Tuesday morning we had an appointment with Dr. Pene scheduled for 10:15 to check Shad's counts and find out his scan results. About 7:30 that morning I got a call, and recognized the number as the hospital. I answered and the lady identified herself as Margie, Dr. Ignacio's intern. She let me know that he wanted to meet with us after we met with Dr. Pene. (Dr. Ignacio is the pediatric surgeon we have worked with previously.) We knew that one of the options after scans was surgery, and this phone call pretty much guaranteed it was going to happen.
Shad and I got up and got ready, ate some breakfast, and then left to pick Trevor up from work. Once we got him we headed over to the hospital. We were there early for once, and of course that was the one time everyone was running a bit behind schedule. We ended up meeting with Dr. Pene before Shad was accessed because Jo was busy. He let us know what the scans showed, and his recommendations. First off he told us that Shad's AFP before the last round of chemo was 30, and after that round of chemo his AFP was still 30. This isn't necessarily bad, but it shows the cancer isn't responding as quickly to the chemo as it had been. Next, he let us know that Shad had two spots that had taken up the contrast on the pet scan. One was in his pelvic area (the one they had seen at the start). It was a bit smaller and the urologist felt he could get it with surgery. The other spot was a 4mm mass in his left lower lung. It has been there for awhile apparently, but has never taken up the contrast so it hasn't been a concern. This time it did take the contrast so they want to get it out. It could be nothing, an infection, something else, or it could be cancer. They plan to send it to be biopsied to find out either way. Dr. Pene didn't know much else about the surgeries, and told us we would be meeting with the surgeons to get all that info. They wanted to do the surgery on Thursday, but his counts weren't high enough. We were kind of relieved because we really wanted to for sure be able to be home for Christmas. The surgery is now tentatively scheduled for the week of the January 6th.
Next we talked to Dr. Ignacio. He pulled up the scans and showed us this tiny little spot that is what they are concerned about. His plan is to do thoracoscopic surgery (more info at the link), where they basically make three small holes and use a scope to remove the mass. They are planning to take a small wedge out of his lung which will include the mass, and will then be sent to biopsy. He let us know the risks, and the recovery. Basically since the mass is so small they may not be able to find it with the scope. If that happens he will try to feel it with the instruments. If that doesn't work then he will have to cut his chest to visually see the are and feel/see the mass. He will have a chest tube after surgery to allow time for the lung to heal and to make sure no air gets into the area around his lung. He estimates he will have it in for about 3 days. Because of the chest tube he will be in the PICU after surgery rather than on the regular pediatric floor. When they remove the chest tube they will give him a local anesthetic, but he will be awake. If his lung collapses once they pull it out then they will have to put it back in, but they will sedate him before putting it back in if that happens. The biggest risks involved are if his lung collapses after the surgery, and the possibility of a nicked diaphragm which is not good. The chances of that happening are small though.
After meeting with Dr. Ignacio we walked over and talked with Dr. Christman the urologist who will be performing the second part of the surgery. We have worked with him before and really like him. He explained how they will do the surgery for the mass in his pelvic area. Basically they lay him on the table on his back, push his feet up almost into the birthing position, and then cut the section of skin between his scrotum and his anus (perineal incision). They will go through the tissue and muscle there to get to the area where the tumor is and then remove as much of the affected tissue as possible. This surgery involves a lot more risks. It is possible that it could cause erectile dysfunction (could possibly be fixed at a later date (much later)), urinary incontinence (there are procedures to help correct it if necessary), damage to the rectum (would be repaired during surgery and shouldn't have long term effects, could possible have to temporarily redirect bowel movements to bag outside the body to allow time to heal). This is definitely the more intense surgery, but if everything goes according to plan, it will have a much quicker recovery time than the chest surgery.
Right now the plan is to have the surgery the week of the 6th. Once the surgery is complete we will be in the PICU for recovery for at least 4 or 5 days. Once he is well enough to go home we will do so. He will be limited a bit in his physical activity for a couple weeks after that. Stay home, no school, no contact sports, no park trips etc. Once he has recovered from the surgery he will have at least one more round of chemo. Dr. Pene wants to see what happens to his AFP after surgery and then he will decide if he wants to do one or two rounds of chemo.
