Last chemo treatment put me in hospital

Phenomenal PETscan report today, revealing near complete resolution of all cancer sources.
I found it hard to believe what my oncologist was saying, but he assured me that it is true. While I’m only mid-treatment, I feel confident I’m hanging around this side of the topsoil for some time to come!!!

Congratulations!!
Yes, it’s always better to look down at the sod, than up.

I am delighted to hear of your excellent clinical response. Have they discussed further treatments regimens with you? If so, what did they suggest?

Dave

Hi David, My oncologist was at somewhat of a loss as to the cause of the pneumonia. I’ve personally begun to suspect enteral aspiration pneumonia from a mild aspiration episode one evening about 3-5 days before the chemo and onset of symptoms. I’ve been aspirating minor amounts of feed for the past few days from intractable hiccups -a side effect of chemo. I’m regaining lung function by the hour and expect to be off oxygen in few days. I just had a chest X-ray to confirm the pneumonia is gone. If so my oncologist will resume treatment Tuesday introducing individual components I think every few days in order to flush out the most likely chemical to be the trigger, if any. I will trust his judgement. I began a medication to control the hiccups and prevent aspiration from happening.
I’ll let you know what he does and how he will implement treatment next week. For now I’m just glad my lungs weren’t permanently damaged.

I glad to hear that your pneumonia is resolving.
Aspiration pneumonia is a often a complication of EC. It would appear that the broad spectrum antibiotic treatments have largely cleared your pneumonia. It may take a bit longer to fully resolve but your report of improved breathing and oxygen saturation suggest marked clinical improvement. X-rays will likely show resolution as well along with some residual areas of bronchiectasis and minor atelectasis. These should improve/resolve with time and continued therapy. I assume that your care team has suggested that you should consider a PPI to reduce acid reflux and sleeping in an elevated position to minimize risk of aspiration.

David. Not long after returning home from getting the chest xray my oncologist ordered, he phoned me directly and said he was prescribing a diuretic rx because there was a high volume of water within the thoracic region. He asked about my hospital stay and I told him they pushed a great amount of fluids in me presumably because of the hypotension. He told me to reduce fluids and take the diuretic. He also wants me to get an echocardiogram right away out of concern for the Keytruda heart muscle warnings. After the call, I called him back to remind him that I’ve been aspirating mostly tube fed formula because of intractable hiccups. In fact I told him a recent aspiration event may possibly have been the source of the post chemo pneumonia infection. So now he also wants me to see my gastroenterologist ASAP about the spastic diaphragm and aspirating problem which must be corrected. I’ve also been quarreling with my wife with her insisting on heavy enteric feeding at night and me telling her it’s causing aspiration which she thought I was doing on purpose. Anyway I hope to see it all work out quickly. Taking a weekend trip with my wife to western Pennsylvania to meet my first grandchild ( grandson) who was born on the 4th of July, and to spend the weekend at a hotel half way from our homes.

I was not aware that you were given Keytruda. This adds an interesting twist to your current predicament. Knowing this and reviewing the symptoms described in your prior posts, while suggested that you may have experienced an adverse reaction to oxyplatin, it's also likely that the true cause of your woes may be attributable to an adverse immune reaction to your last Keytruda infusion.

While I am not a physician, I did my post-doctoral training in cardiopulmonary physiology followed by a clinical fellowship in pathology & laboratory medicine. With regard to Keytruda's adverse profile, I know where of I speak. I suffered a severe adverse immunologic event immediately after my 3rd dose of Keytruda. It triggered a serious relapse of my previously quiescent MS as well as the same cardiopulmonary complications such as myocarditis which you may have experienced.
In my case, I was hospitalized for 2 weeks and spent 2 months in inpatient rehab. I still have residual reduced cardiac output issues.

The fluid in your thorax that your doc is concerned about is also referred to as plural effusions where fluids build up in the plural/mesothelial space outside of the lungs. In plural edema, the fluid buildup occurs within the the lungs tissue.

I don't recall if you mentioned any prior cardiovascular health issues. However, you did mention that during your hospitalization, they used a continuous saline infusions to address your severe hypotension. Excessive saline infusion is strongly associated with worsening of a patient's incipient/acute heart failure symptoms. The added fluid volume can overload the pumping capacity of your already struggling heart. This produces symptoms like pulmonary edema and further complications such as pneumonia, congestive heart failure or renal failure.

