Ablated updated

I've been through all the good drugs today keeping me sleepy, silly, itchy and pain-free. They're not letting me have solid foods yet so I have been cycling through all the hospital's clear liquid offerings; broth, jello, Popsicles, repeat. I had to ask, "Why no solid foods?" Apparently they don't want to risk my nausea causing me to puke. That would not be a good thing to be retching when you have a liver that's in a sensitive condition. But I really do feel great. Not much pain and good spirits.

I had a doctor whom I had not met before, slip into my room earlier and spent about 30 seconds telling me that the surgery went "beautifully". Her word. It is nice to know that the mass is now toasted, and therefore an impotent mass.

My job now is to relax for about a week. I think I can handle that.

____________________________________________________

I wrote the above entry the evening of my surgery while sitting in a hospital bed.  I just realized that I forgot to hit the "publish" button, which explains all my family members checking in to see how things went. That was yesterday and today I am resting in the comfort of my home, falling asleep while watching documentaries on Netflix.

Right after I wrote that, Dr. Pimiento popped in and gave me a more detailed account (and also updated my chart to include solid foods).  He was a bit more reserved in his analysis about how things went.  He said the mass was a bit oblong and so he blasted it with two intersecting orbs of tissue death.  He also said that one of the wires did not heat up, probably due to the heat sink properties of a local artery.  He said we would check it in a month to see if another treatment would be required. 

Dr. Pimiento reappeared first thing in the morning to prepare my discharge papers.  When does that guy sleep?

One thing I forgot about surgeries and hospital stays is all the poking that happens... and bad poking.  They needed redundant IVs plus an arterial line and for some reason could not use my port.  The Nurse assigned to poke me before surgery failed in her first two attempts.  Thankfully, she called in someone else who managed a successful tap in the other arm and at that point the Anesthesiologist with a cool Russian accent stepped in and said she would do the other one after I was asleep.  At Lacks, you get regular heperin injections plus an early morning (as in 5:00 a.m.) visit from the hospital vampire charged with gathering blood samples.

Right before leaving, I had a surprise visit from Amy, the Lacks nutritionist who was making her rounds with an intern in tow.  She introduced me as her "fastest healing patient ever" and added that it was not an exaggeration.  She has never seen anyone respond better following major surgery and major chemo.  At least that is what she said.

Everyone was incredibly nice at the hospital and took care of all my little needs but it is good to be home.

A new doctor and a new approach

On Friday, Mary joined me for a consult with the Lacks Center's new surgeon, Dr. Pimiento (who replaced Dr. McCahill, the surgeon who relieved me of my esophagus).  His nurse went over my medications and it is clear they were picking up from Dr. McCahill's records because all the medications were what I was taking after my big surgery a year and a half ago. She got them up to date and shortly Dr. Pimiento whisked into the room.

Dr. Pimiento is a highly engaged, good-looking, young, Latino with a heavy accent and expressive manner.  He launched right into everything he knew about my case, summarizing medical events from the beginning up to what had happened last Tuesday. He then asked if I had seen the x-rays.  I had not but I was glad he asked because I always want to see pictures.  He quickly pulled in a cart with a monitor, called up my CT scan and navigated from the neck down to the spot on the liver.

It was rather a disappointment as I was expecting an ominous, dark, ugly blotch, but it was more like a shadow.  (In the picture to the left you can see it in the yellow crosshairs measuring its size as 23mm x 19mm.) He showed how it was fairly deep into the liver and reiterated how difficult it was for Dr. Skrtic to see with his ultrasound on the outside and the ribs blocking the best views.

He agreed that the ablation was still the best alternative but that it was fairly experimental because my case was unusual and there was very little data on metastasized esophageal cancer in the liver.  If it was colon cancer, there was lots of data showing that liver resection was the most successful approach resulting in longer survival periods.  But so far, all my cancer activity has been limited to this very small area for a fairly long stretch of time and this minimally evasive procedure with a short recovery period and low risk seemed to make good sense.

He then went on to talk about how much he loved doing a liver resection and how it was a beautiful operation. Mary thought that the way he talked about the liver was pretty sexy.

