The Language of Cells: A Doctor and His Patients Paperback - 2010

First line

The axillary lymph nodes arrive buried in fat.

From the jacket flap

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.

Excerpt

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 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.

I retrieve all her breast and lymph-node slides from the file and move her chair opposite mine. With effort, pain maybe, she leans across the desk to peer through the alternate set of eyepieces on my two-headed microscope. Resting her elbows on the desktop, she looks in on the events of her body-cells long dead, now fixed and colored-that have given rise to her illness.

She listens quietly as I move the pointer across the microscopic landscape. "These clustered islands of glands are the lobules," I tell her. "Milk is produced here in the lactating breast."

"They look more like pink hydrangeas to me," she says, "a sprawling garden of them." She talks excitedly, asserting interpretive authority over her own cells. I can only imagine the variety of forms a cellular array such as this might suggest to an uninitiated eye.

"And these?" she asks. "What are they?"

"Ducts," I say. "They transport lobular milk outward to the nipple."

"My God. Look at them," she says. "Ponds, lakes, rivers, estuaries that carry milk. It all looks so peaceful." With her legs braced in the chair, she hoists her torso onto my desk and hunches over the microscope to get a better view.

There is little need for pedagogy; she is finding her own truths with metaphor. I switch from the four-power objective, the scanner (a magnification of forty), to the forty-power objective (a magnification of four hundred), and individual cells take prominence over cell patterns.

She clasps her hands together. "It's as if all the planets in the universe have come together here."

"See the uniform cells lining the lobules and ducts?" I point out the blue nuclei, the pink cytoplasm, the discrete nuclear membranes.

I switch back to the scanner and we pass over fields of ducts and lobules. I suspect it is a whimsical leitmotif she sees, hydrangeas, ponds, rivers suspended idly in fat and fiber, floating serenely.

I wait a few minutes, allowing her to absorb the beauty of her own cells. Sitting perfectly still, crooked like a pliant ballerina, she inspects her cellular self.

Reluctantly, I replace the slide of her normal breast tissue with one of the cancer.

"Whoa," Hanna says.

She stares into the microscope, transfixed by the disarray of her malignant growth, a raw view of her life spread out before her. "These cells look like distorted hula hoops," she says. "It's all damaged, isn't it? Just like my real world."

"This is your real world, too," I say.

She looks at me over the top of the microscope. "People don't shun me because my tumor ducts look like reckless hula hoops."

Like Charon ferrying between the living and the dead, she glides back and forth between her threatened life and her dead, stained biopsy cells. She quickly grasps the cause and effect-critical cell changes are twisting her life. For years I have processed thousands of such cases, determined the manifold forms of disease, but I've never been an intimate part of anyone's illness, never felt the connection of cells to a larger self.

"Losing my hair terrifies me," she says. She fingers it, pulls at it gently. Not a single strand comes out, and she is reassured. "I've got a wig, but I hate it. So I wear baseball caps and tie scarves through my hair. I'm lucky. I look good in scarves. Still, I feel hideous. People think it's just vanity. It's much more than that," she says. "Every time I see my scalp poking through, I'm reminded. I feel how different I am. How lonely."

"You'll have your hair back in a few months," I say.

Tears well in her eyes. "That'll help a whole hell of a lot."

In The Notebooks of Malte Laurids Brigge, Rilke writes, "If I am changing, then . . . I am no longer the person I was, and if I'm something else, then . . . I have no acquaintances." I believe that Hanna's perception of her disease-tainted self is one source of her loneliness; she will have to be her first new acquaintance before others can come along. And it pains me that all I can offer her is my familiarity with her cancer cells.

"What chemotherapy does to me is unbelievable," she continues. "After a treatment I wake up around midnight with a funny taste in my mouth, and then boom, an incredible indigestion-like a volcano-with nausea and vomiting that rips my insides out. It's excruciating. Every bone in my body aches. Things stop for a while, then it starts all over again. Off and on for the rest of the night."

She is on Cytoxan and Adriamycin, she tells me. These drugs act during mitosis to prevent cell reproduction, destroying the rapidly growing cancer cells, hair cells, bone marrow cells, and cells lining the gastrointestinal tract. Hence the tumor destruction, hair loss, reduction of blood cells, nausea, and vomiting. It's a savage exposure, a supervised chemical warfare.

"I was alone in bed one night last week," she says, looking up from the microscope. "My husband was out of town, my kids were asleep, it was after midnight. I lay there staring at the ceiling, scared out of my wits, shaking uncontrollably. Suddenly a warm white light beamed through the window and rested on my chest. It was a miracle, the way it soothed me to sleep." She slides back into her seat. "I realized when I woke up that God was looking out for me."

I am moved by the way Hanna aligns herself with all her positive expectations.

six years go by before Hanna Baylan reenters my life. I have not asked after her, nor have I received word of her struggle. I have retained the professional cool, the isolation that has been so much a part of my life.

Once again Hanna appears at the end of a long day. She walks slowly and sits down with some difficulty in the chair by my desk. She's frailer now, and her pallor makes her eyes seem dark, watchful. Her cancer, she tells me, recurred the year before. Three spots in her ribs, one in a lung. She submitted to high doses of chemotherapy, more toxic than before, then underwent a bone-marrow transplant.

"The cancer in my bones was like a little old lady," she says. "It puttered around, came and went. But I could deal with it." Her jaws tighten. "It's the drugs, not the cancer, that are so hard to take. People who haven't had chemo never really understand that. And it's the fear that you may die. It's been hard to come to terms with that."

She outlasted the poisons, metabolized them. The cancer in her bones and lung disappeared from view. Cells harvested from her marrow before this chemotherapy were then returned to replace what the drugs had destroyed, hopefully to spawn a new remission.

If she is to succumb to her illness, her bearing shows no hint of defeat.

"I'm here to see my cancer cells again," she says. "I'd like to see them projected on the big screen, like you did at your lecture." Her arched brows reflect her resolve. "I need to confront them one at a time to get a handle on them."

I set up the xenon projector in the hospital auditorium. Before long we are alone in a large, quiet space.

I project one of her biopsy slides onto the screen, magnifying her cancer cells to the size of golf balls. They glare at us like cyclopean monsters-granular pink bodies clinging to one another, each nuclear blue eye reflecting its own confusion.


From the Hardcover edition.

Media reviews

“Sensitive, often charming, always informative. . . . Moments of poignant realization abound.” –The Los Angeles Times

“Dr. Nadler’s book is rich with the revelation of self-discovery, with lessons learned through the microscope, with eloquent observations of how human life ‘must transcend the lives of its cells.’” –The New York Times

“Nadler’s essays glow with intelligence and sympathy.” –San José Mercury News

“Nadler takes medical narrative to a whole different level, both in his wonderful prose and in his focus on the story playing out under the lens of the microscope.” –Abraham Verghese