Thursday, April 08, 2010

The consolidated read of my ct scans

I promised in my prior post to add in the radiologist's answers to the questions I posed concerning my 3 sets of ct scans that have been done of my neck and chest. Rather than add them to that post, I offer it here separately because the doctor mixed her responses in with my original email. The doctor's comments are italicized to dstinguish them from email as the paragraphs were somewhat rearranged from my original.

Mrs Cullen,
I have answered some of the questions that you have directed to Dr. N*****. I hope the answers help you somewhat.

I want to impress to you that the reports that we generate are to be read by physicians. The terms of anatomical descriptions and jargon that we use are standard with some variations. All the reports I reviewed are using variations that are within the accepted norm. Often, we edit or omit to report findings that may not be significant when we report. For example, a patient has 20 lung nodules we (at least I) may not describe them all because there is no difference between having 10 lung nodules versus 20.

M****** O*, MD
Central radiology

Additional questions:

1. Why are there 6 identified node sites with cancer in the 12/09/09 lung ct scan and only 5 in the other two lung ct scans?

Sometimes we miss reporting a node/nodule/mass. The nodule that you refer to was there but was not reported on the initial study. Unfortunately, on these lung nodules, it is quite difficult. We do our best but sometimes, they get missed. For lungs, we review apporoximately 90 to 100 images. Due to technical factors, small nodules can be easily overlooked because they look very much like normal vessels in the lungs. We look at images back and forth multiple times but we do miss them from time to time.
Even if we find them, there is another issue of whether these are cancer or not. No one knows for certain. We make inferences based on the total number, appearance, interval growth. This is why follow up scans are so important.

Perhaps, Dr N***** can point out the nodules versus adjacent vessels to you when you visit next.

2. Do you think that having different radiologists read the exams can create inconsistencies?

There is always inter-observer variability. However, we try to use similar language to describe what we see. Ultimately, it is the images themselves that give the final answer. We have to line up the CT images at the exact same location on the computer and measure the abnormality. Even if the wording may be selected differently, the important fact is if the nodules are getting either smaller or larger. This information is not confusing to the referring physicians. If there is a concern from the referring physicians point of view, we coordinate with that physician so that there is no misunderstanding.

Would it be too much to ask that one very good radiologist sit down with all three of my ct scans, and read them, to give a more uniform interpretation of the development/shrinkage of my tumors?

I think the information has been conveyed to the referring oncologist, Dr N*****, without confusion regarding what is happening in your case. Your masses/nodules are all shrinking. If the referring oncologists are confused regarding our reports, and wishes to have one radiologist read all of the studies, then we can pursue that. However, if the radiologist that reads your study is on vacation for 2 weeks, for example, then the study will not be read for that duration. There are other logistical issues regarding such specified arrangements. For example, I only work 3 days or so every week (as do many other radiologists who work part time), and the CT would sit waiting until I returned to work 4 to 5 days later. Again, if you wish so, we can arrange for it.

3. What is going on with the neck scans? I really don’t know what the reading on the last one means.

Very evident left vocal cord paralysis today. Stable
adenopathy in the low left neck.

This is impression from your most recent neck CT. The impression from the reading radiologist is that the adenopathy is stable. Form that statement, I make an inference that there are no new findings. I do not understand your question.

B. Lung (reader: M****** O*, MD)

1. Paraspinous location of left lower lobe, 22 x 16 mm previously 30 x 22 mm at same location (there’s no nodule that matches this measurement in the 12/09/09 lung ct scan—which one is she talking about?)

As radiologists, we do not use other people’s reports as much as the images that are in front of us. The images “save” the measurements that the last radiologists have used. Unfortunately, the measurements from the study from 9/16/09 were not saved with the study, a computer glitch. Therefore, I had no record of what image was measured. Therefore, I needed to re-measure the nodules (mass is another word that we use to describe nodule). I could not get 2.6x2.1cm (which is what Dr Burns did). I reported what I measured and compared to what I got on the 2/19/10 study. What is important is that the size is decreasing, measured at the exact same location. I suppose that I probably did not have to give the re-measurement from Sept, which would not have lead to confusion. However, I wanted to emphasize that the mass is decreasing considerably so I gave the measurement that I made.

2. Right lower lobe posterior nodule, 4mm, down from 5mm (which one is she referring to here?)

This was reported in 12/9/09 but not in Sept 2009.

3. Left upper lobe anterior lesion appears slightly smaller and less plump as well (is this the apical nodule, B.4 from the 12/09/09 lung ct scan? If not, which is it?)

Apical = left upper lobe. Apical actually refers to very highest point of left upper lobe. Even in the same day and on the same scan, we may call it apical or left upper lobe, when describing the location. This is never confusing to the referring clinicians.

4. Subplueral posterior left lower lobe superior segment, 9mm-- previously 15 mm (which one is this?)

Yes. Again, these are descriptions that we use that we understand to be the same.

5. Adenopathy in the AP window decreased, 32 x 14 mm (is this B.1 in the 12/09/09 lung ct scan? If not, which is it?)

AP window = aortopulmonary window = aortopulmonic window.

A. Neck (reader: A*** N**, MD)
1. right thyroid lobe, 5mm nodule –is this cancer?
2. left thyroid lobe, 2mm—is this cancer?

Thyroid nodules are very prevalent in normal population, as much as 70 to 80% of people. Only a tiny proportion of nodules are cancer. Unless there is a reason to pursue these nodules, we do not pursue them for the presence of cancer. There are criteria that determine if they need to be pursued. Since they are there, they were reported.

3. Pretracheal node, 13mm—is this cancer?

We use a size criteria to describe if something is abnormally enlarged or not. We have no idea of knowing if something is cancerous or not unless it is biopsied. We can give an educated guess regarding any node based on size, interval growth, and morphology. A 13mm node is abnormally enlarged node in this location. The abnormality is based on the statistical analysis of all nodes that are seen in the chest and the biopy correlations that were done as a clinical study performed many years ago. (We use the knowledge base that is generated over many years of clinical data accumulation.) It is up to the oncologist, surgeon, and the patient combined with the imaging information to decide if this is something that needs definitive answer or not, which will require biopsy. In your particular case, we know that you have metastastic lung cancer. Whether this particular node has cancer or not does not change your cancer staging. The staging information is what is used to direct therapy, not whether or not each nodule is cancerous. Dr N***** can probably explain this to you better.

4.Heterogenous mass seen in aortopulmonic window, 24 mm (what’s the difference between this and the aorticopulmonary window?)

They are both routinely accepted ways of describing the same thing.

1 comment:

odp said...

In other words: "We're the experts; you're just the patient. Don't you worry your little head about what we say."

Balderdash! Along with lobbying for consistent procedures, perhaps we could lobby for consistent vocabulary, and for doctors not to assume that all their patients can understand is "yes" and "no."

I really think the thing doctors fear most is the patient asking "why?" or "how?"

Looks to me like that Dr. "M. O." did not spend a rotation at the Bedside Manor...

Illegitimi non carborundum!