The Last Supper and Chemo 1A

Since I’m not supposed to eat raw meat during chemo (due to risk of infection) the guys and I went to Sushi California in Coquitlam for my final sushi meal.  Sushi Cal has the best spicy tuna sashimi I have ever eaten (and I have tried it at over 40 sushi restaurants in the GVRD).  Julio the Judas did not show up so he will have his legs beaten next week.

Spicy Tuna Sashimi :)

My first chemo treatment was yesterday and went smoothly.  The chemo ward is on the top (6^th) floor of the BCCA; the south side view of Vancouver is excellent.

Infusion started at about 9:15AM after I took my oral antiemetics (12mg Dexamethasone and 8mg Ondansetron).  Accessing my portacath was slightly more uncomfortable than a normal needle poke but was much more comfortable than a peripheral IV once the needle was in.  

The IV drugs started with the ‘Red Devil’ Adriamycin.  Some people can taste this drug (apparently it tastes metallic) and it often causes them to hate drinking red drinks.  I felt a bit of warmth in the back of my throat with a hint of taste but nothing significant; I sucked on a lifesaver, which easily overwhelmed this taste.  Adriamycin also turned my urine red; this could have been disconcerting but I expected it.  Next up were Vinblastine, Hydrocortisone (a steroid to help with nausea and appetite), and Bleomycin (the bastard that can cause lung damage).  Finally we finished with Dacarbzine, and while it is a clear liquid, it comes out in a dark brownish green bag to protect it from light.  We finished with the trial drug SGN-35 (Brentuximab Vedotin).  Infusion finished at 12:35PM but I was not yet free to go.  They needed to keep me for an hour to ensure I did not explode from the SGN-35.  Once freed from the chemo ward I had to hang around the BCCA for 3 more hours to give blood at 2:35PM and 4:35PM.  Luckily I PVR’d the Canucks game so I didn’t miss any of the game.  For more details on the drugs see my Previous Post on the subject.

Post chemo I felt mostly normal; I was tired and wanted to go home but other than that I was fine.  I even went to the gym and managed to get about 30 minutes of cardio in.  In the evening I ate normally without issue.  I did have a lot of trouble sleeping.  Despite being very tired I didn’t not get to sleep until about 4:00AM and was awake by 8:00AM; this is a common issue with large doses of corticosteroids.

The day after chemo (today) I have felt pretty good although I have been fairly tired.  This is probably due to the lack of sleep.  My taste is also off: water tastes terrible which is annoying since I am  used to drinking about 8L (2 gallons) per day.  I have been drinking Gatorade 20 (basically diet Gatorade). Fruit does not taste as sweet as normal and ginger ale tastes ‘off’.  The lymphadenopathy (inflammation of the lymph nodes) in my neck and left armpit is greatly reduced especially on the right side of my neck where the tumor was getting very large (about 8cm x 5cm and very thick).   Hopefully I’ll actually be able to button up a shirt now. ;)

PET Scan Results

On Friday April 8^th 2011 I had a full body PET scan as per the requirements for the SGN-35 clinical trial.  The scan itself was straightforward and uneventful.  About an hour before the scan I was injected with the FDG tracer (radioactive glucose analog that the cancer cells will consume causing them to appear on the scan).  After injection I was not allowed to move around or do anything repetitive including reading or chewing gum as it would cause uptake of the tracer into the area being used so I sat and listened to tunes on my phone and took a short nap. Once my hour was up I spent 15 minutes being scanned on a machine that looked exactly like a normal CT scan machine then was free to go with instructions to avoid children and pregnant women for 12 hours (due to the radiation). 

PET scans measure the degree of metabolic activity by standardized uptake value (SUV).  High SUV indicates high metabolic activity and potentially aggressive disease.  Uptake of the tracer does not necessarily indicate malignancy; inflammation will also cause uptake and organs will consume the tracer.  For post HL treatment scans generally lymph node activity greater than 2.5 is a concern.  One study of the efficacy of PET scans indicated a mean SUV of 7.3 for newly diagnosed HL patients.

