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Dr Uzair
Dr Uzair, Doctor
Category: Medical
Satisfied Customers: 6579
Experience:  MBBS, FCPS (R) General Surgery. Years of experience in Emergency Medicine.
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Dad with type 2 diabetes, 77 yrs old, loss of balance and

Customer Question

Dad with type 2 diabetes, 77 yrs old, loss of balance and fell, over several weeks with increasing frequency while standing or walking, initially family physician directed to hospital for further evaluation/root cause determination.
Hospital Dr. prescribed Meclizine, thinking it was due to inner ear problem, and ordered/performed tests - MRI of Head, Renal sonogram, CT of abdomen and pelvis, CA19-9 blood test.
Renal sonogram results:
- kidneys normal,
- abdominal aorta normal,
- vena cava normal,
- multiple lesions throughout liver.  Therefore, dr. recommended and performed further evaluation via elective CT of the abdomen and pelvis.
CT of abdomen and pelvis results:
- multiple parenchymal lung nodules
- multiple hypodense lesions throughout the liver
- pancreas = focal hypodensity of the body and tail
- kidneys are normal
Blood test CA19-9 performed.  Results, = 73 (not less than desired level of 35 or less). Indicator for pancreatic cancer.
Appointment made at cancer center.
Since 3 days later, no improvement in loss of balance and halucinatiins began - therefore, Meclizine was discontinued. Loss of balance attributed to likely cancer by family physician (and later this conclusion was supported as likely by oncologist at cancer center).
Cancer center visit - looked at hospital test results, did additional blood work (tests, results?), resulting in thoughts that likely root cause = pancreatic cancer that spread to liver and lung.
Non-smoker past 10 years, smoker for decades prior - potentially explaining lung nodules?
Many medications post 55 for cholesterol (including Lipitor) and diabetes treatment - potentially explaining liver lesions?
Cancer not definitively concluded - liver biopsy was next step to conclude, but fear of rapid cancer spread leading to death from test/tissue extraction witnessed for others in similar circumstances.
Loss of balance increasing in frequency, bed ridden duration increasing significantly last 5 weeks.  Currently, most of day and night bed ridden (and actually sleeping) due to tiredness.  Awake ~7 am for ~1 hour, awake 11 am for 1-2 hours, awake 4 pm for ~2 hours.
So, questions...
1. How to definitively determine root cause for loss of balance?
2. how to proceed with treatment for health improvement without biopsy and likely pancreatic cancer?
Submitted: 1 year ago.
Category: Medical
Expert:  Dr Uzair replied 1 year ago.

Hi and thanks for the details.

The loss of balance is most likely due to metastatic spread of the cancer to the brain, if that has been ruled out then I would suggest that the first thing be done is an ENT examination and an Epley's maneuver which is used to treat benign paroxysmal positional vertigo, one of the most common causes of dizziness and loss of balance in the elderly. The epley's maneuver is a simple set of movements that the doctor performs on the patient in his office and it rearranges the fluids and the microliths in the inner ear canals and gives relief from dizziness almost instantaneously. Most of the other causes like space occupying lesions, stroke and electrolyte imbalances have possibly been ruled out in all the tests he has had. The dizziness can also be due to hepatic encephalopathy which is an accompanying feature of liver metastasis and liver failure. That might be the reason he is sleeping so much nowadays. So, you should discuss that with his doctor.

I would also suggest that a liver biopsy be done under ultrasound guidance or a CT guided biopsy of the pancreatic nodule be done to confirm the presence of cancer, since treatment can only be started on the lines of cancer once the cancer and its type has been established.

There is really no other way to confirm cancer, than a biopsy, all the rest of the tests are just speculation and can be erroneous, the most sensitive and accurate way is a biopsy. Percutaenous image guided biopsies are safe procedures and if the clotting profile of your father is not deranged, there is very little chance of a major complication from an image guided percutaneous biopsy. I would definitely, encourage you to get the biopsy done so that treatment can be initiated.

Hope this helps.

Please do let me know if you have more queries about this.

Do not forget to leave a positive rating.

Best wishes.

