Friday, September 14, 2018

I DON'T KNOW

     In medicine we , physicians do not ever want to sat ,'I don't know.' nor the patients want to get answer from their that they don't know . But truthfully we do have patients where we truly don't have the answer or know what else to do .If the physicians don't  know the diagnosis or have answers , then what kind of hope patient has or what kind of treatment they can expect ?Recently I came across some patients where I had not much to say . My unfortunate problem is that there is no other physician who has answer.

      So I saw this 70 years old patient almost a year ago . He has been a smoker and had some cough . His primary care physician did a chest x- ray and it showed abnormality . So I saw the patient . I did the work up . He had claustrophobia and could not and refused PET scan . I had tried mild sedation , but he could not do it . He did have a CT scan and that showed a mass at the center of the left lung . I did the bronchoscopy and there was narrowing of the bronchial tube going to left lower part of the lung . I did do some biopsy and that came back OK . I did follow up and did new CT scan . He also saw thoracic surgery and it was felt that we will do follow up on the CT scan . The follow up CT scan continued to show the abnormality and it was not any better or worse. I did second bronchoscopy and that showed the same findings and so I again did some biopsy and it did not show any cancer. I sent him back to the surgeon and asked him to do bronchoscopy or any other biopsy that he could do . I was concerned about the cancer . He told me that only 100% way to get the diagnosis was to take out entire lung . The patient was not keen on it and I was not sure if that surgery would be curative in view of the CT scan findings. He did do the Bronchoscopy under anesthesia and he had the same findings and the deeper biopsies were negative for cancer . We did new CT scan and it showed increase in the mass .So I sent him to a different chest surgeon. The new surgeon did get the PET SCAN done and it did show that the mass was metabolically active . This was highly suggestive of  a cancer . There was no other area in the body that showed the uptake , which meant that if this was cancer , there was no spread of the cancer. So he suggested taking out entire left lung . He came to me with family . He agreed and so the surgery was done . The left lung was taken out He did well.
      He came back for the follow up with  his wife. The surgery was done in different hospital and I had not gotten the report . So when he came for the follow up , I git the pathology report. To my surprise the pathology showed that indeed there was cancer . But not like I had suspected . It was not lung cancer . It was SALIVARY GLAND CANCER THAT HAD SPREAD TO THE LUNG !!
He does not have any abnormality in the salivary glands and there is no cancer there. nor the PET SCAN ever showed any abnormal pick up in salivary glands . So when they ask me as to how can he have cancer of the salivary gland spread to lungs , when he does not have cancer in salivary gland , I had to say 'I  DON'T KNOW '.