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. 

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.