I once had an experienced colleague named Paulo who claimed that within a second of starting to examine a Pap smear on his microscope he could tell whether it was going to be abnormal or not. Paulo “could smell it.” Since most pathologists I know have long had their olfactory sense dulled by the constant fetor of formalin and xylene, it was clear he was not literally smelling the glass slide on the microscope stage. Rather, his subconscious mind had taken notice of some subtlety, some minute, undefinable but not insignificant clues, that had his frontal cortex on alert. Soon he would find the cells that would lead to his assigning a grade of atypia to the slide and necessitating follow-up for the patient from which it had come.

I think of Paulo’s words often as I scan through hundreds of prostate biopsy cores each workday. There are definitive characteristics that define cancer of the prostate. Look up the description in a general pathology textbook and you will read about things like large nucleoli and invasive growth pattern. Turn to a text geared more for someone who specializes in urologic pathology and little tips like blue-tinged mucin and red crystalloids are pointed out as useful aids in the diagnosis. But frequently, long before I see those signs, I know I am dealing with a malignant prostate biopsy.

Just like Paulo with his Pap smears, thousands of hours of training and experience have made me aware of undefinable, indescribable, attributes in the patterns I see below me on a microscope slide. Maybe it relates to the density of glands on the slide. Maybe it is the way a certain cluster of those glands traverses the narrow width of the biopsy core. Whatever the signs are they trigger my “lizard brain,” deep in the primitive parts of my grey matter. It puts me on high alert–the odor of cancer is around the corner.

I am sure this feeling is widespread among pathologists. Whether dealing with a colon biopsy, a breast biopsy, or a thyroid gland aspiration, the well-trained, finely tuned pathologist has a sixth sense. Sure, we need to find the definitive microscopic signs, the nucleoli, the abnormal mitoses, the intranuclear inclusions– but sometimes we know before we see them that they will show up.

I suppose the radiologist feels the same way when he first looks at a chest x-ray and the surgeon does too when she first puts her hands on a tender belly. He knows there is a lung tumor, she knows the appendix is ready to burst. It may take a moment before their frontal cortex can describe how they know what they know–but as Paolo used to say, they can smell it.

Jim Morrison was the Lizard King. I will settle for just listening to my internal lizard. Especially when it roars.

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