SURPRISE

    In medicine I don't like surprises. The surprise is not good for patient  and not for the physician. But we do have them  and since we are not 'all knowing ' the surprises do occur. The story that I am going to tell you, is one of such patients. 

   I saw this patient for abnormal CT scan .The lady was a smoker and had quit 2 years ago and had some persistent cough and so had chest X- ray done and then CT scan. The CT scan did show a mass in the central part of left lung . I saw her and I knew that in all probability it was cancer and the bad part was that due to the location of the mass - dead center of the lung where main bronchus enters the lung - it was not operable. I did the Pet scan and the miss did pick up glucose and was hot and then I did bronchoscopy. It showed that there was a mass in the bronchial tube and that was partially blocking the tube. In such cases the surgery is not possible as there may not be enough bronchial tube to resect / cut. If the cancer is also in central lymph nodes then also surgery will  not be successful. The biopsy came back as SMALL CELL CANCER. The small cell cancer is treated with chemotherapy and sometimes radiation .She was seen by both the physicians - radiation and also oncologist and received treatment.

   She was seen by me few times and she needed oxygen and had done overall OK Then one day she was short of breath and so came to ER and the x- ray showed complete whiteness of the left part of the chest . In X- ray there are only 2 colors - air is black and everything else - fluid - tumor - collapse of lung - all look white . The CT scan was done and the left lungs was collapsed and there was fluid around it . The natural conclusion was that the fluid was due to cancer and that had caused the collapse of the lung. The treatment would be to drain the fluid and then the lung expands. 

   The catheter to drain the fluid - which was though to be very large - was inserted. But then only small amount of fluid came out. The X- ray barely changed - the lung continued to be collapsed . I was nnot happy and that was not expected . But what had happed was that the lung had collapsed DUE TO EXTRISIC PRESSURE from the tumor on the covering of the lung and so the fluid was secondary  to that and the lung was unable to expand . So the catheter did not help much. So, now only option was to do new chemo and may be radiation and see if the lung would expand . The chance of lung opening is not very good . 

   When we see chest x- ray with fluid and collapsed lung in 90% of the time when we drain the fluid the lung expands , but the surprise that the lung could not expand was not a good news for the patient. 

ONE AFTER OTHER

    In medicine we have some of theses saying that is true in majority of cases , but there are exception. The patients have not heard them and so sometimes we have problem . What may be true in many patients or cases , may not apply for one  of the patients. We in medicine go by probability  and that is statistics The 2 words that we talk are 'probable' and 'possible'. Anything and everything is possible , but not everything is probable. The probable is what can happen in majority of cases - say more that 50%. But possible means it can happen but not more than 50 % . So if it can happen 1 in a million it is still called possible though not probable. That brings me to the story for today. 

  I saw this patient in my office . She had a lung nodule and that was less than an inch in size. We did the work up and she had bronchoscopy and PET scan and also breathing tests. She was a smoker and has some shortness of breath, The CT scan had shown the nodule and it also had shown another nodule of 6 mm in size. 25 mm make an inch . The PET scan showed that the larger nodule was positive and the smaller one was not picking up any activity. Certainly that could be a scar or cancer , but with not enough number of cells it was negative on the PET scan. The lungs functions were showing some compromise  and she still had enough reserve to have part of the lung taken out . 

  She did have lung surgery and the nodule was cancerous and all the other things - like lymph nodes, margins and covering of the lung etc. were ok and so she had a high chance of having 'cure. 'She was sent to an oncologist and he told her no need for any additional treatment and she had her family were happy. She was happy . He did new CT scan in 3 months  and that was OK but the smaller nodule had grown by 2-3 mm , So the oncologist wanted to do PET SCAN in 3 months . She saw me and I saw the CT scan and the growth though only by 2 mm was bothersome . So I called the surgeon and pushed for having new PET SCAN done sooner . The PET scan was done  and she had pick up in the nodule though faint. I talked to the surgeon. Interestingly enough her lung function had not gone down much in spite of having a part of the lung removed . So the surgeon did do second surgery and took out the nodule that had grown  and IT WAS CANCER . The good part -if there is anything good about having cancer - was that it was a different  type of cancer . If it was of same type then that means she had a spread of a cancer in first place and that would not have been a good news . So she seems to have had 2 separate independent lung cancer starting at the same time - something that we don't see commonly . Or to state it differently, it is possible but not probable to have 2 lung cancers in the same lung at the same time . But she did !!

