Reading a Prostate Biopsy-Inside the Mind of a Pathologist

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One Patient's Prostate Biopsy Slides

West Suburban Chicago

6 a.m.

"Let's see, how many prostate cases do we have today. Looks like I get nine. Better get started now before the phones start ringing and before the lab techs start popping their heads in. And oh yeah, I will have urine cytology slides and FISH heading my way.

"Too deathly silent in here though, better turn on the radio. The Sox lost last night, so no point in listening to the Mulley and Hanley on The Score. I'll flip to FM  and go with Lin Bremer on "XRT.  A little music and a chance at 'Three for Free."

"Got my tea, let's find the first case. My case list start's with Bobby Bright, routine 12 part biopsy. That will be one of the big trays that can hold all 24 slides. Oh, here it is, top of the stack. All the slides have their labels, and the labels match the requisition and billing sheet. Good, no issues. Flip on the microscope light, grab the first slide and we are rolling.

"Part A is from the right apex.  A few inflammatory cells, but nothing that looks suspicious for cancer. Check off the benign code on my worksheet. Part B, right middle, oh-oh. I don't like that group of glands. Their growth pattern is too irregular. Let's look at a higher microscopic power. Yup, there are big nucleoli, and I don't see any basal cells. Pretty sure this is malignant, but am I sure? I think I will order a PIN4 stain. The insurance company won't be happy paying for it, but they would be more unhappy paying for a prostatectomy the patient doesn't need. Mr. Bright wouldn't be too happy about any of that either. So let's do the stain. I should have it by this afternoon in time for case review, so there won't be any delay. Rest of the case is benign, good for this guy, he might only need active surveillance, no surgery or radiation for now. Oh, I better remember to flag this case for possible molecular testing. That will help decide the treatment question.

"There's my microphone. I guess I forgot to turn it off last night, but it's still charged. Good thing, I can dictate the diagnoses without having to recharge. The staff can start typing early.

"OK, next case, Grant Aspen. Wow, these glands look really stunted. And the cells are so bizarre. But that blood vessel doesn't look right either. Hmm, I think I know what's going on, but let me check the medical chart. So glad we have the electronic health record, it really makes my life easier. Yeah, just what I thought. This guy had prostate cancer five years ago and was treated with radiation therapy. All those freakin' changes are from the rays. No cancer here. Let's get this dictated and move on.

"Next case is one of those MRI-Fusion biopsies. Sometimes that MRI is really good at picking out the area in the prostate where the risk of cancer is high. That will be Part M on this case. Here it is, yeah, that's tumor for sure. But how do I want to grade this. Is this a Gleason 3+3, or a Gleason 3+4. It's hard to tell on this level. Good thing we have 6 levels on each biopsy. This next level definitely has poorly formed glands, so we've got some Gleason Grade 4 here for sure. That will make the Gleason Score a 3+4=7. And I see cancer in some of his other biopsies as well. I am afraid he is going to wind up in the OR for a robotic prostatectomy. Better dictate to flag this patient for our Quality Assurance audit. After he has his prostate out  I can check that pathology report against our biopsy report.

"Damn, there goes the fire alarm. Forgot that we are having a fire drill today. Oh well, the sun is shining and a few minutes standing around in the parking lot will help clear my mind.  Gotta keep sharp, never know what the next slide will show."

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