[Medical Human Story - Episode 79]: Part I: People Reading the Dark Signals

 

Beyond the Stuffy Nose: The Dark Shadow Within

Prologue | Part 1 | Part 2 | Part 3 | Part 4 | Epilogue    

Part I: People Reading the Dark Signals

In the prologue, I left a single sentence:

"Where did this mass precisely originate?"

That question may seem like a simple anatomical inquiry.

However, to the medical staff dealing with cancer, it is far from simple.

We must know where the tumor started.

We must know how far it has spread.

We must know which structures it has invaded.

And above all, we must judge what kind of treatment is possible for this patient right now.

We decided not to reveal the patient's name here.

I wanted his story to linger longer than his name.

There was a man in his fifties.

One morning, he blew his nose in front of the mirror.

His left nasal passage felt stuffy.

At first, it didn’t seem like a big deal.

It was a symptom anyone could experience when the seasons change.

However, it did not get better even after a few days.

Then, he experienced a few episodes of nosebleeds.

Only then did he visit the hospital.

That was the beginning of everything.

And now, we had to return to that starting point.

1. The First Image

The radiology reading room was quiet.

Unlike the outpatient clinic, the patient’s voice is not directly heard here.

There are only screens.

Tissues are represented in shades of gray and white against a black background.

Yet, to an experienced radiologist, that screen is not silent.

Instead, it raises countless questions.

I gazed at the monitor.

"It seems to have started from here."

The radiologist moved the mouse.

It was an Axial T1-weighted image.

A soft tissue mass was visible, centered in the left nasal cavity.

The lesion was distinguished from the normal mucosa, and a relatively high T1 signal was observed in some areas.

He zoomed in to check the borders of the lesion.

"This is different from simple mucosal thickening."

I did not answer.

That statement already carried multiple meanings.

If it were mucosal thickening, inflammatory disease would come to mind first.

However, the presence of a solid mass that fills the space and expands into the surrounding paranasal sinuses tells a different story.

"Where do you think the primary site is?"

At my question, he flipped through the images for a moment.

"The left nasal cavity is the most suspicious. It appears to have subsequently extended toward the ethmoid and maxillary sinuses."

At that moment, I was gradually finding the answer to the question I raised in the prologue.

Where did it start?

The left nasal cavity.

And the next question remained.

How far did it go?

2. The First Rule of Viewing Tumors

I often tell young doctors:

When you discover a tumor, do not try to measure its size first.

Of course, size is important.

However, you cannot understand a tumor with a single number alone.

First, look at the location.

Next, look at the direction of extension.

Then, look at the borders.

Finally, look at the relationship with surrounding structures.

This is especially true for the nasal cavity and paranasal sinuses.

Because it is an anatomically complex space.

Around the nasal cavity lie the ethmoid and maxillary sinuses, and above it are the orbit and skull base.

Going deeper, critical nerve and vascular structures exist.

Therefore, accurately grasping how far the tumor has invaded is a crucial process in judging resectability and determining the scope of treatment.

The doctor flipped through the images again.

A Coronal image appeared.

"It is seen more clearly here."

The mass in the left nasal cavity had expanded in the superior and inferior directions.

The structure of the ethmoid sinus was affected, and the lesion continued toward the maxillary sinus.

I stared at the screen for a while.

There was information there that could not be expressed in numbers.

The location of the tumor.

The direction of invasion.

The anatomical borders.

And information that even hinted at the scope of surgery the surgeon would have to perform.

[Insert Figure 1]

3. What It Means for T1 to Be Bright

I looked at the T1 image again.

I knew the part of that image that bothered me the most.

High T1 signal.

It is an important clue that makes one think of melanoma.

Why is that?

Because of melanin.

Melanin is not just a pigment.

In MRI, it is a substance with distinct physical properties.

The paramagnetic property of melanin can affect the surrounding magnetic field and proton relaxation, shortening the T1 relaxation time.

As a result, melanoma containing melanin can show a relatively high signal on a T1-weighted image.

