Evaluation: Difference between revisions

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==Microscopy settings==

[[File:Parts of a light microscope (english) - larger text.png|thumb|300px|Usual parts of a microscope.]]

If only one eye piece has adjustable '''focus''', you generally raise or lower the stage until you are in focus on the non-adjustable eyepiece, and then adjust the other eyepiece. {{Memorization-worthy}} With objectives that are close to the microscope slide, start focusing from what you know is a lower stage level, and slowly raise it from there, to avoid colliding with the objective and potentially damaging the slide.

<noinclude>Low magnification has a greater span of focus compared to high magnification, so it is normal to need to re-focus if you're switching to a higher magnification objective. However, if you find that you need to '''change focus''' even if going from high to low magnification, try the following (if you can adjust the eye piece):

#Use high magnification and focus on a specimen using the main focus knob.

#Switch to low magnification, and focus using the eye piece adjustment.</noinclude>

===Condenser===

Generally the '''condenser''' is placed in its highest position or just slightly lower. At low magnification objectives (mainly 4x and 10x objectives), the opening of the condenser (or iris) diaphragm should be wide open. This corresponds to turning away or "lowering" the condenser on microscopes where the condenser apparatus can be turned to the side (and is shown as "without condenser" in images below). For high-dry (40x) and oil-immersion objectives (100x), the diaphragm should be closed slowly while looking at a sharply focused section until the level of illumination is just slightly reduced, in order to attain optimal contrast and resolution (and corresponds to "with condenser" in images below).<ref>{{cite web|url=https://histologylab.ctl.columbia.edu/HistologyLabManual.pdf|title=Histology Laboratory Manual, Vagelos College of Physicians & Surgeons Columbia University|author=Patrice F Spitalnik|accessdate=2021-09-20}}</ref>

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</gallery>

Low magnification has a greater span of focus compared to high magnification, so it is normal to need to focus if you're increasing magnification.<noinclude> However, if you find that you need to '''change focus''' even if going from high to low magnification, try the following (if you can adjust the eye piece):

~~#Use high magnification and focus on a specimen using the main focus knob.~~

~~#Switch to low magnification, and focus using the eye piece adjustment.</noinclude>~~

If there's a '''constant visual artifact''', even after you've cleaned the eye piece and objective lenses with lens tissue, try raising or lowering the condenser if you can, and the artifact may disappear out of focus.

</noinclude>

==Priority==

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* There's a significant probability that it will require '''further workup''' such as [[immunohistochemistry]], especially when there is an impending deadline for ordering it.

* The optimal person to ask for '''advice''' may not be available later. {{Further|Consultation}}

For a pile of many cases of relatively low risk of a need to prioritize any one over another, such as [[gastrointestinal biopsies]], a very quick glance at the forms and/or a naked eye look at the glass slides is generally ~~acceptable~~.

As part of initial triaging, also determine what tasks can be '''delegated'' to juniors or pathologist assistants.

For a pile of many cases of relatively low risk of a need to prioritize any one over another, such as [[gastrointestinal biopsies]], a very quick glance at the forms and/or a naked eye look at the glass slides is generally sufficient.

==Main steps==

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*Try to pick up glass slides '''without touching''' the tissue area, as fingerprints may interfere with the evaluation.

*Look at each microscopy slide by plain '''eye''', to plan the microscopy scanning so as to not miss peripheral fragments.

*Have a '''systematic direction''' of scanning through microscopy slides, such as from top left to bottom right as seen in the microscope. When the microscope makes what you see two-way mirrored, the starting position is with the objective pointing at the bottom right of the glass slide. You may center on findings on interest and evaluate them at higher magnification, and then resume the scanning

*Have a '''systematic direction''' of scanning through microscopy slides, such as from top left to bottom right as seen in the microscope. When the microscope makes what you see two-way mirrored, the starting position is with the objective pointing at the bottom right of the glass slide. You may center on findings on interest and evaluate them at higher magnification, and then resume the scanning.

File:Position of objective (edited).jpg|Example starting position of objective.

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File:Screening method 1.jpg|Starting at top left in the view, aim to scan a strip that trajects a circular field of view approximately at the clock positions shown...

File:Screening method 2.jpg|...When reaching the end of relevant material, set your eyes on any object at the edge of the strip that you just scanned...

File:Screening method 3.jpg|...Move the field of view over so that the object is seen on the opposite side. The new strip to be scanned will now be juxtaposed to the one you previously scanned~~, both making sure you don't miss any area, as well as minimizing redundant scanning~~.

