It all started with a telephone call from a senior colleague who was in Istanbul, asking me to drop by to see his friend who had flown in from India. The patient, aged 59, had just been admitted to the ward under the care of an infectious disease physician as the problem appeared to be that of an infection of the lymph nodes in the neck.
However, when I saw the patient after finishing my outpatient clinic at 6 pm that evening, I was concerned that it may not be an infection but rather a cancer that involved the lymph nodes. But there was no point guessing.
“Give us 48 hours and I’m quite sure that we’ll be able to find out what the problem is!” I proclaimed.
It was a false bravado since I keenly wanted to test the team against a key goal we set ourselves for the New Year – to make the diagnosis of cancer and present the treatment options within two days – 48 hours, that being the sort of turnaround time that top hospitals achieve globally. No reason why we can’t try for it too – or so I thought.
The next morning, the patient was brought to Mount Elizabeth Novena for the PET-MRI (magnetic resonance imaging). The PET-MRI is definitely better than the PET-CT, for studying the head/neck and pelvic regions, as it allows better delineation of the structures like nerves, vessels and soft tissue.
The other advantage of the PET-MRI is that the patient is not exposed to the additional radiation associated with computed tomographic (CT) scans.
Two hours after the scan was completed, the radiologists huddled together reviewing the films and deciding the best part of the lymph nodes to stick a needle into, to extract samples of the diseased tissue.
As usual, the interventional radiologists used a fine needle to extract the dislodged cells from the nodes. This is followed by a core biopsy, where they drill a bigger bore needle to extract a toothpick-like sample.
An hour after the procedure, the pathologist gave a preliminary report – there appeared to be some inflammatory cells, suggesting that this could indeed be an infection. When this news was broken to the patient and the family, there was a palpable sigh of relief in the room. Perhaps the patient could be discharged and continued on oral antibiotics. But, despite the reassuring preliminary results, the doctors were not convinced. Somehow, the picture did not fit. The lymph nodes were swollen and painful but the patient did not have any fever and did not “look toxic” – this term is difficult to define but often used by doctors to describe a sick patient whose face appears flushed, with sweaty or oily skin, and looks tired.
The blood tests were even more puzzling. They were all normal. All the tests which are associated with infection were well within the normal limits.
The next morning when I visited the patient during my morning rounds, I explained the team’s niggling doubt. I suggested that he should continue to stay on in hospital until we were sure what was happening.
This worrying over nothing that is definite is derived from pattern recognition which comes from experience. The more patients you see, the more you would tend to trust this feeling.
As Dr William Osler, a great physician, is often quoted to have said: “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.”
By noon, I started harassing my colleagues in the pathology department. After all, I had stuck my neck out to say that we would reach a diagnosis by 6 pm that evening.
When I spoke to the pathologist, it was clear that she was no longer convinced that the lymph node swelling was caused by an infection. From the appearance of the cells, she suspected that this was a malignant lymphoma (a primary cancer of the lymph node). She had ordered a full panel of immunostains to aid in the diagnosis.
I sent a text message to a pathology colleague, an expert in lymphoma, who happened to be clearing his annual leave. “Overseas or Singapore?” I enquired.
“Singapore,” came the reply.
I called him and he came back from leave to review the pathology slides. By 3 pm, consensus was reached – this was indeed a malignant lymphoma.
When I broke the news to the family, there was some anxiety – it is a big leap from infection to cancer. I went on to explain that lymphoma is often very responsive to treatment and carries with it an excellent chance of cure.
The patient has since been started on chemotherapy, the pain has subsided and the lymph nodes have responded marvellously.
As I reflect on those 48 hours, I remembered my initial reason for setting that goal – to measure up against the best. But what struck me during that time was the anxiety and stress of the family. Within that time, all of us on the team were deeply engaged with this problem, racing against the deadline.
For the patient, and his family, the gains from a shortened time in anxiety and dread cannot be measured. For the team, it is a far more economic use of medical and human resources, which can then be freed up for the next patient.
I see now that a short but intense period is really the best way to tackle diagnosis. So, 48 hours – not just a Key Performance Index, but a great and fortuitous mix of the medical, the economic and the very human.
Written by Dr Ang Peng Tiam
Tags: cancer diagnosis, cancer doctor stories, head & neck (ENT) cancer, pathology, swollen lymph node