Preparing to see your surgeon.

A friend of a relative on the other side of the country phoned me recently to discuss her medical condition.  The woman had been referred to a surgeon by her OBGYN because of a suspicious lump in her breast that also was evident in her mammogram.  She was anxious to discuss the “next steps” which I was happy to do but I also helped her prepare to see her surgeon for the first time.

The first thing I suggested was for her to bring one, even two people with her to the appointment.  When patients are anxious or confronting a potentially serious medical condition, they often are not in the best frame of mind to hear everything the surgeon may relate.  Others in attendance can take notes or operate a tape recorder.

Other advice I offered – prepare for the visit.  Write out a list of questions and bring those with you to the appointment.  If you’ve researched your condition on the internet, be sure to share the information with your surgeon and ask questions.   Not all information on the Web is accurate. It may sound trite, but there is no stupid question.  Do not be shy.  If you do not understand something the surgeon is saying, ask the physician to slow down, repeat or reword what’s been said.  If you wish a second opinion, get a second opinion.  The surgeon will not take offense.  Ask for a referral if you do not have one.

Finally,  if you would like further information, ask your surgeon for other reliable sources.  Taking charge and planning for meeting with your surgeon can help keep you in control and ease the anxiety.



Breast cancer – surgical treatments

Treatment for breast cancer usually starts first with surgery.  There are generally two parts to the operation:  1) the breast, and 2) the axilla (armpit).

In the breast, there are two choices: 1) lumpectomy (removing the cancer lump and some surrounding tissue), or 2) mastectomy (removing the entire breast).  Not long ago, almost all patients had mastectomy, even if their breast cancer is small.  But over the past few decades, clinical trials have shown that for small cancers, lumpectomy followed by radiation treatment is just as good as mastectomy.  Now, “small” is a relative term.  The goal of a lumpectomy is that the breast would still look like a breast after the operation.  In someone with small breasts, a “small” cancer may occupy a significant portion of the breast.  A lumpectomy with good margins in this case may result in an unacceptable cosmetic outcome.  Therefore, the patient may actually prefer having a mastectomy (with reconstruction) and avoid radiation altogether.  Another factor is the number of cancers in the breast.  Usually, mastectomy is required for multifocal cancer (cancer in two or more locations in the same breast)

At the same time as the breast operation, staging surgery in the axilla also is carried out for invasive (or infiltrating) breast cancer, as well as in selected cases of extensive DCIS (ductal carcinoma in situ).  This is done to determine whether the breast cancer has spread to the lymph nodes in the armpit.  In general, sentinel node excision is done first.  The surgeon maps the lymphatic drainage of the breast cancer to the first nodes that receive this lymph, i.e. the sentinel node(s).  Only a few (1-5) nodes are then usually removed.  If there is cancer in more than two nodes, or if the cancer has broken through a node capsule, then axillary node dissection is carried out.  Here, more lymph nodes are resected, usually 8-25.




Treatment for early in situ breast cancer – an update

Breast cancer is the most common form of cancer in women and the second leading cause of cancer deaths in American females.  In 2013, approximately 238,590 patients were estimated to be diagnosed with the invasive form of this malignancy.  An estimated 40,030 died of this disease in 2013 alone.  About 64,640 additional patients had the early form called DCIS (ductal carcinoma in situ).

Recently, there have been articles in the popular press suggesting that breast ductal carcinoma in situ is “over-treated” with surgery, radiation, and hormone blocker pills (usually prescribed for five years).  It is still standard of care to remove DCIS with surgery.  Some people question whether radiation therapy is really necessary after lumpectomy.

A new study indicates that radiation reduces the risk of recurrence by a factor of two.  This was published on 11/10/13 in the Journal of Clinical Oncology (Breast-conserving treatment with or without radiotherapy in ductal carcinoma In Situ: 15-year recurrence rates and outcome after a recurrence, from the EORTC 10853 randomized phase III trial, by M Donker, and others).  Between 1986 and 1996, 1,010 women with complete surgical excision of DCIS (size less than 5 cm) were randomly assigned to no further treatment (503) or radiation therapy (507).  In this European Organisation for Research and Treatment of Cancer study, the median follow-up time was 15.8 years.

