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The Differential

The Whirlwind Cases I Saw During My Pathology Rotation

Kolin Meehan, Medical Student, 10:00PM Aug 20, 2017

My first week of surgical pathology ended yesterday, and already I've seen some very interesting cases. Over the course of the last few days, my caseload filled up with tissue specimens, including tongue, colon, tonsils, bladder, uterus, and ovaries. Part of the learning curve forces me to identify important landmarks--especially resection margins--and adequately sample areas that represent both potential pathology and healthy tissue for comparison. Needless to say, I felt a little in over my head. But with a PGY2 present and a fellow trainee with some prior grossing experience, I was in a perfect position to learn plenty about the human body. Even more so, I came to appreciate the impact Pathologists exert over the clinical course of disease.   

Take, for example, the following whirlwind of a case. A male patient endured a nonhealing foot ulcer for quite some time. His doctor eventually ordered a PET scan that incidentally revealed a large, vibrant mass in his neck. When the FNA was analyzed, he was given a preliminary diagnosis of papillary thyroid carcinoma (PTC). No doubt, the word "cancer" drew focus and likely caused immense anxiety. Fortunately for the patient, PTC remains a relatively indolent cancer: More than 90% of patients are alive 10 years following the diagnosis.

Fortunately for me, I received this man's case on my first day in the grossing lab. My trainer and I oriented the tissue, crafted a plan of attack, and subsequently dissected the entire specimen. Turns out, PTC can become so calcified that sections must be placed in an acidic decalcifying solution normally reserved for bone samples. This softens the tissue enough for histology technicians to cut very thin sections for stains. The entire process became an incredible learning experience not only in preparation and diagnosis of classic pathology, but served as a reminder of how quickly someone's life can fluctuate between the mundane day-to-day toward a (seemingly) catastrophic scenario all on the word of the Pathologist.

The man's case turned out similarly to another I handed this past week. A young woman had experienced hematochezia for weeks before she received an EGD and colonoscopy. Although the upper studies revealed normal tissue, her lower GI tract produced a visible polyp on imaging. Normally, a solitary polyp isn't too much cause for concern, even in a young-adult patient. Yet this woman would not leave the operating table unscathed: the pathology report revealed a moderately differentiated, invasive adenocarcinoma. Nothing in her history remotely suggested this outcome, and not even her parents nor grandparents carried such a shocking diagnosis.

My involvement in her case centered on the subsequent sigmoidectomy specimen. My mind prepared me for the worst, but throughout the tissue prep I noticed no obvious defects apart from a polypectomy scar and corresponding tattoo ink. To everyone's surprise, no cancerous cells sat at the former polyp site nor in any lymph nodes. The patient was effectively cured of a devastating disease that can ravage the peritoneal cavity.

Once again, a patient had experienced the extremes of emotions all in a manner of weeks. And even though I do not meet these people face-to-face, I take pride in the fact that I can still be a part of the patient care team behind the scenes. 

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Medical school and residency can be a stressful, demanding time. These medical students share their insights and experiences, good and bad, in order to create a community of support and understanding for medical students everywhere.

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