Mark Birch

The MRI and CT Scan's

GOOD NEWS!!!
There is always good
news, just look
around and thank
GOD.

2/15/08
CT scan results
Here is some very
good size and
number of tumors in
Liver, huge
reduction of the
main tumor in the
Pancreas (6.3 cm to
4.5 cm!)

3/14/08
Infusion Friday - last
infusion of cycle 5 -
start "off-week" on
Monday. Blood work
came back good as
ever.
Reduced Steroids
has helped the
tense and irritability
that I experienced in
the previous cycles,
however a bit more
fatigued from the
Chemo regiment.
But all said and
done, When on
chemo, Tuesdays
thru Thursdays are
normal days for me
Friday thru Monday I
may seem a little
tired to you. On the
"off-weeks", I feel
absolutely normal
Tuesday thru Sunday.
(I know "normal" may
not be a word many
of you use in the
same sentence with
my name!)

When you pray,
Thank God!

4/11/08
CT Scan results
The news is
great...no
recurrence in the
liver or lymph nodes
(still clear).
Even more reduction
in the Pancreas. The
news just doesn't
get better than this!!!!
Thanks for all the
prayer's!!!!

1. PA and Lateral View of the Chest, 06/24/2008.
Clinical History: Pancreatic carcinoma.

Findings: The lungs are clear. No adenopathy is seen. The cardiac size is
within normal range.

IMPRESSION:
No metastasis.

2. CT Chest, 06/24/2008.

Clinical History: Pancreatic carcinoma.

Findings:   Current CT was done with IV contrast. Comparison was made to
04/08/2008. There is no pulmonary metastases or adenopathy.

IMPRESSION:
No metastases.

3.   CT of the Abdomen and Pelvis, 06/24/2008

Clinical History: Pancreatic carcinoma.

Findings: CT was done without and with IV contrast. Gastrointestinal
contrast was used. There is a biliary stent in place. The tumor involving the
head of the pancreas is not identified with confidence. There is change in
the texture of the pancreatic tissue in the head just proximal to the papilla.
The hepatic metastases are not identified any longer. There is no
adenopathy. No implant is seen.

The adrenals, kidneys, spleen are within normal range. There is no evidence
of disease in the pelvis.

IMPRESSION:
The known treated metastasis and primary tumor of the pancreas are not
identified with confidence any longer. There is no new site of disease.

Findings: Metallic wall stent is identified within the common bile duct. The pancreatic
mass, as has already been noted for the study of 09/04/2008, venous structures
(portal vein or superior mesenteric vein) nor is there involvement of the celiac artery
or superior mesenteric artery. There is a Findings: Metallic wall stent is identified
within the common bile duct. The mesenteric artery. This artery is also not involved.
No adenopathy. Adrenal glands are unremarkable. No hydronephrosis. Stable small
low density foci within the kidneys are nonspecific.

Evaluation of the liver is somewhat limited because of fatty infiltration with sparing
seen near the gallbladder fossa. Previously there were very subtle questionable
abnormalities identified within the liver on the prior CT examination that cannot be
definitely identified today on CT. Workup had been recommended for MRI and there
are two lesions seen on the interval MRI that were T2 bright and that cannot be seen
on other sequences and were assumed to probably represent small hemangiomas.
These cannot be seen on the CT, which will be supported that these represent solid
lesions such as hemangiomas rather than cysts. There is also a small hypervascular
lesion seen in the posterior aspect of segment VII on image 26 that measures only 9
mm, and is seen on the early phase of dynamic imaging on the MRI of 09/17/2008.
This abnormality is not seen on later phases. It could represent an etiology such as
focal nodular hyperplasia and is seen on the prior CT of 09/04/2008. It is located in
close proximity to where at one point there were clearly seen metastases on the study
of 11/30/2007. This could represent unusual manifestation of residua of the patient's
prior metastatic disease.

There is an ill-defined region of heterogeneous enhancement in the liver segment V
on image 37 of series 4. This can be followed. This may be simply a perfusion
abnormality at this time. Currently, I cannot definitely identify metastatic disease within
the liver and close attention and followup would be advised. The gallbladder is
contracted. The spleen, adrenal glands are probably unremarkable. There are
degenerative changes of the lumbar spine.

IMPRESSION:
1. Primary lesion within the pancreatic head cannot be visualized. This was also the
case for the prior study of 09/04/2008. No evidence of involvement of vasculature.
2. In this patient with clear evidence on the study of 11/30/2007, of multiple liver
metastases, today, I cannot definitely identify metastatic disease to be within the liver
on CT examination. There are subtle areas of heterogeneity that can be monitored.

