“The future is much bigger than the past." Tim Berners-Lee My...

“The future is much bigger than the past."

Tim Berners-Lee

My Friends,

Tiresias would like to share a little story which he thinks has some relevance to Optiscan Imaging real-time in-vivo cellular Confocal Laser Endomicroscopy

A long time ago, when Tiresias was a young newly minted doctor, he naturally spent some time in the operating theatres, assisting. One of his tasks was to be second-assistant surgeon in head and neck surgery. This was very lengthy, boring, tiring, disfiguring and at that time questionably effective. Operations would regularly go for eight hours or longer, and this experience is one of the reasons that Tiresias did not go down the surgical line. He didn't like having a sore back and sore legs aching at the end of the surgery. Tiresias was sceptical of the efficacy of this surgical exhibition of daring “heroics” He also realised, to do that kind of surgery, one needed a strong back, strong legs and not much in brains. He particularly recalls one operation, being done by, shall we say not the best surgeon around. The surgeon was a nice enough chap, a bit of a plodder, in surgical terms, as there are many. Tiresias would estimate on par with an average car mechanic. He was also ageing, by the time of this surgery. One day, some seven or eighth hours into one of these “radical neck dissections”, which the junior staff called “Horrendo-plasties”, Tiresias was thinking about his sore back and legs and fighting back boredom and wishing just to sit down. The chief surgeon asked the anaesthetist, as he did every hour or so,

“How is the patient doing?”

The anaesthetist, in a bored voice, replied,

"Oh, the patient died an hour ago, but I didn't tell you because I thought you needed some practice".

This is eight hours into an operation, where all the rest of us were there to be just witnessing this pedestrian obsessional, not particularly skilled theatre. The patient could well have been dead, as far as Tiresias or any of the rest of the theatre knew. If you looked at the operating site, it was truly horrendous. The whole neck was open and exposed. The carotid arteries, the main blood conduits to the brain, were to the air, still pulsating. Every bit of non-vital tissue had been removed because we knew there Cancer about in them-there tissues. Everything had to be removed because we didn't know where the cancer was or wasn’t. Yes, there were lymph nodes which are obviously cancerous, but the rest had to go as well. But did it? Why had it come to this?

Anyway, the operation finally finished in the 10^th hour. There were massive skin flaps and the result looked truly horrible. The anaesthetist, always the cynic, summed the result as he was about to extubate the patient.

"I'm afraid to take out the endotracheal tube because the head might fall off" he said.

Well, this is a morbid and perhaps a somewhat macabre anecdote. But things must have changed much since Tiresias was a mere acolyte, haven’t they? Well, actually, not much at all.

Tiresias was reminded of this story because, just recently an acquaintance of Tiresias’s developed a neck lump. As usual, it was initially thought to be a benign lump. Subsequently, initial excisions and re-examination confirmed it was a squamous cell carcinoma. He hadn't had any previous cancers, or so he though. Except, then he remembered that he'd been to a skin clinic and had a “sunspot” “burnt off” on his scalp, with liquid nitrogen, some three years ago. That lesion was undoubtedly the primary squamous cell skin carcinoma. The PET scan shows that it has now spread, and he is due to undergo the said “Horrendo-plasty”. But these days he will have a long course of post-operative radiotherapy and then chemotherapy. The surgery for him, given that he's got multiple lymph nodes, will be 8 to 10 hours.

Will any of this help?

Well undoubtedly!

Will it cure the cancer? Hard to say.

Certainly, without any intervention my poor friend would have died a very unpleasant death. within a couple of years. With the operation and the radiotherapy, and the chemotherapy the prognosis is still pretty poor. Local tumour recurrence is 50% to 60% within two years. And why is this so? Because after all that heroic surgery, cancer cells, invisible to the naked eye, were left behind. Does Tiresias need to spell this out? When is Optiscan going to spell it out?