Neck Dissection

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Vickie just got the results of her CT scan after undergoing three rounds of Chemo. Her scan showed that a subtle enhancing node within the left posterior cervical triangle remains, but no other enhancing nodes or seperate mass lesions are evident. Our oncologist says this is incredibly good news and wants to just do another round of chemo to get the remaining node and then go right to the IMRT radiation therapy without having the neck dissection. However, our ENT is telling us that her prognosis would be better if she had the neck dissection.We don't know what we should do. I know there are some here that have not had the neck dissection (Nancy and John) and some that have. Any advice would be most appreciated.Bob
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  • longtermsurvivor
    longtermsurvivor Member Posts: 1,842 Member
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    I had similar situation
    my Ent oncologist, who I have now known for 14 years, and I trust implicitly, told me my survivalnchances went down by 20percent without the neck dissection.

    best to you and your wife
  • ratface
    ratface Member Posts: 1,337 Member
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    I had similar situation
    my Ent oncologist, who I have now known for 14 years, and I trust implicitly, told me my survivalnchances went down by 20percent without the neck dissection.

    best to you and your wife

    I've spent weeks researching it
    and have come to almost exactly the same conclusion as LTS states. My research concluded the survival rate is almost 22 percent better with dissection. You might want to consider the dissection after radiation to cleanup anything possibly remaining that has moved along the lymphatic system. My ENT advised against the dissection wanting to wait and see? I found a new ENT specifically the one who had published the research and who had no objections to performing the operation. You will get some dissension on this but you ultimately have to choose between your tolerance of risk. It's a 1 out of five roll of the dice. Some can live with that, I could not.
  • MarineE5
    MarineE5 Member Posts: 1,031 Member
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    Agree
    Bob,

    I will have to agree with LTS and RF on their posts. I had a Radical neck disection and it sounds as though Vickie may have the Modified disection if she chooses to have it done.

    In my case, I did not have the Chemo after my surgery of base of tongue cancer. Had the surgery to remove the tumor on my tongue and part of my tongue was removed along with the neck disection. I told the Surgeon that I wanted any and all cancer areas removed. He did so and I am now 7 years out of surgery.

    Keep in mind, there may be some side affects from the neck disection. Of course the scar, but my Surgeon did it in such a way, he followed the wrinkles in my neck, so you can barely see the scar. Lymphadema may be an issue depending on the number of lymphnodes removed. My swelling didn't happen until after my Radiation treatments were completed. Had treatments after the surgery. I went to a Cancer Physical Therapist and she taught me the exercises and massage that is listed in SweetBloods Super Thread. I have control over the swelling now.

    My Best to Both of You and Everyone Here
  • jim and i
    jim and i Member Posts: 1,788 Member
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    Jim did not have the
    Jim did not have the surgery. ENT surgeon said tumor to large (4cm) and at base of tongue which would create more risk than acceptable. He did say he would remove the two affected lymph nodes if they were not clear after rads and chemo. PET showed the nodes are clear so hopefully no surgery. We see the ENT surgeon next week to confirm no surgery.

    Debbie
  • fisrpotpe
    fisrpotpe Member Posts: 1,349 Member
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    Time
    My thoughts are just that. My ENT has been the lead for 15 plus years and have survivorship has been successful since. You need to pick a leader and go with him.

    Cancer may continue to grow and multiply if being treated by chemo. If surgery is done not does not mean all the cancer will be taken out. To me radiation is best attack as it gets alot more area than surfer. Then after radiation do a wait and see about surgery. I know for me it would be much easier long term if all I had was radiation and chemo.

    Lot the wonderful news from chemo treatments.

    I do suggest strongly that you make sure if you do the radiation that the treatment is done with Tomotherapy. So much less side effects happen by using it. The reason I say this is not all cancer centers have it.

    prayers going out for both of you.

    johnvg
  • Baygal
    Baygal Member Posts: 34
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    fisrpotpe said:

    Time
    My thoughts are just that. My ENT has been the lead for 15 plus years and have survivorship has been successful since. You need to pick a leader and go with him.

