As the number of vaping-related illnesses continues to climb in the U.S., pathologists who diagnose lung injuries as part of a larger healthcare team, say it’s not easy to see the signs of vaping under a microscope.
But that may be changing as scientists identify the visual cues common in patient specimens, whether or not they are forthcoming about their vaping habits. A new study published in the New England Journal of Medicine (NEJM) and reported in The New York Times compared vaping related lung damage to the same type of damage caused by chemical burns.
Moises Velez, M.D. is the director of the Thoracic Pathology subspecialty service at the University of Rochester Medical Center. He and fellow cytopathologists, Tanupriya Agrawal, M.D., Ph.D. and Ellen Giampoli, M.D. shared more about the ways in which vaping is showing up in everyday diagnoses, and how recognizing the signs can get patients help quicker.
What exactly does a thoracic pathologist do, and what do they look for?
Normal lung cells as seen under a microscope after staining, at 20x magnification.
Visible inflammation in lung cells of a patient known to have vaped (magnified at 40x).
Normal lung fluid magnified 40x.
Lung fluid (magnified 60x) of a patient with a history of vaping. The lipid or oil in the cells stain red with Oil Red O. This is presumably caused by vaping or inhaling an aerosolized oily substance.
Velez: A thoracic pathologist is a specialized doctor that diagnoses diseases of the thorax, or chest cavity, by looking at tissue or fluid specimens under a microscope. Hundreds of disease which fall into this category.
Have you ever encountered a case in which a patient had lung damage due to vaping?
Agrawal: To date, I have received four bronchoalveolar fluid specimens (BAL) that came from patients with a history of vaping. Each patient presented with signs of respiratory failure.
In recent months, I had a teenage patient who was admitted to the ED with respiratory failure. They had a history of marijuana use and couldn’t remember what they inhaled the day before, but had vaped a few months before.
What is known from the literature is that vaping can present acutely and up to 90 days. So if someone has vaped in the last 90 days, it can present later. Because of the history for vaping, the patient was treated with steroids and antibiotics and later discharged.
Why is it difficult to know what damage is caused by vaping?
Velez: Recent literature in the NEJM reported patterns of lung injury such as diffuse alveolar damage, organizing pneumonia, granulomatous pneumonitis and foamy macrophages in patients with a history of vaping. We know these patterns of lung injuries described are not specific to any disease process.
For example, they can also be seen in an infection, sepsis, drug toxicity, toxic inhalation, and collagen vascular disease to name a few. If the history of vaping is known, Oil Red O may be performed to identify lipid in macrophages. Knowing the clinical history is the key make the association of vaping and lung injury.
Aren’t there other methods, like CT images, to detect a lung injury that could be vaping-related?
Velez: Clinicians suspect lung injury if someone has been inhaling something recently (such as e-cigarette vapor) and they develop shortness of breath and come to the ED. Then they may undergo a chest CT. The radiologic findings are not specific and show patterns that can correlate with eosinophilic pneumonia, diffuse alveolar damage organizing pneumonia and lipoid pneumonia. The history of inhalation coupled with the radiologic and histologic evidence of the lung injury, means you can suspect this was due to vaping.
In other words, a pathologist can probably tell a person is sick because of vaping, based on what they see under the microscope, but unless you know from the patient’s doctor that they vape, you can’t link the two?
Agrawal: Correct. If we are not provided with the patient’s history, it’s just an acute lung injury for us. Maybe the patient has an infection, but unless a history or clinical report is provided or there is some clinical suspicion, we as pathologists cannot make a determination.
Do you think patients don’t want to disclose that they’ve vaped for fear of stigma, or that they’ll be punished for doing something illegal (especially if they vape an illegal substance like marijuana)?
Velez: It’s uncertain if vaping carries any stigma at all, but it’s possible that youth may conceal their habits. There are over 2,000 flavors of vaping cartridges, so it’s enticing. The nicotine vaping cartridges also contain as much nicotine as a pack of cigarettes. None of this is FDA-regulated.
Agrawal: With teenagers especially, they want to experiment with vaping and mixing edible oils so nobody knows exactly what they’re inhaling, how it’s being transformed as it goes into the lungs. There is no research out yet on this.
Some see vaping as an epidemic. What’s one practical way clinicians can help fight it?
Giampoli: Our physicians and ER docs on the front lines need to get nosy and ask patients if they vape. At the moment there’s nothing specific for us to identify it with until we see more cases and can identify patterns in what we’re looking for.
Our whole job is finding patterns with the information we have. We will be able to recognize these cases faster, pick up these connections quicker, and hopefully be able to help our clinicians help these patients much more quickly.
