure to diagnose and treat cancer.
In addition to poverty and overcrowding, Haitians face many barriers to treatment, especially when it comes to breast cancer. Many women live with symptoms of breast cancer before seeking medical attention, Griggs explained. As in other countries, they often fear what a diagnosis might mean for their lives.
"(Women fear) what treatment will involve, losing a breast and no longer being desirable if they lose a breast,” Griggs wrote in an email. “They fear that, even if they get treated, they will still ultimately die of their disease. Major public health efforts are needed to inform women that medical care, when delivered early, can improve their chance of cure.”
After her presentation, Griggs asked how to set up a pathology lab for breast cancer specimens. McMahon and other staff put together a list of equipment to summarize the supplies needed to build a histology lab from scratch. McMahon's interest in joining the effort started to snowball from there.
She contacted Dr. Vincent DeGennaro Jr., an internal medicine doctor and public health specialist at the University of Florida who works for the nonprofit Project Medishare, an organization that built a hospital in the capitol city of Port-au-Prince after the devastating 2010 earthquake rocked Haiti.
After postponing the trip due to political unrest in the country, she arrived in February 2016. McMahon spent the first week of her trip in Port-au-Prince where she trained two young lab technicians at the National Public Health Laboratory (NPHL) and began to set up immunochemistry (IHC) testing on site.
Right: Members of a Project Medishare breast cancer support group (photo courtesy of Vincent DeGennaro).
IHC – the detection of proteins indicative of certain diseases in tissue cells – is almost nonexistent in Haiti. Pathologists are extremely rare, and work in private pathology labs that lack resources to perform IHC. As a result, many send their specimen slides to the U.S. for IHC testing. The resulting turnaround time for lab results is outrageous and the need for independent testing greater than ever.
The mindset of healthcare providers in Haiti is different from that of Western institutions. Hospitals are overcrowded, so treatment must be quick. If a patient has surgery to remove a tumor, the problem is considered "fixed" unless the lump comes back. The tissue is thrown away and the patient is sent home. Needless to say, these conditions put medical research at a great disadvantage.
During the second week of the trip, McMahon saw just how severe things were on the ground. Gone was the air-conditioning and running water at the NPHL in Port-au-Prince as she and her trainees went to Justinian Hospital in the city of Cape Haitien.
The hospital was a collection of fenced-in buildings guarded by armed security while sick and injured patients and their families crowded into an outdoor waiting area. On the first day, McMahon turned on a faucet to wash her hands and nothing came out, so she started bringing jugs of water to work each morning.
The outdoor waiting area at Justinian Hospital. Below: The early beginnings of a histology lab.
Despite the difficult working conditions, the two trainees showed great enthusiasm as McMahon instructed them via the translator who was hired off the street. They were laying the groundwork for a working histology lab at the hospital. They were making small advances every day as McMahon learned to work through interruptions, like frequent power outages that brought her lessons to a halt.
"There were a couple times during the week where I was like, this is way too much," she said.
"I'd come home at night and be like, this is just pointless - Why am I here? Then the next morning the techs would be there before I arrived and be excited and ready to learn."
It's the start of real progress, and McMahon hopes momentum will continue to build as more volunteers provide help. At the time of this interview, a breast pathologist from Canada planned to go in March and bring lab supplies to Justinian Hospital.
Four additional volunteers were slated to go as well, but the project was stalled because the Haitian government would not renew expired paperwork authorizing the crew's large equipment to be taken into the country.
When the lab equipment is finally installed, McMahon hopes the lab at Justinian Hospital will start to see specimens trickle in. As Haitian doctors and nurses start to realize the benefits of pathology in patient treatment, she believes the nation has a fighting chance to combat the cancer epidemic.
"I started telling the surgeons to save their (tissue) specimens. Even if you got a lab tech to take the specimen at least get is started so it doesn't go to waste," she said. "At least practice."
McMahon says she eventually wants to go back to help move the mission forward, but understands that real progress will not happen overnight.
"By the end of the two weeks I saw that this is way bigger than making a histology lab," she said. "But you have to start somewhere."
For information Project Medishare, or to make a donation, click here.
Behind many patient diagnoses is a process that starts in the operating room and ends under a microscope.
UR Medicine Labs has a team of histotechnicians (HT) and histotechnologists (HLT), often referred to as "histotechs," who work around the clock to complete the steps leading up to patient diagnoses for cancer and other diseases.
Histotechs are responsible for taking human tissue to prep, cut, and stain before it's examined by a pathologist. We recognize this important work in honor of Histotechnology Professionals' Day on Thursday, March 10.
"I think most people have never heard of histology," said histotech Wally Pryjmak, who has worked at UR Medicine Labs for two years. He didn't even know what a histologist was when he became a certified medical lab technician. Nevertheless, Pryjmak wants patients to understand the link between his work and their treatment. As he says, "We create the slides your diagnosis is based on, so without us it would be a lot harder to get diagnosed."
The tissue prep process starts after a patient has surgery to remove tissue from the body, often in a biopsy. This tissue is brought to the Surgical Pathology area (located on the ground floor of SMH) and is most often examined first by a pathologist's assistant (PA) who dissects the tissue at a grossing station.
The tissue sample then goes into the hands of a histologist who processes it through a series of alcohols to remove any water, clears tissue in xylene and infiltrates it in paraffin wax. The tissue is then embedded into a paraffin block and the histologist cuts it into paper-thin slices.
Wax slices of tissue then go into a warm water bath to stretch them out and prevent wrinkles before carefully placing the tissue onto a glass microscope slide. The histologist gently scoops the section of tissue onto the slide to dry. He or she then treats the slide with a basic stain (hematoxylin and eosin) to make the sample is easy to see under the lens.
There are up to 75 different stains that reveal certain tissue elements, fungus, or bacteria. A pathologist can request any combination of stains be added before viewing the slide close-up.
In this way, the histologist is part artist and part chef: they must follow a "recipe" of stains to yield a proper reading. Even a small misstep can compromise the diagnosis. Once the slide is treated with the proper stains, it goes to a pathologist who examines it and issues the diagnosis.
The work of a histologist requires careful attention to detail and physical stamina. On average, the histology team at Strong prepares between 800 and 1,200 slides each day.
Diana Scott is the supervisor for histopathology at Strong. To her, the work of a histologist is like an art form. And while patients don't see or speak with the lab team helping behind the scenes, the connection is still very meaningful.
"We care about the production side of things and the quality of the slides," said Scott. "We treat every specimen like it belongs to one of our family members waiting for their test results to come back."
(Top) Histologist Lisa Torregrossa embeds a tissue sample into paraffin wax. Once the wax hardens, the block can be sliced for examination. (Top right) Elizabeth Pilon uses a microtome instrument to slice a piece of human breast tissue that has been embedded in wax.
(Above right) There are more than 75 special stains used to dye tissues so they can be viewed clearly under a microscope. The stains highlight specific tissue components (nuclei, muscle, etc.) or microorganisms (bacteria, fungus) and a combination of stains is often necessary.
(Right) Tissue blocks, or cassettes, are preserved and filed for at least 20 years after a diagnosis is given.