NOTHING IS KOSHER

    In medicine we have often talked on rare bird or certain things that we feel comfortable about certain findings .But the medicine is statistic and as one knows that not 100%. So I say there is nothing is Kosher. I have often stated that with statistic ,one can put one hand in boiling water and other in ice cold water and YO ARE AT COMFORT !! But in medicine we have certain things that are common and when we are proved wrong or we have deviation from 'usual; we don't like  as we did not expect it. That brings me to the story for today.

  I saw the patient about 70 years old male who has been 2 pack a day smoker. He had a CT scan done by PCP and that showed a nodule about 13 mm - just half an inch in size . So he was sent to us . I did start the work up .I explained the patient that, I am concerned about high chance of cancer and needs to answer 3 questions ,i.e. Is it cancer , Has it spread and What can be done as treatment. I ordered a PET scan and breathing test and did bronchoscopy. Some how he did not do pet scan for 6 weeks and rest of the work up was done. He came to see me again . The bronchoscopy did not show much and so when we had done washing and brushing - what I call as pap smear of the deeper parts of the lung came back as normal. But the PET scan was not normal and to my surprise, the nodule which was 13 mm was now 21 -23 mm and had increased uptake, indicating that it was likely to be cancer. But more than that the growth in such a short time indicated rapidly growing or aggressive cancer .I also was not very happy that many of the lymph odes which were not reported as enlarged , were enlarged and had uptake, indicating spread of the cancer. 

  I explained it to him and decided to send for additional biopsies and also have chest surgeon look at him in case the nodes are not positive then he can resect it out. 

NATURE OR NURTURED OR KARMA

    I have been in practice for many years and I have seen patients and their family members. It is is not uncommon to have patients - husband and wife to go to same family physician, but for them to have same system problems like lungs also is not that uncommon. Again we ac see lung related problems in both husband and wife simply due to smoking history or exposure. So I have seen husband and wife with COPD - EMPHYSEMA as both were smokers and I have few pairs of husband and wife who had cancer of the lungs. But I have also seen some families that have diseases that cannot be explained on the basis of smoking or exposure that could have happened being living together. Again genetics could explain, but it is not that common. That brings me to case for the day. 

  I had seen this lady several years ago - may be 25 years ago. She was a smoker and had high blood pressure. She quit smoking and had abnormal chest x- ray. We did the usual work up and she had cancer of the lung and she had decent lung capacity and there was no evidence of spread of the cancer . So she underwent a surgery and she had cure . She did well and came to me for follow up for 2-3 years and then stopped coming . She came back again for some cough. She had not smoked for almost 30 years and she had no new diagnosis other than high blood pressure . Her daughter also used to be my patient . She had 3 daughters and each one of them had major medical problem. One that was my patient had scleroderma  and had some scar tissues - fibrosis of the lungs and had other problems associated with scleroderma . She was on oxygen and she did not want lung transplant and she continued to get worse over period of 5-6 years and then dies . Her other daughter who had seen me for short time had diagnosis of lupus and had developed kidney failure and over period of time she got worse and then needed dialysis and that was continued for several years and then she also died . Her third daughter also had many medical problem and I never saw her as patient as she was not here and when I talked to patient about her , she was in nursing home at very early age due to medical issues . 

   So, here we have a mother who had cancer of the lung and she got cured , had 3 daughters who all had various medical problems and they all dies BEFORE patient and they did not have smoking related diagnosis but had so called Autoimmune disease like scleroderma and lupus etc. What could explain such sad story? How could they had that bad gene that made caused the diseases and made them so sick that they died before their mother? Certainly all were in the same environment and that could not explain. So then what was the cause ? I do not know  But may be KARMA and some kind of give and take that brought them together . 

   By the way may patient had new spot of the lung and she refused the work up as she told me that if she has new cancer she was nnot going to do anything about it. 

THINGS ARE UNUSUAL - BUT MAY BE NOT THAT MUCH

    I have been in medicine for many years and have seen things that are very very common like asthma or COPD , pneumonia and may be even cancer. But sometimes even common diseases can present as very interesting presentation, though anything that is interesting for for health care professionals is bad news for patients . That brings me to today's story.

  I have been seeing this patient for a while , She has been ex smoker -quit many years ago and had some COPD . She has had routine x- ray - CT scan in past and that was ok . But this time she had sputum tinged with blood. So I did new CT scan and the report was very sketchy, There was mention of some abnormality in right bronchus , but no mention of any tumor.  I had planned bronchoscopy any way and  then with the abnormal findings on CT scan, i also ordered PET scan. In PET scan glucose pick up of normal tissues / organ is compared to the abnormal areas seen on CT scan and if the pick up is increased that indicated cancer - infection etc. . The accuracy of picking up cancer is about 80%.The bronchoscopy was done before the PET scan was done and that showed that the main bronchus - was narrowed and that looked like external pressure. There was no mass as such that I could biopsy. I did do some brushings - pap smear from  the bronchus. The PET scan was done and that showed that there was a mass and that was making the right bronchus narrowed and there was greatly increased in that mass suggesting that it was cancer. But the scan also showed that she had increased uptake in thyroid .She had seen thyroid specialist less than one year and had biopsy and that was OK. But the PET scan was abnormal and so I asked interventional radiologist to do biopsy of the thyroid . The lung mass was there too and so I called interventional pulmonary doctor and he did do ultrasound guided biopsy and he called me that preliminary report was that it was thyroid cancer . The thyroid biopsy was done before the lung biopsy and that also showed thyroid cancer. 

  So I called patient and told her that she seems to have thyroid cancer that has spread to lungs . I also called oncologist too and ask him to see her. But the story did not end there . I checked the final report on the lung biopsy and that was not a thyroid cancer but it was usual lung cancer !!So she had 2 different cancers -one thyroid and other lung cancer . Due to location and spread  to the central lymph nodes , that was not resectable or operable and so we will need chemo and may be radiation . I am not sure what would be best for thyroid cancer - ? surgery or some different chemo or both ? I will let oncologist decide on that.