            The authors report that radiotherapy reduced the risk of any cancer recurrence by 48%.  The recurrence rate was 30% in patients treated with surgery only, compared to 17% in those who received both surgery and radiation.  Of these recurrences, 48% were again the early type, ductal carcinoma in situ.  However, 52% of cases recurred as invasive breast cancer.  These women had five times higher risk of death than those who did not recur.

Therefore, radiation therapy is still beneficial in cases of ductal carcinoma in situ.  Exceptions to the standard of care may be acceptable in older patients with small DCIS, who prefer to avoid radiotherapy.



Exciting news in novel personalized medicine for breast cancer

Three new targeted drugs approved by the FDA

Active research in breast cancer is producing novel targeted drugs at a rapid pace.

Perjeta (pertuzumab)

In September 2013, the FDA approved Perjeta for use in combination with Herceptin (trastuzumab) and docetaxel for the neoadjuvant (prior to surgery) treatment of patients with HER2-positive, locally advanced, inflammatory or early-stage breast cancer (either greater than 2 cm in diameter or node positive).  Pertuzumab is an antibody that targets the extracellular dimerization domain of HER2, and thereby blocks ligand-dependent heterodimerization of HER2 with other HER family members.  Clinical trials have shown that neoadjuvant therapy with this combination resulted in a 39% complete response rate, meaning that cancer can not be found at the time of surgery.  This rate is superior to any other existing neoadjuvant treatments.

Kadcyla (ado-trastuzumab emtansine)

The FDA approved Kadcyla in February 2013.  Kadcyla is a HER2-targeted antibody-drug conjugate.  Upon binding to the HER2 receptor, ado-trastuzumab emtansine results in intracellular release of DM1-containing cytotoxic catabolites. Binding of DM1 to tubulin disrupts microtubule networks in the cell, which results in tumor cell death.  Kadcyla is indicated for patients with HER2-positive, metastatic breast cancer who previously received Herceptin and a taxane, separately or in combination.  A large clinical trial has shown that this new drug gave patients a median overall survival of 31 months, in comparison to 25 months with other drugs.

Afinitor (everolimus)

In July  2012, the FDA approved Afinitor for the treatment of postmenopausal women with advanced hormone receptor-positive, HER2-negative breast cancer in combination with exemestane, after failure of treatment with other hormone blocker pills.  The tumors in these cases essentially developed resistance to existing hormone blocker pills.  Afinitor is an inhibitor of mTOR, which is important for cancer cell proliferation.  A large clinical trial yielded a median progression-free survival of 8 months for patients receiving this new drug, versus 3 months for those on placebo.  The final analysis of overall survival is expected to occur in June 2014.



Lymphoma in breast implants

Lymphoma occurring in breast implants is extremely rare.  This is called anaplastic large cell lymphoma (ALCL), an very uncommon type of malignancy.  Approximately 1 in 500,000 women is diagnosed with ALCL (anywhere in the body) in the United States each year.  Only 3 in 100 million women per year in the US are diagnosed with ALCL in the breast.  Breast ALCL has been most often identified in patients undergoing implant revision operations.  There are now about 60 case reports of ALCL in women with breast implants worldwide.  The total number of implants worldwide is estimated to be between 5-10 million.  Based on these numbers, for women with breast implants, the estimation is that one out of 125,000 would develop breast ALCL.  To put things in perspective, in the same women, the rate of breast cancer is one out of 7-8.

A recent publication provides an update on these 60 women (Breast Implant-Associated Anaplastic Large-Cell Lymphoma: Long-Term Follow-Up of 60 Patients, by Roberto Miranda and others, published on 12/9/13 in the Journal of Clinical Oncology).  Patients who had lymphoma confined to the capsule (the scar envelope around the implant) did well, with 93% (39/42) achieving complete remission.  In patients who had a tumor mass, 72% (13/18) had remission.  Survival was also worse in cases with lymphoma mass.

The recommendations are as follows:

1)  In women without any abnormal signs or symptoms, breast implants should not be removed due to fear of lymphoma.

2)  No screening for lymphoma in breast implant patients who do not have symptoms.  Furthermore, there is no yet identified reliable method to screen for breast ALCL in a non-invasive fashion.

3)  If breast ALCL is confirmed, the implant and the capsule around it should be removed.  If disease has spread outside the capsule and presents as a mass, then radiation and chemotherapy should be administered as well.



