|Over 1400 attendees at 2011 SNO meeting in Anaheim|
| Dr. Aldape discussed brain tumor biomarkers |
|Same view as above, at 40X|
Neuropathlogy took center stage at the Society for Neuro-Oncology (SNO) meeting today as Dr. Kenneth D. Aldape
, neuropathogist at the University of Texas MD Anderson Cancer, was introduced as the next president of the society. Dr. Aldape also delivered an address to more than 1400 attendees about the future of surgical neuropathological reporting. Aldape's research centers on the clinical utility of brain tumor biomarkers as prognostic indicators. He described how the use of biomarkers will change the way surgical neuropathology diagnoses are rendered. He noted that the broad morphologic spectrum one sees in gliomas makes the recommendations of the World Health Organization sometimes difficult to implement. For example, the difference between a WHO grade II and grade III astrocytoma is based principally on whether or not mitotic figures are "brisk" as interpreted by the examining neuropathologist. Yet, the imprecision of that approach is obvious when one considers variables such as the diligence of the neuropathologist in identifying mitotic figures, the often equivocal morphology of apoptotic-versus-mitotic cells, as well as the variable technical quality of tissue processing and staining. The use of biomarkers will make diagnoses more reliable and will provide more useful prognostic information to the oncologist. Dr. Aldape projected onto the screen an example of a recent surgical
pathology report he had generated at MD
Anderson. The report highlighted the status of the several biomarkers, including G-CIMP, IDH1, pHH3, MIB1, 1p/19q deletion, and MGMT. Then, only in the
last sentence of the comment, was it noted that the histology and
biomarker profile was most consistent with a WHO grade III (anaplastic)
astrocytoma. It was as if the WHO diagnosis and grade were a perfunctory afterthought. Finally, Aldape noted that biomarkers will become even more important in the coming years as biomarker data becomes "actionable", allowing the oncologist to personalize the treatment of a particular tumor depending on the biomarker profile. These are exciting times....
I think that the lax use of histopathologic criteria (e.g. mitoses per hpfs, without specifying the area of the hpf) does not justify the contention that these newly developed biomarkers are, by themselves, superior. I've been thinking about renaming my H&E diagnoses "histiosomal analyses" (and charging a lot more money). Or, as I sometimes ask my lab rat friends: genome + epigenome +
transcriptosome + proteosome = ?
Answer: H&E section.
Not that biomarkers cannot supplement histologic..I mean histiosomal analyses, but what if the last line of the report had read pilocytic astrocytoma? or meningeal melanocytoma?
**End Luddite Alert**
Nicely argued, Agent 86!
If neuropathology heads towards this vision of providing clinicians with a panel of biomarkers for them to base their treatment decisions on, won't that ultimately mean the end of the neuropathologist as an independently practicing physician? That model seems more like a technician model in which values are simply reported without interpretation.
These may be exciting times for biomarkers and tailored treatment plans but unfortunately they are coming at a time of global economic downturn that American doctors don't seem to fully grasp. Who is going to pick up the tab? National news headlines are reporting shortages of cancer treatment drugs. This while my local news details an embarrassing scandal over tailored cancer treatment plans that were based on bogus, flawed statistical models. Page two covers the TCE contamination of drinking water at a nearby military facility that went on for decades. Exciting times for me would mean preventing the need for expensive and unattainable treatment plans. PCB's,PBB's, dioxin, BPA, heavy metals, pesticides, herbicides, oil spill in the Gulf, an EPA relying on industry to clear itself. Perhaps Agent 86 could factor these variables into his equation and come up with a simple prevention plan.
The neuropathologist can't be replaced by a stream of molecular data. (Molecular data can supplement the pathology, but not replace it.) We just had a case of GBM vs. lymphoma, and it turned out to be toxoplamosis. I wonder if toxo can be MGMT/IDH-1/BRAF/ABCDEFG-positive?
The more I hear people commenting about the end of 'pathology' or 'neuropathology' based on the integration of genomic data, I realize that these comments are made by people who don't actually analyze genomic data and appreciate the inherent systemic limitations and errors. Dr. Aldape is highlighting individual studies such as 1p/19q, IDH1(R132H), etc, but soon these will all be replaced by high throughput sequencing methods which will generate terabytes of information for each patient and make individual 'static' studies like IDH1mutation status irrelevant.
The question becomes who will have to analyze all the terabytes of data that will be collected...will it be the oncologist, primary care physician, neurosurgeon...probably not since i'm sure they wont be able to bill for it! That said, it will all fall into the realm of pathology because it's going to require EXPERTISE, time and knowledge to analyze, interpret and distill the volumes of data into a few meaningful and actionable bites.
That said, if genomics is the future (and it is), it might in fact make Pathology the most relevant and integrated field of medicine moving forward.
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