Dilatation for Today, Almost an Emergency

This morning, after taking my Hydrocodone-Homatropine cough syrup and 2 small pills, I tried a mouthful of well chewed Rice Krispies. It would not go down, In fact, for the next 45 minutes, nothing would go down, not even my own saliva and I was having severe pain. There were lots of oral secretions which I had to spit out, and with coughing, some of the cereal came back up.  I could not even drink my coffee.
This is significant progression of symptoms. Yesterday, I was able to eat a whole bowl of cereal without much discomfort.
I attribute this to flow dynamics. The flow through a tube is related to the 4th power of the diameter. Reduce the diameter by 1/2, and the flow rate is reduced to 1/16.
The symptoms now have abated somewhat.
My appointment with Dr. Lewis is for 3:00 PM but he has thankfully moved me up to 1:00 PM.
I will post again when I get home.

Another Complication of Radiation Treatment

As I reported in my previous post, I am having difficulty eating. I get spasms of pain which appear to come from my lower esophagus. The pain is worse later in the day, and is worse with eating dry solid foods. Liquids go down better, and in the morning, I can eat my Rice Krispies with raisins, banana and blueberries without these spasms. Pudding,  ice cream and yogurt are OK. Today, I called Dr. Flam and asked to see him. He had come back from vacation earlier than I thought, and I was there at 4:00 PM. The office was surprisingly busy. I got my port flushed and had labs which are stable. I have not lost weight. A chest X-Ray showed improvement from the previous, and I was better able to take a deeper breath. I realized that in that respect, I am significantly improved. Dr. Flam is quite certain that this is not due to recurrence of Merkel Cell carcinoma but is a stricture of the esophagus due to radiation. He called my gastroenterologist, Dr. Robert Lewis to set up an appointment for an esopho-gastroscopy  and dilatation of the stricture, but it was too late to reach him. I expect this to be scheduled tomorrow, and hopefully to be done by early next week. In the meanwhile, I am to have only liquids and "pureed food". "No bagels and lox" in the words of Dr. Flam.
Stricture of the esophagus is a relatively common complication of radiation treatment and usually responds well to balloon dilatation. The major complication of rupture of the esophagus is relatively rare, less than 1% for all strictures, but greater for radiation strictures. The procedure may have to be repeated more than once as the stricture has a tendency to recur.
I think it will be an out-patient procedure.
It is of interest that I am feeling otherwise quite well and am functioning at a good level.
I will report a follow-up when I have more information.

First Update for 2012. Google Ads Pay Out!

I received a check from Google for ad revenue from my blog. $100.95 was sent to me as a result of people reading my blog and clicking on the ads Google places on the right side of the posts. As a result, I am matching the amount and sending $201.90 to the University of Washington care of Dr Nghiem to be used for research into Merkel cell carcinoma.
I was home alone for almost a week as Judy went to the Renaissance meeting in Charlotte mainly to take care of Eva, Sara and Bel. She left last Tuesday and came back yesterday. I worked 4 full days while she was gone, and managed to handle the work well, although I was tired by the end of the day. While at home, I watched a DVD of Season 3 of 24, all 24 episodes, and read a book of 850 pages, 11/22/63, a science fiction thriller by Stephen King.
I am feeling quite well, but there are some symptoms. Apart from the dry mouth, hearing loss and neuropathy, I have gradually been developing discomfort on swallowing, particularly dry foods. There have been episodes of heartburn. I thought this was due to a virus as I was in contact with my contagious grandchildren during our family cruise. However, I now think I am developing a radiation stricture of my esophagus. I will mention this to Dr. Flam when I see him on January 18. I think there is little to do now, unless it gets worse. If it is due to new tumor growth, the area has had a full dose of  radiation and I doubt if any more chemotherapy will be effective. Right now, it is not a quality of life issue.
Treatment, if needed would likely be balloon dilation of the esophagus, which I am reluctant to undergo at this stage.
My shortness of breath and cough have improved but I continue to take a narcotic every morning for the cough. (Just a small dose, I am not addicted.)


Here is a story from my youth. It teaches about life and death.

The Mouse and the Minnow Trap.

When I was about 10 years old, I used to go to the country with my parents and my brothers. My parents would rent a cabin by the side of the lake and there were quite a few children of similar age to me we spent the summer there.

One day, we found a mouse in a minnow trap. We kept the minnow trap and a small locker when it was not in use. There was still some bread inside it, and when in the water, was very efficient at catching small fish. It was somewhat cylindrical in shape, with conical openings at either end. These openings allow the fish to swim in, but then they couldn't find the openings to get out. It worked very well on this little mouse which got caught inside.

