NATURE OR NURTURED OR KARMA

    I have been in practice for many years and I have seen patients and their family members. It is is not uncommon to have patients - husband and wife to go to same family physician, but for them to have same system problems like lungs also is not that uncommon. Again we ac see lung related problems in both husband and wife simply due to smoking history or exposure. So I have seen husband and wife with COPD - EMPHYSEMA as both were smokers and I have few pairs of husband and wife who had cancer of the lungs. But I have also seen some families that have diseases that cannot be explained on the basis of smoking or exposure that could have happened being living together. Again genetics could explain, but it is not that common. That brings me to case for the day. 

  I had seen this lady several years ago - may be 25 years ago. She was a smoker and had high blood pressure. She quit smoking and had abnormal chest x- ray. We did the usual work up and she had cancer of the lung and she had decent lung capacity and there was no evidence of spread of the cancer . So she underwent a surgery and she had cure . She did well and came to me for follow up for 2-3 years and then stopped coming . She came back again for some cough. She had not smoked for almost 30 years and she had no new diagnosis other than high blood pressure . Her daughter also used to be my patient . She had 3 daughters and each one of them had major medical problem. One that was my patient had scleroderma  and had some scar tissues - fibrosis of the lungs and had other problems associated with scleroderma . She was on oxygen and she did not want lung transplant and she continued to get worse over period of 5-6 years and then dies . Her other daughter who had seen me for short time had diagnosis of lupus and had developed kidney failure and over period of time she got worse and then needed dialysis and that was continued for several years and then she also died . Her third daughter also had many medical problem and I never saw her as patient as she was not here and when I talked to patient about her , she was in nursing home at very early age due to medical issues . 

   So, here we have a mother who had cancer of the lung and she got cured , had 3 daughters who all had various medical problems and they all dies BEFORE patient and they did not have smoking related diagnosis but had so called Autoimmune disease like scleroderma and lupus etc. What could explain such sad story? How could they had that bad gene that made caused the diseases and made them so sick that they died before their mother? Certainly all were in the same environment and that could not explain. So then what was the cause ? I do not know  But may be KARMA and some kind of give and take that brought them together . 

   By the way may patient had new spot of the lung and she refused the work up as she told me that if she has new cancer she was nnot going to do anything about it. 

THINGS ARE UNUSUAL - BUT MAY BE NOT THAT MUCH

    I have been in medicine for many years and have seen things that are very very common like asthma or COPD , pneumonia and may be even cancer. But sometimes even common diseases can present as very interesting presentation, though anything that is interesting for for health care professionals is bad news for patients . That brings me to today's story.

  I have been seeing this patient for a while , She has been ex smoker -quit many years ago and had some COPD . She has had routine x- ray - CT scan in past and that was ok . But this time she had sputum tinged with blood. So I did new CT scan and the report was very sketchy, There was mention of some abnormality in right bronchus , but no mention of any tumor.  I had planned bronchoscopy any way and  then with the abnormal findings on CT scan, i also ordered PET scan. In PET scan glucose pick up of normal tissues / organ is compared to the abnormal areas seen on CT scan and if the pick up is increased that indicated cancer - infection etc. . The accuracy of picking up cancer is about 80%.The bronchoscopy was done before the PET scan was done and that showed that the main bronchus - was narrowed and that looked like external pressure. There was no mass as such that I could biopsy. I did do some brushings - pap smear from  the bronchus. The PET scan was done and that showed that there was a mass and that was making the right bronchus narrowed and there was greatly increased in that mass suggesting that it was cancer. But the scan also showed that she had increased uptake in thyroid .She had seen thyroid specialist less than one year and had biopsy and that was OK. But the PET scan was abnormal and so I asked interventional radiologist to do biopsy of the thyroid . The lung mass was there too and so I called interventional pulmonary doctor and he did do ultrasound guided biopsy and he called me that preliminary report was that it was thyroid cancer . The thyroid biopsy was done before the lung biopsy and that also showed thyroid cancer. 

  So I called patient and told her that she seems to have thyroid cancer that has spread to lungs . I also called oncologist too and ask him to see her. But the story did not end there . I checked the final report on the lung biopsy and that was not a thyroid cancer but it was usual lung cancer !!So she had 2 different cancers -one thyroid and other lung cancer . Due to location and spread  to the central lymph nodes , that was not resectable or operable and so we will need chemo and may be radiation . I am not sure what would be best for thyroid cancer - ? surgery or some different chemo or both ? I will let oncologist decide on that.