Members of the University of Rochester Medical Center’s Department of Pathology & Laboratory Medicine will join thousands of pathologists from across the globe to present abstracts at the 2018 meeting of the United States and Canadian Academy of Pathology (USCAP).
The meeting, which is the largest of its kind in the world, will be held March 17-23 in Vancouver, BC, Canada. Below is a schedule of events that include URMC faculty and residents. In addition to presenting research, we are pleased to again host a cocktail reception for alumni and friends at the conference on Monday, March 19 (details below). All are welcome!
For general USCAP meeting information, please visit their website.
PP – Pan Pacific Vancouver
FW – Fairmont Waterfront
FPR – Fairmont Pacific Rim
PH – Pinnacle Hotel Harbourfront
SUNDAY, MARCH 18, 2018
University of Rochester Fellowship Fair
5:30 - 7:30 PM
Table #4, VCC West Ballroom D
MONDAY, MARCH 19, 2018
8:00 AM - 12:00 PM
Real Time Cytopathology Feedback (RTCF) versus traditional Rapid On-Site Evaluation (ROSE) for Endobronchial Ultrasound Guided Fine-Needle Aspiration (EBUS-FNA) of mediastinal lymph nodes (MLN). Alexandra Danakas, Carolyn E Jones, John Plavnicky, Christian G Peyre, Sierra Kovar, Joseph J Wizorek, Mary Beth Kearns, Donna Russell, Shawn Evans, Luis De Las Casas.
HIV Enteropathy: Real or Myth? A Histologic Review. ILKe Nalbantoglu1, Raul S Gonzalez.
Poster Session I
9:30 AM - 12:00 PM
74 Significance of Clinicopathologic Parameters, Including Margin Distance and Tumor Budding, on Local Disease Recurrence Following Esophageal Endoscopic Mucosal Resection. Phoenix Bell, ILKe Nalbantoglu, Justin Cates, Raul S Gonzalez.
85 Perineal Carcinoma Cuniculatum: Histology Review of 38 Cases. Dongwei Zhang, Raul S Gonzalez, Michael Feely, Hwajeong Lee, Kavita Umrau, Daniela Allende, Dipti Karamchandani, Michael P Zaleski, Jingmei Lin, Maria Westerhoff, Xuchen Zhang, Lindsay Alpert, Jinping Lai, Xiuli Liu.
171 NKX3.1 Expression in Salivary Gland Neoplasms: A Marker for Mucinous Differentiation and a Potential Diagnostic Pitfall. Anna-Karoline Israel, Abberly Lott Limbach.
273 Extent of Lesional Cell Spread in Hepatic Epithelioid Hemangioendothelioma: Implications for the Diagnosis in Minimal Samples. Diana Agostini-Vulaj, Burcin Pehlivanoglu, Sharon Weiss, Alyssa Krasinskas, Michael Feely, Jason L Hornick5, Justin Cates, N. Volkan Adsay, Raul S Gonzalez.
1:00 PM - 3:00 PM
Moderators:Timothy D'Alfonso and Megan Troxell
Room: VCC West 211
A Novel Detection Methodology for HER2 Protein Quantitation in Clinical Samples: Correlation with Pathologic Response to Trastuzumab-Based Neoadjuvant Therapy. Bradley M. Turner, Brandon Buscaglia, Hideki Goda, Loralee Mcmahon, Takako Natori, Hisatake Okada, Armen Soukiazian, Yasushi Nakano, David Hicks.
Moderators:Tracy George and Annette Kim
Room: VCC West 208 - 209
Microarray CGH-SNP Analysis Detects Frequent Chromosomal Abnormalities Indicating Clonal Cytopenia(s) in Patients With Indeterminate Bone Marrow Dysplasia - An Institutional Study Of 94 Cases. Nisha Patel, Michelle Pitch, Andrew G Evans, M. Anwar Iqbal.
Moderators: Dhanpat Jain and Lei Zhao
Room: VCC West 224
Does ASS1 Immunohistochemistry Predict an Increased Risk of Hemorrhage in Hepatocellular Adenomas? Heidi Lehrke, Taofic Mounajjed, Raul S Gonzalez, Riyam T Zreik, Laura J Denham, Rory Smoot, Daniela Allende, Bita V Naini, Roger K Moreira, Rondell Graham.
Poster Session II
1:00 PM - 4:30 PM
123 Immunohistochemistry of Androgen Receptor and Related Signaling Pathways in Bladder Cancer as Prognosticators. Satoshi Inoue, Taichi Mizushima, Hiroki Ide, Takashi Kawahara, Guiyang Jiang, George J Netto, Hiroshi Miyamoto.
