Saturday, May 27, 2017

CyberKnife Follow-up MRI and More on the BBB

     As enthusiastic as I've been about the CyberKnife procedure I had to treat my metastatic brain tumor at the end of March, the only way to know if it worked is to have another MRI.  So, that happened last week.  

     I was disappointed when the report stated that the lesion is still there - big enough to be measured.  But, the report also stated that it is smaller than prior to CyberKnife and is "less enhanced".  Overall, the report sounded like it was trying to tell me that it looks like CyberKnife worked.  I realized that among all the questions I asked before and during my CyberKnife procedure, I never asked what to expect of the tumor following radiotherapy. I know.  A few days after my MRI, Wynn and I met with the radiation oncologist.  She entered the room with a big smile on her face and said, "The lesion is smaller and less enhanced, so I'm very happy.  It appears the treatment worked."  Following radiotherapy procedures, and after tumors are exposed to radiation, they usually dissipate slowly.  I had to admit to the doctor that, in my excitement of getting my tumor zapped, I thought it was going to be burned to a crisp...fried...annihilated.  I used the word "poofed".  The doctor, apologetically, said that she usually tells patients what to expect - and perhaps she did, but in my over-zealousness to get the show on the road, I didn't hear her.  

     The other good news I received that day is that there are no new tumors seen on this last MRI.  

     Since my last blog post about the blood brain barrier, (BBB), I've received some replies and comments that had me asking more questions about it.  I asked a few experts more questions and learned that although the BBB's permeability is altered following procedures like CyberKnife, this change in permeability is usually temporary :( .  I was really hoping that the alteration in permeability would work well for me, allowing Xalkori to get into my brain and protect it - forever.  The other thing I learned was that since my tumor was relatively small and the overall amount of radiation I received was low, the change in my BBB would also, likely, be small :( .    

     For now, I will stay on Xalkori because it's working well for me below my neck and I will continue to get regular brain MRIs looking for metastatic tumors.  As long as any future tumors are treatable with CyberKnife, I will continue on Xalkori.  There are two new, second generation, targeted medications, (lorlatinib and entrectinib), that are getting close to FDA approval, both of which cross the BBB.  My hope is that they will be available to me, when I need them, either because they are FDA approved, or through a clinical trial.  I'm scheduled for another brain MRI in 10 weeks.    

Photo credit:  Copyright: <a href=''>vectorshots / 123RF Stock Photo</a>

Wednesday, May 10, 2017

CT Scans #13 and the Blood/Brain Barrier

CT Scans:

     My last scans were in January and I was hoping to avoid my next set until at least June. However, while traveling in Israel, I noticed more upper right quadrant pain so I recently had CT scans and blood tumor markers drawn.  I am happy and relieved to report that everything continues to indicate that my disease is stable, below my neck.  I still don't know why I have periodic pain in my abdomen, but I'm glad that when it eventually goes. 

Copyright: <a href=''>highwaystarz /

The Blood/Brain Barrier (BBB):
     ...has been something I've referred to in previous blogs.  I didn't know very much about the BBB, or how it works, so I thought I'd read up and blog about it.  As fascinating as it is, it's pretty complicated.  Some aspects of the BBB are still not fully understood by researchers and some aspects could not be fully understood by yours truly.  Since I only understand the basics, that's all I can share.  Here goes...

     The BBB's purpose is to protect the central nervous system (the brain and spinal cord), from potentially harmful chemicals and infections.  It is semi-permeable, allowing molecules needed to maintain stability, (necessary hormones and key nutrients), into the brain while keeping toxins out.  The brain is the only organ that has a protective mechanism such as this. 

     The BBB runs within the blood vessels of the brain and is not present in the vessels in other parts of our body.  The smallest blood vessels in our bodies are called capillaries.  Capillaries are lined with endothelial cells, which are loosely packed together.  This "loose-ness" allows most molecules, big and small, to flow around the endothelial cells and then pass from our blood capillaries into our organs.  

     The endothelial cells lining the capillaries of our brain are different. Unlike the endothelial cells found lining the capillaries in other parts of our body, the endothelial cells of the brain's capillaries are very tightly packed together, leaving virtually no space between the cells.  So tightly wedged together, these cells create an almost impermeable barrier between the brain and the bloodstream...especially for large molecule compounds.  Compounds that are very small molecules and/or fat-soluble easily pass into the brain.

