Expert: Claes-Gustaf Nordquist, M.D. - 1/8/2008

Question
QUESTION: My 81 year-old mom who has history of breast and lung CA 7 years ago, clear since then, has been bedridden the last 1.5 years from a spinal fx. In the last 3 weeks she became much more confused, weak and on 12/24 she was admitted to the hospital to RO a CVA. On brain MRI many small "tumors" were identified and the doctors are divided as to whether they represent widespread metastatic cancer or possibly an infection like toxo. The MRI is unusual they said because of no midline shift or swelling usually seen with cancer. They are repeating the whole body CT scans today and then maybe we will know; if negative then an LP and if negative then questioning a brain bx.  She is so debilitated and weak I don't want to put her thru too much invasive testing. Should I consider brain radiation if offered, or the brain bx? Thanks for any advice (I am very pleased with her medical care, just confused becuse the MDs are divided in opinion.)


ANSWER: A brain PET scan MAY be of some help in determining if this is infectious/inflammatory or the result of cancer spread. I'm somewhat reluctant to start radiation therapy without a biopsy confirming that there really is cancer there, but if a PET scan confirms it I think radiation therapy can be tried as a palliative measure. You must unfortunately understand that no curative therapy is possible in that case! I'm sorry I have nothing better to tell you!



---------- FOLLOW-UP ----------

QUESTION: Thanks for your quick response. Mom had a PET scan in Sept. that was negative. Today the chest-abdominal CT returned negative for cancer, so the MDs are assuming the brain lesions are noncancerous and are planning an LP in a couple days (after Plavix wears off) to study the CSF for what kind of infection she has. I was told she probably has toxo. How does this happen? She does not have AIDS or transplants, but has been debilitated and bedridden for some time now. They said she would have antibiotics--do you know would this be IV, in the hospital and for how long? She is stable right now on a regular floor and pretty oriented, neurology has signed off on her, no seizures.
Thanks again.

ANSWER: Ok, that makes an infection probable. Sorry, now you are asking me questions well outside my area of expertise here! I have a contract with this site which I must follow. Besides I'm a specialist of medical oncology & radiation therapy NOT of infectious diseases AND it is almost 40 years since I studied infectious diseases at medical school! So I must ask you to direct this question to an expert of that subject here.


---------- FOLLOW-UP ----------

QUESTION: Hi there--Now Mom has been in the hospital 15 days, still no diagnosis. All blood cultures, echocardiogram, CSF analysis from LP, all results are negative. The infectious disease specialist said he didn't think there was an infection. Today neurosurgeon is being re-consulted to see about brain bx. THe chance of MS is being considered also--and Mom has had a many, many year history of increasing sleepiness (lately sleeping 16 hours a day), mild hand tremors, mild depression, urinary incontinence, going on for some time before this sudden worsening in the last few weeks. Do you think MS could be a possibility? The medical oncologist and radiation oncologist still aren't convinced it is cancer and now waiting to see if the neurosurgeon still believes it is cancer. Thanks for any input. This idea of MS is new and would it show on the bx? The hospital does not have its own PET scanner, she would have to be discharged and have it done as outpatient which nobody wants to do at this point. Thanks!

Answer
Are you telling me it is not possible to keep her as an in patient - which evidently she is in need of - and have a PET scan done for some administrative reason?! Is the hospital there for her or not? Threaten to sue them! MS is at least a possibility. A brain biopsy of one of her lesions may turn out to be the only way of getting a sure diagnosis! IF the neuro surgeon is prepared to do it! Please do keep me posted!