New treatments for advanced and metastatic melanoma

In the United States in 2014, there will be an estimated 76,100 new cases of invasive cancer and 63,770 of in situ melanoma.  Also in 2014, approximately 9,710 people will die from this malignancy.  Most patients with metastatic melanoma die within one year.  Until recently, the only two approved treatments are dacarbazine (a chemotherapy agent) and interleukin-2.  Neither drug has clearly demonstrated improved survival.

Now, there are four new drugs that can be used for unresectable (cannot be completely removed by surgery) and metastatic melanoma.  The first drug is Yervoy (ipilimumab), which was approved by the FDA in 2011.  Yervoy is an antibody that blocks T-lymphocyte associated antigen 4 (CTLA-4).  This blockage increases T-cell proliferation, which results in a more active immune system to attack the melanoma cells.  In clinical trials, Yervoy reduced the risk of death by 34%, and median overall survival was 10 months.

The second agent is vemurafenib, which was approved by the FDA in 2011.  Vemurafenib targets a mutation in the gene BRAF (Serine/threonine-protein kinase B-Raf) V600E.  About 50% of melanoma cases have this mutation, and these patients would qualify.  This drug reduced the risk of death by 56%, compared to treatment with dacarbazine.

Last year 2013, the FDA approved two more drugs.  Dabrafenib was also indicated for unresectable or metastatic melanoma cases that have the BRAF V600E mutation.  Compared to dacarbazine chemotherapy, Dabrafenib delayed tumor growth by 2.4 months.  The fourth drug is trametinib, which can be used for melanoma cases that have the BRAF V600K mutation, as well as the V600E mutation.  Compared to dacarbazine, trametinib delayed tumor growth by 3.3 months.

In general, these new drugs add a few more months of life to these terminal melanoma patients.  Further research is needed to produce better treatments for this deadly disease.



Colon Cancer – An Update

In the United States in 2014, there will be an estimated 96,830 new cases of colon cancer and 40,000 rectal cancer.  Also in 2014, approximately 50,310 people will die from these two malignancies.

Once colon cancer is diagnosed on a complete colonoscopy, a CT of the chest abdomen and pelvis should be done.  If there is no distant spread of disease, colectomy (resection of the colon) is recommended.  The extent of colon removal depends on the location of the cancer.  Usually, it is not necessary to remove the entire colon.  Surgery may be performed with an open midline incision, or with the laparoscope via multiple small incisions.  Both approaches have similar long-term outcome in regards to recurrence and survival.  After surgery, adjuvant chemotherapy is given in cases where cancer has spread to surrounding lymph nodes, or if cancer has penetrated through the wall of the colon.  FOLFOX is the most commonly used regimen, and includes folinic acid (leucovorin), 5-fluorouracil, and oxaliplatin.

About 25% of colon cancer cases present with concurrent spread to the liver.  If possible, the liver metastasis should be resected as well as the cancer in the colon.  If surgery is not feasible, the liver metastasis may be treated with:  1) chemotherapy delivered into the hepatic artery; 2) occlusion of the artery feeding the cancer; 3) radiation; or 4) radio-frequency ablation.  Sometimes, a patient may have a single metastatic nodule in the lung that can be removed with surgery.  In advanced or metastatic cases, chemotherapy is usually administered first.  This treatment may sometimes be successful in shrinking the tumor enough to make surgical resection possible.

After treatment for early colon cancer (stage 1), follow-up includes colonoscopy at 1 year, 3 year, and then every five years.  Locally advanced (stages 2-3) patients should also have blood tests (with tumor marker CEA) and contrast-enhanced CT of the chest abdomen and pelvis during the first five years.



Ovarian Cancer – An Update

In the United States in 2014, there will be an estimated 21,980 new cases of ovarian cancer.  Also in 2014, approximately 14,270 people will die from this malignancy.  Hereditary cases account for only 5% of ovarian cancer.  However, any patient with ovarian cancer should be tested for the BRCA gene.  Women who carry a BRCA gene mutation are usually advised to have bilateral salpingo-oophorectomies (removal of both tubes and ovaries) to prevent the occurrence of ovarian cancer.

