Juan Rosai - Full Transcript

Rosai Director, Centre for Pathology Consultations at the Centro Diagnostico Italiano, Milan;  Adjunct Professor of Pathology and Laboratory Medicine at Weill Medical College of Cornell University; and Visiting Professor of Pathology at Harvard University

Interview location:  Centro Diagnostico Italiano, Milan, Italy
Interview date
: March 12th, 2008


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Juan Rosai at his microscope

SA:  Dr Rosai, start by telling me a bit about your family background – what sort of family did you grow up in?

JR:  I was born in a small town called Poppi in central Italy, close to Florence, in 1940, three months after Italy entered WWII.  I grew up there until the age of eight, at which time my family decided to emigrate to Argentina, mainly for financial reasons.  My father was a plumber, my mother was a housewife.  I was an only child until they moved to Buenos Aires, when they had a second boy.  My brother is now a physician and a lawyer, has a nice family and lives in Argentina.

SA:  What did your father do in Argentina?

JR:  He worked for Harrods, the famous London store – they had a branch in Buenos Aires and he was in charge of the heating system for the whole building.

“The dream of every immigrant”

SA:  So what made you aspire to medicine?

The dream of every immigrant is for his sons and daughters to be doctorsJR:  Two main factors.  One was my parents. You know, the dream of every immigrant is for his sons and daughters to be doctors.  So from early childhood, they made clear to me that they would be very happy if I graduated in something.  As far as medicine is concerned, I got a taste of it when I was about 13, and had just entered high school. I had a fractured femur from falling off my bike.  It was a very complicated healing process. I had several operations and stayed in several hospitals in Buenos Aires, so I had an opportunity to view medicine in action.  I would say those were the two main factors that influenced my choice of medicine. 

SA:  And were you good at science at school?

My choice to become a pathologist was made very earlyJR:  I was better in the scientific disciplines – physics, chemistry, mathematics -- than I was in the humanistic disciplines.  So I knew I would have a career in some scientific rather than humanistic field.  My choice to become a pathologist was made very early.  Pathology was taught then in the third year of medical school, and I fell under the influence of a very charismatic individual – one of the best professors in the medical school.  His name was Eduardo Lascano.

It happened in a fortuitous fashion.  At that time, in the medical school in Buenos Aires, there were 4,000 students in the first year, so it was impossible to have any sort of one-to-one relationship with the teachers.  Some teachers were allowed to have special courses for small groups, and Dr Lascano happened to have one in pathology for about 20 students.  It was the first time during medical school that I had the opportunity to be close to a professor, and Lascano was a very inspiring man who convinced me that pathology was the scientific basis of medicine.  So I had already decided by the fourth year of my medical school that I was going to be a pathologist -- to the point that for the rest of my years as a medical student I was spending most of my time in the pathology department.  The day after I graduated from medical school I started my pathology residency.

Many things have happened at the right momentI have been very lucky in my life in the sense that many things have happened at the right moment.  Just at the time I was finishing medical school, they opened in the seaside resort of Mar del Plata a new hospital in which they instituted, for the first time in Argentina, formal residency programmes.

SA:  What had they been doing before that?

JR:  Well, they had an informal apprenticeship system.  You went to a hospital and asked to be taken in as an observer with no pay, hoping that eventually a salaried position of some sort would materialise.  But there was no formal programme.

SA:  Can I just ask you, when you chose pathology were you frustrated at the idea that you wouldn't be working directly with patients?

JR:  That is not completely true; as a pathologist I interact with patients quite a bit. In any event, Dr Lascano convinced me that the excitement I was going to get from the scientific aspects of medicine was going to compensate for any lack of direct patient contact I might have had. It was not an issue.

SA:  And did you enjoy the science?  When you started working in his labs did you enjoy the microscopy?

JR:  Very much so.  I was very enthusiastic about it from the very beginning.

A revolutionary idea

So, I would have stayed in Argentina had it not been for the fact that political events in the country led to upheavals in the hospital where I was working.  There was a big confrontation between the Ministry of Public Health and the hospital staff so one day everybody, the entire hospital staff, resigned en masse.  I was one of them.

SA:  What was the issue?

I have never worked with a more idealistic group of people in my lifeJR:  It was an inspiring and ultimately sad experience. I have never worked with a more idealistic group of people in my life.  At the time, medicine in Argentina was carried out in two types of structures: the public health system, which was grossly underfinanced, and the private clinics.  For many physicians, perhaps for most, this was a good arrangement, because they made a good deal of money in the clinics.  Only people who could not afford otherwise would end up in public hospitals.  Well, just at the time I graduated, a group of Argentinian physicians who had trained in the United States came back to Argentina and said, "Let's try to change this rotten system; let’s see whether we can build something like what we saw in the States, with residencies in all the major specialties, rotating internships, 100% autopsy rates... ”  In other words, a modern hospital.  They went to see the Minister of Public Health, who liked the idea, but said, "There is no chance for you to implement this in a hospital which is already running, they (the medical establishment) will not let you.  But it just happens that there is a hospital in Mar del Plata in which I would let you try.” 

Mar del Plata is a resort city in the province of Buenos Aires, and the hospital had been built by Peron during his first presidency.  At the time it was ready to open a revolution toppled Peron and the hospital remained closed. Since it had been made under the Peron regime, no one wanted to get close to it, so it stayed closed for years.  The Minister said, "If you want that hospital, you can have it and do whatever you want with it.  We will support you if we can."

It was a fantastic adventureSo there we went; it was a fantastic adventure.  Until then I was living in Buenos Aires with my family. We left our families and friends, and went to live in that hospital like monks.  I was the single pathology resident -- there were residents, of course, in the other disciplines.  I handled every biopsy, every surgical specimen and every autopsy under the supervision of Dr Lascano, who had decided himself to participate in this adventure.  It worked very well for four years.

A dream defeated

For a while it looked like it was going to survive and become a model for the country despite the fierce opposition from the private clinics, which were in competition with us.  They did not want for the city to have a public hospital where good medicine was practiced.  They wanted all the patients who could afford it to come to their private clinics.  They achieved their end when there were national elections, and a change of government took place.  The new Minister of Public Health had a private clinic himself.  So what did he do?  He said, "Well, this is a very interesting experiment you have made, but now four years have gone by, the time has come to evaluate it." 

We resigned en masseIt seemed reasonable enough; the catch was that he sent as the evaluator the son of the director of one of the private clinics who had gotten his M.D. degree only a few months before.  It was too much to take!  So when he came for the evaluation we were all standing outside the hospital entrance, and we didn't let him in.  Next day he came with the police, and it was then that we resigned en masse.  Then there was an exodus: some people went back to the cities they had come from; others stayed in Mar del Plata and tried it again, but this time in a small private setting, far from the politicians’ grasp.  And others, like myself, decided to go to the States.

