Cryo-Ablation

Last week I mentioned my upcoming cryo-ablation surgery scheduled for October 22^nd. It’s complete, though the experience was a little more than I bargained for. I checked in at 9am and the admitting and pre-op processes were smooth and well organized. By 11am I was in the OR. I didn’t get a chance to look at the apparatus; I had too many connections (electrodes, IV, etc.) to move around. Then the first blast of anesthesia and it was all over in a minute. Of course it lasted for just over two hours, but the anesthesia makes me feel like no time has passed. I woke up in a recovery room. Everything was fine. I gradually shook off some of the anesthesia and was discharged at 5pm. I stayed groggy and went to bed early.

The surprise came on Friday. Absolute agony. It was so painful it’s hard to describe. Every breath caused a sharp pain that felt like a knife going in between my ribs. But there were no significant wounds. Just a couple of holes near the center of my chest. I was able to medicate the pain down to a tolerable level, but by Saturday morning it was the same agony. I couldn’t move without crying out. I medicated that too. Today, Sunday, things have improved a little more. The problem is that I’ve been completely sedentary and have deconditioned significantly, as most older people do after bedrest.

Where did the pain come from? With a web search I was able to piece together the equipment used and how the procedure is done. Basically, a long cryo-ablation needle does not go straight in. It enters the intercostal muscles that are between the ribs and is pushed at an angle through the muscle until it reaches its destination. It leaves a channel through the muscle, not just a little hole as if it went straight in. In my case there were two needles and each channel was poked twice, leading to further muscle damage. One wound was poked three times, the first being a larger needle used to get a biopsy. Note that this description may be unique to my individual needs. I'm sure that there are many other approaches to cryo-ablation, even specifically on the interior of the chest wall. 

The intercostal muscles are between your ribs and are breathing muscles (along with many other muscles in your upper body). That’s why it hurts when I breathe and when I move even in small way. Ribs are flexible and they move around more than you think. So I went back and looked at my discharge papers, which I reviewed briefly under the influence of morphine when discharged. Sure enough, the pain is expected to last for two or three days. The recommended pain medication is oxycodone and Tylenol. The pain is accompanied by breathlessness due to reduced volume in the chest cavity; the lung is squeezed and cannot fully expand. Fatigue is expected for a week, and the final healing is one to two weeks. It looks like I’m right on schedule.

The doctor who did the procedure said he has multiple clear images that show a favorable result in terms of location and the production of the deadly ice balls. There will be a follow up CT in December and that will be a confirmation of success or failure. But this story isn’t over. There are other suspicious nodules. The two they just froze to death happened to be the ones that were “easy” to get at. The road continues.  

Post Summer Update On Several Things

Since I last posted in April many things have happened and they have mostly been good. Heart problems have been front and center so I’ll start with that.

My heart failure (HF) treatment required three months of total rest starting on January 3^rd and during that time I lost a lot of weight, mostly due to muscle loss. It left me weak. I started to rebuild in the gym, but you know, it’s a long haul. I’ve had “breathlessness” as a problem since 2018 and both of my shoulders have their own problems. I can’t lift a lot of weight and I have to find a pace that keeps me moving without having to stop and catch my breath. Things improved, and I also started to walk again. The big win for me was to start cycling. Even on an e-bike, my first few rides were one or two miles around the neighborhood, and it required the use of a throttle, which kept the bike moving while I rested my legs or went up steep hills. That improved too and I now ride without use of the throttle, with the exception of starting from a dead stop. Year to date I’ve done 30 rides, logging 436 miles, and now I don’t consider it to be a ride unless it’s ten miles minimum. My current goal is 35 rides and 500 miles, but it’s gotten cold and I’m not as tough as I used to be.

We’ve taken our first vacation in two years, driving to Montreal and staying for five days. We were walking 4 or 5 miles every day and it was hard, but it was also an improvement. We’ve had a few other local trips, staying 1 or 2 nights. There was a mid-summer visit to the emergency department of my favorite hospital due to unusual pain in the flank. It was not heart related, but I was stuck there for 12 hours and they would have admitted me if I didn’t fight against it. The cause of the pain was not determined, so I left the hospital with the same problem that sent me there. However, some CT imaging studies showed significant pleural effusion in the left lung. This led to a thoracentesis procedure on week later. About 400ml of fluid was drained from the left lung cavity. I’ll return to this shortly.

While we were sitting in the ED waiting room I spied a mouse running around in the corner of the room. Harmless but unexpected. There was a security guy in full uniform so I told him about it, thinking that the mouse might upset some of the other patients. He summoned a couple of maintenance people and then he got curious while waiting for them. He accumulated a small crowd of fellow employees as he cautiously approached the corner. The mouse appeared! The guy shouted and leapt up onto a chair. One of his colleagues laughed and said there was no danger. Mr. Security said that mice can jump and he didn’t want to be attacked by it. It was pretty funny to see this full grown man in a police uniform dancing around on the furniture to avoid a mouse. Great entertainment for everyone in that end of the waiting room.

Overall the summer was wonderful. I missed the previous summer entirely due to 18 weeks of chemotherapy. This year I had very few summer doctor appointments and was far healthier. Last week I had a follow up echocardiogram and it shows that everything has remained stable since April. This is good news because the result in April showed a huge recovery to “normal.” With the help of a drug regimen, my heart apparently remains mostly normal. My next meeting with the heart doc is in early November.

Now back to the thoracentesis. This was ordered by my mesothelioma doctor. He pointed out that the CT images from the emergency department showed growth of two small spots on the left chest wall. This is the advance of pleural mesothelioma. He recommended a process called cryo-ablation to kill the nodules. He also told me about a small clinical trial that has shown some success with at least one other mesothelioma patient. The treatment is immunotherapy, where DNA is extracted from the patient, modified, amplified, and re-injected. I think this is the future of cancer treatment, so I have tentatively agreed to enter the trial, given that mesothelioma is uncurable and has returned to invade my left lung. This coming Thursday, October 22^nd, both nodules will be biopsied for DNA analysis and then destroyed with cryo-ablation. It’s a low risk, minimally invasive outpatient  procedure, but it happens in the operating room under general anesthesia. The unique operating suite is very high tech. I might post about it next week, assuming all goes well.

Also lurking in the background is stage 4 prostate cancer. This has been treated since 2010 and knocked back repeatedly, but my PSA level is rising once again. The next treatment will be androgen deprivation therapy (ADT), which I have experienced in the past and I have to say, it’s pretty awful. It’s a major downgrade for quality of life. Why treat all of these different cancers, feel like shit, and then die? For now I am not in any treatment, which is rare for someone with stage 4 PC. My oncologist prefers to hold off on treatment and monitor the PSA level every two months to see how quickly it changes. The rationale is that I’ve taken a beating from other cancers and treatments. I still need more time to re-build (something impossible to do on ADT) and to enjoy life. It’s a balancing act based on quality of life, and ADT may become a reality. Time will tell.

Long post, and it’s a lot to absorb.