Reading a Prostate Biopsy-Inside the Mind of a Pathologist

tray — 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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Our Seven Worst Theater Experiences-One for Every Day of the Week!

The play’s the thing

Hamlet Act 2, Scene 2

William Shakespeare~1603

Plop down in front of the TV? That’s a near daily occurrence. Visit the local Cineplex? We may do that a couple of times a month. But for most of us, live theater is a rarer, more delectable experience. It no longer requires donning a sport coat and tie, but whether it is plotting a route to the Loop, planning a theater weekend in New York City, or just a suburban drive to Lincolnshire or Oakbrook, there is a specialness about the experience. I have written about some wonderful theater we have seen. But what goes around comes around, and it’s time to let loose on some of the stinkers. So, in no particular order, here are seven shows we have seen, and wished we hadn’t.

Biggest Disappointment: Claude-Michel Schönberg and Alain Boubil, composers of Les Misérables, will always be our heroes. But their miserable concoction The Pirate Queen, which played Chicago in 2006 before debuting in New York in 2007, managed to avoid any of the tunefulness or dramatic story lines of its predecessor. No surprise that the show quickly walked the plank on Broadway.
Easiest Show for Us to Make an Early Exit: We have seen some wonderful shows with our intermittent subscription at the Marriott Lincolnshire Theater. Cabaret, from the 2014-2015 season, comes to mind. But that same season also had a production of Godspell that was absolutely dreadful. Half the audience, including Barb and I, filed out during intermission with no intention of returning. Maybe everyone was inspired to head to their favorite church, synagogue or mosque to seek divine forgiveness for buying tickets to this snoozer. Did people really like the original production in 1971?
Best Show to Leave When Your Son Gets a Fever: While we are dissing the Marriott, here’s one more low blow. A production of Chess, the Tim (Evita) Rice/Benny Anderson-Bjorn Ulvaeus (both from ABBA) collaboration was so dreadful we almost cheered when we learned at intermission that Michael had a temperature of 102°. Good thing we left. The reviews said the second act was even worse than the first.
Lacking Star Power: Back in 2009 you had to know someone to get a ticket to see James Gandolfini and the rest of a great cast in God of Carnage. It wasn’t quite Hamilton but it was big. By the time we caught the show a few months after the openning, the cast had turned over, and we were more interested in whether or not we would make our post-matinee flight back home than in the on-stage shenanigans.
Overheated: This should have been a winner. F. Murray Abraham starring as The Merchant of Venice at the Private Bank Theater downtown. We might have enjoyed the show if someone had mentioned to the theater manager that it can get hot in Chicago, even in March. Without air-conditioning the theater was absolutely stifling; our view of the stage was blocked by everyone fanning themselves with their Playbills.
Sob Story: Barb cried and cried at the movie theater during the Bette Midler tearjerker Beaches. I cried and cried being forced to sit through the interminable stage version at the Drury Lane Theater in Oak Brook. As far as I know, this Pre-Broadway tryout has still not found a path to the Great White Way.
A Hot Mess from Start to Finish: Who remembers the theatrical version of Women on the Verge of a Nervous Breakdown. I didn’t think so. A good cast featuring Patti LuPone, Laura Benanti, Sheri Rene Scott, and Brian Stokes Mitchell trapped in musical nightmare. I hear the London version lasted a little longer than the New York City version. That’s reason enough to kick Britain out of the EU.

What’s your worst theater experience? Leave a Comment below. Just remember the Comment section on the ChicagoNow website is after that row of ads. I hate that set-up but that’s the way it is.

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Why do we never get an answer…

…when we’re knocking at the door.

Moody Blues–1970

To those of you who didn’t try last week’s “Downsize, Maybe” Easy Squeezy Tuesday Music Trivia Quiz, shame on you! I told you the contest was easy. I told you that you didn’t even have to get the answers right to qualify for the prize. And I bet you would have known most of the answers anyway. Aren’t you sorry now you didn’t try? Fortunately, a lot of you DID try the quiz. Anyone who answered even one question,right or wrong, was entered in our prize drawing, except for the few of you who didn’t enter a return email address. Sorry about that, but you have to read the directions, folks! I bet the people who didn’t were all guys who throw out the directions before they put together IKEA furniture and then wonder why they have so many left over parts. (Alert, Alert—As I was writing the blog I heard about big IKEA recall–do you know where your dresser is?)

