I was contacted by a patient from Mississippi, who was referred by her close friend. That friend is one of our patients who has had an exceedingly good response to a novel drug combination crafted two years earlier in our lab for her HER2 (+) breast cancer.
This patient had recurrent breast cancer that upon biopsy proved to be triple negative. As triple negative disease is much more challenging, we agreed she would benefit from laboratory analysis and she arranged travel.
As luck would have it, she developed COVID and her surgical biopsy plans had to be postponed. When the hospital’s overly strict COVID policy denied the patient’s scheduled surgery citing COVID risk (despite complete COVID recovery and fully two weeks elapsed), we had to refer her to another medical center where the biopsy was successfully completed without additional delay.
As sometimes happens with triple negative breast cancer, the cells had an atypical appearance under the microscope. We reviewed the specimen with our best pathologist but the case remained equivocal and because the actual tissue sample (a surgical specimen fixed in paraffin) was at the outside hospital, and it was not yet available for our review.
The clock was ticking and we needed to start the analysis, hoping that our sample was consistent with her tumor. Confirmation would have to wait.
The term we apply is “sampling error” when we get one thing and the pathologist gets something different. It happens very rarely but is easy to resolve by simply comparing theirs with ours. Unfortunately, I couldn’t do that with a surgical specimen 40 miles away.
When I met the patient several days later, I explained my concern. The patient was resolute. If we did not have an adequate sample, she would cancel her flight and stay in California until we got the biopsy we needed.
To resolve the dilemma I needed to put our specimen next to theirs under the microscope and use the special stains that they had conducted to confirm the cancer.
Our team reached our surgical colleague and he arranged for the hospital slides to be available.
The patient drove to Santa Monica, retrieved her microscope slides and drove back to our laboratory. There were only a few hours left before her flight was scheduled to leave.
My medical student and I rushed to the Pathology department, microscope slides in hand.
By a stroke of luck the same pathologist was on duty. “Oh, I remember that case,” she said. The instant she looked at the Santa Monica specimen she said, “It’s the same”.
With the luxury of special stains we were able to absolutely confirm it was the tumor. We rushed back from Pathology to inform the patient. She was in our waiting room anxiously anticipating our return.
“It’s cancer.” I said.
“Oh, Thank God” she said.
I have never known a patient to be happier to discover their biopsy was positive for cancer.
No additional biopsy would be required. We could complete our study and report it to her physician a couple of days later. The patient departed for the airport, caught her flight and made it home uneventfully.
The story reflects our unwillingness to yield. This patient deserved the best result and I did not want to put the patient through additional surgery unless it was absolutely necessary.
With her help, our attention to detail, and the assistance of our dedicated colleagues we were able to confirm that the patient’s original sample was a tumor. With immunohistochemical confirmation of tumor, our laboratory analysis could go forward.
As a final comment, I have since completed the patient’s analysis, and I am pleased to say that there are many active treatments: A successful outcome all around.