iowagirl

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  • in reply to: First scan #94308
    iowagirl
    Member

    Kim,

    By any chance, was Rich given Prednisone back when he had that crud 4 years ago.? The reason I ask is that it was Prednisone that set off my type II diabetes. There’s a tiny little line at the end of the warning pages for side effects. It simply says that sometimes the use of prednisone can cause diabetes insipidus which usually goes away when the drug is discontiinued. However, sometimes it does not and instead changes to diabetes mellitus .

    Yup…..I had a doctor in training also…..but I think it was close to the start of his fellowship and he was covering everything he could think of as I’m sure they are scrutinized by their overseeing staff doctor very closely in the beginning. So, that’s why he took so long. Plus they were still trying to diagnose what was wrong with me even though the local oncologist at the time had already diagnosed it as ICC. I had the trainee for two years and really liked him after he seemed to settle into things and was really upset when he graduated the fellowship. I hated the next guy they assigned to me and we eventually pushed for and got another oncologist. Visits with other doctors up there at Mayo were more like 45 minutes. One appt went over that time period and the doctor mentioned that he had to “move on” to the next appt. So, apparently 45 min is about what they usually allot. Back in 1979, I went up there and spoke with a top notch surgeon about a problem I had…..he was listed in a book for one of the two top gynecological surgeons in the world. He spent about 4 hours talking with us the first day…..and I became aware that he had actually memorized my home doctor’s file , which was about 3 inches thick. Wow!!! I’d like to think there are still doctors around like him.

    As for Dr. Zenk in Dubuque. I would just call and see if he is still there or not. I believe he was part time and thus, may not have had a picture up on the wall. Let me know what you find out if you call.

    I’m much better today. Stomach really didn’t feel good last night even when I went to bed. I tried a Tums, but that did nothing. This morning, I felt the same as soon as I woke up…..got dressed and then it hit…..the dry heaving. Through the Gem/Cis, I never actually vomited…just dry heaves…a LOT. And….yes, the nausea would hit about three-four days after the infusion, though the dry heaving would be right after I’d get out of the shower or before I went to bed at night. This morning, once I dry heaved (and it wasn’t as violent as it has been in the past) then I was just fine. The awful feeling in my stomach went away and I’ve been okay the rest of the day. That is how it has always seemed to go in the past as well…….stomach is gnarly until the heaving happens and then, poof, it’s like nothing is wrong again.

    So…..next week, I should be getting back to normal (I have the drug infusion every day this week). My husband is having surgery on Monday, but he should be doing better in a few days….having a nodule removed from the back of his tongue. They said sore for a few days….or not even that. Where is your husband in his current round…..day one….day eight?

    Julie

    in reply to: First scan #94306
    iowagirl
    Member

    I’m going through a chemo week for this other cancer, so bear with me. I’ll try to answer your questions and make a couple comments.

    The doctor in Dubuque is in the same practice where you are right now (IF he is still there……though it’s only been two months since I spoke with the receptionisht there). His name is Dr David Zenk 563-582-1881 (I think that is the right number)…..at 1500 Delhi St. His name does not appear on the website but obviously I had spoken to a receptionist who confirmed that he was working there early January. I never did meet him personally to see what his personality was. I was interested in the fact that he had graduated with honors from MED school and had some Mayo training.

    Diabetes and Blood Sugar: I have been type two diabetic since 2002. I discovered in reading that blood sugar lows sometimes occur with liver cancer and an unexplainable blood sugar low is a sign of liver cancer. I had the experience myself…..with a low of about 40 something. It took a LOT of sugar and time to get the number up to 88. Six McDonald choc chip cookies and two large glasses of OJ later ….I hit that 88 number and it stayed there for quite a long time. That was a Friday. My tumor was found the following Tuesday.

    As for the steroids …yes, they do increase blood sugar…..but only for a couple days or so around the time it’s given. Mine would often climb up to 300-450 during that time. Normal amounts of insulin wouldn’t bring it down either. With your husband’s tumor still there and obviously affecting the liver’s production of glucose output, it makes some sense that the steroid wouldn’t have as much of an effect as it normally would. The effects of the tumor on your husbands are counterbalancing the effects of the steroid apparently.

    My GP confirmed the above when I mentioned it to her.

