Archive for the ‘meningioma’ Category

My wife had stereotactic radiosurgery

August 29, 2016

The computer would focus the beam,

And I would doze, perchance I would dream.

And turn after turn

The tumor would burn

Ramsay Hunt wasn’t part of the scheme. 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. My wife’s brain tumor put all other plans on hold.  Any identifiable patient information has been included with permission. 

Bethany had her stereotactic radio surgery on schedule. Even though the tumor involved no malignancy, the procedure took place at the June Nylen Cancer Center and involved a radiation oncologist.  The festivities started off with the neurosurgeon using 4 screws to affix a frame to her head.  Then followed a CT scan of the head, and three hours wait.  When all was ready I walked Bethany to the linear accelerator, which didn’t make much of a visual impact.   The frame screwed to my wife’s head got bolted to the table under the linear accelerator.  I made a small contribution by suggesting a couple of rolled towels under her shoulders would favorably change the angle of her neck.

Then I walked back to wait. They said it would be an hour, and I thought about going out for lunch, but I stayed around, and twenty minutes later we walked out into the heat.

The next twenty-four hours went well but then the full impact of the radiation hit with nausea and vomiting. A couple of quick calls brought a prescription for Zofran which helped a lot.

Bethany seemed to have bounced back well, and she drove me to Omaha on a Saturday to catch a plane to Alaska very early the next day.

I brought a cooler full of 50 pounds of sweet corn to friends who live in Anchorage, before I started work on Monday.

By the time I’d landed, blisters had broken out on the left side of Bethany’s hard and soft palate; her description brought shingles to mind.

A while ago, leafing through a free medical journal called a “throw away” for good reason, I came across a photo quiz which showed zoster inside the mouth. I flipped the page to find the diagnosis of Ramsay Hunt Type 2.  I scoffed, figuring if I hadn’t seen something like that in 30 years I probably wouldn’t ever.  But three weeks later I looked in the mouth of a patient complaining of a “sore throat” and found exactly that.

I posted a poll on my favorite doctor’s social media site, and found that 80% of physicians haven’t heard of Ramsay Hunt Type 2, but 10% have seen it.

But it was the weekend. I told Bethany to schedule with her physician, and by the time she got an appointment she’d broken out with the worst cold sores she’d ever had, on the left side of her nose.

The viral culture eventually showed Herpes 1 (cold sores), not its cousin, the varicella zoster virus, or shingles.

Valcyclovir will treat both, but shingles requires a much higher dose.

And I can’t say I’ve seen two cases of Ramsay Hunt Type 2.

An Abnormal MRI, too close to home

July 13, 2016

We’re doing the best that we can

To follow an abnormal scan

The rumor was tumor

But the answer was no cancer

And the treatment’s a flash in the pan.

 

Synopsis: I’m a Family Practitioner from Sioux City, Iowa. In 2010 I danced back from the brink of burnout, and honoring a 1 year non-compete clause, travelled and worked in out-of-the-way places in Alaska, Nebraska, Iowa, and New Zealand. After three years working with a Community Health Center, I went back to adventures in temporary positions until they have an Electronic Medical Record (EMR) system I can get along with. A winter in Nome, Alaska, assignments in rural Iowa, a summer with a bike tour in Michigan, and Urgent Care in suburban Pennsylvania stretched into the fall. Last winter I worked western Nebraska and coastal Alaska.  After the birth of our first grandchild, I returned to Nebraska. All our plans have been put on hold pending resolution of my wife’s brain tumor.  Any identifiable patient information has been included with permission. 

Three weeks ago on Tuesday my wife, Bethany, awakened with severe vertigo. She couldn’t get out of bed without vomiting.  Over-the-counter meclizine helped but little.  I posted the case on a physician’s chat site the next day, and got the recommendation for the Transderm Scop patch (she had one left over from a recent trip).  It helped but the problem persisted.

I don’t like to be my family’s doctor, so that Friday morning we went to the Clinic Formerly Known As Mine. Bethany’s doctor found horizontal nystagmus (a twitching gaze), when looking to the right, and ordered an MRI with contrast.

Chaos dominates Friday afternoons, thus Friday’s MRI happened without contrast.

I have the training and education to imagine a large collection of really bad things, and by now I’ve learned that the awful moments in life come to us unanticipated. So I went through my catastrophic catalog and felt better for having done so.  My phone went off while I was gardening.

In general, you don’t want your doctor to have bad news, especially not on Friday afternoon.

The MRI showed a 2.2 centimeter something behind the left eye. The original report mentioned possible glioma with the strong recommendation for a contrast study.  The thing’s location didn’t account for the dizziness.

With advances in imaging, we have had to come up with a term that means an abnormal finding found by coincidence; we call it an incidentaloma.

I called my locum tenens recruiter to say I had put all plans on hold; she relayed the information to those facilities expecting me in Nebraska and Alaska. Bethany phoned our daughter to say she wouldn’t be coming to help with the new grandson.

That night I read Bethany the Wikpedia article on glioma: 1/3 benign, 2/3 cancer.

Bethany’s cousin’s first wife died three weeks after getting her glioma diagnosed; she only had time to pick out her husband’s next wife, and say a loving goodbye to her family. In the ‘80’s I had a patient with a glioma who lived for less than 100 days after diagnosis.

We didn’t talk about those things.

Bethany took the information in stride, with understated courage. I focused on the moment with the joy of uncertainty that gives hope.  I embraced not knowing and did my best to focus on the moment: stripping the last tart cherry tree of its fruit, bringing in the first green chiles from the garden. I clung to things precious for their normality.

We suffered through the next four days, our plans shredded, as Bethany’s dizziness faded and her balance improved.

With her vertigo improved and her calm unruffled, Bethany went in for the contrast MRI the Tuesday morning before July 4. In the afternoon our fax brought the new diagnosis of meningioma, a well-behaved tumor with little if any malignant potential.

Relief of a magnitude that brings tears defies description.

I relied on my status as a physician and on friendship to get us an appointment with a neurosurgeon the next morning.

He explained the choices: leave it alone, open surgery, or radiation. He said if it were his tumor, he’d prefer the radiation.  He also showed us the MRI image, with a bright cylinder an inch long and half-inch wide growing up from the floor of the skull just behind the left eye.

He doesn’t do that procedure, but his partner does. And that partner wouldn’t be back in the office till Tuesday the following week.

Basking in the light of a better diagnosis while marinating in the darkness of an upcoming brain procedure, we went about our business. We had ice cream with our neighbors, and friends over for dinner on Friday.

Yesterday we met with the neurosurgeon, who explained stereotactic radiosurgery. And today we met with the radiation oncologist.

The actual treatment consists of focusing a radiation beam on the tumor, zapping the same way sunlight, focused with a lens, burns one point.

The next step, the 3D MRI, remains unscheduled.