He Makes You Want To Try Hard To Live
June of 1997, Frank Dens began to have difficulty breathing. He felt a deep pain on his right side accompanied with a nagging, aching cough. A chest x-ray showed a very large right pleural effusion. In fact, the effusion filled up about two-thirds of his thoracic cavity between the visceral and parietal pleura. Frank's doctors in Roseville, California drained two (2) liters of fluid from his chest. Frank, at the age of 68, and his wife Barbara were both worried.
A few days after the fluid was drained, Frank had a thoracotomy (a surgical incision in the chest wall) so that a biopsy could be taken. His doctors performed a pleurodesis with talc. The objective of this procedure was to create a fibrous adhesion between the parietal and visceral pleura. The insertion of talc into the pleural space was supposed to obliterate the space, leaving the two linings bonded together. The talc treatment seemed to improve Frank's breathing and pain. Unfortunately, his relief was short-lived. The doctors advised Frank that the pathologist had determined the cause of the effusions and the news was not good. Frank had epithelial mesothelioma.
Frank and his family set out to learn what "mesothelioma" was and how to fight back. The internet led Frank to a surgical oncologist in San Francisco by the name of Dr. David Jablons at USCF/Mt. Zion Medical Center. Dr. Jablons is a board-certified cardiothoracic surgeon whose specialty is thoracic oncology. He trained under Dr. David Sugarbaker at Brigham and Women's Hospital and Dr. Valeri Rusch of Memorial Sloan Kettering. On July 15, 1997, Mr. Dens met Dr. Jablons for the first time. Dr. Jablons was impressed with Frank's physical well-being. Frank's pain was manageable, his weight was stable and he was otherwise very healthy and active. His breath sounds were clear on the left and moderately diminished throughout the right chest. His heart beat was strong and regular. Dr. Jablons' overall assessment of Frank was that he was in the early stages of epithelial mesothelioma, either a stage I or stage II. Under the circumstances, this was good news, as it gave Frank more options from which to choose.
Dr. Jablons discussed each option with Frank. At the University of California San Francisco, they currently have a very aggressive and modern approach. Here is a summary of their protocol. First, the surgeons perform a pleurectomy / decortication. Second, during surgery, the doctors administer radiotherapy. Third, following surgery, the doctors again adminster 3-D (three-dimensional) conformal radiotherapy. In addition, they adminster combined agent CAP (Cytoxan, Adriamycin and Cisplatin) chemotherapy. With this multi-modal method, an excision (cutting away) is made in the pleura (the serous membrane around the lung) and the surface layer of the lung or part of the surface lung tissue is removed. Layers of other organs, such as the diaphragm, where the tumors may have invaded are also removed. During the surgery, the disease is treated with the application of radiation therapy. The surgeons then administer postoperative radiation and chemotherapy.
On July 22, 1997, Frank went to the Northern California P.E.T. Imaging Center. He was given eight (8) millicuries of F-18 FDG by IV injection and a whole body imaging was conducted thirty (30) minutes later. Two more 30-minute scans were conducted which concentrated on the chest and upper abdomen. The findings were favorable. They confirmed the presence of two densities in the right lung only.
Frank met Dr. Mack Roach III, Associate Professor of Radiation Oncology at Mt. Zion, on July 25, 1997. They discussed the plan, which called for intraoperative radiotherapy and a three-dimensional conformal boost after he received the pleurectomy and decortication. After reviewing the protocol with Frank, Dr. Roach agreed that Frank was a suitable candidate. Frank was determined to go for it.
Following his thoracotomy and talc pleurodesis, Frank was in a quasi-holding pattern. Not exactly "homeostasis" but under the circumstances he was doing well. Dr. Jablons decided to act quickly before Frank's symptoms and fluid had a chance to return. They scheduled Frank Dens for surgery on July 30, 1997. However, two days before his surgery, Frank had a routine chest x-ray which revealed the formation of a new left pleural effusion. Mesothelioma is like a shark that never sleeps, always feeding. Dr. Jablons was forced to scratch the original surgery and opted for more reconnasiance via thoracoscopy. A thoracoscopy is a diagnostic examination of the pleural cavity done with a "telescope-like" instrument connected to a video camera. They removed and sent specimens of serous effusion and pleural plaque to pathology. The tumor was back, and the tumor was advancing.
When Frank woke up, he reached over to touch the bandage, "...but there wasn't one. I thought it was the end of the line. My wife, Barbara, was thinking the same thing. She said that she knew I would not have a good feeling when I found out I didn't have the operation." He had prepared himself for the surgery. Now he would have to wait again.
