Welcome to the Gross Room
…where tissue is the issue
A cancer diagnosis begins here: on a cutting board atop a stainless steel table, with a slab of flesh and fat splayed apart, its edges painted with blue, green, red, and orange dyes. A greasy patina from the fat glistens on the cutting surface and next to the tissue are dissecting instruments thick with blood. A hand, gloved in blue latex, guides a scalpel through this tissue. Found tucked away precariously close to one of the specimen edges is a tumor, only a few millimeters, firm and stellate. Over the course of the day, a motley spectrum of other human parts will pass over this table — a length of distended colon with a large obstructing tumor, kidneys massively enlarged and distorted by innumerable cysts, and a flesh and bone segment of jaw with a tumor eating into the mandible. At day’s end, a curious amalgam of blood, marking ink, pus, serous fluid, and other detritus will have accrued in the margins of this workspace. Welcome to the gross room (aka gross lab), so named not because it is disgusting (though it sometime is) but because it deals with tissue on a macro rather than a micro level. Amidst all the buzz of molecular medicine, the gross room remains the unglamorous beginning of a cancer diagnosis.
Like much of medicine, the gross room can be messy. There is both science and art here and the edges are not angular, they are rounded and imprecise. This is reflected in the lexicon we use to describe things. Lesions may be fungating or ulcerated, bosselated, turgid, or grumous. They may be filiform, bilobate, scirrhous, circumscribed, or stellate. I like to note the way a specimen looks, the way it sits on the table, and the way it behaves when you manipulate it. Some essence of this should be captured in the language of the pathology report.
Sometimes, while the patient is still in surgery, we take a piece of fresh tissue, freeze it, and take a thin section to examine under the microscope. I like it when the cells first come into focus. When the surgeon comes into the room and looks at the tissue through the microscope with me I like to point out the salient features of the tumor. Do the cells clump together, or are they dispersed? Are they round or elongated? Are they haphazard or are they organized like, for example, a school of fish?
The human brain, they say, is the ultimate pattern recognition machine. With experience you can get a very good sense of a tumor and how it is likely to behave — the cut of its jib, just by observing how it fills a space and how it feels between your fingers or how the scalpel blade slices through it. More data points are later added when viewing the tumor under the microscope, culminating ultimately in a diagnosis.
Attempts are made in textbooks and medical journals to codify this diagnostic process, but there are elements of making a diagnosis that do not lend themselves to text or evidence-based metrics. Some of these observations can be taught and are, indeed, put into textbooks. Some facets of pattern recognition remain ineffable, however, like the way you can only describe someone’s face to a certain point, yet you recognize a familiar face instantly. In order to develop this “sixth sense”, this “will to diagnose”, you have to spend time in the gross room and time looking through the microscope. You have to pay attention, and you have to get your hands dirty. (Gloved, of course). You have to get close to the tissue.
Medicine has long romanticized the notion of the molecular. Perhaps never has it created greater hype than in its latest permutation — “personalized medicine”. I dislike the term. It seems to imply that medicine has been somehow impersonal, or at least less personal. By “personalized medicine”, also referred to as “precision medicine”, what we mean is that genetic based testing will be used to help guide treatment. This is a noble and worthy pursuit, in concept.
As a community hospital pathologist, this is what personalized medicine looks like to me: I choose a piece of tissue to put into a small cardboard box, which is then picked up by Fedex or UPS and shipped across time zones to a large commercial reference lab. In about two weeks I receive a clean, highly stylized report, perhaps on glossy cardstock and always with the company logo prominently displayed. It may include a bar graph or pie chart and a few numbers or percentages. Nothing about these reports would look out of place in a corporate quarterly report or insurance presentation. What’s so personal about that?
The stylized report with a graph and some numbers is a far cry from the gross lab where one may come across a uterine tumor the size of a volleyball, witness the strange reptilian appearance of a larynx ex vivo, or get squirted in the eye while cutting into an ovarian cyst. Good thing you were careful to wear your personal protective gear, right? Cyst fluid in your eye- now that’s personal.
Surely the glossy and sterile report must retain a clear connection to the tissue from which that data is derived. When these numbers become detached from the tissue they represent, then they risk becoming an abstraction. It will always be important to know if a result makes sense based on what you’ve seen of that patient. Was the tissue examined carefully when it was in the gross room? You can’t test something that wasn’t found, and test results from a poorly sampled specimen lose meaning.
For the best clinicians, medicine centers around the patient. All the computerized imaging and laboratory data is a necessary resource, but it is always secondary to direct interaction with the patient. (Though much has been written about how this physician-patient relationship is buffeted by electronic health records and the ever increasing demands of time efficiency.) In this same way, I believe the foundation of cancer diagnosis will continue to be made starting in the gross room, close to the tissue.
Welcome to the Gross Room
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