Monday, July 12, 2010

Pathological Immersion, Week 4

The highlight of week 4 was the time spent shadowing Dr. Wernicke in Radiation Oncology. After sitting in on patient visits, we discussed my research in Ithaca. Dr. Wernicke challenged with me questions that probed the basic scientific hypotheses as well as the clinical relevance of my work. Of course, I wholeheartedly defended my research, offering several potential ways in which my research could aid in the clinical diagnosis, treatment, and follow-up of breast cancer patients (I was relieved to see that she seemed satisfied by my arguments). Finally, we discussed the benefits of a collaboration involving the Reinhart-King lab and her own lab (I find that this exercise is particularly useful to the aspiring researcher). I was invited back for the next day when an "interesting" new consult was scheduled. This patient was an 80-year-old woman who underwent a lumpectomy several years ago to remove a locus of ductal carcinoma in situ (DCIS). She was accompanied by her caretaker as well as an interpreter (neither the patient nor her caretaker spoke english). I joined Dr. Wernicke in the exam room as she discussed the patient's history and treatment options through the interpreter and caretaker. It was decided that the patient would undergo radiation therapy to reduce the likelihood of a recurrence. I will be following this patient in the coming weeks for her planning session, exploratory mammogram, and the start of radiation treatment. The "interesting" part of this case was that the patient's chart said that the patient and her family had previously refused radiation treatment, but according to the patient, her daughter, and the caretaker, it was actually her previous doctor who didn't want her to get radiation. Lesson learned: as a patient, always make sure to ask questions, make it clear what you want, and perhaps keep your own notes about doctor visits...

This week in pathology I continued to learn more about characterizing slide-mounted tissue samples; specifically, I focused on tumor grading. Relatively straight-forward, yet very subjective, tumor grading is a process that breast pathologists enjoy on a daily (if not hourly) basis. Grading a tumor is based upon both cytology (how the cells in the specimen generally appear) and architecture (organization of both the cellular and non-cellular components of a tissue). For breast tissue, the important characteristics are: how well-defined cellular tubule structures are, how atypical the cell nuclei are (in absolute size, size relative to the rest of the cell, and general appearance), and the frequency of cell division. Each of these are graded on a scale of 1-3.

While the grade of a tumor is primarily useful to pathologists, tumor staging is used universally by oncology clinicians, cancer researchers, and cancer patients. The "stage" of a cancer refers to three factors: tumor status (essentially the size of the tumor, 1-4), the nodal status (degree of regional lymph node involvement, 0-3), and systemic metastases (0 or 1). Pathologists are responsible for determining both the tumor and nodal status.

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