My surgery date is scheduled a month from today, on October 16th. The ENT is going to resect the tumor in level III during a radical neck dissection, and Radiation Oncologist, Physacist do High Dose Rate Intraoperative Radiation Therapy (HDR-IORT), which are photons produced from a high dose rate gamma emmitting radioisotope with Ir-192 mounted on a mobile afterloader (phew), with various sized flexible applicators used to deliver radiation, that can be fitted to any location, crevice, with the molded HAM Applicators, which my Radiation Oncologist designed, to the area, with a large single fraction that is administered at the time of surgery in a large fraction dose between 10-20Gy, which is equivalent to 20-45Gy in IMRT, and thst is usually no more than 2Gy each day, so its like getting 4 weeks of radiation at once, and primarily focused on a surgically exposed tumor or tumor bed while the other healthy organs, and tissue, are either shielded by lead shields or displaced from the radiation field.

This is my second time with IORT, my 4th radiation Tx, that basically a newer type form of brachytherapy. My first was with 15Gy, probably equivemant to 45Gy, and then addition 50Gy of IMRT, with chemotherapy for 5 weeks later on. I don't think I'll receive further radiation this time having radiation with a total of 150Gy or 210Gy that is equivalent to IMRT, and the oncologist laready said no chemo.

The advantage of HD-IORT is its ability to use a higher radiation dose while reducing exposure of normal tissue, and with patients with recurrences that were previosly treated with radiation. This takes coordination with the Surgeon, Radiation Oncologist and Medical Physicist to see if it's possible, and are there during surgery to perform set-up, measure tumor area, pick out appropriate HAM applicator, calculate dosage, do control checks, and do the radiation after the resection.

The special OR is completely shielded by lead. There are only a few like this, maybe 5, in the country, otherwise one would have to be transported from the OR to the radiation department to have radiation, and back to the OR again. This OR has a lead shielded room, adjacent to the OR, to house the whole surgical team where I'll be monitored by 7 CCTV, intercom, remote applicators, monitors, delivery system for the anesthesiologist, nurses for vital signs, and to remotely do radiation, which can be up to 60 minutes. Maybe I'll finally be able to meet the elusive physicist, but doubt it, and the Wizard will probably be behind a closed doors, and I'll be knocked out lol.

The concern is the toxicity level to the carotid artery in my case, being the tumor is close to it, and my prior radiation Tx, among other concerns like the tumor being small at 3x7mm making it difficult to find, but the ENT is confident he knows where to find it. The carotid artery will be shielded with molded lead, as well as other vital structures, which is not possible with other external beam radiation, like IMRT. Last year's surgery took 5 hours, but I think it will be less time being I already have the pec flap, and there is not much to remove from the three prior neck dissections, but who knows to what extent surgery will be until it's done.

I'll probably be in the hospital for several days, and believe last year it was four days. If it is, it will be four years from the date I was diagnosed with cancer.

Paul, your treatment plan sounds like it is a good one. Wishing you all the very best with everything you are dealing with.

Thank you, Christine. I have excellent doctors, and my RO is an expert in IORT, brachytherapy, head and neck cancer, and knows head and neck anatomy better than any surgeon, other surgeons have said, so I have confidence in them. Sometime after healing, I have to do HBO again to have my teeth removed

Hi, Paul -
Glad that you have a plan in hand. You might ask to meet the elusive physicist - you will probably get the 'long answer' to whatever you ask, but I'll bet that it would be interesting.
My very best wishes during the waiting and for the upcoming procedures.
Maria

Thank you Maria. Off to see the Wizard .....

Good news Paul and I certainly am praying for wisdom and guidance for your medical team. I'll sneak in another request for the Wizard to appear. You certainly deserve it with all the magic you have mustered up in this long and drawn out battle. You are an amazing man!

Get well and maybe we can plan 20-30 scuba dives so you can enjoy the dives at least. Hang in there. I would imagine you have some sense of relief but a bit of worry mixed in over the next month as you prepare for yet another round.

Thanks. It is a relief knowing where I'm going. I do have some concerns, and one is recurrences before surgery, which happened twice last year after two cancer diagnoses only to have two recurrences before surgery. In one way I'm lucky in finding them early.

Tell them to cook it good this time!!! Hugs!

Just reading the treatment plan is fascinating and I wish I could be there to see this nut obviously I do wish that you didn't have to go thru this but let's hope they accomplish everything they hope for.