Epithelial ovarian cancer accounts for 90% of ovarian malignancies.  Surgery is the initial treatment for all stages of ovarian cancer.  This includes a hysterectomy and bilateral oophorectomies (removal of both ovaries).  Any tumor seen in the abdomen should be resected, as well as lymph nodes.  Sometimes, other abdominal organs may need to be taken out, if they are invaded by ovarian cancer.  This “debulking” surgery has been shown to improve survival.  Most patients receive chemotherapy after surgery.  Chemotherapy may be administered intravenously or intraperitoneally (directly into the abdomen).  Radiation is rarely used for this malignancy.  Recurrent cancer may be treated with more debulking surgery and more chemotherapy.

Less common ovarian malignancies include germ cell neoplasms, sex cord stromal tumors, and ovarian LMP (low malignant potential) tumors.  Less radical surgery is recommended, and if fertility is desired, one ovary may be saved.  If advanced disease is discovered at surgery, patients would benefit with adjuvant chemotherapy.  Other uncommon ovarian malignancies such as carcinosarcoma and fallopian tube cancer are aggressive and are managed similarly to epithelial ovarian cancer.

Active research is carried out to discover better treatments for this deadly disease.  Avastin (bevacizumab), an inhibitor of blood vessel growth, has been approved by the FDA.  Other agents are available to patients who enroll in a clinical trial.  One promising drug is olaparib, which inhibits PARP (poly-ADP ribose polymerase), is being tested in chemotherapy-refractory ovarian cancer.



Rectal Cancer – An Update

In the United States in 2014, there will be an estimated 40,000 new cases of rectal cancer and 96,830 colon cancers.  Also in 2014, approximately 50,310 people will die from these two malignancies.

Once rectal cancer is diagnosed, a complete colonoscopy and a contrast-enhanced CT of the chest abdomen and pelvis should be done.  Furthermore, an MRI or endorectal ultrasound is carried out to determine the depth of the tumor and potential involvement of lymph nodes.  This is important to decide what kind of surgery to recommend to the patient.  For selected early small superficial cancer, transanal excision is appropriate.  This operation is performed through the lumen of the anorectum, without any incision in the abdomen.  In most patients, abdominal surgery is required.  If the tumor is far enough from the anus, a Low Anterior Resection (LAR) operation removes the middle and upper rectum and reconnects the colon to the rest of the anorectum.  However, if the tumor is close to the anus, an AbdominoPerineal Resection (APR) is required.  Here, the patient receives a permanent colostomy.  Both LAR and APR may be performed with an open midline incision in the abdomen, or with the laparoscope via multiple small incisions.  Both approaches have similar long-term outcome in regards to recurrence and survival.

If preoperative testing indicates that the tumor has penetrated the wall of the rectum or cancer has spread to surrounding lymph nodes, the patient should have chemotherapy (and radiation) up front.  This treatment is often successful in shrinking the tumor enough to make surgical resection more successful, and decrease the chance of a permanent colostomy.

Many cancer cases present with concurrent spread to the liver.  If possible, the liver metastasis should be resected as well as the cancer in the rectum.  If surgery is not feasible, the liver metastasis may be treated with:  1) chemotherapy delivered into the hepatic artery; 2) occlusion of the artery feeding the cancer; 3) radiation; or 4) radio-frequency ablation.  Sometimes, a patient may have a single metastatic nodule in the lung that can be removed with surgery.  In advanced or metastatic cases, chemotherapy is usually administered first.  This treatment may sometimes be successful in shrinking the tumor enough to make surgical resection possible



Anal Cancer – An Update

In the United States in 2014, there will be an estimated 7,210 new cases of anal cancer.  Also in 2014, approximately 950 people will die from this malignancy.  Risk factors associated with anal cancer include HPV (human papilloma virus), HIV, immunosuppression, and anal intercourse.  HPV vaccination decreases the risk.  High grade anal intraepithelial neoplasia (AIN) is a precursor to invasive cancer, and should be treated with electrocautery, or topical imiquimod or fluorouracil.  When AIN is discovered, the patient should be tested for HIV infection.

The diagnosis of anal cancer requires a biopsy.  Subsequent staging tests include anoscopy, CT of abdomen and pelvis, and Pet scan (if indicated).  For non-metastatic cases (no spread to distant organs), primary treatment includes systemic chemotherapy and anal radiation.  Approximately ten weeks after completion of therapy, the anus is re-examined and biopsied if needed.  Patients are classified as having complete remission, persistent disease, or progressive cancer.  Patients with complete remission are re-checked every four months for five years.  Patients with persistent disease continue monthly followup, to see if regression will happen.  If there is progressive cancer, a repeat biopsy should be done, as well as CT of abdomen and pelvis and Pet scan.  If there is no distant metastasis, surgery is recommended.  This is called an abdominoperineal resection (APR) with permanent colostomy.

