For the first time since I-don't-know-when, I did not need to wait for my appointment. Less than three minutes after checking in, I was whisked off to an examination room.
Dr. Erinjeri walked in. I did a double-take as I processed this sharply-suited young man. The last time I saw him he was wearing scrubs and a hair net. Yes, he is the doctor who performed my first biopsy.
"Your hair looks longer than I remember it," he said.
"That's because I water it every day."
And we were off...
He pulled up my CT scan onto the monitor and scrolled through it, narrating along the way.
Looking at the images, he pointed out the tumor, the bowels, and the common iliac artery. I had seen the images before, but I did not have the benefit of a clear explanation of features and positions. My previous interpretation was mostly educated guesswork. This was the real deal.
This is a slice of my CT scan (with oral and IV contrast) from August 26. The view is from the bottom, looking up. Imagine I am on my back, and you are naughty and decide to look up my skirt. The tumor is center-right in the image (corresponding to the the left side of my pelvis).
Intestines are directly above and around the tumor. The darker grey is my small intestine. The whitish grey is part of my large intestine.
The tumor is the circle in the center-right. The dark portion in the center is necrotic tissue. The lighter color surrounding it is malignant tissue. It is now roughly the size of a medium egg.
The common iliac artery is immediately adjacent to the tumor. Viewing this image it is easy to understand why the surgical margins are so poor.
I have no idea what the dark spot is. It looks like poop, don't it? OK, I'm lying. They are veins. The one I labeled "Poop" is the vein through which they took my first biopsy.
We looked at the image, scrolling up and down my virtual pelvis. In homage to black-and-white film noir, my hands sweated as I learned more—to the point where I smeared the ink in my notebook. It was that intense for me as we spoke in detail about my first biopsy.
Dr. Erinjeri performed my initial biopsy with a very fine needle, piercing the vein (labeled "Poop") to access the tumor. As previously noted, this was a marginally successful procedure. It was successful in that it captured sample tissues. It was a failure in that the samples were inadequate to our needs.
Secret #1
Over the course of the conversation, I learned that it very nearly was a complete failure. I was sedated throughout the procedure. I remember the nurse pushing the plunger to sedate me, and I remember being wheeled out of the room. I remember nothing in-between.Apparently, however, I was talking to the team throughout the experience. I can be loquacious, It seems that I was on-form.
Non-stop chatter, or so he tells me. Unfortunately, I don't remember any of it, I certainly do not remember that there were three attempts at the biopsy—each with increasing levels of risk. It was on the third—and final—attempt that they were able to get anything from the tumor.
This explains the discomfort I experienced afterward (and now, as I write this, two weeks later). There was far more manipulation of my tissues than I knew previously.
Here's a closer look at the tumor and the artery. I cropped and enhanced the image with a histogram equalize filter, to give it more contrast. Note that the tumor (center of image) is approximately 4.5 centimeters in diameter. It is approximately five times the diameter of the artery. To my imagination, it looks like Harry Potter's bezoar. Alternatively, think "hard boiled egg".
Our conversation turned to my next biopsy, for which the only recommended procedure is hydrodissection. It is a rarely-performed procedure. Of the 3,000+ needle biopsies performed at MSK each year, maybe five are hydrodissections. However, of those five or so, Dr. Erinjeri does four.
Hydrodissection
In this procedure, two needles are used, one is inserted between folds in my bowels (maintaining the integrity of my intestines). This needle is used to "inflate" the area with contrast saline liquid or a gas (carbon dioxide or nitrogen). The idea is to use hydraulic or gas pressure to push the bowels apart, enabling the second needle to have a straight, clean path to the tumor (see annotated image). Basically, it's fracking my bowels (as opposed to frikking my balls, which is a cheap joke used to provide a moment of levity).
The blue line represents Needle 1, which will be inserted into the belly. It will then be used to pump fluid or gas into the area to separate the tissue masses. The red dashed line represents Needle 2, which is the needle used to sample the tumor. The position in this image is approximate. The intention is for the hydraulic pressure to push the masses apart, enabling straight-line access to the tumor.
