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CASE REPORTS
SECOND OPINION IN MALIGNANCY
SURYAKANT CHOWDHARY*, PRAKASH PATIL**
Management of malignant lesion depends upon histological diagnosis and opinion of oncologist. Patient seeking second opinion is not uncommon. Independent clinicoradiological evaluation should be done without getting biased with first opinion and if there is mismatch in diagnosis, a repeat biopsy is mandatory.
We report a case of 9 month old baby from overseas whose limb could be salvaged because of second opinion.
INTRODUCTION
Histopathological diagnosis is the mainstay in management of malignant diseases. It is mandatory to review outside histopathology slides before starting treatment. If the histopathological report is not matching with clinico-radiological findings it is advisable to do a repeat biopsy.
CASE REPORT
A nine month old girl resident of Middle East presented with swelling of left elbow since February 1999. X-rays revealed osteolytic lesion in lower end of left humerus with periosteal reaction. MRI showed enhancing lesion with preserved fat planes (Fig. 1). Bone biopsy done at Middle East showed round cell tumour. Patient was advised left elbow amputation.
Parents wanted to take second opinion in Bombay as they had suspicion of mixing of slides. Two babies with similar problem were biopsied on the same day in that hospital. Patient was reevaluated in Cancer Institute and the slides from Middle East were reviewed which confirmed the diagnosis of round cell tumour in favour of neuroectodermal tumour. Patient was advised chemotherapy. Parents insisted on repeat biopsy which the oncologist thought unnecessary on the basis of available radiological and histopathological evidences. Patient’s parents opted for a third opinion in the same week at Bombay Hospital. One month had elapsed between the first diagnosis at Middle East and the third opinion. We noticed a gross discrepancy in the clinical findings and the radiological pictures taken one month back. Examination showed complete regression of local swelling without any definitive treatment. This aroused a suspicion in our mind of a non-malignant pathology, hence a repeat X-ray and MRI was done which showed regression of osteolytic lesions with scarring. Bone biopsy was repeated which showed no evidence of malignancy. Parents were reassured about the benign nature of the disease and were advised regular follow up of the patient with X-rays and MRI.
Patient was reassessed by us at Bombay Hospital after 3 years with repeat X-ray (Fig. 2) and MRI which showed healed scar.
RESULT
Timely second opinion helped in salvaging the limb of the child (Fig. 3) as the diagnosis changed from malignant disease to a benign one.
DISCUSSION
It is a common misunderstanding that a definitive cancer diagnosis can be made on the basis of X-rays, CT scan, mammograms, blood tests and physical examination. It is only when a pathologist studies a biopsy sample taken from a suspicious lesion that a definitive diagnosis can be made.
Diagnostic accuracy depends on the individual pathologist’s training, experience and judgement. Scientific articles have confirmed that such errors occur in cancer diagnosis in an average of 2-4% of cases. Based on these calculations approximately 30,000 incorrect cancer diagnosis occur annually in the United States.
Why should one take second opinion?
1. There may be an error in the diagnosis by pathologist1-3
2. Your first doctor may be unaware of all treatment options4
3. Your first doctor says cancer is inoperable or does not need surgery. Make sure that it really is the case by seeing another doctor.
4. There are over 100 types of cancers, no one doctor will know everything about all of them. Find a doctor who takes special interest in your type of cancer as he may be updated about the latest in the management.
These errors can lead to incorrect or inappropriate treatment that could cause serious medical consequences.
Contrary to the above causes mentioned, in our case the reason for difference of opinion in treatment from amputation to chemotherapy to conservative treatment was probably because of the suspected mixing of the slide at the hospital in Middle East. This possibility also should be kept in mind though occurs rarely. Hence repeat biopsy should be done in cases of gross mismatch of clinical findings and relevant investigations. We noticed complete regression of swelling clinically which compelled us to do repeat biopsy to rule out cancer.
CONCLUSION
While giving a second opinion do not get biased with the reports which the patient already has instead do a proper clinical evaluation and correlation of the relevant investigations. Review the pathological slides by a reputed pathologist or do a repeat biopsy in case of gross mismatch of the findings. A lot depends on your valuable second opinion from the patient’s management point of view.REFERENCES
1. European Journal of Surgical Oncology 2001 Sep.; 27 (6) : 589-94.
2. American Journal of Clinical Pathology 2001 Oct.; 116 (4) : 473-6.
3. Cancer 2001 Apr. 1; 91 (7) : 1284-90.
4. Cancer 2002 Feb. 15; 94 (4) : 889-94.
PREHOSPITAL THROMBOLYSIS
Early patency of the relevant artery is now the holy grail of management. Difficulties remain, however, in delivering effective and timely treatment, with a target “call to needle” time of less than 60 minutes stated by the national service framework.
The feasibility of prehospital thrombolysis has been shown in studies that have used a variety of models for delivery of treatment.
Primary angioplasty offers an alternative means of early restoration of coronary flow in acute myocardial infarction and may be more effective than thrombolytic treatment, as it achieves higher coronary arterial patency rates and improved coronary flow.
The advantages of thrombolysis and primary angioplasty may be complementary and not mutually exclusive. Further reductions in mortality and morbidity may be obtained if transfer time could be utilised to administer optimal lytic regimens prior to urgent angioplasty. The adoption of the approach would require a fleet of modern intensive care ambulances with electrocardiographic monitoring, defibrillators, and modern communication facilities, and staffed by trained paramedics and nurses with direct access to angioplasty centres, thereby avoiding time consuming stops in local emergency departments or coronary care units.
Thus although the anticipated increase in infarct angioplasty may radically alter acute management in future, early thrombolysis remains the current goal for reperfusion. In the immediate term, prehospital thrombolysis should be strongly considered in rural communities and congested urban areas where transfer to hosptial is likely to be delayed.
BD Prendergast, BMJ, 2003; 327 : 1-2.
