REI (Reproduction Endocrinology and Fertility clinic)

Hello everyone,

I had an appointment with the reproductive/infertility clinic doctor (my regular OB knows her and said that she was very good).

First I'd like to report that it was very easy to find a parking spot.

This doctor (she's the director of the women's health center there) made an excellent impression on me. She seems to be knowlegeable, understanding of how I might be feeling and also asked peripheral questions, such as "do you have any family living here as you go through this?" - which was much more human than what I got w/ my first oncologist. She hasn't had a patient with my type of cancer but she deals with patients that have uterine or cervical cancer all the time. She was very worried that I didn't have a partner to help me through this. I said that was very sorry about that and that I was thinking about putting up an ad on Craiglist.

"Fairly short, neutered female cancer patient, with a blood pressure of 120/70 and a heartrate of 60 seeks some local guy with some kind of degree and basic language skills for sperm donation and maybe more"

She was also concerned that my family was far away. I blamed it on local Real Estate prices.

She also took the best part of an hour to sit down with me, understand my condition and situation (the oncologist wrote a 3-page long report as a referral though, so she must have had a ton of info already) and patiently take me through the various options, as well as associated risks and timeline. We even talked about things that haven't been invented yet.

Our little chat started with her saying that I have seen quite a few doctors by now - I politely replied that I loved the service (they do come and check up on you every HOUR) and the food (I mean those ice chips are delicious) and that I was thinking about requesting a membership card. In fact, even if you walk 50 yard to another building at the same Medical Center, they check your blood pressure, temperature, weight and height again. I'd love to be able to gain a few extra inches over a couple of days...

Anyway...onto the lecture.

She first freaked me out by saying that when doctors perform surgery on cancer patients, they get you to sign a consent form that allows them to remove a lot more than what was initially planned if they find anything suspicious (eg if it is worse that what they initially thought). This could mean in my case, that they could remove the ovaries for instance. So here's what we talked about in chronological order.

- We need to ask the oncologist if a) it's OK to wait for ~ 3 weeks to harvest some eggs and b) if it's dangerous or not to do this. The needle that they would use for eggs would go through the cervix and the fertility doctor is worried that this might bring some of those flea-like cancer cells where we don't want them to be, eg the ovaries.

- If the oncologist says it's all fine, then we will proceed with this to keep as many options as possible. They would work as an insurance policy. If the ovaries can be conserved, then fresh eggs will be better. This means that I need a lot of blood tests, ultrasound scans, pills and I need to learn to inject some ovary stimulant myself as I will have to do this for a few days...(I expressed some concerns that I would mess things up, she replied that 21-yr old girls can manage this just fine - what's that supposed to mean????). She also recommended to use 50% frozen eggs and 50% frozen embryos.
I asked about the difference in success rate but apparently, it's partly due to the fact that very few people choose the frozen egg method, over the frozen embryo method. So there isn't a lot of data and there isn't a lot of expertise...

- After the cervix is removed (she explained to me the circlage thing, obviously had to find a French term for it) since this doesn't seem to be debatable anymore, then she said that we would have to wait for 2/3 months for the cervix to heal. Then, and assuming that the oncologist feels that it is safe, we could consider a pregnancy. She said that women have a 55% chance to get pregnant/hold a pregnancy without a cervix. Most pregnancies end up with early labor, however, in the majority of the cases, and with thorough medical care, the babies are old enough to survive in an incubator. So assuming I can get pregnant and can go through the first few months, the changes of a successful pregnancy would be high, certainly enough to justify a trial. Sarcomas, in her experience, are not hormone-sensitive so a pregnancy should not alter the risk profile of the cancer, however, obviously, time is of major concern here.
So next steps is for me to talk to the oncologist (Thursday) after she hears back from the tumor board. The fertility doctor thought that it was great that they accepted to look at my case.

Now, there are several possible complications in my case...
a) even if I chose a natural method to get pregnant, if the cervix doesn't heal right (and there's no guarantee that it will), the opening that's left will be too damaged/small to let a lot of sperm go through...makes it just a bit more challenging for those little guys to swim all the way through to the ovaries.
b) the uterus might not function properly because of cancer
c) if they use insemination, they might not be able to go through the new "opening" and reach the uterus
d) if they use IVF, they might not be able to put the embryo back in what's left of the uterus for that same reason.
and of course, she kindly reminded me that we have not done any test re: my reproductive system and there will probably be no time for a full battery of test, and it is possible that there are other problems that have not been found yet

Now if that was the case, then it would close this option since there is only so much time allowed for trial and the hysterectomy would happen faster...

- She also agreed that this cancer is so rare that she would understand why the oncologist would want to be conservative. On the other hand, if the lab really thinks that it is really early, there might be a real chance that waiting for a year would not affect negatively my prognosis. She also said that this partly explained why the oncologists had differing views. She agrees that if radiation can be avoided, it would be better from a reproductive standpoint. Chemo apparently may or may not affect the ovaries but radiation most certainly turns them into French fries (well French in my case)...She also said incidently that one of the side effect of radiation is cancer. That's hilarious!

- The question of the father is a very good question in my case. At the tender age of 1 and peanuts, my cats are a little young to assume parental responsibilities. She did talk about sperm donors (imagine putting some sperm into your shopping cart on Amazon.com...Apparently, they do offer overnight deliveries!) - and she said that if I wanted to ask a friend to be the donor, then there would be some tests which could be done while I recover from the surgery, and insemination could be used.

Now, if pregnancy is not an option but the ovaries are intact, at least for a little while, then it is possible to harvest more eggs of course, or to use fresh eggs to do IVF (that's in vitro) and a gestational carrier (eg a surrogate).