Thanks all! It's really the only thing that will help at this point for a cure. Surgery alone, probably not, but that's even better than nothing. I'm surprised not many have this done for recurrences, at least from my readings, and neither did I until last year, and would have done it earlier. Goes to show what one doctor may not or can't do, another one may. I didn't even consult for a 2nd opinion at this point, and even MSKCC didn't want to see me last year for some reason, maybe after hearing who the RO was that I was consulting with, who was head of brachytherapy there for 10 years. He told me I know you have been shopping around lol, and you will not get a better offering than this, and was true.

Paul, I am so glad you are in good hands. The treatment plan is amazing, I had no idea they could do things like mold shields to protect structures. It makes me wonder why this isn't used more even for non-recurrences when the tumor bed's exposed and improving the margin is dangerous.

For me waiting to start is so hard, once a plan's been charted. With this sophisticated type of treatment I'm sure they need every last minute to prepare and coordinate -- Just aligning the doc's schedules must be a trick.

Get better, we need you here!

(((HUGS)))

Mama

Thank you Mama. I guess it's the cost of the IORT machine, over a million, a shielded OR dedicated for this, the radiation, and need for a multidisplinary team of doctors for surgery, and expertise in this area. It can be used for almost any area of the head and neck, and used in other cancers throughout the body.

Waiting is the hardest, and correct with coordinating the doctors schedules for this, the radistion plan.

Hope all is well with yourself.

Now I developed a gum infection from hurting my teeth while eating on Saturday. Took tramadol, Tylenol, Gabapentin, no help with the pain, and rinsing with warm salted water for the swelling, so I took oxycodone, knowing I would get sick, and did, vomiting for two days, and took antibiotics I had for the other side last month, being it was the weekend. An abscess may have developed on my jawline, same side as tooth, opposite side where cancer is, and have an appointment on Wednesday with my local oncologist. I hope I don't need to have it surgically removed or need IV antibiotics, which happened before to prevent sepsis, which hapened anyway, and caught MRSA in the hospital too, and when I get sick, take certain medications, stress, eat certain food, I can get hemolytic anemia whereby my RBC die off at a faster rate then they can be replaced from a metabolic disorder, G6PD, and needed transfusions in the past. I'm supposed to have my pre-op physical on Thursday, and hope this doesn't cause a delay with surgery on the 16th. I just won't open my mouth lol

I can't have any teeth removed until HBO is done, and can't have HBO until surgery/radiation is done to remove the cancer. I'm glad kept my feeding tube, just in case.

Things always seem to happen at the wrong time, like it usually does with everyone.

Oh no Paul.
Seems its always pouring around you. Hope you have sorted the pain out by now.
Ain't life complicated.
Keeping you in my thoughts and on my Special prayer list.
Tammy

Thank you Tammy. The oxy helps, but dinner was a waste lol.

That totally sucks! Thank heavens for pain meds feel better soon

Paul, your courage which allows you to take all the complications in stride is inspirational. Wishing you good luck and a quick recovery.

Thank you Cheryl and Gloria. I'll be ok, I have to be

Sorry to hear you are having even more issues. Seems like when times are rough anything that can go wrong will.

Your mouth should have enough time to heal before the surgery on the 16th. If you are like me, you probably heal much slower than you did before cancer and rads. There still should be enough time for your mouth to heal.

Wishing you all the best with everything!

Hey Paul, I'm so sorry about this recent turn of events. Can they find something for your pain that doesn't trigger nausea, or an anti-nausea drug so you can manage the pain med? I hate to think of you suffering, especially due to an innocent meal!

Had to chuckle, though, at your in-house pharmacy -- I'm thinking "Paulgreens"!

Hang tough, my friend --

(((HUGS)))

Mama

Sorry for more complications Paul. Prayers for you my friend.

Ed

Thanks everyone. I would rather be sick than have tooth pain lol. I'll have to check Paulgreens for anti-nausea meds, which I probably have. I see my doctor on Wednesday, and do have delayed healing sometimes due to diabetes also.

Paul, I just wanted to say you are amazing, and such a source of courage for me. All that you are going through right now, and you are still so positive for everyone else. You are truly remarkable and are in my thoughts as you fight through this.

Anything that can go wrong....

Sorry Paul!

I went to my new primary doctor, who gave me a prescription for clindomycin for a two minute visit, and cost me $34 by taxi, and said If not better, to see my dentist to have it drained before surgery. I don't have a dentist, and just seeing the oral surgeon at the cancer center about my teeth, which is unresolved, and don't know their extent of my care being I have no dental with mediscam. Anyway, I'll see about making an appointment next week. Tomorrow I'll see my local oncologist who I can count on more.

