Day 3 Heme/onc + ob/gyn (6/15/16)

Today we rounded on the same patients again. Since cancer is more of a chronic progressive disease and the chemo treatments take a few cycles to show any signs of working, nothing really changed since we last saw them.

However, today, the patient with hepatocellular carcinoma had a family member visit, so Dr. Chen had to give her the bad news about his prognosis. He was clear and concise in telling her that the patient has been unconscious / comatose and is unlikely to improve. She started sobbing and it was heartbreaking to see. Dr. Chen said that it’s always hard to do even now, despite the fact that he’s been doing this for years. That’s is both a comforting and uncomfortable thought. On one hand, it’s good that even after all this time, Dr. Chen is an example of a physician hasn’t lost his sense of empathy for patients and their families despite being in a specialty that requires him to give bad news quite often. On the other hand, that also means that it will never get any easier. I don’t know how he deals with it. I don’t think I could.

In ob/gyn, I was in the outpatient clinic this time. A majority of it was pap smears, but I also got to see some interesting things, such as a myoma on ultrasound, a cervical polyp, a hysterosalpingogram (HSG), and a 28 week old fetus on ultrasound.

I learned that myomas are usually benign and are only considered for removal according to these  criteria:

1. If the myoma is >5 cm (but this is not absolute. If it’s not causing any other problems, it doesn’t need to be removed either)
2. If the myoma is symptomatic (which include pain, constipation, abnormal bleeding)
3. If the myoma is growing rapidly

Myomas are often hormonally-related and will often shrink when the patient hits menopause, so if the patient is around 45-50 years old, instead of choosing surgery, they can also just treat the symptoms until then.

(The patient had a rather large myoma but it wasn’t causing symptoms yet so Dr. Cao didn’t think it should be removed)

The HSG was test used to determine if there is an anatomical reason for infertility. Dye is injected into the uterus and fallopian tubes to check for blockages. The procedure looked incredibly painful though because not only was the speculum rather large, she also had these tenaculums clamped onto her cervix to keep it open:

(Like pointy medieval torture devices)

I felt bad for her. It seems like most gynecological procedures are rather uncomfortable for the patient. Even pap smears produce some discomfort for a lot of patients, often due to the speculum. Isn’t there a better way of doing this?

Still, the HSG itself produced some pretty cool images. And the patient got some good news out of it: she had no obstructions in her fallopian tubes and everything was anatomically normal.

(It’s not typically this clean of an image though. The timing is hard to get right)

After even more pap smears, we ended the day with a check up on a 28 week old fetus.

Dr. Cao measured the biparietal diameter (BPD) and abdominal circumference (AC) of the fetus in order to estimate the weight. He then checked to see if everything else was developing normally, such as the heart, face, spine, etc. The parents were a little worried about the baby’s weight, so they were glad to hear that everything was completely normal. What a great way to end the day.

Day 2 Heme/onc + Pulmonology (6/14/16)

Today Dr. Chen was working in outpatient so he was going through patients very quickly. Despite this, he still tried to give me a brief description of what was going on afterwards, which I greatly appreciated.

Patient 1: Breast cancer being treated with adjuvant therapy. Experiencing nausea.

Patient 2: Lung adenocarcinoma in upper left lobe. His lung function was too poor for surgery so he was being treated with radiation instead.

(Something like this, but a little bigger)

For review on lung cancers: adenocarcinomas are not usually associated with smoking and are a non-small cell lung cancer, typically treated with surgery. Incidence is increasing around the world and Dr. Russell mentioned that it may be related to air pollution. Adenocarcinomas are glandular and exhibit a lepidic growth pattern.

Patient 3: Unsure of what sort of cancer she has, but she just had a port-a-catheter placed in her chest and mentioned that it was hurting. Dr. Chen mentioned that it does carry a thrombosis risk, but it makes it easier to inject chemo drugs repeatedly. This is especially important for drugs such as anthracyclines, which can cause debridement at the site of injection.

Patient 4: Gastric cancer with liver metastasis (and pancreatic involvement?). He doesn’t seem to be taking his medications correctly. I heard that gastric cancer is fairly common in Asians, but this is the first case I’ve seen so far.

Common metastasis sites of gastric cancer: liver, lung, peritoneum

Patient 5: I thought this one was interesting. A younger patient with a tracheostomy tube came in with his parents. He spoke in a hoarse whisper and mentioned that he just had a procedure in a which his stomach was removed and his intestines were connected to his esophagus. I thought that he was a cancer patient, but it turns out that he was referred to Dr. Chen for his anemia. When Dr. Chen explained that he would need to do a blood draw for a CBC and recommended hospitalization for follow-up tests, they all seemed unhappy about it, with his parents exclaiming that he’s so pale already, he couldn’t have enough blood for all that. They did have a valid point. If he’s severely anemic, taking more blood from him hardly seems helpful. However, without the blood draw, Dr. Chen can’t really determine what kind of anemia the patient has.

I wonder what it could be? His parents both seemed to be healthy, so it’s probably not hereditary. Since his stomach was gone, perhaps he had a nutritional deficiency (i.e. iron, vitamin B6, folate, or B12 deficiencies). They didn’t mention how recently the procedure was done, but perhaps there is bleeding, infection, or hemolysis from the surgery. There are only so many reasons why he would need such a radical procedure in the first place and one such reason would be stomach cancer. Perhaps his anemia is from cancer or drug treatments. This is definitely not something that can be diagnosed through history and physical alone.

