Tuesday, March 29, 2011

I have my Pathology Report

The tumor is reported in a two page dissertation describing the specimen grossly and microscopic with multiple special stains.The bottom line is that the lesion is an ulcerated and necrotic focus of metastatic Merkel cell carcinoma, extending through the bowel wall and involving the serosal surface. The small bowel margins are clear. 6 lymph nodes in the mesentary have no Merkel involvement.There is no involvement of mesenteric fat. The entire specimen measures 10.5 cm in length and up to 4.5 cm in diameter. The tumor is described as ulcerating and fungating involving 85% of the small bowel circumference.
What that all means is that the small bowel tumor has been completely removed. The good thing is that the nodes are not involved. The bad news is that it got to the surface of the bowel and I am at risk for cells having been shedded from the surface taking hold in the peritoneum and growing there.
This was obviously the cause of my anemia and was close to causing a small bowel obstruction. It was also causing my weight loss.
My last Hemoglobin was 8 grams. I need to get this up. I have had 2 iron transfusions and have begun oral iron supplements as well.
My appetite has improved and my colon has begun behaving normally.
I was feeling very discouraged last night thinking I was having too much abdominal pain for this late after the surgery. This prompted a careful inspection of my abdomen. I realize that there is a 6cm horizontal incision in my right upper abdomen. This is larger than I had originally reported. I thought the largest was in the umbilicus. However it makes sense that the specimen was removed intact and measured up to 4.5 cm. This cheered me up, thinking that the continued pain is appropriate. I have taken some Advil for pain but did not fill my prescription for narcotic pain relief. A heating pad has been helpful as well for back spasms.
Yesterday, I called my accountant and asked him to get an extension for the deadline for filing my taxes for 2010. Then, in the mail, I get an audit notice for 2009.
I also got a Jury Summons. I requested a postponement based on the likelyhood of needing chemotherapy.
So here is the plan.
Follow-up with Dr Felix Monday afternoon. (April 4).
CBC Monday morning (to be drawn at Dr Flam's lab.
Follow-up with Dr Flam April 12
?Chemo? I don't think I can get away from it.

Sunday, March 27, 2011

My Experience With Laparoscopic Small Bowel Resection

On Monday, March 21, 2011, at 4 PM, I have an appointment with Dr. Edward Felix. Dr. Felix is somebody that I've known as a very good friend for more than 30 years. He has extensive experience with laparoscopic surgery having traveled the country teaching laparoscopic surgery. He has extensive experience with bariatric surgery and before coming to Fresno, was in practice as an oncologic surgeon. In fact, he was recruited by Dr. Marshall Flam to come to Fresno as an oncologic surgeon. I feel very confident in his abilities as a surgeon, and trust him as both a friend and colleague.

During this appointment, I find myself in the unusual position of acting as a radiologic consultant in my own case. I brought a CD with the images of my most recent CT scan, and we review the images together. One thing that surprised me was that Dr. Felix felt that he would have a good chance to remove the  posterior mediastinal tumor at the same sitting, because he is frequently operating in this region repairing hiatus hernias in his bariatric surgery cases. Because I have not been feeling well, I urge  Him to plan the surgery as soon as possible. He tells me the surgery will be scheduled for Wednesday morning.

On  Tuesday, March 22, 2011, at  8:15 AM, I have my appointment with Dr. Flam.  As always, it begins with labs. In addition to a CBC, a metabolic status panel has been requested. My labs have an unexpected result. I have become anemic. My hemoglobin is 9.5 g. This is down from about 13.5 g previously. This is quite a significant decrease and is presumed to be a result of occult bleeding from my small bowel tumor. the lab results or otherwise unremarkable. Now that I think about it, I did experience some shortness of breath, a symptom which has been unusual for me. This has occurred while debarking our Hawaii cruise when the ship arrived in Los Angeles. There was a fairly long upward sloping ramp which had to be traversed going from the ship to the terminal, and I noticed some shortness of breath while navigating this ramp. Before I am allowed to go home, I am given an intravenous iron infusion which lasts about 2 1/2 hours. Before the iron, I'm given some intravenous Benadryl in order to prevent allergic reactions. My understanding of the use of intravenous iron is that it will  improve the level of hemoglobin in patients who are iron deficient, but the improvement occurs over several weeks. It is suggested that prior to the surgery, there will be packed red blood cells which have been irradiated available for transfusion if needed. Dr. Flam and Dr. Felix discuss my case.