SA:  So that's what drove you out?

JR:  Yes.

SA:  You say it had been a very idealistic programme in the hospital?

JR:  It was.

SA:  And who was paying you?  The state?

JR:  The state, yes, whenever they could afford it.  For the first five months they didn't have the funds, and I survived on money that my professor, Lascano, lent me during that period. As you can gather, we were not there to become rich.


The USA offers a lucky break

SA:  So you went to the States…
Juan Rosai (standing in the center back) and the other member of the Czernobyl pathology group, engaged to review all the cases of thyroid carcinomas that had developed in the population exposed to the nuclear accident

JR:  So I went to the States.  Again I was very lucky.  Sometimes I think there is somebody ‘up there’ who likes me, because there have been too many lucky breaks in my life!  Just the week that I had decided to go to the States, a colleague told me, "Do you know who is giving a talk in Buenos Aires this week?  Dr Ackerman."  Lauren Ackerman was at the time one of the most famous surgical pathologists in the world.  He worked at Barnes Hospital and Washington University in St Louis, Missouri, and was the author of the premier textbook of surgical pathology, which we all used. So, the week that I decided to go to the States Dr Ackerman was in Buenos Aires and I said to myself, "This is my chance."  I went to see him, told him I was interested in going to the States, he took me as a resident, I stayed in St Louis as a fellow and then on the staff, and I remained in the States for 35 years.

Ackerman's Surgical Pathology -- the first edition was written in 1953 -- was ‘the bible’ of surgical pathology.  It had gone through several editions, and at the time of the fifth edition he asked me to take over, and I have done the book ever since.  The current edition is the ninth, in two volumes [he shows me massive tomes].  I just started a few weeks ago working on the tenth.  It takes about two years to do it. [He also shows it to me translated into Chinese.]

SA:  So when you started in St Louis, Missouri, what did you see as your future in pathology?  Did you see yourself as a surgical pathologist doing service work, or had you got research interests?

I am not, and I have never been, a basic scientistJR:  Both.  At the time the research of a surgical pathologist was anatomically based   -- it was done using the same tools that we used for our diagnostic work.  In a way our research was an extension of our diagnostic work.  It was, as we called it, clinico-pathologic research, of which Dr Ackerman was a master. That school of surgical pathology is not so much interested in the basic mechanisms of disease, but in the clinical implications of the pathologic findings.  So after having trained with Dr Lascano in Argentina and Dr Ackerman in the States, I became that kind of a surgical pathologist.  I am not, and I have never been, a basic scientist looking for the fundamental mechanisms of disease.

SA:  Okay, so what were you seeing in your service work, and what started to interest you most?

But perhaps the most important branch of surgical pathology is the one that deals with tumours and tumour-like conditionsJR:  Well, surgical pathology basically deals with the study of tissue that has been obtained from the living patient, as opposed to tissue obtained at autopsy.  One of the most important… well I'm biased, but perhaps the most important branch of surgical pathology is the one that deals with tumours and tumour-like conditions.  That's the kind of pathology that Drs Lascano and Ackerman practiced.  So my real specialty, if you want to call it such, is oncologic pathology.

I find it interesting from many angles. I think it's the area in which we pathologists contribute the most.  I mean, so-called medical pathology – the pathologic study of non-neoplastic liver diseases, renal diseases and so forth – is certainly important.  But the pathology is just one of the pieces of information that one has to put together with many others in order to decide what the disease is, how to treat it, and what the prognosis will be.  In oncology what we do is absolutely essential.  Despite all the advances in molecular biology and other disciplines, the diagnosis of solid tumours today is still based in the overwhelming majority of the cases on what we see under the microscope.

A threat from new technology?

SA:  I was going to ask you that, because I've heard differing opinions.  Some people say that all the new technology – scans and molecular biology and things – is going to make pathology increasingly redundant.  Do you think that's so or do you think pathology is still the gold standard?

JR:  It is today.  You know, I have heard the prediction you just verbalised for 35 years.  In a beautiful speech that Dr Ackerman gave about 20 years ago he said that pathologists have always been in danger.  There is always someone predicting that tomorrow they will describe a DNA test that will put us out of business.  It hasn't happened yet, and I don't think it's going to happen any time soon.  Of course the new tests are improving our capacity to categorise diseases better, and in some particular fields like haematopathology they are becoming very important. But for most solid tumours, the microscopic examination remains essential – and often the only thing you need.  Actually, I think there is an excess of special tests being done which are not truly necessary for the diagnosis and treatment of patients.

SA:  Really?  So with a really good eye you can see the differences, can you, even if there is a genetic basis to the differences?

JR:  That's right, because morphology is like a grand summary of all the genetic events that occur in a cell.  I mean, any genetic event of any biologic significance is likely to translate into a morphologic change that one should be able to see under the microscope.  I have written a few essays on this, from which I will give you some examples.  One is the case of a young lady with enlarged lymph nodes in the neck which are biopsied and given to the pathologist.  The pathologist looks at the slides and tells the surgeon, "This lady has a metastatic tumour which is epithelial (that is a carcinoma), glandular, papillary, made up of thyroid follicular cells.  The primary is in all likelihood in the thyroid on the same side as the lymph node. The chances are that the tumour is multicentric, that it will pick up radioactive iodine, and that the patient will be cured of the disease despite the nodal metastasis."  I mean, that's a lot of information from just a simple H&E slide – and very cheap to obtain!

SA:  And genetics wouldn't have told you as much as that?

JR:  That's right, not even as much.


A closer look at a ‘waste basket’ diagnosis

SA:  So what was the state of knowledge about the kind of tumours you were seeing when you started pathology, and what were the big questions it was begging you to do research on?

JR:  By the time I entered surgical pathology the knowledge of tumours had already advanced quite a bit.  But it was still possible to discover new diseases and new findings with the light microscope.  With the passing of the years this has gotten more and more difficult.  But at the time I entered the field it was feasible, and that gave me the opportunity to make my own little contributions.  Are you aware of the fact that there is a disease which carries my name?

Rosai-Dorfman disease

SA:  Tell me about it.

Reticulo-endotheliosis, was in his opinion a 'waste basket' diagnosisJR:  It goes by the name of Rosai-Dorfman disease, and it was discovered just looking down the microscope.  Dr Ronald Dorfman is a South African pathologist who had come to work with Dr Ackerman a few years before I joined the group. During one of his conferences which I attended, he commented that a particular term that pathologists were using, reticulo-endotheliosis, was in his opinion a 'waste basket' diagnosis.  He said, "I'm sure if we were to go to the files and look back at the cases that have been called reticulo-endotheliosis we'll find they are all kinds of things.  It would be an interesting project for somebody." As soon as the conference was over I went to him and said, "I'd like to do this project with you."  He agreed and I pulled out from the files all the cases that had been diagnosed as reticulo-endotheliosis.  And I found that Dr dorfman was right: there were all kinds of diseases in there. 