We had a long discussion about what to do with this mouse. I think the consensus was that we would submerge the minnow trap in the lake until the mouse drowned and then dissect it. You have to realize that this time, we were young children who had no significant ideas about life and death, pain and torture. At that age, you thought you would live forever. Time subjectively seem to pass much lower. A week off from school was a very long time. All summer away from school was an eternity.

My mother saw this group of children in serious discussion, and decided to intervene. She asked what was going on and we told her. She made the decision. We had to let the mouse go. We argued, but my mother was the boss. So we opened the minnow trap, and the mouse  scurried away. He didn't get very far, as the dog, who was watching this with some interest, pounced on the mouse, and within a heartbeat, the mouse was dead.

There is a lesson to be learned from this. Men may be cruel, but nature can be just as cruel.

We're Back!!!

We're back from the cruise. I'm going to divide this post into 2 portions. The 1st will deal with my health status. The 2nd will deal with a description of the cruise and associated events.


Part 1. My health status.
A few days ago, I was thinking to myself that since I began radiation treatments, I have never felt better. My cough and shortness of breath have significantly improved. My exercise tolerance has improved. I even climbed 3 flights of stairs at one point during this cruise. But peripheral neuropathy has changed little, but I think that the extent of the neuropathy has decreased in that there is less loss of sensation in the mid-calf level than there was. Before the cruise, I complained of some pain which appeared to come from the area one of my right lower ribs. Of course, whenever there is unexplained pain, one immediately thinks that it may be metastatic disease. However I think that I must've pulled a muscle while coughing, as the pain has gone away. 
At the end of the cruise, on Friday night, I began to have severe heartburn. This became substantially worse on Saturday and Saturday night. I have had some difficulty explaining this. It felt like heartburn in that it was a burning pain centered on the lower chest, just like  heartburn that I used to have before I began taking Prilosec. However it did not seem to be related to acid reflux as I have been on full doses of Prilosec, and the pain seemed to be at its worst right after  and during eating.  On about 2 occasions, the pain was so severe that I was postulating that may have torn the mucosa of the esophagus.  Of course, when this happens, one immediately becomes convinced that there is now metastatic disease or that the tumor in my lower esophagus has again begun to grow. However I am now theorizing that this was due to viral infection as I was exposed significantly during this cruise as I will describe below. In fact, I am feeling significantly better, and this pain has almost completely gone away.
In summary, I am back to thinking  optimistically, that, knock on wood, I'm feeling about as well as I have ever since I began radiation treatments.


Part 2. The Family Cruise

The photo above was taken on the 2nd formal night of the family cruise. Standing from left to right, are Mike, our youngest son, Leanna, his wife, Brian, our middle son, Dana, Gary's wife, and Gary, our oldest son. Sitting are Judy and me. To my left is Eva, our oldest granddaughter, Age 10 1/2. The bottom row consists of Sara, Eli, Bel, and Sammie.  Sara, 4 1/2  and Bel,  2 1/2 belong to Gary and Dana. Sammie 3 1/2 and Eli 1 1/2  belong to Mike and Leanna.

The cruise began with numerous fiascoes. Mike and his family together with Judy and  I  all stayed at the Holiday Inn in Long Beach. There was supposed to be a free shuttle going to the terminal from the hotel, and we could park the car for a week at no additional charge. It turned out that the shuttle only went to the Long Beach port and our cruise was taking off from San Pedro. we needed to get a shuttle to take us to the cruise terminal, and it was quite a job fitting all the luggage into that shuttle, (not free).

There was a virus going around, and Sara  was sick, and we were not sure that we would be able to get onto the ship. They do have a health questionnaire, and they have the right to bar access to the  cruise if they feel that a person may be a health risk to passengers.  However everybody managed to meet on board ship and get underway.

The premise was that for the family cruise, everybody would be on their own, but we would all meet for dinner. In fact, most of the time, we were together. This was very nice, but did involve more babysitting for Judy than she had anticipated. The 1st two family dinners were terribly disorganized. The wait staff was particularly slow, and this exceeded the patience of the grandchildren.  There were lots of requests for special orders for the small children, and this somewhat overburdened the waiter and his assistant. By the time we had the 3rd dinner, after I spoke to the maître d', the situation was fairly well resolved. However there were many instances where grandchildren had to be taken out of the dining room and food for the parents was sent to the room.

There is an excellent children's program on board the ship. However 2 of the grandchildren were too young to stay there without adult supervision. Much of the time, the adult supervisor was Judy.