    When I went to Mayo the first time, they did not run any additional tests of their own either. We met with an oncologist fellow and then his supervising oncologist for about 3 and a half hours and then waited until 4:30 to meet with a surgical consult. I was in surgery the next day before noon.

    It seems that the oncologists are often only pushing chemo. The last time I had a recurrence, the oncologist at Mayo did not even call in a surgical consult….just immediately said I needed to do chemo. On the way home, we realized that we both were suspicious that he hadn’t called a surgeon for a consult. So, I called my previous surgeon there, made an appt directly with him. He looked at things and told us that it was indeed operable, but he recommended having a microwave ablation instead due to the location and size. He also said that the other place the radiologist was so “concerned” about, did not look like cancer to him. (there were two locations , one in each lobe, that were of “concern”). That second location was along the resection line of the first and second operations I had. He said he could be wrong, but he knew what he’d done “in there” …used some sort of material that is left in to control bleeding….and he felt the scan images of concern were due to healing from that. He checked size from the previous scan….and lo and behold, it was actually smaller on the later scan. Uh…..hello…cancer grows. When the IR guys did an ultrasound, they looked at it and two of them both said it did not look like cancer to them either. Two radiologists reading the two scans……the first…..no concern…..but the second was sounding the warning. They make mistakes, but they don’t want to miss anything either. It’s up to the oncologist to figure out the best way to proceed. In the end, I had one confirmed tumor….it was classic shape and characteristics and it was ablated. Moral of the story…..question EVERYthing no matter how much of a big shot the doctor is.

    lI’m glad to hear that you have reached out to Dr. Fong so quickly. If he was willing to have you send the scans etc to him, then that saves a lot of time and travel.

    If you are interested……the drive to Cedar Rapids, as you probably know, is about and hour and a half…not too bad and HWY 151 a really good road now with the 4-lane. My new doctor here is Dr. Jenigiri and he really does seem to be compassionate and has plans in case the CC comes back again or the times comes with the drug I’m getting for the MDS (Myleodysplastic Syndrome) stops working . He is thinking ahead. My previous onc had pretty much written me off. On Dr. J’s bio it says that he has previously won a “compassionate doctor of the year” award, though I don’t know what organization that was through, but it gives some indication as to his personality, I was hoping he was a combination of compassionate and forward thinking and I believe that’s what he is. At the very first meeting, he mentioned getting “another” Foundation I test if the CC returns again. He works at the PCI building in CR…..Dr. Bharat Jenigirl, hematology and oncology phone 319-397-2900. He would be an excellent “local” doctor for your husband.

    Glad to hear that you’ve heard back from MD Anderson as well.

    I still do not understand why there is a refusal to operate when the lung nodules are unconfirmed as cancer and there is disagreement between radiologist. Concerning for cancer mets and BEING cancer mets are two different things. The liver tumor doesn’t sound “that large” ….mine was 5 cm….not that much different and if it isn’t wrapped around or too close to any arteries….it should be operable. I know of people personally who have had far larger tumors resected and I “think” I remember several who have been on here who have had resections with lung nodules. Marion…..can you confirm that?

    Must go….not feeling 100% tonight. Any other question you have…..I can give you what I know from personal experience anyway. And….if you and your husband would like to meet sometime…..my hubby, Allen, said that he was willing to drive up there. YOu’re VERY close to Petosi, WI, where his favorite beer is made. LOLOL He got a little more interested when he saw that on the map. LOLOLOLOL

    Julie

    in reply to: First scan #94300
    iowagirl
    Member

    My experience with Mayo concerning tumor biopsy testing for mutations: They went ahead and tested for 3 mutations on their own without discussing it with me. It took three weeks to get the results. From the discussions we had, it appeared that they only tested for mutations for which they had a clinical trial at Mayo for which I might be a fit. When all three came back negative for any three of the genes being mutated, I insisted that they send the sample to Foundation One to be tested. I still wonder to this day whether they asked for the fullest testing available. I have mentioned trials to them in other locations and they don’t seem to know anything about them. But, I think this may be the case across the board when it comes to hospitals. They seem to become very narrowly focused. Many CC patients have to look for their own trials by themselves unless the hospital happens to have one that fits your circumstance.