Patient 6: B type breast cancer (which means it’s estrogen receptor positive and thus can be treated with hormone therapy drugs that lower estrogen). Strangely enough, her cancer started off as HER2 negative, but 3 years later, she developed a metastatic RLL lung lesion that was HER2 positive. Dr. Chen mentioned that sometimes, cancers do change after metastasis. Because now she has a HER2 positive lesion, he started her on trastuzumab (in combo with other chemo drugs), which targets HER2 by preventing ligand binding to the receptor. In Taiwan, the insurance covers it for 1 year, despite the fact that it’s incredibly expensive: 1,000,000 NTD/year. Dr. Chen mentioned a study trial called HERA confirmed 1 year of Herceptin (trastuzumab) treatment as the standard of care because there was no difference in disease-free survival rates when treated for 2 years compared to 1 year.

Common metastasis sites of breast cancer: bone, brain, liver, lung

Patient 7: HER2 positive breast cancer treated with radical mastectomy, paclitaxel, and herceptin/trastuzumab.

Patient 8: Lung cancer with metastasis to at least three other locations. Placed on palliative care.

Common metastasis sites of lung cancer: adrenal gland, bone, brain, liver, other lung

Patient 9: Mentally disabled patient who relies on brother as caretaker. Currently treated with an oral chemo drug, 5-FU, as opposed to a more standard IV drug due to the limitations of his caretaker. 5-FU has a <4-5% survival rate for his cancer (which Dr. Chen didn’t get to specify because the next patient had come in).

Patient 10: Triple negative breast cancer with metastasis (this kind has the worst prognosis because it doesn’t have estrogen receptors, progesterone receptors, or HER2, so there aren’t really any specific targets for the drugs). Was being treated with paclitaxel, but she couldn’t tolerate the side effects and developed leukopenia.

Common metastasis sites of breast cancer: bone, brain, liver, lung

Patient 11: Thymic cancer/thymoma with spread to pericardium and pleural cavity, so surgery was not feasible. The remaining choices were chemo or radiation, but both tend to have a poor response. They chose radiation. And to their surprise, there was shrinkage! It’s stayed the same size for 2 years now. This man was incredibly lucky. Cancer is such a tricky disease; one can never fully predict how it’ll turn out. This was also a fairly uncommon cancer as well. What I found interesting was that this patient was at least middle aged, which is the group most commonly affected. It was confusing to me because I thought that with the process of thymic involution (when the thymus starts shrinking and being replaced by fat starting from adolescence), thymic cancer would be more likely in children or adolescents. It’s also associated with myasthenia gravis, but Dr. Chen didn’t mention anything like that when introducing the patient. 

Patient 12: Malignant lung adenocarcinoma with EGFR mutation.

Patient 13: Estrogen receptor and progesterone receptor positive breast cancer (which indicates a worse prognosis) with metastasis to the lung, liver, and brain. She suffers from dyspnea, has a pericardial effusion, and diplopia from the brain metastases in her temporal and parietal lobes. She hasn’t been responding to chemo and needs radiation therapy.

Common metastasis sites of breast cancer: bone, brain, liver, lung

Patient 14: Recurrent microcytic anemia. Dr. Chen suggested endoscopy to check for GI bleeding.

Patient 15: Lung squamous cell carcinoma with a mass outside of the chest wall at the level of T4. Treated with cisplatin but his kidneys started failing, so he was treated with aggressive hydration to reduce the kidney damage and then switched to gemcitabine and carboplatin, the 2nd generation version of cisplatin that is less nephrotoxic.

For review: Squamous cell carcinomas are associated with male smokers and can be keratinized. They can release parathyroid hormone-related peptide, resulting in hypercalcemia.

That was all for the day. Dr. Chen had been sighing a lot during this time; I’m sure that in the field of oncology, the emotional toll must be incredibly heavy.

Since Ob/gyn didn’t have clinic scheduled for the afternoon, I joined Emily for pulmonology.

We started off in the ICU to see a patient who was not in the best shape. He had a CXR showing bilateral infiltrates and round cysts/cavitary lesions, metabolic acidosis, hypoxia (pO2 ~75%), and a creatinine level above 20 when he first came in. They gave him emergency dialysis because with a creatinine level that high, it was a sign that he was in acute renal failure. Since his O2 levels were so low, they also placed him on a 100% O2, which got him up to a barely acceptable pO2 of 92%. They weren’t sure what the cysts/cavitary lesions were from, and suspected pneumonia, so he was placed on levofloxacin and tapimycin antibiotics for now. A nephrology consult was called and they noted nephritic syndrome based on the RBC casts found in his urine. With his kidneys and his lungs failing, he wasn’t likely to live much longer. 

It’s interesting how much we can learn about each patient’s personal lives from the brief time we deal with them at the hospital. This patient, for example, hadn’t seen his wife in about a decade, and yet she signed a DNR for him. He was lucid enough to veto that at least. Obviously, they are not on good terms. Most people do not have get to see a private and personal matter such as this, but as physicians, we get to see our patients at their worst and in their most vulnerable states. It’s a privilege.

The rest of the time, we saw pleural effusions, pneumonia, COPD, and lung tumors. One patient had a tumor that obstructed the bronchus and caused the right lung to collapse. The heart ended up shifting all the way to the right side of the chest!