On Tuesday evening, I received a phone call from Clovis Community Hospital. I am told to arrive late morning for a late afternoon surgery. I hate to do this sort of thing, but I have Judy call to Bluma, to get a hold of Dr. Felix  for me, and it turns out that the hospital made a scheduling error and that indeed I am to arrive at the hospital by eight o'clock in the morning for a morning surgery.

On Wednesday morning, I arrived at the hospital by eight o'clock. Everybody is really very nice to me in the admitting department and I am brought over to the preoperative area where  blood is to be drawn for  type and cross match, and in IV is to be inserted. The technician selects a site in my left forearm, and inserts a needle and I can tell that she is not hitting the vein. She pulls back the needle and begins to apply compression without removing the tourniquet. I tell her she has to get the tourniquet off there, before removing the needle from the vein, but it is too late, and there is now a large black boot area on my forearm as a result. She makes a second attempt on the right arm which is also unsuccessful. A second nurse inserts the IV in my left forearm. I need the anesthesiologist who seems very nice. I've never met him before and have very little recollection of him. He obviously did excellent job because here I am.  Dr. Felix arrives and we are all good to go. His wife, Bluma, also arrives, and when I am taken to surgery, she sits with Judy. We have some discussion about the possibility of removing the posterior mediastinal tumor, and that is left to his judgment that surgery. However the finding of anemia complicates the situation.

The next thing I remember is waking up sometime following the surgery, feeling quite comfortable except for some left-sided mid abdominal pain which it turns out to be located at the site of one of the incisions. There are four small incisions in my abdomen, the largest of which appears to be at the level of the umbilicus. The only one which is painful, however, is in the left mid abdomen. Dr. Felix visits and tells me that the tumor has been entirely removed. However, in view of my anemia, he felt it not to be in my best interest to perform the more complicated surgery. It could always be done at another time if necessary. I find myself in a hospital bed in a room by myself, attached to an IV which is plugged into the wall and which is on a pole with five wheels. There is a lighted yellow button, which I can press to administer a dose of morphine. As long as the button is lit, I can give myself more morphine. I give myself morphine injections, but they don't seem to do very much. On the other hand, I am not having very much discomfort unless I have to cough. I am placed on a liquid diet. Intravenous fluids are being administered. I need to call the nurse whenever I go to the bathroom which seems to be quite often as my bladder capacity seems to be limited. We await the important event, the passage of gas and a bowel movement. I go for a short walk with the nurse at my side, without incident.

Judy stays with me. I don't have much recollection of that evening. I do remember trying to go to sleep and having absolutely no success. The insomnia does not appear to be the result of pain. However I am lying in a rather uncomfortable position. This is one of these modern hospital beds which is designed to prevent bed sores. It inflates and then deflates and then re-inflates and the cycle is about every 35 seconds.  The passage of time is excruciatingly slow.I'm reminded of the dripping faucet method of torture.  In addition, I am having a small amount of post nasal drip which results in some coughing and abdominal pain. At times, I am unable to breathe either through my nose or through my mouth, although fortunately, not both at the same time. I get out of bed and sit in a chair which improves my respirations. I turn on the TV. I felt I did not want to wake up Dr. Felix and asking for sleeping medications. Instead, I watch for consecutive half-hour episodes of reruns of the TV show “Married with Children”.

