Does morphology matter anymore?

[caffeinegirl]

The rise of molecular is replacing the importance of morphological diagnosis.
Really good article here

Digital pathology is just pathology, but does it matter anymore? | Tissuepathology.com

Since the 1990s, many innovators to Fortune 500 and Fortune 50 companies have worked to make digital pathology a reality. While not mainstream and perhaps less than 10% of US based pathology groups have any serious implementations of digital pathology, the technology has caught up to our retinas...

tissuepathology.com

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[WEBB PINKERTON]

Exactly, it's pretty obvious where the field is heading. Digital is the last thing I would be putting any money into.

I noticed a month or so ago that the company Dr. Kaplan works for recently partnered with those in-office pathology fossils. I thought that was sort of interesting.

Versant Diagnostics and In-Office Pathology, LLC Announce an Agreement to Increase Pathology Services Nationwide

Versant Diagnostics announces an agreement with In-Office Pathology, LLC, to increase access to pathologists and build pathology labs nationwide.

www.businesswire.com

 

[octopusprime]

Interesting and depressing. Agree with the lung CA timeline...20 yrs ago was "is this SCLC or NSCLC?" 10 yrs ago it was "is this adeno and enough for EGFR, ALK, ROS1, etc?" Now it's more of an issue of volume for sendout testing. At least doing cyto is *currently* high demand...CC/pulm docs are crazy busy with robotic bronchs...we do about 10/week and they're time consuming but I appreciate the interaction time with other docs and the reimbursement for a nav & staging EBUS is pretty good.
But that's only until the tissue-acquiring process becomes good enough that ROSE isn't needed and the tissue just bypasses our department entirely.

 

[WEBB PINKERTON]

Celtivity and other companies looking to take ROSE as well. Your days of standing around in lead, looking at paucicellular FNA attempts before the pulmonologist finally pulls the forceps out and gets you a real specimen, may be coming to end sooner than you think. I know of health systems using this currently.

Did you really say reimbursement is good for nav and staging EBUS? Those robot cases are easily an hour.

Van Gogh | Aquyre Biosciences

Enhance cellular contrast with Dynamic Cell Imaging by Aquyre Biosciences. Capture detailed histology-level images by analyzing intracellular movements.

aquyre.com

 

[shikimate]

lol the oncologist in his story seems to be more at risk to be out of job than the pathologist.

 

[WEBB PINKERTON]

lol the oncologist in his story seems to be more at risk to be out of job than the pathologist.

If the story is true, that is scary. A repeat biopsy for testing is one thing but there needs to be a proper diagnosis.

Our oncologists are so far up the a** of guardant360, they order guardant even if there is plenty of tissue. Repeat biopsies are definitely down as they just go by the guardant

 

[KeratinPearls]

Exactly, it's pretty obvious where the field is heading. Digital is the last thing I would be putting any money into.

I noticed a month or so ago that the company Dr. Kaplan works for recently partnered with those in-office pathology fossils. I thought that was sort of interesting.

Versant Diagnostics and In-Office Pathology, LLC Announce an Agreement to Increase Pathology Services Nationwide

Versant Diagnostics announces an agreement with In-Office Pathology, LLC, to increase access to pathologists and build pathology labs nationwide.

www.businesswire.com

Yes Versant is buying up pathology practices and are equipping them with digital.

 

[Med Director New England]

To me these changes are OK and even exciting

We still make a morphologic (H&E) diagnosis and then augment with molecular information to further sub type and to guide therapy choices.

Many of the “molecular” classifications can be gleaned or even reliable diagnosed by proteins / IHCs studies, more work for the surgical pathologist.

Plus many more companies out there in pharma / AI now need pathologist input for their product development so more potential job opportunities.

 

[Guest8]

We keep fretting over molecular/digital taking over. But those seem to be in addition to our morphologic diagnoses, not in replacement of them. We're busier than ever here, and all the guided therapies have led to far more IHC use than before what with PD-L1, Her2, BRAF, etc. Cases I formerly would have just signed out on morphology now are all expected to get a battery of IHC, and THEN the tissue gets sent out for molecular/FISH/etc after that. So I'm getting paid far more for the same cases today than 5-10 years ago. So far there doesn't seem to be any move to eliminate morphology at all. We're just making pathology far more expensive/lucrative by doing molecular, etc in addition to the already expensive morphology.

 

[WEBB PINKERTON]

Yes Versant is buying up pathology practices and are equipping them with digital.

I was just surprised to see them partner with those in-office lab people. I'd love to see if they have had any growth at all in the last few years with PE taking over many of their potential customers.