But the most interesting part was that in the course of the review of those several hundred cases I found two cases that had an appearance totally different from the others but identical to each other, and very, very peculiar.  There was something special about it also from a clinical standpoint.  Both of those cases had been called malignant reticulo-endotheliosis, but I traced the patients and found that both were alive and perfectly well.  So I went to Dr Dorfman and I said, "Look what I've found.  These two cases have been called malignant reticulo-endotheliosis; they look very funny and both patients are fine several years later."  He looked at them and he said, "Yah, not only do they look funny, but they look identical to two cases that I have seen in South Africa.   As a matter of fact," he added, "I think I have brought the slides with me."  He found them. We examined them, and they looked the same.  And those patients were cured too. 

It was enough to suggest that this was something distinct, 'an entity', as we call itSo we had four cases. It was enough to suggest that this was something distinct, 'an entity', as we call it.  So we wrote a paper on the four cases, and we got further proof that it was an entity when pathologists reading the paper and looking at the pictures realised that they had seen similar cases, and they sent them to us. So a few years later we were able to write a second paper with 34 cases, and now there are hundreds if not thousands that have been diagnosed.

SA:  But why had pathologists been prepared to throw this into the 'waste bin' diagnosis if they realised it looked so different?

JR: You know the saying, "You only see what you know"?  The tendency of most  pathologists if you see something is to try to put it into one of the boxes that have already been created.  And if you cannot you do one of two things: either force it into one box, with the reasoning that it must be an atypical case of a known disease; or you conclude, "I'm not good enough to recognise this."  That's what has happened with most entities. If you look back and ask the question, "How come something so obvious was not recognised before?" I think that's the reason.  But once it's recognised and people become familiar with it, it becomes an easy diagnosis. Today most pathology residents will recognise a typical case of Rosai-Dorfman disease at a glance.

SA:  What exactly is it and where does it appear in the body?

JR: We called initially the disease ‘sinus histiocytosis with massive lymphadenopathy’. Later on somebody suggested the name Rosai-Dorfman’s disease -- which is actually not quite right because it turned out that a French pathologist had described some cases in an obscure journal of tropical medicine some years before.  In the most typical case it will affect a young person, often of the black race, who will present with bilateral, pretty massive lymphadenopathy (swelling of the lymph nodes) of the neck – it can be so massive that the clinical diagnosis is often of something malignant, like LymphomaCancer originating in lymphoid tissue, a key component of the body’s immune system.  Cancers of lymphocytes (lymphomas) and other white cells in the blood (leukaemia) together account for about 6.5% of all cancers. or LeukaemiaCancer of the white blood cells, which are a vital component of the immune system (see also lymphoma)..  But if you recognise it and do nothing, in most cases the disease will regress of its own accord.  There is no specific treatment for it; but fortunately in most cases you don't need it.  All you need is to recognise the disease and do no harm.

SA:  So if people were misdiagnosing it, were they treating it aggressively and causing problems?

JR:  Yes, that's right, there were several cases of serious complications secondary to chemotherapy which had been given because the disease had been diagnosed as a malignant tumour.

SA:  When did you discover this disease?

JR:  We wrote the original paper in 1969.

SA:  And what did finding it teach you specifically?

A case hits you because it doesn't 'fit' any of the recognized entitiesJR:  That there was still a lot to be learned from Morphology (1) The form and structure of an organism or part of an organism.  (2) The study of the form and structure of organisms. .  When I wrote the first paper another fellow told me, "You were lucky, because this is probably the last 'entity' that was waiting to be described."  It was not true.  Lots of additional tumour entities have been described.  I see many cases in consultation, which by their nature tend to be unusual or peculiar.  A case hits you because it looks like something you've never seen before and it doesn't 'fit' any of the recognized entities.  So you store it in your memory.  Then you see another case, and then a third case, and at that point you start thinking, "Maybe this is something distinct and not previously recognised," and you start your research.  You go to the files looking for other cases, you study them in depth, you discuss the findings with your colleagues, and so on.

Let me give you an example from my years at Minnesota. I got a case in consultation of a young lady who, a few weeks after giving birth, developed a little polypoid lesion in the uterine cervix.  They took it out and it looked like a malignant tumour under the microscope.  It looked like a SarcomaA type of cancer that forms in the connective or supportive tissues of the body such as muscle, bone and fatty tissue. Sarcomas account for less than 1% of cancers., and that's what it was called, although I thought it was strange that a sarcoma would appear so quickly after a normal delivery.  Six months later another young lady had the same thing – and the diagnosis was again that of sarcoma.  I thought, "There is something strange going on here." 

Two months later a man had a TUR (transurethral resection) of the prostate for benign disease, and a few weeks later he developed a little polyp in the prostatic urethra.  It was biopsied and was called sarcoma.  Then I said, "Enough is enough” and I went to the files and I looked for cases that had been called sarcomas either in the prostate or in the cervix, in patients who had had an operation of some kind in the area a few weeks before.  I found four or five cases. They had all been called sarcomas but on follow up all the patients were fine. Then I wrote to Dr Robert Scully, a famous gynaecologic pathologist in Boston, who told me he remembered having seen several cases of the same phenomenon. So we concluded together that these lesions were not sarcomas and wrote them up. They looked like sarcomas, but in fact they were an exuberant reaction to the operative trauma. They were, as we call them, pseudosarcomas – sarcoma-like, benign reactive changes. 

SA:  Again, would these things resolve by themselves if you had just left them?

JR:  Probably. The problem is that they had been called sarcomas and some of the patients had radical operations as a result, like a radical prostatectomy.


Visual memory and a good ‘eye’

SA:  But what did it take for you to put all the pieces together in those cases?  I mean, do you have to have a phenomenal memory?

Visual memory is very important in this fieldJR:  I happen to have a good memory, and that helps, no question about it!  Visual memory is very important in this field.

SA:  And is that a natural endowment or is it something you can learn?

There is no question that some people have a better ’eye’ than othersJR:  It's both.  Like playing tennis or chess, you can certainly improve and play a decent game by practising and taking lessons, but if you have no inborn talent you will never be first rate.  I think the same is true of surgical pathology. There is no question that some people have a better ’eye’ than others.  There are pathologists who have been in the field for 40 years or more and who have tremendous experience but will never go beyond a certain point, so that a third year resident with a good ‘eye’ will see something that they have not.

SA:  So the people who tend to chuck things in the waste basket diagnosis, are they the ones who tend to have a more limited 'eye'?

