Thursday, October 9, 2014


   I watch evening news and many a times there are stories,which include police power abuse and also about medical negligence or missed diagnosis. Recent case in point is in case of Ebola in Texas.I do not no much more about Ebola or about the case in Texas.But the families always believe that the police are not careful in cases of criminal cases and doctors are not careful in cases of medical cases ,especially when the out come is bad.Even though I am sure that there are cases where the doctors are at fault.But I also believe that as in case of police ,the work of doctor is not easy . To get a line from Dr.Atul Gawande, the medical knowledge is wast and incomplete, it becomes difficult to be correct 100% of the time . I am going to tell a story of a patient that had so many complicating issues ,that it was impossible to have something definite diagnostic test than doing a intellectual educated guise work.
      I had seen this patient for many years. She was a smoker , who had quit .She had mild lung problem related to smoking in the past. But she was not bad . But when she saw me she had abnormal chest X-ray.She had some lung congestion or infiltrates and her lymph nodes in the chest were enlarged. The possibility of a condition called Sarcoidosis was entertained by me . In this disease patients do get the enlarged lymph nodes and they do get problem in the lungs Some patients ,<1%will get worsening and will get short of breath.She was quite concerned.I did the lung biopsy, and it did confirmed the diagnosis of the sarcoidosis..She was worried about cancer . So I sent her to a chest surgeon and he did a lymph node biopsy.It was positive for the diagnosis of sarcoidosis.She was happy and we decided to do the follow up.
     Over period of next couple of years , I did the several CT scans . They continue to show the enlarged node and the the lung congestion . The one of these days she had a nodule. I was not sure if this had anything to do with the sarcoidosis or it was a cancer. The further work up was neede . So we did the biopsy and then finally I sent her to a chest surgeon.He did the open biopsy and took out the part of the lung that had the tumor. The good part was that not only it was a cancer that was contained, and the nodes were negative for any spread of the cancer.She was happy . I just wanted to just point out that if in case of lung cancer, if the nodes are involved , patient becomes inoperable and incurable.But in the case of this patient, there was no way to know if the enlarged nodes were due to cancer or due to sarcoid. Even though in latter part our follow up we had PET scan.In PET scan ,tagged Glucose is given IV and images are taken. The glucose is picked up by metabolically active cells and by normal cells. The metabolically active cells pick up glucose more actively and so we can pick up cancer. The problem is that the infection or sarcoid will also pick up glucose more avidly and so it does not differentiate between cancer and sarcoid or infection.So you see the difficult?
    In near future she developed another nodule .I was not sure what to do other than do the usual work up . I did send her to a surgeon and it was taken out .And it did not stop there. She did well with this surgery.But then again developed a small nodule. Please realism that I followed her for may be 10 years or more.This time , the third time when she had new nodule and the nodes were same , I sent her to a surgeon. I am not sure why , but the he decided to do the biopsy of the lymph node and not the nodule . I was thinking that the nodule was cancer and the nodes were sarcoid .She also had develop breast cancer. To my surprise the nodes came back positive for cancer.and she HAD BREAST CANCER in the lymph nodes and the . So I was not sure why he did that but it was more helpful than the PET scan .
    So the difficulty that we have is no test is perfect and your intuition is not perfect and every time one can not do major surgery or do biopsy . So this is not a perfect science and like any other time we go by what is more common.She had 3 lung cancers and a breast cancer and Sarcoidosi , each one can cause the enlarged nodes and positive PET scan.
     The lady was given chemotherapy , continued to have problems and got metastatic breast cancer and died about year and half after the breast cancer diagnosis.

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