ALL GOOD THINGS MUST COME TO END ??

  We often say that all the good things must come to end. So does it apply in medicine? Many a times we have patients who have bad news or a bad diagnosis and it feels like the things are not going well. But then  things improve . We are happy and so is patient. In some cases the events take turn for better and then the patient is on recovery path and certainly that can and does last for long time. But in some cases this does not happen and usually we KNOW that or have EXPECTED that . This is a story for something like that. 

   I saw this patient few years ago - may be 10 years ago. He was a young male who had smoked and had continued to smoke and had COPD - the chronic lung disease that happens when one is smoker. He had diabetes too. He was not very compliant and had blood sugars which were high and the HB A1 c was also high . Every time he came for the follow up we had a talk as he did not even attempt to reduce smoking  and sugars continued to be elevated . One day we did a CT scan and he had abnormality . WE did the work up and he had MAC- atypical TB -called mycobacterial avium. He was treated by me and we did get infectious disease to se him and he did OK . The Ct scan improved and the sputum recheck shoed that the bacteria had cleared . We did do follow up and he was doing well and had continued to smoke and also had uncontrolled diabetes continued . As a routine we did follow up CT scan chest - it was almost 2 years that he was diagnosed with MAC and wanted to see if we could stop the treatment. The CT scan was abnormal in past and i did not expect it to be normal as he had a cavity and that would have healed with scars and so the abnormality will be still there . This time the scan was abnormal and it felt that he may have some lymph nodes swollen. That could be due to the MAC or could be due to cancer as he had continued to smoke. We did the further work up and did what is called EBUS- ultrasound guided biopsy of the nodes and it showed lung cancer. The COPD was bad and he had oxygen and the type of lung cancer was such that he could not have had surgery even if he had normal lung capacity and with lymph nodes positive he would not have been a surgical candidate. He was sent to medical oncologist and he was started on chemo.  He continued to smoke and he had some issues with chemotherapy. As the immunity is suppressed with chemotherapy, we continued him on MAC medicines , as otherwise the MAC would spread with body's immunity reduced. 

  The time was going on and 2 years went by and I was thinking that he is 'cured ' of cancer in spite of smoking and he was off the chemotherapy . But as I said all good things come to end , new CT scan dne had shown new lesion and older spot was growing and the nodes which were down in size were increasing in size . So he had recurrence!

   I have talked to him and the work is started again to see if he has new cancer or old one back.

DO NOT ASK FOR THE DIRECTION TO PLACE WHERE YOU DON'T GO

     In medicine I have said that do not ask for the direction to a place where you do not want to go. As we are seeing aging population, this has become more and more common . Patient having some blood in stool will need work up . But then if the patient is very old - and very old can be determined by family and physician only - and say has dementia , is it worth finding the cause and doing million dollars work up with INVASIVE procedures which have some risk, when we know that we are not doing the treatment which is ideal like surgery. A good doctor may suggest certain work up and treatment and a good doctor will take in account not only the diagnosis , but also other factors. That brings me to story for today. 

    I saw this 85 years old female . She had pain in abdomen and so she went to walk in clinic and they did Ct scan of the belly - abdomen. (I am not sure  as to what was the thought process -or differential diagnosis that they did CT scan -but now a days that is a knee jerk reaction) .The scan showed no abnormality in abdomen or pelvis , but showed a nodule in the lung . She had a CT scan of chest in past - few years ago and that had shown a nodule  and she had seen a lung specialist 4 years ago. And he had told them to watch it , rather that doing additional biopsy etc . That had happened 7 years ago . So she was 78 years old . Again I was not the physician and not sure what was taken in to account when the decision was made. The size of the nodule was smaller and now after several years when CT scan of belly was done it appeared to show increase in size. So she was sent to me. She had not done CT scan of chest. 

