Expert: Claes-Gustaf Nordquist, M.D. - 9/17/2008

Question
We are authors seeking advice on medical matters for an upcoming novel. If you can help you would be credited as our medical advisor. The issue is this, our protagonist gets an MRI for neck pain at which time a tumor is discovered.  How would the report read, what type of form is used is it generally a brief note or do they go into detail we assume that they can not tell the type of tumor from an MRI only that one is present is this a correct assumption ? Would they recommend further study or a biopsy be done or is this not something that the radiologist does. What is a FNA this is the type of biopsy we want our subject to have. Would it be possible to see an actual report with all the personal information blacked out? If a biopsy is done how would the report read?  Again is it brief or lengthy.  Who does this report (the medical specialty) Does the MD ever insert his personal opinion in these reports or are they clearly clinical. Would he ever offer an opinion as to the amount of time the patient might have to live? What type of form is used again would it be possible to see an actual report with all the identifying information missing? We need to get a feel for the tone of these reports and how they are written if you can help please email us at huskey8@mindspring.com

Answer
First of all I'm a Swede, living in Sweden and my entire professional career - I'm now fully retired after a stroke that left me partly paralyzed in my left side, due to high blood pressure now under control, I have been retired almost 6 years now and I'm right now under treatment for prostate cancer - has been in Sweden. So apart from an exchange student period in Israel in 1969 and some visits to Finland, Denmark and Norway (and other shorter ones to Britain, USA, Canada & Australia) my entire clinical experience is from Sweden. I do not know the usual US forms here though of course I'm very familiar with the Swedish ones. Even though biology is the same in Sweden and the US culture and language are not. I'm therefore definitely not sure that I'm the right person for this. MRI can in fact give SOME information on what kind of tumor that can be expected. The radiologist can certainly recommend a biopsy. A FNA is a fine/thin needle aspiration biopsy. This technique was to a large extent developed here in Sweden. One of my former bosses, the late Professor, Dr. Sixten Franzén, M.D., Ph.D. of the Royal Karolinska Institute and the Royal Karolinska University Hospital, Stockholm Sweden was one of the pioneers of this technique (he died in May this year in his late 80'ies). The biopsy instrument to make such biopsies from the prostate gland in males was invented by him and is internationally called the Franzén instrument. However this technique can only provide cellular cytology samples. That is enough in many diagnostic situations but in some real tissue samples are necessary in order to evaluate the microscopical tissue architecture and not just cellular architecture. In such situations wider bore needles are necessary. Brain pathology is VERY DIFFICULT to evaluate. So here FNA is definitely not enough (my urologist did not think FNA was enough in my case either, in order to evaluate so called gleason scores of malignancy in a prostate cancer tissue samples are needed - and I did agree - so in my case he did 8 medium bore needle biopsies of my prostate all in rapid succession). So in your case I think I can rule out FNA! A thicker needle is necessary. A needle biopsy is evaluated by a dr. Here a pathologist. (In the case of an FNA a cytologist or a pathologist). Your whole story depends on what type of tumor you want your poor patient to have! In short the whole clinical picture of the patient and the life expectancy of the patient depends on the location and pathology of the tumor including GRADE (grade of malignancy in a scale 1 to 4 where 4 is most malignant, worst) and size. So location, size, type of tumor and its grade are all essential here! Either you know what will (or what you want to) happen to your patient and a tumor has to be chosen accordingly OR you have decided what kind of tumor you want and THAT will seal the fate of the patient. Make your choice! Most malignant brain tumors at present end with the death of the patient regardless of therapy. The speed of the progress of the illness is mostly dictated by the grade of the tumor. Grade 4 die fastest. I will finish with a sunshine story so you get some feeling for this even if it has a happy ending. I have an old (ex) girl friend, but we have remained good friends. I have known her since she was 18, I was 34 at that time. She is 47 now. She is both a registered nurse and a licensed physiotherapist. She has had her own private practice for around 15 years now. Around 10 years ago she called me with regards of her twin sister (non identical twin), a married home maker very different from her sister (who is a bisexual playgirl though very serious in her work) with at that time 3 small children. This girl had come down with strange head aches that worried her sister a lot. That is why she called me. The sister came to my office early - before the other patients - the next day and based on her symptoms I ordered an emergency CT scan in the medical center one block away in central Stockholm. They sent the report back to me by fax later the same day. In the report it was stated that there was a tumor suspect lesion in her cerebellum and an MRI scan was suggested. I immediately phoned her. Early next morning she an her husband were back in my office. I then sent her to an emergency MRI scan without and with contrast. Again I received a preliminary report by fax stating that there indeed was a tumor suspect lesion there but that there obviously had been a bleeding within the lesion and it could not be excluded that it all was a bleeding within her cerebellum and no tumor. On the other hand a tumor could not be excluded either. I sent her as an emergency patient to the department of neurosurgery of the Royal Karolinska University Hospital about a 15 minute walk from my office and not much more from my home. She arrived there on a Friday. On Monday my fax had a report from her surgeon that it ONLY had been a bleeding for unknown reasons and no tumor. No biopsy was done. Surgery was done more or less immediately. She recovered completely and is healthy today.