To be honest, Allistaire felt anything but strong against cancer on Thursday after being discharged from the hospital.  Nevertheless, it was a glorious day and this was to be our one shot for Allistaire to go to the pumpkin patch.  Minutes before I took this picture she was crying hard because of pain in her face.  Pain where the leukemia is eating away, eroding the bone.  After eating a couple of chips so her stomach wouldn’t be empty, I gave her a dose of oxycodone.   There is now a 3 X 3.8 X 3.6 cm mass of leukemia in her right sinus which is pushing her eye forward, and affecting her sinuses.  Her nose runs constantly now.

“There is expansion and bony erosion of the right maxillary sinus.  The mass extends into the right orbit resulting in mild mass effect on the right globe and minimal right proptosis.  The mass extends into the right nasal canal replaces the middle and inferior nasal turbinates.  The mass also involves the right ethmoid and right sphenoid sinuses and alveolar ridge.” (Brain MRI report)

There is also a growing mass in her left sinus measuring 2.5 X 2.3 X 1.5 cm.  The cancer is pushing its way into the roots of her molars.

It hurts to look at her.  It’s hard not to have my attention drawn right to that eye.  I wonder what other people see.  I feel some strange inward compulsion to tell everyone who sees her, this is not her.  You are not really seeing my sweet girl – this weak, crying, deformed child is not her.  But this is what childhood cancer looks like.

Originally, Allistaire was going to be discharged from the hospital Wednesday.  Her scans that had been rescheduled for Monday had to be changed to Tuesday because her blood sugar level was too low on Monday to make anesthesia safe and the docs couldn’t just replete her glucose because then the PET scan wouldn’t work.  So once Monday’s scans were cancelled we disconnected her NG tube from suction and amazingly 21 hours later she still hadn’t thrown up – this despite drinking a full cup of apple juice in relative short time to get her blood sugar level up Tuesday morning just in time for the cut off for the PET scan and anesthesia.  Thankfully all went well with the scans and the anesthesiologist said she did great.  So just before she woke up, the nurse removed the NG tube from Allistaire.  She was quite excited and proud when she woke up to find the tubie gone.  I was hopeful that with scans done and the tube gone we could get out of the hospital

Sadly, Allistaire’s potassium has been very low for over a week, so discharge was delayed.  The theory is that with all of Allistaire’s stomach contents being suctioned out, her electrolytes have gotten off their normal levels.  Low potassium is dangerous because it can cause arrhythmias in her heart.  So it would seem like the best course of action would be to give her a potassium supplement to replete her levels.  However, Dr. Rosenberg, the attending doc, feared Allistaire might either have or was going to have tumor lysis.  Tumor lysis is the breaking up/death of cancer cells in which the contents of the cells go into the blood stream and eventually have to be processed by the kidneys.  Extensive tumor lysis can be too much for the kidneys to handle and can actually cause acute or even permanent kidney failure.  This is what happened to Allistaire the last time she took the chemo, Mylotarg.  Cancer cells can lys as part of their normal life cycle or because of being destroyed by chemo.

Dr. Rosenberg originally suspected tumor lysis because Allistaire’s uric acid level jumped up.  I questioned this given that Allistaire had ceased taking Allipurinol, which removes uric acid, due to her ileus. Apparently, however, under normal circumstances, the body doesn’t produce uric acid, though Allistaire’s must because she has required long-term use of Allipurinol.  In order to quickly remove uric acid, Allistaire was given one dose of IV rasburicase (which turns out to be about $7,000 a dose).   Because tumor lysis can also cause a dangerous jump up in potassium, Dr. Rosenberg wanted to be conservative and only minimally replete her levels.  For this reason, a low dose of potassium was added to her fluids which helped keep her level up just enough to mitigate the risk to her heart.  However, her level remains too low for her to restart her Digoxin and Lasix at this point.

Allistaire’s face has been getting progressively worse, even in the course of days.  The side of her face along her nose is now numb presumably from a nerve being effected by the leukemia.  She looks like she’s been beaten.  The whole right side of her face is strained and bulging from the relentless march of cancer and its apparent impact on the draining of her sinuses.  There is something so wretched about it being in her face.  It feels like she’s being stolen away.  I look to her left eye to see the Allistaire I know, the one I know is in there, shrouded by this struggle.  She’s had pain before, pain her legs, arms, arm pit – so many places these chloromas have showed up – twenty-nine different tumors or “myeloid sarcomas” as her MRI refers to them.  But the face?!  Not her face Lord!  Please spare her pain and deformity there.

