I have been in medical practice for many years and have realized that the medicine is never perfect or 100% . We can treat 2 people with same condition and same situation and same diagnosis and still not get the same results. We have the same machine but the result of the same treatment is not the same. So someone may say that it may be due to the circumstances or that people are not like car or any other machine and so people have different outcome. Some may say that it is due to KARMA, Whatever may the cause, we know that we get different results. But then the question comes as to how we can anticipate as to who is going to have out of ordinary results and then avoid the same treatment and do something different in these exceptional patients. Yes medicine is trying to do that and I often feel that our tests are not adequate. That brings me to the story for today.
I saw this patient in office sent to me by radiation doctor. She was 70 years old female who had noticed a lump on mammography and so they had planned lumpectomy and then radiation . The radiation physician had ordered a chest x- ray as she was a smoker and that showed abnormality. So she had CT scan done and that showed the abnormality and so she was sent to me. The original thought was that the abnormality may be due to scars. I saw the lady and she was current smoker and I felt that the abnormality could be a lung cancer . So I did the work up and she had Bronchoscopy and PET scan and then a breathing test. I had no 100 % proof that the lung abnormality was cancer but on PET scan it was showing increased activity and so I wanted to have her do surgery. Certainly she had breast cancer also and that needed to be taken out. So she had the breast cancer surgery and then the lungs . The lymph nodes were negative. (The lymph nodes drain different areas and so they can show the spread) So when the PET scan had no uptake in nodes the surgeon still did the lymph node biopsy before taking out the cancer and that was also negative for the cancer spread. So she had the mass taken out and and that was a cancer and the nodes on further biopsy did not show any spread of cancer. She had some issues after the surgery and that needed to be fixed but overall she did OK . So she had breast cancer and then lung cancer - both notice at the same time and taken out and no residual cancer as far as WE CAN TELL The pet scan had not shown any spread and the biopsy had not shown any spread.
We continued to follow her and she had a follow up PET scan about 8 months after the original scan and that showed that there was activity in the nodes . So now the question was is it cancer and if it is then is is RECURRENCE OF THE LUNG CANCER or BREAST CANCER .The breast cancer is notorious in it's tendency to come back after several months and sometimes years .So she did have additional biopsy and it was not breast cancer but it was recurrence of Lung Cancer.
So we had done a PET scan , which is suppose to be 85% accurate in picking up cancer and that was negative . She had the same lymph node biopsy before taking out lung cancer and that also did not show the cancer spread . Then she had additional sampling of the same nodes at the time of surgery to take out lung cancer and that was also negative . And now in less than a year - just 8 months she has the same nodes showing the spread of cancer. So the tests that we did were not adequate to pick up the cancer !
Just a note - some labs are doing what is called circulating tumor DNA - a blood test that will pick up certain DNA of the tumor to predict recurrence of a cancer earlier that it is obvious on scans. So this may be a future .But if CTDNA is positive then the question is How do you treat?