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"I was grasping at anything. I was terrified. I was fasting with juices, doing all these alternative therapies," she says. "And, of course, I was praying...A LOT!"
And by the time of her appointment with the oncologist, her symptoms seemed to have "miraculously" disappeared. Because he had never seen a lymphoma with symptoms that would come and go, the oncologist quelled her fear with guarded optimism.
"He said, 'I don't think you have it,'" Thomas recalls. "So, we were just rejoicing, thinking 'Thank God, we don't have to deal with this again,' especially my children."
But when she walked into his office in January for a follow-up, Thomas knew from the look on the oncologist's face that something was wrong. They finally had an answer to what was causing her unusual and erratic symptoms.
"He said that my slide had been sent all over the country...and in the end, it had come to Vanderbilt."
Robert Collins, M.D., the John L. Shapiro Professor of Pathology, had identified the disease as Ki-1 anaplastic large cell lymphoma – a rare type of T-cell lymphoma that can cause symptoms that wax and wane, just as Thomas' had.
After the rollercoaster of emotion over the preceding months, she at least had a definitive answer. Her oncologist referred her to Vanderbilt's John Greer, M.D., professor of Medicine and Pediatrics, who suggested she go ahead with treatment because of the fairly aggressive nature of the cancer.
Having watched her husband go through treatment and die, Thomas felt uneasy and, at first, declined chemotherapy since she had no symptoms.
But the symptoms returned virulently, and, after Greer confirmed the original diagnosis with another biopsy, Thomas decided to go ahead with the treatment.
Behind the microscope
Getting that answer – even when it is not an answer you want or expect – is the single most important moment in cancer care. Those answers come from people rarely seen by the patient, the pathologists.
Pathologists are medical doctors with extensive training in diagnosing disease from blood, tissue and body fluid samples. Many pathologists specialize in particular areas – for example, hematopathologists focus on diseases of the blood and bone marrow (e.g., leukemias and lymphomas).
"We are largely unknown, behind the scenes," says Mary Kay Washington, M.D., Ph.D., professor of Pathology and director of Surgical Pathology at Vanderbilt. "But we are very invested in
patient care."
From a sample of the patient's tissue or blood, pathologists make the initial diagnosis based on what they see under the microscope.
The first, most important question is: is it cancer? Pathologists can usually, but not always, tell this by the appearance of the cells under the microscope. To their trained eyes, cancerous cells and
tissues look very different from healthy tissue cells, with abnormal shapes and organization.
"The first step for the pathologist is to characterize the tissue – examining its architecture and the appearance of individual cells," says Mary Zutter, M.D., professor of Pathology and Cancer Biology and director of the Division of Hematopathology.
After determining that the cells are malignant, the pathologist identifies other attributes of the cancer, including the type of cancer, how aggressive the cancer appears, and the size of the tumor.
In the case of solid tumors, this usually requires that the tissue be surgically removed, or "resected." During the surgery, pathologists are on standby to provide the surgeon with rapid feedback to help guide the removal of the tumor.
"We are in the surgical pathology lab during the operation, so if the surgeon has a question that can be answered by an immediate consultation with a pathologist, we are there to perform that," explains Washington.
The surgeon may send some tissue samples to the lab, where a pathologist can perform a quick "frozen section" to help identify the edges, or "margins," of the tumor. This tells the surgeon if they have removed the entire tumor, or if more tissue should be removed.
After the tumor is resected, the pathologist examines the characteristics of the tumor that are visible to the naked eye. In this "gross examination," the pathologist notes the tumor's size, weight, color and texture. They also take a closer look at the margins to confirm whether the entire tumor was removed.
To look inside the tumor, the pathologist cuts thin slices, or "sections," from the tumor, stains them, and examines the appearance of the cells under a microscope. This process, called histology, has traditionally been the technique at the core of pathology.
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