Adventures in Pain Management

Michelle was admitted to Poudre Valley Hospital (PVH) on Tuesday for pain management and tests to figure out what's behind the pain. I'll skip the gory details and tell you where we stand as of Thursday morning.

For pain management, the plan is to install an intrathecal pump, aka an epidural pump. This works much like the epidural that they give to delivering mommies to ease their pain, in that a catheter inserted into the intrathecal space in the spinal column delivers pain medicine directly into the spinal fluid and blocks the pain signals from reaching the brain. A hockey-puck sized pump will be installed under the layer of fat in her abdomen to deliver a constant, low-level flow of pain medicine. Michelle will have a remote control to deliver a bolus (larger dose) of medicine if she is having "break through" pain.

The primary advantage of this method is that a tiny fraction of the pain medicine dosage will have the same effect as the oral medication we had been using, resulting in almost negligible side effects like constipation, mental fogginess, and respiratory suppression.

A trial epidural catheter was installed Tuesday evening to experiment with different medications and doses to find the right combination to make Michelle comfortable. She's now on morphine, and it seems to be doing the job. We're also dealing with the consequences of being on pain medication for several days and working to alleviate those symptoms to clear the way for installation of the pump tomorrow.

Michelle will also have an MRI this afternoon to recheck the status of the tumor in her vertebra that was treated with radiation back in February.

Speaking of radiation therapy, it turns out that this whole episode of pain is related to that same treatment. The radiation beam that treated the tumor in her spine had to travel through her liver and her stomach on the way to its target. Normally this is no big deal, but there is always risk of organ damage from the radiation, which we were made well aware of at the time. When no damage showed up by 6 weeks after the end of treatment, we all believed Michelle was in the clear. We were wrong.

It turns out that Gemcitabine (aka Gemzar), the chemo drug that Michelle has been on since January, can act as a radiation sensitizer, even after the fact. Dr. Marschke has used Gemcitabine along with radiation therapy with good results in many other patients, but usually for pancreatic cancer. Since the pancreas is off to the side and well away from the liver, he's never seen an effect like Michelle's. Dr. Simpson the radiologist said he's never experienced a problem, either. Regardless of all that, it is fairly clear from the evidence we have that a portion of Michelle's liver is suffering from radiation damage.

Radiation lingers in the body for a long time after treatment, and continued gemcitabine treatments increased the sensitivity of her liver tissue to the radiation,
resulting in tissue damage over the last 3 or 4 weeks. A CT scan the last week of May showed the early beginning of the damage, but it looked more like a tumor at the time. Just 3 weeks later the damage had spread through both the left and right lobe of the liver, but following an absolutely straight line that fit the radiation beam and didn't match the expected growth pattern of either a tumor or damage due to loss of blood supply, the two other most likely diagnoses.

According to Michelle's gastroenterologist Dr. Dunphy, only 1/6 to 1/7 of her liver was affected. The best news is that the liver is really good at repairing itself, and should replace all the damaged tissue over time. The other great news is that all Michelle's liver function markers are at or near the normal range, indicating that the liver damage is not making her sick, other than causing massive amounts of pain.

In the process of ruling out other causes, they checked the blood supply to her liver and the CA19-9 tumor marker. No clots were found, and her CA19-9 dropped from 127 a month or so ago to 75! This is the same number that was 7998 back in January. Hallelujah! Thank ya Jesus! Amen!

In the mean time, Michelle's parents Ron and Sharon Beyer are driving up from the Phoenix area and are expected to arrive tonight. Dad is bringing his tool belt to help me with the deck - we're getting closer to finishing, and I'm hopeful everything will be done in a couple more weeks. (Ha! Michelle says, like that'll happen!) Oh ye of little faith.

Thanks all for your continued prayers. We're holding up well through this bump in the road and are still looking forward to our Caribbean Cruise in just 3 short weeks. We should know in a week or so if we'll still be able to go, so keep your fingers crossed and stay tuned for further developments.

Bill