[Medical Human Story - Episode 79]: Part III: The Reappearing Black Shadow
Beyond the Stuffy Nose: The Dark Shadow Within
Prologue | Part 1 | Part 2 | Part 3 | Part 4 | Epilogue
Part III: The Reappearing Black Shadow
1. The Call Came at 4:17 PM
4:17 PM.
I still remember that time.
Dozens of calls are made and received at the hospital every day.
Some ask for test results,
some change appointments,
and others are among medical staff verifying a patient's
condition.
Therefore, a single phone ring does not automatically mean bad
news.
However, that day was different.
"Is this Dr. Elias Lee?"
"Yes."
"The patient says his nosebleeds have started again
today."
I paused for a moment.
"Is the volume heavy?"
"Not much, but... he says it feels stranger than last
time."
Those words lingered in my mind.
Stranger
than last time.
There were no medical metrics in the patient's words.
Yet, in the clinical field,
such expressions sometimes become critical signals.
________________________________________________________
2. The Word "Recurrence"
The next day, the patient came to the
hospital.
Fatigue was etched across his face.
"The nosebleeds are back."
"Since when?"
"From a few days ago."
"Is it coming from only one
side?"
"Yes."
I looked into his eyes.
It was the same question I had asked when
he first visited the hospital.
Nasal congestion.
Nosebleeds.
And this time, there was one more thing.
"How is your sense of smell?"
He thought for a moment.
"I think I can smell less than
before."
The caregiver asked cautiously.
"Could it have recurred?"
The air inside the examination room
suddenly grew heavy.
I did not answer right away.
"It is one of the possibilities.
However, we cannot conclude it is a recurrence at this stage."
"Then do we need to test again?"
"Yes. This time, it is especially
important to compare it with previous imaging."
The patient nodded.
He already knew.
What restarting tests meant.
________________________________________________________
3. Same MRI, Different Mind
I stood in front of the MRI examination
room.
A few months ago, when the first images
were taken here, the patient had been anxious.
This time was different.
He even knew the location of the
examination room.
"I will verify your metal items."
"Yes."
"Contrast media will be used."
"Yes."
"You must not move during the
scan."
"I know."
Watching him, I felt a strange emotion.
People who live with illness grow
accustomed to the hospital.
The mechanical hums that once felt
unfamiliar become part of daily life.
The scan room numbers become familiar,
the location of the clinic becomes
familiar,
and the faces of the medical staff become
familiar.
However, becoming accustomed and being free from fear are entirely different stories.
[Insert Figure 9]
________________________________________________________
4. Subtle Differences on the Screen
I flipped through the images one by one.
Preoperative images.
Immediate postoperative images.
The first follow-up images.
And this current set of images.
At first, nothing out of the ordinary was
visible.
Yet in radiology,
sometimes the change itself is the finding.
Has the contrast enhancement pattern
changed?
Has the soft tissue thickened?
Has a new nodular lesion appeared that was
not there before?
Has restricted diffusion newly developed?
Has the relationship with surrounding
structures changed?
I checked the DWI.
There was a signal change in the area
suspected of a lesion.
I also checked the ADC map.
"Here it is,"
I told my colleague.
"Let's compare it with the previous
ones."
We placed the two images side by side.
Over time, the morphology was changing.
At that moment,
I knew the time to explain this to the
patient was approaching.
________________________________________________________
5. What DWI Tells Us
DWI visualizes the movement of water
molecules.
As cellular density increases in a tumor,
the extracellular space may decrease,
resulting in restricted diffusion of water
molecules, which can appear as high signal intensity on DWI and low values on
ADC.
However, there is an important principle:
Just because DWI is bright does not mean it
is true restricted diffusion right away.
This is because T2 shine-through can
influence the signal.
Therefore, the ADC map must be checked
together.
This principle is also important in
sinonasal tumors.
Looking at the screen, I recalled that
sentence once again.
An image is never interpreted from a single
sheet alone.
