Difficult cases

Over the last year a lot of people I know, some research scientists, some friends and relatives, have suggested to me that doctors should be allowed (and in their opinion would prefer to) concentrate on the more ‘difficult’ or ‘severe’ cases, leaving patients or pieces of tissue with ‘straightforward’ diseases to be diagnosed by somebody else (they never suggest who).

There are two assumptions being made here: the first that it is immediately obvious which are the straightforward and which are the complex cases; the second that doctors only want to deal with the complex cases.

The first assumption, that the severity/complexity or straightforwardness of the case is obvious from the start is completely wrong. This distinction is only possible after the diagnosis has been made correctly. For example:

A 55 year old man wakes up in the night with anterior chest pain – heartburn or heart attack?

A 6 year old girl complains every morning that she can’t go to school because she feels sick and has a headache, by the evening she always seems better – school refusal or brain tumour?

A 60 year old woman has felt tired all the time for weeks – depression or bacterial endocarditis?

Making a diagnosis is a difficult task that requires the skills of history taking to establish what has happened to the patient, examination to assess the patient’s physical condition and a broad knowledge of the conditions that might be causing the patient’s problems. I recall as a medical student spending up to an hour struggling to get an adequate and useful history. As a junior house officer I could take a history and examine a patient in around 30 minutes. The registrar could make a better job of it in 15 to 20 minutes and the consultant could extract the relevant history and the clinical signs even faster. It takes years of training and experience to do this. And even then, based on the history and examination, some more tests relevant to the patient’s condition are often needed to establish what is wrong.

The second assumption is that doctors don’t want to see patients with straightforward problems, or that pathologists don’t want to see normal biopsies (how do you know it is normal beforehand?). A lot of straightforward cases can be rewarding to treat – healing the sick, however ‘simple’ the problem, is the whole point of being a doctor. Even for a pathologist, diagnosing normal tissue can be a joy when you know the alternative diagnosis being considered was cancer. A second point in pathology is that seeing normal tissues and common problems helps us keep a handle on what normal tissues and normal variants look like. If we can’t recognise a normal tissue what hope is there of spotting an abnormal one?

Both of these assumptions are wrong. The irony in this situation is that these assumptions and the deduction that doctors do not need to see ‘simple’ cases are made by people who have never had to make a medical diagnosis in their lives.

Christmas entertainment

Christmas is just around the corner, I’ve finished the shopping (hooray!) and I’ve got some time off work (hooray!). So I'm relaxing at home and reading the Christmas bmj. I've been particularly enjoying an article on the portrayal of doctors in children's books, but there are plenty of other illuminating articles available until this issue becomes subscription only.

If you'd prefer a musical interlude, then you can sing along to the NHS version of band aid at Trick-cycling for beginners or check out the latest west end hit from Dr Informed.

Merry Christmas!

On Sunday

After a week at work, Cecil read the latest BritMeds.

A week in the life....Friday

Friday started with more reporting including a biopsy of a liver metastasis (the lesion on the right of this picture)

that needed some immunohistochemistry to determine the most likely site of the primary tumour, numerous gastrointestinal and bladder biopsies and a placenta. There was a tray full of urine cytology specimens with several slides from each patient and Cecil wished the urologists would read the RCPath document Histopathology of limited or no clinical value. There was a skin specimen marked urgent which was a possible melanoma. Cecil found it difficult to decide and went to show it to some of the other consultants, they all decided it probably was a melanoma.

The post arrived with a reply to the referral Cecil had sent to the tertiary centre for bone tumours. He had asked for an opinion on a soft tissue biopsy from the thigh. Everybody in the department had seen it and there were various theories as to what it was. They had thought of osteosarcoma, Ewing’s sarcoma, lymphoma and metastatic small cell carcinoma. The slides and blocks had come back with a letter confirming the diagnosis as a rare small cell osteosarcoma. Cecil dictated a supplementary report to go with the preliminary one they had issued saying there was a malignant tumour which had been referred for a second opinion; and rang the patient’s surgeon.

At lunchtime it was time for the registrars’ slide seminar. Cecil had given them a set of slides last week and wondered if they had correctly diagnosed the Spitz naevus – a benign lesion easily confused with a malignant melanoma.