(There are two other types of cells, astrocytes and pericytes, which also appear to play a role in the BBB.  In the resources I read, their roles don't seem to be as definitively understood yet.) 

     There are a few reasons the brain is not 100% protected, 100% of the time:
  1. Not all parts of the brain are protected by the BBB.
  2. Certain conditions can breakdown the BBB or alter its permeability: 
    • Hypertension
    • Exposure to microwave and radiation
    • Some infections
    • CNS injury or trauma resulting in inflammation, ischemia (an inadequate blood supply) or changes in intracranial pressure
    • Hyperosmolarity, or a high concentration of a substance in the blood
     For me, the BBB has kept my targeted oral chemotherapy, Xalkori, from getting to my brain.  Therefore, I knew my brain was vulnerable to metastatic disease. Now that I have had CyberKnife, (radiation), it's my hope that my BBB's permeability has been altered enough to allow Xalkori into my brain and it will be better protected. The downside is that my BBB has been breached - and of course I now worry that other crap, that I don't want in my brain, can now enter.  

Ohhhhhh...the life of a stage 4 cancer patient.  

Tuesday, May 2, 2017

Visiting Nathan in Israel

     In the past, when my husband and children traveled to Israel, I've opted out because I was afraid.  Traveling to the Middle East seemed irresponsible, given the obligations I felt I have here at home, (family, work, pets, etc.).  Over time, things have changed.  Although it was difficult leaving my elderly mother for nearly two weeks, having bad cancer allows me to shed some hesitations about traveling for two reasons:  I'm healthy enough now to go to far away places and really...what do I have to lose? 

     Our son, Nathan, has been in Israel since last September teaching English to underprivileged children, grades 2-6.  He has been living in a small city, north of Nazareth, called Migdal HaEmek where he works with both Jewish and Arab students. He's created opportunities for himself to see most parts of the country and was a great guide for us.  

     We started in Tel Aviv/Jaffa (aka Yafo).  Jaffa is the oldest part of the Tel Aviv/Jaffa area and is a Mediterranean port city dating back to ancient times.  It remains a busy port, while Tel Aviv looks like any other large, modern city I've been in. It's a hub of commerce and is largely secular.

     Traveling north of Tel Aviv, we drove toward Haifa in our rental car.  (Israeli drivers are crazy.  Nathan did all the driving while I relaxed in the back seat.) Near Haifa is Akko, (aka Acre). Old Akko dates back to Old Testament times with just about everyone (Canaanites, Ottomans, Crusaders, Romans, Byzantines, etc.) having had a presence.  


          This is the entrance of the El-Jazzar Mosque, inside the walls of Old Akko.  It was built in 1782-ish.  

    We stopped at Caesarea, a 4th century, B.C., town that was important to Greeks, Romans and many other groups passing through. There's ongoing archeological digging and the finds tell us that Caesarea was a bustling diverse metropolis in it's day with homes, businesses, bath houses, amphitheater, aqueducts and a network of streets.


     These are believed to be storage vaults or warehouses in Caesarea.  

     This mosaic is on the floor of the bath house.  It's very intricate.                                                                                      

     These arched ceilings were in a sentry building at Caesarea.    

     While in and around Nazareth we visited the Basilica of the Annunciation...both of them.  Roman Catholics erected a church at the site they believe the angel, Gabriel, came to Mary and told her that she would be the mother of Jesus.  Greek Orthodox tradition believes Gabriel came to Mary while she was drawing water from a local spring and erected their Church of the Annunciation at another location, near the spring. 

     Next to seeing Nathan, Jerusalem was the highlight of the trip.  It's a city rich with history, diversity, and conflict, even among groups within the same religion.  I always thought Tel Aviv was Israel's capitol city, but (embarrassingly) learned that Jerusalem is. We hired a guide, Itay, for the day.  He was born and raised in Jerusalem, and served as an artilleryman in the Israeli army for his national service obligation.  He was a great guide - knowledgeable about historical and contemporary socio/religious/political issues.
     This is the Western Wall.  It's a section of a retaining wall of the Second Jewish Temple built by Herod the Great, dating back to 500 BC.  It's a holy sight within the walls of Old Jerusalem, where Jews come to pray. 
     The gold domed building is Dome of the Rock, an Islamic Shrine in Old Jerusalem.   


