Homecoming Queen

Some weeks being a pathologist is like being the coolest girl in school. All the docs, guys and girls alike, hang on your every word. They call repeatedly, stop by your office, ask your advice on how to get the most out of their specimen to get the diagnosis for the patient, and actually listen and bend over backwards to follow.

On no rotation is this more true than cytology. Interventional radiology and ancillary techniques developed in the last decade or so - all have been created to maximize knowledge yield from a minimal amount of tissue. Yep, that's my fellowship trained specialty. I'm proud.

It's also stressful, because you want your advice to work. So do they. It becomes frustrating when it doesn't.

A few months back, I was on cytology and I got a CSF (cerebrospinal fluid) specimen. The patient had a diagnosis of lymphoma, and I saw some atypical lymphoid cells on the SurePath preparation. Tried to run flow cytometry, but cell yield was QNS (quantity not sufficient) to assess the phenotype and prove clonality. I showed it around to a couple of colleagues and they laughed (in fun, of course - we all are elitist about our own areas of expertise). You see, some pathologists think cytology is like voodoo. Smoke and mirrors. "I can name that tune on three notes. I can diagnose that cancer on three cells. No you can't. Yes I can." Every couple of days I got more CSF, two to five milliliters, and every time I got the same complaint from my flow techs. "Not enough cells." Damn it. I saw the radiology. The patient had a diagnosis of lymphoma, and the meninges were lighting up like a Christmas tree, signaling CNS (central nervous system) spread. I knew it was there, I think the oncologists wanted an diagnosis so they could do intrathecal treatment (I'm a pathologist, not a clinician, so don't call me out here), but we weren't getting anywhere.

A couple of weeks later, back on the same rotation, I was saddened to learn the oncologists were still trying to get the diagnosis to no avail. I called one of them up. "Skip cytology. Skip hematology. We've seen the cells, they're scanty but weird, we know what they look like. Draw off more CSF and put it all in for flow." I was trying to get more bang for the buck.

The flow techs were by now jaded and skeptical after weeks of QNS. My hematology trained colleague was scoffing at me. So I was excited when the flow tech popped her head in my office one afternoon and handed me a blue folder. "They're positive for B-cell clonality." Me, the oncologist, hell the PATIENT got their diagnosis so they could begin treatment. I felt like dancing with my microscope.

This week was one of those weeks. I was the most popular girl in high school. My courtiers weren't jocks and stoners - but breast specialty radiologists, oncologists, neurosurgeons, thoracic surgeons, and pulmonologists. My phone never stopped ringing, and some doctors were hand delivering patient specimens to my office. Luckily this week, every effort (sometimes thrice attempted) ultimately yielded good results, and the excitement in each doctor's voice as I relayed the diagnosis gained from their efforts was palpable. They were all giddy with success, armed with knowledge to begin treating their patients. I was heady with the challenge of making tough calls, silently wishing for more straightforward cases, but thriving on each diagnostic dilemma. Poring over my books. Searching for articles on PubMed. Consulting with my colleagues. Thank goodness every week isn't as tough as this one, but I do enjoy them every once in a while.

Who says pathology is boring?? I'm finally the Homecoming Queen. Now I just need a date.