Nipple discharge

Nipple discharge is common after childbearing.  Usually a mother may still have milky discharge a few months after cessation of breast feeding, but sometime longer.  Milky discharge may also be caused by hypothyroidsm or prolactin-producing pituitary tumors, and certain medications (antipsychotics and tricyclic antidepressants).

You should call your doctor or health care providers if you have spontaneous, clear, colored, sticky or bloody unilateral nipple discharge. Leis reported that in 503 patients operated on for one of these types of discharge, 67 (13.3%) had cancer, and 36 (7.2%) had a precancerous lesion. Among the 67 patients with cancer, eight (11.9%) had no palpable mass, 11 (16.4%) had negative cytology ("pap smear of the breast discharge"), and seven (10.4%) had a negative mammogram.

You could also get breast discharge when you stimulate your breast.  It is usually less worrisome if the discharge stops when you stop the breast stimulation.  However, do talk to your health care providers with any of your concern or finding.

Reference:
- Leis HP Jr, et al. Nipple discharge: surgical significance. South Med J. 1988;81(1):20.
- Sabel MS.  Breast mass and other common problems.  Uptodate November 2012. 

I found a breast mass - what do I do now?

Most breast masses are benign such as fibroadenoma.   But most patients and physicians are concerned for possible of breast cancer. There are certain characteristics that are concerning mass for cancer such as single hard, immovable lesion with irregular borders. 

If you found any breast mass, I recommend that you see a physician who will obtain your history and do breast examination. The next steps may include ultrasound, mammography and/or biopsy, depending upon the findings from the history and physical examination, patient age and other clinical factors.  If your age is less than 30 years old, your breast probably more dense.  Thus, your physician may start with ultrasound first.  If you are 30 years or older, your breast usually less dense.  Then your doctor may order mamogram first.

Do remember that no test or exam is 100 percent accurate.  Thus, if you have persistent mass or concern, despite negative test, you should get 2nd or more opinion from other doctors or providers.

Reference:
- The palpable breast lump: information and recommendations to assist decision-making when a breast lump is detected. The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Canadian Association of Radiation Oncologists. CMAJ. 1998;158 Suppl 3:S3
- Sabel MS.  Breast mass and other common problems.  Uptodate November 2012.

HE4 blood test and ovarian cancer prognosis

A study published in December 2012 evaluated the relationship of preoperative HE4 with ovarian cancer survival.  HE4 (Human Epididymis protein) is a blood test that appears to be elevated in patients with ovarian cancer - almost similar to CA125 blood test.

The study found that preoperative (before surgery) levels of HE4 were strongly associated with all ovarian cancer standard prognostic factors. HE4 levels increased significantly with age (p=0.02), cancer stage (p<0.0001), grade (p=0.005), preoperative CA-125 levels (p<0.0001), and residual tumor (p<0.0001). HE4 levels above the median value (394pmol/L) were significantly associated with mortality (HR=2.17; 95% CI: 1.42-3.32) and progression (HR=1.81; 95% CI: 1.21-2.72). After adjustment for the FIGO stage, which was the only factor significantly associated with prognosis in multivariate analyses, the association of HE4 with death remained statistically significant (HR=1.67; 95% CI: 1.08-2.59). However, the association with progression was no longer significant (HR=1.32; 95% CI: 0.87-1.99).

In English, the way I understood it, the high level of HE4 before surgery correlates with aggressiveness of ovarian cancer and the risk of death from this cancer.  Thus, preoperative HE4 level may be used to discuss prognosis of the cancer.  Do be careful since this study is based only on 136 patients.   Usually, we want to see more studies before using this approach clinically.

Reference:

Trudel D, et al. Human epididymis protein 4 (HE4) and ovarian cancer prognosis. Gynecol Oncol. 2012 Dec;127(3):511-5.

 

Painful bones and muscles after Neulasta/Neupogen injection

Patients undergoing chemotherapy usually experience bone marrow suppression.   Our bone marrow is actively dividing, just like cancer cells, thus are prone to be affected by chemotherapy.  As a results, low white blood cells (neutropenia), low red blood cells (anemia) and low platelets (thrombocytopenia) are common in patients on chemo.   When your white blood cells are too low, you may get severe infection.  Your doctor may prescribe you Neulasta (Pegfilgrastim) or Neupogen (Filgrastrim)  injection in between of your chemo sessions.

