Patient LR, like so many of my patients, has an unusual background, with a graduate degree, study abroad, and expertise in art. Before we first met, he had worked successfully in business for many years. His very devoted wife had a Ph.D. and had, before retirement, worked as a college professor. He had been in good health when in July of 1991, at age 70, a routine chest x-ray at the time of his yearly physical revealed a small right lung nodule suspicious for possible malignancy. A repeat x-ray in August 1991 again demonstrated “a parenchymal nodule in the right mid lung…” CT scan studies of the chest in late August 1991 confirmed a “6 millimeter nodule in peripheral lateral aspect of right upper lobe. It is consistent with bronchogenic carcinoma, metastatic lesion or granuloma…” In addition, the radiologist noted “an enlarged lymph node posterior to the ascending thoracic aorta…” A CT scan of the brain in early September was clear, but a CT scan of the abdomen revealed extensive disease throughout: There are about 4 lesions in the upper right lobe of the liver…An ultrasound examination is recommended for further evaluation… There is a round enlargement of the right adrenal gland up to 2 cm in diameter. There is also what appears to be diffuse enlargement of the left adrenal…Both these findings are suspicious for metastatic disease. There is a mass in what may be the cephalad portion of the head of the pancreas or it is a mass or adenopathy just adjacent to the head. The mass measures about 4.5 cm in its greater diameter… A bone scan the same day demonstrated:
Abnormal activity of the right hip and right shoulder suggesting metastatic disease… Though the situation appeared dismal, the patient’s doctors still needed a biopsy specimen to confirm not only cancer, but also the most likely primary site. After reviewing the scans, they decided the lung lesion to be most accessible for tissue sampling, so in late September LR was admitted to his local hospital for...
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