   She was older lady but seems to understand very well and was accompanied by caring family. I looked at reports and also tried to find out any old reports that might help. I tried to check 2-3 hospital and radiology centers to see if there was any scan of the chest in last 3 years and could not find any. She had no pulmonary complaints. If the size seen on scan of the belly was correct the spot or the nodule had grown in last few years . So it was likely to be slow growing cancer or a scar cancer - cancer developing in old scar. Either way we needed work up . I often tell patients that we need to answer 3 questions - 1 Is it cancer 2 Has it spread  and 3 what kind of treatment we need / can do.  The treatment of cancer - if it is - is surgery-radiation-chemo. Here comes the point of making decision as to what kind of work up we should do. If the patient does not want surgery or it is felt that the surgery is too risky then how much should be the work up? Ideally we would do PET scan , Breathing test to assess lung capacity and biopsy. But if patient does not want any  treatment like surgery or chemotherapy, how much invasive work up we should do. If we don't want to go a place why should we ask for the direction to that place ? This lady did not want surgery and chemo and the family agreed . Then do we need to do biopsy ? I suggested doing a PET SCAN which can pick up cancer in may be 80-85% of the cases So I decided to do the PET scan and if that is positive , consider radiation treatment without biosy or just do follow up Ct scan in 3 months and see if it grows . 

    Again I would be curious as to what would AI suggest . 

RIGHT OR WRONG ?

     In life we often say that each one of us has opinion and sometimes we have 2 opinion especially if we are talking about politicians. But even normal people have different opinions and the same hold true in medicine. Most of the time we all have same opinion -may be because we all read the same book or have seen same study. No one will argue about treating high blood pressure or high blood sugars. But then we it comes to certain other conditions in elderly , we have different opinion. No one can state that his way is the only correct way. Take for example HBA1C , the indicator of diabetic control. In younger patients we like it around 6 or may be even less-close to as normal as it could be. But in elderly such a tight control is not good or could be detrimental. In elderly patient who may be living alone or who may be living with spouse who also may be elderly, it is more dangerous to have low blood sugar than high sugar . The low sugar can lead to unconsciousness and brain damage , while high blood sugar -not extremely high sugar is not that bad. This kind of thinking brings me to case for today. 

  I had seen this 80 years old patient in office . He had diagnosis of lung cancer and then we had surgery and he did well and did not need any additional chemotherapy of radiation and did ok .He did have some shortness of breath and I saw him and the work up was ok .He came to me for few months and then stopped . After a gap of 3 years he came to me and had some shortness of breath and we did do new CT scan and that showed density next to  suture line. In past we had seen that density and followed it and it was stable for couple of years. This time it looked like it had increased. So, I saw him . By now he was elderly , fragile and had some dementia. He had reduced activity partly related to shortness of breath and partly related to aging , dementia etc. I did order new PET scan and new breathing test. The wife was a nurse  and she wanted everything done and wanted to see thoracic surgery - the same one who had done surgery 3-4 years ago . I ordered the tests and she saw him. He ordered a biopsy of the mass. I did PET scan and that showed very high uptake in the mass -suggesting that it is cancer . Certainly we did not know the exact diagnosis or what type. The physician who was to do the biopsy is in the same group as the surgeon. I had suggested asking radiation doctor to see him as I did not feel he would do well with surgery cutting out part of the lung and also he would do well with chemo. The wife wanted surgery as 'that is the BEST treatment for the cancer'. But the surgeon agreed with me and told her that doing surgery was too risky. I had suggested not doing any biopsy but just based on PET scan treat with radiation . But the surgeon wanted his group doctor to do lung biopsy. I asked them - if biopsy is positive - would you take chemo the answer was NO. I asked if the biopsy is negative for the cancer would consider radiation treatment based on PET scan? the answer was YES . So my question is why do a test that does not change the course of treatment in this elderly fragile patient.  

    There is no answer and he will have the biopsy and radiation treatment !! RIGHT OR WRONG.

  

GOOD OR BAD ?

      In medicine we make decisions  and then live by it. The decisions are made based on our understandings of the tests  and not all are available for all of us .Could AI make a different outcome - I don't know . I don't think so. So most of the time we are correct and sometimes we are not. So the new tests are developed .That brings me to the story for the today. 

     I saw this lady several years ago. She had mild asthma and she came to me and we did tests and then started her on medicines and she did well. But ew people have this thinking that they can 'cure' the decision and then they will not need medicines . It does not happen in many conditions, but still some think it in that way. So she went to allergist and he did tests and then continued the same meds. But she did not come back to me. She was stable and then after 3-4 years she had shortness of breath and she was admitted and I was called. She had a clot in lungs  and that made her short of breath. The asthma was stable . But when a CT scan was done, she had not only pulmonary embolism, but also ha =d a spot on the lung . This was not seen before  and she was concerned. She has been nonsmoker  and had new clot. So I decided that we will do the out patient work up. But at this time we wanted to have her treatment for the clot. The oncologist was also called and they concentrated on the clot rather that the spot on the lung. She was discharged  and then we did the work up as out patient. 