    My situation now is complicated by the fact that I have now developed another cancer (MDS-a blood cancer) which is also being managed by Mayo (and my home oncologist doing the treatments prescribed by Mayo). If my CC comes back (I am currently NED (no evidence of disease), but it is comes back again, there will be hard choices. Without the MDS, I would not hesitate to go to MD ANDERSON in Houston, and still would strongly consider it, but with the MDS it would make the whole situation far more difficult. However…….nothing is impossible maybe. :)

    I wouldn’t hesitate for a moment going down to MD ANDERSON if and when the time is right for you. I understand about what you said about being in a very rural area. I came from such an area and even where I now live, I’ve often had serious doubts about the quality of health care. I’m in eastern Iowa and Mayo is fortunately only 3 hours from me, which makes it hard to justify going the extra distance to MD Anderson, or out to Seattle for my MDS, but it is what we’ll do if and when we have to do it if Mayo has nothing to offer.

    YOU have a HUGE reason,. that 11 year old, for doing everything you can to push for the best medical care that you can get and to push the envelope if you must to get the medical care your husband needs and deserves. Marion was spot on that most all trials require that you be on chemo first before it either starts failing or you can’t tolerate it any longer before trials will accept you. But, I would demand that a full mutation analysis be done through Foundation One so that you know if there are any mutations that are actionable. Some doctors might prefer that a biopsy be done after the chemo stops working, if the tumor is still big enough to get a biopsy because it seems that after chemo, new mutations can show up. My current local oncologist has told me that if my CC comes back again, he would order a new Foundation one study on a biopsy of the new tumor (if it isn’t operable) However your local doctor doesn’t even sound like he’s interested in pursing anything. It doesn’t sound like maybe he is up to date on mutation testing and the current state of immune therapy or the increasing survival times of many CC patients.

    One note about DNA gene mutation testing. I was told by someone before I had it done, that if insurance does not pay for it, or all of it, Foundation One does not pursue the collection of the balance, for whatever reason. I had it done last August and insurance didn’t cover anything and to this day, I have never received a bill. So, I’m assuming that must have been true. It seems a bit odd, but maybe there is research involved? The quoted price is about $5000 for the testing.

    When you live further away from the “big guns”, and have a less than stellar local oncologist…..or even less than enthusiastic “big gun” oncologist at a center of excellence hospital….you have to take the bull by the horns and search for more optimistic and forward thinking doctors. It takes a lot of time….and the travel can be so daunting, but when you find the right doctor, it would be worth it.

    I know right now, everything seems to grim and it doesn’t help that your local onc sounds like a negative Nellie. There are doctors (and other people) who can give you the facts….and then there are those who give you the facts while explaining that they aren’t giving up on you. I had to fire my first oncologist here at home because she was so abrupt and cruel. It was scary to change oncologists, but I’m here to tell you that it was the best thing I’ve done through all of this mess.

    I’ve been there…..we all have…..those first 6 months after diagnosis, you feel lost in a wash of letters that stand for something, but you can’t remember what, differing opinions, terminology that is foreign, way too many doctor appointments, anxiety over testing, anxiety over the “what ifs”, …..and on and on.

    I also had/have nodules in my lungs, which at first they though were cancer, but they did surgery anyway to remove a 5 cm tumor. The first Mayo oncologist I saw, was fixated on those lung nodules first being mesothelioma with a met to the liver and then maybe ICC with a met to the lungs. The supervising oncologist then came in, reviewed things in about 10 minutes, asked me a few questions and then asked, “What does your doctor at home think this is?” I was a little surprised. I answered ICC and this onc said, “I do too.” I asked what about the lung nodules and she felt they were garden variety nodules….nothing to get excited about. The nodules never changed in size, so now , three years later, they no longer think they are cancerous. I’ve had two recurrences, each dealt with, and now new nodules have shown up in my lungs….again very tiny little things….and this time, they said that since the first ones they saw weren’t anything, that these probably aren’t either. Of course, now I worry again (the worry never goes away). The first ones did not light up in my PET scan done when I was first being diagnosed . Have they done a PET scan on your husband yet? It seems that might answer the question about those unless there’s some reason they wouldn’t light up the scan. Marion?….do you know the answer to that? Anyway, not all lung nodules are cancerous. As your husband has additional scans, it would be helpful to see if they grow at all or shrink.

