Medical Report And Questions on Surgery
September 30, 2004
Mary Susan Maish, M.D.
11818 Wilshire Blvd.
Ste. 200
UCLA
Los Angeles, CA
By FAX: 310 794-7335
Dear Doctor Maish,
This letter relates to UCLA Patient ID, 3474427 6, Bonnie J.
Troescher, with whom you have a consultation appointment for 11 AM, Monday,
October 4, 2004. I hold an Advanced Directive for Bonnie.
I’m writing some information that stresses what I think is
important to us, to describe some additional information and to express some of
the specific questions to which we seek comments at our “Consult.”
Here is a list of documents relating to Bonnie which I sent
to Dr. Dulai some weeks ago and which have probably already been placed into the
UCLA Medical system:
1.
Two Pages, Endoscopy, Dr. Ballan, February 19, 2004
2.
Two Pages, Endoscopy, Dr. Ballan, March 10, 2004
3.
Three Pages, CAT Scan, March 22, 2004
4.
One Page, PET Report, March 24, 2004
5.
Two Pages, Laparoscopy, Dr. Renner, March 31, 2004
6.
Three Pages, Ultrasound Endoscopy, Dr. Nagaraja, April 20, 2004
7.
Two Pages, Swallowing Test, Dr. Mintz, July 16, 2004
8.
Two Pages, PET Report, August 18, 2004
9.
Two Pages, GE Consultation, September 7, 2004 Dr. Dulai
Dr. Nagaraja’s report on his EUS done on September 28th
has apparently been dictated by not yet transcribed. I’m sending a
separate FAX to him, copy to you, requesting that he FAX that report to your FAX
number. (click here)
I have some photos printed on paper from the EUS, but
understand that you want “film.” I talked with Dr. Nagaraja’s office today and
they assure me there is no “film” but rather the EUS equipment produces direct
paper-printed images, both in color and black and white. I have those and will
bring them on Monday.
Here is a short history:
Bonnie has had a very healthy life with no significant health
problems until this cancer. Bonnie had trouble swallowing, intermittently
during 2003, and increasingly in January 2004. She then went for a standard
endoscopy in February. The first endoscopy did only “scrape tests” and the
report was “suspicion” of cancer. The next endoscopy did more normal biopsies
and confirmed cancer of the esophagus. There were then several CAT scans, and
an original EUS, the results showed that a 7 cm tumor had not changed size
during the two months between the first and second CAT scan. A PET scan
confirmed the presence of cancer.
She then started a chemoradiation standard treatment – 28
scheduled radiation treatments and a series of 5FU (on a 24x7 pump), Taxol and
Carboplantinol. About June 1, after about 20 of the radiation treatments, she
was so sick that the Oncologist took her off the chemo, had her admitted to the
hospital for blood transfusions and white blood cell boosters. He wanted her to
resume chemoradiation treatment a few days later and she told him she would
rather die than go back to either chemo or radiation. A CAT scan done during
her hospital stay showed “at least 30% shrinkage of the tumor” according to the
Oncologist.
The surgeon on the case, with the report of 30% shrinkage,
told Bonnie that she was “not a candidate for surgery” and that if he did do
surgery it would be an 11 hour operation, with 30 days in ICU and a 5% chance of
survival.
Bonnie then got admitted to a Hospice and we planned her
funeral for sometime near the end of June. The pain relief from Duragesic and
separation from radiation and chemo resulted in her feeling better and by early
July she was making future plans.
The radiation doctor had originally predicted that her
difficulty with swallowing would worsen to the point that she would not swallow
at all. That happened. He also promised that this swallowing problem would
reverse itself in two weeks after radiation and that within 3 weeks after
radiation stopped she should be eating regularly. That never happened.
She had a Swallowing Test (Barium) on July 16, and discovered
that she had some limited ability to swallow – but then, quite noticeably, the
swallowing got more and more difficult, until not even her spit would go down.
My own research suggested that this may have been the “tightening” of scar
tissue caused by radiation. As I have looked at anatomy books, it appears that
she perceives the blockage at the top of the esophagus (circopharyngeal
sphincter) rather than at the stricture – she recalled that during the EUS she
gargled with a probable relaxant, and has tried some (“Chloraseptic”) at home
lately. We’ll have more reports on that by Monday. Possibly some change in the
upper sphincter’s ability to relax needs to be investigated.
