Turning Up the Heat

On Friday, I had an appointment with Dr. Nancy Lee, my radiation oncologist at Memorial Sloan Kettering-Cancer Center (MSKCC). Upon arrival in the exam room, we discussed the area of increasing, severe pain in my lower left chest/abdomen region.

I was concerned that the pain could be a late gastrointestinal (GI) toxicity from radiotherapy that I received in November 2018 to shrink the lesion on my spleen. GI organs that have classically developed radiation-induced toxicity include the small bowel, liver & biliary system, esophagus, and rectum. But as Dr. Lee produced the CT images used to create the radiation treatment plan on her computer, it was clear that the area responsible for my pain was spared from receiving any significant radiation exposure.

Dr. Lee noticed the distension in my abdomen, which had slightly increased in size following my earlier appointment with medical oncology on Tuesday. This gave rise to concerns about a potential gastrointestinal blockage and the desire for more diagnostic imaging. Accordingly, I was sent to MSKCC’s urgent care facility. A short elevator ride, as it is conveniently located in the same building.

During my urgent care visit, I received stronger pain medications via IV infusion, including Dilaudid® (hydromorphone) and fentanyl. The fentanyl seemed to work better, but the amount of relief was still minimal. I was given a patient-controlled analgesia pump that allowed me to dose as needed (Figure 1).

Figure 1: My patient-controlled analgesia pump

By early evening, a preliminary review of the abdominal CT scan didn’t reveal any significant issues—at least none that would explain the severe pain. For example, there was some moderate growth in the lesion on my spleen, but nothing that seemed to support the level of discomfort I experienced. I was admitted to the hospital by early Saturday morning for more testing.

In some situations, a CT scan can detect abnormalities better than an MRI, including acute bleeding and bone fractures. By contrast, the resolution of newer MRI’s (3-T versus the standard 1.5T) are best at detecting small/subtle lesions or nerve injuries—so an MRI scan was scheduled for 6:30 pm Saturday.

Even before being diagnosed with cancer, I’ve had numerous MRI scans without any issues. In particular, I’m not claustrophobic and haven’t experienced any significant anxiety while being stuck in a tube for 30-40 minutes. Plus, there are no known biological hazards to humans from being exposed to magnetic fields of the strength used in medical imaging today. The fact that MRI systems don’t use ionizing radiation like other imaging modalities is also comforting.

I made it through the majority of the MRI imaging procedure—before the point where the contrast agent would typically be administered (after approximately 20-minutes). At this point, my chest and abdomen started to feel increasingly warm. It was different from any prior MRI procedure and caused me to alert the medical staff to stop.

The radiofrequency power delivered to tissue during an MRI examination results in heating of patient tissues, but MRI scanners have power limits that keep the radiofrequency power deposition to levels that are safe for most patients. In this regard, metals such as used in electronic medical devices, piercings, and tattoos, have the potential to cause severe burns or other harm within an MR imaging environment. For this reason, individuals are given a screening checklist to identify these issues in advance. In my case, there are no objects in my chest/abdomen region to explain the warm sensation.

My heart and mind raced as I tried to calm down after being removed from the MRI tube. Unfortunately, anxiety got the best of me (as I feared being boiled alive…) and I couldn’t bring myself to finish the procedure. I deeply regretted not requesting a dose of Ativan® (lorazepam) before the MRI.

In the past, I’ve experienced an overall warm, flushed sensation with iodine-based contrast agents during a CT imaging procedure. The feeling is short-lived and not as severe as what I experienced in the MRI. Besides, gadolinium-based contrast agents are used during an MRI procedure, not iodine-based agents. And again, my MRI was halted before the contrast infusion.

Without additional diagnostic information from the MRI, it is difficult to pinpoint the source of my pain. The best option is to complete the remaining ~15-minutes of the MRI with the contrast agent, which hopefully I’ll be able to manage today (Sunday) without issue.

In the meantime, I continue pushing away on my fentanyl pump between getting a few hours of sleep in the hospital. While still in varying amounts of pain, at least it isn’t “constant” as it has been over the past few days. Small progress, but I’ll take it.