    Cancer may continue to grow and multiply if being treated by chemo. If surgery is done not does not mean all the cancer will be taken out. To me radiation is best attack as it gets alot more area than surfer. Then after radiation do a wait and see about surgery. I know for me it would be much easier long term if all I had was radiation and chemo.

    Lot the wonderful news from chemo treatments.

    I do suggest strongly that you make sure if you do the radiation that the treatment is done with Tomotherapy. So much less side effects happen by using it. The reason I say this is not all cancer centers have it.

    prayers going out for both of you.

    johnvg

    Made our decision
    We found a very informative article on HPV and Survival of Patients with Oropharyngel Cancer which we sent to our ENT doctor. After he read it, he agreed that we should go ahead with the forth round of Chemo and then start on the radiation therapy. He will then closely monitor Vickie and, if needed, do a modified neck dissection at that time.
    Thanks to everyone for your responses. The article I referred to is below:
    http://oralcancerfoundation.org/hpv/pdf/NEJM_Gillison.pdf
    Again...Thanks to all.
    Bob and Vickie
  • jtl
    jtl Member Posts: 456
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    Dissection
    I think there is less surgery today and more use of radiation therapy with chemo. I agree that Tomo is something to look into. I had it and was pleased with results but then I don't have anyhting to compare it to.
    Regards,
    John
  • ratface
    ratface Member Posts: 1,337 Member
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    jtl said:

    Dissection
    I think there is less surgery today and more use of radiation therapy with chemo. I agree that Tomo is something to look into. I had it and was pleased with results but then I don't have anyhting to compare it to.
    Regards,
    John

    prudent plan
    I think your course of action is prudent as you are open to the possibility of a neck dissection. The article you reference does not address neck dissections but rather compares modes of radiation treatments. Diminished treatment may be warranted in certain HPV cases but the area to be diminished may or may not be the neck dissection. As your article states, metastasis into the lymphatic system is a huge consideration in treatment modality. Dissections can be done either before or after chemo/radiation. It used to be common to do them before because it was a little easier to operate on the non radiated skin. It seems that the trend today is beginning to shift toward post radiation. The poster from Canada just eluded to this in a recent post and conversation with his treatment team stating there was a measurable benefit to post radiation?
  • Goalie
    Goalie Member Posts: 184
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    jtl said:

    Dissection
    I think there is less surgery today and more use of radiation therapy with chemo. I agree that Tomo is something to look into. I had it and was pleased with results but then I don't have anyhting to compare it to.
    Regards,
    John

    Clean-up
    I have said this before and so forgive me.

    My ENT warned me in the beginning that we might be doing a neck dissection at the end of it all but said that the reason why he would rather do it after the rads and chemo was so that they could do the work of getting rid of the active tumor and cells and he could just clean up the dead stuff that was left, if anything. The worry was that doing it before the other treatments killed everything might end up spreading things around worse. He knew where things were then and better to get them all in place. You might think about this. Doug
  • Hal61
    Hal61 Member Posts: 655
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    What's left of my two cents
    Everybody has already covered everything well. As rat/rick says, the tendency today is to do the dissection, if warranted, after the chemo and radiation. Some see it as always warranted. My medical onc did, advised it as a matter of course. My radiation onc said that with todays IMRT and good chemo, dissection was not necessarily needed, by that she meant it served no purpose. How to know if it will serve a purpose? Just as a precaution, when no other scans or signs show anything, was not good enough for me. I had a three month scan that showed dubious radiance levels attributed to scarring, cooking, etc. Somebody help me hear, I couldn't find anything on the radiance levels I was given as an indicator of activity in the nodes after chemo and rads. I think my initial read was like 3.4 and risk level started at 3.5, I'm not sure of the numbers, but it was a borderline ration along those lines. After 6th month scan, still the same nagging borderline radiance. Now my ENT chimed in--he'd been on the fence--and said lets do it, my Rad onc was mum, indicating she'd still wait a bit.

