Neutrophils rule!

Several people have asked me recently, what are neutrophils?  That is a great question, and I can't wait to show you how amazing neutrophils are.  I "phoned a friend" to help me with this post because she is a talented neutrophil enthusiast.  R is one of my best friends from graduate school and has been studying neutrophils (among other things) for several years.  I asked her to write a list of things my audience should know about neutrophils.  Here it is, complete with some truly amazing movies that show neutrophils in action.  (If you only have time to watch one of the movies, let it be the first one, "neutrophil chasing bacterium".  It will blow your mind!  This happens in YOUR body!)  So sit back, open your mind, and release your inner nerd!  Enjoy!

Neutrophils Fun Facts (in no particular order):

1) They’re the first line of defense against bacteria--when bacteria arrive someplace in your body that they’re not meant to be, like a cut in the skin or an abscess in the mouth, a variety of signals are released that make neutrophils migrate to that site, where they do their best to eradicate the infection.  Below is a movie of a crawling neutrophil chasing a bacterium.

2) They’re what pus is made of! The white goo that we call “pus” is actually a big glob of white blood cells, most of which are neutrophils, that have come there to fight infection. Also, one of their main enzymes contains iron, which is why pus is often a little greenish.

3) They live for less than a day--the life cycle of a neutrophil is estimated to be 10-18 hours, although recently a controversial paper suggested that it could be longer, more like 5 days. During their lifespan, they are born and mature in the bone marrow, and then circulate throughout the bloodstream, waiting to detect signals of an infection that requires their presence.

4) Neutrophils can totally change their shape as the situation requires. In your blood, they are completely round and can roll along the sides of the blood vessels. To squeeze between cells, they can deform themselves and squeeze through a gap roughly 1/10 their size. Once in the tissues, they flatten out and develop a leading migrating edge--imagine a bloodhound with its nose to the ground, scenting a trail; this is how they move when they’re trying to follow a chemoattractant path to get to an infection.
Below is a movie showing how neutrophils roll along the walls of a vein and squeeze through the wall when needed.

5) If they don’t find any bacteria to fight, they undergo programmed self-death (apoptosis), and then mark themselves with a molecular flag for other cells (macrophages) to clear them away.

6) They are superpowered killing machines. Neutrophils’ job in the body is to kill invading pathogens, and they can do this in a variety of ways:

Phagocytosis- Neutrophils can eat bacteria, and once they’re inside, kill them via production of extremely toxic free radicals (aka the things that antioxidants protect you from!). Amazingly, the neutrophils can kill the bacteria this way without damaging themselves.

Degranulation- not all neutrophils responding to an infection will meet up with a bacteria to kill. If a neutrophil senses that its killing abilities are needed but doesn’t know exactly where, it can release all of its toxic weapons into the environment near the infection. This includes a number of cool things:

Antimicrobial peptides- these are compounds that kill all kinds of bacteria, often by punching a hole in their membrane or starving them of necessary metals.

Digestive enzymes- neutrophils manage to store very powerful enzymes in granules without hurting themselves, but once they are secreted they go to town digesting everything in sight.

Reactive oxygen species- you know how you can put hydrogen peroxide on a scrape to disinfect it? Well, neutrophils not only produce compounds like hydrogen peroxide, they make an enzyme (myeloperoxidase) that makes these compounds even more toxic. Bad news for bacteria.

DNA nets- This is a supercool finding of the last ten years. Neutrophils can actually excrete all of their DNA, which is sticky and acts as a “net” to trap bacteria, keeping them in place so they can’t escape the other killing mechanisms.

7) Neutrophils are the most abundant immune cell in the blood-- they make up about 50-70% of your circulating white blood cells.

8) Because neutrophils are such powerful killing machines and can release their molecular weapons indiscriminately, it’s very important that we regulate their behavior and make sure they’re only deployed when and where they’re needed. This is accomplished by a step-by-step cascade of signals--picture the game mousetrap, where the neutrophil starts in the bloodstream and ends up killing bacteria in the tissues.