191 Acinic Cell Carcinoma of Salivary Gland Expresses Low Levels of PD-L1 with Retained MMR Proteins: A Potential Biomarker for Therapy. Abberly Lott Limbach.
How to Get Started and Succeed in Academics: Mistakes We Made and What We Wish We’d Known on Day One
Room: VCC WEST 302-304
- Raul S. Gonzalez, MD, University of Rochester Medical Center, Rochester, NY
- Rondell P. Graham, MBBS, Mayo Clinic, Rochester, MN
- Laura W. Lamps, MD, University of Michigan Hospitals, Ann Arbor, MI
- Rhonda K. Yantiss, MD, Weill Cornell Medical College, New York, NY
Description: Making the leap from training to a career in academic medicine is daunting for many pathology residents and fellows. As there are few resources specifically devoted to transitioning from pathology training to academic practice, this Special Course would offer trainees and new academic attendings an in-depth look at the first 1-5 years of academic practice. Through the experience of the faculty, participants will hear about mistakes made along the way, lessons learned in areas where there is little formal training, and strategies that have led to successes. The program will discuss useful approaches to securing an academic position, tips, and pitfalls for the first year, and positioning oneself for academic promotion. The program will also discuss how to develop an early career research program, balancing academic activity and clinical work, and avoiding burnout.
University of Rochester Medical Center Alumni Reception
5:30 - 7:30 PM
Room: Fairmont Waterfront, MacKenzie Rm. II
No RSVP required, all are welcome!
TUESDAY, MARCH 20
Poster Session III
9:30 AM - 12:00 PM
101 Should Ki67 Immunohistochemistry Be Performed on All Lesions in Multifocal Small Intestinal Neuroendocrine Tumors? Numbereye Numbere, Aaron Huber, Chanjuan Shi, Justin Cates, Raul S Gonzalez
104 Mesenteric Tumor Deposits Arising from Small Intestinal Neuroendocrine Tumors are Frequently Associated with Sclerosis and IgG4-Expressing Plasma Cells. Jordan Andrew Roberts, Raul S Gonzalez, Frank Revetta, Chanjuan Shi.
117 Clinical Outcome of Perineal Carcinoma Cuniculatum in a Cohort of 38 Cases. Dongwei Zhang, Raul S Gonzalez, Michael Feely, Kavita Umrau, Hwajeong Lee, Daniela Allende, Dipti Karamchandani, Michael P Zaleski, Jingmei Lin, Maria Westerhoff, Xuchen Zhang, Lindsay Alpert, Jinping Lai, Xiuli Liu.
154 Liver Histology in Septic Patients: Is It All About Ductular Cholestasis? Caroline Bsirini, Raul S Gonzalez.
1:00 PM - 2:45 PM
Moderators: Deepti Dhall and Laura Lamps
Room: Vancouver Convention Centre West 224
Mesenteric Tumor Deposit Number, But Not Size, Affects Prognosis of Patients with Small Intestinal Well- Differentiated Neuroendocrine Tumors. Raul S Gonzalez, Justin Cates, Chanjuan Shi.
Poster Session IV
1:00 PM - 4:30 PM
40 Quantitative Measurement of Human Epidermal Growth Factor Receptor-2 (HER2) Protein Expression in ‘Classical’ and ‘Non-Classical’ FISH Categories: A Comparative Study. Jian Shen, Brandon Buscaglia, Hideki Goda, Bradley M. Turner, Hisatake Okada, Loralee Mcmahon, Jill Henry, Yasushi Nakano, David Hicks.
102 Lymphocytic Esophagitis in Adult Crohn’s Disease is Characterized by Younger Age, Lower Incidence of Reflux Symptoms, and a CD4 Predominant Infiltrate. Elizabeth Yiru Wu, Deepa T Patil, Michael Drage, Amitabh Srivastava.
116 What Remains of Appendiceal Adenocarcinoma After LAMN and Goblet Cell Neoplasms are Excluded? Raul S Gonzalez, Joseph Misdraji, Rhonda Yantiss
132 Clinicopathologic Analysis of Benign Lipomatous Lesions of the Colon. Sam L Barron, Raul S Gonzalez
136 Interobserver agreement in the diagnosis of anal dysplasia. Sohaib Abu-Farsakh, Michael Drage, Aaron Huber, Bradley M. Turner, Sharlin Varghese, Xi Wang, Christa Whitney- Miller, Raul S Gonzalez.
