NO RIGHT WAY

    In medicine there are more than one way to do things  and the AI will not be able to give one final way. In Mathematics, 2 plus 2 make 4  and that can not be changed and it is true under all conditions. In medicine sometimes we do things differently in different patient and there is no right or wrong way. I  saw 2 different patients  and they had very similar problems. And I will tell you one at time. 

The patient that I saw was that of my other patient, who had COPD and he had smoked for many years and he had quit ,but it had taken toll and he had COPD and he had shortness of breath and he  needed oxygen. I saw him and he had large mass and we did biopsy and he had cancer and he was not a candidate for surgery based on many factors like being on oxygen with advanced COPD and also the mass was invading the center of the lung . So we did radiation therapy and he did OK . Then his wife came to me. She was about 80 years old and had smoked many years ago. She saw her PCP  and had some cough and some shortness of breath and when she saw PCP her oxygen was low and she was started on oxygen and she had CT scan of the chest done and that was abnormal and so she was sent to me .

  She was elderly women and she has been on 3 L oxygen and she had some shortness of breath and she had not had any chest x- ray in recent past till she had the CT scan . The CT scan showed Aright upper lobe mass and that had invaded the hilum the center of the lung . She also had significant fluid around her lung  and she was short of breath. She had irregular heart beats and had not seen cardiologist but was on blood thinner. So I had high suspicion for cancer which had spread to lymph nodes  and also the fluid that was seen , was most likely due to cancer. She was on oxygen and had COPD  and she  did not want any chemotherapy same as her husband. So I had a choice . I could do bronchoscopy and biopsy and see if I can get the diagnosis of cancer  and then drain the fluid and see if there are cancer cells in it. If my bronchoscopy and biopsy does not give diagnosis then i will have to ask radiologist to do needle biopsy of the mass and if the fluid  reaccumulates then we have to have a catheter put in for periodic drainage. Since she was on blood thinner, we will have to hold it for 5 days every time we did any invasive procedure. So if I did all these procedures we will be stopping and starting blood thinner many times . So I decided to do thing that I thought was RIGHT for THIS PATIENT. 

  I called radiologist and asked him to do needle biopsy of the lung mass and at the same time put in catheter , under the presumption that the fluid was due to cancer and will come back if just drained and then will need drainage again or the catheter for periodic drainage. 

  THIS WAS THE RIGHT WAY FOR HER IN MY UNDERSTANDING . 

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MINE FIELDS IN MEDICINE

      I have heard this statement that when  Taliban terrorist left certain areas they left the place with mines  and they were unpredictable and can explode anyplace that we did not expect. I have felt the same thing in medicine. This is so true in case of cancer . I don't like when a patient diagnosed with cancer and have gotten treatment with chemotherapy, come for the follow up in my office and tell me that the oncologist told them that the cancer is gone. I know better that making such a statement and so does the oncologist. But patients like that and then when the cancer comes back, then we have hard time explaining the recurrence. And I call this as the mine field where we have no way of knowing all the mines -the metastasis -which are there, but not obvious. That brings me to story for today. 

 I had seen this young woman who had been diagnosed with breast cancer and she has had surgery and then radiation and then chemo. She had some abnormality in lungs and that also was breast cancer. She also had some bone spread. She was short of breath and so she had chest x- ray and she had fluid built up around her lungs and so she came to me. We did drain more than a litter and it showed cancer cells and so we did follow up chest x- ray in 3-4 weeks and the fluid had come back. So we did a catheter to drain fluid periodically at home. She did well and she had some chemotherapy changed and she was ok . The fluid drainage continued to be less and less. 

     More than  months passed by and i get a call from ER . She was in ER for shortness of breath. I spoke to the ER physician and told him to do the CT scan as she had 'white out' on right side - suggesting either the fluid or collapse of the lung. Sometimes the catheter may get clogged or may not be in 'right ' place. The CT scan showed that her right lung had collapsed . I  did bronchoscopy to see if her  right lung bronchus was blocked from 'inside' or it was due to pressure from 'outside' . If she had blockage from inside then I could put in radiation catheter and that would treat / burn the tumor and then that will help 'open' the obstruction. She did not have any tumor inside the bronchus, so she had pressure from outside . So we called radiation oncologist and she was started on radiation. 

    So she had breast cancer - that had spread to lungs - then had pleural fluid  and now mass that was pressing on the bronchus - just like new mines were discovered every so often. Then I had a call from Mayo clinic where she had gone for second opinion. The oncologist called me and told me that she had done MRI of the liver and SHE HAD MULTIPLE METASTASIS TO LIVER. Just like another mine exploding in her face .

CATCH BEFORE ---

    I n case of many medical conditions, if we catch in time , we have higher success. This is true even with infection . heart disease diabetes etc. . If we treat diabetes or high blood pressure early then we can prevent the complications that are associated with it. This is also true with cancer . In medicine we have tried to  diagnose earliest stage and then hope that we can achieve cure. We have stared  doing tests like DNA pieces of tumor in blood, this is called CTDNA . -Circulating Tumor DNA .But it is not a test that many labs do and even many physicians are not aware of it. It also raises some questions as to what to do if the test is positive. 3-4 years ago Medicare approved CT scan of chest as screening for early diagnosis of lung cancer in patients who recurrent smoker or ex- smoker for 14 years. This has certainly helped , but also has raised some anxiety when the CT scan shows some nonspecific abnormality  and needs follow up. But sometimes I feel that it's not always possible to 'CATCH' cancer early. The story that I am going to tell is one of that kind. 

   I saw this patient who was in mid or late eighties. He had quit smoking many years ago. He had quit smoking many years ago . he had some cough and usual treatment with cough medicines and antibiotics did not help. So, he had chest X- ray and then had more antibiotics . He then had CT scan and that was abnormal and so he came to me. He had some cough and no fever . He had no shortness of breath. There was nothing special in special examination. The CT scan showed  abnormality and had a cavitary area in lung . That could be an infection or cancer. So we decided to do further work up . We did PET scan. The PET scan shows where the glucose is concentrated and that depends upon metabolic activity of the cells. So it picks up in 8- plus % of the cancer. The PET scan showed increased activity in the cavitary area and also some lymph nodes. There was no evidence of any activity in any other areas , We did the EBUS - ultrasound guided biopsy through bronchoscope and that showed lung cancer -highly likely. I had discussion with patient and family and decide to send him for radiation treatment to the lession in lung. . Surgery was not an option and I had called and asked a surgeon to some additional biopsy and he had refused. He and his family did not want any surgery or chemotherapy so, radiation was the only option. I called radiation doctor and he gave him appointment 

  3 weeks had passed and he was admitted with weakness and hospital doctor had admitted. .When I was called in ,he was seen by cancer specialist and infectious disease doctor and also cardiologist. Tests were planned. He had chest pain and that happened to be due to spread of cancer. The cancer doctor had planned ordered bone biopsy . I talked to  patient and family they did not want any biopsy and so I called radiation doctor to consider radiation to bones where cancer  had spread . He agreed . 

   The PET scan done few days - weeks ago had not shown any spread outside the chest and now he had bone spread in many bones. I am sure cancer had spread tat time but out tests are unable to detect as the amount of cells must be bellow needed to be picked up. But with just given few weeks / days it showed on bone scan and CT scan.