Get your health question answered instantly from our pool of 18000+ doctors from over 80 specialties
192 Doctors Online

By proceeding, I accept the Terms and Conditions

Dr. Andrew Rynne
MD
Dr. Andrew Rynne

Family Physician

Exp 50 years

HCM Blog Instant Access to Doctors
HCM BlogQuestions Answered
HCM Blog Satisfaction

Suggest treatment for shortness of breath and chest irritation

Answered by
Dr.
Dr. Shashi Dangwal

Pulmonologist

Practicing since :1979

Answered : 1126 Questions

default
Posted on Wed, 8 Feb 2017 in Cancer
Question: Hello doctor,

I'm a non-smoking 22 y/o male who's been through a battery of medical tests trying to find out what's wrong with me, and trying to figure out whether it is lung CA and what type it is or not.

If you'll bear with me, I'd like to share what I've had done so far. I don't really know anyone in my age group who is knowledgeable about lung cancer, so I don't really have a reference point for what to expect on the road to diagnosis.

=====

Symptoms:
1) Shortness of breath on even mild exertion (1.5 months)
2) Cough with white phlegm, occasionally yellow. w/ chest irritation (1 month)
3) Finger Clubbing (2 months)
4) Firm, fixed supraclavicular + posterior cervical lymph nodes (3.5 months):
-Supraclavicular lymph node: noticed in August 2016, was palpable but not firm/fixed; firm-ness gradually noticeable in October 2016 onwards
-Posterior Cervical Lymph node #1 (on side, mid neck) = palpable and moveable until December 2016, rapidly became firm and fixed
-Posterior Cervical Lymph node #2 (rear neck, where shoulder meets neck) = felt firm/fixed since September 2016, can feel progressively worsening shoulder/neck pain near it's location
5) Persistent fatigue (4 months)
6) Odd sharp pains in shoulder, back, and arms (1.5 months)

=====

Radiological Exams:
[1] Chest CTs:
>(12/22/16) CT Chest With Contrast...URL Link -> [https://goo.gl/cYOC9f]

>(12/02/16) HRCT Chest WithOut Contrast...URL Link -> [https://goo.gl/e0X9Q7]

[2] Neck MRIs: Concerned about lymph node growth between Two Exam Dates especially in Left Supraclavicular region, Left Posterior Base of Neck general area. Please also comment on any other lymphadenopathy if spotted

>(12/22/16) MRI Neck With and Without Contrast...URL Link -> [https://goo.gl/ftsEfc]

>(11/05/16) MRI Neck With and Without Contrast...URL Link -> [https://goo.gl/yYDN3K]

=====

Blood Test Results:
Results (from 12/22/16):

(Please See Attached)

=====

History:

Late September 2016 -- First noticed "hardening" of left supraclavicular lymph node. Size is about 1cm.

October 2016 -- Got the node checked out, both primary doctor and ENT can't really palpate it so they didn't order biopsy. Said to wait on neck MRI. Meanwhile, paranoid me went on Dr. Google and found the infamous "Virchow" node and worried that it was a signal of stomach cancer. So we did a upper GI endoscopy, which came back clean.

Early November 2016 -- Neck MRI results came back, radiologist report doesn't mention any node enlargement, so doctors even more adamant to not biopsy. I got an Abdominal MRI and MRCP, which came back negative. Supraclavicular node still there.

Late November 2016 -- Suddenly developed shortness of breath on minor exertion. Noticed fingers were Clubbing. Didn't respond to inhalers, so got referred to pulmonologist. Did Chest X-Ray and HRCT, both came back clean. Full autoimmune disease panel also came back negative. Pulmonary Function Tests came back with reduced diffusion and Restrictive Lung function...unexplained by tests.

Only abnormal things were in the blood tests: D-Dimer, Inflammatory markers (CRP, ESR), and some Blood Cells (Monocytes, Basophils) were moderately elevated.

Late December 2016 -- Shortness of breath, Clubbing still present. Newly onset cough. Had repeat Pulmonary Function Tests, which showed worsening of lung function...still without determinate cause. Blood results still abnormal, gradually worse. Got repeat Chest CT with Contrast this time...had like 3 different radiologists read it. One of them found a "mild geographic ground glass opacification" on my left lung. No evidence of any lung "masses" though, according to the reports. I went to get a second opinion from a different pulmonologist, who said that the ground glass thing was a very subtle finding that was also very nonspecific.

January 2017 -- Clubbing is worse. Doctors can still barely palpate the lymph nodes. We did a Neck CT w/ Contrast that showed multiple visible but subcentimeter nodes. Also in the neck there was some "mild, ill-defined soft tissue stranding", which as you might have guessed, again is very non specific.

