[00:00:00.090] - Dr. Lemanne

But lo and behold, that patient was cured. That was the first case of cholangiocarcinoma I had ever seen cured. And that changed my career at that point. This was--a little in my defense, I would say--that this is early in my career, I think in the first six months or so that I was an independent attending physician. And it changed my thinking to really question the idea that a cancer is incurable. And any curable cancer that's curable now was once incurable. Where's the dividing line? So somebody's going to start curing these cancers at some point, and you might as well get in line for that. 

You have found your way to the Lemanne Gordon podcast, where Docs talk shop. Happy eavesdropping. I'm Dr. Dawn Lemanne.

[00:00:57.950] - Dr. Gordon

I treat cancer patients.

[00:00:59.710] - Dr. Gordon

I'm Dr. Deborah Gordon. I work with aging patients.

[00:01:03.450] - Dr. Lemanne

We've been in practice a long time.

[00:01:05.910] - Dr. Gordon

A very long time.

[00:01:07.510] - Dr. Gordon

We learn so much talking to each other.

[00:01:09.720] - Dr. Gordon

We do. What if we let people listen in?

[00:01:17.050] - Dr. Lemanne

In this episode, Dr. Gordon and I discuss four cases of cancer that weren't at all what they seemed. Some weren't cancer, but all, fortunately, had happy endings, despite errors by doctors, including errors by yours truly.

[00:01:40.370] - Dr. Gordon

I've reflected on the fact that my relationship with patients go on for years and many times decades, and it's a constantly shifting ground. What we're focusing on, what's up for them. And as I was giving somebody the link to your website, I thought how different it must be when somebody comes to you for a problem, you have to diagnose it correctly and figure out an appropriate treatment plan, and you pretty much have one or two shots at it rather than decades. So do you ever think about that?

[00:02:18.330] - Dr. Lemanne

I do. I love it when I have a decades long relationship with a patient that's definitely a success all around. The patient's happier than I am, I'm sure. And, yes, you're in family practice, but now are specializing in cognitive issues and aging longevity. And as an oncologist, I am very grateful when we get to the point where we are starting to focus on those things and I get to send those patients to you. And I think that one of the things about oncology that I want everyone to know is that the oncologist actually doesn't make the diagnosis of cancer. And the surgeon who does the biopsy doesn't make the diagnosis of cancer. The radiologist who does the mammogram and then does the imaging guided biopsy of the breast or other parts of the body doesn't make the diagnosis of cancer. And the doctor who makes the diagnosis of cancer for anyone is a doctor that patients 

[00:03:18.410] will never meet. So at the point of diagnosis of cancer, there's a really important person in your life, and it's someone you will never meet, and that is your pathologist. And I think that's not on most people's radar.

[00:03:31.320] - Dr. Lemanne

People don't think about pathologists, but those are the doctors, they're MDs, they go to medical school and they do a residency in pathology, and they learn how to make diagnoses. And one of the types of diagnoses they have to make using biopsy specimens that the surgeons or the radiologists send them is the pathologist. So I really find that thinking about that has clarified my role in patient care. And I have a lot of stories about what can go wrong in that realm.

[00:04:06.830] - Dr. Gordon

I have a friend who's a pathologist, and she's a very organized, linear, logical thinker. And I thought she's perfectly paired with her profession because ABC are present in a specimen she looks at, and it either is breast cancer or it's not. But you're saying sometimes it's a little more of a gray area, there's a.

[00:04:31.860] - Dr. Lemanne

Lot of fuzz in there. Yes. And I can tell you a couple of stories I'd love to hear. Yeah. I mean, I think we're going to point out some of the errors, the things that can go wrong in medicine. So I had a patient come to me. She was a 30 year old woman, and she was from a coastal county in Northern California that is known for growing a lot of interesting crops. And I think some of it's become legal since then. But at that time, which is about ten or 15 years ago, definitely wasn't. And she came in I don't take insurance, but she said she had heard that I take cash. She came in with cash, I mean, bills.

[00:05:22.150] - Dr. Gordon

I'm getting an idea about what she's growing.

[00:05:24.890] - Dr. Lemanne

That wasn't what was so interesting about her. What was interesting was that she had a lot of tumors in her lymph nodes and in her bones. And she'd had a biopsy that gave a diagnosis of non Hodgkin's lymphoma, which is a common diagnosis. And because there was spread to the spine and the bones were crumbling, they were no longer hard, they were filled with these tumors. They were very, very soft. There was a risk of her spine collapsing, causing paralysis, and so there was some urgency to get her treatment started. And she was set up to see to start treatment with non Hodgkin's lymphoma chemotherapy, which is basically a regimen called R-CHOP And I won't go into the names of all the drugs, but that's an acronym for the drugs that are used. And she was scheduled to start that the next day. Wow.

