IS IT EVER SAFE

     In medicine we have many terms used and one of them is 'cure rate' or recurrence rate. This is tru especially in cancer diagnosis. If we have a patient who has say 1 cm lung nodule  and we  do surgery and it is taken out , and we have no evidence of spread of the cancer at the time of surgery, we call it a success. But is it really a cure ?The answer is yes and no - many will be cured and some will have recurrence of the cancer . We usually do  follow up CT scan for 3 years as the majority will recur in 3 years and if there is no recurrence of cancer in 3 years then we are 'safe' and the chance of recurrence is very little. This brings me to the story for today. 

  I saw this lade few years ago. She was a nonsmoker and had kidney cancer taken out several years ago - 5- 6 years ago. She was followed by a cancer specialist and he did CT scan every so often . One of the CT scan showed some nodule - a tiny density . He told her there is not much and wanted to redo new CT scan . She came to me and I reviewed the scan and really she had very tiny nodules . At the given size not much could be done as diagnostic test. The bronchoscopy, of needle biopsy or open biopsy could not have ben done to get tissues diagnosis. The PET scan is good for cancers that are at least 8 mm in size . Sometimes we do get it positive for little smaller but then most of the time it comes back negative and then radiologist states - too small to be picked up on PET scan- and we have spent money and sometimes patients get wrong impression. So we decided to do follow up on CT scan . 

     I continued to do  new scans for 3 more years , which means the renal cancer now was diagnosed 8 years ago. But the last 2 scans were showing some growth - still less than 8 mm. Then the last one was 11 mm -one of the nodules -the one that was growing . I decided that she will need biopsy  She was having difficult time with appointment  for biopsy and she finally was scheduled for the biopsy. 

     AND THE BIOPSY SHOWED KIDNEY CANCER !

So the cancer took all most 9 years to recur in lungs . That is why we should call not a cure , but 'disease free time '. 

THE MESSAGE AND THE MESSEHGER

     We have a saying that don't kill the messenger. But sometimes the message is bad and not easy to accept, then people kill the messenger. In medicine I have seen it personally. In spite of advances in medical science, we have diseases that are simply bad  and no matter what treatment you offer, it is not enough and certainly no cure. I have had that experience in past and I am sure I will have that in future. This brings me to the story for today. 

    I saw this 70 plus years old male patient ,who had some cough and some shortness of breath. He had moved here from near by place and was seen by lung specialist and followed by them for 2-3 years. He was ex smoker and had not smoked for may be 10 plus years. He had breathing test done and CT scan done in past. He was started on inhalers and he was OK. Then he started coming to me . I saw him and then I felt that he did not have much of COPD or obstructive lung disease which is related to smoking, but had FIBROSIS. I did do new CT scan of chest - called NRCT -HIGH RESOLUTION CT scan and also did breathing test. The Ct scan showed fibrosis and that was significant. I got hold of old CT scan reports and he did have FIBROSIS IN OLDER CT SCANS ALSO. We di assessment for need for oxygen and he needed oxygen. So now he was on oxygen and I discussed with him on the diagnosis of fibrosis and told him that he had it in past and seems like he was getting worse ,and so we needed to start him on medicines for fibrosis. The problem with medicines for fibrosis is 3 fold . Number one is that it DOES NOT CURE OR REVERESE the process. It slows down the decline. I tell patient that the reduction in lung function continues and does not stop , but the rate of decline is reduced - it continues rob dollars but instead of $100 , it now takes only $50 or so. Then second issue is it does not reverse anything. So the damage which is there does not get better , And lastly , it is expensive. My be as much as $25000 per year. So we need forms to be completed and get patient approved and then copay and other things that are associated with these orphan medicines. There are 2 medicines for the fibrosis - now for last 3 months 3 . I ordered one and the insurance denied the coverage. I was not sure why and we appealed and went through circle of calls and transfer and did not come to any conclusion. Then I realized  that they covered other medicine and not one that I had asked for.