She also said that if the oncologist decided to remove the ovaries, then she would freeze them anyway. No one has invented how to get them to work outside of the human body, but hey, it could happen during my lifetime...

Then, she left me the "back number" that I need to call after I talk with the oncologist. If we go down the "harvest the eggs as an insurance policy" path, it means that we would be starting the whole cycle in ~ 1.5 weeks...

Next steps in this little saga:
- Wednesday: discussion with my OB and the renowned Tumor Board (I didn't get invited!!! But a portion of my cervix will be present, I'll ask it to take some notes for me)
- Thursday: discussion with oncologist #2 (I asked her if she would agree to take me on as a patient)

Next step with fertility doctor depends on the Thursday chat...

How do you feel about the suspense in this little story?

Ship's Medical Officer

Hi -

Turns out that one of my boat's crew members is an oncologist! So I have a personal consultant :) I called her today and we talked about the situation. She started by saying that "history of the cancer", meaning previous cases, would be very helpful. When I told her the type, she corrected: "forget about the history, I can count the number of cases on my two hands..."

- She did say that getting 2-3 opinions from the doctors I had spoken to was great
- She did say that the local renowned tumor board was very good so she's glad that they have agreed to review the case
- She did confirm the "jumping" habit of sarcomas
- She did say that most sarcomas are not ERP+ (eostrogen receptive) so would not be affected by changes in hormonal levels. the biopsy should have determined this so if my doctor is offering this option, it means that the tumor is ERP- which would be expected in the case of a sarcoma.
- She did say that 1 year is a long time out and risking to leave cancer cells in the body for that long might not be such a great idea.
- She agreed that removing the lymp node (and sending them for biopsy) is a good idea
- She did say that low grade sarcomas can grow very slowly before they become a problem (1-5 years, consistent with what oncologist #1 said) but since my tumor is > 2 cm, it's hard to tell how old the tumor already is. When I said that the oncologist #2 had recommended radiation, she said that in general
=> low grade <> low grade > 2 cm, surgery + radiation often recommended
=> high grade, surgery + radiation + chemo
=> invasive -> turns into a stage IV cancer.

However, she said that every case will be different so maybe when she sees more data, the doctor will be comfortable taking a calculated risk. She also said that most sarcomas will recur within 1-5 years so the most conservative approach after treatment would be to wait for 1-5 years before starting a pregnancy. After 5 years, relapse is still possible but much rarer and a bi-yearly scan/exam should suffice. And because most sarcoma are not responsive to hormonal changes (unlike breast cancers), patients that have had sarcomas (a non uterine sarcomas) can usually get pregnant later without increasing the risk of relapse.

She also did say that chances of success in the case of a pregnancy probably don't apply to my case. If the uterus is affected by cancer, it may not function properly, so it may not stretch to accommodate a baby. Unfortunately, there will be no way of knowing to what extent its functionality has been impaired without going through a pregnancy. So this 50% number is up in the air apparently.

So she agrees that since the margins are negative, the cervix should be removed - the 50% will depend on how much of the uterus they can leave. She also agrees that there may be no visible tumor, yet aggressive cancer cells developing in the uterus, certainly not what she would leave in for 1 yr.
She also agrees that if the tumor is considered really low grade, meaning closer to the 5 yr mark than to the 1yr mark (eg chances that the cancer cells in the uterus are not yet that aggressive), if the cervix and lymph nodes are removed with no cancer cells in them (or ovaries/or radiation), then it might be possible to calculate the risk associated with waiting 1 year or so before removing the uterus. She said that given the size of the tumor (big), it could be closer to the "getting ready for a high grade boost". The size of the cancer matters a lot since the growth rate is exponential. The more cells there are in a tumor, the faster the cancer will grow, and in the case of a sarcoma, the more likely some cells will have "jumped" places, just because if there a constant x% chance for each cell to jump, this risk increases with the number of cells in the base pool. In my case, a 4cm tumor was removed but looks like all of the cervix is affected since the margins were negative so it's a little bigger than that. Sounds like there could be up to 1 billion cells in there already.

She also confirmed that the more I waited, the higher the chances of needing more radiation, chemo, ovaries removed, etc...later on. although probably really hard to estimate the actual risk.

So sounds like the discussion will focus on determining the actual grade of the tumor (eg likely rate of growth in the coming year). Once they agree on this, then a decision can be made.
Still really low grade, then a calculated risk for a year or so is possible
Unsure or high grade, then probably better to be safe rather than sorry

Have a great week!

Back to Oncologist #1

Hi Anatomy friends,

I just met with my first oncologist. He's so busy that he had to find time over the weekend to meet (he offered, I didn't ask). He does regular trips to Asia so whenever he's in town, he's triple-booked. Even though he "made" time, I had about 20 min with him and I always felt like he was trying to push me out of his office...Of course, this may be only an impression. It is true that not all visits to the other Cancer Center are the same, in this case it was a new patient visit so they plan for a long time as they go over this long lecture (which as very helpful!). So decision #1 is what path I want to follow, and decision #2 is where to have this treatment.

So the good news is that the two doc are not really saying anything different, they just have proposed two different paths toward the same thing. Also note that the second oncologist I talked to wanted to have the opinion of the Pathology lab as well as the recommendation from the tumor board, and that after this, she might feel comfortable taking a greater risk, because she would feel that she could manage it (eg perhaps a stronger treatment but no difference in chances of cure - which is what my first oncologist is saying: risk of having a heavier treatment increases but he's still confident that he can manage the disease by watching it closely. He did say that there was a small risk of course in doing anything that's not a hysterectomy in the next three weeks because it is such a rare cancer). Here's what he said.