However, we must not stop there.

Because a high T1 signal is not exclusive to melanoma.

Hemorrhage can also appear bright on T1.

Especially when methemoglobin is present in subacute hemorrhage, a high signal can appear.

Fat can also show a high T1 signal.

Secretions with high protein content can likewise increase the signal.

Therefore, what a radiologist must do

is not immediately say, "It is melanoma."

The correct question is this:

"Why is it bright?"

I believe this question well illustrates the essence of radiology.

Imaging is a discipline of seeing with the eyes, but diagnosis is a discipline of thinking with the mind.

[Medical Insight]

4. T2 Was Not Silent

I pulled up the T2-weighted image.

This time, the lesion showed a different face.

The internal signal was not uniform.

I briefly looked back and forth between T1 and T2.

The MRI signal of sinonasal melanoma cannot be explained by a single formula.

It can vary depending on the amount of melanin, and hemorrhage may be mixed in.

The density of tumor cells can also have an effect.

If necrosis or other histological components are mixed, the signal becomes even more complex.

In typical melanotic melanoma, the T2 signal can be low due to the influence of melanin.

However, not all lesions appear that way.

Particularly in amelanotic melanoma, melanin is scarce or absent, so the typical high T1 and low T2 signal pattern may not appear.

Therefore, in radiology, understanding the possibility of pattern variation is more important than memorizing a single signal.

"Melanoma equals high T1."

If you memorize only this, you understand only half.

"Melanin can cause a high T1 signal, but it does not appear in all melanomas."

You must understand it this way.

That difference seems small, but in actual interpretation, it is very large.

5. The Second Question

The doctor said,

"Let's look at the DWI."

The screen changed.

This time, a part of the mass shone brightly.

DWI.

Diffusion-weighted imaging.

I opened the ADC map alongside it.

And I checked the lesion again.

High signal on DWI.

Relatively low signal on ADC.

I nodded.

"It supports true restricted diffusion."

The doctor replied,

"Yes."

The mere fact that DWI is bright is not enough.

Because T2 shine-through can occur.

Therefore, the ADC map must be checked together.

If it is bright on DWI and low on ADC, it further supports the possibility of true restricted water molecule diffusion.

In areas with high tumor cell density, the extracellular space decreases, and the movement of water molecules can be restricted.

For this reason, restricted diffusion often appears in malignant tumors.

Of course, this is not a finding unique to melanoma either.

Restricted diffusion can also appear in other malignancies, including squamous cell carcinoma.

However, reading the characteristics of T1 and T2, contrast enhancement, DWI, and ADC together helps narrow down the direction of differential diagnosis.

In the presented case as well, the combination of a high DWI signal and a low ADC signal is presented as a key point supporting true restricted diffusion.

[Insert Figure 2]

6. "Then Is It Melanoma?"

I asked the doctor,

"How strongly can we suspect it based on imaging alone?"

He thought for a moment.

"We can suspect it quite strongly. But it is not a definitive diagnosis."

I like that answer.

In medicine, accurately setting limits is often more important than certainty.

Imaging provides vital information.

However, pathology answers a different question.

Imaging shows where something is, what it looks like, and how it is shaped.

Pathology confirms what that tissue actually is.

Therefore, a biopsy is ultimately necessary.

That process followed for this patient as well.

7. The Endoscopy Suite

The lighting in the endoscopy suite was bright.

The patient was sitting in a chair.

The doctor examined the nasal cavity.

The screen magnified the structure deep inside the nose.

Unlike the normal mucosa, strange tissue was visible.

The patient did not want to look directly at the screen.

Instead, he gazed at the doctor's face.

"Is it very bad?"

The doctor did not answer immediately.

"There is tissue we need to check."

"Is there a high chance it's cancer?"

"We are doing a biopsy because we cannot rule out that possibility."

The patient pressed his lips together.

His companion sitting beside him held his hand.

I watched that scene.

