There are about 21,000 pathologists in the USA. That’s not a lot. And we are a pretty quiet bunch, even though some of us blog, a few of us tweet, and a handful probably Tik Tok and Instagram. Quincy M.E. may have been our show but that ended close to 40 years ago, Jack Klugman himself met his maker early in the last decade.

Yet pathologists matter! We make the diagnoses on the biopsies that influence your treatment. We ensure quality in the numbers that tell how well your diabetes medication is working. We make sure your Covid-19 test is as accurate as current science can provide. We study the genetics of your tumor to predict its aggressiveness or the likelihood of passing it to your children. And we can be the final arbiter of how and why a loved one died.

Whether by nature or whether by circumstances, we are mostly behind the scenes. Unlike your heart surgeon, your internist, or even your urologist, you rarely get to choose your own pathologist. And even less often do you rave about us to your neighbors. “You need a CBC? Your really should get it done at Midtown Clinic–that Dr. Greene is a great pathologist.”

But are there some of you who have known of a pathologist and of the role they played in your healthcare? Maybe it was at a tumor board you attended. Maybe you went out of your way to review your slides with the doctor who read them. Maybe you called with a question about your Prostate Specific Antigen (PSA) blood test.

If any of the above pertains to you, I’d like to know about it. Leave a comment, or drop me a line at les.raff@post.com. Let me know about any pathologists who stood out, who gave you knowledge, who made you feel cared for.

Please share, retweet, or forward this post, especially to those you know who have had an interaction with the healthcare system. I’d like to collect your stories for a future blog, or maybe more.

In the meantime, be well!

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

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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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So we have made your diagnosis. Hopefully, your biopsy was benign, but what if it was malignant? What happens next? What does a lab do with any leftover bits of your tissue?  What happens to the glass slides we looked at under the microscope to make the diagnosis? While I will use the prostate biopsies that we see in our lab as an example, much of this can be extrapolated to other biopsies, such as those from the breast, lung or colon.

Let’s talk about the “left-over” tissue first. With prostate biopsies, all the tissue is processed; that is to say that all of the biopsy material has been dehydrated, rehydrated and embedded in paraffin wax. The diagnostic slides were made from these paraffin blocks, but not all the tissue in the blocks is used up. What happens to the remainder? Sometimes nothing, but sometimes a lot. And more and more is being done with each passing year.

In cancer cases, we use that extra tissue to verify that the specimen we just made the diagnosis on is from the right patient. That’s a no-brainer you say, but we want to do everything we can to ensure that the Mr. Bowl’s cancer didn’t inadvertently get transferred to Mr. Plate’s specimens. So we work with a company that does a DNA double check. The company compares the DNA in Mr. Bowl’s biopsy core to the DNA in cells on a cotton swab that was rubbed against the inside of Mr. Bowl’s cheek when he was in the doctor’s office for the biopsy. The DNA results should be the same. It’s a high tech version of “The Match Game,” and creates a sense of confidence for patient, urologist, and pathologist.

The tissue in the paraffin block has other valuable uses. An increasing number of analyses can be done to determine the aggressiveness of the cancer, usually by using DNA testing to evaluate what genes have been altered in the tumor. There are even tests that look at benign biopsies and “predict” the likelihood of cancer being diagnosed in the next two years.

The glass slides have use as well. We can send them to another pathologist for a second opinion. They can be run through a device which creates a totally digital replica of the slide that can be viewed anywhere around the world. And they can be reevaluated as part of research studies.

How long do we retain the blocks and slides? We follow our accreditation regulations and local/federal laws and dispose of this material after 10 years. Space requirements make maintaining the material for longer than a decade prohibitive. While it would seem valuable to use this older material in research rather than dispose of it, investigation with some of our research partners has indicated the 10-year-old material has degenerated and is not suitable for the studies currently being done on newer material.

One more thing; most pathologists would be glad, and often eager, to show you your slides under the microscope. Usually a phone call is all it takes to make the arrangements. Don’t be shy, it is YOUR health!

And on a closing note–HAPPY LAB WEEK TO ALL MY LAB PARTNERS. Your pride and dedication in your work makes us an outstanding laboratory.

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The above is the opinion of the author and not of UroPartners, LLC.

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