    I decided to do it. 15 removed, and two showed cancer. So, in this case the mopping up surely saved me future treatment.

    I went back to my medical onc after I'd healed a bit from the dissection. I belive I'd had a clean PET/CT by then. He advised a round of chemo, this time Carboplatin, just to be sure, nows the time he said, cause even if one cell remains--he put his thumb and index finger very close to illustrate one cell--then now is the time to strike. He said there was no clinical documentation that supported the efficacy of this course.

    I said no thanks. My ears were already ringing from the cisplatin, and my hearing was much affected. Carboplatin could leave my extremities numb, he said. To me, sometimes you don't throw the whole kitchen sink at it.

    I'm getting close to two years clear, and went for a hike in the Sierras this morning, and I'm hoping Vickie is heading in the same direction.

    best, Hal
  • longtermsurvivor
    longtermsurvivor Member Posts: 1,842 Member
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    Hal61 said:

    What's left of my two cents
    Everybody has already covered everything well. As rat/rick says, the tendency today is to do the dissection, if warranted, after the chemo and radiation. Some see it as always warranted. My medical onc did, advised it as a matter of course. My radiation onc said that with todays IMRT and good chemo, dissection was not necessarily needed, by that she meant it served no purpose. How to know if it will serve a purpose? Just as a precaution, when no other scans or signs show anything, was not good enough for me. I had a three month scan that showed dubious radiance levels attributed to scarring, cooking, etc. Somebody help me hear, I couldn't find anything on the radiance levels I was given as an indicator of activity in the nodes after chemo and rads. I think my initial read was like 3.4 and risk level started at 3.5, I'm not sure of the numbers, but it was a borderline ration along those lines. After 6th month scan, still the same nagging borderline radiance. Now my ENT chimed in--he'd been on the fence--and said lets do it, my Rad onc was mum, indicating she'd still wait a bit.

    I decided to do it. 15 removed, and two showed cancer. So, in this case the mopping up surely saved me future treatment.

    I went back to my medical onc after I'd healed a bit from the dissection. I belive I'd had a clean PET/CT by then. He advised a round of chemo, this time Carboplatin, just to be sure, nows the time he said, cause even if one cell remains--he put his thumb and index finger very close to illustrate one cell--then now is the time to strike. He said there was no clinical documentation that supported the efficacy of this course.

    I said no thanks. My ears were already ringing from the cisplatin, and my hearing was much affected. Carboplatin could leave my extremities numb, he said. To me, sometimes you don't throw the whole kitchen sink at it.

    I'm getting close to two years clear, and went for a hike in the Sierras this morning, and I'm hoping Vickie is heading in the same direction.

    best, Hal

    Hal
    It didn't just save you future treatment, it probably saved your life. Lymphatic spread is a mystical thing. Especially after the lymphatics are altered, either by surgery or by radiation. Retrograde, or skip lymphatic spread could easily have put you into the distant mets arena. Then you would have been just treading water. You did well. Hope you enjoyed the hike. I was prepared for a 200 mile sojourn in the Ozarks this winter when I got my bad news. All packed, conditioned and ready to go. Maybe next year.
  • nwasen
    nwasen Member Posts: 235 Member
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    Hal
    It didn't just save you future treatment, it probably saved your life. Lymphatic spread is a mystical thing. Especially after the lymphatics are altered, either by surgery or by radiation. Retrograde, or skip lymphatic spread could easily have put you into the distant mets arena. Then you would have been just treading water. You did well. Hope you enjoyed the hike. I was prepared for a 200 mile sojourn in the Ozarks this winter when I got my bad news. All packed, conditioned and ready to go. Maybe next year.