In the middle of the cruise, Sammie  ran a fever of up to 104. She did not seem nearly as sick as that number would indicate. However clearly, there was a virus involved.

In Cabo San Lucas, Brian took Eva  ziplining,  and that was a highlight for them. On the last night, there was another fiasco. Eva and Sarah disappeared and were nowhere to be found. There is nothing so terrifying as the disappearance of children. We had the whole ship's crew searching for them, and they turned up at a dance club, where they were having a great time dancing as everybody else was searching.

At the end of the cruise, we all went our separate ways. However everybody but Brian ended up meeting for lunch just south of Bakersfield on the way home. Mike and his family stayed over at our house as it would be too long a trip to drive all the way to San Jose where they were going to stay with  her parents for a week. This is the time when Eli became ill. He spent the whole night crying and could not be soothed enough to get some sleep. On Sunday morning, they took him to a pediatrician, who said that this was a viral infection. We had suspected that it might be an ear infection.

By Sunday at noon, our house was finally quiet. The cruise was over. We were left with fond memories, and viral infections.

Hurray! I don't have a Doctor's Appointment for Today

It's a Wednesday, and I don't have to see Dr. Flam today. In fact, I don't have to see him for another 6 weeks. I will need my port flushed 2 weeks from today.
I am feeling somewhat better. Although I am still short of breath, I can take a deeper breath without coughing. The cough syrup helps. It does contain a narcotic, so I try to take it only in the morning.
My neuropathy has changed a little. Occasionally, I do have some pain in my feet. This is new. However, there appears to be less numbness above the ankles than there was previously. My hands show little change. My mouth is still quite dry, and it makes many foods unappetizing. This includes bread, cake, and cookies. However my sense of taste has substantially improved, and is close to normal.
On Friday, we will drive to Los Angeles and stay over at the Holiday Inn in Long Beach. On Saturday, we will embark on our family cruise to the Mexican Riviera. (These days, the Mexican Riviera includes only Ensenada  and Cabo San Lucas.) There are no other stops. Whether this is because Princess Cruises is trying to save money, or because of unrest in Mexico, is uncertain. This is a vacation we've been planning for some time. It is a real family cruise. It will include our 3 sons, 2 daughters-in-law, and 5 grandchildren. When we planned this, I was hoping I could go, but I was not very confident that I would be in good enough health to enjoy it.  It seems to have worked out well.
We have now booked another cruise, this time, to Hawaii, at the end of February. I am very optimistic about this one.
I have been working about 3 mornings  a week at Kaiser Permanente,  and plan to work 4 full days at  Sierra  Imaging  at the end of December.
In other news,  the IRS has disallowed the deduction I took for the Ponzi scheme that I was a victim of. My  file was sent to Atlanta, but the agent who reviewed my tax return did not have the entire tax return but only the numbers to review. They didn't bother to give him the supporting documentation. Of course, he disallowed what was classified as a miscellaneous deduction. The IRS then stalled the case until the deadline for me to go to Tax Court was so close, that the case would not be reviewed in time. I think that the agent who receive the case in Atlanta did not want to have anything to do with it, and so just delayed to force me to go to Tax Court. This is an annoying bump in the road, and  I would be much more upset, I'm sure, if I did not have the experience of having to fight a malignant neoplasm. That helped put these minor annoyances into their proper perspectives.
I will conclude this post, and hopefully future posts, with an anecdote from the past.
One day I was doing a carotid angiogram. These examinations are done with the patient awake, although sedated. We were most interested in the region of the origin of the internal carotid artery in the neck, but had some interest in the branches at the base of the skull. When the catheter was in place, I was giving instructions to the technologist as to how to position the patient. The conversation went as follows.
Me: "It's important that we get the neck in this patient and not so important that we have the entire brain."
Technologist,  after setting up the equipment, “Is this okay?”
Me: “No. I don't care if you cut off the top of the patient's head. Just make sure you get the neck on”.
Patient:  “I care. Don't cut off the top of my head!”
 The moral of this little story is: Be  careful of what you say, because you don't know who may be listening.

