Navigating the complex realm of oncology often involves a blend of clinical expertise, investigative curiosity, and intuitive sensitivity. A recent encounter with a patient, previously diagnosed with a sizable axillary adenopathy considered “benign”, reinforces the necessity of approaching medical puzzles with an open mind and meticulous attention to detail.
Earlier this year, a patient was diagnosed with an 8-9 centimeter locally advanced bulky axillary adenopathy after initially presenting with a provoked DVT. A biopsy from another facility labeled it as an inflammatory neoplasm without any overt evidence of malignancy. In the wide spectrum of tumors, they generally fall into three categories: benign, which are essentially harmless; malignant, that grow, spread, and can endanger life; and aggressive tumors, which may grow locally but don’t spread, examples include desmoid tumors, giant cell tumors, and Igg4 related inflammatory neoplasms.
Following the biopsy results, the patient underwent steroid treatment by the local oncologist, which led to an alleviation in tumor symptoms but did not eradicate it. The treating oncologist pondered the possibility of it being an Igg4 neoplasm and contemplated using Rituxan. Subsequently, I was approached for insights.
The Second Look
Upon meeting the patient, the enormity of the lymphadenopathy was evident and concerning. In the world of oncology, a dictum often resonates: “If the tumor’s a rumor, and cancer could be the answer, then tissue is the issue.” Diving deep into the patient’s pathology report, there was no direct mention of malignancy. However, it revealed an abundance of inflammatory cells, notably enriched T cells. An addendum in small print highlighted a clonal T cell receptors gamma gene rearrangement. These findings strongly pointed towards a lymphoproliferative neoplasm and possibly even a malignant lymphoma which tend to respond temporarily to steroids!
Discussing this case with my hematology colleague echoed similar concerns. The challenge lay in communicating this shift in perspective to the patient, who believed they were “cancer-free”. Surprisingly, the patient’s response was one of relief, displaying an eagerness to face the possibility head-on. The journey of diagnosis is far from over. With PET scans, bone marrow biopsy, peripheral flow, and a possible open biopsy in the pipeline, along with a consult with our malignant hematologist and review at hematology conference, this patient will have more clear answers and definitive treatment. This patient’s case underscores the significance of rigorous scrutiny and second opinions in oncology. It’s crucial to keep questioning, keep examining, and most importantly, keep the patient informed, ensuring they’re equipped to confront whatever lies ahead.
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. Currently practicing at the renowned Orlando Health Cancer Institute, he brings a wealth of expertise to the complex and challenging world of oncology.
As one of the principal investigators at his cancer center, Dr. Thomas plays a pivotal role in advancing medical knowledge through his involvement in numerous clinical trials. These trials encompass a spectrum of cutting-edge treatments, including targeted therapy, immunotherapy, intra tumoral therapy, and complex cellular therapies. His commitment to research and innovation underscores his dedication to offering the most effective and up-to-date treatment options to his patients.
Embrace the opportunity to engage with Dr. Sajeve’s expertise, and feel empowered to explore the vast expanse of oncology with renewed curiosity and understanding on “Ask MedOnCMD“