Category Archives: Cancer

Essay: The Only Acceptable Option

IV image

Joe and his wife, Carla, talked about it when she got the news – she didn’t want chemo. She didn’t want chemicals to destroy her body. She made that clear to Joe. Her father went through something awful when he got cancer and she just didn’t believe in those poisons. And they had done their research — how much does chemotherapy actually work for cancer of the stomach?

There was only one acceptable option – treatment had to be “natural.” They considered a trip to Mexico for some “alternative” treatments but money was a concern. So they sought out doctors nearby who believed the same as they did — that cancer should be treated without western poisons. After a few weeks, they found their medical sanctuary and the treatments began.

Carla seemed to be doing well on weekly intravenous hydrogen peroxide, Joe explained as we sat in my office. I swallowed and could feel the blood rushing from my face. What kind of doctor treats cancer patients with injections of hydrogen peroxide? My heart sank. This is why I help families — vulnerable in so many way and at such critical times.

Joe’s faith in the “treatment” and his disbelief in the outcome were profound. It was stomach cancer but Carla had been eating — maybe a little trouble swallowing but not much in the way of other symptoms. The tumor must not have been growing, he had concluded. The treatment was working. His older brother, Mark, was with us, nodding and supporting him, listening and asking questions.

What went wrong? Joe wanted an autopsy to find out.

It showed widely metastatic cancer. Outsized lymph nodes formed a slowly tightening noose around the esophagus; a destructive bio-lava of tumor pushed from the stomach into the pancreas; and metastatic growths nested insidiously throughout the liver. Remarkably, the gastric tumor had grown out and away from the stomach, not into the stomach itself. No wonder there wasn’t much in the way of swallowing or digestive symptoms. But this apparent health belied the tumor’s silent and dangerous growth nearby.

When we met again to discuss the results of the autopsy, Joe was shocked. She had seemed to be doing so well. He was surprised that her tumor was so advanced. With diagrams and details, I went through the case step by step.

He was stunned, but understood. And then he understood what this meant — that the treatment had not worked. And then he understood the inevitable — that he had participated in the choice of treatment.

“Did we do the right thing? Should we have gone with chemotherapy?” he asked, wrestling with guilt as so many families do.

I sorted through the question, looking for a way in to help. It wasn’t my judgment to pass. Gastric cancers do not respond well to chemotherapy. Choices at the end of life are important and personal. But he had said “we” and Carla had really made the choice herself with Joe supporting her — it really hadn’t been his decision. She had been adamant. Maybe I could point that out?

And while Carla seemed to have driven the choice of “treatment,” it wasn’t clear to me how deep Joe’s mistrust of chemotherapy was. Many chemotherapies do work. Hodgkin’s lymphoma, for example, can be cured. I thought it could be worth exploring. What if Joe had such a choice to make again? What if that choice was for himself? Feeling protective of him, I thought I could explore it gently and carefully. Autopsies are about the truth and can be turning points for families.

But his brother spoke first, injecting the only acceptable option he could see — that there could be no second guessing.

“Of course you did. Of course you did,” he said, shooting a glance at me and touching his brother’s arm.

It was an older brother’s protection. The dynamic here was powerful.

“Yes,” Joe nodded, losing himself into his brother’s verbal embrace.

I thought Joe could have handled more, and wondered where the conversation might have gone. I grimaced internally as I saw the opportunity dissolve. It was now too risky to start a discussion that could be misconstrued as “blame.” “Do no harm” — my physician oath ingrained — meant that I could not risk infusing guilt on top of grief.

So I said nothing. It was the only acceptable option.

Meeting the Man on the Table

In May I autopsied a man I had gotten to know. He came to the autopsy table more rapidly than usual after he died, because the autopsy was for cancer research. Joseph (yes, not his real name) was a “tumor donor.” Tumor chemistry is unforgiving and ephemeral — the mysteries fly away unchasable unless the tissue is dropped into a test-tube and frozen right away. We move quickly with these cases.

And yet, in the struggle of end-of-life family logistics, it took weeks till I met Joseph. I worried constantly that our difficulty organizing the family meeting would mean that death would intervene before we could make arrangements. We had to be patient, knowing the arms on the end-of-life clock were were swinging and shaking forward erratically and unpredictably.

My first contact with Joseph was by phone. Raspy, gruff conviction and the choppy conversation of a man with difficulty hearing greeted me.

“Yes, I want to donate my tumor! What the hell do I need it for?! I’m not taking it with me!”

Joseph was direct, pointed, and at ease with the process of Tumor Donation. Part of his motivation, I learned later, was that Joseph had received a living organ donation some years prior. He was living — had gotten to stay alive — because someone else had given a part of themselves to Joseph. Now dying of cancer, he wanted and was ready to give his own tissue – “give back” or, in more Joseph-language, a “take-it-the-hell-out-of-me” gift. His gruffness made it all the more moving to see this man — filled with incessant, growing tumor — deciding to donate that tissue for research. My experience with Joseph was not the soft and painful poetry of cancer introspection, but the hardness of a good, working man armed with a cause.

