Swept Off Our Feet

... and making a 180 degree turn.

Thursday night:

• Increased difficulty breathing.
• Put on oxygen since it was assumed low oxygen sats were due to pressure of the tumor on the lungs and diaphragm.
• Hemoglobin dropped again and anticipated another transfusion Friday due to possible bleeding into the tumor.

Friday morning:

• Still spiking fevers, but blood cultures still negative.
• Needed another blood transfusion, but all other labs stable and good.
• Planned to start chemo that night or more likely on Saturday morning.
• Chest x-ray to address breathing issues. (Tuesday scans showed chest/lungs were clear).

Friday noon:

• While walking out of room to go to x-ray, informed that after consultation with surgeons, surgery is scheduled for Tuesday to remove as much of the large tumor as possible.
• Surgery decision made due to bleeding in the tumor for the second time (happened after chemo round 1 too) and greatly increased risk of a large bleed occurring with next chemo cycle that would be too big to manage with transfusions. (see below for more detailed explanation).

Friday afternoon:

• Surprising x-ray results showed left lung completely surrounded by fluid and almost no function in upper or lower left lobes.
• Surgery to insert chest tube scheduled for that evening.

Friday night:

• Chest tube procedure successful.
• More than 500ml (half a liter) of blood and fluid drained immediately.
• Post surgery x-ray disconcerting as almost no improvement in lung function evident.
• Went over CT scans from Tuesday very carefully with the surgeon examining the tumor images.
• Overwhelming.
• 3 tumors in abdomen.
• Very large one in upper left quadrant of abdomen.
• Smaller, more dense one just below it and extending into his pelvis. (non-operable for now)
• Another dense one in the bottom of the pelvis. (non-operable for now)

• Moved to PICU for continued observation.

Saturday afternoon/evening

• Hemoglobin dropped again. Double unit transfusion.
• Chest x-ray reveals no improvement in left lung.
• CT scan to figure things out a little better.
• Left lung: suspected major infection and minimal capacity.
• Lower right lung beginning to gather fluid.
• Becoming critically important to restore lung function or he won't have enough lung capacity to undergo surgery. (need more than a single lung to provide O2 during extensive surgery).
• Intensive respiratory therapy begins.

Sunday:

• Chest x-ray shows improvement. Left lung shows pockets of air opening up.
• Clotting levels are high meaning his blood is not clotting well enough.
• Received fresh frozen plasma to aid in clotting. This will be good in preparation for surgery.

In depth explanation:

His tumors began as fairly solid masses (more or less). Chemotherapy gradually kills the cancer cells. When this happens, sometimes the tumor begins to shrink in on itself. This is what William's tumor did last time and what the two smaller tumors appear to be doing. The large tumor is not behaving so nicely. As the neucrosis (dying cancer cells) is occurring they break apart from each other. This make the tumor become less dense (think of rotting fruit), but the tumor begins to swell as the cells move apart. The tumor becomes inflammed as the body tries to go in and repair/heal. Remember that since the body produced the cancer cells, it does not recognize it as a foreign body. As this is happening, fluid is released from the cells and is also produced by the body. Also, tumors always have a blood source. As the cells die and fall apart, the blood no longer has a destination, thus the bleeding. Often it will dry up on its own and sometimes it doesn't. We do not know if the blood supply to his large tumor is a large vessel or several small vessels. Since the bleeding has occurred after both rounds of chemotherapy, he is at a greater risk of developing a larger bleed with continued chemo that could not be rectified by transfusion. This would occur when the chemotherapy continues to weaken the make up of the tumor and possibly perforates the blood vessel and he could suffer from a massive internal bleed. So the plan is to remove as much of the large, swelling tumor as possible as long as we can get him stable enough.

Monday will be the pow wow with the surgeons as the surgery plans are made and his current state is assessed. Please pray for his lung capacity to improve and sustain him and for the doctors to make the right decisions and be skilled in the surgery process.