INSANITY

   Someone had said that the definition of Insanity is to doing the same thing over and again and expect different results. Certainly I am not talking about  learning or trying to be successful. There one can improve and achieve the goal . There was a Royal Air Force pilot and he had successful mission bombing Germany. But then in one of the missions his plane was shot and he lost his leg. He was POW and Germans made a prosthesis for the leg . They never expected but he got the leg and he escaped . He was back on missions to bomb the Enemy . He was again caught and lost second leg  and he had new prosthesis and he escaped again .In spite of losing both legs, one day he was trying to ride a horse and he fell off 30 or so times before he could ride. This type of repeated efforts is worth appreciating. But I was talking about some other reputations, where doing same thing over and again is not going to change outcome. 

   I have known this patient for many years . Had some low oxygen and then had pneumonia. He also had chronic pain pain and was on pain medicines - narcotics and so her carbon dioxide was high and so oxygen was low . I did work up and found out that he was having aspiration and that means water or food was going wrong way in the lungs causing injury and inflammation and pneumonia. He had further work up and he had very poor function of the food pipe. The contraction of the muscles of the esophagus are not there. She was sent to a surgeon and she had a surgery and that did not work. Unfortunately I have seen this too often . In this condition food stays in  food pipe and it comes up and then trickles down the lungs. Unfortunately patient has difficulty of swallowing . He went from one GI specialist to other . Every one did the same thing - endoscopy . Every time different medications were tried - not much different from one other and she gets pneumonia and then gets admitted . HE has no change in medicines or symptoms , and he has changed GI specialist 10 times locally and out of the our place .He gets endoscopies every time he has seen ne doctor. I have told him that only 100 % almost -100% will be to not eat through mouth but have a feeding tube put in for nutritional support. He does not want it and we are doing same thing over and over again ,expecting different results. 

( This is esophageal motility disorder called Achalasia )

MEDIACAL PROBABILITY

   In past I have stated that in medicine we treat patients many a times based on probability. But at the same time the probability is based on science  and so we know based on education and studies and experience that certain diseases are likely to be present and certain are not likely. But that is never 100%. So, in medicine we talked of 2 words one is Probability and other is Possibility. To understand this I will say that everything is possible but not probable. The word probability means that that the chance is more than 50 %. So it is possible that I will be President of US but it is not probable that I will be President. That brings me to a story for today. 

   I saw this patient who happen to be spouse of my other patient. She was 70 years old and has never smoked , but was exposed to second hand smoke from her husband. Sh started with cough and the PCP gave her some antibiotics and some cough syrup and then the cough continued and so he did chest x- ray and that showed some abnormality and so more antibiotics were given . She had o fever and she has no chest pain and she has stable weight . She had no shortness of breath, She saw me and we did the work up ..I though she may have mild asthma and so did some work up like Pulmonary Functions studies and also allergy blood tests called IGE and RAST. I also gave her some inhalers and steroids - prednisone . She felt better but still had cough . The steroids did help the cough  and when they were stopped she had cough . So I decided to do CT scan and I was surprised. She had a mass like density in upper part of the lung. So we decided to do Bronchoscopy . That was done and no obstructing cancer was seen and the biopsy showed inflammation and there was no bacteria or TB or mold. I decided to allow the body ti=o heal and so did follow up CT  scan in 6 weeks or 8 weeks . The CT scan did not change much . Now I was stuck. She had what looks like pneumonia but that was not getting better and so I did PET scan . The PET scan tends to pick up metabolic activity of the cells  and when there is cancer or infection, there will be cells which are more metabolically active than normal cells, and so they show more glucose uptake.The test is 80 % accurate . In case of my patient it did not show much pick up. I was stuck . I had suggested her to se thoracic surgery to do OPEN BIOPSY. .She came to my office for the follow up. I though that based on the low pick up we could wait and do new Ct scan .The size of the 'mass like density ' was also smaller. So I decided that we will do new CT scann in future  amy be 2-3 months . She had seen the surgeon same day that I saw her  and he felt the same thing, that based on PET SCAN findings , we should wait  and not do surgery now. OUR DECISION IS BASED ON PROBAILITY of cancer being low with low pick up on PET scan. The possibility of cancer is still there but it is less probable based on low pick up on PET  SCAN  and also on smaller size of the mass. 

   Let us see what happens . By the way her cough is gone with inhalers alone.