Frank did not wait long. Three weeks later, in August, Frank returned to the Dr. Jablon's operating table. They had tracked the tumor's invasion and now were ready to fight back. After applying general anesthesia, Dr. Jablons inserted a Foley catheter and perfomed a flexible bronchoscopy, which allowed the doctors to look carefully inside both the left and right lungs. Remember, Dr. Jablons had been concerned that the disease had spread to Frank's left lung and it was mandatory that he scrutinize the left lung for any evidence of tumors before he proceeded with the radical pleurectomy and decortication. Dr. Jablons performed a pleurectomy / decortication (removal of the pleura along the inner chest wall and covering of the lung, where most of the tumors are located). It was a long and difficult procedure. He also performed a mediastinal (in the middle) lymph node dissection and radiated areas of visible tumor.
A day after the surgery, Frank's chest was clear and his heart showed normal sinus rhythm with no displacement or murmurs. The doctors intended to extubate (remove the chest tubes), place Frank on a regular diet and move him from the ICU to the regular acute care floor.
On the second and third day, Mr. Dens continued to recuperate. The chest tubes continued to be drained, resulting in 650 cc on day two and 430 cc on day three. A moderate air leak was detected. He got out of bed for a short walk.
September 1, 1997, was day four of Frank's recovery. He had slightly decreased breathing sounds on his right throughout the right lung field. His extremities showed no clubbing, edema or cyanosis (blue, gray or purple discoloration). An EKG presented a slightly irregular heartbeat, but Frank assured doctors that this type of thing had happened before and that he was under no medication to correct it. They removed the epidural catheter and Mr. Dens was switched over to Vicodin for pain management.
Just five (5) short days from his surgery, Frank was sent home with instructions to resume his normal activity as tolerated and to avoid heavy lifting. Pain medications of Vicodin and Motrin were prescribed.
On September 16, 1997, Frank visited Dr. Jablons' office for a followup. According to Dr. Jablons, Frank was doing very well and had made a strong recovery in a short time. Frank's blood pressure was 118/68 and his heart rate was 100. He had some discomfort surrounding the incision but the Vicodin helped control the pain. Frank's chest x-ray showed some moderate pleural thickening and loculated fluid collection at the base of the right lung, but this was said to be a common side effect following the type of surgery Frank had. One of the most impressive observations made by Dr. Jablons was that Frank's lung was greater than 99% fully expanded throughout the chest cavity.
Today, Frank is at home. On Tuesday, November 11, 1997, he had his last radiation treatment. He had endured twenty-five treatments in total. He was relieved to be at home, as he had to drive one hundred-eighty (180) miles round trip from his home in Rocklin to San Francisco for each treatment. According to Frank, "The worst part of the radiation treatment was the drive through San Francisco at the peak of rush hour traffic and the thirty to forty-five minute wait to cross the bridge." But the treatments are not over. On November 14, 1997, Frank was scheduled to visit with his doctor about the scheduling of his chemotherapy regimen.
Frank will rest a bit before he starts his chemotherapy. It has been decided that he will wait until after the first of the year to start. Frank looks forward to the time when he can live his life on his own terms and not as a cancer patient. He says that he "...has some pain in his back. The nerves and muscles in his back went through three (3) operations and they are still trying to find their mates." The doctor told Frank that pain should subside in about another month.
Frank has "voluntarily changed his diet". In other words, Barbara has him on "her diet", the one with very little meat. He says he eats lots of fruits and vegetables. They have moved into a new house to be closer to their children. He spends most of his time tinkering in the garage. He has no trouble keeping busy.
He recalls his experience with Dr. Jablons as "wonderful". "Dr. Jablons is energetic and very knowledgeable. He makes you want to try hard to live. Carolyn, his nurse, is so nice and encouraging. She takes the time to answer all your questions and elaborates on her answers so that you really know what she is saying." Frank has no doubts that he made the right decision, and adds that he would "do it all over again". In the meantime, he is thinking positive, staying busy and living each moment.
** POSTED NOVEMBER 18, 1997 **
Mr. Frank Dens passed away on December 3, 2000
Barbara Dens has joined a support group to help her get through this. The nights are the hardest for her right now, when she looks over at Frank's chair and she knows he is not coming back. Barbara did have family around her for the holidays which helped, but they were still hard. She has a friend whose husband also died of mesotheliom, so she talks to her frequently. Mrs. Dens knows it's just going to take time.
