Good Friday is Bad

Let me describe the situation.  


Mary's liver is clearly failing and the rate of failure appears to be increasing.  Also, her kidneys are failing.  How do they know this?  They measure (1) CA-19-9, a marker for cancer presence in the body, (2) bilirubin, one of those wonderful chemical compounds that enables the living process and (3) albumin, another one of those wonderful compounds.  There are other confirming tests, but these are the big three. 


In Mary's case, the CA-19-9 results taken last April, prior to the liver surgery, were in the range of 1,500 and higher.  After surgery, they fell to 500 in June and then continuously decreased through February's blood test taken on February 19th at a value under 300 which lead the Oncologist to declare she was cancer free.  The test taken a week ago as Mary entered the hospital produced a value of 1,500, a fivefold increase in 5 weeks.  


The bilirubin and albumin are two body chemistries that are absolutely essential to life and produced all over the body by various organs and body parts.  When the liver stops properly processing, the bilirubin and albumin start to build up in the body because their normal liver exits are blocked.  The data for bilirubin from April of last year to current shows a peak value before surgery, another peak during radiation+chemo therapy and a peak now.  However, all other months showed absolutely in the proper range values. 


Albumin is another compound produced throughout the body and removed, in part, by the liver.  The fluid extracted from Mary's abdomen on Monday was albumin, indicative of a serious blockage of the liver.  However, the cytology test of the albumin has not presented a "pathologically certain" presence of cancer.  


So what we have is a therapeutic diagnosis. I liken this to the description of an animal: It walks like a duck, it squawks like a duck, it swims like a duck and flies like a duck. We cannot see the animal, but what do you suppose it is? A duck. Ya think? 


The CA 19-9, bilirubin, and albumin data taken with the jaundice color of Mary's skin, her fluid retention symptoms, her history of cancer and her overall pain leads one to cholangiocarcinoma.  We cannot see it (pathologically certain) but given what we do know and it behaviors, the only diagnosis that fits is cholangiocarcinoma.  


Why did we think she was cancer free just a few weeks ago? Because all of the test results were absolutely in the correct values, especially the CA 19-9.  The only fly in the ointment was the recurring back pain which we thought was anything but cancer.  And remember, we had cancer specialists looking for a connection between the pain and the cancer tests and could not find anything that would indicated the presence of cancer.  


The bottom line: Mary's cancer has reappeared with a vengeance and is in the process of shutting down her liver and following close behind is her kidneys. 


Is there anything that can be done? Nope, we did it last year with the liver trisegmentectomy.  Can you irradiate the liver to stop damage by cancer? Again, no, for the simple reason that because we cannot see it, we cannot hit it with an x-ray beam and expect any successful effect. Liver transplant?  Nope, excluded by nature of Mary's cancer and last year's operation. What can be done?  Palliative care to provide comfort to Mary.  


We had family meeting with the oncology team and medical team.  As a result, we understand the likely progression from here for Mary. Although we'll never be ready for the ultimate result, we won't be surprised either.