Customer: replied 1 year ago.
Hi Dr. Uzair,
Thank you for sharing your knowledge with me so quickly. I have more questions that arose from your reply, and would appreciate your thoughts.
The loss of balance is most likely due to metastatic spread of the cancer to the brain
{reply: Wouldn’t that have shown up in the MRI of the head/brain? MRI was performed after many falls so the condition existed at that time, and the MRI results were clean, and that is why the additional tests described were performed - in attempt to try to determine the root cause for loss of balance… not always due to dizziness, often legs just buckled without dizziness or other warning symptoms}
… if that has been ruled out then I would suggest that the first thing be done is an ENT examination and an Epley's maneuver which is used to treat benign paroxysmal positional vertigo, one of the most common causes of dizziness and loss of balance in the elderly. The epley's maneuver is a simple set of movements that the doctor performs on the patient in his office and it rearranges the fluids and the microliths in the inner ear canals and gives relief from dizziness almost instantaneously.
{reply: - Ear, Nose, and Throat Examination was performed by family physician. Nothing unusual found there, so family physician advised further evaluation at the hospital. Do you think the examinations performed at these two locations is sufficient from an ENT exam perspective, or is seeing a ENT specialist required to rule this out as a root cause? - Epley’s Maneuver: thanks for that information, we were not aware of this procedure and do not know if it was performed at family physician’s office or at hospital. Is that a long-term fix?}
… Most of the other causes like space occupying lesions, stroke and electrolyte imbalances have possibly been ruled out in all the tests he has had.
{reply: no space occupying lesions were found in the head – MRI of head produced clean results. So, could lesions which have been identified to exist in the liver cause loss of balance? Or could what was described as “multiple parenchymal lung nodules” cause loss of balance?, or could focal hypodensity of the body and tail of the pancreas cause loss of balance? If none of these things can cause loss of balance, how to move forward / continue efforts to identify and eliminate loss of balance problem? }… I would also suggest that a liver biopsy be done under ultrasound guidance or a CT guided biopsy of the pancreatic nodule be done to confirm the presence of cancer, since treatment can only be started on the lines of cancer once the cancer and its type has been established.
There is really no other way to confirm cancer, than a biopsy, all the rest of the tests are just speculation and can be erroneous, the most sensitive and accurate way is a biopsy. Percutaenous image guided biopsies are safe procedures and if the clotting profile of your father is not deranged, there is very little chance of a major complication from an image guided percutaneous biopsy. I would definitely, encourage you to get the biopsy done so that treatment can be initiated.{reply: We have been told that his very high reading on the CA19-9 blood test results point strongly to presence of pancreatic cancer. That along with his general state of declining health when no other issue has been identified to cause a decline in health, indicate high likelihood of this cancer as the root cause for decline in health. Understood that chemical therapy/treatment requires specific knowledge of the chemistry of what needs to be eradicated so that the chemicals/dosage to accomplish that can be determined, but are there treatments that can be invoked to attack cancer cells regardless of specific type – especially when the location of these growths are known? For example, radiation therapy which kills all living cells – directed at the abnormal looking areas likely to be living cancer cells described as lesions or hypodense tissue within the pancreas?
Are there any paths forward made possible when a patient wishes to avoid a biopsy? For example, it would seem that established treatments such as radiated glass microspheres (ref: Therasphere) would seem to be effective on all types of cancer cells (living tissue) acting both through embolism and very targeted radiation, and a good path forward when a patient wishes to avoid a biopsy.
A biopsy performed on a relative caused multiple bad reactions immediately afterwards leading to death, and since that time we have learned of many other similar cases, and my dad was actually scheduled for the type of biopsy you describe, and was in the prep room for the procedure to be performed when the Dr. advised of these very same potential complications as a result of the procedure.
Are there opportunities to be considered for experimental programs? What is the process to apply? We have read about treatments such as HIV T-cell modification therapy, Polio virus, etc. }
Expert:  Dr Uzair replied 1 year ago.

Thanks for the reply.

Yes, metastatic lesions show up on the MRI when in the brain.

Yes, the Epley's maneuver is a long term fix. Benign paroxysmal positional vertigo is more of a diagnosis of exclusion, because the examination in these cases often does not reveal much because the problem is in the inner ear canals which are not visible to the naked eye, and a specialist exam is always better than a general exam.

Yes, lesions in the liver can cause hepatic encephalopathy which can result in loss of balance, confusion, lethargy, sleepiness, etc.

Lung nodules would not cause dizziness. Pancreatic cancer does not directly cause loss of balance either.

I do not think your Oncologist would start chemotherapy or radiotherapy without a biopsy report. But if s/he does agree based on speculation that the CA 19-9 is raised and all other conditions have been ruled out then that is his call. But the protocol is usually that a biopsy is required before treatment is started.

Complications are likely in every procedure, one should always weigh the decision to undergo the procedure based on its necessity and benefit as compared to the risk, in the current situation, the risk to benefit ratio weighs heavier in the benefit's ring. For experimental programs, your oncologist can register you, if there are any currently available in your locality.

Please leave a positive rating for the service.

Best wishes.

Expert:  Dr Uzair replied 1 year ago.

.

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