ALL GOOD THINGS MUST COME TO END ??

  We often say that all the good things must come to end. So does it apply in medicine? Many a times we have patients who have bad news or a bad diagnosis and it feels like the things are not going well. But then  things improve . We are happy and so is patient. In some cases the events take turn for better and then the patient is on recovery path and certainly that can and does last for long time. But in some cases this does not happen and usually we KNOW that or have EXPECTED that . This is a story for something like that. 

   I saw this patient few years ago - may be 10 years ago. He was a young male who had smoked and had continued to smoke and had COPD - the chronic lung disease that happens when one is smoker. He had diabetes too. He was not very compliant and had blood sugars which were high and the HB A1 c was also high . Every time he came for the follow up we had a talk as he did not even attempt to reduce smoking  and sugars continued to be elevated . One day we did a CT scan and he had abnormality . WE did the work up and he had MAC- atypical TB -called mycobacterial avium. He was treated by me and we did get infectious disease to se him and he did OK . The Ct scan improved and the sputum recheck shoed that the bacteria had cleared . We did do follow up and he was doing well and had continued to smoke and also had uncontrolled diabetes continued . As a routine we did follow up CT scan chest - it was almost 2 years that he was diagnosed with MAC and wanted to see if we could stop the treatment. The CT scan was abnormal in past and i did not expect it to be normal as he had a cavity and that would have healed with scars and so the abnormality will be still there . This time the scan was abnormal and it felt that he may have some lymph nodes swollen. That could be due to the MAC or could be due to cancer as he had continued to smoke. We did the further work up and did what is called EBUS- ultrasound guided biopsy of the nodes and it showed lung cancer. The COPD was bad and he had oxygen and the type of lung cancer was such that he could not have had surgery even if he had normal lung capacity and with lymph nodes positive he would not have been a surgical candidate. He was sent to medical oncologist and he was started on chemo.  He continued to smoke and he had some issues with chemotherapy. As the immunity is suppressed with chemotherapy, we continued him on MAC medicines , as otherwise the MAC would spread with body's immunity reduced. 

  The time was going on and 2 years went by and I was thinking that he is 'cured ' of cancer in spite of smoking and he was off the chemotherapy . But as I said all good things come to end , new CT scan dne had shown new lesion and older spot was growing and the nodes which were down in size were increasing in size . So he had recurrence!

   I have talked to him and the work is started again to see if he has new cancer or old one back.