Friday, May 15, 2020


    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

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