Saturday, April 27, 2013


      I remember when the defense secretory Don Rumsfeld made a statement , in which he talked about 'known unknown and unknown known ' . At the first glance it sounded very confusing , but the on the second thought it became very clear as to what he was talking . In medicine there are known unknowns and there are unknown  known.  For example , if a patient is undergoing a surgery , we know what is his risk , based on lung or heart evaluation . But we may not anticipate any kidney problem that he may get in or a stroke that may occur in a elderly patient , that we may not anticipate .I am not sure if the case that I am going to describe fits in to this description . Knowing his or her heart issues is known risk , but not knowing his risk for stroke is unknown risk . The story is not exactly fitting in to this type of case .
     I saw this 65 years old male patient for 'pulmonary clearance ' for the spine surgery . He was a male patient , who had smoked his entire life except for last 5 years . He was having bad back pain for sometimes . The Internist had tried various medication and then done CT scan of the lower spine and referred him to an orthopedic doctor . He was tried on physical therapy , and some 'shots ' . His pain got little better , but came back and he was miserable . So the decision was made to the surgery . Due to his history of the smoking , he was sent to me for assessing his pulmonary risk.
    I saw him in my office . The Internist who referred him to me is one of those rare doctored who sends his notes with the patients . So it becomes easy to evaluate them . His lungs were clear . His oxygen was normal and in his history , there was not much of the complaint of cough or sputum . So his surgical risks would be good . But when I was examining him I noticed a large lymph node in his left side of the neck ,above the collar bone . I asked him about it . He was aware of it , but had not mentioned it to any of his doctors as it had not changed much in last 3 months , since he had noticed it . I was not very happy with the size and it felt firm to hard , suggesting that it may be cancerous . He had chest X-ray done , which was normal . I decided to call the internist and then after discussion I sent him to a surgeon . He did the biopsy . It showed a cancer . The tissue type was such that it could come from the lungs or many other organs . It could be the lung cancer or the throat cancer . I did do a CT scan of the lungs and CT scan of the neck . Both the scans came back normal . I decided to do bronchoscopy and send him to ENT doctor . I did not find the origin of the cancer in either throat or lungs Rest of the work was negative , he had no evidence of the cancer anywhere in the body . So we had a patient , who has definite cancer , but we don't know where it started and once the node was out , there was no presence of cancer in the body , as far as we could say .  I cleared him for the surgery . I was not sure as to what kind of treatment we could give him as we did not know how to asses the effectiveness of the treatment .How can we say that he is benefiting from the treatment , as with the node out there was no evidence of cancer that we could detect .
   I had follow up set for him in 4 months or so . He had surgery and his pain was much better . The surgery was uneventful no complications . I ordered a new CT scan . He was not very keen on doing it . But did it . IT showed a nodule ,a spot in right lung . I redid the bronchoscopy , did not see anything abnormal . I decided to do the needle biopsy of the nodule . IT came back as cancer , same type as was seen in the lymph node that was taken out almost 6 months ago .
    The mystery was solved .He had lung cancer, that spread to the lymph node , but the primary tumor was so small , that we could not see it with CT scan or with the bronchoscopy .

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