Friday, January 13, 2017

Narrow Misses, Part 5

Me: Here's the cases. The pleural fluid is full of signet ring cell gastric carcinoma. Mucicarmine lit up like a Christmas tree. After you look I'd like them back, to show the cytotechs.

I pull the earplugs from my ears to be able to hear her.

Me: Sorry, I forgot these were in. Drilling started around noon. Surprised me, it's been a few weeks. Driving me crazy. Luckily I got most of my work done before it started.

Dr. Earnest (I say this in the kindest light - I was Dr. Earnest my first five years here. I recognize myself in her, and she makes me happy): I know right? I hear this knocking, from this vent in the ceiling, every day. It's unpredictable, but it's daily. It's like there is someone living up there, constantly reminding me of their presence. Every once and a while a shower of dirt and dust will descend upon my desk from the vent. There's something going on in there. I'm convinced someone lives up there.

Me: I'm glad you alerted me of the gastric cancer. Signet ring cells look exactly like normal mesothelial cells, on cytology. A week ago he didn't have the diagnosis, and I just thought they looked a little atypical. I called the oncologist, and amended my report. Metastatic cancer will make a huge difference in staging, prognosis, and treatment.

Signet ring cell carcinoma is the sneakiest cancer of the lot. Everyone has a story to tell, of how they missed it. Dr. Earnest alerted me not only of my miss, but another seasoned pathologist missed it in an earlier gastric biopsy (1mm lit up on immunos. We all would have missed it on morphology). Luckily all of these specimens were taken within two weeks of each other. No harm to the patient.

Reminded me of myself, two years in, discovering a mesothelioma that three other senior pathologists had called negative. Again, normal time frame - no harm to the patient, but still. Gives you the shakes, knowing there are cancers out there that elude our routine evaluation. Still, we argue, it's not reasonable to stain every normal appearing tissue to look for something we will only come across once every five years. The money spent in stains would be a ridiculous waste to the system. It's a hard balance between being thorough and correct, and being judicious with the tools we have on hand. In my experience, as long as we are in good communication with our fellow clinicians, we will get the right diagnosis in time to start treatment, despite occasionally falling victim to the morphology that betrays us.

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