When we met, Joseph was garrulous and eager; clear and open to the discussion. I wondered not only what it would be like to know a person before their autopsy, but to like them.

Only twice in my career have I personally known the the body on the table: once early in training some 20 years ago; and once, more recently, in in my private practice. In the first instance, I walked in to a case and peered through a huddle of residents to find this was the body of an attending from my internship. I hadn’t known he had died. Shocked, I asked my pathology attending to be excused and left the room. The second case I performed unknowingly. Again, it was an attending from a past training experience, but this one had been a mentor and friend. With many years distance, death’s stiffening withdrawal of the spirit, and my professional focus — I hadn’t recognized him. When I realized later, again, it was a shock. I wasn’t prepared.

But my encounter with Joseph on the autopsy table was planned. I knew I would be meeting him while he was alive for the purpose of meeting him while he was not. I both braced myself for the experience and worked to stay open to whatever that experience might be.

When he arrived at two in the morning, I was grateful for the head-to-toe white sheet covering him and took a moment to reflect on our few encounters. I had seen him sitting outside my office after the family meeting, chatting with my assistant as he waited for his family to pick up him along Michigan Avenue. I had seen him later in hospice, quiet and confused, sipping water from an offered cup and straw, vigor and fight traded in for infection and the ability to whisper and nod. I did not want to override those memories yet by looking at his face; and decided to perform the incision with the face still covered. The warmth of his abdominal organs melted through my double gloves, and reminded me that there was no hiding from what was different here.

The tumor was out of the body, sorted into various lab containers and the case over in half an hour. With Joseph cleaned up and sewed up, I still wondered if should look at Joseph’s face. My job was done. Would it be too upsetting? Did I owe it to him to see him? Did it matter? Could I skip it?

I removed the sheet over his face.

Sleeping. That’s all. I was not shocked. He looked like he was sleeping. I covered him up.

And then — never for any other case — I stopped and made a prayer of sorts. Standing by Joseph’s side, hands folded together in front of my chest, elbows bent, more feelings than words, and to no one in particular:

Thank you for this gift, for sharing your tumor, Joseph.

With all my supplies back into their boxes, I took one last look around the autopsy suite and clicked the lights off.

Three labs awaited Joseph’s tumor. I wondered what it would be like to meet the next the patient I’d autopsy, and the one after that. This was no longer the usual autopsy practice.

Monthly case: Undiagnosed Pancreatic Cancer

Rathke pancreas safe viewWhat is shown?   The top photo shows the pancreas split down the middle (horizontally).  To the left is the tumor.  Next to the tumor is a circle.  This is a tube cut across.  It is the common bile duct (the tube that drains bile from the liver).  The tube is abnormal.  It’s too big (dilated).  It is roughly twice as big as it should be normally. To the right is the spleen (the red organ taking up about a third of the image).  Below, the photo is illustrated.  The split down the middle of the pancreas is shown with a dashed red line.  The tumor is outlined in black.  Two red arrows highlight the common bile duct. The spleen is labelled.

What was the story here?  This case was from an autopsy of a man in his 50’s who had cancer of “undiagnosed primary.”  This means that he had cancer in his body but no one knew where the cancer started.  Specifically, he had cancer that had spread to his lymph nodes.  He had a biopsy of one of these lymph nodes.  Testing of the lymph node tissue showed that one possibility was that the tumor started in the pancreas.  But x-ray studies did not report a mass in the pancreas.  The x-rays showed the common bile duct was dilated, but no mass in the pancreas. The pancreas was never biopsied.

Why did the family request an autopsy?  The family wanted to finally find out where the tumor came from.  They were angry that no diagnosis had been made.

Why was the diagnosis not made here?  In this particular case, the tumor did not increase the size of the pancreas very much and, as mentioned, could not be seen on x-ray.  Some pancreatic tumors are not visible on x-ray.  These tumors are called “isodense.”  “Iso” means “same.”  So these tumors have the same density as normal tissue.  Approximately 10% of pancreatic tumors are isodense.  This means they cannot be distinguished in x-ray appearance from normal pancreatic tissue.

On the other hand, a tell tale sign of a pancreatic cancer is that it can pinch off the tip of the common bile duct and cause the rest of the duct to balloon out.  This happened here. But the finding was not considered in thinking about the possibility of a pancreatic tumor.

Lastly, the lymph node that was positive for cancer was in a unique place in the body.  It was above the left collar bone.  A lymph node here is called a “Virchow’s node.”   It is a tip off that the tumor could come from the pancreas.

So overall, there were three tell-tale signs to consider there might be a tumor in the pancreas:  the studies on the lymph node, the location of the lymph node, and the ballooned (dilated) common bile duct.  But because no mass was seen on x-ray, pancreatic cancer was not considered.  There was no consideration the tumor was hidden on x-ray because it was isodense; and, again, no biopsy.  This was a missed diagnosis.

How did the autopsy help?  The autopsy provided closure for the family because it answered an important question they wanted and needed to know: where did the tumor come from?  And it gave them a context for understanding the factors that went into the missed diagnosis.