That was basically the only exposure I was going to have to pulmonology this whole month, so it was well worth it join them for that afternoon. It’s always interesting to see various specialties in action. Maybe next time I have a free afternoon or morning, I’ll check out something like EM.

Day 1 Heme/onc + Ob/gyn (6/13/16)

In the morning, I was with Tim at the heme/onc department, shadowing Dr. Chen. It seems like there were quite a few metastatic cancers, mostly to the lung. I was curious about this and ended up looking it up online afterwards. There are some theories about why there seems to be a preference for certain organs (a phenomenon called organotropism). One is that these are sites that are easier to reach by mechanical means by anatomical proximity or through blood (which doesn’t always explain some examples, such as the fact that lung cancers often metastasize to adrenal glands and ovarian cancers often go to the lungs). Another is that these sites are similar environments to the region where the cancer cells originated (for example, melanomas spread to the brain because they arise from the same embryonic cell lines, and breast cancer cells that use calcium in breast milk spread to bone to use the calcium there). It’s actually a pretty interesting topic that I might want to read up on later.   

But I digress. We went through the patients all pretty quickly but these are the few scribbled notes on the patients we saw:

Patient 1: Neuroepithelial carcinoma (which we haven’t learned about yet and looks really complex because of the many different cell origins and grades) with lung metastasis treated with cisplatin, 5-FU, paclitaxel, and more recently methotrexate. Her WBC count was very low, 1500, so she was also treated with G-CSF and prophylactic antibiotics. As a side effect of the MTX, she also had mucositis. She also has a fever with unknown cause, but pneumonia is suspected based on the appearance of the CXR. However, some other physicians that Dr. Chen consulted with believe it’s actually just tumor fever (which apparently occurs in 7-31% patients with malignancies and is likely caused by cytokine release due to cancer-related mutations or necrosis).

Patient 2: Diffuse large B cell lymphoma (DLBCL). She was treated with 6 cycles of rituximab (targets CD20) and went into complete remission, but now a new tumor was found in her oropharynx. She was treated with radiation, but ended up developing a candida infection that is likely catheter related. She seemed to also be taking glutamine and I wasn’t sure why until I later saw a poster saying that glutamine can polarize cancer from healthy cells. I couldn’t read the rest because it was in Chinese, but a quick search on pubmed reveals that glutamine supplements in cancer patients may be beneficial because many tumors are glutamine traps and end up leaving the patient glutamine-depleted. 

For review, DLBCL is a lymphoid, non-Hodgkin lymphoma that is considered an aggressive cancer. It’s CD20+, CD30+, CD5+, and BCL6+, which explains why rituximab would work. The usual treatment we were taught for DLBCL is R-CHOP: rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone. Dr. Chen only mentioned rituximab, but it seemed to have worked really well until her new tumor was discovered. I’d imagine that this would be incredibly frustrating for Dr. Chen to see a patient come back after complete remission. It must also be frightening for the patient as well, knowing in the back of their mind that their cancer might come back at any time. This is probably a field I would not enjoy much. I don’t have the stamina to fight an uphill battle for so long. 

Patient 3: Terminal pancreatic cancer with a prognosis on <6 months. He was treated with surgery and adjuvant therapy, but it recurred in the abdominal wall. He was then started on gemcitabine, but had no response, only suffering from decreased appetite, abdominal distention, nausea/vomiting, cachexia, and a candida infection. He was given parenteral nutrition but Dr. Chen mentioned that patients with his kind of cancer often die from malnutrition or infection.

Common metastasis sites of pancreatic cancer: liver, lung, peritoneum

Patient 4: Metastatic (to the lung?) colon cancer with k-ras mutation (and presumably also a VEGF mutation because of the treatment choice even though Dr. Chen didn’t specifically mention it). Treated with a VEGF mab (bevacizumab) for 6 cycles. New symptoms of nausea.

Common metastasis sites of colon cancers: liver, lung, peritoneum

Patient 5: Atypical presentation in that she presented with exertional dyspnea, so they originally thought it was pulmonary TB. Also had constipation and bloody stools for weeks, so they found that it was sigmoid colon cancer with metastasis to lungs. It’s nearly obstructing the bowels so they suggested colostomy but she refused because she thinks it means it’s a poor prognosis. 2 cycles of chemo so far resulted in shrinkage. Dr. Chen later mentioned irinotecan as a colon cancer drug that can also cause diarrhea, so I’m not sure if that was the drug used for this patient or not. 

Common metastasis sites of colon cancers: liver, lung, peritoneum

Patient 6: Hepatitis B virus related hepatocellular carcinoma. Usually treated with surgery, but this has already progressed too far. Treated with a drug that can prolong life for 2 months with increased GI bleeding risk, but it’s enlarging still. Dr. Chen mentioned that HBV and HCV related hepatocellular carcinoma is common in Taiwan because many people are carriers (10% for HBV, 15-20% for HCV).

Patient 7: Lung adenocarcinoma with EGFR mutation. Treated with erlotinib but it progressed after 6-8 months. Suspected RLL pneumonia too so she’s being treated with a broad spectrum antibiotic. Dr. Chen noted shallow and low respiration, so he ordered an ABG to check for CO2 retention. Results showed a pCO2 >100 mmHg (normal is 35-45 mmHg). 

