Friday, October 3, 2008

The disappearing cancer


Today was a long day in the OR but once again I loved it. (4:30 am to 8:30 pm) Today's patient was a 54 year old hispanic male with a chief complaint of weight loss, vomiting, epigastric pain, and anorexia. Whenever a patient like this presents the first thing we think of is cancer. So he was worked up with endoscopy and imaging studies. The CT showed a suspicious mass near the pyloric sphincter in the stomach. The mass was visualized with endoscopy and a biopsy was taken from the mass and sent to pathology. H. pylori levels and gastrin levels were measures. H. pylori is a bacteria that can set up shop in the stomach and cause ulcers and lead to cancer. If a patient has high gastrin levels it is a marker for a tumor related to Zollinger-Ellison syndrome which causes hyper secretion of gastrin = too much acid = breakdown of the stomach.

The results of all the tests were as follows; gastrin levels were normal, H.pylori was +, the biopsy of the mass showed it to be cancer. So we had a diagnosis of gastric cancer. The patient was immediately put on triple therapy for the H. pylori and scheduled for surgery. This all took place about 1 week ago and today was his day for surgery. 

Gastric cancer occurs at a rate of 10/100,000 in the USA but at a rate of 80/100,000 in Japan. Japan has always had a high rate of stomach cancers. This is due to there high levels of nitrates in their foods. Smoked fish and other preserved foods have been shown to cause gastric cancer along with smoking & alcohol. Japan leads the world in gastric cancer therapy and they are very aggressive in screening and treating gastric cancer. Gastric cancer is fairly aggressive. In the USA you have a 25 - 50% chance of surviving 5 years if diagnosed with gastric cancer. In Japan you have more than 50% chance of surviving. This is mostly due to their early detecting and aggressive treatments. In the USA patients are not diagnosed until the cancer is too far progressed. 

We went to the OR to remove the patients stomach. The treatment for gastric cancer involves removal of most of the stomach to all of the stomach (complete gastrectomy). We were plaining a partial gastrectomy as the tumor was relatively small and the cancer was in the early stages. The residents and I scrubbed in and began the surgery. We cut through the different layers to ultimately expose the stomach. We had to tie off many vessels in preparation for the removal of the stomach. As we exposed the stomach we looked for the cancer, but to our surprise we could not find it. We figured that it has to be there and that when the attending physician arrived he would point it out to us. We did find 2 enlarged lymph nodes. We continued to prep the stomach when the attending arrived. He scrubbed in and we informed hi that we could not find the tumor. He had reviewed all the images and lab reports and immediately went to the location of where the tumor was supposed to be. He began to laugh and asked if we were playing a joke. He said "this is not the right patient! I do not see any cancer." We actually double checked the patient to make sure it was the right guy even though we had checked all the protocols before the surgery. Sure enough it was the right patient.

We called for the endoscope to look around the inside of the stomach. We had exposed the external portion of the stomach but we needed the endoscope to see the inside of the stomach. We were sure once we were in the stomach we would see the cancer, after all we had a positive biopsy from 1 week ago. We looked all over the inside of the stomach with the camera and could not find anything. It was a perfectly healthy stomach. We could not see any area that remotely resembled a cancer or even an ulcer. This was very mysterious. We spent a few hours going over the inside and outside of the stomach looking for any signs of a tumor. We biopsied the 2 swollen lymph nodes coming off the stomach and sent them to pathology. The attending thought that the lymph nodes looked very suspicious for cancer. However when the labs came back it showed that the lymph nodes were negative for cancer. We were all surprised by this and after much discussion and several different doctors being consulted to look at the case in the OR the attending announced that there was no cancer and that we could close without performing a gastrectomy. 

It was the patients lucky day as there was no cancer and he kept his stomach. Gastrectomy patients do not do very well and have a high risk of mortality. The attending explained that he had only seen this once before but had read several Japanese studies about this disappearing gastric cancer. The Japanese had reported for years that if a patient is diagnosed with gastric cancer in the very early stages and positive for H. pylori as many are they could be treated for eradication of the H. pylori and in some cases the cancer actually disappears. THe treatment involves antibiotics and a proton pump inhibitor (like prilosec). Most USA surgeons do not believe these reports as the Japanese have had difficulty showing this in the lab and only had in vivo cases reported. We were all believers now. We even had the pathologist come down and see  that that cancer was no longer there. 

The photo was taken while we were doing the endoscopy. The bulging structure is the stomach. We pumped it full of air so that it would remain open for easier viewing with the camera. The structure lying above it that is not bulging is the liver. 

We closed up the patient and could not wait to tell him and his family the good news. Sometimes there are happy endings and it is nice to have one once in a while. It was a good day!

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