It’s been 5 years since I saw a scalpel (….but my surgeon is still on speed dial)

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5 years ago today, I had a bunch of lymph nodes removed. Two separate areas were resected, only one was showing growth but both were showing up as hotspots on an Octreoscan.  I had known since shortly after diagnosis in 2010 that ‘hotspots’ were showing in my left ‘axillary’ lymph nodes (armpit) and my left ‘supraclavicular fossa’ (SCF) lymph nodes (clavicle area). Some 10 months previously, I had a major liver resection and 5 months prior to the liver resection, I had a small intestinal primary removed including work on some associated complications.  There had always been a plan to optimise cytoreduction of my distant metastases, it was just a matter of timing. I still can’t get my head round why metastases from a small intestinal NET managed to get to this area but not others!

Distant nodal metastasis treatment

A total of 9 nodes were removed from my left armpit (a very common operation for breast cancer patients). The surgeon had inspected the area and found some were palpable and my normally stable Chromogranin A marker was showing a small spike out of range.  During the same operation under general anaesthetic, an ultrasound directed SCF nodal ‘exploration’ was carried out.  When biopsied, 5 of the 9 resected axillary nodes were tested positive (Ki-67 <5) but the 5 SCF nodes removed were tested negative. The subsequent Octreoscan still lit up in the left SCF area but the lights on the left axillary area were ‘extinguished’. There is no pathological enlargement or pain in the left SCF area – so this is just monitored.

Side effects

Apart from a very faint scar in the left SCF area, there does not appear to be any side effects from this exploratory surgery.  The left axillary area cut is well hidden by hair growth but I do sense a lack of feeling in the area.  Additionally, I have a very mild case of lymphedema in my left hand which occasionally looks slightly swollen – the consequences of cancer and its treatment.  Fluid build-up, or post-operative seroma, can be a side effect of a lymphadenectomy.  In fact, within a month of the operation, I had to have circa 160mls of fluid removed on 4 occasions from my armpit.  It was uncomfortable and painful, resulting in additional time off work.  The surgeon used a fine needle aspiration to draw out the fluid, a painless procedure. It eventually cleared up and everything was back to normal.  The specialist said my left arm would be slightly more susceptible to infections and suggested to avoid using my left arm for blood draws and other invasive procedures and injuries.

Other close calls (“to cut or not to cut”)

I have a 19mm thyroid lesion which was pointed out to me in 2013. This has been biopsied with inconclusive results.  Although the thyroid is an endocrine gland, it looks like a non-NET problem so far. Thyroid nodules are in fact very common and statistically, 50-70% of all 50-70 year olds will have at least one nodule present (i.e. if you are in your 50s, there is a 50% chance you will have one nodule and so on). The vast majority will never bother a person while they live.  I attend an annual Endocrine MDT where this is monitored in close coordination with the NET MDT. It’s actually managed by the same surgeon who carried out the nodal work above.

I have a 3mm lung nodule, discovered in 2011. Apparently, lung nodules are a pretty common incidental finding with 1 per 500 X-rays and 1 per 100 CT scans finding them.  This is monitored and hasn’t changed since noted.

You may also be interested in my post “Neuroendocrine Cancer – to cut or not to cut”

I watch and wait but I also watch and learn.  Make sure you are under some form of surveillance.

Thanks for reading

Ronny Allan

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Neuroendocrine Cancer: Nodes, Nodules, Lesions

www-cancer-gov_publishedcontent_images_cancertopics_factsheet_sites-types_metastaticA fairly common disposition of metastatic Neuroendocrine Tumours (NETs) is a primary with associated local/regional secondary’s (e.g. lymph nodes, mesentery and others) with liver metastases.  Technically speaking, the liver is distant. However, many metastatic patients have additional and odd appearances in even more distant places, including (but not limited to) the extremities and the head & neck.  In certain NETs, these might be an additional primary (e.g. in the case of Multiple Endocrine Neoplasia (MEN); or they could even be a totally different cancer. The worry with NETs is that the little suckers can sometimes make these surprise appearances given that neuroendocrine cells are everywhere.

Cancer doesn’t just spread through the blood steam, it can also spread through the lymphatic system. This is a system of thin tubes (vessels) and lymph nodes that run throughout the body in the same way blood vessels do. The lymph system is an important part of our immune system as it plays a role in fighting bacteria and other infections; and destroying old or abnormal cells, such as cancer cells. The lymphatic system also contains organs, some of which feature regularly in NETs.  If cancer cells go into the small lymph vessels close to the primary tumour they can be carried into nearby lymph glands where they stick around. In the lymph glands they may be destroyed (that is actually one of the jobs of the lymph glands) but some may survive and grow to form tumours in one or more lymph nodes.

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The Lymphatic System

I also had the usual bulky chains of lymph node metastases in or around the mesentery that frequently appear with an abdominal primary (in my case the small intestine). These were all removed as part of my primary resection. However, I knew since shortly after diagnosis in 2010 that I had ‘hotspots’ in my left ‘axillary’ lymph nodes (armpit) and my left ‘supraclavicular fossa’ (SCF) lymph nodes (clavicle). These were found on Octreoscan but at the time, they were not pathologically enlarged – just ‘lighting up’.  They also light up on Ga68 PET.