    In between there was a drug trial going for the medicine - same one but as nebulizer and not a pill and we got him in it . He continued to have cough and continued oxygen . He did not get worse on his breathing test, but he felt he was NOT GETTING BETTER OR CURED. I had to tell him that he is not going to be cured and the disease will continue to get worse INSPITE of medicines . 

   He was not happy and dropped out of the study and decided to seek second opinion.  

   The message was not good and so he did not like it . 

  

THE GOOD AND THE BAD NEWS

      In medicine we often say there is a good news and a bad news. Many a times when I see patient who has abnormal CT scan and then we do the work to get diagnosis, and then the biopsy shows cancer, i sometimes say that there is a good news and a bad news . The bad news is that he has cancer but the good news is that it has not spread anywhere and we can do surgery. But sometimes the situation is different. That brings me to the story for today. 

    I saw this patient who has been a smoker in past and had chronic lung disease, COPD. She was doing good. She had routine Chest x- ray and that was abnormal and so we did do a CT scan of the chest done and that showed a mass . We did usual work up . She had PET SCAN and had  breathing test and also Biopsy. The PET scan showed activity in the central mass on right side and also some in thyroid . We did do the biopsy of the lung mass and that was lung cancer . The thyroid biopsy was also positive for cancer. The tumor in the lung was such that it had spread to nodes in the center of the lung  and so there was no way we could do the surgery. So we decided to do radiation and chemotherapy. The tumor was blocking the bronchial tube and so I we asked for radiation treatment . She had both and did well . 

    The new scan showed that the mass was smaller  and uptake was also reduced . So she was doing good , but she had cough and that was bothering her. She was treated with steroids and she felt better but still had cough. So, I decided to do bronchoscopy  and that was to see if she still had tumor.. What I saw was a significant narrowing of the bronchus which was blocked by tumor. The opening was so much narrowed that I could not see beyond it . It was inflamed  and that probably was the cause of her cough , So, the cancer was not there but the radiation had  killed caner , but also caused narrowing  and so she had cough . 

    There was no medical treatment for such mechanical blockage. I am not sure if we could dilate  it and open it.

 SO THE GOOD NEWS WAS THAT THERE WAS NO CANCER , BAD NEWS WAS R=THAT SHE HAD POST RADAIATION NARROWING WHICH MAY NOT BE IN POSITION TO OPEN UP.

WHEN YOU HAVE ONE YOU MAY GET SECOND

      In medicine we are taught to have one diagnosis and then differential  diagnosis. Which means one is more likely the explanation of the symptoms , but there are alternatives to that also, which is differential diagnosis. But not to have 2 separate  diagnosis for 2 different symptoms. This meant we have to have explanation for 2 different symptoms as one diagnosis not 2. But that is for symptoms at one given time . I want to talk about cancer and want to state that when there is one cancer, then one has higher chance of getting SECOND CANCER. That brings me to the story for today. 

    I saw this lady for abnormal CT scan chest. She was not a smoker and had COVID pneumonia. She was doing better but the pneumonia on the CT scan was not gone. She had no fever and had cough and clear sputum . No chest pain and the weight was stable. She did not have wheezes. I decided to do a follow up CT scan as the x- ray improvement lags behind clinical improvement, which means patient feels better but x- ray take longer time to improve. The new CT scan which was done 6 weeks down the road did show improvement , but the congestion or the abnormality did not improve on one side -right was better but left was still the same. She was feeling better and so I decided to do Bronchoscopy and then if that was OK , do new CT scan. The bronchoscopy did not show much abnormality and the tests that I did did not show any TB , bacteria or fungus or cancer. But this is never 100% and so we did new CT scan in another 5-6 weeks. The left side continued to be abnormal  and right side cleared . So I did PET scan and that showed increased activity in left sided abnormality . The uptake was not very high  and sometimes inflammation and infection can also have mild increased uptake of the glucose. I told her to see chest surgeon. The thoracic surgery did the surgery and that part of the lung was taken out and she had lung cancer . The good part was that there was no spread and she did not need any additional radiation or chemotherapy.