When you pray Thank God!!

MRI ABDOMEN W&W/O CONTRAST 3/17/2009 12:06:00 PM
Accession: 7495415

FULL RESULT:
Examination: Magnetic Resonance Imaging of the Abdomen - 03/17/2009

Clinical History: Pancreatic carcinoma.

Findings:

1. Comparison was made to a previous study dated 01/15/2009. Small lesion in the right lobe of
the liver
(series 3, image 23) which may be related to a small hemangioma is again identified. There is no
MR
evidence of active metastases in the liver. The lesions noted on a CT scan of 11/30/2007 had
previously
resolved.

2. Patient with a reported history of pancreatic carcinoma and no change in the region of the
pancreas since
the previous study, no obvious mass identifiable. Biliary stent is noted in place. Some
normal-sized
abdominal lymph nodes are noted. Renal cysts are identified bilaterally. No lesions in the adrenal
glands.
No hydronephrosis. No evidence of any abdominal fluid.

IMPRESSION:
Relatively stable study since 01/15/2009 with no definite MR evidence of active metastases in the
liver and other findings as described. Study has been obtained in coronal, sagittal and axial
projections utilizing relative T1 and T2-weighting along with some gradient sequences and
dynamic pre- and post-contrast-enhanced imaging through the region of the liver.

489 - VARMA, DATLA
SIGNED BY: 489 - VARMA, DATLA 3/17/2009 4:05:00 PM

I have been getting a lot of e-mails and other inquiries from friends that are just now finding out about
my little battle with Pancreatic Cancer. I thought it was about time that I update the record about my
condition and get everyone caught up to the present.

Nov. 07 – After CT scans, ERCP and EUS (procedures to place a stent and biopsy the tumor), the
Doctors confirm the diagnosis; Pancreatic Cancer, Stage IV, 6cm tumor in the head of the pancreas
(pressing against the Superior Mesenteric Artery, 8-12 metastic lesions in liver, and local lymph nodes
involvement, ...GI Doctor and Surgeon both gave me 3 to 6 months to live!

Dec. 07 – After confirming the diagnosis with their own CT scans and examinations I started the GTX
treatment protocol under the guidance of Dr. David (MD Anderson Cancer Center - Houston Texas). Dr.
Dave doesn’t give expiration dates…we (Missy, me and Dr. Dave) set Sarah’s wedding date as our first
goal... June 21st 2008. Dr. Dave also told me that I needed to gain weight (I was at a healthy 223lbs)
because the cancer makes people lose weight and he wanted me heavier.

Feb. 08 - CT scan reveals great improvement - can't find the spots on the liver, tumor in head of the
pancreas has shrunk by half, lymph nodes appear normal. This is unheard of! Dr. Dave was VERY
pleased. Missy and I were ecstatic! (Weight 235lbs)

April 08 – CT scan results: Still no spots on liver, more tumor shrinkage! (Weight 250lbs – Dr. say’s,
“put on some more”)

June 21 - Walked my oldest down the aisle at her wedding!!! CT scan two days later reveals no spots,
Pancreas appears normal in size and function!!! (weight 275)

Sept. 08 – CT scan reveals that there is no longer any vascular involvement, everything else normal
too!! Doctor tells me to STOP gaining weight! I was at 285!!!

Nov. 08 – Dr. Dave switches me to MRI exams instead of CT scan to get a better look at the Liver and
Pancreas to make sure that the cancer is not coming back. The scan reveals “all normal”! Now we are
starting to worry that the Chemo is going to kill me, not the cancer!! Blood tests for liver function (AST
and ALT) have been rising but go out of the normal range for the first time. Dr. Dave suspects that the
PC is not the culprit, but rather, my chemo!!!

Jan. 09 - MRI reveals that there still are no lesions, but blood work reveals that the AST/ALT numbers
are still climbing. I was still taking the GTX Chemo - cycle 20.

Jan. 16 – Blood test reveal that the AST and ALT are still climbing. To give the liver a break we
suspend all chemo for 5 weeks to see if the liver will improve. I feel great, fewer side effects than ever.

Feb. 20 – Blood test show a slowing of the climb that the AST/ALT have been doing. However, Dr.
Dave wants me back on chemo, so I started back on the GTX.

