Stanford Tackles Tough Tumors Once Thought Beyond Treatment
Michelle Perea has a very clear memory of what went through her head when doctors told her that a rare and malignant tumor had swollen her abdomen and wrapped itself around the major arteries of her chest and abdomen.
"I was 38 years old; my youngest was two years old, my oldest 12, and all I kept thinking about was, 'We have to get things in order,'" Perea said. She went elsewhere for a second opinion and heard much the same, although it was suggested she look around for a clinical trial. "I went home to my kids thinking this would be the last holiday I would have with them," Perea said.
Then, a doctor who was a family friend, who had a sister involved in cancer research, said something different: "Michelle, you've got to try Stanford. You've got to try."
I just knew they were doctors at Stanford, and that people come to them from all over the world.
Stanford Hospital has several tumor boards, specific to particular kinds of cancer, and Perea's case was presented. In on the conversation were E. John Harris, Jr., MD, a vascular surgeon in in the Stanford Vascular Center, and Jeffrey Norton, MD, an oncology surgeon at the Stanford Clinical Cancer Center.
Together, they brought nearly 65 years of experience as physicians to the dilemma of how to treat Perea.
She didn't do any research on Harris or Norton before her surgery. "I just knew they were doctors at Stanford," she said, "and that people come to them from all over the world."
Harris and Norton had recently begun an unusual partnership, one designed to tackle impossible-to-remove tumors like Perea's, laden with risk. Instead of an oncology surgeon handling the surgery alone and calling for help if needed, as has been the norm, Harris and Norton would work together from the start—a move to get beyond the old barriers around certain cancers like Perea's: those that emerge from the body's soft, connective tissue—fat, muscle, nerves, fibrous tissues, blood vessels or deep skin tissues. By nature, these tumors invade and entangle other tissues, and the prognosis is often dire.
Partners in innovation
Perea's malignant sarcoma was located in what anatomy books call the retroperitoneum that middle section of the body where several organs and major arteries are packed together, a tightly-configured space where any surgery is risky, and where, without preoperative angiograms, the need for blood vessel reconstruction can be a dangerous surprise.
Even when a sarcoma appears in an arm or a leg, that blood vessel problem is so great that amputation has been the norm.
Inside Perea, the tumor, the size of a melon and weighing 11 pounds, had grown around the major artery supplying blood to her abdomen. The artery was buried like a straw through the middle of a softball, just the type of situation where few physicians would venture. Another layer of risk: The tumor originated on Perea's spine, so removing it also raised the possibility that she might emerge from surgery paralyzed. Perea was willing to risk that.
Perea met first with Norton. "I told him about my kids and showed him a picture of my family," Perea said. "It almost seemed as though he was thinking, 'She's only 38 years old. We have to try and do something—we have to do these things that seem impossible because that’s what we do.'"
Norton, in the blunt manner of someone unafraid to break new ground, put it differently. "Surgery is the only effective treatment for sarcomas," he said. "Even though this tumor involved major blood vessels, we didn't think it was unreasonable to try to remove it. We are not here to not take out tumors."
Harris, with his special expertise in the vascular system, would do the reconstruction and replacement of the arteries and any other blood vessels damaged by the tumor, the key step to break down the barrier against removing tumors that grow to interfere with major blood vessels.
First of its kind
In his meeting with Perea, Harris explained in detail what the surgery would involve. He also told her something she hadn't known. "My understanding was that this had never been done before," Perea said, "that that large of a tumor had never been removed in that area before, with that much reconstruction."
Norton never wavered from a positive outcome, she said, "but he said we had to do it right away. He rescheduled his vacation so that could happen."
It almost seemed as though he was thinking, 'She's only 38 years old. We have to try and do something - we have to do these things that seem impossible.'
The duo of Harris and Norton brings together two very clear-eyed physicians whose nature is to know their individual limitations and to embrace the power of collaboration. "I've spent my whole life trying to take tumors out," Norton said. "I know surgery pretty well, but there are certain times when I can't deal with blood vessels."
For vascular surgeons, Norton said, knowing "what vessels you can take and those you can't, which you ligate or which you have to reconstruct," is their basic alphabet of working knowledge.
Working with Harris filled out that part of an equation that opened the door to this problematic kind of surgery "where the more you cut, the more you can injure," Norton said. With Harris' expertise in the vascular system, the two could plan ahead, designing an approach to lower the risk of unexpected bleeding, something that can quickly upend a surgery. "That unexpected bleeding is the one thing we all want to avoid," Norton said.
Their collaboration began after Norton had had to call for Harris' help in the middle of a surgery. Later, Harris said, "I told him it would be better if I saw these patients ahead of time—and we came up with a plan." Essential to the plan was a complete mapping of a patient's vascular system, using computed tomography angiography so there would be no surprises.
- The Stanford Cancer Institute coordinates basic research, development of new therapies, clinical trials, patient care, screening, prevention, education, community outreach and psycho-social support. It also houses a tumor registry.
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For more information about cancer care at Stanford, please phone 650-498-6000 or visit cancer.stanford.edu.
Harris and Norton told Perea that her first-of-its-kind surgery would be videotaped so others could learn from it.
The surgery lasted more than 10 hours. "It was pretty complex," Harris said. "It involved all the major blood vessels supplying the kidneys and the intestines. The tumor grew right up out of her spine and pressed up against her heart and traversed her diaphragm." In addition to the threat of paralysis, Harris said, the blood supply to her liver and other parts of her body could have been compromised.
New thinking adds options
Perea was in critical care for a week. After three weeks in the hospital, she went home to restart her life.
Since the account of Perea's surgery was published in the Archives of Surgery, other surgeons have begun to try the joint venture approach inaugurated by Harris and Norton for these types of cancer. "We do have the ability to do this kind of surgery," Harris said. "It's just old thinking that if a sarcoma has invaded a major blood vessel, that there’s nothing you can do but give patients palliative therapy."
The surgery does require what Harris called a skill set that’s not found everywhere—a special combination of experience and knowledge—but he and Norton are both modest. "We're not doing anything totally different than anybody else does, but we do it well," Norton said. "We plan these things out to minimize blood loss and we’re always thinking, 'What’s another way of doing it?'"
It's just old thinking that if a sarcoma has invaded a major blood vessel, that there's nothing you can do but give patients palliative therapy.
One of the basic maneuvers is called debranching, something that neurosurgeons and vascular surgeons bring out for aneurysms—a way to go around a damaged area by connecting the good part before and the good part beyond.
Something else is important, too—that collaborative spirit. "Jeff and I have a good relationship. There is no ego," Harris said. "John is a good guy," Norton said, "easy to work with. A lot of surgeons can't work together."
With the success of their teaming, they have expanded the approach to include surgeries to remove tumors in the pancreas and duodenum, with similar replacements of major veins and arteries. That heralds a bigger role for vascular surgery in tumor removal, Harris believes.
In 2010, Harris and Norton removed a new tumor, another challenge requiring major vascular replacement: This time, the cancer appeared in Perea's liver, invaded her vena cava, the vein that transports deoxygenated blood, and worked its way up her chest wall.
"When I was rediagnosed, I thought, 'Oh, crap, it's back.' But it's just one of those things," Perea said. "Sometimes, I wake up and I don't feel I can do this another day, but then I think about how far I've come and I say, 'I have to.' There's no way I can give up on myself when no one else did. I just keep moving forward."
She has gained more time with her children. Her youngest just finished kindergarten, her oldest is 16. "The bottom line is I just want to be here as long as I can."
About Stanford Hospital & Clinics
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