Sunday, June 27, 2021


   Medical science is getting better every day. Certain things that we did not even imagine in past have developed  and even today it is very difficult to understand certain developments. But certain things which are easy to understand  and difficult to do are also there. In the treatment of cancer now a days blood cells called Lymphocytes are taken out from a cancer patient and are 'programmed '(??)  and then multiplied and then injected in the patient to take care of cancer. This process is easy to understand . But very difficult to actually know as to what is being done . What does a programming of a cell means ?But it is easy to explain. The new treatments for COPD are also such treatments where it is easy to understand  and easy to explain. That brings me to the story for today. 

  I have seen this patient for 3-4 years and she had episodes of respiratory infection when I saw her for the first time . She is in her early seventies and she never smoked . She had cough  and then I saw her . The chest X-ray was normal  and  treated her with antibiotics and the steroids .She did OK  and I did do breathing test and that came as normal . But she had cough and so she was started on treatment for asthma . She did OK and then she weaned herself of the medicines for asthma . She would get periodic episodes of cough and then she would see me and I would treat her with  steroids and inhalers  and she would linger for few days with persistent cough and then would get better . 

   This continued and then the cough got worse and then in spite of doing steroids and antibiotics and inhalers , she would still have bad coughing spells . I did do further work up and we did CT scan and that was normal. I also did measurement of immunoglobulin - These are proteins - globulins that are important for immunity and they prevent the recurrent infection. She did have low immunoglobulin. So I wanted to  give her replacement for the immune globulin . But her hematologist did not want to do that. In any case she continued to have cough and she was admitted few times for the control of her symptoms. Then  I decided to do the bronchoscopy. When I did the bronchoscopy ,I found out that she had problem with trachea and major bronchial tubes . Normally the trachea has cartilages and that gives trachea the support and it does not collapse. Theses cartilages are semicircular and  also extend to main bronchi . That act like scaffolding . But her trachea would collapse when she would exhale or cough  and that   was causing constant cough. So I told her that we need someone to do a stent  and see if that would work out.. She was seen by interventional lung specialist. But he felt that she would need  surgery and stents may not be enough. So I have to send her to Mayo clinic . 

    So such a stent placement was not there 10 years ago and even when they did do it 5 years ago it was in the infancy and also no  one would have thought of doing surgery on trachea in an adult patient few years ago . I still feel that the cause of this is lack of immune globulin leading to recurrent respiratory infections and damage that was caused by persistent inflammation. I feel that she would need replacement for that in future . Stay tune .

Sunday, June 13, 2021


     I have been in medical practice for many years and have realized that the medicine is never perfect or 100% . We can treat 2 people with same condition and same situation and same diagnosis  and still not get the same results. We have the same machine but the result of the same treatment is not the same. So someone may say that it may be due to the circumstances or that people are not like car or any other machine and so people have different outcome. Some may say that it is due to KARMA, Whatever may the cause, we know that we get different results. But then the question comes as to how we can anticipate as to who is going to have out of ordinary results and then avoid the same treatment and do something different in these exceptional patients. Yes medicine is trying to do that and I often feel that our tests are not adequate. That brings me to the story for today. 

   I saw this patient in office sent to me by radiation doctor. She was 70 years old female who had noticed a lump on mammography and so they had planned lumpectomy and then radiation . The radiation physician had ordered a chest x- ray as she was a smoker  and that showed abnormality. So she had CT scan done and that showed the abnormality and so she was sent to me. The original thought was that the abnormality may be due to scars. I saw the lady and she was current smoker  and I felt that the abnormality could be a lung cancer . So I did the work up and she had Bronchoscopy and PET scan and then a breathing test. I had no 100 % proof that the lung abnormality was cancer but on PET scan it was  showing increased activity and so I wanted to have her do surgery. Certainly she had breast cancer also and that needed to be taken out. So she had the breast cancer surgery and then the lungs . The lymph nodes were negative. (The lymph nodes  drain different areas  and so they can show the spread) So when the PET scan had no uptake in nodes the surgeon still did  the lymph node biopsy before taking out the cancer and that was also negative for the cancer spread. So she had the mass taken out and and that was a cancer and the nodes on further biopsy did not show any spread of cancer. She had some issues after the surgery and that needed to be fixed but overall she did OK . So she had breast cancer and then lung cancer - both notice at the same time  and taken out and no residual cancer as far as WE CAN TELL The pet scan had not shown any spread and the biopsy had not shown any spread. 

     We continued to follow her and she had a follow up PET scan about 8 months after the original scan and that showed that there was activity in the nodes . So now the question was is it cancer and if it is then is is RECURRENCE OF THE LUNG CANCER or BREAST CANCER .The breast cancer is notorious in it's tendency to come back after several months and sometimes years .So she did have additional biopsy and it was not breast cancer but it was recurrence of Lung Cancer.

   So we had done a PET scan , which is suppose to be 85% accurate in picking up cancer  and that was negative . She had the same lymph node biopsy before taking out lung cancer and that also did not show the cancer spread . Then she had additional sampling of the same nodes  at the time of surgery to take out lung cancer and that was also negative . And now in less than a year - just 8 months she has the same nodes showing the spread of cancer. So the tests that we did were not adequate to pick up the cancer !

   Just a note - some labs are doing what is called circulating tumor DNA - a blood test that will pick up certain DNA of the tumor to predict recurrence of a cancer earlier that it is obvious on scans. So this may be a future .But if CTDNA is positive then the question is How do you treat?