Mr. Schuttler feels well today: doctor’s notes

Visit Notes

Michael S Hodavance, MD at 4/25/2016 11:14 AM

Status: Signed

Vascular Interventional Radiology

Chief Complaint: Hepatic Metastasis

History of Present Illness: Mr. Schuttler is a 45 y.o. Caucasian male here today with presumed hepatic colorectal metastasis at the request of Dr. Shah for evaluation of radioembolization.

Oncology History: Mr. Schuttler underwent a colonoscopy on 9/24/15 which showed a 6 mm polyp in the rectum and a fungating partially obstructing large mass was found at the distal sigmoid. Pathology came back as Adenocarcinoma. CT demonstrated multiple hepatic masses. He underwent neoadjuvant chemotherapy most recently FOLFOX +avastin; see oncology notes for compete details. Most recent imaging demonstrates decreased size of hepatic lesions but still multiple lesions in the bilateral liver consistent with metastatic disease. At the most recent hepatobiliary multidisciplinary conference, patient was recommended for consideration of locoregional therapy, specifically radioembolization.

Mr. Schuttler feels well today. He denies abdominal pain, nausea/vomiting, SOB, chest pain or other symptoms. Fatigue and appetite are improved since stopping chemotherapy. He still notes some neuropathy related to chemotherapy treatments.

Physical Exam
Constitutional: He is oriented to person, place, and time and well-developed, well-nourished, and in no distress.
HENT:
Head: Normocephalic and atraumatic.
Eyes: Pupils are equal, round, and reactive to light.
Neck: Normal range of motion. Neck supple.
Cardiovascular: Normal rate and regular rhythm.
Pulmonary/Chest: Effort normal and breath sounds normal.
Abdominal: Soft. Bowel sounds are normal.
Musculoskeletal: Normal range of motion.
Neurological: He is alert and oriented to person, place, and time.
Skin: Skin is warm and dry.
Psychiatric: Affect and judgment normal.

Karnofsky Scale: 100 Normal, no c/o, NED

ECOG Score: (0) Fully active, able to carry on all predisease performance without restriction

Laboratory Results:
Lab Results
Component
Value
Date

WBC
4.8
04/19/2016

HGB
14.4
04/19/2016

HCT
42.6
04/19/2016

PLT
92*
04/19/2016

Lab Results
Component
Value
Date

NA
140
04/19/2016

K
3.6
04/19/2016

CL
106
04/19/2016

CO2
26
04/19/2016

BUN
9
04/19/2016

CREATININE
0.8
04/19/2016

GLUCOSE
135
04/19/2016

Lab Results
Component
Value
Date

AST
38
04/19/2016

ALT
46
04/19/2016

ALKPHOS
58
04/19/2016

TBILI
0.6
04/19/2016

ALB
4.2
04/19/2016

TOTALPROTEIN
6.9
04/19/2016

Lab Results
Component
Value
Date

APTT
32.1
12/09/2015

INR
1.1
12/09/2015

Imaging: MR 4/4/2016 reviewed

Assessment: Mr. Schuttler is a 45 yo with metastatic disease to the liver. He is a good candidate for radioembolization based on his good baseline liver function and functional status. Dr. Paul Suhocki had a lengthy discussion regarding the risks, benefits and alternatives to radioembolization. The patient was given the opportunity to ask questions and to have those questions answered to his satisfaction

Plan:
Plan for radioembolization to be scheduled in the next few weeks. Most of the the patient’s lab values are current but we will redraw an INR in clinic today.

I personally interviewed the patient with a fellow.

Revision History
4/26/2016 2:00 PM
Paul Suhocki, MD

4/25/2016 11:47 AM
Michael S Hodavance, MD
Sign at close encounter

A Postscript

I’ve been told I’ve inspired a few people with my attitude during this journey; I wanted to share videos of a couple of people who’ve inspired me… these individuals are amazing. Keep strong, friends.


(Sara passed away 2 weeks after this video was recorded.)

 

Sticking around for a bit

Just got back from the liver surgeon’s consult this afternoon and got the low-down on what the future holds for me: basically, after getting a better look at the tumors in the liver with the recent MRI scan, he’s concluded that while I’ve shown great progress in the past 7 months, there’s just too many small tumors interspersed in my liver on both halves to consider operating right now. I started treatment with more tumor than liver: I now have substantially more liver than tumor. Going into surgery takes out a lot of tumors, sure – but it also takes out a LOT of healthy, functional liver tissue as well. Not to mention the substantial risk of liver failure, if they happen to take too much liver out and I can’t survive.

