This week's highlights were definitely in interventional radiology and pathology so I will focus my blog post on those days. Otherwise, I've been at the Lung Cancer Screening Center working more on determining the structure of the study for their grant proposal on smoking cessation in the context of LDCT screening centers.
In interventional radiology this week, I got to see multiple lung biopsies, several cryoablations, and an inferior vena cava filter insertion. The first biopsy was fine needle aspirations (FNA) on an 82 year old female who was biopsied from the prone approach. I noticed in this case, histology determined how many fine needle aspirations were taken since more samples would be needed if the first samples were inconclusive. However, the pathologists reported the nodule appeared to be adenocarcinoma so FNA was sufficient and a core needle biopsy (CNB) was not necessary. Like all the patients with lung procedures, she was ordered to have an X-ray done immediately after her procedure and then after two hours to ensure pneumothorax did not occur. The second lung biopsy was slightly more complicated since the PA had to deal with an extremely nervous patient. Her breathing patterns were highly irregular, which made timing the movement of the lungs by the diaphragm for accurate needle placement quite challenging. However, once the patient was calmed enough to breathe normally, the procedure was uncomplicated. The first cryoablation I saw this week was actually a soft tissue ablation of a metastatic cervical cancer in the pelvic region. I asked Dr. Pua what types of tissues can be treated with ablation, and he explained that most regions where there isn't a lumen, organ, or system adjacent to the ablation zone that can be damaged is fair game. Also, cases like the GI tract where interrupting a lumen causes dysfunction is not a good target for ablation. After watching this relatively smooth procedure, I took a detour to one of the Angio rooms where a filter was being placed to collect blood clots to prevent pulmonary emboli. The X-ray guided procedure necessitated that we wear heavy lead vests that remind me of samurai armor. A neck strap accessory protects the thyroid gland! It always astounds me to watch how vasculature is navigated using different wires and tools in these procedures. This surgery complimented the filter removal I saw previously this summer. Once the guide wire was in the correct position, just slightly above where they wanted the filter in the vena cava, the filter was essentially spat out of the wire, expanding until it was stable in the vein. The low level of invasiveness allowed by X-ray guidance in filter placement is truly a marvel. After successful deployment of the filter, I returned to the CT procedure room where another lung cryoablation was about to take place. This one was running much like the other until the end of the ablation cycle when the lung collapsed slightly as evidenced by a sliver of dark space, signifying air, in the pleural cavity. As if by magic, Dr. Pua simply took an intimidatingly large syringe, inserted it into the cavity, and aspirated out the space, holding it under vacuum for a short while before withdrawing the needle. Upon inspection of the latest CT image, he remarked rhetorically, "What pneumothorax?" since it had all but disappeared. This was a moment I'm slightly ashamed to admit I was excited to be around for since no one wants a collapsed lung during one of these procedures, but I really wanted to see how they intervene if this does happen.
In Surgical Pathology, I had the opportunity to shadow Dr. Narula as she signed out for the day. I learned that anything removed from a patient has to go to pathology, even if there is no diagnostic assessment needed. I dived in viewing a lung biopsy along with Dr. Narula and her resident using microscopes connected to the same light path (pretty cool setup). This patient had a history of prostate cancer, and thus, pathology needed to assess whether the lung mass was a metastasis or a primary lung tumor. However, the patient's history did not include whether the prostate cancer had well differentiated cells or not so this complicated matters. To add to the complexity of the case, the patient has a history of smoking, a large risk factor for developing lung cancer. It was noted that the biopsy showed poorly differentiated cells and immunohistochemical stains for TTF-1 (thyroid transcription factor-1, used to differentiate between primary lung cancer (+) and lung metastasis (-) in adenocarcinoma patients), P40 (marker for pulmonary squamous cell carcinoma), and PSMa (prostate-specific membrane antigen, marker for prostate cancer) were ordered. Another case along similar lines was a biopsy of lung nodules for a patient that had a history of laryngeal cancer; a diagnosis was desired as to whether the nodules were metastases or an independent primary tumor. It was noted that the sample had fibroelastosis, predominantly scar tissue with mild inflammation. From my understanding, this could be residual from treatment and can complicate the diagnostic assessment since there could still be cancer that was missed by the biopsy needle. Another interesting case was a Stage IV lung cancer patient who had a biopsy of pericardial effusion that showed no malignancy. Dr. Narula had been using the terminology "level x #" intermittently so I asked what that pertains to, and she explained that the levels are depth of the specimen in the paraffin block that gets sampled. For instance, with this patient it had been level x 3, and she wanted to look at level x 5 to ensure they weren't missing anything by not looking deep enough into the block. This is an interesting compromise between thoroughness and efficiency requiring indeterminate cases to get processed again for additional samples while not wasting processing time on cases that turn out to be quite obvious with a few slides. There was a case of a 32 year old male with a Stage IIIb germ cell tumor. Pathology was required to determine if there was any testicular cancer in the biopsy or simply mature teratoma. This assessment would help determine if chemotherapy would have any effect since it could only kill the testicular cancer not a mature teratoma. Further staining with OCT4 and CD30 were considered since this case was not striaghtforward. There was a biopsy of a left-axillary mass identified as metastatic carcinoma that Dr. Narula could do nothing definitive with since there was no patient history; thus, the doctor had to be followed up with later. We looked at synovium from a left patella fracture where inflammation had been taking place as evidenced by macrophages at the fracture site. I also learned that occluding plaques removed from vascular surgery have different morphologis pre/post statins. The most interesting case was the congenital pulmonary airway malformation (CPAM), where the resident actually went and consulted another pathologist who specializes in pediatrics to ensure that the type 1 characterization was correct. Later, I looked up more about CPAM and noted that type 1 is the most common with larger cysts. CPAM is a condition resulting from abnormal bronchoalveolar development and can be detected either during neonatal development or later, even into adulthood, with recurrent chest infection. This sample was from a 19 year old and thus, the case wasn't considered pediatric even though the condition is generally studied by pathologists specializing in pediatric diseases.
All in all, I had a great week being exposed to some new procedures in IR and an entirely new atmosphere in surgical pathology. Can't wait to see more new things in these next two weeks before returning to Ithaca.
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