  She was treated with blood thinner /anticoagulation. She had follow up with her cancer doctor and no new tests were done .She came to me after 4-6 weeks . I ordered a PET SCAN As I have mentioned in my previous blogs the PET scan shows metabolic activity of the cells and is good in 85 % cases for picking up cancer. We decided to do bronchoscopy and we had to hold the blood thinner for 3 days and then the bronchoscopy was OK. We had done breathing test and I had asked her to see a chest surgeon too. The PET scan was showing that the spot on the lung was hot -it had pick up and so I had her see the thoracic surgeon. He saw her and no decision was made. She came to see me and by then it was almost 6-7 weeks from the PET scan. I saw her I was expecting that the surgeon would have done the surgery and then I will see her. SO when I saw her in office and no surgery was planned, I called the surgeon and scheduled her for new CT scan . The surgeon called me and he could not tell me why no surgery was planned , but he agreed that the spot needed to come out. The new Ct scan was done and she had the same spot with may be minimal increase.

    The surgery was done  and - and - there was no CANCER. It was a infarct related to the clot. With the clot part of lung had infarct and bleeding and so that did not get better with time. But it was not cancer. 

   So the decision made based on PET scan was correct , but the Good news was that there was no cancer  and Bad news was that she had surgery- a invasive procedure . 

  We have some new tests - CTDNA - circulating tumor DNA, Nodify etc. . We check the DNA of the cancer cells from simple blood test , we have antibody for cells and protein associated with the cancer etc. But NONE is 100% . Hope we will have it one day. 

DR GOOGLE

    I have done my medical education many years ago and since then the medicine has grown and we have been able to keep with new developments . But now a days we have added the burden of computer educated generation where patients have seen . checked on computer and think they know the answers 

  We still have many patients that trust their doctors , but still we have sometimes problem and we have to explain things . It is difficult to wife off the slate which is not clean to start with and write new things .  Sometimes it is not fault with patients but with people surrounding  That brings me to the story for today.      I saw this 80 plus years old patient in office for shortness of breath . HE was smoker and had diagnosis of laryngeal cancer and that was treated and he was better and was in remission . He had COPD  and he has shortness of breath  and so he came to me . I asked him questions and I found out that he was admitted to hospital  and he had CT scan and that had shown nodule , the so called spot on the lung, He did not have any new Ct scan after the discharge 4 months ago.  So I ordered the new CT scan and that showed that the nodule had grown . That means that it was likely to be cancer . Since he had laryngeal cancer , there was possibility of new lung cancer or metastasis. So I ordered the PET scan . The  PET scan  picks up cancer may be 85% of the time . The PET scan showed activity in the lung nodule and also some activity in food pipe esophagus . We had done breathing test and he had severe compromised lung function. He was older and had bad lungs and enlarging nodule . So I asked interventional lung specialist to see him and do navigational bronchoscopy and biopsy . Ehen the biopsy was done it came back positive for cancer. She called me and the family and she wanted them to see cancer doctor - oncologist  and Gastroenetrologist.  I called the family as I wanted to discuss the further work up and treatment plan . I was told by family that they know it is cancer and what was I going to do . I insisted on bringing them in .

    I had discussion with them  and i was glad that they came . They were confused between oncologist and Gstro. I told them that he did not have great lung capacity and he was not a candidate for lot of invasive tests . But we needed to know if this spot - that had biopsy positive for cancer was ARISING IN LUNG or had started in esophagus and SPREAD TO LUNG . The distinction was very important as if there was no cancer of esophagus , then we could do short treatment of the lung cancer called stereotactic radiation and that will not cause much problem with h9 compromised lungs and has some cure rate . In contrast to that if he has had esophageal cancer, then treatment of the lung nodule will be not useful and then either chemo or localized radiation to esophagus will be needed  and that may cause difficulty in swallowing and need feeding tube - may be. These kind of things was not there when thy had checked on  Google. 

   I cleared him for doing endoscopy and when they left they were happy that they came. .  .