How Should We Interpret "Metastatic Tumor Not Excluded" on an Imaging Report?

In mid-January 2019, a lung cancer patient came to see me from Xinjiang. The patient had been diagnosed with lung cancer in December 2017; after diagnosis she had surgery and chemotherapy, and took Chinese medicine after chemotherapy ended. The patient had a history of cerebral infarction over ten years prior, with persistent sequelae and frequent headaches. Brain imaging showed a few-millimeter shadow; the radiologist noted on every report, "Brain metastatic tumor not excluded." The patient was terrified and desperately wanted to have this few-millimeter lesion eliminated, seeking doctors everywhere.

However, after analyzing the patient's condition and history, I thought the likelihood that her brain lesion was a metastatic tumor was low; it looked more like a cerebral infarction sequela. I asked whether the patient's previous doctors were aware of her past cerebral infarction history; the patient said no doctor had ever asked about her past medical history in detail like I had (with all due respect, medical schools and textbooks should require taking a detailed past medical history). She herself had not thought to report this history to her doctors.

After I gave the patient some medicine according to TCM methods for treating stroke sequelae, her head symptoms changed. This patient had a particular characteristic: if her head did not hurt, she would feel dizzy, but the discomfort from headache was worse than dizziness; later, the dizziness could also be relieved by Chinese medicine.

However, the patient was under great psychological pressure and came back for re-examination every two or three months; the brain lesion never changed — neither shrinking nor growing — for over a year. I told the patient that if it were a metastatic tumor, it would not remain unchanged for so long. Even in the worst case, if it truly were a metastatic tumor, controlling it this well would mean there was nothing to worry about. But every time the patient was examined, the doctor's report would note "metastatic tumor not excluded," and these words caused the patient great distress, plunging her into fear. In conversation, she complained that the softening-hardening and mass-dispersing herbs I was using had no effect at all and wasted her money. The Western doctors at the hospital repeatedly and strongly recommended gamma knife treatment to address the brain lesion, all of which shook the patient's confidence in me.

At first I withstood the pressure and kept having the patient take Chinese medicine while undergoing regular follow-up observation. By the second half of 2020, the patient became impatient, with words full of doubt and accusation toward me, and strongly wanted to undergo radiotherapy as Western medicine recommended. Helplessly, I had to give up my own judgment. But when I suggested on October 23, 2020, that she go to a Western doctor for radiotherapy, the patient then wanted to continue TCM treatment for three more months. After weighing things, I felt I could not bear this responsibility; her Western doctor also strongly recommended gamma knife, so I no longer agreed to continue TCM treatment.

Who would have thought that on January 12, 2021, the patient's daughter told me that after her mother underwent brain gamma knife, the brain symptoms not only did not improve but worsened; she passed away just over a month after the gamma knife. The daughter had been a visiting scholar in Germany for over a year, and we had not communicated much; after her mother died, she contacted me to thank me.

I feel some regret, because this patient had initially been highly compliant to me, and my treatment was effective, relieving her suffering. But later, when she saw that the few-millimeter brain lesion had not changed for a long time, she became anxious and began to doubt me, and her compliance worsened. I was very worried that if I persisted in my opinion, a doctor-patient dispute would arise later, so I suggested the patient follow the Western doctor's advice.

The first time the patient came to see me, her daughter came with her, and I did not communicate much with the daughter. It was only when she was a visiting scholar in Germany and her mother was anxiously searching for Western specialists in Beijing that I had spoken with her via WeChat voice and given mother and daughter some advice. Looking back now, the patient and her daughter had always trusted me. If I had continued to insist on my opinion, opposing the gamma knife and comforting the patient emotionally, this patient would not have passed away so quickly. The daughter is a university teacher in a science/engineering field with excellent qualities, and she supported her mother's TCM treatment; although we communicated little, she was always courteous, and after her mother died she even remembered to thank me. With such a family, I should not have worried about a doctor-patient dispute.

Today, another breast cancer patient whom I have been following for a year has the same problem. This patient has a ground-glass opacity in the lung with regular morphology; the nodule is 13mm, and from August 2019 until now, its size and shape have never changed. But every time she comes for follow-up, the report notes: "Metastatic tumor not excluded," and these words create enormous pressure in the patient's mind.

I comforted the patient, telling her that generally speaking, nodules with regular morphology are benign, and that since it has not changed from August 2019 until now, the likelihood of this nodule being benign is even greater; she should not be frightened by the words "metastatic tumor not excluded." Personally, I think some doctors should be more thoughtful when writing imaging reports, because a few words written by a doctor feel like a verdict to a patient. "Metastatic tumor not excluded" is weighty; reaching this conclusion requires caution. After carefully comparing the patient's successive imaging reports, the doctor might not write it that way.

I also told this breast cancer patient the story of the Xinjiang patient, hoping she could draw some lessons and put down this weight on her heart, follow up regularly, and if there is no change, not rush to treat the lung nodule (some Western doctors have already recommended surgical removal).

Similar situations are common; many patients' imaging reports contain issues that are no big deal to professionals, but for patients, the conclusion "metastatic tumor not excluded" causes them sleepless nights.

The two patients I encountered were both badly frightened by these six words, "metastatic tumor not excluded." If these words were replaced with "nature undetermined," patients might feel much more relaxed. Moreover, judging from these two patients' nodules showing no change for over a year, the possibility that such nodules are metastatic tumors is extremely small. Why don't we consider the patient's psychological pressure and stop writing "metastatic tumor not excluded" on imaging reports? I think doctors' work in caring for patients' psychology is still far from sufficient.