[00:06:15.990] - Dr. Gordon

And she was coming to you when she was all but taking the final step towards starting her chemotherapy.

[00:06:21.630] - Dr. Lemanne

Yes.

[00:06:22.570] - Dr. Gordon

And is that chemotherapy two questions about it. Is it difficult to tolerate and is it likely to succeed?

[00:06:28.790] - Dr. Lemanne

So if you have non Hodgkin's lymphoma, it is very likely to succeed. There's a good chance if you have a high grade non Hodgkin's lymphoma and you take that therapy, which is a very old one, the CHOP part is 30, 40 years old. The R part started about twelve or excuse me, about 20 years ago. And it's a great therapy, three to six cycles of that, and most people are cured never to have a problem again. And that's with certain types of non Hodgkin's lymphoma, especially the medium and high grade, moderate and high grade lymphomas, the slower growing or indolent lymphomas, low grade, aren't cured with this. So that's a different story. But this patient was diagnosed with high grade non Hodgkin's lymphoma, was about to start our chop the next day and a relative brought her in and said, why don't you get her ready with integrative methods to withstand this treatment? The treatment does have side effects and we can deal [00:07:28.830] with them. And so I took the case and I started reading the path report. And the path report said, yes, this is a non Hodgkin's lymphoma. But we had a little trouble with this particular part of the stain and that particular part of the stain because there was a little area that looked more like Hodgkin lymphoma, not non Hodgkins, but Hodgkins.

[00:07:54.250] - Dr. Lemanne

And it's not an academic distinction because the treatments are completely different. The treatments are both curative. So if you have Hodgkin's lymphoma and you get treated with Hodgkin's lymphoma chemotherapy, you're going to get well and recover completely. If you have non Hodgkin's lymphoma, you need R CHOP, the treatment for non Hodgkin's lymphoma. So that kind of worried me. And then I noticed a little line deep in this path report that said so I'm sending this to my friend and colleague so and so in some other town nearby for a second opinion. Now, that second opinion hadn't showed up yet in the patient's chart, so I was a little bit worried about this. If we went ahead and with this plan and she got her treatment the next day, it would take her three weeks to recover from the first cycle of R CHOP. If the diagnosis was wrong, it would be another three weeks before she got the right treatment and she would be at great risk of having the spine collapse and paralysis and all of

[00:08:54.280] that. The other thing about this was that if we delayed and tried to get another opinion about the pathology, then of course, if the spine collapsed in the meantime, I would have been the one that caused this, right?

[00:09:11.000] - Dr. Gordon

A complication of waiting.

[00:09:13.890] - Dr. Lemanne

But non Hodgkin's lymphoma and Hodgkin's lymphoma are usually pretty easy to tell apart. There's a certain type of cell called the Reed Sternberg cell that you see in Hodgkin's lymphoma that you don't see in most non Hodgkin's lymphoma. But there is some crossover.

[00:09:32.630] - Dr. Gordon

This sounds was it was very tricky.

[00:09:35.900] - Dr. Lemanne

So I asked the patient what she wanted to do and she wanted to get the right diagnosis, which in hindsight, it turned out to be the right thing to do. But here's what happened. I sent her pathology specimen to Elaine Jaffe, who's an MD, a pathologist, a world-renowned specialist in lymphoma, and she's still in practice. I sent her a case a couple of months ago, but she was known for being able to distinguish between these very difficult gray cases. And she sent us back a report within a week saying this was definitely a Hodgkin's lymphoma. Wow, a complete turnaround change of diagnosis here. So the patient had waited for her diagnosis to come back. Then the oncologists who were going to treat her did change their treatment plan and gave her the Hodgkin's lymphoma, 

[00:10:36.150] the Hodgkin's disease, chemotherapy, and she was completely cured. I saw her five years later for something else, which was not cancer. She wanted an opinion on a knee replacement. So she was doing fine, was still in her chosen profession and paid in cash again.

[00:10:56.610] - Dr. Gordon

What a fortuitous. Oh, let's just help her support her chemo tolerance. But really, wow, what a difference a day makes, as they say.

[00:11:07.750] - Dr. Lemanne

I consider my role certainly to help patients with their stated complaint, which in this case was help me get through chemo. But if I do find something that suggests that maybe there's a bigger picture that we ought to look at, then we certainly go in that direction. And that was a case that turned out well.

[00:11:26.830] - Dr. Gordon

And that's a relatively common cancer. So you would think the wheels would be well greased to make that differentiation. But any specimen that a pathologist deals with can look inconclusive, I guess.

