Garry 39;s Mod 9 11
Enrique Fats
Garry's story illustrates how very important it is to have regular follow-up CT scans. after surgery. If a surgeon says to you, "Don't worry - I have got it all out and cured you", insist on seeing an oncologist who sees lots of GIST patients. One can't help wondering how Garry's story would have been different if that had been done.
GIST hit me as a major surprise. It was September 14th 2001 (just 3 days after the momentous events of 9/11 and 10 days before my 46th birthday). I had an early start to work as I was driving with two colleagues from Leicester to a research meeting with our collaborators at the Veterinary Laboratories Agency in Weybridge (Surrey). I am a Professor of Biology at Leicester University and, amongst other things, we have been working for the last few years on the development of sensitive live animal tests for scrapie (in sheep) and BSE (in cattle). Anyway, the meeting was underway and we were discussing new data over a cup of coffee. Suddenly I felt very nauseous and this quickly developed into a severe abdominal pain. The local first aiders decided there was something serious going on and so I was helped into a car and driven to the A&E department of the nearest hospital (Chertsey). I recall spending several very uncomfortable hours lying on a trolley and undergoing some X-rays (very painful to get into the correct position). I gave my car keys to my concerned colleagues who had stayed with me throughout this period. I was given fluids and eventually morphine. The morphine helped and I was taken to one of the wards and fell asleep. I was woken later that night at about 11.00 pm to be told that the plan was to perform a laparotomy to check for diverticulitis (the best guess of the doctors).
When I woke from the surgery it was two days later and I was in a different hospital! I opened my eyes to see my wife, Lindy, who explained that I was in Intensive Care at the West Middlesex hospital. The laparotomy had revealed that my descending colon had ruptured due to the presence of a tumour about the size of a grapefruit. This had caused faecal peritonitis with a real risk of septicaemia. I was receiving antibiotics via a Hickman line in the neck. The surgeon at Chertsey had performed a left hemicolectomy and hence a colostomy (Hartmann's procedure). He was apparently not optimistic about my chances and so Lindy had been told to expect the worst. Lindy stayed with me for two days, before returning home to take care of the children. Whilst in Intensive Care I was extremely well cared for with one-to-one nursing. I remember the physioterrorists (sorry, physiotherapists) coming to get me out of bed and go for a walk! I managed this and after another couple of days was transferred to a regular surgical ward. I received a visit from the stoma nurse who told me a little about bowel cancer (which is what she thought we were dealing with) and taught me stoma care. The physiotherapists also made their regular visits and I was soon able to go good distances, once disconnected from many of the tubes in me. It was a couple of days before I saw the Consultant surgeon. I asked about being transferred to Leicester. His view was that this would be unlikely as I would need to find a surgeon in Leicester who would take me onto his/her list. I figured that this would not be a problem because the Dean of my Faculty at the University is also Dean of the Leicester Medical School and the three main hospitals in Leicester are all teaching hospitals. The problem I had was getting access to a working telephone! The patients' telephone on the ward had been vandalised and the nurses informed me that they could not bring me a telephone. Lindy was back in Leicestershire, so I was rather isolated. Then, there in the ward was a long standing friend, Terry, who was now working at the University of East London. He had heard about my plight on the academic grapevine and popped in for a visit. I gave him a complex message to give to Lindy and he went off to deliver the message. A couple of days later, a Saturday morning, I was stretchered into the back of a transport ambulance and driven to Glenfield Hospital in Leicester. Waiting to meet me was Adam Scott, the consultant surgeon who had added me to his list. We chatted and got along really well. I was now more able to relax since I was only a few miles from home. It was great to see Lindy and the children again.
Over the next few days my strength improved and I was visited by Sue, the stoma nurse at Leicester, who gave me excellent instruction in stoma care. I spent my birthday on the ward. One of the junior doctors brought me a copy of the pathologist's report that had been sent up from Chertsey. I read with great interest. The tumour was fully resected with good clear margins. The tumour cells were positive for the cell marker CD117 (also known as c-KIT). This would be something to follow up when I could next get on line.
A few days later I was sent home, but my freedom from hospital was short-lived. I suffered a pulmonary embolism (PE), presumed to be the result of a peri-operative DVT, and was re-admitted. The PE was extremely painful but things settled after a few days and I began a few months of warfarin treatment. Over the next few months I received CT scans, an MRI scan and a PET scan at Guy's Hospital. I also had an appointment with an oncologist at Leicester Royal Infirmary. By the time of that appointment I had done my homework and was well up to speed on GIST and its treatment. I had read the research papers on the cell biology of GIST and the role of Receptor Tyrosine Kinases (c-KIT and PDGFR?) and was aware of the development and use of STI571 (imatinib mesylate or Glivec). The oncologist explained that the resection looked clean and was the front line treatment for primary GIST. There was no evidence of metastasis from any of the scans. We talked about imatinib and he explained that it was not yet licensed in the UK and would not be prescribed for adjuvant therapy anyway. I was given another oncology appointment in one year's time. A few months later I returned for planned surgery - to have the colostomy reversed. This was all pretty straightforward and I recovered quickly. Within a few weeks I was back at work and back to playing golf.