I am holding out for Monday.  Monday will be her first dose of Mylotarg.  Today is day 4 out of 5 for the chemo Decitabine which will be followed by doses of Mylotarg on days 6, 9 and 12.  For Decitabine we go to clinic but Monday she will be readmitted to the hospital in anticipation of the much hoped for, yet dangerous, tumor lysis.  Dr.  Cooper is strategizing how to best prepare her, knowing that due to the limitations of her heart, he cannot simply flood her with fluids to wash out the cancer cell guts we want to break open and spill out into her blood stream.  In coordination with cardiology, she will get what fluids she can and he is planning to give her another dose of Rasburicase to completely wipe out the uric acid.  However, the phosphorus and potassium can also rise to dangerous levels.  Sevelamer can be used to bind-up the phosphorus.  She will remain in the hospital at least through Thursday when she gets the second dose of Mylotarg on day 9.  Should she have any fevers, she would need to stay in the hospital for at least 48 hours.  Around day 21 she may have another brain MRI with the intention of determining what cancer is left in her face and planning radiation for what remains.  Our very dear Dr. Ralph Ermoian is the radiology oncologist who is responsible for determining if and when radiation is an option, what are the risks and benefits and what type of radiation will be best given the location.  He is an exceptionally kind man and I feel blessed to have him be a part of Allistaire’s care.

On another note, in case you haven’t read “The Emperor of All Maladies,” I will yet again highly recommend it.  Something I found so fascinating as I read through the history of cancer was the role of “serendipity” in the progress and advancement of the understanding of cancer and its treatment.  The author used this word on a number of occasions to account for circumstances in which unexplained events and even mishaps resulted in progress.  Whenever I would read of “serendipity,” my face would light up with a smile.  Am I just looking to give God credit where it was really just happenstance, chance?  Yes.  Yes I am.  Because I don’t believe in chance.  I believe in a God who orchestrates – down to the details.  I believe in a God who works through circumstances to accomplish His will.  Please be praying for “serendipity.”  AML experts from around the country will be meeting next week as part of the Children’s Oncology Group.  As well, my friend Julie Guillot, whose son Zach died of AML, will be in New York meeting with the CEO of the Leukemia and Lymphoma Society to challenge them to substantially increase their financial support of research for pediatric AML in their “Beat AML” campaign.  Collaboration of doctors, researchers, funding organizations and parents of kids with AML is imperative to drive us closer and quicker to lasting cures and less toxic treatment options.  There really is excitement in the air.

I didn’t realize it until I was saying it, but I told Dr. Cooper the other day, “We parents are your biggest advocates and promoters.  We are the biggest believers in cancer research.  We are the keepers of the stories and faces that can turn people’s hearts to give to cancer research.  You can’t expect us, of all people, to give up hope, to say we are done fighting, to raise the white flag.  We CANNOT.”  The world of cancer treatment is on the move due to the accomplishments of cancer research.  Just around the corner, yet out of sight, might be the thing that will provide Allistaire’s next open door.

Today such a thing is hard to imagine.  Today there were blasts (cancer cells) in her peripheral blood.  She wants only to sleep.  When she is awake she tenderly holds her hand to her right cheek and cries, saying “ouchie” over and over and over.  She doesn’t want to eat because it hurts to chew.  I will turn to look at her and again see bloody snot running from her nose.  She is miserable.  The last few days have been the first time I can imagine ever saying yes to hospice.  If it were not for the hope of Mylotarg, the hope of something that would work…if this cancer was left to progress…it’s nauseating.  It is a magnificent fall sunny day.  Families are headed to the pumpkin patch while my child languishes in a dark room, moaning in her sleep.  It hurts.  It hurts so bad.

I want to sincerely thank Keith & Janet Stocker of Stocker Farms for their compassionate and generous hearts that have chosen to give the proceeds of this year’s Pumpkin Patch to Strong Against Cancer which is a collaboration of doctors, nurses, researchers, hospitals, companies and people like you who are supporting the medical breakthrough of using immunotherapy to treat cancer – much of which is being developed at Seattle Children’s Ben Towne Center for Childhood Cancer Research.