9)  (This one was added by Heather, because the relationship between neutrophils and neutropenia is a common question that I get asked) The importance of neutrophils in fighting infections is why it is a serious health risk to have too few neutrophils.  Having too few neutrophils (below 1000 in a blood sample) is called neutropenia.  Neutropenia can be caused by a number of medical issues, including chemotherapy.  There is one treatment that can help increase neutrophil levels, and that is a drug called G-CSF (granulocyte-colony stimulating factor).  The formulation I have been given is called Neulasta, but there are others as you can see if you follow the link.  This formulation in Neulasta is auto-regulated, meaning it starts to work once the levels of white blood cells are low.  This is why my white blood cell counts experience a lag--I'm neutropenic a week after receiving Neulasta, but then the Neulasta kicks in and fixes me right up.  Once my white blood cells increase, they get rid of the Neulasta and my body takes care of itself again.  This is important because you wouldn't want Neulasta, or any formulation of G-CSF, working all the time, because having too many white blood cells is a different kind of problem.

Please post questions in the comments section. R and I will either answer them ourselves or direct you to a resource that can.  We hope you enjoyed learning a bit of biology today!  Also, for those of you who pay attention to every detail (ahem sisters), no I did not write this post on my sickest day.  I pre-wrote it and set it to post automatically for you, my dear readers.  All my love!         

Winning the war

Yesterday was my last dose of FEC, as long as there are no more surprise revisions in my treatment plan.  I will have a major huzzah after I get through the FEC aftermath.

I have been fighting many battles over the last 24 hours.  FEC sucks, man.  The first battle I fought was that mysterious allergic reaction to one of the components of FEC (no one knows which one).  Dr. Oncologist's strategy was to prevent an allergic reaction by increasing my dose of steroid (dexamethasone) from 12 mgs to 20 mgs, and my dose of benadryl from 25 mgs to 50 mgs.  I should also say that I did my part by taking the anti-allergy drug Zyrtec prior to the appointment.  Despite these preventative measures, the allergic reaction started up again after receiving the F, the E, and 15 minutes of the C.  It felt like I had snorted black pepper.  The nurse stopped the dose of C, and Dr. O gave me another round of benadryl and 'roids, for a grand total of 100 mgs of benadryl and 40 mgs of steroid.  I asked her, is this legal?  She just laughed at me and said she could give me more if it came to it.  The peppery feeling completely went away after this, so we resumed the C.  Soon after resuming the treatment, the peppery feeling came back and got worse; it was the burning feeling you get when you get water up your nose.  The nurse stopped the C again and waited with me for a bit.  The good news is that the allergic reaction never got worse.  My throat never got sore, my skin never flushed, and, most importantly, my lungs never tightened.  After a few minutes Dr. O came back into the room, assessed where I was, and asked me what I wanted to do.  I said I wanted to finish the C!  As long as my lungs remain clear, bring it on!  I therefore received the full, final dose of C, with little more than a peppery feeling in my nose.  Boom.  Huzzah!

I was more of an innocent bystander in the second battle of my day and night.  This battle was between benadryl and dexamethasone (the steroid), fighting for control of me, aka Side-Effect Hill.  Benadryl quickly gained control of my eyelids, but dexamethasone had a stronghold on my heart.  The dex hunkered down, commandeering my heart to pound out the drumbeats of war, all night long.  Benadryl made numerous offensive strikes, claiming an hour or two of sleep at a time, but overall the strikes were unsuccessful against the entrenched dex.  I finally dragged myself out of bed at 9:30 am, only to go downstairs and take another dose of each drug (as ordered by Dr. O).  I only have to take the benadryl while I feel the peppery nose (yep, still peppery) to prevent the reaction from worsening, and I only have to take dexamethasone one more time tomorrow.  The Battle of Side-Effect Hill will likely continue for at least another night or two.  Damn side effects.  Damn peppery nose.  Good thing I have a comfy couch for epic resting.      

The battles are tough, but I am winning the war.  The FEC has done it's job:  the breast cancer seems to be completely gone.  The tiny lump that Dr. O and I can feel could simply be scar tissue from the biopsy, that's how small it is.  My previous drugs (TCH+P) reduced the cancer substantially, but the FEC has obliterated it.  The most noteworthy fact, in my opinion, is that I had one lymph node adjacent to the cancer that felt swollen throughout all of TCH+P treatments.  In contrast, I can no longer feel this lymph node after three rounds of FEC.  In summary, let it be known that I am grateful for the FEC and remain humbled by its cancer-fighting powers.  But good lord am I glad that the havoc it wreaks is almost over.

