The rain beat mercilessly on the glass windows. It was colder than usual, darker than usual, and doubly hard to get up for work. On the streets below I heard the soft drone of traffic. the electric lanterns were still lit, the neon contrasting brightly against the gray skies.
Life in the laboratory in the past year had been far from routine. From the initial euphoria of being admitted to one of the best programs in Pathology, to disillusionment (Is this what I signed up for?), to despair after being two months Anatomic pathology with solo cutting for service patients during exam season which meant a large volume of work and no study time for all important in-service exams, to more anxiety (Will I be promoted to the next year level?), to feelings of inadequacy and doubt as to having completed the first year and being equipped with enough skill for the next level.
I remember a mentor, who once helped me in making best man speeches , who once remarked at how volatile I was, too careless, too whimsical, too emotional. One moment happy at ranking fourth in a blood bank exam, the next moment wallowing in the depths of melancholy after a less-than-idealconference. At least I am not a clinician, I reasoned. Just imagine if I had to treat patients all the time. I remember as a medical clerk and intern, that didn’t work out too well. I was too emotionally invested, constantly swept up in some mad instinct to try to save all patients, and feeling bad when we failed. I wanted to give patients a voice by writing about them. Essentially,I was more storyteller than scientist.
Ties that Bind
Hematology cases were always difficult. Rina (not her real name) was a teenager who presented with an anterior mediastinal mass. Because of her age, the mass could be anything from a lymphoma to an extra-skeletal primitive neuroendocrine tumor. The diagnosis was an “atypical round cell proliferation”, and a battery of immunohistochemistry studies were recommended.
Immunostaining relied on the principle of antigen-antibody reactions, and the basic concept is that cells that express a specific antigen are targeted and made to “light up” against a background of a pale blue counterstain. For example, in round cell tumors, if Leukocyte common antigen (LCA) would light up then it is most likely of hematopoietic cell in origin, distinguishing it fromneuroendocrine or epithelial-origintumors which would be negative for LCA. In neoplasms where morphology is not determinate, immunostains are most useful.
Rina’s immunostains supported the diagnosis of a lymphoma, unfortunately, the specific chemotherapy would depend greatly on sub-classifying the type of lymphoma. Lymphoma are generally divided into two broad categories: Hodgkin and Non-hodgkin, and the prognosis and treatment are different.
A second panel of immunostains were ordered. The Hema-pathologist and I were on the cusps of discovering the type of lymphoma Rina had, when the clinicians informed us she began having difficulty of breathing. The mass was compressing Rina’s lungs and great vessels. The clinicians did emergency chemotherapy which caused the tumor to shrink dramatically.