THINK OUT OF THE BOX

     Now a days we have 'computer oriented medicine '. The orders are given based on the patients complaints, rather than 'examonining ' patient or 'thinking ' about the patient and then investigating . We also have medicine which is determined by 'standerd of care ' . i.e. what is acceptable way of doing work up or treatment of particular complaint or diagnosis. I often feel that this good foe may be 90 % of the patients, but one has to still think out of the box . Most of the people are afraid  to do so . I feel that we should 'think ' and treat each situation on case by case basis .
     This one a story , which is unusual , as we thought out of the box . I saw this young lady about 55 years old with abnormal x-ray . She had some cough and so the primary care physician ordered the x-ray. It came abnormal, so then CT scan was ordered . It showed that patient had two nodules , one in right lung and the other one in left lung . She came to me , She was  a smoker and had cut down to few cigarettes, and had some shortness of breath on exertion . She had some cough , which she had originally attributed to her smoking . Her examination was normal .I reviewed the CT scan and discussed with her. I told her that we have to answer 3 questions , 1. Is it cancer 2 Has it spread and 3 What can we do about it i.e treatment options --surgery, radiation and chemotherapy .Even today the best and only 100% 'curable ' option is surgery . Even with surgery some patients will relapse. I ordered a PET scan . PET scan shows the metabolic activity as glucose tagged with nuclear material is injected . As every cell needs glucose and the pick up of the glucose is dependent upon the metabolic activity, the cancer cells will get more glucose and then activity is high against the background. This has accuracy of may be 88 to 90 %.The inflammation or infection can also can have more activity than normal tissue/organs. So this is not 100 % but quite good .
      The PET scan was positive.But it was positive in both the nodules .It was also positive in one of the lymph nodes . I did do a bronchoscopy and it did not not show any abnormality. I ordered a needle biopsy . I spoke to the radiologist and decided to do biopsy of one of the nodule . The radiologist did biopsy of the  right nodule .It did confirm the diagnosis of the cancer . But now was the main question . By the data that we had , with  twe nodules, both positive on PET scan and one of them positive on biopsy, she was inoperable .Normally one nodule is likely to be the 'spread ' from the other nodule , and since the spread from one lung to other lung can occur only via blood , there is potential of the Cancer having spread to other organs .  I had refereed her to other MD, namely a radiation oncologist and and medical oncologists . Both of them felt that she was 'inoperable ' I spoke to a chest surgeon . I may be having wishful thinking as I wanted her to be a surgical candidate. I talked to him and also talked to patient and her husband . I told my thought process . Since the nodules were small we could 'take them out ' ,( which meant 2 chest surgeries ) , and then give chemotherapy and or radiation therapy . This was not what was conventional . She was inoperable and 'best ' option ' was chemo and radiation .
     She agreed to our plan . She did undergo left sided surgery and to our surprise , she had 'similer ' cancer as we had gotten from last needle biopsy , but it was different as far as tumor markers are concerned . She did have second surgery and right cancer was also removed . She did have some stormy course after second surgery as she had reduced lung capacity with loss of part or her left lung with first surgery , She is doing quite well . So far there is no evidence of CANCER.
    We are keeping a watch and hope that she will not get the recurrence. So far our 'out of box ' thinking has paid off.