Progress Provides HOPE

New surgical techniques help treat advanced-stage colon cancer.

By Jeff Samoray

When Mary Adzigian received the news in January 2008 that she had Stage IV colon cancer, she didn’t ask for her prognosis or odds for survival. Instead she and her husband moved beyond their initial feelings of disbelief and resolved to battle the disease—no matter what the odds.

“I thought, This diagnosis can’t be right; my previous colonoscopy results were fine,” says Mary, a 61-year-old resident of Grosse Pointe Woods, Michigan. “The experience was almost surreal. After some reflection my husband and I adopted a positive attitude. We have a 12-year-old daughter whom we adopted from China. She had already lost one mother. I was absolutely determined that she would not lose a second mom.”

With nine tumors on her liver and a larger tumor wrapped tightly around her colon, Mary knew instinctively that her chances of beating cancer weren’t good. Colorectal cancer is the third most commonly diagnosed cancer and the second-leading cause of cancer death in the United States, according to the Colon Cancer Alliance. As with most cancers, early diagnosis is critical for effective treatment. More than 90 percent of patients who are diagnosed when the cancer is confined to the colon or rectum survive more than five years. Unfortunately, the five-year survival rate drops to less than 10 percent when the disease spreads to distant organs, as in Mary’s case.

Mary and her husband quickly considered their options, and Mary began a treatment journey that would span three years and include a variety of therapies. Today she’s cancer-free, thanks in part to a series of traditional and newly developed surgical techniques that are successful in destroying large tumors that have spread to vital organs. Mary’s experience gives new hope to patients who are diagnosed with late-stage colon cancer.

Bringing the Heat

Because of the size and the number of tumors in Mary’s case, immediate surgery wasn’t possible. After carefully considering the case, her gastrointestinal oncologists recommended six months of aggressive chemotherapy to shrink the tumor around her colon to prevent blockage. Once the tumor shrank, they used a recently developed, advanced surgical technique called microwave ablation to eliminate the cancer in her liver.

Microwave ablation allows surgeons to destroy tumors without removing them from the patient. The technique directs high-temperature microwaves at the tumor through a small probe with pinpoint precision. The procedure, which uses temperatures at about 90 degrees Celsius, eliminates tumors quickly and can be performed laparoscopically. The speed and the efficiency of microwave ablation often mean less time in surgery, less blood loss, and less time spent under anesthesia. Surgeons can also destroy cancerous cells while leaving healthy surrounding tissue intact.

“Microwave ablation enables us to approach liver tumors in ways that weren’t previously possible due to the sensitive nature of this vascular organ,” says Madhu Prasad, MD, a surgeon at the Henry Ford Health System in Detroit. Dr. Prasad performed microwave ablation on Mary when she was treated at Barbara Ann Karmanos Cancer Institute in Detroit. “Microwave ablation is two to three times faster and more accurate than radiofrequency ablation, which is another technique that uses heat to destroy cancer cells. Microwave ablation can also eliminate larger tumors,” says Dr. Prasad.

The US Food and Drug Administration approved microwave ablation for use in early 2008. Karmanos was one of the first hospitals in the country to purchase a microwave ablation system, and Mary was one of the first patients to receive the treatment.

After performing a colon resection on Mary and removing the large tumor in that area, Dr. Prasad used microwave ablation to resection the right lobe of her liver and to destroy the two remaining tumors on the left lobe in October 2008.

“I was grateful to have the option of microwave ablation, and I had no side effects,” says Mary. “My pain was controlled very well. In fact, within a couple of days I traveled across the state to attend a family reunion.”

Freeze Formation

A CT (computed tomography) scan in December 2008 showed that Mary’s liver had become rejuvenated and there were no signs of tumors. Unfortunately, the cancer returned along the resection edge of her liver in early 2009. This time her oncologists recommended another state-of-the-art ablation technique: cryotherapy.

