CHAPTER THIRTEEN

How to make a percutaneous ethanol injection cocktail

March 28, 2011 was a Monday. On that day, I celebrated my forty-second birthday by undergoing an MRI and receiving a diagnosis of liver cancer; I wondered if I’d have a forty-third birthday. I had also had a CT scan that day—it was like icing on the cake.

Actually, the day started off with a cupcake. Camille, my remaining roommate, had put a little frosted red velvet cupcake on the table with a candle on it for me. It was a sweet gesture, even if she spelled my name Jack. She still called me Jack, now and then, after months of us living together. I didn’t mind. Maybe there weren’t many Jakes in France.

As I packed my bag and looked for my suit that morning before going to the clinic, I felt a strange sense that the year had gone astray. This wasn’t the year I had planned. Had I wound up in the wrong universe?

The year had started well. In 2011, I was still enjoying the fruits of Tokyo Vice being published. I spoke at universities. I spoke to investment bankers—for a fee. I traveled back and forth between the United States and Japan often. I even went to San Francisco to see Michiel. She was happily enrolled at the University of Monterey. She was in remission. It looked like leukemia had lost the battle with her, although I knew I shouldn’t use that metaphor; it always seemed like a stupid thing to say. Cancer isn’t intelligent, and it’s not an opponent.

Michiel and I had a great time while I was visiting; it was like the good old days. We had a wonderful evening at the San Francisco Night Museum. There was music, booze, and access to the aquarium. Michiel and I danced at a little mock disco. At the aquarium, she did a hilarious impersonation of Ariel from The Little Mermaid drowning to death, which was probably in poor taste, but amusing to me at the time. We all sang a few verses of “Under the Sea” together.

But, as my father had told me, nobody is lucky forever.

In February 2011, after I had been in Japan for a few weeks, Michiel wrote to me: “Jake, you’ll never guess what? Actually, you’ll probably guess. The leukemia is back. I may have to return to Japan, because insurance may not cover it all this time.”

She seemed chipper in writing, but when we talked on the phone, I felt a tinge of despair. I assured her it would all be good. She was a survivor.

“Hey, you’ll always have a job with me,” I told her. “Think of it as a great chance to get back to work and earn some serious due diligence money.”

The due diligence business was still good. The Lehman Shock had wiped it out, but, by 2011, people were investing in Japan again. There was plenty of work for me to do. Plenty of work to share with Michiel. Except she would be in the hospital.

In February, I didn’t think I’d also be spending a lot of time in the hospital myself.

So there I was, at 6.00 pm, on my birthday, on the table in a dimly lit room of a very fancy clinic, listening to three doctors discuss the best possible way to remove the 3.6-centimeter tumor from my liver. It was close to a major artery, almost poking out, so they felt that the sooner they could keep it from going mainstream, the better the chances that it might not metastasize—if that wasn’t already the case. As often happens in Japan, none of them seemed to be aware that I spoke and understood Japanese.

I didn’t go out of my way to make them understand that I understood Japanese perfectly. I wanted to know the unvarnished truth. Japanese doctors used to never tell patients they had cancer. They had reasons. Doctors feared that if you told a patient the truth, they’d kill themselves out of despair—even though treatment might be possible. They worried that the word gan (cancer) itself would rob the patient of all hope. And, oddly, the families were told before the patient. That had been the case with my father-in-law, but I wasn’t my father-in-law. I wanted to know exactly what was going on and what my options were. So from the moment I walked into the clinic, after making an appointment days in advance, I had more or less kept my mouth shut and made every effort to only speak in English.

It had been a long morning. Many decisions had to be made.

How does one dress for a visit to a doctor when you’re reasonably expecting a terrifying diagnosis? I decided to go with a dark suit, plain white oxford, and blue necktie. Japan is still a country where wearing a suit means people take you seriously, or that you’re socially aware enough to know that donning a suit and tie means you’re aware of the gravity of the situation. The act of putting on the suit, buttoning the shirt up, and pulling a well-made noose around my neck made me feel like I was somehow in control.

There are many ways to tie a necktie; I only knew the Oriental Knot. The name of the method to do this has probably been changed to something less archaic, but it’s the simplest way. You start with the reverse side out, and the wide blade of the tie is lower than the narrow blade. Pass the wide blade under the narrow blade, loop it up, pass the intersection. You pull the wide blade down through the slipknot, and adjust accordingly.

Most of the time, I can only do it right if I don’t think about it. I was about to leave the house when I looked in the hall mirror and realized that my tie was a strange gift from my time at the Yomiuri Shimbun, with a Yomiuri Giants logo built subtly into the pattern; you could see it if you really looked and the light refracted off it. I thought about changing ties, but it was too late. I was going to carry my past around my neck anyway.

