The Tumor Board's Recommendations

I got a call a while ago from Dr. Weickhardt with the results of the tumor board's review of my CT scans. As I wrote earlier, one area in the latest scan had grown significantly over a six-weeks period while other areas remained stable. The tumor board found that it was unclear from the images whether the area was a collection of fluid or tissue. Consequently, they recommended using a needle under radiological guidance to aspirate the fluid or tissue in order to determine its nature. I was very please with this recommendation because I have a hard time thinking that the area is a tumor because it will settle the question.

I will continue with my pemetrexed chemo on Wednesday, and when my blood counts have returned to normal they will do the aspiration. My money is on the results showing a fluid concentration because the area shrank and then expanded and did not light up the PET scan, but we'll have to wait and see.

David

Chemo Postponed

My next round of chemo has been postponed until next Wednesday.  It was scheduled for today, but the oncologists want to wait until the Tumor Board revoew my PET and CT scans on Monday.  The PET/CT from last Monday found one area that appears to have grown in the last three weeks.  The oncologist showed me the last five or so scans, and the area of interest is associated with the pericardium (the sack around the heart).  Between August and about December the area seemed to shrink.  Then it was essentially stable until this last scan.  It may be an area of fluid collection rather than a tumor, but it is hard to tell.  The Tumor Board is a meeting of the oncology staff in which cases are reviewed.  Multiple radiologists will be there to look at the scans and discuss what they see.  Dr. Weickhardt will call me on Monday to let me know what they think.  I have my next chemo scheduled for Wednesday, but the decision of what to do will be made on Monday.  If it appears that the area is not a tumor, then we will proceed with the current chemo.  If it is growing, then we will go with a new drug, or we might decide to take a pause and think it over.  One other puzzling factor.  The area did not light up on the PET scan which identifies areas glucose uptake like the brain or cancer cells.  That gives me hope that the area is a collection of fluid.  I don't know what that would imply or if it would be significant, but it seems to make the most sense to me--the only area to grow and no glucose uptake.

I'll write a post with the decision next week.

On the family front, we had a great visit from our daughter, Sarah, and her son, Jamie.  It was good to have both girls and their families (but unfortunately without Ryan) here together.  The noise and chatter was like a visit to the grandparents at Thanksgiving or Christmas.

David

Electronic Nose Can Smell Out Mesothelioma

I came across an interesting study today.  An electronic nose can distinguish between people with malignant pleural malignant, those who have been exposed to asbestos but do not have the disease, and normal controls.  I really liked the name of the electronic nose, the Cyranose 320.

Abstract

Background: Malignant Pleural Mesothelioma (MPM) is a tumour of the surface cells of the pleura that is highly aggressive and mainly caused by asbestos exposure. Electronic noses capture the spectrum of exhaled volatile organic compounds (VOCs) providing a composite biomarker profile (breathprint).


Objective: We tested the hypothesis that an electronic nose can discriminate exhaled air of patients with MPM from subjects with a similar long-term professional exposure to asbestos without MPM and from healthy controls.

Methods: 13 patients with a histology confirmed diagnosis of MPM (age 60.9±12.2 year), 13 subjects with certified, long-term professional asbestos exposure (age 67.2±9.8), and 13 healthy subjects without asbestos exposure (age 52.2±16.2) participated in a cross-sectional study. Exhaled breath was collected by a previously described method and sampled by an electronic nose (Cyranose 320). Breathprints were analyzed by canonical discriminant analysis on principal component reduction. Cross-validated accuracy (CVA) was calculated.

Results: Breathprints from patients with MPM were separated from subjects with asbestos exposure (CVA: 80.8%, sensitivity 92.3%, specificity 85.7%). MPM was also distinguished from healthy controls (CVA: 84.6%). Repeated measurements confirmed these results.

Conclusions: Molecular pattern recognition of exhaled breath can correctly distinguish patients with MPM from subjects with similar occupational asbestos exposure without MPM and from healthy controls. This suggests that breathprints obtained by electronic nose have diagnostic potential for MPM.

