Tim had his 5th dose of cyclophosphamide this last week. Since he is in radiation therapy as well, the dactinomycin was skipped but he is back on vincristine. So as expected, this time was a double whammy. Since school was out for parent/teacher conferences on Thursday and Friday, Tim’s appointment was scheduled earlier in the day on Thursday at 1:30. The plan was to visit the clinic, get blood drawn, go to radiation, have the discussion with the doctor and then be admitted to the oncology floor. However, no beds were available in the hospital! The alternate plan then became come back on Friday morning and see if we could get through the treatment at the clinic. Of course Thursday’s radiation dose was administered on schedule.
Perhaps because it was Tim’s regular oncologist’s turn for the free weekend, or the protocol changes at this point, but his dose of cyclophosphamide was upped to 2.2 grams per square meter of body surface area from 1.2 g/m^2. This meant going from a dose that had been about 2.1 grams to over 3.9 grams. This is the nasty drug, the one that makes one throw up. So of course Tim did just that within 30 minutes of treatment. However, a new sequence of anti nausea treatment was tried this time. He got a new drug in the same class as Zofran called Aloxi. This one has a very long serum half life and so the 0.25 mg administered is supposed to last 3-4 days. As a comparison, Zofran is taken every 6-8 hours. He also got a motion sickness patch behind the ear. Even with the Aloxi, he threw up so he got a dose of Ativan to calm things down.
The good thing about Aloxi is that is seems to not make Tim have a “funny” feeling in his stomach and it does do a good job in the anti nausea department. Since the initial incident, he’s been fine. I think we might have to adjust the food intake to better align with the chemo administration or maybe have the Aloxi given 60 minutes prior rather than 30 minutes prior.
The other advantage is that he was in the clinic which is a much better place than evenings on the oncology floor in the hospital. In the end, he was able to go home at 9:30 PM so we didn’t even have to stay over night. The bad thing is he has to at least go to the oncology floor since the clinic closes at 5 but this time it was just to give the remaining two doses of mesna and send him home. He seemed to prefer doing things that way. If we can convince the clinic of the same, then he would still just miss school Friday’s every third week but can sleep in his own bed. That really helped because by the time we got home, the urine output had been reduced so he wasn’t getting up every 90 minutes to go to the bathroom. That makes for a poor sleep experience in the hospital when we stay there on Thursday evenings.
The weekend went really well with no nausea attacks and pretty normal set of activities. We even got our hopefully last leaf raking event in. But he’s a tired pup now and will get his 10 hours of sleep in tonight.
Radiation picks up again tomorrow. We’re already 4 sessions in, just 16 to go. Sometimes things seem to move pretty fast, other times when I think we’ll be doing this until June, it seems so far away. And I’m sure there will be more surprises like this last week where flexibility was the key attribute to possess.
--bob
Sunday, November 12, 2006
Thursday, November 09, 2006
Marching Band Banquet
The high school marching band season was concluded this week with the annual banquet and awards ceremony. What a great group of … everyone! Staff, volunteers, parents, and of course the students make for such a rewarding experience. It was really special that Tim was able to participate in the early part of his treatment. He missed a few things and wasn’t able to march on the field but he certainly participated where he could. Being his senior year, I hope he was able to demonstrate some leadership for the underclassmen. I think he did. What was also really special was that the band director made a special presentation for Tim acknowledging his effort (Overcoming All Obstacles-Award) while being in treatment. It was really unexpected and quite emotional to hear those words and hear the room applaud for Tim. We will always remember this year (well, duh!) but certainly this part of Tim’s senior experience will be an outstanding memory.
--bob
Radiation Begins
Yet another new concept is in the learning mode as Tim begins the radiation treatment. The simulation was completed and a treatment plan computed this past week. Tim will get 36 Gy total dosage spread out over 20 equal treatment sessions. This is at the low end of the range previously discussed since Tim continues to receive the cyclophosphamide during this time. In fact, this week radiation started and he will also get the whammy treatment. Perhaps it will only be a double whammy of cyclophosphamide and vincristine this time because of the radiation therapy being coincident. These 20 days are done Monday through Friday with weekends off. The dose is additive and destroys cancer cells of any micro-tumor pieces left in his neck.
The equipment used is essentially a high powered x-ray machine that can deliver 0.6 Gy per minute of x-ray energy (they call it photon emission). The machine is a mini linear accelerator about one meter long that accelerates electrons and shoots them at a tungsten target which converts them to photons. The resulting beam is bent and then sent through a collimator device that is dynamically configured during treatment to focus the beam to the desired shape and location. Tim’s treatment plan involves exposing him from nine different angles and only takes about 10 minutes to actually administer.
