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The Importance of An Accurate and Timely Diagnosis

Steve A. Kargas , MD, PhD, MBA, FACHE

What sort of cases do you receive at CSI Laboratories?

We receive a variety of cases in our reference laboratory, but most are complex cases that require further immunohistochemical workup.

Typically, our clients have automated staining systems in-house for their routine work. However, when additional testing is needed in order to obtain a diagnosis, the case is submitted to CSI, in which we have more than 225 stains and antibodies available. We work in partnership with our clients to achieve a timely and accurate result for the patient.

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What drove you to follow a career in pathology?

While I was in pathology graduate school, I studied cardiovascular teratogenesis, which involves studying the pathogenesis of embryonic defects of the cardiovascular system. So, after finishing medical school, since I was always interested and enjoyed studying the pathogenesis of disease, it was a natural step for me to enter pathology residency. What’s a typical day like for you? It’s very fast-paced. I review H&E’s and immunostains of our current surgical pathology cases that arrived the day before. I also review H&E’s for tumor adequacy for molecular and Fluorescence In Situ Hybridization (FISH) testing and assign antibody panels on new incoming cases. I am also constantly interacting with our client pathologists, oncologists, or our laboratory personnel answering questions.

How often do you interact with the laboratory managers and staff about cases?

I interact quite a bit with managers and laboratory staff. I’m one of those pathologists who goes in the lab at least five times a day. I want to be close to the Immunotechs and Histotechs to answer any questions that arise in the laboratory, review immunostains, and resolve any issues. At a higher level, I think it’s really about how we as a team help one another, all the way from the instrument manufacturer to managers, laboratory personnel, the pathologist and the clinician. We all share a common objective to render a diagnosis and optimize patient care.

How important to you is the fast turnaround of patient cases?

Timeliness and accuracy are crucial for us. The outside client pathologist, the clinician, and the patient are all waiting for test results, which is why we always aim to get final reports out as soon as we can. Sometimes it is within 24 hours, but when we need additional immunostains, it could lead to the 48+ hour range. If it is really critical, we will call the client directly and relay the final diagnosis verbally.

Why do you feel the pressure to turn cases around quickly?

Patient care is our foremost goal. As soon as a patient receives a diagnosis, they can start therapy and have a chance of a better outcome. I had a case recently where a patient wanted to gain entry into a clinical trial. The oncologist wanted molecular studies done as soon as possible so we rushed it through the lab to get them the result rapidly. A timely result also furthers the reputation of CSI Laboratories because our clients and their patients know they can depend on us.

What if you need to do two or three different rounds of testing on one case?

Sometimes I order stains as a STAT, so the laboratory can rush them through in order to obtain results faster. That’s the advantage of the Leica Biosystems BOND-III staining system, for example. You can automatically add the slides to the instrument and obtain results very quickly. It’s something that makes my job much easier to hit that 48-hour turnaround time frame.

Why is it important to have all slides in a case before making a diagnosis?

One may be easily misled if an inadequate number of immunostains are performed. For example, I received a client case recently that was interpreted as multiple myeloma since by initial immunostains, the tumor was positive with CD138, MUM1, and BCL-1 (Cyclin D1), but was negative with kappa-ISH and lambda-ISH. But since the nucleus looked too atypical and pleomorphic, we felt that both S100 or HMB-45 were also necessary to perform. Since these two immunostains came back strongly positive, a diagnosis of melanoma was rendered, and myeloma was excluded. In other words, one needs to obtain a complete panel of immunostains to elucidate and determine the final and correct diagnosis.

What difference would a two-hour faster case turnaround make?

Two hours can have a major impact. Cancer therapy is different depending on the type of tumor a patient has. I’ve had urgent calls from clients during testing asking if I can tell yet whether it’s invasive carcinoma versus a ductal carcinoma in-situ (DCIS) tumor. If it was an invasive tumor, having the diagnosis two hours faster would mean the patient could begin therapy a lot earlier. Typically, a breast triple cocktail can take seven hours to perform, so a two-hour faster turnaround time would really help us and the patient.

What does faster case delivery mean to you personally in your day-to-day work?

There’s satisfaction in both completing the case and also knowing that we’ve done an excellent job in obtaining the diagnosis. It also gives me time to proceed with other testing if necessary. For example, if it’s lung adenocarcinoma, I can proceed with molecular testing. Lung cancer patients can succumb within eight months, so if you can finish testing as soon as possible, they can start therapy and prolong their lifespan. In the end, it is the patient and their family that counts.

What about workflow – is this impacted by the turnaround time of individual cases?

Yes, you don’t want a traffic jam in the workflow. You want to keep things moving along. The instrumentation, the technologists, the pathologist and the laboratory personnel all play a critical role in improving efficiency. This is why we all work in partnership with our clients to achieve a timely and accurate result for the patient, which is our most important objective.

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About the presenter

Steve A. Kargas, MD, PhD, MBA, FACHE

Dr. Steve A. Kargas is the current Director, Surgical Pathology at CSI Laboratories, Atlanta, GA. He received his medical degree and post doctorate at University of Wisconsin-Madison and his AP residency at Stanford and CP residency at Cedars Sinai Medical Center, LA., CA. Dr. Kargas is highly involved in improving specializing in evaluation, diagnostic immunohistochemical analysis and molecular testing of solid tumors including carcinomas of unknown primary site, soft tissue, colon, prostate, breast, prognostic/diagnostic cases, MMRP, MSI PCR testing, hepatocellular carcinoma, lung including small cell carcinoma vs. non-small carcinoma, and providing solutions to anatomic pathology needs of clients. He is a member of CAP, USCAP, ASCP, ASQ, and ASC.

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