Not Much New, So I Tell the Story of Sadie Cohen

It has been a while since I posted to this blog. That is because there has not been much change. I did visit Dr. Flam on November 9. My labs were unchanged, and my chest X-ray showed little change. because of continuing cough and shortness of breath, he ordered a CT scan of my chest. That was done on Nov 10. I looked at the images but do not have them to post. I would describe the findings using a term I coined. "Mixed Change". That is, somewhat better in the right upper lung annd somewhat worse in the right lower lung and the same on the left. No change was seen in my posterior mediastinum, the site of the only known tumor, which I hope is totally inactive. No liver metastases are seen. I will get the full report when I see Dr. Flam on Wednesday. I still have shortness of breath and a cough, The cough responds well to Hydrocodone/homatropine cough syrop. It allows me to dictate reports with little interruptions for a coughing break.  Drug Info 
This is a narcotic with potential for addiction. Apparently the Homatropine is added to stop people from taking too much at a time. It also helps me sleep all night as the homatropine prevents bladder spasm. Constipation is a side effect but so far has not been too much of a problem. My other symptoms are stable. Dry mouth, arm and leg numbness and hearing loss have not changed and are not too debilitating.
I have been working half days at Kaiser and even worked a full day at Sierra Imaging. 
I was taking Vitamin B Complex, tablets from CVS. On my CT scan, I could see the tablets intact in my colon. Needless to say, they could not be very effective in treating peripheral neuropathy.
We have an addition to the family, sort of. Our oldest granddaughter Eva has a baby (half) brother born yesterday to her mother and stepfather. 


Since I have no more news, I will tell the story of a patient from my internship who I will call Sadie Cohen. 
Sadie was an elderly Jewish diabetic being treated for an ulcer in her foot, with the hope of preventing an amputation. She had Alzheimer's disease and was in pain She would lie in bed constantly moaning oy-oy-oy-oy-oy as only an old Jewish lady could. It was my job to keep her IV running and she would be constantly pulling at it until she dislodged it. There were no ports or PICC lines back then. They were calling me at all times to restart the IV. When I would stick her with the needle, you would hear "oy-oy-oy-oy-GEVALT-GEVALT-GEVALT! Because of this, I invented the decoy IV, some tubing taped to the arm above the real IV. When she pulled this off, the nurse could replace it.
One day I was called to see her because she was in a coma. I checked the IV fluids and there was an error in pharmacy. Too much insulin had been added to the IV. I gave her an injection of Glucose, and a few seconds after I gave the injection, I heard "oy-oy-oy-oy-oy". I knew she was back to normal. (for her).

Some Random Observations About MCC and Me

This is my 100th post.


Here is a graph showing survival of patients with Merkel Cell Carcinoma by stage at the time of diagnosis.

Relative survival for 2,856 Merkel cell carcinoma patients by stage according to the 2009 AJCC staging system. Percent relative survival was calculated for cases in the National Cancer Database using age- and sex-matched control data from the Centers for Disease Control and Prevention. Stages are as indicated in the figure except for Stage IIIA which could not be derived using this dataset. The curve marked “IIIA*” represents pathologically node positive patients, with the clinical node status unknown or negative. It is anticipated that true Stage IIIA patients (clinical node status negative) have better survival than the line marked with “IIIA*.” Total number of patients was 2,856, and individual substages were as follows: IA = 266, IB = 754, IIA = 124, IIB = 414, IIC = 84, IIIA* = 794, IIIB = 143, IV = 277.  From AJCC Staging Manual 2009.

This refers to stage  at the time of initial diagnosis. I was stage IIB at the time of diagnosis, but I would classify myself as Stage IV diagnosed on November 24, 2010, about 11 months ago. If I can survive another 13 months, I will fall into that 20% who survive long term. Those who survive 2 years almost all are long term survivors.
These patients who survive stage IV undoubtedly have had chemotherapy, so I submit my thesis that, in spite of what Dr. Nghiem says, chemotherapy can prolong survival in Merkel Cell carcinoma.




Al Davis, famed and notorious owner of the Oakland (and Los Angeles) Raiders died last week. I have seen his death certificate on the internet. He supposedly died of heart disease and he had a history of cardiomyopathy. He supposedly died of ventricular fibrillation. He also had Merkel Cell Carcinoma, and had undergone a procedure for dysphagia (difficulty swallowing) a few days before his death. I submit that the full story has not been told. I suspect he died of complications of Merkel Cell Carcinoma.


Bridge. The Fresno Sectional Bridge Tournament was held last week. I played in all 8 sessions, and for the first time since I came to Fresno in 1976, I won the Presidents Trophy for winning the most masterpoints. Thanks to my partners, Bert Rettner and Mark Stern.


So how am I doing? I feel pretty good these days, but my shortness of breath has not improved. The worst symptom of this is inability to speak very long without coughing. This bothers me most when working, as I spend all the time dictating reports into Dragon 10 Medical. The software does a good job of ignoring my coughing. I am using cough drops and taking cough syrup at night, and have few symptoms when not speaking.
My neuropathy has not changed.
I will see Dr. Flam next Tuesday and will discuss  possible treatment with corticosteroids.