    Once you have a plan in place and are comfortable with it, things will smooth out. But for now, this is all so new and horribly frightening that it seems like you’re in a pit falling deeper and deeper. That won’t last forever. I wish that your local guy seemed more interested in fighting this with you guys…someone who was a bit more positive and compassionate…..as that would help considerably. I don’t know where in Wisconsin you are, but is there a chance you could switch to another doctor in the area. When I switched doctors, I interviewed him first. Actually, he told me HIS philosophy before I had a chance to ask questions…….and he was spot on what I needed on a day to day basis. I don’t know how are you are from Dubuque, but there is a guy there who used to be in my city. I almost went to interview and switch to him because of his credentials. He graduated medical school with honors, got some training at Mayo, and undergrad at the U of Iowa. He may be partially retired, but he’s still in practice because I had called the office in Dubuque. I honestly don’t know what he’s like in person, but it might be worth talking with him if you are close enough. Heck, if he thought you needed more than what he can offer (depending on if he is semi-retired), you might ask for a referral to someone he knows who is more forward thinking.)

    Chicago may be a good choice for you for somewhere not quite so far away. There is a Dr. Fong there who used to be at the Cleveland Clinic in Ohio. Everything I’ve heard about him is excellent……top notch doctor. It might be worth having your files sent to him for another opinion, though if you can manage it, and they will set it up, I always think in person is best, so they talk to you face to face. If you’re interested, I would try to find out exactly where Dr. Fong is ….what hospital, etc for you.. At MD Anderson, the guy to see seems to be Dr. Javle.

    There are plenty of examples of people who have frequented these boards who are considered stage 4….and have been given short times to live, but 3-6 years+ later, they’re still around. For most of those, CC has turned into a chronic disease that is managed by changing treatments, different trials, some which work and some which don’t. But they’re still here and have lived to see the milestones of their kids’ lives. It’s not easy….but it’s the way it is. AND…..if you get lucky and have a mutation that has a targeted treatment, esp like one for which Keytruda or Opdivo might be used, your husband might be one of the very fortunate for whom the cancer goes away. Look for the posts of Matt Reidy who found he had MSI (microsatelitte instability), His doctor ordered Keytruda off label, Merck gave him the drug for free, and he’s currently NED. Another lady who did a trial out in California had the same results. That molecular testing is very important.

    Would you mind sharing who you met with at Mayo? Did they call in a surgeon for a consult with you? Also, do you know the size of the liver tumor? Is it a single tumor or multiple ones? It kind of sounded like one big tumor, but I just wanted to be sure. Is the tumor wrapped around one of the arteries? Or….what makes it inoperable? If the tumor is so large that it would require too much of the liver to be removed to get it all out, then maybe the Gem/Cis enough to allow surgery. Sometimes surgeons say no to surgery and say it isn’t possible, because they don’t have the expertise, but another surgeon says yes.

    I just looked up where you live…..Cuba City. You are only about 1 and a half hours from us here in the Cedar Rapids, Iowa area. Perhaps we could get together sometime to chat and relax? I’m sure I could convince my husband to go for a day trip on one of my off chemo weeks. :) Just being around someone who is going through what you are…..someone who gets it……can be very helpful. I’ve met several other CC patients in person from these boards and each time, it’s overwhelmingly positive. I feel like I can relax with them and say anything and they won’t judge or assume anything.

    This has been long, but I hope that you can glean some tidbits. Marion is a wealth of knowledge and when it comes to that technical stuff, she’s your go-to gal. She’s also so compassionate as are many others here on the boards….some patients…some caregivers.

    Hang in there…… We’re all here for you.

    Julie (Marion, Iowa)

    in reply to: Chemo caused MDS: Update #94348
    iowagirl
    Member

    Marion, Lainy and Positivity,

    Thank you for your kind and uplifting words. It’s nice to have been missed, but wish it was for something more fun than the MDS.

    I waited to respond because I started the next round (round 4) of VIDAZA today (I get the infusion every day for 5 days in a row and then 3 weeks off), and I wanted to see what the new blood counts were so I could relay them to you all. Of course, I was hoping for improvement.

    Well, improvement came in 2 our of the 3 main blood cell lines. I was disappointed that the white cells went down again, but they didn’t totally tank, so I’m hoping that they will be better in another month.