Option 1 (hysterectomy) is clearly the default treatment for uterine sarcomas. The first oncologist also said that she would feel comfortable leaving the ovaries and not do radiation after a hysterectomy because the chances were < 10% of spread to the ovaries. So in any case, this is going to happen (now or in ~ 1 yr from now, it will have to happen). And a year from now, the risk of having to do radiation (eg cancer spread to ovaries) or have to remove the ovaries is greater. The second oncologist did not say anything against this either. The hysterectomy would be performed through an abdominal incision, may require up to 4-5 days in the hospital and a slightly longer recovery time than the removal of the cervix.

Where they differ slightly is around option 2 but then not that much.

Option 2:
Oncologist #2 said that she would be OK removing only the cervix for now to conserve the top of the uterus. However, she said that she would want me to have radiation over several weeks to manage the risk. This would kill my ovaries.
Oncologist #1 also said today that he would have to remove the cervix. However, he said that to try to help save the ovaries for a while longer - or forever since they might not be affected by the cancer yet - he would remove the lymph nodes in this area through a laparoscopy. This would reduce significantly the risk of further spread and buy me time. He would also send them to the pathology lab. If cancer cells are found in the lymph nodes, the whole thing would get interrupted ASAP and he would remove the uterus and do radiation/chemo. He said that radiation had another side effect which is increased risk of cancer in another part of your body (even if they are very localized) and so he feels that saving the ovaries + avoiding this risk is worth it. He's not sure that there's a clear cut answer on that one.
So they are both aware of the risk and both have a suggestion to reduce it.
Oncologist #2 talked about a 60-70% to have a baby without a cervix. Oncologist #1 talked about a 50% chance, but he said that they can save a lot of premature babies as they put them in incubator which can raise the chances to 60-70% so it makes it worth trying. He also said that to minimize this risk, I'd have to stay in bed for a long long time...to avoid putting any down pressure on the cervix.

After the removal of the cervix, I would have to wait for ~ 3 months before getting pregnant as this would be the time needed for this area to heal. They would place permanent stitches (circlage) in lieu of a cervix to close the uterus and sutture the vagina directly to the top of the uterus. He said that this was a fairly common procedure. Delivery would have to be through a scheduled C-section. In this case, insurance would cover it because there would be a strong medical reason for this.

Both doctors said that ultimately, I would have to have a hysterectomy, there will be no way around this - the removal of the cervix will only be a temporary solution. Oncologist #1 feels that given the pathology report, he can manage the disease during a pregnancy. He also said that sarcomas don't seem to react badly to hormonal changes (Oncologist #2 also said that). However, he did recognize that there was a risk and that he would have to watch me very closely and would not hesitate to interrupt the pregnancy if anything abnormal were to pop up. He also did say that I am putting myself at increased risk for additional therapy but if I felt so strongly about carrying a baby, then I might think that it is worth it, which is why he's putting this option on the table.

He also agreed that success rates of IVF procedures are low with frozen eggs but very decent in his opinion with frozen embryos (although he could not give me a number). And this would remain an option in the future, after the hysterectomy - even if it is for a second child.

So the options with him are now:
option 1: hysterectomy (and lymph node removal just in case) + monitoring (as not 100% sure that ovaries or other abdominal organs are clear of cancer)
option 2: removal of cervix and lymph nodes, monitoring, pregnancy ASAP and then removal of the uterus + monitoring (as not 100% sure that ovaries or other abdominal organs are clear of cancer)

He did say that the cancer was found early (comparatively) even though the tumor was quite big which means that it probably is at least 1 yr old. He also agreed with with a tumor this size, the likelihood of having cancer cells elsewhere in the uterus are higher (Oncologist #2 also said that, that's why she wanted to do radiation). However, he feels that if the lymph nodes are intact, most likely it is still confined to the uterus and an immediate pregnancy might still be possible. He doesn't know for sure, he was clear that there was a risk and that this was not his recommended option. However, he would understand my desire to try to have a child now, and he would support it. He also said that there was a much more aggressive form of sarcomas but that the current biopsy did not reveal signs of that type. However, of course, the cancer can become more aggressive over time. Sarcomas don't turn into carcinomas but they can evolve within the universe of sarcomas and develop what is called an overgrowth (a boost of the malignant portion of the hybrid tumor) or become a combo carcinomasarcoma - there is so little data out there that it's hard to tell what will happen. (eg grow faster, the malignant potential of a cancer is the speed at which it grows and spread. All cancers ultimately grow and spread. Cancers that are too aggressive can grow faster than the time the body needs to recover in-between treatments, often this is due to genetic factors - in the case of sarcomas, there is no known genetic cause. Cancers that are not very aggressive are actually very dangerous too if they have started to spread or if they can jump places because chemotherapy is not very effective at treating them since it targets fastest growing cells, the least aggressive cancer that are non linearly invasive can grow slowly but surely... - the easiest cancer to treat fall in the middle) and he did agree that it was not a common cancer nor the easiest one to treat and that I was unbelievably lucky that it was diagnosed so early.

That's the news for today! - and it seems that co-parenting could still be an option...and the urgency is for him to know whether or not to remove the uterus or the cervix. He did say that I shouldn't wait to remove the cervix because it is still full of cancer cells.

So all in all - getting a much better idea of what's going on. Far from being an ideal situation but far from being the worst possible case.

Have a great week!

The Flea Cancer

I spent a few hours this morning at a local and renowned Cancer Center, an expensive piece of real-estate with an obvious parking problem. Talking to Dr H. there was extremely helpful (finally someone who doesn't draw a uterus that looks like a lightbulb!! I could almost believe that she'd be able to recognize it in a human body)

I have learned a lot about GYN cancers this morning - there are a lot of numbers in this email. If you'd like a book with more images, please go to www.images.google.com every few minutes for a nice interlude.

