CharlesCancerBlog

The objective for today, May 1, 2008, was to determine if the “hot spots” located in the center of the chest as seen on the PET scan and related lymph nodes were cancerous or not.

Jana and I arose at 4:45 AM to get to the NMH Same Day Surgery Check-in on the 5th floor of Galter Pavillion at 6:00 AM. Surgery was scheduled to start at 7:30 for two procedures. I was to be out by 12 noon.

During the preoperative consult, Dr. Woo, the anesthesiologist, described some of the complications of anesthesia during the lobectomy. The lung that is being operated on must be inactive while the other lung must continue to breathe and oxygenate the blood. He did not explain how it is done, but we were amazed that it could be done at all.

After my varicocele surgery at NYU in 1973, the recovery room staff had complained that they had a hard time waking me up. I just wanted to continue sleeping. They had to keep reminding me to breathe deeply. This time I was told that there had been a lot of improvements in anesthesiology and I would come to consciousness very quickly.

The first procedure was a bronchoscopy. A flexible fiber-optic scope is inserted down the windpipe and bronchial tubes to make a visual inspection.

The second procedure was a mediastinoscopy. A 2″ incision was made between and just above the collarbones. A scope was inserted to examine the lymph nodes and to take tissue samples. These have been sent to pathology for biopsy. Results will be available on Monday.

The two procedures required about 15 minutes to prep me in the OR and 30 minutes to complete. After the procedure Dr. De Hoyos, met with Jana in the family waiting room and reported that both the area inside and outside of the lungs, and the lymph nodes all looked healthy. He said that he would be shocked if there were any cancer.

I regained consciousness when I was rolled into an elevator for the trip from the OR on the 7th floor to post anesthesiology care unit on the 5th. Vitals were monitored. I was given a wet sponge to suck on and ended up waiting there for an hour and a half because no rooms were available in recovery.

Before leaving recovery, I had to eat something (a turkey sandwich - it’s always turkey), drink some fluids, take a pain pill, urinate, and walk around briefly.

We ate lunch in the hospital cafeteria and were home by 1:00 PM. Later, Jana and I realized that this minor exploratory surgery areas were. How to get from one to the other. Etc.

After the visit, it began to sink in that now there was an unexpected second surgery. Each step seems to open up more issues and concerns.

While surfing the net, I came across a report by a woman who had had a lobectomy to remove a cancerous tumor. Numerous things went wrong. Despite being told her heart was in good shape, she had a heart attach on the operating table. In performing the lobectomy the doctors found that it had spread to the lymph nodes and was more extensive than had been shown on the CT scan. Her supposedly stage 1 cancer had turned out to be stage 3, and she was having chemotherapy.

At first, the story was frightening. But then I realized why a PET scan, stress test and pulmonary function test were all necessary and was very thankful for the excellent medical care and that I was receiving. If this woman had had a PET scan, the extent of the cancer might have been determined before the surgery, and the course of treatment would have been adjusted. Had she had a stress test, perhaps a weakness in the heart might have been revealed. Yes, I was fortunate to be at NMH and have the best care available.

During this office visit (with Jana taking notes), we were told that the stress, pulmonary and blood tests had cleared me for surgery, but the PET scan had not only shown the tumor in the upper left lobe but indicated some “hot spots” in the center of the chest where the two lungs join. This would require some exploratory surgery to determine the source. If it were cancer, then the treatment plan would be very different because the cancer would not have been confined to the single primary site that had been identified. If the biopsy of the lymph nodes were negative, then the only sign of cancer revealed by the PET scan was the original nodule in my left lung.

Dr. deHoyos reviewed the risks of the surgeries in detail. I signed the release forms for the two surgical procedures.

To avoid further delays, the exploratory surgery was scheduled for Thursday morning. Jana and I wanted to allow time to visit our house in Michigan before the lobectomy (we had not been there for over 7 weeks) and still keep the surgery scheduled for May 12.

A blood T&C (type and cross reference) test had to be completed so Jana and I went to the pre-op testing area immediately. Afterward, it was 1:30 PM and we decided to eat lunch before going home.

Monday, I was called and told that Dr. De Hoyos had the results of my tests, that I would not have the “brachy” procedure but a lobectomy, and that I should schedule an office visit.

To keep the momentum moving, I scheduled the office visit for the next day, Tuesday.