Anyway, for those of you playing along at home, here are the correct answers and a few unrelated comments:

Catfish and the Bottlemen (for those of us still listening to new music.)
Freddie and the Dreamers (how could anyone miss this?)
Florence and the Machine (overshadowed by Adelle, but still a great sound.)
Gladys Knight and the Pips (she was a winner on the Ted Mack Original Amateur Hour at age 7.)
Huey Lewis and the News (would “Back to the Future” be the same without them?)
Bill Haley and the Comets (sometimes called his Comets.)
Tom Petty and the Heartbreakers (tied with Steven Tyler for least handsome rock star in history.)
Bob Marley and the Wailers (no, not the Whalers, I don’t think they have whales in Jamaica.)
Tommy James and the Shondells (Crimson and Clover, over and over.)

At least one hit record from each decade, 1950’s to the 2010’s, from that crew.

My favorite wrong answer was definitely “Florence and the Nightengales”–and that response came from a laboratorian, not a nurse. Way to go lab people! As for the best newly created name, I would call it a tie between “Randi Libido and the Friskies,” and “Dr. Stone and the Lithotripters.” You have to be involved in urology to love the latter, though.

Our winner has been notified and will soon have their Amazon Card. I don’t have permission yet to use their name here, but I will let you all know when I have the OK.

That’s today’s scoop. Back to the house or the wide, wide world on our next post. Until then, keep on rockin’, and don’t forget to subscribe. Just enter your email address in the box below and click “Create Subscription.” Who knows, you might become our next contest winner, or just enjoy some good summer reading.

Speaking of good reading, check out the blog post by fellow ChicagoNow writter Kerri Morris–it’s a very nice piece about life in our pathology lab. Thanks for the shout out, Kerri.

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Today on “Meet the Press”: REXIT–The Raff’s to Leave Long Grove, Local Economy Trembles.

Dramatic Theme Music ♬ ♬ ♬

Chuck Todd (CT): Good Morning, This is Chuck Todd welcoming you to our weekly edition of “Meet the Press.” Today we look at the dramatic and perhaps misunderstood decision by the Raff family to cut ties with Long Grove, ending 26 years of intertwined destinies. With me today is my distinguished panel: Bono, lead singer of the Irish rock band U2, Ken “Hawk” Harrelson, the long-time voice of the Chicago White Sox, and Daenerys “Stormborn” Targaryen, First of her Name, Queen of the Andals, the Rhyonar, and the First Men, Queen of the Seven Kingdoms, Protector of the Realm, Queen of Meereen, Khalesi, and Mother of Dragons.

CT: Bono, let’s start with you. Did you see this coming? Did you really believe that one of your biggest fans would leave the comfort and familiarity of Long Grove for the unknown, moving to the virtually identical suburb of Riverwoods?

Bono (B): It’s what I have been writing about, singing about, for years. It’s all about love. Why stop loving the people of Long Grove? They must be wearing rose colored glasses if they believe they are heading for something better. Raff’s, why not wrap your neighbors in your arms and move all of them with you? It’s all about love, and album sales and downloads. You must lead with your hearts.

Daenarys Targaryen (DT): Yes. Leadership, that’s what it takes. These Raff”s think of themselves as leaders with their Home Owners Associations and their School Boards. But where are their dragons? Where are the people being burned at the stake? How do you lead when you don’t instill fear in the hearts of your subjects? That is what I want to know.

B: And don’t forget, people anticipating a quick separation will be disappointed. Disentangling from the landscaper, the snowplower, the cleaning lady-that all may take months. And then of course there is Comcast. That may take years.

CT: Mr. Harrelson, what ramifications do YOU see from this vote.

Ken Harrelson (KH): Let me tell you Chuck, back in ’67 when I was with the Red Sox if those owners had tried to trade Yaz, I can tell you there would have been all sorts of an outcry. He was the greatest ball player I ever saw and I saw ’em all going back to the Babe.

CT: I’m sure Hawk, though I don’t think you are THAT old. And what does this have to do with the Raff’s leaving Long Grove?

KH: It’s no different than the way the umpires all disrespect our White Sox. We can never catch a break and…

CT: Moving on, we have a special guest to comment on REXIT. With us on the phone is the presumptive Republican Presidential Candidate Donald Trump.

Donald Trump (Don): Hey Chuck, what’s presumptive about me. I hate that word. I’ve got the nomination all sewn up no matter what crap the delegates try and throw at me. And who’s the chick with aal the hair on the panel with you? Doesn’t she know there is only room for one blonde crackpot here?

DT: Off with his head!

Don: She sounds like Lying Hilary to me! Yeah honey, you can dump those dragons, I’ll show you a hot time.