Neulasta/ Neupogen induces your bone marrow to work harder to produce white blood cells.  Commonly, patients would complain of muscle and bone aches after Neulasta/ Neupogen injection.  One patient complained in her blog "My stomach felt like I did a hundred sit ups, without the flat abs to show for it"  :-).
Bone pain has been reported in approximately 22% of patients.

One of rare complications of Neulasta/ Neupogen is it may cause your spleen to enlarged and can rupture.  A ruptured spleen can cause death. The spleen is located in the upper left section of your stomach area. Call your doctor right away if you have pain in the left upper stomach area or left shoulder tip area. This pain could mean your spleen is enlarged or ruptured.  There are other serious risks that you could review from the website below.  

For the common aches, taking acetominophen (Tylenol) before and after the injection usually help.  Sometimes, your doctor may have to give a stronger pain medication such as hydrocodone or oxycodone.  Reducing the dose of neulasta also may reduce the pain while still giving you the benefit of white blood cell production.  Some patients reported that claritin also help reducing the bone pain.  But I could not find a study confirming it.

Reference:
- http://www.neulasta.com/starting-chemo-with-neulasta/white-blood-cell-counts.html?src=ppc&WT.srch=1&SRC=2

- Kubista E,et al; Pegfilgrastim Study Group.Bone pain associated with once-per-cycle pegfilgrastim is similar to daily filgrastim in patients with breast cancer. Clin Breast Cancer. 2003 Feb;3(6):391-8

Herbal medication and surgery

Herbal medications taking before surgery may cause bleeding complications and adversely interacting with anesthetic agents.    I copied a few more commonly usage here and not intended to be completely inclusive from Uptodate: 

• Garlic may increase bleeding risk and should be discontinued at least seven days prior to surgery.
• Ginkgo may increase bleeding risk and should be discontinued at least 36 hours prior to surgery.
• Ginseng lowers blood sugar and may increase bleeding risk and should be discontinued at least seven days prior to surgery.
• Kava may increase the sedative effect of anesthetics and should be discontinued at least 24 hours prior to surgery. An association between kava use and fatal liver toxicity has been reported.
  
• St. John's wort may diminish the effects of several drugs by induction of cytochrome p450 enzymes and should be discontinued at least five days prior to surgery.
• Valerian may increase the sedative effect of anesthetics and is associated with benzodiazepine-like withdrawal. There are no data on preoperative discontinuation. Ideally it is tapered weeks before surgery; if not, withdrawal is treated with benzodiazepines.
• Echinacea is associated with allergic reactions and immune stimulation. There are no data on preoperative discontinuation.
• Ephedra (ma huang) may increase the risk of heart attack and stroke and should be discontinued at least 24 hours prior to surgery.

In general, if you take any herbal medications, please let your doctor and nurses know.

Reference:
Uptodate. Perioperative medication management.  2012. 

Cervical cancer in young girls

Some of you have asked me about the new pap smear guideline where the starting age is now 21 years old.  There are concerns of cervical cancer may be missed in young girls.  A study published in November 2012 evaluated this question by reviewing combined data from US cancer registries and SEER program covering 92% of US population.  The study found that for women younger than age 40 years, only 1% of cancer is found in women younger than 20 years old.  Since we have about 12,000 new cervical cancers each year in the US, the new pap smear guideline will miss about 120 cervical cancer in young girls.

Various organizations (NCCN, American Cancer Society, USPFTF, ACOG, etc) recommend starting pap smear at age 21 (for "average risk" women) knowing that there will be these a few girls missing their cancer diagnosis.  Their reasoning is earlier age pap smear may cause more harm and cost with follow up procedures than the benefit of diagnosing these girls of cervical cancer.   I have to admit that I have a mixed feeling about this...   Intellectually, I understand the concept but emotionally I have difficulty since I have cared for young girls with cervical cancer.