Common metastasis sites of lung cancers: adrenal gland, bone, brain, liver, other lung

Patient 8: Cervical cancer recurrence with retroperitoneal metastasis. It was treated with surgery >10 years ago but came back last year. Enlarged lymph node on left side of neck. Also got sepsis and is being treated with antibiotics.

Patient 9: Lung adenocarcinoma with pericardial and pleural effusion. Patient complained of inflammation at site of IV catheter in arm.

Common metastasis sites of lung cancers: adrenal gland, bone, brain, liver, other lung

Patient 10: Severe iron deficiency microcytic anemia. Complains of hypogastric pain, found an ulcer, treated with proton pump inhibitor.

With this, I realized I needed to review chemotherapy drugs because I barely remembered much about them. Of the ones mentioned:

Cisplatin: a platinum analog and alkylating agent, major side effect to watch out for is nephrotoxicity. Dr. Chen mentioned that Taiwan’s insurance only pays for the less toxic 2nd generation version, carboplatin, when the patient starts showing signs of renal damage.

Methotrexate: S phase specific folate analog, inhibits DHFR, can result in mucositis

5-FU: pyrimidine antagonist that blocks thymidylate synthase

Gemcitabine: also a pyrimidine antagonist, Dr. Chen mentioned that this is standard for metastatic pancreatic cancer.

Paclitaxel: a taxane made from the bark of the Pacific yew tree, blocks microtubule disassembly, M phase specific, can result in peripheral neuropathy, usually used for breast, ovarian, and lung cancers

Irinotecan: a camptothecin made from the Mappia Foetida plant, inhibits topoisomerase I

Cetuximab: EGFR targeting mAb, usually used for colon cancer

Bevacizumab: VEGF targeting mAb, inhibits angiogenesis

Rituximab: CD20 targeting mAb, treats non-Hodgkin’s B cell lymphomas, B cell leukemias

Erlotinib: EGFR targeting tyrosine kinase inhibitor, usually for non-small cell lung cancers

(A – ligands usually bind to the EGF receptor, leading to dimerization and phosphorylation of intracellular domains, eventually leads to K-ras activation and activation of growth factors, B – mAbs such as cetuximab bind to the receptor to prevent the ligand from binding, C –  tyrosine kinase inhibitors such as erlotinib prevent phosphorylation)

Screening for mutations (usually amplifications) for EGFR and VEGF are therefore very important for determining which drugs to use. EGFR is especially important because aberrations occur more often in Asian populations (35% compared to the usual 10-25%). HER2 is also necessary in determining treatment for breast cancer, but we haven’t seen any cases of that yet, surprisingly enough.

Even though mabs are expensive, we learned that they are still paid for by the government, but only for a limited period of time. For example, cetuximab is approximately 180000 yuan/month and is only covered for 6 cycles. Dr. Chen estimates that less than half of patients need it for more than this amount of time, however.

Later in the afternoon, I got to watch a myoma removal through total hysterectomy. It was large, maybe about the size of a papaya, so Dr. Cao, the ob/gyn, said that it could not be removed laparoscopically. He made a midline cut on her abdomen and dissected until he reached the uterus. First, he cut the round ligament because it contains no blood vessels, then the suspensory ligament of the ovary (which Dr. Cao called by another name, the IPL / infundibulopelvic ligament) which contains the ovarian artery and vein. Because the patient was pre-menopausal, he opted to leave the ovaries, so that she could still produce the proper hormones. Next, Dr. Cao cut the uterine artery and vein, and took the uterus out along with the cervix.   

This was amazing to watch. I had never seen such a huge tumor and I can’t believe the patient had been carrying that thing around in her body. I was fascinated; I realized that I would probably enjoy ob/gyn a lot more than I would have expected. What I like is how they get to interact quite a bit with their patients but also perform surgeries, which sounds like a good mix of surgery and medicine. I may actually end up liking this specialty (up until I witness a particularly messy and painful childbirth perhaps).

Week 1/Day 2+3: Hematology/Oncology

On the 2^nd day, a nurse showed us how chemotherapy (化疗 Huàliáo) was delivered through a Port-A-Cath. The device is surgically inserted under the skin and looks like a big bump near the patient’s clavicle. The catheter is inserted into a vein so that the medication can be delivered quickly. The nurse told us that the patients are use to the procedures and pain since they need to come every week. Heparin and saline are usually used to prevent clotting.

We followed Dr. Chen to his outpatient clinic.

Patient 1: One male patient came in cuffed to a wheelchair and accompanied by two police officers. He had thalassemia with a chief complaint of fatigue. Thalassemia is an autosomal recessive blood disorder due to abnormally formed hemoglobin. Hemoglobin is made of 4 protein chains, 2 alphas and 2 beta chains. Depending on which chain type is affected determines the type of thalassemia.

Patient 2: Elderly woman came in her granddaughter. She was suppose to see ophthalmology due to her diplopia (double vision), but was later counseled by Dr. Chen to cancel the appointment. Her vision was due to her breast cancer metastasizing to her lung and brain. The tumor was interfering with her vision so ophthalmology won’t have been able to help her. Fortunately, it seems like her tumor was responding well to chemo.

Patient 3: Another patient came in with a huge bump on his right wrist. Dr. Chen palpated and said it had a firm elastic feeling. He sent him off the ortho and ordered a MRI. Not sure how long it takes to get an MRI done in the US, but the computer system showed no MRI availability for three weeks.

