Why You Should Care About Pathology

So you're a urology resident and it’s your job to treat genitourinary disease. You care for patients; you probably do not care about slides. So why learn GU pathology? When I was a urology resident, back before I decided to become a GU pathologist, I asked myself that same question. I could tell you that GU pathology is awesome, which is true. But the real answer is that by knowing pathology, you will become a better urologist. Ok, I understand your skepticism, so I am going to give you four reasons you should care about GU pathology.

First, by knowing GU pathology you will be able to have better conversations with your patients. We are entering a world where patients have access to their medical records and many will read their pathology report. Most will not understand what they are reading and they will come to you with a ton of questions. Or they will first ask Dr. Google, become even more confused, and still come to you with a ton of questions. By being able to speak the language of pathology, you will be able to interpret for your patients what is otherwise gibberish. So when you read "sarcomatous carcinoma" in a report you understand that this means your patient has a bad tumor that is aggressive and probably won't respond well to chemotherapy. You will be able to better explain to your patients what their pathology means and how that effects their management and prognosis.

Second, by knowing GU pathology you will have better conversations with your pathologist. During my training we had a case where a woman presented with a large renal mass. There was suspicion for lymphoma involving the kidney. If the diagnosis was lymphoma, then the correct management would be chemotherapy, not surgery. A needle biopsy of the mass was performed in interventional radiology. The specimen was very small and basically consisted of fat and scattered lymphocytes. The lymphocytes were clonal and so a diagnosis of lymphoma was made. However, a comment was placed in the pathology report saying that this small specimen might not represent the lesion of interest. In other words, the patient had some lymphoma cells floating around but the biopsy likely missed the mass of interest. Well, the pathologist never called the urologist and when the urologist got the report he ignored the comment. It turns out the patient's renal mass was in fact a renal cell carcinoma. Needless to say, the patient got the wrong treatment. This case highlights one of the most important reasons to have an understanding of pathology. Good communication between pathologists and clinicians is critical. An accurate diagnosis always entails taking into account the clinical setting. And a part of good communication with pathologists is being able to speak and understand the language. It is also important to know how the pathologist arrives at a diagnosis. This means knowing not only about histology but also knowing a little bit about specimen processing. So when a margin on your prostatectomy comes back positive you will understand how that assessment was made.

Third, by knowing GU pathology you will understand that the field of pathology is both subjective and continuously evolving. The classification system for GU tumors has changed over the years, but unfortunately not all pathologists have stayed up to date. This especially applies to some of the older pathologists or pathologists practicing in small community settings where they may not be familiar with the current literature. For example, you may get a bladder biopsy that is diagnosed as “intermediate grade”. By having a basic knowledge of GU pathology you will know that bladder tumors are now graded as either high grade or low grade. Or you may receive a pathology report that says "Gleason score 1+1=2". You will know that the current standard is to not call anything less than a Gleason score of 3+3=6 on needle core biopsy. Alternatively, some diagnoses are neither right nor wrong but are instead subject to interpretation. The perfect example of this is the diagnosis of “Atypical Small Acinar Proliferation (ASAP)” on prostate needle core biopsy. This diagnosis means that there are a few atypical glands that are suspicious for cancer but the pathologist is not comfortable making the diagnosis. Sometimes this is because there are not enough glands or the histology or immunohistochemistry is questionable. However, the diagnosis of ASAP is completely subjective. ASAP to one pathologist may be cancer to another. If you encounter any of these types of issues during your career, you should discuss it with the pathologist who issued the report. And if you still have any doubts, you can always have the case sent out for a second opinion.

Finally, by knowing GU pathology you will become a better surgeon. Pathologists have been guiding the hands of surgeons for years through the use of frozen sections. A “frozen section” is when a piece of tissue is sent to the pathologist during surgery for an immediate diagnosis. A question is asked by the surgeon to help direct intraoperative management. This can be an incredibly useful resource in the operating room. But in order to utilize this resource to its upmost potential, you will need to have realistic expectations. This means knowing the limitations of the technique. Tissue processed on frozen section can have artifacts such as artificial enlargement of nuclei and loss of architectural and cytologic detail. In addition some tissues, such as fat, can be extremely difficult to cut frozen. This can lead to inaccurate diagnoses. So if you are trying to confirm a negative margin on a partial nephrectomy then you can expect an accurate diagnosis. But when the time comes for you to remove a well-differentiated paratesticular liposarcoma, you will know that any margin you send for frozen will have an extremely high false negative rate.

I strongly encourage every physician to have a basic understanding of pathology. For urologists, you will have to know it for your boards. Butmore important than that, knowing pathology will give you a deeper understanding of the diseases you treat. This fund of knowledge will make you a better physician and that will serve you for the rest of your career. 

Jennifer Gordetsky completed 4 years of a Urology residency before joining a Pathology program. Following board certification in anatomic pathology, she went on to accept a fellowship in General Surgical Pathology at the University of Rochester followed by a fellowship in Genitourinary Surgical Pathology at Johns Hopkins University. She recently published a high-yield pathology review book for urology residents.