Unlike microwave ablation, which uses high temperatures to destroy tumors, cryotherapy works using temperatures at –40 degrees Celsius. In this minimally invasive procedure, physicians insert small needles via tubing that is connected to a liquid nitrogen or argon gas-cooling source. The needles are positioned using imaging guidance. As internal tissue becomes frozen, the physician avoids damaging healthy tissue by viewing the needle movement via ultrasound, CT, or magnetic resonance imaging. With the improvement of imaging devices and techniques to better control extreme temperatures, physicians are now applying cryotherapy to an array of tumors.

“Cryotherapy is easily visible on a CT scan, the tissues heal really well, and patients experience only minor discomfort compared with open-incision surgery,” says Peter Littrup, MD, professor of radiology, urology, and oncology at Wayne State University School of Medicine and the Karmanos Cancer Institute. Dr. Littrup pioneered cryotherapy as a technique for destroying cancer tumors, and he is working to create the next generation of cryotherapy devices. “We often discharge patients the same day. Cryotherapy is also very successful in wiping out cancer, with less than a 10 percent local recurrence rate.”

In early 2009 Dr. Littrup performed cryotherapy on Mary twice to ablate all the tumors along the resection line of her liver. A subsequent CT scan in early 2010 revealed another liver tumor, and Dr. Littrup used cryotherapy to destroy that one as well. A few months later, doctors discovered still more tumors on Mary’s left lung. Finally, after completing six months of chemotherapy in December 2010, Mary has again been declared cancer-free based on her CT and PET (positron emission tomography) scans.

“When I talk about my three years of cancer treatment, it’s almost like I’m speaking about someone else because I feel so well,” she says. “I went through an extensive series of medical and surgical treatments, but I was very grateful to have the options. I think a lot of hospitals would have seen the state of my liver and just tried to prolong my life a little bit. But my doctors didn’t follow a cookie-cutter approach. Instead they created an individualized treatment plan that helped me become cancer-free.”

Dr. Littrup says Mary’s case epitomizes the progress that has been made in improving survival rates for patients with late-stage cancers. “Without advanced surgical procedures like microwave ablation and cryotherapy, Mary would likely have faced limited control of the disease with standard chemotherapy drugs,” he says. “For her to show no evidence of disease after being diagnosed with Stage IV colon cancer is amazing. Best of all, these procedures have helped her maintain 100 percent quality of life.”

Colon Cancer Overview

From CancerConnect.com

The colon is part of the body’s digestive system and together with the rectum forms a long, muscular tube called the large intestine. The colon is the first 6 feet of the large intestine, and the rectum is the last 8 to 10 inches.

Adenocarcinoma refers to cancer that begins in the cells that line the colon or large intestine and accounts for more than 90 to 95 percent of cancers originating in the colon. Other cancers, including carcinoid tumors and leiomyosarcoma, also originate in the colon but are not referred to as colon cancer.

The treatment of colon cancer typically consists of surgery and/or chemotherapy and may involve several physicians, including a gastroenterologist, a surgeon, a medical oncologist, and other specialists. Care must be meticulously coordinated among the various treating physicians involved in managing the cancer.

Colon cancer begins in cells that line the colon. As the cells increase in number, they spread circumferentially around the colon like a napkin ring. If detected early, cancer cells may be found only in the colon. If not detected early, the cancer may invade adjacent organs and spread through the lymph and blood systems throughout the body to the liver, lungs, and other organs.

After colon cancer has been diagnosed, several tests may be performed to further classify the cancer and determine the optimal treatment strategy. Based on the stage of the cancer and the results of these tests, treatment of colon cancer is personalized for each individual. Treatment may involve surgery, chemotherapy, targeted therapy, and radiation therapy.

All treatment information concerning colon cancer is categorized and discussed by the stage.

Stage I: cancer is confined to the lining of the colon.

Stage II: cancer may penetrate the wall of the colon into the abdominal cavity or other adjacent organs but does not invade any local lymph nodes.

Stage III: cancer invades one or more local lymph nodes but has not spread to distant organs.