[00:11:44.720] - Dr. Lemanne

Since then, there has been the development of an entity, a new diagnosis category in lymphomas called gray zone lymphoma, which is tumors that contain elements of both Hodgkins and non Hodgkins lymphoma. There's not a strict line between some of these diagnoses, and I think that's something that people need to be aware of. The baskets aren't as well defined as we might think on first encountering them.

[00:12:11.760] - Dr. Gordon

I would say that is also true in working with cognitive medicine, cognitive patients, the overlap of different shades of what by many is all considered Alzheimer's. Alzheimer's, Frontotemporal Dementia, Lewy Body Dementia. Sometimes they overlap, sometimes they're very separate, sometimes they all respond well to Alzheimer's treatment, sometimes they don't. So I understand gray zones and constantly trying to do the best I can for the patient without ruining their life while I do it.

[00:12:47.930] - Dr. Lemanne

Yeah, I have another case. Oh, good. That was similar in some ways, but I had a 55 year old woman who lived in Washington State, and she had presented to her local large university oncology group with an axillary tumor, meaning a big tumor in her armpit. And this is considered a breast cancer in women until proven otherwise. So she had a breast exam and there was no tumor that anybody could feel. She had breast imaging, MRIs, mammograms, ultrasounds, no tumors in the breast. But this was considered breast cancer. It's a common, not an uncommon. I've seen several of these in my career, large axillary tumors in women of reproductive age or past who are treated for breast cancer, presumed breast cancer. So she was prepped for breast [00:13:48.020] cancer chemotherapy and was about to start that.

[00:13:51.980] - Dr. Gordon

Can I interrupt you since we just talked about path, I mean, it was biopsied or I assume just not a clinical presentation. It was biopsied and found to be and wasn't that clear that it was breast cancer or not.

[00:14:07.200] - Dr. Lemanne

So that's a great question. And that's where the problems just started. There were some elements on the path report again, where the pathologist hemmed and hawed a bit. Yes, this is breast cancer. There are some things on this tumor that aren't quite consistent with breast cancer, but overall we think this is probably a breast cancer. And by the time this patient had gotten to me, the oncologists in her university oncology practice had sent this pathology specimen to another university and these were big important universities. And the second university said, well, we think this is probably a breast cancer. We agree with the first pathology, so go ahead and treat it as a breast cancer. So I was the third person to take a look at this case and I read the path report and I was not convinced that this was a breast cancer. There was something on this pathology 

[00:15:07.320] report that looked like it might have been a skin cancer and not a melanoma, but a basal cell skin cancer.

[00:15:16.130] - Dr. Gordon

It can make that kind of a solid tissue tumor.

[00:15:19.410] - Dr. Lemanne

Basal remote basal cell cancers are so common.

[00:15:22.380] - Dr. Gordon

I think, of basal cell cancers if at their very most insidious and pernicious, migrate inside and make a tumor right near the lesion itself, which I imagine for basal cell sun exposure was not her armpit.

[00:15:41.630] - Dr. Lemanne

So the tumor in the armpit was likely a lymph node. I think everybody was expecting that this was a breast cancer that had spread to the lymph node. For some reason the tumor in the breast had involuted or disappeared, but the tumor in the lymph node had not and had grown. That was the working diagnosis and mental model that was in operation here. So there was something about this that didn't sit right. And I sent her to a basal cell skin cancer specialist, a dermatologist at Johns Hopkins University in Maryland, and the patient packed up her bags and went there for an exam and everything. And he actually took a long history. And it turned out and I hadn't done this, and the oncologists in Washington hadn't done this. It turned out that she, when questioned, gave a history of, in her early twenty s [00:16:41.750] of having a couple of tumors on the skin of the back of her arm, on the side where the axillary mass was. And these were basal cell carcinomas cancers of the skin.

[00:16:59.210] - Dr. Gordon

Removed how many decades before you met her?

[00:17:01.770] - Dr. Lemanne

She was in her 20s when this happened. She had forgotten about it. She didn't think it was important and didn't think that there was any connection. It was not something she had really thought about. She had these two funny looking warts removed when she was in her early twenty s and was done with that part of her life. It turned out that at Johns Hopkins, with that information, this dermatologist was able to work with his pathologists. Get a piece of this tumor specimen from Washington State. Look at it again with the mental model that this might be a basal cell carcinoma. They put the correct stains for basal cell carcinoma on this specimen and lo and behold was a basal cell carcinoma. She was not treated with breast cancer chemotherapy, which would have not worked at all, would have given her all the side effects and would have allowed the tumor to grow and it would have killed her, not the treatment, but the tumor would have killed her because it wouldn't have been treated with breast cancer chemotherapy. She was treated with a newer immunotherapy that works well with basal cell carcinoma and is doing well to this day.

