Pearls for the People From a Prostate Pathologist

A tray of prostate biopsy slides is ready for microscopic review.

As my career in pathology heads toward the home stretch, some pearls I have picked up along the way, particularly during the last 17 years as a prostate pathologist.

I Can Name That Surgeon in 3 Cores

You all know that no two people have the same exact fingerprints or DNA. I can tell you that no two surgeons send the same exact prostate biopsies.

I can look at a case and know right away who the urologist is. Fourteen cores? That tells me this case is from Dr. B. A ten-pack? Got to be Dr. M. Lots and lots of cores from every location in the prostate? Dr. Y must be the urologist of the day. Long, thick cores come from Doc A, while Doc B sends more fragmented specimens. Sixty different urologists, sixty different biopsy “fingerprints.”

It’s Not Over Until the …

I sometimes get a bit exasperated looking at 15 or twenty prostate biopsy cores from a patient, all of which look perfectly normal; well-formed acini with lots of basal cells, bland stroma, nice even spacing.

But today I got a reminder why I need to look carefully at each and every one of those cores, all the way to the end. In two consecutive cases, I found nothing, nothing, nothing, until the final core in each case demonstrated prostate cancer. And not the potentially insignificant Gleason 3+3 kind, but high-grade cancers that will require treatment to preserve the patient’s health and hopefully prevent a cancer death. It’s humbling to realize that the 12th biopsy found what the first 11 didn’t.

Statistically, Things Tend To Return To The Mean

There is a saying in baseball that a ballplayer’s batting average is going to match the numbers on the back of his baseball card. A .250 hitter might go on a hot streak, but eventually, he is going to go back to being a .250 hitter.

It’s like that in the lab, too. Some days every prostate I look at will be malignant and I feel like Dr. Death. Other times, every case is benign, and while that is great for the patients, I worry that I am missing things, that I have forgotten what prostate cancer looks like under the microscope. But over time, it all evens out. From month to month, the percentage of cases I diagnose as cancer is the same. The diagnostic peaks and valleys cancel each other out. Statistics just don’t lie.

Whatever Remains…

Sherlock Holmes once said, “Once you eliminate the impossible, whatever remains, no matter how improbable, must be the truth.” Over a long career, I have realized that a pathologist’s most valuable skill is recognizing the many faces of non-cancer. While scanning prostate tissue, my brain automatically eliminates the benign, the inflamed, the reactive.

Whatever remains is where my concentration needs to be focused. Those areas might not be malignant, but I need to look at them carefully to make sure they aren’t. When in doubt, a second look the next morning, or a special stain, or a consultation with my colleagues will guide me to the truth. The Holmesian method of diagnostics.

I am sure I have learned a few other things, but I will save them for another snowy day.

This blog is the opinion of the author and not UroPartners LLC.

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