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In this episode of “Lab Medicine Rounds,” Justin Kreuter, M.D., sits down with Jorge Torres-Mora, M.D., assistant professor of Laboratory Medicine and Pathology at Mayo Clinic, to discuss the importance of integrating molecular information into your anatomic pathology practice.
A Mayo Clinic podcast for laboratory professionals, physicians, and students, hosted by Justin Kreuter, M.D., assistant professor of laboratory medicine and pathology at Mayo Clinic, featuring educational topics and insightful takeaways to apply in your practice.
- (techno music)
- This is Lab Medicine
Rounds, a curate podcast
for physicians, laboratory
professionals, and students.
I'm your host, Justin Kreuter,
the Bow Tie Bandit of blood,
a transfusion medicine
pathologist at Mayo Clinic.
Today, we're rounding with
Dr. Jorge Torres-Mora,
assistant Professor of Laboratory Medicine
Pathology at Mayo Clinic.
Dr. Torres-Mora is an anatomic pathologist
and program director of
the Bone and Soft Tissue
Pathology Fellowship at Mayo Clinic.
Thanks for joining us today.
- Hey, thank you very much, Justin.
Thank you for inviting me.
This is, I feel honored, and
I think it's a very relevant,
very current hot topic in
molecular in pathology.
I'm happy to be here
and hopefully I can help
to spread a little bit more
of awareness on this discipline.
- Yeah!
I think that's exactly
what we're going for.
Is this kind of blending on
how do we think about anatomic pathology,
but then also all this
molecular information,
maybe you can kick us off with
why is molecular information
important for you
in your practice to
integrate anatomic pathology?
- Oh, sure, definitely.
That is a great question.
Of course, nowadays, with
all these molecular advances,
the field of pathology
is completely different
to what it was only, let's
say a decade ago, right?
So many new discoveries,
so many new technologies
and we are doing a good job
incorporating them into
the clinical practice.
So, molecular pathology
is important for me
as a pathologist, as a
diagnostician for several reasons.
But I would say three important things.
One is Diagnosis, which is what I do.
That's my main job.
I diagnose what a tumor is, et cetera,
is it benign, malignant,
what's the type, what lineage.
The other important thing that
is a little bit more helpful
for the clinician is therapeutic
and prognostication, right?
I can tell you a little bit about more
of every one of those reasons,
diagnostic, for instance,
we are lucky nowadays
to have one extra layer
of verification for our diagnosis.
In the past, it was
okay, unusual two more,
not very specific, or it
doesn't fit in a specific box,
so I don't know what it is,
I think it's this.
Other people, other experts would say,
"I think it's the other thing."
Other expert would say a different thing.
Now a day, we have an
extra layer of information
that we can incorporate.
We can do a molecular technique
and we can tell us, "Oh, you know what,
"this has a specific fusion.
"Oh, pathologist one, two or
three has the right answer."
This fusion is diagnostic for
such a such specific entity.
So that's one reason, more
accuracy in diagnosis.
Second reason is, you know,
we are discovering nowadays
that what we thought the
normal morphologic spectrum
of some tumors is actually wider
than we initially believe, right?
We see that for instance,
recently, we have seen a couple of cases
I give you one example of many,
Extraskeletal Myxoid Chondrosarcoma,
very classic malignant tumor,
but with a protractive clinical course.
Nowadays we are seeing cases that,
look High-grade spindle cell sarcomas,
and then you look at it,
and you wouldn't think
this are Extraskeletal
Myxoid Chondrosarcomas
until you do the molecular
and you find the characteristic fusion
or characteristic gene rearrangement,
and you say, "Oh! Wait a minute,
"let me go back to that slide."
And then just sure enough
in retrospective you go back
and look at those little foci
in between the high grade
tumors, that look like classic
Extraskeletal Myxoid
Chondrosarcoma, right?
So, is very important for us to expand in
you know, the spectrum,
the two spectrum of tumors.
Another layer of verification in further
expand our knowledge about tumors.
The other reason, you know, recently
one of the best example is
more round blue cell tumors.
Ewing sarcoma, one of the most common
small cell sarcomas in
kids, if not the most.
In the past, everything was Ewing sarcoma
or Ewing-like sarcoma, right?
