It Might Get Messy

There is power in photographs. How much would change if a snapshot from the new Mars rover had a green blob with a little raised limb giving a peace sign? How much of human history vectored down a new course the day the photointerpreters recognized soccer pitches instead of baseball fields in the Cuban missile facilities, letting Kennedy and Kruschev face down their respective war-clamoring advisors and dodge thermonuclear Armageddon? And how much can one life be derailed by a small series of diagnostic medical photos?

Let’s find out.

Friday morning at 0700 I signed into the general surgery department at GBMC, coincidently they plopped me in the same waiting cubicle I had the last time I went through. Dr. H finished up his first patient and came in to check on my as we headed for the OR, asking me how the pain in my throat was. I told him it was gone. He said “huh”. But since the radiology showed that white-hot spot on the PET scan and the radiologist could see a coincidental lesion on the MRI (neither Dr. H nor I could see the latter very clearly, if you go back to last week’s entry the best guess is that little beanlike nugget at the center base of my tongue), we figured it was best to proceed.

Which makes much sense from a risk management perspective. If we look now and things are clean, we can be certain with a high probability that they are indeed clean, that we’re not committing a Type 2 Error (mistakenly accepting that tissues samples are similar when in fact one is tumorous). The risks of the biopsy procedure, despite the need for full anesthesia are low and well known—chipped teeth while they root around in the oral cavity, slipping and stabbing the throat wall, anaphylactic cascade from the drugs. The payoff, especially here at the end of a year and a half of cancer treatment hell, is high. Knowing I’m clean would set me up for getting back in physical condition, rebuilding my shattered professional life, catching up on all the time I’ve missed in the kitchen, and with all of you

Let’s see how it plays out. First photo following orients you to things. That round tunnel to the left is my airway, working just fine, thank you. The rabbit hole right in front of you is my gastrointestinal tract—throat-behind-tongue, place the massive tumor took up its impositional residence last year. You can see the dysfunctional shards of my epiglottis—that cream-colored ring that forms a sort of structural coping around the ring that supports that vaguely “v” or stealth-fighter shaped slab across the top of the throat opening.

Now the one below is a little closer up. See how the creamy color of the epiglottal remnants run around from left to right across the top of the “v” shape, and you get that change to the sort of angry red color right about at 1 o’clock? And in that red splodge, there’s some darker red spots and stripes? That’s inflammation. Until we talked just prior to surgery, Dr. H would have assumed that to be a tumor, making him wrong and me right about there being “something” growing in my throat these past few months. However, he says, and this is interesting, the fact that the pain subsided on its own and isn’t increasing linearly or worse could mean something more benign—maybe an infection in the beat up epithelial tissues of my throat. You know, a nice, normal microbial infection, treatable, with a beginning, an end, and a middle that doesn’t involve radioactivity and human cellular toxins.

Damn, THAT would be nice. But let’s finish out our lesson in medical methodology. Here’s a shot after Dr. H hacked out the first sliver of biopsy tissue. Now things are coated with blood, and there’s that trough up top there, right around 11 o’clock. That’s where the hunk of throat meat headed for the lab originated.

Finally, here’s a shot on the way out. The rough surface running from about 8 o’clock to 1 o’clock around the top curve of the throat circle there is where the remote-activated scalpels sliced off the tissue to go to the lab. In top-notch professional fashion, they did the exchange with the biopsy lab in real time. That is, they sent the tissues to the lab while I was still open on the operating table to make sure the lab had sufficient tissue mass to do the appropriate tests. If they needed a few more milligrams, or maybe saw something warranting additional investigation, they could phone it in.

But they didn’t. Everybody did the job spot-on the first time.

So here’s where things stand. There is definitely “something” wrong with my throat tissue. It’s in a reasonably coherent spot, and it looks like what a reconstituted or residual tumor would look like at this point following on a year-and-change after treatment for the OTHER big-ass tumors across the way on the left side of the throat there. But the fact that the pain hasn’t been consistently increasing, and my swallowing hasn’t gotten increasingly impaired, gives Dr. H at least the thought that it might be something non-malignant, like a bacterial or viral infection taking advantage of the radiation-ravaged tissues down there deep in my throat.

We’ll find out this week. The samples are all in the biopsy lab. If ya’ll decide to take up a pool, I’ll put $20 on 70:30 odds that is malignant. But I don’t know have any particular insider information. Remember I’m the guy who before I went in for the first tumor thought I was having a sore throat that needed some mouthwash treatment!

