Troubling News

So - it's not what I wanted to hear and I don't know how concerned I should be at the moment. Here's a summary of our appointment with Dr. Picozzi that I sent to my sisters. I pray that this is all due to "sequela of radiation therapy".

- Mom had blood drawn for her CA 19-9 this morning and then had her CT scan. Then we saw Dr. Picozzi this afternoon. I picked up 2 CD copies of Mom's VMP scans (both the Jan and the current one) and also have copies of the CT reports. I will give these to Dad along with Mom's other records so that he can bring them to Virginia. I think we should give Dr. Laheru a copy of the CT CD on the May 10 visit so Hopkins can look at it as well. Maybe Laheru will also want to do another CT scan.

- The CA 19-9 tumor marker test results will not be in until next week on Monday. Recall that Mom's CA 19-9 pre-surgery was in the 800s I think. In Dec., the Hopkins CA 19-9 showed a value of 15.9 I believe. In Jan., the VMP CA 19-9 showed a value of 7. Note that the tests have an amount of variation - i.e. 2 tests on the same day could show some variation (I didn't ask how much). So we shouldn't be too alarmed if it is higher than before but we should hope I think that it is below the normal range of 37 I think. Anyways, when we get the results from Picozzi we should ask him how to interpret it and what course of action to take.

- Mom's Chest X-Ray was normal. CT scan though revealed an area on the liver that he said is "less homogenous" with no defined boundary. This area was there on the Dec. Hopkins and Jan. VMP scans but has grown in size. It could be "suspicious" for metastatic disease. He said that he discussed this with the radiologist and that their opinion is that if the tumor marker CA 19-9 tests are still in the normal range, then we can just continue to follow the area via periodic CT scans. If the marker is not in the normal range then he would recommend having the area biopsied. This would not be good news. I've put the radiologist report at the end of this email.

- Mom's potassium level was somewhat low. Also her white count was still a little low (about the same as when she left). He said it was not dangerously low but that we may need to think about using Neupogen (sp?) during the next chemotherapy rounds.

- I asked how often that Mom should do follow up marker bloodwork and CT scans. Dr. Picozzi recommended that we do the blood marker CA 19-9 about once a month. We should do a CT at least when her next course of treatment is done and maybe one in the middle. Her next course of treatment is about 3-4 months long.

- I asked if we need to transfer records to Hopkins. Dr. Picozzi said that he will be writing and sending a letter to Dr. Laheru directly that will summarize Mom's condition and his recommendations. Dr. Picozzi did not think that Dr. Laheru needs any other medical records. So if we can give to Dr. Laheru the CD with the CT scans and maybe make sure he verbally knows about the results of the CA 19-9 tests, I believe that will be adequate.

- Dr. Picozzi thinks that Mom should start her next course of treatment by the middle of May. She should be strong enough to begin at that point. He recommended that we choose between the following 2 protocols. a) 5FU via continuous infusion pump with 2 6-week courses separated by a 2 week break in between. (this is the same drug mom got from the pump in the first phase) b) Gemcitabine + Taxotere given by IV for a few hours once every 2 weeks with a total of 8 treatments over 16 weeks. Dr. Picozzi mentioned that Mom's white blood cell count should be stimulated by giving Neupogene (sp?). He couldn't clearly recommend one over the other. The advantages of the 5FU are that it is "easier" and proven since this is what was used in the original VMP results that have been documented. The advantages of the GemTax is that it seems more promising in that it has been shown to be more effective in advanced pancreatic cancer for metastatic disease. Whether it is better in the adjuvant therapy case is not yet known. However, it is "harder" than the 5FU and has more side effects like nausea and hair loss. If Mom's first phase of the VMP was a 10 in difficulty, then the 5FU is rated as a 2 by him and the GemTax a 4.5.

- Mom should increase her Protonix to 2x a day since she is feeling indigestion. A part of the discomfort might be caused by scarring due to the scar and radiation. Mom was also prescribed Potassium supplements which she is to take until she sees Dr. Laheru and then it can be reassessed.

RADIOLOGIST REPORT

CT of the abdomen without and with IV contrast, pancreas protocol, May 2, 2006. The patient received 125 cc of Isovue-370 has IV contrast. Compared with the prior study dated January 5, 2006.

Findings:

There is an ill-defined low attenuation lesion in the left lobe of liver near the biliary anastomosis. This measures 2.4 x 2.1 cm, image 75 series 4. Previously it measured 2 cm x 1.8 cm. On an earlier study dated December 28, 2005 from Johns Hopkins this lesion measured approximately 2 cm x 1.1 cm.

There is a comma shaped fluid density lesion in the liver which measures 3.2 x 1.1 cm, image 79. This has increased in size significantly compared to the earlier studies. This has the appearance of a dilated duct or perhaps a pseudocyst.

There is diffuse decrease in attenuation in the medial aspect of the liver. There is increasing soft tissue in the periportal region with loss of the fat in this region.

No masses identified within the residual pancreas. There is no dilation of the pancreatic duct.

The portal vein splenic vein and SMV are patent.

No adenopathy is appreciated.

Impression:

Increasing size of irregular low density lesion in the left lobe of the liver suspect for increasing metastatic disease. Increasing ill-defined soft tissue in the periportal region and diffuse decreased density in the medial aspect of the liver. It is unclear this is due to sequela of radiation therapy or progression metastatic disease and clinical correlation is necessary.

Comma shaped fluid density lesion in the liver which is increased in size and may be an isolated bile duct or pseudocyst.