A rough week then a visit to the Emergency Dept

This has definitely been my hardest non-chemo week.  So far I have not recovered from the last round of chemo, I have felt quite ill most of the week (as if I have a cold or mild flu) but I am very sure the problem is just the progressive effect of the chemo on my body.

Making matters worse, I have had a painful left knee for most of the week, just moderate pain, but it has slowed me down and is quite debilitating.  I have had this sort of pain in my left knee before, since an ankle injury about 5 years ago, so I was not too concerned.  By Saturday morning the pain had resolved and my left knee feels fine now.

However late Friday a sharper pain appeared in my right knee, it was much worse than that in my left knee and made movement very painful.  On Saturday I found that panadol did provide some relief - panadol does generally work well for me.  Come Sunday morning and my knee was up like a balloon and I felt I needed to take some action.  My chemo "rules" require me to call the oncology unit if anything unexpected happened, so I called them at 8:00 AM this morning and explained the situation.  By 8:30 AM they called me back, after referring to an oncologist.  They strongly recommended that I report to the Emergency Department of Christchurch Hospital.  They suggested I turn up at 11:00 AM as by then the Registrars and Consultants would have finished ward rounds and should be available for me.

We arrived at about 11:00 AM and were taken straight in to the ED, due to my green chemo card which puts me high up on the triage process.  I did feel a bit sorry for the others still waiting.  I was taken to an isolation room, to keep me away from all the sick people there.  Much blood was taken, tests were done, and fluid taken from my knee.  In total 60ml was extracted from my knee, to relieve the swelling.  The fluid was a light straw colour, which was good, apparently.  After another hour the results of the tests on the extracted liquid was that I have gout. I was not impressed at all, but apparently it is not unknown for chemo to trigger it.

The recommendation from the ED Doctor was to reduce alcohol, particularly red wine, shell fish and tennis.  This will be very hard to do for me as I don't drink any alcohol since going on chemo, don't like shell fish and the last time I played tennis (badly) was about 40 years ago.  They prescribed prendisone  and Ibuprofen.  I am not happy about the side effects of prendisone and will wait and see if there is any improvement on just panadol and ibuprofen  before I try it.

This week is a biggie in terms of hospital visits;

• Tuesday - CT Scanning
• Wednesday - Chemo starts
• Thursday - Meet with Sugeon to look at results of CT scan and consider and maybe plan surgery to Lung and Liver
• Friday - Chemo pump removed.

I will post an update here after the Thursday meeting.

Visit To The Surgical Clinic

We met today with Saxon Connor, my liver surgeon.  He described various options, but the key next step is to see what the CT scan, scheduled for 2nd August, turns up.  If it shows no more mets and shrinkage in the known ones then I am a candidate for surgery.  My CEA has dropped again, to 4.0 now, which is consistent with the chemo doing its job.

If there is no reduction in tumour size, and most likely it would be growing, then I have about 15 months left to enjoy.  This is worst case and in view of the CEA result, is highly unlikely.

Assuming a reduction then I can continue with the full 12 rounds of chemo (just done my 5th round) and then look at surgery, but this will cause some damage to my liver.

The other option, which we favour, is to finish this cycle of chemo, one more round to go, then take a break for a few weeks and have the lung tumor removed.  Then about 4 weeks later have the liver tumour out, along with any other suspicious bits.  Following recovery from surgery I would then have another 12 rounds of chemo.

The surgeon has booked an appointment for 4th August, by then my CT scan results would have been reviewed and he will have discussed my case with the oncologist and the cardio-thoracic team.

According to Saxon, I have a 20-30% chance of cure after this surgery and chemo, median survival is about 40 months.

Oncologist Visit

Today we met with the oncologist for a scheduled review after 2 cycles (4 rounds) of chemotherapy.

Just before we left I got an appointment in the mail with my liver surgeon, Saxon Connor.  The appointment is for next Thursday 21st July and likely means that he is assessing me for surgery in the near term.