The surgury involves inflating the gut with CO2 to give him room to work and poking a couple of holes for instruments, including an ultrasound wand placed inside this time. The ablation catheter must be plaed exactly in the center of the tumor because it kills tissue within a sphere and all the cancerous cells must be on the inside of that sphere.  It takes 3 months before you will know if you were successful.

 He said that he could do the surgery on Monday but since he wanted to have a radiologist on hand, it was too late to arrange this for this coming Monday so he put me down for the first surgery of the day a week from Monday on the 11th. There would be one night in the hospital required and week staying home from work.

I'm a bit anxious to have this done but I can wait a week.

Good concept, failed execution

The short version is this: The ablation was unsuccessful due to the very inconvenient location of the tumor.  They will likely try again next week with a slightly more invasive procedure for getting at the tumor for ablation.  If you like gorey details, read on:

My brother-in-law, Bruce, delivered me on time yesterday morning to St. Mary's Hospital Intervention Radiology department at 8:30 a.m. for the ultrasound guided ablation procedure.  A very friendly nurse named Darcy (who had also called me at home the night before to fill me in on details) got me ready with the standard issue gowns, one-size fits-all pants and non slip slippers (an oxymoron?). The I.V. was a breeze because she was able to access my port.   I was further informed about the procedure by Kevin, a physician's assistant and then again by Dr. Skrtic himself. All seemed confident of a good result.  Feeling incredibly well-informed having it explained to me be nurses, P.A. and the doctor twice, I was beyond ready to go.

There must have been some kind of emergency because I had to wait an hour beyond the scheduled 10:00 operation time.  When they finally rolled me in, I was prepped by a nice person named Meghan who offered me a choice of Pandora channels to listen to. Dr. Skrtik came in to pre-visualize the tumor using an ultrasound wand and a giant TV Screen suspended on a gimbal above.  I can tell you that a liver is a less gratifying site on an ultrasound display than say, a baby. I really wanted to see what a tumor looked like but it was tough to see anything that looked like an ominous mass. Dr. Skrtic was having a difficult time seeing it to.  It was in a really difficult place to visualize, on top of the liver, behind the ribs. Ultrasound cannot see through bone.  He had me run through a series of breath-holding options and seemed to have decided to go between the ribs.  But then he tried a wedge on my left side so I was at a 45 degree angle with one arm above my head.  He moved to the other side of the table and found a position he liked better.  It required a smaller "breath-hold" from me and the approach was under the rib cage.  Satisfied with this strategy, he then left to make some measurements from last week's CT scan to establish depth. I could see him working oin the corner of the giant monitor.

Three other people with masks came in and began hooking up equipment.  One of them must have been an anesthesiologist (although she did not introduce herself) because I felt a cool liquid flowing into my port and felt the effects of the Versed. This was to be conscious sedation and I knew that they would give me enough to feel groovy but not so much as to put me to sleep.  I found it no problem to remain engaged with what was going on around me.

There was a big box next to me and all three people seemed to be hooking it up for the first time. They were looking for instructions and trying to figure out where patch cables and a five-channel piece of tubing were supposed to go.  Eventually, Dr. Skrtic reentered and joined them in trying to figure it out.  It seemed to me that they were struggling with this for about 10 minutes.  I was in an altered state but from my angle I could see a slot with five channels where it seemed likely this tube was supposed to be inserted. Eventually, Dr. Skrtic lifted a block on some sort of hinge that revealed the five channels that I could see and everyone seemed satisfied that the mystery was solved.  At least that is my spaced-out recollection. It could have been a dream.

When the operation commenced, Dr. Skrtic started with local anesthesia, warning me each time about a "pinch and a burn".  Each shot went to a deeper layer of tissue and I found them easy to handle.  My strategy for shots is to drive a fingernail into my side with self-inflicted pain distracting the needle pain.  The catheter was then painlessly inserted.  I tried to watch on the monitor but could rarely see anything that looked like anything. Repeatedly, he asked me to take a deep breath (or a medium breath or a small breath) and he would push in a little farther.  These often did hurt, similar to the pain of getting the wind knocked out of you.  Deep and unfamiliar.  I wanted to tell him to just push a little harder and get it over with.  Eventually I felt myself getting a little clammy and wondered if I was in danger of passing out.  The shoulder above my head was getting sore and at one point I think I moved my arm for relief and somehow brought it into the operation arena, touching skin. I remember a barked order to restrain my arm and re-sanitize the area.

