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Dr. David
Dr. David, Doctor (MD)
Category: Oncology
Satisfied Customers: 9246
Experience:  Experienced Oncology Physician trained in New York City. I'm ready to help.
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I'm a non-smoking 22 y/o male who's been through a battery

Customer Question

Hello,
I'm a non-smoking 22 y/o male who's been through a battery of medical tests trying to find out what's wrong with me, and trying to figure out whether it is lung CA and what type it is or not.
If you'll bear with me, I'd like to share what I've had done so far. I don't really know anyone in my age group who is knowledgeable about lung cancer, so I don't really have a reference point for what to expect on the road to diagnosis.
Symptoms:
1) Shortness of breath on even mild exertion (1.5 months)
2) Cough with white phlegm, occasionally yellow. w/ chest irritation (1 month)
3) Finger Clubbing (1.5 months)
4) Firm, fixed supraclavicular + posterior cervical lymph nodes (3.5 months):
-Supraclavicular lymph node: noticed in August 2016, was palpable but not firm/fixed; firm-ness gradually noticeable in October 2016 onwards
-Posterior Cervical Lymph node #1 (on side, mid neck) = palpable and moveable until December 2016, rapidly became firm and fixed
-Posterior Cervical Lymph node #2 (rear neck, where shoulder meets neck) = felt firm/fixed since September 2016, can feel progressively worsening shoulder/neck pain near it's location
5) Persistent fatigue (4 months)
6) Odd sharp pains in shoulder, back, and arms (1.5 months)
Radiological Exams:
[1] Chest CTs: Please re-assess and comment on abnormalities like the GGO or lesions. Changes between two test dates as well...
>(12/22/16) CT Chest With Contrast...URL Link -> [https://goo.gl/cYOC9f]
>(12/02/16) HRCT Chest WithOut Contrast...URL Link -> [https://goo.gl/e0X9Q7]
[2] Neck MRIs: Concerned about lymph node growth between Two Exam Dates especially in Left Supraclavicular region, Left Posterior Base of Neck general area. Please also comment on any other lymphadenopathy if spotted
>(12/22/16) MRI Neck With and Without Contrast...URL Link -> [https://goo.gl/ftsEfc]
>(11/05/16) MRI Neck With and Without Contrast...URL Link -> [https://goo.gl/yYDN3K]
Blood Test Results:
Results (from 12/22/16):
The format is : Result Name = Value [ref. range]
Below are the abnormal results....
-WBC = 11.0 10^9/L [3.5-10.5 10^9/L]
-Abs. Monocytes = 1.0 10^9/L [0.0 - 0.9 10^9/L]
-Abs. Basophils = 0.12 [0.00 - 0.10 10^9/L]
-MPV = 10.2 fL [7.0 - 10.0 fL]
-C-Reactive Protein = 6.7 mg/L [< 3.0 mg/L]
-ESR = 30 mm/hr [0 - 10 mm/hr]
Here are the rest of the Complete Blood Count results that were normal...
-RBC 5.17 10^12/L [4.32-5.72 10^12/L]
-HGB 15.0 g/dL [13.5-17.5 g/dL]
-HCT 44.6 % [38.0-50.0 %]
-MCV 86.4 fL [81.0-95.0 fL]
-MCH 29.1 pg [26.0-34.0 pg]
-MCHC 33.7 g/dL [30.0-36.0 g/dL]
-RDW 13.5 % [12.0-15.0 %]
-Platelet 246 10^9/L [150-450 10^9/L]
-Abs. Neutrophils 7.3 10^9/L [1.7-7.7 10^9/L]
-Abs. Lymphocytes 2.0 10^9/L [0.7-4.0 10^9/L]
-Abs. Eosinophils 0.4 10^9/L [0.0-0.7 10^9/L]
History:
Late September 2016 -- First noticed "hardening" of left supraclavicular lymph node. Size is about 1cm.
October 2016 -- Got the node checked out, both primary doctor and ENT can't really palpate it so they didn't order biopsy. Said to wait on neck MRI. Meanwhile, paranoid me went on Dr. Google and found the infamous "Virchow" node and worried that it was a signal of stomach cancer. So we did a upper GI endoscopy, which came back clean.
Early November 2016 -- Neck MRI results came back, radiologist report doesn't mention any node enlargement, so doctors even more adamant to not biopsy. I got an Abdominal MRI and MRCP, which came back negative. Supraclavicular node still there.
Late November 2016 -- Suddenly developed shortness of breath on minor exertion. Noticed fingers were Clubbing. Didn't respond to inhalers, so got referred to pulmonologist. Did Chest X-Ray and HRCT, both came back clean. Full autoimmune disease panel also came back negative. Pulmonary Function Tests came back with reduced diffusion and Restrictive Lung function...unexplained by tests.
Only abnormal things were in the blood tests: D-Dimer, Inflammatory markers (CRP, ESR), and some Blood Cells (Monocytes, Basophils) were moderately elevated.
Late December 2016 -- Shortness of breath, Clubbing still present. Newly onset cough. Had repeat Pulmonary Function Tests, which showed worsening of lung function...still without determinate cause. Blood results still abnormal, gradually worse. Got repeat Chest CT with Contrast this time...had like 3 different radiologists read it. One of them found a "mild geographic ground glass opacification" on my left lung. No evidence of any lung "masses" though, according to the reports. I went to get a second opinion from a different pulmonologist, who said that the ground glass thing was a very subtle finding that was also very nonspecific.
January 2017 -- Clubbing is worse. Doctors can still barely palpate the lymph nodes. We did a Neck CT w/ Contrast that showed multiple visible but subcentimeter nodes. Also in the neck there was some "mild, ill-defined soft tissue stranding", which as you might have guessed, again is very non specific.
Present -- We decided to go for it and order an Ultrasound-guided Core Biopsy of any Neck Lymph Nodes that we could get. Getting that done next week, and that might give us some answers.
Concerns:
With my symptoms and past tests ruling out benign causes, it seems that the only differential diagnosis possibility is Lung Cancer. I'm just frustrated that I have some sort of "invisible/massless" or rare but metastatic Lung Cancer of some kind.
---In your experience, have you ever encountered anyone with a strange symptom presentation like this?
---Are there any rare subtypes of Bronchogenic Cancer that present in this manner?
---Are there any other tests we can do to determine the cause?
---As for the Core biopsy of lymph nodes, what information can we get from it? Possible to do genetic/mutation testing on it?
Submitted: 6 months ago.
Category: Oncology
Expert:  Dr. David replied 6 months ago.

