The gross room is a dynamic locale in any hospital. Anything that is removed from a patient must come through this room to the pathologist’s attention. Located next to the operating room suites, pathologists and surgeons quickly consult on problematic cases. The close proximity facilitates quick delivery of specimens by the OR nurses. Other specimens came from the gastrointestinal endoscopy suites, urology endoscopy suites, and pulmonology bronchoscopy suites. Radiology also contributes biopsies obtained by CT guidance.
Faded photographs of exotic objects removed from the bowels and buttocks of patients are taped to the cabinets. Inside the cabinets are pickled placentas, stomachs, breasts, and various sizes of orthopedic metal hardware and old cardiac pacemakers.
This is Franklin Washington’s kingdom. He is a pathology assistant, a PA, a title he inflicts upon everyone within earshot. In the hospital, many nurses mistakenly interpret PA as representing a physician’s assistant, a far more common term. Franklin would lose no time correcting their ignorance further stressing the fact that a PA is only earned with a master's degree.
Franklin is 47 years old. His muscular build is accentuated by surgical scrubs that are usually a size too small for him. His café-au-lait complexion is a combination of a Greek mother and innumerable hours spent sunning himself on the front lawn of the hospital, much to the chagrin of hospital administrators.
Franklin's primary role is to assist the residents and attendings with gross examination and dissection of surgical specimens as well as assist in the frozen section. With attendings, he is appropriately respectful. With new residents, he is patronizing, at times condescending. His former position at a prestigious hospital in Boston is his gold standard for how pathology residents should be trained. "At Boston, I had my own office, my own phone. They treated me with appropriate respect."
"Then go back there!" Dan Rosenthal would often shout back.
"Who would make sure you don't screw up, Doc?"
At 7:30 AM, the operating rooms begin the day's cases. The OR schedule is posted in every office and important cases that may require an intra operative consultation are highlighted bright yellow. Franklin dutifully reviews the schedule and retrieves the previous paperwork and slides of any case that has previously been biopsied or has had a prior surgery. In this manner, a pathologist may reveal the original pathology material with the current case. As cases arrive in the gross room, Franklin organizes the containers with the corresponding paperwork, assigns a case number linking it to a computerized database, and prepares tissue cassettes labeled with the case number.
Small biopsies such as needle biopsies of breast or prostate and punch biopsies of skin are usually handled directly by Franklin. For larger complicated cases such as colon or stomach resections, the residents are expected to dissect the specimen, under Franklin's supervision.
"Uh...Doc...you better squish that fat pad a bit more, there are a few more lymph nodes for you to find."
James bristles at Franklin's remarks. Americans show far less respect to their superiors than Asians. Underlying the irritation is the truth of Franklin's observation as two additional tan lymph nodes appear from the fat emulsifying under the pressure of James' fingers.
"That's it...you're gonna make it!"
Carlos enters the room in time to hear Franklin's comment. Catching James' glance, he rolls his eyes and mouths, "Ignore him."
"James...you're going to get a thyroid lobectomy on a case I did the FNA on last week. Haas and I thought it was a follicular neoplasm but there were some cytologic features suggestive of papillary carcinoma so we recommended an excisional biopsy. They're going to need a frozen. Call me when it comes...I want to see it. Thanks!"
A frozen section on a thyroid lobectomy is a common intraoperative consultation. Depending upon the diagnosis rendered at the time of frozen section, it may result in a total thyroidectomy, complete removal of the both lobes of the thyroid. James turns to Franklin to request the previous cytology slides on the case.
"Way ahead of you, Doc. Got the slides and the previous cytology report waiting at the scope for you."
James forces a smile and mutters an inaudible thanks. Annoying as he is, Franklin is very good at what he does. James discards his soiled gloves, removes his apron, and seats himself at the microscope placing a slide on the stage. James' next rotation is cytology and to this point in his training, has had only minimal exposure to the specialty. As daunting the task of learning surgical pathology, cytopathology is, in some aspects, more arduous. Instead of entire tissue sections, only a limited sample of cells are smeared on the slide. A skilled cytopathologist may render a diagnosis, sometimes circumventing a painful and costly surgical biopsy for the patient.
The task at hand appears with a nurse from the OR bringing a thyroid lobe on a green surgical cloth. "Room 5, Dr. Martin's case." He leaves the specimen with Franklin who immediately enters the patient's data into the computer and assigns a case number.
"Let's rock and roll! I'll ink it for you then you can slice and dice with your Ginsu!"
Franklin quickly paints the surface of the thyroid in black ink, designating the true surgical margins and capsule of the thyroid. After measuring the dimensions of the lobe and weighing it, he positions it in front of James, strategically placing a dot of green ink on the superior margin.
"Don't eat it all at once, Doc!"
The thyroid lobe is about the size of a small chicken egg. A few slices with the scalpel and James is breadloafing the specimen, creating slices at about 1 cm intervals. Halfway through the dissection, a tan nodule appears, cutting with a gritty consistency.
"You found the cream filling!"
"Franklin, please get me two clean glass slides. I want to make a scrape prep of this surface."
