FIND THE ABNORMAL THING IN THE PICTURE

     When my kids were growing, there used to be a puzzle where the kids have to find out abnormal thing in the picture like a bird with one wing or a flower is missing a petal etc. Sometimes in medicine I feel the same way . Thre are so many things that are wrong that we have to go through them . In medicine we used to have dictum that symptoms are most of the time explained by one diagnosis or condition and one need not try to get to 2 or 3 different conditions that could explain them. That brings me to the story for today. 

   I saw this  years old male for pulmonary problems . He was nonsmoker and had been diagnosed to have asthma . He was admitted to a hospital and had treatment done for the asthma and then discharged. As usual he did not come with any old records .So I looked at the hospital records and realized that he had CT scan done and that had shown a nodule. So I asked him if any additional work up was done like special scan or biopsy etc. . and the answer was no. It looked like he had severe asthma and he needed steroids all the time . He had a nodule and he was wheezing . So I ordered a PET scan and scheduled him for the biopsy /bronchoscopy. The PET scan was done and that showed that the nodule had high pick up of glucose on PET scan and so the nodule was likely to be cancerous or at least needed further work up. 2 days before the bronchoscopy ,I was informed by my office that his insurance denied doing the biopsy and the procedure at the hospital where I had scheduled it . This was the same hospital where he was admitted  and had CT scan done , but they told us that it was emergency. He had missed doing the breathing test and he also did the blood tests for allergies , but he had continued taking steroids and so they would not be accurate. I saw him in office again. We decided to start him on some biological agents for control of asthma and did the forms. At the same time I called a interventional pulmonologist to do the biopsy who was affiliated with the hospital system where the insurance would allow the procedure .You might think that story would end here ,but no. The pulmonologist called me telling me that they made several phone calls and he did not answer even when they left messages .He also had severe back pain and so he was seeing spine surgeon. I again called him and made sure that he comes for the breathing test and also made appointment for him to see this new pulmonologist.

     So like the picture where we had to found odd or abnormal things , we have several things here . He has more than 1 problem - asthma , back pain and pulmonary nodule . He was admitted and and they did find the nodule but no additional test were ordered or done or follow up set - may be he did not want or do it -I don't know . Then the insurance covered the hospital for the admission and work up but would not cover out patient procedure . He did not show up for breathing test .He did blood tests while taking steroids - making the tests invalid. He did not respond to new pulmonologist for the biopsy.

    Hope we can get new medicines for his asthma and he will keep appointment with new pulmonary doctor and also get the biopsy done.

CENTURY OLD PROBLEM

     In changing face of medicine ,we are seeing more and more older patients. It is not uncommon to see 3-5 patients in a day who are more than 80 years old . But sometimes I have seen patients who are more than 90 years old . The problem with some of theses patients is that some are in good physical state but not mentally and some are good mentally and not good physically. So it becomes an issue as to how to treat such older population and many patients and families are not ready for conservative management till end. This brongs me to the story for today. 

      I have seen this patient for many years . He was admitted with some cough and then I was consulted .He was worked up and was dx to have fibrosis - scarring in the lungs .He had rheumatoid arthritis and the conclusion was that the fibrosis was due to rheumatoid arthritis. When I saw him in hospital , we had started getting new drugs for fibrosis but they were approved for fibrosis of 'unknown cause' - the so called 'Idiopathic fibrosis '. So I was not very keen on starting him on new drug at advanced age especially since the drugs have side effects on liver and also DO NOT CURE or REVERSE the process. As time went by we did get the drug approved for any fibrosis and . So, I started him on the medications He had some drop in oxygen when he would walk and so he was also started on oxygen. He was also getting medications for arthritis. He was doing OK . He was very active and had a day care enter and had 65 kids in it and used to go there every day for few hours . He was using oxygen ,but sometimes did OK even without it . He did have a set back when he had bleeding from the stomach ulcer and needed blood transfusion. 

    Years passed by . He was now 99 and then would be 100 years old soon . We do breathing test to see if he was any better or worse . WE HAD DONE IT BUT WE HAD NO NROMAL VALVUES FOR 100 YEARS OLD PATIENT. Then the specialty pharmacy called our office informing us that he had passed away. He was old and so I did not think much. The disease was bad and he was very old and more oxygen dependent now. But then he showed up in office as the medications were stooped by the drug company. We were surprised and we did new forms for him to get the medications. 

    He had been getting worse and was more short of breath and also needed to be on oxygen 24 hours a day. He was 101 years old . I ordered CT scan . Now here is a problem . If the CT scan would have shown 'worsening of the fibrosis ' I could have changed nothing. He was mentally fine and was only physically getting worse .But I did and the CT scan showed that he had 3 MASSES and had swollen Lymph nodes suggesting inoperable lung cancer!