Several months passed and it was back to the oncology clinic. A different doctor saw me and I had a very brief examination. I asked about the next scan and was informed that there was no need. My next appointment was in a year's time. By now my life was essentially back to normal. My next oncology appointment followed the same pattern as the previous one; a brief exam, no need for scans and another appointment for next year.
This pattern continued until the end of 2005 (over 4 years since the tumour was discovered). At that oncology clinic it was decided that an ultrasound scan would be a good idea. I received an appointment for the end of January, with a follow-up at oncology for the following July. However, over the Christmas period I began to experience abdominal pain. My GP suggested a scan - which I was already waiting for. By the time of the scan the abdominal pain was getting worse and it was obvious from the sonographer's demeanour that something was amiss. I received word that I would need a CT scan. This happened in the next few days followed by a hastily-arranged oncology clinic. It was a recurrence at multiple sites throughout the peritoneum! With the benefit of hindsight, I should have been more insistent about CT scans.
I asked to see the head of oncology, a colleague at the University - Prof Will Steward, whose research interests included sarcoma. He prescribed Glivec at 400 mg per day. I began taking the drug that day. I experienced a wide range of side effects to Glivec therapy (including stomatitis, rashes, nausea, diarrhoea, sensitivity to the cold and headaches). Within a few weeks my abdomen began to enlarge and it was speculated that this could indicate a response to Glivec. Unfortunately, my abdomen continued to enlarge enormously and after a few weeks I suffered a complete blockage of the bowel (such that I was vomiting faeces!). This was clearly a serious situation and I was admitted to the oncology ward at Leicester Royal Infirmary. The surgeons there were not keen to operate, despite the severity of my condition. Fortunately, Adam Scott said he would be prepared to have a go at de-bulking some of the tumour masses and so I was transferred to Glenfield Hospital. The surgery (April 2006) lasted eleven hours and I was in bad shape. It turned out that the tumours had responded to Glivec with their centres becoming jelly-like, hence the enlargement and abdominal swelling etc. I recovered from the surgical ordeal and was soon back at home, then eventually back to work and back to golf. At this stage I was put on a regime of CT scans every three months or so.
All went reasonably well until early 2007 when a routine scan revealed tumour growth and new lesions. I was prescribed an increased dose of Glivec (800 mg per day), but there seemed to be little or no response and the tumours continued to grow rapidly causing another complete blockage of the bowel. After much debate, Adam Scott agreed to have another go at de-bulking the tumours. This surgery (March 2007) was extremely difficult because of the highly vascularised nature of the tumours, and was spread over two days. I woke on the third day in ITU. This was an especially difficult time for Lindy as she was given very little information about my condition or the prognosis. However, I did eventually recover from the surgery and the very next scan confirmed that Glivec was not working. In June 2007 the registrar in oncology told me that Glivec was to be stopped and I was offered only palliative care. The registrar was not aware of any other options or trials, so I contacted Will Steward about Sutent and some of the trials that were recruiting. At that time my PCT were not funding Sutent at all, so I asked Will if he would refer me to Ian Judson and his team at the Marsden. Will was happy to do this. At this stage I was quite poorly, I had lost a huge amount of weight (ca. 70 lb!) and was severely anorexic and experiencing early satiety because of two peri-gastric tumours (i.e. around the stomach). Adam Scott was contemplating inserting a feeding tube when I received word from the Marsden. I met with Ian Judson and we talked about research and about a trial of AZD2171, a multi-receptor tyrosine kinase inhibitor from Astra Zeneca with an activity profile similar to sunitinib (Sutent). I agreed to go on the trial, subject to a pre-assessment. This was fine and the trial began at 45 mg of AZD each day. The trial protocol meant very frequent visits to the Marsden (both the Fulham Road site and the Sutton site) and a regime of biochemical tests as well as PET/CT scans. My GIST was genotyped; I am wild type at both c-KIT and PDGFR? (so a rare form of GIST). The AZD side effects that I suffered are very much as described by some of those taking Sutent (persistent diarrhoea, fatigue and myalgia). The most troublesome was hypertension, which required me to take a range of drugs to control blood pressure. Over time I developed hypothyroidism (another side-effect) and had a few breaks from the drug and eventually a reduced dose (30 mg). I began the trial in September 2007 and for about six months the disease was stable.
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