So check back next week, boys and girls. The suspense’ll be killing me. So to speak… . 

It Might Get Messy

It Might Get Messy

Technology…you can’t live with it…no, that’s not right. You can’t live withOUT it. Whatever your feelings about Bill Gates, automakers, music listening devices, or whichever hellishly sluggish wireless internet service you’re living with, it’s a shitload better now than it was 10 years. And WAY better than it was 35 years ago.

Because in 1977, nuclear magnetic resonance technology was engineered for noninvasive, high-resolution imaging of living human tissue. Magnetic Resonance Imaging (MRI) is a very sensitive—subatomic, if it comes right down to it—technique for ascertaining…uh, imaging…the surface structures of stuff.

It works like this. You whip up one bad-ass massive magnetic field and stick a chunk of matter in that field, then the directional “spins” of the protons and neutrons in the atomic nuclei of the stuff your chunk is built from all line up nicely in a uniform plane. But not direction. The spins may run “frontward” or “backward”, but the thing is they don’t run at angles or “awkward”. Oddly (or maybe it’s not odd, I flunked chemistry twice and almost flunked physics twice, so I may not be the best person to ask), just about 50% of the atoms spin “front” and 50% spin “back”. Basically, when you are the chunk of matter in the magnetic field, the nuclear particles spin toward your head or your feet, but not toward your hands or your butt. But the symmetry is not exact. A few atoms out of each million don’t pair up with a converse-spinning doppelganger.

Those asymmetric or unpaired atoms are important to what happens next. You run a pulse of radioenergy into the field, guided by some additional “gradient” magnets. The unpaired atoms respond to the radioenergy in a distinctive fashion depending on their atomic bonds (i.e. electron-to-electron-to-nucleus, thus MRI uses NMR technology but is not limited to “nuclear” signals), that is, their structural properties. The edges of things—organs, cells, tumors—have discernibly distinct structures. By converting the return energy of the radio-perturbed magnetic field to pixels for imaging, well voila! A high-rez look at anything you care to look at!

By comparison, the Positron Emission Tomography (with the radiolabeled glucose) we looked at last week has spatial resolution—detection of the atomic decay—at centimeter scales. With the MRI, you’re looking at submillimeter scales. So it’s the MRI that surgeons use to localize, characterize, and size up a tumor.

I’m not a surgeon (as the Bitchin’ Kitchen lady would put it on Food Network, “it ain’t rocket surgery”). Nor am I trained in use of the awesome software that comes with the set of digital images from the radiology shop these days. So I’m not going to be able to show you the marvelous detail and full certainty of what’s going on in the MR images. I will try to get Dr. H to look at the slices I’ve picked out and see if I’ve got the right concept. Because here’s the thing:

I’m pretty sure that ragged edge on the northeast of my tongue there, and the dark splodge on the southeast are evidence of the “old” tumor—the one we took care of last year. My tongue is ragged because… well, my tongue is ragged. Radiation and chemotherapeutics killed the tumor tissue, which eventually rotted out and fell away, leaving raggedy edges on things.

And here’s my present difficulty. See that little bean-like nugget down there near the center and base of my tongue? That’s on the right side, if I’m reading the imaging “slices” correctly. And it’s where I’ve been having pain. And, more ominously, where that white-hot spot of radioactivity was in the PET scan a couple weeks ago.

When we congratulated ourselves last year at kicking my cancer’s ass, we did so in the face of the close-out PET scan report that mentioned sort of spraddled out but metabolically hot tissue on the right side tongue base. At that time, all the docs agreed it was an artifact of radiation damage. The sugar uptake was in inflamed tissues still healing.

I wasn’t quite so sanguine, but understood their point. The residual metabolically active tissue was right where the most intense collateral damage from the radiation would hit, and didn’t look like a coherent tumor.

That was then. Tomorrow I go to my GP’s shop for pre-surgery checkouts. On Friday I go to the hospital early for nine o’clock surgery to biopsy that nugget on my tongue. I’ll keep you appraised. Oh, and remind me to tell you about “contrast” materials in MR imaging sometime…. .

