A day in the life of a gynaecological cellular pathologist

This Cervical Cancer Prevention Week, Gynaecological Cellular Pathologist, Dr Jackie McDermott, tells us about her average day at work and explains why a pathologist is such a crucial cog in the wheel of cervical screening.

Cellular pathologists are doctors who specialise in making diagnoses from tissue that is sent to them, mainly, by surgeons. There are many people involved in the processing of the tissue so that a slide can be prepared and we can examine it under the microscope. I specialise in gynaecological specimens. These range from cervical and endometrial (womb) biopsies that may be only a couple of mm in size to large whole organs removed by surgeons for cancer treatment.

Our job is to tell clinicians and surgeons if there is disease, what type of disease and /or where the disease has spread to. This information is essential for providing patients with the most appropriate treatment plan.

Cellular pathologists play an important role in the NHS cervical screening programme. When a woman has a cervical screening test and is found to have high-risk HPV and abnormal cells, she will be invited to a colposcopy appointment. Colposcopy takes place in a clinic in the hospital and is run by colposcopy nurses and gynaecology doctors. Here, the cervix will be carefully examined using a speculum and a magnifying instrument. The cervix will be painted with a substance that helps the colposcopist identify any abnormal areas. These areas can then be biopsied and those small pieces of tissue sent to the cellular pathology department in the hospital. The biomedical scientists within the cell path lab will process the biopsies and provide slides for the cellular pathologist. They use automated processes to fix the tissue, then embed it in wax so it can be very finely sliced. These slices are placed on glass slides and then a further automated process occurs whereby the tissue is dyed so that the cell details can be visualised under the microscope.

I am a NHS Consultant cellular pathologist at Imperial College Healthcare Trust. I am part of a large department that deal with around 70,000 specimens each year. It is an exciting and stimulating job and each day can be quite different. Here is what a typical day might look like for me:

  • I arrive at work on my bicycle (Charing Cross Hospital) at about 8.30am, make a cup of tea and deal with emails.
  • I will then go to the lab to pick up the cases to report for the day. If I am on lab supervision, I will check in with the junior doctors who are preparing the larger surgical specimens and supervise them to do this.
  • Back in my office, I sort out my cases for the day and arrange a time with my junior doctors who are training with me to come and report together.
  • I will spend the morning looking at my cases under the microscope and then writing a report for each one on our pathology software which is then uploaded onto the hospital software so that the results can be accessed by the nurses and clinicians.
  • I usually have quite a few cervical biopsies to examine during the course of my morning. These can be either very small biopsies or they can be larger specimens called loop biopsies or LLETZ biopsies. A LLETZ stands for laser loop excision of the transformation zone. The laser loop is used by the colposcopist to remove a larger area of the cervix including the transformation zone (this is the area where HPV infection occurs and abnormal cells can be found). A LLETZ is performed if an initial small biopsy shows an abnormality or sometimes it is done directly after an abnormal cervical screening, in the colposcopy clinic.

When we report cervical biopsies we must include specific items; is the transformation zone included? is there an HPV effect? is there dysplasia? is there cancer? We may also comment on inflammation or any other abnormalities we see. The purpose of the cervical screening programme is to detect dysplasia- a pre-malignant change in a cell. If left in the body, there is a small risk that it may develop into cancer. In the cervix, dysplasia is known as cervical intraepithelial neoplasia (CIN) or cervical glandular intraepithelial neoplasia (CGIN). When we report LLETZ specimens we must also comment on whether the edges or margins of the tissue are free from CIN or CGIN. If the margins are not clear, a further LLETZ may be required.

Sometimes it is not easy to see if there is CIN under the microscope and we need to do a further stain called p16 which helps us to detect HPV-infected cells. Sometimes we need to look further into the block of tissue and need to request deeper levels. If our tissue diagnosis does not match the cytology result of the cervical screening test, or we find cancer or CGIN, the case is discussed at the colposcopy multidisciplinary team meeting. At this meeting, the colposcopists, cytologist (who examine the cervical screening test) and the pathologist discuss each individual case and decide on appropriate management.

  • During the course of my morning I may be asked for an opinion on a tricky case from a colleague. It is important that we ask each other about difficult cases to ensure that the best diagnosis is made.
  • At lunchtime, I may lead a teaching session for our junior doctors and show them some interesting or challenging cases to help with their training. Training junior doctors is an important part of my job as a consultant in a teaching hospital. However, some lunchtimes I go for a relaxing swim in the Charing Cross sports centre!
  • In the afternoon there may be queries from the lab that need my attention or I will work with trainee pathologists to report the cases that they have looked at, give them advice and help.
  • I may also prepare for a multidisciplinary team meeting (MDT) or present at one. MDT meetings can take a whole morning or afternoon or just one or two hours. At the gynaecological cancer MDT the surgeons, oncologists, clinical nurse specialists, radiologists and pathologists discuss each patient with a new cancer diagnosis and devise the most appropriate treatment plan to discuss with her.

This is a typical day for me. I am also an honorary senior lecturer at Imperial College so some days I will do some of my own research (vulval cancer prevention) or do some pathology research for a collaborative researcher. I may also attend a meeting or conference for my own professional development, or I may meet with trainee pathologists to work on audits to improve our clinical service.

As you can see, each day can be quite varied! This variety, along with the challenges and the knowledge that I play a small part in helping patients, is why I love my job. I feel privileged to be an NHS cellular pathologist working alongside excellent colleagues committed to the NHS.