RFS news highlights resources, issues, and news relevant to in-training members of the ACR. If you have a topic idea or would like to contribute to the blog, please email RFS Secretary Nathan Coleman, MD.
Waiting It Out
A doctor-turned-patient’s point of view
My eyes fixed on the ultrasound monitor, I watched as the core biopsy needle was advanced into the lymph node and then deployed with a loud click. It wasn’t the first time I’d been part of an ultrasound guided biopsy.
As a second-year radiology resident, I had already performed dozens of ultrasound-guided procedures, but it was the first time I’d been the patient laying on the table, rather than the doctor holding the biopsy needle.
Once seven fine needle aspirations passes and four core biopsies had been obtained, the third-year resident performing the procedure, the attending radiologist, the ultrasound technologist, and the pathology team stepped out of the room to examine the aspirated cells under the microscope. I remained in the room, holding still on the table with towels draped over my neck, in case more samples were needed.
Ten minutes felt like a millennia. Would they discover the enlarged cervical lymph nodes that I had noticed for the past several months were lymphoma or simply reactive? Could these be metastatic nodes from head and neck cancer (even though I was completely outside the typical demographic and had never smoked a cigarette in my life)? With each passing second my speculative prognosis got worse and worse.
Tobben wears a radiation face mask during treatment.
When the care team finally returned to the room, the attending radiologist told me that the biopsy showed a lot of lymphocytes — not exactly reassuring, but at least it ruled out my imagined worse case of metastases... I braced myself for a week of waiting for pathology results.
One week became two. Then, rather than yielding a definitive diagnosis, the core biopsy results were read as “suspicious for Hodgkin lymphoma,” and an excisional biopsy was recommended. Another week passed before the procedure ; then, nearly two more weeks went by before I received the call from my otolaryngolist.
Bad news ... Hodgkin lymphoma.
Yet I almost felt a sense of relief. The month-long diagnostic process was finally over. While I had held out hope that the pathology results would come back benign, I’d been bracing myself for a worst-case diagnosis for weeks. The torture during the wait was the uncertainty of not knowing.
It’s been almost one year since I received my diagnosis. The subsequent lab tests and PET/CT staged my Hodgkin Lymphoma at “Ia” (the earliest possible form of the disease with the best prognosis). I underwent two months of chemotherapy, followed by two weeks of local radiation. While very unpleasant, both chemo and radiation went as smoothly as could be expected. I was able to continue residency without missing substantial time and never developed a neutropenic fever. My post-treatment PET/CT showed complete response. I spent the winter and early spring recovering my strength and even ran a half marathon in May.
In short, I’m fully recovered and feeling great.
I’d like to think I have always been an empathetic person who, as a physician-in-training, strived to provide the best possible care for all my patients. Nevertheless, experiencing the diagnostic process from the patient side did affect my perspective.
The time between my initial otolaryngology appointment to my final diagnosis spanned just over a month. While it felt interminable, my month of waiting was short compared to most patients. My access to the radiology department allowed me to schedule my initial biopsy and PET scan quickly.
As radiologists, our role in providing valuable diagnostic information is readily apparent: we raise the concern for lung cancer when we see a suspicious nodule or mass on a chest radiograph or for ovarian cancer if we detect a large complex ovarian lesion on CT in a postmenopausal female. Yet, it is also important to consider the way in which some of our recommendations for additional diagnostic testing affect patient care.
If a suspicious lesion needs to be biopsied, it may seem adequate to simply highlight that suggestion in the impression section of our reports. The impact of calling and informing the ordering physician of the need for biopsy (or additional imaging studies) may not seem necessary to the patient’s ultimate prognosis, but it certainly could affect how promptly the necessary testing is ordered and scheduled.
If a few days more of waiting may seem insignificant, I can attest from personal experience that such a delay feels immeasurably more excruciating to a patient than waiting for an ordering physician to return your page, even if at the end of a workday. Having been on the other side, I can assure you it will make a huge difference for our patients.
John P. Tobben, MD, radiology resident at Indiana University Health, Indianapolis