It’s hard to believe that the post that I wrote earlier was the same day as today, as if somehow the emotional weight of that meeting with my CT surgeon had distorted space time itself.
As for my surgeon (Dr. W.), my first impression of her matched my expectations, and many characteristics I found desirable in a surgeon that would be cutting me open. She looked like someone who routinely skipped social hour in school to favor studying, and it was clear that she took her work very seriously. She was personable enough, but not without quirks. Mandi and I were both a little caught off guard as she guided us into her office and walked us through my PET scan, talking as openly as she might have if we weren’t present at all and she was talking to herself. She walked us through how she was thinking about approaching the surgery, but it was apparent that she was having new ideas and realizations even in the moment with us. What was clear is that she is passionate about her profession and it showed.
She took out a piece of her mostly blank office stationery and drew an impromptu sketch of the lungs, bronchii, and trachea. Some crash course in pulmonary anatomy was required before entering the thick of the conversation. Using her lung sketch, she attempted to give us an idea of where the tumor is likely to be sitting, which was either the lower lobe, or central and lower. Dishearteningly, the scans did not exactly make it a slam-dunk. Though they provided much needed information about the mass, they were insufficient to give us a complete picture on where exactly the tumor is “occupying for the moment”, vs “fully moved in and unpacked”. Dr. W commented that a lot of the information will be known to us on the day of the surgery, which Mandi and I both agreed, was unsatisfying. She showed us a scroll-through tour of my PET and CT scans, slide by slide, pointing out the major landmarks as she went. “There is the pelvis, those are your kidneys, here are your ribs, and starting right here…that’s the tumor.” The center of the image suddenly lit up bright yellow and orange, menacing colors on an otherwise bland screen. I was struck by the size, once again. Even now knowing what to expect, the shock is new each time I see it in comparison with my chest cavity. Metabolically speaking, the tumor is an energy hog, second only to my brain in the competition for resources. She said that it probably explains my recent 5 lb weight loss. Here I was thinking that my dedication in the gym was finally paying off. The doctor then pointed out that the image was darker in the center than it was on the outer edge. It was a result of the tumor growing rapidly on the outer edges, but not developing enough blood vessels to feed its other parts first, resulting in that dark, central necrotic tissue. Great the tumor is dying on its own! – a fleeting thought that I had before she clarified that this affords us no real advantages. Either way, all of it will have to come out.
That brought us to the next stage in our conversation; how to approach the surgery. To begin with, Dr. W commented that the surgery would either be a lobectomy, or a pneumonectomy. The latter word, I had expected, but the former…that would mean that they would only remove a lobe, and I would get to keep a portion of my existing left lung. As I mentioned in a previous post, I had already accepted that I would be losing the entire thing, so this came as welcome news. Her best estimates were 50/50 odds, which under the circumstances seemed like a win.
I had read in advance about the different types of lung procedures, finding many articles that spoke of minimally invasive surgeries with shortened recovery times. Other articles I read mentioned that those robot assisted surgeries would not work for my type of tumor given its location. At times it felt as though each new article only served to contradict the previous one. The internet is a wild place. Dr. W confirmed that due to the size of the mass, the only and best option would be the more invasive thoracotomy. A brief description of this would be an incision on the side of the patients chest, between the ribs, long enough to begin toward the front of the chest, and end toward the back. After this incision, a rib-spreader is used to do exactly what it sounds like it would to give the surgeon a good visual and workspace to perform the surgery. Before the surgery begins, the patient is put completely to sleep under general anesthesia, and a breathing tub is inserted to feed the right lung. The left lung is then deflated while the procedure is performed, while the right lung does all the work. If you want a better idea, just do a Google image search of “thoracotomy”, but I’ll warn you in advance; it’s gnarly.
Once she can see the true shape, size, and features of the tumor, she will be able to decide if a part of the lung will be removed, or all of it. She will be able to see which areas it has invaded, and which nerves are affected. These positive outcomes, would result in a 5-7 day hospital recovery, followed by 6-8 weeks of home rest and recovery. She also made sure to prepare us for the possibility of more unpleasant findings: the tumor has invaded the heart, is wrapped up in too many arteries/nerves, is too risky to attempt removing, or is generally inoperable. Even though she doesn’t believe that any of these realities are the case, the mere possibility of their existence unsettled me. As I was attempting to regain my center she doubled down on the risks of the different outcomes. In a partial lobe removal, there is a risk that the removed portion leaks air into the chest cavity. In a full lung removal, there is the danger that your internal organs literally begin to “drift” into the now empty chest space. This can cause a kinked bronchial tube, difficulty breathing, and other problems. **As bonus knowledge, the way that they would address this problem is to fill that empty chest cavity space with saline breast implants as placeholders. Yes that’s right. Someday I could proudly and accurately state that I have breast implants.** Another possibility is for fluid from the chest cavity to leak into the opening left from the surgery and fill the “good lung” with chest fluid starting an infection. The risks of everything doubled for a full lung removal vs a lobe removal. It seemed like the risks and complications segment took longer than every other part of the conversation, but perhaps it’s just another space-time distortion at work.
At this point in the conversation the air was thick and I felt empty for words when Dr. W asked if we had questions. We did, of course, but in that very moment it was difficult to access them. I looked at Mandi silently, who looked back at me. I could sense her anxiety and I’m sure I radiated it myself. My cheeks felt hot, and my mind was racing, but could not grasp onto a single useful thought. I cannot remember what broke the silence, but the questions began to flow. We learned that my lung function test produced an 84%, which under the circumstances was impressive. And also that Dr. W has done over 1000 lung cancer removal surgeries. At this point I don’t think I could recall every question asked or answer we received, but I do remember that she was very confident that she would be able to successfully remove the tumor, a confidence which I had decided was a prerequisite. Dr. W is convinced that surgery is the best next step, and is ready to schedule a date to operate before the end of August, and even possibly as early as next week.
Post Surgery/Recovery
After the surgery, I would be moved to the PCU floor, which is similar to the ICU, but the patients are not as critical. The first 1 – 3 days I would have a chest tube that helps the care staff monitor for infection, correct air leakage issues, and generally be prepared to intervene. After enough stable time has passed, the chest tube is removed and I will be kept on pain medication to help with the soreness from the incision. It’s worth noting that Dr. W commented that I might be more sore than most because of how much muscle I have in the area being cut open. I’m not sure if that is medically relevant but it’s good to have on the record.
Provided that the surgical recovery goes well, it will be followed up with several rounds of chemotherapy that will likely span 2 months or more. This is to make sure that there are no rogue cancer cells that made it out and decide to make their home somewhere else.
Next Steps
One test that Dr. W wants done before scheduling a surgery date, is a brain MRI. The only thing that would prevent surgery as a first course of treatment, is to find cancer in the brain, and it’s the only part of my body that has not been scanned yet. She has ordered this MRI immediately, and potentially within 3 – 5 days of that scan, would be my surgery. For now, just waiting for the MRI appointment. Will update again soon.
My Daily Thoughts 