Reference:
- Benard VB, et al.  Cervical carcinoma rates among young females in the United States.  Obstet Gynecol.  2012; 120:117-23.
- US preventive services task forces. 2012
- Saslow D, et al. CA Cancer J Clin. 2012;127:516-42

Shark cartilage and cancer

Shark cartilage has been promoted to cure cancer since around 1950.  It started with surgeon John Prudden claimed that shark cartilage reduced tumor almost by half the size.  Laboratory studies suggested that it may have anti angiogenesis (reducing cancer blood vessels).  Unfortunately, clinical studies showed no prove of its effectiveness in cancer patients.   Most recently, a purified shark cartilage extract (Neovastat) failed to help survival of patients with non-small cell lung cancer.  The Federal Trade Commission has prevented several companies from promoting this cartilage for cancer treatments.

My opinion is to leave the shark cartilage alone.  Sharks should be allowed to live too....

Reference:
-Loprinzi CI, et al.  Evaluation of shark cartilage in patients with advanced cancer.  Cancer. 2005; 104:176-82
- Lu C, et al. Chemoradiotherapy with or without AE-941 in stage III non small cell lung cancer: a randomized trial.  J Natl cancer Inst.  2010; 102:859065
- Federal Trade Commission.  "operation cure all" nets shark cartilage promoters. http://ftc.gov/opa/2000/06/lanelabs.shtm

Malnutrition and cancer

Malnutrition and weight loss are common in patients with cancer for 3 reasons.  First, experimentally, cancer has preferentially gotten our calorie then the left over is distributed to our healthy cells. Secondly, cancer treatments such as chemo and radiation decrease our appetite.  Finally, depression is common after diagnosis of cancer and may affect our mood and appetite.

It is logical to conclude that our nutritional technology could help cancer patient patients.  Some of my patients have asked about having nutrition given to them using intravenous way (TPN-total parenteral nutrition).   TPN is a solution mixture of sugar, fat and protein and infused usually in the hospital or sometimes at home.   The American Gastroenterological Association (AGA) reviewed 26 randomized trials of parenteral nutritional support in cancer patients, including 19 in those receiving chemotherapy, three in patients being treated with radiation therapy (RT), and four in those undergoing stem cell transplantation.  AGA concluded that TPN in cancer patients have no effect in mortality, 40% increase in overall complication rates (16% increase in infection), and 7% reduction in tumor response to treatment.

TPN may play role for a short period in very malnourished patients undergoing surgery.   If you are not malnourished, TPN seems to increase complications.   In the Veterans Affairs Cooperative Study, 395 malnourished patients who underwent abdominal/chest surgeries (65 percent of whom had cancer) were randomly assigned to TPN for seven days before surgery and three days after surgery or no TPN. Overall, patients receiving TPN had a higher rate of infectious complications (14 versus 6 percent) and a nonsignificant reduction in 30 day mortality (7.3 versus 4.9 percent). However, in the severely malnourished subgroup (n = 24), those treated with TPN had significantly fewer noninfectious complications than controls (43 versus 5 percent)

 So, what should we do if we have cancer and losing weight.  I recommend to eat 5-6 small meals a day, instead of 3 large meals.   Do eat more thick creamy soups, dairy (milk, milk shakes, cheese, yogurt, ice cream) and peanut butters.  Nutritional supplement such as Ensure and Boost also are useful but more expensive than milk (Milk has about the same amount of protein).  Your doctors could also prescribe appetite stimulants (Progestin and Marinol).   However, they have some potential side effects such as depression, blood clot and hallucination.  If you ended up in the hospital, some studies suggest that giving you food thru feeding tube is healthier than using TPN.  However, there are some circumstances that TPN would still be suitable.  Do discuss with you doctor.


Reference:
- Koretz RL, et al.   AGA technical review on parenteral nutrition. Gastroenterology. 2001;121(4):970
- Perioperative total parenteral nutrition in surgical patients. The Veterans Affairs Total Parenteral Nutrition Cooperative Study Group.  N Engl J Med. 1991;325(8):525.
- Bozzetti F, et al. Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: a randomised multicentre trial.  Lancet. 2001;358(9292):1487.

Can you get cancer from obesity?

Indeed several cancers such as postmenopausal breast, endometrial, renal, colon and esophageal cancer have been associated with obesity.   Fat contains enzyme called Aromatase which produces excess estrogen.  This constant production of estrogen is postulated to lead to development of breast and endometrial (uterine -womb) cancers.  In colon cancer, obesity is thought to increase the risk thru insulin and inflammatory pathways.

In my practice, I see many patients with uterine cancer related to excess weight.  We have about 40,000 new uterine cancers in the United States but see it very little in Africa or China where obesity is not yet a problem. Thus, reducing risk of cancers is another reason to lose weight.

