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Local Interventional Radiologists Deliver Minimally-Invasive Solutions

From the very beginning of my new normal, which began on June 11, 2009 when Dr. Ken Ogan used a DaVinci robot to surgically remove my diseased left kidney and 12 lymph nodes, I was left with an incurable case of renal cell carcinoma (RCC) and the stark realization that my job was to seek out the very best medical care I, with my great medical insurance and the shallow pockets of a small business owner, could afford. I had to use whatever medical wisdom was in existence to stay alive long enough to be strong enough to endure a more meaningful treatment if and when it came along.

To date, an initial occurrence and six separate subsequent battles with RCC mets have not managed to take me out and one of those “more meaningful treatments” was available to me locally and I have been fortunate enough to have been rendered NED (No Evidence of Disease) for the 7th time.

Here is a brief recap of the procedures (except for listing all CT/MRI scans, which have continued to occur at about 3 – 6 month intervals, depending on what was going on) and decisions we’ve made that got us to the office of Dr. Nishant DeQuadros:

June 11, 2009: Dr. Ken Ogan at Emory University Hospital performed radical left nephrectomy + 12 lymph nodes (1 positive for RCC).

August, 2009:  Started ASSURE clinical trial (Sutent/Nexavar/Placebo) and ultimately completed trial.

September, 2010: Discovered 2 cm tumor in spine at L-2, and was unblinded from placebo arm of clinical trial. Drawing the placebo arm of the trial turned out to be the good news, in that going forward I would be drug naive, allowing me more access to other therapies.

October 21, 2010: Biopsy of spine determined the lesion is metastatic RCC.

December 2, 2010: Stereotactic Radiosurgery (SRS) at Emory Midtown Hospital in Atlanta

March, 2010: Radiation oncologist says that I’m NED.

August, 2011: Medical oncologist says the tumor at L-2 wasn’t completely killed and it is growing again.

August 19, 2011: Lumbar fusion surgery and fixation with pedicle screws and fusion with bone morphogenic protein at L 1-3. Three weeks post surgery, developed severe (#10) back pain. Treated with time-released morphine and dilaudid for breakthrough pain. These weeks of pain and insomnia were the darkest days of my life. As I write this, I’m having trouble conjuring what the pain felt like. What it was like to be just aware enough to see the little hand of the clock find every click on its way around the dial, yet gladly not aware enough to be forced to remember some of the truly stupid television shows and movies I watched. Alone in a dark room with my ever-present plastic trash can, a box of tissues, a glass of water and a sack full of narcotics. The world looks very different from that room.

October 8, 2011: Some time before 5 a.m., I bent over to remove power plug from wall socket and experienced a dramatic loss of strength on my right side. I contacted my neurosurgeon, Dr. Michael Gorum, early Saturday morning. He instructed me to get to the emergency department immediately. His partner, Dr. Marc Goldman met me and we went immediately to surgery, where he performed a lumbar laminectomy (bilateral inferior L1, complete bilateral L2 and bilateral superior L3). Pain was immediately gone and according to physical therapist, the strength can be regained in legs with therapy. Two major spine surgeries within 8 weeks and a quickly-growing kidney cancer metastatic tumor trying its best to put me down.

October 10, 2011: I was moved by ambulance to the John B. Amos Cancer Center, where I was evaluated for stereotactic radiosurgery to attempt to kill the tumor in my back and returned to my room at the hospital. Got food poisoning (Yes, the day after my second back surgery in eight weeks! Can you believe it?) from a non-hospital meal I ate on Monday evening, so we delayed SRS until Thursday,

October 20, 2011: 16-greys of radiation in a single one-hour treatment aimed to kill the tumor in my spine.

October 26, 2011: Started monthly Xgeva injections to prevent further bone mets.

December 7, 2011: CT scans show NED.

March 15, 2012: CT scans show NED.

