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.