Good News Today

I just realized that I hadn't mentioned that the day after I talked to Dr. Amatruda, I had a brain MRI done to check whether or not it had spread there as well. Oops. Sorry. It was on the Calendar in the sidebar.

Angie had been asking me whether or not I'd heard any results on the brain MRI I took last week. "When are you going to find out?" She was far more impatient than I was. I figured they'd tell me something when they had something to tell me, and that there wasn't really anything that being in a rush to find out would buy me.

So she called me up this afternoon and called to tell me that they had called the house and said that it turned out okay. Obligatory jokes ensued:

"What took them so long?" "They had to find it first, I guess."
"Maybe it was too small."

I was happy with the good results as soon as she said they'd called. I knew that if they weren't going to talk to me directly that it would be good news. And with her impatience, I think it was best that she took the call anyways.

So now it's onward to take care of the liver. I've pretty much switched over to Busch N/A these days. I do allow myself two non-consecutive Busch Lights a night. Angie tells me that has done wonders to curtail my obnoxious snoring. But the strangest side effect has been having an appetite. Oh, well. I'm sure I'll have more oddities to get used to in the near future. :p

Mayonnaise Jar and 2 Beers

When things in your life seem almost too much to handle, when 24 hours in a day are not enough, remember the mayonnaise jar and the 2 Beers.

A professor stood before his philosophy class and had some items in front of him. When the class began, he wordlessly picked up a very large and empty mayonnaise jar and proceeded to fill it with golf balls. He then asked the students if the jar was full. They agreed that it was.

The professor then picked up a box of pebbles and poured them into the jar He shook the jar lightly. The pebbles rolled into the open areas between the golf balls. He then asked the students again if the jar was full. They agreed it was.

The professor next picked up a box of sand and poured it into the jar. Of course, the sand filled up everything else. He asked once more if the jar was full. The students responded with a unanimous 'yes.'

The professor then produced two Beers from under the table and poured the entire contents into the jar effectively filling the empty space between the sand. The students laughed.

'Now,' said the professor as the laughter subsided, 'I want you to recognize that this jar represents your life. The golf balls are the important things---your family, your children, your health, your friends and your favorite passions---and if everything else was lost and only they remained, your life would still be full.

The pebbles are the other things that matter like your job, your house and your car.

The sand is everything else---the small stuff.

'If you put the sand into the jar first,' he continued, 'there is no room for the pebbles or the golf balls. The same goes for life. If you spend all your time and energy on the small stuff you will never have room for the things that are important to you.

'Pay attention to the things that are critical to your happiness. Spend time with your children. Spend time with your parents. Visit with grandparents. Take time to get medical checkups. Take your spouse out to dinner. Play another 18. There will always be time to clean the house and fix the disposal. Take care of the golf ball first---the things that really matter. Set your priorities. The rest is just sand.'

One of the students raised her hand and inquired what the Beer represented. The professor smiled and said, 'I'm glad you asked.' The Beer just shows you that no matter how full your life may seem, there's always room for a couple of Beers with a friend.'

I've heard this before, but it's worth sharing. Thanks, Andy.

Next Steps

I had another consultation with Dr. Amatruda today. We first went over bits and pieces and how I've been doing since the liver biopsy. And then we got into a next step being an MRI of the brain, to figure out if it may have spread there yet. And in a segue from what to do it it and spread, we then discussed some of the treatment options. I caught enough of what he said to surf for more information, which I found here.

Determining treatment options

The staging system for virtually every primary cancer is unique, identifying the progress of disease for that particular cancer. The stage of the cancer determines the treatment choices. For cancer confined to a specific area, local treatment may be used. Examples of local treatment include excision (surgical removal), or ablation, which means destroying the tumor with radiofrequency (high frequency energy), cryosurgery (freezing), or percutaneous alcohol (alcohol injection), or by blocking the blood supply to the tumor.

For this he referred me to Dr. Sielaff. I have a consultation set up, and I'm sure in the meantime he'll be reviewing my case. Following that consultation I will be undergoing one of the treatments to get rid of the liver cancer.

Following whatever that is going to be, Dr. Amatruda would like to get me to do one month of interferon, which sound less than fun. And after that, I believe he mentioned Leukine.

