RIGHT AND WRONG OR NEITHER

   In medicine we have situations where WE feel most of the time ,things are right or wrong. If I see a patient with blood pressure is elevated, I think it is RIGHT TO TREAT WITH MEDICINES. It is NEVER RIGHT not to treat high blood pressure. The same is true of elevated blood sugars and pneumonia and asthma and so on. But sometimes a good doctor and good patient can make decision which are different, but they both could be right. This brings me to case for today. 

   I had seen this patient 88 years of age , who had quit smoking many years ago . She had no major complaints , but had some cough and so her primary doctor did chest x- ray and then send her to me 

     She had work up and we did CT scan chest and that showed a nodule . The nodule was not the cause of her cough, but I had to do the work up . So we suggested doing a PET scan and a bronchoscopy. The PET scan showed that there was some uptake of the glucose in that nodule , but not very high. So the possibility of cancer was low though not zero. We discussed the situation. We could do a needle biopsy or a navigational bronchoscopy and biopsy or open biopsy - the open biopsy would be 100 % . She did  not want any invasive procedure. So we decided to do new scan in 3 months . 

    She did new scan in 3 months and that showed that the mass was same size .She had refused any additional invasive procedures , and the nodule had not grown, we decided to do new scan in 3-4 months. I did new scan, and she came for the follow up. The nodule had grown Now I had a problem . A slow growing cancer may have low uptake on PET scan as the metabolism of cells is not very high compared to normal cells .The growth means there was most likely a slow growing cancer. So we again had the same discussion- do a needle biopsy . do navigational bronchoscopy or do nothing. This time I had one additional suggestion . The lady and her family did not want any biopsy and so I suggested asking radiation doctor and see if based on the growth and PET SCAN if they could treat it as cancer WITHOUT BIOPSY. 

   So Doing nothing could be RIGHT, Doing biopsy also could be right and doing radiation WITHOUT BIOSY  is also right.