Monday, June 28, 2010

Pathological Immersion, Week 2

During the second week of Summer Immersion, I shadowed Dr. Shin and her residents in Pathology, as well as Dr. Drotman in the Women’s Imaging Center (Radiology); I also continued to work on my research project and got a much more hands-on experience than I would have liked (see below for more details!).

The primary role of Radiology in breast cancer medicine is to screen patients to identify both consistencies and inconsistencies in patients’ scans. The focus is on classifying features observed through X-ray, MRI, and ultrasound screening to provide recommendations for the future. Such observations and recommendations include: no findings, standard 12-month follow up; somewhat suspicious findings, 6-month follow up; suspicious findings, perform biopsy and determine course of action from pathology; biopsy-proven cancer, discuss options with surgical and medical oncology. Shadowing Dr. Drotman, I learned a great deal about gross tissue structure and was encouraged to learn about the clinically-relevant link among breast tissue stiffness, calcification, and cancer as this connection represents the crux of my research in the Reinhart-King lab. During my visit, a patient underwent a stereotactic, X-ray-guided needle core biopsy because calcifications were identified on her mammogram, and were not successfully removed by a previous biopsy. I was surprised to see that low-dose X-rays were used not only to identify the region of interest, but also to position the biopsy needle and confirm the presence of the suspicious calcifications in the biopsied tissue. My experience in Radiology gave me a better understanding of the full progression of cancer diagnosis, from screening and biopsy in Radiology to analysis of biopsy tissue in Pathology. Next week, I will shadow a medical oncologist who specializes in breast cancer.

I continued to observe the sign-out service in Pathology, where I worked with residents to identify features at both the cellular and tissue scales that are characteristic of certain types of breast cancer. On Thursday, I experienced a moment of controlled chaos in the Pathology department when “frozen section” work quickly piled up. Imagine the “front line” of the Pathology department: there is a single resident who spends all day in the specimen receiving area. This doctor is responsible for receiving non-urgent tissue specimens from biopsies and surgeries all over the hospital. He or she catalogs them and performs a number of different procedures depending on the specimen. In addition to this near-constant influx of specimens, runners bring small canisters of tissue (ranging from red-speckled gauze that appears to contain no more than a drop of blood to entire excised organs) to Pathology to be “frozen sectioned”. Essentially, what this means is that there is a patient undergoing surgery, and the surgeon wants to confirm the identity of an excised region before continuing the surgery. One memorable example was the case of a patient having a benign goiter removed; the surgeon excised tissue and sent two pieces of gauze, each containing a speck of tissue (one was from the thyroid and the other was possibly parathyroid, which they did not want to remove), up to pathology. The resident began processing the samples by embedding them in a snap-freezing gel, slicing the now-solid blocks into 4 micron sections, and submerging the slides in a series of about fifteen chemical baths to fix and stain the tissue. The whole process from beginning to end takes the average (frantic) resident no more than three minutes to complete, but, as it turned out, even that wasn’t fast enough. In a matter of minutes, there were five other frozen section samples waiting (and thus, five other surgeries that were temporarily suspended until pathology called the operating room with the identity of the specimen). After a number of pages and loudspeaker announcements, a small army of 5 residents stormed into the already-cramped room, ready to help (I retreated to a corner to get out of the way). Back to the goiter surgery... The slides were stained and ready to look at under the microscope. By now, I had seen a fair amount of tissue under the microscope, so I can tell you that this tissue looked rather unremarkable. Nonetheless, another resident appeared in the room, and, knowing nothing of the case or surgery, peered into the microscope and confidently explained that the tissue was definitely parathyroid and not thyroid. Apparently, the cell morphology and presence of a unique crystalline substance were the give-away. One by one, the other residents offered their input on the identities of tissues from neurosurgeries, plastics procedures, and more. Fifteen minutes later, all of the frozen sections were done, the ORs were all notified, and the receiving room emptied.

I began the next stage of my research project this week, which required me to collect more than 1000 slides from the hospital archives. This task is typically reserved for lab techs, but because of the volume of slides I needed, I was volunteered to go. I jumped into the back of Joe's van - behind the car seat, between the tricycle and Dora the Explorer - to drive up the FDR to a non-descript warehouse building in the Bronx. I spent about 3 hours in the 100-degree, windowless, fanless warehouse pulling dusty slides from 10-year old cases. I came back to tell the residents of my journey, and they laughed, conceding that they didn't know it was that bad (as they redacted any previous wishes to go see The Warehouse). Although this experience was entirely unpleasant, it gave me an appreciation for the work of the Pathology lab techs, and I look forward to reviewing the slides that I gathered.

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