Throughout fellowship, my experiences working with patients in clinic have taught me many lessons. In particular, I’ve learned the true value of a physical exam. While working in a continuity clinic alongside my program director, who has a special interest in breast cancer, I’ve had a special opportunity to observe and learn from him the proper way to conduct a breast exam. Working with this program director has also taught me to be mindful of certain important considerations in patients with metastatic disease.

In this article, I present the case of a woman with widespread disease in the bone, lung, and colon. Initially, she was thought to have colon cancer based on imaging results. However, a simple physical breast exam revealed something very different.

Our patient is a 66-year-old woman with an unremarkable past medical history. In fact, this patient reported no history of ever being seen by any healthcare provider. She presented to the emergency department with worsening neck pain and right-sided chest pain, which had been bothering her for weeks. She denied symptoms of weakness, tingling, numbness, and urinary or fecal incontinence. When she was seen by our team, her initial physical exam was normal.

Upon meeting with this patient, our team ordered a CT scan of her neck. Results revealed multiple lytic lesions, with C5 cord compression. Because these findings raised suspicion of malignancy, a CT scan of the patient’s chest and abdomen was conducted as well. Results of the second scan revealed diffuse osseous metastatic disease. Extraosseous soft-tissue components were noted at numerous levels in the cervical, thoracic, and lumbar areas of her back. The scan further revealed several bilateral pulmonary nodules with mediastinal adenopathy and indeterminate mural-based soft tissue that involved a short segment of the ascending colon. An MRI scan of the woman’s spine also revealed diffuse osseous metastatic disease throughout her spine, with cord compression at C5 and epidural disease at L1 and L2.

In light of this information, an oncology service at an outside hospital was consulted. The patient’s physical examination, which included a neurological exam, was normal. It was after this that she received a recommendation to be transferred to our facility for a neurosurgical and radiation oncology evaluation, as metastatic colon cancer had been suggested as a diagnosis based on imaging results. She was transferred to our hospital and examined by the neurosurgery service, who (since she had no neurological deficit), preferred to wait to make a treatment decision until receiving an actual tissue diagnosis. However, she was started on high-dose steroids and our service was consulted.

When I reviewed her chart, I really did not feel that this patient had metastatic colon cancer. I considered her amount of bone disease and her intact liver. I also considered the basic principles of medicine and noticed that despite being seen by several doctors, not one had performed a simple breast exam. After getting up to speed on this patient’s medical history, I asked her if she had noticed any changes in her breasts or other symptoms, such as discharge. She said she had felt something in her right breast 8 months earlier that she thought was a painless cyst and showed no concern about it.

I conducted my own physical exam and, as it turned out, she had a 5-cm mass in the middle of her right breast. The mass was firm and nontender to palpation. The patient had nipple inversion, but no signs of rash or erythema. Her axillary exam was normal. This right-breast mass was not previously detected during any of this woman’s imaging scans.

The results of an ultrasound-guided biopsy of her right breast were consistent with estrogen-receptor/progesterone-receptor—positive and human epidermal growth factor receptor 2–negative invasive ductal carcinoma. Neurosurgery deferred surgery, and radiation oncology started treating her C5 disease since there was no neurological defect.

I communicated these findings to the initial oncologist who had seen this woman, and he was very appreciative of my attentiveness and willingness to dig deeper into this patient’s case. He explained to me that, “We, as oncologists, sometimes forget to do a breast physical exam because of all of the imaging technology available. But this patient serves as an excellent example of why it is important to conduct a complete physical exam, especially during an initial patient encounter.”

Cases such as this one highlight an important principle in oncology. We frequently talk about pathology and imaging results, but we rarely talk about physical exam findings, even in tumor boards. This case clearly demonstrates the importance of the physical examination in oncology, as it can play a huge role in a patient’s diagnosis and treatment.

Articles

Throughout fellowship, my experiences working with patients in clinic have taught me many lessons.