It Might Get Messy

Indeed. And we’ve been here before. Having completed whirlwind visits to Europe and Asia and spent two wonderful weeks at the beach, I’ve settled back in to the office routine (as best I can—it still takes me a while to get my shit together in the morning. But I’m plenty strong enough to work a full day now, so I often end up at my desk until well after 6 pm). But that sticky pain down at the base of my tongue on the right side seemed to be more consistent. I was happy to have incipient appointments scheduled with doctors. Because it was starting to strike me that that pain might be problematic.

I put my best people on it.

Dr. N and Dr. H, both at GBMC, got together and designated Dr. H as point person. Actually, they figured if there WAS something there, as surgeon, he’d have to biopsy, so it was best to get him on board early. Last week, Dr. H and various associates took turns running a scope through my sinuses and peering around my throat (more on this in a bit). Everything down there looked as smooth as a baby’s bu…well, no, they actually looked liked the cooked remains of a dog found at ground zero in Hiroshima or Nagasaki in the summer of 1945. But they did NOT look tumorous. And they even showed me. I could see on the screen. Indeed, there was nothing the least bit disturbing down there.

But.

I was by then convinced that the pain was real, not some figment. So Dr. H, skeptical as he was, went ahead and scheduled a PET scan. He didn’t think the insurance company would pay for it. Actually, they took out a 10% co-pay ($190), which they hadn’t done the first time. I’m not sure what the hell they’re thinking. Absent early diagnosis, presumably it’d cost a lot more to reestablish my viability. Anyway, I paid the $$, and sat down for the injection of radiolabeled fludeoxyglucose intended to show metabolic hotspots of unusual intensity.

Took ‘em 20 minutes to come back into the waiting room and tell me there’d been a screw up, the isotope had been sent to another lab facility. But it wasn’t that far away. So I drove over, and after some additional contretemps in the parking lot, got settled in for the imaging.

Hell, apparently in the year since I had this done last, the technology has already improved fantastically. Just look at these images!

First up: my liver.

It’s the big orange chunk in the upper left photo (in my browser, if you click on the photo, it enlarges to full screen and you can see just how cool this imaging is). It’s orange because it’s cranking, keeping things clean. Including busting up the radiotagged glucose molecules. The torso image in the lower right is, on the CD of the entire 300-some-odd suite of slices, a nifty 3-D, rotating avatar that you just click on to select the slice you want to examine.

Like this one. 

Look at my kidneys. Also working hard, sorting the dissolved solids from the body fluids and shunting the recyclable good stuff out one end of the plumbing, the waste material out the other.

My brain? 

Not as dim as it seems most of the time. See here? Nice and bright and radioactive, keeping itself in creative thought and storing more scientific names in its data base than god.

And my heart. 

Robust and healthy. Never a problem there. Muscular, and, per James T. Kirk, “steady as she goes”.

But.

HERE’S the problem. They did an extra close-up set of images of my head.

Here’s one, a slice through my throat at the base of my tongue. See that really bright yellow spot glinting in the top left PET image? That’s probably new tumor material. It’s the place the original set of post-treatment images showed unsettled tissue of indeterminate makeup. Then, it was probably just inflammation. Now, it’s a new growing tumor. Look close, you can see it as a black, walnut-sized blob in the 3-D black and white image in the lower right, which is a composite of the PET and CT imaging.

This is icky. Dr. H needs to biopsy, which is a hospital surgical procedure. On Wednesday, I go in for an MRI, because the PET and CT imaging like the above don’t provide adequate resolution for planning the cutting.

Dr. H still doesn’t think there’s anything there. He says his scoping would have shown something if there was tumor tissue blooming. I’m afraid I think he’s wrong (for once). I’m pretty sure I can feel something growing down there. The pain gets incrementally more steady, and when I swallow there’s the sense that the food bolus is slipping around a protuberance.

And not in the good sense. My apologies for this blip of bad news in the otherwise sunshiny path to recovery and full health. Check back at least weekly from here on out, as I’ll keep things updated and they’re likely to move fast from here. I’m guessing more radiation and chemotherapy and follow-up surgery, but it might be that they follow the more classic pattern with this newer tumor, and try surgery first with radiation to suppress regrowth.

I’ll let you know. Meantime, I haven’t updated either docviper.com or aehsfoundation.org in the past couple weeks. I’ll get back on those this week, so check over there at http://docviper.livejournal.com/ and http://aehsfoundation.org/ . I’ll keep writing as long as the treatment lets me access the keyboard. Love you all. Hang in there!