Summary: I enjoyed my few days of heme/oncology. Even though I don’t think I could become an oncologist, I appreciated seeing Dr. Chen’s interactions with his patients. Special thanks to the coordinators and the nephrologist for letting me tag along in the afternoon. Nephrology was a great review! We have a 4-day long weekend for the Dragon Boat festival. We went out last night and had Zongzi, sticky rice dumplings eaten traditionally for the festival. Yumm!

Week 1/ Day 1: Hematology/Oncology with a bit of Nephrology

Hello Reader! I’m excited to start our rotations in Taiwan. Hopefully you’ll find our blogs helpful and fun to read.

Steven and I started our day rounding with Dr. Chien-Ming Chen, the only physician in Hem/Onc. Steven wrote a lot about what we saw already, so you can refer to his posts. 🙂

Patient 1: Female patient had triple negative breast cancer, which means that the cancer does not express the estrogen receptor, progesterone receptor, or Her2/neu. Monoclonal antibodies used for breast cancer usually target one of the receptors, such as trastuzumab targeting Her2/neu. With triple negative breast cancer, prognosis is usually poor as targeted treatment cannot be used. Treatment options include surgery and chemotherapy.

Dr. Chen mentioned that many times, biopsy results can take up to 3-4 weeks and getting the approval for an expensive drug can take up to a week. This can be frustrating as the therapy is highly effective and results can be seen within 1-2 days. Within that time frame, a patient’s symptoms can worsen, which is very frustrating to the oncologist.

When shadowing Dr. Chen, he often had to tell the family members to prepare and make plans in case the worst happens. He mentioned that doctors have difficulty telling patients bad news, even after many years of practice. It is even harder when the doctor becomes friends with the patient and his or her family.

We finished early on the 1^st day, so I went to Nephrology with Felicia in the afternoon.

Patient 2: Dr. Lin and Felicia had already rounded on most of the patients but we made a quick stop to the ICU to see a patient with septic shock and an UTI. She came in initially with abnormal extension posturing.

Abnormal extension to pain indicates decerebrate rigidity, which usually indicates brain stem damage below the red nucleus. Posture is an indication for brain damage and is used to determine the severity of a coma with the Glasgow Coma Scale. 

When we saw this patient in the ICU, she wasn’t extended anymore, but was still in pain and confusion. On Day 3 during rounds, we found out that she also had VRE: Vancomycin Resistant Enterococci. Our physician warned us not to touch or get too close to her. With VRE, optimal approach is uncertain but linezolid and quinupristin-dalfopristin are approved for use after susceptibility testing.

Next, we went to the dialysis department. Patients come in every 2-3 days a week. Monitoring patients is important as dialysis can cause ischemia, hypotension, shock, thrombosis, etc. If there seems to be clots, heparin is used. Low molecular weight heparin is not available in the hospital due to financial reasons. In Taiwan, patients coming in for dialysis usually present with high uremic syndrome or arrhythmias already. The nephrologist explained how the machines work and how they monitor their patients for complications. Interestingly, the machine acts only 10% as effectively as an actually kidney.

Our kidneys do so much work for us! Our nephrologist also mentioned that even current doctors have difficulty managing kidney problems and often refer to him. Makes sense, renal physiology and pathology is tough! I learned a lot the first day. Thanks for reading.

Heme/Onc & Gen Surg – Day 2

For today’s rotation I began the day in Gen Surg with Joe again. The morning the fairly quiet in terms of number of cases, but I was able to observe a debridement and removal of necrotic tissue in a patient with Fournier’s Gangrene. For those curious what Fournier’s looks like, you can do your own google image search of it. But I will forewarn you that the images are pretty graphic so do so at your own discretion.

Fournier’s Gangrene is a necrotizing fasciitis that most commonly affects the perineum. It commonly affects elderly men in their 50s or 60s, usually with other comorbidities such as diabetes, morbid obesity, or alcoholism. Essentially any disease that hinders cellular immunity can predispose a patient to infection with bacteria that commonly cause Fourniers. Patients will usually present with symptoms of fever, lethargy, and intense genital pain and tenderness with progressive inflammation and erythema. Cultures obtained from patients usually show an infection that is polymicrobial consisting of both aerobic and anaerobic bacteria. It is thought that the aerobic and anaerobic bacteria form a synergistic relationship leading to rapid progression and necrosis of the infected tissue.

Treatment for Fournier’s requires surgical intervention along with early, broad-spectrum antibiotics to cover aerobic and anaerobic bacteria. Surgical intervention is important for definitive diagnosis of Fournier’s and once Fournier’s gangrene has been established the surgeon can then begin to remove the necrotic tissue from the area. In the case of our patient, Hank, the resident surgeon performing the procedure was able to successfully remove the necrotic tissue. Following early surgical intervention and antibiotics, prognosis for patients with Fournier’s is usually good, however many patients may need to undergo reconstructive surgery following scar formation post-op.

Later in the day I joined Benfie with Dr. Chen for our Heme/onc rotation. Today Dr. Chen was primarily doing outpatient work and we later did rounds and checked in on our the patients we saw yesterday. One thing that struck Benfie and I today was how cheerful each patient was who came in to see Dr. Chen in the outpatient clinic. Although each encounter was rather quick, each patient left cheerful and very thankful for Dr. Chen. We wondered why this was the case, and thought perhaps maybe because healthcare is so widely available and affordable in Taiwan, patients are more grateful for the care they receive. This contrasts the cost of healthcare in the States, where a simple procedure or trip the ER can cost a patient thousands of dollars. Because of the immense cost of healthcare in the US, this often leaves patients disgruntled and cynical to the healthcare system as a whole. I can’t say for sure that this is the reason why each patient was so cheerful, and this is a really small sample size to make any conclusions, but this was just an observation that we both noticed.