PET Scan Report:

Indication

Lymphoma Screening for clinical trial

Technique

438MBq of FGD was administered intravenously following a six-hour fast and informed consent.  Prior to injection, the blood glucose level was 5.3.  Approximately one hour later, low mA non-contrast CT and co-registered emission PET images were acquired of the total body.  Comparison was done with a previous CT abdomen and pelvis dated March 4. 2011.

Findings

There is extensive bilateral mostly lower posterior cervical lymphadenopathy seen (moreso on the right) which is intensely FDG avid, with a maximum update SUV 9.2.  Extensive bilateral surpa and infraclavicular, axillary, mediastinal and bilateral hilar lymphadenopathy is also seen with intense FDG update [SUV max 8.8].  Multiple pulmonary nodules are seen with focally increased FDG uptake [SUB max 5.8] likely representing pulmonary involvement.  Pericardial effusion is seen with no pleural effusion.

Splenomegaly is seen with 3 focal moderate to intense FDG-avid lesions [SUV max 6.8].  Multiple retroperitoneal, celiac, gastrohepatic and lower para-aortic FGD-avid lymph nodes are seen with intense FGD activity [SUV max 8.6].  No other focal FDG avid abdominal or pelvic lesion is seen.  Mild diffuse activity in the right psoas muscle.  No definite focal FDG avid osseous lesion is seen but there is mild diffuse accentuation of bone marrow activity and bone marrow involvement may be present.

Impression

Extensive widespread intensely FGD avid lymphadenopathy, with splenomegaly and multifocal spleen lesions, pulmonary lesions and possible bone marrow involvement. 

My Translation (written specially for you Rez):

There is extensive enlargement of the lymph nodes on both sides of the neck (moreso on the right) with a maximum uptake value of 9.2.  Extensive enlargement of the lymph nodes on both sides of the chest with a maximum uptake value of 8.8 (see image below for specific locations).  Multiple collections of cells are seen in the lung with maximum uptake value of 5.8, likely representing lung involvement.  Excess fluid surrounds the pericardium (sack that contains the heart and the roots of the great vessels.) with no fluid around the lungs (a previous CT showed a pleural effusion but it went away when I was on Dexamethasone in late February after having my wisdom teeth removed). 

Enlargement of the spleen is seen with three moderate to intense lesions with a maximum uptake value of 6.8.  Multiple abdominal cavity lymph nodes are seen with a maximum uptake value of 8.6 (see image below for specific locations).   Mild diffuse activity in a right pelvis muscle.  No definite bone lesion is seen but there is mild scattered increased bone marrow activity indicating possible bone marrow involvement (bone marrow biopsy performed February 15^th 2011 showed no bone marrow involvement).

The PET results indicate there may be bone marrow involvement although the previous BMB was negative.  Given that the BMB was done almost 8 weeks ago it is possible that bone marrow involvement started after the biopsy.   In addition it is possible for BMB’s to produce false negatives.  I have not spoken with Doc Restrepo about this yet but I don’t expect them to perform another BMB to find out since the results would not change the treatment plan.  Bone marrow involvement is not considered an adverse prognostic factor.

Treatment (6 cycles of ABVD + SGN-35) will start on April 19th at 0900.

Click for 360 view

The Decision

Yesterday I went to see Doc Restrepo to discuss the SGN-35 and give him my decision.  Before arriving at his office I was pretty sure I was going to join but I wanted to hear what he had to say first.  Doc and I both believe joining the trial is a good decision for me.  The drug’s success rate with relapsed and refractory patients has been excellent and other monoclonal antibodies have been very effective when combined with chemotherapy for frontline Lymphoma treatment.

During the physical Doc noticed minor lymphadenopathy in my left armpit.  This was not present during the last physical.  The enlarged node is approximately 7.5mm (my estimate).   

I have a PET scan scheduled for April 8^th.  Normally in BC PET scans are not done before frontline treatment but it is a requirement for the clinical trial so I will be getting one.  In the US and UK PET pre-treatment PET scans are the standard for staging, but in BC normally just a CT scan is done. PET scans differ from CT’s in that they show molecular activity instead of structure.  This is achieved by injecting the subject with a radioactive glucose analog then monitoring its uptake into cells with a gamma camera.

Chemo will begin on April 19^th 2011.  In case it wasn’t clear in my previous post I will be getting SGN+35 in addition to the original treatment plan of six cycles of ABVD, rather than instead of.