Meeting with the Oncologist Round 2

Portland cherry blossoms. 

Today Dr. Shao summarized the state of my cancer thus far – no surprises based on the test results and our previous conversation.

The tumor is a synovial sarcoma, the same cancer I had in 2005. The lung tumor is discrete in the meaning that it is not a metastasis from another spot – if that were so there would be several spots of cancer in my body. The PET scan did not reveal any other tumors.

Surgery will be the primary tool to attack the tumor. In two weeks I will meet with the surgeon. He may insist that for a better outcome some form of chemotherapy be done. In that case, there are some options, but Dr. Shao stressed that chemo and radiation will be periphery treatments this time around.

My lung, recently drained of fluid, is not refilling at a fast rate and there is the feeling from Dr. Shao that I am not in a race against time. Nobody is delaying anything but having to wait two weeks for a surgical consultation should be no big deal.

Robin, Jonah, and I will get our second shot of the vaccine April 10^th and soon after we hope to modestly increase our social exposure. My mood is generally good and with the better weather I hope to distract myself with walks and bike rides.

Thanks for reading.

 

Biopsy Report

My previous cancer, synovial sarcoma, has come back.

Pet Scan Result

I'll consult with the oncologist next week and share the summary. But for those who want to know, here are the results of the PET scan. For reference, my C6 vertebrae was the site of my 2005 cancer:

Study Result

Narrative

NUCLEAR MEDICINE F-18 FDG PET-CT SCAN, SKULL TO THIGHS, INITIAL dated 3/24/2021
2:42 PM.

CLINICAL DATA: New left lung mass and pleural effusion. Primary malignant
neoplasm of oropharynx (HCC) [C10.9 (ICD-10-CM)].

COMPARISON STUDY: Contrast-enhanced CT of the chest, abdomen and pelvis March
12, 2021.

DOSE: 12.4 mCi F-18 FDG IV via a left antecubital fossa intravenous access
site.
Serum glucose level: 86 mg/dL.

TECHNIQUE: Approximately 1 hour following F-18 FDG tracer injection, F-18 FDG
PET images were acquired from the base of the skull through the proximal thighs.
Noncontrast low-dose CT imaging skull base and neck, chest, abdomen, pelvis and
proximal thighs was acquired and used for F-18 FDG PET attenuation correction
and for anatomic correlation, but is not of diagnostic image quality.

FINDINGS:
F-18 FDG PET Imaging: Reference data includes a volume of right hepatic lobe
parenchyma which contains maximum SUVs of 3.7 and mean SUVs of 2.6. Superior
vena cava mediastinal blood pool SUVs are up to 2.3.

The large left lower lobe mass measures about 7.2 x 9.2 cm (image 114, series
3). It is very hypermetabolic though it contains central zones of relative
photopenia, hypometabolism or reduced vascularity. It contains SUVs up to 12.1.

The fairly large left pleural effusion is not hypermetabolic, the left pleural
space generally containing SUVs less than 0.6. There is low-grade glucose
metabolism in the medial left lower lobe atelectatic appearing parenchyma such
as seen lateral to the descending thoracic aortic course.

Previously noted small, up to 0.7 cm diameter, left anterior juxtadiaphragmatic,
epicardial fat region lymph nodes (images 137 and 138, series 3) are not
identifiably hypermetabolic. This area contains SUVs up to 1.1.

There is marginal glucose hypermetabolism in the region of the left pulmonary
hilus, with SUVs at the anterior left hilar level up to 3.0.

No metabolically active mediastinal or right hilar lymph node sites are
identified.

There is reduced F-18 FDG uptake in the mid to upper cervical spine bone marrow
at and cephalad to the C6 level.

Other sites of F-18 FDG tracer uptake between the skull base and thighs are
explainable by expected physiologic processes.

Other low-dose anatomic correlation CT imaging findings:

Noisy low-dose images of the inferior portions of the brain show no evidence of
focal mass or mass effect upon the midline intracranial markers.

There are right neck surgical clips and postsurgical scarring. No metabolically
active enlarged cervical lymph nodes are identified.

