Working Through Images

The Language of Cells: A Doctor and His Patients
by Spencer Nadler, M.D.

As a surgical pathologist for more than twenty-five years, Spencer Nadler was not content with the distance between his lab and the patient. Meeting with those whose diseased cells he has diagnosed, he offers them a rare understanding.

Hanna Baylan is a woman as determined as he is to confront the cancer cells biopsied from her breast. Comille, a young boy with Sickle Cell anemia, has frequent racking pain, but doesn't let it interfere with his gusto for life. And 91-year old-conductor Mehli Mehta inspires comparison between the cellular rhythms that threaten his heart and those that govern his work.

In these intimate, lyrical portraits of people and their cells, Nadler brings a unique clarity and compassion to medicine.

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 glass window. With gloved hands I unveil a round fatty mass, its yellow surface smeared with fresh blood. It has the look and consistency of a ripe nectarine. I bisect it with a knife and see a mass the size of a pit at the center, white and gritty as sandstone. Its retracted, deep-rooted look and rock-hard feel imply carcinoma.

The axillary lymph nodes arrive buried in fat. There are twenty-two in all-soft, oval, encapsulated like beans. Two of the beans are hard and white, gritty when cut. The cancer has exceeded its breast of origin. I pass on this information to the surgeon.

At 6:30 the following morning I remove the plastic cover from my microscope and continue my examination. I stare at the sprawl of Hanna Baylan's tumor. The foreboding bulkiness of the cancer cells, the scowl of their thickset nuclear faces looms through the lenses. They are gathered into inane configurations that crudely mimic breast ducts. Although this cancer splays out garishly into adjacent breast tissue, the biopsy margins are free of malignant cells: the local cancer has likely been entirely removed. Eleven of twenty-two axillary lymph nodes bear cancer cells, however, and the probability of spread to other organs is high. I classify this tumor as an infiltrating, moderately differentiated carcinoma arising from breast ducts.

I have completed my evaluation of Hanna Baylan. I await two more breast biopsies, a lung biopsy, and three skin biopsies. All are suspected of being malignant. By tomorrow Hanna Baylan will become a memory for me, a name on yesterday's surgery schedule with tumor cells attached.

By confining myself to cells, I stay clear of the fiery trials of illness. I remain detached; I can render my diagnoses with a cool eye. My fascination with the microscopic form, color, and disposition of cells drives me like a critic to interpret, to applaud or decry them for others. Paradoxically, observing so much of life through a microscope all these years has left me feeling, lately, that I've sampled too little, that I've missed the very warp and woof of it.

"Dr. Nadler?"

A young woman is standing at my office door.

"Sorry if I'm disturbing you, but no one was at the reception desk so I walked right in," she says. "I wonder if I can see the slides from my breast tumor?"

"Now?" It's six o'clock, the end of a long day.

She enters and sits in the chair by my desk. "You don't remember me, do you, Doctor?" she says. "I was at the lecture you gave at the Wellness Community last month."

Her cropped blond hair has a uniform thinness that suggests chemotherapy; her face is gaunt and pale. Still, she seems valiant somehow, undaunted, her self-esteem intact. During the lecture I had used a projecting microscope to show on-screen what the cells and patterns of different tumors look like.

"I'm Hanna Baylan. You diagnosed my cancer forty-three days ago."

I don't recall seeing her at the lecture, but I do remember, in vivid detail, the nectarine lineaments of her lumpectomy tissue. I'm like the surgeon who selectively focuses on the organs he's rectified or removed. My work lies apart from Hanna's face, among the tiniest kernels of bodily things; my work lies in her cells.

"It's pretty late," I tell her.

"Yes, it is," she says. "Maybe it's already spread to my bones."

This is not what I meant. "Why don't I see what I can do." I wish she had called ahead, given me a chance to review her slides.

Copyright © 2001 by Spencer Nadler. Excerpted by permission of Vintage, a division of Random House, Inc. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

About the Author

Spencer Nadler, M.D., has practiced surgical pathology for more than twenty-five years in Southern California. His essays have appeared in Harper's, The Massachusetts Review, Cross Currents, The Missouri Review, The American Scholar, and Reader's Digest. The Language of Cells is his first book.