Emily's Cancer Treatment

Emily's Cancer Treatment

During her 18 months of treatment, Emily received the following cancer treatment:

A craniotomy with sub-total resection (they couldn’t get all of it) was performed on August 10, 1998. The tumour was located in the posterior fossa occupying most of the fourth ventricle and pushing into the cerebellum and brain stem. The portion (about the size of a pea) which had entered the brain stem was inoperable. The incision was made at the back of the neck slightly left of mid-line. Emily recovered from the surgery very quickly, with little complications. Her speech, swallowing reflex and motor skills were unaffected, and within days she was eating, cruising around, playing with her stickers and reciting pages from Curious George. Though the need for a shunt was a possibility in the days following surgery, Emily did not end up requiring one.

Emily had a port-a-cath inserted on August 24, 1998, through which she later received her chemo, blood products and some of her meds. The port gave us a number of clotting problems in September 1998, just days after it was inserted. The doctors came close to removing it, but with much difficulty the clots were resolved and from then on the port worked just beautifully and never caused any infections or other complications.

ICE (Ifosfamide, Carboplatin, Etoposide) administered I.V. over a three-day hospital admission.
- Day 1: Ifosfamide & Etoposide.
- Day 2: Ifosfamide & Etoposide.
- Day 3: Carboplatin.
The cycle was repeated every 3 to 4 weeks for a total of 10 cycles from August 1998 until April 1999. The drug Mesna (not a chemo drug) was administered during the chemo admission to protect the bladder from the irritation caused by the breakdown products of Ifosfamide. Despite needing daily G-CSF injections (starting after cycle 3) to boost her white counts, as well as repeated fever-neutropenia requiring hospital admission, low platelets and low hemoglobin requiring transfusions, and some nausea, Emily tolerated the chemo very well and had a good response; by February 1999, MRI revealed no visible tumour, only a "slight enhancement" in the fourth ventricle which we were told could be attributed to a number of things (scar tissue from the surgery, for example). ICE was stopped after cycle 10 because of potential kidney damage and loss of salts after prolonged treatment.

CCNU & Vincristine.
- Day 1: CCNU (lomustine) given orally, Vincristine given by I.V. push.
- Day 8: Vincristine (I.V. push).
- Day 15: Vincristine (I.V. push).
Emily received her first cycle in May 1999. The cycle was to have been repeated every 6 weeks (in a 3 weeks on, 3 weeks off fashion), but Emily received only one cycle. Because she relapsed when she did (just before the start of the second cycle), it was assumed not to have had any effect.

From June 25 to August 11, 1999, cranio-spinal radiation was given in 30 hyper-fractionated doses, with 36Gy given to the whole head and spine in 23 doses (originally only 20 doses were planned, but this was increased because of suspect areas on the spine) and with 54Gy boost to the posterior fossa (site of the active tumour) in 7 doses (10 planned originally, but reduced to accommodate increased dose to spine). Radiation therapy was delivered by a Phillips SL25 Linear Accelerator at 6MV (megavolts).

Clinical Trials

Irinotecan: A phase 2 clinical trial chemotherapy drug. Irinotecan was infused I.V. over one hour, once a day for five consecutive days. This cycle was repeated every 3 weeks. Emily received two cycles, in November and December 1999. It is hard to say if it had any effect in slowing the tumour down. Her symptoms didn’t progress nearly as dramatically as they did during her first relapse, but CT on day 5 of cycle 2 showed significant progression in tumour size (40% growth in 6 weeks) and the treatment was stopped. She suffered no adverse side-effects at all other than some hair loss (diarrhea is usually the dose-limiting factor for Irinotecan, but Emily did not experience this).

Fotemustine: A phase 1 clinical trial chemotherapy drug. Fotemustine was infused I.V. over one hour, a one-day treatment repeated every 3 weeks. Side-effects include a drop in platelets, and low platelets is usually the cycle-limiting factor. Emily received only one cycle, in January 2000. Cycle 2 was delayed repeatedly due to low platelets, and when her condition took a slide it was believed fotemustine was ineffective in Emily’s case and we opted to halt all treatment.