Friday, November 7, 2008

Latest Summary

I had my consultation with Dr. Sielaff, the liver and pancreas specialist, on Monday. I meant to post an update sooner, but I was a bit occupied with the election and the other blog.

We went over my history thus far, and then he added his analysis and recommendations. He showed me some of the scans (the PET/CT and the liver MRI) and pointed me towards the areas in question. Instead of just the one spot, he said that there were two likely spots (see diagram).

Procedure-wise, he would prefer the RF ablation. This would be done laproscopically, going in through the navel like when Angie had her gall bladder removed. They will have the two areas of interest, but they would inspect and treat everything they find in one go. Because of the location of the one spot hear the gall bladder, that might have to come out as well. And if the need to resect anything instead of the ablation, they would do that.

So I've got my pre-op physical next week on Tuesday, and the surgery is scheduled for Wednesday, December 3. (At this point, I'm to assume that I will be able to be in Bismarck for both Thanksgiving and Christmas.) Approximately 6 weeks after this surgery, then, is when I believe we might begin the immune-enhancing therapies.

I received a copy of a letter from Dr. Amatruda to Dr. Sielaff yesterday, and I'll excerpt some of it here.
Dear Dr. Sielaff:

Mr. Sinkula is a 38-year-old man who has malignant melanoma. He has a single liver metastasis of melanoma. I would like you to give consideration to surgical resection or other local therapy directed at this liver nodule.

[...]He had some dizziness around June 2008. When he was seen in the ER, he was advised to seek attention for a mole on his back. This is a mole that was blistered, raised, flattened out, and began to raise up again. It was biopsied by Dr. Kortuem and was a melanoma, 5.2 mm in depth, down to Clark level IV. He had surgical resection of this and sentinel lymph node biopsy. The sentinel lymph node biopsy was negative. He had a PET scan which showed no other nodes in this area. However, he had a small abnormality in the liver seen on PET scan. An MRI of the liver showed a single lesion of 14 mm, with early enhancement and prompt washout. It did not have the characteristics of an adenoma nor of hemangioma. It was visible on ultrasound and was biopsied. Unfortunately, the biopsy showed melanoma.

I met with Mr. Sinkula on October 14, 2008. He was somewhat queasy after his biopsy. I met with him, his wife, and one of his young-children. I noted the following:

  1. This is a single focus of metastasis. Unfortunately, this has defined him as having stage IV disease.

  2. I think he should have local therapy of this single lesion. Two possibilities present themselves. There is a Mayo Clinic clinical trial which involves cryoablation of liver lesions, followed by immune-enhancing therapy with Leukine GM-CSF. He is not eligible for this clinical trial because his HLA blood type would not allow him to have the immune monitoring necessary to measure the benefit of the Mayo Clinic therapy. However, Dr. Markovic at Mayo Clinic would treat him off trial with cryoablation, followed by GM-CSF.

  3. A second option would be to resect the lesion and then to pursue GM-CSF. I would like you to give consideration to either of these possibilities. I would prefer resection, if this is technically possible. [...]

  4. Another issue is the location of this lesion. It is in the lower right liver and actually, it should be fairly accessible. If he does have resection of this, I would then treat him with Leukine GM-CSF for three years and then assess what further immune therapy we could pursue after that point.

  5. [...]

  6. I would like to arrange to have his tumor banked with the group in California for possible use as a source of tissue for autologous vaccine. You have done this previously with other patients. I will get the process going with E-mail.
There's a bit of jargon, but what I take from it is this.
  • The cancer I've got is now staged as Stage IV. Let me substitute "a nasty one" instead of the clinical terms.

  • The liver surgery with Dr. Sielaff is to remove any and all tumors on my liver. This I'll paraphrase as "they'll get rid of the bad stuff that they know about".

  • Then I'll be following up with some alphabet soup of stuff that will help me keep any more tumors popping up from the nastiness.
And then we go from there.

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