The oncologist said that the most common type of uterine cancer is squamous cell cancer. This cancer invades progressively (eg, if you remove the area and the margins are clear, eg no sign of cancer, then it means that you got it all). This type of cancer can be detected by PAP tests and when detected early only requires surgery. If I had this type of cancer, she would be happy with removing only the cervix and a wait and see approach.

(do I sound like a rocket scientist?)

The second most common type of uterine cancer is adenocarcinoma - this usually originates in the glands that are located throughout the cervix. The cancer will spread around quicker than squamous but it will go from A to B to C. Because it is more aggressive in general, a hysterectomy is performed in most cases and radiation/chemo is added only if the cancer is already quite advanced. Surgery is usually enough for the great majority of cancer since this type of cancer can be detected by PAP tests.

The most rare type of cancer is sarcomas. The most rare type of sarcoma is adenosarcoma (and the ones that start in the cervix are virtually unseen). They are called mullerian adenosarcoma (that's what I have!). Let's take a look at some more numbers: Adenosarcoma is a variant of mixed mullerian tumors of the uterus. Sarcomas in the uterine cervix are rare, comprising 0.5% to 1% of all cervical malignancies. Uterine sarcomas make up 2% to 3% of malignant corpus tumors, whereas mullerian adenosarcomas are observed in 8% of uterine sarcomas. Oh and the median age for diagnosis is 37, most reported cases are for women aged 40+. In fact it is so rare, that the oncologist would also like to present my case to the center tumor board (hehe :))

Now that we are all certain that I am an extremely rare specimen, worth conserving at all cost (in fact I wonder if I shouldn't ask doctors to pay for the benefit of working on my case), here's where we can go from there.

Sarcomas are special cancer in that they touch both the glands (in cervix/uterus) and the muscle tissues (linen, and everywhere). They originate in the gland but the glands themselves tend to be benign. The sarcomatous part is much more aggresive though, and it is not uncommon for sarcomas to mutate into dual tumors (adenosarcomacarcinoma) . Also, they can "jump" places. So you can find cancer cell at the bottom of the cervix, then no cancer cells, and a few at the top of the uterus as the cancer spread. As a result, removing part of the cervix EVEN with clear margins (eg, no cancer cells for 1-2 cm around the tumor) doesn't mean that the cancer was removed. In my case, there was no clear margin (eg, cancer cells were found at the boundaries which means that there are 99% chances that there are still many cancer cells in the cervix - the latest scan didn't show clear boundaries either meaning that the cancer goes deeeply into the tissues. Upon exam, my cervix looks way too firm for being normal. So as a very minimum, this oncologist said that she would definitely remove the cervix completely.

Now, if she does this, because she would not be sure that there are no cancer cells left in the uterus, she would order radiation and possibility chemotherapy (although sarcomas are known not to respond very well to some chemo treatment, so she would always double up with radiation). She would also have me constantly monitored. So I can lose my cervix, keep my uterus and lose my ovaries. She also said that if I were to try to carry a baby with no cervix, I would have a 30-40% chance of losing the baby (eg not complete the pregnancy), and this will go up with age.

She said that the recommended treatment is hysterectomy because it is uterine cancer (eg, it could affect all the uterus for all she knows, it does not have to show visible tumors). If she does this, she would probably feel comfortable not removing the ovaries because there's only an 8% chance that they are affected (although it's the next level up). If upon biopsy, the uterus shows a lot of cancer cells, she will probably order radiation/chemo and want to remove the ovaries. To be conservative, she would recommend to remove them, which is actually the standard procedure for tumors that are bigger than 2cm (my case, was double that size and 3 after partial removal)

Now if she does this: harvesting eggs and freezing them is possible (and they stay the age they were when they were harvested) but chances to have a successful fertilization is very small. Freezing embryos has a higher chances of success but not that high (so I'd have to have quite a few in reserve...

To help me make those decisions, she has referred me to the endocrinologist/fertility doctor across the road - another expensive piece of real-estate with even less parking.

She said that there is also a slight possibility that the sarcoma has gone extra-uterine. It's small but not zero. That's because of this A to C jumping B thing. So in any case, she would want to have me monitored closely. This is also why in tumors that are bigger and higher grade sarcomas, radiation/chemo is usually recommended even after surgery.

At this stage, she believes that there is a strong chance to cure the cancer (although it could recur for example in the vagina). She needs more data but she'd say 90% with complete removal (including the ovaries). She wants the local pathologist lab to look at the slides (sample from the biopsy) to confirm the sarcoma diagnosis and make sure it's not another type of cancer.

Hormonal changes and genetics don't seem to affect sarcomas that much (they are quite happy to develop on their own apparently) but she said that there was so little to work with that no doctor will want to make a call on this. In any case, she would not recommend a pregnancy because I have a life-threatening disease and until it is cured, I might be making a decision to bring into the world an orphan. She said that definitely in a year from now, it would be super hard to tell what can happen. So she has no idea about a timeline. The tumor is pretty big and I had experienced the symptoms for several months (there are symptoms only for advanced sarcomas) -

And the reason why they are hard to detect via PAP test is because the small area of the PAP swab may contain zero cancer cell since it is a heterogenous tumor, but everything else could be affected...Biopsy of the tumor itself is the only way to diagnose this type of cancer. She did say that I was very lucky to have found the tumor "by chance" a lot of people don't find out about it until very advanced stages.

