Sunday, June 28, 2015


         We in medical practice come across situation when we have to think and decide as to if our actions or decisions are a success or failure. I am often amazed as to how we evaluate a success or failure of our treatment or actions. I had come across an article in which they were talking about a chemotherapy for lung cancer.The chemotherapy agent was approved for treatment of the lung cancer. The study that the FDA looked at showed that the 'survival' was increased by may be 30 days. (It was long time ago and I do not remember the name of the agent or the exact prolongation of the time ,but it was not more than 30 days . )The cost of the treatment was enormous, may be $10000 or more. Is prolonging life for 30 days with metastatic cancer -irrespective of cost , a success ?To some it is and to others it is not . Look at Steven Hawkins, He is paralysed and has trach ,but still does so many things scientifically important in Astrophysics .So sustaining life was worth it for him. So we will call success.I had a patient who also had myopathy and did go on respirator at home for last 25 years. She had young kids and it was worth it and I call that a success. But today the story that I am going to tell is that of different angle .
        I saw this patient who was 65years old . He was a had abnormal chest X-ray and was smoker and so was sent to me . I did the work up and did the CT scan and bronchoscopy. He had a cancer of the lung. He had breathing test done and it showed 'adequate reserve' or the lung capacity for doing resection of the lung cancer. So I referred him to a surgeon .He was evaluated and he agreed to do the surgery. He had no other history except high blood pressure. So he underwent the surgery. The surgery went well .He had resection of the lung cancer. The surgeon had to resect 2 lobes out of 3 .He was doing OK post operatively. When lung is resected there is always some air leak and fluid leak as the lung has to heal .This usually takes about 7 -10 days to heal and then the tubes that are inserted to drain fluid and the air, are taken out. In this case the lung or the remaining lung would not heal. The fluid drainage was less , but air leak continued. The surgeon did couple of things, including going back in. But there was no change . So we decided to put a one way valve on the chest tube . This valve would allow the air to get out but not get in .
       So he was discharged and was followed by the surgeon . .Even after one month the air leak continued. So then he was referred to other university centers . He decided to go to one place . They did another surgery and the problem continued . So he went to still an another place and they did another surgery . They 'crushed' the chest wall and collapse the lung . This stopped the air leak. But this deformed the chest to such an extent , that his remaining lung was almost nonfunctional. As not much blood going to the remaining lung and it was deformed , it was causing recurrent infections. We had to treat it with antibiotic and most of the time intravenously.
       I was not too sure as to what could be done . I did the lung scan and it confirmed that the right lung showed very little air going to it and very little blood going to it . So essentially it was not 'contributing ' anything to the lung function, but was cause of all the problem. So I suggested to go to the surgeon who had done the last surgery ans see if he could take it out. He thought about it , but did not do much . But then he decided and saw the surgeon and did have surgery . It did not 'cure' anything and he was admitted to our hospital . Some of his problems are still there and the 'jury' is still out as to if this last surgery was a 'success'.By the way there was no cancer for last 10 years. So the 1st surgery was a"SUCCESS' ,or was it ?

Thursday, June 25, 2015


       In the past we were old a story of Emperor The story was that of a emperor. He wanted to have a new clothes. But he wanted to have the best and the lightest clothes.So many tailors tried and failed . Then there was this shrewd tailor ,who accepted the challenge. He took the measurements and then stated in palace, had good food and enjoyed the life . He never stitched any clothes. So the day came in when the king was suppose to get new clothes . He pretend to dress the king with new clothes . There were no clothes , but he made all the actions . He convinced that the clothes were so 'thin' that no one could see them . So the king went in the city wearing nothing . But no one could say anything as the king was convinced that he had the most thin and the lightest clothes . Then a small kid who was standing to watch the parade ,said loudly,"why is king going in the streets naked ."
   This story comes to mind, when we see certain patients. So I thought of this phrase,when I saw this patient. I saw this lady who was 65 years old , She was a smoker and had usual smoker's complains. She had some cough , with minimal sputum. She had cheat X-ray and then had CT scan of the chest . The CT scan showed clear lungs , absolutely no abnormality. But the CT scan showed lymph node enlarged. There was single node enlarged, which was located under the division of the main bronchus. This is not the easiest place to do biopsy. (this could be biopsied with a ultrasound guided needle insertion through bronchoscope . This is a relatively new technique.) I talked to her about the choices . She refused to do any tests. I wanted to do a scan called PET scan . The PET scan picks up cancer ,may be 85% of the time. She did not want it.The PET scan was done after several attempts to convince her that this would help. The PET scan did show' increased activity ' in the lymph node . But showed no activity in any part of lung or any other lymph nodes or any where in the body..This is very unusual. But I had to do the biopsy . I called another doctor who does the special biopsy and he gave her an appointment . But on the day of his appointment , she did not show up . So we again called her . She did not want biopsy. She however agreed to do follow up CT scan . By this time the CT scan was more than 2 months old.  So doing CT scan in next 2 months was not a bad idea. In my mind the one isolated lymph node without seeing anything in lungs and no other nodes being enlarged , was not likely to be cancerous . And if it was cancerous , that was not a surgically resectable. cancer. We continued to have some problem getting her to do tests and follow up. After some efforts ,she did do a follow up CT scan , and it showed no change. So she was happy and so was I. But then she saw a cancer doctor for some other reason ,. As a routine he ordered some blood tests and it showed abnormality. So he called me . I convinced her to to have biopsy. She did agreed for the biopsy.
      She had the biopsy and it showed the lung cancer , The new scan did not show ANY ABNORMALITY IN THE LUNGS . But she had the lung cancer . This is mind boggling to me . So she has lung cancer showing in the lymph node , but there is no primary tumor seen even on CT scan or PET scan . This is what I called the Emperor's new clothes.