Tremendous progress has been made in the diagnosis, treatment and survival rate of many cancers. But for the individual family, it remains a formidable challenge to cope with this dreaded malady. And as a doctor, there are cases that mark one’s life forever
By Dr R Neerunjun Gopee
She was eight years old, one of two sisters, the other one being two years younger. They were doing quite well at school, and the older one – let’s call her Cindy – was the pride of her class. She was learning to play the violin, in which she was already showing her talent, as the proud parents told me.
She was bubbling with life until the day she started having some pain in her left thigh, in the lower part. About six months later she was no more: the cancer of the thigh bone had snatched away this wonderful child from her family.
When the X-ray had shown an abnormality in the lower half of the femur it had looked suspicious, and I took the next step: doing a biopsy of the bone. It confirmed my fears: this was an osteosarcoma, the most notorious and most dreaded bone cancer. But what was unusual was its location – in the lower limb in children, usually osteosarcoma of bone occurs around the knee, either in the upper end of the tibia which forms part of the knee joint, or the lower end of the femur which is the other bone in the knee joint. But Cindy’s lesion was a few inches higher up in her femur, away from the knee.
That abnormal location was unusual enough, but what came as an even greater surprise was the complete diagnosis that we had received from a pathologist in the UK, to whom the local pathologist had sent the specimen for a second opinion. It bore the grandiose name of ‘juxtaparosteal osteosarcoma’, with a note from the London colleague that it was the worst variety of osteosarcoma of bone.
I carried out what we call a high amputation of the thigh, well into the upper half so as to – hopefully – cut through normal bone, clear of the cancer. Alas, my hope was belied, because although the bone had looked normal, subsequent events showed that it was already invaded by the disease which had travelled upwards, but was not at that stage visible to the naked eyes.
In fact, what had happened was that the operation wound was not healing, and after a while I had to do something that tears apart the heart of a surgeon, and more so when it concerns a child: I had to remove the remaining thigh at the hip joint level, what is known as a disarticulation. Unfortunately that wound also, after initial healing, broke down, exposing a raw area that required dressings almost daily, and was excruciatingly painful.
By then, a few months already had passed, and an X-ray of the chest had shown that both the lung fields were studded with white round patches, what we call in the jargon ‘cannon ball appearance’, indicating metastatic spread of the thigh cancer. This was at the PMOC in the early 1980s, where I had recently been transferred from the SSRN Hospital. Cindy had been brought by her mother, a housewife who epitomized for me nari shakti: the tremendous courage, strength and resilience of a woman battling alongside us for those fateful months with an insuperable enemy.
She had made arrangements to stay over at night, and the nurses in the ward had done everything to make her as comfortable as possible, giving her an armchair by the side of her daughter’s bed as well as helping her in every possible way during the several weeks that Cindy had to remain in hospital. Afterwards, when she went home not far away from the hospital, I had arranged for dressings to be done at home, under the supervision of a general practitioner colleague who had been my junior at the hospital and who was a great support to the parents. Besides, twice a week on my way to hospital in the morning I would stop by and check on Cindy.
Several of the nurses had attended her funeral, which had profoundly touched the mother as she told me when I visited the next morning – I hadn’t had the courage to look at her still face, and had preferred to keep away when I heard the news from tearful nurses, so attached to Cindy had they become. I had to accept defeat quietly, and I was relieved to see the mother serene, comforting her younger child. The father was inconsolable.
Many years later during one of my Sunday morning treks with friends we were passing through the locality where Cindy had lived. I saw her mother walking with a young lady by her side holding a baby in her arms. I went over and introduced myself – to the great surprise and delight of the mother, who told me it was Cindy’s younger sister, who I could recognize of course, and presented me with her grandchild, as proudly as she had commended Cindy’s skill with the violin all these years ago.
Life moves on…
A few months later there was this fourteen years old lad who was brought by the mother with pain in the left shoulder after falling and hitting the shoulder on the ground while playing. In this case, the X-ray showed a clear-cut lesion which was unmistakably an osteosarcoma. I discussed the case with Dr Paul Taikie, who was then the Consultant in charge at PMOC, and the verdict regarding treatment was: a disarticulation through the shoulder (after confirmation of the lesion by a biopsy) – that means removing the whole of the upper limb at the level of the shoulder.
These were completely unschooled parents, the father being a labourer in his fifties, and the mother nearing forty. I was wondering how they would react when I would talk to them about the proposed operation. But once again I was flawed by nari shakti: the mother was fully in control, as she told me ‘don’t worry doctor, go ahead and do the operation’!
Dr Taikie told me that he’d be around in case I needed his help because in a small country like ours with a small population, and in a general orthopaedic setting, it is not often that such an operation is done. But all went well, and the next morning after the surgery when I saw the child in the ward, with a drip in his right arm, he was smiling. No pain, he said when I asked if he had any. All he wanted was the drip to be out. But sadly, this child also soon developed lung metastases (that is, the cancer had spread to the lungs), and passed away after a few months.
My first encounter with osteosarcoma was when I was a third year medical student in Kolkata, and we had started to attend the wards in the teaching hospital. And my first posting was in the surgical ward (in those days general surgeons also looks after some orthopaedic cases), and it was on the very first day in the ward that we the batch of students shadowing a surgeon, were instructed to examine this 20-something young woman with a big swelling of her knee with tortuous veins coursing over it.
We did not even know the term and the implications of the diagnosis of osteosarcoma at that stage of our training, everything was yet to be learnt. This lady had come from a faraway village; she was several months pregnant when the swelling had appeared, and the family had waited until she delivered her baby before they brought her to the city for treatment. It was already too late, for the cancer had already spread to the lungs.
She died a few days later under our very eyes as she developed cardiac arrest while we were on a ward round. The Registrar who was teaching us was called to her bedside, and for the first time we witnessed the procedure that we would ourselves be called upon to perform later: injection of adrenaline into the heart.
As the world ‘celebrates’ World Cancer Day, we learn that tremendous progress has been made in the diagnosis, treatment and survival rate of many cancers, with many new techniques and technologies deriving from the many forays into fundamental research that is going on around the world. In Mauritius too, there have been marked improvements in the management of many cancers. But we are a small country, and both financial and technical resources are insufficient, although every effort is made to continuously upgrade the facilities.
But for the individual family, it remains a formidable challenge to cope with this dreaded malady. And as a doctor, there are cases that mark one’s life forever, human stories that, as the saying goes, are too deep for tears…