Mr. Reinsdorf, It Is Time. This Pathologist Says So.

Loyalty. Forgiveness. Redemption

I rarely write about sports, but today I am compelled to do so, feeling a parallel in my life to something happening with my beloved Chicago White Sox.

In 1986 Tony La Russa was fired as manager of the White Sox. He went on to have a wonderful managerial career for other teams, winning three World Series and being elected to the Baseball Hall of Fame.

Before last year’s baseball season, Jerry Reinsdorf, the long-time owner of the White Sox (and Chicago Bulls) stated that firing La Russa was the biggest mistake of his career. In an effort to do a “make-good” and turn back the clock, Reinsdorf made an unpopular choice and rehired La Russa to manage the team.

For those who don’t follow the fortunes of the Sox, the team is populated by several young stars. Going into this season the Pale Hose were considered a strong competitor for their first World Series championship since 2005. But so far, this season has been mired in mediocrity.

Injuries have played a big part in this season’s disappointing results, but much of the blame needs be laid at the feet of La Russa. In the fairly unanimous opinion of fans and sportscasters, both local and national, many of his managerial decisions have been wrong, bizarre, and have cost the Sox victories.

Mr. Reinsdorf’s loyalty and desire to right what he perceives as an almost 40 year ago mistake have kept La Russa in his job, despite an outcry from most of us to dismiss him, hire a better manager, and give the team a chance to fulfill its destiny.

So where is the parallel to me? Almost twenty years ago shifting loyalties and relationships led to the ending of my partnership with a large pathology group. I went on to create and direct the UroPartners Laboratory, and while I may not be in any Hall of Fame, I think I have done a pretty, pretty, pretty good job.

And since then two of the principals in the group that “divorced” me have told me it was the biggest mistake of their careers. Just like Reinsdorf’s comment about La Russa.

But you know what? Neither of my former partners had any inclination to bring me back. Nor would I have wanted to. My time with them was in the past, and I would have had no business looking at a brain or bone biopsy after my years immersed in prostates and bladders. They told me they were wrong, I appreciated it, and that was that.

So, Mr. Reinsdorf, I understand you are trying to make up for what you perceive as your past mistake. But you have made your apology. La Russa’s time as an effective manager has passed. Now it is time to move on…and that means moving on without Tony La Russa managing the White Sox.

I am waiting.

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

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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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Am I A Prostate Guru? Someone Thinks I Am!

As a 12-year-old camper in the summer of 1968, I was my cabin’s nominee for the title of Guru of Camp Chi, 3rd Session. I ran a strong campaign, with a catchy jingle based on “Strawberry Fields Forever.” Sadly I lost in a heated battle with a candidate from another cabin. As was customary way back then, I graciously conceded the election to my opponent, without asking for a vote recount. However, I never returned to Camp Chi.

I haven’t thought about being a Guru in the 53 years since then. People who weren’t alive in the 1960s may ask “What is a guru?” Webster’s has several definitions for the word, including “a personal religious teacher and spiritual guide in Hinduism,” and “a person with knowledge or expertise.” Definitely an honorable thing to be. So I was quite surprised (and quite pleased) to have that appellation given to me the other morning.

Dr. M, one of our more senior urologists had stopped by to introduce his young new associate to the corporate and laboratory team at our facility. I gave the two physicians my standard lab tour, one that I have been giving to new employees of our group for years–a little lab history, a bit of explanation of our lab processes, and some back-patting of our staff. Fifteen minutes of time, and a chance to put a nice shine on the lab’s place in the corporate hierarchy.

As the tour moved from histology to chemistry, from cytology/FISH to our new molecular studies lab, Dr. M became more and more effusive about how excellent the lab was, and how we were the glue that held the group together. I was certainly smiling behind my mask.

And then came Dr. M’s final pronouncement. “Les is the Guru of Chicago prostate pathologists.”