This cancer doesn't metastase as quickly as some more aggressive forms of cancer (that's good news) but as they are non linearly invasive cancers and don't respond well to some kind of chemotherapy, they are hard to treat. Also once they get to another organ, they can mutate and start to metastase quite happily, or remain undetected unless they are too advanced to be contained with surgery only. Also, they are unknown entities, little data, high mutation rate and they become more and more aggressive as they grow (ultimately spreading like all the other types of cancer). However sarcomas of the uterus that have spread outside of the uterus also have extremely poor prognosis.

So she said even with surgery, there would be no guarantee that I would be cancer free, just a high chance. She would still want me to have regular checks up every 3 to 6 months (MRI) for 2-5 years. then at least once a year.

I obviously don't know anything about sarcomas, so all of this is my understanding of today's visit...

ps: Adeno means that it starts in glands

Until next time!

Until next time!

Two Weeks Post-Op

Catching up on late stuff!!!

Well, sounds like there was a little drama going on today! Experienced some "heavy bleeding" which means a completely soaked pad every half hour or so, then every hour, had to be evacuated from the boat I was racing on and transformed in a few minutes my bathroom into a slaughterhouse. Fortunately, the oncologist on call at my doc office responded to my call within 5 minutes. His expert opinion confirmed what intuition had already told us: this is a bit much and a trip to the ER would probably be quite appropriate.

All is well now - Sarah came to "supervise" the operations for a few hours and to bring some fresh supplies! We had nice little pizza dinner and watched a beautiful movie. The doc just "allowed" her to leave and I can now stay at home. Bed rest tomorrow (the cats will love it) and I am to call the doctor in the morning. If all is well then, should all be back to normal!

Airplane

On a recent trip to Europe.

So there was this burning smell on the plane, a lot of running around, flight attendant saying "I know folks, I know, we're investigating", captain coming out to check and all that and then the following announcement:

"we have an unusual announcement to make. We are experiencing a small...(*silence*)...minor electrical problem, resulting in a small...(*silence*) minor fire. We have to switch off all power to the main cabin and run on emergency lighting. As we will have no power in our galleys, this means that we will be able to serve only cold and non-cooked food. We won't be able to serve you coffee or tea. Also, we will have to shut off the entertainment system"

News From Cancerland (or confirmation of diagnosis)

Hi everyone,

Welcome to Cancerland where the local temperature is 37 degrees Celsius and pain levels are hovering around 1. I have just had the immense privilege to meet my oncologist again. Why am I saying privilege? Here's an overview of the decorations in his waiting room...

"Top 500 Doctor's in 1992 and 2001 - Top OBGYN oncologist"
"Top doctors as selected by his peers in 2002 and 2003"

Next to this pedigree, my resume looks like a wafer. To my credit I must say that I am developing an uncommon specialty: that of always having to face events that have a chance in 1 billion to occur. I need to buy a lottery ticket, feeling very lucky these days.

Now that we have all agreed on a standard of greatness, I will do my best to honor your expectations and share with you the minutes from my medical meeting.

The oncologist opened up the show with a metaphysical question: "Do you want the bad news or the good news?" (<= note, this is oncologist humor) In the mouth of a waiter at a local restaurant, this sentence does not quite convey the same meaning as it does in an oncologist's office. But then, faithful to my principle of rarest event specialist, I figured "in an oncologist office, the most common occurence outside the staff has to be people with cancer, so the good news must be the least common event in the lot" so I asked for the good news first. "So the good news is that I am now certain of the diagnosis, there's no argument in the lab anymore about the nature of the tumor - ** odds were 2 against 1 in favor of cancer before ** and we don't need a specialist from Harvard. The bad news is that this diagnosis is cancer. It is called an adenosarcoma, or also called malignant adenosarcoma" (I don't mean to be pedantic here or to interrupt the grand master, but the second moniker sounds redundant to me) I looked this thing up - here's what I have found: "Adenosarcomas of the uterus are seldom observed and diagnosed". how useful is this definition to you on a scale from 1 to 10?

Anyhow - the oncologist seemed to remember the difference in size between my resume and his and decided to illustrate this cryptic medical language with a drawing. On a small piece of paper advertising "Fosamax, alendronate sodium tables", he went on drawing what looked like a light bulb with a rusty filament. I was wondering if this was a symbolic way of telling me that he had an idea but I was stunned to hear that this was a drawing of my uterus and cervix and that the part that was blacked out was what he had just removed (read 80% of the cervix). Darn, I'd never want this guy on my team if we play Pictionary. He would draw a picture of a spaceship and want me to guess an egg.
So, he explained to me that this form of cancer is actually not a cervical cancer but a uterine cancer (why it was on my cervix will probably remain a mystery until the end of time I suppose). It is a very rare form of cancer, and unseen to his knowledge in a patient falling in my age group (faithful to my principle, if there's one thing that I will remember it certainly is the fact that he doesn't see this every day) and it now looked pretty aggressive.

So apparently, they took loads of pictures during the surgery and the results of the biopsy are making their way around the high spheres of the medical authorities. I wish this would make me famous but I bet that everything is labeled case EO69-4. Trying to get hold of these for my family album. But I am going on a tangent here, let's go back to our main storyline.

There is only one permanent solution: a hysteric tummy, huh, no sorry, a hy-ste-rec-to-my. (although, technically, there is a high chance of this cancer developing again in nearby tissues, it is also recommended to do regular general screening. It is apparently also a cancer of the lungs and breast. I am sure that I could do with a little bigger breast but this approach would not be my preferred option).

So my oncologist has given me two options and two weeks. His main recommendation is a complete hysterectomy (I can hear my cats laughing already at the idea that their "mom" will be "neutered"). Given my young age ( (<= note, that is a man's compliment) and the fact that he's confident that he's removed the bulk of it for now, he said that he would allow me to wait and be watched (read, regular biopsies and scans). However, the cancer is not cured. So technically, I have cancer.