In early 2012, 15 months after removal of primary and 10 months after liver resection, one of the axillary lymph nodes became palpable (signs of growth) and this coincided with a small spike in Chromogranin A.  A total of 9 nodes were removed very shortly after this surveillance, 5 of which tested positive for NETs (Ki-67 <5%).  As part of the same operation, 5 SCF left clavicle nodes were removed but tested negative.  On a subsequent Octreoscan, the armpit was clear but the clavicle area still lit up.  However, there is no pathological enlargement or pain – so this is just monitored. Also lights up on Ga68 PET I have a 3mm lung ‘nodule’, discovered in 2011. Apparently, lung nodules are a pretty common incidental finding with 1 per 500 X-rays and 1 per 100 CT scans finding them.  This is monitored.

thyroidI have a 19mm thyroid ‘lesion’ which was pointed out to me in 2013. This has been biopsied with inconclusive results.  Although the thyroid is an endocrine gland, it looks like a non-NET problem to date. Thyroid nodules are in fact very common and statistically, 50-70% of all 50-70 year olds will have at least one ‘nodule’ present (i.e. if you are in your 50s, there is a 50% chance you will have one nodule and so on). The vast majority will never bother a person while they live.  That said, my thyroid blood tests are abnormal and on 20th March 2018, following an Endocrine appointment, I was put on a trial dose of 50mcg of Levothyroxine to counter the thyroid panel results indicating hypothyroidism. Levothyroxine is a thyroid hormone replacement. Early in 2017, during my Endocrine MDT, a surveillance ultrasound spotted a slightly enlarged lymph node on the right side (measuring 9mm x 9mm) described as a ‘level 4’ node (a location indicator meaning the ‘lower jugular group’).  The report was passed to the NET MDT for their consideration with the surgical rep on the Endocrine MDT recommending a conservative approach – the NET MDT agreed. I suspect that’s right, it’s still below the worry threshold, nothing is palpable (no lumps) and I don’t have any specific symptoms.  There could have been a number of reasons for the enlargement and it might even be back to normal size on my next scan (spoiler alert – it was). All my issues have been left-sided to date, so that was interesting. That said, I did have an MRI in 2014 to investigate pain and a swelling at the site of my right ‘sternoclavicular’ joint – subsequently declared a non-issue. Showed as inflammation on recent Ga68 PET.

Life as a metastatic Neuroendocrine Cancer patient is interesting and efficient surveillance is absolutely critical.

You may enjoy my posts:

“Living with Neuroendocrine Cancer – 8 tips for conquering fear”

“Worrier or Warrior”

My treatment is a pain in the butt!

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This header is a bit ‘tongue in cheek’ (….did you see what I did there?)  I’m very happy to have this treatment every 4 weeks – I can think of far worse scenarios.  When I was first diagnosed, the dreaded word ‘Chemo‘ was discussed.  Actually, Chemo isn’t particularly effective in treating Neuroendocrine Cancer, although I’ve heard of cases where it has made a difference.

Today’s letter is ‘L’ and there are a few.

Lanreotide

This is currently my mainstay treatment and I look forward to it once every 4 weeks.  It is injected ‘deep subcutaneous’ in the upper outer quadrant of the buttock.

Prior to my diagnosis, I was a tad squeamish when it came to injections, even the smallest would make me cringe and I couldn’t bear to watch any needle pierce my flesh! Nowadays, as a daily self injector (see earlier blogs), I no longer have a fear of injections. However, the Lanreotide is the biggest injection I’ve ever had.  It’s not so much the length but the bore as the drug has a certain viscosity.  

The main job of the drug is to inhibit the secretion of dangerous levels of specific hormones from the remaining neuroendocrine tumours, wherever they might be, whatever size they are.   For more detail on this see ‘Does my flush beat yours’ published on 6 May 14. 

Is it a pain in the butt?  Not really, you can feel it go in and you can feel the release of the drug but nothing to worry about.

Check out my experiences with Lanreotide here.  Check out the differences between Lanreotide and Octreotide here.

Liver

One of the main sites for secondary tumours in many cancers is the Liver and this is the case with many types of Neuroendocrine Cancer – if the cancer cells pass into the bloodstream, the liver is a likely place for them to settle. Your liver is the hardest working organ in your body—it acts as a filter, picking up and then removing the toxins from your body and keeping your internal organs running smoothly.  If it isn’t working properly, you’re in trouble.   Fortunately, liver surgery is an effectively way to debulk NETs

Lymph Nodes

Everybody has hundreds of small oval bodies that contain lymph.  Lymph nodes act as our first line of defence against infections and cancer.  Unfortunately with cancer, they very often need to be removed to prevent it spreading further.  I have had a few naughty ones removed including a chain of bulky ones from my abdominal mesentery and over a dozen from my left armpit and collar-bone areas.  

 

Thanks for reading

Ronny

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Remember ….. in the war on Neuroendocrine Cancer, let’s not forget to win the battle for better quality of life!

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