Recently, a friend reached out — a loved one had just been diagnosed with cancer. As is often the case in those early days, the picture was hazy, and the scans were raising more questions than answers. The initial CT suggested the possibility of metastatic disease, but a subsequent PET scan cast doubt on that assumption. Some of the suspicious spots lit up, yes, but not in a way that was definitively cancer. The team was leaning toward a biopsy to clarify: Were these distant lesions truly related to the primary tumor, or something else entirely?
It made me think of similar situations I’ve encountered — including two cases that left a lasting impression. These are the kinds of stories that remind us why we have to stay humble in the face of complex disease, and why, in oncology, “trust but verify” isn’t just a saying — it’s a survival strategy.
A Case from the Road: Chronic Pain, Suspicious Bone Lesions, and a Surprising Turn
While working locums this past year, I evaluated a patient with what appeared to be squamous cell carcinoma of the lung. The PET scan showed suspicious uptake in the spine — it looked metastatic. Frankly, I was convinced. But something didn’t sit right. This patient had a long history of severe chronic back pain, was on chronic opioids, and even had an intrathecal pump. Could these bone lesions be something else?
We decided to biopsy one of the spinal spots. And sure enough, it wasn’t cancer.
That changed everything. The patient was no longer stage IV. Instead of being limited to palliative systemic therapy, he became eligible for potentially curative treatment. We moved forward with a few cycles of chemotherapy in the neoadjuvant setting and then sent him to surgery. His care shifted entirely — not because the cancer changed, but because we asked the right question and waited for a clear answer.
When Sarcoidosis Masquerades as Metastasis
Years ago, I cared for a man with locally advanced melanoma — a neck lesion with cervical nodal involvement. He enrolled in a clinical trial and had a phenomenal response. The tumor completely flattened; the nodes disappeared. No surgery needed.
Months later, though, new nodes started lighting up on his scans — this time in the mediastinum. On PET, they were unmistakably hot. Based on the location and pattern, we suspected disease progression. We started preparing him for TIL (tumor-infiltrating lymphocyte) therapy, which was just becoming available through a compassionate use program.
But as part of the prep, he underwent a mediastinoscopy. The surgeon came out of the OR with a hunch: “I don’t think this is cancer.”
And he was right. The biopsy revealed sarcoidosis — a benign inflammatory condition that can mimic metastatic disease on imaging. We didn’t need TIL therapy after all. The patient stayed on surveillance, and even years later, he remained in remission.
I still remember walking into the room and telling him, “This is the best news we could have hoped for.”
The Takeaway: When in Doubt, Biopsy
These stories — and others like them — underscore a critical point: Imaging is powerful, but it isn’t perfect. PET scans can light up for infection, inflammation, and benign conditions. CTs can suggest patterns that seem ominous but turn out to be red herrings.
That’s why, when the findings will change management — especially when the difference is between curative and palliative treatment — we have to push for tissue. A biopsy doesn’t just clarify the diagnosis. It protects patients from under- or over-treatment. It keeps hope alive when things seem dire, and it helps us avoid false reassurance when the stakes are high.
Look at the Scans — Don’t Just Read the Report
Another key lesson: don’t rely solely on written reports. There’s real value in reviewing the actual scans. Sometimes, subtle visual patterns — symmetry, location, density — tell a different story than the radiologist’s summary. Whenever possible, collaborate closely with your radiology colleagues. Pull up the images. Ask the questions. Dig deeper. If I’m being honest, I say this as a daily reminder to myself when it’s easier to just read the report.
False positives are more than clinical puzzles — they’re moments that test our commitment to precision. And for patients and families navigating the emotional storm of a cancer diagnosis, these moments can offer unexpected relief, renewed hope, and even a second chance at cure.
If there’s one takeaway from these stories, it’s this: A well-timed biopsy can make all the difference in how we treat — and understand — the patient sitting in front of you.
About the author
Dr. Sajeve Thomas is a distinguished medical professional and a compassionate guide in the field of oncology. With over a decade of dedicated experience as a board-certified medical oncologist/internal medicine specialist, Dr. Thomas has become a trusted expert in the treatment of melanoma, sarcoma, and gastrointestinal conditions. He brings a wealth of expertise to the complex and challenging world of oncology.
Disclosures:
Dr. Thomas serves as a speaker for Bristol Myers Squibb (BMS), Merck, Ipsen, Natera, Immunocore, Pfizer, and SpringWorks. He also receives industry grants in support of numerous clinical trials.