    The Platelets went from 209K a week ago to 230K today on a scale of 130K to 450K)

    The Hemoglobin went from 11.2 a week ago to 11.6 a week ago (12 is the bottom end of normal)

    The white blood cells went from 3.94 down to 3.24. (4.5 is the bottom end of normal). It wasn’t a horrible drop, but definitely the wrong direction. Still must be careful about any infections…lots of hand washing.

    Tomorrow or Wednesday, I am supposed to call Mayo to set up whatever they want me to have for tests when I go up there and exactly when that will be. Originally, I was to call just before I started round 4 and it would be for a bone marrow biopsy, but now I don’t know exactly what it is that they want.

    The good news is that the platelets continue to climb and the hemoglobin appears to be now climbing on its own without benefit of a transfusion or the Procrit shot. That’s two out of three…..and appears to be a “partial” remission thus far for hemoglobin and platelets and those white cells are “trying”. They bottomed out after hanging in there until the last round which I assume indicates the VIDAZA was killing off the bad white cells that are abnormal. Now, it seems that it’s a tug of war between the abnormal cells and new good ones. Keeping my fingers crossed the good guys win.

    On another subject. Back when I was having chemo after the first ICC surgery, I had a horrible time with a port that was apparently very badly put in place by an IR guy. It wasn’t unusual for up to 8 needle pokes before the chemo nurses (often two of them working to get it in) could successfully access the port. I never allowed the blood labs to be drawn from the port in case something was too low or high to allow for chemo…..it was that awful. Each insertion was very painful., even with the lidocaine cream. I had that port taken out the Monday after chemo was done and said if I ever needed another one, then I’d get a new one….but was not keeping that first one and have to have it accessed monthly to keep it open. NO WAY!

    Well, I was advised to get another port for the VIDAZA infusions, since there’d be a lot of them and we could keep it accessed for the week of treatments, so only one access with the needle unless I needed transfusion on an off VIDAZA week. It was the best thing I ever did. The new IT doctor (I refused to allow the first one touch me again) spent a lot of time working to put it in in such a way that it wasn’t too deep, wouldn’t move around or flip inside. I had one nurse have a problem accessing and frankly,something made uneasy about her to start. She tried once and then called in another nurse who got it immediately. The two times I’ve had it accessed at my new local oncology office, I barely noticed the nurse inserting the needle. They have one nurse who apparently only inserts needles in ports. She didn’t feel around for 10 min trying to decide where the port was…just touched it once and put the needle in. NO PAIN!!! I’m now to the point where I feel that it’s going to be okay in the future. For the first couple months I had the new port, each time, I would start to cry before they even cleaned the area….I had had such horrible experiences the first time and it’s all I could think about. What a difference.!!!

    in reply to: Chemo caused MDS: Update #94344
    iowagirl
    Member

    Thank you , Deb. The last 6 months have been a nightmare, worse than when I was diagnosed with ICC, and to think part of the treatment for the ICC post resection caused all of this. I’m hoping to be back on the boards more often again as time goes forward now that I feel better. My time is divided though between these boards and the MDS boards now. I’m kind of in a minority over there as well, so …..like I don’t really belong because there is no treatment for me past what I’m doing. I’m kind of the “cousin nobody wants to play with.” :( But, I still learn some things there at the MDS site and watch for new things. They have to really speed them up in trials though or I won’t get a chance to use any of them.

    Meanwhile…..enjoying those two little grandsons so much and fielding such questions from the 5 year old as, “Grammy, if I died and went to heaven, would I come back to earth as another baby?” or “So, how does heaven work?”. It actually got a LOT deeper than that. That child is an “old soul!” But, I feel good that he is comfortable to ask me…..just glad the lights were dimmed before bed not to see my tears.

    Julie

    in reply to: Sean Bellefontaine – Please Take a Look Here Everyone #94036
    iowagirl
    Member

    Michael, I’m so sorry to hear of your father’s passing from this awful cancer so many of us are fighting. Julie T.

    in reply to: GI ASCO 2017 #94007
    iowagirl
    Member

    Thank you ladies for attending the conference and Marion for the summary. I’m wondering if this is the same conference that my Mayo oncologist attended recently (would think so).

    Julie

    in reply to: brief history #51234
    iowagirl
    Member

    MCE…….Savor every moment together. Lift each other up. You and Richard have been through so much and it’s totally understandable that you’d want more time. In the end, that is what we all want ….simply, more time. Prayers for you both.