Nowadays, with the all these availability
of molecular techniques,
we are seeing that,
the tumor that in the past we
used to call Ewing-like sarcomas
are actually a very
heterogeneous group of tumors
that have different molecular iterations,
different prognosis, different
response to treatment,
and it's not just a single entity.
So that's very useful for the
clinicians, for the parents
to know what what to expect,
this tumor is gonna respond
to you in therapy or not, et cetera,
for a variety of reasons.
And lately, therapeutic is so important,
with all these precision
targeted treatment
for a variety of tumors.
I can tell you many of
them, but one of the most
successful stories we heard
of lately in Trachomas, right?
One of those, tissue
agnostic treatment, right?
Like the clinicians can
treat locally advance
or metastatic NTRK-rearranged tumors,
regardless of what we see on the light.
They're trying to get rid
of us in a way but (laughs).
Hopefully, it doesn't
happen in my lifetime.
But it's one of those
things that, we tell them,
listen this tumor has
an NTRK1 rearrangement.
They can treat it with NTRK inhibitors
and the patient can respond wonderfully.
And it's just one story of many others.
I think we are in the earliest stages.
But I hope in the near future,
these stories become more
and more and more frequent
and everybody can have a very
specific tailored treatment
to specific tumor, specific person.
- Yeah, I like how you're highlighting
how this is really made
and really continues
to reinvent pathology really
in the tip of the sphere,
for what's the accurate diagnosis,
therapeutic, we should use.
What kind of prognostic information,
you've really articulated that.
Something else in your
answer that I just wanted
to pull out here and maybe
ask a follow up question.
You're talking about,
this is something that,
in the last 10 years really
has been a revolution.
And so something I'm interested in,
because, interested in how
do we learn new information?
I imagine that, could say, well, you know,
there's a lot of molecular
information thats come out new.
But I'm certainly here focused
on my morphology or something
But, how did you recognize
that molecular information
was really a critical competency for you
to develop as an anatomic pathologist?
Cause' this has happened
during your career so far.
- Yes, exactly.
And I can tell you, even, like I said,
at 10 years ago I was
in a different hospital.
A very big cancer center,
doing my fellowship there.
And we didn't even have the availability
of fees for MDM2 for well
different cell liposarcomas,
which nowadays is almost unthinkable,
not to have it, right.
So yes, my career has been developed
along the new discovery.
So I have seen this evolution
along my relatively short career.
It is very important.
So how do I recognize it?
Well, it's kind of impossible not to
in the place we work, right.
We work with so many
different teams and colleagues
that are always up to date
trying to find what's the best
for the patient what's
out there, what's new?
And then, that's very important,
they call me, "Hey, listen."
The oncologist, for
instance, they tell me,
what about this, you know
Imatinib for genes, is this
Gene's KIT mutation or not?
It's just a example of many.
So that make me, oh,
let me look into that.
Let me see what's out there.
What can we do to to tell you
this particular tumor has
a KIT mutation or not?
Then I go and ask my
molecular colleagues, right?
I don't do molecular.
I'm not part of that select
group of smart people.
I just do whatever they come up with.
But every time I have a question,
I go ask them, "Hey
listen, what do I have?
"I wanna prove this
tumor has a KIT mutation.
"What do I do?"
So they tell me, okay, go do
the Genes paneling on a test
you know, mutation for
the exon, so and so.
We gonna test for PD for alpha.
We gonna test for SDHV, et cetera.
So, first of all, going
back to your question,
the other colleagues always push you
especially here at Mayo Clinic to be
at the advance in the front age
of the most recent advances, right?
The other thing, my all
pathology colleagues
who that do similar things that I do
there is always communication
sharing of cases.
And I learn from them, right?
The most senior colleagues
they all also from the more juniors,
that we exchange information
and we share cases and stories,
like it'll have a similar
case and I did this,
and I contacted this and this.
I have this new paper.
I went to this course, et cetera.
So is a group effort where
you have to be always alert
and try to be up to date,
to see what's out there.
- I see.
And so, I like that you're
highlighting colleagues
both within your team, as well as outside
and as I hear you, sorting to pick up,
what are people interested in?
What are the oncologist talking about?
That's been a driver, as
well as conversations,
it sounds like, during your
pathology conferences with them.
Do you find yourself going
to different sessions
than when you go to conferences?
Are you specifically
kind of paying attention
to ones that have a molecular
thread through them?
