This short story was published in the Winter 2021/2022 issue, volume 42.2, of the literary journal Pennsylvania English. The story is, at least in part, about a quality of life issue. I was not consulted about the cover design.
     Not infrequently, someone asks me if a story or a blog I have written is autobiographical. This story is not autobiographical, except for the fact that once, many years ago, when I was a very young pathologist, I had the opportunity to study the tumor described.

 

 


HARRY’S CHOICE

     Harry Moore was in his third year of pathology residency when he had the opportunity to study the extremely rare, malignant Leydig cell tumor of the testis. The cells he saw with the microscope looked bland with ample granular, pink cytoplasm and uniform, central nuclei. He didn’t appreciate any signs of malignancy until his teacher, Dr. Otani, reviewing the case with him, pointed out a few dividing cells as well as some subtle, but worrying, nuclear variation.
     “Is that enough to call it malignant?” Harry asked, anxious to add this information to his growing store of knowledge.
     “Enough,” Otani said, nodding. And then, tilting his head to the side as a mischievous smile formed, he pointed to the information slip accompanying the specimen that clearly stated the patient already had evidence of the tumor spreading to other organs and added, his accent obvious, “Especially with other evidence. But double-check to see if this is accurate.” He pushed the paper at Harry. “Call the clinician. Look at X-rays.”
     Now, for only the second time in his almost fifty-year career as a pathologist, Harry again encountered that distinctly unusual malignancy. The bone scan image showed a single metastatic lesion in the mid-shaft of the femur.
     His femur.
     He didn’t recall most details about the behavior of the neoplasm or anything about that particular patient’s course those many years ago. He just knew the tumor was decidedly uncommon. Despite not keeping up with the literature about this type of cancer, he was sure an unwelcoming path lay before him.
     Three years before, his wife, Evie, died of pancreatic carcinoma. A year after her death, still mourning, Harry began a brief affair with Monica Briscoe, the former wife of a colleague, after a chance encounter in the food market. Unfortunately, to his dismay, even after taking Viagra and then Cialis, he couldn’t be aroused. Monica was kind and caring, and although they promised to remain friends, they only went to dinner once after that. When his urologist, Marty Berg, did a full evaluation and told him the over-the-counter remedies advertised on television weren’t for him, he was depressed. The blood serum testosterone value was much lower than it should be, but Marty didn’t think testosterone injections would be of use. “Besides,” Berg said, “some people get accelerated coronary artery disease after being treated with it.”
     Harry’s unhappiness was obvious—many questions from friends and colleagues asked if he was all right—and then he accepted that sex was no longer important for him. That the years had caught up with him. That some of his receptor cells were worn out. That he was old. He thought about retiring, but he still enjoyed teaching residents, still liked working with clinicians, still got pleasure from solving interesting diagnostic problems. After staring into his bathroom mirror, particularly at what was left of his chalk-white hair, he accepted the reality that there were other things to think about.
     He was completely content to concentrate on his work, his research, and giving lectures when invited to other centers. Then he met Nora Woodruff, a pediatrician, at the annual pathology department winter holiday party. She came with her cousin, Meg, one of Harry’s newer colleagues. Nora was twenty years younger than Harry and quite attractive. Her husband, Sean, a surgeon Harry had known, succumbed to a highly aggressive sarcoma the week before Evie died. Holiday cheer all around them, Harry and Nora sat in a relatively quiet corner of the festively decorated conference room, sharing their experiences in grieving. He felt attracted to her, a feeling he had not had in a long time. He also recognized a once-familiar sensation and felt sure he could have an erection in the right setting. They were still talking when Auld Lang Syne played, signaling the end of the party. Because it was raining, and since he usually walked or took a bus to the hospital, Harry accepted her offer to drive him home.
     The rain was over by the time they left the garage, although it was quite foggy by the time they reached his building. Later, neither of them recalled who suggested the late-night drink, but before too long, they were heading up to his apartment. They leaned into each other and kissed as the elevator bounced to a stop at his floor. As soon as they were in the foyer, they kissed again, and she started undoing his tie and unbuttoning his shirt. Soon, they were in bed and, to his great relief, he was able to have sex without that little blue pill.
     As they lay there, side touching side, he told her about the long time since he had been aroused, the more than three years without sex.
     “Should you see if there’s a reason you can do it now?”
     “I thought you were the reason.” He turned and kissed her again.
     “Yes,” she laughed, now fully facing him and patting his cheek, “of course, I am. But should you make sure there’s no other reason? A medical reason?”
     He reached down under the sheet, a half smile on his face and his brow wrinkled, and carefully palpated his testes. “I don’t think there’s anything abnormal there. I don’t feel any nodules.”
     “My pediatric patients are a lot smaller than you, and sometimes they have very tiny lesions. Let me see,” she said as she examined him. There was another erection, and they again had sex, less rushed and more passionate than before.
     Breathing heavily, a thin sheen of perspiration over his body, he said, “You didn’t tell me what you found.”
