Novel Freezing Surgery Used on Pancreas Cancer
Surgeons at Century City Hospital have for the first time used cryosurgery to treat pancreas tumors, a painful, intractable form of cancer that is almost universally fatal.
The innovative technique of killing tumor cells by freezing them to minus 300 degrees Fahrenheit is increasingly used on liver and prostate cancers, but had not been applied to the pancreas because of technical difficulties in the surgery.
Dr. Kenneth P. Ramming and his colleagues at the John Wayne Cancer Institute have spent two years working on dogs and cadavers to develop surgical techniques that allow it to be used on the pancreas, and the cryosurgery offers a first hope for prolonging the lives of victims.
Pancreas cancer strikes 27,000 Americans each year, killing 25,900. Only 3% of patients now survive five years.
Ramming’s second patient, operated on Tuesday, is Erwin Muskatt, a 58-year-old businessman from New York City. Muskatt was moved out of the intensive care unit Saturday and hopes to be released from the hospital next Saturday.
In a conversation Sunday, Muskatt was optimistic about his prospects but discounted his pioneering role. “Being a pioneer doesn’t matter,” he said. “Being alive is good.”
The first patient was a 65-year-old Santa Barbara housewife who underwent the procedure late last month. She has required a subsequent surgery to halt gastrointestinal bleeding not directly related to the cryosurgery but is now doing well, Ramming said.
Ramming is optimistic about both patients’ prospects for long-term survival. One key predictor is the housewife’s level of a blood tumor marker called CA19-9, which is specific for pancreas cancer. In a healthy person, the level is not usually above 37 units. “When we operated, her value was 9,650 units. . . . Two weeks later, it was under 100. Now it’s normal. That’s a spectacular result,” Ramming said. “That’s pretty objective evidence that the cancer is dead.”
Further evidence came when he re-operated to repair the gastrointestinal bleeding, Ramming said. “When we looked back in there (at the pancreas), we didn’t see anything. It looked like the pancreas had melted away.”
The idea of freezing tumors to kill them has been around for half a century, but only within the past few years has the technology become available to implement surgeons’ visions. Newly devised coolers, costing upward of $200,000, pump liquid nitrogen through thin probes inserted into the tumor by surgeons using ultrasound as a guide.
The rapid cooling available with these probes can freeze a large tumor down to minus 300 degrees in just a few minutes. When liquid inside the cells freezes, sharp ice crystals form, rupturing cellular membranes and completely disrupting metabolic processes. When the tumor thaws out, Ramming said, it is a gray mush that is generally resorbed by the body.
“There’s no question that cryosurgery kills cancer,” he said. “The only limiting factor is our creativity in applying it.”
The technique is most commonly used for cancers of the liver and prostate, in large part because conventional surgery is very difficult. That is due to the fact that both organs are suffused with blood vessels that produce bleeding, impeding vision in conventional surgery and increasing the chances of damage to crucial nerves and blood vessels.
Ramming and Dr. Wilson S. Wong of Alhambra Hospital have been the foremost proponents of cryosurgery in the Los Angeles area.
Ramming has performed the procedure on 120 liver cancer patients and 55 prostate patients. Like other researchers, he has no long-term figures for survival, however, because the first patients were operated on little more than two years ago.
But the pancreas, which secretes powerful digestive enzymes that aid the body’s breakdown of food, is a special case. Advanced tumors are not often susceptible to conventional surgery because usually, by the time a tumor is detected, it has invaded surrounding structures, particularly crucial blood vessels.
While cryosurgery can kill the tumor cells without damaging the blood vessels, if the tumor is simply frozen in place the enzymes leak and eat the pancreas itself, producing lethal pancreatitis.
Working in dogs, Ramming’s team devised ways to seal the tumor from the rest of the pancreas, sewing partitions through the organ so that enzymes could not leak when the tumor was killed. They had to provide artificial ducts so that the enzymes they had sealed off could still be released into the stomach or intestine.
They also had to partition off a portion of the duodenum--the intestine--so that they could insert the liquid nitrogen probe through it into the hidden pancreas.
When the procedure successfully destroyed pancreas tumors in dogs, they learned how to scale up the operation by performing the procedure on cadavers. “Surgeons don’t like to see a dead body on the operating table,” he said, “but without the practice, our first operations wouldn’t have gone nearly as well.”
Muskatt was referred to Ramming by his friend Sue Neuman, a volunteer at John Wayne who knew Ramming had developed the new procedure. Muskatt had been having stomach problems and severe pain since February, but was not diagnosed as having pancreas cancer until June. Laparoscopic surgery showed that the tumor was advanced and not “locally resectable”--the language physicians generally use to say it’s inoperable.
Radiation and chemotherapy temporarily reduced the disabling pain but did nothing to shrink the tumor. That was when he heard about Ramming. Electing to fly to Los Angeles for treatment seemed logical, his wife Roberta said.
“It was not much of a decision. Since anything else is less than desirable--they’re not cures--this was the obvious choice because it was a chance to get rid of the tumor entirely. We were very happy to take it,” she said.
Now, Muskatt and the unnamed housewife can only wait to see how well they recover. Because of the relentlessly progressive nature of pancreas cancer, “it won’t take too long to see how well it is working,” Ramming said.
For his part, Ramming plans to operate on an average of one pancreas patient a week until the team has accumulated 50 cases. Then they will take a little time to assess their results and see if their optimism is justified.
