Pushing Glass-Daily Rounds

Pathology Rounds

There are two mandatory weekly conferences. Monday morning is frozen section review where interesting frozen sections from the previous week are presented to the residents. Each resident is called upon to describe the histologic sections and provide a differential diagnosis of what they are viewing.

Wednesday morning is unknown slide conference. Interesting cases are put out for review for a week before the conference. Occasionally the cases are from a specific organ system, such as liver. Residents are expected to formulate a differential diagnosis and research the answers.

Dr. Daniel Rosenthal is the Chief resident and directs both conferences. Seated at the driver’s seat of the multi-headed microscope, his demeanor transforms like an actor placed on a stage before his adoring fans. His movements are broad and exaggerated. His voice takes dramatic dips and turns when he emphasizes key points. Stanislavski would be envious.

Boundless energy can only begin to describe his enthusiasm for his job. Lest anyone miss the point, he would remind the residents, “I’m the catalyst of the department!” He regales every resident with the well-worn story of how he once performed 45 frozen sections during an eight hour span, laboring to 3AM, then joining the surgeon for a beer.

“DON'T MOVE!”

A resident shrieks throwing her hands in the air at the sudden shout.

"DON'T....move...." Rosenthal lowers his voice and slowly looks around the table. "Carlos...be very careful and look next to your right foot. See it?"

Carlos is familiar with the routine, finding the dropped glass slide.

"Got it Dan."

"Good boy!"

The confused looks by the younger residents prompts Rosenthal's explanation. "Whenever you drop a glass slide on the ground, never....NEVER, move your chair or stand up! The second you do this, you will always smash the slide. Don't just sit there...do nothing! Everyone should look around their seat and if you still don't see it, then one person will carefully get up and look for it while the others remain seated."

Rosenthal carefully wipes the dust from the retrieved slide. "This slide is 20 years old, given to me by my attending in pathology when I was in medical school. He used to charge his residents $100 if they broke one slide, $300 for a second broken slide and if they broke a third, he fired them! He said that anyone that clumsy should never be a pathologist. Of course, we are a kinder and gentler residency program...our payment plan is tied to the prime rate."

"Deanna...what did you think of this case?"

"Looks like an incisional biopsy of skin with a proliferation of spindle cells and histiocytes with rare giant cells, almost some ill-defined granulomas present. I guess my differential diagnosis would be a dermatofibroma, a xanthogranuloma...but since it's your slides, it is probably some zebra case for us to see so let me just add a mycobacterial spindle cell pseudotumor. Are you going to surprise us with an acid fast stain?

A forced smile appears on Rosenthal's face.

"Aaaah...Dr. Berkowitz...ol' eagle eyes!" Rosenthal produces a slide of an acid fast stain of the same tissue section and places it under the microscope. A diffuse collection of bright red, rod shaped organisms fills many of the cells in the tissue, revealing the characteristic signature of an infection by Mycobacterium leprosum. "Patient lived in Texas and developed several slowly growing nodules on the distal extremities. The biopsy was originally misdiagnosed as a dermatofibroma but when the nodule continued to grow, it was rebiopsied and my professor was asked to review the case. He immediately made the correct call."

"Ok....Dr. Deetan, you've been quiet, so unusual for you....what did you think of this case?" Rosenthal places another slide on the microscope stage.

"It is another skin biopsy, but this time of a pigmented lesion. It is an assymetrical proliferation of melanocytes, arranged at the dermal-epidermal junction in expansile and discohesive nests, showing upward intraepithelial spread and downward extension along adnexal epithelium. The melanocytes are pleomorphic, with prominent nucleoli, and numerous atypical mitotic figures. Melanin pigmentation is scant but evident in some cells."

"So what's your diagnosis?"

"Melanoma. It is in the vertical invasive growth phase, a level four."

"I am impressed Dr. Deetan! What did you do, rehearse that description all night?" Rosenthal shot a knowing glance at Deanna.

The conference continues for a few more minutes then abruptly adjourns when the call for a frozen section blares over the department speaker. Deanna winks at James as he rises from his seat. Blushing, James fumbles and drops several of his papers.

"Good things these weren't slides, you would owe a small fortune!"

"Deanna...thanks for going over those conference slides with me. You saved my life...again."

"Anytime James...I know what it's like, looking at these slides, can't even figure out what organ you're in, much less the diagnosis. Here let me help you."

Jasmine flowers waft pass James' nostrils. A butterfly takes flight in his stomach.

"Did I ever tell you about Jerry the Barbarian and the frozen section conferences?" A wicked grin flashes across Deanna's face.

"Sounds like a sitcom."

"That's funny! More truth than fiction, though. Ever heard of Jerry Taylor? He finished his training here about 2 years ago, just before you came. He and Dan used to compete with each other over who was the best. Every conference, each one trying to one up the other. Don't ever tell Dan I said this, but he had the better eyes. I think Jerry knew this too, so he would stoop to anything to get the edge on Dan. One day, Dan walked in to the frozen section area and saw Jerry going through the log book for the frozen section, you know, where we record the diagnoses for each case. This was the night before the frozen section conference. Jerry was looking up the diagnoses for each frozen section done during the prior week."

"He was cheating!"

"Exactly! So Dan concocted a plan to humiliate Jerry. Before Jerry went to see the frozen section log, Dan changed the diagnoses in the book, all wrong."

"Oh no!"

"Yup...the next day at conference, Jerry looked like a complete idiot!"

James laughed out loud. "I wish I could have been there!"

"Well, I was! It was priceless!"

The laugh and smile lingered for a few more minutes followed by an uncomfortable silence. James is obligated to break the tension.

"So why was he called the barbarian?"

"Oh that? Believe it or not, he was more bombastic than Dan is! Jerry was Dan Rosenthal on steroids! Frightening concept, isn't it?"

"Where is he now?"

"You know...he was working up in St. Charles, at the hospital there. But I know he left and rumor had it that he went to Alaska of all places!"

"Alaska!"

"I think he burned himself out!" Laughter erupts from Deanna. "I gotta go! See you at lunch."

Her lab coat enclosed around her and in a second, Deanna disappears around the corridor.

"Bye..." James whispers in a voice only his conscience can hear.