DO WE NEED 'TESTS' FOR DIAGNOSIS

      We in medicine have seen pendulum swinging from one end to other in many aspects of medicine. We have seen popularity of different tests or treatments . With time we may have n=better tests or the tests becomes less reliable with more tests being done. CT scan or PET scans can be considered belonging to this category. When the PET SCAN came in we thought that it was going to be 100%  accurate in getting diagnosis of cancer. But as more and more tests were done and we gained more understanding in to the tests, we realized that the accuracy of getting diagnosis of cancer , was reduced and not closer to 100%.But now we know that it's close to 85% . But sometimes things that we assume based on history and physical examination, are not 100% and we need additional information . Sometimes we order tests to confirm our suspicion  and then we are surprised. That brings me to story for today.

       I saw this 60 years old male who came to me for shortness of breath. This was going on for years  and he has seen new PCP and he had sent him to cardiologist .He was nonsmoker  and had history of high blood pressure and mild diabetes. The cardiologist di the work up and the work up did  not reveal any cardiac problem and he came to me. He had shortness of breath for long time. His physical examination was unremarkable. His lungs were clear and he had good oxygen saturation. He was obese  and may have had sleep apnea, but that was not related to his current problem or complaints. I thought that he had increased BMI  and overweight had caused decreased activity and exercise  and so he was DECONDITIONED . So the shortness of breath was due to that, especially as cardiac problems were ruled out . But I was going to do the work up . My presumption was that the work up will be good  and then I can tell him on weight and lack of exercise and shortness of breath. 

    I did do the pulmonary function studies  and to my surprise he had moderate obstruction - indicating ASTHMA . So even though he had shortness of breath for long time and the lungs were clear  and oxygen was fine - he had asthma .So sometimes we need TESTS to diagnose !!

IS THERE END TO IT?

        I have often seen patients that have medical problems  and the treatment is started  and patients  and the physicians look for the completion of therapy. Certainly this is not true for high blood pressure or diabetes, in many cases the treatment is life long . But say someone has lung cancer  and we decide to have surgery  and so when the surgery is done  and that is successful, the so called treatment is over-complete. Pneumonia would be other condition . Do antibiotics  and the treatment is done with. But in some patients we end up having one thing leading to other. This is such a story.

    I saw this patient in my office who was seen by other lung specialist in past. She had abnormal CT scan of chest  and the physician had done bronchscopy  and she had MAC -the atypical TB called mycobacterial intracellular and so she was started on medications but somehow he did not do much follow up and so she came to me. She came to me . We did the follow up on CT scan and also did new sputum for TB bacteria  and then continued to do the follow up. She was doing OK  and at the end of almost 1 year of treatment we did new CT scan . The treatment for this disease is usually for 18 months , Or 6 months after the sputum is negative. This is done as the chance of recurrence is high if treated for shorter duration. The CT scan showed some worsening of the findings  and so I did do new bronchoscopy  and that showed that she still had MAC. So I added 4th medicine . So now she was on 4 drugs  and we had already exceeded 18 months . But then i did do new sputum check in 3 months  and that was negative . The scan was OK and she had no complaints. So we were happy  and we had plan to stop the medication in short time. But we did new sputum check  and IT SHOWED A DIFFERENT MYCOBACTERIUM.  

    So now we are stuck with treating her with NEW DRUG  and for HOW LONG ?

   But I know there is a light at the end of tunnel. 

    

NON SMOKER AND LUNG MASS

     We often talk about the smoking and the lung cancer. The incidence of lung cancer is high or 20 times that of nonsmoker. So when we see a spot on the lung it is easy to make decision . But even though the incidence of cancer is low in nonsmoker, it is not zero. So the decision making is difficult. The general public has a belief that the incidence is zero. That brings me to  the story of today. 