- No!
Well, first of all, we go to
interdisciplinary conferences here.
That are more focused on what I do, right?
The Bone soft tissue with my colleagues,
the interdisciplinary groups,
orthopedic oncologists, right?
We have every Thursday morning,
we have a joint conference
with other services,
radiology, oncologists,
radiation, oncologists, et cetera.
We all get together.
And they present cases and at the end,
they give a very nice little summary
what's out in the literature
and we all get to pitch in.
If somebody has a question
for a specific discipline,
specific specialty, somebody answers.
And that's how you learn
from your colleagues.
And now from, also the
outside conferences,
I don't go to a specific molecular.
I try to go mostly virtual.
Morphology in general, because I do
a lot of general surgical pathology.
And there is a little bit
of everything morphology,
immunohistochemistry, molecular
in every single one of them.
So basically you put everything together,
and then you integrate and
adopt what your colleagues need
and why you think it is important.
- I see.
And so what do you think
for our audience, right?
which is a mix of students,
clinicians, laboratory professionals.
How do you recommend that
we all kind of continue
to embrace new opportunities
in clinical practice?
- Well, I guess the most
important thing Justin is
to create a channels of communication
with your colleagues,
with the other teams.
If you don't create those
channels of communication,
you're going to get cut off
of the the most cutting edge technology.
What do your colleagues need from you?
You're gonna be stuck in the past.
So most important thing
is create relationships.
Communicate with them.
What do you want from me?
What do you need?
We sometimes, I try to ask my colleagues,
"Hey, what do you need?
And my report, is this enough for you?
Do you want me to do any specific tests
that is gonna help you?"
Sometimes, not every molecular
test is helpful for them.
So we have to be aware that
not to waste resources, right?
So it's a constant communication.
But I would would say
that the communication
with your clinical colleagues
and your own interest
to keep yourself up to date.
What's out in the literature
to what are your other
leading hospitals doing,
is very important.
Of course, very important to
keep in mind that you are here.
The main reason are the patients
and the better you do your job,
the most the patients are gonna benefit,
and is gonna give you more
satisfaction and fulfillment.
That's why we are here.
- You know, I'm kinda struck by
how you're talking about setting up
these channels of communication.
I'm curious, how has this changed
or has it changed since
you started practice?
We're talking about how molecular has
kind of come down the pike
and really been something new
that's added onto your practice,
is this importance of
channels of communication.
How has it changed in
recent years do you think?
- Well, I think it may
be just my imagination,
but I think, in the past,
at least when I was a fellow resident,
a lot of times it's like the pathologist
just tell them what it is.
And then the clinician decides what to do,
because you just tell them the diagnosis
and just a diagnosis and you don't offer
a too much more information, right?
Of course, prognostication
is always important,
and the morphology is enough
to prognosticate case sometimes
But nowadays there are so many things that
as a pathologist we can offer.
Like I said, therapeutic
implications, new entities
that in the past we didn't know about.
And we are starting to create
new classifications, new schemes.
So, I think the pathologists
nowadays have way more to offer
not only diagnostic, again
therapeutic and prognostication
even more than in the past.
- Wow!
So it sounds like that communication
has always been a constant.
But has gotten more
complex in recent years.
- Exactly, way more complex.
And that's a good point.
You're right, hitting
the nail right there,
because there is so complexes
that were so much information out there.
So many new discoveries every day,
that is hard to keep up.
Now, you have to work with your colleagues
to filter what's important,
what's clinical significant.
What's gonna help the patient,
basically through signal, what
is background noise, right?
So for that, you cannot do it by yourself.
You need the help of your
colleagues and a good team effort.
- Wow!
That's been wonderful.
So, we've been rounding
with Dr. Torres-Mora.
Thank you for taking the time to talk
about molecular in anatomic pathology,
and really on this theme of
talking about complexity
and communication.
- Awesome!
It had been my pleasure and I'm available,
you guys have my contact information.
If anybody has any interest,
will be my pleasure to talk about it.
- Thank you.
And If you or audience would
like to hear more on this topic
be sure to register
for the Virtual Surgical
Pathology Symposium 2022,
where our very own Dr.
Torres-Mora will be presenting
cases on Bone soft tissue.
This conference is being held on May 13th.
So, check the show notes
for the link to register.
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