Dave and I consulted with Dr. Patel after yesterday’s PET scan and he told us pretty much what we’ve been expecting, i.e. while the lymphoma has definitely regressed, there’s no way to tell from the scan if it’s “gone” because Dave’s sarcoidosis lights up on the scan just like lymphoma would. There are several key indicators that the lymphoma might be gone, like a much smaller spleen, but the answer to the question, “is Dave’s lymphoma in complete remission?” is still a definite “maybe.”
In an effort to get a more satisfying answer, the “Tumor Board” at Swedish is going to meet with Dr. Patel, Dave’s radiologist, and a pathologist, pour over Dave’s before and after scans, and try to select an accessible lymph node for excision and analysis. Their selection process will be guided by a desire to minimize risk (since removing a lymph node is a bigger deal than a simple needle biopsy) as well as a desire to select that lymph node most likely to unambiguously rule out lymphoma. (My guess is they’ll grab a couple while they’re in there. You’ve got thousands of them after all.) Surgery will probably happen around 7/27; the biopsy will probably take another week after that.
Meanwhile, Dave’s oxygen saturation was 97 to 98, which is good, but he’s noticed that he is often short of breath. I thought that this, along with his odd sweating, runny nose, fatigue, and the flare up of eczema on his ankle might be because he finished his prednisone and his adrenals, which regulate inflammation through cortisol, might be temporarily suppressed (as happens with protracted corticosteroid use), but Dr. Patel disagreed. Dave admits he’s put on some weight in the last couple weeks, and Dr. Patel believes that as he continues to challenge his cardiovascular system with increasing activity, that he’ll find his breathing issues will improve.
Dave’s biggest complaint continues to be his neuropathy; I’ve spoken about that at length in prior posts. The nurse who took Dave’s vitals said it might never go away. I personally find that to be very unlikely. Everything I’ve read and experienced indicates it’s almost always temporary, particularly if it doesn’t progress to motor issues, which it hasn’t, and indeed, Dave has already seen some improvement.
Both Dave and Sarah noted that Dave’s hypertension has returned. His reading this morning was 140/100; hers was 157/90. Sarah advised Dave to check with his primary care doctor, Dr. Moen, about restarting his lisinopril. Dr. Patel noted that prednisone can increase blood pressure, but doesn’t give undue weight to that hypothesis in this case given Dave’s history.
The pneumonitis has clearly improved (per PET) and LDH is stable at the top end of the normal range.
Consensus seemed to be that it would be worthwhile making an attempt to treat the sarcoidosis, if for no other reason than to minimize confounding variables at follow-up. Dr. Patel previously recommended a rheumatologist, though any drugs s/he might prescribe would very likely be similar to the ones that were in Dave’s chemotherapy protocol, including Rituxan, a drug to which we assumed he was allergic — though according to Dr. Patel, the pneumonitis we blamed on Rituxan could just as well have been sarcoidosis too. Either way, a consult is probably worthwhile, and perhaps some self-education about environmental factors or dietary issues that could modulate symptoms. I wouldn’t be surprised if there was a relationship between A1C and flare ups, since sugar is well known to be pro-inflammatory.
As for Dave’s weird sweating, Dr. Patel says that chemo affects sweat glands. Some people even stop sweating during cancer treatment. Then when treatment stops they resume sweating, and there can be temporary changes.
Dave’s PSA is undetectable (< 0.1) but Dr. Patel would still like him to check in with Dr. Lily, who has recently moved to Pac-Med.
Dave’s lymph node surgery is tentatively scheduled for July 27th.