MRI, CT, PET and color flow ultrasonography have markedly improved our ability to stage cancer patients before an operation and to indicate if a tumor is likely to be resectable. However, these technologies are imperfect and don’t always detect the full extent of disease.
I slowly opened the door to a patient room on the surgical floor and quietly walked up to my patient’s bedside one day a couple of months ago. It was late afternoon on the day I had operated on this lady. The patient’s husband and sister sat nearby, heads down and silent. They knew what I was going to say.
I asked an inane question, “How are you feeling?” What answer could I expect? I had just performed a surgical procedure leaving a 6 inch midline wound on her abdominal wall. The patient’s eyes fluttered opened, and she whispered, “I am hurting.” Ask an obvious question; get an obvious answer.
I reminded my patient she had a button to push to self-administer a dose of intravenous narcotic using a pain pump. I pushed the button for her, and a low volume beep emitted to confirm a dose was delivered. She gave an affirmative nod and admitted she had not been pushing the button. She then asked the question I knew would come, “How did the operation go?” I spent the next 10 minutes describing the surgical findings and the emotionally painful reality her tumor was unresectable.
A retroperitoneal tumor
This patient had been referred to me by a medical oncologist who had seen her and told her she had a surgical, not a medical problem.The patient had first presented to her primary care physician approximately a month earlier complaining of weight loss, pain upon eating, and for a week prior to her visit, nausea and vomiting after every meal. The physician examined her and found nothing abnormal, but ordered a CT scan. The CT scan demonstrated a retroperitoneal tumor involving the posterior (backside) of the second portion of her duodenum and the head of the pancreas. There was no evidence of any additional tumors or metastatic spread of disease.
A gastroenterologist performed an upper gastrointestinal endoscopy including an endoscopic ultrasound and biopsy. The biopsy returned fibrous and spindle cells consistent with a sarcoma. The patient was referred to a medical oncologist, who just as quickly referred her to me.
During her first clinic visit we reviewed her CT images, which were only two weeks old, and it appeared the tumor was resectable with a pancreoticoduodenectomy because the inferior vena cava, portal vein, superior mesenteric vein, and superior mesenteric artery were well clear of the tumor. I explained the operation at length to the patient and her husband. She was having difficulty eating because of pressure of this tumor applied to the first portion of her small intestine, the duodenum, so an operation was scheduled three days later.
Modern imaging studies are remarkable. Magnetic resonance imaging (MRI), computed tomography (CT), color flow ultrasonography, and positron emission tomography (PET) have markedly improved our ability to stage cancer patients before an operation and to indicate if a tumor is likely to be resectable. However, these technologies are imperfect and don’t always detect the full extent of disease. Cancer can be like an aging baseball pitcher; it may no longer throw a great fastball or sharp curveball, but it can serve up a knuckleball which breaks and moves unpredictably.
The chief resident and I opened the patient’s abdominal cavity with a skin incision and then continued down through the layers of the abdominal wall and opened the translucent peritoneum. Upon entering the peritoneal cavity, there was no visual evidence of tumor spread, and initial cursory inspection indicated the small and large intestine and stomach appeared normal. Everything changed when I lifted the omentum, the fatty apron of tissue hanging down from the transverse colon over the small intestine, because I found tumor growing directly through the transverse mesocolon and attaching to a loop of small intestine. The tumor was clearly encasing the middle colic artery and vein, the blood supply to the transverse colon. The resident and I mobilized the right colon and the duodenum to get a better look at the retroperitoneal tumor. Fortunately, it was not growing into the inferior vena cava, but as we explored further we recognized the tumor had spread like an advancing wave on the beach to flow around the portal vein and superior mesenteric artery. The latter blood vessel is a crucial artery, supplying all blood flow to the small intestine and over half of the colon. I performed a detailed ultrasound of the pancreas and the liver, finding no additional sites of tumor except for the monster invading key blood vessels.
Recognizing we would not be able to remove this tumor completely, safely, and with negative margins, I performed additional tumor biopsies for advanced genetic and pathology testing. It was clear this patient would need chemotherapy and possibly radiation therapy. Knowing radiation treatments would be an important potential option, we placed a series of small metal clips around the tumor, including those regions not seen on the pre-operative imaging studies. We removed the short segment of intestine where the tumor had invaded directly into it, and then anastomosed, or reconnected, the small intestine to itself. Finally, we brought a limb of jejunum (first part of the small intestine after the duodenum) up to the stomach and opened part of the stomach wall and the jejunum and sewed them together to create a new route for food to exit from the stomach into the intestine. We had to assure she was able to eat while receiving other treatments.
After the operation was complete, I went out and had a difficult and detailed conversation with the patient’s husband and sister. Thus, they were already apprised of the situation when I walked into her room later the same day. I took my time explaining the situation to the patient, knowing she was still drowsy from the general anesthetic and from the intravenous narcotic pain medication. I stopped several times and answered questions, or repeated previous statements if she seemed uncertain about what I was saying to her. She eventually voiced full comprehension of her situation and understood potential treatment options in the future.
Faith in humanity restored
As I finished, her eyes brimmed with tears. She grasped my left hand with her right, and then shocked me by saying, “I am so sorry you had to tell me that.”
Unbelievable. This lady was demonstrating thoughtfulness, concern, and compassion for me during a moment of extreme duress for her. Despite me just telling her she has a locally advanced, rare, and aggressive cancer. She told me she was worried about me and how delivering this information would ruin my day. I bent down and gave her a gentle hug and thanked her for genuine care and empathy. I confirmed I was disappointed and sad to be delivering bad news, but my job was to provide treatment and assistance to her and her family. I affirmed I would continue to be available at any time to provide support.
I must admit there are days I feel depressed, distressed, and even disheartened about the state of humanity. This is especially true if I make the mistake of watching news programming describing the latest nefarious, dishonest, or unethical exploits of our polarized politicians, government officials, or malicious, hateful people around the globe. I’m disgusted by the zealots, the haters, the hurters, the self-serving politicians aligned with special interest groups and lobbies, and the indiscriminate cowardly killers of civilians. Thank God for my patients, particularly ones like this lady, who give me hope and remind me there are decent, good, considerate, and non-egocentric individuals still present in the world.
Blessings come from common people and common events. I remember every day I have much to be thankful for.