I spoke with my husband's surgeon yesterday after faxing this letter to him:
I hope this letter finds you well. I have some post-surgical follow-up questions, if you don’t mind.
I am faxing you the safety sheet for the 40-80 TLC75 staples that are present in M----’s abdomen. Last week, we sent requests for clarification to the SVMC Radiology Department and to Dr. Ives regarding the conditional safety of performing an MRI on a patient with implanted TLC75 staples. Since we have not received responses from either the Radiology Department or Dr. Ives, we are hoping that you might be able to advise us regarding the following requirements for M-----’s liver MRI:
• Static magnetic field of 3 Tesla.
• Spatial gradient field of 720 Gauss/cm.
• Maximum whole body averaged specific absorption rate (SAR) of 2.7 W/kg for 15 minutes of scanning.
If not, then he cannot have an MRI.
Also, M----'s PET/CT scan report states that there are “multiple small surgical clips within the central abdominal mesentery.” I just want to make sure that these are the aforementioned TLC75 staples that you used to create the anastomosis and not something else. This information would be greatly appreciated.
Next, M----'s PET/CT scan report states that "there is a hypermetabolic focus within the proximal transverse colon. This is worrisome for an additional colon carcinoma." The phrase "hypermetabolic focus within the proximal transverse colon" would be an objective fact that presumably could be confirmed by any other competent viewer of the scan CD, but the sentence, "This is worrisome for an additional colon carcinoma", is an evaluative comment that may or may not be made by another radiologist viewing the very same PET scan CD.
In my opinion, this particular evaluative comment is a bit out-of-place because it is forcing the reader to accept the radiologist's interpretation. A better way to state this kind of reality would be to say something like: "This suggests the possible existence of a new neoplasm in the transverse colon, but it does not exclude the possibility that the increased uptake is due to a benign inflammatory condition linked to the recent hemi-colectomy surgery".
From what I understand, it should be up to the surgeon and the oncologist to look at the range of objective findings from the PET scan and to make their own subjective evaluations of what the increased metabolic activity might mean. M---- has an appointment with Dr. Ives this Thursday.
My own laymen's view of the situation is that the left hemi-colectomy must have produced some degree of trauma in the area of the transverse colon, since the surgery required the transverse colon to be moved away from its anchored position in the upper abdomen so that the distal part of the transverse colon could be stretched enough to reach and join the rectum in the lower pelvic area. Thus, prior to surgery the transverse colon was more-or-less horizontal in orientation in the upper abdomen, but now it is probably oriented at an angle in such a way to span the 35 cm where the resected section of colon used to be.
We know this to be the case from our discussions. All of this would presumably produce some degree of injury to the transverse colon and some degree of persistent inflammation during the recovery period, especially if there is any persistent tension in the segment of the colon that now leads down to the anastomosis.
Further, M---- had just recently finished the course of antibiotics you had prescribed for him. The side effects of the cephalexin have only just begun to diminish. Also, M---- had not had a bowel movement for nearly 18-22 hours at the time of the PET/CT scan. Since peristalsis can increase uptake of 18F-FDG and create “hot spots,” his digestive activity in the transverse colon could also have caused this hypermetabolic focus, particularly because of its location as precursor to the anastomosis. We hope that the above very benign conditions are the case.
However, there are other, more serious, non-cancerous conditions that could cause the hypermetabolic focus that I believe could be consequences of the surgery. These include, but are not limited to: suture granuloma, abscess, mesenteric fibrosis, reactive lymphoid hyperplasia, histiocytosis, and a reaction to foreign bodies such as staples. His surgical incisions are still healing and the central one at the navel has not yet scabbed. However, from what we understand, that process can take 6-8 weeks to complete.
At Dr. Seyferth’s appointment approximately 10 days ago, he asked us when M----'s next post-surgical follow-up appointment with you was. He appeared to have the impression that one was needed, so I stopped at the General Surgery office to inquire. We never heard back about that.
In sum, to recap, we would greatly appreciate your input as to the following:
1. Will the MRI at SVMC meet the three listed conditions?
2. Will it be safe for M---- to have an MRI June 30th, five weeks post-surgery?
3. What would be your impression of the PET/CT scan finding?
4. Are those "clips" on the PET scan the staples, or does M--- have clips in him?
5. Should M---- have another surgical follow-up appointment? If so, we would greatly appreciate it.
As always, we are deeply thankful for your care and attention.
Dr. Surgeon kindly reviewed the PET scan for us (he's awesome!). He clarified that he had examined the transverse colon externally with his eyes and hands, squeezing it to feel for any masses. He did not feel anything but equivocated about the possibility that there could be more cancer, saying that just because he did not feel anything it does not mean that something isn't there. He emphatically advised further testing for confirmation and said that the upcoming MRI (scheduled for June 30th) might give us enough information to form an opinion.
I explained that my husband refuses any procedure that will require him to have a ileostomy/colostomy "bag for life." Dr. Surgeon assured me that if he was to have another surgery on this area of the colon, which is apparently in the region of the gall bladder, that he would require a "J pouch" but no lifelong stomy. Dr. Surgeon would not be performing this additional surgery as it is beyond his expertise and would be referring us to a CR surgeon.
Apparently, M---- has some clips that we had not been informed of, so I looked up their safety profile. They are the same as the staples. He avoided saying anything about the safety of the MRI at exactly 6 weeks post surgery. Since he is not the doctor ordering the test, this is understandable.
4/12/17 - Dx CC, age 45
5/19/17 - Laparoscopic left hemi
Tumor size: 5 x 4 x 1 cm
Tumor grade: low
T3 N2b M1a
Stage IV A
Positive lymph nodes: 9 out of 54
CEA: 1.4 Pre-op(8weeks from surgery); 2.1 2 days Post-op
Tumor extension: Invasive through muscularis propria into pericolic fat
Proximal margin: >14 cm Distal margin: >14 cm Mesenteric margin: 3 cm
Lymphovascular invasion present
Lynch - unlikely
Immunohistochemsistry: Normal expression of MLH1, MSH2, MSH6, and PMS2