30 AUGUST 2012

When not all nails need to be hammered

It has often been said that the best types of “cancer” to treat are those that are not cancerous.

The week after National Day had been special for me because I miraculously saved two “cancer” patients without a drop of chemotherapy.

Although both the patients came to me with what looked like cancer, both, in fact, did not have cancerous tumours.

Madam Irawaty was brought into my consultation room on a wheelchair. She was elderly and frail.

“She lives in a small village by herself and nobody knew that this was happening,” her niece, who accompanied her to see me, said of the tumour.

When she first noticed the tumour growing in the middle of her abdominal wall, it had been no bigger than a peanut.

Over the past five years, this mass grew so massive that when I saw her, most of her abdomen was a large, fungus-like mass of protruding tumours, large and small.

They stuck together like a menacing bunch of oversized grapes. Some of the larger ones had ulcerated and were infected, giving off a smell like that of a dead rat.

I sent her to an interventional radiologist who inserted a biopsy needle into the mass to core out a sliver of tissue for a histopathological examination.

The next day, to my absolute delight, the pathologist confirmed that the tumour was a fairly rare but benign one called dermatofibrosarcoma protruberans.

To date, I have looked after no more than six patients with this type of tumour and, thankfully, all have been cured with surgery alone.

Madam Irawaty underwent surgery two days after seeing me.

When I saw her the day after her operation, she was propped up in bed, beaming.

While I did not dare to open up the bandages, what struck me was that the foul smell of rotting flesh was gone.

I am cautiously optimistic that she will do well. Although there remains a chance that this tumour may recur in and around the surgical area, this tumour does not have the propensity to metastasise (spread) like cancer.

I have stressed to her family the importance of vigilance through follow-up treatment.

Should the tumour recur, it should be removed before it becomes too large.

Another patient, Madam Yeow, had numbness of her right shin for almost a year.

She saw a number of doctors, who treated her symptoms but were unable to make a firm diagnosis of the underlying cause.

She even had a magnetic resonance imaging (MRI) scan of her leg which found nothing wrong with it.

However, her complaints persisted and she had an MRI scan of her spine recently.

Unexpectedly, a tumour was seen in the muscle beside the spine.

She underwent a positron emission tomography (PET) scan, which allows doctors to “see” where cancer is located.

Most types of cancer have an affinity for glucose. So the patient is injected with a tiny amount of sugar tagged with a radioactive material, which will show up on a PET scan.

The PET scan has proven to be very useful in the management of cancer patients.

However, it is important to remember that a positive PET scan does not mean that the patient definitely has cancer.

The PET scan on Madam Yeow showed that the tumour had a moderate affinity for the glucose labelled by radioactive material, raising the suspicion of cancer.

She was seen by a neurosurgeon, who correctly advised her to undergo a biopsy of the tumour – which removes a sample of the tumour for testing – guided by a computed tomography (CT) scan.

A week after the biopsy, she was told that the limited sample suggested that she could have malignant lymphoma (cancer of the lymph node).

With that diagnosis, she was immediately referred to see me for consideration for chemotherapy.

Madam Yeow and her husband were extremely nervous about the possibility of cancer, the potential side effects associated with chemotherapy and the risk of recurrence and death.

I explained to them that the diagnosis was not conclusive and that lymphoma was highly curable.

Not entirely satisfied with the small sample, I encouraged her to undergo a second biopsy under CT guidance.

She agreed and after a day of anxious waiting, she was confirmed to have a benign tumour arising from the nerve sheath, called shwanoma.

No chemotherapy is needed in the treatment of this tumour. Surgery is the treatment of choice and chances of cure are excellent.

I happily referred the patient back to the neurosurgeon for consideration for surgery to remove the benign tumour.

At our recent monthly board meeting, our chairman raised his concern that patients are often confused about who to see when they suspect they have cancer.

“Patients think that they’ll inevitably end up on the operating table if they see a surgeon. If they see a medical oncologist, they will be offered chemotherapy,” he said.

“Patients want to know who they should see first.”

There is no right answer to that. My suggestion is that they should see someone whom they trust and get a second opinion if they are not satisfied.

It is true, generally, that if you have a hammer, everything looks like a nail. But in medicine, nothing could be further from the truth.

For me, at least, not all nails need to be hammered, especially if they are benign.

This article first appeared in “Mind Your Body”, a Straits Times Supplement.