So, is the mass 17 cm or 1.7 cm?
One of my favorite YouTube videos is entitled “Surgeon vs. Pathologist” but it could easily be “Pulmonologist” or “Gastroenterologist” or “Urologist” or more “vs. Pathologist”. Every pathologist has their own stories about these incidences and cases. The one below really happened to me years ago (parts of it are intermixed with some details of other cases for illustrative purposes). Names are changed (with the exception of mine) to protect the guilty (and the innocent).
Me: Dr. Clinician, this is Keith Kaplan calling from Pathology. I am calling on your patient, Ms. Patient. The duodenal biopsy has a mass that looks like a poorly differentiated malignant neoplasm.
Clinician: Yes. It looked like cancer. That is why I biopsied it and sent it to the lab.
Me: I understand. Is there any prior history of malignancy in this patient. This does not look like a typical GI neoplasm. Is there any history of breast or lung or ovarian cancer perhaps?
Clinician: I don’t recall. Let me check the EMR…there is no history of malignancy…she does have a 1.7 cm ovarian cyst on the left on her chest, abdomen, pelvis CT done for abdominal pain.
Me: OK. That is interesting. I am concerned about an ovarian cancer metastatic to the duodenum. I will show it around and get some other opinions as well and send off some immunohistochemistry as well for completeness. The tumor is so poorly differentiated I am not sure what it is. She doesn’t have any other masses on her recent CT scan?
Clinician: Just the ovarian cyst that is 1.7 cm on the left.
Me: OK. I am going to do some ovarian markers as well as others for GI, lung and breast, for a start.
Clinician: Keep me posted.
Two days later, after completing 2 rounds of immunohistochemical stains and showing the case around we favored a papillary serous carcinoma from the ovary.
Me: Dr. Clinician, I am calling you back on Ms. Patient. We spoke a few days ago.
Clinician: Yes.
Me: The tumor looks like a met from the ovary.
Clinician: That makes perfect sense.
Me: Why?
Clinician: Because she has a large, 17 cm mass in her right ovary.
Me: She does?
Clinician: Yes, remember we talked about this Keith. When I looked in her record and told you she has this large, 17 cm mass in her right ovary.
Me: I remember you telling me that she had a benign appearing, 1.7 cm cyst in the left ovary. I added breast, lung and other markers without a more convincing history to rule out other sites as potential primaries. I am not sure I would have done that with a history of a 17 cm ovarian mass.
Clinician: Well she went for surgery at another hospital and the tumor looks like a metastatic ovary. I think they said “papillary” or “serous”. Interesting case. The tumor was confined to the submucosa.
Me: Okay…
Clinician: They also removed the ovarian mass.
Me: What did that show?
Clinician: I don’t know, the gyn onc team is following her now.
Me: Okay…
Clinician: So you don’t think that biopsy is a duodenal cancer?
Me: No…
Clinician: Odd, it looked like cancer.
Me: So, is the mass 17 cm or 1.7 cm?
Clinician: Yes.
