Oncology Day Two, Three, and Four! - Viet

Day 2,3,and 4 was much like day 1. At 9:30am Dr. Hsu would go through the charts of all of his patients and check on their status. He would explain to me what disease the patient had, background about the disease, and treatment the patient was receiving. While he did this, he also asked me some tough questions...

Pimp Question #1: Why are tumors more malignant in young people?

My answer: They have more growth factors readily available for the tumor.

Correct answer: The immune system in young people is much stronger so the tumor has to be even stronger to evade the body's defense system.

Pimp Question #2: What are some causes of malignancy?

My answer: Chronic irritation (from persistent infections, etc.)

Answer he was looking for: Oncogene and p53 tumor suppressor gene.

Pimp Question #3: Why do you not want to give this patient who is suffering from oxygen hunger more morphine?

Me: ???

Answer: Morphine decreases breathing rate and in her situation, can decrease it to less than 8 breaths per minute (toxic).

After looking at all the patients' charts, I followed Dr. Hsu on rounds.

Patient 1: Recurrent Tumor
Patient has tumors in lung fields and bone metastatis. Patient presented with leg pain because of L5 destruction. Prognosis is poor. Treatment for this patient is pain management + Erbitux + C.T.

Patient 2: Bone Metastasis
Tumor started in the tonsil and metastasized to the pelvis. CXR shows pneumonia in lung fields. There is a PEG (percutaneous endoscopic gastrostomy) tube to provide nutrition. Again, morphine is prescribed for bone pain and the prognosis is very poor. This patient is put in hospice care.

Patient 3: Esophageal Cancer
Because of dysphagia, the patient is only 47kg now. The first thing we must do here is to recover the patient's body weight. If the patient isn't healthy, he won't be able to handle the cancer therapy. CT scan shows tumor obstruction in the middle to lower 1/3 of esophagus. A jejunum tube is required in this case. Bone scan is negative.

Patient 4: Nasopharyngeal Carcinoma
This patient is a 30yo female who was diagnosed with NPC (very treatable with 90% success rate) 2 years ago, but refused treatment. She opted for chinese herbal treatments instead of chemotherapy but ended up not doing anything about it. The tumor is now malignant and has spread systemically to bone and liver. She does not smoke or use betel nut. The NPC in this case is due to natural causes.

Patient 5: Oropharynx Tumor
This patient did not respond to chemo. CXR shows lung metastasis. Waiting for CT scan for better evaluation of the lung.

Patient 6: Nasopharyngeal Carcinoma
CT shows a large tumor with liver metastasis that is causing abdominal pain. The patient has a very high creatinine level, which suggests renal insufficiency. The x-ray shows effusion (hemoptysis). Treatment is chemotherapy and pain control.

Patient 7: Buccal Cancer
This patient has a recurrent tumor and it is huge - T4. There is perineural invasion. Patient also has infiltrates in lung fields -->baumannii - MDR (multi drug resistant) strain. There's only 1 antibiotic that isn't resistant.

Patient 8: NPC
This patient is dysphagic and required an NG tube. The patient received radiotherapy and chemo (cisplastin) this week and lost 10kg. Before more chemo is given, the patient has to gain more weight or else he won't be able to tolerate it.

Patient 9: Adenocarcinoma
The patient is a 50yo female . Initially, it seemed like the tumor was of axilliary origin. They later found out that it was breast cancer. This is good because if the primary cause is unknown, better chemo drugs are not covered by the insurance. The prognosis is good for this patient.

Patient 10: Unknown Primary Cause
There is bone metastasis to the right pelvis.

Patient 11: Hepatic Duct Cancer
There is no response to chemotherapy. This patient is in dire need of a new liver, but probably won't get one because of his cachexia (he is less than 50kgs). Most likely less than 3 months survival.

Patient 12: Left Tonsil Cancer
Chemotherapy in this patient is stopped because the patient could not tolerate it. Radiotherapy is continued.

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On Wednesday, at around 4:00pm I received a call from the chief resident asking if I wanted to see ascites tapping. I said yes and brought along Jack, Bill, and Sean. When we got to the wards, patient 6 was coding. There was blood everywhere. Nurses were running around frantically while two attendings were busy manipulating an endoscope through his nasal cavity. The chief resident was putting in an IV line through the femoral while a nurse was putting in a foley catheter. They also had to intubate him because the blood was obstructing his breathing and he was going into cardiac arrest. I glanced at the heart monitor and it looked like atrial fibrillation. It was exciting and reminiscent of a scene from ER. After about 15 minutes, the patient's condition was under control again and he was sent to the ICU. The attending explained to me that the patient just started to bleed all of a sudden and they didn't know where the blood was coming from. He thinks that the chemotherapy probably caused the hemorrhage.

After this, the chief resident showed us ascites tapping (peritoneocentesis). He emptied 5L out of the woman's abdomen!

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Although I only got 3hours of experience each day (9:30am-12:30pm), I learned a lot from Dr. Hsu. The way he explains things makes even the most complex mechanisms easy to understand and retain. On day 4, I did a short presentation on telomerase target cancer drugs. Afterwards, Dr. Hsu and I talked about the future of cancer therapy and where he thinks it is going. He doesn't think there will be a cure for cancer because it is an ever evolving disease. But we don't have to find a cure--we can just keep the disease latent. The reason cancer is so harmful is because it metastasizes and invades normal tissues. If we can keep it contained, we can coexist with the disease and not have it affect our daily lives.