Sunday, November 22, 2015

Back in the saddle...

Quick recap of the last two weeks:

11/10/15:  We met with the radiation oncology team at MGH about Emmett's radiation plan.  They want to treat this spot as AT/RT recurrence.  While it's not growing quickly like AT/RT, they say given Emmett's history, it's more likely AT/RT than anything else.  They also say the spot has qualities that make it look like a secondary tumor and not a primary tumor.

They also mentioned that just the day before, Dana Farber sent word that their final review of Emmett's 8/27/15 MRI revealed two spots that are enhancing slightly.  There's no bulk to be seen here, but the nerves in these areas are picking up contrast.  Looking back in time, these spots have been picking up contrast since 2014, so whatever is happening here is nothing new (good news -- we think).

These spots are very close to the nodule of concern (within millimeters) and could be included in the radiation field and treated.  They may be part of the nodule (best case) or they may represent metastasis.  Dana Farber asked MGH to closely examine these spots with a KISS (?) image sequence on their MRI the next day.  They also wanted MGH to carefully screen the rest of Emmett's brain and spine to make sure there were no other areas of enhancement, suggesting possible metastasis (this scenario would beg for systemic treatment first instead of focal radiation treatment).

They want to treat Emmett with 30 days of low dose radiation instead of 5 days of SRS radiation.  The main reason is because Emmett got 30 days of treatment last time and he tolerated it very well and it appears to have controlled his disease.  They can't predict if SRS would have the same effect on his tumor, although they believe the SRS and 30-day dose are "biologically equivalent". 

11/11/15:  Emmett has his radiation planning MRI at MGH.  The preliminary word from the fellow was that they do not see any other spread of disease (great news), that the two additional areas of concern are still showing enhancement, and the nodule is showing a small increase in size (approximately 1 mm in each direction).  This is on par with the last few MRIs (i.e. the nodule is slowly growing).  We were hoping for a reduction that would lead the team to reconsider the need for treatment...but at the same time, were very glad to see that things hadn't changed much from his scan in August. 

11/12/15:  Emmett had his radiation planning CT.

11/16/15:  We heard from the radiation oncologist on the radiation plan.  They plan to include the two additional spots in the radiation field.  Because they're so close to the nodule they can easily be included in the radiation field.  And the radiation field will still be quite small.

When asked about the size of the nodule compared to Emmett's last MRI, she said that because they did a more detailed image sequence this time with 1 mm slices, there's no fair baseline of comparison to say exactly how it changed from last time.  They call it "no appreciable change".  She said that it might have grown slightly, and that she's sit down with us to go over the images in the coming weeks, but her travel schedule has prevented that from happening yet.

11/17/15:  We met with Dr. Chi at Dana Farber.  This is only the second time we've met with her since coming to Boston in September.  It was insightful to get her perspective.  She said that MGH wants to treat this really aggressively, Dana Farber wants to be more conservative, and at the other end of the spectrum you have Children's Hospital of Philadelphia which suggests we watch and wait (though we haven't talked to them since Emmett's last MRI).  She was a little concerned when she heard that Dr. MacDonald at MGH was going to reduce the inner ear radiation field from 50 to 45 Grey, and she wanted to talk to Shannon about that.  Dr. Chi apparently thinks we should give the full dose, even to the outlying areas.  So they need to get on the same page....especially since radiation is supposed to start tomorrow.  Likely this will result in a delay in the radiation start date.

Chi also talked about options for follow-up, systemic treatment at the conclusion of radiation.  At this point she's not in the camp that we MUST do systemic treatment after radiation, though it sounds like she would recommend it.  But the question is WHAT -- there's no protocol for recurrent AT/RT.  Essentially you're on clinical trials exploring new drugs and options.  Thankfully there is a new drug that's shown some promise against AT/RT that will be available in the next month or so.

