Sunday, October 27, 2019


      The phrase of 'back to the square one' is very commonly used when we do something as a plan  and that does not work . This probably came from one of the board games  may be chutes  and ladder  when we are going to the higher squares  and suddenly we find our-self going down due to chute. The same things happen when someone is trying to solve the criminal case and the clues lead us to dead end  and then we are back to original level. The same thing happens in medicine , but not often. This brings me to the present story.
      I saw this lady for shortness of the breath. She had smoked  and had diagnosis of COPD  and in past she had lung cancer diagnosed  and she had treatment for it She also had breast cancer  and she had surgery and she was cured. I saw her  and did  act scan  and also breathing test and started her on oxygen. She was started on medicines for the COPD  and then the CT scan showed tiny nodule. I told her that we will need to do the follow up fort the nodule  and it was too small for the further work up to know the diagnosis. Doing bronchoscopy , or doing needle biopsy or doing PET  scan or asking surgeon open biopsy were not options as they would not have given the diagnosis. So we decided to do the follow up . I continued to see her for next year and we did couple of CT scans  and they did not show any any change or growth . She did not come to me for follow up a year. Then she  had shortness of breath and she was hospitalized.I was asked to see her . She was very sick and she had to be in ICU for short time  and even after getting out of ICU. She had new CT scan done  and that was abnormal . The nodule that we had seen was same but she had new 'mass' in rt middle part . She was not in very good shape for biopsy and so we did PET scan  and that did show that the mass was likely to be cancerous -had increased uptake of the glucose.She was never a candidate for the resection  as she had advanced COPD and the location was such that she could not have had resection or entire lung and then also she would not have been cured. I did do bronchoscopy  and I had to get help from anesthesiologist and she did OK . I did see narrowing of the middle part of the right lung and i though that she may have external pressure from cancer or it may be narrowed due to cancer itself. I did do the biopsy and other things  and they came back with 'atypical cells but not conclusive for cancer.
      She was getting better  and i told her that we need new biopsy but she needs to be better  and so after 2 weeks i had do EBUS - biopsy with help of ultrasound , This was done and they came showing no cancer . I knew the CT scan , I knew the PET SCAN  and i also knew her history. She had 2 different cancers  and she also had OXYGEN dependent COPD.So now what I can I do to get to the diagnosis? As you can see every time we did a test thinking that we will get the diagnosis we were back to the square one.
     So I had a surgeon to review her scans  and he called me stating that the situation was very difficult, but he felt that he could do some biopsies  and get the diagnosis. He saw her and did a procedure called Mediastinoscopy  and biopsies came back showing no cancer. So he did see her again and did biopsies through chest  and they also came OK. So she came back to me  and she was hurting from the surgery and we had no diagnosis. I asked radiation doctor to see her and see if they can do radiation WITHOUT the tissue diagnosis of cancer. They were not very happy to do such a treatment without the proof for cancer . This is not like giving antibiotics.
     So I decided to do new CT scan in 3 mo this The month before she was to have new CT scan done she was in hospital  and I saw her . She had developed fluid collection around the lung - same side as was the mass. I did new CT scan  and that did show the fluid  and also that the mass has increased. So there was no question that she had cancer . But we had no proof. So I called the same surgeon  and told him the situation . I was concerned that she had fluid due to cancer and just taking it out once may not be enough.She was also on blood thinner . So I asked the surgeon to do the  catheter insertion to drain the fluid  and do some additional biopsies.
    He did do the catheter and did  not do he biopsies .The fluid was sent for cancer cells  and they came back as No cancer . So we were back to square one - same place that we started after  5 procedures to get the answer. So now I  again called the radiation doctor and asked if they could do radiation without the diagnosis OF CANCER..
   This time they agreed  and she got the radiation therapy without tissue diagnose of the CANCER . 

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