Reference:

- Wolin KY, eta l. Physical activity and colon cancer prevention: a meta-analysis. Br J Cancer. 2009;100(4):611

 - Wolin KY, et al. Obesity and cancer. Oncologist. 2010;15(6):556.

Vitamin B12 injection for energy

A few patients had asked me for Vit B12 injection to boost their energy.   I was not aware of this and thus ended up reviewing the history and literature of vit B12 supplementation.

Vit B12 was discovered when malnourished dogs were found to be anemic (low blood volume).  This anemia seemed to be resolved by feeding the dogs food containing liver.   After much experimentation, Vit B12 was purified from liver juice.  Indeed, Vitamin B12 which plays role in folate (Vit B9) generation.  Lacking folate could contribute to pernicious anemia.

Since Vit B12 mostly contained in animal product but little in vegetables, complete vegans are at risk for poor vitamin B12 intake. Vegans who still take dairy products are usually not at risk for Vit B12 deficiency. Similarly,  alcoholics, and people with little dietary variation (such as some older adults) may be vit B12 deficient.   Vitamin B12 supplementation in healthy adults and in those with vitamin B12 deficiency is well-tolerated without significant adverse effects.

To test for vit B12 deficiency is very simple.  Your doctor could order CBC (complete blood count) including a subtest called MCV (measure the size of red cells).  If the red blood cells are larger than normal and your hemoglobin (red blood cell) level is low, then you may have a type of anemia that may benefit from vit B12 and folate supplementation.  There are blood tests that could also test vit B12 directly.

My recommendation is to have large variety of diet as recommended by USDA.  Following this diet recommendation, you risk of vitamin deficiency is minimal.

Reference:
Uptodate. Vitamin supplementation. November 2012.

Numbness and pain on fingers/toes with chemo

Some chemo agents are responsible for neuropathic pain.   This pain on your nerves is defined as numbness, tingling and/or pain on feet and/or fingers associated commonly with chemo Taxol (Paclitaxel) and cisplatin.   The pain is increasing as you receive more of these chemo agents.  Severe nerve pain occurs in 20 to 35 percent of patients receiving 250 mg/m² of Taxol every three weeks compared to 5 to 12 percent in large series using doses ≤200 mg/m² every three weeks (1). 

Prevention is usually better than treatment.   Thus, when you start to have these sensations, please let you oncologist knows who then can reduce the dose or change the chemo.

There are medications you may receive for neuropathic pain such as Gabapentin (Neurontin).  Recently, an early study of a randomized placebo-controlled trials have shown a benefit for Duloxetine (Cymbalta),  an antidepressant of the serotonin norepinephrine reuptake inhibitor (SNRI) category, in patients with diabetic neuropathy, and the drug is approved for this use in the United States. In a preliminary report reported at the 2012 meeting of ASCO, duloxetine reduced pain and improved quality of life in patients with painful chemotherapy-induced peripheral neuropathy following chemotherapy (2)

Reference:
1.Lee JJ, et al. J Clin Oncol. 2006;24(10):1633
2.Lavoie Smith EM, et al.  CALGB 170601: A phase III double blind trial of duloxetine to treat painful chemotehrapy-induced peripheral neuropathy. J Clin Oncol 30, 2012

New pap smear guideline 2012

The American College of Ob.gyn just came out in November with the new guideline for cervical cancer screening (pap smear) for women.  It recommends:
- To start getting pap smear: age 21 years old
- age 21 to 29 years old: pap smear every 3 years
- age 30 to 65 years old: pap smear with HPV testing (both tests combined called "cotesting") every 5 years
- Older than age 65 years old: no pap needed

Do remember that these are just guidelines.  Your doctor may modify them depends on your clinical situation.  Also, you may get pap more frequently if you have had abnormal pap smear, cervical cancer or other conditions.  do talk to your doctor. 

Reference:
ACOG practice bulletin, no 131.  November 2012

Hysterectomy and a tummy-tuck

Who would not want to get that extra belly fat removed while you are getting a hysterectomy?  Many of my patients ask me if I could just remove their belly fat while I am removing their uterus.   If I just need to revise their previous old surgical scar and some fat, I usually don't mind.  However, to remove large amount of fat, skin and tighten the abdominal muscle (Tummy tuck or abdominoplasty), it would take considerable amount of time and effort.   The hospital and your surgeon would probably charge you extra $4000 to $6000 since insurance company does not cover the cost.