During rounds with Dr. Chen, one of our patients, an elderly woman with lung cancer and pneumonia was particularly impactful. This woman had come in for dyspnea about a week ago and it was determined that she had a right lower lobe pneumonia. Empiric antibiotics were prescribed, however upon followup chest X-ray the pneumonia had worsened significantly and her condition was not looking very good. After giving her the bad news, our patient was very disappointed that she would not be able to go home. She had hoped to return home soon, but Dr. Chen informed her that even the 1 hour trip back home would be too much for her body to handle and that her condition was not stable enough for her to make the trip.

After leaving the room, Dr. Chen informed us how difficult it can be to talk to patients and give them bad news. He told us that even now, though he has had so many years of experience as an oncologist, it is still difficult at times to have to deliver bad news to patients. It is humbling to hear that even Dr. Chen, a well established and practiced physician still struggles at times with this. It reminded me of the position we are in as physicians and the role we have in our patient’s lives and inevitably we will all have to deliver bad news to our patients.

Overall today was a very interesting day, and I enjoyed being to see procedural work in the OR as well as work in the outpatient setting. Looking forward to what tomorrow has to offer!

Heme/Onc and a lil bit of Gen Surg – Day 1

Hello y’all, greetings from Taiwan!

After arriving yesterday to thunderstorms, humidity, a power outage, and the all-necessary Xiaolongbao fix we are all set to go on our first day of our internship! For our first day of internship Benfie and I started off with Heme-Onc with Dr. Chen. He is the only oncologist in the hospital and the surrounding region, so his patient load is quite heavy. He told us that he mainly sees solid tumors, which are treated with surgical resection and chemotherapy.

In total, we saw 13 patients with Dr. Chen today. Of the 13 patients we saw, one in particular that stood out was a patient with hepatocellular carcinoma (HCC) which was determined to be inoperable upon diagnosis. The potential for surgical resection depends on a number of factors including its size, number, and patients current liver function. In patients with inoperable hepatocelluclar carcinoma, the next step of treatment is either Transcatheter arterial chemoembolization (TACE) or Transarterial embolization (TAE). TACE aims to occlude a tumors blood supply by injecting small embolic particles coated with chemotherapeutic agents into an arterial supplying the tumor. This allows for prevention of tumor angiogenesis as well as providing a higher concentration of chemotherapeutic agent to the tumor itself.

TAE functions similarly except there is no chemotherapeutic agent added to the embolic particles. Although both TACE and TAE are first-line therapies for patients with advanced HCC, benefits for one treatment over the other are still unclear in treatment of HCC.

In the case of our patient, treatment was done via Sorafenib, which is an inhibitor of several small tyrosine kinases, such as VEGFR, PDGFR and Raf family kinases. Only about 5% of patients respond to the medication, and even if a patient does show improvement from the medication, life is only prolonged for an additional 2 – 3 months.

Additionally, Dr. Chen informed us that Taiwan has a high prevalence of Hepatitis B and C, resulting in high rates of liver failure, cirrhosis, and hepatocellular carcinoma. However, in recent years Taiwan has begun implementing vaccinations to its population resulting in a decrease in incidence of HBV.

As we continued to due rounds with Dr. Chen we saw several other patients with non-small cell carcinoma of the lung, mostly adenocarcinomas. A recurring theme in these patients with lung cancers was to obtain a biopsy and send it in for EGFR2 mutation sequencing. Approximately 10% of patients with NSCLC in the US and 35% in East Asia have tumor associated EGFR. Due to the greater prevalence of patients in East Asia with a tumor associated with EGFR mutations, treatment can be targeted to the mutation and help improve patient prognosis.

After breaking for lunch, I joined Joe in general surgery for the 2nd half of my day. I was only able to see one case, which was a laparoscopic appendectomy. The patient had presented earlier in the day with right lower quadrant pain for the past 24 hours, and was sent for an appendectomy. The attending physician on hand informed us that the procedure itself is fairly simple and it was good that this patient had come in the ER early for treatment. Three incisions are made which allow the surgeon to access the peritoneum and easily remove the appendix. The appendix is supplied by only one artery, the appendicular artery which is a branch of the ileocolic artery. Once they isolate the appendix from the surrounding peritoneum, it is simply a matter of ligating the artery and removing the appendix. Snip, snip and some cauterizing and you’re done – easy.