Thursday morning finally arrives. I am greeted at about 6 AM by the lab tech who comes to draw blood. At about 7 AM, my breakfast arrives. The morning newspapers also provided. My breakfast consists of juice, Jell-O, and if there was something else, I don't remember.  Later in the morning, Judy arrives. It is absolute the pouring rain outside. Dr. Felix arrives and by now, I have forgotten that I intended to ask him for sleeping pill for Thursday night. He seems to be satisfied with my progress. My hemoglobin has gone down to below 9 g. He explains this as viewed to improve hydration from intravenous fluids which results in dilution of the same amount of hemoglobin in a larger volume of fluid, and is not concerned by this at all. I again begin to go for short walks during the day. I'm given a device to encourage breathing. It sort of reminds me of a plastic pot pipe. You exhale as much as possible and then inhale through the mouthpiece. This raises up a blue marker which you have to get up to the arrow which is set at 1500. I'm having some difficulty at getting the marker up to the 1500 level. However I'm not terribly uncomfortable doing this. A small amount of post nasal drip, however, results in coughing which is uncomfortable.  I am having some gas pains, and you're some gurgling from my abdomen, but still await evidence of colon activity. My diet has advanced to the full liquid diet. This allows the addition of sherbet, milk, and  pudding.
I have visitors. My son Gary arrives with very touching get well cards from his three girls.Bert Rettner, My good friend and bridge partner also visits.
Thursday night is a repeat of Wednesday night. I have forgotten to arrange to have a sleeping pill. I spent much of the night awake in a chair. Since I woke up from my anesthetic, I have had virtually no sleep. I am making frequent visits to the bathroom to empty my bladder. With everything attached to the IV device, I am frequently getting things tangled and having to untangle them so that I can maneuver my way back and forth. I have completely stopped taking the morphine which doesn't seem to be doing any good whatsoever. I watched three more episodes of "Married with Children".
I may have mentioned before that I am not a religious man. However early  Friday morning, my prayers were answered. There was an explosion of gas followed by a small amount of liquid stool. Thank God, My colon had begun to do its job. Friday morning, after a breakfast consisting of 1 ounce of cream of wheat, Jell-O, a half cup of milk, and some sherbet, and after having more blood drawn, I have an early visitor. It is Dr. Felix. He gives me the wonderful news that I can go home. I will be able to leave the hospital about 48 hours after my surgery.
Here are a few other things that I did not mention above,
 I was given two intradermal injections of Lovenox in the abdominal wall. I believe that this is a drug designed to reduce the incidence of thrombophlebitis and pulmonary embolism.
I received another intravenous iron infusion.
I had to wear a device that goes around the foot that regularly is inflated and deflated, also designed to reduce the incidence of pulmonary embolism. This device kept coming off of my feet, and I discarded it.
A hybrid stock/slipper was also given to me to be worn. It kept coming up, and it was not much fun reaching down to my foot to put it back on.
The intravenous device which was being used had a loud, shrill alarm system which would go off when the device detected increased resistance to flow, or when the volume of fluid remaining became low. Somehow, the nurses did not pay attention to this alarm, and frequently I would have to use the nurse call button. I would then place the microphone of the call button up to the alarm to let them know that the alarm was going off.
I was in room 322 of Clovis Community Hospital.  I have to give kudos to the nursing staff and all of those people who helped take care of me during the two days that I spent in room 322 following surgery. I rarely had to wait any significant amount of time after calling the nurses. They went out of my way to be helpful and to answer all of my concerns. Whenever complaints I expressed above, I do not have any complaint about the nursing care that I was given.
Late Friday morning, I leave the hospital.  I have to say that there is no place like home. However, I developed an unexpected complication of back spasms.  These are relieved quite well with a heating pad which I alternate from my left upper abdomen to my lower back. I continue to be successful passing gas, but have not had a significant bowel movement.
Two quiet days  have passed. My abdominal pain has substantially decreased. However there is still a small amount of residual discomfort in the left upper abdomen particularly on coughing. I have returned to a relatively light diet.
I continue to use the breathing device. I now quite easily get the marker up to the 2500 level.
Today, we were visited by our friends, Ray and Andrea Schwartz. Our dog, Rocky was visited by their dog, Joey, a full size poodle.  They have been very encouraging to me. Many years ago, Andrea was diagnosed with breast cancer and was given only a short period of time to live. She is a shining example of what can happen when you stand up and fight your disease. I plan to emulate her example.