The most common sites of metastasis are lung, liver, and lymph nodes in and outside the pelvis.  Here, cisplatin chemotherapy is administered.  Radiation is directed to sites of cancer involvement that cause symptoms.  If cisplatin does not work, no other chemotherapy drug has shown any effectiveness.  The patient is strongly encouraged to enroll in a clinical trial to have access to newly discovered drugs.



Lung Cancer – An Update

In the United States in 2014, there will be an estimated 224,210 new cases of lung cancer.  Also in 2014, approximately 159,260 people will die from this malignancy.  This blog addresses the more common non-small cell carcinomas (more than 85% of lung cancer cases), not the small cell type.  Risk factors associated with lung cancer include cigarette smoking and asbestos exposure.

A biopsy is crucial to establish diagnosis, with a needle and/or bronchoscopy.  It is important to distinguish primary lung tumor from metastatic tumor, because many  cancer in other organs spread to the lungs (and these cases are treated differently).  Workup includes CT of the chest, abdomen, pelvis and Pet scan.  Sometimes, a mediastinoscopy (surgical insertion of a scope) is necessary to determine ahead of time if lung cancer has spread to the nodes in the mediastinum (upper central chest around the main airway).  If the cancer is localized, surgery is recommended.  Depending on the location of the cancer, resection of 1-2 lobes or of an entire lung can be performed.  The patient must have enough lung function reserve to tolerate this.  Surgery may be performed with an open incision, a thoracoscope or a robot.  If the patient has significant co-morbidities, then partial surgery (segmentectomy or wedge resection), radiofrequency ablation, or stereotactic radiation may be considered.

Radiation is recommended after surgery if the cancer has aggressive features or if it has spread to lymph nodes.  Lung cancer that cannot be removed with surgery can be treated with radiation.  Cancer that has spread to distant organs (such as brain) may also be given radiotherapy.

Adjuvant (after surgery) chemotherapy is administered to patients with large cancer or if nodes contain cancer.  If these cancer features were known ahead of time based on pre-operative workup, neoadjuvant (before surgery) chemotherapy is recommended in the hope that it would shrink the cancer and make surgery more successful.  Chemotherapy is also given to patients with advanced or metastatic lung cancer.

For advanced lung cancer, there are several new approved “targeted” drugs in addition to chemotherapy.  These agents target specific molecular pathways that drive the proliferation of cancer cells, such as VEGF (vascular endothelial growth factor) and EGF (epidermal growth factor).



Gastric Cancer – An Update

In the United States in 2014, there will be an estimated 22,220 new cases of gastric cancer.  Also in 2014, approximately 10,990 people will die from this malignancy.  In other countries, gastric cancer is much more prevalent.  In Japan, it is the most common type of malignancy in men.  The incidence of gastric cancer is much higher in China than in any other country.  There is no screening program in the US for this disease.  Therefore, gastric cancer is usually diagnosed when the patient develops symptoms.  Risk factors include H. pylori infection, smoking, and heavy alcohol use.

Surgery is the primary and most effective treatment for early gastric cancer.  Yet, only about 50% of patients were able to have complete resection of their tumor with negative margins (an adequate rim of normal tissue around the cancer).  Gastric cancer is considered unresectable if:  1) there is distant metastasis (for example, to liver or lungs); 2) spread into the abdomen; 3) encasement of major blood vessels in the abdomen; or 4) involvement of many lymph nodes.  Sometimes, even when the disease is incurable, surgery is still done for relief of obstruction or bleeding.

For selected patients with gastric cancer, neoadjuvant chemotherapy is given before surgery.  This is done to shrink the tumor, so to maximize the chance that surgery would be successful.  This treatment includes epirubicin, cisplatin and 5-fluorouracil (ECF).  In other cases, chemotherapy and radiation may be offered after surgery if the cancer is deep/large, or if lymph nodes are involved.   In cases where the cancer is deemed unresectable or has metastasized to distant organs, chemotherapy is recommended as palliative therapy.

