Saturday, September 22, 2018

HOW AND WHY IN MEDICINE

       In medicine we often asked the question as to how does someone get cancer and why does this happens . The common diseases like high blood pressure or diabetes , no one asks this question . In pneumonia or Tuberculosis , we know the answer of how , but not why . One can say in case of Diabetes , that the insulin lack causes the diabetes , But we do not have the answer to 'why' . In high blood pressure we do not have any answer as to how and why . In case of cancer  we know NOTHING . We do have bits and pieces on to how cancer develops . We know that chronic irritation or tobacco increases the 'chance ' of getting cancer . But we still don't have the answer as to how and why . But today I am talking about a patient where there is how and why , but in a different way .

      I saw this patient who was 68 years old and had some cough and then the primary care physician did the chest X -rat and then the CT scan , The CT scan showed a nodule . He was a nonsmoker . He had history of prostate cancer and it was treated and 'cured ' He also had tonsillar cancer and it was treated and he was 'cured ' He was not a smoker and he had no other major medical issues . His physical examination was unremarkable . He had clear lungs and the oxygen saturation was good. I did PET scan and also the Bronchoscopy . I also did the breathing test . The breathing test was good and was normal . He underwent bronchoscopy and it was normal . The nodule was too small for me to do any biopsy. The PET scan where glucose is injected and the uptake is majored . The higher the metabolic rte , higher is the glucose uptake and higher is the chance of cancer . The PET scan showed increased uptake though it was not very high . So i saw him in the office and discussed the various options . One option was to do a needle biopsy . The needle biopsy has some risk of collapse of the lung and the sample is small and so not 100 % if it does not show cancer . The other option was to do follow up of the Ct scan . The good part about it is that it may 'save' an unnecessary  surgery , but the disadvantage is that if cancer , 'waiting' may increase the chance of cancer spreading . The first Ct scan and the time that all this happened was almost 6 weeks . I sent him to chest surgeon . The surgeon did a new CT scan and it showed that the Nodule had increased by very small amount . But taking in to account the PET scan finding and the small but definite though small increase in size in short time , we decided to do the open biopsy .
      The surgery went well and he came back for the follow up . The pathology showed that he had MELANOMA which is skin cancer in lung . That meant that the melanoma - a skin cancer has spread to lung , But he had no history of the melanoma ,nor the PET scan had shown no activity or pick up anywhere but lung nodule. So the patient asked me as to how can he have the skin cancer spread to lung when there was no skin cancer in first place. HOW is this possible and WHY did this happen ?I do not have the answer .