Jana and I considered the likely outcomes and concluded that the PET scan must have identified some inflammation left over from a recent bout of viral infection that had centered in the lungs. We looked to the exploratory surgery for confirmation.

Dr. De Hoyos had scheduled three final pre-surgery tests for a few days after I returned from Birmingham.

Until now, I had no idea what a PET scan was, how it worked or what it could identify. It is truly amazing. The Nuclear Medicine department performs these scans. PET stands for Positron Emission Tomography. Evidently, the technique was first used to differentiate healthy and unhealthy cardiovascular tissue.

The PET scanner detects radioactivity in the body. The location of the radioactivity is a result of the carrier and its interaction with cells. For cancer a radioactive glucose is injected in a person’s vein. It is quickly distributed throughout the body. Healthy cells process and waste the glucose in a short period of time. Cancerous cells (and other inflammation) hold on to the glucose. So the radioactivity is left in locations of possible/probable cancerous cells.

The scanner looks like a CT scanner; it is a donut ring with a long, too narrow (12-14″ wide), movable table passing through it. I rested for 45 minutes after the injection. Then I was placed on the table. I held my arms along my side. Large elastic bands were wrapped around them and my body to hold the arms in place and to make sure I would not fall off the table. Another band wrapped the feet together so the legs would be held in place. At this point, I began to understand why they asked if I was claustrophobic.

The scanner scans about 6″ at each pass and then the table moves a comparable distance. Each scan takes about 10-11 minutes. The process is repeated until the entire body from the crotch to the top of the head has been scanned. Because I am so tall it took 77 minutes to complete the scans. By the time it is over, my arms were asleep, my back was aching, and claustrophobia is beginning to increase.

I arrived at six to sign in. I had been told that the PET scan would take two to three hours; the stress test, two hours; and about an hour for the pulmonary function test. With waiting time, I was to be out no later than 12:30 PM. To my surprise, I was out by 10:30.

Researching on the internet I found the following factoids (which might even be true):

BAC is most common among women who never smoked.

Thirty years ago, BAC accounted for about 12% of all lung cancers.

BAC now accounts for 40% of all lung cancers.

Stage 1 lung cancer has a 5 year survival rate of 75%.

Jana and I met with Dr. deHoyos. This was the first meeting. He walked in with a model of the left lung (with little schooling in biology, I had not thought about it, but of course the left and right lungs are not symmetrical - for one thing the left has the heart right next to it). He described the options and how they depended on tests that I should undergo.

There were three primary options.

The decision of which to use would be based on the results of the tests. The PET scan can identify cancerous cells in the body. The pulmonary function tests determines if removal of a lobe would still leave one with adequate lung capacity. The stress test determines ones heart’s ability to handle the prolonged anesthesia and surgery.

If the heart is unable to withstand the stress, the only option is chemotherapy. If removal of the upper lobe would make the lungs unable to perform adequately, a segmentectomy would be performed rather than a lobectomy. If the PET scan revealed other cancer, then surgery might not be a possible treatment; but there were lots of issues to be considered and until we had results from the tests it was impossible to say.

Immediately after the office visit we left for the airport to fly to Birmingham for Mother’s grave side service and memorial service on the following day.

At first, I had thought this physical exam was unnecessary, but it did turn out later that the surgeon appreciated my primary care doctor’s update of my health and ability to handle the surgery.

Back to outpatient radiology for another chest xray. Then the escorted walk to IR where I learned that the air pocket had not returned. They had me lie down, took the tape off the vent, and as if by magic removed the vent by just yanking it toward my feet.

I was shocked when I saw that the tube that had been inside my chest was almost 5″ long.

Immediately afterward, I talked to Helen, my sister, and we agreed to try to hold the memorial service for Mother on the next Thursday, the day after I was free to fly.

About 6:30 PM Dr. Becker called with the pathology report. While not definitely conclusive, in all probability the cells contained BAC. I was referred to Dr. De Hoyos for the surgery.

Less than an hour later, my sister Helen called to let me know that Mother had died. She had been more or less unconscious for the last day. Cancer had killed her mother and it became the great fear in our family. At least she did not have to face my having cancer. But her death on top of the pathologist’s report was emotionally traumatic, to say the least.

I had been told that I could not travel by airplane with a partially collapsed lung.