After that Cecil had a quick look through the latest issue of Histopathology and signed some more reports before the slides from yesterday’s cut up started arriving. The stomach had a poorly differentiated adenocarcinoma (the groups of large cells in this picture)

with a few malignant cells invading through the wall to the serosa. Before he went home he dug out the autopsy report for a patient who had died due to acute alcohol poisoning after a night out and was having an inquest next week. The last thing he wanted was a last minute panic on his way to the coroner’s court.

Pathology pictures from the Pathology Education Instructional Resource.

A week in the life...Thursday

Luckily for Cecil he could finish off the EQA slides this morning as their senior biomedical scientist put the small biopsies in for processing, after which Cecil cut up the bigger specimens. The kidney he’d opened yesterday was still quite pink on the inside so he left the blocks he cut in formalin for another day before they would be put in for processing. The gastrectomy was better fixed and had an irregular ulcerating tumour like the one in this picture.




The last specimen was a gallbladder and the biomedical scientist showed him the specimen pot which had a different patient’s name on it than the name on the accompanying card, although the address and date of birth were the same. They left that specimen undissected so one of the surgeons could sort out whether the histology form and specimen definitely belonged together and what the patient’s name was.

After lunch he made a start on some of the research slides he was supposed to be looking at, but grading the immunohistochemical expression of receptors on a stack of very similar breast carcinoma cases was pretty repetitive and always got pushed aside in favour of more urgent diagnostic work.

He spent the rest of the afternoon reporting more cases with one of the registrars. The extra slides on the bronchial biopsy showed more of the odd looking cells appearing in groups in the sections cut further into the tissue. The cells were large with big, abnormal nuclei and Cecil reported the biopsy as non-small cell carcinoma. There was a series of colonic biopsies from a patient with ulcerative colitis which showed minimal inflammation and no dysplasia, a tray full of normal duodenal biopsies, a gastric biopsy with inflammation and Helicobacter, and a breast biopsy from a patient thought to have definite carcinoma clinically, which turned out to be a benign granular cell tumour.

The interesting cases at today’s slide meeting included a thyroid gland from a patient with both Hashimoto’s thyroiditis and papillary thyroid carcinoma.


Picture from the Pathology Education Instructional Resource.

A week in the life...Wednesday

The breast MDT started at 8am and most of the pathology was straightforward ductal carcinoma this week. There was one pleural fluid specimen which contained metastatic carcinoma in a patient with a previous mastectomy for a grade 3 carcinoma, who has now developed a pleural effusion. After the MDT there were some cervical smears to look at. Luckily the cytoscreeners report the majority of them and only pass them to the pathologists if they aren’t sure about something. The department will be changing over to liquid-based cytology soon which promises far fewer ‘inadequate’ smears but means learning what normal and abnormal smears look like all over again due to the differences in the way the cells look using the new technique.

Over lunch in the office Cecil checked and signed some histology reports, and added SNOMED codes to them. After lunch he made sure the registrars weren’t too swamped with work and offered to report the unexciting looking tray of basal cell carcinomas so that they could concentrate on a laryngectomy case instead.

Cecil picked up the slides that had arrived for him. He put the cases marked ‘urgent’ at the top of the pile. The first was a bronchial biopsy from a patient with suspected lung cancer. It was only a small piece of tissue but there were some odd looking cells in the submucosal tissue at the edge of the specimen. Cecil asked the lab staff to cut some more slices from the tissue block to see if there were more of those cells in the specimen. The next two bronchial biopsies looked inflamed but there was no cancer visible. The next specimen was a lymph node with nodular sclerosing Hodgkin’s lymphoma. A Reed-Sternberg cell (large purplish cell with two nuclei), characteristeric of Hodgkin's can be seen in the middle of this picture.

Cecil dictated a report, requested some immunohistochemistry to confirm the diagnosis, and put the slides aside to show the registrars later.
When he had finished the afternoon’s reporting, he went into to the cut up room to open any large specimens that had arrived during the day so they would fix overnight. There was a gastrectomy which Cecil opened along the greater curvature, and a kidney containing a large tumour which he cut into two pieces, leaving them connected at the hilum. The kidney tumour looked like a typical renal cell carcinoma – it was yellow and lobulated with areas of haemorrhage.

The specimens would fix much better now the formalin could get inside.