Present -- We decided to go for it and order an Ultrasound-guided Core Biopsy of any Neck Lymph Nodes that we could get. Getting that done next week, and that might give us some answers.

=====

Concerns:

With my symptoms and past tests ruling out benign causes, it seems that the only differential diagnosis possibility is Lung Cancer. Since only finding was "mild ground glass opacification" I am worried that there is a rare but metastatic Lung Cancer of some kind.

1) The second Chest CT with Contrast showed "mild ground glass opacification", but "no mass". Furthermore, this finding was NOT present in the first Chest CT, so it must have appeared in a few weeks. I have attached the radiologist's report. Could this still be a presentation of bronchogenic CA?

2) We ruled out every autoimmune disease and interstitial lung disease, since those had blood tests in addition to the imaging. Whereas lung cancer would only have imaging to rely on...so isn't that the only remaining condition that we are less certain of ruling out?

3) The blood tests are concerning to me. Why are the basophils/monocytes, D-Dimer, and inflammatory markers elevated? They have been progressively increasing in past few months, not going down

4) Neck MRI findings included: "mild, ill-defined soft tissue stranding in left neck". Can you please explain what that means and whether it is concerning or not?

5) The lymph nodes being investigated are the supraclavicular and posterior cervical at the base of the neck. If they are indeed malignant, aren't these particular nodes most likely to point towards an abdominal or lung cancer? ...of which we've ruled out abdominal causes, leaving only lungs?

6) Are there any other tests we can do to determine the cause?

7) The shortness of breath is very concerning to me. I cannot breathe properly and my inhaled Breo Ellipta medicine does not seem to help either. What options are there to improve my breathing?

The shortness of breath is the most concerning, and in conjunction with worsening PFTs and Clubbing, I am worried about malignant process.

Lab Reports:
(Please refer to attached files): CBC, Inflammatory Markers, CMP, Urinalysis, Protime INR, Pulmonary Function Tests on (Dec.02, 2016) and (Dec. 22, 2016)
doctor
Answered by Dr. Shashi Dangwal 16 hours later
Brief Answer:
There is no suggestion of lung cancer from your reports.

Detailed Answer:
Hello XXXX,

Thanks for posting your query on HCM.

Have gone through your query in detail and also seen your reports.

Your symptoms in no way suggest that you could be suffering from lung cancer. Your reports also do not indicate that there is any suggestion of lung cancer. Your PFT is fine. The lymph nodes found are non specific and may be enlarged due to repeated attacks of sore throat, some dental problem or some infection in the ears even in the past. CT chest says only a focal area of ground glass opacity which also is non specific.You are a non smoker. Diffusion is absolutely normal. Then why are harbouring this fear of lung cancer.

The breathlessness could be because of asthma that you have and you have to be regular with your inhaler for it to be effective. Has nay doctor seen your clubbing as I cannot comment on it without seeing. Some people may have congenital clubbing. Have you got an echo test done to rule out any cardiac cause for your breathlessness?

I suggest that you should not worry so much. There does not appear to be any thing grossly wrong with you. Stop worrying unnecessarily.

Take care.
Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
default
Follow up: Dr. Shashi Dangwal 2 hours later
Thank you for responding doctor. I have a few more follow-up questions, if you don't mind. Sorry if it seems excessive, I'm just trying to cover all bases here.

We have done Cardiac Echo test, also attached here.

> The reasons I am worrying about lung cancer is because my local pulmonary specialist said I have clubbing, and also because I have heard of a type called Brochioalveolar Carcinoma that presents with a ground glass opacity.

(i) For this sub-type of lung cancer, is it possible to see only ground-glass opacity before any other abnormality is observed?

====
I am using a Breo Ellipta Inhaler (fluticasone furoate/vilanterol) which doctor prescribed under earlier presumption of asthma/COPD. It does not seem to help much with breathlessness...

(ii) You mentioned asthma, but I thought asthma almost always presented with airway obstruction and normal-to-elevated DLCO? And asthma would improve with inhaler, which I have been on since the 1st PFT. So PFTs should have improved if it were asthma, right?

(iii) Just to be safe, would you mind looking through the links/URLs to the imaging exams I have provided (unless you already have)? If those do not work, I have attached a small sampling of CT images from GGO region..

What is your interpretation of findings based on your observer perspective?

(iv) I am getting Arterial Blood Gas on room air this week. Will that give us any new information?

(v) What could be causing the finger clubbing? (I have attached some images)

(vi) As for bronchoscopy procedure, I am unsure about doing it for a few reasons. First, is that I am concerned about complications of collapsed lung or additional infection. Second, I am not sure how my pulmonary physician can justify a bronchoscopy Order with a relatively nonspecific CT finding.

