Commentary by Jonathan Cohen, MD, on "Betting Your Life"
By Alice Stewart Trillin (The New Yorker; January 29, 2001:38-42)

The "Personal History" piece in the January 29, 2001 issue of The New Yorker is of such general as well as medical (including orthopaedic) interest that it deserves comment. The author, Alice Stewart Trillin, a superb storyteller, describes her four-month experience with an illness that was difficult to diagnose, despite proper handling in a prestigious hospital by competent physicians. Trillin’s tale begins in September 1990 with a flu-like persistent cough and slight fever. Because she had been treated for lung cancer, for which she had had a lobectomy, resection of the involved mediastinal lymph nodes, chemotherapy, and radiotherapy with cobalt in 1976, the persistence of the cough demanded investigation. During the fourteen-year interval since her treatment, she had been well.

The investigation of these new symptoms began at the Memorial Hospital Sloan-Kettering Cancer Center in New York (where she had been treated for her cancer). A chest x-ray revealed pleural fluid (both cavities) that was aspirated and found not to contain cancer cells. So far, so good, but the cough persisted. The following January, Trillin felt a sharp pain in her midthorax posteriorally, and another x-ray revealed a fracture of a thoracic vertebra. At this point, while harboring her worst fears that these symptoms were the "wake-up call of the sleeping dragon," she discussed the problem with a neurologist friend at Memorial Hospital whom she had consulted previously, Dr. Kathleen Foley. Dr. Foley ordered an MRI, which "looked ‘funny’ to the doctors who read it." Thus began a series of tests, including a needle biopsy of the vertebra (which showed no cancer cells) and a bone scan that revealed five "hot spots," one in a fractured vertebra, two in ribs nearby, and two in the pelvis. (For nonmedical readers, the bone scan is an x-ray of the entire skeleton, taken after intravenous injection of a radioactive isotope of very short half-life. The isotope concentrates in those bony sites where there is abnormal metabolic activity, but does not reveal the cause of the abnormal activity.) At this point, physicians might well want to know what looked "funny" on the MRI—was there a soft tissue mass?; was the fracture a pathologic one?

Trillin was next seen by three consultants, one radiologist and two neurosurgeons, but the consultations with the two neurosurgeons did nothing to calm her mounting anxiety and actually heightened it. The first neurosurgeon suggested a series of operations, including resection of the vertebra and a later reconstruction procedure. The second neurosurgeon compounded the patient’s anxiety by suggesting a back brace, for prevention of severance of the spine and the paraplegia which could result from a simple fall. Dr. Foley, now greatly troubled, arranged a consultation with a trusted oncologist, Mark Kris, who, after reviewing the medical records and the recent history, gave Trillin, in her own words, "a thorough examination. This was the first physical I’d had since this drama began; everyone else had just looked at the x-rays and scans. After he finished, he asked me how I felt. It was the only time in these months that anyone had asked me that question." When Trillin replied that she felt fine except for the severe pain in her back, Dr. Kris observed that the fact that she both felt generally well and looked well were not congruent with "widely metastasized cancer."

Dr. Kris then discussed the uncertainty in the diagnosis, not mentioning any alternatives to metastasis, but advising a "wait and see" attitude rather than any urgent measures. Foley had arranged a final consultation with Joseph Lane, an orthopaedic surgeon, who reviewed Trillin’s charts, checked her back and chest for radiation damage, and noted the small tattoo that marked the focal point of her previous radiation treatment just above the fractured vertebra. Dr. Lane’s diagnosis was "Nope, this doesn’t look like tumor to me. Radiation necrosis—a lot of that now in women radiated for breast cancer. Not so much in lung cancer; not that many live long enough."

The therapy that he recommended was calcitonin, calcium, and multivitamins. Trillin’s first injection of calcitonin was, in her own words, "the first therapeutic action I’d taken since all this began."

So there was a happy ending. Trillin gives a one-year follow-up, but publication of the story implies that she is okay now, ten years later.

For the general reader and for orthopaedic surgeons, several questions arise. Why did so many experts not think of radiation necrosis as a possible cause? One wonders if the other consultants knew of osteonecrosis as a sequel to the type of radiation that was administered ten to twenty years previously for certain cancers. Lane was able to be confident about the diagnosis of osteonecrosis, not only because he had had experience with it but also because he quickly put together several crucial bits of evidence—the "funny" MRI, the tattoo, the location of the fracture, the radiological characteristics of the fracture and of the hot spots, the radiation scarring of the skin on the back, and the long interval between the lung cancer therapy and the present illness. Another important observation, made by Dr. Kris, was the fact that the patient was feeling quite well, except for her cough, and patients with metastases generally do not feel at all well.

The correct diagnosis was elicited by those physicians who listened to the patient’s story, examined her, and put the pieces of evidence together in proper perspective.