See ya!
I saw him in the clinic the following week and we reviewed the results from the surgery. I explained that the pathologist had found not only the single liver tumor we knew was present, but also three additional two-to-three-millimeter tumors near it. None of these tumors were close to the liver transection line, meaning we had achieved a negative-margin operation. Furthermore, three of the twelve lymph nodes removed from around the blood vessels supplying his liver contained metastatic colorectal cancer.
He was nonplussed, and asked if it was still possible to be cured, the question I get every week from many of my patients. I explained the finding of the small tumors in the liver combined with lymph-node metastases meant there was a high probability he could have microscopic cancer cells hiding elsewhere in his body. In other words, his chance for long-term cancer-free survival was significantly reduced, but it was not zero. I finished with the assurance that I planned to follow him closely and watch for any recurrence. That earned me a grand smile, more damage to my right hand, and an exhalation-inducing embrace.
He returned home and spoke to his medical oncologist. They decided to proceed with another six months of a different chemotherapy regimen. At the end of the second six months of cytotoxic drugs, he returned to see me in the clinic. All of his blood tests and CT scans showed no problem, no clinically evident cancer.
I wasn’t sure if my right hand or my chest was going to remain intact thanks to this patient.
Unfortunately, the good results and good news were short lived. Six months later, a blood test we measure in patients with colorectal cancer called carcinoembryonic antigen (CEA), was elevated in him. When I saw his lab results, I immediately scrolled through his CT scans, and then quietly cursed at the computer screen. He had four new tumors in the hypertrophied left lobe of his liver along with at least a dozen small lung metastases scattered throughout both lungs.
I walked into the examination room to tell him the news. He knew from my face I was about to drop a bomb on him. Before I could say anything, he stood up, hugged me, and to my amazement said, “We’ll beat this thing!” I reassured him we were in the fight together and then I went over all of his results. He sat, quietly nodding and occasionally asking for clarification. Finally he asked, “Okay, what’s our next move?” I spoke with my colleagues in medical oncology, and we determined a new sequence of drugs to treat him for this rapid recurrence.
At a visit with me three months later, he launched the question patients often ask, he wanted to know how long he would live. He was a motivated, insightful, intelligent individual, and as we sat together in a clinic room, he rifled through copies of scientific papers describing chemotherapy and novel treatments for stage IV colorectal cancer. He noted from his reading the median survival rate with the chemotherapy drugs he was receiving ranged from eighteen to twenty-four months. I affirmed that those perceptions and statistics were correct, but there was no way to predict if he would live less or more time than the average. He laughed, tossed the research papers on the floor, and said, “These don’t describe me!”
This man was tough. He kept working despite major surgical procedures and significant side effects from chemotherapy. He was also a fountain of optimism, regardless of seemingly daunting odds against him. He found a way to make things work. I certainly was not going to shoot holes in his belief he was going to beat the odds and outlive the predictions.
After six months of additional chemotherapy, CT scans of this gentleman’s chest showed the lung metastases had completely disappeared, and the liver metastases appeared to be calcified scar tissue. His CEA blood test had returned to a normal value. After considering his situation and excellent antitumor response in a tumor-board meeting, my colleagues and I decided we would stop chemotherapy and follow him. This we did with blood tests, CT scans, and physical examinations every three months for another year.
At the one-year mark, his CEA value was again elevated and CT scans revealed recurrence in the liver, lungs, and peritoneal cavity. Grimly, I walked into the examination room to have a heartrending discussion. As I reviewed the test results, his wife quietly wept. Before addressing me, he turned to her, gave her a hug, and told her he would be all right. He pivoted to me, flashed a dazzling smile, and said, “Remember, we are in this together.”
Yes, we are.