B: Love, people, just love.

CT: I’m afraid that’s all the time we have today. Join us again next week, and remember, if it’s Sunday, it’s “Meet the Press.”

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Our music contest has ended. The winner of the $25 Amazon Gift Card will be announced in our next post.

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A Progress Report at the Half Way Mark–Will I Get Steamed?

If it takes a year to build a house, then the calendar on the wall tells us we are just about 50% complete. So our glass is both half full and half empty. Let’s take a look at where we are, and where we still need to go.

Work on the outer shell of the house is well beyond the midpoint. The concrete with additional waterproofing? Done. The wood framing with the green Zip System sheathing? Done and done. Masons are progressing well with the exterior stone; the roof shingles are more than 90% installed. All the sleepless nights (Barb’s, not mine) worrying about the best stone and shingle to choose have paid off, the colors and styles blend beautifully. And for those of you following since the beginning, the muntons look swell too.

The interior framing of the house has been completed for weeks. A few walls have been shuffled, with a larger powder room appearing here, a closet melting away there. The design for the stairs leading to the loft space continues to perplex, with Ham and Jeff (you remember our architect Alexander Hamilton and builder Thomas Jefferson) going five rounds in a UFC cage match before agreeing on how many steps need to be above the middle platform and how many below. Working with designer Betsy Ross, we all agreed on a creative “slat” effect for the top of the stairs. We like the way it will allow light from the picture window in the loft to filter down the staircase.

PVC and copper pipes have sprouted on all levels, and sheet metal HVAC ventilation shafts are blooming as well. Routing the ventilation has led to some redesign in the office and the basement, but the changes are improvements, not defects. We also did the first half of our walk through with the electrician, placing outlets and switches. Although these were all on the original blueprints, furniture placement has required some variation. No sweat at this point.

As we toured the master bathroom with the electrician, Barb said to me “This is your last chance for a steam shower. Are you sure you don’t want it?” After a ten minute exposition by designer Betsy on the merits of steam on aging bodies (ours, not hers,) I caved and agreed to go for it. But when Ham and Jeff did some back of the hand calculations and whispered in my ear the cost of adding steam to our shower, I decided I had no problem with a few aches and pains as I age. The steam shower was vaporized.

So here we are, six months down, six months to go. All the behind the scenes work Barb has put in will start paying off soon, as the flooring, light fixtures and appliances that have been selected begin to appear at the construction site. Add in a little landscaping, and we will be partying with all our new, friendly, neighbors before you know it.

The first drink will be on me!

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It’s still not too late to take our very, very, easy music quiz and qualify for out Amazon Gift Card giveaway. Just click here!

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Am I Cooked? Hot Tea and Other Risks

Oh I like coffee…

…and I like tea

Blues Traveler–1994

Coffee drinkers are rejoicing. A UN study shows no increased cancer risk for java juicers, no matter how many jolts of Joe you go for in a day. So until the next study comes out disputing these findings –give it a week or two–Starbucks, Dunkin’ Donuts, and McDonalds can keep your magic elixir flowing. But for me, the news was not so good.

Other than enjoying an occasional scoop of Baskin-Robbins Jamoca Almond Fudge and a rarer slice of tiramisu, I keep away from coffee. It isn’t the caffeine I am avoiding, I just have under-developed coffee savoring taste buds. But I revealed my little secret here a few months ago. I am a tea tippler (though not a teetotaller.) And I like it hot. Microwave my tea? You have got to be kidding. “Instant” hot water? Not a chance. I require either a steaming tea pot on the stove or my high powered electric kettle to give me the boiling brew I crave.

And that’s the problem. The UN study points at the temperature of beverages as a risk factor for cancer. Drinks over 150° F appear to be the culprit, and here I am gulping down about 6 cups of tea a day, as close to 212° as humanly or mechanically possible. I have accepted the risk of a burned lip or a scalded tongue, but am I really ready to increase the chances of esophageal carcinoma? I choose to believe my non-smoking and less than average alcohol imbibing life style make the risk of esophageal cancer pretty low. Add in the lack of family risk factors and I think I am safe enjoying my cups of tea.

Prostate disease is a different matter. Knowing I have the genetic risk factor, I do occasionally consider how my diet effects my chances of prostate cancer. Tomatoes seem to have some preventive effect, validating my love of pizza and a good Caprese Salad. All the other fruits and vegetables I munch on also may also offer some protection. It would be beneficial if I could once more wean myself from red meat, but I returned to that indulgence many years ago. At least we have replaced beef hamburgers at home with Barb’s 5 Star turkey burgers, and I haven’t seen the inside of McDonalds for years. If only I could give up those tasty, garlicky, SuperDawgs.

