Tumor Diagnosis Challenges: A Case Study on Bone and Lung Issues

Positron Emission Tomography (PET) Report

Hello Doctor, my father started experiencing severe coughing after the Lunar New Year this year.
He has visited many hospitals, and by mid-March, he was admitted to the emergency department due to persistent fever and chills every night.
At that time, it was suspected to be caused by an infection, and numerous blood tests were conducted, but the actual cause could not be identified.
After two weeks of antibiotic treatment, he was discharged.
However, two days after discharge, he began to have fevers again, mostly in the afternoon and evening, reaching over 38.5°C.
He returned home and switched to oral antibiotics, but the fever did not subside.
At the end of April, he was sent to the emergency department again.
Given that my father had a history of spinal stenosis pain and had undergone an MRI at another hospital, the emergency physician reviewed the report and indicated bone metastasis, stating it was stage IV.
However, the source needed to be identified, so he was hospitalized again for two weeks, during which many tests were arranged.
Initially, lymphoma was suspected, and he underwent bone marrow aspiration, bone scans, and various tumor markers, including CA19-9, which were elevated.
Chest X-rays, colonoscopy, and gastroscopy were also performed, including biopsies, but no cancer cells were found.
Ultimately, a biopsy of the spine, which was the most concerning issue, was performed, and the report indicated no cancer cells were seen.
Tuberculosis was suspected, but it appeared that the bones on both sides of the pelvis were eroded.
Subsequently, a self-funded blood test for tuberculosis antigens was conducted, which returned negative.
The infectious disease physician believes that the possibility of a tumor cannot be ruled out, but due to the lack of relevant evidence, treatment for tuberculosis was initiated.
Currently, after one week of medication, my father has not had any more fevers, and his mental state has improved, although his appetite has not significantly improved.
Nevertheless, to facilitate medication treatment, he is trying to eat smaller, more frequent meals.
I would like to ask for your advice, Doctor.
Are there other aspects we should pay attention to? My father's liver function has not been very good, and I am concerned that if his liver enzymes remain elevated, we may need to stop the medication, which would leave us without a clear treatment direction.
I hope to hear more of your suggestions.
Thank you!
Bone, spine, vertebral, T9 and L1, biopsy, necrosis, see description.
Description: The specimen submitted consists of more than ten tissue fragments measuring up to 0.4x0.4x0.3 cm in size, fixed in formalin.
Grossly, they are brownish and elastic to firm.
All for section and labeled as A1; Jar: 0 X/E.
Microscopically, it shows necrotic debris and some bone fragments.
Immunohistochemical staining demonstrates CK(-) and mycobacterium antigen(-).
The PAS, GMS, and acid-fast stains for microorganisms are negative.
In summary, caseous necrosis is considered.
Please correlate with clinical settings.
Dr.
Kun-Tu Yeh Ref: B12302746, B12302842, B32300669.

Vanessa, 30~39 year old female. Ask Date: 2023/05/23

Dr. Chen Sirong reply Oncology

Vanessa / 30 years old / Female
Hello,
1.
The content does not include a PET report; the final section contains a pathology report.
2.
Tuberculosis and cancer can sometimes be difficult to differentiate, and even our attending physicians have encountered similar situations.
Initially, there was suspicion of cancer, but later it was believed to be tuberculosis, and the patient received pharmacological treatment.
I also do not believe in a 100% certain diagnosis.
3.
The certainty of a tuberculosis diagnosis relies on biopsy and testing for the tuberculosis bacteria, as diagnosing bone tuberculosis is more challenging than pulmonary tuberculosis.
4.
However, regarding the response to medication, your father's condition has improved, and the side effects of the medication typically include decreased appetite.
It is advisable to encourage him to eat smaller, more frequent meals and to tolerate the elevated liver enzyme levels as a side effect.
With patience over six months, discontinuing the medication will lead to improvement.
Wishing you a successful treatment,
Dr.
Chen Sih-Rong
Taoyuan Hospital

Reply Date: 2023/05/23

More Info

The case you've presented highlights the complexities involved in diagnosing potential malignancies, particularly in the context of lung and bone health. Your father's situation, characterized by persistent cough, recurrent fevers, and subsequent investigations, underscores the challenges that both patients and healthcare providers face when navigating through ambiguous clinical presentations.

Initially, your father's symptoms of severe cough and fever suggested an infectious process, which is common in clinical practice. The fact that he was treated with antibiotics for two weeks without resolution indicates that the underlying issue may not have been purely infectious. The subsequent discovery of potential bone metastasis raised significant concerns about malignancy, particularly given the elevated tumor marker CA 19-9, which can be associated with various cancers, including pancreatic and colorectal cancers.

However, the biopsy results showing necrotic debris without evidence of malignancy, coupled with negative tests for tuberculosis (TB), complicate the diagnostic picture. The presence of necrosis could suggest a non-specific inflammatory process, which might be due to a variety of conditions, including infections or even autoimmune disorders. The clinical suspicion of lung cancer remains, especially given the context of bone involvement, but without definitive evidence from biopsies, it is challenging to confirm.

In terms of management, the current approach of treating for tuberculosis, despite negative tests, reflects a cautious strategy often employed in clinical practice when there is a high index of suspicion for TB, especially in endemic areas or in patients with risk factors. The improvement in your father's condition following treatment is encouraging, but the lack of appetite and persistent liver function concerns warrant close monitoring.
Here are some recommendations and considerations moving forward:
1. Continued Monitoring: Regular follow-ups with your healthcare provider are essential. Monitoring liver function tests is crucial, especially if he continues on anti-TB medications, as these can be hepatotoxic.

2. Nutritional Support: Given the appetite issues, consider consulting a nutritionist who can provide tailored dietary advice to ensure he receives adequate nutrition, which is vital for recovery and overall health.

3. Further Investigations: If symptoms persist or worsen, further imaging studies (like a PET scan) may help in assessing metabolic activity in the lungs and bones, which could provide additional insights into whether there is an underlying malignancy or another process at play.

4. Multidisciplinary Approach: Engaging a team that includes oncologists, infectious disease specialists, and possibly a palliative care team could provide a comprehensive approach to managing symptoms and improving quality of life.

5. Psychosocial Support: Given the emotional toll of such a diagnosis, consider seeking support for both your father and family members. Counseling or support groups can be beneficial.

6. Alternative Diagnoses: Keep in mind that conditions such as sarcoidosis or other granulomatous diseases can mimic malignancy and should be considered if symptoms persist.

In conclusion, while the absence of malignancy in the biopsy is reassuring, the clinical picture remains complex. Continuous evaluation and a flexible approach to treatment will be key in managing your father's health. Always consult with his healthcare team for personalized advice and to ensure that all potential avenues for diagnosis and treatment are explored.

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