Pathology pictures are from the Pathology Education Instructional Resource.

A week in the life....Tuesday

This week Tuesday was Cecil’s autopsy day. There were three cases – two for him and one for the registrar. All were coroner’s cases because the causes of death were unknown. His first case was a 57 year old man who was found dead at home and came with the usual scanty coroner’s office information via a police report.

“Found dead at home, collapsed in kitchen. Last seen at midday the day before by his son. House secure, no suspicious circumstances. Medical history: high blood pressure. Medication: losartan, ibuprofen.”

On external examination Cecil saw tar staining on the fingers of the patient’s right hand, a sign of smoking, and an old appendicectomy scar. Internally he found widespread atheroma throughout most of the arterial system. In the heart there was thrombosis over an atheromatous plaque in the left anterior descending coronary artery. Blood clot can be seen in the sections of coronary artery in this picture.

This would have cut off the blood supply to part of the heart and caused a heart attack. There was left ventricular hypertrophy, one of the consequences of high blood pressure. The thickened wall of the left ventricle can be seen in this picture of transverse slices of a heart (the right ventricle is the irregular slit-like space on the right of the slices).

The lungs were filled with frothy fluid, suggesting that the patient had been in heart failure at the time of death. There was an incidental simple cyst in the left kidney. Cecil gave the cause of death as:
Ia Coronary thrombosis
Ib Coronary artery atheroma
II Hypertension

The second case was a 74 year old man who had been admitted to the hospital on Friday with a two week history of back pain, lethargy and loss of appetite. When he had been seen on Friday he was noted to be thin, and have some tenderness in his upper abdomen but there was nothing else found on examination. His blood results showed a microcytic anaemia, a slightly raised urea, and slightly raised bilirubin and liver enzymes. He had been stable on the ward over the weekend while waiting for more tests, but collapsed on Sunday and could not be resuscitated. His hospital notes said that he had had an uncomplicated hernia repair 8 years previously.

During the autopsy Cecil found a large ulcerated tumour on the back wall of the stomach. It had invaded through the stomach wall and into the pancreas. There were metastases in the liver (the paler lesions in this picture) and a single metastasis in the brain.

There was a rib fracture, probably due to the resuscitation attempts, and the patient also had gallstones and diverticular disease. The local coroner did not allow the pathologists to take any histology unless they could not identify a cause of death without it, so Cecil could not sample the tumour to prove that it was an adenocarcinoma, although that was the most likely type. He gave the cause of death as:
Ia Metastatic gastric carcinoma

Then he went over the registrar’s autopsy, dictated his autopsy report and faxed the causes of death to the coroner’s office.

After lunch it was time for more reporting, including some reporting on the double headed microscope with one of the registrars. Some of the specimens he cut up yesterday had come through. The slides from the uterus and ovaries showed a benign leiomyoma in the uterus and a benign serous papillary cystadenoma in the ovary. The breast specimen contained a grade 2 ductal carcinoma. Cecil had to measure the size of the tumour and distance to the resection margins. When he’d gone through all 23 lymph nodes that came with the specimen he filled in a minimum dataset with all the information about the tumour on it.

Then it was time for the department slide meeting. All the pathologists got together round the multi-headed microscope with interesting or difficult cases to discuss. One of the other pathologists had brought some slides from a soft tissue tumour from a patient’s thigh. Everybody seemed to come up with a different idea about what it was and the registrars just looked a bit blank. They decided on a selection of immunohistochemical stains which should help.

Pathology pictures are all from the Pathology Education Instructional Resource.

A week in the life...Monday

It’s Monday and our fictional pathologist, Dr Cecil Polyp (yes we really do get biopsies called this sometimes), started the day with some cut up. Not a euphemism for an autopsy, ‘cut up’ is specimen dissection. There were lots of small pots containing biopsies of things like stomach, colon, bladder and bronchus which went straight into cassettes whole. Cecil had to measure and describe the gallbladders and the appendix while cutting important pieces out to be processed into blocks.