I asked the oncologist if he could rate the chance of re-occurence on a scale from 1 to 10. He gave me a 9.9999. Going back to 3rd grade math, I deduct that this type of cancer has a high risk of re-occurence in the uterus as well as the cervix that hasn't been permanently zapped (where did my 1 chance in a million go???), and it is not quite the type of baby I'd like to see grow in there.

Now, there are risks associated with this approach.
Risk 1: that not everything is caught in time and that there will be more need for chemotherapy and/or radiotherapy. A hysterectomy preserves the ovaries. This type of gentle treatment does not.
Risk 2: that if I did decide to wait (to start a pregnancy), the process might have to be cut short to treat cancer and if it is a tiny bit early, it might treat another growth in the uterus at the same time :(((
Risk 3: that his "surveillance" isn't 100% proof (this type of cancer cannot be detected by a pap test - don't ask me why, I don't know why the oncologist chose a red tie today either)

Finally, he is ordering a scan but we have to wait for the cervix to heal, right now, the scan would show only scar tissue and disturbed matter...I was so much longing to go back into this tube-like machine of MRI (took them TWO hours last time to get those pictures. I say, they should have been happy with the first shot and use Photoshop for the others)

So - that is the story in a coconut shell. See you in 2 weeks, guys, for Alien 2.

Ripley

2nd Operation

Hi everyone,

I am just back from the hospital where I spent a lovely couple of days.

The oncologist decided not to wait and see because the tumor was growing much faster than he had anticipated. Since it was already pretty much over the cervix, sounded like he didn't want to risk an invasion :)
In any case, the oncologist removed the entire tumor (or so he thinks, he still wants to order a scan to make sure that there are no cancerous cell left). And in doing so, he removed most of the cervix (about half maybe?). He also said that he zipped the nearby cells with a small electrical blast to reduce the risk of re-occurence in the same location. But then, my regular doc didn't believe that this could be done after she looked at the MRI (she had cancelled this procedure) and Lili (my babysitter these days) said that one of her friends (physician) knows Dr S. and thinks that he's the best oncologist/GYN in town!

Apparently, when I woke up, the first thing I said was to make sure that someone would feed my cats...and those ungrateful animals chose to poop on the kitchen floor as a thank you gesture.

Frankly, they should pay patients who spend nights in hospitals. Nurses wake you up every hour on the hour to check random things such as your blood pressure, temperature and oxygen levels which I am sure change drastically from dream to dream. They decide to draw some blood at 4AM for some lab work - there obviously isn't a better time to do that and I am sure that it can't wait. And they also like to bring you back from the cozy universe of dreams to ask you if you feel like having some more of those delicious ice chips at 2 and 3AM (I asked the nurse to convey my compliments to the chef, she looked at me as if I was a visitor from Mars) or engage me on a very intellectual exercise: estimate my pain level on a scale from zero to 10, whether or not I am complaining about pain. I replied 5.687 once but she couldn't find this on her charts so she didn't know how much of those nice narcotics she would have to administer.
And just like at work, you agree on your OKRs right after you're admitted. The nurse writes on a board by your bed "Goals". My goals were
1) pain control
2) diet: ice chips
3) clear out lung, deep breathes + cough

I did my best to eat as many ice chips as I could, to accurately measure my pain level to the hundredth decimal and to cough loud enough to wake up the entire floor.
I particularly liked the nurse who tells me: "Don't worry, Dr S. always comes early in the morning and he will change your diet". The Dr in question turned up at 11AM and moved my diet to "clear liquids" - but I had a treat of jello...a tasteless gelatinous blob. Not sure if this was an upgrade or if I had been demoted.

I was almost forgetting. Just to make sure that you do NOT get any sleep in-between check ups, they also place you in a room with someone who is being treated for sleep apnea and who snores louder than you can cough. Thank God for those narcotics and whatever chemicals there were in this anesthesia cocktail.

Doc said that I should spend at least 24hr in the hospital so they could keep an eye on me (I guarantee, they had all their senses fixated on my vitals all night), he ordered antibiotics/anti-fungal and electrolytes through IV for the entire duration of my stay (so not only are you not allowed to drink anything but you also experience all the drawbacks of fluids as you need to go to the bathroom every hour, transporting with you a heavy and clumsy IV pole which means that the door can't close). Oh, and they also want to measure your "output" so they can adjust the levels of electrolytes. I am now officially "discharged", even though they wheeled me to the parking lot so I looked more ill than when I arrived at the hospital (I was walking just fine back then). The doctor has asked me to stay home and not walk for a week, has given me more painkillers and antibiotics. After this weekend, I can switch to non narcotic pain killers :) I am not supposed to drive nor drink alcohol and I have a 24hr emergency number to call if there's any problem (fever, heavy bleeding, craving for ice chips, etc...) that's not 911...eg, I get to talk to someone who actually has heard about me and will no doubt ask me to describe my pain level on a scale from zero to ten. No exercise for 2-3 weeks (until doc says it's OK), no travel for over a month. I need to go see him next week for a funny stitches removal exercise and have regular scans/check ups for the next 1-5 years after which I will reach cruising speed of 2 OB/GYN visits/year as opposed to one.

Now, I could not finish this little story without thanking Lili who got bored with me prior to the surgery, got bored in the waiting room during the surgery and got bored waiting for my wheelchair in the parking lot upon my discharge. She managed to trick the security guards at the hospital into getting her in after hours so she could wish me a good night. Sweet Lili also filled up my fridge with tropical fruits and brought wonderful flowers to decorate my living room. Unfortunately, - and I feel SO bad - the cats can recognize a good salad when they see one and feasted on the flowers...

