"What do you see?"
"Blood, blood, blood. A little colloid. No cells."
In order to have an adequate thyroid biopsy, six groups of ten thyroid follicular cells are required. That is what we search for, under the microscope.
Randy asked, "Aren't those cells?"
He had performed the needles. Four passes under ultrasound guidance. Quick in and out gestures with a 27 guage - usually enough for adequacy, if lucky.
"No. Just platelets caught up in clot. A few naked nuclei. Doesn't count."
I kept looking. To no avail. I decided to rib the tech.
"I think it's Jeff's fault. He must have done something."
Jeff is the newest tech, so I have to be careful in my teasing. He's still pretty literal.
Randy took my lead.
"Jeff was there when I arrived. They called him too early, to make the smears. He was probably pissed, so he may have sabotaged the needle."
I continued, "That's just like Jeff. He likes to smear the diagnostic cells right on the floor, and step on them for good measure." Jeff smirked.
"Whoa. Wait a minute. There are some groups. Beautiful, honeycombs. Not stuck in clot. I think we may have adequacy. Do we have any paps? Is there a cell block?"
Jeff replied. "Paps, yes. No cell block, not enough blood."
"I think we're gonna be ok. You're done. What's next?"
"We have a neck coming after lunch. Large lesion, under the muscle. Outpatient from ENT."
Later on, after lunch . . .
"I see lymphoid cells. That's it. Heterogeneous. What's the story?"
"48 year old. Long time smoker. Just lymphoid cells? Shall I get flow?"
"Doesn't make sense. This shouldn't be lymphoma. Wasn't he referred by an ENT? Large neck mass? We are definitely in a node, but based on the history, we should be seeing squamous cell carcinoma. I'm not satisfied. Go back."
Second pass . . .
"Blood, fibrous tissue, and fat. You aren't even in the lesion. Go back again."
Third pass . . .
"Bingo. Positive. Squamous cell carcinoma. Metastasis to a neck node"
Sometimes you've gotta hold out for the obvious diagnosis. Because you know it is there, somewhere.