Pushing Glass-Pathology Rounds

Pathology Rounds

There were two mandatory weekly conferences. Monday morning was frozen section review where interesting frozen sections from the previous week were presented to the residents. Wednesday morning was unknown slide conference. For both conferences, residents were expected to review the cases and if called upon, to describe the histologic sections and provide a differential diagnosis.

Dan directed both conferences. Seated at the driver’s seat of the multi-headed microscope, his demeanor transformed as his audience hung on his directions. He was the star. Broad and exaggerated movements accompanied the dramatic dips and turns of his voice, as he emphasized key points. Most residents chose a position at least two seats away to avoid being struck or sprayed with his spit. He regaled every resident with the well-worn story of how he once performed 45 frozen sections during an eight hour span, labored to 3AM, then joined the surgeon for a beer.

“DON'T MOVE!”

A resident shrieked throwing her hands in the air.

"DON'T....move...." Dan lowered his voice as he slowly looked below the table. "Carlos...be very careful and look next to your right foot. See it?"

"Got it Dan."

"Good boy!"

The younger residents look at each other and shrugged their shoulders. "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."

Dan carefully wiped the dust from the retrieved slide. "This slide is 20 years old, given to me by my mentor in pathology when I was in medical school. He used to charge his residents $100 if they broke one slide, $500 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."

"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 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?

Dan forced a smile.

"Aah...Dr. Berkowitz...ol' eagle eyes!" Dan produced a slide of an acid fast stain of the same tissue section and placed 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?" Dan placed another slide on the microscope stage.

"It's 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?" Dan shot a knowing glance at Deanna.

The conference continued for a few more minutes then abruptly adjourned when the call for a frozen section blared over the department speaker. Deanna winked at James, rising from his seat. Blushing, James fumbled and dropped 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 floated by as a butterfly took flight in his stomach.

"Did I ever tell you about Jerry the Barbarian and the frozen section conferences?" A wicked grin flashed 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!" A few precious moments of laughter alighted.

"So why was he called the barbarian?"

"Oh that? Believe it or not, he's more bombastic than Dan is! Jerry is Dan Rosenthal on steroids! Frightening thought, 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 erupted from Deanna. "He had to cool off! I gotta go! See you at lunch."

Jasmine tickled his nose as her lab coat enclosed around her as she disappeared around the corner.