150 Significance of Method of Lymph Node Involvement in Pancreatic Ductal Adenocarcinoma. Diana Agostini-Vulaj, Justin Cates, Richard Dunne, Raul S Gonzalez.
151 Low Union (Lower Insertion of Cystic Duct into Common Hepatic Duct) as a Major Etiologic Factor in the Development of Pancreatic, Distal Bile Duct and Ampullary Cancers: An analysis of 860 pancreatobiliary resections. Takashi Muraki, Michelle Reid, Raul S Gonzalez, Aarti Sekhar, Bahar Memis, Burcin Pehlivanoglu, Yue Xue, Pardeep Mittal, Juan M Sarmiento, David Kooby, Shishir Maithel, Ken Cardona, Bassel El-Rayes, Alyssa Krasinskas, Gwen Lomberk, Raul Urrutia, Kathleen K Christians, Susan Tsai, Douglas Evans, N. Volkan Adsay, Alpharetta.
162 Loss of ARID1A Expression Predicts Worse Overall Survival in Patients with Resected Pancreatic Adenocarcinoma and Is Associated with Inactivating Mutations of the ARID1A Gene. Annacarolina da Silva, Vicente Morales-Oyarvide, Douglas A Rubinson, Margaret M Kozak, Wenjia Wang, Diana Agostini-Vulaj, Aaron Huber, Daniel T Chang, Thomas E Clancy, Aram F Hezel, Shuji Ogino, Brian M Wolpin, Jonathan A Nowak.
202 Clinical Significance of Perivesical Lymph Node Metastasis in Radical Cystectomy for Bladder Cancer. Meenal Sharma, Jerome Jean-Gilles, Hiroshi Miyamoto.
261 AID-Generated Acquired IGH Glycosylation Sites but Not Somatic Hypermutation Rate Differentiate Low-grade versus High-grade Follicular Lymphoma. Chad Hudson, Janice Spence, Diana G Adlowitz, Richard Burack.
262 Increased AID-Generated Acquired Glycosylation Sites in Diffuse Large B-cell Lymphomas with IGH-BCL2 and CD10 Expression. Chad Hudson, Janice Spence, Diana G Adlowitz, Madalynn Bryant, Richard Burack.
277 Unexpectedly High Prevalence of Cystoisospora belli in Acalculous Gallbladders of Younger Patients. Mushal Noor, Christa Whitney-Miller, Laura W Lamps, Raul S Gonzalez, Aaron Huber, Jennifer J Findeis-Hosey, Zhongren (David) Zhou, Lawrence J Saubermann, Rebecca L Abell, Philip J Katzman, Michael Drage.
WEDNESDAY, MARCH 21
Poster Session V
9:30 AM - 12:00 PM
103 Relationships Among Histologic Characteristics, Molecular Phenotypes, and Patient Outcomes in Mucinous Colorectal Carcinoma. Raul S Gonzalez, Justin Cates, Mary Kay Washington.
149 Evaluation of Histologic Changes in the Livers of Patients With Early and Late Hepatic Artery Thrombosis. Michael J Lee, Raul S Gonzalez.
243 Autoimmune Disease and Lymphoma: A Method for Large Scale Search of the Electronic Medical Record Enables Correlation of Clinical Parameters with Type and Risk of Lymphoproliferative Disease. Genevieve M Crane, Amy Duffield.
265 Next Generation Sequencing-Assays Detect B-Lymphocyte Clonality in Formalin-Fixed Paraffin Embedded Specimens of Classical Hodgkin Lymphoma without Microdissection. Cynthia Reyes Barron, Andrew Campbell, Paul G Rothberg, Richard Burack, Yi Ding DING4 1University of Rochester Medical Center, Victor, NY, 2University of Rochester Medical Center, 3University of Rochester, Rochester, NY, 4University of Rochester Medical Center, Rochester, NY
350 Is the Rate of Frozen Section Discordance Affected by Subspecialty Sign Out? Joseph H Blitman, Brandon Buscaglia, Christa Whitney- Miller, David Hicks, Aaron Huber.
Poster Session VI
1:00 PM - 4:00 PM
162 MCM7 Expression Correlates With Tumor Size and Ki67 Index in Well-Differentiated Small Intestinal Neuroendocrine Tumors. Zhongren (David) Zhou, Numbereye Numbere, Aaron Huber, Chanjuan Shi, Raul S Gonzalez.