Then I remember instantly realizing it was over.  I must have fallen asleep. No one was working on me and there was only one other person in the room.  Somehow I gathered, or was perhaps informed, that they had given up.  The tumor kept sliding out of the way whenever he pushed into it and he would also lose site of it on the ultrasound.

Bruce filled in the gaps with these notes:

Before you came back into the room, Dr. Skrtic came and gave me the overview directly after finishing your procedure. He was disappointed he couldn't lance the mass because it moved up every time he poked it, seemingly up and under the ribcage if I understand it correctly. He said the placement of the needle was tricky and though in one attempt he could get approx. 1/2 cm into the mass, it slid back out with normal breathing, as you recall…

He said it was important to know for certain that the placement was perfect before applying the zap, (my meager attempt to remember the term) so that's why they abandoned the effort.  He said you did an outstanding job, it was the limitations of the device under the circumstances and normal breathing mechanisms that were a reality… so know you were doing an excellent job throughout… The seven or so times you tried were exceptional, it was simply a mechanical issue -- the diameter of the needle (thick as a ball point pen tube he seemed to suggest, because of the prongs stored inside of it) that kept nudging the mass away.

So then he straightaway said there's two options, and that had he had permission, he would have attempted the pure alcohol ablation, with a much thinner needle which would have more easily made it into the center of the mass; the idea being to then inject pure alcohol in proportion to the volume of the mass and attempt to destroy the tissue. He said that's the effect of pure alcohol on the mass. He also said that had been the standard procedure they all used regularly up till the radio frequency method was developed.  So he would have done it yesterday, yet was considering doing that even this week… just needed permission, scheduling, etc., and since you were "snowed" (his word) yesterday, he couldn't proceed.

However, this is interesting - it's possible the delay will likely be the best thing that could have occurred!  When you came back into the room, he visited, and again said to you there's two options; one being the alcohol ablation and the other - minimally invasive laparoscopic surgery to ensure plenty of access, the latter being more invasive, but he wanted to consult with Dr. Pimiento (sp).  So, a bit later Darcy said they were on the phone, comparing notes and looking at the scans, etc., and then sure enough Dr. Skrtic came back to tell you the laparoscopic method seems best. That's interesting, because Skrtic said while the alcohol treatment is very effective, he didn't seem to say it's 100%, and Darcy reinforced that idea saying it's often possible to re-do the procedure as needed over time… However, in describing the details, Skrtic said the laparoscopic procedure enables them to use CO2 to easily expand the space to work, etc., etc., and with surgery you get more of a guaranteed exact placement of the same radio frequency technique preferred.  He also mentioned they sometimes get him up there in the OR to help during the operation as they as really good at assisting with guided imagery technique.  Then, Darcy in a separate conversation later said she too knows the RF is preferable -- the fact being that radio frequency technique has much better precision getting a larger area and any "feeders" (her word describing blood supply that is hard to see) and with the extended radius of area covered by the 'zap' you are in much better shape. And she said again, that because you're such a healthy person, and can live fine with some loss of liver, she seemed to suggest 'why not'… and that it's a much preferred solution in her experience.

 Back in my recovery room, I was very hungry.  I had to wait a little bit and was given some juice at first and then eventually a chicken salad sandwich and some orange sherbet. Bruce was still there, getting details and instructions as evidenced above. I made a few "Facetime" calls and emails and sent Bruce home while I slept for much of the mandatory 5-hour waiting period.  Mary and Marlee picked me up around 7:00p.m. and when we got home, Marlee made me some macaroni and cheese while I rested in an easy chair. I took a Vicodin but was not in much pain

Again, the emotion is disappointment. All that rigmarole plus a lost couple of days and the tumor is still there, un-burned and growing. Next week, a new doctor and another procedure.  Until then, moving slowly.