[00:18:03.530] - Dr. Gordon

Was it her left arm or her right arm, do you remember?

[00:18:08.570] - Dr. Lemanne

I don't remember for sure.

[00:18:10.650] - Dr. Gordon

I think I've noticed from looking at sun exposure in the days when I was much more careless about sunscreens is that my upper outer arm from driving around before we had air conditioning in all the cars, that was an area that got a lot of unintentional sun exposure.

[00:18:33.500] - Dr. Lemanne

Well, you know, we call that when a cancer arises on the left forearm, we call that truck driver's cancer.

[00:18:40.630] - Dr. Gordon

But if it's on the upper arm, that's just cruisers cancer.

[00:18:45.410] - Dr. Lemanne

Yeah, I don't know. It depends on what kind of shirt, truckers wear and all that. Sure, yeah.

[00:18:50.800] - Dr. Gordon

Wow, that is quite a turnaround. That served her very well.

[00:18:58.750] - Dr. Lemanne

So both of these cases had biopsies, but the biopsies were difficult to interpret by the first set of pathologists. They did ask for help in both cases, but in the first case, the help wasn't quickly forthcoming or I don't know what happened to it. And in the second case, the first help second opinion was pretty much confirming the first opinion. So in that case it wasn't very useful for that patient. Turned out all of these are hindsight is 20/20. But I just want to point out that to people who've just received a diagnosis of cancer, you definitely want to look at the path report and you want to go over it yourself. It's hard to read. It's sort of like I equate it for me, looking at the tax codes, I have no idea what I'm looking at, but I have to go over it with my accountant and you have to go over your path report with your doctor and have them explain each line to you. And if there's anything that hems and haws like, well, maybe this is and maybe it [00:19:58.760] isn't, or it sort of looks like something else, but we're going to call it this.

[00:20:04.530] - Dr. Lemanne

You want to pay attention to that and maybe get the second opinion.

[00:20:09.890] - Dr. Gordon

For this axillary tumor, though, it's interesting that what guided that Johns Hopkins oncologist correctly was taking a lengthier.

[00:20:19.360] - Dr. Lemanne

He was a dermatologist.

[00:20:20.400] - Dr. Gordon

Oh, a dermatologist.

[00:20:21.710] - Dr. Lemanne

That was the difference. He took a skin history. I didn't do that. That also points out the value of having a different brain and a different set of eyes on something that's difficult and something from a completely different discipline. It's very valuable to always valuable.

[00:20:42.440] - Dr. Gordon

Yeah.

[00:20:43.790] - Dr. Lemanne

So I have another case.

[00:20:45.100] - Dr. Gordon

Oh, good. These are fascinating, because I tend to think of you start down this cancer pipeline, and the road just gets narrower and narrower and narrower and narrower, but you're saying sometimes really there's look at the road less traveled. The less obvious route might really be the one the patient's supposed to be on. So thank you for sharing these.

[00:21:06.950] - Dr. Lemanne

Yeah.

[00:21:07.130] - Dr. Gordon

What's the next one?

[00:21:07.980] - Dr. Lemanne

So, the next one was a developmentally disabled 30-year-old woman who was in long term care, and her caregivers noticed that she was losing weight. They took her to her family doctor, who noticed a mass in the abdomen and ordered a CT scan, which confirmed that there was a large mass in the abdomen. It looked like it was in the pancreas on CT scan. And so this patient was diagnosed with pancreatic cancer, and because of her developmental disability, was placed in hospice. It was felt that it would be cruel and to proceed with chemotherapy for what's always a fatal condition, advanced pancreatic cancer. At least it was considered that at that institution at that time, and the patient was deemed unable to give consent. And I recall that there was possibly no person who had a vested interest in proceeding with this patient. But one of the doctors called me in for a second opinion on this 

[00:22:08.890] case, and I examined the patient. Patient had very long, unkempt hair. It was very scraggly looking. The patient didn't really speak. The exam was quite dramatic. The patient was cachectic very, very thin and had a mass in the abdomen that was so large it protruded.

[00:22:28.200] - Dr. Lemanne

You could see it kind of right in the upside down V of the rib cage at the top of the abdomen. And I remember looking at the hair, and the hair was really, really frizzy and odd-looking like it had been gnawed or something like that.

[00:22:48.630] - Dr. Gordon

And I asked her hair looks like she was maybe chewing on it.

[00:22:53.620] - Dr. Lemanne

Yeah.

[00:22:54.360] - Dr. Gordon

So I asked the quite an observation.