File:Screening method 3.jpg|...Move the field of view over so that the object is seen on the opposite side. The new strip to be scanned will now be juxtaposed to the one you previously scanned.

</gallery>

*Look in particular for whatever is '''requested''' or '''suspected''' on the requisition form or equivalent. ~~While learning~~, you will generally focus relatively more on high magnification features with high specificity, but still have a habit of ~~learning how your cases look~~ at '''low magnification''' as well. In time, you will increasingly correlate diseases and conditions with their overall low magnification patterns - patterns that may require 1000 words to describe and thus cannot conveniently be part of written criteria, but will nevertheless allow you to make quicker and more accurate diagnoses. When you find something suspicious, it is helpful at least in the beginning to evaluate them ~~from~~ a low-to-high magnification (example showing a basal-cell carcinoma):

This scanning technique above makes sure that you don't miss any area, and also minimizes redundant scanning. The width or clock position that you scan in each field of view is not exact, as you may scan up to the entire width in cases where you think relevant findings will clearly present themselves even if only partially showing in the periphery of your view.

*Look in particular for whatever is '''requested''' or '''suspected''' on the requisition form or equivalent. For each type of condition, initially you will generally focus relatively more on high magnification features with high specificity, but you should still have a habit of looking at '''low magnification''' as well to get an idea of its pattern. In time, you will increasingly correlate diseases and conditions with their overall low magnification patterns - patterns that may require 1000 words to describe and thus cannot conveniently be part of written criteria, but will nevertheless allow you to make quicker and more accurate diagnoses, or at least clues thereof.

*When you find something suspicious, it is helpful at least in the beginning to evaluate them systematically by a '''low-to-high magnification approach''' (example below showing a [[basal-cell carcinoma]]):

File:Systematic microscopy 2 - Orientation.jpg|'''Orientation''' (lowest magnification): In this case oriented by the skin surface (green). A lesion is seen (red) and its demarcation can be discerned (diffuse in this case)

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File:Micropapillary urothelial carcinoma, very high mag.jpg|'''Micropapillary''': Papillary tufts without fibrovascular cores

File:Histopathology of fascicular growth in a leiomyoma.jpg|thumb|'''Fascicular''': Generally the same cell type throughout, but some form band-like groups that are aligned in the same direction.

File:Micrograph of prostate cancer with Gleason score 10 (5+5) with solid sheets of cells (crop).jpg|'''Solid''': More or less the same cell type throughout, with no spaces between, and no other particular pattern.

File:Histopathology of woven or storiform pattern.jpg|'''Woven''' or '''storiform''': Elongated cells or nuclei wherein small bundles are aligned in an otherwise haphazard pattern.

File:Micrograph of prostate cancer with Gleason score 10 (5+5) with solid sheets of cells (crop).jpg|'''Solid''' or "'''sheets'''": More or less the same cell type throughout, with no spaces between, and no other particular pattern.

File:Papillary urothelial carcinoma with cribriform morphology, very high mag.jpg|'''Cribriform''': Solid with multiple clear spaces.

File:~~Whirled or woven pattern in histopathology~~.jpg|'''~~Whirled~~''' or ~~'''woven'''~~ pattern, ~~comparing to a plant whorl and woven fabric~~. ~~Also termed~~ '''~~storiform~~''' ~~(from Latin ''storea'' meaning "woven")~~

File:Bovine Bone Sample and 430 times Magnification.jpg|'''Whorled''': Multiple concentric objects, or spiral-shaped

File:Histopathology of cartwheel pattern in dermatofibrosarcoma protuberans, annotated.jpg|'''Cartwheel pattern''': Center points that radiate cells or connective tissue outward

</gallery>

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File:Histology of deep zone of articular cartilage.jpg|'''Hyaline''' usually refers to extracellular material that stains homogeneously pink on H&E stain (like the matrix of hyaline cartilage, pictured).

File:Histopathology of hyaline membranes in diffuse alveolar damage.jpg|Example of hyaline material (in alveoli of lungs, indicating diffuse alveolar damage)

File:Glass for pathologist.png|This is what pathologists also refer to as "glassy" (because hyaline cartilage looks like glass grossly).

</gallery>

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==Marking slides==

The main indications for marking slides are hard-to-see findings on a slide, and/or to distinguish one slide out of many. Just make a figure rather than a word if you are not sure what it is, as it might be confusing for reviewers if the pathology report ends up being something different.