June 21, 2012: CT scan showed 3.9 cm tumor on left adrenal gland and slight enlargement of cyst in right kidney.

July 16, 2012: Decided to confer with specialists at M. D. Anderson in Houston, Tex. and met with genitourinary medical oncologist Dr. Lance Pagliaro there at M. D. Anderson.

July 17 – 18, 2012: Had bone scan, brain MRI, CT of chest, abdomen and pelvis with no contrast and a chest x-ray.

July 20, 2012: Met with interventional radiology to discuss needle biopsy of adrenal tumor.

July 25, 2012: Still at M. D. Anderson and needle biopsy of left adrenal tumor confirmed it was metastatic renal cell carcinoma.

September 3, 2012: Started HD-IL2 therapy at Duke University Hospital under care of Dr. Dan George and Dr. Michael Morse. Received 9 doses and creatinine spiked and didn’t come back to my baseline of 1.8, so I washed out. They wouldn’t allow me to finish part B of round one.

October 19, 2012: Had CT of chest, abdomen and pelvis W/O contrast, because of high creatinine.

October 26, 2012: Met with Dr. Pippas and found out adrenal tumor and nodules in kidney are stable. He recommends starting a TKI and plans to confer with Dr. George to determine which one they recommend.

November 13, 2012: Started with 800mg daily dose of Votrient. Took for 2 weeks and high blood pressure and other side effects caused oncologist to reduce daily dosage to 400mg. On 400mg dose for 3 weeks, increased to 600mg dose for 2 weeks and now on 800mg dose daily and dealing with side effects well.

July 11, 2013: CT scan of chest, abdomen and pelvis (W/O contrast) showed 90% reduction in adrenal tumor, no sign of two small right kidney lesions. Have lost 80 pounds due to GI complications with Votrient, but getting along fairly well. Have been able to stop taking Norvasc completely and have halved my daily Coreg dosage. Getting great blood pressure control, likely due to dramatic weight loss. Creatinine also looks good at about 1.5. So, might be able to get CT scans with contrast next time out.

November 1, 2013: CT scan with contrast of chest, abdomen and pelvis showed NED! Have lost 90 pounds due to GI complications of 800 daily mg of Votrient. Creatinine at 1.32 and other labs looks fantastic.

January 14, 2014: Have lost 100 pounds. Blood pressure is rising and with weight loss, this shouldn’t be the case. Hovering at around 180/115. So, went by to see Dr. Pippas to check blood pressure and they decided to triage me and work me in to see the doctor. Warned me that if I’m developing liver toxicity, we’ll have to make some changes. Had liver panel blood work done in lab. Dr. Pippas TOLD me to stop taking Votrient for 14 days and to take 20mg Prilosec every morning for next 14 days. Says he hopes my body will reset and that I can go back on Votrient after 2 weeks. Also, he added back 5mg of Norvasc to my daily meds to see if we can drive back the elevated blood pressure.

January 16, 2014: Got results of liver panel and we’re in normal range, so stopping I’m stopping Votrient for 14 days and taking Prilosec, carvedilol and Norvasc.

February 7, 2014: CT of chest, abdomen and pelvis shows completely stable and normal. Dr. Pippas says I’m NED again. Still tired, so he suggested I go back on nightly CPAP therapy and start some kind of exercise regimen. Also, wants me to maintain good immune system boosting diet and to not gain weight. At 155 pounds, about what I weighed when I left high school. Options presented to Jill and me:

A) stay off Votrient, scan every 3 months for a year
B) restart maintenance dose (either 200mg or 400mg) of Votrient

I asked Dr. Pippas to confer with Dr. Dan George at Duke, a colleague of his and someone who knows my case quite well. Also, I called Dena Battle, who knows this disease better than most doctors on the planet to ask her gut reaction to what doctor has advised. Made decision to stop taking Votrient.

July 22, 2014: CT scan with contrast shows 2.5cm metastasis on left adrenal. Same side as nephrectomy.