Getting him positioned on the table in the same place is really important and so this is why a mask was made and crosshairs placed on the mask. Tim lies on a table and the mask anchors his head to the table. A laser guidance system is used to place the table in three axes and then an x-ray picture is taken. The process is to compare the baseline locating x-ray to one just taken to see if any adjustments need to be made. All these x-ray pictures are taken digitally, so they are immediately available to be viewed on the computer screen. That allows the technician to line up the baseline and the new x-ray and compute the correction factors to move the table. So far, things have been repeatable to 3mm or less. From there the nine doses are delivered.
The machine used is a Varian 21ex. There is a lot of information on their site for the technically interested at http://www.varian.com/. This link has a video you can look at that explains the methods used to administer Tim’s radiation therapy. http://www.varian.com/pinf/res005.html
--bob
First Diagnostic Scans Done!
We’re through the first set of diagnostic tests to look for any spreading of the tumor and no evidence was found. This was a slightly different session at the hospital because Tim had to go through the “normal” admitting process for this set of CT scans. Since all of the early initial work was completed, we have been fortunate enough to skip all the paperwork to be admitted to the hospital. Even though these tests were outpatient ones, we had to do that again, but we’re old pros at it now anyway. Have your insurance card available because they have to take the 21st copy of it “for the files”. Oh well.
This test was a pair of CT scans of the chest with contrast both oral and injected. Injected contrast is not a feature of these tests that Tim looks forward to. He was, and so were we, nervous about these tests because they were the first taken since treatment started. Was it possible that the treatment had not been working? Could there be tumors developing in the lungs? These were possibilities to be considered. Even though the oncologist told us outright that he expected no disease to show up, there is still that concern. So nerves were at a high level. Tim couldn’t keep the oral contrast medium down.
They mix the solution into a 7-up and he has to drink all 16 oz of it over a 20 minute period. This is after not eating or drinking since the previous night and on a nervous stomach. At least they didn’t make him start over and went ahead with the scans. The other contrast medium has to be introduced through an IV in the arm since the volume is 75 ml introduced over 30 seconds. The port-a-cath can’t handle that rate.
After the scans, the data is pretty much available right away and we were able to leaf through the CT slices in the oncologist’s office. A quick scan showed no issues and so that was a relief. Further review is always done by a radiologist of course, but this was really good news.
In the discussion about the treatment plan, we began to explore the variability of plans. These plans are really created over time by committee and are recommendations. The oncologist more or less looks up the type of cancer and voila, the plan is there. The two plans we talked about are for low and medium risk patients and what goes against logic is that the low risk protocol is more aggressive than the medium one. So we’re going to have a thorough review of the plan to determine if Tim has to go through all 16 cycles or if 12 might be just fine. There are also variations of administration of vincristine and dactinomycin.
The first 4 cycles are the same for all plans, even the clinical trial. So it’s really no problem that we are only now entertaining how to proceed from here. This was really good news that the number of cycles might be reduced while still being aggressive enough to be successful. We’ll have that consultation shortly. For now though, we are through the first diagnostic scans and Tim is doing great with no spreading of the tumor.
--bob
This test was a pair of CT scans of the chest with contrast both oral and injected. Injected contrast is not a feature of these tests that Tim looks forward to. He was, and so were we, nervous about these tests because they were the first taken since treatment started. Was it possible that the treatment had not been working? Could there be tumors developing in the lungs? These were possibilities to be considered. Even though the oncologist told us outright that he expected no disease to show up, there is still that concern. So nerves were at a high level. Tim couldn’t keep the oral contrast medium down.
They mix the solution into a 7-up and he has to drink all 16 oz of it over a 20 minute period. This is after not eating or drinking since the previous night and on a nervous stomach. At least they didn’t make him start over and went ahead with the scans. The other contrast medium has to be introduced through an IV in the arm since the volume is 75 ml introduced over 30 seconds. The port-a-cath can’t handle that rate.
After the scans, the data is pretty much available right away and we were able to leaf through the CT slices in the oncologist’s office. A quick scan showed no issues and so that was a relief. Further review is always done by a radiologist of course, but this was really good news.
In the discussion about the treatment plan, we began to explore the variability of plans. These plans are really created over time by committee and are recommendations. The oncologist more or less looks up the type of cancer and voila, the plan is there. The two plans we talked about are for low and medium risk patients and what goes against logic is that the low risk protocol is more aggressive than the medium one. So we’re going to have a thorough review of the plan to determine if Tim has to go through all 16 cycles or if 12 might be just fine. There are also variations of administration of vincristine and dactinomycin.
The first 4 cycles are the same for all plans, even the clinical trial. So it’s really no problem that we are only now entertaining how to proceed from here. This was really good news that the number of cycles might be reduced while still being aggressive enough to be successful. We’ll have that consultation shortly. For now though, we are through the first diagnostic scans and Tim is doing great with no spreading of the tumor.
--bob
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