There is active research to discover new and more effective therapies for this deadly disease.  Patients are highly encouraged to participate in clinical trials in the fight for better treatments for gastric cancer.



Esophageal Cancer – An Update

In the United States in 2014, there will be an estimated 18,170 new cases of esophageal cancer.  Also in 2014, approximately 15,450 people will die from this malignancy.  Risk factors associated with esophageal cancer include cigarette smoking, alcohol, obesity, and reflux disease.  Persistent reflux can result in Barrett’s esophagus, a condition where normal cells become replaced with abnormal cells.  When the cells become precancerous (high grade dysplasia) despite maximal anti-reflux therapies, one may consider treatments such as endoscopic mucosal resection (removes the inner lining), cryoablation, radiofrequency ablation, or photodynamic therapy.

A biopsy is crucial to establish diagnosis, and is usually done with upper endoscopy.  Workup includes Pet CT and endoscopic ultrasound to assess the size and depth of the tumor as well as possible spread to surrounding lymph nodes.  If the cancer is high up, bronchoscopy is also done.  This workup separates patients into two categories:  local versus metastatic (spread to distant organs) disease.  Metastatic cases do not proceed to surgery.  Because esophagectomy is a major operation, patients are also assessed for their ability to tolerate surgery, based on their co-morbidities.

Surgery involves complete removal of the esophagus (esophagectomy), and bringing the stomach up into the chest to reconnect the alimentary canal.  When the stomach is not adequate, then a portion of the colon is used for this re-connection.  If the cancer is large or involves surrounding lymph nodes, usually chemotherapy and radiation are offered up front before surgery (neoadjuvant) with the hope that the cancer will shrink and subsequent surgery would be more successful.

If the cancer is too large to be resected, or if the patient is too sick to undergo an esophagectomy, then chemotherapy and radiation are usually recommended.  Similar treatments are also used in metastatic cases.  Unfortunately, esophageal cancer is often discovered at a late stage, thus it has a high mortality rate.



Liver and Bile Cancer – An Update

In the United States in 2014, there will be an estimated 43,840 new cases of hepatobiliary cancer.  Also in 2014, approximately 26,630 people will die from this malignancy.

Risk factors associated with liver cancer (hepatoma) include alcohol, hepatitis B and C.  Initial workup should include 3-4 phase contrast CT and/or MRI.  A needle biopsy is attempted but sometimes does not yield enough tissue for a pathologic diagnosis.  If resection is contemplated, the patient should be assessed for hepatic reserve, using various criteria.  This is major surgery, with a perioperative mortality of 5%.  Some patients may qualify for liver transplant (where the entire native liver is removed).  However, there is a waiting list for this procedure, due to organ shortage.

Ablation of the liver cancer is offered for cases that cannot undergo hepatic resection or for those waiting for liver transplant.  Here, the cancer is killed by direct exposure to a toxic substance (ethanol or acetic acid), or change in temperature (radiofrequency, cryo-freezing, or microwave).  Another approach clots off the blood supply to the cancer by injecting its feeding artery with beads.  Alternatively, very high doses of chemotherapy can be selectively injected into the arterial branch that supplies blood to the tumor.  In advanced cancer where there is no surgical option, radiation and/or chemotherapy are recommended.

For gallbladder cancer, an operation is the best treatment.  When surgery is not possible, chemotherapy is offered.  In bile duct malignancy (cholangiocarcinoma), again surgery is the best treatment, with chemotherapy and radiation as alternative options.  Some selected patients with cholangiocarcinoma may qualify for liver transplantation.



Brain Cancer – An Update

In the United States in 2014, there will be an estimated 23,380 new cases of primary brain tumors.  Also in 2014, approximately 14,320 people will die from this malignancy.  Symptoms include headache, seizure, weakness, difficulty walking, nausea, vomiting, blurry vision, or a change in a person’s alertness, mental capacity, memory, speech, or personality.

There are different types of primary brain tumors, with vastly different prognoses.  Low grade astrocytomas and oligodendrogliomas usually get treated with surgery.  If complete resection is not achieved, postoperative radiation is recommended.  Meningiomas are slow growing tumors, that sometimes in small cases may be observed.  If meningiomas grow larger, then surgery is recommended.