Other than surgery, what options are there for me? well, there’s 2 (3, really): either travel up to Sloan-Kettering in NYC to get a pump implanted within my system to deliver chemo directly to the liver, or stay here and get an IR embolization in a couple of weeks. And then probably more chemo after that.

The third option, is, of course, do nothing and see what nature has in store for me.

While I’m confident in battling this crap by myself, I also stand behind the progress I’ve made already with the help of modern medicine. And since the pump procedure done in NYC isn’t known to be totally effective, the only real option that makes sense is to get the embolization done here.

Since surgery is off the table I’ve been told I’m going to have to live with this cancer for the foreseeable future, if we can’t get it cleared up within the liver to at least a point where either half goes cancer-free and we can get rid of the rest of it via surgery. The colon is no longer an issue, as long as my symptoms don’t come back. So no colostomy bag for me — which, along with the relief of not going under the knife, is a welcome outcome.

I feel great (being off of chemo for a month will do that to you). Because of my friends and family, I’m still positive and mentally strong. While I need to get settled with the prospect of having to live with cancer for a while, I am reminded that it’s something I’ve been living with for unknown weeks before I even knew I had it. If anything, this meeting reinforced the fact that I’m on a journey here, and it’s far from over; and I need to settle in for the long haul. The cancer isn’t going anywhere but away, as it has been since I discovered I had it. And since I’m constantly being tested and scanned and checked, it’s not going to suddenly sneak up on me (again) and overtake me without my knowing.

All of this is disheartening news and at this point, I need to pull as many positives as I can out of this situation: at least he didn’t give me a number of how many more months I have left… at least the cancer isn’t anywhere else in my body and complicating things… at least I can continue to handle the meds like a rockstar… at least I have an incredible support system behind me, feeding me positive energy around the clock. I wish my body could work faster to get the tumors out quicker… but I’m doing my job, and staying on top of it. The situation might be a bit different in another year; it will be, because I want it to be.

Thanks for being here with me. Can you stay for some time longer?

MRI Findings

Had my MRI first thing Monday, here’s what the findings look like:

Findings:
Limited views of the lung bases demonstrate no significant pulmonary opacities. No pleural effusions.

The liver is normal in size and contour. Numerous hepatic lesions are seen. The largest lesion measures approximately 2.1 x 5.2 cm in segment 2 (series 12 image 45), similar to recent CT. Lesion in segment IVb measures approximately 2.6 x 3.8 cm (series 12 image 59), similar to prior exam. Lesion in segment 5 measures approximately 2.0 x 2.3 cm (series 12 image 81), similar to prior exam. There is a minimally complex cyst in segment 5 measuring 1.1 x 1.5 cm (series 12 image 87), similar to prior exam. Numerous other smaller lesions are identified throughout the liver, some of which are not definitively seen on prior CT. While lesions are better visualized on MRI, differences in lesion size and number are likely related to differences in imaging modality. The portal and hepatic veins are patent. There is no intra or extrahepatic biliary ductal dilatation. The gallbladder is present. The spleen is normal in size and appearance. The pancreas is normal in appearance. There is no peripancreatic inflammation. The adrenal glands are normal in appearance. There is no pelvicaliectasis. There are no suspicious renal masses.

There is no abnormal bowel dilatation, and there is no focal or diffuse bowel wall thickening. There is no free air or free fluid in the abdomen. There is no retroperitoneal or mesenteric lymphadenopathy. The abdominal aorta is normal in caliber. The aorta and the central aspects of its branch vessels are patent.

There are no aggressive appearing osseous lesions.

Impression:
Multifocal hepatic metastatic disease, similar in appearance to most recent prior CT. Differences in lesion number and size are likely related to differences in imaging modality. Recommend attention on follow-up exams.

I can’t go into analysis on this, as it appears they just got a better look at all of the lesions in my liver. Probably looks like a minefield in there. At least that seems to be the extent of my issues, nothing else is going on in me, I can take some sort of relief in that at least. I can also take some comfort in knowing that the one organ we humans have that can regenerate, is the one they need to cut out.

“So I got that going for me…. which is nice.”

Ironically the damned organ that started this whole mess (colon) looks and functions as it’s supposed to now, and is of secondary concern. Just figures. Gunga galunga.