The First Commandment of Oncology

Several years ago I saw a man who was referred to me for further evaluation of enlarged lymph nodes in his neck. They seemed suspicious on examination, so I ordered the simplest and least invasive type of biopsy available: a needle biopsy of the most prominent node, thus sparing the gentleman from an incision in his neck.

The pathology report returned a few days later and stated that the patient had a low-grade lymphoma. I made arrangements for him to undergo further testing, and prepared to refer him for radiation therapy to the neck.

Everything seemed to be copacetic, except for one tiny problem...

I couldn't shake off a lingering doubt about the diagnosis. The proper diagnosis of lymphoma includes identifying what grade it is, and this information could not be determined on the needle biopsy. I held the path report before me and asked myself the following (oncologists often perform interior monologues, just like Hamlet):

"Forsooth! Doth this diagnosis reflect all that is true? Say, why is this? wherefore? what should we do?"

Myself considered the situation and summoned up the courage to yodel back "I ain't so sure!" This was all I needed to yank on the brakes and stop this patient from rolling on into the radiation oncology station house. I called him up and made him see a surgeon for a formal excisional biopsy of the lymph node. The next pathology report was nothing but good news for him, for it revealed that he did not have lymphoma. His sigh of relief could be heard for miles until it crashed into an identical gale emanating from the building where my office was located.

The moral of this story could be chiseled onto a tablet as this First Commandment of Oncology:

Thou shalt make certain the diagnosis is the truth before thou terrifies the patient.

In order to ensure that a patient does indeed have a malignancy, and that the exact type of cancer is identified, medical oncologists, pathologists, surgeons and other specialists must work together. They must consider several maneuvers to pin down the correct diagnosis, such as staining the biopsy specimen for immunhistochemical markers specific for a type of cancer, or even using electron microscopy on the specimen. If no agreement can be made as to what this lesion represents, they should send it out to another experienced pathologist for an outside review.

Sometimes, such as in the case I presented above, the specimen is simply inadequate to establish a diagnosis. Then the lesion of interest must either be re-biopsed, or a lesion in a different location should be considered for biopsy. Patience is required by all parties when atttempting to come up with the proper diagnosis before proceeding with chemotherapy, surgery, or radiation therapy.

The best way in my opinion to ensure beyond any doubt that a patient will be diagnosed correctly is to consider the whole person before you. Each aspect of a patient's clinical presentation is a clue as to what the final diagnosis will be. Oncologists must place these pieces before them as if they were working a jigsaw puzzle, analyze all the different parts with the precison of a watchmaker, and then solve the puzzle as if it held the secret to immortality itself. We fulfill our commitment to our patients by taking each case as seriously as did that great detective with the deerstalker cap, whose most famous quotation is:

"When you have eliminated all which is impossible, then whatever remains, however improbable, must be the truth."