 

[octopusprime]

Celtivity and other companies looking to take ROSE as well. Your days of standing around in lead, looking at paucicellular FNA attempts before the pulmonologist finally pulls the forceps out and gets you a real specimen, may be coming to end sooner than you think. I know of health systems using this currently.

Did you really say reimbursement is good for nav and staging EBUS? Those robot cases are easily an hour.

Van Gogh | Aquyre Biosciences

Enhance cellular contrast with Dynamic Cell Imaging by Aquyre Biosciences. Capture detailed histology-level images by analyzing intracellular movements.

aquyre.com

Obviously if you compare sitting in endo for an hour vs signing out colon polyps for an hour, the latter wins, but that's not the way pathology works...you're never substituting one for the other, and there are AMPLE time sucks that don't reimburse anything, that may or may not be covered by your lab management fees. Over the course of a 6-8 hr day you have "X" amount of work to do, which usually only takes 2-3 hrs of continuous work to be honest.

Cases can last an hour, can last 20 min, can last 90 minutes...some are in endo, some in the OR with lead...but if you have partners working and are efficient and have efficient pulmonologists, you get a pretty good system.

Standard robotic ROSE procedure for us:
Robotic FNA (not infrequently multiple sites as the sensitivity for low-dose CT makes them able to sample tumors <1cm)
88173x1
88172x1
88177x'X' (usually 2-5 passes)
88305x1
[often a few IHC stains, 88342x1 and 88341x1+ if there's enough tumor to differentiate adeno from squam]

Staging EBUS (if obvious cancer usually just station 7 otherwise usually 2-4 nodes)
88173x1
88172x1
88177x(2-4 usually, some 5-8 passes)
88305x1
[+/- IHC or specials]

Robotic biopsy:
88305x1+
(+/- IHC)

[+/- BAL so 88112 for ThinPrep and 88305 for cell block +/- special stains and/or IHC]

Professional -26 reimbursement rates (don't know exact 2024 CMS rates but these are close):
[and obviously we CHARGE alot more than what we receive)
CMS
88305 ~$35-36
88173 ~$67
88172 ~$34
88177 ~$20
88112 ~$26
88342 ~$33
88341 ~$27

BC/BS for our region
88305 ~$75-80
88173 ~$150
88172 ~$75-80
88177 ~$45-50
88112 ~$60
88342 ~$75
88341 ~$60

Not counting the 88305s, the cyto portion of our ROSE stuff amounts to mid 6 figures of income for us annually.

 

[WEBB PINKERTON]

88172 , 88177, 88333 and 88334 are really the only ROSE codes. You can get all the other codes listed (and more) without giving up large swaths of time.

 

[octopusprime]

88172 , 88177, 88333 and 88334 are really the only ROSE codes. You can get all the other codes listed (and more) without giving up large swaths of time.

Again, the assumption that it's an alternative to sitting my office signing out easy tissue is inaccurate. It's an inconvenience in the sense that anything that pulls you away from your home scope is, but that goes with the territory of being a hospital based pathologist and being an integral part of lung cancer diagnostics. We have plenty of cases that don't get ROSE and just go right to cell block and ThinPrep, and diagnostically those cases are more challenging and less accurate.
Is it more worthwhile to spend 30-60 min signing out the scope portion of a bone marrow? I don't do heme but can't imagine.

The case I just signed out was a 5 node staging EBUS. Took 30 min. 88172x5 and 88177x7, on top of the 88112s and 88305s and specials. Some cases are more time sucks, but again, efficiency is a thing.

 

[Alteran]

To me these changes are OK and even exciting

We still make a morphologic (H&E) diagnosis and then augment with molecular information to further sub type and to guide therapy choices.

Many of the “molecular” classifications can be gleaned or even reliable diagnosed by proteins / IHCs studies, more work for the surgical pathologist.

Plus many more companies out there in pharma / AI now need pathologist input for their product development so more potential job opportunities.

I think what also gets lost in conversation is that these fancy pants molecular assays only get reimbursed if the sample is malignant. Therefore, we do have to render a diagnosis for these tests to proceed.

 

[mike-sheree]

Interesting and depressing. Agree with the lung CA timeline...20 yrs ago was "is this SCLC or NSCLC?" 10 yrs ago it was "is this adeno and enough for EGFR, ALK, ROS1, etc?" Now it's more of an issue of volume for sendout testing. At least doing cyto is *currently* high demand...CC/pulm docs are crazy busy with robotic bronchs...we do about 10/week and they're time consuming but I appreciate the interaction time with other docs and the reimbursement for a nav & staging EBUS is pretty good.
But that's only until the tissue-acquiring process becomes good enough that ROSE isn't needed and the tissue just bypasses our department entirely.

And, it was a hell of a lot more fun 20 years ago!