Lymphoma, a post mortem

Six weeks of anyhing will get tiresome near the end, doubly so if it involves taking a 6am train and not getting back home until 7. Combined inpatient/outpatient juggling twice a week didn’t help either, and neither did the high turnover1. Still, as inpatient rotations go, this one was reasonably busy—enough for me to learn quite a bit, but never overwhelming. More importantly, the attendings were awesome, the cases interesting, co-workers friendly, etc.

As the slide set I’ve linked to above shows, lymphoma are tricky in that many are either curable or indolent enough to be kept at bay until something else gets to the patient; but when it’s bad—and with current technology we can’t with certainty say which ones those are at diagnosis, though we’re getting there—it can be catastrophic. Thankfully, those cases are rare.

Though most chemotherapy I was ordering was EPOCH-R or, for NCI’s new primary CNS lymphoma protocol, TEDDI-R, there were several patients with non-hematological malignancies getting IL-15. If you hadn’t heard of this particular interleukin being used for treatment before, it’s becuse the results of the first-in-humans phase I trial done by NCI have just been published in JCO. The maximal tolerated dose was somewhat low when administered as an intravenous bolus, so the patients are now getting it either as a 12-day continuous infusion, or a subcutaneous injection. I’d rather not steal Dr. Conlon’s thunder—or break any government regulations—by writing how these patients did. Just keep an eye for a follow-up paper. And maybe a tumor board presentation from me in the next few months.


  1. I am sure a medical transcriber somewhere is cursing under his or her breath every time they hear my nasal baritone—the last time I had dictated so many discharge summaries was during my intern year. 

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Myeloid sarcoma, a slide show

This tumor board was almost two month ago. The case is fascinating, but the presentation had too much patient-related information for me to be comfortable posting it here. I ended up removing most of the interesting slides, though it remains a decent introduction to GATA2 mutations/MonoMAC syndrome, and a nice overview of chloroma/granulomatous/myeloid sacroma.

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On medical euphemisms

Observe George Carlin discussing how euphemisms are invading the English language:

I first heard a version of this years ago, back in Serbia, while I was still a med student. It hadn’t left much of an impression, but I can imagine myself nodding my head and thinking ha ha, yes, stupid Americans, ruining their own language, or something comparably obnoxious.

Well, I’ve, erm, matured since then. True, some euphemisms now inspire rage instead of vague amusement, like my two favorites:

  • I just wanted to let you know” instead of “I’m telling you”, and its relatives “Please let me know”, and “Thank you for letting me know”. Physicians are particularly fond of this, for we are the gatekeepers of knowledge, and the only reason you know something is because we are letting you. Don’t worry though, it’s not just you, we say that to each other all the time.

  • I don’t feel comfortable doing xyz” instead of “I don’t want to do xyz”, as mentioned here.

Most of them, though—particularly ones we use with patients—have a good reason to exist. The Radiolab segment which inspired this post made fun of “making someone comfortable” being used for dying ICU patients. Instead of… what, exactly? Euthanasia? There is a difference between giving someone drugs usualy meant for comfort—opioids, primarily—in order to kill them, and giving them opioids for pain and comfort knowing it may shorten their life.

Then there are turns of phrase used because they are euphemisms. “You should get your affairs in order”, “your time is becoming limited”, “at this point we should concentrate on quality of life, not quantity” are all ways of saying “I don’t know when you’ll die, but it will be soon, so start planning the funeral”. I am sure Mr. Carlin would appreciate getting it straight, but not every patient is as stoic. We can easily be more blunt if asked to do so, but you cannot un-hit a patient with a sledgehammer like that. So the default is to err on the side of softness.

Then again, most of the euphemisms we use with patients also make us more comfortable with the sitation. What I wrote above may then just be my rationalizing it away with a convenient it’s-best-for-the-patient mantra. In truth—to use another common phrase—euphemisitis is a multifactorial condition (as in, I have no idea what the reasons are, but it’s probably a little bit of everything).

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T-cell/histiocyte-rich large B-cell lymphoma

Another month, another tumor board talk. The slides aren’t self-sufficient, I’m afraid, but the references might be a good starting point for learning more about TCHRLBCL[^wtf], or diffuse large B-cell lymphoma in general. I’d start with [this excellent review article on DLBCL treatment][ccr], written by several NCI attendings[^attnd].

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History of advance care planning in the US

Here is a slide show I had to make during my [pain and palliative rotation][ppc], which ended up being an updated rehash of [a review article I wrote for Cancer Journal on the history of end-of-life care][eolreview]. The article itself is behind a paywall, but you can find the PDF on [ResearchGate][rgate].

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Stem cell transplants, a slide show

As first-year fellows, we have to present a case at the Medical Oncology Service tumor board every four weeks. Obviously, I can’t share the details of those talks here. But I can post a sanitized version of my slides, with all identifying information removed.

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Pain. And Palliation.