In a hospital, the hand of a family member sometimes feels like the oldest medical device.

It measures nothing.

It does not measure blood pressure.

It does not display oxygen saturation.

Yet, it gives the patient an uncanny amount of strength.

8. Pathology Results

While waiting for the biopsy results, the medical team reviewed various possibilities.

Esthesioneuroblastoma.

Squamous cell carcinoma.

Lymphoma.

Melanoma.

Malignant tumors of the nasal cavity and paranasal sinuses can produce similar symptoms.

Nasal congestion.

Bleeding.

Discharge.

Decreased sense of smell.

Facial pressure.

However, imaging and pathological characteristics may point in different directions.

Esthesioneuroblastoma is a tumor that mainly arises in the olfactory region of the upper nasal cavity and must be differentiated.

Squamous cell carcinoma is a major malignancy occurring in the nasal cavity and paranasal sinuses, which can be accompanied by bone destruction and an invasive soft tissue mass.

Lymphoma may present as a relatively homogeneous soft tissue mass, and the bony structures are sometimes relatively well-preserved compared to the size of the tumor, which can aid in differentiation.

And in melanoma, melanin can be an important imaging clue.

However, the final word ultimately comes from the pathology department.

9. A Call from Pathology

The phone rang.

"The pathology results are in."

When I heard those brief words, I felt a peculiar tension.

Results are familiar to medical staff.

Yet, being familiar does not mean they are light.

I checked the results.

Sinonasal melanoma.

At that moment, the diagnosis changed from suspicion to reality.

A diagnosis name had been created to deliver to the patient.

And with that diagnosis name came countless questions.

What is the stage?

Is surgery possible?

Is there orbital invasion?

Is there skull base invasion?

Are there lymph node metastases?

Is there distant metastasis?

Are additional imaging studies needed?

Is postoperative radiation therapy necessary?

Is systemic therapy required?

Can immunotherapy be considered?

The medical team began to move again.

[Medical Insight]

10. Why CT Appeared

MRI does not answer every question.

The medical team also checked the CT.

The very first thing we look at on a CT is bone.

The bony structures of the nasal cavity and paranasal sinuses provide vital information for judging the invasion pattern of the tumor.

The maxillary sinus walls.

The ethmoid sinus.

The orbital walls.

The skull base.

The nasal skeleton.

Whether there is bone destruction.

If so, in which direction it has progressed.

If MRI creates a map of soft tissues, CT creates a map of bones.

Therefore, when I explain it simply to junior doctors, I say this:

CT reads bone, and MRI reads soft tissue.

Of course, actual medical imaging is not that simple.

CT also provides soft tissue information, and MRI also displays anatomical structures.

However, it is a useful expression for remembering the strengths of both modalities.

[Insert Figure 3]

11. Multidisciplinary Conference

People gathered in the conference room.

Otolaryngology.

Radiology.

Pathology.

Medical oncology and radiation oncology participate when necessary.

It is a setting where multiple people look at one person's disease.

This is the advantage of multidisciplinary care.

Even when looking at the same images, each specialist asks different questions.

The otolaryngologist thinks about the surgical approach.

The radiologist explains the extent of invasion.

The pathologist explains the histological characteristics of the tumor.

The medical oncologist reviews the possibilities for systemic treatment.

The radiation oncologist thinks about the role of radiation therapy.

There was silence for a while during that meeting.

The patient's MRI was displayed on the screen.

"This appears to be the primary site," the radiologist said.

"It is centered in the left nasal cavity and has extended toward the ethmoid and maxillary sinuses."

The otolaryngologist asked,

"What about orbital invasion?"

"We are currently verifying the critical parts on the images."

The screen zoomed in.

Multiple people were reading one person's body together.

Watching that scene, I was reminded once again that medicine is not something done alone.

12. Time to Explain to the Family

The patient and his companion sat together in the clinic.

The doctor first explained the facts confirmed up to that point.

"The biopsy results confirmed sinonasal melanoma."

