Saturday, September 22, 2018


       In medicine we often asked the question as to how does someone get cancer and why does this happens . The common diseases like high blood pressure or diabetes , no one asks this question . In pneumonia or Tuberculosis , we know the answer of how , but not why . One can say in case of Diabetes , that the insulin lack causes the diabetes , But we do not have the answer to 'why' . In high blood pressure we do not have any answer as to how and why . In case of cancer  we know NOTHING . We do have bits and pieces on to how cancer develops . We know that chronic irritation or tobacco increases the 'chance ' of getting cancer . But we still don't have the answer as to how and why . But today I am talking about a patient where there is how and why , but in a different way .

      I saw this patient who was 68 years old and had some cough and then the primary care physician did the chest X -rat and then the CT scan , The CT scan showed a nodule . He was a nonsmoker . He had history of prostate cancer and it was treated and 'cured ' He also had tonsillar cancer and it was treated and he was 'cured ' He was not a smoker and he had no other major medical issues . His physical examination was unremarkable . He had clear lungs and the oxygen saturation was good. I did PET scan and also the Bronchoscopy . I also did the breathing test . The breathing test was good and was normal . He underwent bronchoscopy and it was normal . The nodule was too small for me to do any biopsy. The PET scan where glucose is injected and the uptake is majored . The higher the metabolic rte , higher is the glucose uptake and higher is the chance of cancer . The PET scan showed increased uptake though it was not very high . So i saw him in the office and discussed the various options . One option was to do a needle biopsy . The needle biopsy has some risk of collapse of the lung and the sample is small and so not 100 % if it does not show cancer . The other option was to do follow up of the Ct scan . The good part about it is that it may 'save' an unnecessary  surgery , but the disadvantage is that if cancer , 'waiting' may increase the chance of cancer spreading . The first Ct scan and the time that all this happened was almost 6 weeks . I sent him to chest surgeon . The surgeon did a new CT scan and it showed that the Nodule had increased by very small amount . But taking in to account the PET scan finding and the small but definite though small increase in size in short time , we decided to do the open biopsy .
      The surgery went well and he came back for the follow up . The pathology showed that he had MELANOMA which is skin cancer in lung . That meant that the melanoma - a skin cancer has spread to lung , But he had no history of the melanoma ,nor the PET scan had shown no activity or pick up anywhere but lung nodule. So the patient asked me as to how can he have the skin cancer spread to lung when there was no skin cancer in first place. HOW is this possible and WHY did this happen ?I do not have the answer . 

Friday, September 14, 2018


     In medicine we , physicians do not ever want to sat ,'I don't know.' nor the patients want to get answer from their that they don't know . But truthfully we do have patients where we truly don't have the answer or know what else to do .If the physicians don't  know the diagnosis or have answers , then what kind of hope patient has or what kind of treatment they can expect ?Recently I came across some patients where I had not much to say . My unfortunate problem is that there is no other physician who has answer.

      So I saw this 70 years old patient almost a year ago . He has been a smoker and had some cough . His primary care physician did a chest x- ray and it showed abnormality . So I saw the patient . I did the work up . He had claustrophobia and could not and refused PET scan . I had tried mild sedation , but he could not do it . He did have a CT scan and that showed a mass at the center of the left lung . I did the bronchoscopy and there was narrowing of the bronchial tube going to left lower part of the lung . I did do some biopsy and that came back OK . I did follow up and did new CT scan . He also saw thoracic surgery and it was felt that we will do follow up on the CT scan . The follow up CT scan continued to show the abnormality and it was not any better or worse. I did second bronchoscopy and that showed the same findings and so I again did some biopsy and it did not show any cancer. I sent him back to the surgeon and asked him to do bronchoscopy or any other biopsy that he could do . I was concerned about the cancer . He told me that only 100% way to get the diagnosis was to take out entire lung . The patient was not keen on it and I was not sure if that surgery would be curative in view of the CT scan findings. He did do the Bronchoscopy under anesthesia and he had the same findings and the deeper biopsies were negative for cancer . We did new CT scan and it showed increase in the mass .So I sent him to a different chest surgeon. The new surgeon did get the PET SCAN done and it did show that the mass was metabolically active . This was highly suggestive of  a cancer . There was no other area in the body that showed the uptake , which meant that if this was cancer , there was no spread of the cancer. So he suggested taking out entire left lung . He came to me with family . He agreed and so the surgery was done . The left lung was taken out He did well.
      He came back for the follow up with  his wife. The surgery was done in different hospital and I had not gotten the report . So when he came for the follow up , I git the pathology report. To my surprise the pathology showed that indeed there was cancer . But not like I had suspected . It was not lung cancer . It was SALIVARY GLAND CANCER THAT HAD SPREAD TO THE LUNG !!
He does not have any abnormality in the salivary glands and there is no cancer there. nor the PET SCAN ever showed any abnormal pick up in salivary glands . So when they ask me as to how can he have cancer of the salivary gland spread to lungs , when he does not have cancer in salivary gland , I had to say 'I  DON'T KNOW '.