 

 

Greg (7/14) Hematology/Oncology Day 3,4,5

Day 3 was cancelled due to a typhoon, while day 4 was cancelled because Dr. Chen took the day off due to personal reasons.  During one of our days off, we visited a family friend of Patrick’s, and learned some more about TCM.  All of us even got some TCM done on ourselves!  My last day in Heme/Onc was spent with Mira in the OPD and on rounds; this was a very busy day for Dr. Chen, and we saw many patients.  Here are some of the more interesting cases which we saw and learned from:

 

Case 1

A 70 year old male with a prior history of adenocarcinoma in the pancreatic head as well as colon cancer.  Primary treatment for his cancer was done with; this was a regular follow up since he was on adjuvant chemotherapy with Fluorouracil (5-FU) in order to lower the recurrence rate.  Dr. Chen scheduled him for a blood test in his next appointment to check the WBC count, and told us a little about the patient.  He had initially come in for 8kg weight loss and clay-colored stool.  A CT and ultrasound confirmed his cancer, and treatment was started.  Dr. Chen talked a bit about the use of 5-FU.  One study found that 5-FU increased patients’ survival rate and lifespan, but Dr. Chen said that the numbers showed only a marginal effect.  A possible alternative to 5-FU is Tx-1, an analog of 5-FU taken orally.  5-FU is more toxic than Tx-1; however, the insurance in Taiwan does not cover Tx-1.  The cost for Tx-1 is approximately 30,000NTD/month (~$1,000US/month).  This is extraordinarily expensive by Taiwanese standards and income levels, so 5-FU is used instead even though Tx-1 would be the better medication to give to patients.  Dr. Chen lamented the restrictions which the national insurance program put on patient care:  cost is much more a factor to be considered in Taiwanese healthcare than in American healthcare.

 

Case 2

A 48 year old female with unspecified anemia.  The patient had gotten her blood drawn yesterday for a bloodtest, but the results were not out yet.  Dr. Chen said that she would need to wait 3 weeks for the results, and tried to reschedule her.  Unfortunately, the patient was resistant to Dr. Chen’s recommendation.  She was very worried/nervous about her condition, and insisted on doing something immediately about it.  With insufficient information to go on, Dr. Chen kept explaining that the better course of action was to wait for the report in order to get more information, then see what their options are since he did not know what her diagnosis was at the moment.  The patient did not seem to hear Dr. Chen’s repeated explanations, and kept asking for a blood transfusion to “fix” her anemia.  Although Dr. Chen tried to explain that blood transfusions also carry risks and that he deemed it unnecessary to expose her to these risks prior to seeing the report, the patient was extremely insistent.  Dr. Chen finally acquiesced to the blood transfusion, and referred her to the ER to get one and to also check her iron levels.  He explained to us that he had an obligation to the other patients since he believed that this patient would not leave until she got what she was demanding, and reasoned that the blood transfusion would placate the patient and make her feel better at the same time.  This case was quite interesting, as it was a classic example of a physician succumbing to a patient’s demand in order to make the patient happy and to move on to the other waiting patients.  There was an obvious change in tone during Dr. Chen’s conversation with the patient after he had to keep repeating himself.  It was obvious that he was getting exasperated with the patient, and when he finally agreed to the patient’s demands, he did so in a heated tone.  After the patient left, Dr. Chen chatted with the nurse, asking her opinion on if he had been too sharp and his tone too confrontational.  The nurse told Dr. Chen that he may have lost his cool a little towards the end, though it wasn’t really his fault since she was unreasonable and not listening to his reasoning/explanation.  The nurse said she would continue to try and convince the patient not to get the blood transfusion.  Over the next 20 minutes, during which we saw 2-3 more patients, the nurse repeatedly went out of the room to talk with the patient.  In the end though, she was also unsuccessful in her attempts, and the patient was referred to the ER for a blood transfusion.

 

Case 3

A 53 year old male with non-keratinizing carcinoma in the neck (nasopharyngeal cancer).  He was on induction chemotherapy (chemotherapy given to induce a remission) with 5-FU (the standard treatment), and his treatment was almost over.  Treatment usually involves 6 cycles of treatment, and the patient was on the last cycle.  He also was on concurrent radiation therapy after the second cycle.  The patient only had a partial response to the 5-FU, and still had palpable residual left neck lymphadenopathy.  The patient said he vomits within 30 minutes of getting home after treatments, and jokingly asked if he could pause the treatment.  Dr. Chen reminded him that he was almost done, and encouraged him to keep up his spirits and endure through to the end.  The patient’s WBC counts were borderline okay, but he was scheduled to finish his chemotherapy after next week.  Dr. Chen’s plan for the patient was to monitor the patient’s WBC counts and continue/finish treatment if the numbers were okay or stop the treatment if they weren’t.

 

Case 4

A 78 year old male with a STEMI related adenocarcinoma.  Given the patient’s age and that the typical chemotherapy cocktail is very toxic, Dr. Chen had not recommended chemotherapy to him a year ago.  Instead, he received only radiation therapy.  The patient had been symptom free for one year; the tumor was stable.  Surgical resection was still not recommended due to the proximity and possible attachment to the aorta/heart.  However, the patient was stable, and would continue to come in for regular follow ups.  Dr. Chen explained that this case was a great example of how more is not always better when treating patients.  I will definitely remember this concept and its associated case in the future.

Greg (7/9) Hematology/Oncology Day 2

Day 2 was spent in the OPD and rounding, though Dr. Chen did not have many patients to see in the OPD today (only 8).  Here are some of the cases we saw:

 

Case 1

A 53 year old female with right breast cancer, EGFR(+).  The patient had erlotinib to shrink the mass before surgical resection was performed.  The CT after her surgery showed 8-9 enlarged lymph nodes in her right breast region.  From Dr. Chen’s experience, this meant a higher chance for recurrence, so this patient needs to be followed closely with regular check-ups.  Her last CT in May showed a small LUL lesion, so she had another CT done in late June to check the lesion.  She was here today for the results of that CT, which revealed that the lesion was still present, but had not grown.  Given this, Dr. Chen set up a f/u in 2 months; he wanted to continue keeping an eye on this lesion in case it was a recurrence.