March 09 – MRI reveals, still no sign of cancer anywhere! But the blood tests are still not great so
Dr. Dave wants to cut out the Gemzar and Taxotere from the GTX to see if these two drugs are having
an effect on the liver. So, we are cut back on the Chemo to give the liver a rest (just taking Xeloda). Re-
evaluate in 6 weeks.

Apr. 3 – Blood test show no change in rate of climb of the AST/ALT, all other numbers look great! I am
still feeling wonderful. Missy, Rachel, Melissa and I did the Disney trip in the middle of March. My weight
has crept up to 297. I’m having a problem with the weight!

Apr. 24 – Blood test show that the AST and ALT are still climbing. Of course, I have been studying the
problem for weeks now on the web, and have learned just enough to be dangerous! Dr. Dave, Missy
and I were all discussing what could be the cause of this problem and just how bad is the problem…after
all we have been talking about nothing else for months. So I ask Dr. Dave where I stood on the liver
failure scale (something I learned about on the web). Was I a “one”, or a “two” or worse? He looked at
me like I had “two” heads!! Seem that this problem is a long ways away from liver failure or the stages of
failure…for a second there I could read his mind. He must have been thinking about some other patient
because I got a clear reading of “Dumb Ass”!

So, after he got me straight about the liver numbers we went on to discuss what else other than just the
Chemo could be affecting the ALT/AST. We looked up all the med that I’m currently taking, none had
any warnings about liver problems… other than the two we had already stopped taking, the Gemzar and
Taxotere. Finally, I asked if it could be caused by being so overweight? He said that that definitely was
a possibility. So we talked about diets to lose some weight…Dr. Dave wants me to lose 25 lbs. He is still
wants me to keep the weight up! I told him that that was ridiculous that I needed to lose about 75 lbs.
We compromised at 50 lbs. Will I go to hell for lying to an Oncologist?

May 15th - Feeling G-G-G-Great!!! Just left the Doctors Office and got G-G-G-Great news...AST and
ALT have been on the rise since last September...Today the AST dropped from 109 to 76...the ALT
from 130 to 88...HUGE improvement!!! So when you pray make sure you thank God!!!

June 5th - The MRI test results have been incredible! "No sign of metastic disease in the liver...No
indication of a mass in the head of the pancreas" That's the verbal report from Dr. Fogelman. Does it
get any better than that. Coupled with the news earlier in the week about the AST and ALT dropping
more... ALT from 88 to 82 and AST from 76 to 65. I'm walking/jogging more each day (just completed
my second 1 mile jog as part of todays 4 miler) I'm getting stronger each day...All the glory goes to
God!!!! Be sure to thank him for answering your prayers and mine. And if you don't think he is working
miracles TODAY, could you please think again, because what He is doing in me is, and has been, a
Miracle. I was diagnosed Stage IV PC with mets to the liver, inoperable...19 MONTHS AGO!!!! I ran a
mile today...for Christ's sake (literally)!

If you scroll down far enough
you will find some of the actual
CT scans and notes that I wrote
at the time.
Be sure to give credit to God for
all these wonderful blessings!

May 2010

diagnosed in 11/2007. Patient had multiple liver metastases at that time. The patient had complete radiographic
response to chemotherapy. In 03/2010, the new nodule was identified between the uncinate process and the SMA
which was biopsy-proven as adenocarcinoma on 03/19/2010. The patient resumed chemotherapy. Restaging.

Technique: MRI of the abdomen was performed with and without gadolinium according to pancreatic protocol.

Comparison: 03/04/2010.

Findings: Previously identified 1.3 cm nodule in the most medial aspect of the uncinate process is noted again,
decreasing in size to about 1 cm. The signal intensity and enhancement pattern of this nodule currently becomes
identical to the rest of the pancreas. Without knowledge of previous location and biopsy-proof of this finding, it would be
very difficult to identify it as abnormality on the current exam. This nodule is best seen on the axial FIESTA on series 9,
image 53 and on the LAVA on series 8, image 416.

There is no evidence of liver metastasis. There is no focal abnormality in the spleen, adrenals, and kidneys. The
gallbladder shows diffusely thickened wall suggestive of chronic inflammatory changes. There is no ascites. There is
no abnormality in the visualized bones.

IMPRESSION:

Nodule medially to the uncinate process representing either metastatic lymph node or an exophytic portion of the
primary pancreatic cancer, currently measures 1 cm versus 1.3 cm in March, with more uniform enhancement pattern
suggestive of response to treatment.
Again, there is no evidence of liver metastasis or other distant metastasis.