6/17 - Appointment with the Surgeon

Kristine's 5th cycle is officially over after finishing her weekend IV fluids. She had a tough Thursday night after a single raspberry turned her nausea into a string of vomiting episodes. She felt pretty good for the rest of the weekend with less nausea than in prior cycles.

To continue where I left off in the last posting I'll jump back a week and a half to when we met with the heart surgeon, Dr. Charles Bridges. Our appointment started out with an introduction to Dr. Bridges' surgical assistant, Alice Isidro. Since Bridges was running behind (he fit us into his schedule at the request of Dr. Staddon within a week when he's normally booked months in advance) we had some time to talk with her. Alice was a big cheerleader for Bridges, pulling out a multitude of factoids about his expertise and credentials. She explained his degrees (a B.A. and M.D. from Harvard, a Masters in Electrical Engineering and Doctorate in Chemical Engineering both from MIT), his recognition in Philadelphia Magazine's ranking of top regional doctors from 2004-2007, his recognition in the Guide to America's Top Surgeons, his position as chairman of the Workforce on Evidence-Based Surgery for The Society of Thoracic Surgery (an organization that authors standard surgical procedures) and the recipient of some huge government grant for his current research (she mentioned something about it being the largest ever given in his field, which I have not been able to confirm). She went on about how well respected he is in his field.

Quite a bit of time had passed and we had grown a bit irritable from the wait. Dr. Bridges joined us after almost an hour and a half. He had a cerebral manner about him, while still remaining very approachable. He apologized for his delay explaining that he had been reviewing all of Kristine's scans and had contacted Dr. Staddon to get the latest on her progress and treatment before our meeting. He proceeded by explaining what he had seen from the scans. It appeared from the CT scans that there was a sizable tumor in the right atrium of the heart (one of four chambers of the heart where blood, depleted of oxygen from the body, is first deposited). There was also a string of mass leading up through the superior vena cava (the main vein leading into the heart from the head and neck). He confirmed that there had been material shrinkage in the mass from the earlier scans. He said that it was unclear how much of the mass was tumor and how much was clot. In other words, the size of the mass in the CT scans could be obscured by clotting that accumulated around the tumor.

We jumped right in with our questions. Our first and most pressing was, had he ever seen and operated on any similar cases. He affirmed that he had operated on several patients of Dr. Staddon's where tumors had formed in the heart and surrounding vessels. He described a recent surgery where a patient's tumor was so large that it required the reconstruction of the entire back of the heart. He immediately pacified our visceral anxiety explaining that Kristine's diagnosis was no where near as severe. In fact, he expressed that the surgery would be an "easy one," that is, as far as heart surgeries go.

Bridges explained that the method of surgical procedure would depend on the results of further testing, specifically an echo-cardiogram that would better represent the topography of the area. He did talk about two options. If the mass in the superior vena cava does not reach too far up through the vessel than the procedure would involve a small incision in the right side of the chest, midway down the rib cage under the arm. If, however, the mass extends into other veins in the chest the incision would be made near the sternum in the center of the chest.

One thing confused both Kristine and I. During the entire first half of our conversation with Dr. Bridges he never mentioned the tumor that was previously described under Kristine's right clavicle nor the metastasis tumors in her lung. When asked Bridges seemed puzzled by the question as if he had not been adequately briefed on these other masses. He began to look through the CT scan reports. He read back that the two masses previously thought to be metastasis in the lung were no longer visible and were likely pulmonary emboli (blood clots) that resolved themselves from the blood thinner that Krisitine has been taking. He went on to read that the subclavicular mass was open to interpretation and was thought to possibly only be a bulge in the blood vessel. Bridges explained that before proceeding he would need to discuss this in further detail with Dr. Staddon and possibly a vascular surgeon to ensure that he has all the information.

In short, we were impressed with Dr. Bridges and comfortable with his ability to do the job. We are, however, a little less comfortable with the still ambiguous diagnosis of the subclavicular tumor. Upon questioning Dr. Staddon about it, he responded that he was not convinced that it was a tumor at all, referring to the report from the CT scan.

Our realization is that we've entered the gray area of medicine. The point where imperfect tools and educated theories are the only pieces of data from which to based decisions upon. It is for this reason that we have requested a second opinion. Dr. Staddon has agreed to reach out to his colleague, the chair of the sarcoma department at M.D. Anderson in Houston, TX, Dr. Robert Benjamin. Although we will likely continue Kristine's treatment at Penn, a second opinion will serve as added assurance that we are proceeding in the right direction.

Kristine has her nadir appointment this Wednesday.