If the "inflation" technique works, he will take a 2+ centimeter core sample of the tumor. This sample would include material from the tumor's dead center, the malignancy, and surrounding healthy tissue. Doing so gives the analysts a complete perspective on the tumor, allowing for definitive testing to be performed on the tissues.
And that's what we want.
However, as I mentioned in a previous post, it may not work. Lacking a virgin bowel (I feel dirty writing that...) it is possible that adhesions have formed from my previous surgery. If this is the case, then the "inflation" will not work. Adhesions are not bad—they are merely scarring from previous surgeries—unless you are trying to balloon my bowels.
This procedure is done on an outpatient basis. This means two very big things:
- I will know—as they wheel me out of the ER—if it worked.
- I can get back to the business of life the following day.
Secret #2
At this point that I learned another untold secret.I asked if Hydrodissection would be an inpatient or outpatient procedure, fully expecting that it would be an inpatient procedure. My reasoning was that the last biopsy had kept me in the hospital for two days.
So, I was dumbfounded when he replied, "Outpatient."
I asked him how that was possible, considering my previous hospital stay. He looked at me in that curious, tilt-headed way a scientist looks at an unwanted specimen. Then, a moment of recognition, and he told me something that almost knocked me out of my chair.
"I remember now...they kept you in because they thought you might have had something different, and they wanted you here in case they needed to start you on immediate chemotherapy."(gulp)
I elected not to pursue that conversation. My brain was getting full. It was another reminder that I was being well-managed by my medical team.
Confidence
"I'm very confident that this will work. Now, I'm a confident guy, but I don't see anything in the scans that indicates that this wouldn't work for you. Of course, we won't know until we try."You see, my interventional oncologist is known as "the crazy-biopsy guy." (Honest Reader, please note the use and position of the hyphen.) He's the guy who does the tricky, difficult, or complex procedures. He as a healthy ego, and (yes) he is a little crazy. He's also terrifyingly young, energetic, and sharp. And ladies, he's unmarried...jump that train!
But I digress..
He's a creative a problem-solver. To that end, he referenced Neils Bohr's famous quote:
We are all agreed that your theory is crazy. The question which divides us is whether it is crazy enough to have a chance of being correct. My own feeling is that it is not crazy enough.Hydrodissection is crazy. Is it crazy enough?
So, What If It Doesn't Work?
There is one more option.As a last resort, I would get to play the role of "guinea pig" in the ongoing farce that has become my life.
It's inelegant. One might say it is brute force...
The "crazy enough" solution? Drill through the hip.
Dr. Erinjeri: "It's never been done, but we have high confidence that it would work, and we've been waiting for the right situation to come along for us to do it."
Frightened and flattered, I listened.
"We already routinely go through the flesh of the hip to drill the hip bone to take bone marrow samples. We've been doing this for years. And we already use needles to biopsy the muscle inside the hip. This would be connecting the two. We would drill the hip and then insert the needle through the tubule we put in the bone. It doesn't effect the integrity of the hip at all. it's just a matter of doing it."And listening, nodding, grokking, I realized that it is just crazy enough to work.
As I continue to become a smaller slice of pie, it seems more and more likely that this will happen—it's gotta, right?1 This is crazy!
But we will not cross that bridge until we absolutely must.
Next Steps
Monday, September 23 will become moanday. I will be on a liquid diet, and I will be cleansing my bowels. The purpose is to help shrink the area and prepare it for manipulation.Tuesday, September 24 will be the day of my procedure. I do not know the time yet. As of now I plan to head up to New York frightfully early and return the same evening. It may be insane...we shall see.
And the following Tuesday, October 1, I return to New York to learn my fate.
What will be will be what will be.
I've got this.
1For the record, we talked about other options. They do have a number of techniques that they are developing (using animals, not cadavers...yes, I asked), but that are not quite ready to be used on cancer patients. One involves micro cameras, using them in a way similar to a laparoscopic procedure. In this procedure they use what they see in the laparoscopic scope to guide them (as opposed to CT scans). As I understand it, this presents some challenges.
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