[00:22:56.930] - Dr. Lemanne

And I asked the gastroenterologist to just humor me and do an upper endoscopy. And we got permission to do an upper endoscopy on this patient that was considered reasonable. And in the stomach, an upper endoscopy is the patient is sedated. A tube is placed down the throat into a flexible tube into the stomach, and you can look around in there. It's got fiber optics, and if you need to, you can do a biopsy, those kinds of things. What was found, what they found in there was a hairball. This patient had a bezoar. It's called that's the medical term for hairball. This patient had gnawed on her hair for years and had developed and swallowed it and had developed a very large it was the size of a cantaloupe, and it was removed bit by bit during that procedure. And the patient's hair was when the patient woke up, her hair was clipped so that she could no longer reach her hair to chew on it, and she made a full recovery.

[00:24:04.030] - Dr. Gordon

Is this a rare event? I've only heard of bezoars. I've had lots of animals. The only animals I've ever had that have had bezoars are cats. And is this an unusual occurrence in a human?

[00:24:18.080] - Dr. Lemanne

Humans have been reported to have bezoars, and it's usually in a situation like this, developmentally disabilities, sometimes just children with long hair who have a tick and chew on their hair as part of that tick and swallow it, and bezoars have been reported in humans. Yes.

[00:24:35.190] - Dr. Gordon

Well, in that case, it was a lucky hairball for her.

[00:24:39.040] - Dr. Lemanne

So she didn't have cancer and didn't need to be in hospice. This was a completely easily curable situation, and the recurrence was easily preventable. That was an interesting case. I have another case of pancreatic cancer that wasn't. 

[00:24:59.380] - Dr. Gordon

Oh, this is great. You could set up a whole side specialty in this if you can keep your streak going.

[00:25:05.170] - Dr. Lemanne

Well, I'm going to talk a little bit about where I'm on the wrong side of this situation, where I'm the one making the error in a minute, but this next one is going to make me look good again. But then we'll get to the part where I was the one who made the error. So the next case was a 45 year old woman who was a bartender in Nevada, and she was a smoker. She admitted to using alcohol heavily daily for many, many years, decades. And she came to me to be treated with chemotherapy for pancreatic cancer. Now, the risk factors for pancreatic cancer are smoking and alcohol abuse. Those are two risk factors for pancreatic cancer. And she indeed had symptoms consistent with that. She had pain in her belly, she had nausea, she was vomiting, she had weight loss, and she had abnormal blood tests that suggested that her liver, her pancreas were struggling. And it was all very consistent with pancreatic cancer. And to top it off, she had a mass in her pancreas on CT scan.

[00:26:14.940] - Dr. Gordon

They there's something they biopsied.

[00:26:18.070] - Dr. Lemanne

So they tried to biopsy missed. They missed, yes. Said, well, this all looks like normal tissue. We think that this is not cancer.

[00:26:28.440] - Dr. Gordon

They didn't miss the pancreas. They missed the tumor.

[00:26:31.990] - Dr. Lemanne

Well, they thought they did.

[00:26:33.730] - Dr. Gordon

Right?

[00:26:34.110] - Dr. Lemanne

Yeah, right. And so the treatment for pancreatic cancer is also not considered curative. I was getting ready to give her the chemotherapy. That was what I was thinking of doing. And the patient was getting her affairs in order, and she was very, very tearful. And she stopped drinking, changed her diet, started taking vitamins and eating better, stopped smoking, but she was still preparing for death, but hoping that she might live. And there was something odd about this case that bothered me, that this looked so very, very normal. So I asked the gastroenterologist to please go back and try again to biopsy this. And they said they hemmed and hawed and finally said, yeah, okay, that's good. We agree with that. So they did the biopsy again. This time they came back with a diagnosis, but it wasn't cancer. It was something called chronic pancreatitis.

[00:27:33.960] - Dr. Gordon

Oh, chronic.

[00:27:35.410] - Dr. Lemanne

And they were sure that they had gotten into the mass. They did some scanning during the mass, some imaging during the biopsy to make sure they were in the right place. And this was not cancer. This was damage to the pancreas that had caused some scarring and some cystic structures in the pancreas due to alcohol abuse.

[00:27:53.920] - Dr. Gordon

Due to lifestyle choices. Yeah.

[00:27:57.310] - Dr. Lemanne

So we canceled the chemotherapy. I remember that appointment where I actually told the patient, I mean, this is a rare and interesting situation where I had to call the patient in and say, look, I have good news.

[00:28:16.830] - Dr. Gordon

I was wrong.

[00:28:18.290] - Dr. Lemanne

Yes, of course. Her first reaction was absolute shock, and then there were tears, and she went away, having found religion and not literally, but a life changing event for her. And she went on and got well, felt good again.