July 23, 2014: Discovered 2.5cm adrenal RCC metastasis and Dr. Pippas said surgery would be best option. We left the next day for a long weekend with friends in Destin, Fla.

August 6, 2014: Met with local surgeon Dr. Andy Roddenberry to discuss adrenalectomy procedure. Here’s an excerpt from my blog:

August 21, 2014: Excerpted blog post named “Eight Months:”  There is considerable scar tissue left over from the massive nephrectomy that cost me my left kidney, twelve lymph nodes and a lot of digging around looking for cancer. Additionally, the organs in my body have recognized that there is some stuff missing now that used to be there and they’ve wiggled around and taken up that space in my abdomen. So, scarring, colon, pancreas and a mass of arteries and veins are all congregated in that area, as well as a vascular renal cell tumor that is very much like a 2cm bubble of blood inside the thinnest tissue paper you can imagine. The surgery has been described to me like a person trying to pick up a balloon full of blood with razor sharp pins. One prick of that bubble and I’ve got cancer cells released all over my body and my prognosis suddenly would take a big turn for the worse.

We left Dr. Roddenberry’s office feeling the dread of making a decision to opt for a surgery that, even if successful, would really take me down physically and could significantly compromise my immune system. This is where the story gets really interesting, if you believe in karma. If you believe in a god, or if you worship from the torn front seat of a 1960 rusted, formerly white Chevrolet pickup at the 2nd Dirt Road Church of What’s Happening Now — this was the perfect information for me to hear at exactly the right time….

My friend, Dr. Granville Batte, called me and suggested we might want to meet with new Interventional Radiologist Dr. Nishant DeQuadros. That contact from a friend helped us find clarity. I promise you this: If you are a cancer patient who doesn’t have full faith in your doctor, and/or if you can’t see your a clear view of your feet along the path you have chosen, you are surely miserable. It is bad enough to feel bad, but to feel bad and be weighted down by stress related to your treatments makes the journey that much more difficult.

Here’s what I did to find that sweet spot of clarity before a new therapy: We made an appointment to meet Nishant DeQuadros and my work began. My doctors are my business partners. They provide a service that determines what is wrong with me and the crystal-clear vision backed up with the talent, experience and will to deliver a treatment path that will, at the very least cripple and at the very best in my case, completely shut down the disease process. I, and my insurance company pay them, their professional assistants and clinicians, staffs, technicians, labs, bean counters and hospitals. Then, the real work starts — research.

I fill whatever amount of time I can carve out prior to the first meeting with a new doctor with finding out everything I can about them. Where they’re from. Where they went to school. I seek out their professional writings, look for any feedback I can get from ratings sites, inquire of them with every one of my trusted medical sources and see if they have any kind of social media paper trail I can follow. I also like to find out who their friends are and if I happen to know them, I can’t pick our mutual friends’ brains to find out if they would put their life in the hands of this doctor. Melissa and Jim Thomas are friends of the DeQuadroses. That was a great thing to hear, right at the start.

I got a sweet surprise when I started vetting Dr. Nishant DeQuadros. The more I learned about him and his company, Georgia Radiology Imaging Consultants, the more excited I got. The doctors in this practice are extremely well trained. They do the kinds of procedures that are hard to come by in a community hospital setting. Often these highly-specialized radiologists are doing these kinds of procedures in larger urban or university hospitals. I found out later, just how important it was that these superdocs were here and that one of them was able to take my case.

Jill and I walked into Dr. DeQuadros’ office and a young, handsome guy in a white coat greeted us. We sat down, looked at my scans and we talked about how the ablation would be done. He brings mad experience to the table. At the end of that visit, we had that clarity that is so important.

