CharlesCancerBlog

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.

When I saw Dr. Rosenbaum in July, I asked him about the follow-up lung CT scan with contrast. He gave me an order for the scan. I then waited a month to schedule it

Again the radiologist saw something unexpected but still indiscernible. Dr. Rosenbaum then told me I needed to see a pulmonary specialist and referred me to Dr. Frank Becker. I set up the appointment.

After checking prices, I selected Heart Check America for the lung CT scan that I was going to have to pay for. Their price was $650 compared to $850 at Northwestern Memorial Hospital (NMH).

The whole office, waiting area and exam areas, was “the pits.” Worn surfaces, cheap seating. The space felt dirty and border line derelict.

After a 20 minute wait, I was ushered into the CT Scan room, told to lie on the table, hold my arms over my head, remain still while the table moved me through the donut shaped scanner.

Two days later the radiologist’s report arrive by email. I could understand nothing except I should have a follow-up CT Scan with contrast in six months because the radiologist could not discern what a grey area on the CT scan was.

Around the fall of 2005 my internist, Dr. Rosenbaum, recommended that I get a CT scan of my lungs. I had smoked until 1985 (for the 28 prior years) and was experiencing bronchitis or pneumonia every year or two.

He explained that with the new CT scans they can see much smaller growths on the lungs than had been possible. My symptoms could be early indication of lung cancer. Of course, when I quit smoking I was told that in 10 years your lungs rejuvenate so that they are as if you never smoked.

I put off doing anything about it, until Peter Jennings was diagnosed with lung cancer. He too had quit twenty years before, but now he was going to die. So at my annual physical in 2006, I asked Dr. Rosenbaum about arranging a CT scan. He said I was in luck and gave me a number to call for an appointment for a free CT scan. Insurance companies and medicare do not cover these diagnostic techniques without symptoms.

NMH had a grant to evaluate the scans for early detection of cancer. When I arrived for my appointment I was told that the study had already been closed; they were taking no new subjects. They called NMH outpatient radiology and told me that they could schedule me for $850. I decided to price out the options.