CharlesCancerBlog

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.

As instructed, I returned to the Interventional Radiology Department for a chest x-ray to see if the air bubble was being absorbed and the lung was expanding to fill the void. But I was told that they could not perform the chest xray at IR, I would have to go to Outpatient Radiology. I argued but was told that was policy.

Unfortunately, the bubble was still there. It was decided to place a vent tube in my chest to the air bubble, suck the air out place a vent in case more air leaked out of the lung. I had to wait until a radiologist would be available and until 4 hours after my morning meal, which was very late since we slept in. Plus, I had driven in and would not be able to drive home after being anesthetized. I took the car home and got Jana and we took a taxi back.

Placing the vent is minor, outpatient surgery and is done with a combination of local anesthesia and a “twilighting” anesthesia that puts you in a semi-conscious state (I think I was unconscious for part of the time). I was sent back to the recovery area, where Jana met me. They had me wait a short time to make sure I was fully conscious and then released me with instructions to return in two days to make sure that the lung was fully expanded. When they told me to return to IR for an xray, I said, “No, I’ve been through this before. I should go to outpatient radiology.” After a while the radiologist returned to say I was correct.

When I finally removed my clothes and looked at the vent, this is what I saw. The tube enters the chest at the lower end of the vent (the white box) and extends vertically up about 5 inches into what was the air pocket.

If the air bubble did not reoccur, I would be able to take the plane to Birmingham for my mother’s memorial service in a week.

At 6:00 AM on Tuesday, I checked into Interventional Radiology for my needle biopsy.

A needle biopsy is done by inserting a needle in the chest and into the lung. It is guided by a series of CT scans. To select the starting point, they place a grid over the general area of the tumor. Grid lines were spaced about a centimeter each way. I assume the lines show up on a CT image. The radiologist can select a point to insert the needle which will miss a rib and will allow a clear path to the tumor. Mid-course corrections are made as necessary guided by CT scans until the needle is at the tumor.

When the radiologist is certain that the needle is at the site, cells are extracted. As I understand, a slide is made and then someone determines that the sample is adequate for a pathology determination. In any case, they took two samples from my tumor.

What makes this all tolerable is anesthesia. First, you are given a local anesthetic. Then a light anesthesia that maintains half consciousness. Nevertheless, I averted by eyes when they began to insert the needle. You can take directions for simple actions but little more. It is very similar to anesthesia for a colonoscopy.

One of the interesting experiences of the process was how comforting a warm blanket can be. They roll you into the CT scanner room and you are transferred to the CT scanner table. The room is cold, but not so cold that you are aware of it. Then they bring in a warm blanked and cover you with it. It is not only physically comforting but emotionally relaxing.

When I left the room and was being rolled back to recovery, I had terrible chest pains (maybe 7 on the 1 to 10 pain scale). I was immediately hooked up for a ECG, which was normal. After a while the pain subsided somewhat.

In an hour I was sent in for a chest xray. I was unable to stand up so they took the xray with the film against by back as I lay on the gurney.

Back to recovery where I was told that there was a small air pocket between my lung and the pleura. I would have to wait another hour for a follow up xray. What I later realized was that the air that leaked into the interstitial space from my lung had resulted in a partial lung collapse.

The second xray showed no change. I could not eat or have liquids because if they decided to insert a tube to suck the air out of the air bubble I would go into surgery under anesthesia which has to be done on an empty stomach.

This continued through a total of four or five chest xrays, I can’t even remember at this time. By the third I was able to get off the gurney and stand up for the xray.

At a little after 4:00 pm after the last xray, I was sent home with instructions to return the next day to make sure that the lung collapse was being corrected. If it did not, I would have to have a vent installed.

I had not eaten anything since 8 the night before nor had any liquid other than melting ice that was offered in the recovery area; so Jana and I went to the cafeteria for some refreshments.

I went home in some discomfort but by morning I was feeling fine. I was sure that the air bubble had disappeared and that my lung had returned to normal.

I had a CT scan scheduled for 11 AM and then an appointment with Dr. Becker after lunch. By the time we met, he had reviewed the CT scan. He began with telling me there was some good news and some bad news. The bad news was that there was an 80-85% chance that I had cancer. I guess the good news was that it was probably Bronchiolo-alveolar Carcinoma (BAC) and was apparently early stage, or that it still could be something else.

He took me to a computer station and pulled up the CT images from October and the current one. Side by side the change was apparent; the edges were more definite and in the latter image there were branch-like or root-like forms within the area of the tumor.

Dr. Becker explained that if the nodule was cancerous and was BAC, it would most likely be operable. They might take out the entire upper left lobe or just take out the nodule. Taking out the lobe was the usually preferred operation. I somehow came out with a cavalier attitude and told a number of people that if it were cancerous, they would just whack off the upper left lobe. Later after I learned more, I realized that it was not so simple.

I did ask him about the long-term effect of having the upper lobe removed. He told me that the upper lobe accounts for 30% of the left lungs capacity. But that the lower lobes were where the bulk of the work was done. So it should not effect me very much, and that I might not even notice it in daily life. He did add that I would not be capable of running a marathon. (But then I’m not capable now.)

Dr. Becker planned to review the CT scans with several of the pulmonary surgeons at NWMFF to discuss the recommended course of action but suggested that a needle biopsy would be justified.

Two days later, he called to tell me that everyone agreed that a needle biopsy was recommended. It was scheduled to take place in less than two weeks.

On reflection we have realized how lucky I have been. First, I had Dr. Rosenbaum pushing me to get the CT scan in the first place. Secondly, had I not delayed getting that scan, the nodule might not have been evident, and I would have believed that everything was o.k. until it was too late.

This was probably the best, most satisfying, doctor visits that I have ever had. I arrived for my appointment and was almost immediately called in to see the doctor.

Dr. Becker started with “I have reviewed your CT scan and …” Before seeing me he had studied the information that was available - the CT scans, the medical records available at the Northwestern Medical Faculty Foundation computer system. He knew what medications I was taking. He knew I had RA, BPH and arrhythmia. He did a simple physical exam, concentrating on the lungs and heart, and asked about my medical history.

He interpreted the radiologists findings in simple, clear terms and outlined a number of alternatives to explain the unknown feature on my lungs. They were:

He recommended that I have a follow-up CT scan in six months and see him the same day a few hours after the scan. I was given a TB test which turned out to be negative.

I left with the knowledge that this doctor knew his stuff, was diligent and thorough, and extremely professional.