Thankfully my infection, abscess, is clearing from the antibiotics, salt rinses, but still have to take them for two more weeks. Basically I'm eating soft foods, due to teeth missing, and down to gum line, but also I don't want to cause irritation, and reinfection, which this last one was caused by chewing on tender porterhouse steak, med rare, and the one prior was from the flatbread with the falafel. Bought new soft toothbrushes too not to reinfect.

Good news Paul.

vegetarian anyone? and skip the bread? just joking... paul your determination is applaudable I sincerely hope you kick your infection in the butt.

I made New England corn and clam chowder yesterday I did vegetarian a few times, but with no fish, poultry, meat, dairy, butter or oil, but many years ago. I'm enjoying tasting food too much to do that now.

Oh my God, I hope you're getting some GOOD in your life, Paul! Damn. I haven't read all of your threads but I sure hope you have some help??? You were so informative about your next procedure. Very interesting & very appreciated!

Thank you Auditie, I manage, and do everything by myself, sometimes preferring that, but I will get a ride to surgery.

Paul, I just wanted to check in and say Hi. What an amazing treatment plan they have developed. I am beyond impressed that you even are able to understand all that well enough to then describe it. I am glad to hear you are recovering from the recent bout of infection. Good luck with everything.
Best,
Mary

Thank you Mary. I had it done last year too, but never heard of it before that either, and did a crash course to get educated. My Radiologist wrote a book on it, so I read it. They had fun one day asking me questions to see if I knew the answers. Good luck also with the upcoming PET.

That is a lot of stuff going on. Best of outcomes, Hopefully you will have enough space in your Sig. line. And hopfully it will be one of your last additions. Incredible that you have come this far.(radiation, Surgery and a cure. Oh my).

Shawn u.

Thanks Shawn, I left out a lot, and ran out of space already lol, but have some room for NED. Just trying to keep my infection at bay for surgery, trying to relax, getting sick from the occasional Oxycodone, missing my bucket list foods before surgery, due to my teeth, is all in a days work lol. That is one of my favorite movies, Wizard of Oz, believe it or not. Once, long time ago, at work In presented some employees certificates for courage, knowledge, heath etc, so they would leave me alone lol. We used to have fun in those days, but took care of buisness when we had to.

This procedure has risk for carotid blow out, others, and read somewhere could be around 17%, but that's over time, 3-24 months. This is my second IORT, and two prior IMRT in the same area. A neck dissection is 1-2%. Usually, pre-surgery, I reflect how I got here.

My surgey/radiation day is finally here on Wednesday, and it was a long wait, and not relaxing at all, which is no surprise. I've been busy trying to keep a mouth infection, and a jaw abscess at bay with antibiotics, salt water rinses, the heck with adding baking soda, which tastes like fish, and biotene mouth wash, the past three weeks, which could have delayed surgery. This prevented me from eating certain foods on my pre-surgery bucket food list, but I did alright with a few meals.

During this waiting period, I tend to reflect back from diagnosis to present, and prepare myself mentally for battle. It's also good because sometimes you are asked the same things over and over by other doctors, staff, and my situation can be confusing, even for myself. I can't believe I had 8 recurrences in 4 years, and feel lucky somewhat, although it was no picnic to get here, and more than paid my dues. My radiation oncologist said he has a lot of respect for me, and few could do what I did, and modesty aside, maybe he's right, but we do it because we have to, and anyone would in the same situation.

As mentioned, surgery will be a RND, along the same surgical lines, but after three neck dissections, two radical, there is not much left, so I don't know how radical it is, but they are to take out the cancer, so you never know, and they don't really either until surgery is done, and hopefully this point does not effect the carotid artery, being it was close two months ago. After the dissection, before closure, radiation will be done directly on the tumor site with an applicator, 5mm away, and everything else protected by lead shield or clamped out of the radiation field, and dosage will be equivalent to 45Gy or more, continiously, less than and hour, instead of 4.5 weeks with IMRT. Having already had 130Gy to this area, it will be 150Gy total, my 4th radiation treatment, but is really like 210Gy. At that time, the whole surgical team, including my radiologist, the physicist, leave to the adjacent leaded control room, the OR is leaded too, and continue monitoring me by CCTV, and other life support monitors remotely controlled from there. Then when all systems are go by the physicist, the radiation oncologist presses the radiation button, I don't know if it's Red lol, to administer radiation, and authentication seems like sending off a nuclear missile, which mabe is what my cancer needs, and my thought is, "On My Signal, Unleash Hell." From Maximus in "Gladiator."

