Saturday, January 16, 2021

Heterogeneity

     The physical sxs are out of control. I don't know if it's pandemic anxiety or what but I've hit new lows. Thursday when Jack and I went to Walgreen's around five to buy some presents for a belated Christmas get together for him and his friends - Izzy just got back from two months in France - I puked all over the sidewalk near the entryway while Jack stood on as a concerned sentinel. All day at work Friday thoughts of throwing up in broad daylight at Walgreen's made me laugh at myself. I was fine to shop afterwards and take him to get his haircut - he had an out of control tumbleweed growing out the side of his head. But there was a clean up process the puke got all over my mask and my glasses it was gross. I thought about alerting the staff of the incident for clean up purposes but decided hell no. I didn't want to call attention to myself.

    When I upchucked again at the same time of day last night (Cecelia worriedly got me some ice water and stood by) I assured them both I had no nausea I felt fine after it was related to the state of being of my mouth. On Wednesday I was certain I had a fever blister erupting in the corner of my mouth but the mucosa took on a more cobblestone feel that was truly disconcerting. Yesterday after the shower I reached in and was able to scrape out fingernails full of dead mucosa - it was sloughing off like never before. So now I'm not only brushing my teeth but my entire mouth.

    I have an acquaintance who had mucosal ischemia of the bowel while running marathons - she would bleed out her ass (which reassured me that marathons are not meant to be run by me) in the middle like she had colon cancer but it was just sloughing of the mucosa due to extreme activity and I googled it and it is a thing. Mine isn't bloody ischemic sloughing it's just white build up I'm not sure what the hell is going on but it causes no end of dry heaving during the day I'm sure the secretaries are sick of it I'm reassured that they are listening to transcription most of the day and hopefully miss it.

    Okay enough of that. At tumor board on Thursday morning one of the thoracic surgeons Jason Muesse (pronounced Missy according to the gross room Jessica said he told them) presented a case of a youngish guy, thirty something, who had a 19 cm mass in his lung. IR (interventional radiology) had done two biopsies that yielded nothing. I asked where he said Baptist I told him I'd pull the cases to review and see if it was worth sending off. He was worried about solitary fibrous tumor which is a rare diagnosis and tough to make. He said I cannot subject him to a third biopsy please help.

    I pulled the cases and damn. I took pics of the slides and sent them to him lamenting about the state of radiology today. I have told Ken Robbins more than once the new guys are not getting us enough tissue. Back in the day I did FNA's if soft tissue was in the differential I'd bring my 18 gauge core needle you need a lot of tissue to even conjecture a diagnosis and still you might be wrong. Years ago Derlis Martino - super sweet thoracic surgeon who moved on - did a core on a 20 something year old with a mediastinal mass and I made the mistake of calling it benign cartilage (like maybe a chordoma?) but soft tissue tumors are heterogeneous and when the resection occurred it was sent out and proved to be a low grade chondrosarcoma. Taught me to say bland instead of B9 because the part you see might look B9 but the other parts might contain malignancy.

    So I tried to do immunostains on the paltry sample (name that tumor on 30 cells) and came up with not much more than my chief had signed out but we did an addendum and hedged and suggested it could be and SFT but the CD34 didn't bear out and 90% of SFT's have CD34 but the BCL2 was beautifully positive need resection to give definitive dx. Jason was super thankful - I got a second phone call I assumed was a question he forgot to ask but it was just profuse appreciation for the extra work we did I was a little embarrassed. He asked about synovial sarcoma and I was like we didn't stain for that and there isn't much tissue left but that is a rare dx and if I ever entertained it I would send off to Cleveland Clinic for the characteristic translocation we learn for our boards (X;18) because that is the gold standard for that tumor and I've seen it like once in my years of practice so I'd have to research the current immunos.

    Jason was ok with that. He told me that he was going to probably take the guy to UAMS because the tumor was so big and pressing on the liver he wanted  a certain GI guy to be in the OR with him to help. He told me he would take lots of pics and share and update me. He said y'all are much quicker than UAMS I might not have a diagnosis for a few days (he is not the first thoracic surgeon that has told me this Matt Steliga sang our praises in quick turnaround) and I told him with a soft tissue differential they would struggle too so don't expect a rapid dx. Plus the heterogeneity is confounding in these tumors like a squame is a squame and adeno is easy and small cell is straightforward but a higher grade lesion in a soft tissue tumor can be elusive. Sampling is the key.

    So that was one case of over 30 yesterday but definitely the most challenging looking forward to the follow up. I'm so happy it's Friday looking forward to a relaxing weekend maybe tackle the 30 or so boxes we have left in the living room. I'm on call next week and Jessica assured me when I went to gross room for frozens yesterday afternoon (name that brain cancer on 30 cells it was a doozy I called for consult the uterine cancer frozen was much easier) that we will have an epic block count on Monday her people came in at three and four am to gross. She posited that people are rushing electives (and surprisingly cancer is elective) because Covid is hitting so hard we might get shut down again. I honestly would welcome that to get caught up on QA and admin but we will see whatever happens happens. Happy weekend much love, Elizabeth

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