That may or may not work; so he also mentioned "Plan B", which amounts to trying other things, some experimental. There was some possibility of sending the tumor to California where some place might be able to create some sort of anti melanoma vaccine. If so, this one would be compatible, unlike my incompatibility with the Mayo one (mentioned here and here) he had presented earlier -- before my HLA test showed I wasn't the right type.

Music Break

Heather and I were jammin' to Dire Straits - Sultans of Swing (lyrics) last night and today.



Update: I've been having trouble with embedding the video.

Diagnosis

Recap

I got a copy of a letter from Dr. Amatruda to Dr. Korteum the other day. I thought Dr. Amatruda did a dandy job of clearly and concisely encapsulating the issues. With a few edits, here is what it said:

Today I had the opportunity to meet your patient Mr. David Sinkula. Thank you for referring this 38-year-old man. He was seen for medical oncology consultation regarding management of malignant melanoma which was just resected from his left shoulder.

Mr. Sinkula is a generally healthy man of 38. He works as a software engineer. He also has an avocation as a blogger. He does not have active medical problems. He acknowledges problems with anxiety and depression. He is currently on Zoloft 100 mg daily. He also notes [...] alcohol intake of probably ["more than two" --Dave] beers per night. He has been advised to cut this down because his liver tests have been off a bit in the past. He smokes about one pack per day.

About a year ago he had a scaling lesion taken off of his scalp. This was a seborrheic keratosis. He had an episode of atrial fibriliation about five years ago. This has not recurred. However, he had an episode of lightheadedness around June. He came to the emergency room and had no overall problems related to dizziness. However. they advised him to seek attention for a mole on his back. He described this as a lesion that blistered, got raised, then flattened out. and then began to raise up again. It had a pigmented area as part of it. You saw him and biopsied this. It was a melanoma 5.2 mm in depth down to Clark level IV. There were 4 mitoses per 10 high powered field. It was ulcerated. It was a T4b lesion. We recommended removal with sentinel node biopsy. Prior to this time he had a PET scan. The PET scan showed no abnormalities in the region of the melanoma. There were no supraclavicular, cervical. or axillary nodes. There was a small area in the dome of the liver of a nonspecific nature. There are no abnormalities in the chest.

On September 16 he had wide excision and sentinel node biopsy. The sentinel node in the left supraclavicular region was negative. The test was technically difficult because the injection from the signal blocked some of the nodal groups. Therefore, it is reassuring that he did have his PET scan which showed no abnormal uptake in nodal groups prior to surgery. He also had some esophageal inflammation. No mass or density was seen. I suspect this is related to [...] alcohol use and maybe to tobacco to some extent.

He is recovering nicely from his surgery which was only a week ago. The wound is coming together well. I see him now to advise on follow-up and therapy options. His family history is negative for early-onset cancers to the extent that he knows it. He does not really know his father's family history that well because his father was the youngest of a large family and the patient himself is the youngest of a large family [correction: family of four: Mom, Dad, my sister, and me]. He has one sister. There is no cancer on his mother's side of the family. His maternal grandmother had COPD. His father had COPD. One paternal aunt had some form of liver disease. He has two children; one biologic and one stepchild.

On examination he is a slender man in good spirits. He is noted to be pretty chipper. This relates to his nice recovery from surgery and also. I think, a relatively good period of time at work. There is really not too much that is notable on exam. He has no scar or abnormality on his scalp. The lesion on his left shoulder is excised with a scar that is coming together over the top of his left shoulder. There is no posterior cervical. supraclavicular. or axillary adenopathy. His back shows no masses or density. His liver and spleen are not enlarged. The cardiac exam is regular and rapid. He has a brownish-red mole on his left chest which he has been watching. He does not believe that it has recently changed.

