Atrophy

• looks suspicious for adenocarcinoma at first glance.
• the nuclei are small and hyperchromatic.
• No prominent nucleoli are seen.
• Some glands are lined by obviously benign flattened atrophic epithelium.
• The immunostain for high molecular weight cytokeratin can be helpful in distinguishing between atrophy (fragmented basal cell layer) from atrophic variant of prostatic adenocarcinoma (no basal cell layer).

Atypical adenomatous hyperplasia

• It may show the infiltrative architecture of cancer,
• lacks the cytologic features such as prominent nucleoli.
• The immunostain for high mol. wt. Cytokeratin will show fragmented basal cell layer in most cases.

Post-Atrophic Hyperplasia

• Post-atrophic hyperplasia architecturally mimics adenocarcinoma
• lacks the cytologic features.
• In difficult cases, the immunostain for high mol. wt. cytokeratin can be performed which would show at least a few basal cells in post-atrophic hyperplasia.

Sclerosing Adenosis

• small glands with infiltrative growth pattern in a cellular spindled stroma.
• The plump spindle cells in the stroma are nicely seen here.
• The lining acinar epithelial cells lack cytologic atypia – no significant nuclear or nucleolar enlargement is seen
• Myoepithelial differentiation in basal cells of the acini of Sclerosing adenosis is illustrated with the immunostain for muscle specific actin.

Cowper’s Glands

• They have a lobular configuration and are often associated with skeletal muscle fibers
• The glands are lined by goblet cells distended with mucin.
• The small hyperchromatic nuclei are pushed to the periphery.
• Sometimes ducts lined by cuboidal cells are present in the center of the lobules.

Mucinous Metaplasia

• Mucinous metaplasia is seen in about 1% of prostates.
• It may occasionally resemble prostatic adenocarcinoma. However, it lacks prominent nucleoli and the does not show immunoreactivity for PSA and PAP.
• The cells are positive for PAS, mucicarmine and Alcian blue.

Prostatic xanthoma

• Prostatic xanthoma is an uncommon benign lesion that may mimic high-grade prostatic adenocarcinoma.
• It consists of lipid-laden macrophages that may be arranged in small circumscribed nodules or infiltrating cords extending into the stroma
• diffusely positive for CD68 (shown here), and negative for CAM5.2, PSA, and PSAP.

When I was a resident (not said in a gravely old voice…yet) Joe ran the blood bank at Walter Reed Army Medical Center teaching several years of residents throughout the national capital area everything you wanted to or needed to know about blood banking and not a lot of minutia to clog your brain in risk of losing the big picture and important need to know material. During that time Joe also taught at the Osler review course for pathology. My class and those before and after me benefited from Joe’s interests in computer programming, going through courses and quizzes written on a Macintosh! Of course, Joe at the time was the only one smart enough to have a Mac but I eventually caught on. Last but not least, around the same time Joe started the website Blood Bank Guy (no doubt with a Mac) and was responsible for our department website, still in the infancy of the Internet and later dismantled to a shell of its former shelf following increased DOD restrictions on public web content in 2001. Little remains of that today.

Fortunately, as Joe has moved on he has kept up Blood Bank Guy, lecturing, teaching and mentoring & has added podcasts and a Blood Bank Guy Blog.

Joe’s teaching style is to inform and educate through evidence-based medicine. Those of us who were fortunate to learn blood banking from Joe learned as much about the subject as we did about being effective communicators and being part of the treatment team and being able to defend your decisions that clinicians would respect. He was one of the few attendings I had who could do this and teach it.

Now if Joe could just stop being an ardent Detroit Red Wings fan, I might just have a little respect for the guy, but no one is perfect.

Look forward to your posts Joe as one of my continued references for those 3 AM blood bank calls for the right answer.

“The studies were biased,” he says. “Sometimes they were overtly biased. Sometimes it was difficult to see the bias, but it was there.” Researchers headed into their studies wanting certain results—and, lo and behold, they were getting them. We think of the scientific process as being objective, rigorous, and even ruthless in separating out what is true from what we merely wish to be true, but in fact it’s easy to manipulate results, even unintentionally or unconsciously. “At every step in the process, there is room to distort results, a way to make a stronger claim or to select what is going to be concluded,” says Ioannidis. “There is an intellectual conflict of interest that pressures researchers to find whatever it is that is most likely to get them funded.”