    neck dissection
    I met with the chief oncologist who was also the surgeon. I had stage 4 tongue with cancer in 3 nodes. There was HPV found in my cancer, which some have told me is why the surgery was not pushed on me. I was offered the gold standard of surgery; numerous hours on the operating table, followed by a week in the hospital, then 5 weeks of being home and then my 35 radiation treatments and 7 chemos. The other option was no surgery and go straight to radiation and chemo. I wasn't afraid of the surgery per se but didn't like the longterm possible side affects.
    I am coming up on one year out since the end of treatments; I go for checkups every 3 months and so far so good. In January I will go for my next PET and hoping that my feeling good means the beast has not returned.
    I guess if that would happen, then I would have to rethink surgery.
    But that being said; we all have the same disease of cancer but we are all different. Right now I am glad I turned down the surgery. My chemo doc, my radiation doc and my ENT all said I made the right choice! We each have that decision to make. Go with your gut.
    wishing you health!
    Nancy
  • Hal61
    Hal61 Member Posts: 655
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    Hal
    It didn't just save you future treatment, it probably saved your life. Lymphatic spread is a mystical thing. Especially after the lymphatics are altered, either by surgery or by radiation. Retrograde, or skip lymphatic spread could easily have put you into the distant mets arena. Then you would have been just treading water. You did well. Hope you enjoyed the hike. I was prepared for a 200 mile sojourn in the Ozarks this winter when I got my bad news. All packed, conditioned and ready to go. Maybe next year.

    Next year it will be
    I didn't figure to be able to hike a year and half ago LT, it seemed to me then I was destined to spend my time over the sink, holding up my end of the mucous beam that extended into the drain. Good point about spread. I'm not familiar with retrograde, but I do know skip. No argument with you. Where I differ with some people whose opions I always respect is the idea of throwing another round of variably disabling treatment at something that can't be seen or documented, and the advantage of the treatment can't be shown. I am not for continued, unwarranted (as above) treatments as they stand--Tomo therapy looks like a nice step in the direction of where they might better stand--ust because they can be done. (I appreciate you don't believe doctors do this, and I believe that mostly they doo't, but sometimes do) I can't defend that very well, because someone will say, but what if you don't and you get cancer. But at some point you have to weigh the almost certain effects of repeated chemo/rad/surgery against the possibilies or recurrance that can be measured, quantified, or otherwise detected.

    That wasn't my case--though, as said, I did decide against furter chemo for the reasons I've listed; and it isn't yours or Vicie's.

    Well, forgive the tangent, I just meant to say thanks and wish you well. Ha, if 200 miles with a pack is a sojourn for you, I expect you to be back on the trail in no tine.

    I'll be thinking my best thoughts for your recovery, Hal
  • Hondo
    Hondo Member Posts: 6,636 Member
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    Hi Bob
    I did not do the neck dissection; but I did do Radaition and Chemo, I still have a light little lump that can barley be seen there but it is nothing but left over scar tissue now. I know it is a hard decision to make especially when you have two doctors and each is telling you something different.

    Wishing you both the best
    Hondo
  • longtermsurvivor
    longtermsurvivor Member Posts: 1,842 Member
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    Hal61 said:

    Next year it will be
    I didn't figure to be able to hike a year and half ago LT, it seemed to me then I was destined to spend my time over the sink, holding up my end of the mucous beam that extended into the drain. Good point about spread. I'm not familiar with retrograde, but I do know skip. No argument with you. Where I differ with some people whose opions I always respect is the idea of throwing another round of variably disabling treatment at something that can't be seen or documented, and the advantage of the treatment can't be shown. I am not for continued, unwarranted (as above) treatments as they stand--Tomo therapy looks like a nice step in the direction of where they might better stand--ust because they can be done. (I appreciate you don't believe doctors do this, and I believe that mostly they doo't, but sometimes do) I can't defend that very well, because someone will say, but what if you don't and you get cancer. But at some point you have to weigh the almost certain effects of repeated chemo/rad/surgery against the possibilies or recurrance that can be measured, quantified, or otherwise detected.

    That wasn't my case--though, as said, I did decide against furter chemo for the reasons I've listed; and it isn't yours or Vicie's.