    Now what ?I called him and his wife in office. I was not sure how much work up we can do in this 101 years old patient with need for oxygen all the time. I also knew that unless we have biopsy, we cannot give him treatment like chemotherapy and the chemotherapy would not cure him but cause many side effects, which will make his life worse. So, what can I offer ?I decided to send him to radiation doctor and also to interventional pulmonary specialist and also radiologist. The radiologist could do a needle biopsy - but he was not very keen due to to his advanced age and high risk of collapse of lung due to location of the mass. The same was with the interventional lung specialist. The patient and his wife made it easier for me . They decided NOT TO DO ANYTHING at this time. 

THE CHANCE

    I have seen progress in medicine and many of the diseases which had no specific treatment in past ,now has some and we are making progress. But sometimes when a new drug comes to market , there are people who 'demand' it be used and there are some physicians who use it. I feel that sometimes there is some  overuse. Recently a drug came in market for COPD -chronic obstructive lung disease, which is relatively old drug and approved for asthma and  some other conditions in past for last few years , and now approved for COPD. The drug representatives were in my office the other day and were asking me how come I am not using it yet . My answer was I need to find appropriate patient for the use . But your collogues are using a lot  ,was the comment. My answer was may be they have more appropriate patient . But that brings me to the patient for today.  

  I had seen this male patient - may be  years old 3-4 years ago . He had chronic cough and so we did the work up . It looked like  that he may have some allergies and some mild asthma. I did some investigations and did treat his asthma , which was seen on his breathing test , but he had some reduction in his diffusion capacity. The oxygen and carbon dioxide 'diffuse' across the lungs  or air sacks and when we m= checked that as part of breathing test , we found out that that was reduced . So I did CT scan and he had some  ILD - Interstitial  Lung Disease. - something that can cause fibrosis - scarring in lungs and also can cause cough and shortness of breath. ]This also can be seen with allergies and also can be related to certain medications and then some have no known cause and so we call it Idiopathic . This last one has poor prognosis . 

  I did the work up and he had no known allergies  and no work history and the bronchoscopy did not show any infection. So we talked on the diagnosis and some treatment . The drugs that were approved in may be are costly , do not reverse or cure the disease , but just reduce the rate of decline . In my personal opinion, which I had expressed in an interview when the drug came out in USA is that we do not have clear cut knowledge as which patient will get worse and which will not. So, it is very difficult to decide - o tests that can tell us on the 'chance' of worsening .So I do repeat tests in 4-6 months and anybody who worsens we start the drug . If they are very sick and have need for the oxygen ,then I start then quickly. 

  This patient had family history of such lung problem and so he was to go to John Hopkins for some research. We watched him . He did not get worse , but he was stable for a year or more and then I continued to do follow up. He had also gone to Hopkins and they did some blood tests on genetics work up. He continued ton do follow up and the cough had subsided and then the diffusion got better and after 3 years or more his last CT scan shows minimal scarring - the CT scan is significantly improved. 

   He does not need medications and if I had started him on medications , he would have been counted as 'success story'. The drug company has data that shows that when medications were started 'early ' they did better , but how many of them could have not had progression of the disease even if they were not on drug? This is impossible to be determined as we cannot and will not hold the drug if we have the worsening disease.

   My be in future we will have some tests - markers that will tell us as who is going to get worse and we can start drug quickly, and not overuse it.   

DOUBLING TIME AND VARIATION

    I see many patients who have abnormal CT scan and the scan shows nodule , we do tests to find out as to the cause of the nodules . Just for the sake of knowledge, the solid nodules , and nodules with speculations are more likely to be cancerous than ground glass  nodule which is like haziness. There are many things taken in to account when we think of the nodules and they may be male- female, size of the nodules and characters of the nodule , smoking history, age , upper lobe -lower lobe etc. But with smaller size we tend to do follow up of scans . How often one should do scans is based on possibility of the nodule being cancer and growth pattern and how our science can detect it at it's earliest . The nodules which are very small are impossible to be biopsied. Her we think of doubling time of cancer - how long does it take for the nodule to become double it's size in volume. The fast growing cancer will double in 45 days and slow growing will double in more than 1 year , but many will do size change which can be detected , in 90-120 days . This brings me to the story for the day. 

   I have seen this patient and his wife for last 10 years or so. Bothe of them were smoker and had COPD -emphysema and they were on medications , needed oxygen at times and steroids . Also needed hospitalization. But continued to smoke . He had a ct scan of chest may be 2and half years ago and gthat showed a nodule . The nodule was small and so we talked about the possibility of cancer as he has been smoker and he did not want much testing and ,so, we did do follow up of the scan and he agreed . The new scan was done and that did not show much change . Then we did do another follow up and that showed that the nodule had grown and now it was over an centimeter . So I asked him to do PET scan . He was not very keen on doing PET scan, but finally he did it. The nodule did pick up and so it was now more likely to be cancerous . He was not a good candidate for surgery as he needed oxygen and had poor reserve - based on breathing test to undergo surgery and resection. So I suggested doing radiation after doing a needle biopsy. He refused biopsy and did not want radiation, but wanted to just do follow up .I told him that if the nodule becomes too big - larger than an inch, short course f radiation will not be option and then he will need prolonged course of radiation. He still did not want radiation. So I have done few more scans and then nodule has grown by very small amount may be 2 mm - 25 mm make an inch . Almost 3 years have passed by since we detected the nodule first time. I am sure that he has a cancer , but it is growing at such low rate that he falls out side the 90-120 days rule. 