JR:  That's right.  Or they may lack imagination.  Or sometimes conviction.  That's one of the things I have been telling people over the years: "If you see something that's doesn't fit any disease you know or that is in the books, don't assume automatically that you don't recognise it because you are no good.  Maybe it is something that has not yet been described."

SA:  Okay, so besides the pleasure of discovering new things, tell me about some of the other big moments in your life.

Becomes editor of Surgical Pathology

A great source of pride and satisfactionJR:  Well, another big event was when Dr Ackerman chose me as the person to succeed him in the writing of his book Surgical Pathology. The book was at the time – and I dare to say it remains – the standard textbook of surgical pathology:  there are very few pathology departments in the world in which you will not find it. To realise that through that book I am influencing and helping pathologists all over the world is a great source of pride and satisfaction.

SA:  I bet it is!  So what are your main aims when you sit down to write it?

JR:  Basically, to help people whose job is to make microscopic diagnoses.  Of course, there are several other books in the field, some of them outstanding and probably more authoritative, but an important difference between mine and these others is that the latter have been written by many authors, resulting in a heterogeneity that you will not find in my book, most of which has been written by one person.  You get accustomed to a particular style, to a single voice speaking. In any event, what I try to do in that book is to be very practical, in the sense of pointing out the main clues and pitfalls to a diagnosis, as well as providing an updated terminology and classification of the various tumours.  It is meant to be used where pathologists are working. 

It's not a book for medical students; not a book to learn general pathology or to read from cover to cover.  It's there as a guide and reference when you need it.  My professor in Argentina, Lascano, used to say that the best test for a book of this sort is to see whether it helps you when you need it.  So I'm trying with my book to help people when they need it.

The role of the “subconscious” in diagnosis

SA:  Give me some examples of particularly tricky diagnostic situations that it might help in.

JR:  Well, people may need help because they see something they do not recognise, or because they cannot decide if the lesion is benign or malignant, or because there's a discrepancy in their own group.  In some instances it's a matter of them not being aware of an entity.  There are some entities which, if you are not familiar with them, you will be lost, whereas if you have seen it before you will recognise it immediately.  So in many of the cases the problem is not having seen an example of that lesion before.  If you have, you can make an instant diagnosis, and that can be very impressive to your audience, but it's only because you have seen it before and they haven’t.  In other instances it is a matter of judgement, for instance whether there are enough abnormalities to call a lesion malignant, and those are the cases I find most challenging. 

A very difficult thing is to express in words the mental process you use in order to reach a diagnosis, because it works to some extent at a subconscious levelMy most difficult consults are not the very rare diseases, but the disease that we all know and are trying to decide whether to call it benign or malignant, or whether to call it Carcinoma in situLiterally, "cancer in place", which means the tumour is non-invasive, and has not spread. or invasive. A very difficult thing in surgical pathology is to express in words the mental process you use in order to reach a diagnosis, because it works to some extent at a subconscious level.  People will show you a case, you realise immediately that it is an alveolar rhabdomyosarcoma, so you make that diagnosis.  But if they ask you, "Why did you say that?" then you have to think!  You go ahead and list the reasons or criteria, but you haven't thought of them, at least consciously, while you were looking.  It was just an instantaneous recognition.

I’ll tell you a funny story about that. Someone took a slide to Dr Fred Stewart, a famous surgical pathologist at Memorial Hospital in New York. He looked at it for a second and said, "Synovial SarcomaA type of cancer that forms in the connective or supportive tissues of the body such as muscle, bone and fatty tissue. Sarcomas account for less than 1% of cancers.{." The pathologist who had brought the case said, "How can you say that so quickly?  What are your criteria for saying this is a synovial sarcoma?"  Dr Stewart replied, "What do you mean 'criteria'?  If you walk down the street and you see your grandmother coming along, what do you do?  You say, 'Hi grandma.' You don't say, 'What are the criteria for saying that is my grandmother?'.”

Some years ago I was running a session in which pathologists would come from other hospitals in town to show their difficult cases. We would gather around a multi-headed microscope and we would discuss the cases and reach a diagnosis.  There was a pathologist who taped the whole sessions trying to figure out the mental mechanism by which we reached a diagnosis, but gave up very quickly.

As I said, there is something innate about it, about having a good 'eye'.  If we knew exactly how to test this quality, that would be very useful, because then we could tell people, "You are not really fit for this business."  I have seen over the years many cases of extremely bright individuals, some near geniuses, who failed miserably as surgical pathologists, whereas there are people with just average intelligence who flourish in the specialty.


The history of pathology

SA:  As well as the textbook of surgical pathology, I see that you have also written a book about the history of surgical pathology – can you tell me a bit about that, put this field into its historical context?

JR:  It's called Guiding the Surgeon's Hand. The title was suggested to me by one of my former fellows, and I liked it a lot.  The history of surgical pathology was very rich; nothing comprehensive had been written about it, and the founders of surgical pathology were fading out, so I thought that maybe somebody should record their experiences before it was too late to do so.

The parent discipline, started with physicians doing autopsies during the Renaissance in ItalyThe way that surgical pathology developed is the following [he gets a piece of paper to draw me a schema of how it's developed].  Pathology, the parent discipline, started with physicians doing autopsies during the Renaissance in Italy. A physician would follow a patient for years. When that patient died, that same physician would perform an autopsy to try to understand the reasons for the symptoms and the signs that he had been monitoring.  Most physicians did not record their experiences, or the records were lost, but it just happened that one of them, by the name of Antonio Benivieni, from Florence, was very good at documenting his cases from both a clinical and a pathological standpoint.  Some years after his death his brother found his record book and had it published.  It is now recognised as the first book in anatomic pathology and clinico-pathologic correlations.  This must have been around 1300. 

SA:  So these were just clinicians who would cut up the bodies once their patients had died to find out more about their illness?

It was an attempt to understand diseases from the symptoms and the signs and the anatomic causes behind themJR:  That's right.  They were not pathologists as we understand them today.  The autopsy was done by the same physician who had treated the patient.  Those were true clinico-pathologic studies.  For instance, the physician would write a letter to the relatives of that patient explaining what he had found at autopsy and giving advice to the other family members.  So the approach was very clinically orientated – it was an attempt to understand diseases from the symptoms and the signs and the anatomic causes behind them.  From Italy the discipline moved to England, with pretty much the same approach.  By the way, this is all nicely documented in an excellent book entitled Ten Giants, written by Dr Ruy Perez-Tamayo, the dean of Mexican pathology. To continue my travelogue, from England it moved to France (now we are in the years 1600, 1700), and from France it went to Germany in the 1800s, where it took a very significant turn under the influence of Rudolph Virchow.  Virchow was a scientist.  He was not very interested in diagnostic pathology or in clinico-pathologic correlations; he was interested in understanding the mechanisms of disease.