I don’t find his conclusions particularly surprising, but I think it’s interesting that they’ve found their way into the mainstream media. He makes an excellent point about why public disclosure of these problems is the right choice, despite the fact that public confidence in medical science may be shaken. The ability to admit that we’re wrong is what separates us from the snake oil salesmen.

“If we don’t tell the public about these problems, then we’re no better than nonscientists who falsely claim they can heal,” he says. “If the drugs don’t work and we’re not sure how to treat something, why should we claim differently? Some fear that there may be less funding because we stop claiming we can prove we have miraculous treatments. But if we can’t really provide those miracles, how long will we be able to fool the public anyway? The scientific enterprise is probably the most fantastic achievement in human history, but that doesn’t mean we have a right to overstate what we’re accomplishing.”

100x original magnification

200x original magnification

200x original magnification

Diagnosis?

What is the most common source of infection worldwide? What about in the United States?

Below, you’ll find a list of links to some excellent Pathology-related websites from professional organizations, to study cases, to blogs.  These are all sites that I’ve found useful over the past three years as a resident at Albany Medical Center, and, hopefully, they can be of use to you as well!
(Note: none of the following links are sponsored; I just like them.)

Obviously, this list is far from comprehensive, and if you have more links that you find useful, please post them as a comment below, as I’m sure we are all always looking for additional great online resources!

Organizations:

• College of American Pathologists
• United States and Canadian Academy of Pathology
• American Society for Clinical Pathology
• American Board of Pathology

Journals:

• Modern Pathology (included with USCAP membership)
• Archives of Pathology (included with CAP membership)
• Journal of Pathology Informatics
• PubMed (for completeness’ sake)

Helpful Websites (not exclusive):

• Pathology Outlines (Great for IHC Stains/CD Markers, also COW)
• Pathology Links (Good link farm)
• Hopkins Unknown Conference (Registration required, free membership)
• PathMax (Another Pathology link farm, many links are out of date now, however)
• UPMC CP COM (Check AP case of the month too)
• TraQ Program (Case studies)
• USCAP (Excellent site for AP educations material)
• ASCP Journal Online (Electronic access included with American Society of Clinical Pathology membership, free for residents, good articles for rounds presentations and board preparation)
• May Clinic Online Labs (Free, registration required. Check hot topics and management strategies videos.)
• Derm 101 (Registration required. Some free, some not. One of the better derm sites)
• PathConsultDDx (Good site for differential)
• U of Utah (Gross images and tutorials)
• California Tumor Registry (Super anatomical pathology case of the month)
• Lab CE (MCQs for CP)
• Kansas State U Parasitology (Good tutorial for parasites)
• Cytology Stuff (for cytology study)
• UT Houston Coag Studies (cases for study coagulation)

Books with online resources (require purchase/registration):

• Sternberg’s Diagnostic Surgical Pathology
• Robbins Pathologic Basis of Disease
• Weedon (Dermatopathology):
• Rosen’s Breast Pathology
• Diagnostic Pathology: Genitourinary
• Gastrointestinal Pathology
• Flow Cytometry and IHC for Hematologic Neoplasms
• AFIP Fascicles

A couple “smiley” faces from a bone marrow we reviewed a few months ago.  I haven’t posted in a while, but promise to publish a couple interesting cases soon!

These things happen. It was going to cost me an extra 10-15 minutes.

An equally elderly customer about 5 people behind me yelled out “This is what your healthcare is going to look like”.

I disagree. We can only hope healthcare reform allows for what I consider a normally efficient service.

For some of the shortcomings of the US mail, with its rigid policies and procedures I can count on 1 finger the number of times an intended delivery or sent item was not received over several decades of using the US mail for pen pals, college applications, med school applications, licensing forms and business transactions. Of course, e-mail and other electronic services have minimized the necessity for traditional “snail mail” services which has affected the bottom line for the quasi-governmental organization. I find the need for delivery confirmation or certified letters to be negligible given the time and accuracy of mail delivery.

Let’s assume some components of the healthcare reform do look governmental or quasi-governmental if you don’t have “private insurance”. Having worked and received care in military, VA and large academic institutions, my experience is that quality overall is the same, the speed (meaning wait time from definitive diagnosis to definitive care/management) varies greatly with access issues and beaurocratic inefficiencies sometimes causing delay between getting seen and getting treated. While commerical hospitals are not immune from their own inefficiencies, generally access is simplified and referrals are timely.