Our perspective:
  • While we were hoping for a miraculous reduction, we are encouraged and thankful that whatever this spot represents is progressing very slowly.  In fact, we DO consider this a miracle.  AT/RT doesn't creep back; it explodes back.  So why is this growing so slowly?  Maybe because Emmett's body is recognizing it and fighting it.  Maybe it's because of all the prayers.  We like to think it's a little of both.  And throw in radiation, hopefully it runs away with its tail between its legs.  No disease has returned where Emmett was radiated.  Maybe radiation's the silver bullet.
  • We're still very anxious about commencing radiation treatment...and for several reasons.  It's scary stuff.  It's lots of sedation.  It comes with side effects, and only some of them are known.  But probably the most overwhelming aspect is the fact that by commencing radiation we're admitting that Emmett has least in some fashion.  We're stepping into the ring watch our child fight cancer.  And that's my biggest nightmare come to life.
As we mentioned in our last post, we have so so SO much to be thankful for.  We're in a great place in so many ways, and continue to feel very blessed.  The last two years since Emmett finished treatment have been absolutely wonderful.  And Emmett's still doing wonderfully.  He's loving and enjoying every day so much.  And we have reason to hope he'll continue to do well for a very long time, and ultimately will beat this disease.

And those are the things we will focus on this week as we commence radiation and celebrate Thanksgiving.

Tuesday, November 10, 2015

The Glad Game

We have a big week ahead of us here in Boston.  We meet with the MGH doctors for radiation planning.  In some ways it feels like we're stepping back in time three and a half years to when this whole thing started with Emmett...and that thought is terrifying.  However, we're not in the same place now that we were then.  We're far from it.  And it's been helpful the past few days to count the ways things are better now than they were then.

We're already connected with the best doctors for Emmett's cancer

Whatever this is, it's growing very slowly.  Emmett's tumor was fast growing before, at least at one point.

We're discovering whatever this is at the very earliest stage of visibility instead of being rushed into emergency surgery when Emmett stopped walking.  This provides the doctors the opportunity to be methodical and deliberate.

There are new treatment protocols that are showing promise against atrt

I don't have fears about losing my job like I did last time.

Emmett is doing wonderful clinically.

Emmett can communicate and tell us what he's feeling now that he's older.

This may not be cancer.

We've been in a much worse place than this before.  We've been told there's nothing left to do and your son likely won't make it.  And Emmett pulled through.

Yes, things are much better now than they were then.  And we're hopeful that this isn't a big deal at all.  We appreciate everyone who has been praying and fasting for us the last few weeks.  The ward back in Albuquerque fasted for Emmett last Sunday, and more people fasted this week.  And we've felt the strength of those prayers!

Tuesday, October 27, 2015

October Update

Mass General has scheduled Emmett for proton radiation starting 11/23.  Before they can begin radiation they need a new MRI combined with a CT.  These two scans fused together will allow the hospital to plan how they will administer the radiation (i.e. what shape should the radiation beam be, what angles should it come from, what structures will they have to go through, etc.).  This should also let them determine what the expected side effects will be.  We haven't committed to this treatment yet, but to learn the side effects you have to at least go through the planning process.

If Emmett's spot hasn't grown in size, they will probably recommend stereotactic radiation.  This will mean only a few treatments to zap a small spot.  If Emmett's spot is larger, they may recommend a larger radiation field and more treatments.  They have him on the schedule for 30 treatments, but will cancel the ones that are not needed.

As I mentioned in my last post, the doctors have seen spots get smaller on their own without treatment on rare occasions.  They still don't know if this spot represents cancer.   But they don't like to take chances.  And if Emmett's next MRI on 11/11 still shows this spot, they will definitely recommend we go through with radiation, and perhaps other follow up treatments.  We have taken Emmett's treatment a different path than they have recommended before, though, so we will see what happens this time.

Emmett continues to do wonderfully clinically.  From all appearances he's your normal happy, healthy boy.

We're praying that Emmett's body addresses this spot on it's own, whether it's malignant or not, such that his next MRI will lead the doctors to consider a different course of action.  We are also praying that if Emmett needs more treatment, that his mind and his body will be protected from any ill effects.

We invite any and all to join us in this prayer.