But again, if you have less than appealing old surgical scar and you are about to go to another abdominal surgery, do ask you surgeon if he/she could revise it for free.  Does not hurt to ask...

Vaginal spotting after my hysterectomy

It is common to have vaginal spotting a few days after hysterectomy.  This is usually due to the healing of vaginal cuff.  During surgery, the end part of the vagina was cut then sutured.   In contrast to your outside skin that was cut then dried up and forming scab, the vaginal areas are usually moist and take longer time to heal.  Thus, vaginal spotting is OK for a few days after hysterectomy.   But if you have heavier bleeding than just dark spot, or if you have bright red bleeding or you are concerned, please call your surgeon.

Occasionally, you have a few blobs of dark blood coming off from your vagina in the first day of being home.  This could come from blood that clotted after surgery but left over in the vagina.  if this is all you have, you usually will be OK.  But if you have persistent vaginal clot, please call your surgeon.

When you come, we usually examine your vaginal cuff and stop the bleeding using a chemical cautery (Monsel solution or silver nitrate).  The cauterization usually has minimal or no pain but the exam is somewhat uncomfortable since you are still sore from the surgery. 

Shingle (herpes zoster) and chemotherapy

Varicella-zoster virus (VZV) can cause two types of diseases.  First, primary infection with VZV results in varicella (chickenpox), characterized by skin blister.   After this infection, the virus could live dormant in your nerves.   The 2nd type of disease is what we called Herpes zoster or shingles.  Herpes zoster is due to reactivation of VZ virus that live dormant earlier in your nerves - not the same as sexually transmitted herpes. Herpes zoster/ shingle usually causes painful, one sided painful blisters on your skin.  Before the rashes or blisters show, you may have nerve symptoms of pain, itching, burning, or tingling. The rash has blisters that scab over in about a week. Although shingles isn’t contagious, the virus can spread to others and can cause chickenpox.

We don't know what exactly causing the reactivation of the VS virus in shingle but it occurs more often in immunosuppressed persons such as with HIV or in chemotherapy.  Thus, if you have any painful skin rash or blisters during chemotherapy, do come see your oncologists or PCP.  Your doctor may give you antiviral therapy to help healing of the rash and decrease the painful inflamed nerves.  Antiviral medications are Famciclovir or Acyclovir or Valacyclovir pills.  Pain medication such as tylenol or stronger narcotic prescription may be needed depending the degree of your pain.

Can I just take aspirin for my blood clot, instead of coumadin/warfarin ?

Patients are usually asked to take coumadin/ warfarin (blood thinner pills) for about 6 months after diagnosis of blood clot.  Coumadin or warfarin are vitamin K antagonists.  Thus, it is inconvenient since patients need to avoid certain green leafy vegetables, which contain vitamin K, in their diet.  In addition, they have to get their blood tested frequently to make sure that their blood is not too thin or too thick (INR test).

Some of my patients have asked if they could be switched to aspirin alone.  It would be a lot easier than taking warfarin.   In this month New England Journal, a study randomly assigned 822 patients who had completed initial anticoagulant therapy after a first episode of unprovoked venous thromboembolism (blood clot) to receive aspirin, at a dose of 100 mg daily, or placebo for up to 4 years.  The results showed aspirin, as compared with placebo, did not significantly reduce the rate of recurrence of venous thromboembolism but resulted in a significant reduction in the rate of major vascular events, with improved net clinical benefit.

Sorry, you still have to take the warfarin if you have blood clot but discuss this question with your physician.  Furthermore, there are newer pills that may be easier to take than warfarin.  FDA just approved Xarelto for blood clot but I expect this drug would cost a lot more than warfarin.

Reference:
Brighton TA, et al. Low dose aspirin fo recurrent thromboembolism.  NEJM. Nov 2012.

Should I take vitamin supplements?

Vitamins have done wonder in our medical history.  Vitamin D supplement has made Rickets a rare disease.  Folic acid intake by pregnant women have reduced the incidence of spina bifida in newborns.   These public health achievements led many of us thinking that if a little is good, then more is better.   Some have speculated that antioxidants such as beta-carotene, vitamins A, C and E, may protect human cells from premature degradation.  Thus, they may prevent or even cure cancers.  Not surprisingly, many of us jump into conclusion of taking multivitamins is good for our health.

