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We have written Dick's story so often that I suppose every one on the Y-90 list has heard of his tale or has been exposed to it. I can think of only a few quirky anecdotes about his treatments and results, that may be different from others' experiences. He was down to 5 tumors in his liver after 7 rounds of chemo, to which he responded extraordinarily well. The radiologists could not even document how many tumors were in his liver at the level of resolution of the scan when first evaluated. The two largest tumors on his right side were the most problematic. The largest which I believe was 10 x 18-22 cm at diagnosis was down to about 10 x 12 or so when chemo ended. It was right at the edge of the right lobe of his liver, pressed against his right kidney. Standard irradiation to this tumor would have destroyed his kidney, and he even had told his oncology team that if he had to, he would sacrifice the kidney. The other problem that he had is the aberrant circulation in his liver. 95-98% of people have only one hepatic artery, but Dick had three, meaning that his circulation was just plain weird in his liver! He has a PhD in genetics, and I teased him that it was only fitting that he was a real mutant! The interventional radiologist who headed his team involved in the clinical protocol for SIRspheres at the University of Colorado Health Science Center literally spent hours studying his angiogram of his blood flow throug h the liver and mapping out a strategy about how to do this in a liver with such variant circulation. I had forgotten from studies in college that the predominant circulation providing nutrients to the liver was through the veins, not the arteries, since the liver is the great washing machine of the body taking out all of the waste products as the blood flows back to the heart. I am sure that all of this group is aware that leaking of microspheres out of the liver and carrying irradiation to the stomach and other organs is one of the major concerns in such a procedure. So Dr. Durham made the decision that she could block these extra arteries with tiny stainless steel microcoils and proceed on the first SIRspheres implantations to the two largest tumors. This was done in August, 2005, with absolutely no complications and no problems on Dick's part. However, Dr. Durham had a real problem when she tackled his left side. The tumors there were quite small by comparison to the right ones, but she knew that what she did to his circulation pattern on his right side would make the left side extremely difficult. Basically she had blocked one of the main ways to get to the tumors on the left. Apparently she studied videotape of his blood flow for hours to figure out how to proceed. When Dick had the procedure on the three small tumors in his left liver, in Sept 2005, it took much longer than the first procedure and when Dr. Durham came out to tell me the procedure was over, she explained the whole dilemma to me. To get to one of the three tumors, she could not use direct flow from the artery into that tumor because of the original microcoils. So she created a backflow by putting another microcoil downstream from the tumor. She was not certain that the backflow would be strong enough to carry the spheres into the heart of that tumor, but she was willing to give it a shot. As she injected the spheres into the tumor the rate of backflow did begin to slow and she was able to inject only about 3/4 of the allotted radioactivity dose for that tumor. She was concerned that she may not have gotten a large enough dose, but then she gave me some reassurance that her colleague and assistant in the SIRspheres protocol, who does radiofrequency ablation and cryotherapy as his specialities, already had Dick on his list. We were doubly lucky to be covered by a backup plan.

There are only two other remarkable aspects to Dick's story to me. One is the extended time over which the SIRspheres worked their magic. We were told that the spheres blocked microcirculation to the liver tumors for months afterwards and extended the process of killing the tumor cells by starving them of nutrients. However, I never expected that process to last more than 6 months. Dick did not have a PET/CT scan until April 2006 to access the effects of the Y-90 therapy in liver in August and Sept 2005. In the interim he had undergone 28 straight days of irradiation to his esophagus plus 6 rounds of chemo to destroy the remaining tumor cells in the wall of the esophagus. This brought him very close to death because of all the complications he faced. When he finally had the PET/CT scan, there were no signs of active cells in 4 of his tumors, but a small marginally active 1 cm cubed area in what had been the l argest tumor on his right. When I asked what we do about that, his oncologist said we wait and see. I feared that after 8 months, if the tumor cells were not dead, they never would be. But it was a miracle that at a PET/CT scan two months later in June 06 to decide where to go next, the last vestige of activity in his liver was gone. It literally took 9-10 months to completely eliminate his liver tumors and I don't think anyone expected that, even his physicians.

The only other anecdote I have to tell you about Dick is the quandary that radiologists reading his subsequent PET/CT scans have had. First of all they cannot figure out what these strange metal objects are in the blood vessels of his liver, since they evaluate the films before reading the medical history in detail, and learning what kinds of problem he may have had to require them. Second, as his oncologist says he now has one of the most bizarre appearing livers that anyone has ever seen on scan. The whole right side of his liver has essentially collapsed as the tumors shrank, so that the contour of the liver is compressed leaving an irregular outline and a space in his adominal cavity. There are similar collapses on the left side, but not so dramatic. Since the liver is one of the few organs that can regenerate, I asked if the contours would ever regain normal shape, but the answer was negative. The SIRsphere s essentially killed those regions of the liver. Neither of us care what his liver looks like now. What remains functions perfectly normally now, he has essentially normal liver enzymes, and he is considered a miracle.

As some of you know, his team will not call him NED, for they cannot believe that he is truly free of tumor. No one with stage IVb esophageal adenocarcinoma with mets to liver, lungs and lymph nodes in the experience of his physicians has achieved this and lived more than two years since diagnosis. His oncologist calls him "clinically stable". As the great Bard said, a "rose by any other name....". We'll take it!

We do not know why we have been so blessed, but I hope that Dick's story will give others the courage to keep fi ghting against what are almost insurmountable odds. We have been blessed and we hope for all of the rest of you that you also have the benefit of additional golden days to share because of the SIRspheres and Therasphere protocols.

Richard Dickerman PhD
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