The large left pleural effusion, left lower lobe mass and left lower lobe
atelectatic appearances are similar to that seen on previous CT imaging. There
is respiratory motion obscuration of the lung bases. Previously noted small
inferior right lung zone pulmonary nodules (not well seen owing to respiratory
variation and blurring) are not metabolically detectable by F-18 FDG PET imaging
There is again some rightward displacement of the chest and heart. The ascending
aorta caliber of 4.0 cm is within normal limits.

Other low-dose anatomic correlation CT imaging findings in the chest, abdomen
and pelvis are similar to that better demonstrated by the recent diagnostic
technique contrast-enhanced CT imaging study.

There is no evidence of a soft tissue mass in either proximal thigh.

IMPRESSION:

1. Large left lower lobe mass is hypermetabolic with irregular central zones of
photopenia, presumed necrosis.

2. Large left pleural effusion is not noticeably hypermetabolic. The small left
juxta diaphragmatic lymph nodes are not identifiably hypermetabolic.

3. Borderline left hilar region F-18 FDG tracer uptake.

4. Cervical spine reduced bone marrow metabolic activity, query previous
radiation therapy

5. Evidence of fairly extensive previous right neck surgery.

Verified by Henry Vea, M.D. on 3/24/2021 3:28 PM in PowerScribe 360 

Rip Van Winkle and Medical Tech

This week saw the completion of a PET scan and lung biopsy. I’ll have to wait until next week to learn what these tests reveal. 

One immediate takeaway is that I need to view cancer treatment in the current 2021 frame – my mind keeps me thinking about what I experienced previously. For example, the same PET scan now takes 90 minutes and not six hours as it did 2005. Also, back then the doctor needed a small slice of the tumor to identify the cancer, a procedure that did not go well and kept me in the hospital for nine days. Today a delicate needle gathered enough material for the biopsy, and I was out of the hospital in under two hours. This was possible because the doctor used a CT scan in real time to pinpoint the tumor. 

I don’t want to make any predictions that technology will bring salvation, but I appreciate the fact that the medical world kept evolving even when I wasn’t looking.

No Result from Lung Fluid Analysis

I remember being on a bus in Tel Aviv that stopped near the Tel HaShomer hospital. An elderly man got on and took a seat. After a while he removed an X-ray from a folder and began telling the general public of the bus about his condition.

I guess this sort of thing is in my Jewish DNA.

The above screenshot refers to the fact that I now need a biopsy of the tumor, as there was no information about the nature of cancer in the fluid removed from my lung. 

The Story Starts

It shouldn’t take a serious illness to appreciate the amazing people in my life, but when the heavens fall, and friends and family step up, I get overwhelmed with the generosity of the world. For everyone who has expressed concern and offer of help – many thanks.

Thursday: I had an appointment with my primary care physician where I voiced uneasiness over a shortness of breath starting several months previous. I told him I chalked this up to aging and generally felt healthy but wanted to have it checked out.

He administered an EKG in the office, which was normal, and had me do an X-ray and comprehensive blood test. Within a few hours of the X-ray he called me told me my left lung was filled with fluid and I needed more tests.

Friday: Using an ultrasound machine a doctor located the best place and drained my lung of 1500ml of fluid. I then had a CAT scan. Within a few hours my doctor called and told me about the tumor at the bottom of my left lung.

Monday: Today was my first meeting with Dr. Shao in 15 years. He got me through cancer once before and I am confident he will do so again. He believes the tumor is again a synovial sarcoma, the same cancer I had in 2005, based on the tumor’s smooth exterior, the slow growth, and no markers in blood or other areas of my body indicating cancer. He will not be sure until he can sample cells from the tumor, or analysis of the fluid from my lung gives a clear indication of the type of cancer.

This time around there are a few differences from 2005, a significant one being that the tumor is in a place that can be easily biopsied. Dr. Shao noted that in 2005 he relied heavily on chemotherapy but that now such a treatment would not be a good idea. Today I am older and weaker and most likely unable to withstand the toxicity of the chemo drugs, and they would not be as effective the second time. Dr. Shao thinks surgery will be the primary way to attack this.

Next Steps: Over the next several days I will schedule a biopsy and get a head-to-toe PET scan, an imaging test that has even finer resolution than the CAT scan.

I will continue to post all updates here to share any news.