HOW MUCH DOES IT MATTER?

    In medicine we are often faced with diagnostic dilemma.We see patients  and many are simple  and routine . But then we come across some of the patients,that trigger our thought process and puts our medical knowledge to test. We do more tests  and also do some explanations  and try to get to the diagnosis . But sometimes I wonder if it really matters in certain cases. I have heard that there a professor in NY that seeks advice from allover world in case of very unusual cases  and then she is able to help get the diagnosis. But I am not talking about that kind of diagnostic problem. I am talking about something else.We may do tests  and find out something that may give us the diagnosis  and there may be no answer as far as treatment is concerned or may not make difference in out come or life.
    This brings me to the today's case. I saw this lady in my office may be 8 months ago. She was a 68 years old female who was smoker  and was admitted with shortness of breath and then was diagnosed to have pneumonia . The work up was done with CT scan and then bronchoscopy and that showed that she had COPD  and also cancer of the lung.. The further work up was done  and she had spread of the lung cancer to bones  and her left hip was affected . She saw me  on office after the discharge . I don't recollect why she came to me  and not do the follow up with the lung specialist who did see her in the hospital. But any way I did not have much to do . She did breathing test in my office  and I started her on some inhaler for COPD.I had extensive discussion with her son and her  and told them that she will need Radiation treatment to the hip for cancer spread as otherwise she might get fracture  and pain . She had been seen by oncologist and she had not seen radiation doctor  and I managed to get that done . So she was treated by oncologist and also radiation  doctor  and she was treated with chemotherapy and radiation to lungs  and also to hip.
   I saw her in office may be 2 more times  and then she was admitted to hospital for pain in the leg and hip . So she was seen by me in the hospital. She had a blood clot in the left leg  and she had further work up by oncologist and she has fracture of hip. Just to mention here the incidence of blood clot is much higher in patient with any kind of cancer. and that is due to blood clotting too quickly in patients with cancer.So she had clot and we started her on treatment for it . During the work up she was found to have mass in kidney. As per report the the mass was there in past and the oncologist was aware of it . But the mass had grown to much larger size in spite of treatment for lung cancer and so the possibility of kidney cancer was there . She had hip fracture  and clot in the same leg . So the oncologist ordered the biopsy of the bone . This was the same area that had shown spread of cancer in previous tests but it was not confirmed by biopsy. It was also the same area where the radiation was given . The biopsy was done  and that came back with 'no diagnosis' .
      So now we have this patient who has lung cancer  and spread to bones  and had treatment with chemo and radiation  and also now has enlarging kidney mass  and fracture of hip due t cancer and clot in leg due to cancer  and immobility and also has new mass in lungs  and has COPD. Due to the previous radiation to hip we are very limited in giving her more radiation to the hip , so she can not do much or any walking  and we still do not have the diagnosis of kidney mass .
    But does it really matter on long term prognosis ? We could do biopsy of kidney though we do not do it normally due to fear of spread of spread with biopsy . She has new lung abnormality and also rest of the problems - and all of this in spite of the treatment with chemo. and radiation . So it appears that the prognosis is poor even if we get diagnosis of second cancer - that of kidney  and or spread of lung cancer  and the quality is poor as she can not walk due to pain and fracture  and our options of treatment of the fracture are very limited due to previous radiation given to the same area.
   DOE IT REALLY MATTER weather we get the diagnosis or not ?

