5 Syllables That Change Everything

Inoperable.

Amazing how a single word can rock your world.

We met Thursday morning with the multidisciplinary cancer team at the CU Denver Medical Center. After reviewing Michelle’s case and all the detailed information, they came to the conclusion that it would not be possible to remove all of Michelle’s cancer with an operation. Due to the location of the tumor within the common bile duct, and the suspected (and probable) tumor in the left hepatic duct, it would be necessary to remove ½ her pancreas and ½ her liver, along with all the ducts. We are dealing with a particularly aggressive and stubborn cancer, which is likely to recur postoperatively. They said it would be of small benefit to perform such a radical surgery when the outcome is unlikely to improve significantly. For this reason they are very doubtful of the efficacy of transplant in Michelle’s situation.

The only remaining option they presented to us was radiation therapy concurrent with chemotherapy. The radiation treatments would occur daily for 5-6 weeks, with chemo on the same days, immediately after radiation. There are 2 options for chemo: the current standard treatment or a clinical trial. If we chose the more standard treatment, we can receive both therapies close to home in Fort Collins. Participation in the clinical trial requires receiving the treatment in Denver.

The best chance for a cure is surgery followed by radiation and chemo. Without surgery, the chance of cure falls dramatically, but is still possible. Part of the problem is that this is a rare cancer and there have not been enough cases to study.

Obviously, this conversation changed the entire game. Prior to this meeting, I wrote a blog entry (see below) detailing the trials and tribulations we went through leading up to that time. It all seems trivial now, so I’ll summarize in the next paragraph and you can read on if you want all the gory details.

Early Tuesday morning, Michelle was wheezing loudly in her sleep. When I work her up she was very disoriented and incoherent, and could not catch her breath. She couldn’t hear very well and was in obvious distress. I called 911 and they stabilized her on the way to the hospital. the ultimate diagnosis was that a significant increase in her pain medication caused over sedation which interfered with her breathing. She was admitted to the hospital to establish a new pain management protocol. A nerve block procedure similar to a spinal was performed which successfully suppressed the majority of her abdominal pain and reduced her need for narcotics. Since her oxygen saturation was unsatisfactory, she stayed in the hospital Wednesday and skipped the scheduled ERCP to undergo x-ray, CT, and ultrasound procedures to identify any lung issues. Since all came back negative, she was discharged early Thursday morning to attend the consultation in Denver.

The cancer team said the ERCP we missed may not ultimately be necessary. It would most certainly add to the body of knowledge about Michelle’s condition, but would have only a trivial impact on the course of treatment. The chemo drugs and radiation therapy would be the same, but the ERCP might help slightly in targeting the radiation. We did reschedule the ERCP and will find out at our next meeting with the team whether we should proceed or not.

The following entry was written in the waiting area of University Hospital on Thursday, December 18, while the multidisciplinary cancer team consulted and worked out a treatment plan.

What a week this has been already! Michelle spent all day Tuesday and Wednesday at Poudre Valley Hospital in Fort Collins. The doctors determined that Monday’s increase in the dosage of Fentanyl caused Michelle’s wheezing Monday night, and admitted her until an alternative Pain Management plan could be developed. Tuesday evening they performed a procedure called a “Celliac (sp?) Bundle Block”. Using 4 needles near her vertebrae, they injected a potent form of alcohol (stronger than Isopropyl alcohol) which dissolved the protein coating of several nerve bundles, deadening their ability to transmit pain signals. Fortunately the procedure was a success, and Michelle’s abdominal pain has been greatly diminished. Hallelujah!

Michelle was on put on oxygen Tuesday morning as part of the treatment for her breathing problem. Her O2 saturation remained low all day Wednesday, and although we were able to reduce the volume of O2, we were unable to switch her completely to room air. As a result, we cancelled* the ERCP scheduled for Wednesday and she spent the night in the hospital.

To investigate the continuing breathing problem, a chest x-ray, a CT scan of her chest, and Doppler ultrasound analysis of her legs were performed. They found a partial collapse and fluid in both lungs, but no clots in her lungs or legs. Apparently Bile Duct Cancer brings with it a significant increase in the risk and incidence of blood clots, so they were particularly concerned about ruling this out before she was discharged. Since all was well, they wrote discharge orders for 5:00 AM Thursday so we could keep the appointment with the CU Hospital Cancer Team in Denver at 8:00 AM.

Michelle now has a portable oxygen tank. The pulmonary specialist said her current problems are most likely due to an acid reflux incident Monday night (before the wheezing problem which resulted in the call to 911.) It is common for people with hiatal hernia to aspirate stomach acid, causing lung irritation and ultimately scarring. While this has almost certainly happened to Michelle, she has plenty of residual lung capacity and should have no long-term complication from this incident. He expects her to come off the O2 in roughly 48 hours, or sometime on Friday.

As you can imagine, these complications have been crushing to Michelle’s spirits, but she’s hanging in there. All your kind words of support have been a great comfort to her, so please keep them coming. Michelle and I are great believers in the power of prayer and positive thinking, so please don’t stop praying for her.

Physically, Michelle is very tired and experiencing some pain when coughing and/or breathing deeply, both of which are critical to regaining her lung function. We are armed with pain medications that are effectively handling the discomfort but still leave her feeling “druggy”.

[I’m taking care of myself as well. I had a very uplifting visit with our family counselor and spiritual advisor Allen Brandon, which helped me immensely. Our daughter Kelly has been a great help, and has given me the space I need to rejuvenate and stay strong for Michelle.]

Next up: PET scan scheduled for tomorrow in Fort Collins.

* - The ERCP originally planned for 12/17 has been rescheduled for Monday January 5. Dr. Chen expects to have the advanced scope back from Japan by then, which will only improve the data gathering. The main difference between this scope and the previous version is the addition of a Narrow Band Imaging (NBI) tool.