(vii) Any additional less-invasive tests than bronchoscopy/BAL we can do quickly to get clues on diagnosis?

(viii) I know you mentioned that PFTs are roughly the same. But DLCO seems a bit low in both cases, and below LLN on more recent PFT. Why could this be happening and is it a reversible/improvable process?

(ix) What is the possible differential dx if (a) infection? and if (b) inflammation? Is ILD still possible?

(x) As in (ix)...possible treatments. If infection, treatment is antibiotics, right? If inflammation, what are the options? Is any lung damage sustained from infection/inflammatory process reversible or is the treatment only to prevent further deterioration?
default
Follow up: Dr. Shashi Dangwal 16 hours later
I have my images uploaded on MedDream Online DICOM Viewer. I am not sure of whether they can be downloaded, but they can definitely be viewed online. There does seem to be an "Export" option, where you can select and download the "Study" as "DICOM" or "JPEG".

I also have included Google Drive download links for the JPEG versions of the studies.

Please let me know what is possible.

Thank you


[1] Chest CTs:
>(Dec/22/16) CT Chest With Contrast...
--DICOM Viewer Link -> https://goo.gl/cYOC9f
--Google Drive Link -> https://drive.google.com/open?id=0B8VVRuIADGiaeXAyWFZ4M2hGeEE


>(Dec/02/16) HRCT Chest WithOut Contrast...
--DICOM Viewer Link -> https://goo.gl/e0X9Q7
--Google Drive Link -> https://drive.google.com/open?id=0B8VVRuIADGiaR19FRUx2R2hJMkk


[2] Neck Scans:

>(Dec/22/16) CT Neck With Contrast...
--DICOM Viewer Link -> http://www.dicomlibrary.com/meddream/md5/?study=1.2.826.0.1.0000.8.1055.1.0000.0000.0000
--Google Drive Link -> https://drive.google.com/open?id=0B8VVRuIADGiaUXVhQUxXSTJ4cWs

>(Dec/22/16) MRI Neck With and Without Contrast...
--DICOM Viewer Link -> https://goo.gl/ftsEfc
--Google Drive Link -> https://drive.google.com/open?id=0B8VVRuIADGiaTlFVRUs5RGJaaDg

>(Nov/05/16) MRI Neck With and Without Contrast...
--DICOM Viewer Link -> https://goo.gl/yYDN3K]
--Google Drive Link -> https://drive.google.com/open?id=0B8VVRuIADGiaTlhrM2w2RlNwaDg
doctor
Answered by Dr. Shashi Dangwal 3 hours later
Brief Answer:
There is nothing to suggest that you have lung Ca.

Detailed Answer:
I have gone through your questions again and have also seen the reports uploaded by you and my answer is the same. There is nothing to suggest from your symptoms and reports that you could be suffering from lung cancer.

I could not access the various links provided by you but the reports you have uploaded provide adequate information. The clubbing picture has only the side view. Though there appears to be some clubbing, its difficult to comment without actually seeing it.

As of now only possibility high on card is ILD. You may repeat your HRCT chest after sometime to see any progression of ground glass opacity and repeat PFT and diffusion to see any deterioration in the values.

I suggest you consult a local pulmonologist who can address all your queries and allay your fears.

Wishing you all the very best.
Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
premium_optimized

The User accepted the expert's answer

Share on
Question is related to
Diseases and Conditions ,   ,  
Medical Procedures
Lab Tests
Medical Topics ,  

Recent questions on  Bronchoscopy

doctor1 MD

My husband had a splenectomy and a colectomy in 2006. He has had a chronic productive cough since that time. He was hospitalized in jone 2011 with...

doctor1 MD

Hi
My mother recently went through broncho-scopy to get her lungs checked. Doctors suspected TB. Did a CT Scan too but they were not sure since she...

doctor1 MD

I have had blood came out from my throat while coughing. I am also suffering from cough since a long time. Doctor suggested chest can Ray. Please...

doctor1 MD

Hello Doctor I am suffering from a wheezing sound that is coming from my windpipe and when I cough a small amount of blood comes up. This only...

doctor1 MD

Hi, My 13 month old daughter was playing with a mirror and dropped it. The mirror did not break so i didnt pay attention but after sometime when i...

doctor1 MD

Hi,

4 years back incidently doctors found one pulmonary nodule on my right lung on chest X-rays. They asked for CT and the result shown 1.5 cm...

doctor1 MD

In jaunary I was rear ended and pushed into car in front of me. I have had two cervical epidurals and one lumber epidural. Prior to first epidural...