Physician Update - Burn, Baby, Burn
Burn, Baby, Burn
Date: September 1, 2010
With a fulminant cancer raging just below the surface in a young father's belly, Johns Hopkins brings the heat -- with HIPEC chemotherapy.
When Nita Ahuja first took her measure of the man who had an angry cancer spreading through his abdomen, she quickly proceeded to her “foot-of-the-bed” test. Could this patient handle a 14-hour operation that would peak with chemotherapy fluids flooding his belly at 107 degrees?
If anyone could do it, thought the specialist in gastrointestinal cancers, this was the guy. At 33 and a robust 205 pounds on that first visit in November 2008, Todd Painter still displayed the athletic vigor of his days as a competitive wrestler, despite having waged a bout with cancer two years earlier that had cost him most of his colon.
But after a cancer-free year, Painter’s original oncologist told him the monster was back, this time as shallow malignancies woven near the skin surface from the middle abdomen up through the torso. The gelatinous little tumors were like spring dandelions in an uncut field, “too many to count,” the oncologist said. Furthermore, Painter was at stage 4. The cancer was in his spleen, bladder, kidneys, maybe even his liver.
At Johns Hopkins, however, oncologist Luis Diaz said it was premature to surrender.
After a rapid series of work-ups, a sliver of hope emerged: A surgical intervention that deploys heated chemotherapy midway through the procedure was making headway in patients who could handle it. And Ahuja thought Painter could handle it. She scheduled his surgery for January 2009.
Ahuja and Diaz recognized Painter’s cancer as a form of peritoneal surface malignancy and that it now dominated most of the thin membrane that enshrouded his abdomen. Just by palpating his belly, they could feel the lumpy “pencil dots” that represented dozens of tumor nodules.
Hopkins oncologists like Ahuja have been advancing the surgical answers. Beginning in 2008, Ahuja and Hopkins surgeon Barish Edil linked up in an ambitious campaign to combine two key treatments. First, they would perform a wholesale surgical sweep of the afflicted peritoneum with a tactic called cytoreductive surgery, with a goal of reducing the masses by about 99 percent.
Then the team would temporarily close the patient and use large-capacity abdominal tubes to unleash a bolus of heated chemotherapy fluids into the cavity for up to 90 minutes, rocking the patient from side to side to ensure saturation of the abdominal organs. The procedure, hyperthermic intraperitoneal chemotherapy, or HIPEC, has gained a foothold in several U.S. cancer centers.
Before the operation, Ahuja told Painter that if she saw the cancer had become too extensive, they’d remove some of the bulk, close him back up and fight on from there. But if they thought they had a chance, he would get the HIPEC. In either case, Painter would probably emerge with a colostomy bag.
In the operating room, Ahuja and Edil removed Painter’s spleen, scraped tumors off the liver and pancreas, and performed a surgical purging of the abdomen’s fatty tissues, prying away every vestige of the tumors. Painter also responded well to the HIPEC and was spared the need for a colostomy bag.
“He did amazingly well,” says Ahuja, but adds that his case is not unusual: The 15 Hopkins specialists using HIPEC against a range of surface malignancies have tallied nearly 30 such cases so far, “and they’re all doing well,” she says.
Ahuja says the group has established a beachhead just within the cases that stem from colon cancers. Of the 150,000 colon cancers discovered in the United States annually, she says, about 10,000 take on this peritoneal character.
The group is now planning to extend their work into gastric cancers and others that afflict areas of the upper abdomen.
Their typical patients, says Ahuja, “are people who are very sick and don’t have a lot of options.” Though she says her group is shy of using words like cure, they occasionally are willing to declare patients like Todd Painter “free of disease.” In any case, she says, “we now have more weapons.”
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