Friday, October 30, 2009

PET/CT SCAN 10-30-2009


Findings: Diffuse inhomogeneities are seen throughout osseous structures on the mapping CT. There are some frankly lytic areas such as the right acetabulum.  Other areas appear sclerotic.  There is an L3 compression fracture deformity.  There is diffuse increased metabolic activity throughout the osseous structures on the PET portion of the examination.  This involves axial and appendicular skeletal structures. CT and PET findings together indicate the presence of diffuse osseous malignancy.

Two metabolically active right breast masses are identified.  There is a 9 X 12 mm of nodule in the upper outer quadrant of the right breast seen on image 89.  Peak SUV measures 2.2.  In the deep right breast just above the nipple line, there is a 14 X 15 mm mass seen on image 99 which shows a peak SUV of 5.0.  no metabolically active axillary nodes are seen.  Metabolic activity in the thorax and neck is physiologic.  No pulmonary nodules are seen in the mapping CT.

A 16 X 16 mm pancreatic node is seen in the abdomen on image 136.  This is associated with elevated metabolic activity.  Peak SUV measures 5.3.  No other metabolically active or enlarged nodes are seen in the abdomen or pelvis.  Increased metabolic activity is seen in the right pelvis that appears to be associated with the right ovary.  There does not appear to be an ovarian mass.  This may be physiologic in etiology.  Metabolic activity throughout the remainder of the abdomen and pelvis is physiologic.

Tuesday, October 20, 2009

Cabbage Leaves and Nursing

After a few days in the hospital I realized that I was going to have to stop nursing. It was taking some time to figure out what was wrong with me but all signs were pointing toward cancer. I had been through one bone marrow biopsy, which was unsuccessful in obtaining a good sample for diagnostic purposes. It was very clear though, that whatever was wrong was affecting my bone marrow as the sample did indicate a problem.

Being in so much pain from the compression fracture in my back I was on pain medications which caused me to be unable to nurse. I had to make a difficult, but inevitable decision. The doctor was talking about a mammogram and PET Scans and all sorts of other tests that require injections of various materials. In the back of my mind I knew that I would be unable to nurse while being treated for cancer and I tried not to think of the second scariest word in the English language...Chemotherapy. The first, of course, being the word Cancer, in my humble opinion.

Giving up nursing was by far the most painful part of this whole affair. It was just shy of the six month marker in Tan (pronounced Thun like thunderbolt) Nguyen's life, which was a good start, but much to soon for me. He already had formula occasionally since I worked and couldn't always keep up with the demand. This made the transition for him fairly easy.

So there I was in the hospital, on pain medications, not nursing and leaking like crazy. The nurses in Memorial Hospital's Oncology unit are fantastic and they really felt for me. One of them went up to the Pediatric Unit to inquire about how to help me. I, of course, wanted a pill or something to dry me up immediately. I had remembered from my pregnancy being told not to take Benedryl or other form on nasal decongestant as they would have a drying affect on my milk supply. I talked to my Doctor and got him to prescribe me Benedryl as a sleep aid in the evenings which helped put me out of my misery by putting me promptly to sleep.

The word from the Pediatric Unit was that there was nothing I could take but there had been some decent anecdotal stories of how helpful cabbage leaves were. The nurse then sent my husband Huy out for head of cabbage and upon return she rolled them using my water bottle as a rolling pin and handed them to me. I can admit to feeling more than just a little silly as I inserted them into my nursing bra but desperate times call for desperate measures.

Now if you are picturing me wearing a hospital gown or "Johnnie" with a bra stuffed with cabbage leaves your picture is inaccurate. I refused to wear a "Johnnie" during my hospital stay. My Mom bought me some cute pink pajamas with black polka dots and my husband brought my other pajamas from home. I couldn't bear to be in the hospital much less wear hospital issue clothing. Also, I confess, they now have snap together "Johnnies" and with my back pain I couldn't sit upright long enough to figure it out.

I must have made quite an impression because when I was hospitalized on April 15, 2010 I ran into some of the same people from my October visit. One nurse's assistant told me I looked familiar and when I mentioned I had been there in October she asked, "are you the one who always wore your own pajamas and had the cutest baby in the world?" I replied, yes that was me.