Burn tumor, burn

I met Dr. Skrtic this afternoon.  No, that is not a typo. His last name simply lacks enough vowels for a proper two syllable word.  It's pronounced "Sker-tic".  Dr. Skrtic is an Intervention Radiologist.  He gets called in to do the highly skilled procedures that involve visualizing beneath the skin using ultra-sound equipment, X-rays and CT scans. 

I first sat down with a Physician's Assistant named Brad whom I also liked. In my limited experience I've found Physicians Assistants to be both knowledgeable and and good communicators and they seem to be less in a hurry to escape a barrage of questions.  Brad fit this description and did a good job of making me feel like I was being heard.  We talked about my past experiences with liver biopsies and the challenges of getting to a spot resting on top of a liver.  He told me that Dr. Skrtic was just finishing a procedure and he would be with me shortly.

It wasn't long before Dr. Skrtic arrived.  I liked him right away. He was also a great communicator and did not seem impatient.  I really liked that he conveyed how much he enjoys the trickier, more challenging procedures and that he was very interested in working on my case.  It had been presented to him at "Tumor Board", a regular meeting of oncologists who go over interesting cases together to share ideas about what would work best.

He did say that most often the metastasized cancers that migrate from other areas typically come from colon cancer and that esophageal cancer is much rarer in the liver.  In fact, there were no statistics about how effective this procedure would be for this type of cancer but in other ways it was a perfect case to apply this treatment.  My tumor is 23mm and the maximum treatable size for ablation is 30mm (3cm).  And it is just in the one spot and I am otherwise in excellent health.  Ablation effectively kills all the living cells in a 3cm sphere and thus, all the visually active cancer cells identified as thriving inside my body.  I have often visualized wanting to be able to do just that; fry the little sucker. If I understood him correctly, it uses radio waves to heat up tissue to just over 100 degrees, making a little localized "fever" that engages my immune system to kick into gear and cut off the blood supply to this area. I'll be left with some scar tissue on the organ but a liver is robust enough to handle it.

Brad came back with a "surgery" date of next week Tuesday, the 29th at 10:0am.  They want to treat me soon so the tumor does not grow to exceed the 3cm limit.  It takes an hour and then they'll watch me for most of the day to make sure there is no bleeding (there are lots of blood vessels in a liver) and then send me home to chill for a couple of days. 

I'm very excited about this approach.  No guarantee of success but it just feels right... and is much more palatable than another round of chemo.

Interventional Radiology

I got a call from lacks Center this afternoon.  I have an appointment next Thursday with an Intervention Radiologist to discuss options.  Found this video that describes the procedure:

I guess I'll find out if I would be a good candidate.  I think I could find a pair of gray undies.

Change of seasons

Autumn is a time to reach back into the closet and pull out that thick sweater that you put away mere seasons ago.  That sweater smells and feels like another time and pulling it over your head brings back memories and feelings and anticipation of change. The sweater I dug out of the closet this week was the one that I put in there with the fantasy that it would stay in there getting threadbare and musty and would be revisited as only as a faded memory.

Last week I had my 3-month CT Scan after a year of great health and good energy following that weary summer of chemotherapy.  I knew that my scan would be clean because my body and spirit were so on top of the world.  But the minute that Dr. Scott came into the room after reading my report I gathered that the news would be different this time.  Instead of a proclamation about great test results, he began asking if I had any pains or congestion, and did it hurt when he touched me here or there.  “No, I feel great!”

At the end of the exam, he sat down and showed me the printout of the summary analysis and explained that the CT scan had indicated that the previously inactive spot on my liver had grown from 7mm to 23mm; still very small but clearly active.  He then showed me the blood report where the “tumor indicator” reading had spiked from neutral to positive.  This second report pretty much confirmed the first.  The esophageal cancer in my liver was back.

There was a second anomaly in my right maxillary sinus, which showed a “development of opacity”.  This could be nothing but it will need to be checked out.  I have no pain or pressure so I am pretty sure it will turn out to be nothing.

