A couple weeks ago, the nurse practitioner gives me a copy of my pathology report from the tissue removed during my “re-excision” surgery March 8. If you strip away all the jargon, the take-away is extremely simple: “Clean margins. No cancer.” Yay.
But I don’t file the good news report away in my “cancer binder.” I leave it on the desk. Pick it up and scan it now and again. I’m struck by the formality of the form. The sections—Source (of the tissue), Diagnosis, Clinical Data (summary of my case), Gross Description (detailed description of the tissue samples), Comments, Addenda, and then a doctor’s signature—are obviously standard, like the movements of a symphony or the meter of a sonnet. Likewise, the report language is formal:
“The patient is …status post left breast partial mastectomy…”
“The patient now undergoes re-excision of the lumpectomy following neoadjuvant chemotherapy…”
“The specimen is received in three parts…”
“The entire specimen consists of unremarkable soft breast tissue…”
I think this is what people mean when they say that a bit of prose is “clinical.” Some of the usage also invokes the liturgical. Communion, for instance, is “received,” not “sampled” or “delivered. It’s marvelous how this clinical language formalizes and sanitizes the inherent creepiness of what it describes: Some three bits of breast have been cut out of me. Part A is “received fresh.” Parts B and C are “received in formalin,” a preservative. Then they’ve been sliced, placed on slides (“cassettes” in this idiom) and then analyzed by the pathologist who, this time, gets to report the good news.
Of course, I’m glad the pathologist knows his job. But I’d be lying if I didn’t admit that it’s a little weird to think of my body parts being sliced like salami. And there are some things about the form that I don’t quite understand. So I call a friend who is a UC-trained pathologist.
“So what does it mean under ‘gross description’ where it says, ‘short=superior, long=anterior.’?”
“Well,” he says. “When the surgeon cuts out the tissue, they lay it out on Telfa, a gauze pad. Then they put sutures in to show how it was oriented. So, in this case, the surgeon put in a short suture to mark the upper edge and a long suture to mark the front edge.”
“And there’s a similar reason for the section marked ‘inking’ on the report? It says ‘green: old posterior margin,’ ‘black: new medial margin,’ and so on? ”
“Yes, every hospital has its own system. Different colors mark different directions in space. Different hospitals do it differently,” he says. “Remember that specimens are always irregular. Have you ever picked up chicken fat? It has no structure. It falls around. It’s like that.”
Strange to think that one minute this tissue was part of the complex system that is my body. Then next minute, it’s flopping around in a lab and needs all kinds of marking to put it in context.
“The ink can also be a problem,” my friend continues. “It can run into lobules of fat and blur the margins. It’s hard to know if you’re looking at the true margin or where the ink ran into the fat. Each pathologist differs in how they allow for that.”
“So that’s why they designate the specimens as A, B and C? That’s why they number the slices? If the pathologist finds something, then those designations make it possible to orient it and find it again in the patient’s body?”
“Right. Say the pathologist finds something in specimen B, slice 1. The letters and numbers make it possible to go back to that exact region and remove more tissue, or irradiate it, or whatever is needed. At a big hospital like UCSF, it’s likely that a resident is the one who slices the tissue and puts it on the slides. Then the attending physician looks at the slides. Since I work at a smaller hospital, I section every specimen that I analyze. How long is that specimen B? Three centimeters? Then, given the number of slices indicated, each slice would be approximately 3 millimeters thick.”
“So what about this part of the report where it says there is a ‘less than 0.1 centimeter focus of atypical ductal hyperplasia’? Shouldn’t I be worried about that?”
“Atypical ductual hyperplasia, or ADH, means there are some cells that are not quite normal but not quite cancer. They exhibit some of the characteristics of cancer cells, but not all of them. Plus, it seems that the report says this is a very small area, and a long way, half a centimeter, from the margin.”
“So what characteristics signal ADH? How do they decide?”
“It’s a wishy-washy thing,” he says. “They don’t want to call it cancer, but they don’t want to call it nothing either. One pathologist’s ADH is another pathologist’s DCIS [i.e. cancer]. There’s a lot of angst and discussion about this, about where to draw the line. Different MDs have different thresholds.”
“So, like so much of this, it’s a crap shoot,” I say.
“Well, not quite a crap shoot,” he says.
Then he asks for the name of the pathologist who wrote the report. He’s surprised that there’s not an “additional pathologist,” i.e. a resident, or a specialist in training, mentioned. It turns out he knows the pathologist who received, sliced and analyzed those bits of my left breast. He tells me that he’d respect this colleague’s judgment, no reason to ask for a second opinion.
I hadn’t been planning to ask for a second opinion. Even if it is a numbers game—a weighing of variables, a matter of judgment, a guess at many possible risks and outcomes— I’m glad my pathologist is apparently a respected player.