The companion asked,

"Then is it a very dangerous disease?"

"Sinonasal melanoma is a rare malignancy, and it is often discovered in an advanced state, requiring aggressive evaluation and a treatment plan."

The patient said nothing.

"Can he get better with surgery?"

The patient asked this time.

After a brief moment of thought, the doctor replied,

"At this stage, accurately confirming how far the lesion has spread comes first. Surgery and additional treatments will be decided based on those results."

"Then we still don't know?"

"Yes. But the things we need to check are clear."

The doctor took out a piece of paper.

And wrote them down one by one.

Staging evaluation.

Surgical resectability.

Invasion of surrounding structures.

Lymph node and distant metastasis evaluation.

Multidisciplinary treatment plan.

The patient stared at those words.

"It's more complicated than I thought."

The doctor replied quietly,

"Yes. But being complicated doesn't mean nothing can be done."

At those words, the patient raised his head for the first time.

13. The Person Asking About Treatment Costs

The companion asked cautiously,

"Doctor, how much will the treatment cost?"

The doctor fell silent for a moment.

This question is very realistic.

To the patient and family, disease is simultaneously a medical event and an economic event.

However, it is inappropriate to state the treatment cost of sinonasal melanoma as a single number.

How extensive is the scope of surgery?

Is endoscopic surgery possible?

Is skull base surgery required?

Is radiation therapy needed?

Is there recurrence or metastasis?

Is systemic therapy like immunotherapy necessary?

How long is the hospitalization period?

What is the health insurance coverage range?

All of these factors can influence the cost.

Ultimately, the doctor said this:

"Treatment costs are important, but right now, confirming the exact stage and the treatable scope first is the most important thing."

The companion nodded.

Those words probably did not provide complete comfort.

However, at least it became clear what needed to be done first.

14. The Choice of Surgery

In the conference room, the topic of surgery came up again.

If it is a locally resectable lesion, surgery is a vital therapeutic component.

However, the nasal cavity and paranasal sinuses are anatomically complex.

Achieving complete resection and securing negative resection margins may not be easy.

Deciding on surgery is not simply about removing a tumor.

While removing the tumor, normal structures and functions must be preserved as much as possible.

At the same time, oncologically sufficient resection must be secured.

Looking at the imaging screen, the doctor said,

"To judge resectability, we need to look at the extent more accurately."

I thought that remark was important.

Resectability is not determined by willpower alone.

The anatomical extent, the biological characteristics of the tumor, the patient's general condition, and treatment goals must all be considered.

And sometimes, surgery alone does not end the treatment.

Radiation therapy may follow, and systemic treatment may be necessary depending on the stage.

15. Another Face of Melanoma

I reviewed the literature again.

Sinonasal melanoma shares the same name as cutaneous melanoma, but they should not be considered biologically identical.

Unlike cutaneous melanoma, mucosal melanoma has a low direct association with ultraviolet exposure.

Molecular biological characteristics can also show differences.

Recent pathological reviews have suggested a relatively low tumor mutational burden and structural genomic alterations as features of mucosal melanoma.

These differences are important when understanding treatment response.

In particular, one cannot simply assume that treatment strategies proven effective in cutaneous melanoma will work to the same extent in mucosal melanoma.

The medical team must determine the treatment direction by comprehensively considering the patient's disease type, stage, molecular characteristics, and the presence of recurrence or metastasis.

[Medical Insight]

16. A Doctor's Night

Late that night, the hospital corridors were nearly empty.

I stood alone in front of the radiology department.

Countless people passed through during the day, but at night, the hospital feels like an entirely different place.

The voices of patients subside, the hallway lights dim, and the doors of each clinic close one by one.

Yet, the day of those who think of patients does not end easily.

The radiologist opened the MRI again.

I sat beside him.

"Does this patient look like he has advanced significantly?"

He stared at the images for a long time.

"We cannot determine prognosis from imaging alone," he said.

"But it's clear that the extent matters."

I nodded.