Living with Cancer--a Young Oncologist's Experience

I have a membership in a website, Oncostat, that provides periodic emails with links to cancer journal articles and analyses.  Today I found an article by an oncologist who learned that he had a rare kind of cancer just as he was entering his residency.  His article follows his response to his father's cancer, his reaction to his own cancer, and its affect on his work with his patients.  I've been planning to write a post about what it's like to live under a death sentence, but I just haven't done it.  I'll probably wait until my prognosis is clearer, but his article provides an interesting perspective on living with cancer and the uncertainty of individual prognoses.

http://jco.ascopubs.org/content/early/2011/04/04/JCO.2011.35.1122.full.pdf

David

Good Chemo News

I saw my oncologist this afternoon to get the results of my CT scan and blood work following the second round of my second course of chemo. I had been concerned that the tumors were continuing to grow because one blood test, a measure of the carcinoembryonic antigen (CEA), had increased by about 40% (from 2.3 to 3.2) since the last blood test three weeks ago. The good news is that the increase was not meaningful, and my tumors were either unchanged or apparently smaller in a couple of cases. The pemetrexed seems to have had a positive effect. Consequently, I had another round of chemo following my doctor's appointment.

To explain why the CEA values were not significant, the doctor showed me a graph of another patient's CEA values (with the name obscured, of course). His scores had risen from 100 to 400 at the start of therapy (for non-small cell lung cancer) but had declined back to around 50 over the course of a year, and he said he had patients with much higher values than that. He said that the increase in CEA at the start of treatment may be the results of dying or stressed cells producing more of the antigen. We'll see in three weeks if the values continue to rise, but it will six weeks before the next CT scan.

All in all is was a good afternoon at the hospital.

Cancer Cells Can Change over Time

Cancer cells do not always stay the same throughout the duration of an individual's disease.  A recent blog post on Discover Magazine's web site describes how the cancers can change through mutation and selection over time.  The post describes changes in acute myeloid leukemia, a disease similar to Jana's chronic myeloid leukemia, but the process can occur in any cancer.  The changes parallel the way in which new species arise through natural selection.

http://blogs.discovermagazine.com/loom/2012/01/12/inside-darwins-tumor/

Single-Drug Chemotherapy: Second Round

Another round of chemo to document. 

Tuesday, Jan 3:  Had my blood drawn early in the morning and got the results online before noon.  The tests determine whether or not my blood counts are adequate for the chemo.  Everything looked good.  Began taking the steroid Dexamethasone to reduce side effects of the chemotherapy.  The steroid revs up the body, and I felt good and energetic. Only slept about four hours that night even though I had taken a benadryl.

Wednesday, Jan 4:  Started my oral anti-nausea medicine in the morning and worked on installing the new dishwasher.  Had a doctor’s appointment at noon and began my infusion about 1:30 pm--an anti-nausea drug and pemetrexed.  It took about an hour or so.  All went very smoothly, and when it was done, I felt no different than when I went in.  Went home and worked on the dishwasher.  Taking the steroid made getting up and down on the floor easier.  Again only about four hours of sleep that night.

Thursday, Jan 5:  Stopped taking the steroid but continued the anti-nausea medication.  Finished installing the dishwasher.  Felt good all day.

Friday, Jan 6:  Not so energetic because no more Dexamethasone.  Continued anti-nausea medicine.  Did not do all that I had planned for the day.  Read Michael Connelly’s The DROP.

Saturday, Jan 7:  Got up and fried some ham and scrambled eggs for breakfast.  Then began feeling fatigued so I took a two-hour, after-breakfast nap.  Still not much interested in doing any work around the house.  Tiny pimple-like spots forming at the hairline on my neck.  Occasional coughing and tendency to gag.  Slight tingling in my hands.  Big snowflakes falling outside.

Sunday, Jan 8:  Didn't have the same fatigue as Saturday morning.  Took a nap after noon.  Occasional waves of feeling ill and a little short of breath.  Pretty much the same as yesterday, but I did get out and shovel and sweep some light snow.

Monday, Jan 9:  Pretty good day; however, felt bad at times in the evening.  I hope the feeling doesn't presage a bad day tomorrow.  Last time, Tuesday was a bad day.

Tuesday, Jan 10:  Today was not as bad as the first Tuesday of the last round.  Occasional waves of feeling ill stopped, but I easily became short of breath.  Had a cough and a low fever (99.2).  Mouth sores larger than last time.

