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.