SA:  It took a very significant turn under the influence of Rudolph VirchowSo was Virchow not a physician?

JR:  He was. He was also an anthropologist and an active politician.  Almost single-handedly, he transformed pathology into a science – into the scientific basis of medicine.  And when pathology was imported into the United States in the late 1800s it came through the German schools, and therefore it followed the German philosophy.  The departments of pathology in the American medical schools were research departments, and the more prestigious the medical school, the more likely this was the case.  This was where most of the medical research was being carried out, to the point that the first important journal these pathology departments published was not called the Journal of Pathology, but the Journal of Experimental Medicine.

While this was going on, there were surgeons, gynaecologists, dermatologists and other physicians who were interested in learning the pathology of their patients in order to treat them better.  They would go to the pathologists, but found them not interested; they were busy doing science.  So what did these physicians do?  They said, "Well okay, if you don't want to do the pathology for us, we'll do it ourselves; we'll become pathologists."  And so what happened in the States was that departments of surgery, gynaecology, dermatology, neurology and other specialties developed their own laboratory pathology within their departments.

SA:  So people who'd already specialised as surgeons or whatever then studied pathology?

JR:  Exactly.

SA:  What period are we talking about now?

JR:  In the early part of the 20th century. 

SA:  And when did the centre of pathology move from Germany to the States?

JR:  In the late 1800s.  This was the big migration in terms of medical knowledge, and the United States became the leader.

SA:  And this new development with surgical pathologists was in the early 1900s?

JR:  In the 1930s, for instance, at Johns Hopkins, and I think around 1935 at Columbia Presbyterian in New York.  The surgeons were the most active in this endeavour, that's why the specialty is called 'surgical pathology', because it was pathology done on surgical specimens by surgeons in the surgery department.  What would happen was that the chairman of a clinical department would call one of his staff and tell him, "Starting tomorrow, you will do the pathology; you'll be the pathologist for our department".

The first surgical pathologists were surgeonsSo the first surgical pathologists were surgeons -- they had a good background, of course, in the clinical discipline because they were surgeons before being pathologists, but they were not scientists.  As a matter of fact, they were belittled by the members of the pathology department, who regarded them as 'practitioners' whereas they saw themselves as scientists. 


The original philosophical gap between the two remained, and it is still there today In a way, American surgical pathology is a continuation of the original line of pathology that went from Italy, to England, to France – the practical, clinically orientated pathology.  And what's happened over the years has been a merging of the two so that, beginning in the 1960s, the pathology laboratories housed in clinical departments moved to the pathology department. There were several reasons why this happened. One of them was the fact that pathology had become too complex a discipline, and it was becoming very costly to duplicate those facilities for each clinical department.  It made sense instead to gather all pathology laboratories under one roof, so these laboratories moved into the pathology department. But the original philosophical gap between the two remained, and it is still there today.

The dilemma for pathologists

SA:  Okay, so as a young person in medical school learning pathology, are you essentially learning surgical pathology or 'scientific' pathology, or can you go either way?

The Surgical Pathology team of Washington University-Barnes Hospital in its golden years. Dr. Lauren Ackerman is sitting at the center. Juan Rosai is sitting at the far leftJR:  That's a very good question: what is the pathology that should be taught to medical students?  Ideally, both; in practice it is mainly the scientific one. It's called ‘general pathology’ or simply ‘pathology’, and it deals with the study of mechanisms of diseases. There are books such as Robbins and Cotran Pathologic Basis of Disease that deal specifically with that aspect.  Surgical pathology is instead taught in conjunction with the clinical specialities.  For instance, in the course on lung diseases there will be among the teaching staff a pathologist who will teach the pathology of the lung from a clinical standpoint.  In other words, the general pathology course will be run by a 'scientist', and the surgical pathology connected with the clinical discipline by the surgical pathologist.

SA:  So when you decided to do pathology, were you aware of the split and did you know which direction you wanted to follow?

JR:  I gradually became aware of it. In retrospect, I realized that Dr Lascano, my teacher in Argentina, was torn between the two approaches, because he wanted to do both.  The problem is that it is very difficult to do even one well; to do both well is almost impossible.  He wanted to do both and he was very frustrated.  I have the feeling that he was more inclined to the science side, but because of the circumstances he did mainly surgical pathology.  As for Dr Ackerman, he was all the way on the practical side.  Sometimes he would make fun of people on the science side -- he would call them ' mouse pathologists'!  Once I heard him say, “The scientists always tell you that they study diseases in animals with the purpose of applying the findings to humans. I do the opposite.  I work in humans, but if they want to apply those findings to mice, I have no objection whatsoever"! [We laugh.]

SA:  I hadn't appreciated the existence of this gap, though people have talked about the service side and the research side of pathology practice.  But there are people who seem to be doing both?

Many pathologists are caught in this dilemma, and some suffer from itJR:  They do, but as I already mentioned, it is the most difficult thing in the world.  Many pathologists are caught in this dilemma, and some suffer from it.  But at some point in your career you have to face the issue and make a choice.  I made that choice -- or rather that choice was forced on me at the time I was with Dr Ackerman.  I was happily working there, in the surgical pathology lab, so in a way I had made my choice since he was the premier surgical pathologist and it was a very exciting time. I was very happy with what I was doing, when one day I got a call from Dr Paul Lacy, the chairman of the department of pathology, a scientist.  Dr Ackerman was with him. Dr Lacy said, "Sit down. We think you are doing pretty well, and that there is a possibility that you will become prominent in pathology. You have already demonstrated that you are a good surgical pathologist.  But that's not enough. To succeed We will send you to a place where there are no microscopesin American academia you have to be also a scientist, so we want you now to become a scientist."  I said, "How do I do that?"  And he said, "Well, we thought of sending you to some basic science department in our medical school, but then we decided against it because we knew that you like surgical pathology so much that you would have taken any excuse to go back there.  You need to be totally isolated.  So, we will send you to a place where there are no microscopes, so you will have no option but to do science." 

I accepted, and they sent me to the NIH (National Institutes of Health).  I was there for one year in a basic science laboratory run by Dr Vincent Marchesi, a very good scientist.  I worked very hard and I liked it, but I realised that I liked surgical pathology better.  So after one year I went back to Washington University and to surgical pathology.  See, their hope was that after one year of intense exposure to science I would come back as a surgical pathologist/scientist.  It didn't work that way.  I went back to my natural inclination, which was surgical pathology.

SA:  So they're very different in the end are they?  Is it a mindset that's different?

JR:  Yes, it is a mindset.  So the question again is: can you do both?  I have seen some people who seem to be able to do both, but they are the exception. Actually, if you look at them closely, you will find that most of them are very good at one aspect and just competent in the other.  Are there people who are very good at both?  Very, very few.