Different sequences cross-validate one another.
[Medical Insight]
________________________________________________________
6. "Is It a Recurrence?"
I returned to the examination room.
The patient looked at my expression first.
A physician communicates a great deal even
before speaking.
The patient tries to read the doctor's
eyes.
"There are changes in the imaging
compared to the previous ones that require verification."
The patient's expression tightened.
"Has the cancer come back?"
"We cannot confirm this with the
current images alone."
The caregiver asked.
"Then how do we verify it?"
"We need to review the endoscopic
evaluation and clinical findings together, and consider a biopsy if necessary.
A process is needed to confirm whether the suspected area on the imaging is an
actual tumor."
The patient lowered his head.
After a long silence, he said,
"Do I... have to go through that
treatment again?"
I answered.
"Nothing has been decided yet."
What he needed was neither rash hope
nor hasty despair.
Checking what could be checked, one step at
a time.
That was what we could do right now.
________________________________________________________
7. Meeting the Tissue Once Again
The suspected area was examined via
endoscopy.
The medical team compared the previous
surgical site with the newly observed lesion.
A biopsy was performed.
After returning from the examination room,
the patient said,
"Waiting for the results is the
hardest part."
I understood those words.
Sometimes the time spent waiting for
results feels longer than the test itself.
Time flows in reality,
but to the patient, it feels as though it
has stopped.
Morning passes,
lunch passes,
and even when evening arrives,
the mind remains standing right before that
single line of result.
________________________________________________________
8. Pathology Results
A few days later, the results arrived.
I read the pathology report.
And I checked the images once more.
Clinical information.
Endoscopy.
MRI.
CT.
Pathology.
Each piece of information pointed in the
same direction.
I had to explain to the patient that the
possibility of recurrence was very high.
The caregiver asked.
"What should we do this time?"
The medical team gathered again.
The multidisciplinary meeting began.
[Insert Figure 10]
________________________________________________________
9. Can It Be Operated On?
It was the first question raised.
"Can it be locally resected
again?"
The surgical team reviewed the images.
Orbit.
Skull base.
Major blood vessels.
Surrounding nerves.
Previous surgical boundaries.
New lesions.
Possibilities and risks had to be evaluated
simultaneously.
Surgery is not simply the act of cutting
away a tumor.
It is a balance between how far to remove
and what to preserve.
Saving the patient's life is paramount,
but that process can affect vision,
neurological function, facial structure, and quality of life.
In medicine, "removing as much as
possible" is sometimes not synonymous with "the best treatment."
________________________________________________________
10. Tears of the Caregiver
The caregiver asked.
"Can his eyes be saved?"
The surgeon was silent for a moment.
"It may depend on the extent of
invasion confirmed in the imaging."
"Please save them if possible."
Those words were not a medical question.
They were a plea.
I looked into the caregiver's eyes.
To a family, an eye is not merely an
anatomical organ.
It is the face they shared together,
the expression in photographs,
the gaze that looked upon their child.
Therefore, a surgical decision always
carries a meaning far beyond anatomy.
________________________________________________________
11. Redefining Treatment Goals
The medical oncologist said,
"Instead of judging based solely on
local treatment, we must consider systemic status and the possibility of
recurrence together."
The patient asked,
"What is systemic treatment?"
"Depending on whether the cancer is
confined to a specific site or present elsewhere, the treatment strategy can
vary. Systemic treatments like immunotherapy can become important
options."
The patient remained silent for a while.
"Does that mean there is still
treatment I can receive?"
"Yes."
The doctor's answer was brief.
Yet those few words held profound meaning
for the patient.
________________________________________________________
12. Hope and Probability Are Different
I thought about the part we must be most
careful with when medical staff conveys hope to patients.
Giving hope must not mean guaranteeing
treatment efficacy.
Conversely, a poor prognosis must not mean
denying the possibility of treatment altogether.
Medical reality lies somewhere in between.
There are treatments from which we can
expect efficacy.