Finally, I have an appointment for a PET scan on Tuesday, July 8th.  This is three days before resuming three more rounds of the TH+P-C treatment.  I normally hate PET scans because I frequently have false positives (I know they are false positives because I've had to go through the explorative procedures to prove it).  This one, however, excites me because we will see that nothing is glowing in my lungs.  I never felt like I had lung cancer, and I definitely don't feel like I have it now.  Dr. O did not say anything about the results of this scan changing the course of my treatment.  I am not even allowing myself a glimmer of hope about that.  But I agree that it's a good time to assess what's going on in those lungs.  I am quite curious.  Quite.  Again I say, bring it on!  Huzzah!

I'll end with a public service announcement.  I wrote this post while listening to Ray LaMontagne's new album ("Supernova") on Spotify.  Wow, it's excellent.    

One point for being your own advocate!

The data:

My liver enzyme functions (AST and ALT) were elevated last week.

The problem:

This result could be a sign of liver cancer.

OR It could be a side-effect of the antibiotic I was taking at the time, levoquin, as reported in 5% of patients who take levoquin.

OR it could be caused by other unknown factors.  

What Dr. Oncologist ordered:

Abdomen CT scan to rule out liver cancer (tomorrow).  

What I requested:  

A blood test the day before the CT scan (today), which is one week after quitting the levoquin, to see if removing the levoquin from my system allowed my liver functions to return to normal.

The result:

My liver functions are back to normal today!  This is strong evidence that my two abnormal liver enzyme results were indeed linked to the levoquin in my system and were not indicative of liver cancer.

The outcome:

No abdomen CT scan tomorrow!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!  Huzzah huzzah huzzah!

The moral:

Pay attention to your own healthcare, ask questions, and suggest solutions.  You have nothing to lose by being wrong.  You might even save the time, money, and stress of an abdomen CT scan.  

    

Thank you

In my previous post I teased you with a riddle and a photo.  If you guessed, "henna tattoo on scalp", you were right!  Here is a photo of the finished product from behind:

Scalp henna tattoo, two days after application
Photo by Mike Gatzke Photography

 My understanding is that many people assumed it was applied using a stencil, but I assure you it was not.  The henna artist drew every detail free-hand.  Also, this was her first scalp tattoo, so she was nearly as excited to perform the artistry as I was to receive it.  It took her two hours to paint the henna on my head.  It dried in less than 30 minutes, then I slept with the dried substance on my head.  It was very crusty and did not flake off.  To remove the henna in the morning, Ian and I scraped it off with cardboard before washing away the remnants.  It is recommended to scrape before washing because washing could blur the lines.  Here is a photo of the henna tattoo from the front:

Henna tattoo from front, photobombed by family.
Photo by Mike Gatzke Photography  

What a magical evening.

Thank you so much for coming to my party!  And if you weren't there, thank you for your donations, time, and thoughts!  Look at all of these people, all of whom were having a blast (or so I've heard):

Photo by Mike Gatzke Photography

It was five times bigger than my wedding!  Incredible!  You can view all of the photos, for a limited time, at the Mike Gatzke Photography website.

I need to broadcast our thanks beyond the party itself, so here I am going to post the words that my husband and I spoke at the party.  I knew that I would not be able to give my own speech without becoming a sputtering mess, so I read a poem and then my valiant husband said what I could not.  I chose a poem that allowed me to share my heart, at that moment, with you all.  It is called "And for no reason", written by the 14th century Persian poet Hafiz (translated by Daniel Ladinsky).

And

For no reason

I start skipping like a child.

And

For no reason

I turn into a leaf 

That is carried so high 

I kiss the Sun's mouth

And dissolve.

And

For no reason

A thousand birds

Choose my head for a conference table,

Start passing their

Cups of wine

And their wild songbooks all around.

And

For every reason in existence

I begin to eternally,

To eternally laugh and love!

When I turn into a leaf

And start dancing,

I run to kiss our beautiful Friend

And I dissolve in the Truth 

That I am.

Then Ian gave the most beautiful speech.  Here is his speech (edited slightly for relevance and posted with his permission):  

I really want to thank the planning committee for organizing this great event and putting everything together.  I hope they are all in here.  I think some of them are laying asphalt for more parking spaces.  They are two family friends with Heather's aunt, uncle, stepmother, and father [and were introduced with flair].  [We also appreciate the efforts of other people behind the scenes, including the food line that was overrun by Aunts.  I'm sure we don't know the half of who or what contributed to this event.]

I’ve known and loved Heather for over half my life.  That strikes some people as magical… or unusual, weird, old-fashioned.   I think it is something else.  Meeting Heather almost eighteen years ago started one of the longest streaks of blind, stupid, wandering dumb luck that humanity has ever seen. And I wouldn’t count on it ending anytime soon.