    I saw this new patient 55 years old male who had abnormal scan. He had no major complaints  related to lungs, but in 2019 he had car accident and he had been to er and had work up. He had a CT scan of chest and that had shown a spot on the lung , size of dime. He was told to do new , follow up scans .He did not do any scan till now in 2022. It may have been due to the belief that the non smoker do ont get cancer or may be that it was pandemic and since he had no symptoms , he thought he was OK .Any way he did not do new scan till 2022. The scan showed that the spot had increased in 3 years and it was now of a size of quarter  the coin. His primary care physician send him to me. He had been non smoker and has no cough , fever , chest pain or weight loss. He had no shortness of breath.

   His physical examination was unremarkable . He was not on any medications. I saw the scan . The mass had increased  and so i had discussion with him  . I told him that we have to do work up and then decide if we can do surgery to take it out. The usual things that I tell patients is that we need to answer 3 questions , namely is is cancer , has it spread  and what is the treatment . So I have ordered  PET SCAN , a breathing test and bronchoscopy. There is a tumor called carcinoid which some people call a cancer which rarely spread or benign tumor which can spread . I thing it may be carcinoid and only 100% way to know is to take it out. When we tried to schedule the tests , he wanted to postpone them . 

    So there are 2 points , one is that if he was a smoker he would not have waited for 3 years to do new scan or see lung specialist  and now that we know THAT IT HAS GROWN he was not in hurry to take steps to take it out . This comfort comes from the feeling that nonsmokers are immune to getting cancer. He may have cancer or carcinoid , the slow growth rate suggests that this may be carcinoid , but one cannot be 100% sure till surgery is done.

NEW TESTS AND NEW QUESTIONS

    We have great progress in medicine in last few years - as I can say 'in front of my eyes.' We did not have pet scan 40 years ago and CT scan was easily available for us in medicine for only 40 years. But sometimes the new tests add to answers and help in making decisions in maedicine  and sometimes it add to more questions. We started about what was then called as Liquid Biopsy few years ago  and that was trying to detect TUMOR DNA in blood or urine  and that would help to detect cancer at earlier stage - in hope that it was 'curable'. We also have some newer tests called NODIFY2 where detecting certain protein would help us to calculate probability of cancer . So we can do calculation without the tests and then redo it after the blood tests are done and see if the probability is 'increased' or 'decreased'. But still that did not give us the diagnosis. This brings me to case for today. 

    I saw this patient in office may be 67 years old , She had routine ? CT scan . So few years ago the Medicare approved doing CT scan of the chest to detect Lung Cancer at earlier age without having abnormal chest x- ray in certain group of patients. The smokers and nonsmoker  for 14 years are  included. So this patient was having CT scan done - which is called LOW DOSE RADIATION SCREEING CT SCAN OF CHEST . (There is a special code for doing this tests) So when she had CT scan in 2018 there was no abnormality . She continued to have new scan yearly except in 2020. Due to COVID in 2020 she did not have the scan . She has no major  symptoms like cough , fever or chest pain or shortness of the breath. So she had new scan in 2022  and when that was compared to one done in 2021 ,she had new nodule ,size of 9 mm . For some 15 mm make an inch . So it is very small but not of that size that we can just do follow up as that could be due section variations . (The sectioning variation may be due to size of cuts in CT scan ) She came to me . I saw the CT scan and decided to do the test called PET scan . In PETS scan one is injected with glucose  and that is picked up by ALL the cells in body and then a scan is done  and where ever the glucose concentration is high compared to normal cells in that organs will indicate cancer or infection or inflammation.. The cut of for doing this test is 8 mm as the nodules bellow that size may not have enough cells to 'show up ' on the scan . So she had borderline size for PET SCAN and i did that and the activity came as 'borderline . I have also ordered blood tests called NODIFY2 which is good for nodules with size of 8 mm minimal. Again borderline size . I don't have the report yet . But now I have a patient who has 9 mm NEW nodule and the PET scan is borderline pick up. The size is not large to do needle biopsy, and now we have to make a decision as to what to do. We can do open biopsy and take out 1/3 of lung and get diagnosis. Or we can do follow up CT scan in near future - may be in 3 months .So the new tests have not added much to help us change the course of our action is diagnosing the cancer. If I did not have PET SCAN ,I would have done the follow up on scan only . So by doing the PET SCAN i now have more question as the metabolic activity was not 0 but was lower level where I HAVE TO MAKE A JUDGEMENT CALL !! 

