‘Chinese Dumplings’ and Neuroendocrine Cancer

Chinese Dumpings
Chinese dumplings

One of my daily alerts brought up this very interesting article published in the Journal of Gastrointestinal Oncology last month (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.  

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 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, this 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 which will not show up on any type scan, 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 dumpings’ 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.

So…. this form of intra-operative treatment is very interesting. Incidentally there is already a form of intra-operative treatment using radiotherapy (IORT) which is a similar concept but essentially still in its infancy. However, the first IORT machine of its kind in the UK was deployed in Jun 2016.  I blogged about this here.

You can read the report in full here:

Adjuvant intraoperative post-dissectional tumor bed chemotherapy—A novel approach in treating midgut neuroendocrine tumors

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.

Thanks

The Mother of all Surgeries

surgery
Surgery

My plan for this week’s blog was to continue with a surgery theme using the story of a lady who had what was described as the “Mother of all Surgeries” after being late diagnosed with a very rare and advanced type of appendiceal cancer. With NETs, surgery is a topical subject as not everyone will be able to have it and some might not even need it. Check out my blog to cut or not to cut.

I suggested in a previous blog that Surgery is a gift that keeps on giving and that is probably true for many cancer survivors. However, I then added that NETs were one of a small number of tumours for which surgical debulking can provide some survival advantage for those with metastatic and incurable disease. In my own case, I’ve had my primary removed as part of a small intestine resection and a right hemicolectomy ‘en bloc’ – plus a bunch of mesenteric and retroperitoneal ‘stuff’. Other metastases were removed at a later date including a 66% liver resection (which included an opportunistic removal of gall bladder for treatment side effect control), 9 lymph nodes removed from my left axillary area (armpit), 5 lymph nodes removed left clavicle area and two hotspots are still under investigation.  I’m now under constant surveillance but I’m doing OK …… and I intend to outlive my Oncologist 🙂

However, my experience would appear to be fairly straightforward when you consider the types of surgery some Neuroendocrine Patients with a Pancreatic primary (pNET) have to undergo. These include the ‘Whipples’, ‘Distal Pancreatectomy or ‘Total Pancreatectomy’.  These are all long and complex operations which remove numerous organs or parts of organs – and no doubt there are variants of these for unusual scenarios.

Although there are long term side effects from my surgery, I’m gradually adjusting my lifestyle to cope (a work in progress, even after 8 years!).  This is mainly through (not too drastic) diet adjustments and nutritional level surveillance.  My other weapon is to learn as much as I can about my disease in order that I can learn how best to live with the side effects of both the cancer and the treatment. Despite the extent of my surgery (to date) and my cancer’s stage, I still consider myself fortunate to have been diagnosed earlier than the average for this disease (….sheer luck) and then had access to what some might describe as aggressive surgery shortly after.  I suspect 7 years of ‘Lanreotide’ is also playing a big part.

My experience has given me the incentive to read a lot and occasionally I come across articles about cancer patients who have been treated surgically for very unusual cancers – even less common than NET Cancer.  One which recently caught my eye was a lady who had been diagnosed with Pseudomyxoma Peritonei (PMP).  This is a very rare condition (1 in every 1,000,000) characterised by the presence of mucin-producing tumours (and the mucin) in the abdominal cavity. There are a number of possible origins of PMP, but the most common source is appendiceal (appendix) cancer.  If you’re interested in learning more, further information can be found here.

When I was drafting this blog a couple of years ago, I had been carefully watching the story unfold about the death of respected ESPN anchor Stuart Scott from an “appendiceal cancer”.

RIP Stuart Scott
RIP Stuart Scott

The media presented a confusing picture about the exact type of cancer Stuart had and some of you will have seen the debate on social media. It’s amazing how quickly and ‘assumption’ can circulate to thousands of people in a very short space of time.  I read conflicting mainsteam media articles and social media posts; some referred to the disease as ‘gastrointestinal carcinoid’ and others insisted that it was unrelated to NETs. As the dust settled, it appears his appendiceal cancer was not a Neuroendocrine Tumor.

On the same subject, many NET patients claim Audrey Hepburn was a NET Patient but this is not accurate, she had PMP.

Back to the Mother of all Surgeries story ………

I was totally amazed by the extent of the surgery the lady had to undergo and wondered how she was going to cope with the side effects.  She was clearly an extreme case and many patients are caught early on and treated accordingly. They removed her appendix, large bowel, most of her small bowel, gall bladder, spleen, womb, ovaries, fallopian tubes and cervix as well as most of her stomach lining and navel.  Her surgery was described as the “Mother of all Surgeries” and included a 90 minute ‘chemo bath’ (formally known as Hyperthermic Intraperitoneal Chemotherapy (HIPEC)). Interestingly she was originally diagnosed with IBS, a similar scenario to many NET patients. I was also struck by the similarities of some of the symptoms with those found in NET Cancer.

The UK is very well equipped to deal with PMP and HIPEC with two centres in Basingstoke and Manchester renowned worldwide as treatment centres for this rare condition.

You can read more here about this amazing story where the patient had 9 organs removed.

And another here –  “9 organs removed”

And another here – “tumour weighing one stone”

Thanks for reading

Ronny

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