     She saw the oncologist and he did follow up and new CT scan. The CT scan showed new fluid around her left lung where the cancer was taken out. She came to me and had no idea of the new fluid as she had not had any call from oncologist. I decided to treat her with prednisone as sometimes patients get fluid related to the surgery and that is due to inflammation from surgery. If she did not improve , I will have to drain fluid with a catheter. We did follow up in 4 weeks and the fluid was gone.

    I continued to do follow up as she also had sleep apnea and some cough off and on. Overall she was stable for next 2 years . Then one day she had blood in the stool. The work up was done and she had colon cancer. She had surgery and has done well. The point that I want to make is that when someone has one cancer diagnosed , they have higher chance of getting second cancer over period of time -it could be other lung cancer and I have seen that also or it could be another organ cancer. One has to be watchful. 

IS IT JUST LUCK?

      In medicine we act based on what we think or know as facts. But many a times the facts are based on statistics. When we treat someone with  bronchitis- cough with yellow sputum, fever and wheezes= we treat with certain antibiotics and expect it will help and cure the respiratory infection. I believe that treating with antibiotics to cure him his based on FACTS .But in reality it is based on statistics and experience that antibiotics work in certain infection. But it may or may  not. But I often used to say that if one puts one hand in boiling water and other in ice cold water , 'statistically ' he is at comfort. That brings me to the story for today. 

    I saw this 70 years old male who was a smoker for cough and congestion. He had been smoker for 50 plus years and had no desire to quit. He had cough and wheezes and we did work up. he had breathing test and chest x- ray and was started on some bronchodilator. He continued to see me for 2 years and was doing OK .He had COPD and that was mild and he was active and cough improved . Then when I did new chest x- ray , he had abnormality . When I called him and wanted to do CT scan, he wanted to hold off and wanted antibiotics. So I did that and the repeat chest X- ray continued to show the abnormality . We did work up and he had cancer diagnosed . He underwent surgery and cancer was taken out. But he had some lymph nodes positive for cancer spread and so i sent him to oncologist and radiation doctor. He was told that the chance of recurrence in increased when the nodes show spread and he should have chemotherapy and or radiation . He did not want any further treatment. 

     I continued to do follow up and in next year or two, he had ne scan showing new mass . Again we did the work up and he had new cancer. I sent him to thoracic surgery and he did not feel surgery was an option as he had cancer spread to lymph nodes and so we decided to do radiation and suggested chemo and he was not sure . I continued to do follow up and he was doing OK . He had continued to smoke and the breathing test did not show much worsening. He did get radiation and no chemo.

   I continued to do the follow up and did periodic CT scan . 2 years or so after the second cancer. He was doing great and he had continued to smoke and was having no new complaints. He had new CT scan and he had some chest wall pain. The CT scan showed that he had new tumors and the ribs on rt side were also involved  and showed cancer. I sent him to radiation oncologist and medical oncologist . He was started on radiation and immunotherapy. He had some additional medications for pain . Almost 2 years have passed and he has continued to smoke  and has had new scans and breathing test . The breathing test does not show any significant worsening from previous one . He does not need oxygen .He has not been on any cancer medications for more than a year .AND HE IS AGAIN CANCER FREE . 

NOT SURE WHAT SHOULD HAVE HAPPENED TO HIM STATISTICALLY !!

MEDICAL DILEMMA

       In medical practice, we see different types of patients . Some that want medicines and others who are reluctant to take medicine. Some want every test in the world and others don't want any tests - including ones that could help diagnose and treat the element. One of the problem that I face is that if the medicines are not taken at right time then the disease could progress. But we do  not have clear cut understanding as who will will get worse and who will be OK. Certainly high blood pressure , diabetes and cancer are exception and I am sure there are many others conditions including  infection. But one infection is such that we have some variation. That brings me to story for today. 