August 28, 2014:  Interventional Radiologist Dr. DeQuadros and Anesthesiologist Dr. Mark Pinosky performed a microwave ablation of my left adrenal and its encapsulated RCC met. Complications during procedure caused Dr. DeQuadros to have to make four passes to get enough of a burn to completely finish the job. Disruption of my adrenal gland and the presence of the RCC metastasis caused a 300/200 blood pressure spike during the procedure. Because of the fear of cardiac damage from the BP spike, I spent the night in an intensive care room, so I could be monitored.

In my intensive care room the next morning after the procedure, I learned how serious the situation became during the minimally invasive operation. When they saw that I was having a major hypertensive reaction, Dr. DeQuadros ran a central line to my heart from behind me left knee, and, along with Dr. Pinosky, they monitored my blood pressure with every beat of my heart, utilizing drugs and procedures they had at their disposal to control wild blood pressure swings while still completing the procedure.

August 29, 2014: I was released with an appointment to see Dr. Shane Darrah to determine whether the high blood pressure had damaged my heart muscle.

September, 4, 2014: Saw Dr. Darrah and had stress test.

September 8, 2014: Had echocardiagram in Dr. Darrah’s office. It was determined that no heart damage resulted from blood pressure spike during microwave ablation.

October 2, 2014: CT scan with contrast (80% of dose). Still NED.

February 12, 2015: CT scan with contrast (80% of dose). Still NED.

The microwave ablation therapy I received here in Columbus was one of those cutting-edge treatments that can extend the life and protect the quality of life of a patient. In this process, I appreciated the candid advice given to me from Dr. Roddenberry that I should seek another, less invasive option that wouldn’t expose me to such a large, dangerous surgery that might negatively impact my compromised immune system. The incredible truth is that the huge surgery and the minimally-invasive microwave ablation should yield the same results (if perfectly executed). One would have cost me six days in the hospital and another six weeks of recovery. The other was performed on a Thursday and I was back in the office on Tuesday. I would have returned to work on Monday, had it not been the Labor Day holiday.

The list of vascular and interventional radiology treatments that are offered here by Drs. DeQuadros, Hart and Vo is quite long. If you receive a diagnosis that might be remedied by one of the treatments from this list like I did, you’d be wise to do a little Googleing to see if you might be better served by this type of care. Here’s the best part: When the therapy is finished, you can go home and sleep in your own bed. That is a mighty good thing.

April 30, 2015 | Tagged With: adrenalectomy, ASSURE trial, blood pressure, bone scan, brain MRI, carvedilol, Coreg, cpap, creatinine, CT scan, DaVinci robotic surgery, Dena Battle, dilaudid, Dr. Andy Pippas, Dr. Andy Roddenberry, Dr. Dan George, Dr. Granville Batte, Dr. Hoang Vo, Dr. James Hart, Dr. Ken Ogan, Dr. Lance Pagliaro, Dr. Marc Goldman, Dr. Mark Pinosky, Dr. Michael Gorum, Dr. MIchael Morse, Dr. Nishant deQuadros, Dr. Shane Darrah, Duke University Hospital, echocardiogram, Emory Midtown Hospital, Emory University Hospital, Georgia Radiology Imaging Consultants, HD IL2, Houston, insomnia, interventional radiology, John B. Amos Cancer Center, kidney cancer, laminectomy, liver toxicity, lumbar fusion, M. D. Anderson Cancer Center, medical oncologist, microwave ablation, Midtown Medical Center, morphine, MRI, NED, nephrectomy, Nexavar, Norvasc, placebo, Prilosec, radiation oncologist, renal cell carcinoma, stereotactic radiosurgery, stress test, Sutent, Votrient, Xgeva| Filed Under: Uncategorized | 1 Comment

New Appreciation for the Microwave

Please accept my apology for leaving you all hanging. The pressures of helping to run a business, keeping up with all of the landscaping I’m responsible for (especially with diminished physical capability) and the sheer joy of returning to life have had me blocked beyond belief. Under normal circumstances, my brain lights up when I touch the keys on my MacBook Pro. Much like me, my “S” key is beginning to show some wear. Am I living my life too safely? Command-S is the keyboard command to save. Caution has been at the very front of my consciousness AC. After Cancer.