Yet there are also patients who do not
respond.
Treatment can shrink a tumor.
However, it can also progress again.
Some patients maintain a stable condition
for a long period.
Therefore, what a patient needs is not
vague optimism,
but realistic hope they can choose after
understanding their own situation.
________________________________________________________
13. Starting Immunotherapy
Treatment was decided.
The patient sat in the treatment chair.
The nurse verified.
"Are you experiencing any
discomfort?"
"I'm fine."
"You will receive your treatment
today."
The patient extended his arm.
The infusion began.
Watching that scene, I thought:
Immunotherapy is quiet on the outside.
There are no loud mechanical hums like
surgery,
nor massive equipment moving around like
radiation therapy.
However, complex immunological processes
take place inside the body.
The core principle is to restore anti-tumor immune responses by blocking immune checkpoint signals that inhibit T-cell function.
[Medical Insight]
________________________________________________________
14. Unexpected Symptoms
Not long after treatment began, the patient
said,
"I've been feeling so tired
lately."
"Since when?"
"A few days."
"Any other symptoms?"
"I feel a bit itchy too."
The medical team checked the symptoms.
With immunotherapy, various immune-related
adverse events can occur, ranging from skin symptoms to the gastrointestinal
tract, liver, lungs, and endocrine system.
Therefore, when a patient experiences new
symptoms, it must be evaluated whether they are related to the treatment.
"Can I just tough it out and let it
pass?"
The patient asked.
"No,"
I said.
"Please tell us about even the
smallest changes during treatment."
He nodded.
________________________________________________________
15. The Sentence Medical Staff Hate Most
I recalled a sentence used almost jokingly
among medical staff:
"I didn't mention it because it didn't
seem like a big deal."
To a patient, it might seem like a minor
symptom.
However, for a patient receiving
immunotherapy, small changes can be early signs of significant side effects.
Therefore, one of the most important
principles explained to patients is this:
Do not endure it in silence.
Especially if you have new or rapidly
worsening symptoms, it is safest to inform the medical team.
________________________________________________________
16. And the Second Imaging
Time passed.
Follow-up imaging was scheduled once again.
This time, everyone was nervous.
It was different from when we looked at the
pre-surgical MRI.
This time, we had to verify treatment
efficacy.
Has the tumor shrunk?
Is it stable?
Have new lesions developed?
Is it responding to treatment?
The images posed questions once more.
[Insert Figure 11]
________________________________________________________
17. Subtle Changes
I looked at the images.
"It seems smaller than before,"
the medical team said.
"Yes. But it is not a complete
disappearance."
I explained to the patient,
"There are findings showing response
to treatment."
His face brightened a little.
"Then it got better, right?"
"We can view this as a positive change
on the current imaging. However, we must continue to monitor it."
The patient smiled.
"You always say we 'have to keep
watching,' Doctor."
"That phrase is vital when treating
cancer."
He smiled.
This time, I smiled too.
________________________________________________________
18. Yet Cancer Was Not Simple
Months later,
changes occurred again.
This time, it was in a different location.
It was small.
Very small.
Yet it had not been there before.
The medical team reviewed the imaging and
clinical information together once more.
We discussed whether a PET/CT was
necessary, whether additional MRI was required, or if tissue confirmation was
needed.
The difficulty in cancer treatment is not
merely finding large lesions.
It is judging what small changes signify.
________________________________________________________
19. That Night's Meeting
There were five doctors in the conference
room.
Radiology.
Otolaryngology.
Pathology.
Radiation Oncology.
Medical Oncology.
All of them were looking at the same
images.
"This area was not present in the
previous images."
"Could it be post-surgical change?"
"The morphology is a bit
different."
"What about the DWI?"
"Restricted diffusion is
suspected."
"Then do we need tissue
confirmation?"
A brief silence.
Someone spoke.
"We must explain this to the
patient."
The meeting ended.
Yet no one rose from their seat with a
light heart.