Overall, I feel fine. Some cramping but nothing that the narcotics can't deal with, I feel very sleepy but nothing that the narcotics can't help me with. I have an iPod, a nice collection of books and two cats to pass the time in the coming days. Oncologist said that if risk of miscarriage/early labor could probably be managed with a reinforcement (stitches) of the cervix at that time + special care, eg. get bored in bed for three months before birth. In any case, he said that he didn't have a choice, did his best and that it was better than no cervix at all. So most importantly, and unless the scan shows otherwise, I am now cancer-free.

Now that you're done reading - on a scale from zero to 10, how did you like this essay?

Ship Wreck Short Version

In July, Finance Monkey, a regular sailor, was helping deliver a boat from Hawaii to San Francisco. After four sun-bathing days of sailing in calm seas, the crew noticed a pod of what turned out to be sperm whales about a mile away from them and took their cameras out. But when they heard a loud BANG and felt the boat shake, they were surprised as the skipper had warned Finance about properly securing her shoe collection. They soon realized that the boat had been hit by a descendant of Moby Dick. The 40 to 80-ton whale (the crew being inexperienced in the sexing of large marine mammals, especially at 7am and before coffee, greater precision wasn't possible) rammed the 40-foot yacht, opening a large hole in the ship's hull. For non-sailing readers, this is generally considered a bad thing.\n\n

So what did\nthe intrepid crew do? They tried to stuff the hole with sails and sail bags,\npump out and bail water for a half hour but courageously decided to abandon\nship after the rapidly rising water reached knee (or waist for female VPs)\nlevel and ruined the 5 kgs of Snickers kept for emergencies. Meanwhile, the\nskipper managed to fit in a most dramatic Hollywood\nsequence "Mayday, Mayday, Mayday – this is yacht XL, etc…" which unfortunately no one picked up. It was\nreally well put.

\n\n

The Coast\nGuard was alerted by the most sophisticated devices such as satellite phone, a\nyellow emergency position indicating radio beacon, an ICOM hand-held radio\ncharged at 60% and a hand-held Global Positioning System device (your VP works\nat Google). They immediately sent a\nplane and organized a model rescue operation resulting in the safe retrieval of\nthe crew after only a day of drifting around on a life raft. After a few\nhours on a container ship, the inquisitive crew found out that it was bound for\nJapan.\nFor Americans and other geographically-challenged readers, this is not close to\nSan Francisco.\nFortunately, a passing fishing vessel returning to Hawaii, accepted the by-now famous crew on\nboard. A few days later, the Fantastic Four made it safely back to Honolulu with 152\npictures of a sinking ship and whale backs.

\n\n

The reason why\nthe whale attacked the boat remains a mystery. However, marine biologists\nbelieve that it was a French whale practicing head butting on an Italian boat.

",1] ); // in the ship's hull. For non-sailing readers, this is generally considered a bad thing.

So what did the intrepid crew do? They tried to stuff the hole with sails and sail bags, pump out and bail water for a half hour but courageously decided to abandon ship after the rapidly rising water reached knee level, the bow disappeared under 3ft of water and salt water ruined the 5 kgs of Snickers kept for emergencies. Meanwhile, the skipper managed to fit in a most dramatic Hollywood sequence "Mayday, Mayday, Mayday – this is yacht So and So, etc…" which unfortunately no one picked up. It was really well put.

The Coast Guard was alerted by the most sophisticated devices such as satellite phone, a yellow emergency position indicating radio beacon, an ICOM hand-held radio charged at 60% and a hand-held Global Positioning System device. They immediately sent a plane and organized a model rescue operation resulting in the safe retrieval of the crew after only a day of drifting around on a life raft. After a few hours on a container ship, the inquisitive crew found out that it was bound for Japan. For Americans and other geographically-challenged readers, this is not close to San Francisco. Fortunately, a passing fishing vessel returning to Hawaii, accepted the by-now famous crew on board. A few days later, the Fantastic Four made it safely back to Honolulu with 152 pictures of a sinking ship and whale backs.

The reason why the whale attacked the boat remains a mystery. However, marine biologists believe that it was a French whale practicing head butting on an Italian boat.

Ship Wreck - long version

Detailed Account of events (as per the captain log):