Strength and Honor

Again Paul, you are simply amazing.
I will be keeping you in my thoughts and looking for your updates.
I think that as you really have done your research regarding your treatment options, all will be well. You are a Pioneer aren't you.
You certainly do have Strength and definitely Honor.
Take care, be well ,
Tammy

Thank you Tammy. All will be fine, and like another doctor of mine said, I'm like a cat with 9 lives lol. Anyway, I have to go back to get another hug from my doctor in a few weeks, makes it worth it

Good luck Paul!

Thanks David.

Strength and Honor! That is exactly what I think of you Paul. As you suit up in your armor in preparation of one of the biggest battles in this never ending war know I and many will be praying for the best possible outcome for you. You have become a beacon for all of us, lighting the path into darkness like no one before us.

Get through this and I will be in line for one of the biggest hugs of my life...if she lets me! LOL

Thanks Uptown,that made me smile, and can feel the support. Funny you say suit up, that's what I do besides metallly, visually, I'm getting a haircut today, clipped my nails, shaved already, as I don't shave day of surgery as a habit, and have to look good even in battle

Best to you on this next battle, Paul. I know you are geared up for it but still want to offer some encouragement.

I guess the worst part is after all the grays you will no longer be able to pass through any security checkpoints. All the sirens will blare this dude is packing a nuke! lol

Again, best to you on a speedy recovery. don

Thanks Don. I need encouragement. I have to be there 5:30am. Surgery is at 7:30am. Actually there is a geiger counter in the OR to measure the radiation level, and hope I don't set that off.

Thinking about you, Paul - and sending you my very best positive vibes, prayers and wishes for a successful surgery today, and for everything to go just the way it's supposed to. Sounds like you are well prepared (love the haircut!) and you have an excellent team working for you!

Thanks.

Waiting to see a post saying everything is finished and the surgery was a success. Thinking of you today Paul. Best wishes!!!

Good luck today Paul were all in your corner wishing you the best...ken

Good luck my dear. I am surprised that with an infection they are going to operate. It just leaves you open to a bigger and more systemic infection. Hopefully all will go well, and the treatment they are giving you will do what it's supposed to so you can have some peace and enjoy your cooking and eating... ;o) hugs.

I finally arrived back home a little while while ago, on Wednesday with some mixed reviews. Surgery started at 7:40pm, and ws in recovery arounnd 10:30am. My surgeon came in too see in recovery, and said radiaition could not be given nor given safely being so close, maybe attched to the carotid artery, and microscopic cancer was still there. They want to go back in and remove what they can, including the cartotid artery, and do the radaition as planned, which I agreed to, and know this is no easy task. After a few hours, I was send to another sister hospital by ambulance for testing to see how i would fare with one carotid artery with a baloon inclusion aertery test via the femoral artearery and sealed by baloon temporaally, similar to an angeoplasty, that was later closed with suture mediated closure and Mynx Vasculature closure device was supposed go go back to by hospital, but stayed in their neuro ICU. The test showed my carotid and other veins in good working order, so I can have the carid artey in my left neck sealed or remved and surgey and radiation done next Thusday.

Paul, thanks for checking in! Sorry the surgery didnt go better but there is at least a good treatment plan. Wishing you all the best with your recovery and upcoming procedure.

Hope everything goes well with the new treatment plan, Paul. Good that your carotid artery and other veins are OK so that they can proceed on a more positive note. Sounds like they are moving fast and taking good care of youl Keep us updated whenever you can.

Good to hear from you Paul. Sounds like quick reaction and move to the alternate plan. Hang tough. Keep you in thoughts and prayers.

Paul-
Thank you for updating us. Good heavens, you just continue to amaze us all. I am wishing, hoping and praying for a good outcome for the next procedure.

Best,
Mary

Sending you good thought Paul!

Actually, that is very good news Paul. Now treatment can progress.
Thursday will come around soon enough, though I'm sure you wish they would just get on with it. Keeping you in my thoughts, take care,
Tammy

Due to the trismus, they had to administer anthesesia, oyygen through the nasal passage. Once knock out it was ok, but they had to do several numbing sprays, some on cotton sticks, in the nose and mouth, before they started. Still better than a trach I was somewhat expecting, and I tried to open my mouth as far as I could to help prevent, which my ENT said was fine, but not for the anesthesiologist.

Cheryl, my infection is gone, for now. I did the pre-op physical, blood work with flying colors . I was given several antibiotic infusions for another reason after the test I had with some closing devices installed in the femoral.