A Dispatch From Behind the Microscope

Hi-


I am not hunched over a murder victim at the moment, the glare from the overhead lamp revealing some important clue about the perpetrator. Yes, I am a pathologist; no, that is not how my day goes. I suppose that solving murders all day would be cool, but I also like what I do here at the hospital. I thought that I’d share my day with you so far:

8:00 a.m. Arrive at work. Talk with my associate about what’s been going on in his absence; the interesting cases, and a little hospital gossip.

8:30 a.m. An oncologist (cancer doctor) calls, and is interested in knowing about one of his patients, a person who has a colon cancer that has recurred after treatment. The surgeons just took out a portion of the colon with the new tumor; the oncologist wants to know if the tumor has spread to the lymph nodes and the tissue around the colon. I tell him that I will call him back once the pathology slides are ready for me to read, so that I can look under the microscope at the lymph nodes and the tissue and give him that answer. He’ll have to decide what to do next: whether he’ll give chemotherapy and, if so, what kind and how much.

8:40 a.m. A fax comes through with a report on special studies done on a woman’s breast cancer. The test helps determine what type of treatment the woman is going to receive, and also can help tell how aggressive the tumor will behave. I dictate a report to send to the doctors, and give them this additional information

9:00 a.m. Time to get ready to present cases at Tumor Board. I have taken pictures through the microscope of some interesting cancers; I put these pictures and additional information into a Power Point presentation for the noon conference. I also head to the textbooks to find out some additional information about the cancers that I am going to present at the conference; I like to teach the audience some stuff, occasionally.

9:45 a.m. I get to look at the first microscope slides for the day. The first case is one that we are especially interested: a gentleman with a large mass in the middle of his chest. He’s having a lot of trouble breathing, so it’s very important that we find out what’s wrong with him so that we can treat him appropriately. The surgeon removed one of his lymph nodes for us to look at. He definitely has some kind of cancer, and, from looking at the slides, it looks like he may have a very aggressive lung cancer. We are waiting for a couple more outside studies to be done to be sure, but we are pretty sure that we can tell the doctors what it is for sure today.

10:00 a.m. Making up clues for a scavenger hunt here in the lab. It’s a fun way to take a break.

10:30 a.m. A surgeon sends some tissue samples from the operating room. He needs a frozen section, which is a special procedure where we freeze the tissue, cut it, stain it, and put it on a microscope slide quickly so we can put the slide under the microscope and give him a diagnosis. This sample is a lymph node from under the arm of a woman with breast cancer. He needs to know if the tumor has spread to the lymph node; if it has, he will need to take out all of the lymph nodes in her axilla, both to find out how far the cancer has spread, and to take out as much tumor as possible. If the tumor hasn’t spread to the lymph node, he won’t have to take out all of the nodes (do an axillary dissection); this is a very good thing, because oftentimes women who have an axillary dissection have problems with swelling in the same arm after the surgery, which is very uncomfortable (lymphedema).

11:00 a.m. It’s time to look at more slides (tissue samples) under the microscope. Essentially, the pathologist is supposed to look at every piece of tissue that’s removed from a person when they have surgery. For the most part, that’s true. So I look at skin biopsies, and make sure that skin cancers have been completely removed; I look at gallbladders that were taken out because they had gallstones and caused a lot of pain in the patient; I look at pieces of fallopian tubes from women who had their tubes tied (it’s important to make sure that the doctor cut all the way through the tube, so that the woman can’t get pregnant again, which is exactly what she wants). I look at the slides, then dictate a pathology report that I will sign later.

12:00 p.m. It’s time for Tumor Board. Technically Tumor Board is called a “Multidisciplinary Cancer Conference.” In English, the primary care physicians, surgeons, radiologists, oncologists and pathologists all get together to discuss their patients with cancer. We hear their histories, look at their x-rays, and I show the pictures of their tumors, that I took from the microscope. Then all of the doctors put their heads together and decide what the best treatment for the patient is (this is all confidential, by the way; we don’t use the patient’s names). Things can get a little heated in there, by the way, when all of the doctors don’t agree on the best course of treatment.

1:00 p.m. Tumor Board is over. Whew! I’m a little nervous about public speaking, so I am always happy when I am finished. I take a break and eat pizza with the lab employees. It’s National Medical Laboratory Professional Week, so we’re celebrating and having a party. Since pathologists are lab professionals, too, I get to party too!

1:15 p.m. And on we go. We talk to a few more doctors about their patient’s pathology reports; I call a doctor for more information on his patient, which will help me make a diagnosis on his biopsy; we talk to a surgeon, whose patient is in the examination room, waiting to hear if her breast tumor is benign or malignant (it’s most likely malignant, but we have to do some additional studies to confirm that; it’s not always a matter of looking at a slide and diagnosing a cancer— oftentimes, there are a lot of grey areas between benign and malignant, and even after all of the tests, you may not be able to tell—but, of course, try to tell that to a malpractice lawyer).

2:15 p.m. And our report is back on the very sick guy with the respiratory problems: it is indeed a very aggressive lung tumor. Fortunately, chemotherapy and radiation can shrink the tumor quickly, so he may be feeling better soon. Unfortunately, the long term prognosis is not so good.

2:30 p.m. My fourth Diet Coke of the day.