Based on probabilities, patterns, and the rapid recurrence of his cancer in multiple sites, this man would have been predicted to survive no more than two or three years after his initial cancer diagnosis. Recently I received a note from his brother informing me my patient had finally lost the battle (his brother’s words) and had passed away—almost eight years after his original cancer diagnosis. Throughout those years I saw him every three months and arranged for him to meet numerous specialists administering a variety of new clinical trials for colorectal cancer. His medical oncologist at home was, and still is, very active in treating patients with established and new regimens for gastrointestinal malignancies. Whenever we spoke on the phone about our mutual patient, it was always with a note of admiration for his courage and formidable spirit.
I loved watching boxers and faux wrestlers (performance athletes?) with my grandfathers. Several of the wrestlers we saw on Saturday-afternoon television had been college wrestlers, some even competing in the Olympics. They were indeed athletes. Not great actors, but athletes nonetheless. Perhaps the ability to work hard, to strive, to endure pain and discomfort and defeat is what led my patient, the wrestler, to survive as long as he did. I have seen similar powerful and courageous efforts from patients of all ages and backgrounds. I am reminded of words from one of my favorite songs, “The Boxer,” performed by Paul Simon and Art Garfunkel describing a fighter who is cut, knocked down, and beaten in the ring, but he chooses to remain and battle on.
Warrior terminology abounds in the cancer lexicon: “The war on cancer.” “She lost her battle with cancer.” “I am fighting cancer.” “We are going to attack your cancer with every weapon in our arsenal.” “He refuses to surrender and will keep battling.” “She is soldiering on through this fight with cancer.” “I am going to beat and defeat this cancer.” “It was a courageous fight.” “We have your cancer on the ropes.”
Patients diagnosed with cancer and treated with our multidisciplinary approaches are knocked down physically and emotionally, but they pick themselves up off the canvas and struggle on. They carry the reminders of the acute and chronic side effects from cytotoxic chemotherapy and radiation-induced skin and functional-organ changes. They endure the scars, complications, and impairments imposed by the blades of surgical oncologists like me. Though sometimes they want to, they don’t leave. They remain. They maintain. I respect the effort, the invincible spirit, and the patients who don’t give a damn about the odds or probabilities; they are going out swinging. We are tag-team partners in oncology, entering the ring to attack cancer with every move and method we know. Hell, I’ll even throw a few chairs if it will help.
Indomitable. The wrestler.
Respect, my brother.
17
The Deacon’s Wife aka “The Real Muhthuh”
“Faith consists of believing when it is beyond the power of reason to believe.”
Voltaire
Faith: Complete trust or confidence in someone or something
We surgeons would not be able to perform major operations safely without the collaboration and cooperation of our anesthesiology colleagues. Hepatobiliary surgeons ask their friendly neighborhood anesthesiologist to maintain low central-venous pressure (CVP) anesthesia during liver resections. This means the patient is maintained in a slightly dehydrated state to reduce the pressure in the vena cava, and as a result, in the hepatic veins that drain directly into the vena cava near the heart. Bleeding caused by high CVP, in the range of four-to-ten millimeters of mercury of pressure, transmitted back into the hepatic veins coursing through the liver is a bane of the existence of the liver resectionist. We can easily c
ontrol the blood vessels (specifically the portal vein and hepatic-arterial branches) flowing into the area of the liver being removed. But bleeding from unintentional avulsion of small branches or minor rents in the thin-walled, fragile hepatic veins draining blood out of the liver can increase intra-operative blood loss. Though preventable, this is potentially problematic, higher volumes of bleeding will occur unless low CVP is maintained. Most hepatobiliary surgeons prefer to keep the CVP as low as possible, from negative one to one millimeter of mercury if the patient’s blood pressure, heart rate, and kidney function are stable at these low pressures.
