This week was split largely between watching ablations and biopsies in interventional radiology and the Lung Cancer Screening Center. My week started off sort of slow since the first patient that was to receive a lung biopsy was suffering from dementia and was being noncooperative. Thus, he had to be rescheduled so that he could be put under anesthesia before having the biopsy. The next patient that was brought in did have their biopsy. The patient was a 68 year old female with no significant prior medical history who had a very clearly defined nodule in the left lung. Dr. Pua explained that the clear boundary indicates that the mass was most likely of carcinoid, granuloma, or metastatic nature. This is compared to adenocarcinomas, which generally have a more spiculated appearance. In addition, the location of the mass near the bronchus leant more weight to it being carcinoid. I was intrigued by this distinction and did not know what carcinoid meant so a quick Wikipedia search provided some basic information: carcinoid tumors are slow growing tumors of neuroendocrine origin which are common in the GI and respiratory tracts. The next patient needed a lung biopsy for a nodule that appeared adjacent to the pericardium of the heart. This struck me as a potentially dangerous situation; however, Dr. Pua assured me that this was not an issue. The PA who was performing the biopsy used a wedge under the patient to move the scapula out of the way of the intended trajectory of the biopsy needle. Seeing the before and after of this rearrangement via CT was cool because I haven't been exposed to a case yet where the skeleton made a certain trajectory seemingly impossible. Another major concern was pneumothorax, or lung collapse. I learned that by traversing more than 4 cm, there is a much higher risk of pneumothorax. However, this biopsy was expertly navigated to avoid excessive traversing and no interventions were needed. Next, I was fortunate to see my first cryoablation. This case was particularly interesting because Dr. Pua had treated this patient before, performing an ablation in the exact same location. What was strange is that generally recurrences usually happen within 6 months or not at all, and this patient had a recurrence after ~2 years. At the end of the procedure, 3 cryoablation needles were inserted at the site within 1 cm of each other for a synergistic effect. Three cycles of freezing and then either passive or active thawing was then applied. Argon and helium gases were used in the cryoablation needles for freezing and thawing, respectively. What was particularly striking to me was the ice crystals that coated the wires connecting the needles to the rest of the system about a foot's length outside of the patient. During thawing cycles, these completely melted. It was definitely a testament to the amount of freezing that it took to necrose the tissue with the desired margins.
At the Lung Cancer Screening Center, I have continued to work with the program coordinator and smoking cessation counselor on the R01 grant they intend to submit. I also got to sit in on several shared decision making consultations. One patient was a former smoker with a history of HIV who had recently had bronchitis, something that could interfere with the efficacy of the lung screening since nodules often appear due to inflammation and other insults that occur with respiratory illness. Brooke made a note of this so that whoever reviews the scan has some context. It was also interesting that she had during her illness coughed up bloody sputum, which she had thought to photograph to show her doctor. Although the bloody sputum was definitely not a good thing, something that should have been investigated earlier, Brooke did not think it was indicative of lung cancer since it was in the context of respiratory illness. Another particularly noteworthy consult was with a Russian woman whose English was actually quite good but was still not up to some of the medical terminology that most visits included. Brooke did an excellent job of making sure that there was ample opportunity for her to ask questions and checked that she understood the important takeaway messages of the discussion. After the consult, she explained that with patients whose English is not as good as hers, an interpreter is often used and over the phone this is quite cumbersome, such that some patients even request no interpretation even though some information might be lost without translation.
Thoracic tumor board meeting was exciting as usual. I arrived early and briefly heard a doctor on the phone recommending that face masks be worn around a patient with a homicidal history. I picked up on statements like "he's well known at Bellvue" and "has stalked his doctors in the past," which all seemed quite absurd like something out of a Law and Order episode. It is interesting to consider how mental illness can really complicate the treatment of otherwise noncomplicated physiological maladies. As the meeting started, the case of a patient who was a 9/11 responder was reviewed. In his situation, hemoptysis was noted and chemoradiation was recommended since the cancer was noncurative and there was no palliative surgical recommendation. Another case was a 72 year old female with apical segmentectomy of the left upper lobe. In this case, the doctor was anxious that some cancer had been left after the resection since atypical cells with a high N-C ratio surrounding the scar had been noted. This was uncertain since the PET scan results that can determine metabolic activity (high metabolic activity being a common indicator of cancer) were still pending. It was also brought up that segmentectomies exert a lot of force and thus trauma on the lung tissue when staples are applied. Another case was of a woman with Stage IV adenocarcinoma who had been on tarceva for a year. The comparison of scans showed that the tumor was growing so the doctor wanted an opinion on whether systemic therapy should be used instead. Systemic therapy was ultimately decided although stereotactic radiation was brought up as a possible alternative. There was some controversy surrounding the quality of a mediostenoscopy done on a patient with hylar and mediostinal adenopathy and pneumonia (this board seems to have some drastically varying opinions, which increases the level of scrutiny certain cases are subjected to, something I see as a large benefit to these meetings). Towards the end of the meeting, there was a case of metastatic cervical cancer and a patient with mesothelioma so far gone that they were neither a chemotherapy or radiaiton candidate and were to be pushed towards hospice care. Overall,
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