Anyway, if you are looking to stop nursing for strictly positive reasons and are not looking forward to all that entails remember to buy a head of cabbage and a package of Benedryl. You can thank me when I see you.


Monday, October 19, 2009

October 16th From a Mother's Point of View

October 16 is a day I will also never forget. I knew that something serious was going on because a seemingly healthy 38 year old does not sustain a compression fracture of her lumbar spine spontaneously without significant trauma. When we learned of the fracture (and we were skyping at the time so I watched as Susan got the news from Rachael via telephone) We were dismayed. I spoke to a radiologist the next morning and he offered several possibilities that included breast or other cancer. I felt she was in trouble. She called me days later after the MRI report was in and the decision was made to hospitalize her. It was one of those defining moments, I know the time and place as I was driving to a hair appointment which I promptly cancelled. Driving home, I knew what had to be done. I burst through the door, grabbed my laptop and starting searching for a flight out the next day (thankfully, Saturday). I told Paul we were going to Colorado. His reaction was the same as Susan and Huy's. "Let's just slow down and see what happens in the next day or two." I told him I was going come hell or high water and he could come along or stay home. Within the hour we were packed, the fridge cleaned out, and plans made for an early airport run. At 2pm the next day, we were walking down the airport ramp gazing at Tan Nguyen who was secure in his Baby Bjorn carrier, flopping his arms and legs and smiling at us with a big wide grin. With him in my arms, I could take a small breath again and then when we were with Susan a few minutes later, a bigger breath. We were going to need all the oxygen we could store in the coming days.  It was a dark time of uncertainty, fear, dismay, and the realizition that a nightmare was taking place right in the middle of our lives.  Yet there were bright moments too.  Tan totally charmed the entire nursing staff until he was banned from the hosptial due to the Swine Flu scare.  He was adorable, stretched out beside Susan on her hospital bed, all six months of him, chubby and bald and sound asleep.  His world was not falling apart, in fact it was two times better now with four of us to play with him and give him stroller rides.  We slept those nights in Susan and Huy's bed with Tan snuggled in between us, all soft and sweet smelling.  One night, Paul lifted up a little, looked over the sleeping baby and whispered to me "I wouldn't have missed this for the world."     I knew exactly what he meant.   Deb recently reminded me of Isaiah 41:10  So do not fear, for I am with you; do not be dismayed, for I am your God. I will strengthen you and help you; I will uphold you with my righteous right hand.

Friday, October 16, 2009

October 16, 2009

This is a day that I will never forget.  I was laying on my couch in my therapy office praying that I would recover from this immense pain when my phone rang and Rachel my PA from my family doctor called.  She stated to me that she wanted me to check myself into the hospital and I found myself asking her dumbly, "on purpose"?  She then explained that they wanted to run some tests and this was the best way to get it all done.  I had already seen the results of the MRI which suggested possible explanations for my back issues and listed among them were leukemia and different types of cancer. 

In light of this I thought I should be more cooperative and I said "ok, when"?  I was shocked when she told me today.  She stated that I had a 5pm appointment with a Hematologist.  At this point my head was spinning and I began to stumble over my words.  I told her that I had clients scheduled and she said that I should cancel them.  I then stammered that I needed to talk to my husband first and couldn't get a hold of him but I knew then that I was making excuses and then asked her which hospital.  She asked me which I preferred and I told her I had never been hospitalized before (that I remembered) and she asked me where I had my baby.  I reminded her that I had a home birth.  She then said she would ask the Hematologist and call me back.  I called my mother who immediately stated she was on a plane.  I asked her to slow down and suggested she wait until I met with the Hematologist and then we would go from there.  Mom informed me that a Hematologist meant cancer.  I called my clients and cancelled them.

I then drove home and mulled over what to pack to bring with me.  Huy got the baby ready while I threw some things in an overnight bag.  I don't know how you pack for a hospital stay.  I think I brought a couple pairs of underwear, a pair of socks, my charge cords to my electronics and my medication. It was a pretty empty overnight bag but then Rachel had said I would only be in the hospital a couple of days.

