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Brave New World: Pathology in 2020 Dr. Clive Wells University College London EWGBSP.

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Presentation on theme: "Brave New World: Pathology in 2020 Dr. Clive Wells University College London EWGBSP."— Presentation transcript:

1 Brave New World: Pathology in 2020 Dr. Clive Wells University College London EWGBSP

2 Paul J van Diest Head, Department of Pathology University Medical Center Utrecht The Netherlands Breast pathology 2020 With thanks to:-

3 No more sentinel nodes! sentinel node procedure is for staging in 2020 we can accurately stage based on primary tumor features

4 No more axillary lymph nodes! wait-and-see policy for the axilla under ultrasound follow up or radiotherapy of the axilla  lymph node dissection only in case of recurrence

5 No more resections! non-invasive ablation therapy for smaller tumors radio frequency ablation highly focused ultrasound laser induced thermal therapy neoadjuvant chemotherapy for bigger tumors adjuvant radiotherapy  only (bigger) biopsies remain

6 Extensive typing on biopsies! Intermediate/high risk benign lesions reliable markers that predict presence of DCIS or invasive cancer  resection, non-invasive ablation reliable markers that predict progression to DCIS or invasive cancer  follow up strategy, resection, non-inv. ablation

7 Extensive typing on biopsies! DCIS markers that predict presence of invasive cancer  resection, non-invasive ablation markers to guide image guided surgery

8 Extensive typing on biopsies! Invasive cancer markers that predict presence of DCIS  resection, non-invasive ablation markers to guide image guided surgery

9 Extensive typing on biopsies! Invasive cancer prognostic markers  type of adjuvant therapy predictive markers  type of neoadjuvant therapy  response monitoring by PET

10 …. but not histological typing…. … except for quality control! typing will be overshadowed by biomarker typing classical typing will merely serve as quality control ER+ PR+ HER2- ER- PR- HER2-translocation Luminal ABasal SecretoryAdenoid Cystic

11 Test to detect early breast lesions in nipple fluid Nipple aspiration intranasal oxytocin vacuum nipple fluid > 90% 10 gene QM-MSP (APC, BRCA1, BRCA2, CyclinD2, ERα, E-Cad, HIN1, p16, RARβ, RASSF1A, TWIST)

12 Test to detect breast cancer in blood DCIS and invasive cancer? methylation same genes as in nipple fluid microRNAs circulating tumor cells mutations?

13 Ductoscopy ductoscopy guided surgery fluorescent markers ductoscopic excisions ductoscopic biopsies fluorescent markers (LIFE)

14 Tissue processing 2020 uniform protocols to avoid interlaboratory variation during the day fully automated (including embedding) no more toxic chemicals formaldehyde xylene

15 Immunohistochemistry 2020 fully automated uniform protocols within 2 hours

16 Molecular pathology 2020 based on “whole” genome sequencing set of 200 genes that matter costs 2000 US $ replaces single gene mutation amplification tests translocation tests

17 Whole genome sequencing 2020 primary tumours and metastases in search of treatable mutations with drugs implies that molecular makeup is more important than morphologic typing and origin requires large pipeline of new targeted drugs requires a huge setup of early clinical trials

18 Digital pathology 2020 all labs have a scanner and decent storage digital consultation, remote revision, digital slide panels

19 Digital pathology 2020 all breast multidisciplinary meetings done digitally

20 Digital pathology 2020 enough bandwidth, processor speed and screen resolution to go wireless on PDA/iPad

21 Digital pathology 2020 image analysis guided immunoscoring

22 Digital pathology 2020 we use image analysis applications to find mitoses SN metastases mitoses

23 Breast pathology 2020 no more histological grading

24 Breast pathology 2020: no more grading… Markers of mitotic arrest - Therapeutic targets in cell cycle

25 Breast pathology 2020 uniform and sensible nomenclature  no more “atypical” for lesions without atypia good classification of apocrine lesions precursor of high grade DCIS identified more reproducible classification based on immunohistochemical and molecular markers

26 Breast pathology 2020 web based image archive for matching rare cases all labs have superspecialists in breast pathology needed or just for consultation? probably required molecular breast pathology in all pathology labs in developed countries (ISH, PCR)

27 Breast pathology 2020 What about microarrays? no more microarrays for prognosis Mammaprint Oncotype Dx no microarrays for molecular typing 2000 euro 3000 $

28 What is stopping us? Money for research to explore new areas Bureaucracy to be overcome before use of tissue (especially UK) Creating innovation only valued once a commercial market is visible Salary scale for academics discourages the best people Multicentre research needed but difficult to organise


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