My impression:

1. Malignant melanoma. He has a stage IIC melanoma with a T4b primary tumor. Therefore, he has a significant risk of recurrence. I would estimate about a 50% recurrence risk in ten years' time and about a 35% recurrence risk at five years' time.
2. He needs to have some additional staging before we firmly define what therapy he should take. Specifically he needs an MRI scan looking at the liver to evaluate the small area of abnormality in the liver seen on PET scan.
3. I recommended that he consider adjuvant therapy with interferon. I recommended one month of interferon given intravenously. I note that that this therapy reduces the risk of recurrence. In his case it reduced the risk of recurrence by about 5 to 10%. The cost of interferon is a significant increase in fatigue. It sometimes causes severe headaches. It sometimes causes nausea. It can cause aches in the muscles. The overwhelming symptom is that of fatigue. It may cause depression. I do not think it would necessarily make his depression worse since he is already taking effective antidepressant agents for it. Interferon is designed to cause autoimmune toxicities. These may include patchy depigmentation of the skin, autoimmune hypothyroidism, autoimmune elevation of rheumatoid factor antinuclear antibody. If these occur it is a good sign. It predicts that someone will not likely have recurrence of melanoma, at least in the first five to ten years. We discussed how melanoma might come back. I noted that recurrence refers to melanoma coming back in a site aside from the primary site in the skin. It may involve spread to lymph nodes and to other areas more distant in the skin or possibly to lungs or liver. If melanoma does come back, as you know, it tends to keep coming back. Therefore, it is very difficult to cure in that setting. I think that interferon given for one month intravenously is his best option. He also could take interferon for one month followed by 11 months of subcutaneous shots. Right now I would probably avoid the 11 months. He does not have any nodal disease. I think 11 months of lower dose therapy might be a significant drain on his energy and might set him up for worsening depression. He could take part in a clinical trial which is a comparison of a month of interferon with observation. At this point I do not think he is inclined to take part in a trial. He also could take part in a trial at Mayo Clinic which is evaluating the effects of an antimelanoma vaccine. The vaccine is given as injections into the skin; usually a total of seven or eight injections over two to three months. The toxicity of this is much less than interferon. However, there is no clear evidence that vaccine does help to keep melanoma from recurring.

I think he understood things pretty well. He took notes. I asked him to review the copy of this letter.

Plan:

1. MRI scan of the liver.
2. Liver function tests. CSC. and HLA typing. The HLA typing is done to define his ability to take melanoma vaccine.
3. Cut back on alcohol. He needs to be on a lower level of alcohol intake to safely get the interferon since the interferon by itself causes liver function abnormalities. If he already starts off with abnormal liver function enzymes, he won't be able to get much interferon before he has to stop the dose to allow recovery of the liver. I think he understands this and is in agreement.
   

I have asked him to return to my clinic in three months. At that time we will review his thinking regarding interferon versus the Mayo Clinic clinical trial and also further define the schedule and location of follow-up.

Thank you for the opportunity to participate in David Sinkula's care. Please call if you have any questions or concerns.

Sincerely,

THOMAS AMATRUDA, M.D.

The Latest

In addition, Dr. Amatruda called me this afternoon. As before, the good/bad comes in either of two starts: "Do you want to hear the results?" or "I'd like to set up a for you to come in and..." I drew the latter.

I'm nowhere near as gifted as Dr. Amatruda in summing up the situation, so I'll have to wing it a bit. The result of the liver biopsy was melanoma on the liver. I believe this means
metastatic melanoma on the liver. Wikipedia doesn't paint a pretty picture of it:

When there is distant metastasis, the cancer is generally considered incurable. The five year survival rate is less than 10%. The median survival is 6 to 12 months. Treatment is palliative, focusing on life-extension and quality of life. In some cases, patients may live many months or even years with metastatic melanoma (depending on the aggressiveness of the treatment). Metastases to skin and lungs have a better prognosis. Metastases to brain, bone and liver are associated with a worse prognosis.

Well, I'm always one to examine the worst case first and then see that things can only get better -- so I guess that's the tale of the tape that shows me running behind the odds.

Now to the bright side. One of the things that Dr. Amatruda mentioned in our discussion this afternoon was that he thought it was odd that the liver biopsy result came back the way it did. I took that as meaning, to one degree or another, I was possibly an outlier in the statistics of medical outcomes. That is, in my words, I was likely in the group of one of the small tails.

I take that as being positive, insomuch as with a few of the things that Dr. Amatruda mentioned, because being so is possibly making more treatment options available to me. There sounded like there is quite a variety: from surgery to in-situ heat-something, to the immune boosting, to combinations of these and others.