2:35 p.m. Looking at a particularly hideous tumor under the microscope: a malignant blood vessel tumor. The surgeon couldn’t get the whole thing out. He took a large piece of skin and fat, but there is still tumor at the edge. It looks like he may have to go back and get more; luckily, he was very careful to mark the skin, so I can tell him exactly where he has to go back and take more tissue. Surgeons rock.

2:55 p.m. I am signing reports now, on the computer. We used to have to manually sign the typed reports, not so long ago, but now that we have electronic medical records it’s a lot better. These reports will all go onto the patients’ medical charts, and copies will be sent to their doctors.

3:00 p.m. A little down time. It’s not my turn to gross today: that’s when you look at all of the tissue that comes out of the operating room, with your eyeballs, not your microscope. You can tell a lot just by looking with your eyes, and feeling the tissue. Breast cancer will look like a crab and feels very hard when you touch it, for example. After we look, and touch, and measure, and describe the tissue in a report, we take little pieces of it that our techs will make into slides that we will look at the next day. I will take a little piece of the hard area that feels like a breast cancer; I will take a little piece of tissue from the edge of the specimen to make sure that the tumor has all been taken out. Not everything that we examine is cancer; we look at tonsils from little kids, and appendixes; we look at tissue when a woman has a miscarriage, and try to find out why her pregnancy failed.

3:30 p.m. The slides from the colon cancer are here, the one the oncologist and I discussed this morning. Her tumor has gone through the whole colon; the cancer has spread to most of the lymph nodes around the tumor. The oncologist has to figure out what to do now.

4:00 p.m. Things start winding down for the day, in my office, anyways. I finish signing my reports, check my email, check my snail mail, check my inbox, and check my list of pending cases, to see what I’m going to need to do tomorrow.

5:00 p.m. Outta here. I wear a pager, and carry the phone at all times in case a doctor has a question, or a surgeon needs us in the OR, or there is an autopsy that may need to be done. So it’s never really done here- I am still pretty much tethered to the hospital. We take turns taking call, though, so each of us can have a break, or go out of town- as per our contract, we have to be within 20 minutes of the hospital if we are needed.

I will post, eventually, on the thing that makes us pathologists notorious: The Autopsy. I think it’s not quite what most people envision, and maybe I can dispel some myths.

Terrible Beauty

We call these "signet ring" cells, because they look like rings viewed from the side.  Pretty description, pretty cells-  bad, bad cancer.

And it’s back to the Chinese Buffet for more Fortune Cookie fodder. Fortune cookies, I am learning, are a great source of inspiration for blog posts, when life seems too mundane to discuss, and when the brain seems to be lacking in wisdom to dispense.

Today's fortune:

“Everything has beauty, but not everyone sees it.”

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During the course of my workday, I frequently pop into my colleague’s office with a glass microscope slide in my hand.

“Look at this. It’s beautiful,” I’ll say.

It is invariably a cancer of some sort.

Cancer cells are basically cells that are growing on their own, who refuse to listen to the body’s signals and that invade into the normal tissue that surrounds them, get into the bloodstream like seeds carried by the wind, to land somewhere far away and grow more cancer. Mean, nasty cells.

Cancer shouldn’t be beautiful under the microscope. It should be ugly, and hurt your eyes to look at. It should be a great big blob of gray mush. But it’s not.

Under the microscope, cancer is pink and purple, because those are the colors that we use by convention to stain the cells so we can see them. Pink for the outside of the cell, the cytoplasm, and purple for the core, the nucleus. Pretty pastel colors, like Easter eggs.

Normal cells, cells that aren’t cancer cells, look like each other. They are orderly, and respect their neighbors’ space. Cancer cells, however, can be arranged in a marvelous array of patterns: swirls, whorls, bundles. They can march all over the microscope slide in straight little lines, and encircle nerves and blood vessels. They can make stars, bursting out into the tissue (cancer, of course, means “crab”- these crablike projections, these starbursts, are very characteristic of many cancers). The cells themselves can assume all kinds of fantastical shapes and sizes.


Pathologists, the ones that I know, acknowledge the fact that the things we find most attractive under the microscope are often the most deadly. The mass of long, spindly cells that have arranged themselves almost like the sky in Van Gogh’s “Starry Night” is a sarcoma, a tumor of muscle, nerve or fat, a tumor that has grown deep inside the patient’s tissue, sometimes reaching massive sizes before they’re found— discovered too late to stop the tumor cells from traveling into the lungs, or the brain.

I think that we pathologists also ask “why?” Why does “Starry Night” have to be such a horrible disease?

“Why” made me a pathologist. I wanted to know, needed to know why a person was damaged…why their lungs couldn’t take in air….why their heart ultimately stopped. I wanted to be able to trace it down to those cells down there, to the ones with the messed-up DNA. There. That’s why.

But some of the “Whys” still evade me. Why pretty cells make ugly diseases. Why wonderful people get ugly diseases.

Why don’t I know? Why can’t I know?

I must accept that all of my “why”s will not be answered.

I believe that it’s not meant for me to know.


Where were you when I laid the earth's foundation? Tell me, if you understand. Who marked off its dimensions? Surely you know! Who stretched a measuring line across it? On what were its footings set, or who laid its cornerstone- while the morning stars sang together and all the angels shouted for joy? (Job 38: 4-7 (NIV))