BACK TO SQUARE ONE

     In our life we say this not too infrequently. We apply for a job  and the interview goes well and then we have second interview  and then we get rejected  and we are back to square one .Sometimes people date  and things are going well and then there is engagement and then they break up , again back to square one . In medicine we also see this sometimes . After extensive work up we are still at same level of confusion or state as we were before the work up. This brings me to today's patient.
   I had a call from a cardiologist requesting to see one of his patients . She was 71 years old female  and has progressive shortness of breath, He saw her  and the cardiac work up and the heart was 'fine' . She was also seen by a lung specialist for 3 years  and was told that she had some damaged bronchi and may be COPD . She was started on medications  and she was not getting any better . She had 3 CT scans  and several pulmonary functions studies . At one time the cardiologist thought of a condition of Polymyalgia rheumatica, and started her on steroids  and had her see specialist - rheumatologist , Some additional tests were done  and the steroids were continued with weaning schedule for the steroid dose. She had gained weight due to steroids  and she was still short of breath  and also needed some oxygen . She came to see me with her husband .Their frustration was that they did not know the diagnosis  and she was not better and may be worse . She was now on oxygen that she did ot have a year ago .They had all the records from previous pulmonalogist - This is very unusual -most patients come with no records  and then I have to request them . So I reviewed the records .
        I saw the CT scan reports  and the notes  and the lung function data . She had several of them . The Ct scan had mentioned some scars  and also the breathing test had shown that the mechanical function of the lungs - taking breath in and forcing it out - was almost normal -about 80 % -Nothing to suggest ASTHMA or COPD , but the diffusion - how oxygen is transferred from air sacks to blood - was markedly reduced  and also it had gotten worse in last 6 months . No wonder she needed oxygen supplementation. I though of 2 conditions - one where ver tiny bronchi get inflammation and get clogged up called Bronchiolitis Oblitarance  or Pulmonary Fibrosis.
    I did a High Resolution CT scan  and that did show FIBROSIS . So I told her that we could start her on medications which will help . It does not CURE nor does it PREVENT PROGRESSION , BUT IT REDUCES RATE OF PROGRESSION .I alos told her that only way to get exact diagnosis was to do OPEN LUNG BIOPSY.
  They wanted to know the diagnosis . So I sent her to a surgeon and she had biopsy. The biopsy showed that she had fibrosis , but the local pathologist sent the specimen to Mayo clinic for opinion
I had a call from Mayo clinic pathologist as he was not too sure on the diagnosis  and wanted to KNOW THE CLINICAL PICTURE . So I spoke to him in great detail describing him the CT scans  and the Pulmonary Function tests  and also the other problems . After the discussion he concluded that MOST LIKELY SHE HAS FIBROSIS OF UNKNOWN CAUSE  and so from my stand point the treatment would be what we had prescribed  and got on hold due to the open biopsy.
                        SO WE ARE BACK TO SQUARE ONE !!

RULE OUT OR RULE IN

    In medicine,we often write a diagnosis as RULE OUT --THIS OR THAT . This means we suspect but do not have proof for it.The unfortunate problem with this system is that we can not order a test to RULE OUT  any particular diagnosis.So if I see a patient with a mass  and has all the tests pointing to cancer on CT scan, I can not say that it is cancer of the lung. So I would say RULE OUT CANCER.But I can not order say PET SCAN without writing the diagnosis as CANCER OF LUNG.
But sometimes we know that it is not Cancer  and we want to prove that it is not  and so we order tests . Our ordering tests are based on our CLINICAL SENSE  and possibility and probability of various diagnosis. This brings me to today''s patient.
     I saw this patient , who had moved to our area. She was 68 years patient who had smoked many years ago . She had no major problems but has minimal cough . She had history of sarcoma in past and she was followed by family physician in her place . She had seen cancer specialist few times after the sarcoma was operated , but she was stable  and so she was followed by family doctor. .She came here  and she came to see me . She had Ct scan done by her doctor here  and that was abnormal and sp she came to me She had no chest pain , fever, cough or shortness of breath.
   The CT SCAN showed some swollen lymph nodes in chest  and tiny nodules. I could not get any old records and she felt that she never had old CT scan of chest.She had no pulmonary problems  and so I talked to her. If the lymph nodes were due to cancer , that is not a surgically curable state .The lymph nodes are enlarged due to cancer of lymph nodes like Lymphoma or may be due to a SPREAD of Cancer  and so in any case that is not surgically resectable or curable state . The lymph nodes get enlarged due to infection or cancer.She had no constitutional symptoms and so I decided to do follow up CT scan . She had come to me almost 6 weeks after the ct scan and so I told her to get old CT scan and do follow up CT scan in 3 months . If the nodes were due to inflammation, they should improve  and if not better , we will do biopsy .
    She had new ct scan  and she did not show any change in Lymph or nodules in lung . In normal situation , when no change has occurred, we tend to conclude that that is less likely to be cancer , though 3 months is not long enough and so tend to do follow up CT scan again . In her case she had history of sarcoma  and sometimes it can come back after long time.She was concerned  and she WANTED TO KNOW as to the cause . I told her that sometimes in a condition called sarcoid , we may have swollen lymph nodes  and nodules in lungs . But she wanted to know . In this case I had to get a biopsy .I had 2 options , one was to do Biopsy through bronchoscope  and ultrasound guidance or have surgeon to do biopsy . The sample obtained with bronchoscope  and ultrasound - called EBUS  are very small and they may not be 100% diagnostic . So I decided to have her see thoracic surgeon. She needed definate diagnosis  and even though my level of SUSPICION WAS LOW , I sent her to surgeon .So when I suspect Cancer I call it do biopsy to RULE IN , this time it was to truly RULU OUTE