Anaplastic astrocytomas and glioblastomas are more common, with glioblastomas being the most deadly of brain tumors.  Other aggressive cancers include medulloblastomas and supratentorial PNET (Primitive Neuroectodermal Tumor).   In general, surgery is carried out first, followed by radiation therapy.  Chemotherapy may also be recommended, in some cases placed as wafers during surgery.  Brain lymphomas are treated differently in that surgical resection is usually not recommended.  Steroids and chemotherapy are administered instead, with radiation as well.

Cancer from other organs that has metastasized to the brain are ten times more common than primary brain tumors.  Because of the importance of the brain to bodily function, this metastatic site needs to be aggressively treated, unless the patient has a very short life expectancy.  Therefore, surgery, radiation, and chemotherapy can be offered.  This same treatment recommendation extends to cancer metastatic to the spinal cord.



Pancreatic Cancer – An Update

In the United States in 2014, there will be an estimated 46,420 new cases of pancreatic cancer.  Also in 2014, approximately 39,590 people will die from this malignancy, making it the fourth most common cause of cancer-related deaths in both men and women.  Risk factors associated with pancreatic cancer include smoking, alcohol, obesity, diabetes, and repeated pancreatitis.

This blog addresses the deadly pancreatic adenocarcinoma, not the neuroendocrine tumors.  Prior to an operation, a pancreatic-protocol CT or MRI should be done to determine whether the cancer can be surgically resected.  Endoscopic ultrasound or endoscopic cholangioscopy are used to obtain cells from the pancreas to establish pathologic diagnosis of cancer.  However, sometimes this is not technically possible and surgery should still be carried out if the suspicion for cancer is high.  Surgery is the only potentially curative treatment, but only 20% of patients present with disease that can be cured with surgery.  Criteria for surgery include lack of metastasis to other organs, tissue margin (seen on preoperative imaging) between cancer and the major blood vessels (celiac, hepatic, portal, and superior mesenteric).  Resection of the pancreas is a major surgery, with a perioperative mortality of 5%.

In some patients, chemotherapy and radiation are recommended after surgery.  However, the benefits of these additional therapies are usually small.  A number of oncologists advocate neoadjuvant therapy, i.e. chemotherapy or chemoradiation before surgery.  Neoadjuvant therapy may shrink the cancer and make surgery more successful.  On the other hand, about 25% of patients have worse disease after neoadjuvant therapy.  Some argue that these patients were thus spared major surgery; others may say that these patients should have had surgery in the beginning when it was possibly resectable.  Thus, neoadjuvant therapy is usually offered when preoperative imaging reveals borderline satisfaction of resectable criteria.  For unresectable or metastatic pancreatic cancer, chemotherapy and radiation are offered for palliation.



Thyroid Cancer – An Update

Palpable thyroid nodules are very common and occur in 5% of the adult population, four times as often in women compared to men.  Thyroid cancer is much less common – the lifetime risk of getting thyroid cancer is less than 1%.  In the United States in 2014, there will be an estimated 62,980 new cases of thyroid cancer.  Also in 2014, approximately 1,890 people will die from this malignancy.

When a thyroid nodule is felt on exam, workup includes an ultrasound and serum TSH (thyroid stimulating hormone).  Fine needle aspiration (FNA) is recommended if the nodule is large or looks suspicious on ultrasound.  FNA is also prompted by suspicious clinical features or in a high-risk patient.

Most thyroid cancers are of the papillary, follicular, Hurtle, or medullary types.  Unilateral lobectomy (removal of 1 lobe – the thyroid has two lobes) is sufficient if the cancer nodule is less than 1 cm and is confined inside the lobe.  Otherwise, total thyroidectomy (removal of both lobes) should be done.  After surgery, radioactive iodine treatment is recommended for patients at high risk of recurrence.  Radiation may be offered in cases where the cancer has spread to surrounding neck lymph nodes.  Isolated distant metastasis may be considered for surgical resection and/or radiation.  Chemotherapy is also administered.

Anaplastic carcinoma is the least common type of the thyroid malignancies.  However, it is the most deadly with nearly 100% mortality.  There is no effective treatment for anaplastic carcinoma.  However, surgery may be required to maintain an airway so the patient can breathe.  Chemotherapy and radiation may also be offered.  The patient should enroll in a clinical trial, as there is active research to discover new drugs for this deadly disease.  In the end, the median survival from the time of diagnosis is only 5 months.  Fortunately, this cancer type comprises only 2% of all thyroid malignancies.