Anyways, that's my story and I'm sticking to it. (Until I hear otherwise.)

Liver Biopsy

This morning I had my liver biopsy. If I'd try to describe it, I might do it much less technically than this:

After Arriving

A radiology nurse will:

• Ask you a few questions regarding your medical history
• Do a brief clinical assessment (pulse, blood pressure, etc.)
• Place a special plastic needle in your vein (intravenous line) before your exam

You will be asked to change into a hospital gown for your procedure.

The diagnostic medical sonographer and imaging physician will explain the procedure to you and answer any questions you may have.

The imaging physician will explain the risks and benefits of the exam prior to having you sign a consent form.

During Your Exam

You will be requested to lie on the examination table on your back.

Ultrasound images of your abdomen will be obtained to locate the precise area of biopsy.

A warm gel will be applied to your abdomen, this gel is very similar to hair styling gel. The gel allows the sound waves to travel from the machine into your abdomen more easily.

A transducer, a small, microphone-like device, will be placed over the area being examined. There is no pain; however, you may feel mild pressure from the transducer.

Once the location is identified, the imaging physician will clean your abdomen and place sterile drapes over the work area.

The imaging physician will numb the biopsy site; however, you may experience a slight stinging sensation as the medication is injected.

As the medication takes affect, the imaging physician will explain how you should breathe during the actual biopsy and will ask you to practice that technique until you are comfortable with the instructions.

During the biopsy, a special needle device is used to remove the sample of your liver. You will hear a "staple gun-like" noise as the sample is taken.

That probably plays a lot better than my version. Chatting with an online friend in the IRC above, I'd described it as follows:

• They used an ultrasound to find what they were looking for.
• Then they had some funky needle thing that they inserted a few cm.
• It had some spring-loaded thingamajig that scooped up a sample of the lesion in question.
• They took four samples and cleaned up me.

Dr. Close, I believe, did the work today (with several others), and I had asked him about the MRI and other results. He mentioned which series it was that the lesion in question was best seen on, but I took a peek when I got home and still didn't find what I thought he had told me. I may find it yet, though -- he said it's the size of a regular grape.

Since I had the camera out, I had Angie snap a few shots of how the big incision is coming along. So there should now be plenty of good information heading to Dr. Amatruda for my next visit next week.

At the moment I feel pretty much fine; the same. One of the first things I did when I got home was to try to follow up with some work stuff that's been spilling over a couple days. We've owed a European-voiced panel to them, and I was struggling with pieces of getting multiple-voice support. I believed I had finally made it ready last night, but I wanted to check in and make sure we were able to get a verified build of the main code. I believe I was able to verify another's build, so that should hopefully be ready to go.

More Test Results

I had the MRI done on Thursday. The machine did indeed look like the one at the right. Of course, the lighting was far less ominous. It went quicker than the PET/CT scan, and I didn't need the radioactive injection.

Even though Suburban Imaging gave me a CD loaded with pictures and 3D viewing software, I didn't really know what I was looking for. Neat pictures, though.

Dr. Amatruda's office left a message for me on Friday, but I didn't get it until after work. And today we played a little phone tag. In part because...

Today I went in for my followup with Dr. Economou, who had done the wide excision and such the other day. For our "wound management" visit, he was happy with the way that the skin is healing. (I should take pictures again one of these days.)

In addition to discussing the results of his work, we talked a little bit more about what news I had in regard to Dr. Economou. But at that moment I didn't know all that much more. He is really easy to talk to about such things, and I enjoyed the visit.

When I returned to work, the phone tag continued, but I finally got through to Michelle (I believe) with Dr. Amatruda's office. She told me that the MRI showed a lesion on the liver and that they would want to do a biopsy. From my understanding of what she described, it sounded like some sort of poking thing going in and being guided by ultrasound to get wherever they're going: the good thing being that it's not a surgery type of thing.

Anyways, with regard to what they're looking for, I don't really know. I'm sure they've got some idea, but it is likely standard procedure to simply do the test and present the results rather than offer any speculation initially. Michelle summarized it as [paraphrasing], "We don't know if it's good or bad; we need to take a look."