File:Photograph of marking a microscopy slide.jpg|To mark a microscopy slide, use an objective that gives you enough space underneath. Rest a finger on the stage, while holding the marker pen relatively close to its tip. Move the tip of the marker pen into the field of view but at least a few millimeters from the slide...

File:Micrograph of marking a microscopy slide.jpg|...Then slowly approach the slide while making sure that the tip remains in the location you want to mark. Be careful not to obscure findings of interest with the mark.

File:Micrograph of marking a microscopy slide.jpg|...Then slowly approach the slide while making sure that the tip remains in the location you want to mark. Be careful not to obscure findings of interest with the mark. If the slide is likely to undergo whole slide imaging, make the mark on the back and not on the coverslip (as it reduces the risk of erroneous focusing of the cameras).

File:~~Removing marks from~~ a ~~microscopy~~ slide.~~jpg~~|You can generally remove marks from a microscopy slide by using alcohol. Don't press hard against the glass, as it may disrupt the tissue.

File:Wiping a slide.png|You can generally remove marks from a microscopy slide by using alcohol. Hold the cover slip in place with two fingers while wiping from side to side, to avoid the risk of moving the coverslip. Don't press hard against the glass, as it may disrupt the tissue.

</gallery>

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*Background, mainly if it is clear or dirty

*Overall cellularity

{{further|Cytology}}</noinclude>

==Consideration==

Consider the '''adequacy''' of the specimen. Have a somewhat lower threshold to make a report of "inadequate" or "insufficient" if it is easy to resample from the patient, such as remaining diagnostic tissue at a superficial location.

First, generally suspect the '''common conditions''' for the location at hand. A less common variant of a common condition is often still more likely than a rare condition, so generally call the latter only if it really fits the picture.

Whenever you consider a certain diagnosis, also consider whether it is one step '''better or worse'''. For example, when you consider a non-invasive but high-grade dysplasia, also consider both low-grade dysplasia and invasiveness.