FullSizeRender

In the last post I described the adrenal microwave ablation procedure performed by Dr. Nishant DeQuadros and his team and anesthesiologist, Dr. Mark Pinosky. In order to assure us that no heart muscle damage or other cardiac damage had occurred with the 300/200 blood pressure spike during the procedure, Dr. DeQuadros ordered a full cardiac workup. Echocardiogram, treadmill test and lab reports later, the good news is that I suffered no damage from the spike in blood pressure.

So, all that was left was a follow up scan called an arterial phase CT scan with contrast. I had that scan done last Thursday, October 2 and was happy to have been able to have an immediate consultation with Dr. DeQuadros after the scan.

During that meeting he told us that he was looking for a short list of things (margin around tumor and adrenal gland, margin around pancreas and color (degree of dark shading) of fat layer around the site of the ablation) that would indicate how successful the procedure had been. He scored a trifecta with excellent skills, a great team and an anesthesiologist who reached for and got his hands on exactly the right mix of medications and mad skills to keep me from either cardiac arrest or stroke while the procedure was being completed under very scary and trying circumstances.

The tumor appears to be dead. The adrenal gland has been banished to a growing ash heap of my internal organs. Pitched into the black ether of my insides. A perfect gut shot, suitable for TV replay on The Medical Channel (if there is such a thing). My joints ache. I don’t move as well as I used to. My hair appears to be holding on, but irrevocably grey. Parts of my feet are numb. I get completely freaked out sometimes by a phantom pain, worrying that something is knocking on my cancer door again.

In spite of all this stuff, I could be arguably NED again, for more times now than I can remember. If I could live with all of these and maybe even a few more encumbrances for another 30 years, I’d take it and run! Chances are, we haven’t seen the last of this ugly disease. I’m ready for the son of a bitch, if it decides to come at me again.

Meanwhile, I will get to witness the marriage of our eldest son on October 25, wish my father a happy birthday on October 23 and get tuned up for my favorite holiday when we host another Thanksgiving Day dinner. With just a few modifications, life could really be good for us next year.

October 10, 2014 | Tagged With: arterial phase CT, blood pressure, Dr. Mark Pinosky, Dr. Nishant deQuadros, kidney cancer, MacBook Pro, microwave ablation, NED| Filed Under: kidney cancer | 15 Comments

Microwave Ablation Completed Despite Blood Pressure Spike

Heartbeat ECG. Volumetric concept. VectorI have two new best friends as of this past Thursday. Dr. Nishant DeQuadros and Dr. Mark Pinosky.

Nishant is an interventional radiologist. He’s young, engaging, handsome, articulate and well trained. Here’s where he was trained:

Henry Ford Hospital/Wayne State University
Residency, Radiology, 2006–2011

Brown University
Fellowship, Vascular and Interventional Radiology, 2011–2012

Case Western Reserve University School of Medicine
Class of 2006

Mark is an anesthesiologist. I took an instant liking to him as he talked. He seemed focused and knowledgeable and because he is chief of the anesthesia group at Columbus Regional Health and is responsible for several offices in other states. He spent quite a bit of time with me before the procedure I had on Thursday morning, explaining what types of things they’re preparing for in a microwave ablation of a renal cell tumor in my left adrenal gland. He is board certified and licensed in several states. Here’s where he was trained:

Medical University of South Carolina
Class of 1989

Internship and Residency
Georgetown University Hospital

Thank God in heaven that my world intersected with these great doctors at just the right time. If not for them by my side on my case Thursday morning things would be very different in my world today. If I had a world at all.