I gave a talk on the subject some years ago in which I said that there are two ways to organise the activities of the department of pathology.  They can hire people who divide their time and efforts equally between research and diagnosis, or they could hire somebody who is a very good diagnostic pathologist, but who has enough understanding of basic science to communicate with his counterpart -- that is a basic scientist who has a good understanding of diagnostic pathology.  I like this team approach much better than that of the all-knowing Renaissance man.

SA:  Enough knowledge and respect to be able to communicate properly across the divide?

JR:  Yes, that's right.

SA:  And what about you, where do you fit in to the picture?

JR:  I am a surgical pathologist, no question about it.

SA:  And what is it that most appeals to you about that side?

Although I do not have the background or the time to do science, by looking at the cases I can come up with ideas that I can transmit to others who have the means to explore them  JR:  First of all the satisfaction of looking at cases and making a diagnosis which I hope is correct.  By doing that I feel I am helping patients.  And the fact that, although I do not have the background or the time to do science, by looking at the cases I can come up with ideas that I can transmit to others who have the means to explore them. 

SA:  So you have raised questions for the pure scientists, have you?

JR:  Yes, I have.  Actually that is something that I’ve tried to do in every place I’ve been -- I have to say, with mixed results.  Most basic scientists don't want to hear from us.  They don't think that we have anything to tell them.

SA:  Why?

JR:  Well, that's just how they are!  As a group, they feel that the only way to really understand the mechanisms and the biology of diseases is through basic science.  They believe that with plain morphologic observations you may get some ideas, but you will never get very far.  They also think – and I hate to say that maybe they’re right – that overall, as a group, they are more imaginative, more curious than surgical pathologists.  Like Lascano, I’m a little frustrated, because although I do surgical pathology, and I'm very satisfied doing it, I regret the fact that I was not able to do basic pathology, other than for that lonely year at the NIH when perhaps it was too late.  I wonder what would have happened to me if in my younger years, I mean as a medical student, instead of taking this route I had taken the other.

SA:  You think you could have been just as interested in the science route if you'd gone that way?

JR:  I will never know if that is true, but I wonder...


Questions of motivation

If the surgeons were gracious enough to tell the patient, "Our pathologist, Dr Smith, has concluded that this is…" maybe they would at least know that there is a pathologist in the hospitalSA:  Okay, what would you say is your motivation for the work that you do?  You said that at your first hospital you were all very idealistic, are you still an idealist?

JR:  I don't think you can duplicate exactly that state of mind – I was in my twenties then.  And I was idealistic in the sense of wanting to devote my life to a mission, which was the development of modern medicine in my country.

SA:  So what has become the motivation in your work now?

JR:  Again, the fact that I help patients by making the right diagnosis, teach young people to become good pathologists, and at least think about mechanisms of diseases. I’d like to mention something.  At the beginning of this conversation we talked about contact with patients.  One of the main problems that pathologists have always faced is the fact that we are, as you said, not very well known by the community.  Or we are known in a partial or distorted fashion, such as forensic pathologists or autopsy pathologists.  Is there something we can do to improve this situation?  One way could be through our clinical colleagues.  If the surgeons were gracious enough to tell the patient, "Our pathologist, Dr Smith, has concluded that this is…" maybe they would at least know that there is a pathologist in the hospital.  But most of the time they don't do that.  They just say, "The test came back, and this is the result…"  Or sometimes they even make the patients believe that they have looked at the slides themselves!

I have always liked the idea of contacting patients directlyI have always liked the idea of contacting patients directly whenever it was indicated.  Not only do they appreciate it but sometimes you get information from them that you have not received from the clinician and that may influence your diagnosis a great deal.  I have found that some clinicians do not welcome that – they want to keep the doctor/patient relationship pretty close to their chest.  As a matter of fact, I was criticised more than once in the States – like a surgeon saying, "You called my patient, Mrs. White. Why did you do that?  If you want to know something about that patient, call me." 

My consultation practice in Italy is quite different from the one in the States.  The consultation cases I get from the States are almost all from pathologists.  The consultations I get from Italy are almost always directly from patients, often because the oncologist advises them to get an opinion from me.   And it's a very personal encounter.  The patients bring the specimen and ask to talk to me.  At the beginning I was a little nervous about doing this, but I have found it a very rewarding experience. 

Juan Rosai at a lecture, listening to a question from the audienceFirst of all, the patients appreciate it tremendously.  Many have told me that nobody had given them the time and explained to them the disease the way I did.  Second, as I mentioned before, they often provide me with information that the clinician has not given me and which is important for the interpretation of the slides, such as the fact that they had another lesion treated in the past that is related to their current ailment, or that other members of their family have the same problem. They go out very often relieved and grateful, so this is something I think we should be doing more often.

Special cases

SA:  Okay, so tell me some of the most memorable cases you have seen.

JR:  It's very difficult, because we're talking about thousands of cases… Cases that have something special about them?  Well, one is the group of cases out of which I have described for the first time an entity.  Second would be the cases in which a diagnosis has been made of some terrible SarcomaA type of cancer that forms in the connective or supportive tissues of the body such as muscle, bone and fatty tissue. Sarcomas account for less than 1% of cancers. that would need a radical operation and I see the slide and realise that it is a benign process and that nothing needs to be done about it.

SA:  And has that happened?

JR:  A few times. Not all of them are as dramatic as that.  But for instance the thyroid, which is an organ of special interest to me, I think I have saved a lot of thyroids by telling the surgeons not to remove it because it was not needed.

SA:  And this Rosai-Dorfman disease we were talking about, were a lot of them treated the wrong way before you described it? 

JR:  That's right.

SA:  How common a disease is it?

You see more and more variations and exceptionsJR:  It is rare, but I think I have myself seen close to 1,000 cases, so it's not that unusual.  Now people recognise it easily when it presents in its typical form, with huge lymph nodes in the neck.  However, sometimes it presents in an unusual place and then they have problems.  Because it can appear anywhere: in the skin, in the eyes, in the central nervous system, anywhere.  That's another thing you discover when you describe an entity -- that as you get more and more experience you see more and more variations and exceptions.  So in the end the entity is still there, but it's very different from the one you originally described.  That’s certainly what happened to Rosai-Dorfman’s disease.

SA:  And do they all resolve themselves eventually without treatment?

JR: Most of them.  But when the disease involves multiple sites, the patient may suffer a lot or may even die, not because the disease has become malignant but because it affects a vital organ.  For instance, if you get the disease in the brain, it can kill you just because of its location, even though the disease itself is still benign.

SA:  So what other entities have you found?

