Update of one of my posts from 2015 which was interesting in that year. This is not really about a treatment which is available everywhere but was a novel approach by one of the world’s most gifted and innovative NET surgeons.
Please note this is not a nutrition post!
One of my daily alerts brought up this very interesting article published in the Journal of Gastrointestinal Oncology in June 2015. I personally found it fascinating. Moreover, it gave me some hope that specialists are out there looking for novel treatments to help with the difficult fight against Neuroendocrine Cancer.
This is an article about something generally described as “Intra-operative Chemotherapy”, i.e. the administration of chemo during surgery. This isn’t any old article – this is written by someone who is very well-known in Neuroendocrine Cancer circles – Dr. Yi-Zarn Wang.
“I am now in Permian Basin-Odessa Midland Texas as the new Program Director of a new general surgery residency program. I have officially joined the faculty of Texas Tech University Health Sciences Center on October 1, 2021. I have privileges at TTUHSC and our two teaching hospitals. I’ve resumed seeing patients and operating. Thank you again for your unconditional support. My clinic number is 432–703–5555. Fax number 432- 335–1693. Amanda Mendoza will handle my patient appointment appointments. Her email is: amandamendoza@ttuhsc.edu. Her phone number is 432–703–5555 then choose option one. Christina Rodriguez is my nurse.”
The general idea behind this isn’t exactly new as there’s also a procedure known as HIPEC (Hyperthermic Intraperitoneal Chemotherapy) or “chemo bath”. This is mostly used intra-operatively for people with advanced appendiceal and peritoneum cancers such as Pseudomyxoma Peritonei (PMP). It normally follows extreme surgery – you can read more about this in a blog I wrote at the beginning of the year entitled “The Mother of all Surgeries”.
However. Dr Wang’s novel approach is both different and significant because it is targeted at midgut neuroendocrine tumour (NET) patients who are often diagnosed at an advanced stage with extensive mesenteric lymph node and liver metastasis. Despite extensive surgery which needs to be both aggressive and delicate, there can sometimes be small specks left behind, particularly in the mesentery area. It is possible these specks could eventually grow big enough to cause fresh metastasis or syndrome recurrence/worsening and then need further invasive treatment.
The treatment aims to eliminate potential tumour residuals in mesenteric lymph node dissection beds using a safe and local application of chemotherapy agent 5-fluorouracil (5-FU). The 5-FU is delivered via ‘intraoperative application’ of 5-FU saturated gelfoam strips secured into the mesenteric defect following the extensive lymphadenectomy. The term ‘Chinese dumplings’ is used to describe the 5-FU saturated gelfoam strips once they are in place in the treatment site. I understand from other research that they can also be used in liver surgery (anecdotal from a forum site).
The report concluded that those who were treated with the intra-operative 5-FU received less follow-up surgery than those who were not (the control group). However, it added that further studies were required to evaluate its effect on long-term survival. You can read the report in full here:
p.s. If you get time, the introduction section of this article is a very powerful explanation of the problems and challenges faced by surgeons when presented with extensive abdominal neuroendocrine disease.
Dr Wang is also noted as someone trying to reduce surgery and it’s long term side effects, particularly in small intestine NET (SI NET) patients.
He was also involved in the proposal to reduce risk in mesenteric surgery which is notorious for radical approaches or declarations of non-operability. He and others (including notable surgeons such as proposed that as with breast cancer and melanoma surgeries, SI NET patients can benefit from intraoperative lymphatic mapping using blue dye. It has been hypothesized that due to the extensive mesenteric fibrosis, the lymphatic drainage of the small bowel can be obstructed and SINETs may develop alternative lymphatic drainage paths. Wang et al preformed lymphatic mapping procedures in 112 SINET surgeries and found that this practice changed the traditional resection margins in 92% of these cases. They concluded that lymphatic mapping could help preserve intestinal length without hampering the surgical outcomes and may even improve long-term survival. To date, this practice is not standardized and further research is needed to prove its necessity.
In another study covering 10 Years’ Experience at a Tertiary Referral Centre (Imperial College Health Care NHS Trust (an ENETS Centre of Excellence)).
The challenges of small intestine primary surgery were noted, including the task of seeing primary tumours (plural) pre-operatively and/or finding them (plural) intraoperatively, lymph node clearance (locoregional and more distant) etc etc. However, they did discuss their own approach where in recent years they applied a modified approach in selected patients by starting the procedure laparoscopically, mobilising the bowel, and manually exploring the intestine after longitudinal enlargement of the port site incision for the camera and evisceration of all small bowel loops and mesentery. Cytoreduction of peritoneal carcinomatosis was applied as appropriate (peritoneal stripping and/or local electrocautery). In patients considered for liver surgery, the panel of procedures included debulking and segmental resections combined with intraoperative radiofrequency ablation (RFA). Liver resection was performed as an isolated measure or in combination with primary tumour resection. It’s interesting that their figures indicated not all patients had a right hemicolectomy but worth pointing out that not all SI NETs are located in the terminal ileum.
Dr Wang reminds me of my own surgeon, he would do surgeries no one else would do and innovation was there when necessary. He arranged for charity-funded intra-operative radiotherapy (IORT) to be provided some years ago. This is giving patients a blast of radiotherapy to nearby tissue during surgery to help get rid of cells and improve margins. I blogged about this here.
In some ways it is similar to Dr Wang’s ‘Chinese Dumpling’ approach discussed above which I guess is a form of intra-operative chemotherapy.
There is nothing normal about abdominal surgery for small intestine NETs.
Read more by clicking here or on the picture below.
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