145 – Margaret’s Cancer Spreads
to Her Lymph Nodes: 12 January 2025
This was how Margaret looked on 27 April 2019. By September 2021, she was dying and she no longer
looked like this.
****
Margaret had
another endoscopic ultrasound on Tuesday 14 September 2021. The report of the operation was optimistic. The report said this.
|
Findings On
endoscopy, the ampulla was small but has some polypoid/ villiform tissue at
the orifice. Biliary discharge was
noted. The ampulla was biopsied using
a forcep. On EUS,
the ampullary mass is barely noticeable and has reduced in size to 8 mm the
max. There was no obvious extension of
tumour into the distal CBD or PD. Neither
duct was dilated (CBD 7 mm and PD 1-2 mm).
Overall, the appearance suggestive of ongoing remission!. The
previous 2 cystic lesions[s] within the pancreas: neck (23 mm) and tail (8
mm) were both seen. Both has no high
risk or worrisome features. The
previously enlarged node in the celiac axis, measuring up to 15 mm was again
see and was hypoechoic. This it was
biopsied using EUS FNA technique.
Material was collected for histology. EUS
= Endoscopic Ultrasound; CBD = Common Bile Duct; PD = Pancreatic Duct |
****
This
operation confirmed that the cancer remained in remission, but it raised a
question about its possible presence in the lymph nodes. This would be resolved by the tissue
sample the surgeon sent for testing.
On 23
September, the oncologist told us that the tissue sample taken from the lymph
nodes was indeed cancerous. The terrible
news was that the cancer was now present in Margaret’s lymph nodes.
The Cancer
Council of Australia says this about lymph nodes.
|
Lymph
nodes or lymph glands, are part of the lymphatic system which is part
of both the immune and circulatory systems. The lymphatic system
consists of lymph vessels, lymph fluid and lymph nodes and other lymph
tissue. Lymph nodes
are small, bean-shaped structures that are found along the lymph
vessels. They filter lymph fluid as it passes
through your body before emptying into the bloodstream. Lymph
fluid, which is normally clear, travels to and from the tissues
in your body. It carries nutrients but also takes away harmful
substances such as bacteria, viruses, cell debris and abnormal
cells such as cancer cells. The
filtered fluid is returned to your blood circulation. |
The lymph
nodes are, in effect, a separate “blood stream” containing lymph fluid instead
of blood. A cancer which is present in
the lymph nodes, has access to virtually every part of the body. It can grow and prosper throughout the body.
The surgeon
scheduled another operation for a further endoscopic ultrasound for Wednesday
29 September.
****
Margaret had
a PET (Positron Emission Tomography) scan on Monday 27 September. The $950.00 cost of this procedure was not
covered by either Medicare or our private health insurer. The imagery produced by a PET scan is
extremely detailed. Margaret’s PET scan
was so detailed, it highlighted a “hot spot” on her arm where she had received
a Covid vaccination one week earlier. Here
are some extracts from the PET scan report.
|
Lymph
Nodes: A focus of
intensive uptake FDG uptake, SUV max 5.6 is noted at the left para-aortic
lymph node (level of L 2/3), suspicious of modal metastasis. Another
focus of moderate grade FDG uptake SUV max 4.9 is noted at right pelvis, (see
key image), raising suspicion of nodal metastasis. CONCLUSION: The
intense focal activity anterior to the vena cava, at level of L 4, is
suspicious of ampullary malignancy, given adjacent dilated common bile duct
on low dose CT … Correlation with gastroscopy and/ or endoscopic ultrasound
is suggested if clinically indicated.
Differential diagnosis includes a precaval lymph node at the level of
L 4. 2
The low grade focal activity in the liver, may be due to
physiological variable liver uptake, although early liver metastasis not
completely excluded. No obvious liver
lesion is seen on separate CT today … Follow up +/ - MRI is suggested if
clinically indicated. 3
Foci of bowel uptake as outlined above. Correlation with colonoscopy to exclude
benign or malignant polyps before attributing them to physiological bowl
uptake is suggested if clinically indicated. |
****
The
website Radiology in Plain English says “FDG is a radioactive
sugar that is used in PET imaging. The idea is that FDG is taken up more
in abnormal tissues then normal ones. That is, abnormal tissues use
glucose or sugar more than normal ones. This is reflected in PET scans as
more uptake and a hotter or brighter tissue on the scan.”
Margaret’s
PET scan report confirmed a high uptake of FDG in her lymph nodes. This was a clear indication that the cancer
had spread to the lymph nodes.
****
We
both tried to digest this terrible news.
The cancer had spread to Margaret’s lymph nodes.
This surely
meant she was doomed and her death would probably happen before the end of
2021.
****
Another operation
took place on 29 September, just two days after the PET scan. The aim of this operation was to enable the
surgeon to “zap” the cancer with radiotherapy administered inside Margaret’s body
through an endoscope.
The surgeon
was unable to administer any radiotherapy.
The findings
of the 29 September operation were a little inconclusive, but they were not
good. The written report from the surgeon said this.
|
Duodenal
Papilla Major
Papilla – due to previous radiation therapy, the ampulla was markedly
deformed with ulceration. The biliary
and pancreatic duct orifices could not be identified. Whilst the
CBD was successfully cannulated, the PD could not be entered despite the use
of different cannuli and wires. Given
the risk of pancreatitis is high without PD stenting, RFA was not performed. A sphincterotomy (5 mm) followed by balloon
dilation of the distal CBD stricture was performed. The CBD was markedly dilated (up to 30
mm). The biliary duct was stented with
2 plastic stent[s] and this resulted in good contrast and bile drainage. CONCLUSION Ampullar
cancer causing a tight stricture at the distal CBD. PD not accessible and thus, cannot be
stented. No RFA due to high risk of
pancreatitis. CBD = Common Bile Duct PD = Pancreatic Duct RFA = Radiofrequency Ablation;
Cannulation = insertion of a stent
|
****
The cancer
had stayed in remission only until I had ceased being in danger of imminent
death. Once my life was safe, the cancer
roared back into vigorous life. It was determined
to end Margaret’s life as quickly as possible
I do not have the words to describe how truly horrible this news was.
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