Friday, March 25, 2011

A Brief Update

I came home from the hospital today. My laparoscopic surgery was done Wednesday morning. I came home today, Friday morning after only about 48 hours in the hospital. The small bowel mass was removed. I await the pathology report. The posterior mediastinal mass is  still there, and could possibly be removed at a later date. I am feeling fairly well, but still have some gas pains. I am off all pain medications.
I thank all those who have wished me well. I will post a detailed narrative of the events as I remember them, hopefully this weekend.

Monday, March 21, 2011

Surgery Wednesday 10:00 AM

The plan is to remove my small bowel tumor using the laparoscope. If successful, the morbidity of the operation should be minimal. Dr. Felix looked at my CT scan with me and thinks he may also be able to get the posterior mediastinal mass out.
Tomorrow, I see Dr Flam in the morning and will get labs done. EKG wednesday morning before the surgery. Colon prep tomorrow with Magnesium Citrate. I am not looking forward to that.
I will post again after my surgery, probably next week-end.

Thursday, March 17, 2011

The Emotional Roller Coaster

Today, I went with Judy to Sierra Imaging in Fresno for a follow-up CT scan. On my last study, there was an unexpected new mass in my posterior mediastinum that was treated with a low dose of radiation in the hopes that this would stimulate my immune system to control the disease. I have been looking well and feeling quite well although I have commented in the past about some indigestion.
My CT scan was completed and I went to visit the Radiologist, Glen Hananouchi, a former partner of mine, to review the results, with Judy there as well. I realize this is always a difficult spot to put him in but I have been in this position many times. We reviewed the images and saw the mediastinal mass was smaller. There were no lung or liver metastases. I left the room elated and we sat in the waiting room as I had requested a CD of the images for my records.
Shortly Glen came to get me, appearing crestfallen and I knew the news was bad. There was a totally unexpected new finding. A new lesion had appeared in my small bowel, surrounding the lumen and thickening the wall, measuring about six centimeters in length and about three and a hanf centimeters in diameter. Well, at least the feelings of indigestion were not psychosomatic. There is no doubt that this is a real abnormality and I can't imagine it is anything other than a recurrence of Merkel Cell Carcinoma. This reminds me of the carnival game "Whack-a-Mole" where as soon as you whack it, it reappears elsewhere.
Here are some images from my CT scan. The mass is in the left upper abdomen. The magnigied view shows the bowel lumen (area through which digesting food passes) in white with the wall around it.

Those images are in the coronal plane. Below are axial images.

Again, the small image shows the tumor surrounding the bowel.

So, what next. I await a callback from Dr Nghiem. I have spoken briefly with Dr Flam. I have also spoken with Dr Ed Felix, a good friend, who is well known in the field of laparoscopic surgery and who has trained as an oncologic surgeon. I wii see him on Monday. I think he can remove this tumor using laparoscopic technique, with relatively little morbidity. Hopefully this will happen in the next week or so before I develop a small bowel obstruction. After that, who knows? Chemotherapy? Watch and wait for the next mole to pop up? It may be a while before I get some answers. 
I would not have been surprised to see liver or lung metastases on this examination. In fact, I was almost expecting liver metastases to account for the indigestion. This was a shocker, and speaks to the variability of this disease.
Well, I still will not give up. If the bowel lesion is removed and is confined to the bowel, and the mediastinal lesion is not growing, maybe we can get rid of every trace of this bully for good.

Tuesday, March 15, 2011

Returning From Hawaii Cruise

Tomorrow, we leave the Golden Princess after a wonderful two week cruise to Hawaii.
It will be back to real life with a CT scan on Thursday and an appointment with Dr. Flam the following Tuesday. Once again, I am cautiously optimistic that there will be no new disease, but if there is, I am prepared to face whatever treatments will be required, likely Chemotherapy.
Wish me luck. I will post the results when I have them.