We had quite a good session with the oncologist, with some focus on my down state on the Thursday through to Sunday after chemo.  The plan is that I will stop taking one of my anti-nausea medications, Dexamethasone.   I will need to be more aware of potential nausea and take additional medication if needed, but it should resolve some issues causing me real grief, including hiccups, insomnia and potentially depression during the black 4 days.

We talked about the potential for surgery and how many more chemo cycles I could or should have before surgery.  We discussed this paper, it proposed that under normal conditions I should have any liver surgery before having more than 6 rounds of chemo, that is the plan as long as all the right conditions are met, which means no more that 2 more rounds of chemo before a break.  The oncologist is scheduling a CT scan shortly to see if a break for surgery before the 6th round is appropriate.  It is possible, but remote, that my chemo cycle next week will be my last.

We also talked about the object in my lung.  It is not 100% confirmed as cancer because it did not light up during the PET scan.  It likely is a cancer met, but may be too small yet to be confirmed.  We are going to park consideration of it for now and see what happens with future scans.

A Great Result

Started next round of chemo today, all went OK, and I now have my infusion pump attached.

While in the chemo out-patients ward I asked if they had my latest CEA results, taken 10 days ago.  I was quite apprehensive even asking for the results because there was little chance they would be good so soon into chemo and because chemo can push the CEA levels up.

My earlier results were 2.7, 6.6, and recently 7.3.  Today's result is 6.1, that can only happen because the chemo is shrinking the tumour.  This is a really good result for me, and it means that surgery is most likely to be possible and effective.

I feel really good about this, but the logical part of me is waiting to see what develops....

Oncologist Update

Friday afternoon we went to the caravan at Glentunnel, we could only stay one night due to baby sitting duties, but we really needed to check that all was OK with the caravan as it had been 6 weeks since we were there last.  No problems with the caravan as such, but we got a frost of -2 C and the 1Kw oil heater inside did not cope well.

On returning home I spent about one hour water blasting 1/3 of our drive, I now feel like I have done the Coast to Coast race. The chemo is clearly having an inpact on my energy level.

On getting home there was a note from the oncologist, recording our last meeting.  Here is the relevant content:

Diagnosis:
13.10.06 Anterior resection for sigmoid carcinoma — T2NO (0/16) Dukes A adenocarcinoma.

26.05.10 Hepatic wedge resection segment 5 for CEA secreting solitary liver metastasis
Consideration adjuvant therapy, declined. For watchful monitoring with 3-monthly CEA and imaging on CEA rise.

Apr2011 Rising CEA. CT documents new right pulmonary 1.1cm nodule plus further 2cm segment border liver metastasis.

May2011 PET-CT confirms right middle lobe pulmonary lesion and FDG avid segment 8 hepatic metastasis, along with several subcentimetre foci specific for additional hepatic metastases
MRI liver confirms segment 8 35mm metastasis, however no clear evidence of metastases at the two other FDG avid areas 

ECOG performance status: 0 

I saw Tony today in outpatient clinic. He had seen my registrar the week earlier, but had some questions regarding the longer term management. His MRI scan has not demonstrated two of the small liver lesions emphasised on the PET. The feeling of the imaging border is that this may represent a false positive PET as MRI liver tends to be a more gold standard investigation.

I discussed with Tony that I envision that we would continue to manage him relatively aggressively. I would plan for him to proceed on with 3 cycles of FOLFOX, of which he has completed one. At this time, we would perform imaging with a CT scan of the chest, abdomen and pelvis to identify any evidence of response in the lesions. I would be hopeful that we would see a response given the slow disease growth pattern and recurrence, and the fact that he is chemo naive. His CEA is also a good marker of disease and, he believes, it is down as he relates the CEA also with a pattern of itch, which he feels has resolved since commencing the chemotherapy.

I’ve recommended that we reimage him after 3 cycles and assess the lung lesion, along with the liver lesion. The liver lesion, I believe, is resectable and we will give further thought to the merits of whether or not to investigate the PET areas with intraoperative ultrasound or other possibilities. With regards to the pulmonary lesion, we will base our decision making on if it responds to chemotherapy or not. Thought could be given to RFA or a lobectomy were an aggressive surgical path to be taken, but this would require control of his systemic disease with response in the liver and other sites.