I AM LOST

    I AM LOST !I have been in medical practice for many years and I often see things that rea not that common and sometimes I am surprised . But sometimes we have a patient that defies all odds . When it happens to be a patient who has say inoperable - wide spread cancer ,that we think will not make 6 months mark with or without treatment, and then something happens and  patient is cured , we are happy. Though in that case we also have surprise - uncommon - unusual outcome. But since the 'ending' is happy' we are happy and no one questions success. Then we have patient in whom the pendulum swings on the other side, when we expect patient to either not have a cancer or cancer that looks like can be cured  and then either it turns out to be cancer or shows spread etc, then we are more stunned. That brings me to the story for today. As always 

    I saw this young lady, who had abnormal CT chest . She was nonsmoker and had h/o positive skin test for TB , Positive test means she was exposed to TB and so the body reacts and has positive skin test . It does not mean one has TB now. She had never smoked and she had minimal cough and no other complaints. The Ct scan did show a small  nodule -less than an inch. She had no old CT scan to know if this was new or old .Since she had exposure to TB, it could have been related to TB . But I did the work up. I did order PET scan , In PET scan glucose uptake is measured and in cancers the uptake is high , as the metabolic activity of the cancer cells is higher that normal cells. The PET scan showed minimal activity. I also did bronchoscopy and that showed no TB or mold. The nodule was too small for me to do any biopsy and I did do brushing and washings and that came back no cancer but showed chronic inflammatory cells. I  decided to do follow up on CT scan in 6 months. The CT scan was done and showed no change in the nodule. But I decided to send her to interventional lung specialist . Since there was no change in nodule they decided to do a new scan. The new one was done in 2 months . It showed no change in 8 months. Normally the cancer will grow and her we have a patient who has never smoked and has history of exposure to TB and bronchoscopy showing inflammatory cell .I do not know the reasoning behind doing a navigational bronchoscopy where a computer helps getting to the nodule . But it was done by the interventional lung specialist . The biopsy showed SHE HAS LUNG CANCER . 

      So a nonsmoker patient , who has no change in nodule in 8 months , no uptake on PET scan and inflammatory cells on first bronchoscopy - defies all odds of being BENIGN and has cancer . That is heart breaking. 

SOMETHING NEW EVERYDAY

     I am in medical practice for many years and feel that 'i have seen this movie before,' many a times . But every now and then , we come across a case where something new is seen and that stuns me..

   I saw this patient who had cough and some fever . He had not smoked for many years but had been admitted to hospital with pneumonia more than  6 months ago. I had no old records, but when he saw me his Primary care doctor had done chest x- ray and that had shown pneumonia and so he was treated with antibiotics and was sent to me. I looked at old reports and hospital records. He was admitted with cough , fever and then was admitted and then the chest x- ray had shown pneumonia - in the same place as it was seen now - upper part of the lung. I looked at the old CT scan chest done few months ago. He had pneumonia and looked like he had obstruction of the bronchus going to that lobe - segment of the lung - the same upper lobe , that he had pneumonia now. I was now worried and may be convinced that he had a tumor in the upper lobe bronchus , and that had blocked the bronchus , and that had caused recurrent infection and HE MAY HAVE CANCER. 

    I explained him  as to what I was concerned about. We ordered new scans and also the PET scan . As I have stated in many blogs , the Pet scan is done to see glucose uptake in abnormal areas and usually the uptake of the glucose is high when there is cancer or infection. I also decided to do Bronchoscopy. The Pet scan was done and that showed only mild uptake . So it may have been a blocked bronchus with only pneumonia. 

     The bronchoscopy was done and I saw a blocking mass that was occluding the opening of the bronchus. As I looked at that carefully to consider biopsy, I realized that it was very hard . There was no way I could biopsy as it was not a soft - friable cancer, but was a STONE -HARD STONE that was blocking the bronchus. It was a broncholith or a stone in the bronchus. There was no way I could biopsy it or remove it as it was embedded  deep. 

   I sent him to a chest surgeon , but he did ot want surgery. .