The Language of Cells: A Doctor and His Patients
By Spencer Nadler, M.D.
How very different was the clinical behavior of George Gershwin's glioblastoma: In February 1937, while playing his Concerto in F at Philharmonic Auditorium in Los Angeles, he suffered a momentary loss of consciousness. He missed a few bars, then continued as if nothing had happened. He later spoke of smelling burnt rubber. When physical examinations found nothing wrong, the incident was attributed to fatigue, the stress of his enormous success. In April of that year, in a barbershop chair, his momentary loss of consciousness and subsequent smelling of burnt rubber recurred. By June, he was suffering agonizing headaches and had become periodically listless, irritable, and confused; there were lapses of coordination; the smell of burnt rubber now haunted him. In this era that preceded neural imaging, his neurologist found no evidence of an organic lesion, and his signs and symptoms were attributed to hysteria. The glioblastoma had avoided clinical detection, living symbiotically with its host brain. It had probably been growing in this furtive way long before Gershwin's first loss of consciousness.
On July 9, 1937, Gershwin had a seizure and fell into a coma. Subsequent surgery disclosed a large cystic mass in the right temporal lobe; it involved too many vital brain structures to be removed. A biopsy revealed glioblastoma. He died several hours after surgery without ever regaining consciousness.
Despite the perilous ingress of his tumor, Gershwin composed two of his most beautiful songs, "Love Walked In" and "Love Is Here to Stay," in the last few months of his life. The processing of music is not as lateralized in adult males as is speech. Notwithstanding the volatile simmerings of Gershwin's right-sided tumor, his left brain could have assumed, over time, essential functions of his musical genius, allowing for his terminal inventiveness.
I see Gershwin, his neurons moving like piano keys, playing his concerto; his tumor cells press atop the neurons like so many thumbs, until the music stops.
B.R. is a forty-five-year-old Caucasian woman who presents with a four-month history of headaches. A brain scan reveals a well-circumscribed mass lying beneath the skull and compressing her right frontal lobe. The neurosurgeon is able to scoop out this discrete bulk from the brain tissue it compresses. I receive it in three gray-pink, rubbery fragments that fit together as an oval mass about the size of an egg. I note the gentle protuberances of its surface, the lobulations of its cut edge. These are the overt features of meningioma-a benign tumor arising from the fibrous vestments of the brain. The microscope reveals a whorled growth pattern of meningeal cells that are as furled as a spiral galaxy. The nuclei are agreeably uniform, oval and blue, and the cytoplasm is faded pink, poorly defined. Many of these nuclei are so crammed with their own cytoplasm that they seem eclipsed by it. An occasional amethyst calcification, concentrically laminated-a psanimoma body-is visible, and clusters of xanthoma cells stuffed with lipid are scattered about.
Each tumor has its own life story-the nature of its cells, the imposition of its growth on surrounding body tissues, the threat it poses as an illness. This type of meningioma has a slow centrifugal growth that usually yields a globular or oval tumor. Reluctant to invade the brain, it displaces it. When favorably situated, it can grow insidiously beneath the skull to the size of a large lemon before producing symptoms. It is usually cured by surgical removal.
B.R. can expect a happy ending.
The benign swirls of this meningioma energize me. Although I am rarely part of a patients emotional experience, I am not completely extricated from it either. The sight of malignant cellular disarray burdens me with all that it forebodes, gnaws at my own mortality. The vision of a benign tumors orderly cell growth absolves me, makes me feel as if I myself have been granted a reprieve.
The brain can deceive those who would know it. I remember a thirteen-year-old boy who presented with seizures. Scans revealed a space-occupying lesion in his brain that suggested a malignant neoplasm. A needle biopsy was done under radiologic guidance. I distinctly remember the tissue I received; it was as white and friable as feta cheese.
Under the microscope, a spread of tubercle bacilli, the organisms that cause tuberculosis, appeared as minuscule blood-red leeches. Body cells in their wake, as if sucked dry of lifeblood, had disintegrated into amorphous fields of debris that stretched to the ends of the cellscape. Against a brilliant green background stain, these organisms resembled red tinsel heralding a high-colored microscopic Christmas.
In reality, the causative bacilli of tuberculosis act more like passive bystanders than active bloodsuckers in the wasted tissue of disease. With infection, the body's complex defense mechanisms slowly kick in to destroy these bacilli and the human tissues harboring them. In an effort to kill off tubercle bacilli, the human body is perfectly capable of destroying itself; it has done so for centuries.