</noinclude>

@@ Line 6: / Line 6: @@
 ==Microscopy settings==
 [[File:Parts of a light microscope (english) - larger text.png|thumb|300px|Usual parts of a microscope.]]
+If only one eye piece has adjustable '''focus''', you generally raise or lower the stage until you are in focus on the non-adjustable eyepiece, and then adjust the other eyepiece. {{Memorization-worthy}} With objectives that are close to the microscope slide, start focusing from what you know is a lower stage level, and slowly raise it from there, to avoid colliding with the objective and potentially damaging the slide.
+<noinclude>Low magnification has a greater span of focus compared to high magnification, so it is normal to need to re-focus if you're switching to a higher magnification objective. However, if you find that you need to '''change focus''' even if going from high to low magnification, try the following (if you can adjust the eye piece):
+#Use high magnification and focus on a specimen using the main focus knob.
+#Switch to low magnification, and focus using the eye piece adjustment.</noinclude>
+===Condenser===
 Generally the '''condenser''' is placed in its highest position or just slightly lower. At low magnification objectives (mainly 4x and 10x objectives), the opening of the condenser (or iris) diaphragm should be wide open. This corresponds to turning away or "lowering" the condenser on microscopes where the condenser apparatus can be turned to the side (and is shown as "without condenser" in images below). For high-dry (40x) and oil-immersion objectives (100x), the diaphragm should be closed slowly while looking at a sharply focused section until the level of illumination is just slightly reduced, in order to attain optimal contrast and resolution (and corresponds to "with condenser" in images below).<ref>{{cite web|url=https://histologylab.ctl.columbia.edu/HistologyLabManual.pdf|title=Histology Laboratory Manual, Vagelos College of Physicians & Surgeons Columbia University|author=Patrice F Spitalnik|accessdate=2021-09-20}}</ref>
 <gallery mode=packed heights=200>
@@ Line 13: / Line 19: @@
 </gallery>
-Low magnification has a greater span of focus compared to high magnification, so it is normal to need to focus if you're increasing magnification.<noinclude> However, if you find that you need to '''change focus''' even if going from high to low magnification, try the following (if you can adjust the eye piece):
-#Use high magnification and focus on a specimen using the main focus knob.
-#Switch to low magnification, and focus using the eye piece adjustment.</noinclude>
 If there's a '''constant visual artifact''', even after you've cleaned the eye piece and objective lenses with lens tissue, try raising or lowering the condenser if you can, and the artifact may disappear out of focus.
+</noinclude>
 ==Priority==
@@ Line 24: / Line 28: @@
 * There's a significant probability that it will require '''further workup''' such as [[immunohistochemistry]], especially when there is an impending deadline for ordering it.
 * The optimal person to ask for '''advice''' may not be available later. {{Further|Consultation}}
-For a pile of many cases of relatively low risk of a need to prioritize any one over another, such as [[gastrointestinal biopsies]], a very quick glance at the forms and/or a naked eye look at the glass slides is generally acceptable.
+As part of initial triaging, also determine what tasks can be '''delegated'' to juniors or pathologist assistants.
+For a pile of many cases of relatively low risk of a need to prioritize any one over another, such as [[gastrointestinal biopsies]], a very quick glance at the forms and/or a naked eye look at the glass slides is generally sufficient.
 ==Main steps==
@@ Line 30: / Line 36: @@
 *Try to pick up glass slides '''without touching''' the tissue area, as fingerprints may interfere with the evaluation.
 *Look at each microscopy slide by plain '''eye''', to plan the microscopy scanning so as to not miss peripheral fragments.
-*Have a '''systematic direction''' of scanning through microscopy slides, such as from top left to bottom right as seen in the microscope. When the microscope makes what you see two-way mirrored, the starting position is with the objective pointing at the bottom right of the glass slide. You may center on findings on interest and evaluate them at higher magnification, and then resume the scanning
+*Have a '''systematic direction''' of scanning through microscopy slides, such as from top left to bottom right as seen in the microscope. When the microscope makes what you see two-way mirrored, the starting position is with the objective pointing at the bottom right of the glass slide. You may center on findings on interest and evaluate them at higher magnification, and then resume the scanning.
 <gallery mode=packed heights=140px>
 File:Position of objective (edited).jpg|Example starting position of objective.
@@ Line 38: / Line 44: @@
 File:Screening method 1.jpg|Starting at top left in the view, aim to scan a strip that trajects a circular field of view approximately at the clock positions shown...
 File:Screening method 2.jpg|...When reaching the end of relevant material, set your eyes on any object at the edge of the strip that you just scanned...
-File:Screening method 3.jpg|...Move the field of view over so that the object is seen on the opposite side. The new strip to be scanned will now be juxtaposed to the one you previously scanned, both making sure you don't miss any area, as well as minimizing redundant scanning.
+File:Screening method 3.jpg|...Move the field of view over so that the object is seen on the opposite side. The new strip to be scanned will now be juxtaposed to the one you previously scanned.
 </gallery>
-*Look in particular for whatever is '''requested''' or '''suspected''' on the requisition form or equivalent. While learning, you will generally focus relatively more on high magnification features with high specificity, but still have a habit of learning how your cases look at '''low magnification''' as well. In time, you will increasingly correlate diseases and conditions with their overall low magnification patterns - patterns that may require 1000 words to describe and thus cannot conveniently be part of written criteria, but will nevertheless allow you to make quicker and more accurate diagnoses. When you find something suspicious, it is helpful at least in the beginning to evaluate them from a low-to-high magnification (example showing a basal-cell carcinoma):
