Friday, July 2, 2010

Immuno Junkie

"Rex, I need a third pair of eyes. It looks like in situ, but the immunos are telling me it's invasive. How much of this is invasive cancer? Is it invasive? How do I measure it?"

He came into my office an hour later.

"Multiple choice test. There are three things that a simple H&E stain can tell you. It's way more powerful than any immunostain."

He recited them:

"A. Looking for Helicobacter pylori.

B. Looking for microinvasion in a breast cancer.

C. Looking for microinvasion to sentinel nodes, in a breast cancer.

D. All of the above."

An immunostain takes advantage of protein interactions between specific antigens and targets in the tissues. In looking for subtle invasion in breast cancer, we look at the myoepithelial cells surrounding intact ducts and lobules. P63 and calponin light up these cells. A lack of expression suggests invasive over in situ tumor cells.

"OK, I get it. You favor the H&E, in all of the above. What does that have to do with my case?"

"E - you didn't need immunos. Your calponin is fooling you. Your p63 sucks."

"Well, p63 is pretty weak this week. I told Rick, he's going to work on it. It doesn't always suck this bad."

"Yes it does. It always sucks. Actin worked all right, but that's in the past. You don't need your immunos."

"I do. I'm a junkie. I trained on immunos."

"What did you think before you did the immunos?"

"I thought it was all in situ. They confused me."

"This breast is a mess. If you want to favor microinvasion, you can. I'll support you. Based on the H&E, I favor retrograde extension in ducts and lobules. It's crawling around in the sclerosing adenosis. I really don't think it is invasive."

"Point taken. I just want to do right by the patient."

Rex is old school. Sometimes, like now, old school is better. This was a FLK - funny looking kid. Funny looking DCIS - lots of weird clear cell change.

"In my opinion, you should lean against invasion. Look at the stroma."

"It looks OK. In the places where I am worried about microinvasion, there is no desmoplastic change."

"No promises. This is an ugly cancer, and it's all over the margins. I see, by your dots, that you noticed that. She needs a mastectomy. But we haven't yet proven that it is outside of the box."

Sometimes new tools confound the nuts and bolts. Sometimes, you don't need fancy supplemental tests. You just need a good pair of eyes.


rlbates said...

Glad you have good colleagues for that extra pair of eyes.

Kyla said...

I only understand part of this, but I totally get what you are saying. Sometimes you can run all the test in the world, but in the end, you've just got to trust your own judgment (or eyeballs).

Gizabeth Shyder said...

Some cases need lots of eyeballs. This was one of them. I'm lucky to have great colleagues to help me guide patient treatment.

tschlick said...

Don't you have smooth muscle myosin heavy chain?? It is sooo much better then the others.

Gizabeth Shyder said...

No, we don't. Did you learn that in Boston?