While we are talking prostate cancer, just a plug for the SEABlue Prostate Cancer Awareness Run on September 11 in Lincoln Park. Donations are still gratefully accepted. Just click on the link. You will have my thanks!

Donate to SEABlue.

Also–our easy music quiz is still going on! Don’t miss a chance to win an Amazon Gift Card.
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Easy Tuesday Music Trivia with a Prize!

“B.B. Bumble and the Stingers…

…Mott the Hoople, Ray Charles Singer”

Life is a Rock (But the Radio Rolled Me)–1974

Summer days, full moons, and the heat is rising. Chicago may not have it as bad as many parts of the country, but it is still time for chilling out, cracking out your favorite lemonade and listening to the music “soundtrack of your life.” I get my tunes from a Pandora stream, a personal station I have named “Decades.” I chose the name to remind me to include music from all the periods of my life, not to strictly focus on the classic rock of The Drive (sorry Greg), or today’s pop that sneaks in past my headphones in the fitness center. It is sort of like ‘XRT without Lin or Terri. I preloaded the selections with Steely Dan, U2 and Foo Fighters, and Pandora fills in the blanks from there.

But let’s not dwell on my musical tastes. Instead, let’s celebrate summer with an easy peasy lemon squeezy music contest–and this one even comes with a prize. One Amazon $25 gift certificate will be given away, and everyone who enters the contest is eligible. So give it a try, even if you don’t know a thing about the music of the last 50 years. And share the contest, by email or Facebook–give your friends a chance to win too. Then sit back and have that lemonade.

Contest Rules:

Follow this link: Les’s Music Quiz

All entries received by midnight June 26, 2016 will be eligible for random drawing for a $25 Amazon Gift Card. You must include your name and email address to win. Answering all questions correctly earns a double chance to win!

And remember–the quiz is easy! Just fill in the blanks. And pass it on.
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The Curse of the Clumsy

“Move, move, move!” I shouted out. Yes, it was an over-reaction, but it got through to Barb. She quickly slid out of of the deli booth at which we were just settling into our soup. She was just swift enough to escape being deluged by the drink sluicing from the glass I had knocked over. Tea and ice cubes now covered the banquette Barb had been sitting on, but she was still immaculate. The wait staff quickly hustled us over to another table, refilled my glass, and our dinner continued unhampered. My quick alert had prevented the damage that my clumsy hands had almost caused.

But there is no denying it, I am a klutz. I am a butteringers, a stumbler, a clod. It is a fact of my life, one that my loved ones and colleagues have to accept and deal with. That fancy microscope I bought last year? At least monthly a turn of my head has sent it crashing to the ground, my glasses landing right between the eyepieces. Those bruises on my elbows? A trip over the pavement at the end of my run. Was it because the pavement was crumbling or uneven? No, I was just gliding along until my toe got tangled in a non-existent crack. I have catapulted into duck ponds and crashed into walls of tennis courts. But I don’t want to believe this curse is all my fault. And when looking for something to blame, turn to scientific research!

So I asked Google Search to tell me what causes clumsiness. The only widely circulated study into the topic tested college students and found that “clumsy” people have depressed reaction time. But that doesn’t feel quite right to me. That makes it sound like us klutzes move in slow motion. In fact it is just the opposite. My hands, my head, my feet–they all seem to be moving at hyperspeed when those little crashes happen. The study does say that focusing on a task can reduce clumsiness, but it takes a lot of conscious effort to slow all those moving parts down, and at the end of the day, who wants to think that hard?

Barb, in her therapy lingo, says I have a “figure-ground” problem, a perception issue which makes it hard to separate objects from the background. Her theory also explains why I can never find the spatula in the kitchen gadget drawer. Hmm, an inability to separate objects from their background. Just what you want your pathologist to be plagued with when he’s looking through his microscope, mentally trying to separate the good cells from the bad. How did I wind up making a pretty successful career out of this?

So I stumble along, never knowing when I will take the next tumble or send the next glass of wine crashing to the floor. But at least my family knows. When I yell “Move,” they get moving!

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Am I a Homophobe?