However, the science of vitamins is not very clear.   The Women's health initiative study which followed 160,000 women for about 8 years showed that 42% of study subjects who took multivitamins suffered the same rates of cancers, heart attacks, and strokes as the study participants who did not take the multivitamins.  A trial showed concerning increased rate of lung cancer in patients who took beta-carotene and other supplements.  A randomized trial of 30,000 men was halted in 2008 when preliminary analysis of the study showed that selenium and Vit E supplements were increasing number of cancers.

From Uptodate, I found this statement: The US Preventive Services Task Force (USPSTF) clinical practice guideline provides several recommendations for vitamin supplementation and can be accessed through the website for the Agency for Healthcare Research and Quality at www.ahrq.gov/clinic/uspstfix.htm. The USPSTF recommends 400 to 800 micrograms/day Folic acid for all women planning of pregnancy. The USPSTF found insufficient evidence to recommend for or against the use of supplements of vitamins A, C, E, multivitamins with folate, or antioxidant combinations for the prevention of cancer or cardiovascular disease. The USPSTF also recommend against the use of beta carotene for the prevention of cancer or cardiovascular disease.

What shall we do?  My suggestion is we should follow the USDA's dietary guidelines: for most of us, our vitamins should come from our foods rather than vitamin supplements.  Our meals should consists of wide variety of fruits, vegetables and even some proteins (lean meat).  I usually tell my patients that their meals should have variety of colors and variation.  Foods are very complex with many undiscovered biologically active ingredients and we have evolved for many millions years adapting to them.  A few single vitamins, recently discovered, are too simple solution to meet our dietary needs. 

Reference:

- U.S. Preventive Services Task Force. Ann Intern Med. 2009;150(9):626

-Routine vitamin supplementation to prevent cancer and cardiovascular disease: recommendations and rationale.Ann Intern Med. 2003;139(1):51

- Uptodate. Vitamin supplementation.  November 2012

Genetic testing for ovarian cancer

About 10-15% of epithelial ovarian cancer are due to BRCA genes mutations.   Some of my patients with ovarian cancer are concerned that their daughters and sisters may also have an increased risks to develop ovarian cancer.   They are correct that first degree relatives (mother, sister, child) of an ovarian cancer patient would increase their baseline life time risk from 1.4% to around 2%.  If they have BRCA genes mutations, their life time risk jumps to about 50-85% for breast cancers and15 to 40 percent chance of developing ovarian cancer.

BRCA genes mutations are found more commonly in patients with a personal history of breast cancer and/or a family history of breast and ovarian cancer, especially if associated with young age of onset, multiple tumors, and involvement of male family members affected with breast cancer.  Ashkenazi Jews ethnicity is also a known risk factor.  Thus, if you have these histories, do talk to your physician about getting genetic counseling.  The genetic counselor will obtain more detail history and use a program to estimate your risk for BRCA genes mutations.  Genetic testing is usually recommended if your risk is estimated to be around 10% or higher.

Patients may have concerns of being discriminated after a genetic testing.  Fortunately, the Federal Genetic Information Nondiscrimination Act (GINA) of 2008 prohibits health insurers and employers from asking or using genetic test information in decisions about employment or insurance eligibility/coverage.
 
References:
- Pharoah PD, et al. Int J Cancer 1997; 71:800

- Hudson KL, et al. Keeping pace with the times--the Genetic Information Nondiscrimination Act of 2008.N Engl J Med. 2008;358(25):2661.

-Colditz G, et al. JAMA 1993; 270:338.

Does air cause my cancer to spread during surgery?

A few patients have concerns that when I operate to open their abdomen that air would make the cancer to spread.  Usually the story goes as "my grandmother went to surgery for cancer.  The surgeon opened her abdomen and closed.  Then she died a few days later because the cancer spread faster".  

I searched the literature and could not find the scientific basis for this.   However, the story may have a merit.  I could only speculate that the grandmother's cancer was too extensive that the surgeon decided to open, (may be biopsy), then closed the abdomen again.  She probably died from the extensive cancer or cancer complications (such as blood clot), but not from the air that entered her abdomen.