Wednesday, Jan 10:  Better today.  No waves of feeling ill, cough less, no fever.  On the mend.  Unless there's something else to report this will be the last entry for this round.

David

An Epigenetic Day

About a year ago in the post entitled "Uncle Sam and Gini," I speculated that poverty and income inequality might have negative biological affects on children that take multiple generations to overcome. That could happen through changed in which genes are turned on and off during development through the action of epigenetics.

Well, yesterday was an epigenetic day. First I read an article in the Denver Post that was reprinted from the LA Times. The article reported on research that suggests that the conditions of women during their pregnancies in the 1950's laid the groundwork for the obesity epidemic we see today.

http://www.latimes.com/health/la-he-obesity-causes-20111219,0,6170668.story

Then later in the day I caught part of "Talk of the Nation" on NPR which discussed how identical twins are not truly identical because of epigenetic differences. They may have the same genes, but interactions with the environment impact the activation and deactivation of those genes which result in differences between the twins.
http://www.npr.org/player/v2/mediaPlayer.html?action=1&t=1&islist=false&id=144583977&m=144583970

If you find these article interesting, then I'd like to share a recent Science New article that goes to the molecular level to explain how lincRNAs coded from the parts of the DNA that do not code for proteins may orchestrate the differences between cell types within the organism and may be involved in epigenetic differences. These RNAs appear to be involved in cancer promotion and/or prevention.

http://www.sciencenews.org/view/feature/id/336570/title/Missing_Lincs

David

First Round, Second Course of Chemo

On Wednesday the 14th I had the first round of my second course of chemo. So far, it has been much easier to tolerate than the first course. The steroid I take at the beginning of the round wound me up a little, so I had trouble sleeping the night before the treatment, but a Benadryl the next two nights helped me get to sleep without a problem. The steroid also caused a spike in my blood sugar, but I think that should drop now that I’m through taking it this round. No nausea, no particular loss of appetite, and only minimal feelings of being unwell and fatigued. Interestingly, I felt worse today than any day so far. Maybe the damage done by the drug to cancer and normal cells is now affecting the body.


Bottom Line: If this is as bad as it gets, and the drug does slow down the growth of my tumors, I can keep this up through many rounds. I get the next round on January 4.

David

Starting Another Round of Chemotherapy

In late October I wrote a post telling about how my tumors appeared to be growing at a more rapid pace and about the difficulty of knowing what to do in response.  I had by bimonthly imaging on Friday, a CT scan this time, and saw the oncologists today.  The cancer continues to grow more rapidly, so we talked again about possible responses.  The bottom line is that we decided to return to chemotherapy because my first round of chemo appeared to have halted the growth while it lasted and for a few months afterwards.

Last year at this time, I was receiving a combination of pemetrexed and cisplatin.  This time I will be getting pemetrexed alone, and we will monitor to see if it slows down the growth.  Apparently, there has never been a trial of pemetrexed alone, but it is used alone as a second line treatment.  Pemetrexed was introduced as an agent to kill the cancer cells, but Dr. Camidge said that it is seen now to have the effect of keeping cancer in check rather than killing it.  Later, his nurse noted that one patient would be coming in today for her 38^th cycle of pemetrexed therapy.  At three weeks between treatments, that’s over two years of treatment.  I doubt that she is being treated for mesothelioma, and I would be surprised to see mesothelioma turned into a chronic disease by pemetrexed, but it does indicate that the treatment is not so debilitating that it must be stopped even if it is working.

I am very pleased with this plan.  It feels good to be taking action, and I am convinced that this is the best approach to slow down the cancer growth with a minimum dent in my quality of life.  I also see it as a way of living longer in case a good clinical trial opens or an ongoing trial proves successful against mesothelioma.  I’m certainly not looking forward to the treatment, but it will be intellectually interesting to compare my experiences this time with the first round of chemo.  Pemetrexed in generally well tolerated and only takes about 10 minutes to infuse.  I’ll have to avoid contact with sick people during part of the cycle, but it should create only a minimum amount of fatigue and anorexia.  

I’ll post again in probably a couple of week to say how this new round is going.

Thanks again for reading my posts.  It’s rewarding to know that some people find them interesting and perhaps helpful.

David