It Takes More Than My Microscope For Me To Give You A Diagnosis Of Prostate Cancer

Microscopic appearance of prostate cancer (left) with special stain (right.)
Microscopic appearance of prostate cancer (left) with special stain (right.)

When I talk to folks, or blog to you all about making diagnosis, what I usually chat about is the time spent looking down the twin ocular barrels of my Olympus BX43 binocular microscope. After all, that is when my eyes and brain are most engaged in looking at the prostate tissue and forming a diagnostic impression. But in fact, that microscope time is probably less than half the time I spend on the hundreds of pieces of prostate tissue I see every day.

In the morning, while our crack anatomic pathology team is busy grossing, processing, embedding, cutting, staining, and cover-slipping prostate tissue to prepare beautiful slides for me, I am getting my paperwork rolling. I download a spreadsheet of all my cases for the day, using it to create individualized worksheets for each case. That lets me know the age of each patient, the name of the urologist doing the biopsy, and how many parts I can expect with each case. Basic stuff.

I then take my worksheets and progress to our online medical record (I love those online records!) Here I can get information on the patient’s past prostate history. Has he been biopsied before? What did we find? I can look at the most recent PSA blood test, and also look at a timeline of all the past PSAs to see how the values have changed over time. In addition, many patients have a “targeted biopsy,” aimed at “regions of interest” in an MRI of the prostate. I can read the radiologist’s report and learn just how suspicious those ROIs are.

All this information is running through my head when I look at the slides. Although it is a pathology maxim that “the truth is in the glass” the other data can guide me as I am making decisions on what I see. Oh, and while I am looking at that glass I am recording my findings on my worksheet, leafing through textbooks or websites for help on difficult cases, ordering the special stains I need, and filling out billing sheets. Sometimes it feels like my head is bouncing back and forth like a ping-pong ball, with a glance through the ‘scope as I am turning left and right.

Once I have handled the last slide of the afternoon I drop the worksheets with our administrative team. It is their job to transfer all my codes into our Lab Information System to create a nicely formatted report.

Next morning, I review the reports and add any information I have garnered from the special stains I ordered the day before. It is almost time to electronically sign the reports, and whisk them via the magic of interfaces to the performing urologist. But before that can happen, especially in malignant cases, there is one essential review step.

Nobody wants to call a benign biopsy malignant. So before a cancer case is signed out, we have it reviewed by at least one additional member of our pathology staff. In the oldest days that would be done at a multi-headed microscope. In the more recent old days (i.e. pre-Covid) we would review cases on a video screen in my office. Since the pandemic, we have avoided congregating and now place our slides on a tray and pass them to another pathologist for review in their own offices. A log sheet ensures all cases are seen and diagnoses are concurred with. Only then are the cases signed and distributed.

Am I done at that point? Almost! Since UroPartners has a very vibrant Cancer Registry, my final step is to mark the parameters of each cancer (grade, number of positive cores, length of involvement, other findings) on a sheet for our Tumor Registrar. This data allows our group to have an ongoing understanding of the patients that pass through our doors and to follow large cohorts of patient data. This has fueled numerous scientific papers and advancements in prostate cancer treatment.

My microscope may be my best friend, but it has lots of help in making sure our patients have the correct diagnosis in a timely manner. And that is always my goal.

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The above is the opinion of the author and does not necessarily reflect the opinion of UroPartners LLC.

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