Stage IV: cancer has spread to distant locations in the body, which may include the liver, lungs, and bones.

Recurrent/relapsed:cancer has progressed or returned following initial treatment.

Prevention Begins with Regular Colonoscopies

Mary Adzigian maintains regular health screenings and tells her doctors when things don’t seem right. Unfortunately, nearly one in three men and women age 50 and older has never been screened for colon cancer, according to a recent nationwide poll conducted by the Colon Cancer Alliance and Quest Diagnostics. The top-three reasons respondents gave for not being screened were lack of a screening recommendation from a healthcare provider, time constraints, and fear.

“We should not be complacent about detecting colorectal cancer at an early stage,” says Philip A. Philip, MD, PhD, FRCP, professor of medicine and oncology and leader of the Multidisciplinary Gastrointestinal Program at the Karmanos Cancer Institute in Detroit. “We need to empower the public and educate healthcare practitioners about the importance of regular colonoscopies. They save lives by detecting colon polyps before they become cancerous.”

During a colonoscopy a doctor examines the entire colon and rectum using a video camera attached to a long, flexible, slender tube. The doctor can remove any suspicious tissue for biopsy by passing surgical tools through the tube. Other screening methods include fecal occult blood tests and fecal immunochemical tests, which involve drawing blood and using dye and X-rays to take a picture of the colon. The American Cancer Society recommends that men and women of average risk of colorectal cancer begin colonoscopy or another screening method at age 50.

Many people are hesitant to have a colonoscopy because of the necessary bowel preparation, which includes laxatives and fasting. But Dr. Philip says that these discomforts are short-lived. “A colonoscopy is usually completed less than 24 hours after taking the bowel preparation medication,” he says. “The procedure is done under general anesthetic and does not cause any pain.”

Researchers continue to develop new screening methods for colorectal cancer. Virtual colonoscopy uses CT images to create a three-dimensional image of the colon. This method doesn’t require instrument insertion in the colon. Standard bowel preparation is still necessary, however, and a colonoscopy must be performed to biopsy any suspicious tissue, such as polyps. DNA blood testing for detecting colon cancer has also recently been introduced in the United States, but this method has not yet been validated for routine use.

“The colonoscopy is still the gold standard for colorectal cancer detection,” Dr. Philip says. “Newer techniques are being developed, but none to date has shown to be better than standard colonoscopy.”

New Medications Offer More Hope

In addition to the state-of-the-art surgical techniques available for advanced-stage colon cancer patients, there’s more good news: Over the past decade, researchers have introduced a new generation of effective cancer-fighting drugs. These medications take advantage of major advances made in understanding the molecular biology of how the disease develops within the body.

“By gaining a better understanding of the molecular biology of cancer cells, we’re now able to design better treatments,” says Philip A. Philip, MD, PhD, FRCP, professor of medicine and oncology and leader of the Multidisciplinary Gastrointestinal Program at the Karmanos Cancer Institute in Detroit. “We’re increasing the cure rate for patients with Stage II, III, or IV colorectal cancer and prolonging the survival of patients with advanced disease. These drugs have certainly added to our success rate.”

Among the more common medications recently introduced are Avastin® (bevacizumab), Erbitux® (cetuximab), and Vectibix® (panitumumab). Avastin works by preventing the formation of new blood cells that feed cancer tumors and choking the tumor cells. Without nutrients from blood vessels, the tumor cells cannot survive because they do not have access to blood circulation. Erbitux and Vectibix target a protein on the surface of cancer cells and shut down the signals that drive them, thereby preventing the disease from growing and further spreading to other parts of the body. The Food and Drug Administration approved Avastin and Erbitux for treating colorectal cancer in 2004; Vectibix received approval in 2006.

“From the late 1950s to the mid-1990s, we had only one drug to help colorectal cancer patients,” Dr. Philip says. “Since then researchers have introduced six more. These medications have helped prolong the life of patients and even cure patients who were previously deemed incurable.”