SOME SIDE EFFECTS OF CANCER

    All of us know what are the common signs or symptoms of early cancer.Some of warning signs of caner are described by cancer society or  many other institutions. So we know that persistent cough, non healing ulcer in the mouth unexplained weight loss etc are well known to doctors  and even to common public. But some other symptoms are not so well known  and some doctors may not know about it . Sometimes they are treatable  and sometimes they are not and the treatment of cancer it self will be the treatment for them. So these are called 'para-neoplastic syndrome'. They are thought to be related to certain chemicals that the cancer cells secret and their effects on body.I have seen this few times  and my last patient had it.
    So I saw this 60 years old male patient who had persistent  cough and he started loosing weight. He do=id not go to doctor for 3 months  and then when he had lost 30 lbs of weight, he decided to .go a doctor. He had been smoker  and had  had continued to smoke.He had chest x- ray done  and then a CT scan . The chest X- ray showed collapse of left lower lobe  and he had mass in middle of left lung and had some fluid around his left lung . So all the signs were that of Lung Cancer. He came to me , but he had also been sent to cancer specialist and also radiation doctors. But they can  not do anything until the diagnosis is established. I saw him in office . He was a very tall guy and he had lost so much weight that he was weak and had difficulty walking and so he came in a wheel chair . He also had clubbing of nail - changes in nails where the curvature of nails changes  and there is some thickening of skin at nail bed. This change happens in any chronic lung conditions ,but now a days we do not see it often as we have antibiotics  and the diseases that used to be chronic get treated quickly.He had muscle weakness . and also had clubbing and weight loss. He then had PET SCAN  nd that was positive for high uptake in left middle part and so there was high chance of cancer.

   So I did do bronchoscopy  and he had a mass obstructing left main bronchus .It was friable  and I did do biopsy and it came back for suspicious cancer. So I did not have definitive diagnosis  and he was not a surgical candidate  ad so we did needle biopsy and that did give us the diagnosis.He was started on treatments .
     I saw him in office . He had weakness  and also clubbing and also low blood count  and also had LOW sodium . I discussed with him on the para neoplastic syndrome. He HAD  WEIGHT, which is due to chemical secreted by cancer. This one called Cachectin - though no such chemical had been identified . But it cause weight loss. He had ANEMIA   and that is well known  and that is also Indirect effect of cancer. He also had low sodium  and that is due to a hormone secreted by tumor ,which is like hormone called ADH. and lastly is the clubbing which is due to any chronic pulmonary disease. And some patients have elevated calcium  again due to cancer. These  and some other that are not related  directly due to cancer but indirectly from some chemical secretion .