The EUS on September 28 included dilation (I recall dilation
to a size of about 28 French) and she has been able to drink small amounts of
tea or water. By Monday we hope she will have even a better report on
swallowing.
We had a useful consultation with Dr. Dulai, and Dr. Farrell,
both UCLA. Dr. Farrell is insurance-approved to place a stent and at one point
Bonnie felt that the stent was the best option. However, Dr. Farrell thought
that Bonnie’s earlier surgical opinion was unduly pessimistic and that she
should get your opinion on surgery before deciding. Right now Bonnie “leans
toward” surgery on the basis that it will bring better results for swallowing
than a stent, despite the much longer recuperation time.
The biopsy report from the latest EUS shows no cancer, but
you’ll see that his ability to examine was limited because of the large size of
his probes. He verbally suggested another EUS with a “7 French probe.”
One biopsy he did was at the GE Juncture – not testing or
even measuring whatever remaining mass (tumor or scar tissue) may still be
there, presumably adjacent to and outside the esophagus and higher than the GEJ.
Dr. Nagaraja also noted a “larger than normal” lymph node too near the Aorta for
him to risk a biopsy – he had noted this same node in his earlier EUS, and also
then felt it would not be prudent to biopsy it. He promised a comparison of
images to see whether or not that node has changed in size.
Bonnie wants to understand as best as you can advise:
1.
Whether you have sufficient tests to decide whether a clean resection is
possible or not, or description of the further tests that would allow that
decision to be made.
a.
Specifically the value versus the risk of a biopsy of “that” lymph node
that is close to the Aorta. (If there is no other cancer found, what is the
risk for surgery of NOT testing that node?)
b.
Can this lymph node be addressed (biopsied or removed) more safely during
surgery rather than another EUS?
c.
Is Laparoscopy of any value here?
d.
If a clean resection is possible, we’d like details on the procedure, the
estimated time in ICU and the prognosis.
e.
If Bonnie’s problem with swallowing is possibly related to the
circopharyngeal sphincter what procedure would you
recommend to test for that, and/or treat it?
2.
Whether, with more tests, cancer being found, palliative surgery is
possible and what would be the procedure, estimated time in ICU and prognosis.
3.
Data on a comparison between a stent placement and surgery, as to the
risks of surgery versus the life style changes from surgery compared to a
stent. (We assume the life-style changes from surgery would be much improved
from surgery than from the stent – but that the stent placement would be much
less traumatic.)
4.
If cancer is found and the prognosis is death (without chemoradiation),
what would be the best method of achieving life-style improvement even if for a
limited period? (Bonnie would probably prefer 6 months of near-normal living to
12 months of getting all nourishment from a J-Tube.)
5.
Bonnie wants to get rid of her PortaCat and has had the opinion that
those who urge her to keep it in “for now” are simply so convinced that she will
have cancer showing again that she should keep the PortaCat for future chemo
need. Bonnie intends to never allow chemotherapy again, and wants your opinion
on the reasons for taking it out, or not – and would prefer it be removed either
during surgery or on some schedule.
6.
She has a somewhat different attitude toward the J-Tube. She looks
forward to being to eat reasonably normally, but if there is good reason to
leave it in, after surgery, she would like to know why, and when it might be OK
to remove it.
I expect that any optimistic report, including a report of
“no cancer found” would be discounted by most doctors based on statistics and
experience with other esophageal cancer patients. On the other hand we believe
that a very optimistic outlook is warranted because of the various alternative
remedies we have been using throughout this time period. I am not surprised at
the PET scan and the EUS to report “no cancer,” but I am also not surprised at
the lack of surprise by traditional doctors – they typically discount any such
optimistic report and “know” that cancer is there – waiting to be found. I do
not seek any validation of any of these alternative remedies, but am quite ready
to describe any or all of them in whatever detail is asked. They have been
described and published in hundreds of pages amongst my many web pages about
Bonnie’s cancer and treatment.
We look forward to meeting you on Monday, and learning more
about Bonnie’s options.
Sincerely,
Loren C. Troescher
This
web site is a breath
of fresh air in a world of pollution.
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