Health Update - September 2011

Dear Friends and Family,

Expectations are a tricky thing. They can be a positive, up-lifting force in anticipation of good things to come. However, we are inevitably let down by our expectations at some point because nothing stays the same forever. For me, chemo treatment has been going so well for the past 12 months that I just expected positive results to continue. My most recent scan shows that my expectations were both right and wrong.

The tumors I was diagnosed with have either stayed the same or continue to shrink as a result of my current chemo regimen. Unfortunately, 3-4 new, small tumors have developed in the healthy part of my liver (right lobe). These new tumors are treatable with directed therapy. Since my current chemo regimen of oxaliplatin and gemcitabine is "working", save for those few new spots, I am going to continue with that to treat the systemic (whole body) part of my disease. This will be done concurrently with the directed therapy for the new spots.

The directed therapy for the new spots is done by an interventional radiologist. There are 3 main options for the treatment of my tumors because of the size and location of them. All of which are minimally invasive and involve placing a thin catheter up the femoral artery by the groin as the only incision in the body. (Most guys cringe any time they hear catheter and groin - I certainly did when this was first described to me). Using live x-ray technology (medial term is angiogram), the catheter is directed into the hepatic artery. The mysterious thing about liver tumors is that the majority of their blood is received by the hepatic artery, while the rest of the healthy liver tissue receives blood from the portal vein. Modern science does not have answer for why this happens, but the fact you can put toxic things into the hepatic artery and leave the healthy liver tissue largely unaffected is the main reason embolization is particularly effective in the liver. Anyway, back to the catheter. There are 3 things that can be fed through the catheter: 1) an agent that cuts off the blood supply to the tumor 2) a high dose chemotherapy cocktail, known as chemoembolization 3) millions of tiny radioactive yttrium "beads", known as Y90 radioembolization. My physician and I chose to go with option 3, radioembolization, because it has proven to be as successful as the second option and it leaves open the possibility to use the other 2 options in the future. Radioembolization also has less side effects than chemoembolization. So why would anyone choose anything but radioembolization? Well, for one, radioembolization is very expensive and some insurance companies won't pay for it. Secondly, it takes a lot of "practice" for the physicians to do it correctly and there is a lot of operational red tape associated with the radioactive material, so not too many hospitals offer this as a treatment option. Finally, a "mapping" procedure is required for radioembolization.

The mapping procedure is the most critical aspect of radioembolization. It determines how many of the radioactive beads can potentially "leak" (medical term is shunt) out of the liver to other parts of the body. Leakage into the intestines or stomach is the most concerning and every effort is taken to prevent it from happening because if even one of the beads leak into these areas, it is potent enough to cause an ulcer. During the mapping procedure they insert tiny coils into any veins from the liver to the intestines or stomach to block anything from passing through them, especially the radioactive beads. The physicians also don't want too much radioactive material leaking to other parts of body - no one wants to turn into a glow stick. Once everything is sufficiently blocked off, a tiny tracer protein is inserted into the liver at about the same dose as the Y90. The tracer protein helps to measure the exact amount of leakage by taking a complex CT scan after the procedure.

I underwent a "mapping" procedure to see if I was eligible for radioembolization this past Thursday. It turns out I am eligible because they were able to successfully block off any direct passage from the right lobe of my liver to the intestines and stomach using about 5 small coils. The procedure was uneventful and relatively painless, save for the back pain I had for laying down for so long (9 straight hours). Thank God there was the Saints vs. the Packers to watch on TV during my 7 hour "recovery" where I had to lay still! The procedure itself took about 2 hours. I was given "conscious sedation" for the procedure and will be given it for the radioembolization as well. Conscious sedation is like anesthesia in that you don't feel any pain, but you are awake in an altered state of consciousness. I have no recollection of being awake, but the nurse said I was awake for the last hour of the procedure and was quite chatty. Me, voluntarily & excessively chatty with complete strangers, I must have been high! :)

My radioembolization is scheduled for Friday, 9/23. In the meantime, I will continue with the same chemotherapy schedule I've been on but will hold off on getting one of the drugs, gemcitabine, before and after the radioembolization because they don't know how that will interact with the Y90 and are concerned it will make me really sick. Better safe than hugging the porcelain and feeling completely trashed for days or weeks. I'll publish another post after the radioembolization appointment.

Hope you can enjoy what's left of summer. I'm definitely ready for some football, although I may be singing a different tune once we get a couple games into the regular NFL season with the way the 49ers have looked thus far in preseason.

Stay well,

Rhone