Three connected events:

One of the most tragic incidents in contemporary American history occurred early Sunday morning in Orlando. 49 people slaughtered in a nightclub. Some, most, or all of the victims were gay. All of the victims were people who did not deserve to die at that time or that place. Their loss will be felt by 49 families, 49 groups of friends, 49 communities.
Sunday night Broadway held a celebration, the annual Tony Awards. It was a spectacular show, though tinged with sadness as evidenced by the comments of the host, several presenters and several awardees.
On Monday morning, inspired by the success of Hamilton and its rap framework, I published a blog, a little doggerel, saluting the Tony awards. Eight short verses, tagging a few of the honored shows and big names of the night; James Corden, Lin-Manuel Miranda, Barbara Streisand. I did not mention the Orlando tragedy.

For item number 3, I have been labelled a homophobe, and I am stunned. I thought about including a reference to the shooting ion the blog. But I do not have the talent to include such a serious, deadly event in light verse that was meant to leave readers smiling and tapping their feet. Perhaps I was insensitive not to have a closing paragraph, in prose not in rap, expressing my sadness at the needless loss of life. But I don’t comprehend how my omission warranted the application of a label denoting “irrational fear of, aversion to, or discrimination against homosexuality or homosexuals” (Merriam-Webster On Line Dictionary.)

Some of the victims I didn’t write about were women. I don’t think I am a misogynist. Some of the victims I didn’t write about were Hispanic. I don’t think I am a xenophobe. I also did not write a blog about the terrorist shootings in Tel Aviv last week. I know I am not anti-Semitic. The useless tossing of names and slanders does nothing to bring about understanding and healing. It lowers each of us, just as it lowers a Presidential candidate.

You will each make your own judgement about me, about my blog, about whether you will continue to read. And I appreciate that most of you will give me a fair shake. That’s all I ask for.

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Fathers Day and Lee –The Dad I Hardly Knew

Fathers Day is near. Time for our annual homemade Margarita inspired blowout. Loads of fun, but a bittersweet day in a few ways. It is always a joy to be celebrating with Barb and our kids, with our extended families, and with our friends. But this will be the last time in our home of 26 years that I juice all those lemons and limes, make my simple syrup, let the tequila and triple sec flow. Yes, we will still be living here for the 4th of July, but that is not “our” holiday to host. This is truly a Fathers Day Farewell.

As happy as I am to be the father of two wonderful children, and a grandpa to two more, Fathers Day is also a time of sadness as I remember my dad. We share so many traits; our looks, our early morning energy, our preference for listening over talking. I miss his presence, but at least I know I had the chance to learn from him over many years.

I wish I could say I had the same opportunity with my father-in-law Lee. He was very different from my dad in so many ways. Dark complected, a salesman’s ability to put everyone at ease with his friendly patter, a sportsman who loved his new toys. His home would have the first microwave in the neighborhood, the first Pong game hooked up to a TV console, and the first (and only) remote controlled golf cart. With his best buddy Oscar he would roam the golf courses of the northern suburbs on weekend jaunts. I never heard a complaint, though I think he regretted turning down the opportunity to own a McDonald’s franchise in the early 60’s. It’s a pity he didn’t accept. I am sure he would invented the world’s first automated burger flipper.

I was absorbed with medical school and not much of a golfer, so I never got out on to a course with Lee. I figured the day would come. But after I had been dating Barb for a few months, Lee handed me a slip of paper with the words “Leukemic Reticuloendotheliosis” on it. He asked if I knew what it meant. It rang a bell in some recess of my anterior lobe. Through a little research (no Internet in 1978) I uncovered that it was an old name for a disease that had been renamed “Hairy Cell Leukemia.” Lee had been diagnosed a few years earlier, and after a visit to a specialist, was advised there was nothing to do for a disease that could be indolent or life threatening. And Lee felt and looked great.

Lee was in his glory at our wedding, “giving away” his princess to me, a young man that he was confident would be a lifelong partner for her. It was just a few months later that the diseased blood cells, now with a deadly aggressiveness, reappeared in his blood stream. He lapsed into coma quickly, ironically in the very hospital I was doing a student rotation and where the two grandchildren he would never know would be born. He woke into consciousness just once, giving me the details about his accountant and reminding me to have the family income tax filed on time. Were these the anxieties that filled his locked down brain?

Lee’s end came barely 6 months after our married life began, from a disease that soon became eminently treatable. If only one of his beloved toys had been a time machine that would have moved him ahead just a few years, to a time when effective therapy was available. That would make this Fathers Day would be so much sweeter. It couldn’t happen, didn’t happen, but I will be sure to drink an extra Margarita on Sunday — in honor of my dad, and in honor of Lee, the dad I barely got to know.

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