[00:28:42.200] - Dr. Gordon

Did she work as a bartender going forward?

[00:28:44.500] - Dr. Lemanne

You know, I don't know that. But she did keep in touch for a while, and she gained her weight back, had good appetite, and felt well.

[00:28:55.080] - Dr. Gordon

Oh, that is great. Everything's lined up, but it still wasn't conclusive because they had just presumed they'd missed the tumor, but that it was there.

[00:29:07.860] - Dr. Lemanne

Yike. Right. Yeah, exactly. And then I have a case where I was the one who made the mistake. Do you want to hear that?

[00:29:14.930] - Dr. Gordon

Yeah, it's hard to yeah.

[00:29:17.250] - Dr. Lemanne

Well, doctors are human, and every time you see a doctor, just remember that, please, and be kind. But what is the saying? Trust but verify.

[00:29:30.000] - Dr. Gordon

Trust but confirm or verify. I think you're right. Yeah.

[00:29:32.460] - Dr. Lemanne

Trust but tie your camel. So this one was a 52 year old man, again from a Northwestern state. He was the sole caregiver for a disabled adult child, and he had presented with weight loss, nausea, and vomiting. And he had blood tests and scans that were consistent with a type of cancer of the liver called cholangiocarcinoma. I had seen several cases at Stanford when I was in training, and they all died within weeks or months, one or two months of diagnosis. It was a pretty dramatic disease, and these were often youngish people.

[00:30:17.320] - Dr. Gordon

Dr. What is the cholangio?

[00:30:20.790] - Dr. Lemanne

Thank you. That's the medical ease for bile duct. So within the liver, our bile ducts, one of the jobs of the liver is to make bile and ducts carry the bile from the liver into the gallbladder. So there are a lot of little bile ducts in the liver, and there's one big one leading to the gallbladder, and then there's another duct leading from the gallbladder into the small intestine. So Cholangiocarcinoma can arise anywhere in that system of bile ducts. And this patient presented with pretty classic Cholangiocarcinoma. And I had seen what happens to these patients. I started palliative chemotherapy in those days that was with a medication called Gemcytobene. We still use that in this disease and told the patient things weren't probably going to go very well, so he should prepare for that. And he was very distraught because he had this adult child that was disabled and he was the sole [00:31:21.490] caregiver. But another son showed up and insisted, arranged for my patient to go see a Stanford surgeon. And I recall that it kind of, oh, they don't trust me, and that's too bad. I want patients to trust me and all of that.

[00:31:42.310] - Dr. Lemanne

But the patient went down to see this famous surgeon at Stanford, and the surgeon said, we can cure this. That really surprised me because that was not what I had been taught in the medical oncology department at Stanford, in his department. So the surgeon removed the tumor and then called me up and said you know, give him some more chemo, bump it up, give him a little bit bigger doses, and continue it for a few more months after surgery. And I asked, well, how many cycles would you like me to give? And he said, we'll give as many as you can. And that was kind of a different approach as well. Medical oncology where we were taught, give, you give three cycles or four cycles or a six cycle or twelve, there was a number attached to this, not just give them some. So that was a little different. But lo and behold, that patient was cured. That was the first case of cholangiocarcinoma I had ever seen cured. And that changed my career at that point. [00:32:42.530] This was a little in my defense, I would say that this is early in my career, I think in the first six months or so that I was an independent attending physician.

[00:32:51.370] - Dr. Lemanne

And it changed my thinking to really question the idea that a cancer is incurable. And any curable cancer that's curable now was once incurable, where's the dividing line? So somebody's going to start curing these cancers at some point, and you might as well get in line for that. And that was a career-changing realization for me.

[00:33:16.960] - Dr. Gordon

There's a little bit of a thread with this one and the pathologist, which is it really matters who's on your team. So if you had asked wherever you were practicing at that time, a local surgeon, do you think you can debulk this tumor, which I think is done in cancer a lot, to take some or all of it out and then go on with chemotherapy, am I right? Right, sure. Yeah. But probably if you'd asked your local surgeon, they would have said, oh, no, it's inoperable, it's just in your ballpark.

[00:33:48.350] - Dr. Lemanne

I think so. Liver surgery, then and now is a surgical specialty. So general surgeons typically won't do a complex liver operation. That is truly the purview of super specialists. So if you have to have liver surgery and something has to be gently and precisely excised from the liver, that's a really big deal. And it requires a surgeon who specializes in that, which we don't have in small communities, really, such as the one we live.

[00:34:23.860] - Dr. Gordon

This reminds me, I'm just going to go back to one of your favorite food topics, you know, that I prepare and consume liver, and when I'm eating liver, it's not uncommon to find that a part of the gallbladder is still attached and that's removed easily by a surgeon with a cholecystectomy. But the thing that drives me crazy is if there's still a great presence of these bile ducts because they wrap.