Oncological surgeons are fastidious about avoiding blood loss because we prefer that our patients not require or receive transfusions. We are not concerned about style points, but we limit blood loss because, while controversial, multiple clinical studies over the past two decades suggest blood transfusions during or shortly after cancer surgery inhibit components of the immune system and increase the likelihood of recurrence of malignant disease, reducing the patient’s probability of long-term survival. This is a frequent “Current Controversies” discussion in national and international surgical oncology meetings. Currently, for some types of cancer, evidence suggests a causative relationship between blood transfusion and a higher risk of cancer recurrence, and more rapid cancer recurrence. So the question has been raised often and is definitely on the radar of the surgical oncologist. Thus, during an operation, close communication and ongoing conversation with our anesthesia colleagues “on the other side of the drape” is mandatory to optimize intra-operative care, reduce blood loss, and maximize patient safety.
After a routine scheduled operation is completed, the patient is transported to the recovery room, also called the Post-Anesthesia Care Unit, or PACU. Patients generally remain in the PACU for a few hours to allow nurses to closely monitor their vital signs and to assure they are recovering well from the effects of anesthesia. General anesthesia and narcotic pain medications often used directly after major surgical procedures combine to produce some interesting reactions in patients. Dissociative events are common, meaning the patient, while obviously a bit groggy, is apparently awake and able to converse and respond to questions. Occasionally, people in this early postanesthetic state will blurt out bizarre, nonsensical, unexpected, or inappropriate remarks. Interestingly, the person usually has no recollection of the comments. This phenomenon has led intelligence services worldwide to use anesthetic drugs, like the barbiturate sodium pentothal, as a “truth serum.” Great material for spy novels and movies, but the truth is there’s no predicting what somebody may say after receiving a dose of psychoactive anesthetic drugs.
Some years ago, an almost-seventy-year-old woman was referred to me after being diagnosed with a rare hepatic tumor, epithelioid hemangioendothelioma. EHE is an interesting tumor that can present as solitary or multiple lesions within the liver, and it can arise in other organs as well. EHE originating in the liver is scarce indeed; only several dozen are diagnosed annually in the United States. Not all EHEs are malignant; some have little or no propensity to spread elsewhere. But the lungs are the most common site for metastasis from malignant EHE in the liver. Malignant EHE is biologically fascinating because there are documented episodes of removal of the liver tumors that led to reduction or even resolution of lung metastases in some patients. When local treatment (like surgical removal or ionizing-radiation therapy) of a tumor at one site in the body leads to reduction in the size of metastatic lesions in other organs like this, it is known as the abscopal effect. In oncology, we wish we witnessed abscopal events more frequently. Unfortunately, like EHE, it is relatively rare.
My new patient was diagnosed with EHE when routine blood tests during her annual physical examination revealed mild inflammation of the liver. Her family practitioner thought this might be related to gallstones so an ultrasound study was performed. It showed a normal gallbladder but also detected a six-centimeter tumor in the left lobe of her liver. After a CT scan and needle biopsies of the tumor were obtained, she was referred to me to consider surgical management.
This woman was a quiet, prim, proper, and reserved individual. She was accompanied to her first office visit by her husband and three adult daughters. They were from a small town in east Texas, and when I asked them questions, their most frequent response was a simple “Yes, Sir” or “No, Sir.” The patient’s husband was a businessman in their community, and felt it was important to inform me that he was a deacon at the local Baptist church, where his wife and daughters were also Sunday school teachers. After my patient’s children were grown and had left the house, she worked as a secretary at the church. Prior to being diagnosed with epithelioid hemangioendothelioma, the patient had been in good overall health, having only mild hypertension that was well controlled with a single medication. She was active, engaged in her church and community activities, and proud of her children and grandchildren. She told me she was not worried about undergoing an operation because she knew she was going to be well.
This woman and her family were salt-of-the-earth folks.
A couple of weeks after meeting this calm, unpretentious lady, I performed a straightforward surgery to remove the tumor-bearing left lobe of her liver. The operation took approximately one hour to perform; it was routine, unremarkable, and uncomplicated, and she was completely stable throughout. Her blood loss was minimal and transfusion was never considered or necessary. I walked out to the family waiting room and informed my patient’s husband and daughters that the operation had gone well and she was stable and resting comfortably in the PACU. When they asked to see her, I said they could go to the PACU in one hour. I mentioned that by then she should be awake enough to talk with them.
