“CONCLUSION: Primary chemotherapy based on high-dose MTX and ARA-C is highly efficient in PCNSL. Response rate and response duration in this series are comparable to the response rates and durations reported after combined radiotherapy and chemotherapy. Neurotoxicity was infrequent.”
(http://www.ncbi.nlm.nih.gov/pubmed/14597744?dopt=Abstract)

Two things: first, HD-MTX + Ara-C was what I did back in the beginning of the year. Woo! Second, PCNSL is lymphoma that originates in the brain. It is much more scary of a situation than mine.

And our attending doctor, after reviewing my case some more, agrees with the opinion that this isn’t a CNS relapse. This is good news! A relapse of lymphoma in the CNS, especially this soon, would be a sign of a particularly tenacious (and difficult to kill) lymphoma.

It is looking like I’ll not want to get the boost (but still get the conditioning TBI). I’ll sleep on it to make sure.

This time I wanted to do everything I could to avoid suffering through the joint pain on Saturday morning. My lizard brain considered trying to stay in the hospital a few extra days (or checking into Extended Observation) to be somewhere that had IV pain medication available.

My rational brain said this was silly. Checking into an expensive room for a night to avoid a few hours of pain seemed excessive. And my rational brain won, as it often does.

Besides, the pain showed up a day early. Friday morning my knees and ankles hurt like the dickens for a few hours. Engage opiates! And ibuprofen! I got up and read stuff for a few hours, and eventually (after an hour or two) the pain subsided enough for me to go back to sleep.

I did the same thing on Saturday, and on Sunday. That would’ve been a lot of days in the hospital!

I’m glad that’s done with.

Next we scheduled an appointment with a transplant specialist doctor at the SCCA to see what she recommended as the next step. Apparently the speed with which the lymphoma asserted itself in my CNS suggests that we ought to do a stem-cell transplant.

My case was discussed by a bunch of well-regarded doctors at the SCCA, and the consensus was that I ought to do an autologous stem-cell transplant.

This is a biblical-flood sort of treatment. When we collected the blood stem-cells back in November, that was us preparing am ark. Now we’ll irradiate my entire body and fill it with a crazy amount of chemo, in a stage known as “conditioning”. This will hopefully kill off any remaining individual lymphoma cells. Unfortunately it also kills offy bone marrow (and along with it, my body’s ability to produce new blood cells).

A few days later they give back my collected stem cells and my body starts to rebuild. The stem cells find their way to my bones and start producing the cells that make up bone marrow.

As part of this, I think I’ll lose a lot of the immunities my body has built up over the year. We’re really hitting the reset button!

There’s one additional question to be answered: there wasn’t a solid consensus among the SCCA doctors on whether or not to recommend extra radiation focused on my brain and spine. Lymphoma in the brain can be sneaky (as we’ve found), and am aggressive approach is more likely to get it all.

This can, however, cause damage to healthy brain tissue. Possible decreases in memory strength, among other undesireable things.

I need to decide soon, but I’m leaning toward going for it. The goal of a treatment like this is a cure, and I want to do everything I can to get there.

Last night we began the MTX infusion around 6:30 or 7pm. It finished near 11pm or midnight. I’ve had a bit more nausea this time around, but nothing so bad that we can’t stay ahead of it with Lorazepam (Ativan). This also has the side-effect of making me a little loopy; I completely forgot that Dr Norman came by to visit this morning!

It is very important to have a teammate that has all of his/her marbles, because sometimes you lose yours. Thanks Jana!

He came back by to reiterate that he DID, in fact, stop by and to re-mention what we’d discussed earlier.

As for the rest of the day, he schedule calls for 24 hours of “grace” before we start sending in the rescue dose of Leucovorin.

The Methotrexate works (generally) by pretending to be one of the nutrients needed during the cell replication process. When a cell (let’s suppose a lymphoma cell) starts to duplicate, it needs raw materials like Folic acid. MTX finds the places that are seeking Folic acid and grabs onto them, locking them down. Without the ability to absorb Folic acid, the cell ends up starving to death.

The “rescue dose” of Leucovorin is able to sneak around some of the MTX lock-down. We give the MTX 24 hours to work on starving the really fast dividing cells, and then bring in the Leucovorin to start saving the stuff that hasn’t already been caught replicating.

Early bird gets the chemo.

This morning I got to be a teaching aide, too! A program coordinator stopped by and asked if I would mind having a second-year UW medical student come in to ask about my patient history and perform some physical examinations. I said “sure!” and for the next hour and a half Preetma asked me about the events leading up to today and did a basic patient physical examination. Not long after, her entire group (along with the coordinating instructor) piled into the room and Preetma was prompted to give a very condensed 5-minute summary of my how-did-we-get-here story.

The instructor had some of the other students examine points of interest regarding my neurological signs, which revealed that some less obvious things still remain to recover. My left eye seems to still exhibit a bit of nystagmus at its extent and my uvula remains a bit deviated to one side (though my velopharyngeal inadequacy feels resolved).

After the session with the class we all chatted for a bit about Jana and my perspectives on what make for effective relationships between doctors and patients.

And now I’m back to working on my computer and enjoying the entirely reasonable room service offered here. My view out the window, while a bit hazy, is nice and interesting. Out of the corner of my eye I can see I-5 and the commute that I’m not stuck taking.