PERSISTENCE PAYS

   In medicine sometimes persistence pays. We see things and with previous experience we think we know the diagnosis  and then the tests are carried out and the diagnosis is not obtained . So sometimes the persistence pays. In past it has also happened that we think that there is cancer or some other diagnosis  and then the tests show something different. But one has to go by what we think  and continue the work up. This brings me to the story for today. 

  I had seen this patient in office for the shortness of breath. She had been smoker in past  and had quit many years ago and she was getting short of breath and so the primary care doctor sent her to me .I knew that she must have COPD the disease that happens when people smoke and over period of time it must have gotten worse. So I did the work up . She had o chest X- ray in long time . I did the chest X- ray and breathing test and AAT a genetic test to see if she had lack of certain enzyme that can cause emphysema in smokers. The chest X-ray came showing some abnormality and so I did CT scan. The CT csna showed 2 masses  and she had it quite close to center of left lung. I did PET scan and in Pet scan  glucose is used and that is picked up by every cell in the  body and the concentration of the  glucose pick up is measured. .Higher the pick up more likely to be due to cancer. So the PET scan is 80% accurate in picking the diagnosis of cancer. So there are cancer where the metabolic activity of the cells is not much higher than normal cells and so the pick up is not that high. This is seen in very slow growing cancers. And there are infections that will be positive on PET scan . So it is not 100% . Her Pet scan was positive and so I was sure that she had cancer of the lungs . I did bronchoscopy and I did see narrowing of the bronchus and I was sure that the biopsy will be positive for cancer, but it did not. So, I did ask radiologist to  do needle biopsy. . That also did not show cancer. I had told family that most likely based on our tests , she had cancer. But we did not get the tissue diagnosis. 

    I sent her to a chest surgeon   to consider open biopsy . I thought that was the only 100% test to get the diagnosis of cancer. I was sure that she had cancer. The surgeon called me Her lung function was not that great  and so he wanted to redo needle biopsy with larger needle - so called CORE Biopsy.She had the core biopsy  and that showed the CANCER!

    So the persistence paid.

LESSIONS TO LEARN

     The medicine is fluid. Everyday we get new information and new tests and new drugs and treatments . Sometimes what we learned in past may be partly true or may not be true at all. The classic example that I can give is frontal lobotomy where frontal lobe of brain was removed as a treatment and I think he got Noble Prize for that. But now we know that that is not correct and no one does Frontal Lobotomy any more .But certain principle still guide us They are almost eternal in that sense. The work up of anemia is one of them. But I often see patients who have anemia or low blood count get iron as treatment and many a times that may not be the problem. This brings me to the patient for today. 

     I saw this patient in my office . She was one of my patient's wife and had been diagnosed to have CIOD  as she was smoker . So she had bad lungs - damaged from smoking and she must have been so bad or advanced that she was on oxygen all the time . She had no recent work up and so I decided to do new work up. But then she felt more short of breath and so went to ER and was admitted . She was found to have anemia - her hemoglobin which is normally 14 grams,  was less than half at 6 grams . So the hospital doctor ordered gastroenterologist to see her . No anemia work up as to the cause of anemia was done . Th gastroenterologist saw her and told that she does not need any work up in hospital  and she should be worked up for anemia as she had normal stools and there was no evidence of blood loss . I was notified of her hospitalization 3 days down the road . I saw her and realized that her worsening of shortness of breath was due to anemia rather than COPD . But she also had wheezing and she was not started on any bronchodilators which she used to have at home . I started her on her usual inhalers and did anemia work up. She also had some other problems . 

     Her condition improved and her shortness of breath was better as she was started on medicines and she had a blood transfusion. But the anemia work up showed that she had abnormal protein. Just to give an idea we have raw material that is needed to make hemoglobin - like B12 , Iron, Folic Acid  and vitamin C and some other  and then there is factory - which is bone marrow. We tend to lose blood  in conditions like stomach ulcers or diverticular disease or polyps in colon  and colon cancer  and in younger ladies menstrual blood loss. So one has to find out if anemia - low count is due to poor or lack of raw material iron being one of them or if factory - the bone marrow is defective or if we have blood loss. In this patient the work up showed that she had problem with bone marrow . The abnormal protein which is produced by overgrowth of certain cells in marrow leads to reduction in production of red cells which carry hemoglobin

     So her shortness of breath was made worse by low hemoglobin and that was due to somewhat unusual cause of abnormal growth of certain cells in marrow and iron will not work 

      LESSION LEATNED !. 

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. .