JR:  One is called desmoplastic small cell tumour. It is a malignant tumour that usually involves the peritoneal cavity of children or adolescents, usually males, and it's a very aggressive, often fatal disease.  And that has been very gratifying to me for another reason. I identified the entity on purely morphological ground, and I wrote a paper about it.  An argument soon arose as to whether it was really an entity or not.  While the discussion was going on, somebody described in those patients a specific chromosomal translocation -- many tumours are associated with specific chromosomal translocations -- which led to the discovery of a specific gene fusion resulting from that translocation.  And that has led to some diagnostic tests that search specifically for that gene fusion, and to some promising therapeutic attempts.  And it all started with the Morphology (1) The form and structure of an organism or part of an organism.  (2) The study of the form and structure of organisms. .

SA:  But with Rosai-Dorfman’s disease, no one has been interested in investigating it?

JR:  I have not yet found anybody who was interested in devoting a significant portion of his time to study this disease.  Which is a pity, not necessarily because of the disease itself, being that it is rare and benign, but because I think it can teach us something about immunologic mechanisms or infectious diseases.

SA:  Because it's probably an infection in the beginning?

JR:  It's either an infection or the result of an immunologic disturbance, one or the other.  I'm sure it's not a tumour.

Complementary skills: science and Morphology (1) The form and structure of an organism or part of an organism.  (2) The study of the form and structure of organisms.

Was the most original aspect of the studySA:  Okay, so this other entity you've found where the science has given you some answers, is it just serendipitous that the two things come together or do they start from there being a clinical question in the first place?

JR:  Actually, that's the gratifying thing about pathology.  When I was discussing not too long ago with a group of people the desmoplastic small cell tumour and pointing out that without the molecular biology we would not have gotten where we are, somebody said, very generously, "Yeah, that's true, but if you had not described the entity in the first place, we would never have known of its existence”.  The pathology, the Morphology (1) The form and structure of an organism or part of an organism.  (2) The study of the form and structure of organisms. , was the most original aspect of the study. 

If you look at soft tissue tumours you will find that a majority of them are associated with a specific chromosomal translocation which leads to a specific gene fusion, and that's very impressive.  But then you think, well, that being the case, you would expect that, once in a while, a geneticist would discover a new type of gene fusion and would say to us, "Will you please look at these tumours and find out if they are a morphologic entity?"  Well, that has happened very, very rarely.  What has happened instead is that first somebody discovers the entity morphologically, and later the geneticist will say, "Oh, this is associated with fusion such and such."  It has almost never happened the other way round. 

SA:  So you always have to start from the outside and work in?

You start with the morphologyJR:  Exactly, you start with the morphology.  You give them the clue.  You say, "I think this is an entity, look at it", and sometimes then they will find something interesting.

Lauren Ackerman remembered

SA:  So tell me more about these two people who were your mentors.  What was Ackerman like as a person to work with?

JR:  He was a real character.  Let me show you a picture of him, it will give you an idea of the man.  There he is, he looks a little bit like [the French actor] Fernandel.  He had a remarkable personality. 

SA:  He looks mischievous!

JR:  Oh he was!  He was more than mischievous.  He was undoubtedly a great surgical pathologist, but what made him unique was his personality.  I mean his sense of humour, his mischievousness, as you say, and even his malice!  He was a remarkably smart man. Talking about having a good eye, he sure did.  He would look at a slide for a fraction of a second and immediately recognise the disease.  As I already mentioned, he was not much interested in the scientific aspects or nomenclature and classification of tumours. You would show him a case and he would say, "What do you think?" I'd answer, "Well, I think it is either an eccrine acrospiroma or an eccrine spiradenoma, or…" and he'd say, "Call it what you want, as long as you call it benign."  He was the most clinically orientated pathologist I ever met.  Sometimes he looked to me like a clinician doing pathology the way that Benivieni did during the Renaissance.

Our main job is: to answer the question, what does this mean for the patient?My first experience of him was when I attended one of his conferences.  When I entered the room the conference had already begun, and I thought I was in the wrong place because they were discussing the clinical history, the signs and symptoms, showing the X-rays -- everything except looking at the slides.  In pathology conferences you mainly show slides. When I left the room, I said “So this is the way American pathology is?” Another pathologist said, “No, that’s how Ackerman’s pathology is.”
Some years ago he gave a lecture at Memorial Sloan-Kettering Cancer Center in New York in which he lamented the fact that pathologists were moving away from this approach.  He said during the conference, "This morning I met with your fellows. They are very smart people.  They are very sharp diagnosticians; they know all those morphologic minutiae.  But when I asked them, ‘Now what does this mean to the patient?’ they were in trouble.  And that's not good.  Because, after all, that's what our main job is: to answer the question, what does this mean for the patient?"  I think that summarises beautifully his philosophy.

Drawing on experience

SA:  I was going to ask you exactly that.  For yourself, when you start looking at slides, how much are you seeing a human being behind the pathology and how much are you looking at fascinating science?

JR:  If you are doing your job correctly, you should not end your work on a case by simply making a diagnosis, but rather by making sure that the surgeon or oncologist gets the message about what that diagnosis means to the patient.  This can be done in several ways.  I am very direct about it, in the sense of making the diagnosis and then suggesting what I think is the correct therapy.  Not everybody likes that.  Some people will say, "You are a pathologist, just give me the diagnosis and let me decide on the treatment." 

There has been some controversy between surgeons, oncologists and pathologists in the literature about that.  I think that it's our responsibility to provide the surgeons and oncologists with general information that we have learnt from previous cases of the same disease, which they can use then in any way they want.  It's obvious that the choice of treatment is based on many factors, one of which is the pathology.  So I will say something like, "This type of disease usually behaves in this fashion, and therefore the possibility of performing this type of operation should be considered," and I give them a key reference.


Autopsies during the Renaissance

SA:  Okay, going back to this book Guiding the Surgeon's Hand, you said at the very beginning it was clinicians who wanted to see what their patients had died of who performed the autopsies.  So a lot of them were pioneers really?

During the Renaissance performing autopsies was the standardJR:  That's right.  But during the Renaissance performing autopsies was the standard.  People today don't realise that.  People think that autopsies were only started in the 1800s, that for religious reasons they were not allowed before that.  Actually, they were so common in Florence during the Renaissance that Benivieni, in his book, commented about a case in which the autopsy was refused, and he was indignant about it.  He wrote, "The autopsy was refused because of some superstition on the part of the family.”

Like today, the physician needed the consent of the family except in cases of doubtful death or in case of epidemics.  For instance, when they had epidemics of bubonic plague they would do autopsies on everybody to be sure that it was plague and not something else.  And in those cases the relatives could not refuse.  As I said, the practice was widespread.  By the way, this book of Benivieni, I'm still trying to get a copy, but there are not many copies left.

SA:  And have you seen the original?