[00:34:55.460] - Dr. Lemanne

The liver part of things that you're going to eat. Yeah.

[00:34:58.270] - Dr. Gordon

And so I try to cut it away, but even with a completely separated from the body liver, that is not an easy procedure to do without taking a bunch of liver with it. And I could imagine, wow, if this is a living person from whom you're not just cutting out the gallbladder, because now we do that practically as a same day surgery. I think if you're actually having to remove those bile ducts, that would require some expertise beyond the norm.

[00:35:26.910] - Dr. Lemanne

Yes. And there are a lot of blood vessels in there. The liver is basically like a big sponge. And imagine trying to cut a sponge apart and then sew the remainder back together. You're not going to well, that's not a great analogy, but you get the idea. It's not a simple excision where you make a cut around the tumor and just pull it out and everything's fine.

[00:35:51.380] - Dr. Gordon

Yeah, I think they actually have to if my insights from watching televised surgery and medical dramas serves me well, they just put something on the liver to try and thwart its blood flow, blood loss, rather than actually sew it back together. And it's a fingers crossed kind of situation. So hats off to the Stanford surgeon for taking that in their day's schedule and doing it successfully.

[00:36:19.270] - Dr. Lemanne

That was Dr. Niederhuber, and he was a very famous surgeon. After he retired from Stanford, he had a second career at the NIH. Very successful, very brilliant surgeon, one of the greats.

[00:36:37.550] - Dr. Gordon

Can I ask a little bit about that other comment you made about his advice to you, which was kind of feel your way through this chemo, give how much you can. How often do you end up doing that in your chemo applications with cancer patients?

[00:36:52.430] - Dr. Lemanne

Very often. That opened my mind to the idea of using chemotherapy a little more artfully and rather than following recipes. And I think that that was something that really helped me mature as a physician. Recipes or protocols, we call them, or algorithms, they're a starting point and they're not the goal. So the goal is not to get through the algorithm. The goal is to get the patient better. I think that's not obvious to a young physician, necessarily.

[00:37:22.850] - Dr. Gordon

Right.

[00:37:23.150] - Dr. Lemanne

And learning the algorithms and learning what the previous paths were through these tumors and toward recovery for patients, so that was a really big turning point.

[00:37:35.860] - Dr. Gordon

Yeah. That sense of protocols and pathways sometimes being very rigidly guarded by the old guard, where this comes up more frequently in primary care is antibiotics. And you and I have talked about how the older you get, the more devastating to your gut's health is a course of antibiotics. And I think this is what got me thinking a number of years ago, but I've since looked into it, and this is true for young people as well. Oh, you've got a bladder infection, I'm going to give you these antibiotics and you take them three times a day for ten days, be sure and complete the course.

[00:38:10.350] - Dr. Lemanne

Right.

[00:38:10.860] - Dr. Gordon

And I never do that anymore. And I think the literature is mixed because there are the rules and then there's the maybe-it-could-be-different point of view. But I have people take antibiotics generally for 24 to 48 hours until 24 to 48 hours after their symptoms are relieved. And yes, there might be some surviving bacteria, but they will have a healthier immune system because they'll have a healthier gut flora to maybe handle some of those bacteria on their own. I think that's the thinking in mind about why antibiotics might be given carefully. You have to tell somebody, don't just stop it because you're tired of taking the penicillin if you've still got your sore throat, but maybe you don't really need to take ten days.

[00:38:57.720] - Dr. Lemanne

So rather than paint by number, it's actually doing some art. The art of medicine.

[00:39:05.130] - Dr. Gordon

Yeah. That's nice. So there's probably people listening to us talk about this who wondering if their cancer or their aunt and uncle's cancer falls into any of these categories. What kind of guidelines do you tell people who are wondering whether they should seek a second opinion or go along with their oncologist treatment?

[00:39:27.040] - Dr. Lemanne

So that's a wonderful question. And for both patients and their doctors, including their oncologists, read and question the pathology report. And if there is any hemming and hawing, if there's any justification that's too strong or too weak, get a second pathology opinion. That's kind of another pathology.

[00:39:52.600] - Dr. Gordon

Yeah, that's kind of like a door opening to another possibility.