Hello, this is Dr. David. I am reviewing your question now and will be with you momentarily.

Expert:  Dr. David replied 6 months ago.

I am a cancer doctor who treats patients who have lung cancer

you don't have lung cancer

your symptoms of shortness of breath are most likely caused by anxiety and panic symptoms

it is normal to see lymph nodes in your chest and neck on CT and MRI scan and ultrasound. these lymph nodes are there to help fight off infections and to help filter lymphatic fluid in your body.

I hope you don't smoke cigarettes

show me your nails. you most likely don't have clubbing of your nails.

Expert:  Dr. David replied 6 months ago.

do you have other questions?

Customer: replied 6 months ago.
Hi doctor,No I don't smoke cigarettes. Pulmonary function tests clearly showed worsening restrictive pattern and reduced diffusion capacity.As for the lymph nodes, it is in particular the supraclavicular node that is worriesome, among other nodes. These nodes' texture is also rock-hard and non-moveable.Also I had mentioned the Ground Glass Opacity in left lung, but no mass. Maybe there is a rare subtype of lung cancer that only presents with this Ground Glass Opacity?I have attached some pictures of the nails below.
Expert:  Dr. David replied 6 months ago.

you don't have clubbing of your fingers.

Customer: replied 6 months ago.
07 January 2017 12:43
Hi doctor,No I don't smoke cigarettes. Pulmonary function tests clearly showed worsening restrictive pattern and reduced diffusion capacity.As for the lymph nodes, it is in particular the supraclavicular node that is worriesome, among other nodes. These nodes' texture is also rock-hard and non-moveable.Also I had mentioned the Ground Glass Opacity in left lung, but no mass. Maybe there is a rare subtype of lung cancer that only presents with this Ground Glass Opacity?
Expert:  Dr. David replied 6 months ago.

do you have a copy of your pulmonary function test?

what was your diffusion capacity?

asthma can cause some restrictive lung function

it is normal to have supraclav lymph nodes.

if you have lost weight, or if you are feeling these lymph nodes often, you can cause them to be hard from irritation. they can be normal less than 2cm in size. everyone has supraclavicular lymph nodes in their bodies.

I looked through your whole lung chest CT scan. you don't have any grown glass opacities in your lungs which are worrisome for lung cancer.

you have a bit of hazziness in your left lower lobe lung, most likely from not taking a deep breath when you had your chest CT scan.

Customer: replied 6 months ago.
I have attached Pulmonary Function Tests from 2 dates. There is a decline from the original to the more recent one.Ok doctor, just to be sure you were looking at the recent Chest CT with Contrast, right? [https://goo.gl/cYOC9f]
Please see the report I have attached from radiology
Expert:  Dr. David replied 6 months ago.

the decline is most likely from less effort on your part. it takes a lot of coaching and effort to properly to do a pulmonary function test.

yes, I was looking at your chest CT scan online at that site.

not taking a deep breath can cause that sort of ground glass opacification.

abdominal obesity can cause you not be able to take a deep breath

you don't have lung cancer.