JR:  I have seen it.  Actually some years ago I went to an auction of medical books at Sotheby in New York, and they had the book. It is a little thing, about 60 pages.  It went to $12,000 and it was just too much for me.  But maybe one day I will get it.

SA:  Fascinating!  So how did you get interested in the history of pathology and decide to write about it?

JR:  Well I think we have an obligation to know where we came from and why we do things the way we do.

“Consumed by pathology”

SA:  What does being a pathologist mean to you yourself, in terms of your identity?

Much of my life has been consumed by pathologyJR:  It has always played a very important part in my life.  As a matter of fact, much of my life has been consumed by pathology.  I have some sense of guilt towards my children in that regard, a sense of not having devoted enough time to them.  I have three sons and during the years that they were growing up I would come home usually around 8pm, spend maybe half an hour with them, and then go and work until midnight.  And that was true for weekends too.  So I didn't give much of me to them.  Fortunately, all three turned out to be wonderful and successful kids.  The oldest, Alberto, is a pilot for Delta; the second, Carlos, owns a computer company in San Francisco; and the third, John, is a trader at Paribas in London.  So they have done very well, and my relationship with them couldn't be better.  Maybe it was good to leave them alone – it has worked out well!  Now I am 67 and I think I have a more balanced view of life, and a greater portion of my time is spent in non-pathology activities.  But in my younger years pathology was a full-time job.

SA:  So what do you like to do in your free time now?  What are your passions outside of your work?

The fact that I can read in Italian, Spanish and English comes in handyJR:  I have had many hobbies over the years that have come and gone.  I like reading a lot.  Now that is my most important extra-medical activity.  I like very much books on history, and essays in general.  I like those better than fiction, though I read fiction too.  My favourite essayist is somebody who's not well known -- Joseph Epstein is his name.  I think he's wonderful.  He writes about all aspects of ordinary life, and tends to be autobiographical.  He's professor of English literature at the University of Chicago, and I have been following him for 20 years.  The fact that I can read in Italian, Spanish and English comes in handy, because I like the literature of all three languages.  For instance, I like very much Italian classical poetry.  I cannot read poetry in English or Spanish, but I love Italian poetry.  I like music a lot, too, particularly opera, and living in Milano, of course, is very good for that.

SA: Was it your ambition all along to come back to Italy?  Because you were obviously a very long time in the States.

JR:  Yes, but in my mind I always felt Italian.  I mean, I grew up in an Italian house, we spoke Italian, most of my friends in Argentina were Italian, so I always felt this Italian  ‘thing’.  I was warned over the years by many people, including my wife, that the picture I had of Italy was not real, that it was a nostalgic vision.  And they were right to some extent.

SA:  You got back and found it wasn't what you had thought?  You'd been looking with rose tinted spectacles?

JR:  Yes, I found that reality didn't match completely my idealised view of Italy!  Still, I'm glad that I came back.  I like it a lot, actually, and the more I stay, the more I like it -- despite some frustrations. My wife Dr Maria Luisa Carcangiu, also a pathologist,  is more Italian than I am since she grew up and studied medicine in Italy and lived in the States for a shorter period than I -- she misses the States more than I do, particularly the practical aspects of life in that country.  But despite all that, I like living in Italy, and if I had to I would make the same decision.

SA:  What are the professional frustrations here?

Appointments are given more on the basis of political and social considerationsJR:  Well, one thing that does not affect me personally but it bothers me is the fact that appointments are given more on the basis of political and social considerations than on the basis of merit.  That touches every aspect of professional life.  And it is very difficult, you know, to create an environment of excellence if you make your choice of people on that basis. 

SA:  And that's worse here than in other places, is it?

JR:  It's certainly worse than in the States, and just as bad as in Argentina.  In the States, as chairman or director of pathology, all the appointments I made were on the basis of merit.  If you had asked of somebody whom I had just picked for a position, “What political party?  What social group?  What religion?” I could not have answered, because none of those factors would have influenced my choice at all.

SA:  Tell me, what have been the particular high points of your career?

Fighting the establishment is much more difficult than starting from scratchJR:  High ones?  Well, again a big satisfaction has been to see how the surgical pathology book has been received.  Receiving honorary degrees from four prestigious universities was also very flattering.  Getting the Fred Waldorf Stewart award, that's was a big recognition.  And being the chairman of pathology at Memorial Sloan-Kettering, which is reputed to be the best cancer hospital in the world -- that was a high point. 

The low points? You see, the places where I worked once my training was over were Washington University in St Louis, where I was a young assistant under Dr Ackerman, then Minnesota where I was head of anatomic pathology, then Yale, again as head of anatomic pathology, then Memorial, in New York, as chairman of pathology, then at the Cancer Institute of Milan as chairman of pathology, and now here, at the Centro Diagnostico Italiano. 

Minnesota was very good, but I didn't realise until later how good it was. When I went there with my good friend and colleague Louis Dehner to run anatomic pathology, there was very little in place.  There was only one person doing anatomic pathology, and he left three months after I arrived.  So I was able to do whatever I wished, to hire the people I wanted and to organise the laboratory the way I wanted.  That was a luxury that I didn't have in any of the other places I've been.  In all of them I had to deal with ‘the old order’ and I discovered that fighting the establishment is much more difficult than starting from scratch. 

That's one of the great things about pathology: you never get boredOf course, I understand it very well. In each of these places there were people who had been there for 20 or 30 years who were probably bitter about the fact that they were not selected for the job, and who believed that the only way to do pathology was the one they had practiced for decades.  I didn't feel I had their full support in the sense of working together towards one end, and that was frustrating.  That's why I'm here now.  At one point I decided it just wasn't worth it.  I like surgical pathology too much, and I felt it was not worth it for me to spend most of my time fighting an environment that wouldn't allow me to do what I wanted. I was very lucky – again -- to find a place where I can do that, and only that -- consulting, writing and teaching. 

The pleasure of infinite variety

SA:  Of the consultation cases that you get, how often are you completely flummoxed by something?

JR:  It happens often, and I have to write to the referring pathologist, "I am so baffled by this case that I cannot even tell whether it is benign or malignant, I just don't know what it is."  Then I may suggest that they send it to another ‘expert’.  To quote Dr Ackerman again, he often started a consultation letter saying, "This is the first time I have seen a case like this.  But then I have to say this every day!"  I remember the day he retired, I showed him a case and he said, "I have never seen anything like it." 

That's one of the great things about pathology: you never get bored. It almost seems like the variety of diseases is infinite.

SA:  You have talked of Ackerman and Lascano a lot in this interview – have there been others who have influenced your career as a pathologist?

JR: I have met many, many interesting people in my profession, but those two individuals stand out as the two giants.  I have been very fortunate to have been taught, influenced and modelled by them.


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