The Mystery of the Stubborn Mass

[Editor's Note: at the request of our readers this will become a recurring feature. The C.O. in his infinite wisdom created a new character, Dr. Noce Saggio, to serve as the protagonist in this series of medical mysteries. And now, if you would please, raise the curtain... ]

"Another espresso, Doctor?" The waiter stood crisply by the table as his customer drained the last of his cup. The cafe swelled with the sounds of early morning conversation.

"I don't think so, Raoul. I've got to be off to my clinic. My secretary will not stand another late start this week." The waiter bowed and backed away, and Dr. Noce Saggio placed his napkin on the petite table in front of him.

"But wait, Saggio - you were going to tell me about this startling case you were involved in," said the man across the table. He leaned forward and pulled on his moustaches, affecting an air of nonchalant eagerness.

"Oh, yes - I had forgotten. Well, it is a rather straightforward story. If you will accompany me to my car, Colonel, I'll give you the gist of it."

Colonel Georg Senf held the door for his colleague and the pair ambled toward the parking lot.

"I had the opportunity to see a sixty-something year old man for a second opinion," remarked Saggio. "He had recently finished concurrent chemotherapy and radiation therapy for a stage III non-small cell lung cancer."

"Just how stage III was he?" asked the colonel.

"He brought with him a chest CT that showed an eight centimeter right suprahilar mass with direct extension to the mediastinum - completely inoperable. The pathology report called it 'adenocarcinoma.' He came to see me because his tumor had grown despite this aggressive therapy. His oncologist had told him that no further treatments were likely to be of any benefit."

"And did you agree with this assessment?"

"That, my dear Senf, is the essence of this case. After reviewing all of his records I noticed something was missing - something important at the time of diagnosis that was easily overlooked. I wasn't certain that this bit of information would be helpful but ordered the missing test anyway. Once I saw the results I told the patient that I disagreed with his oncologist's assessment and that he should start treatment immediately."

"Is that so?" asked Senf. "Are you implying that the path report was wrong?"

"No," grinned Saggio. "The pathology was correct, but the patient had been treated for the wrong diagnosis." He folded his arms and leaned against his car like an Alabama sheriff.

"No kidding? Now how did you come to this conclusion?"

What was Dr. Saggio's response?

Saggio opened his car door and turned to his friend. "I told you that he had brought with him a chest CT, which as you know does provide views of the abdomen - the upper abdomen, but nothing below the adrenal glands."

He climbed into the driver's seat. "The doctors had forgotten to check a separate abdominal CT as part of his staging work-up. When I got one it showed a large renal mass - the origin of this patient's disease, rather than the unusual metastasis to the right lung which mimicked a primary lung cancer. I recommended that he start on targeted therapy for metastatic renal cell carcinoma, and his oncologist agreed - not surprisingly. Thank you for breakfast, Colonel - until next time. Ciao."