    The MAC or Atypical Mycobacterial Infection ,also called Mycobacterial Avium is one such. I have seen many patients and some are old and some are young. This is  a chronic infection and may present as cough , abnormal CT scan of chest or may have additional complaints .Recently came across few patients , that taught me that we have a CLINICAL CHOICE . 

    I have seen 2 patients both over 80 years of age now who had MAC. One had it more than 5-7 years ago and we treated it . The treatment is for 18 months with 3 drugs and many do  not like it. This lady continued to have problem and we treated her. Then a new medicine came in and we added that and she was cured. She had no new pulmonary complaints and she seems to be doing OK But after a gap of no treatment for more than a year she had some more cough and so I did do CT scan and then sputum check and she had recurrence of the MAC. I talked to her and started her on medicines. But within a month or two , she called me and told me that she has decided to stop it and just want to see what happens . We have talked to her on dangers of not taking medicines , and then continued to do follow up. In next 18 months , she had no problem and continues to have no worsening of CT scan and no positive sputum cultures. The same thing has happened to one of my other patient . She had MAC and abnormal CT scan and we did try treatment and she could not take medicines as she felt miserable .So after 8 months of treatment she stopped it. We have followed her for 2 plus years  and initially the Ct scan was worse , but in spite of no treatment, the CT scan was stable or may be little better. She has stable weight and we have not done any treatment. 

  The contrast to that we have a young lady who had abnormal CT scan and then diagnosed as MAC and treated her. After 3-4 months she had  positive sputum and so we added 4th drug and she did well and we could stop medicines after 18-20 months of treatment and she did good for 1 year . She had low weight and new scan showed worsening  and so we wanted  to start medicines and she did not want. So after 6 months of observation , we did testing and she agreed to start medicines.

   So in the older patients no medicines has worked so far , but in some other younger patients it has not .

VITAL SIGNS

     In medicine we  have something called vital signs . These include pulse rate ,blood pressure ,temperature and respiratory rate. These are recorded in every patient - in out patient settings and also in ER and in patients setting  or hospitalized patients . The reason these are called Vital Signs , as they tell us about any  disease that needs immediate  treatment. If the Blood Pressure is high or low , it needs treatment and same with temperature - fever or hypothermia  and so on. In an average day in office - clinic , we do not have major issues with anything that needs emergency treatment related to Vital Sings abnormality. Certainly if Blood Pressure is very high we treat it and of someone has fever we treat it . This brings me to the story of this patient for today.

    I had seen this patient few times . He had abnormal CT scan of the chest and after doing the work up , we had done bronchoscopy , PET scan and breathing test and determined that he needed surgery and he had under gone surgery to take out part of the lung that had the growth. It was not a cancer . But we had done follow up CT scan as he was ex-smoker .This time he came to me and had a CT scan that was good , no abnormality was seen. But when I checked his pulse and oxygen saturation , the pulse was 33pwe min. This is very low heart rate - pulse rate . The Blood Pressure was normal , He had no shortness of breath or chest pain . He was not feeling dizzy He felt 'fine'. I checked hos pulse and heart rate to make sure that it was low. I tried to call his cardiologist and could not get anyone to call me . So I called his primary care and told him to see him ASAP. I was concerned that he would need to be admitted or may need pacemaker. 

   The patient and his wife were not very happy as 'he is fine '. I insisted that he goes to his primary doctor NOW . I also called him and he agreed to see him. He was seen and had HEART BLOCK , which means his electric circuit in heart was broken. He was sent to ER and he needed pacemaker . He was ot very happy and initially refused to have pacemaker ,but I called his wife and then he agreed  to have pacemaker. 

      The Vital signs are recorder thousands of time in office and this is one of those rare examples where they proved to be VITAL  and save life .