ART, SCIENCE AND MAC

     I have often felt that there is an ART in medical science. But most of the time doctors feel that medicine is science and not art and many a times in controversial cases we are held accountable as we did not treat as science. But there is individuality  and there must be variation n work up and treatment of the same disease in different situations. If I see a mass in a very old person, who has dementia and is wheel chair bound, i will have different choice of work up and treatment than when I have another patient who is 40 years old and has all his faculties intact and is physically also fit . This applies to almost every disease. The control of diabetes is much more strict when we are treating younger person than we are looking at 80 years old person . The damage that can happen with low blood sugar is bad and the chance of missing it in elderly person is high and so we allow the blood sugars higher than what would be acceptable for younger patient. This brings me to todays story .

   I saw this lady who was a nurse  and she was in her mid fifties . She had never smoked and she has some cough for long time. She saw a lung specialist and he did the usual work up and then did follow up. She had CT SCAN and breathing tests and some inhalers tried on her . She had no shortness of breath and she has no chest pain and she looked OK. She did not have any weight loss and no low grade fever. But she had abnormal CT scan of chest done. So she had bronchoscopy  and that grew a bacteria called MAC. This is also called mycobacterium Avium or MAC for short  and also falls under NTG -NONTUBERCULOUS MYCOBACTERIA. She was sent to Infectious Disease specialist  and he sent her to me for whatever reason. She being a nurse was somewhat aware of the treatment options and the side effects etc and wanted my opinion. The treatment for MAC which is a chronic condition and it needs treatment which is prolonged . The current treatment is that with 3 drugs for 18 months . The medicines are given either daily or 3 days a week depending upon the disease severity . The medicines are continued for 12 months AFTER the sputum shows no bacterial growth after the treatment is started . One of the medicines has sometimes effect on Liver and so we need to watch blood test for liver damage . Other one can cause problem with vision - optic nerve and so we need to check the vision periodically  and so we need close watch . If the sputum continues to shoe the bacteria ( it's mycobacterium and not the bacteria )then we have to start 4the drug. Some may have problem with stomach.

    So, she wanted to know my opinion if she could avoid it . Here is art  and science mixed . Ideally if she has 2 samples positive for MAC then she needs treatment - this is science . But if we can watch her clinically and with CT scan and also with sputum culture then that will help . I have no test that can tell me if a particular patient will get worse or not. So it becomes purely an art . The science is -TREAT and the art is treat or not treat and just WATCH . There is risk in either approach - she can have side effects with medications or she may get worse without the treatments. 

        Now you know what I mean by ART and SCIENCE mixed in medical practice. . 

GGOD AND BAD NEWS

    When we see doctor, many a times people say that there is a good news and bad news . Like " you have diabetes is the bad news , but it's mild and we can treat it easily is the good news '. But sometimes we see patient who has cancer it's impossible fond much good other that may be that we can operate and cut it out . This story is something like that but much different. 

   I saw this 68 years old female in my office . She had some cough and had been going on for 2-3 months and then had a chest x-ray and that showed abnormality and so she had CT scan and she came to me She had not smoked for many years and she had no weight loss or fever or shortness of breath. She was little overweight and came with her friend. She had clear lungs and her oxygen saturation was good. I saw her CT scan and she had a mass in the left middle part of the chest and it was very large almost 7-8 cm . The location was such that she could not have been operated and also the lymph nodes in the center of the chest called hilum were also involved. This makes it inoperable stage. I told her like I tell every patient with suspected cancer that we have to answer 3 questions . IS IT CANCER - HAS IT SPREAD - WHAT CAN WE DO - TREATMENT CHOICES . The surgery was out of question due to location and the lymph node involvement . That left us with chemo and radiation. But we needed the diagnosis . Any time we exclude surgery as treatment choice, that is not a good news as the radiation and chemotherapy are not 'curative ' treatments. But we needed a diagnosis . So we proceeded with biopsy  and PET SCAN . The GOOD News was that the cancer was limited to LUNGS  (though inoperable) At least I told her that that was the good News. The biopsy was done and that showed the cancer to be what is called 'SMALL CELL CANCER'.