 So much for the doubling time discussion.

MISSED STEPS ?

   In medicine we often see that the patients  have come symptoms and then the investigation is done and then we end up with dead end .But then tracing back the work up we realize that we should have taken different course of action / work up. It is often stated that 3rd doctor is smarter than first two as the first 2 physicians have done some work up and have ruled out certain diseases. I also often say that your eyes don't see what your mind does not think.'That brings me to the story of today's patient. 

   I saw this patient in office as the care giver was my patient. She had no relatives and this patient of my was taking care of her in her own home. She was relatively young late sixties and had been smoker and had high blood pressure and dementia. She had some cough and then a chest x- ray was done and that showed some abnormality and so the PCP ordered CT scan chest and when that came back abnormal , snt her to oncologist. This is first missed step. When the diagnosis of cancer is not established what is oncologist going to do? The oncologist does treat cancer with chemotherapy or now a days Immunotherapy. But when we don't know if patient has cancer or what type , the oncologist cannot do anything . The oncologist decided to do PET scan. The PET scan shows uptake of glucose in whole body and organs and when the uptake is higher at a particular area which correspond to the abnormality on CT scan , the suspicion for cancer is increased . Again the diagnosis is not yet established and it is only the possibility of cancer that is increased as infection and inflammation also can show increased uptake of glucose. The PET scan was scheduled but not done and the oncologist sent her to Chest or thoracic surgeon. In my estimate this was second missed step. The CT scan findings were indicative of left lung mass and possible SPREAD TO CENTRAL LYMPH NODES . With is findings the patient will not be  candidate for resecting or cutting out cancer. If the central or hilar nodes are involved by cancer, then cutting out primary cancer does not help to improve prognosis  and patient is 'inoperable'. In addition to that ,she was  a smoker and had COPD the lung disease that is caused by smoking and that reduces lung capacity. We did not know if she had enough RESERVE lung capacity to undergo surgery in which part or whole of left may need to be removed. In between someone sent her to radiologist to do biopsy of the mass in the lung and that did confirm the lung cancer. Again this may have been miss step as we still did not know if the lymph node was showing spread or not , and that is a crucial step Then the care giver asked me to see her . We did schedule PET scan and also did breathing test. She was also sent to a interventional lung specialist for the biopsy of that lymph node which was seem to be involved.

    The PET scan did confirm uptake in lung mass and also in various nodes .So essentially she was not operable / resectable. The breathing test did show significant reduction in lung capacity and so she would not do well with surgery. I explained that to patient and the care giver . Patient had some dementia and so I was not sure how much she understood. I spoke to the care giver, but she was told by oncologist that she needs to be seen by chest surgeon and have surgery. So they had mind set on surgery. 

  

NOTHING IS KOSHER

    In medicine we have often talked on rare bird or certain things that we feel comfortable about certain findings .But the medicine is statistic and as one knows that not 100%. So I say there is nothing is Kosher. I have often stated that with statistic ,one can put one hand in boiling water and other in ice cold water and YO ARE AT COMFORT !! But in medicine we have certain things that are common and when we are proved wrong or we have deviation from 'usual; we don't like  as we did not expect it. That brings me to the story for today.

  I saw the patient about 70 years old male who has been 2 pack a day smoker. He had a CT scan done by PCP and that showed a nodule about 13 mm - just half an inch in size . So he was sent to us . I did start the work up .I explained the patient that, I am concerned about high chance of cancer and needs to answer 3 questions ,i.e. Is it cancer , Has it spread and What can be done as treatment. I ordered a PET scan and breathing test and did bronchoscopy. Some how he did not do pet scan for 6 weeks and rest of the work up was done. He came to see me again . The bronchoscopy did not show much and so when we had done washing and brushing - what I call as pap smear of the deeper parts of the lung came back as normal. But the PET scan was not normal and to my surprise, the nodule which was 13 mm was now 21 -23 mm and had increased uptake, indicating that it was likely to be cancer. But more than that the growth in such a short time indicated rapidly growing or aggressive cancer .I also was not very happy that many of the lymph odes which were not reported as enlarged , were enlarged and had uptake, indicating spread of the cancer. 

  I explained it to him and decided to send for additional biopsies and also have chest surgeon look at him in case the nodes are not positive then he can resect it out. 

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.