James positions the glass slide and lightly scrapes the surface of the tumor. He immediately takes another slide and gently places it atop the first. The two slides adhere spreading the cells and blood. With a quick motion, James pulls the two slides apart, creating a thin smear on both slides. He allows one slide to air dry while the second slide is immediately placed in alcohol to fix and preserve the cells. He hands the alcohol container with the slide to Franklin. "Stain this up with H and E."
"The air dried slide for Diff-Quik stain?"
James nods and positions his scalpel along the long axis of the thyroid, slicing a representative section about the size of a nickel, from the tumor. The section samples the inked margin and the tumor. "I'll use this section for the frozen section."
"You got it, boss!"
The tumor sample is placed on a metal platform, called a chuck. A polymer that quickly freezes is now added to the sample, engulfing it, slowly dripping around the edges of the chuck. The entire chuck is placed in the cyrostat, set at -20C. Within a minute, the tissue is frozen within the polymer which has now turned white. Franklin retrieves the chuck and places it in the cutting apparatus also located within the crytostat. Securing the chuck, James deftly moves the razor sharp blade to within few millimeters of the frozen tissue. His right hand turning the large wheel connected to the cryostat, the blade advances in increments of 4 microns, slowly shaving off wafer thin sections of the frozen tissue. The outline of the red-brown thyroid tumor contrasts with the surrounding frozen white polymer. His left hand positions a small paint brush next to the thin sections of tissue, carefully teasing the sections from the chuck as the blade provides the advancing edge. The section rests on the dull slide of the blade and James places a clean glass slide into the cryostat. The frozen section immediately anneals to the warm slide which is quickly placed into an alcohol fixative. "One down..." James glances at the second hand of the clock. "In at 5 after!"
Franklin takes the slide, now placed in a metal slide carrier, and places it through a series of tissue stains and alcohol rinses. Within 3 minutes, the tissue is stained. A small drop of adhesive, a glass coverslip, and the slide is ready for microscopic viewing.
James continues the regimen for a second deeper section, hands the completed section to Franklin, and seats himself at the microscope to view the first fruits of his labor. Frozen sections, if done correctly, may sometimes yield a slide that rivals a completely fixed tissue section. However, there are subtle though important differences, the most important being the thickness of the frozen section tissue section, almost twice that of a completely fixed tissue. Depending upon the reason for the frozen section, the cytologic detail of individual cells may be critical in the diagnosis.
"Ready?" Both Carlos and Dan walk in at the same time. "Let's take it to the multi-head scope." James obliges and takes the flat of slides to the microscope in the conference room so the three of them could view the slides.
"Let's see what we have..." Dan quickly scans the slide at low power. "Follicular neoplasm, capsule looks intact, no invasion." Dan flips the microscope objective to a higher power. "Hmmm...I don't know why but I am getting a papillary feel for this. Is there a scrape prep on this?"
James quickly hands the stained slide to Dan. "Good job, James. Aaah...there it is, little Orphan Annie!"
Dan and Carlos both smiled as they recognized the characteristic cytologic findings of nuclear inclusions within the cells. James feigned understanding but his face betrayed his confusion. "James, you didn't grow up here. Little Orphan Annie is a cartoon character that was drawn with empty eyes. Several years ago, a pathologist noted that papillary carcinomas of the thyroid had a characteristic inclusion within the nuclei that resembled these empty eyes. So, we call them Orphan Annie eye nuclei. Cute, huh?"
James nodded at Dan's explanation. "That is exactly what we were concerned about when we say the initial FNA on this case."
"Good call, Carlos. All right, James, tell the surgeon that it is a papillary carcinoma, so they can do a complete thyroidectomy."
A quick trip to the operating room and within a few minutes, the remaining lobe of the thyroid is delivered to the gross room. After inking and slicing this thyroid lobe, James returns to the microscope and examines the frozen sections.
"Nice frozen sections and scrape prep, James."
"Thanks Carlos. Do you have a minute?"
"Sure...want me to go over the frozen section with you?"
"Do you mind? I don't understand why you called it a papillary carcinoma. There is nothing papillary about it, just follicular."
Carlos nods. "Yup, you got it. The architecture of the tumor is follicular but the cytology is papillary. This is an uncommon variant of a papillary carcinoma which, for a long time, was misdiagnosed as a follicular adenoma. Only after these cases metastasized did someone re-examine these cases and realize it was really a papillary carcinoma masquerading as a follicular neoplasm. Pretty subtle, eh?"
"So it is the cytologic features that make the diagnosis."
"Uh huh...that's why it was great you did a scrape prep on it. That's what Dan and I were looking for. We suspected it on the frozen but frozen sections are too thick. You can really nail it on a scrape. And if we called it a follicular adenoma, they would have stopped the surgery and not completed the thyroidectomy. When we get our permanent sections back the next day, we would have to change the diagnosis to a cancer. The surgeons would have a major cow and would have to take the patient back to surgery to remove the other thyroid lobe. They would tell everyone that pathology screwed up the case...which of course, would be true."
"Of course..." James sighs. There are so many things to know, he thought.
Franklin is busy cleaning the cryostat but leans over the microscope in time to hear the last words of Carlos. "Yeah...and when you screw up too often, its sayonara!"
"So why are you still here?" Carlos grins and points his finger at Franklin.
"Dr. Haas likes my eyes!"
The intercom announces another frozen section. It can barely be heard over the laughter.
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