    Well, forgive the tangent, I just meant to say thanks and wish you well. Ha, if 200 miles with a pack is a sojourn for you, I expect you to be back on the trail in no tine.

    I'll be thinking my best thoughts for your recovery, Hal

    Hal
    For what it's worth, I wouldn't have taken the additional course of chemo either. Biologically, it makes no sense to me, any more than it did to you.

    Best regards
  • MarineE5
    MarineE5 Member Posts: 1,031 Member
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    nwasen said:

    neck dissection
    I met with the chief oncologist who was also the surgeon. I had stage 4 tongue with cancer in 3 nodes. There was HPV found in my cancer, which some have told me is why the surgery was not pushed on me. I was offered the gold standard of surgery; numerous hours on the operating table, followed by a week in the hospital, then 5 weeks of being home and then my 35 radiation treatments and 7 chemos. The other option was no surgery and go straight to radiation and chemo. I wasn't afraid of the surgery per se but didn't like the longterm possible side affects.
    I am coming up on one year out since the end of treatments; I go for checkups every 3 months and so far so good. In January I will go for my next PET and hoping that my feeling good means the beast has not returned.
    I guess if that would happen, then I would have to rethink surgery.
    But that being said; we all have the same disease of cancer but we are all different. Right now I am glad I turned down the surgery. My chemo doc, my radiation doc and my ENT all said I made the right choice! We each have that decision to make. Go with your gut.
    wishing you health!
    Nancy

    True words
    Nancy wrote---But that being said; we all have the same disease of cancer but we are all different.

    Nancy, another Veteran on another site told me that he had gone to 3 different ENT's to find out about his throat cancer. He received 3 different ways to attack the problem. He finally went to the VA Doctor and asked his opinion on all the different ideas. The VA Doctor simplfied everything and told him this. It is basically the same as baking Bread, you have 3 different Bakers trying to get the same results. They use similiar ingredients for the same results of a finished loaf of bread.

    Our Doctors try to get the same results, a clean bill of health for us. I know that I was given 3 options by my Surgeon.

    My Best to You and Everyone Here
  • RogerRN43
    RogerRN43 Member Posts: 185
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    Mixed thoughts, tough decision
    If it wasn't for her chemo first, latest research says neck dissection without any prior treatment runs the risk of cell spillage so chemorad first is the standard these days, however, she did get three rounds already. Looking at it another way, rad encompasses what can't be seen and getting rad earlier forgoing the surgery shortens the window of cancer cells adapting in any way so that they are all killed by the sole chemorad approach.

    What was explained to me was the affected node(s) die from the inside out with rad, they eventually implode and dissolve, sometimes leaving scar tissue. If still present after and more suspicious than not, they are dissected. A neck dissection has it's own inherent risks and sometimes longterm effects. I would weigh this in her decision to have one prior to IMRT. Her ENT did say prognosis is better if she had neck dissection first and it's hard to go against a professional who is up to date on scientific research. Just wondering if her ENT specializes in H&N, mine does not. I did speak with one that does and according to my own disease presentation, he agreed that he would follow the same course I am following, chemorad, then neck dissection if needed.
  • MarineE5
    MarineE5 Member Posts: 1,031 Member
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    RogerRN43 said:

    Mixed thoughts, tough decision
    If it wasn't for her chemo first, latest research says neck dissection without any prior treatment runs the risk of cell spillage so chemorad first is the standard these days, however, she did get three rounds already. Looking at it another way, rad encompasses what can't be seen and getting rad earlier forgoing the surgery shortens the window of cancer cells adapting in any way so that they are all killed by the sole chemorad approach.

    What was explained to me was the affected node(s) die from the inside out with rad, they eventually implode and dissolve, sometimes leaving scar tissue. If still present after and more suspicious than not, they are dissected. A neck dissection has it's own inherent risks and sometimes longterm effects. I would weigh this in her decision to have one prior to IMRT. Her ENT did say prognosis is better if she had neck dissection first and it's hard to go against a professional who is up to date on scientific research. Just wondering if her ENT specializes in H&N, mine does not. I did speak with one that does and according to my own disease presentation, he agreed that he would follow the same course I am following, chemorad, then neck dissection if needed.

    before or after?
    I guess this is one of those issues that falls on the Doctor and Patient as to what to do.