When I hear people talk about how lucky they are, it almost always involves a close call or a second chance.   “My canoe tipped over in the middle of a glacial lake and I had forgotten my life jacket, but right before the hypothermia set in I was able to use my dead dog as a flotation device.” or “I got bit by a Raccoon and I didn’t even get tetanus!”
 That might sound kind of lucky; not really though.  The truly lucky person simply paddles across that lake without issue and knows better than to climb into a Taco John’s Dumpster, no matter how good it smells. When it comes to the life that Heather and I have together, I’m lucky because I got it right the first time.  

Why I’m the Luckiest

With my deepest sincerity, there are countless reasons why we do feel so lucky and so incredibly loved. We are lucky that…

We have four hundred friends that have come out here tonight to show their love and support.

We are lucky for the understanding you lend every day. We are lucky that you can cook, and bring us nutritious meals a couple nights a week.   We are lucky for the hard-earned leave that you have donated so that Heather can work on feeling better.  We are lucky that you give so generously to online fund drives, that you organize online fund drives; that you’ve found it in yourselves to send my family on a dream vacation. We are lucky that we have such wonderful people to watch over, care for, love, and teach our amazing children every day (Well, that’s lucky you). We are lucky for grandmothers and grandfathers, moms and dads, aunts and uncles, family and friends, to step up and be the people, the parents, the friends that we sometimes cannot be. We are lucky to have the OC to keep the world at bay.  We are so incredibly lucky to have life-saving doctors and nurses doing everything they can so my children will know their own mother. We are lucky for those close-calls and second chances that make our love stronger.  We are so very lucky for the last four years; the best years we’ve ever had.  And we will be lucky…for the next four, and the four after that, and so on.

When Heather and I think about our luck, when we think about all the love and support you have given us, we are often overwhelmed to tears.  No words can truly convey my gratitude. But, if you could feel what I feel, right now; I think you would understand. 

Thank you.    

Thank you.  Again, thank you.  The cancer cannot compete with this.  With all of this.  Thank you.

And in case you were wondering, I am totally getting my fight back this week.  I made Father's day brunch yesterday, worked a few hours today, and went to yoga class tonight.  I feel physically victorious, as if I have performed a dozen chin-ups in 30 seconds.  I'm not even sure that that is possible...I've never done an actual chin-up.  But when I close my eyes I do chin-up after chin-up until I have kissed the sky so many times it pushes me off the bar and onto my pillow.  I'm getting my fight back.  

Getting my fight back

My neutrophils are just over 1000!  That means I am no longer neutropenic and will be able to attend my own party on Saturday.  Huzzah!  I still have far fewer neutrophils than a normal person, however, so we'll all still be careful and stick to eye hugs.  

My platelets are up quite a bit, but my hemoglobin has not yet improved.  This is continues to cause weakness and dizziness, but with all of the other healing going on in my body I feel better nonetheless.

The other great part about not being neutropenic is that I can quit taking the prophylactic antibiotics.  This will lead to further gut improvements, and hopefully solve my liver function issue.  Yesterday's blood testing revealed that my AST and ALT levels are still elevated.  Dr. Oncologist doesn't like this because one of the many things that could cause this is liver cancer.  She therefore signed me up for an abdomen CT scan for next Wednesday at 3:30, despite the fact that there are numerous benign causes of elevated AST and ALT.  One benign potential cause is one of the antibiotics that I've been taking, as I pointed out in my previous post and to my oncologist.  I feel that this is a very real variable to consider because the timing of antibiotic (levoquin) administration perfectly corresponds with my liver function results.  Given these data, I requested a bonus blood test to occur the day before the CT scan.  This will give my body a full week off of levoquin, during which my liver functions could return to normal.  If this occurs we'll cancel the scan and save some stress and money.  Huzzah for employing the scientific method in my care!

At the end of the appointment yesterday Dr. O told me to gain some weight, keep going on walks, and get my fight back so that I'm ready for the last FEC round next Friday.  I love this notion of getting my fight back.  That is indeed what it feels like I need to do.  It's a challenge because I am starting at rock-bottom and I don't have much time to do it, but I know I can.  Quiche and dancing, quiche and dancing, quiche and dancing.

I had a special rest time today.  While I was resting, someone came to my house and gave me something.  It's a surprise for the party, but here's a preview:

Ooo it's so pretty!  I'm so excited!