Do We Still Need Physical Exams in the Era of Advanced Imaging Technologies?

	I’ve learned many lessons throughout fellowship. One of the most valuable has been recognizing the importance of regular collaboration among the members of a patient’s care team. No matter how engrossed we become in our own work, teaming up with other healthcare professionals can help ensure an accurate diagnosis and improve quality of care.

	In this article, I present the case of a woman with chronic pancytopenia and a “normal bone marrow biopsy” felt to be related to rheumatoid arthritis (RA) and immunosuppression. However, a visit to the pathology department two years after the initial diagnosis revealed something quite different. Cases such as this one serve as a reminder to us all about the importance of working together with others as part of a team-based approach.

	Our patient is a 62-year-old woman with a past medical history of RA, hypertension, and hypothyroidism. This patient was initially seen in August of 2013 by one of our oncologists. During the initial evaluation, it was noted that she was being treated for chronic immunosuppression for active RA with prednisone (10 mg daily) and etanercept. Her complete blood count showed leukopenia 1200/mcL, neutropenia with an absolute neutrophil count of 300/mcL, and thrombocytopenia 55,000/mcL.

	The patient’s physical examination revealed mild to moderate splenomegaly; a computed tomography scan of her chest, abdomen, and pelvis came back negative; and a bone marrow biopsy looked fairly normal except for increased cellularity relative to her age. Her hematologist assumed that she did not have a bone marrow disorder and attributed her pancytopenia to her autoimmune disease and immunosuppression. Based on his assessment, the hematologist began treating her with growth factors and transfused blood products on an as-needed basis.

	In November of 2015, she presented to the hospital with a gangrenous finger attributed to vasculitis. At this visit, she was found to have worsening pancytopenia with a white blood cell count of 600/mcL, hemoglobin of 10.7 g/dL, and platelets of 61,000/mcL.

	My team and I began putting all of the pieces to this puzzle together. Based on her previous diagnosis of RA, splenomegaly, and pancytopenia, we began to strongly consider that she may have large granulocytic leukemia (LGL). LGL is a chronic type of leukemia that is more common in the western world and is characterized by pancytopenia and splenomegaly, and sometimes fever or weight loss. Notably, LGL is usually associated with autoimmune disease.

	Based on my suspicion, I performed another bone marrow biopsy and specified an order to evaluate for LGL. To make sure that the pathologist was aware of my patient’s health history, I went to the department and reviewed the case further. Sure enough, the pathology report revealed CD57+CD8+CD4- T cells consistent with LGL. The pathologist was very grateful that I had pursued the case so diligently, as she explained to me that LGL is commonly missed if there is no suspicion for it.

	I notified the patient’s oncologist right away and together we discussed this new diagnosis and the treatment options that would be most appropriate. We decided on a treatment plan that involved a long-term, slow tapering of the patient’s steroid along with weekly methotrexate and growth factors, as needed.

	Cases such as this one highlight an important principle in oncology. We frequently talk about physician communication and tumor boards; yet often, we merely read the reports and notes when making clinical decisions. This case clearly demonstrates the importance of communication and working as a team to reach the right diagnosis.

	Always remember that “If it looks like a duck and walks like a duck, it is a duck.” Do not hesitate to discuss your thoughts with other providers. Our case was a slam dunk after finally detecting our patient’s LGL. Initially, the diagnosis was missed because the potential for LGL was not considered and discussed with a pathologist.

Faisal Musa, MD, is an oncology and hematology fellow at the University of Florida Health Cancer Center of Orlando Health in Orlando, FL.

Faisal Musa, MD, reviews the case of a patient with large granulocytic leukemia and discusses why collaborating with the patientâ€™s pathologist was so important to her diagnosis.

Faisal Musa, MD

Articles

Do We Still Need Physical Exams in the Era of Advanced Imaging Technologies?

Does Physician-Physician Communication Matter?