All of Tokyo had decided to conserve energy after the nuclear disaster—and maybe we all believed that with a few nuclear reactors offline, we’d run out of power. For reasons that I never understood, everything was kept dark. When I got out of the elevator on the clinic floor, it appeared to be shut down. There was no one in the immediate reception area; no one waiting for an appointment. The vending machine in the corner of the foyer in front of the clinic was the only thing emitting light. Had I turned up at the wrong place?

As I stepped into the reception area, the motion sensors turned on one of the lights, illuminating a woman behind the counter in a classic nurse’s uniform with even a hat on. The only nod to modern fashion was the blue sweater over her uniform. She said my name.

“Adelstein-san, we’ve been expecting you.”

The facility was empty. As we passed down the hallway, lights went on and off on our way to the room where the doctors were waiting for me. I could hear my footsteps, the clack of the nurse’s high heels, and the click of the lights turning on and off.

It had been weeks since the Fukushima reactors had exploded, and the Japanese press and the government were still refusing to acknowledge that there had been a nuclear meltdown. I understood the decision made by people who decided to flee Japan or get out of Tokyo. I never really saw that as a choice, but maybe I would have considered getting out had the situation been different.

When I opened the door to the examination room, there were three doctors waiting for me. I guess that was lucky. There were no other patients at that hour, or maybe even that day, and so with time on their hands they were there to greet me. There was a senior doctor with a white beard and a lot of pomade in his black-and-white hair. There was a middle-aged doctor with short hair who was wearing a polo shirt underneath his open lab coat, and who looked like he had spent a lot of time at the gym. The young doctor was tall and thin, and had square wire-frame glasses and a faux Beatles haircut. Quite a crew. The middle-aged doctor, perhaps only a few years older than myself, greeted me in good English, and I responded. The other doctors nodded their heads.

They explained the findings so far and what they were going to do next. I went through a battery of tests.

I thought about the possible outcomes. What if I needed a new liver? Holy fucking Buddha, that would be irony for you. What would I do? I was a poor candidate for a liver transplant, and I wasn’t a politically connected and wealthy gangster. Could I blackmail Goto’s surgeon into bumping me up the list? The blackmailing-a-rich-doctor thing I was okay with, but jumping to the head of the line might mean someone more deserving of a liver would certainly die.

I thought about this, sitting in the park during the lunch break, freezing my ass off, drinking a hot can of Boss coffee and wishing I had someplace to go. The park was mostly concrete, and whatever leaves had been on the two trees in it had withered away. I was the only living thing in it.

When I got back, I was told that they had decided that I should have a CT scan to be absolutely sure it was a tumor, and I agreed.

There was a discussion of whether performing a biopsy was a good idea or not. The Elder doctor stroked his beard and said, “The AFP blood test, CT scan, and MRI all indicate HCC. The other test results are typical of HCC, and look at this thing—it’s huge.”

I wanted to ask my father what all this meant, so I took notes in my head. AFP. CT. MRI. HCC. All those years of getting drunk with cops and crooks, and mentally taking notes so I could write them down later, was coming in handy. I had it all down in my brain.

I knew what a biopsy was, of course. My father has been a pathologist for most of his career, and worked at the Ellis Fischel Cancer Hospital for a few years; he was still doing “frozen sections” when I was in college. Anyway, not doing a biopsy sounded good to me. The less surgery, the better. HCC, well, that stood for hepatocellular carcinoma. I had no idea what AFP meant.

And so I listened as they discussed all the options. The Elder thought an operation was the best plan.

The tumor still appeared to be in one place in the liver, and to be the primary tumor. A skillful surgeon could do the resectioning with minimum damage to the liver. The Younger was gung-ho on radiofrequency ablation, even though he wasn’t sure it was the thing to do for a tumor this size. The Elder was not convinced. “I don’t think that has a proven track record yet. It’s fancy, but will it get it all?”

The Jock doctor interrupted them both as they were jabbering: “Let’s do a percutaneous ethanol injection. It’s perfect. Not invasive. It’s fast, and he seems to be the perfect case. I’ve done it before, and it worked well.” He appeared very confident.

And that’s when I raised my hand and spoke in Japanese.

“The percutaneous ethanol injection thing sounds great to me—what is it?”

And at this, the Elder and Younger did a doubletake. It was the classic, “Oh, look, the dog can speak!” expression of bemusement and surprise. Andrew Morse, a reporter at The Wall Street Journal, had coined the phrase to describe the reactions he got when querying bureaucrats at the Ministry of Economy, Trade, and Industry in Japan.

The Jock doctor was not surprised; he just laughed. He switched to speaking to me in Japanese immediately.

“What we do,” he said, gently poking me where my liver was, “is inject 100 percent pure alcohol into your liver, where the tumor is. That’s ethanol. The tumor dies, but the surrounding tissue is unharmed. We take a very thin needle, we use ultrasound or something like it to guide it—and we inject the booze into your liver through the skin. It usually takes about five or six sessions.”