+This scanning technique above makes sure that you don't miss any area, and also minimizes redundant scanning. The width or clock position that you scan in each field of view is not exact, as you may scan up to the entire width in cases where you think relevant findings will clearly present themselves even if only partially showing in the periphery of your view.
+*Look in particular for whatever is '''requested''' or '''suspected''' on the requisition form or equivalent. For each type of condition, initially you will generally focus relatively more on high magnification features with high specificity, but you should still have a habit of looking at '''low magnification''' as well to get an idea of its pattern. In time, you will increasingly correlate diseases and conditions with their overall low magnification patterns - patterns that may require 1000 words to describe and thus cannot conveniently be part of written criteria, but will nevertheless allow you to make quicker and more accurate diagnoses, or at least clues thereof.
+*When you find something suspicious, it is helpful at least in the beginning to evaluate them systematically by a '''low-to-high magnification approach''' (example below showing a [[basal-cell carcinoma]]):
 <gallery mode=packed heights=180px>>
 File:Systematic microscopy 2 - Orientation.jpg|'''Orientation''' (lowest magnification): In this case oriented by the skin surface (green). A lesion is seen (red) and its demarcation can be discerned (diffuse in this case)
@@ Line 59: / Line 67: @@
 File:Micropapillary urothelial carcinoma, very high mag.jpg|'''Micropapillary''': Papillary tufts without fibrovascular cores
 File:Histopathology of fascicular growth in a leiomyoma.jpg|thumb|'''Fascicular''': Generally the same cell type throughout, but some form band-like groups that are aligned in the same direction.
-File:Micrograph of prostate cancer with Gleason score 10 (5+5) with solid sheets of cells (crop).jpg|'''Solid''': More or less the same cell type throughout, with no spaces between, and no other particular pattern.
+File:Histopathology of woven or storiform pattern.jpg|'''Woven''' or '''storiform''': Elongated cells or nuclei wherein small bundles are aligned in an otherwise haphazard pattern.
+File:Micrograph of prostate cancer with Gleason score 10 (5+5) with solid sheets of cells (crop).jpg|'''Solid''' or "'''sheets'''": More or less the same cell type throughout, with no spaces between, and no other particular pattern.
 File:Papillary urothelial carcinoma with cribriform morphology, very high mag.jpg|'''Cribriform''': Solid with multiple clear spaces.
-File:Whirled or woven pattern in histopathology.jpg|'''Whirled''' or '''woven''' pattern, comparing to a plant whorl and woven fabric. Also termed '''storiform''' (from Latin ''storea'' meaning "woven")
+File:Bovine Bone Sample and 430 times Magnification.jpg|'''Whorled''': Multiple concentric objects, or spiral-shaped
+File:Histopathology of cartwheel pattern in dermatofibrosarcoma protuberans, annotated.jpg|'''Cartwheel pattern''': Center points that radiate cells or connective tissue outward
 </gallery>
@@ Line 88: / Line 98: @@
 File:Histology of deep zone of articular cartilage.jpg|'''Hyaline''' usually refers to extracellular material that stains homogeneously pink on H&E stain (like the matrix of hyaline cartilage, pictured).
 File:Histopathology of hyaline membranes in diffuse alveolar damage.jpg|Example of hyaline material (in alveoli of lungs, indicating diffuse alveolar damage)
+File:Glass for pathologist.png|This is what pathologists also refer to as "glassy" (because hyaline cartilage looks like glass grossly).
 </gallery>
@@ Line 98: / Line 109: @@
 ==Marking slides==
+The main indications for marking slides are hard-to-see findings on a slide, and/or to distinguish one slide out of many. Just make a figure rather than a word if you are not sure what it is, as it might be confusing for reviewers if the pathology report ends up being something different.
 <gallery mode=packed heights=140>
 File:Photograph of marking a microscopy slide.jpg|To mark a microscopy slide, use an objective that gives you enough space underneath. Rest a finger on the stage, while holding the marker pen relatively close to its tip. Move the tip of the marker pen into the field of view but at least a few millimeters from the slide...
-File:Micrograph of marking a microscopy slide.jpg|...Then slowly approach the slide while making sure that the tip remains in the location you want to mark. Be careful not to obscure findings of interest with the mark.
+File:Micrograph of marking a microscopy slide.jpg|...Then slowly approach the slide while making sure that the tip remains in the location you want to mark. Be careful not to obscure findings of interest with the mark. If the slide is likely to undergo whole slide imaging, make the mark on the back and not on the coverslip (as it reduces the risk of erroneous focusing of the cameras).
-File:Removing marks from a microscopy slide.jpg|You can generally remove marks from a microscopy slide by using alcohol. Don't press hard against the glass, as it may disrupt the tissue.
+File:Wiping a slide.png|You can generally remove marks from a microscopy slide by using alcohol. Hold the cover slip in place with two fingers while wiping from side to side, to avoid the risk of moving the coverslip. Don't press hard against the glass, as it may disrupt the tissue.
 </gallery>
@@ Line 221: / Line 233: @@
 *Background, mainly if it is clear or dirty
 *Overall cellularity
-{{further|Cytology}}
+{{further|Cytology}}</noinclude>
+==Consideration==
+Consider the '''adequacy''' of the specimen. Have a somewhat lower threshold to make a report of "inadequate" or "insufficient" if it is easy to resample from the patient, such as remaining diagnostic tissue at a superficial location.
+First, generally suspect the '''common conditions''' for the location at hand. A less common variant of a common condition is often still more likely than a rare condition, so generally call the latter only if it really fits the picture.
+Whenever you consider a certain diagnosis, also consider whether it is one step '''better or worse'''. For example, when you consider a non-invasive but high-grade dysplasia, also consider both low-grade dysplasia and invasiveness.
+</noinclude>
 {{General notes}}
 {{Bottom}}
 </noinclude>

Evaluation: Difference between revisions

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