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. 

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