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Dr. Andrew Rynne
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Dr. Andrew Rynne

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Suggest treatment for shortness of breath and chest irritation

Answered by
Dr.
Dr. Jawahar Ticku

Oncologist

Practicing since :1979

Answered : 431 Questions

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Posted on Thu, 16 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 cancer or not and what type it is or not.

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) Odd sharp pains in neck and rear-left portion of head, shoulders, and arms (1.5 months)
6) Persistent fatigue (4 months)


=====

Radiological Exams:
[1] Chest CTs: Concern about ground-glass opacity
>(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 Scans: Concerned about lymph node growth between Two Exam Dates especially in Left Supraclavicular region, Left Posterior Base of Neck general area.

>(12/22/16) CT Neck With Contrast...URL Link -> [https://goo.gl/sDM32G]

>(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 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. I can still feel the lymph nodes. We did a Neck CT w/ Contrast that showed multiple visible, but super-enlarged nodes. Also in the neck there was some "mild, ill-defined soft tissue stranding"

Present -- Not sure what to do about lymph nodes, still worried about supraclavicular node. But doctors cannot palpate the node, so will not do biopsy.

=====

Concerns:

With my symptoms and past tests ruling out benign causes, I am concerned 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 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) The lymph nodes I'm most concerned about are the supraclavicular and posterior cervical at the base of the neck. I have heard that the "Virchow Node" is ominous.

--If they are indeed malignant, aren't these particular "Virchow" nodes most likely to point towards an abdominal or lung cancer? ...of which we've ruled out abdominal causes, leaving only lungs?

3) I asked for lymph node biopsy before, but since Doctors were not able to palpate the lymph node and since CT/MRI did not show super-enlarged beyond 1 centimeter, they did not give the order for lymph node biopsy.

--How can I justify asking for lymph node biopsy? With this node size, What biopsy kind is best to use?

4) 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?

5) 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

6) Neck MRI findings included: "mild, ill-defined soft tissue stranding in left neck".

--Can you please explain what conditions that is caused by and whether it is concerning or not?

7) I have been having weird pains radiating from posterior left neck Up into Head and Down along Left Arm

--Is this concerning regarding a Brain or Neck lesion?

(Also I have attached Radiology_Links.pdf file that has URLs to Google Drive images of radiology exams)
doctor
Answered by Dr. Jawahar Ticku 32 hours later
Brief Answer:
suspicion of cancer

Detailed Answer:
DEAR XXXX,
THANKS FOR YOUR TRUST IN HEALTHCARE MAGIC.
I HAVE GONE THROUGH YOUR DETAILED HISTORY AND ALL THE INVESTIGATIONS YOU HAVE UNDERGONE.
INVESTIGATION WISE THERE IS NOTHING SPECIFIC, BUT SINCE YOU HAVE THE SYMPTOMS WE NEED TO RULE THEM OUT.
SINCE YOU GET THICK SPUTUM YOU NEED TO GO FOR SPUTUM EXAMINATION TO LOOK FOR MALIGNANT CELLS AND ALSO RULE OUT KOCH'S. RARELY CAUSE MAY BE SARCOIDOSIS AS WELL.
SIMULTANEOUSLY IF THE NODES ARE SIGNIFICANT I WILL RECOMMEND FINE NEEDLE ASPIRATION WHICH WILL DEFINITELY RULE OUT BOTH THE PROBLEMS.
BECAUSE YOU HAVE BEEN A SMOKER WITH A PATCH OF GROUND GLASS APPEARANCE IN THE CHEST BASE IT COULD ALSO BE SIMPLE BRONCHIECTASIS.
YOUR DOCTOR MUST HAVE ALREADY THESE THINGS IN MIND.

REST BE ASSURED THINGS WILL BE OK ONCE THESE POSSIBILITIES AS SUGGESTED ARE ALSO RULED OUT. TILL SUCH TIME YOU NEED TO BE ON SYMPTOMATIC TREATMENT, LONG BREATHING EXERCISES, AND GOOD BALANCED DIET AND OFF COURSE IF YOU ARE STILL SMOKING GET RID OF IT.
THANK YOU AND WISH YOU QUICK RECOVERY.
TRULY,
DR. J. TICKU
Above answer was peer-reviewed by : Dr. Nagamani Ng
doctor
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Follow up: Dr. Jawahar Ticku 11 hours later
Hi doctor,

-I am a NEVER-smoker. Have never smoked for all my life, and also very low secondhand exposure.

--I have asked for node FNAC several times, but doctors are unwilling to perform because of node size (short axis diameter < 1 cm). What are the minimum dimensions for being able to FNAC or core needle?

--What do you mean by "significant" nodes?
doctor
Answered by Dr. Jawahar Ticku 7 hours later
Brief Answer:
suspicion of cancer

Detailed Answer:
DEAR XXXX,
THANKS FOR REVERTING.
AS I STATED THAT SIGNIFICANT NODE MEANS IF IT HAS THE SUFFICIENT SIZE FOE ASPIRATION OR IT IS MORE THAN 0.5 CM SIZE.
AS FAR AS SMOKING IS CONCERNED IT IS A FAVOURABLE POINT THAT YOU ARE NON SMOKER.
NOW REMAINS THE SPUTUM EXAMINATION TO RULE OUT ANY INFECTION IN WHICH FUNGAL INFECTION IS ALSO A POSSIBILITY.
REST YOU SHOULD NOT WORRY, CONTINUE WITH THE CONSERVATIVE TREATMENT TILL THE SPUTUM EXAMINATION IS ALSO THERE.
TRULY,
DR. J. TICKU
Above answer was peer-reviewed by : Dr. Nagamani Ng
doctor
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