    Julie

    in reply to: inoperable, but clean scan at 15 months (now 39 months) #86218
    iowagirl
    Member

    Absolutely phenomenal news, Catherine. While your mom is not the norm for CC, she is absolutely proof of hope and what might be available to others if they push for more. Prayers for both your mom and dad and your also to the rest of your family as your dad comes to the end of his fight with lung cancer. My love to you alll.

    Julie

    in reply to: 3 years since diagnosis #94011
    iowagirl
    Member

    Thanks Marion. I decided that it was time to post as a “survivor” of ICC. Even though the MDS has me in its grips right now, it doesn’t diminish the three years since my ICC diagnosis.

    Catherine, yes, one thing at a time…..at least that was my hope and prayerss. Withouut the ICC to deal with, I can concentrate on what I need to do for the MDS and hope for a remission for now……..and in the meantime maybe some new treatment will come along.

    Julie

    iowagirl
    Member

    Ali,

    In August, I underwent a microwave ablation of a 1.5 cm tumor in my my liver lobe. It was operable, however, my surgeon suggested the IR ablation route to destroy it because the location was deeper in the liver than my past tumors and as such, he’d have to destroy more liver in a surgery than the IR guys doing in an ablation. So, he referred me to IR and I had a successful ablation.

    Previously, I’d had a resection of a 5 cm tumor in my left lobe (original diagnosis) and then a surgery of the same area where the tumor started to regrow 22 months later. Both surgeries were laproscopic. The first was followed by 6 rounds of Gem/Cix, but obviously, that didn’t stop recurrences and I’m now battling and getting treatment for Myleodisplastic Syndrome, (MDS) basically, bone marrow failure caused by the chemo.

    I’m a total believer in the ablation route to get rid of a tumor if at all possible. While there are constraints ……..they are now doing bigger tumors with ablation.

    Julie

    in reply to: In Rememberence of My Beautiful Husband #93866
    iowagirl
    Member

    I’m so sorry, Lynn.

    in reply to: Blood counts dropping/Hospital/transfusions #93554
    iowagirl
    Member

    Blood counts today:

    Hemoglobin at 7.4
    Platelets at 11,000 (11K)
    White blood cells at 7 (holding in the middle of nomral)

    Got a transfusion of platelets this afternoon and go back next Monday for another set of blood counts. I imagine the Hemoglobin will be ready for a transfusion then as well. Just hoping that the white blood cells at least stay stable. This is scary stuff.

    Julie

    in reply to: Hearing Loss Due to Cisplatin #93761
    iowagirl
    Member

    Melinda,

    yes……your last statement is what I voiced to my doctor. It’s a tradeoff and I can live with it, as you said . Julie

    in reply to: Blood counts dropping/Hospital/transfusions #93552
    iowagirl
    Member

    Janet,

    Hair: I was told by two oncologists, two different things. One said that my hair would “slightly thin” and the other said it would all fall out, but only the scalp hair. Both were wrong. I ended up with several strands (and I do mean strands) of hair on my hair that my hairdresser trimmed off very short to be the same length as the new hair coming back in. I lost all my eyelashes, hair under my arms, on my arms, most of my eyebrows (a couple individual hairs on each side), and all the hair where the sun doesn’t shine. The hair all eventually grew back……the hair on my head “maybe” a bit thicker, but not much….and it was the same, very fine, thin hair as ever. Couldn’t even get a break on that…..was hoping for a throw back to my mom’s coarser, thicker and wavy hair. No such luck. It started regrowing even before the actual end of the 6 rounds of chemo, but I did take a week off between the 5th and 6th rounds, so maybe that is why. I had a wig or two…..and used them sometimes, but hated them as they did not fit my head shape…..no wig will….they slip up in the back on me. Hats and scarves do the same things, so you can imagine they weren’t an optimal choice either. I sometimes wore a winter hat even at home inside because it was winter and I was just “cold” because of lack of hair. If I were to go through that again (I won’t be….but IF), I’d screw the wigs and just go the way my head was…naked.

    SIck: Yes, I was sick. I had dry heaving every morning and nausea usually every afternoon or more. I slept a LOT. It seems that I must have run a temp also sometimes, but I’m not 100% on that part anymore because it was 2 and a half years ago.

    Julie

Viewing 15 posts - 46 through 60 (of 851 total)