167 Expression of TIM3 (CD366) and LAG3 (CD223) in Colorectal Carcinoma-associated Inflammatory Infiltrate Suggest Novel Therapeutic Targets for Immune Checkpoint Blockade. Michael Drage, Max Klapholz, Ana C Anderson, Amitabh Srivastava.
280 L1 CAM – A Potential Biomarker for Recurrent and Aggressive Endometrial Carcinoma. Ioana Moisini, James R Richter, Tanya Pulver, Raphael Hellwegg, Boris Winterhoff, Molly Klein.
318 Lack of MUM1 Expression Characterizes B-Lymphoblastic Leukemia/Lymphoma. Chad Hudson, Roula Katerji, Richard Burack.
THURSDAY, MARCH 22
7:30 PM – 9:30 PM
Secrets from the Consult Files: Puzzling Cases Solved Piece by Piece
Room: VCC WEST 301-305
Moderator: Michael Torbenson, MD, Mayo Clinic, Rochester, MN
- Maria Westerhoff, MD, University of Michigan, Ann Arbor, MI
- Tom Smyrk, MD, Mayo Clinic Rochester, MN
- ILKe Nalbantoglu, MD, Yale University, New Haven, CT
- Raul Gonzalez, MD, University of Rochester Medical Center, Rochester, NY
- Oyedele (Dele) Adeyi, MD, University of Toronto, ON, Canada
We recently caught up with Dr. Brooke Koltz, a former Pathology resident at the University of Rochester (2008-2012) and Cytopathology fellow (2012-2013).
After training and working in Rochester, she and her family moved to the Philadelphia, PA area for a year and recently moved to Perrysburg, OH, near Toledo. This is a homecoming of sorts for Koltz, who grew up in nearby Whitehouse, OH.
She will start a new role this month at the University of Toledo Medical Center (where she also attended medical school). Her clinical responsibilities will include surgical pathology, cytopathology, and resident education. Here, she shares more about the experiences that led her to this moment in her career.
Tell us about your family.
I am married to Peter Koltz, who was also a resident at University of Rochester in Plastic and Reconstructive Surgery. We have four children, Eleanora (9), Henry (7), Cecilia (4), and Simon (2).
What first sparked your interest in pathology?
I went into medical school thinking I would become an emergency medicine physician, but I am so glad that I didn’t. I was one of those rare students that was fascinated by histology and pathology labs in the first and second year of medical school.
Even so, I was still set in pursuing clinical medicine until I took an elective pathology rotation on a whim late in my third year. In about a week, my whole outlook changed. As I sat across the multi-headed scope from the attendings and residents, I realized that what they did was ‘medicine’ to me. From then on I pursued a career in pathology. So far, I have no regrets.
When you look back on your time here, is there a particular person or experience that made a great impact on you professionally or personally?
The entire Cytopathology department had an impact on me both professionally and personally. Not only did the department educate me and prepare me for my future career, but I truly enjoyed being a small part of the talented team for a few years.
I often find myself repeating things that Dr. Giampoli, Dr. Zhou, and Dr. Yao taught me when I sit down with residents. The entire team of cytotechnologists, including Donna Russell, Mary Ann Rutkowski, and Michael Facik, accepted me into their offices, the occasional inside joke, and gave me the benefit of their years of experience and knowledge. I couldn’t have asked for a better fellowship.
Aside from the Cytopathology department, many of the surgical pathology attendings, especially Dr. Hicks and Dr. Whitney-Miller, encouraged me and gave me a solid experience to pursue my career goals. My co-residents were fun and supportive as well. There are too many people to name, but I appreciated my time in Rochester and felt that I received a positive educational and personal experience.
How do you like to spend your free time? Do you have any hobbies/interests?
Like most mothers, my free time is often spent chasing my kids around and getting them to their various activities. But I do love to read books, and I read often. I am happy to read almost anything: fiction, non-fiction, poetry. I also enjoy playing and watching sports, including soccer.
What’s next for you career wise?
I am looking forward to spending more time teaching residents, medical students, and student fellows in my new position. I have always enjoyed teaching, and am happy that I have found a position that puts a large emphasis on education.
What advice would you give up-and-coming pathology trainees looking to start their careers?
Because I am one half of a two physician household, I have had to change jobs frequently in the last four years as my husband’s training has taken him to various hospitals. While I haven’t always wanted to leave positions, the benefit has been that I have gained experience in a lot of different practice settings.
My advice would be to learn as much as you can from each place you end up, even if it isn’t necessarily your dream job. Seek to find what you can take away from each place or experience that will grow your knowledge. Each place (and person!) has something unique to teach you that will contribute to your success as a physician, a pathologist, and a person.