The check in process was a blur and soon I was in a wheelchair with my baby in my lap.  Huy pushed me and the volunteer showed me to my room.  Tears slid down my cheeks as we rolled under the sign announcing oncology.  I was happy to see it was a private room and I exited the wheelchair and slid into the lazy boy in the room.  Huy looked nervous and paced with the baby.  The nurse Beth came into the room and sat down next to me.  She asked me why I was there and when I responded, "I guess I have cancer since I just got admitted into oncology" she looked horrified and told me that this was a terrible way to find out.  I tried not to panic and tried not to scream as she asked me lots of questions.

The rest of that night is a blur.  I can tell you that I met the Hematologist who was a sweet man and that the didn't make me have an IV.  After Huy took the baby home I read the hospital room service menu and quietly thanked God that my mother and father were on there way to Colorado.  I couldn't imagine that it could be true that I had cancer.  I thought my back pain was due to flabby post pregnancy stomach muscles and I just needed to firm up.


Monday, October 12, 2009


INDICATIONS: Compression fracture, eight months postpartum

FINDINGS:  The bone marrow is very heterogeneous on the T2-weighted images with multiple areas of markedly high intensity outlining nearly geographic contours in the vertebral bodies and more punctate areas in the lamina and spinous processes.  On T1, the overall intensity is moderately diminished, still slightly higher than the adjacent psoas muscles.  On T1, there is one particularly low intensity area in the posterior right side of the L2 vertebral body with slight target configuration on T2 on series 3, image 6.  The lesion measures 11 mm in diameter.  There is a second possible focus of similar low signal in the left iliac crest on series 7, image 34 measuring 7 mm in diameter.  After contrast, the marrow enhances heterogeneously with most of the bright areas corresponding to the T2 bright regions.  The areas of low signal do not appear to enhance significantly.  The overall appearance of the bone marrow may reflect a fairly aggressive decalcification and/or recalcification.  However other more common marrow processes must be considered such as malignancy, hemolysis or multiple bone marrow infarcts; close clinical follow up and correlation with DEXA, peripheral smear and reticulocyte count is recommended.  A bone marrow biopsy should be considered, the left iliac crest should provide a representative sample.  The leading alternate possibilities are leukemia, lymphoma, multiple myeloma, breast cancer, recovering red marrow from hemolysis, multiple bone marrow infarcts as seen in SLE, Gaucher's, and many other conditions.  Note that there is no evidence of retroperitoneal adenopathy.

The L3 vertebral body shows a mild chronic compression fracture.  There is a fracture line extending obliquely almost in the axial plane from the superior anterior endplate into the mid posterior vertebral body.  This vertebral body has lost approximately 10% of vertical height.  There is a slight posterior retropulsion slightly indenting the dural sac.  No marrow edema is seen within the vertebral body.  However, there is slight edema in the surrounding paraspinal soft tissues with slight increased enhancement as seen on series 9, image 13.  The paraspinal soft tissue changes suggest a late subacute fracture.

The vertebral body alignment is normal.  The spinal canal is normal size.  The lower thoracic cord and cauda equina appear normal.  No abnormal enhancement is seen within the spinal canal.  The disc heights are preserved with no disc desiccation.  No disc bulges or disc protrusions.  No joint or foraminal changes.  The SI joints appear normal.  The retroperitoneal soft tissues appear normal.

OPINION:  1.  Heterogeneous appearing bone marrow on T2 and post contrast T1 images with much more homogenous moderately decreased T1 signal and two foci of markedly decreased T1 signal aggressive severe osteoporosis probably in the healing phase possible with very heterogenous appearing marrow.  Close clinical follow up is recommended.  Correlation with CBC and peripheral smear plus reticulocyte count is recommended.  I do not have plain films at this time; correlation with the DEXA values is recommended to confirm that this is osteoporosis.  Bone marrow biopsy should be considered if there is no significant radiographic or DEXA confirmation of osteoporosis or if there are signs of a malignant process.  As there is back pain currently in view of an essentially healed L3 compression fracture perhaps this is a sufficient sign to warrant a bone marrow biopsy.

[ Note that the patient has a remote family history of aggressive adenocarcinomas (breast and colon) and breast cancer accelerated by pregnancy is a worry.]

2.  Late subacute to chronic milt L3 vertebral body compression deformity and fracture.  No bone marrow edema is seen currently.