The Pathologist and the Pea


A tray of slides that may demonstrate prostate cancer under the microscope.

You all remember the story of the Princess and the Pea. In the fairy tale, a beautiful young woman of questionable parentage is proven to be royalty when a pea at the bottom of a stack of mattresses disturbs her enough to prevent her from sleeping. (I know, they had weird tests for royalty back before 23andMe made it simple.) Hans Christian Anderson wrote one version, and a young Carol Burnett starred in a Broadway adaptation called Once Upon a Mattress.

As you may have surmised, I have NO royal blood. I usually sleep through the night like a petrified log. You could put a dozen squawking chickens under my mattress and I wouldn’t budge until my alarm clock chirped at 5:05.  But at the lab, something smaller than a pea can cause me immense discomfort.

Looking at slides through a microscope for at least 3 or 4 hours a day takes concentration and good equipment. An ergonomic microscope, an equally ergonomic chair, my assortment of favorite pens and markers, and most importantly, well made and expertly stained tissue slides are all I need. And that is exactly what I get most of the time. But all it takes is a speck, be it dirt, paraffin wax, or mounting medium, on the back of a slide to throw me thoroughly out of whack.

Diagnosing prostate cancer is, of course, a science. A small bit of the knowledge is picked up in medical school, more in a pathology residency, and much more in a fellowship or certification training. But as I have learned through years in practice, it is the art of pathology that is the secret to managing a pile of slides with its stack of requisitions. Sure, there are cases where the tumor practically jumps off the slides and writes itself onto the Final Pathology Report. Those are important to diagnose and doing so is essential to the well being of the patient. But they offer little intellectual challenge for the pathologist.

The artistry is in the less obvious cases. Your eyes look through the microscope at the slide, and there are benign glands and stroma, the normal structures you expect to see. But with that first look, some primal scream tells you there is a disturbance in The Force. Something is out of alignment, there is trouble ahead. The abnormality may not show up on that first slide, but extraordinarily careful examination of each millimeter of the patient’s multiple biopsy cores is called for.

Could what appear to be benign inflammatory cells in actuality be small cell cancer? Are those bland, pale cells fading into the background a clear cell variant of prostatic adenocarcinoma? Has a bladder cancer sneaked into the prostate while I was looking the other way? An associate once told me he could “smell” cervical cancer on a pap smear two seconds after starting to look at a slide. I know that he too was talking about a ripple in The Force, some subtle change that he only recognized after looking at tens and hundreds of thousands of slides.

Going back to the tiny speck of wax or mounting medium stuck to the bottom of my slide. That tiny speck is just enough to throw the slide off balance on the microscope stage. All of a sudden the slide and I are both out of focus. The subtle, subconscious clues disappear. I am back to being a first-year pathology resident, looking for the obvious, seeing only what bites me in the behind on my comfortable, ergonomic chair.

It’s enough to make me feel like Carol Burnett with that blasted pea under her mattress. Broadway here I come!

Best Comments on Tuesday’s Post:

“If you host, I’ll watch!” – Lu Leach

“You are smart enough for jeopardy, classy enough for the Oscars but way too intelligent to get involved with show business!”– Jimmy Nuzzo


The opinions expressed are those of the author, not of UroPartners LLC.

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Filed under: Health, medicine, pathology

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