Moving the mouse, he said,

"What we can do is look as accurately as possible."

Those words lingered long.

To see as accurately as possible.

That was the role of the radiologist.

Not the person who decides the patient's future,

but the person who provides the most accurate map so the treatment team can make the right decision.

[Insert Figure 4]

17. What the Patient Feared Most

The next day, the patient came back to the hospital.

This time, his companion was with him.

"Doctor," he said first.

"Could I die?"

The clinic grew quiet.

It is one of the most difficult questions for a doctor.

Because there is no right answer.

Sinonasal melanoma is an aggressive malignancy, and it is known for having a poor prognosis because it is often discovered in an advanced state or because distant metastasis occurs subsequently. In recent literature reviews, though varying by study, the 5-year overall survival rate has been reported to be around 30 to 35%.

However, statistics do not prophesy an individual's destiny.

The number 30% does not dictate a person's life.

What the patient needs is not just numbers.

He needs to know what his stage is, whether it is currently treatable, what treatments are available, what the treatment goals are, and what he needs to prepare for ahead.

The doctor said,

"It is true that it is a dangerous disease."

The patient's eyes wavered.

"However, we cannot pre-judge the outcome at this exact moment."

The doctor paused for a moment.

"We will check what we can verify, one by one."

The patient nodded.

That might not have been enough.

Yet, what he needed on that day was not all the answers,

but knowing what his next step was.

18. What a Single MRI Changed

I thought to myself.

What would have happened if he had ignored the nasal congestion a little longer?

What if he had thought the nosebleeds were simply caused by dryness?

What if he had only received repetitive medical treatments?

What if he hadn't gotten an MRI?

In medicine, we cannot give exact answers to such questions.

Because we cannot know the future that did not happen.

However, one thing is clear.

The imaging study became a crucial turning point in the diagnostic process.

We identified the location and extent of the mass on MRI,

discovered the abnormal signal on T1,

evaluated the T2 characteristics together,

confirmed contrast enhancement,

and assessed restricted diffusion on DWI and ADC.

And the biopsy followed.

Imaging created suspicion, and pathology confirmed the diagnosis.

That was the most important diagnostic flow in this case.

19. Looking at Unilateral Nasal Congestion Again

That evening, I returned home and looked in the mirror.

I suddenly wanted to check if my own nose was clear.

Strangely enough, when people hear stories about disease, they check their own bodies first.

If the head hurts, they worry about a brain tumor.

If the chest feels tight, they worry about heart disease.

If the nose is stuffy, they unconsciously check one of their nostrils.

However, I do not want to give readers unnecessary panic.

Most nasal congestion is not cancer.

This is a very important fact.

Sinonasal melanoma is rare.

Therefore, there is no need to worry about melanoma just because you have a stuffy nose.

However, if there are warning signs such as persistent unilateral nasal congestion, recurrent nosebleeds, and an intranasal mass, it is important not to delay accurate evaluation.

What is needed is verification, not fear.

20. The One Thing a Doctor Must Uphold

A doctor cannot save every patient.

That is a harsh reality that anyone in the medical field eventually faces.

Yet, a doctor must treat every patient equally.

You must not give up just because a disease is rare.

You must not strip away hope from the very beginning just because the prognosis is poor.

Conversely, you must not exaggerate the possibilities of treatment.

One of the most important things a doctor can do is accurately distinguish between what is currently known and what is not yet known.

It was the same for this patient.

What was confirmed was the diagnosis of sinonasal melanoma.

What still needed to be confirmed was the stage.

And the path of treatment could vary depending on the stage.

Therefore, the medical team prepared for tests once again.

[Medical Insight]

21. And the Next Step

New items were written on the whiteboard in the conference room.

Staging.

Surgical planning.

Local control.

Systemic therapy.

Follow-up.

They were difficult English words for the patient's family, but to the medical team, they were the plan ahead.

I looked at those words.

Now the diagnosis was over, but the story was not over.

Rather, the real story was just beginning.