________________________________________________________
20. The Moment to Tell the Patient
I met the patient and the caregiver.
"There are changes in the tests that
we need to look into."
The patient looked at my face.
"Is it metastasis?"
"We cannot confirm it with the current
images alone."
"Then the fact that the doctors
gathered again means..."
He could not finish his sentence.
I said,
"Yes. It's a change worth checking,
too significant to simply pass over."
Tears pooled in the caregiver's eyes.
"Do we need tests again?"
"Yes."
The patient said quietly,
"I will do it."
Those few words lingered long.
________________________________________________________
21. What the Patient Feared Most Was Not Pain
Days later, he told me,
"I'm not afraid of surgery."
"What are you most afraid of?"
He thought for a long while.
"I hate making my family wait
again."
I could say nothing.
The patient was worrying about his family's
pain more than his own.
Conversely, the caregiver said,
"We can wait."
"It's hard on you."
"We'll wait anyway."
In the examination room that day, silence
lasted longer than medical explanations.
________________________________________________________
22. A Doctor's Vow
I could not promise the patient,
"You will definitely get better."
I could not say those words.
"It will not recur."
I could not say that either.
The promises a doctor can make are limited.
Yet there is one thing I can say:
"I will examine things as accurately
as possible."
The patient looked at me.
"And I will make sure we are not late
when the crucial moment arrives."
He nodded.
That was the promise I could keep.
________________________________________________________
23. How Time Changes a Person
On the day he was first diagnosed,
the patient struggled even to pronounce the
name of his disease.
"Sinonasal... melanoma."
Now he spoke naturally.
"My melanoma."
The process of a disease's name becoming a
part of oneself is a sorrowful thing.
At the same time, however, as people
understand the disease, they gradually reclaim agency.
They understand test results, ask about
treatment goals, discuss side effects, and deliberate on choices with the
medical team.
The patient was no longer passive.
He was becoming a member of the treatment
team.
________________________________________________________
24. Numbers Called Prognosis
One day, the caregiver asked,
"Doctor, I looked online and the
survival rates were so low."
I remained silent for a moment.
Sinonasal melanoma is known as a rare yet
aggressive malignant tumor.
While historical literature has reported
low 5-year survival rates, recent systematic reviews and meta-analyses—varying
by study—report an overall 5-year survival rate of approximately 30 to 35%.
However, I did not lead with numbers.
"Statistics describe
populations."
The caregiver looked at me.
"They are not numbers that accurately
predict an individual patient's future."
"Then what should our family do?"
"We must judge based on the current
stage and treatment response."
That was the most honest answer.
________________________________________________________
25. The Person Behind Statistics
I do not dislike statistics.
On the contrary, statistics are essential
in medicine.
They are necessary to evaluate treatment
efficacy, compare risks, and provide realistic information to patients.
However, the denominator and numerator of
statistics are human beings.
Each patient has a different stage and
biological profile, receives different treatments, and lives a different life.
Therefore, statistics are a compass
pointing in a direction, not a verdict determining an individual's destiny.
________________________________________________________
26. The Question About Treatment Costs
One day, the caregiver asked a practical
question.
"How much will the treatment
cost?"
I felt a pang in my heart because the
question was so grounded in reality.
In cancer treatment, medical and financial
issues are inseparable.
The burden can vary depending on the extent
of surgery, whether endoscopic surgery is used, length of stay, radiation
therapy, immunotherapy, recurrence status, metastasis, and insurance coverage.
"It is best to check the exact costs
with the hospital's administrative and counseling department once the treatment
plan is finalized."
The caregiver nodded.
That day, I realized once more:
Healthcare is not just about treating
tumors.
Creating an environment where the patient
can sustain treatment is equally important.
________________________________________________________
27. The Patient's Final Question
One day, as treatment progressed a step
further,
the patient asked me,
"Doctor, have you seen many patients
like this?"
"Yes. I've met several."
"It must be hard, right?"
I smiled.
"Some days are."
"Are doctors sad when patients
die?"
