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Ten years ago, while still in the operating room, I asked the surgeon to show me what he had
removed. Before my sleepy eyes, he placed a vial containing what looked like a bloody pea, a
small piece of me that was about to seal my fate. If I was lucky, the tumors that a recent CT scan
had revealed would be benign. Unlucky, and I was facing cancer. And somewhere in a
remote area of the hospital, a pathologist I would never meet- who couldn't possibly know how
much I wanted to live - would decide whether I was lucky or unlucky. So when a scan
indicates a suspicious mass, what is the next step in identifying if it's malignant or
not? So if a patient has a CT scan or MRI that shows something that shouldn't be there the
question is what is that? Just seeing a mass doesn't mean it's malignant. And so it is critical
to obtain a biopsy of that mass. We make the determination as to whether it's cancerous,
malignant or benign by looking at it under the microscope. So when a surgeon or a clinician
does a biopsy of a mass they will send it to the department of pathology. In pathology they
have specialists that look at masses or biopsies from different organ systems. In the
best of all worlds, the physician or surgeon will have already spoken with the
pathologist to determine what type of biopsy, how the biopsy should be done, how it should be
sent to pathology, so that all the most appropriate tests can be done on that sample. The type
of the biopsy does impact the ability to render a diagnosis. In terms of types of biopsies,
one is called a fine needle aspiration. In that procedure, a needle is attached to a syringe
and placed into the mass and cells are basically sucked out of the mass individually. That
procedure will allow us to tell if there are carcinoma cells there. Cancerous cells of a
solid tissue, basically. It can also give us an idea if there is a malignancy of the blood system
or immune system called leukemias and lymphomas. For final diagnosis of leukemias and
lymphomas, you typically need to get a biopsy that looks at the architecture of the tissue. The
excisional biopsies offer you an opportunity to evaluate the entire architecture of the
specimen that is being submitted. Now architecture is important because it gives you
an opportunity to evaluate the cells in the context of its environment. To put it this
way...the large number of cells that do not belong in a particular compartment, you
start to ask yourself some questions about, what are they doing there? If you now take a
closer look at the cells and see that they exhibit malignant characteristics, then you start
to imagine well these cells look malignant and they are no longer where they should be. Normal
tissues are organized and they are organized in a normal way, curiously. You both spoke about
architecture. Can you address what this is in lay language? It's important to assess the
relationship between the cells and its environment. The way to do that is to have a tissue
material that provides you with the opportunity to evaluate that relationship. If you were to
assess the individual cells and not know what they are doing in that environment, it becomes
difficult to contextualize their cancerous nature. So cancers can occur in a variety of tissues
and organs. And those tissues and organs have different functions and the appearance of
those normal tissues under the microscope really tell you what that tissue is doing. So, for
example, cells that line the urinary tract, cells that are part of glands, those organs are
made up of cells that are related to each other. In other words, they stick together. They
have junctions that keep them together. What we're talking about when we say 'architecture'
is that we can see how those cells are bound together in a carcinoma cancer of one of those
types of tissues. On the other hand in lymph nodes, the organ of the immune system, the cells
have a different relationship to each other and the appearance of the cancerous tissue is very
important in telling us what type of tumor it is. One of the most important questions that
the oncologist will ask of the pathologist before assigning therapy, is how confident they
are in the diagnosis based on the adequacy of the specimen received. What do you expect the
results of the biopsy to tell you? The first thing an assessment has to be made..was
the right tissue biopsied? Sometimes we get back a report saying the biopsy appears
normal. Yet we know that there is something abnormal in that tissue and the clinician
physician has to make the decision of whether the right piece of tissue was obtained in
the biopsy. Sometimes we request a second biopsy if the results just don't make any sense. But
if the biopsy is done correctly of the correct organ, it tells us if it is an inflammatory
mass, just cells of the immune system invading in terms of some type of infection or auto-immune
disease. A number of different things can cause that. Or if it is related to a malignant growth
of cells of that organ. And if that's the case, then specifically what type of