    Many good points in this thread. I lean toward the disection before hand, verses after only because, as it was explained to me by my Surgeon. He said that he would rather operate on my neck before the Radiation because in his words, the DNA changes in our bodies after being exposed to all the Radiation. He said that the tissue would be more like wet tissue paper when he is operating and would take much longer to heal along the incisions and inside.

    I have read on here and another site the problems with healing after surgery when the person was radiated first. There is no right and wrong way as long as the results are the same, survival. The side effects may vary.

    As my Dad would have said many times, why do you think they call it a "Practice". He wasn't one much for Doctors and said they are still practicing on us. My wife says I have a DNA problem, you Don't No Anything. : )

    My Best to Everyone Here
  • nwasen
    nwasen Member Posts: 235 Member
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    MarineE5 said:

    before or after?
    I guess this is one of those issues that falls on the Doctor and Patient as to what to do.

    Many good points in this thread. I lean toward the disection before hand, verses after only because, as it was explained to me by my Surgeon. He said that he would rather operate on my neck before the Radiation because in his words, the DNA changes in our bodies after being exposed to all the Radiation. He said that the tissue would be more like wet tissue paper when he is operating and would take much longer to heal along the incisions and inside.

    I have read on here and another site the problems with healing after surgery when the person was radiated first. There is no right and wrong way as long as the results are the same, survival. The side effects may vary.

    As my Dad would have said many times, why do you think they call it a "Practice". He wasn't one much for Doctors and said they are still practicing on us. My wife says I have a DNA problem, you Don't No Anything. : )

    My Best to Everyone Here

    Doctors
    I asked my two docs why the first doc recommended the surgery and their reply was well he is a surgeon. After turning down surgery, I did see him after treatments were over when I went back for my first PET. I was curious as to how he would treat me since I opted not to use his services. He was super kind and very happy that I was doing so well and gave me a big hug.
    I did have issues with the after effects of radiation but stretches and electrode therapy have dissolved most of the scar tissue. I still have some on my tongue and was told that will more than likely never go away.
    My new normal is very livable. I have a small amount of dry mouth when I first get up in the morning and that is about it.
    It is a big decision to make; listen to your gut and if you feel comfortable with a certain doc, go for it!
    peace, Nancy
  • Goalie
    Goalie Member Posts: 184
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    nwasen said:

    Doctors
    I asked my two docs why the first doc recommended the surgery and their reply was well he is a surgeon. After turning down surgery, I did see him after treatments were over when I went back for my first PET. I was curious as to how he would treat me since I opted not to use his services. He was super kind and very happy that I was doing so well and gave me a big hug.
    I did have issues with the after effects of radiation but stretches and electrode therapy have dissolved most of the scar tissue. I still have some on my tongue and was told that will more than likely never go away.
    My new normal is very livable. I have a small amount of dry mouth when I first get up in the morning and that is about it.
    It is a big decision to make; listen to your gut and if you feel comfortable with a certain doc, go for it!
    peace, Nancy

    and biopsies
    is the other reason why they did it after I was done with rads and chemo. Yes, he waited until the skin had healed pretty well (two months) and took out the 26 lymph nodes on the known cancer side. They were able to biopsy them and found that the known one - which was still a pretty good sized mass - was just dead tumor and that the other 25 were never bad. Sure, it would have been nice to be able to put those "good" ones back or not to have taken them in the first place, but you don't know until you know for sure, and this assurance was definitely worth the pain and bother of the surgery ... to me, anyway. I would always have wondered otherwise.

    BTW, my new picture is me a year ago at Thanksgiving. I was 40 pounds lighter and was not allowed anything other than that glass of Boost+ because of my lingering propensity to return my food whence it came. The wine and beer were also not for me, alas.