THE GOOD AND THE BAD NEWS

      In medicine we often say there is a good news and a bad news. Many a times when I see patient who has abnormal CT scan and then we do the work to get diagnosis, and then the biopsy shows cancer, i sometimes say that there is a good news and a bad news . The bad news is that he has cancer but the good news is that it has not spread anywhere and we can do surgery. But sometimes the situation is different. That brings me to the story for today. 

    I saw this patient who has been a smoker in past and had chronic lung disease, COPD. She was doing good. She had routine Chest x- ray and that was abnormal and so we did do a CT scan of the chest done and that showed a mass . We did usual work up . She had PET SCAN and had  breathing test and also Biopsy. The PET scan showed activity in the central mass on right side and also some in thyroid . We did do the biopsy of the lung mass and that was lung cancer . The thyroid biopsy was also positive for cancer. The tumor in the lung was such that it had spread to nodes in the center of the lung  and so there was no way we could do the surgery. So we decided to do radiation and chemotherapy. The tumor was blocking the bronchial tube and so I we asked for radiation treatment . She had both and did well . 

    The new scan showed that the mass was smaller  and uptake was also reduced . So she was doing good , but she had cough and that was bothering her. She was treated with steroids and she felt better but still had cough. So, I decided to do bronchoscopy  and that was to see if she still had tumor.. What I saw was a significant narrowing of the bronchus which was blocked by tumor. The opening was so much narrowed that I could not see beyond it . It was inflamed  and that probably was the cause of her cough , So, the cancer was not there but the radiation had  killed caner , but also caused narrowing  and so she had cough . 

    There was no medical treatment for such mechanical blockage. I am not sure if we could dilate  it and open it.

 SO THE GOOD NEWS WAS THAT THERE WAS NO CANCER , BAD NEWS WAS R=THAT SHE HAD POST RADAIATION NARROWING WHICH MAY NOT BE IN POSITION TO OPEN UP.

WHEN YOU HAVE ONE YOU MAY GET SECOND

      In medicine we are taught to have one diagnosis and then differential  diagnosis. Which means one is more likely the explanation of the symptoms , but there are alternatives to that also, which is differential diagnosis. But not to have 2 separate  diagnosis for 2 different symptoms. This meant we have to have explanation for 2 different symptoms as one diagnosis not 2. But that is for symptoms at one given time . I want to talk about cancer and want to state that when there is one cancer, then one has higher chance of getting SECOND CANCER. That brings me to the story for today. 

    I saw this lady for abnormal CT scan chest. She was not a smoker and had COVID pneumonia. She was doing better but the pneumonia on the CT scan was not gone. She had no fever and had cough and clear sputum . No chest pain and the weight was stable. She did not have wheezes. I decided to do a follow up CT scan as the x- ray improvement lags behind clinical improvement, which means patient feels better but x- ray take longer time to improve. The new CT scan which was done 6 weeks down the road did show improvement , but the congestion or the abnormality did not improve on one side -right was better but left was still the same. She was feeling better and so I decided to do Bronchoscopy and then if that was OK , do new CT scan. The bronchoscopy did not show much abnormality and the tests that I did did not show any TB , bacteria or fungus or cancer. But this is never 100% and so we did new CT scan in another 5-6 weeks. The left side continued to be abnormal  and right side cleared . So I did PET scan and that showed increased activity in left sided abnormality . The uptake was not very high  and sometimes inflammation and infection can also have mild increased uptake of the glucose. I told her to see chest surgeon. The thoracic surgery did the surgery and that part of the lung was taken out and she had lung cancer . The good part was that there was no spread and she did not need any additional radiation or chemotherapy.

     She saw the oncologist and he did follow up and new CT scan. The CT scan showed new fluid around her left lung where the cancer was taken out. She came to me and had no idea of the new fluid as she had not had any call from oncologist. I decided to treat her with prednisone as sometimes patients get fluid related to the surgery and that is due to inflammation from surgery. If she did not improve , I will have to drain fluid with a catheter. We did follow up in 4 weeks and the fluid was gone.

    I continued to do follow up as she also had sleep apnea and some cough off and on. Overall she was stable for next 2 years . Then one day she had blood in the stool. The work up was done and she had colon cancer. She had surgery and has done well. The point that I want to make is that when someone has one cancer diagnosed , they have higher chance of getting second cancer over period of time -it could be other lung cancer and I have seen that also or it could be another organ cancer. One has to be watchful.