It seemed like a crazy idea, like homeopathic medicine. When you consider that consuming large amounts of alcohol probably was part of the reason I had liver cancer, treating it with direct injections of alcohol seemed wonderfully ironic. It wasn’t the equivalent of treating lung cancer by smoking cigarettes, but it sure sounded like it.

Amy Plambeck once told me that they treat methanol poisoning with ethanol, which is weirdly funny. One letter of the alphabet can be the difference between life and death.

I wound my head around the idea some more. In Japan, they say that sake is the all-purpose medicine, that it cures ten thousand ills. I guess if it’s taken as pure alcohol, maybe it could.

“Is it painful?”

He cocked his head. “Not normally. Your tumor is sort of surrounded by scar tissue. If it doesn’t leak out of the target area, you should feel nothing. Even if it does leak onto the surface of the liver, maybe you’ll have a fever and some pain. It certainly won’t hurt as much as surgery.”

The Elder nodded. As the Jock doctor explained a little more to me, the Younger “Let’s blast it with radio frequency” doctor made a small objection with what normally would have been huge repercussions.

“The Ministry of Health, Labor, and Welfare only allows for percutaneous ethanol injection for tumors with a diameter of less than 3 centimeters,” he said. “He doesn’t qualify for this procedure.”

At that, there was silence. A thousand things crossed my mind, but all of them boiled down to a crude realization: I’m probably fucked.

And then something extraordinary happened.

The Jock doctor pulled up the MRI, the CT, and the other files, and took a look at my file and my data. And he looked at both the other doctors and said, “Well, you know, in light of what we know now, I think we should recalibrate our findings.”

And as he typed data into my file on the computer screen in front of him, with a light touch and a clickety-clack, suddenly the diameter of my tumor was a mere 2.9 centimeters. He showed both the doctors the screen. They shrugged their shoulders, and nodded. The Elder doctor smiled and said to me, “Well, it’s just barely under the guidelines. We will need to start therapy as soon as possible. There’s a hospital we can introduce you to. Can you go there next week?”

The Jock looked at me at the same time and raised an eyebrow, as if to say, “Last chance, kiddo.”

I got it.

“Yes,” I said, “I’ve got nothing going on. Schedule me in.”

And that was that. I thanked them all profusely for their time. They asked me what I did for a living, and I told them. We talked about baseball, the nuclear accident, energy conservation, the fleeing foreigners, and the Tokyo Electric Power Company. The Younger doctor scuttled off to another room, and the Elder doctor left after him. I attempted to thank the Jock doctor for going out of his way to make sure I qualified for treatment. He seemed to sense what I was going to say. He cut me off.

“There are many ways to cure cancer,” he said. “Almost all of them work. The only problem is that in curing the cancer, the treatments usually kill the patient. I know this treatment works—and hopefully it will work for you. That’s the best-case scenario. But you can’t miss a single appointment, and you need to listen to what the doctors at the hospital tell you. Check in with me any time.”

He gave me his card. I gave him my card.

It didn’t take long for the nurse to give me the bill for the day. It was around 11,000 yen ($110) for the MRI, CT scan, bloodwork, and time spent with the doctors. Japanese public health care is amazing. I couldn’t even imagine how much that would have cost me in the United States.

I left the clinic with all my data on a CD, and my next appointment printed on my clinic card. When I got home, I copied the data and the photos, and sent them to my father for a second opinion. He agreed. Percutaneous ethanol injection was the best treatment. There was no guarantee that it would work, he said, but it was unlikely to hurt me. It was the best possible option.

After I’d read my father’s replies, I took off my necktie and hung it on the coat rack, crawled up to my room, and turned out the lights. I hadn’t done anything, and I was incredibly tired. It seemed to me that I could still feel the CT ink swishing around in my veins. I was tired, but sleep would not come.

I sat up on my futon reading a book of sayings attributed to Dōgen Zenji, the founder of Soto Zen Buddhism. I had been reading the book hoping it would help me find some of that Zen master calm and equanimity in the face of what seemed to me a rather premature death. I had marked a few passages that resonated:

All things are impermanent

What is born will also die

There is no meeting without parting

What has been gained will be lost

What has been created will be broken

Time flies past us like an arrow fired into the void

All is evanescent

Tell me—

In this world, is there …

Is there anything that is not transient?

Nope. The answer is a big fat, no. Dōgen, you make a good point.

There are many ways to enlightenment, or so I have read.

Remember the favorite of Californians, Tantric Buddhism, where you free yourself from desire through desire. That always sounded appealing—to defeat sexual desire by having lots of long, slow sex.

There was something tantric about this cure that they were offering. Think about it: they were going to cure my liver cancer by injecting alcohol into my liver.

Fight fire with fire. Fight poison with poison. I was willing to try anything at this point.

I’d spent so many years worrying about getting killed by an angry yakuza that I’d never really prepared to deal with my worst enemy: myself. But thanks to the article I’d written on my way home, I suddenly found that a great many yakuza no longer regarded me as an enemy; they regarded me as a friend. Funny how that worked out.