Retinoblastoma: Ugly like hell

Thursday, September 25, 2008

Neoplasm/cancer or an abnormal growth of cells is longer unfamiliar in this society. It instills fear in anyone who knows how deadly it is, crushing every of your hopes that you have left for this hostile world. Some people would rather have a radical double mastectomy after knowing that they have a high risk of developing breast cancer due to the inheritance of the mutated BRCA1 and BRCA 2 genes, giving up their sex life, begging for survival as helpless as a baby. Have anyone of you all actually thought about how cancer cells look like? For me, if you are speaking in terms of microscopic views, it is gorgeous, captivating. Somehow I find that abnormal cell growth either benign or malignant represents a parasite that has long been residing inside your body, waiting for the right chance and the right time to be released from the surveillance of the body's immune system, and thus ending a life by proliferating out of control.

It all happens in chronological order. First the patient will present to you with an emanciated condition, loosing weight, fatigue, reduced physiological function and etc. Then, as the cells starts to proliferate by having a shorter cell cycles, it denotes the start of a loosing battle. The body's effort to kill off the cells seems futile, day by day, the expansion occurs. Practically till the last breath you could probably gasp.

Yes, cancer cells, you are undoubtedly beautiful and attrative to me. For those that does not catch what I mean, below is a histological cross section of an adenocarcinoma at 10x taken from one of the slide from the histopathology lab.
The irregular architecture of the cells, with features of dysplasia,enlarged/darker nuclei and bizzare rate of mitosis together with a high N-C ratio is bringing out the message that : the battle has just began. Look at it..Isnt it wonderful? Microscopicly i mean, ugly like hell if you consider the consequences of its presence.

Recently, I have the opportunity to meet a patient who is diagnosed with retinablastoma in one of the private hospital in KL. Jason* a 27 year old male presented with distorted facial features is diagnosed with retinoblastoma when he was at the age of 2 ( if i am not mistaken ). Asymmetry of the face was noted with prominent atrophy of the muscles on the left side of his face due to the fact that he undergone a series of chemotheraphy and radiation treatment to kill that cells that apparantly had destroyed one of his eyes causing complete loss of vision on the right eye. Series of chemotheraphy and radiotheraphy have severely damaged the vascularization of the left side of the face resulting in asymmetry and delayed facial bone development. Back at that time, the surgeon removed the eye and arranged plans for him that include a few different modalities of treatment. From then, his life has been totally different from the normal children.

Name of the patient has been de-identified to protect confidentiality.

"Retinoblastoma - (Reh-tin-oh-blast-oma) is a cancer of one or both eyes which occurs in young children. There are approximately 350 new diagnosed cases per year in the United States. Retinoblastoma affects one in every 15,000 to 30,000 live babies that are born in the United States. Retinoblastoma affects children of all races and both boys and girls.

The retinoblastoma tumor(s) originate in the retina, the light sensitive layer of the eye which enables the eye to see. When the tumors are present in one eye, it is referred to as unilateral retinoblastoma, and when it occurs in both eyes it is referred to as bilateral retinoblastoma."

I am here not to talk about the pathophysiology of retinoblastoma but instead to tell you how I feel after i met and talked to him personally. Well, to give a clearer picture, shown below is the actual CT scan of the patient. The scan denotes the deformity suffered by the patient well.

Being a retinoblastoma patient, he did not have the chance to further his education to the tertiary level. From the way he talks, I probably think that he is in denial as he did not even know that he suffered from retinoblastoma after years of theraphies and treatment. The mother who was the one who is doing the talking all the time. From the mother's look, I could understand the feelings that she is going through. Although I did not go through what she has gone through, being placed in a situation like this is unbearable for me. The uncertainty of his future would be the matter that worries her the most I guess.

As a parent, the fact that your child has cancer is one of the worst situations you can be faced with. You may have many different emotions, such as fear, guilt, sadness, anger and uncertainty. These are all normal reactions, and are part of the process that many parents go through at such a difficult time.

(Retinoblastoma, white color in the center circle of the eye (pupil) when light is shined in the eye, such as when taking a flash photograph)

As a first year meddie, this case do really widen my horizons. Being a doctor or a surgeon does not involve only slicing and cutting. They deal with the quality of life of the patients as well. Jason is completely cured I would say. What he needs is a facial reconstruction to help him regain his self esteem.