He did the big specimens last. There was a time-consuming breast specimen - a wide local excision consisting of a lump of breast tissue with a tumour in the centre. The surgeon had put sutures into it to mark the top, bottom and lateral (nearest the armpit) sides so Cecil painted the lump with ink in different colours to identify which side was which before slicing it into 1cm thick slices (although some of them were a bit wonky) and looking at all the cut surfaces to find the tumour. Unfortunately in some cases it isn’t that obvious, especially when the breast tissue itself is quite fibrous. Cecil had to photograph the slices and describe his inability to find any obvious malignancy, before putting most of the specimen into cassettes for processing. There was enough to make 20 blocks. The next specimen was a right hemicolectomy for adenocarcinoma which had been diagnosed on a colonoscopic biopsy a few weeks ago. Cecil photographed and described the specimen, cutting into the tumour to measure its size and depth of invasion into the colonic wall. The tumour is the white lesion in this picture.

He dissected the whole of the mesentery which was attached to the colon to look for lymph nodes, all of which needed to be put into cassettes, even the tiny ones only a few millimetres across. The last specimen was a uterus with both tubes and ovaries, one of which contained a 10cm cyst filled with fluid. The uterus had a 6cm fibroid which was partly calcified and blunted the knife.

By this time Cecil was starving and rushed to the hospital canteen for a dose of revolting hospital food before the gastrointestinal MDT (multidisciplinary team) meeting. Most of the GI surgeons and gastroenterologists were there with the registrars and house officers clutching huge piles of notes. Dr Scanalot, the radiologist, was putting up some CT images on the lightbox, the stoma care nurse and sister from the GI surgery ward were there, and a few other people he didn’t recognise. Cecil sat down at the front with his trays of slides and switched the microscope on. They had ten patients to discuss, some of whom were more interesting from the surgical or radiological point of view. One patient had had a gastric biopsy which showed dysplasia and gastritis. It was difficult for Cecil to say if the dysplasia was a real premalignant change or if it was simply due to the stomach being inflamed. The patient was elderly and after some discussion the MDT decided to offer him treatment with proton pump inhibitors (strong antacid drugs) and repeat his biopsy afterwards.

After the MDT Cecil got down to some reporting. There was still a pile of slides from last week waiting, as well as the general EQA slides to look at. Some immunohistochemistry stains had come through on a supraclavicular lymph node from last week’s cases. The H&E had shown adenocarcinoma in the node and the patient hadn’t had any type of cancer diagnosed before. In this picture the node is filled with adenocarcinoma which is forming round glands on the left of the picture.

The immunos would help to work out where it had spread to the node from. Two likely sites would be lung and gastrointestinal tract, and the staining pattern was typical of lung cancer.

Pathology pictures are from the Pathology Education Instructional Resource where you can find loads of histopathology pictures.

I can't keep up

but Dr Crippen can - read the latest Britmeds online now.

Death

Death is something that people imagine pathologists are surrounded by, although for most of us autopsies are not the majority of our workload. There is an assumption that we are unaffected by death since we apparently see it so often, but the reality is that a surprising number of pathologists chose the specialty partly to escape the distress and death we were seeing on the wards.

The number of people and families whose lives were shredded by disease and death that you can see in hospitals sometimes seems relentless. Maybe the ones who recover and the tales of hope are some compensation but the continual round of death in the face of your best medical efforts can get depressing. Non-medics imagine it gets easier but it doesn’t; something I realised when I was a house officer when I saw my macho surgical SHO crying on the ward after the death of a patient.

I was on the ward when one of our post-op patients started bleeding. It was several days since the operation and he had been doing well. I’d seen him on the ward round in the morning and he’d told us a joke but the next time I saw him he was grey and sitting in a pool of blood, blood down his chest and blood on the floor. Two of the other patients, both big men, were shuffling out of the bay, white-faced and shaking. We struggled to get a cannula in while the blood kept coming. I can still see the look of terror in his eyes.

The autopsy showed that a major artery had burst and there would have been no way we could have saved him.

Watching somebody die is not something I have to see at work anymore. A dead body is very different, the soul, if you believe in such a thing, has gone and looking into the eyes give no clue as to who once lived there. Dead bodies hold no horrors, the process of death is another matter.

Review 1/52

Incredibly it is only a week since the first ever Britmeds. How Dr Crippen manages to find and read so many blogs in one week, as well as posting up to 200 times more frequently than me and being a GP, I really don't know. But Britmeds 2 is online now with more new blogs to discover, go and have a look.