Author Topic: Tingling and pain on face (Read 14084 times)

msampl · « **on:** July 02, 2009, 06:29:18 PM »

Hi Dr. West - My wife, age 47 with NSCLC dx 5/07 stage iv, just got out of the hospital after being treated for a massive blood clot. The clot was from the calf up to the groin area where she had filter installed last year. An old clot blocked the flow at the filter. The hospital inserted a catheter in the vein and put TPA and iv heprin in it for two days. This got the vein opend up and flowing again. She is on daily lovenox shots. After being home from the hospital for the last week and a half, she has started to feel tingling on her face, mostly on left side, with some tenderness and pain if she touches it. Went to the ENT doctor today and he did a ct scan of her sinus and everything was perfect - no sinus infection. But she has a stopped up nose also, ears seemed to be blocked up and was expelling some green mucus out her nose. Her urologist put her on Cipro from a bladder infection a few days ago. This might have helped both the bladder infection and sinus, but the other symptoms remain. When she was in the hospital, they did a brain ct scan before the vein procedure and said everything was fine, because if there was a met they wouldn't be able to do anything. Her next scans are next week with oncologist. In the meantime, any ideas on what these symptoms are from. Thanks.

Regards,

Michael Sampl

Dr Sanborn · « **Reply #1 on:** July 02, 2009, 08:11:06 PM »

Hello Michael--

There are a few different things that come to my mind when I hear a patient tell me about pain and tingling in the face, with the nose congestion. Starting literally at the top of the body, I would wonder about a brain metastasis or cancer involvement of the lining around the outside of the brain (called leptomeningeal involvement). Although a CT may help, it may not pick up small tumors and is not good at finding leptomeningeal involvement. An MRI is really the imaging study that is used to look for those problems.
It sounds like your doctors have ruled out a major sinus infection, although sometimes a viral sinus infection might produce thick mucus from the nose without too much swelling on a CT scan.
I would also wonder about a problem farther down, in the chest. Sometimes patients can have tumor pressure (most commonly from swollen lymph nodes in the center of the chest) that squeezes the major blood vein returning blood to the heart from the upper body (the superior vena cava, or SVC). This can cause rapid-onset one-sided facial pain, swelling, redness, tenderness, swollen nose, etc.

It is a good sign that the nasal mucus improved with the antibiotics. I would be advising my patient in a situation such as this that if anything were getting worse, I would want to know right away. This is definitely something to monitor and keep the doctor aware of the progress.

I hope this helps, and that with the antibiotics things improve on their own.

Dr West · « **Reply #2 on:** July 02, 2009, 10:05:56 PM »

The only other thing that comes to mind is the unlikely possibility of a shingles infection (also known as herpes zoster, which is the same virus that causes chickenpox) that can involve one of the nerves of the face, most typically around the eye, and would affect just one side of the face. That's a real long shot, but if any skin lesions appeared in the area, it would suddenly be high on my list.

-Dr. West

Dr Harman · « **Reply #3 on:** July 03, 2009, 10:56:06 AM »

I would echo Dr. West's suggestions of shingles and also add that it is treatable with medications for nerve-related pain and anti-viral medicine. Another consideration, though also a real long shot, is whether there is something going on with a tooth/teeth on the left side--sometimes that pain gets referred up into the sinus or cheek area.

-Dr. Harman

msampl · « **Reply #4 on:** July 03, 2009, 06:28:13 PM »

To All Doctors - Thanks for your help with suggestions. We are meeting with her oncologist next week after getting a new Pet/CT scan from eyes to thighs.

One other symptom she has been having is nausea. Almost every night around dinner time or there after, she get it and then vomits sometimes. This has been going on off and on for about 2 months. Thought it was the flu earlier before the blood clot, then it got better. Now after being out of the hospital for the past two weeks it has been happening almost everyday. She is fine in the morning, eats breakfast. Does o.k. with lunch. But she doesn't have a very good appette. She takes a zofran (sp.?) pill and it dissolves under her tongue when nausea hits. If she can get the pill quick enough it stops the nausea and vomiting. She also complains that there is a pain in her stomach just before the nausea comes on. She had a CT of her abdomen before going in the hospital and all the doctors said, everything looked o.k. So I just don't know what is going on. May her scans next week will pinpoint something. Any other suggestions you might have would be appreciated.

Also, do you think we should ask the doctor to get the MRI of the brain along with the Pet/CT scan? Thanks for your help.

Regards,

Michael Sampl

Dr West · « **Reply #5 on:** July 03, 2009, 09:27:27 PM »

Brain mets are certainly a potential contributor to nausea, though not the leading cause. Obviously, chemotherapy and sometimes other treatments (radiation to the abdomen, for instance) can cause nausea, but the cancer itself can as well, along with many, many other things. The abdominal scan not showing anything argues against it being the cancer, but the cancer can also cause proteins to be released into the bloodstream and cause nausea.

