Don't Believe the Hype! Diagnosing Cancer Not for the Birds.

dylanIt's my work, he'd say...

...and I do it for pay

Bob Dylan

Hurricane, 1975

For most pathologists, it is more than a job, it is a calling. We are trusted to examine tissue from patients that we will most likely never seen or ever talk to, and provide a diagnosis that will often change their lives. The task requires a thorough knowledge of medicine, years of specialty training in pathology, and countless hours of microscope time learning the art, as well as the science, of our chosen profession. A well trained staff is also essential in making the correct evaluation, we are very much subject to "garbage in, garbage out."

So most of us chuckled at bit at all the news reports last month about pigeons being trained to diagnose cancer. It seems that with a few pellets, any creature with good vision can be turned into a pathologist! Since progress on the new house is on short term (we hope) hiatus this weekend, I thought I would take the time to explain just how a pathologist actually renders a diagnosis, and how it gets back to the treating physician. There are many different types of labs, and the processes is different at each one, but I will focus on how we do things at my laboratory, an outpatient lab specializing in urology, and key in on prostate biopsies.

Our lab is part of the largest urology practice in the Chicago area.  About 60 urologists across the region identify men, who either because of physical examination findings or because of abnormal blood work, require prostate biopsies. I will spare you the messy details about how the biopsies are taken, but generally 12-16 areas in the prostate are sampled, with a needlelike core of tissue about a 20th of an inch thick and an inch and a half long taken from each site. Those samples are placed in jars filled with formalin, and yes, it smells just like what you remember from high school biology. The jars are carefully labelled and packaged for delivery, while patient information is  entered into the electronic health record we share with the urologist's offices.

We use a courier service that specializes in handling medical specimens to bring the biopsies to the lab. That's where our great processing team takes over. After verifying that all the information we have in the health record matches the specimen jars we have received, a description of the cores is dictated for our  report. They are then "cooked" in a microwave processor, embedded in paraffin wax (yes, the floors get slippery), and then cut into ultrathin sections which are placed on a labelled glass microscope slide and stained with colorful dyes. The sections of prostate turn blue and purple and pink.  Some of this work is automated, but much is done carefully, by hand, one slide at a time.

One of our four pathologists then looks at each slide under the microscope and formulates the diagnosis. How do we do it? We each  have an encyclopedic knowledge of what normal prostate looks like. We look for changes in the appearance of the stained tissues, subtle or obvious, that signal a change from normal to abnormal. We then mentally run through the myriad of possibilities that the abnormality could represent. Some of these are benign and of no significance, others indicate cancer, or a potential for future cancer. When we are uncertain, we can have additional slides made and use stains beyond the routine ones. Our diagnoses are then entered into the lab report. Before releasing the report, we have a final checkpoint. Each afternoon, our pathology group meets in my office. We gather around a video monitor connected to my microscope and review cases together. We do this for every case with a cancer diagnosis. Once we all agree, our completed report is signed and becomes part of the electronic health record, available to the urologist for action. In our lab, the whole process takes about 2 days from the time the urologist does the biopsy.

I love birds. Counting Crows, The Eagles and Flock of Seagulls are all music to my ears. But when it comes to making a diagnosis, leave the feathers behind. We may get paid in more than bird seed, but if you want the right answer, find a pathologist!

One last thing. An apology to all those who got tossed and turned by the broken links on our last post. If you missed it, you can find it here. This link will work. I promise!

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