So, while your health and your mail are not the same, if 42 cents buys you 2-3 day delivery at the expense of a few minutes to get it going, perhaps cost can be controlled with quality outcomes with reasonable wait to get the necessary service particularly for those who would not normally be afforded these services or for whom alternatives are not available.

Would it be so bad if healthcare ran like the post office?

In May of last year I came down with what I thought was a community acquired pneumonia. This was about the time of the first reported cases of H1N1 and out of fear of quarantine at the time for what I was sure was not H1N1 I avoided doctors and hospitals. After trying a couple courses of antibiotics prescribed by a colleague, without relief, I found myself at an “express care” facility on a weekend morning desperate for relief from my symptoms of fever, cough and chest pain.

After completing a short medical history, I was seen by a nurse practioner with minimal waiting who was professional yet focused her questions and examination on the current problem. Within a few minutes I had prescriptions for another course of antibiotics and medication to relieve the cough and subsequent chest pain.

“Are you going to do a chest x-ray?” “No.

“Sputum culture?” “No, why?”

“Referral to infectious disease or pulmonary?” “Huh?”

By the next morning, my symptoms were gone. Of course, this likely would have resulted had I not seen this healthcare provider but for fifty bucks that my employer sponsored healthcare plan paid for I feel like it was time well spent and was able to sleep through the night for the first time in a couple of weeks.

Some time after this I asked a pulmonary colleague had I been seen by him or one of his colleagues what may have transpired. At the least he claimed a chest x-ray and consideration of bronchoscopy and possible PFT testing to exclude other underlying conditions. Seems like a stretch compared to what I needed and with the treatment being an inexpensive visit, antibiotic and cough supressant.

During my acute illness one of our fellows presented with acute flank pain to the ER on the same weekend. After sitting in pain for four hours in the ER it was determined he had a kidney stone and conservative managment was warranted. An ultrasound and CT later, twelve hundred bucks for the ER visit plus radiology costs. No pain relief. By the next week after conservative measures failed and he underwent additional urology consultations, lithotripsy and eventually surgical removal of the stone. Tack on another five grand. A post-op follow up, subsequent IVP and his bills were pushing $10K. This does not count time off from work and lost productivity. The insurance covered a minority of the expenses.

While I am not a pulmonologist or urologist and do not manage acute clinical conditions I wonder what may have happened if my colleague had gone to see the nurse practioner on the weekend as I did. Save the ER costs for same diagnosis, perhaps some more immediate relief of symptoms, quicker appropriate referral as this could not be managed in their setting and definitive care rendered with less delay and patient suffering.

Perhaps this model can be expanded. What is the real cost of healthcare by being overly investigative or delaying definitive care at the expense of conservative measures? It is obviously a difficult balance without the medicolegal implications either way.

I think that we should be looking at outcomes and a cost per outcome (or expected outcome) as function of dollars spent as a significant factor in terms of appropriately providing care while insuring the standards of care are met.

Would I have benefited from a more extensive work up? Would the outcome been different? Probably not. While it may not have been contraindicated and not harmful, or low risk, the costs beyond using emperical data may not justify a similar outcome.

Physicians are driven by data. But what is the data worth as a function of its cost?

I know what you’re thinking: an amyloid angiopathic bleed, or perhaps a hypertensive bleed, in a patient with Alzheimer disease. That’s what I was thinking until I saw in the chart that abnormal white matter changes on MRI prompted the neurologist to order Notch3 genetic testing on the patient, which surprisingly came back positive for a mutation. The patient therefore carried a clinical diagnosis of Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL), despite the fact that she had no clear family history indicative of this disease and despite the advanced age of symptom onset. At autopsy, there was no evidence of amyloid angiopathy on Congo red stain. She did appear to have the PAS-positive vessel wall deposits that would be consistent with a diagnosis of CADASIL (see photomicrographs below). Plus, it is hard to refute a positive genetic test. The Notch3 test has excellent specificity, from what I hear. Also, I hear that there was some Korean study showing a relationship between CADASIL and brain hemorrhage. If anyone has any other ideas about what might be the diagnosis in this case, I would love to hear from you.