Overall, there are so many potential causes that it's hard to suggest anything to narrow the search -- this often requires a pretty broad workup, given the many possible causes.

-Dr. West

Dr Harman · « **Reply #6 on:** July 04, 2009, 06:32:55 PM »

Dear Michael,

Indeed, the workup for nausea is quite broad. When there is a more consistent pattern to the nausea, an anti-nausea medication like zofran can be taken "preventatively" to pre-empt the nausea episode. It sounds like your wife has had a good response to zofran. That might be helpful in the meantime, until you meet with her oncologist. As a reference, here is a more general post on nausea and anti-nausea medications:
http://cancergrace.org/cancer-treatments/2009/05/22/cancer-nausea-pt-ii/

-Dr. Harman

msampl · « **Reply #7 on:** July 08, 2009, 05:49:56 AM »

Hi Dr. West - My wife got the MRI of her brain and her doctor called yestersday with preliminary results saying there was multiple mets. He is scheduling an appointment with the radiation oncologist for this Thursday.

My wife is now ready to give up. She doesn't think she wants to do the whole brain radiation because of the side effects and hair loss. She would consider the cyberknife treatment if they would do it. Can you give us an words of advise or encouragement. Also, could she go back on tarceva as it is the only drug I know that could cross the blood brain barrier and possibly help with the brain mets.

Thanks for your help.

Regards,

Michael Sampl

Dr West · « **Reply #8 on:** July 08, 2009, 07:24:28 AM »

I'm truly sorry to hear that.

For more than a few brain metastases, whole brain radiation is simply the leading treatment option, by far.

Cyberknife is a far more profitable treatment, but it is really not the ideal treatment for more than a few metastases and wouldn't decrease the risk of further metastases. There is a very significant risk for other brain metastases down the road if multiple ones are being seen now. There could easily be some that aren't even seen yet but would be a problem later if they aren't treated now. WBR would likely treat the metastases that are visible, others that are invisible, and overall decrease the likelihood of symptomatic brain metastases later. In my opinion, seizures, headaches, and nausea from worsening brain metastases is a more immediate, real, and significant side effect than hair loss or other potential adverse effects.

Many cancer physicians feel that brain radiation has been made out to be far worse than it generally is. Is it side effect free? No, but worsening brain metastases are no picnic either. And I strongly suspect that some of the negative image of WBR is cultivated by people who have a financial stake in selling a more expensive radiation option like stereotactic radiosurgery.

I'd view the idea of treating 8 or 10 or more brain mets with cyber knife like leaving the dimly lit room where you lost your contact lens in favor of the better lit room where it's easier to look for one. It's a treatment for a different problem, and it's not well suited for treating many brain metastases.

As for tarceva, I really would be dubious about the value of any treatment on which the cancer has progressed previously. The oral chemo agent temodar is being looked at, but I personally haven't used it as a treatment for brain metastases, since it's being studied but hasn't been shown to be beneficial in that setting yet.

-Dr. West

Dr Sanborn · « **Reply #9 on:** July 08, 2009, 09:30:32 AM »

Hello Michael--

I would agree with Dr. West's opinion about the value of whole brain radiation as opposed to cyberknife or stereotactic radiosurgery in the setting of multiple brain mets.
Your wife is not alone in her concerns about brain radiation. However, the quality of life with untreated brain metastases becomes progressively worse and worse. With brain radiation, quality of life is generally much better preserved.
In my discussions with many patients, I tell them that as a chemotherapy doctor, I do not personally have a stake in the radiation aspect, but regardless of any further decisions or desires about chemotherapy or targeted therapy, I strongly urge people to consider brain radiation. This is actually a pretty well-tolerated procedure for most people, and although there is hair loss and fatigue, in general there are fewer side effects than with most chemotherapy regimens.

Please keep us updated about how things are going.

msampl · « **Reply #10 on:** July 10, 2009, 07:04:40 AM »

Hi Dr. West - My wife got the results of her brain MRI and PET/CT scan. Things turned out differently than we expected. The brain MRI did show 10 or so very small mets. Her PET/CT scan showed an increase in her tumor from 3.0x1.8 to 3.4x2.1. It also showed a lot of "junk" in both lungs, wispy white stuff. Her oncologist thought that her symptoms were not consistent with the brain mets as they were so small and he said that he sees patients with bigger mets without her problems. He is concerned that the lung progression (last scan three months ago did not show any of this) is the main problem. So he is starting her on cisplatin/gemzar on Monday. She has not had this chemo before. She had carboplatin/alimta/avastin at the end of last year and the beginning of 2009. The oncologist is concerned that if she dosen't get ahead of this now, things could really go downhill. He also said that her symptoms might be from the cancer giving off protiens in the blood, something he called neoplastic syndrome (Sp.??)
Also he is sending her to a pulmonologist to have a broncscope to check the lungs to find out what the wispy stuff is. He said it could be something like pcp (??) some type of infection.