     She laughed once more—her laugh was warm and generous, and he thought he was already becoming familiar with the sound of it—and whispered, “Nothing. At least nothing other than a terrific reflex.” She leaned over and kissed him. “That was nice.”
     He got them each a glass of sherry as they were dressing. Then he walked her to her car and said, “I’d like to see you again. Soon.”
     They got together three or four times a week and, each time, he was able to have sex, sometimes twice and once three times in a night, not counting the morning sex when she stayed over and he woke aroused.
     Harry never liked dancing, but Nora insisted on taking him to a dinner club where they still played slow music. The second time there, he enjoyed it even more and said, “Let’s come again soon.” Harry was not a sports fan, but she insisted they go to see the Lakers play the Celtics. Before long, he was jumping up and down, cheering every basket until he was hoarse. She wasn’t particularly fond of classical music, but he took her to Disney Hall to hear Hilary Hahn play the Brahms violin concerto. “That was amazing,” she said. Her eyes sparkled, and he knew she meant it. He agreed to go to a cooking class with her. They would drive up to San Francisco during an upcoming three-day weekend. He knew he was in a whirlwind, but he loved it. Periodically, she would again palpate and find nothing, but he always had the same reaction and did not object. She repeatedly urged him not to act like a typical physician and, instead, go see his doctor. “Harry, I still have this nagging worry. Go see your urologist. This can’t all be from my allure.”
     “Look here, Harry,” Marty Berg said after the urologist examined him. “I wasn’t sure if I felt something, but there’s no question with the ultrasound. There’s a very small tumor on the left side. You need a workup.”
     “Oh?”
     “You’re probably thinking adrenal tumors secrete androgens more often than testicular tumors. And that there are other things. You probably know more about it than I do.”
     “I’m not sure about that but, yes, I guess we should do a workup.”
     “Benign is more common than malignant,” Berg reassured him. “You know that, right?”
     “Yes. I agree. But not in the testis at my age. And I know that you know that.”
     “Let’s just find out what it is before we decide what to do.”
     The workup scans revealed an eight-millimeter bone lesion, and blood studies showed a testosterone value fifteen times greater than expected. “We need a biopsy. The testicle is the smaller lesion, but I think it’ll be easier, less traumatic, to go after that.”
     “Ouch.”
     “You know, it’ll only be sore for a couple of days, but you won’t have real pain.”
     “I believe you, but ‘ouch’ is still my dominant thought.”
     Nate Freeland, the pathology department’s genitourinary tumor expert, called the morning after the biopsy.
“Nate, thanks. That was quick.”
    “Yes, well, you know the techs start cutting at five, and I had them put this first.”
     “I appreciate it,” Harry said as he gingerly sat down at one side of the two-headed microscope.
     “Painful?” Freeland asked, adjusting the eyepieces on his side.
     “More like aching. Acetaminophen holds me, but I still try and protect it.”
     “Understood.”
     Harry slowly moved the glass slide on the microscope stage, changing from low to high magnification every now and then. “Are these Leydig cells? I can’t find a typical Reinke body, but that’s what I think it is.”
     “Not bad for a liver pathologist. Good for you. I’ll do some of the usual immunostains—inhibin, vimentin, et cetera—but I know you’re an old-school guy just as happy with hematoxylin and eosin.”
     “It’s been a long time since I last saw Leydig cell tumors. All benign, as far as I know, except one when I was a resident. The cells here look pretty bland.”
     “Yes, I did expect a little more cellular variation, a little more pleomorphism, but this is still consistent with…” He hesitated, then looked directly at Harry.
     “With it being malignant.” Harry finished the sentence.
     “Yes. With it being malignant.”
     “When I last thought about this tumor more than forty years ago, there wasn’t much to do. Radiation didn’t help, and I don’t remember any useful chemo. Has therapy changed?”
     “You know, this is really in the rara avis category. I don’t think there’s a specific therapy, but you should check with the oncologists. Bob Hendrix would be good. Don’t you think?”
     “Yes, of course. Thank you. I appreciate your help.”
     “Should I prepare extras to show around? To get a second opinion?”
     Harry put his hand on Freeland’s shoulder. “Nate, I don’t need to show it around. Your word is as good as I’ll get.”
     Walking back to his office, Harry kept thinking about Nora. About how much he enjoyed being with her. About all the things they had done together. About how much he enjoyed the sex. Until today, he felt as young as he had twenty years ago. Energized. Vital. Now his chest felt tight, and there was weight on his shoulders. He knew he had a deep frown, and he couldn’t make it go away. He passed two lab techs he knew well and barely nodded at them.
Back at his desk, he called Hendrix.
     “Bob. I didn’t expect to get you so easily. It’s Harry Moore. I need to ask you something. About therapy for metastasizing Leydig cell.”
     “Harry, there’s not much. I’ve treated a couple, one just last year. That’s a really rare bird. Some folks have been trying the b-e-p combo…”
     “Sorry, what’s b-e-p?”
