Thursday, August 25, 2011

My take on the latest turn in Mr. S. Jobs' medical condition

Now that Mr. Jobs has stepped down (in effect admitting the seriousness of his condition) I feel free to discuss further my feelings about what's going on with Mr. Jobs. Again I'm not directly involved in his treatment but this is based on personal observations and publicly posted information
1) The Carcinoid had recurred and had recurred in the transplanted liver.
2) He had been undergoing a palliative treatment called 'chemoembolization' which involved essentially injecting chemotheraphy directly into the main artery of the liver.
3) (This is based on my observations) This treatment has not had the desired effect on slowing/halting the progression of the disease to any significant effect. I am saying that based mainly on his progressive muscle wasting which is apparent on any recent pictures of him and his final decision to 'step down' as the CEO of Apple. The pictures I refer to are not the photoshopped ones but those from publically broadcasted events.

OK, now some more technical background.
What is chemoembolization?
The liver has the relatively unique property of having a dual blood supply. First the hepatic artery and secondly the portal vein. Unlike any other organ the liver derives the vast majority of it oxygen and nutrient supply from the portal vein instead of the artery. Conversely, and to most patient's benefit, tumors in the liver derive those vital elements from the hepatic artery. This gives us the option to infuse chemotherapy directly into the hepatic artery directing the chemo to the tumor and sparing the healthy liver. In patients with metastatic tumors this is not commonly curative but can provide excellent palliation (alleviation of symptoms & slowing or halting the progression of the disease) & extending the potential survival for years. The issue for Mr. Jobs is that there is little data as to the effect of this treatment on a transplanted liver which may have alterations in the 'normal' blood flow. This has most likely limited the amount of treatment that they are willing to infuse into Mr. Jobs liver and may be part of the reason that his condition has progressed.

His future options/prognosis
1) A new liver transplant is 'potentially' possible if there is no recurrent tumor anywhere else but I would put the possibility into the less than 'single digits'. His first transplant was done at one of the only centers in the US willing to transplant for metastatic carcinoid (there's no good evidence that transplant is better than primary chemoembolization) & I would be very surprised if they were willing to retransplant in the face of recurrent tumor. The reason for this is that recurrence after removal of the affected organ (his liver) indicates micro implants of the tumor elsewhere which have not been controlled and the likelihood of a second recurrence is extremely high.
2) More chemo. That can always be done & may be preceding but in view of the apparent failure of his current treatment he would need to be entered into an 'experimental' study to find something different.
3) Under the best circumstances, if no further treatment is possible Mr. Jobs will suffer from progressive liver failure slip off into a painless coma and not 'wake up'. That was the condition he was approaching when the first transplantation was done. Depending on the amount of liver function that he has left this time can be estimated from weeks to months although without some new treatment, and based solely on statistical data, I would be surprised but not amazed to find that he made it to the end of the year. It all really depends on how rapid the tumors in his liver, & elsewhere grow and impair his functioning. What I have been waiting for, fearfully, was that he would suffer a catastrophic complication of his treatment, i.e. rapid liver failure due to ischemia of the liver, overwhelming infection as a result of the immunosuppression needed to prevent rejection of his transplanted liver and would die unexpectedly in a spectacular fashion (Sorry if that sounds callous but that's what we usually call rapid, catastrophic death when you're surrounded by all the high tech medical equipment doing everything possible to try and save you).

My personal hope is that he goes easily surrounded by family & friends and that he gets the most quality time possible.

I've attached links to a technical article (above the level of 'lay public' but not too esoteric) which further explain chemoembolization and the only article I've found on the treatment of metastatic carcinoid by that method. I have been able to find NO REFERENCES to chemoembolization into a transplanted liver & talking to my radiology colleagues it is a rarely done & is an essential experimental procedure.

1) Chemoembolization of liver tumors (for the lay public but a good review)

2) Hepatic artery embolization and chemoembolization for treatment of patients with metastatic carcinoid tumors: the M.D. Anderson experience. (The best article I've found, you'll get what you need reading the abstract)

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