Surgery for prostate cancer – an update

Prostate cancer is the most common form of cancer in men and the second leading cause of cancer deaths in American males.  In 2013, approximately 238,590 patients were estimated to be diagnosed with this malignancy.  An estimated 29,270 died of this disease in 2013 alone.

In recent years, there emerges a trend to not treat prostate cancer, called “watchful waiting”.  This is because in some cases, this malignancy does not affect life expectancy.  Screening for prostate cancer also became optional for men of “normal” risk.

A new study, however, indicates that radical prostatectomy reduces mortality among men with localized prostate cancer (cancer that has not spread).  This was published on 3/6/14 in the New England Journal of Medicine (Radical Prostatectomy or Watchful Waiting in Early Prostate Cancer, by Anna Bill-Axelson MD PhD, and others).  The Scandinavian Prostate Cancer Group Study Number 4 (SPCG-4) randomly assigned 695 men with early prostate cancer between 1989 and 1999 to watchful waiting or radical prostatectomy.  The follow-up lasted through the end of 2012, for about 23 years.  The overall death rate was 58% (200 of 347) in the surgery group, and 71% (247 of 348) in the watchful waiting group.  Prostate cancer-specific mortality was 18% (63 of 347) in the surgery group, and 28% (99 of 348) in the watchful waiting group.

The authors concluded that the benefit of surgery with respect to death from prostate cancer was largest in men younger than 65 years of age and in those with intermediate-risk prostate cancer.  There was no significant difference in mortality in either high-risk or low-risk cases.  In patients 65 or older, surgery reduced future cancer spread (metastasis), although it did not change mortality rate.


Thus, surgery for early prostate cancer may be more beneficial than previously thought.  This decision should take into consideration the significant side effects that accompany radical prostatectomy, such as incontinence and impotence.



Breast Implant Capsular Contracture – Natural Therapies

Capsular contracture occurs in patients following breast implant placement.  Basically, a capsule or a scar develops around the implant.  It manifests as breast pain and/or breast deformity or hardening.  It appears to be due to a low grade, chronic inflammatory state triggered by the presence of a “foreign body”, which an implant is.  The cells that mediate the contracture are called “myofibroblasts” and are the same cells that make a wound contract.  So, the scar forms a capsule around the implant and squeezes breast tissue, causing pain and/or deforming the breast and/or pushing the implant resulting in asymmetry.  The chemical pathway that mediates this chronic inflammation is very similar to one of the chemical mediators seen in asthma and is called a “leukotriene”.  Leukotrienes are naturally occuring compounds made by the body in response to inflammation.  They are made by the same pathway for natural compounds that produce pain in arthritis (prostaglandins) and airway spasms in asthma.


Prevention:  The simplest prevention for capsular contracture is manual massage of the breast. This

should be started when it is no longer painful after implant surgery (about a month).  Some

patients find that laying down on their stomach also helps to stretch the capsule out in

all 4 directions simultaneously by using their chest weight on the implant capsule. This

is safe to do but should not be started until it is not painful to do so.

Natural Products:

Once capsular contracture starts, there are many natural products that have been shown in the laboratory to inhibit leukotriene synthesis.  None of these have been clinically proven in any clinical trial to prevent or treat capsular contracture, but they are very safe and have minimal to no side effects when taken as a supplement.

There are no standardized doses for any of these compounds.  Here are the most popular ones:

  1. Boswellia serrate (aka Indian olibaum) and Boswellia carteri – these are the plants

                        that are used to make Frankincense

  1. Ananas comosus (aka Bromelain) – this is an extract from Pineapple that is a

leukotriene inhibitor.  Eating lots of pineapples will not give you enough of

this extract, however.

  1. Uncaria tomentosa and Uncaria guianensis – these are also called Cat’s claw.

Both species produce natural products that are leukotriene inhibitors

  1. Delphinidin – This is a natural compound called an anthocyandin which is

found in many fruits and vegetables.  It can be concentrated and taken

as a capsule

If the patient continues to suffer despite the above natural therapies, the doctor may consider using drugs for the treatment of asthma that are leukotriene inhibitors, such as Singulair or Accolate.  Ultimately, the patient would need to have surgery to remove the capsules and the implants too.