Fate occasionally intervenes at opportune moments. By sheer coincidence, a surgical oncology fellow who was born and bred in the borough of Brooklyn in New York and had the accent and attitude to prove it, was on my service that day. He and I went to check on our patient in the PACU at the same moment her husband and three daughters arrived at her bedside. Before I could say anything, her husband grasped her hand and asked with concern, “How are you, Honey?”
From her mouth erupted a string of invectives, curses, words banned for on-air use by the Federal Communication Commission, and open questions about the parentage, lineage, and even species of every person present. Her husband recoiled a few steps and grasped his chest, asking, “Honey, are you all right?”
Almost seventy years of suppressed foul language again poured forth from this respectable church lady. One of her daughters managed to utter a monosyllabic question, “Mom?” More cursing. Swear words used as nouns, verbs, adjectives, and adverbs; it was a masterful extravaganza of expletives.
Four astonished family members turned to me, and one asked, “Is this normal?”
No. No it is not. But it happens.
In a state of psychic shock, one of the daughters said, “She is not acting like my mother.”
At that moment, my fellow, apparently caught up in the dissociative frenzy, muttered audibly, “Oh, she’s a real Muhthuh, all right!” The Brooklyn accent was icing on the cake.
There was a pause of stunned silence. Suddenly, all three of my patient’s daughters started laughing. Loud, hold-on-to-your-belly, tears-running-down-your-cheeks guffaws.
The fellow apologized, “Uh, sorry ’bout dat comment,” causing them to laugh louder. We were creating quite a scene in the PACU. I wanted to laugh because of the absurdity and improbability of what had just transpired, but I refrained, fearing the husband’s blasphemy-induced angina pectoris (he was still clutching his chest) would be converted to a full-blown myocardial infarction if I chuckled openly.
Primum non nocere (First, do no harm), right?
During our riotous commotion, the patient had drifted back into postanesthetic sleep. Staring at his wife in disbelief, my patient’s husband shook his head and mustered a weak smile. Clearly incredulous about what he had just heard, he told me he ne
eded to go sit down for a few minutes. His daughters pulled it together, and I escorted them out of the PACU. As we walked I explained that anesthetic agents and pain medications may sometimes cause unusual comments and behaviors in patients. I admitted I had never heard anything quite like that explosive, profane tirade, but I reassured them this was not a lasting side effect of the operation or the anesthesia. One of the daughters pulled me aside and exclaimed, “I didn’t think she even knew all of those words!”
Now she knew.
I quietly returned to the PACU and stood at the end of my snoring patient’s bed. I hoped I was correct and the profligate profusion of profanity was a drug-induced, solitary, and never-to-be-repeated episode. A PACU nurse strolled by and simply said, “Wow!”
Yeah, wow!
The next morning my fellow and I visited the patient in her hospital room. Her husband and three daughters sat expectantly awaiting our arrival. Again, before I could say anything, one of the daughters spoke, “Tell her. Tell her what she said yesterday.”
My patient looked at me with pleading eyes, “Please tell me I didn’t say anything rude or inappropriate?”
Well, Ma’am, I can’t exactly do that. Clearly, the patient’s husband and daughters had told her about the profundity of profanity she had loosed upon us after her operation. I didn’t recount the details, but I did confirm she had used some words that would have gotten my mouth washed out with soap had I said them as a boy. She blushed furiously and apologized to her family, my fellow, and me. Her daughters and husband (now fully in the spirit of the ridiculous) started laughing, and one of the daughters pointed to my fellow and said, “He has a great name for you, Mom. A real Muhthuh!” We all laughed.
Well, not all. My horrified patient continued to blush and apologize.