My questions are:
1. Can you give me more information on the neoplastic syndrome?
2. Is pcp in the lungs a common thing for NSCLC patients?
3. What do you think of the cisplatin/gemzar combindation? Do you think is could work for her?

Thanks for your help.

Regards,

Michael Sampl

Dr West · « **Reply #11 on:** July 10, 2009, 09:12:07 AM »

I'm not familiar with that specific term. It sound like he's talking perhaps about lymphangitic spread, which is when some patients develop tumor spreading through the lymphatic channels of the lungs. This can lead to a diffuse nodular pattern progressing quickly. We try to jump on this when we can, but the cancer often behaves aggressively when we see this pattern.

The other thing I can imagine this possibly referring to is that patients can have a spiral of decline clinically that we believe is from proteins made by the tumor itself, called cytokines, that go out in the blood stream and cause people to feel awful, feel very fatigued, lose weight, etc.

PCP (pneumocystis carinii pneumonia) in lung cancer patients is not common, but we do see it rarely in patients who have been on steroids chronically, most commonly for brain metastases, and they become symtomatic whenever you taper the steroids.

I think cisplatin/gemcitabine is a fine regimen. I think her situation is a very personal, individual one for which an individualized recommendation makes sense, and this needs to come from someone who is actually seeing her and has all of the right information.

-Dr. West

msampl · « **Reply #12 on:** July 18, 2009, 09:29:28 AM »

Hi Dr. West - My wife has started cisplatin/gemzar treatment last week for the lung cancer. Things seem to being going o.k. with this for now, no real side effects. However, she feels that the brain mets are causing her increased problems. She has headaches, pressure on various spots on her head that seem to line up with MRI met locations, balance problems and vision problems with reading from the computer. She just started on 4 mg Dexamethasone per day yesterday. She still has some nausea and coughing problems, thickness of sputam. The doctor wanted to get a start on the lung cancer before doing any brain radiation.

She has a few questions for you.
1. What is the life expectancy after brain mets are discovered for untreated and treated?
2. If she does the WBR, does it really increase the quality of life and possibly for how long?
3. She is also have some problems with neuropathy in her feet and face - is there a way to treat that?
Thanks for your help.

Regards Michael Sampl

Dr West · « **Reply #13 on:** July 18, 2009, 05:32:11 PM »

I can't quote numbers for untreated brain mets, because we don't just watch people to see what happens. I would anticipate a survival of weeks to a couple of months at most without treatment, and it can be all over the map with treatment. You see some people with a survival of just 3-6 months, but I see many patients going beyond a year, and sometimes many years. WBR can allow the brain metastases to be treated effectively enough to have it take them not drive the prognosis -- instead, the treatment may be effective enough to make the cancer outside of the brain the driver of prognosis.

As for what WBR will do for quality of life, the real answer is "nobody knows". But not doing it is consigning to a very high probability of increasing headaches, nausea, possible seizures, balance problems, vision changes, and other neurologic problems.

There are many controversial areas in lung cancer, but whether to recommend WBR for someone with lung cancer and multiple brain metastases isn't one of them. Like the vast majority of oncologists, I don't hesitate to recommend WBR for such patients.

I don't know of any effective way to treat existing neuropathy. Some people try B12, or drugs for neuropathic pain, such as lyrica or neurontin, but I'm not aware of anything that has been shown to be particularly effective.

-Dr. West

msampl · « **Reply #14 on:** July 21, 2009, 08:47:29 AM »

Hi Dr. West - I have a few more questions for you regarding my wife. We talked to her dcotor today and he sent me this correspondence.

I agree that generally we always do WBRT to CNS mets but the brain tumors are all very small and the extracranial disease so great the we had elected to defer (not omit) radiation. If she is having that many CNS symptoms, I would first do a LP to see if there are cancer cells in the spinal fluid - if there are we could do chemo in the spinal fluid directly and if not we could start WBRT now becasue of her symptoms even though the tumors are quite small. I talked with the radiation oncologist and he agrees with this plan.

Can you give some insight into the spinal tap and check for cancer in the fluid? Is this a risky procedure? Is it very painful?

Thanks for your help.

Regards,

Michael Sampl

Author Topic: Tingling and pain on face (Read 14084 times)

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