OK, Chicago prostate pathologists are not the biggest set of which to be Guru. The network of Chicago area pathologists who do mostly urologic pathology isn’t enormous. But between all the university medical centers, the giant private hospital systems, and a few big commercial labs in the area, there are a lot of great pathologists and lots of prostate biopsies being analyzed. But yes, I probably see more prostate biopsies than anyone else in the metro areas — 18,000 prostate cases seen under my microscope over the last 15 years would be my best guess.

But I think Dr. M’s comment about “Guruness” was meant as more than just a comment on the number of cases I have seen through the years. I hope he was summing up that along with my associates, I have helped our large urology group provide sterling health care to our patients throughout Chicagoland. That is certainly our goal, and it’s good to know the lab is appreciated.

And after more than 50 years, I am proud to say I am finally a Guru. But I still don’t think I am ever going back to Camp Chi!

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“But Doctor, How Do You Know that is MY Biopsy?” — Maintaining Patient Identification.

It ain’t me babe
No, no, no, it ain’t me babe.
Bob Dylan, 1964

Get the right diagnosis to the right patient. That is the mantra of any good laboratory. No institution does it exactly the same way, but linking each specimen received to the patient it came from is an essential part of laboratory management and quality. A laboratory cannot receive accreditation without having the process totally embedded within standard operating procedures. But a lab like ours that handles hundreds of core biopsies of the prostate a week faces a special challenge. To the naked eye, all those biopsies look the same. How do we tell one from another?

Our system actually begins in the urologists office. Prostate biopsies usually consist of between eight and 12 very skinny cores of tissue taken from different areas of the prostate, each placed in a separate jar of formalin preservative. Before the doctor performs the biopsy, an order is placed in the electronic health record. Our system is designed to automatically print labels to be placed on each formalin jar. These labels are required to have the patient’s name, plus at least one other “identifier,” such as birth date or a medical record number, unique to each patient. The label goes on the jar (NEVER on the lid!) the tissue goes in the jar, and then our medical group adds one special documentation. The patient is required to look at each jar and sign a statement indicating that the label on the jar has his name on it. We even want the patient involved in our quality process!

Once the specimen is received by the lab, our team takes control. In every step of the processing protocol which transforms the tissue cores into thin, stained slices on glass slides, we take care to maintain proper identification. We require that only one patient’s specimens are in any working area at a given time so that jars or specimens can’t be mixed. We have rules that require a second technologist review labeling at certain key steps. We also utilize bar coding, though we plan on taking a great leap forward in that area with installation of a new information system this fall. And then we take an added step. All cores from each patient are inked with one of five different colors, and the color noted in the working documents. If at any time we see an outlier such as one blue core mixed with 11 yellow ones, we know we have a potential problem.

bx cropped — A prostate biopsy after formalin fixation

bx ink cropped — The biopsy following inking with black ink.

How would we resolve that problem? I’ll tell you in a minute, but first I want to mention a new step we have taken to ensure that our process has worked as planned. We now have available a system from a company in Indianapolis that compares the DNA from a patient’s cheek, obtained with a cotton tipped swab at time of the procedure, with the DNA in the patient’s biopsy. A match here is a virtual guarantee that the biopsy is from the right patient. The system is not free, and some of our patient’s elect not to utilize it, but we appreciate the certainty it provides. We would also use that system to straighten out the blue/yellow mix up I hypothesized above.

No matter what system we use, we must always be diligent. Good patient identification means never having to say you’re sorry.

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When It Hurts to Say I Told You So: Advanced Prostate Cancer Cases on the Rise

Diagnose a patient’s prostate cancer in its earliest stages and you have a great chance of curing it. Starting in the early 1990’s, that was the philosophy behind Prostate Specific Antigen (PSA) blood testing in men. It wasn’t a perfect test, and many men with increased PSA proved not to have cancer when their prostates were biopsies. Some other men underwent heavy duty treatment such as prostatectomy or radiation for prostate cancers that were SO small and bland they probably would never have spread. Despite the drawbacks, the death rates from prostate cancer dropped in men who were being screened.

