Language of Cells: Life as Seen under the Microscope

CHAPTER ONE Working Through Images My work, as an interpreter of human-tissue biopsies, is largely an art. I carefully observe changes of color, delicately feel for variations in texture, and, with my microscope, peer in on the cells to study their form and tableau. The impact of disease can be very subtle. The need for my diagnoses to be free of error can provoke unwanted stress. Often the image of a challenging biopsy stays with me for hours, even days. These cells, floating freely in my mind like anxiety, play their tricks, show me their elusive faces, their phantom patterns. They seem to conspire to confuse me. Through the years I've developed tricks of my own-serial sections, step cuts, a host of special tissue stains-designed to counter their deception. When nuclei are marred by craggy clumps of chromatin, and cell patterns appear baroque or abstract, I cull from memory similar compositions and interpretations. After many years at my microscope, the number of different cells and patterns that I recognize, the blueprints of disease, seems infinite. I rely on this experience. And although the majority of biopsies are no longer diagnostic challenges for me, interpretation can, on occasion, be tortuous-but never so formidable as living with the disease itself. My surgical pathology office is within the hospital histology lab, appended to the surgery suites. A sliding glass window separates me from ten operating rooms. It is twenty-five steps from my desk to that window. A biopsy, if it is to be interpreted during surgery, is processed within minutes of its arrival. I am mindful that the patient is under anesthetic and that time is of the essence. When I arrive each morning, I scan the operating-room schedule for surgeries with biopsies that will require rapid, frozen-section interpretation. Then I have my coffee in the surgery lounge and listen to the surgeons' stories. A surgeon's demeanor-anxious, diffident, vague-might stir me to anticipate problems, to consult the patient's X rays and chart prior to receiving the biopsy. I am most comfortable with surgeons whose judgment I feel is beyond reproach; they tend to be meticulous, obsessive. An accomplished surgeon I have practiced with for years tells me about a thirty-five-year-old patient I'll call Hanna Baylan. She has a palpable mass in her left breast; on the mammogram it looked suspicious for malignancy, and the core needle biopsies of it I interpreted a week ago showed infiltrating carcinoma that originated in her breast ducts. This morning she is having a lumpectomy to remove the cancer-containing portion of her left breast as well as a lymph node resection in her left axilla. These nodes are markers for tumor spread beyond the breast. She is worried, the surgeon tells me, that she will not live to see her three small boys grow up. preoccupied with cancer cells, I have no social or psychological sense of a cancer patient. I retrieve Hanna Baylan's core biopsy slides from the file and review them in my office. I fix on elements of function, not form: milk-producing lobules, milk-transporting ducts, nipples, fat, connective tissue. I fix on cancer. After her surgery, my responsibility will be to classify the cancer, grade its aggressiveness, and determine the extent of its local spread. I will glean the facts that are pertinent to any use of radiation or chemotherapy to help her physicians mount their therapeutic blows. "Biopsy, room two," the operating-room nurse shouts. I walk through the histology lab, which smells of formaldehyde. The counters are crowded with vats of tissue-processing chemicals-alcohol, formalin, xylene, paraffin-and glass vessels of vivid red and blue tissue stains. A cryostat-the frozen-section machine standing in the corner-hums like a fluorescent lamp. Hanna Baylan's lumpectomy tissue, swathed in gauze and labeled, sits on the counter beneath the sliding glasNadler, Spencer is the author of 'Language of Cells: Life as Seen under the Microscope' with ISBN 9780375504167 and ISBN 0375504168.