The Practice of Surgical Pathology-A Beginner’s Guide to the Diagnostic Process

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Preface

On This Book
Welcome to pathology. If you are reading this book, it is Iikely that you are either in pathology
training or considering pathology as a specialty. This book is an attempt to bridge a gap
between the way pathology is taught to medical students and the way you must learn to
practice it as a resident. In medical school, with tacit acknowledgment that most students are
not going to become pathologists, we teach pathology as it intersects with pathophysiology
and pharmacology. Robbins and Cotran’s Pathologic Basis of Disease is the most prominent
example of this approach and is an excellent and comprehensive text for this purpose.
However, the Robbins does not teach the more practical aspects of pathology practice, such
as differential diagnoses, special stains, biopsy interpretation, the assessment of margins, and
tumor grading. These are the nuts and bolts of pathology practice, the countless subtleties,
shades of grey, and conventions of semantics that go into creating a patient’s diagnosis. For
this, the resident must turn to the huge volume of literature for practicing pathologists, from
the general surgical pathology texts such as Sternberg’s Diagnostic Surgical Pathology and
Rosai and Ackerman’s Surgical Pathology to the highly detailed organ-system texts. For the
beginner, not yet fluent in the foreign dialect that is pathology, these professional-level texts
are simply too much, too soon. This book, inspired by my own rocky and somewhat prolonged
learning curve, is an attempt to create an intermediate step.
This book is intended to be a quick crash course in the basic facts that you are expected
to know when you begin your surgical pathology rotations. In this book, you will find
organ-based chapters that describe the approach to specimens, descriptions of common
diagnoses, pitfalls, practical pearls, differential diagnoses, and key requirements of written
diagnoses. The goal is for you to be able to read a chapter in 20 minutes and come
away knowing enough about a specimen to hold an intelligent conversation with the
attending at the microscope. Early in training, you do not have to get the diagnosis right
to get credit—you just need to demonstrate a sound thought process and some background
knowledge. If you already know the language, you can focus on asking the really practical
questions, such as “How do you know it is X and not Y?” and “How do you handle this if
you cannot show definite invasion?” These are the conversations that will enable you to
function independently when you are finally out in the real world.
This book will also be useful to medical students rotating through pathology. Many students
are given the opportunity to preview cases like a resident but will quickly find their second-year
pathology course does not really help in formulating a diagnosis. This book is written at a level
that should be accessible to students, enabling them to get more out of their pathology rotation by
understanding the more interesting diagnostic challenges involved in even routine specimens.

On What This Book Is Not
Complete or comprehensive: This book is a very oversimplified view of pathology and, in the
interests of brevity and clarity, is deliberately scant on details in many areas. Some advanced
topics have been omitted entirely.
An atlas: Photographs have been chosen to complement some of the specimen descriptions,
but you will get more out of this book if you have a good illustrated text or atlas to supplement
your learning.
A grossing manual: For many organs, this chapter deals with either the biopsy or the organ
resection, but not both, depending on which specimen type is more common or more illustrative.
Therefore, while some grossing tips are included, this book complements, rather than
replaces, your grossing manual.
A board review book: While you do need to know just about everything in this book to pass
the boards, this text is in no way sufficient for that. However, many senior residents who have
seen the material have commented that it was a good way to begin their study, to caulk up any
small gaps that existed in their big-picture views.

On Learning Pathology
In pathology resident education, there are two main categories of knowledge. One is factual
knowledge, and the second is experiential knowledge. To understand the difference, think
about how a child learns her colors. The rote question and answer of, “What color is the sky?”
“Blue!” can be taught to a child as soon as she learns to talk. She may know the standard
colors of apples, leaves, bananas, and so forth, purely by repetition and games. However,
when you pick up a blue block and ask her to identify the color, she may not actually know
the answer. You can tell her, “This is blue,” but she does not yet understand what particular
quality you are pointing out. Is it the shape of the block or the texture? Is it the wood it is made
from or the letter on the side? It takes many, many repetitions of pointing out different blue
things (a towel, a crayon, a book) before she finally understands the quality of blue, the thing
that is similar across all those different-looking items. In the same way, an intern may know
that “hyperchromatic” or “atypical” are indicators of malignant cells. However, he or she will
need to see countless examples of what the experts call atypical to really understand what
qualities of the cell they are identifying. To that end, the more glass you see during your training,
the better your eye will be. No book can give you that kind of experiential knowledge.
On the other hand, you can have the best eye in the world and misinterpret what you are
seeing for lack of factual knowledge. Part of the goal of this book is to give you a head start on
the factual knowledge. There are many examples in this book of very basic principles that are
more or less assumed to be common knowledge and so are rarely, if ever, explicitly taught. I
had multiple head-smacking moments in my own residency, when I thought in exasperation,
“Why didn’t anyone tell me that in the beginning?” My hope is that getting these company
secrets up front will smooth the learning curve for future residents.

On Teaching Pathology
This book began over the course of a 2-year experiment at the Johns Hopkins Hospital. In my
fourth year of residency, I started a weekly microscope-based slide session for interns. Each
session was accompanied by a handout and approximately 20 glass slides representing the
most common diagnoses in that organ. The conferences were designed purely for the interns,
with the intent of creating a protected didactic environment in which no question was too
basic, no prior knowledge was expected, and “zebras” (unusual or exotic diagnoses) were
ignored. Sitting around a large multihead scope, we began with normal histology and the
mental approach to the biopsy or resection and then covered the array of nonneoplastic entities
or changes that could simulate cancer. Finally, we looked at common tumor types and their
variants, comparing and contrasting normal with tumor, low grade with high grade. This book
is a compilation of those handouts, with the addition of illustrations.
The conference has now passed to a group of fourth-year residents committed to teaching
and will hopefully become a sustainable tradition at Johns Hopkins. With the curriculum
written, however, and the focus on common entities seen at hospitals of all sizes, this conference
could easily be duplicated at other programs, either by faculty or by senior residents.
This book is an experiment in teaching, and feedback is welcome.

Diana Weedman Molavi, MD, PhD
Sinai Hospital
Baltimore, MD
diana.molavi@gmail.com