Pembrolizumab Overstimulating the Immune System

I was discharged from the hospital on 1/23 because my liver function blood tests (ALT, AST, Bilirubin, ...) had stabilized. These are indicators of damage and inflammation to the liver. My ALT was around 300 (ten times higher than normal) but it was steady for several days so they discharged me and scheduled a biopsy of my liver for the next week, 1/28. When they ran the labs before my biopsy, my ALT had tripled to 907, about 30 times the normal level so my oncologist asked that I be readmitted to the hospital for monitoring, scans, and daily consultation with a hepatology team. 

I got a beautiful single room (Feldberg 887) with a private bath and shower and amazing views of the Muddy River area over the hospital complex. It has below freezing every day and the steam coming from the buildings added an interesting dimension...

The liver is a very important organ that does a lot and liver failure can lead to death. They put me on 80 mg of a steroid, prednisone, every morning to try to stop the inflammation.

In the hospital they took an ultrasound of my biliary system (liver, gall bladder, pancreas, spleen, various ducts, etc. which looked fine, but my LFT numbers kept going up, so they ordered an MRI (at 2am) of the same area, and this also came back OK, but my LFTs kept going up. 

Both the ultrasound and MRI showed that my lung cancer tumors were shrinking and there were no new metastases.  This suggests that my body had a very strong reaction to the immunotherapy and that it has trained my killer T-cells to attack my cancer cells, but it also is attacking my liver. There is some evidence that people who have strong adverse reactions to immunotherapy (Pembrolizumab for NSCLC) often have better outcomes and sometimes can just be monitored with regular CT scans and no new infusions. It is unlikely that I will continue with the infusions because I had such a severe reaction, but I might not need to, and there are other options including chemotherapy if needed.

The hepatologists decided to let the prednisone have some time to work, but it didn't help, so yesterday my hepatology team decided to also put me on MMF (CellCept) which is an immuno-suppresant widely used to prevent transplant rejection. My LFTs (ALT, AST, ...) dropped a bit this morning and they sent me home at noon!

Next Monday I have a brain MRI and go to the Brain Tumor Clinic, then on Tuesday I have a battery of blood tests and meet with my oncologist, Dr. Costa. It may take several weeks or months for my liver function tests to get back to normal, but that's OK as long as they keep improving.  I'll eventually need to taper off of the CellCept and then the Prednisone, and that is a slow process as well.

During my hospital stay I met almost every day with my Oncology Hospitalist, Dr. Nas, who is like the quarterback of my medical team. She consulted daily with the hepatologists, oncologists, radiologists, and all other specialists and then met with me every morning to explain the recent tests and what the current plan was. She patiently listened to my questions and provided clear and cogent answers so I didn't have to meet individually with all of the specialists.

Dr Costa's oncology fellow, Dr Caradonna stopped by and we had a very informative discussion about the implications for future cancer care and the challenges of dealing with uncertainty which is rife in a hospital setting.

My nursing care was excellent. Alas I get confused about which nurses I had on which days, but Nurse Julia O'Toole was key in getting me the scans in a timely manner, and my other day and night nurses, Michelle, Ashleigh, another Julia, ... and my Patient Care Technicians were excellent. I got much stronger and was walking a mile a day around the Feldberg 8th floor loop (15 laps) as well as doing my PT (lots of deep knee bends, etc.)

Yas visited me every day and often brought lunch and/or dinner, then we binged watched the

Hulu series Murdock Mysteries about a Detective and a Coroner in 1888 Toronto. Ryan stopped by to visit after work and Caitlin and her boyfriend Scott also came by to chat, so I had a lot of social support, in addition to the group chat with my siblings and others that let me keep everyone informed about my treatment plan.

I'm happy to be home and excited about all of the new tests and scans coming up next week 

and I feel great (excellent appetite, increasing strength and stamina both physical and mental) probably because I'm pumped full of steroids, but I'm not complaining.