As I have written about before. some scientific panels, as well as CMS, the federal agency that oversees Medicare, took a dim view of PSA screening, and the number of men being screened decreased. Some men were never tested, others were still getting tested, but maybe a few years later or a little less frequently than they had been in the past. As a busy prostate pathologist this delay in testing worried me, and I never missed an opportunity to tell the men I knew to have PSA testing. I told women to nag the men they love. And I never failed to have my PSA tested as part of my annual physical

My worries soon began to become reality. My colleagues and I, examining biopsies under the microscope, began to see more cases of aggressive looking (higher Gleason Grade) prostate cancer than we had in years past. This was what is called anecdotal findings; it was our impression, but we did not do a statistical study or a publish a peer reviewed scientific paper to state our claim and have it verified (or debunked) by other pathologists around the country. But we wondered, was there a correlation between what we were seeing and the amount of spread of cancer in the men being diagnosed?

We now have the beginning of an answer. A study published this week from my alma mater, Northwestern University, confirms that a higher number of men are once again being diagnosed with advanced prostate cancer. By the time of diagnosis, their cancer has spread to bones or lung, making cure much more unlikely. The window of catching a small, treatable, tumor has passed. The authors do not claim this is entirely due to lack of PSA screening, but to quote the lead author, Dr. Edward Shaeffer, “If I were a patient, I would want to be vigilant. I firmly believe that PSA screening and rectal exams save lives.”

PSA isn’t perfect. We hope someday to have a better test. And, very importantly, any man diagnosed with prostate cancer needs to have a long discussion with his urologist about the best way to manage his disease. But mammas, don’t let your babies grow up to be victims. Tell them PSA’s save lives.

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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.”

——

5 Things Your Pathologist Never Told You

Doctor, doctor…

…give me the news.

Robert Palmer-1979

We have been called “The Doctor’s Doctor.” Pathologists stood in the background for decades, running laboratories, interpreting biopsies, staging tumors and making diagnoses. We rarely exposed ourselves directly to patients. There is even a law in New York State that explicitly prevents such contact. But now we live in a much more connected world. At the dawn of the digital age I created Pathwise, a company that “translated” biopsy reports from medical jargon to easy to understand English for patients with a desire to know. Now pathologists communicate via the Web, via Facebook, via Twitter. But even with all this improved interaction, there are still things you may not know about what really happens to your blood or your kidney or breast once it exits your doctor’s office, your hospital bed, the O.R. And even less that you might know about the pathologist who coordinates all the activity.

Most likely, the laboratory that analyzes your specimens has a pathologist as a Medical Director. To have an accredited laboratory, there is a long list of obligations and requirements that the Medical Director must ensure are occurring. This does NOT include running every blood test or making every slide personally. It DOES include verifying that qualified, well trained personnel are on hand to perform those tasks. And the scrutiny we are under to guarantee that keeps on growing.
Pathologists deal with our own version of Moore’s Law. In computing, Moore’s Law predicts that over time, denser and more powerful integrated circuits will be developed. In pathology, we are faced with the proposition that tissue samples are getting smaller and smaller, but the amount of information we need to derive from them is getting greater and greater. In the last decade, tests looking at cancer cells for the various changes in their genes–how these cells differ from normal cells–are becoming essential in determining the precise type of tumor in a biopsy, as well as in deciding what chemo- or immunotherapy treatments will work best for a particular patient. And by the way, those tests are not cheap.
The concept that there is a sharp line that separates “benign” from “malignant” can be a false one. Yes, in the vast majority of cases I can unequivocally call a biopsy benign or malignant. But that border line can be fuzzy; there can be a gray zone. Sometimes we just cannot accurately predict how a tumor will behave. And it is not just us local diagnosticians who are in this quandry. National experts don’t always agree on the nature of what they see under their microscope. And it can be a moving target. As new techniques are developed, and as our knowledge of the molecular underpinnings of illness grow, our interpretations and naming of disease processes change as well.
You may be surprised to see a bill from a lab halfway across the country. Not all of your blood tests or tissue tests are performed locally. Some large national laboratories operate central hubs which may handle all specimens from a wide geographic area. Some more esoteric tests, particularly molecular and genetic studies on tumors, may only be performed at one laboratory in the country. Laws relating to patenting of genetic testing have changed, but laboratories can still create test combinations that are difficult to duplicate elsewhere.
Pathologists are frequently leaders in a Medical Center. With offices and laboratories in the hospital, the pathologist often spends more time in the building than their clinical colleagues. This, combined with a general sense of trustworthiness, lead to many roles both within the administration of the hospital and the concerns of the physicians that make up the medical staff.