Monthly Case: Second lung cancer

Safe Lung cancer

What is shown?  The picture shows a large tumor (oval) of the left lung.  The tumor is about 3 inches wide, from top to bottom. The tumor is right next to the main airway (arrows).

How did this patient die?  The lung cancer grew into the airway and blocked this patient’s breathing.

What type of tumor was this?  Tumors in the lung (and any organ) come in different types. This one was a “small cell carcinoma.”  It’s called this because of the small size of the cells seen under the microscope.  This is a very aggressive (fast growing) lung tumor.  Prognosis is commonly six to twelve months, even with treatment.

What was the clinical story here?  This patient was an elderly woman who had been a smoker and had emphysema.  She had had lung cancer in the other lung – the right lung – about ten years before. That right lung tumor was completely taken out by surgery and was not thought to have spread (metastasized) anywhere back then.

Why did the family request an autopsy?  The family wanted to know why there was a tumor in the left lung if the surgery “got it all out” from the right lung ten year ago.  This was confusing to them.  They began to feel mistrustful of how first treatment went.  Did they really get it all out?  Were they being dealt with honestly?  How could there be a second tumor in the lungs now?

What did the autopsy show?  The autopsy showed the past surgery on the right lung. About a third of that lung had been removed. There were normal healing changes and no “left over” tumor on that side.  The left lung tumor was found (described above).  There were two metastases in the liver and metastases in the bone marrow.

How did the autopsy help?  The autopsy allowed for a discussion of the biology of tumors and gave a perspective on the patient’s care.

Here were the possibilities to consider:

-That the second tumor was part of the first because some was, in fact, left behind after surgery ten years ago and had just kept growing.
This could not be.  Because small cell carcinoma is so fast-growing, if there were any tumor left from the surgery, it would have grown quickly at that time.  It would not grow so slowly to take ten years to come to medical attention.  Also, the tumor was in a completely separate lung.  Any tumor remaining on the right side would have grown in the right lung not the left.

-That there were tiny metastases at the time of the first surgery that were undetected but then grew and showed up ten years later. 
This is also could not be, again because small cell carcinoma grows so quickly it would not take ten years for metastases to come to medical attention.

That the new tumor was a complete different tumor from the first.
This can only be what happened here, because the above possibilities were ruled out.  Also, it is known that once a patient gets one lung cancer, they are at increased risk of a second, different lung cancer. It is something that is known to happen.

How did the discussion impact the family?  The information staved off anger towards the original surgeon.  The family could rest at ease knowing that the original surgery had, indeed, accomplished its medical goals.  The family did not need to feel any concern for any past medical mismanagement, error or dishonesty because there had been none.  Past treatments were completely unrelated to the new tumor.  This was an entirely new and different tumor.  The family had not known this could be a possibility.

The discussion also provided a reminder of the risks of smoking. 

Lastly, learning more about the biology of lung cancer gave the family a language and context to understand and talk about their loved one, each important in the grief process.

April Case: Liver metastases

Photo Cases Newsletter

Diagnosis: Liver Metastases

What is shown?
The picture shows two slices of the liver, each with a metastasis (arrows). These were the only metastases in the liver.

Where did the metastases come from?
They came from a lung cancer.

How did this patient die?
The patient died from the lung cancer (which blocked her breathing). The metastases did not cause the patient to die.

What is a metastasis?
When a tumor spreads through the blood to other areas of the body (where it takes hold and grows) this is a metastasis.

What do metastases mean for the patient in life?
Metastases mean the tumor is more advanced and often less likely to be curable. This is because surgery to remove the main tumor will still leave behind the metastasis somewhere else in the body. It also often means the amount of tumor is large. This can affect the success of other treatments (e.g., chemotherapy).

Is this always true?
No. Some tumors can still be curable even with metastases. It depends on the number of metastases, their size, where they are in the body, and if the anatomy allows for a surgical approach. Also the type of tumor matters. For example, some Hodgkin’s lymphomas, and a testicular tumor called seminoma can be curable even with metastases. Each case is different.

Is there any other reason to remove or treat a metastasis?

Yes, this can sometimes relieve symptoms (palliation).

In this case, how did the autopsy help the family?
Anxiety over possible suffering. The amount of tumor is often connected in the family’s mind to the amount of suffering. It is important for this reason to give an exact description of the amount of tumor, where it is located, and how it affected that organ. In this case, the majority of the liver was preserved, and the patient would not have had clinical liver problems. The metastases likely caused this patient no problems.

Guilt/anger over treatment issues: Families often need to know if the autopsy findings indicated that some treatment may have saved the patient “if only” it had been tried. They may feel guilty for not having “tried harder,” or angry with the medical system for the same reason. Here, the patient’s lung tumor overwhelmed her breathing and this was the cause of death. No treatment approach dealing with the liver metastases would have helped – they were not the cause of death. This relieved the family from their worry about the liver metastases.

Summary. The finding of metastases allowed for a discussion of the progress of the disease, but did not at all suggest suffering or a missed opportunity for treatment. This allowed the family to proceed with a sense of calm, peace, and understanding.