I am not spiritual, or religious. Living in an atheist country that suddenly takes a turn towards militant Christian fundamentalism does that to you. I don’t believe in woo. I do believe that American doctors are overtreating their patients’ pain, and that American patients are too sensitized to it. Yes, the understaffed orthopedic VA surgery wards where post-op patients were screaming for their morphine may have led to the Kabuki of a nurse coming in every couple of hours to ask you about where your pain is, and what is the QUALITY of the pain, and howbadisitfromonetoten? But a cancer center is no VA. The ritual only reminds those with chronic cancer pain that yes, it is still there, and yes, it hurts more than it did 3 hours ago, and now they can’t finish reading their book because there is a twinge every couple of minutes while they are thinking about it.

Which is all a longwinded way of saying that I should not have enjoyed the pain and pallitavie rotation that much. There is spirituality, there is woo, there is a lot of pain. And yet I did.

These people know what they are doing. They have plenty of resources available to do it. And yes, they may “do Reiki”—nothing more than elaborate Kabuki for patients with advanced diseases—but there are times when that is exactly what the patients need. When 4am vital signs and checking for hepatomegaly every day just aren’t enough.

Some useful questions to ask your patients with any serious chronic disease, if and when you have some extra time in clinic:

  • Are you the same person now as you were before the diagnosis? How did you change?
  • What do you fear the most?
  • What do you hope for?
  • Who(m) do you rely on for support?1

The patients’ answers may surprise you.


  1. Whom” is gramaticaly correct, but interrpreted as pretentious by most patients. Use it judiciously. Yes, I realize that what I have written here is just as bad. 

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Posle USMLE-a: pozivi

Programi su pre nešto više od dve nedelje počeli da skidaju prijave sa ERAS-a. Ako vas je neko već pozvao, čestitam! Ako nije1, još nije vreme za brigu—većina programa pozivnice šalje u talasima, svake dve-tri nedelje, sve do kraja oktobra-sredine novembra.

Ako vam ni do tada ne stigne ništa, evo šta sigurno ne treba raditi—spemovati jadne direktore i njihove koordinatore generičkim molbama za intervju. U najboljem slučaju će ignorisati vaš mejl, u najgorem će vas skinuti sa spiska potencijalnih kandidata jer ne umete da pratite molbu sa sajta da ih ne kontaktirate za takve stvari.

Šta onda? Dve stvari: ako znate nekoga ko može garantovati za vas, zamolite ih da proslede vaše podatke koordinatoru ili direktoru koje poznaju2; i ako ste već u Americi, pošaljite mejl okolnim programima da ste dostupni u kratkom roku, za slučaj da neki kandidat otkaže razgovor dan-dva pre. Za tako nešto je dobro biti u mestima sa visokom koncentracijom programa koji primaju strance (čitaj: Istočna obala, Čikago). Naravno, prijavite se na te programa preko ERAS-a pre slanja mejla.

Ako ste završili sve stepove ali još niste dobili ECFMG sertifikat, slobodno se prijavite—programi to obično gledaju tek kad dođe vreme za rangiranje. Ako već morate da se prijavite bez svih stepova, Step 2 CK je najmanje bitan. CS je i dalje najlakši za prolaz, ali je njegovo padanje najveća crvena zastava koju nečija aplikacija može imati, tako da se stranci bez položenog CS-a obično ne pozivaju.

Sledeća bitna stavka su pisma preporuke. Nema svrhe plaćati prijavu za program koji na sajtu traži četiri pisma, a vi to četvrto još čekate. Srećom, većina je OK i sa tri, dok se poslednje može dodati naknadno. MSPE (“dekanovo pismo”) i transkript su neophodni, ali za strane kandidate nebitni pošto sistemi ocenjivanja nisu uporedivi. Na žalost, to je još jedna stavka za koju morati čekati na šalterima, hodnicima fakulteta, itd.

Srećno!


  1. Ili ako još niste poslali prijavu, u kom slučaju, šta kog đavola čekate‽ 

  2. Upozorenje: morate biti sigurni da su u dobrim odnosima. Postoje ljudi čija bi preporuka bila garancija za brisanje sa liste. 

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It’s well-known that most common knowledge is false

Did you hear the one about not prescribing angiotensin receptor blockers to patients with ACE inhibitor-induced angioedema? I’ve had heated debates with residents in my old clinic who did not want to even consider ARBs for a patient with worsening diabetic nephropathy who’s had lip swelling while on an ACE-I ten years ago.

Or the one about not giving these patients amlodipine, since there are two—yes, two—case reports on amlodipine-associated angioedema? Should we also stop giving them water?

Then there are shellfish allergies and iodine contrast, fever and atelectasis, morbid obesity and hypothyroidism… No matter how many studies show these associations to be too weak to be clinicaly significant, or just plain false, there will always be an attending somewhere giving them as his or her pearl of the day.

We need some medical mythbusting for physicians, not just the lay public.

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