Saturday, October 3, 2015

Radiation Option

So we heard from Dr. Chi this week that MGH will consider Emmett for proton radiation.  We should hear from them to setup a consultation any day.  We also met with the radiation team at Dana Farber for consideration for photon radiation.  (If MGH will do proton, however, that's where the doctors would send us because it has fewer side effects.)

It sounds like the doctors are getting on the same page that irradiating this spot is what we should do.  We're not sure how we feel about it yet.  Well, really we are sure - we don't want to do it!  Emmett's brain has not been irradiated yet, and we would like to keep it that way unless absolutely necessary.  We heard from Dr. Fisher at the Children's Hospital of Philadelphia earlier this week and he sounded like he would recommend observing this spot instead of treating it at this point.  He also believes that stereotactic radiation against a recurrent rhabdoid tumor is not effective, so why subject Emmett to the side effects of radiation?  Especially when we have no idea what this spot represents? 

"...but so great were the confusion and strife among the different [institutions], that it was impossible for a person young as I was, and so unacquainted with men and things, to come to any certain conclusion who was right and who was wrong."  Sound familiar?

Thankfully another MRI would be required for radiation planning since it's been over a month since Emmett's last scan.  I asked Dr. Chi what she would recommend if another scan showed a reduction in the size of this spot.  She said that while not expected, a reduction in size would give them pause to reconsider their path forward.  I then asked her whether she has ever seen a tumor reduce in size without any intervention.  I had asked her this same question three years ago and her answer was "no".  This time however, her response was different: "Funny you should ask that today Micah, in our tumor board meeting this afternoon we reviewed the case of a girl who's latest scan showed a significant reduction in the size of her spot, and that was completely unexpected."

We do believe in miracles.  We hope and pray that Emmett's body will find a way to address whatever exists at this spot in question, be it inflammation, infection, or malignancy, such that the best path forward for our Brave Little Lion becomes clear.

We're thankful for the opportunity to watch General Conference this weekend and pray the Spirit will bring peace and comfort to our family as we prepare for the decisions ahead.

Tuesday, September 29, 2015

Orthopedic, neurosurgery consultations

Yesterday we met with the orthopedic and neurosurgery teams.

The orthopedic team was asked to evaluate Emmett for spinal instability resulting from spinal surgeries and radiation treatment.  I've been anxious about this consultation for several months now.  We would hate to put Emmett through a spinal surgery that might limit his mobility and ultimately change the way his body functions.  It was hard when he was 18 months; it would be so much harder now that he's older.  He understands so much and asks such probing questions. 

Thankfully the orthopedic team doesn't think that anything is needed at this point - hooray!  Hopefully that message is repeated for years to come.  They did suggest he stay away from contact sports, however.  Tennis and golf were his recommendations.  What a 'coincidence' that those are the two sports I play the most!  I guess I was meant to be a pansy.  Incidentally, we brought tennis rackets for Katy's birthday yesterday to have here in Boston.  Emmett got so excited and begged us to sign him up for tennis instead of soccer.  He asked me to go play tennis with him no less than eight times today.  Hopefully it sticks!


The consultation with neurosurgery was also insightful.  We've been waiting for weeks to hear what Emmett's neurosurgeon thinks about this spot in his brain stem.  She is concerned about it.  She thinks it would be risky to get to surgically, and the risks would be great.  She said she recently went after a similar spot on another patient, and in the end the tissue wasn't good enough for a conclusive biopsy, so it was a lot of risk for a little benefit.  I assume if this spot started growing quickly she might reconsider.  But for now surgery is off the table.

She did recommend we proactively treat it with stereotactic radiation as the oncology team has discussed.  She thinks that the side affects will be minimal for this location.  I guess they irradiate kids with tumors in this vicinity regularly, and in her experience the side affects are very minimal. 

Keep in mind that this is a surgeon speaking for a radiation oncologist, so take everything she says with a grain of salt.  I'm anxious to talk to the radiation oncology team to see what they believe the risks and benefits are.