One more thing. Most pathologists love their job!

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Don’t Believe the Hype! Diagnosing Cancer Not for the Birds.

It’s my work, he’d say…

…and I do it for pay

Bob Dylan

Hurricane, 1975

For most pathologists, it is more than a job, it is a calling. We are trusted to examine tissue from patients that we will most likely never seen or ever talk to, and provide a diagnosis that will often change their lives. The task requires a thorough knowledge of medicine, years of specialty training in pathology, and countless hours of microscope time learning the art, as well as the science, of our chosen profession. A well trained staff is also essential in making the correct evaluation, we are very much subject to “garbage in, garbage out.”

So most of us chuckled at bit at all the news reports last month about pigeons being trained to diagnose cancer. It seems that with a few pellets, any creature with good vision can be turned into a pathologist! Since progress on the new house is on short term (we hope) hiatus this weekend, I thought I would take the time to explain just how a pathologist actually renders a diagnosis, and how it gets back to the treating physician. There are many different types of labs, and the processes is different at each one, but I will focus on how we do things at my laboratory, an outpatient lab specializing in urology, and key in on prostate biopsies.

Our lab is part of the largest urology practice in the Chicago area. About 60 urologists across the region identify men, who either because of physical examination findings or because of abnormal blood work, require prostate biopsies. I will spare you the messy details about how the biopsies are taken, but generally 12-16 areas in the prostate are sampled, with a needlelike core of tissue about a 20th of an inch thick and an inch and a half long taken from each site. Those samples are placed in jars filled with formalin, and yes, it smells just like what you remember from high school biology. The jars are carefully labelled and packaged for delivery, while patient information is entered into the electronic health record we share with the urologist’s offices.

We use a courier service that specializes in handling medical specimens to bring the biopsies to the lab. That’s where our great processing team takes over. After verifying that all the information we have in the health record matches the specimen jars we have received, a description of the cores is dictated for our report. They are then “cooked” in a microwave processor, embedded in paraffin wax (yes, the floors get slippery), and then cut into ultrathin sections which are placed on a labelled glass microscope slide and stained with colorful dyes. The sections of prostate turn blue and purple and pink. Some of this work is automated, but much is done carefully, by hand, one slide at a time.

One of our four pathologists then looks at each slide under the microscope and formulates the diagnosis. How do we do it? We each have an encyclopedic knowledge of what normal prostate looks like. We look for changes in the appearance of the stained tissues, subtle or obvious, that signal a change from normal to abnormal. We then mentally run through the myriad of possibilities that the abnormality could represent. Some of these are benign and of no significance, others indicate cancer, or a potential for future cancer. When we are uncertain, we can have additional slides made and use stains beyond the routine ones. Our diagnoses are then entered into the lab report. Before releasing the report, we have a final checkpoint. Each afternoon, our pathology group meets in my office. We gather around a video monitor connected to my microscope and review cases together. We do this for every case with a cancer diagnosis. Once we all agree, our completed report is signed and becomes part of the electronic health record, available to the urologist for action. In our lab, the whole process takes about 2 days from the time the urologist does the biopsy.

I love birds. Counting Crows, The Eagles and Flock of Seagulls are all music to my ears. But when it comes to making a diagnosis, leave the feathers behind. We may get paid in more than bird seed, but if you want the right answer, find a pathologist!

One last thing. An apology to all those who got tossed and turned by the broken links on our last post. If you missed it, you can find it here. This link will work. I promise!

As always, thanks for reading. Please comment, subscribe and share.

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