When the surgeon asked him what are his current wishes, he said:

"I just want to put on a spec, thats all"

Simple thing like this do touched me. Right till the bottom of my heart I would say. Looking at the doctor and then at the patient. Even as an observer, I am satisfied. Satisfied spiritually. Now I know, medicine is really satisfying. As a doctor, you have a pair of hand that is capable of healing, putting things back into their order. Isnt that a noble thing to do?

Anyway, I am looking forward to the reconstructive surgery that will be held maybe next week. Hope to see him regaining his self esteem after being given a new "face".

Well, this post is getting kinda long and boring. So i think I better put an end to it.

Anyway, I saw a patient with footdrop when I was on my way to uni yesterday morning. He was waddling as he was trying his best to make his foot clear the ground. I suspected it was due to a common peroneal nerve injury. Went to the old folks home today, did a neurological examination on a patient with parkinson. Saw what is pill rolling and shuffling gait all about.

It is so satisfying to tie what you have learnt with what you see.

Seriously, "What you dont know, your eyes wont see", thats rule number one in the world of medicine.

Signing off,

My first post- Surgery and Me

Saturday, September 20, 2008

It has been a while since I blog. The last post was 5 months ago if I am not mistaken. Life has been very rewarding for me during this transition period, practically living with medicine from day to night while trying to clear up all the mess in my life and to find a new direction and meaning in life.

I don't need sex, medicine is my orgasm. When I turn around and look at all time that passed by me without even me noticing, I know that I missed out a lot of interesting stuffs in my life due to the fact that I spend most of the time with books, atlases, notes, somehow trying to stuff the vast amount of knowledge into my tiny little brain. I have a limited social circle. I no longer hold 3 presidentships like I used to be in high school. I am no longer the president of SOSAM, like i used to be in Inti College. I am just an ordinary emanciated guy here in the university trying his best, with his utmost ability just to make sure that he is competent and is ready to be in the first line of health care one day.

Life has been too routine for me, hmmm, I guess.

I was told by Dr Kelvin that " There are a lot of interesting stuffs in life other than medicine. Get a life". I start to ponder whether all the sacrifices that I have made is worthwhile. From the moment that I am keen that I would want to devote my life to serve the humanity, I know that my life is going to be different from others. Yet, I am rambling and ranting, complaining about my life. Frankly speaking, I do not know what I want.

Been really into surgery since the first semester and I managed to attend a few surgeries involving MVA ( Motor Vehicle Accident) such as mandibular fractures in Gleneagles Intan under the supervision of Dr Kelvin. Somehow in the OT, I can feel my the adrenaline pumping, the scent of the operating theater seems to stimulate my olfactory receptors. Looking at the surgeons working meticulously, surgical nurses assisting, I somehow feel that I belong to the group. I truly feel that this is my calling.

"10 blade scalpel, retractor, suction", looking at how the surgeon works amazes me. From the first incision to the last suture, every movement is done with the highest level of confidence. Even as first year medical student, I know that there is no room for errors. Even the slightest mistake the surgeon makes could jeopardise the patient's health. Every nerves should be avoided. Every incision should be precise. Somehow the surgeons have this quality that attracts me.

"Sometimes wrong, but never in doubt". This shows how confident they are when they are holding the scalpel and lives are at stake. However, fallibility is unevitable and medicolegal issues are common.

You can say that as a first year medical student, it is rather ambitious and not down to earth to be so sure that you are going to end up in a particular field. However, I see it as a motivation, for me to strive for exellence. I am truly blessed as I am given a chance to study medicine. Although the journey is long and I could not see the end of it. I can assure you that this is a journey with a lot to lose, life time learning, commitments and devotion.

Passing medical school is easy. But making yourself a competent medical practitioner requires more than just academic qualifications. Year 1 is coming to an end soon, and I am going to be officially a 20% doctor. Hopefully, I am able to note down all the interesting events that I go through along the journey, provided I am not suffocated by the never ending work load.

As what i said in my previous blog,

This is my story and I promise I wont leave anything out.