Dr. Dimitris Hatzibougias
When you first meet an oncologist, you may notice that their attention is, by necessity, divided. It may seem rude for someone to be preoccupied with other matters during a consultation—almost as improper as flirting with two identical twins at the same time. Yet we ask you to forgive any offence, because on each occasion we have only an extremely limited amount of time to gather information about the two distinct, dual and often opposing subjects that concern us: you and your Other Half.
We learn about you—the involuntary host—through an investigative approach, both verbal and physical. Your “visitor,” however, is studied through a different kind of investigation. We measure its dimensions through scans and search your blood for traces of its presence. Above all, however, we examine the foreign tissue itself under the microscope. This tissue is collected through a biopsy, during which one of our appropriately trained colleagues—a surgeon or an interventional radiologist—guides a needle, selected from a range of different gauges, into the mass to obtain a sample, which is then sent to the histopathology laboratory. This entire process requires precision and care, because every decision that follows rests upon this exact step—rather like planning a five-course meal while relying on the successful preparation of one particular garnish.
Call us dreadful, but we rarely make a diagnosis without first inserting a needle somewhere into your body. There is an almost nauseatingly light-hearted saying: “If tumor is the rumor, then tissue is the issue.”
Admittedly, we detest its sing-song quality, yet we cannot deny the truth behind it: we are obliged to zoom in and examine the cancer under high magnification before zooming back out to see the broader picture. The oncologist is “blind” without the pathologist, but with the pathologist’s guidance can identify where the problem lies and, perhaps, where its solution may be found.
There is a multitude of myths surrounding the belief that biopsies can “irritate” a cancer, as though it were a wasp’s nest being prodded with a stick. It is true that care must be taken not to create, through the biopsy, a “track” by which a deeply situated cancer might gain access to the surface. However, the exaggerated fear of exposing cancer to the air is merely a remnant of an era when a full exploratory surgical procedure was required to determine the extent of the disease.
In the era before computed tomography, the precise extent of a cancer usually remained unknown until a laparotomy was performed. During the operation, the surgeon might see with their own eyes that the internal surfaces of the abdominal cavity—the peritoneal membrane and the fatty tissue covering the omentum—were covered with countless cancerous deposits. It was like switching on a light and revealing vermin that had flourished and multiplied in the darkness until becoming an unbearable infestation. Having discovered such irreversible and inoperable spread of the disease, the surgeon would withdraw, close the patient’s incision and inform the family that “the cancer has spread.”
These revelations—bad news delivered by masked physicians following disappointingly brief operations—gave rise to the mistaken belief that exposure to air was what caused the disease to spread, like oxygen feeding a fire.
Very few patients, if any, ever meet the doctor who made their diagnosis. Pathologists generally carry out their critical work bent over microscopes in laboratories into which the patient enters only in the form of a… specimen. These specimens—fragments of tissue collected by biopsy—are labelled with numbers even more impersonal than a medical record number: tissues rendered anonymous twice over since their collection.
The science of pathology is a truly abstract and dispassionate discipline, in which the patient’s problem is distilled onto a glass slide and examined through precision lenses. Yet this is not a case of seeing the tree while missing the forest. It is more like diagnosing an olive fruit fly infestation from the foliage without ever having set foot in the olive grove.
The tissue to be examined is cut into slices so thin that even the most skilful gourmet chef would be envious. Before the microtome can perform its task and produce these exceptionally thin sections, however, the specimen is fixed, embedded in paraffin and formed into blocks. When the tissue is cancerous, the cells resemble angry mosquitoes trapped in amber—a swarm that one might imagine is still buzzing with murderous intent, even though its wings have been frozen in mid-flight. This exquisite “cold cut” is then ready to be examined by a physician who has devoted an entire career to the microscopic world: the pathologist.
We did not always know that we are made of stardust. Nor did we always know that we are composed of cells. Over time, various patterns became familiar enough for us to begin classifying them, and scientists gradually became able to distinguish the body’s normal patterns from cancer’s works of modern art with the same ease that art critics distinguish Impressionism from Cubism. One must know the rule in order to recognise its violation, although cancer resembles Pollock’s random splashes more closely than Picasso’s structured mosaics.
Cells generally do not become defective all at once; they usually change gradually. As with most serial killers, there are generally warning signs before the massacre. Hyperplasia becomes dysplasia and then neoplasia: first the cells multiply, then they become distorted, resembling an earthquake that spreads outwards from its epicentre and leaves destruction in its wake. Surveying this mitotic devastation, the pathologist observes the damage that has been done. Compared with the beauty of a perfectly structured organ, a malignant mass is as ugly as sin and inspires an almost sensuous fascination.
After scanning whole pages of uniform order, the sudden appearance of disorder exerts a peculiar attraction. Like Charles Darwin, the pathologist derives the detached satisfaction of one who brings order to chaos—who classifies pandemonium itself.
The description of countless nucleoli evokes the image of a many-eyed monster staring threateningly through the glass slide. Mitotic figures are counted in order to determine the rate at which the DNA of a particular cancer is unwinding from its double-helical form so that it may be replicated. In the fastest form of cancer-cell reproduction, this unwinding resembles a dancing dervish—a deadly whirl.
Sometimes, the appearance of a cancer under the microscope is so startling that the pathologist cannot wait for the clinician to be informed through the written report—the histopathology report.
Every oncologist anticipates such an urgent telephone call from a colleague in the laboratory, informing them of the presence of a new and formidable opponent—for example, the early flakes shed in the lungs of a three-pack-a-day smoker that are now developing into small-cell lung cancer. Such calls, however, are rare. More often, the diagnosis of cancer arrives in the form of cold text, stripped of all emotion by the written word: invasive carcinoma.
The pathologist’s work is characterized by painstaking attention to detail, through the handling of the smallest possible tissue specimens and with absolute respect for the material under examination.