Speaking of Cancer
Daily Observer
The Importance of Biopsies
S.Q.
Lapius always enjoyed presiding at joint medical-surgical staff meetings. It gave him a chance to wear his blazer, and
to display his red cashmere vest with the gold buttons. (“It helps to rivet attention on the chair”
he told me). Fortunately he had to doff
his alpine hat with the feather in the cloak room, but nevertheless he resembled
the king pea-cock at a bird sanctuary.
Today,
however, Lapius wore a conservative blue plaid, the squares accentuating the
several acres of abdomen that they were forced to cover. As a matter of fact he was annoyed, possibly
angry.
He
called the meeting to order with a tap of the gavel and made a few acerbic
remarks.
“Today
we have to review five cases, three of breast cancer, one of uterine cancer,
one of cervical cancer. In each instance
there have been extensive metastases.
All the patients are dead or dying.
But I’ve taken the trouble to review the charts and note that in each
case of breast tumor a biopsy was performed, another was performed in the case
of cervical cancer, and the woman with the uterine cancer had a diagnostic
curettage performed. –“
Before
Lapius could enunciate another word he was interrupted from the floor. It was Dr. Ty Cotton, his favorite surgical
sparring partner.
“May
I address the chair?” Cotton asked in a commanding voice.
“You
may make a few comments, Dr. Cotton. I’m
not sure we are prepared for an address.”
“I
think we can anticipate what you were going to say, Dr. Lapius, having heard
you express your sentiments on the subject so often before. In fact it is becoming somewhat boring. The fact is -.”
Now
it was Lapius’s turn to interrupt. “At
the risk of boring you further and for the benefit of newcomers to this
conference, I would like to state my position before you continue with your
well-prepared extemporaneous remarks….I have been trying to make a point about
biopsies. –“
Cotton
was up on his feet. “Yes. Dr. Lapius is trying to make the point that
we shouldn’t do biopsies in all cases.
Just go ahead and do the radical surgery. Preposterous.”
Lapius regained the floor, and with it some momentum. “Had Dr. Cotton not missed so many meetings,
and refrained from sleeping through those he did attend, he would have
understood me to say that biopsy is obviously necessary to determine whether or
not there is a cancer, but that to cut through a malignant lesion does nothing
but spread it.”
“Now
hold on there,” Cotton was on his feet again.
“These are breast lesions.
Sometimes there is a big mass. If
we don’t cut through the mass we have to excise it. This will disfigure the breast. Women don’t like that.”
“Better
disfigure than take the chance of spreading the lesion.”
“There’s
no proof that the lesion will be spread by cutting through it.”
“Perhaps
not,” said Lapius, “But when you cut through cancer you open blood vessels and
the cancer cells may drain through these channels to be disseminated to the
rest of the body. It puts the tumor
beyond immediate control. If you do have
to cut through the lesion, then you should be prepared to do radical surgery
immediately, not wait three days for the pathology report, as you did in one of
these cases.”
“Well,”
Cotton stammered. “I thought that it was
a benign lesion. It fooled me.”
“Yes,
of course. These things happen
sometimes. But I think that definitive
surgery should follow immediately any biopsy, and the excision biopsy in which
the entire suspicious lesion is removed is preferable to incisions which chance
a cut through the tumor. The same thing
occurred in the gynecology cases. A week
was lost between the initial surgical diagnostic procedures and the ultimate
surgery. This, in my view is too long.”
“But,”
Cotton reiterated, “You can’t find any proof that surgical biopsy spreads
cancer.”
“It
does in experimental animals. I don’t
believe there have been any definitive studies in man. It would be a very difficult study to
undertake. But in medicine sometimes we
should go along with what is reasonable, instead of always waiting for proof.”
Wanda
Scrape, the only female gynecologist at the institute waved for attention. There was silence as everyone turned towards
her. She was almost too pretty to be a
doctor.
“Dr.
Lapius what is the gynecologist to do?
After all you can’t expect frozen section diagnosis of endometrial
fragments that are removed during curettage.
There isn’t enough tissue to take the chance.”
“With
the modern techniques you could probably get away with it, Dr. Scrape. Certainly if you enter the uterus with a
sharp curette and penetrate an invasive cancer with it, the cancer cells will have
more of a chance of spreading than if they were left alone. Agreed the diagnostic curettage must be
done. There is even instrumentation now
that will permit a proper paraffin section for pathologic diagnosis to be
turned out in an hour. All hospitals
should have such equipment.”
Afterward,
Cotton came over to Lapius, and said “Why don’t you stop belaboring the point
Simon. You are in the minority you
know.”
“Of course. But if I
convince enough people, then I will be in the majority and you will be the
minority.”