     “No, I’m sorry. I hate abbreviations but I can’t help using them. It’s bleo—bleomycin—etoposide, and platinum. The same cocktail we use for germ cell malignancies, but it doesn’t seem to have much efficacy on the Leydigs. The results with mitotane are confusing. How old is the patient?”
     “It’s me, Bob. I have a small testicular lesion and a single bone met.”
     Hendrix whistled and then said, “Well.” Then he went on, “My high school chemistry teacher used to say ‘well’ is an intellectual burp when it’s at the start of the sentence. But that has nothing to do with your tumor, does it? Do you want to come over and talk about it?”
     “I probably will, at some time, but for now, just give me the skinny.”
     “There’s some molecular work in animal models, but I’m not aware of any clinical trials. Of course, nobody has a lot of cases. Even the biggest collaborative studies don’t have a tremendous number.”
    “What would you do?”
     “I would put together some combination of drugs. I don’t exactly know what at this stage, Harry. I’ll call around and see if anyone has recent experience with better results. I’ll get back to you in a day or two. Whatever we find, I’d like to start treating soon.”
     “But, as of now, your best guess is that I’m still going to lose what’s left of my hair, and I will vomit and have diarrhea. I might become anemic. Unless you give me something like bleo that gives me a fibrotic lung and—correct me if I’m wrong—also kills heart cells.”
     “Almost definitely on the hair, but it depends what we do. I can’t tell you about all the rest until we decide what to try. I probably won’t use bleo unless somebody tells me they had great results with it. I don’t expect that. But you know we can do a pretty good job of controlling the intestinal toxicity.”
     “And the tumor will likely stop secreting testosterone.”
     “Most likely. That will be one goal.”
     “I believe you, Bob. Thanks. Let me know.”
     Harry started to call Nora, but at least for the moment, couldn’t figure out what he would say. He also realized he was thinking how he would like to talk with Evie. With his dad. With Dick, his best friend. But they were all dead. His kids? No, too early in the game for that. It would only terrify them and wouldn’t be of any help to him.
     He had a stack of liver biopsy cases to review. The liver Fellow was off interviewing for a job in Chicago, and Harry was happy to be alone for the day, at least until one or another clinician inevitably barged into his office. He turned on the radio—a Beethoven string quartet played—and got to work. Every now and then, he turned to the computer to look up a patient’s laboratory test results or check the findings of imaging studies. Other than that, and one quick visit to the men’s room, he stayed glued to the microscope. Concentrating on the liver biopsies, he didn’t think about himself and didn’t even pay close attention to the music. Now, resting for a few minutes and drinking some water, he leaned back in his chair to listen to some violin piece he couldn’t identify and didn’t like—definitely not Beethoven.
     After dictating the last case, he turned once more to the computer and starting Googling “malignant Leydig cell tumors,” “metastasizing Leydig cell tumors,” “malignant Leydig cell tumor therapy,” and other variations. He didn’t find anything he didn’t already know. “Damn,” he said aloud.
     Nora didn’t pick up on his call. She was probably with a patient or in a conference and would phone back sooner or later. Her first question would be about the tumor. He thought about the autopsy that would be done on him. About which of his colleagues would perform it. He started to think about whether or not he would have an easy death, but shook his head and decided he needed a diversion. After breathing deeply for a few seconds, he suddenly jumped out of his chair and went down to the cafeteria for a frozen yogurt and then walked outside. It was a little chilly until he found a bench directly in the sun.
     What to do? What to do? reverberated in his head. What to do?
     Recollections of the lonely times he had in the months after Evie died came to mind. There were plenty of supportive phone calls—his children each called almost every day, as did his sister and brother—and plenty of invitations for dinner, most from widows he knew and some from widows he didn’t know.
     How he was okay without women until he and Nora met and, at about the same time and without his knowing at first, his tumor cells started secreting.
     And now? He checked his watch. He was scheduled to review the week’s liver transplant biopsies with the surgeons and others on the liver team in an hour and needed to prepare.
     Still, he sat there. What to do? What to do?
     Clouds began to cover the sun, and it was getting quite cold.
     What to do?
     He tossed his empty yogurt cup into a trash can and went back into the cafeteria.
     Inside, a freckled young woman—possibly still a teenager—wearing a hospital robe over blue-striped pajamas, with pink pom-pommed slippers, was heading toward the elevators. She pushed an intravenous fluids pole with some yellow liquid dripping into a vein in her arm. She wasn’t wearing a cap, and her hairless scalp was pale and quite shiny, but otherwise, she didn’t look at all sick. Her white earbuds were connected to an iPhone in one side pocket, and there was a plastic-wrapped sandwich in the other. Her head was bobbing side to side, and she was murmuring the words of some song—Harry couldn’t hear, but her lips were moving—as she took tiny dance steps back and forth. A big grin filled her face.
    Harry asked himself once again, What to do? What to do? And then he looked back at the girl as she sidestepped, almost hopped, into the elevator. He felt content, even happy, delighting in her carefree smile, and then he chuckled, thinking, Nothing. I’m not going to do a damn thing. Except call Nora. I’ll ask her to meet me at home as soon as she can. We’ll catch dinner after.