[00:39:56.590] - Dr. Lemanne

Get that opinion outside of your medical community. And when I say that there are different types of communities, so there are academic communities, there are community pathology communities, you want to go as far outside of your pathologist's medical community as you can. So I tell people, go to a different state and you don't have to go. The specimen--people don't know this--but a pathology specimen, a surgical specimen that's removed from the body, it's kept for seven to ten years, depending on the state in the laboratory. It's there for a long time just for such occurrences. So you can get a piece of that specimen and have it sent for special testing. You can have it sent for genetic testing, you could have it sent for a second pathology opinion for all sorts of things and take advantage of that and do have that done. You don't need to do anything if you're a patient, you don't need to do anything special like go to the path lab and pick it up in a box or something. [00:40:56.930] You can just ask for this to happen and the pathologists know what to do. They will package it up and send it to the place, the right place.

[00:41:03.270] - Dr. Lemanne

It happens automatically once you've requested that. And then the next thing I would say is, and this is for both patients and doctors, is always get a tissue diagnosis. Or the other word for that is biopsy. You really have to have a biopsy if you're going to make a diagnosis of cancer. If you don't have that biopsy, you cannot be sure it's cancer. And I see this a lot in the alternative medical world. We see patients who say, well, I had a lump, it was on my chest X ray, or I felt it, or something like that, I had cancer and I cured myself with some herb, or something like that. Well, maybe it might not have been cancer. Unless you have a biopsy that's really and you really can't say that. So people can kind of lead other people astray people that might be cured by saying, well, I was cured of my breast cancer, when they really they didn't have breast cancer, they had a breast lump that might not have been cancer. And other people will believe them and try that and maybe die. 

So it's not a benign thing to not have a biopsy and for doctors especially, and also for patients.

[00:42:12.480] - Dr. Lemanne

But this was impressed upon me by that last case. Remember that all curable cancers were once considered incurable. And so look for a cure for your patient's incurable cancer. Look outside of the textbooks that say that this is incurable. Look somewhere else and try things if the patient is willing. Those are my take homes from this.

[00:42:38.930] - Dr. Gordon

So if somebody wants to get a second opinion on a pathology specimen, do they have to find the second pathologist? They just call up 

[00:42:50.300] - Dr. Lemanne

No, that would be the job of the oncologist or the pathologist. And so that would be the first place I would start with your oncologist. Say, I want a second pathology opinion. Can you help me get one from.

[00:42:59.930] - Dr. Gordon

Out of state, from some other?

[00:43:01.660] - Dr. Lemanne

Where can we go that's outside of this pathology community?

[00:43:04.440] - Dr. Gordon

Okay.

[00:43:04.730] - Dr. Lemanne

And I'll help you. And it sounds really difficult for patients, but it's not for doctors. It's easy to do.

[00:43:15.260] - Dr. Gordon

I have to tell you a funny story about your little allusion to not having a biopsy. I had a new patient yesterday, and he was telling me about some earlier part in his point in his life when he was an avid smoker and smoked way too much and kept trying to quit and never succeeded until he developed a little lump on his chest wall and mistakenly thought that probably was lung cancer. And he stopped smoking the moment he felt it. And it so happened that the lump went away. And I would say, whatever gets you to stop smoking, that's really great. And if the lump didn't go away, I know him well enough to know he would have sought some counsel on that. But, yeah, you can't hang your hat on something for very long without knowing what it is.

[00:44:02.910] - Dr. Lemanne

Yeah, that would be life threatening.

[00:44:06.170] - Dr. Gordon

Yeah, it could be life threatening. Well, this is fascinating, and it's reassuring to think that what seems like a bitter end diagnosis may have other possibilities. Some that you could never even conceive. I mean, everybody's conceiving that they have a different version of cancer or none at all, but you could have completely cancer or something that's more surgically removable. That's great. Well, those are great. And really opening my mind to thinking about how I think about things, which is in my field, which more precision medicine. Yes. Just trying to keep narrow down and find things and maybe need to think more often about getting a second opinion on something. So thank you.

[00:44:56.350] - Dr. Lemanne

You can't know it all. That was one thing I've learned. Yeah.

[00:45:01.170] - Dr. Gordon

What a relief. This is great. Thanks for the chat today.

[00:45:07.160] - Dr. Lemanne

Thanks, Deborah. Always good to talk to you.

[00:45:08.950] - Dr. Gordon

Good to talk to you. See you next time.

[00:45:10.280] - Dr. Lemanne

Bye bye.

[00:45:13.490] - Dr. Gordon

You have been listening to the Lemanne Gordon Podcast, where docs talk shop.

[00:45:19.220] - Dr. Gordon

For podcast, transcripts, episode notes and links and more, please visit the podcast website at docstalkshop.com.

[00:45:28.840] - Dr. Lemanne

Happy eavesdropping.

[00:45:38.990] - Dr. Gordon

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[00:45:55.480] - Dr. Gordon

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[00:46:22.110] - Dr. Gordon

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[00:46:37.530] - Dr. Lemanne

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