From the moment it earned the name cancer, time begins to flow faster for the patient.

They must decide on surgery,

prepare for the necessary treatments,

and the family must accept reality.

And the medical team must deal not only with the patient's body, but also with his mind.

As that meeting drew to a close, the otolaryngologist said,

"Let's find every possible treatment we can."

No one objected to those words.

22. The Two Faces I Saw

Medicine has two faces.

One is cold and precise.

Numbers.

Imaging.

Pathology.

Staging.

Treatment response.

Survival rates.

Recurrence rates.

Metastasis.

This is one face of medicine.

The other is warm and wavering.

The patient's eyes.

The family's hands.

The doctor's silence.

The anxiety the day before surgery.

The time spent waiting for test results.

And the brief smiles shared after treatment ends.

I do not wish to abandon either of these two faces.

Medical information alone cannot explain a person's life.

Yet, emotion alone cannot treat a patient.

That is why the Medical Human Story is necessary.

A story that accurately explains the disease while never forgetting the person facing it.

This case was precisely that kind of story.

23. The Meaning of the Dark Shadow

Black and white on an MRI have no emotions.

Just because it looks bright on T1 does not mean the image knows the patient's fear.

Even if the lesion appears bright on DWI, the image does not know the patient's family.

Just because the ADC is low does not mean the screen worries about the patient's future.

It is all the result of physics and biology.

However, the moment a doctor reads that image, the story changes.

Physics turns into diagnosis.

Biology turns into a treatment plan.

And diagnosis and treatment return once again to a person's life.

That is the remarkable power of medical imaging.

Imaging does not show the person, but it can be used to save the person.

24. The Last Night

Late that night, I looked at the patient's MRI one last time.

I looked at T1.

I looked at T2.

I looked at the contrast-enhanced images.

I looked at DWI.

I looked at the ADC map.

And I went back to the beginning.

Axial T1.

The mass in the left nasal cavity.

I thought to myself.

When this patient first came to the hospital, the words from his mouth were simple:

"My nose is stuffy."

Who would have known that so many stories were contained within that single sentence?

I closed the screen.

Yet, I did not turn off the computer.

There was still work left to do.

The next day, I had to explain the staging to the patient.

I had to discuss the possibility of surgery.

I had to explain the reality of treatment to the family.

And the entire medical team had to answer a single question:

"What is the best we can do for this patient right now?"

That question was not easy.

Yet, just the fact that the question had become clear meant taking a step forward.

I walked down the hospital hallway.

I passed the chair where the patient's family had sat.

It was an empty chair.

However, I did not think that chair was empty.

A few hours ago, a family had sat there.

Worrying about one person's life.

Waiting for one person's future.

And entrusting their beloved to the medical team.

I paused for a moment.

And said in my heart,

"We will look as accurately as we can."

That was both the radiologist's resolve,

and a promise as a human being.

[Core Memorization Method for Readers]

The Door to the Next Story

Just because a diagnostic label has been set does not mean the patient's story is over.

Rather, from that moment, the longest time begins for the family.

Will we perform surgery?

How far should the resection go?

Must we do radiation therapy?

Is systemic treatment necessary?

Is there already metastasis?

And even after treatment ends, how do we monitor for recurrence?

The patient asked again,

"Doctor, is there still something I can do?"

The doctor replied,

"There is."

It was a brief phrase.

Yet, behind those words, the time of countless people was required.

Starting the next day, the medical team unfurled a broader map.

This time, it wasn't simply about finding the tumor.

They had to find how deep inside the patient's body the tumor had reached.

And in that process, the family learns for the first time how heavy the word "treatment" truly is.

I did not yet know the ending.

However, I knew one thing:

From this point on, this story would no longer be a simple diagnostic tale,

but a story of a family fighting alongside the medical team to hold onto the life of someone they love.

Prologue: That Day, I Rethought the Word "Nasal Congestion"☜ Previous Chapter

Next Chapter ☞ Part II: What We Can Still Do