 

Case 2

A 41 year old male who was referred for elevated Carcinoembryonic antigen (CEA) levels.  This tumor’s normal levels are 1-5mg/mL, but it was 7.00mg/mL in this patient.  In addition to being elevated in some types of cancers, CEA can also be elevated in smokers.  This patient was a smoker, so it is likely that the elevated CEA is due to his smoking.  The patient also had 2 other issues.  The second issue was a secondary finding of Osteopenia based on lab tests; Dr. Chen likened the condition of the patient’s bones to that of a 60 year olds.  This was vindicated when the patient revealed a history of repeated episodes of bone fracture with no trauma.  The third issue was a prolonged Herpes infection over the left T10 area along with progressive abdominal distension.  Dr. Chen’s plan for this patient was to have him quit smoking, follow up on the patient’s CEA levels, and to prescribe Famciclovir for his herpes infection.  The patient was also referred to an orthopedist for his osteopenia.

 

Case 3

A 86 year old male with myelodysplastic syndrome/chronic kidney disease related anemia.  He has been getting Erythropoiesis-stimulating agent  (ESA–physicians commonly call it EPO or Erythropoietin) therapy regularly, and receives blood transfusions when needed, although the transfusions often give him a fever and rashes.  With his history of CKD, the patient’s hemoglobin (Hb) levels need to be monitored, since it is not recommended to give ESA/EPO to patients with Hb>10g/dL.  The patient also has a history of COPD and exertion dyspnea, as well as heart issues (ejection fraction was ~56%).  Dr. Chen stressed the difficulty and requirement of maintaining an equilibrium during treatment of the patient’s heart, lung, and kidney issues.  He was also concerned with the long-term use of ESA/EPO:  the longer you inject, the lower the efficacy/effect (Dr. Chen explained that this is similar to antibiotics resistance).  There are two solutions to this issue:  either stop the injections, or switch to another brand of ESA/EPO (given that ESA’s are analogs of EPO, another brand may not have this resistance issue).

Greg (7/8) Hematology/Oncology Day 1

I was introduced to Dr. Chen, the only Heme/Onc physician at Taipei Hospital, when he was almost done with his rounding.  Though I only got to see two of his patients, Dr. Chen gave a lengthy and detailed history lesson on the primary medications used to treat lung adenocarcinoma, which I will detail here.

To start off with, we classify lung cancers broadly into two categories:  small-cell lung carcinoma (SCLC) vs. non-small-cell lung carcinoma (NSCLC).  SCLC is chemotherapy sensitive, heavily associated with smoking, and has over 20 subtypes.  NSCLC has three major subtypes:  squamous cell carcinoma, large cell carcinoma, and adenocarcinoma.  Most of the targeted therapy used to treat NSCLC came out in the early 2000’s.  Primarily, the two most common targeted therapies involve Erlotinib and Gefitinib.  Erlotinib is still being used today for lung cancer in general:  it was shown to be effective in patients with or without the Epidermal Growth Factor Receptor (EGFR) mutation.  As a reminder, EGFR is a receptor tyrosine kinase that is part of the ErbB/Her family, and is often found to be mutated in lung cancers.  Targeted therapy therefore involves inhibiting EGFR if it is mutated.

When these two drugs first came out, all of the different subtypes of lung cancers were not differentiated, since phenotyping was not possible at the time.  We will focus on Gefitinib, since its history is not as straightforward as Erlotinib, which is still approved for use today for lung cancers in the U.S. and in Asia.  As with any new drug, Gefitinib was put through clinical trials, which revealed that the response rate to Gefitinib was low.  However, these trials revealed that response was very effective in a certain subgroup of patients.  We now know this subgroup to be EGFR (+) patients.  Gefitinib was approved by the FDA in 2003 for NSCLC treatment, but the FDA withdrew approval in 2005 due to lack of evidence that it was actually beneficial for patients.  However, it was not taken off the market in Asia; studies in Asia found that over 70% of Asian non-smokers responded positively to it.  As a side note, the studies also found that if patients had a skin rash as a symptom as well, the response was more likely to be positive.

Further studies in Asia compared the use of Gefitinib and chemotherapy on a patient’s condition 6 months post-diagnosis and treatment.  It revealed that Gefitinib was more beneficial in patients with the EGFR mutation.  Therefore, Dr. Chen’s conclusion was to use targeted therapy if the patient has the EGFR mutation.  With no mutation, chemotherapy is more effective; with the mutation, Gefitinib is better than chemotherapy since it is less toxic.  Thus, Gefitinib is used in Asia for patients with the EGFR mutation, but is not approved for use by the FDA in the U.S. for treatment of NSCLC.

There were a couple of side comments that Dr. Chen made which I found intriguing.  There are no drugs at the moment approved for k-ras targeted therapy; they are all in phase 2 of clinical trials, and none are in phase 3.  Targeted therapies all target oncogenes; there are none for tumor suppressors.  Therefore, since researchers have been unable to find an oncogene for squamous cell carcinoma, there is no targeted therapy for this subtype.

 

UPDATE July 13, 2015:  Gefitinib has just been approved by the FDA for treatment of EGFR(+) NSCLC!