I could not answer for a moment.
"Yes."
He looked at me.
"Then how do you endure it?"
I said,
"I don't forget."
"You don't forget?"
"No. Instead, I use that memory as a
reason to take better care of the next patient."
He nodded quietly.
________________________________________________________
28. Walking the Hospital Corridors Again
That night, I walked the hospital
corridors.
The space, filled with people during the
day, had grown quiet.
Automatic doors opened and closed.
A nurse's footsteps could be heard.
In the distance, a monitor alarm sounded.
I stood in front of the window.
Instead of Seoul's city lights, the
patient's face surfaced in my mind.
The day he first came to the hospital.
The day his nosebleeds wouldn't stop.
The day we took the MRI.
The day we waited for surgery.
The day treatment first began.
And the day we suspected recurrence.
Every scene connected like a long film.
________________________________________________________
29. What Saving a Life Means
Medical professionals often say, "We
save lives."
Yet we cannot save every life.
No matter how precise the imaging,
how prompt the diagnosis,
or how optimal the treatment selected,
there are moments when the disease wins.
That is painful for doctors too.
However, that fact does not erase the
meaning of medicine.
Reducing suffering while the patient is
alive, creating treatment opportunities, extending lifetime, and protecting
the time they can spend with their family.
And treating the patient as a human being
until the very last moment.
That, too, I believe is part of saving a
life.
________________________________________________________
30. It Is Not Over Yet
That patient's treatment continued.
And my observation continued as well.
I looked at MRIs, compared CTs, checked
pathology reports, and recorded treatment responses.
Sometimes there was good news.
Sometimes there was concerning news.
Yet every time, we had to find the next
choice.
Disease does not give us the correct
answer.
Instead, it keeps asking questions.
What should we do next?
To answer that question, the doctor looks
at images, the pathologist looks at tissue, the medical oncologist looks at
treatment possibilities, and the patient and family think about the direction
of life.
And all those gazes converge on a single
person.
________________________________________________________
31. What I Have Learned
I have viewed countless medical images.
I have seen countless masses, hemorrhages,
fractures, and blood clots.
Yet there was always a person inside those
images.
The same was true for the diagnosis of
sinonasal melanoma.
On MRI, it appears as black-and-white
signals.
On CT, it appears as bone destruction and a
soft tissue mass.
On DWI, it may appear with high signal
intensity.
On ADC, it may appear with low values.
In pathology, it is explained by cells and
immunomarkers.
Yet to the patient, it is a father's
diagnosis,
a husband's illness,
and a family's daily life.
[So, whenever I look at medical images, I
ask myself:
"What is the person behind this screen afraid of right now?"]
[Insert Figure 12]
________________________________________________________
[Medical Recommendations]
________________________________________________________
33. After That Day
The patient went home.
I was left alone.
On the computer screen, the last MRI we
looked at remained.
Black.
White.
Gray.
Numerous signals in between.
I closed the screen.
And for a long while, I did not move.
For a doctor, the hardest moment is not
just making a diagnosis.
It is the moment you must convey the truth
to a patient while knowing how their life will change.
We do not know the future.
Yet we know what needs to be done today.
We check again.
We compare again.
We run the necessary tests.
We find ways to treat.
And we stay by the patient's side so they
do not stand alone.
Tomorrow morning, I will come to the
hospital again.
The patient will come too.
We will look at images once more.
And we will make another choice.
No one knows how long those choices will
continue.
Yet one thing was certain.
We had not given up yet.
However, I did not yet know
that a few months later,
the patient's state would change
drastically once again,
placing the medical team before the hardest
choice of all—
and that at the end of that choice,
both the doctor and the family would face a
day neither could ever forget for the rest of their lives.
Until that day, we walked.
Slowly.
Yet without stopping.
_______________________________________________________
Part II: What We Can Still Do☜ Previous Chapter
Next Chapter ☞ Part IV: The Final Scan, and What We Must Protect Until the End
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