Sparkly

I'm feeling deceptively good today.  I'm betting that my hemoglobin is up, but I won't find out for sure until tomorrow.  It must be the amazing spinach and mushroom quiche that my mother-in-law made for me.  I've eaten half of it in 24 hours, and it tastes so good, particularly to someone who has been living off of yogurt and oatmeal for 10 days.  I've decided that it's pretty much the world's most perfect chemo recovery food--protein, fat, veggies, and just a few carbs.  This is in stark contrast to Jimmy John's vegetarian sandwich, which I puked up yesterday.  I might need to place a standing quiche order for every 10th day after chemo, for a gentle rebound after the nauseous/bland food week.  Huzzah for finding strength-building food that I can keep down!  Huzzah for my mother-in-law!

The reason I say "deceptively good" is that I myself am trying not to be deceived.  You have no idea how hard it is not to leap into Doing Stuff on the first day in 11 days that I don't have a belly ache, head ache, bone ache, or undefined ache.  For example, I felt the energy and desire to apply the girls' sunscreen before they left for the pool.  This activity left me winded and light-headed, which is perfectly fine.  I have to do stuff!  But it was a good reminder that I have to keep it in moderation and not try to, say, reorganize a closet or draft a manuscript.  

In addition to physical types of Doing Stuff, it has been difficult to do even non-physical Stuff like check emails.  Sitting up for too long would cause my brain to feel sparkly, like someone was pouring tonic water directly on it.  It was so strange, and unfortunate that it lacked gin.  It made lengthy electronic activities uncomfortable.  Fortunately my girls provided me with numerous activities that are suited to lying down.  The card game Crazy 8's has been a mother-daughter favorite lately (loser plays first, next hand--house rules).

Today, friends, today I have freedom from the sparkly brain.  Sweet freedom.

What I do not have freedom from are new and unusual test results.  Last night the nurse called to tell me that two of my liver enzymes (ALT and AST--no idea what these are) showed elevated activity in Monday's analysis of my blood.  She ambiguously said that there could be many causes of this, which Dr. Oncologist will discuss with me at my appointment on Wednesday, and that there is not yet a reason to be alarmed.  She also said that Dr. O might order a scan to investigate.  

I thought I knew the culprit already--levaquin (aka levofloxacin).  Every time I'm neutropenic, Dr. O has me taking both augmentin (aka amoxicillin + clavulanic acid) and levaquin.  These are two antibiotics frequently used to fight bacterial infections, but she has me taking them to prevent the infections.  These two drugs are my daily variables that changed concomitantly with the liver enzyme result.  I happen to know a fair bit about augmentin, so I started my google searches with levaquin and liver enzymes.  Literally less than one minute after I got off the phone with the nurse, I had this information from a National Institutes of Health website:

"In short term studies, levofloxacin has been associated with minor elevations in serum ALT and AST levels in approximately 5% of patients.  The abnormalities are usually asymptomatic and transient are rarely require dose modification."

Boom.  Done.  Problem solved.  No scan needed, people, unless my ALT and AST are still elevated after ceasing the levaquin.  Also, I find slight humor in the fact that I continue to generate diseases and symptoms that are statistically rare.  It's as if my body think's it's going to survive magna cum laude if it responds in the top 5% to every treatment.  I need to explain to it that that's not how it works.

I plan to be ceasing the levaquin tomorrow when we find out that my neutrophils are through the 1000-foot roof.  Then there will be nothing between me and that party on Saturday.  Jazz hands for optimism!

My Kid's Breast Cancer Waltz: a poem by my dad

My dad wrote a waltz, too.  He says that there is no orchestra, but there might be a steel guitar.  He wrote it in the comment section of my previous post.

My Kid's Breast Cancer Waltz

She tells me
She’s tired
Her blood counts are low.
She goes to
The doctor
She calls Doctor O.
She’s fighting this battle,
No matter the cost.
And my kid
Does the breast cancer waltz.

Her friends are
Amazing
The party’s been set.
Her husband’s 
A soldier
She’s lucky she met.
An over-achiever,
She never has lost 
And my kid
Does the breast cancer waltz.

And oooooh...oooooh...oooooh
Don’t she look lovely.
And oooooh...oooooh...oooooh,
Don’t she show class.
And oooooh...oooooh...oooooh,
In three quarter only
Dance while
The band plays
And my kid
Beats this breast cancer’s ass.