    The thought that bothers many patients is that if they would have the diagnosis SOONER - EARLIER ,then it would be smaller an the surgery to give CURE would be there. So what would be the good news in the diagnosis of inoperable cancer ? The answer is the SMALL CELL CANCER CANNOT BE OPERATED and the treatment of choice is chemotherapy. So even if I had seen her 2-3 months earlier when the tumor was sat 2 cm , it still would be treated with chemotherapy . So in this case the BAD NEWS is that she has cancer  and the GOOD NEWS is that it is  type OF A CANCER THAT IS ALWAYS TREATED WITH CHEMO AND NOT SURGERY !!

GREAT TALKER IS GOOD LISTNER

    I have been in medicine for many years and I have realized that many times all that one has to do is to listen to a patient's story . Now I can also say that many times the diagnosis is simple or straight forward and the talk may not help e.g. straight forward asthma. But when there is a diagnostic dilemma we need more history , so we can order tests that can clinch the diagnosis rather than ordering tests that may take us on wrong path and delay in knowing what a patient has. That brings me to my story for today. 

     I had known this patient from my evaluation in office . He was 73 years old and was quite obese. He seemed to have sleep apnea, but did not want sleep apnea. He had also smoked and had COPD - the disease that one gets due to smoking. He had be started on oxygen and his activity level was very limited and he had not done any diet. He went to ER one day. He felt weak. The ER doctor saw him and did some routine tests and was admitted .The hospital doctor saw him and at the request of patient. I happen to see the doctor and he told me that he has admitted my patient and has called me for the consult ,but 'he looked ok and should be ready to ho home in 1-2 days . ' I went to see the patient. He had his family with him . I asked him as to what was the reason that he came to ER he was not short of breath but felt weak. I told him to tell me what exactly happened . So he told me that he was sleeping on floor - rather unusual thing in this country. But then when he tried to get up he could not  and he had to crawl to his bedroom. He barely pulled himself in the bed  and then when he had to go to kitchen he had to crawl again and so then his family called 911 and he was brought to ER. I am a lung specialist .But I told him to raise his arms and he could barely do it  and to me it looked like shoulder problem may be rotator cuff injury , but he told me that it was worse than his usual shoulder problem. I asked him to raise the legs  and he could not. His oxygen saturation was ok and his lungs were clear . His chest X- ray was fine and routine blood tests were OK. But I was concerned about his weakness and so I ordered CT scan of cervical - neck spine and also Lumbar spine  and consulted a neurologist. 

     The scans were done  and they showed as expected lots of arthritis. So then the neurologist ordered a MRI of spine  and concluded that he had a SPINAL STROKE . He suggested physical therapy. He felt that there was issue with spine  and that will need physical therapy and some time . He signed off the case. Next day he looked weak and little short of breath  and then I send him to a monitor bed as I was concerned about worsened neurological status . The spinal stroke is where the function bellow  certain level of the spinal cord there is muscle weakness or paralysis. I talked to him and his family. I told them about my fear that he may have paralysis of breathing muscles and then may need respirator. He told me that he would never go on respirator  and wanted to sign papers right there . His family also felt the same thing and so we made him DNR . I called the neurologist  and talked to his associate as he was not in the office  and told him my fear of what is called ASCENDING POLYNEUROPATHY. In this condition the weakness ASCENDS from lower level to higher level So when respiratory muscles get involved then one cannot breath. He came in and agreed  and started treatment. Patient did not want any artificial support to sustain life  and so in next 24 hours he passed away. 

     The story that patient had was suggesting that something was happening  and this was not  the usual 'weakness ' that happens in many older patient who are obese and who have other lung and heart problem like this patient had. Just allowing patient to tell what exactly happened  helps  and then diagnosis becomes clear.