Refresher Course

Now, you too can be on your way to becoming an oncologist! (Or, at least sound like one.) Impress people at the dentist's office, Jazzercise, and fondue parties with your new vocabulary!

Here's a handy reference guide for those of you who want to know what's going on, but don't want to go back and start from the beginning.



The Treatment Plan we received from Duke:

"Your child has been diagnosed with Wilms tumor. Wilms tumor is a type of cancer that occurs in the cells of the kidney. Your child's disease is considered higher risk because there are tumors in both kidneys (bilateral Wilms tumor).

"The most common way to treat bilateral Wilms tumor is to give two common anti-cancer drugs (chemotherapy with Vincristine and Dactinomycin) to shrink the tumors and then to do surgery to remove the tumor tissue. In some cases, an entire kidney and part of the other kidney are removed. Sometimes radiation therapy (treatment with high energy X-rays) is also done.

"There is some recent evidence that giving one extra drug (total of 3 drugs) may help get rid of the tumor cells while saving the largest amount of normal kidney tissue. This would not be considered 'standard' therapy."


The drugs:

1. Vincristine Likely side effects include hair loss, reversible neuropathy, and constipation.
2. Dactinomycin Likely side effects include nausea, vomiting, hair loss, and a drop in white blood cells, red blood cells, and platelets.
3. Doxorubicin Likely side effects include nausea, vomiting, hair loss, a drop in white blood cells, red blood cells, and platelets, and damage to the heart muscle.
   

(I will spare you the "less likely" and "rare but serious" side effects. Trust me on this one.)


The port:

Eve's port is a long, soft tube (central venous catheter) that was inserted into a large vein that leads into the heart. It is completely implanted under the skin. It is used to take blood, give drugs and IV fluids, and transfuse blood. We put Emla cream over the bump in Eve's chest where the port is to numb the skin before the port is accessed. The port is a blessing and a half, and then some.


Bone Marrow Suppression:

The bone marrow is where white blood cells, red blood cells, and platelets are made before they are released into the bloodstream. Chemotherapy works by blocking cell growth which includes both cancerous and normal cells. This causes low blood counts.

1. White blood cells (WBC) fight infection.
2. Red blood cells (RBC) carry oxygen to the body's tissue.
3. Platelets (Plt.) prevent bleeding.

Eve must have an Absolute Neutrophil Count, or ANC, of 750 or greater to get Dactinomycin and Doxorubicin. The ANC is an estimate of her body's ability to fight infection. If it is under 500, she is considered neutropenic, which means she is at a higher risk for infection. The ANC is calculated using a sub-type of white blood cells called neutrophils, which are most important in fighting dangerous bacterial infections, and bands, which are immature neutrophils.

For anyone who likes to geek out to this type of thing, the equation is:

WBC x (%Neutrophils +%Bands) = ANC

Although Matt likes stuff like this, I am happy the doctors at Duke always do the math for me on chemo days. On the days I have to take Eve into her pediatrician's office for those in-between chemo blood checks, I call Matt on my way home and rattle off some numbers and let him compute to his heart's content. He and Texas Instruments go waaaaay back...


Our home pharmacy:

1. Septra, twice daily, three days a week, to prevent pneumocystis pneumonia.
2. Miralax, daily, to prevent constipation.
3. Lisinopril, daily, to regulate blood pressure.
4. Zofran, thrice daily, for 48 hours following Doxorubicin and Dactinomycin administration to prevent nausea.
5. Reglan, to prevent nausea if Zofran doesn't work.
6. Benadryl, to be given 30 minutes before Reglan.
7. Emla, to numb port site 30 minutes before access.
   
8. Flintstones Vitamins, because it can't hurt, right?

Scans and tests:

1. Complete Blood Count (CBC) gives us the number of WBC, RBC, and Plt. This test is done before chemo and a few days after chemo.
   
2. Differential indicates the percentage of each sub-type of WBC. This is done with the CBC.
   
3. Ultrasound (U/S) uses sound waves to detect changes or abnormalities. Eve has had two of these; the first time showed the presence of tumors and the second time showed how much they were shrinking from the chemotherapy.
4. X-ray is electromagnetic radiation. Eve had an x-ray done after her port surgery to make sure it was placed correctly.
   
5. CT Scan is an x-ray test with a special machine that rotates around the patient, giving cross-section pictures of the body. For Eve, this provides better imaging of the kidneys and tumors than an MRI. She is sedated for these scans so she will be still.
   
6. Magnetic Resonance Imaging (MRI) uses magnetic waves to see inside the body. For Eve, this gives better images of the blood vessels inside of the kidneys which is important for the surgeon. She is sedated for these scans so she will be still.
   
7. Echocardiogram (Echo) is an ultrasound of the heart. Eve has had two echos- once before the start of chemo and another at week 7 to make sure her heart is okay from the Doxorubicin.
   
8. Electrocardiogram (EKG) studies electric signals of the heart. Eve has had one EKG prior to the start of chemo.

(Did you make it this far?)


After the surgery:

We wait for the pathology report to come back from the tumors. The doctors need to see how the tumors responded to chemotherapy in order to decide what the therapy post-surgery will be. There will definitely be more chemo and perhaps some radiation.




I hope you got all that. There will be a test in the morning, folks.