Lily, Part I

Nearly two years ago, 14 year old Lily was diagnosed with bone cancer. Not the "bone metastases" that old people get from other primary cancers, but an actual cancer of her bone cells- the kind that usually only happens in children. Lily first underwent a few cycles of intense chemotherapy to shrink the size of the tumor, which worked fairly well. The next stage of her "roadmap," as we call it- the path of things that has to happen to lead to a cure- was surgery.

In the old days of osteosarcoma, up until around 10 years ago, children had the entire limb affected by a bone cancer amputated. That was the safest way to ensure a cure, to know that you had gotten all the cancer. In more recent times, and luckily for Lily, orthopedic oncologists have devised a limb salvage surgery, in which the entire cancerous bone and any surrounding involved muscles are removed. The bone is then replaced with an allograft, or fake bone made of a strong, metallic alloy, and muscle and skin grafts from other places are reconstructed to ensure continued function of the salvaged limb. These kinds of limb salvage resections are so extensive that they take much longer to recover from than most other kinds of surgeries.

Lily had her limb salvage, and it was extensive. The first time I met her in early 2010, she had a long, two and a half foot, well-healed scar running down the shaft of her left leg. Even with the help of physical therapy, she was still struggling to recover the entire use of her leg. At that appointment, I distinctly remember feeling deeply sorry for her- 15 years old, and already disfigured. At that time I had no idea that the scarred leg was totally insignificant, and the worst was only waiting to come.

Following her limb salvage surgery, Lily had about six months of remaining chemotherapy. This was to ensure any possible microscopic cancer cells left anywhere in her body would be totally destroyed. Included in this list of life saving poisons was Etoposide, also known as VP-16. Etoposide has very few side effects, at the time it is given; nausea, vomiting, maybe some electrolyte abnormalities.

If you were to look at the chemotherapy chart found in our 10th floor work room, you would find Etoposide somewhere around the bottom third. Mechanism of action: Topoisomerase II Inhibitor. Most Likely Side Effects: Nausea, vomiting, etc. Unlikely Side Effects: Electrolyte abnormalities, nephrotoxicity, etc. Rare Side Effects: Small chance of secondary malignancy, acute myelogenous leukemia (AML).

Two percent. Everyone who gets Etoposide has a two percent chance, after being totally cured from their first cancer, of getting a SECOND cancer, leukemia. When we explain to parents that the chance of avoiding this second cancer is 98% percent, they almost always sign the consent to give it anyway. Lily's family would have been crazy not to. After all, two percent almost never happens.

But three months after she finished therapy for her first bone cancer, Lily walked into our clinic with low platelets, and walked out with a diagnosis of leukemia. Acute myelogenous leukemia, or AML.

To be continued...