Let me take you back through our decisions that led us to deciding to undergo microwave ablation to remove the renal cell metastasis in my left adrenal gland this past Thursday: My CT scan from July 22 showed that a tumor in my left adrenal gland had started growing again 23 months after I started a drug, Votrient, that kept the tumor at bay. I took the terrible drug for 15 months and stopped it in January of this year, after it became apparent that the drug might kill me. It robbed me of my dark hair, 100 pounds of my flesh, my taste buds, my favorable vomit streak and visited upon me some other even more awful things that I’ll spare you from reading.

Dr. Pippas said at the meeting after the scan that he felt a surgical option might be the route we should take. I visited with Dr. Andy Roddenberry at St. Francis Hospital and he gave us a good understanding of how serious this surgery would be: Open incision of 10″, 6 days in the hospital and a full six weeks of recovery. A lot of pain and a real solid blow to my already compromised immune system.

A few days later, after a lot of thought, Andy Pippas called me on the phone and said he had a change of heart about the direction he had advised me to take. He felt that a big surgery shouldn’t be done at this point. It was better to find a less invasive procedure that could take out the tumor, not negatively affect my immune system and still leave us with surgery as a next step if we needed it later.

About that same time, Dr. Granville Batte called me and told me about Dr. DeQuadros and his skills as an interventional radiologist. All my research told me that this young doctor had the chops to do this procedure. That he was highly skilled and he was the right person to choose to do the procedure. We went to see him and Jill and I both felt like I was in good hands with him. So we scheduled the procedure for Thursday, August 28 at Midtown Medical Center.

I had never met Mark Pinosky until Thursday morning, when he appeared at my bedside to discuss my case prior to surgery. I’m thankful he was there and all his excellent training was brought to bear to save my life when my adrenal gland sent my blood pressure into the stratosphere right in the middle of the ablation procedure.

The CT-guided microwave ablation takes place in a CT suite, not in a surgical suite. I was placed face down in the CT machine and Dr. DeQuadros used the CT to guide a needle-like probe into the tumor. In a discussion on Friday morning in his follow up visit after the procedure, he told me that he needed a four-minute burn to kill the tumor. He said he inserted the probe into the adrenal gland and started the burn.

My adrenal gland did what it does and ramped up my blood pressure and the procedure had to be stopped multiple times while efforts were underway to drive my blood pressure down. Dr. DeQuadros ran a central line into a vessel behind my knee that gave them beat by beat access to my heart.

They were able to deal with blood pressures that went as high as 300/200, the corresponding bottoms that would have followed with the introduction of powerful drugs to drive my blood pressure down, and still get the procedure completed. Both of these great doctors have promised me some time to talk about the procedure for inclusion in this blog. I want to be sure to capture my thoughts and the thoughts of the doctors about this promising minimally-invasive way to deal with RCC mets in the adrenal gland.

I’m writing this from memory and from audio recordings of my talk with doctors after the procedure, so I’ll likely revisit this after I have a clearer view of how the procedure unfolded. But, regardless of my description, the medical talent with me in that room on Thursday was brought to bear on a difficult situation to what will likely be a good outcome. So thankful to my God, my medical team, my family and my prayer warriors.

Needless to say, I’ll be in my pew this morning at St. Matthews in-the-Pines Episcopal Church. I have much to be thankful for. Please excuse this rambling post. I wanted to get something out and I don’t think I’ve been as articulate as I try to be in this space. Just wanted everyone to know that I’m OK and hopeful about what lies ahead.

 

August 31, 2014 | Tagged With: adrenal gland, blood pressure, Brown University, Case Western Reserve University School of Medicine, Columbus Regional Health, Dr. Andrew Pippas, Dr. Andy Roddenberry, Dr. Granville Batte, Dr. Mark Pinosky, Dr. Nishant deQuadros, Georgetown University Hospital, Henry Ford Hospital, Medical University of South Carolina, microwave ablation, Midtown Medical Center, renal cell metastasis, Votrient| Filed Under: renal cell carcinoma | 8 Comments

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