A lucky old puffer

PUBLISHED : Tuesday, 08 May, 2012, 12:00am
UPDATED : Tuesday, 08 May, 2012, 12:00am


Every day for the past five decades, Jerry Wang, 71, would smoke 21/2 packs of cigarettes. Predictably, he racked up a host of health problems along the way: high blood pressure, gout, gastric reflux issues and other ailments.

Despite these health concerns, Wang (whose name has been changed for patient confidentiality reasons) shrugged off pleas from loved ones over the years urging him to stub out. After all, he was still alive and kicking. What was the problem?

The problem began as a crick in the neck. The pain plagued him for two months, and Wang finally consulted a doctor. The doctor ordered a chest X-ray. Although it shed no light on the cause of Wang's neck pain, it did show up something unexpected: a 1cm lesion in the upper lobe of his right lung.

Given Wang's long history with cigarettes, the doctor was gravely concerned that the lesion was lung cancer, the No1 cancer killer of men and women worldwide. Most cases of lung cancer are caused by smoking. According to Dr Lam Bing, director of the Respiratory Medicine Centre at Hong Kong Sanatorium and Hospital, about 4,000 new cases of lung cancer are diagnosed each year in Hong Kong, two-thirds of whom are men. There are about 3,500 deaths annually from lung cancer in the city.

The cancer is so deadly because symptoms often don't show in the early stages, when surgery can still cure it. By the time symptoms such as chest pains or prolonged cough surface, the cancer has already spread, making it inoperable and incurable. According to Lam, 80 per cent of lung cancer cases are diagnosed at a stage that is too late.

Wang's example is typical of many cases in which the cancer is discovered incidentally as a result of a chest X-ray being taken for some other reason. Wang had a Computed Tomography (CT) scan, which offered a clearer look at the lesion, and a positron emission tomography (PET) scan, which highlights regions that have unusually high metabolic activity and helps doctors stage the disease. Cancer, infection and inflammation can all lead to metabolic 'hot spots' in PET scans.

The CT and PET scans confirmed the lesion in Wang's right lung, but the PET scan showed something even more disturbing: a lymph node on the right side of his neck displayed mildly active metabolic activity. Wang's doctor told him that the cancer had metastasised to the lymph node in his neck, meaning he had late-stage, terminal cancer. Wang was shocked.

With death sentence and test results in hand, Wang sought out Lam for a second opinion.

Reviewing Wang's file, Lam was less certain of the terminal lung cancer diagnosis. 'A CT scan just tells you something is there but not what that something is,' says Lam. 'A PET scan tells you metabolic activity is raised, but not why it is raised.'

What's more, Lam noted that the pattern of the suspected metastasis to the lymph node in the neck was inconsistent with the behaviour of the lymphatic system. If the cancer had spread to the lymphatic system, the lymph nodes closest to the site of the lesion should be affected first. 'The lymphatic system is a bit like the MTR system,' says Lam. 'It doesn't make sense for the cancer to skip all the nearby stations and affect a lymph node so far away. The symptoms may not be related.'

To investigate further, Lam proposed a bronchoscopy - a procedure in which a scope is passed down the airways to the site of the lesion to remove tissue for a biopsy. The tissue sample returned showing inflammation but not cancer. The result was inconclusive: they may have missed the lesion and instead obtained tissue around it.

Next, Lam needed to know more about the enlarged lymph node in Wang's neck. He wanted to use ultrasound to investigate the lymph node and remove some fluid for analysis. But during the procedure, he could not find the enlarged lymph node - instead, he found a nodule on Wang's thyroid.

Nodules on the thyroid gland are common and require only monitoring. More importantly, it meant the issues in Wang's neck and lung were unrelated. Therefore, the lesion in Wang's lung was localised.

Lam proposed removing the lesion to properly analyse it. To do so, he would need to remove the right upper lobe of Wang's lung in a surgery called a lobectomy. If there was indeed cancer, this operation would effectively cure Wang in the process. Wang agreed.

During surgery, the lesion was sent for frozen section, a procedure to rapidly analyse the tissue sample. It confirmed that Wang had non-small cell lung cancer, which makes up 80 per cent of all lung cancers. But it was only stage-one lung cancer, which has very high survival and cure rates once the lesion is removed.

Three days later, Wang was discharged from hospital.

Lam says: 'The lesson to be learned here is that the tissue is the issue. Only pathologists can confirm a cancer diagnosis. Scan results alone are not conclusive.'

After cheating death this time, Wang has wised up and quit the sticks. Lam often asks smokers to consider the price they want to pay for smoking.

'Would you like to lose a lung, suffer a stroke or something else?' he asks. 'It's best to quit before you need to pay a heavy price.'