Our primary team still hasn't heard back from Mass General on options for proton radiation treatment, which is what I believe our primary team will recommend.  I think they have options for photon radiation locally, but proton is the preferred option.  So we're still waiting.

So that's where things stand today.

We appreciate the outpouring of love and support we continue to receive.  And we especially appreciate all the prayers.  So many people have been involved in bringing Emmett to where he is today.  We love and thank you for all you do for our Little Muncher!

Saturday, September 19, 2015

Lumbar Puncture is clear!

For those who didn't see this yesterday, let me re-post it here:

Emmett's lumbar puncture came back clear; yay!!! A wonderful tender mercy, and on his fifth birthday. The clear LP doesn't necessarily mean this mass isn't cancer, but it is a step in the right direction. We are all feeling very thankful...and are grateful for a weekend of good weather in Boston. 

Emmett wanted to go to the beach this weekend, so we headed to Wingaersheek yesterday and went to Walden Pond today.  The weather couldn't have been better and made for some wonderful family time.  Clayton crawled right out into the water and would have kept going if we hadn't stopped him.  He screamed when we finally pulled him out.  I'll add some pictures later!

Thursday, September 17, 2015

Waiting in Boston...

Executive Summary:

1.  The doctors have a identified a slow growing mass, but do not know what it is.
2.  Please pray that Emmett's lumbar puncture comes back clear.
3.  Pray that the mass in question manifests itself as something that is not cancerous.

So we met with the team in Boston this week. In reviewing his prior scans they were able to see something in this location in his April, February, and January MRIs (which were all done in Boston -- how did they miss it? #RadiologistsShouldntFacebook&ReviewMRIsSimultaneously).  So it's been there for a while.  Since his scan in April, it has only grow perhaps 1 mm.  However, nothing showed up in this area in his October 2014 MRI.  So there has been significant change over the course of a year.

This news is both encouraging and discouraging.  The good news is that whatever this spot represents, it's slowly growing.  AT/RT is anything but slowly growing as evidenced by the time that Emmett's tumor grew back in 10 days after his first resection in Boston.  A 1 mm change in four months is not much.

The downside is that we've confirmed that something is definitely in this area, and growing...however slow.

The challenge is that there's no good way to tell what it is.

Though the neurosurgeon hasn't weighed in yet, the oncologist thinks this spot is we can't get a biopsy. 

The next best option is to do a lumbar puncture to take some spinal fluid and look for cancerous cells.  Emmett had his LP yesterday and we're anxious awaiting the results. 

The third option is to wait and see what happens.  Does the spot continue to grow?  Does Emmett start showing symptoms?

Options for treatment aren't great.  Emmett's still too young for full brain radiation.  Without confirming it's cancer, probably the only thing they might consider is stereotactic radiation.  This is a "gamma knife" procedure where they send low energy radiation beams from many angles that all converge at the spot in question.  This way the brain gets a low dose overall, but the treatment area gets a high dose.  Stereotactic radiation only works for spots that are small (less than a few cm) -- if we wait too long, it may not be an option.  One upside to stereotactic radiation is that it would not preclude Emmett from full brain radiation down the road, if needed for future treatments.

We don't know the risks for stereotactic radiation in this part of the brain yet.  A radiation team at Dana Farber is reviewing Emmett's case and we hope to meet with them next week.  We also plan to consult with the radiation oncology team at Massachusetts General Hospital where Emmett received his proton radiation.  If the risks are significant, it would be hard to justify if we don't know for sure this is cancer.

We hope and pray that no further treatments are necessary!  As minimally invasive as radiation might be, the side effects may be significant, and we hope that the doctors come to the conclusion that everything is okay and nothing else is needed.

On the upside, Emmett had an LP and a PET/CT scan back in January which both came back clear.  If the spot existed then, and the tests showed no evidence of cancer, we're hoping the same is true today.

Please keep Emmett, our family, and his doctors in your prayers as they work to determine what this spot is and the best path forward.  We're praying specifically that his lumbar puncture accurately reflects no cancer in his brain and that this mass ultimately is determined to be non-cancerous.

We greatly appreciate your prayers and faith!