Some day in July in 2006...
Double reefed main for the night as we are going through regular squall passages. 15 knots of wind. Beating at 4-5 knots. Course 350 degrees N. Sunny days, calm seas. About 450 miles off the Big Island, 500 miles off our starting point, Kanehoe Bay.
10am boat time (PST): I go off watch after 4 hrs on deck and get ready for a well deserved rest. 10 minutes later, James (crew member on watch) comes below and tell us that whale were spotted about 1 mile ahead of the boat on starboard. I go out in time to see spouts of water. We alter our course to stay clear off the whales. 10 minutes later, James calls again to get us to see a pod of 4 whales behind the boat on port side, about 3-4 boat lengths. I take a look at the whale, we take a few pictures and I go back below to sleep. James and David (watch captain) bring the boat back on course.
10:30am boat time (PST): I am dozing off when I hear a big "BANG" and feel the boat shake. My first thought is that we have hit a submerged container. I hear that 10,000 of them are lost at sea every year and they take a while to sink. Watch crew looks up thinking that something is wrong with the rigging (mast, forestay, etc...) - in their peripheral vision, they see the fin of a whale disappearing under the boat. I jump out of my bunk to check it out.
I go to the bow which is where the noise was coming from. I see a crack in the hull at floor board level (below the water line). I call out "we have a leak". This looks repairable with epoxy. I try to bring the two sides of the cracked hull together and press against it to try to plug it. The water flow doesn't seem to stop. I push aside the lines that were dangling off a bungee in this area. I then face a 3x4 ft (or more) hole in the hull. We are taking on water. I call out "we have a hole in the boat". The skipper comes to the bow to check this out. The hole extends from just underneath the foredeck all the way down to the floor board at our feet.
The skipper gives us orders to contain the leak, goes to the radio and issues MayDay calls every 5 minutes. We start the engine in neutral to charge up the hand held radio and the satellite phone (as well as use the engine water system to pump out water). No one is picking up the Mayday calls, which probably means that no one is within VHF range.
I am pressing a sail bag against the hole to try to limit the water intake from the inside. I secure this with bungees and lines. We have the bilge pump going and James is activating the manual pump. The watch captain (David) and I bring the jib #4 (small headsail) on deck and try to patch the hole from the outside of the boat. We attach the head of the sail to the rail on the starboard side, have the sail go under the boat, in front of the hole and tie it up at the mast/stanchion on the port side. This is not water tight but helping a little bit reduce the water flow. James abandon the manual pump, and join David and myself for a bucket line to bail out water. The owner is still trying to contact someone on the VHF single-banded radio. He also sets off the EPIRB, the emergency beacon. This sends a signal via satellite to the coast guard with the name of the vessel and the last recorded position off the boat GPS.
After about 30 minutes of battle against flooding, we have water at knee level, and it is still rising. Our plugs don't seem to be very effective. The skipper decides to get the liferaft ready and order us to bring water and food up on deck, near the transom (stern).
We bring up two cases of MREs (emergency food), and all the gallons of water. The skipper has the liferaft ready to go on deck, a handheld GPS, and our communication equipment. He orders us to put on our foul weather gear and get our grab bag (IDs, medication, cameras, etc...) - everything else needs to be left behind as we won't have space for it in the liferaft. I shout regular update on the water level. My last message is that the bow is now covered in water.
11:30am Boat Time. We inflate the liferaft and transfer food and water into it. We transfer our bag and board the raft. We have a line attached to the boat. The bow of the boat is about 3-ft under water.
11:45am Boat time (PST): we cut off the line tying the liferaft to the boat as we watch the yacht sink. We have officially abandoned the ship. It is now up for grabs if anyone wants to salvage her. We organize watches to check for passing vessels. We have flares ready just in case any one comes within sight. We have a drag to keep the entrance of the liferaft off the wind (and waves). The liferaft feels like a water bed. The canopy keeps us cool. We are all wet and salty. We make one phone call to the Pacific Cup race committee on the satellite phone as well as friends/family. The mast of the yacht is still visible and is the only part of the rig that remains above water.
13:30am Boat Time: we hear a Coast Guard plane, a C130. The Coast Guard drops a water-tight canister with radio and sponges which James swims for and keeps us on a half hour schedule for updates. There are 3 vessels within 100 miles of us. A container ship (90 miles), , a fishing vessel (40 miles), and a second fishing vessel (60 miles). All distances are given in nautical miles. The first fishing vessel has a vietnamese crew who does not speak English. We are left with the other two.
All day: waiting in the liferaft through a couple of squalls and rising seas, although still mild/calm by Ocean standards. We update the coast guards flying around the liferaft (then relieved by a second airplane) every half hour with our new position read off the hand-held GPS. The Coast Guard are guiding the rescue ships to the EPIRB signal. The Coast Guard spot whale 2 miles off our current position. We hope that they won't come near our precarious raft. We also hope that any sharks in the area will have enough food with our 5 loaves of bread, 2 kgs of peanut butter and strawberry jam and 5 bags of sneakers that sank with the boat.
10:30pm Boat Time: the container sh arrives on site, drifts next to the liferaft and launches a lifeboat.
11:30pm Boat Time: lifeboat reaches us.
Midnight Boat Time: We board the lifeboat and dispose of the liferaft (so that no one will try to go after it thinking that there might be people on board)
1am Boat Time: we are on the container ship. They feed us a full (and nice meal) and give us water. They are en route to Yokohama, Japan so will hand us off to the fishing vessel. 3.5 hrs later, the fishing vessel arrives on site. The inital transfer attempt (directly off the side of the container ship) inflicted $50,000 worth of damage to the fishing boat. We launch the lifeboat and are transferred onto the fishing vessel in a nerve-wracking jumping exercise. We were bouncing around a lot, and we had to jump, catch the rail of the fishing vessel and hoist ourselves up over it.
We go back to Honolulu as the fishing vessel is done with their fishing trip. We catch two fish along the way. It takes us a few days to get back to the island.
All 4 people abord the yacht which sank 500 miles off Hawaii are back on land and in one piece 4.5 days after the wreck.

the type and angle of the hole rules out a sharp-edged container. The force with which the boat was hit seems to suggest that it was an intentional strike. Other elements that corroborate this assumption. We were going only 4-5 knots. If we had hit a whale from the bow, the damage would not have been on the side, just forward of the mast. If we had hit a whale on the side, there would have been scratches along the boat, not a big impact in one place. The whales that we could spot were motionless in the water. It is possible that one of them was sick, or a calf and that the whale reacted in a protective manner.
Whales are a protected species so we couldn't strike back - it is also illegal for boats to get near them. Ideally this should be a reciprocal rule. We have recommended an education program for whales off of Hawaii as they don't seem to be aware of this rule.

Post-MBA Musings from FinanceMonkey

Hello dear zoo visitors!

Succumbing to general pressure, I have decided to come back with another blog :) Upcoming posts can feature some catch up items such as:

- Improv Classes
- Ship Wreck
- Trekking in Patagonia
- Work/life balance
- Cats
- 2 x 200-mile running races
- Fire onboard a plane
- the World of Dating
- Boat ownership

And some new ones such as:
- Battle Against Cancer

See you soon! I promise to populate this blog super regularly...