      This is the unassuming entrance of the Church of the Holy Sepulchre in Jerusalem.  It houses 3 important Christian sites:  The place where Jesus of Nazareth was crucified,  the Stone of Anointing, and Jesus' empty tomb.  There are 6 Christian groups that control the church, the Greek Orthodox, the Armenian Orthodox, the Roman Catholics, Egyptian Copts, Syriacs and Ethopians.  

     Inside the low entrance is the site where it is believed that Jesus' crucifix was secured into the ground.  The line was too long, so we didn't go in, but I'm told there are also rocks believed to have held the crucifix in place.

     This is the Stone of Anointing, believed to be the place where Jesus' body was placed when he was taken down from the cross.  It is said that his body was prepared for burial here.

     Inside here is Jesus' tomb.  Again, the line was a mile long, so we didn't go inside. 

     Above the structure that houses Jesus' tomb is a domed ceiling with an opening, symbolic of his rising to the heavens.  Notice the sunlight streaming in the window on the left. 

     Many of the walls and ceilings inside the Church of the Holy Sepulchre are decorated with mosaic designs.  Each piece of mosaic tile was about 1 cm x 1 cm.  The artistry and craftsmanship were noteworthy.

     The Romans were everywhere, as evidenced by the Roman columns and arched entrance that were excavated in Jerusalem. The current "street level" is the top of the retaining wall in the back.  These columns were buried 2-street levels below.

     The domed structure is the Al-Aqsa Mosque in Old Jerusalem.  It is the third holiest site for the Sunni Muslims.

     From Jerusalem we headed to the southern part of Israel, making stops at the Dead Sea, Masada, and an oasis called En Gedi, now a national park.  Much of the southern portion of Israel is a desert called the Negev.  There weren't the expected rolling sand dunes in the areas we traveled to, but rather dry, rocky, tan-colored mountains and hills clearly created by erosion.  I was relieved to be in a car with plenty of gas, food and water as we drove through the Negev.  There's no shade.  None...and few landmarks, so getting lost in the desert would be a given if not driving on a paved highway. While speeding along we saw a few random camels loping along the desert hills.  I wasn't able to get my camera out quickly enough, so didn't get any pictures. 

     The Dead Sea has two parts, the Northern and Southern.  The sea, (actually a very salty lake...think the Great Salt Lake in Utah), is the lowest elevation in the World.  It's fed by the Jordan River from the north, but because so much water is taken out of the Jordan River for drinking, irrigation, etc., the Southern portion of the Sea is very shallow - like you can walk through it over to the country of Jordon.  

   These are ruins of homes on top of Masada - which was Herod the Great's winter retreat.

     Seeing the sudden greenery of an oasis was remarkable.  En Gedi is lush with greenery and has three water falls.

     Spring flowers were in bloom there.

     Visiting far away places, like Israel, opens my mind and my heart.  Beyond feeling tolerant of people so different from me, I make note of the differences and get an appetite to learn understand betterI find myself focusing on the things we have in common.  

     When Wynn and I went to Italy, I noticed how beautiful and fashionable the women are.  While in Spain, I noticed how beautiful the men are...think Ronaldo.  In Israel it's the children that caught my attention.  Perhaps being born in the "promised land" makes them remarkably beautiful.  My favorite thing to do is people watch...

Hasidic Jewish kids playing at the City of David in Jerusalem

A group of kids dancing and raising money to fund a summer camp for underprivileged kids.

Arab women walking in the market in Akko.

A Hasidic Jewish family, dressed up for the last day of Passover.

A traditionally dressed Hasidic couple at the ATM...old meets new. 

An American girl had her bat mitzvah atop Masada.

While I was taking a picture of this door to a home of an Ethiopian Christian on the roof of the Church of the Holy Sepulchre...
...this man walked out.  I asked if I could take his picture and he nodded in agreement, but didn't open his eyes.  I think he's beautiful.