Yesterday was Mayo Clinic day.

We started by meeting with my neuro oncologist (Dr. H). She was very patient as I walked her through the history of my cancer. The fun part was when she subjected me to all the neurological tests. Like balancing on one foot, walking back and forth, memorizing words, and solving (what Alicia says are) simple math problems. 36-12? Like I’m supposed to know that off the top of my head. Dr. H continues.

He is alert and articulate. He scores 36/38 on mental status testing. Language exam is normal. The cranial nerve exam including visual fields to confrontation is unremarkable. Funduscopy shows no papilledema. There is no facial asymmetry. He has excellent strength throughout. His deep tendon reflexes are symmetrical and the plantar responses are flexor. Gait is normal. He can rise on toes and heels without difficulty. There is no Rombergism or drift in tandem walking is well performed. Sensory exam including cortical sensation is intact.

Dr. H Clinical Notes (2/18/18)

Regardless of my somewhat normal exam, Dr. H seemed confident that we are dealing with cancer again. She pulled up all of my MRI’s for the last 8 years and showed us how the disease has slowly progressed. I remember my hands beginning to shake as Dr. H reached the crux of my scans. The part somewhere between 2016 and 2017 where she explains how she can tell that it’s not scar tissue anymore – that this is likely cancer growing. My watery eyes glued to the screen, Alicia clutched my hands as they became unstable. I felt her say I’m scared too. But we got this.

After reviewing my case, Dr. H recommends surgery. She’s already consulted with her colleague, a neurosurgeon who actually specializes in tumors of the insula, the part of my brain the cancer has spread to. She says the surgery is up to me, but she suggests I should at least talk to the surgeon. Either way, Dr. H also recommends another round of Temodar – the same chemotherapy I took in 2010. She says there are other options, including a couple clinical trials I may be eligible for. Regardless, she thinks surgery and Temodar is the route we should we should start with. I trust her. We take the shuttle from the Gonda building to St. Mary’s hospital, where the neurosurgeon is located.

Dr. B walks in with a smile on his face and an eager medical student in tow. Within moments I can tell this man is brilliant and that I will trust him with my life. Admittedly, part of this must have had something to do with his Australian accent. I like this guy. I think Alicia is suspiciously interested with the inflection at the end of his sentences and the way he pronounces his vowels. Dr. B goes on to very articulately and thoroughly explain why this cancer needs to be taken care of, what he recommends doing to take care of it, and the risks associated with doing the surgery vs. not doing the surgery. Alicia is crying. I’m not sure if it’s because she is mesmerized by Dr. B’s sophisticated accent, or if it was because of the incredible weight of the world suddenly mounted on her shoulders as she digests the possibility that cancer may be something we have to deal with for the rest of our lives together.

Dr. B has a sense of humor. We joke about having to put a metal plate in my head in the event there is an infection with the piece of bone they have to remove to access my brain hardware. I ask him about awake vs. asleep surgery. He says that this is completely up to me. During an awake surgery, he explains, there is an opportunity for us to push the limits a little farther than a surgery where I am completely sedated. He explains that there is potential to get more tumor removed during awake surgery. He even says I can play my guitar during surgery. Like this guy did.

Nonetheless, there are risks with the awake surgery that I’m not sure I want to expose myself to. Something about not being able to provide a breathing tube, something about seizures, and something about how some patients become very uncomfortable during the surgery. Dr. B says the surgery will last an entire day. He says to take a few days and think about things, and then give his nurse a call back when I make my decision.

I had a lengthy discussion with the patient regarding the potential risks and benefits of further surgery. The risks would include neurologic deficit including vascular injury which we would do our best to avoid. Risk of infection and other complications were also noted. I would recommend using the intraoperative MRI and if schedules permit having a baseline neurocognitive evaluation. We discussed the possibility of doing the surgery awake to facilitate mapping of the inferior fronto-occipital fasciculus via nonverbal semantic function testing during the surgery. I think the amount of tumor in the insula is relatively less than the amount of tumor that would be accessible elsewhere. Nevertheless, if he did want to have that testing done intraoperatively, we might be able to obtain a slightly more aggressive resection into the inferomedial insula whilst minimizing long-term cognitive risk. I will leave this to the patient to consider.

Dr. B Clinical Notes (2/18/18)

We left Mayo Clinic in good spirits, but Alicia and I needed a beer. I talked everyone into dinner at Buffalo Wild Wings. I rode with my Dad to the sports bar. When he started the car, Keith Urban (an Aussie, like my doctor) was playing on the radio. Dad and I both looked at each other and smiled. A sign from God or something? I don’t know. I’m not a Keith Urban fan, but I’d like to think God has a sense of humor.

We get to Buffalo Wild Wings and sit down. The music is blaring on the radio like it always does at B-dubs. I immediately recognize the funky beat on the speakers and the words blaring:

Do you come from a land down under?
Where women glow and men plunder?
Can’t you hear, can’t you hear the thunder?
You better run, you better take cover

Yes, it was the 1981 hit by Australian pop band Men at Work I was hearing at B-dubs, after I heard the Australian country guy song on the radio, after I met with the Australian guy who wants to saw my head open and remove my amygdala. This is no coincidence. Not only does God have a sense of humor, but apparently he sends messages through Keith Urban and the Men at Work.

I am having surgery next Friday, March 1st. I’m not going to bring my guitar.