Summary: A cough and shortness of breath in December turned out to be caused by a pleural effusion—the collection of fluid between the right lung and chest wall. When my primary care physician could not diagnose a cause of the effusion, he sent me to a pulmonologist who also could find no cause for the problem. He sent me to a thoracic surgeon who performed a thoracoscopy that found cancer. Additional tests have been performed and soon we will have sufficient information to determine whether or not I am a candidate for a radical surgery to remove my right lung.
It all started in December with a cough and shortness of breath. I finally went to the doctor in January, and he diagnosed my problem as pneumonia and sent me for a chest x-ray. The x-ray did not show pneumonia but a pleural effusion in my right chest cavity. A sack-like membrane, the pleura, lines the space between the lungs and the chest wall. The outer surface attaches to the lungs and chest wall, and the inner surface is moist and provides a friction-free zone where the lungs and chest wall meet. Normally, the body produces and absorbs equal amounts of this friction-reducing fluid each day (3-5 liters); however, with a pleural effusion, the amount produced is greater than the amount absorbed. The resulting fluid builds up in the envelope and presses on the lung producing a shortage of breath. That along with some bronchitis had caused my symptoms.
Antibiotics took care of the bronchitis, but the fluid remained. My primary care physician ran a number of tests, including a CT scan of my chest, but could not find any clear cause for the effusion. After some time he referred me to a pulmonologist who extracted the fluid from my chest through a process called thoracentesis and had it analyzed. Still there was not enough evidence to form a diagnosis, so we decided to watch it for a few weeks and tap the chest again to see if there was any change. When the second thoracentesis proved no more enlightening, he sent me to a thoracic surgeon who could go in and look around and take tissue samples for biopsy.
I went into the Scott & White hospital in Temple on Thursday, May 27 for the thoracic examination, a thoracoscopy, and got out on the following Monday. The procedure involved putting three tubes into my chest cavity--one for a drain, one for a scope, and a third for tools to move the lung around and take tissue samples. A breathing tube was used that allowed the right lung to be closed off which caused it to quickly deflate. Initial tissue samples were taken and sent immediately to the lab to be frozen, sectioned, and analyzed. The analysis shows that the tissue was malignant, and additional samples were sent to the M. D. Anderson Cancer Center for detailed analysis.
My stay in the hospital was uneventful. The worst part was being tied to machinery by a chest tube, a urinary catheter, an oxygen line, an IV, and an epidural. The epidural was introduced high on my back prior to the operation and then activated when the surgery was complete. It worked great. I had little or no pain, not what I expected. I had to stay in the hospital until my chest stopped draining and until they could be sure that the transition from the epidural to pain pills was successful.
On Jun 9, we saw my surgeon in Temple to received the results of the biopsies. I have mesothelioma. It comes in two basic flavors, and I have the epitheloid type that generally has the better prognosis. The doctor’s task now is to weigh the nature of the tumor and my state of health to determine what course of action to take. To that end, we went up to Temple on Monday Jun 9 for a couple of lung function tests. Basically, I followed a technician's orders and breathed in and out of a tube. The intent is to see if my lung function is sufficient for me to survive on one lung.
On Tuesday (15th), I checked into the hospital for more surgical procedures. They did a mediastinoscopy, which involved making a small incision just above the collarbone in my neck and threading a scope down into the space below in order to biopsy some lymph nodes there. This will tell whether or not the cancer has spread to the lymph nodes. From what the doctor could tell, the results looked good.
Then they did a laproscopic examination to see if the cancer has spread into the abdomen through the diaphragm. I would have enjoyed watching these procedures, but unfortunately, they were done under general anesthesia. The laproscopy involved inserting another scope just above the belly button. The procedure was complicated by scar tissue from gall bladder surgery from many years ago and from an incisional hernia that came from the gall bladder surgery. So, while they were in there clearing up the scar tissue that got in the way, they repaired the hernia. The examination of the diaphragm showed no obvious tumor tissue which was good. Jana was relieved when she met with the surgeon while I was in recovery because he came in smiling this time.
The hernia repair was the most interesting part of the day's procedures. Somehow, they inserted a polyester mesh into my abdomen and attached it beneath the hernia. The surgeon said that he put permanent stitches in the corners and then anchored the mesh to the abdominal wall with a sort of small nail gun that used a material that will be absorbed by the body. When the surgeon met with Jana, he warned her that my abdomen looked like I had been attacked by a small animal. It really does look funny with three laproscopic incision points and the nine sites (in a 3X3 pattern) where the "nails" were put in.
Women sometimes complain that men cannot empathize with some of their difficulties such as the pain of childbirth. My medical history, however, has given me three ways to empathize. First, my prostate cancer treatment gave me hot flashes, so I understand part of what women go through at menopause. Then, when they did the thoracoscopy, I had an epidural infusion similar to what women have during childbirth, and finally the surgeon who did the hernia repair gave me a corset to wear while that heals. It feels pretty good when I cough or lay down, but I don't think I'll continue to use its slimming effect.
I go back to Temple on Tuesday (22nd) for a lung scan. On Wednesday I have an appointment with the doctor, and then on Thursday I will have a positron emission tomography (PET) scan. That should be interesting and boring at the same time. They will inject me with radioactively tagged glucose and have me lay on a narrow bed under a special camera for about three hours (the boring part). Rapidly dividing cells will take up the glucose at a higher rate than other cells, and the tumor will be highlighted on the image. The purpose of the test is to see if the tumor is confined to the right side of my chest. If not, then I will not be a candidate for the surgery and another treatment approach will have to be used. This will be an expensive test, and Blue Cross didn't want to pay for it, but the doctor finally convinced them that it was worth it.
I still have to do a cardiac stress test and an echocardiogram after the PET scan. Then they will have enough information to make a decision about the surgery.
David