Generally, first line treatment is the use of a diuretic such as furosemide (Lasix) or stronger loop diuretics to help off load excessive tissue volume. If this proves ineffective, they may need to utilize invasive methods such as thoracentisis to drain the excessive fluid.

Back to Keytruda. While rare, it may trigger a number of adverse cardiac events such as myocarditis, an acute inflammation of the heart that can lead to heart failure, arrhythmias, and sudden cardiac death. It occurs when T cells attack a protein in heart cells. Keytruda may also cause pericardial effusion, cardiomyopathy, atrial fibrillation, myocardial infarction, and/or cardiac arrest.

With more widespread use of Keytruda in various cancers, particularly those with little to no PD-L1 expression, more reports of these adverse immune related cardiovascular events have appeared in the literature. Because of increased reports of adverse events associated with the use of Ketruda in EC and other GI related cancers tumors that have low or no expression of PD-L1 the FDA's Oncology Drug Advisory Committee (ODAC) recently issued revised recommendations against the use PD-L1 inhibitors in low PD-L1 GI Cancer Patients.
There has been growing evidence and recent recommendations suggesting that the use of PD-L1 inhibitors (like Keytruda) in gastrointestinal (GI) cancer patients with low PD-L1 expression may not be as beneficial as previously thought.
Here are some key points to consider:
* FDA Recommendations: The FDA's Oncology Drugs Advisory Committee (ODAC) has voted against the risk-benefit profile of frontline PD-1 inhibitors in HER2-negative, microsatellite stable or mismatch repair proficient gastric/GEJ adenocarcinoma with PD-L1 expression under 1.
* Limited Benefit: Studies have shown that patients with low PD-L1 expression may not derive significant benefit from PD-L1 inhibitors.
* Potential Risks: The use of these drugs can come with potential side effects, and if there is limited benefit, the risks may outweigh the rewards.
It's important to note that these are evolving recommendations, and ongoing research is exploring the optimal use of PD-L1 inhibitors in GI cancer patients.
If you or someone you know is considering PD-L1 inhibitor therapy, it's crucial to discuss these recent findings with your healthcare provider. They can assess your individual situation, consider your PD-L1 status, and recommend the most appropriate treatment options.

I am providing this information to you for your background information only. It should not be construed as a definitive diagnosis and treatment recommendations for your medical conditions. However, you may want to discuss this information with your oncologist to get their clinical opinions on the topic.

Hang in there and maintain a positive mental attitude.

Dave

Thanks for that , I’m hoping to give it a try.

I think once your pulmonary issues resolve you'll be in much better shape to address the optimal therapeutic regimens to effectively provide you with a sustained clinical response. Did you recieve any reports with regard to the cytopathology, immune staining and oncogene expression detected in your biopsies. These may be instructive as to composition of a targeted chemotherapeutic regimen to attack your tumor. On the upside there are several new agents in development for EC. You may want to investigate your eligibility for participation in these trials. You can find a list of current ongoing trials that are currently recruiting participants or that are planned/approved at the FDA's Clinicaltrial.gov web site.

On another note, if you wish to speake with me directly, I would be happy to do so. You can DM through WhatsApp or Facebook.

In the interim, you'll just have to embrace the suck and power through the physical challenges that cancer presents to you on a daily basis. Maintain a positive mental attitude and resolve that you are going to do everything in your power to beat your disease. I always remind myself of two of the Stoic philosophical mantras:

Obstaculum fit modo: the obstacle becomes the way.

Memento mori: remember, we all die

Carpe diem.
Dave

Thanks again, for your thoughts, I think they’re valuable and I’m definitely sharing it with my oncologist as I did your first one. I thought I might be able to work a few hours tomorrow, but the best I can do without oxygen ( at rest) is 78-82, which I don’t know why I feel generally well. I can’t work while on oxygen and I don’t understand why my oxygen level isn’t improving alike I believed even yesterday. My weight has returned to its normal 120 ( from 132 last Wednesday and zero edema most of the fluid has gone. Also barely any wheeze or cough. Perhaps any fluid in and around the lungs is why my oxygen saturation isn’t bouncing back. ( that or lung damage). Anyhow, tomorrow I need a rush appointment with my gastroenterologist about my aspirating while on the feeding tube, and get an echocardiogram ordered for ASAP, from my cardiologist, to check for heart muscle or valve damage brought on by Keytruda, which is their most serious stated possible side effect.