When a tumor is removed from a patient, the first report from the media is usually a statement that the doctor's are waiting for the result. There may be a vague reference to sending the specimen to the "lab" or "run some additional tests". Only rarely does the media report that the specimen is sent to the pathologist who will review the tissue under the microscope and render a diagnosis. After a few days, the diagnosis is given to the patient, usually by the surgeon. The grateful patient usually believes the surgeon has spent the last few days "running those tests" and can now deliver the diagnosis.
What Does the Doctor's Doctor Say?
If you could follow the tumor from the time it is removed by the surgeon, to the moment the diagnosis is given, it would become very clear that the surgical pathologist is the single most important physician that is responsible for the diagnosis, and hence, the final treatment decisions for the patient. This interaction may even begin before the surgery or initial biopsy. To better clarify the role of the surgical pathologist, I would like to describe a recent case that illustrates the interactive, proactive, and dynamic role that is demanded of the surgical pathologist.
At 6PM, I receive the operating room schedule for the next day. My usual routine is to review the cases, highlighting ones that may require an intraoperative consultation, occasionally necessitating a frozen section. On this day, a planned excisional biopsy of a groin mass in a 36 year old man catches my eye. I checked the hospital's computer and found no prior biopsies or surgeries at the hospital or in our pathology records. Sometimes, the best friend a pathologist has is a previous biopsy slide. If the tumor is rare, it is very important to compare the microscopic features of the current case to the original biopsy to ensure that it is the same cancer and not a new cancer. A more subtle reason to compare the cases is to determine whether the tumor has acquired features that may make it more resistant to treatment or more prone to recurrence or metastasis. The case is scheduled to begin at 7:30AM the following morning so I made plans to meet the surgeon in the surgeon's lounge just before the case begins.
Nearly every hospital has a surgeon's lounge, usually located in the operating room. Surgeons can relax between cases, grab a quick snack, and bond with their colleagues. It is sometimes intimidating for a non-surgeon to enter this room but familiarity leads to quick acceptance. I find time spent in the surgeon's lounge an invaluable experience, not only to solidify relationships, but as in this morning, a chance to glean information about scheduled cases. I spy my patient's surgeon and after a brief discussion, I am relieved that I took the time to speak with him. This is no ordinary case. This young man was in previously good health when he developed a rapidly growing groin mass. He is now experiencing low grade fevers and weight loss. There is no previous biopsy diagnosis and thus, they will be needing an intraoperative consultation, and probably a frozen section, to determine the definitive type of surgery. At this point, the surgeon is unsure about the diagnosis. A series of differential diagnostic considerations race through my mind. What can cause a mass lesion in a young, previously healthy man? The first thought that comes to my mind is whether this groin mass is really a lymph node, involved by a disease process. His symptoms suggest an infection and I query the surgeon about this possibility. Any recent travel history or exposures to ill persons? What does the chest x-ray show? All negative answers but tuberculosis or another granulomatous infectious process must be considered. Of course, a cancer is always a possibility and in this age group, I immediately think of a lymphoma, in particular Hodgkin's disease. This captures the surgeon's attention as he divulges addtional information. CT scans of the patient's abdomen showed a large mass in the left adrenal gland and possible enlargement of the retroperitoneal lymph nodes, adjacent to the left adrenal gland and kidney. So yes, definitely a lymphoma is a possibility. What else? In a young man, a testicular tumor metastastic to the lymph nodes is a possibility. However, ultrasound examination of the testicles revealed no mass lesions. This does not completely exclude a testicular tumor but it makes it less likely. I suggest that a measurement of oncofetal proteins in the serum may be helpful to further exclude a testicular tumor. We both agree that it will be considered depending upon what I find on frozen section. In a few minutes, I have learned more about this case by speaking to the surgeon than by reviewing any document. Most importantly, I have formulated a differential diagnosis ranking the likelihood of variety of disease process which may account for this young man's symptoms.
Within an hour, the operating room calls my office informing me the surgeon has taken a portion of the groin mass, submitting it for frozen section. When I arrive in the grossing area, the tissue is waiting for me on my cutting board. It is a tan-red segment of tissue measuring about 1 inch in maximal dimensions. I make several slices through it and examine the cut surface, which sometimes differs from the outside. It is a firm tissue, not fleshy like one would expect for a lymphoma. It also does not appear to be a lymph node involved by an infectious process such as tuberculosis. I proceed to make touch preparations of the tumor by placing a clean glass slide on the surface of the tumor and then quickly placing the slide in an alcohol fixative. I then cut off a small piece of the tumor and place it in the cryostat. This machine, specifically designed for the frozen sections, rapidly freezes the tissue on a special metal mount and mounting medium. Within 2 minutes, my tissue is frozen and I am cutting very thin sections of the tissue to be placed on a glass slide. These slides are immediately placed into a fixative and through a rapid series of stains, the tissue is colored shades of red and blue by the hematoxylin and eosin stain, and readied for analysis under the microscope.
Basic Principles of Disease
Learn the basic disease classifications of cancers, infections, and inflammation
Commonly Used Terms
This is a glossary of terms often found in a pathology report.
Learn how a pathologist makes a diagnosis using a microscope
Surgical Pathology Report
Examine an actual biopsy report to understand what each section means
Understand the tools the pathologist utilizes to aid in the diagnosis
How Accurate is My Report?
Pathologists actively oversee every area of the laboratory to ensure your report is accurate
Recent teaching cases and lectures presented in conferences
Pathologists Who Make A Difference
Search for a Physician Specialist
Last Updated 4/19/2004
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