I have no feeling of shock; just some disappointment about having to let go of the affirmation that I had been healed. I wanted the doctors to be wrong about their sureness of a malevolent return.  The worst part is the disappointment of others who shared this fantasy.  It was easy to believe in the wrongness of doctors and their remote diagnoses.

I still know very little about what this will mean about my immediate future and my new job.  Dr. Scott said that he would be taking my case to his oncologist roundtable to gather a consensus about what steps should be taken next.  He suggested that maybe they might try an ablation.  Using radio waves at point blank range, they would fry the tumor (with a little onions on the side). That’s one possibility.  I asked about another round of chemotherapy and Dr. Scott said it would come down to weighing quality of life versus invasive procedure.  That sounds a bit too much like a palliative care issue.  I’ve been in denial about this whole “making life comfortable” thing.  I can handle some discomfort.  I really enjoy seeing what comes next in life.

My friend Bob Russell succumbed to his esophageal cancer in late August.  He had entered into Hospice care back in June and was spending his last days on Glen Lake, just spitting distance from Gram’s cottage.  I visited him just a couple of weeks before he died while I was up there staying with my extended family at the cottage. He was in good spirits and we had a lucid conversation about recognizing the end.  For him, the cancer had spread into his brain and after valiant attempts at getting it under control, he finally conceded that it was time to let go.  He told me that he knew that his skills and intelligence were no longer viable for solving problems or contributing to society in any way.  He added that there were two things that still needed to happen: One, his loved ones need to find a way to let him go. And two, he needed to find a way to let go of life, himself. “It’s damned hard”, he said. “I don’t know how to do that.”

I feel that I am a very long way from where Bob was on that day.  I’ll likely get there sooner than most of you reading this, but right now it feels like that day is still years away.  We are all dying and you never know when and rarely how. Any of us can die on any day.  I could get hit by a car while crossing the road and so could you.  We should all live for the day and enjoy every minute and embrace every situation, good and bad, as an interesting experience that we are privileged to comprehend at this moment.

That sweater is back out of the closet and stretched across my torso and I find it a bit itchy and uncomfortable but I quickly remember that I get to experience another change of seasons. It does not feel as bad as the last time.  I’m grateful that I can go back to work tomorrow.

Out of retirement, into the fire

So I got a job.  This was highly unexpected. I had pretty much resigned to an early "retirement" living on Social Security Disability and doing "love" projects as a volunteer and avoiding any long-term commitments.

One of those "love" projects was helping out my friend Kim Dabbs who is the new Executive Director of a local organization, the West Michigan Center for Arts and Technology (WMCAT) with a video project. This is an organization whose mission has always interested me and I was happy to contribute in some way.  I met several of the staff through my volunteer activities and my esteem for the organization grew.

Unrelated to those volunteer activities, I started seeing references (on Facebook and some email lists I belong to) to a job opening teaching video to teenagers part-time.  Of course this interested me.  I thought I might be able to refer this job to ma friend. When I read the job description I kept thinking, "Wow, this would be a perfect job for me if i was not retired.  My resume perfectly matches their requirements too." But I am retired and so I forwarded it on to some friends and tried to forget about it.  After all, who would hire someone with stage 4 cancer for a 9-month contract anyway?

While I was up north at Glen Lake for a vacation, I received an email from one of Kim's WMCAT staff members in charge of the youth program asking me if I knew anyone who was qualified as they were having a hard time filling the position.  I replied that I would send the description to a few of my friends and then I added, "I'm tempted to apply, myself."  She replied, encouraging me strongly.

I guess I nailed the interview.  I really had nothing to lose.  And now I find myself contractually obligated to survive another 9 months in good health as I teach two groups of 12 teenagers how to make videos with community partners.  I meet each group twice per week in the afternoons, Tuesday through Friday.

I'm incredibly impressed by the other teachers and staff members and humbled to be accepted into their company.  They all LOVE what they do and assure me that this will be a rewarding experience.  I'll meet my students for the first time at a retreat the weekend of September 20.  Until then, I need to come up with equipment and curriculum plus the courage to embark on a new adventure with many unknowns. It will be a leap of faith, but so far the signposts are all very positive.

Here goes!