Saturday, February 29, 2020


   I have been in medicine for many years. Now a days we are doing CT SCAN of the chest 1000 times more than what we did 10 years ago . In doing CT scan that often, we are seeing things that we never saw  and when we see some abnormality , we tend to do work up or follow up. So we do more consults  and procedures  and also follow up CT scan - so more CT scans are done . In 194 or so I attended a meeting for work up of LUNG NODULE . The lung nodule is a small density seen in lungs on the Ct scan . The size has to be less than 2.5 cm or an inch. Not much came out of the meeting We continued to do the follow up CT scan. The some one came out with criteria as to how often to do the CT scan based on the size of the nodule. Again for many years no new test was there . This brings me to today's patient.
   I have seen known this 70 years old female for many years  and she had been smoker and had diagnosis of COPD . She needed oxygen and she also sleep apnea. She had quit smoking for many years but the damage was done  and she had some decline  and then she did better . One of the days she called me . She had been to Vegas  and had hard time breathing and she was quite concerned . She had portable oxygen that she had not used  and now she wanted it. So I saw her  and started the work up . We did walk her in office called 6 minute walk test  and she did drop her oxygen as I expected . I had treated her with steroids  and she was little better . I did new CT scan . The Ct scan showed NEW NODULE. So I had to do further work up and so I did PET scan . As I have mentioned in my past blogs , the PET scan is based on glucose uptake  and it picks up cancer 80 % of the time . Spo it is good . She had PET scan and also the bronchoscopy . The PET scan did show increased uptake in the nodule suggesting possibility of cancer and also there were lymph nodes positive - suggesting spread of the cancer. My bronchoscopy did not show cancer , but the nodule was too small for me to do biopsy. I decided to send her to 2 different surgeons .She had a node  in armpit  and in chest . The general surgeon was not concerned  and so I did ask radiologist to do the biopsy of the lymph node in armpit and it came back OK . What I was trying to do was to get the diagnosis without chest surgeon needing to any major biopsy. She was oxygen dependent COPD  and was not a candidate for resection of the cancer if she did have one  and would not do well with and after surgery. The chest surgeon did do biopsy of the chest nodes  and they came back OK-NO CANCER.He agreed with me that any additional biopsy will not be possible due to her medical condition.
    So at this time in spite of doing many tests I had no diagnosis . I came across a new blood test . This blood test was approved by FDA 2 October 2019. The test does not give diagnosis of cancer , but does give a probability calculation based on presence or absence of certain proteins in blood . So one calculates the probability of a nodule being cancerous based on age , sex, smoking history, size of nodule , which part of lung it is in and the characteristics of the nodule . Then the blood test is done  and the probability is 'increased ' or decreased . In the case of my patient the probability was decreased to mid 10 % from 38% before the blood test.
      But now I got my bronchoscopy culture for TB  and SHE HAD ATYPICAL TB  SO THE TEST DID HELP. 

Friday, February 21, 2020


     In medicine we like  and wish certain things  and the medical judgments are accurate in most patients . But sometimes we know what to expect and wish it is not so  and so the disappointment happens when we get what we expected but were wishing something simpler or something less toxic
Then there are cases where we think of something and get some other thing  and that was unexpected  and may be nicer or may be worse than what we thought it would be . I have seen sometimes patients who come for what looks like simple pneumonia  and then further work up shows that there is wide spread cancer which was not suspected at all.That brings me to to the story of a patient that happened sometimes ago.

     This was a 78 years old male who had smoked for many years  and he had COPD - emphysema  and he was short of breath all the time but used to travel from up north to Florida .He was on oxygen  and he did use it with sleep  and did not like to use it when he walked , though he needed it . When he came to Florida , a bladder cancer was diagnosed  and he had treatment for it  and he was doing good . He has some chest x- ray abnormality in past  and I had done CT scan  and the CT scan was stable. The problem sometimes with these kinds of patients is that due to severely impaired pulmonary status , they are not good candidate for invasive work up. So this time I did regular chest X- ray  and he had some abnormality and so I di CT SCAN of the chest . That showed some problem in the middle part or the lobe on the left and some also on right side . The possibility that a cancer could block a bronchus  and cause the collapse was there . So I decided to do bronchoscopy . I had actually expected a cancer  and did not want to see the cancer as he was not a candidate for surgery and even chemo may not be the best thing . So I did the bronchoscopy and I noticed a growth on his Vocal cords . It looked like cancer . I did not expect that . When I looked inside the bronchial tubes I did not see any obstructing cancer  and so I did some brushings  and washings  and expected that it will be OK .So I did not expect the vocal  cord cancer and he had one  and i expected the cancer in lung and he did not have it . So in a way I was happy  and I told them that we will do new CT scan  and hope that nothing new would pop up. So in 2 weeks or 3 weeks I found out that the lab called me  and he was growing an unusual bacteria on the culture. This was not expected . It was called Nocardia  and needs treatment for 6 months to 1 year with antibiotics  and the usual antibiotic is a combination of sulfa drug - simple one .But he was allergist to sulfa  and so that was added problem . So he had unexpected throat cancer  and no cancer in lungs that I though he had  and he had Nocardia that I did not expect .
      The story has happy ending , his throat cancer was treated with radiation  and he has done well. He has no lung cancer  and his Nocardia seems to to be responding very well  and his bladder cancer is also in remission.