Tuesday, February 26, 2013

Apple Green Birefringence

I wandered into CT, to do a wet read on a needle biopsy.

Radiologist:  "I don't really need you, but heard you were on service this week.  I just wanted to see that beautiful smile."

Me:  "What?  You didn't call me in for my brilliant intelligence?"  I looked at radiology tech.  "Ha ha.  Kidding."

Radiologist, about patient on table:  "She has a history of ** cancer.  We are in a node."

Me:  "What kind of node?"

Radiologist:  "Groin node."

I walked into the room with the microscope.

Cytotech:  "I hope I didn't mess this up for you.  It was air dried, so I did a rapid pap smear."

Me:  "Not a Dif-Quik?  Yikes.  I'm going to need your help.  Look with me."  She looked into the other eyepiece on the double headed scope."

Radiologist:  Wandering in.  "So what do you see?"

Me:  "Who did that fad pad aspirate in radiology last week?"

Radiologist:  Smiling, "Me.  I consider that an area of expertise of mine."

Me:  Laughing, "What a claim to fame.  We do those too.  They are never positive.  Yours was.  You got so deep - fat and muscle!  I looked at the Congo Red first.  The stain for amyloid.  It lit up like a Christmas tree."

Radiologist:  "You are speaking in tongues."

Me:  "When there is amyloid, we see the characteristic apple-green birefringence when we polarize the Congo Red.  I looked at that first, and was shocked to see all that green!  Shiny and lovely.  In the muscle.  In the fibrous tissue around the fat.  Highlighting the small capillaries.  It was textbook!  I was so excited I showed three people before I could move on to the next case.  On the H&E you could see that amorphous pink stuff infiltrating the fat - just like in Robbins."

Radiologist:  Proud, "Fantastic.  I do those a lot.  The patients ask if I can do it again - to get more fat."

Me:  Laughing, "We have that joke too.  What a painful way to get liposuction - over and over with an 18 gauge needle.  Look here.  I see background lymphocytes.  You are in the node.  See those epithelial clusters?  They shouldn't be there.  This is not my stain, so I am going to be conservative and call it suspicious for metastatic malignancy.  But I think you got good material.  How's the day?"

Radiology tech:  "Busy.  Pelvic mass.  Lung.  Thyroid."

Me:  "OK great.  See you soon."

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