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Winthrop-University Hospital Physicians Cultivate Oncology Protocols to Reproduce Remarkable Outcomes

UNDERPINNING STATE-OF-THE-ART

TECHNOLOGIES and techniques for every stage of cancer care, the foundational principle Winthrop-

University Hospital physicians rely on to cultivate best outcomes is as simple as it gets — multidisciplinary communica-tion. Weekly tumor conferences muster the experience of advanced endoscopists, interventional and diagnostic radiologists, geneticists, medical and radiation oncolo-gists, nurse practitioners, nutritionists, pancreatologists, pathologists, and surgeons to determine the most appropriate course of treatment, based on information gleaned from preliminary examinations, radiological studies and endoscopies.

The preconference process illuminates critical information, catalyzing and direct-ing subsequent treatment plans. This becomes particularly helpful with difficult-to-treat diseases such as pancreatic cancer, the fourth leading cause of cancer death.

Pancreatic or other hepatobiliary cancers commonly present with symptomatic jaundice, which, once present, signifies the tumors have already become estab-lished, notes Stavros Stavropoulos, MD, Director of Endoscopy and Director of the Program in Advanced GI Endoscopy at Winthrop-University Hospital.

“Most pancreatic cancers are diagnosed when they become large enough to impinge

Cultivate Oncology Protocols to Reproduce Remarkable Outcomes

its predecessor, a nearly defunct bypass procedure — is fraught with undesirable consequences. In percutaneous drainage, physicians puncture the skin of the upper abdomen and insert a needle into the liver and into the obstructed duct, dilating the tract to drain the bile to a plastic bag attached to the patient.

“This intervention diminishes quality of life,” Dr. Stavropoulos explains. “Apart from the undesirable cosmetic issues, it’s also painful having a drain going through the skin and muscle, which have more sensitive nerves than viscera. It’s also prone to skin breakdowns and infections.”

Winthrop-University Hospital and a few other select centers around the country now offer a novel technique that allows endo-scopic internal drainage in patients when first-line therapy for drainage using ERCP is impossible. This innovative technique, called endoscopic ultrasound (EUS)-guided biliary drainage (EGBD), spares the patient from the need for percutaneous drainage and external drains and bags.

Because of Dr. Stavropoulos’ extensive experience with EGBD, including having performed the first such procedures in the United States, Winthrop-University Hospital was one of few U.S. centers selected to par-ticipate in a multicenter prospective EGBD study led by Johns Hopkins University. A retrospective of the study demonstrated

SUCCESSFULLY TREATING GASTROINTESTINAL (GI) AND HEPATOBILIARY CANCERS REQUIRES REACHING BEYOND TRADITIONAL TECHNIQUES. INNOVATIVE SURGICAL AND NONSURGICAL TECHNIQUES REPRESENT A NEW HOPE FOR PATIENTS WHO FACE A TRADITIONALLY POOR PROGNOSIS.

By Michael Ferguson

Winthrop-University Hospital Physicians

on the bile duct and cause obstructive jaundice. Unfortunately, they are often silent until this point. Patients cannot receive chemotherapy when jaundiced, and jaundice reduces their quality of life, so for most patients, drainage is indi-cated,” says Dr. Stavropoulos, who is also Adjunct Professor of Clinical Medicine at Columbia University College of Physicians and Surgeons.

Drainage is accomplished using endo-scopic retrograde cholangiopnacreatography (ERCP), which combines endoscopy and fluoroscopy. During ERCP, an endoscope is advanced just beyond the stomach into the duodenum to the small nipple at the bile duct’s opening. The physician inserts a wire through this opening and places a stent over the wire and across the segment obstructed by the tumor, achieving bile drainage and jaundice resolution.

Dr. Stavropoulos adds that such endoscopic drainage with ERCP may be impossible if large cancers obliterate the opening of the bile duct or obstruct the path to the duodenum.

Toward a Patient-Friendly Procedure

Today, many physicians in these circum-stances turn to percutaneous transhepatic biliary drainage under X-ray guidance, but this procedure — though safer than

Director of Winthrop-University Hospital’s Pancreas Program, John Allendorf, MD, Vice Chairman, Department of Surgery; Chief, Surgical Oncology; Director, Endocrine Surgery, uses robotic-assisted laparoscopic methods to perform minimally invasive surgery with unprecedented precision.

excellent safety and efficacy. During an EGBD procedure, Dr. Stavropoulos inserts an ultrasound-capable endoscope into the patient’s stomach and “sonars” the liver through the wall of the stomach to find the obstructed biliary ducts. Once a suitable duct is located, Dr. Stavropoulos inserts a needle into it through the stomach wall and liver tissue, and dilates the tract so a stent can traverse it. A stent is then inserted allowing direct drainage of bile from the obstructed bile ducts into the stomach.

Better BiopsyBile duct cancers are often smaller in

size than their pancreatic counterparts, but also obstruct bile ducts, cause jaundice and carry equally poor prognosis. Additionally, pathologists face great difficulties in con-firming a cancer diagnosis because bile duct cancers do not yield cells as easily.

Dr. Stavropoulos began using probe-based confocal endomicroscopy (PCLE) at Winthrop-University Hospital to solve the diagnostic problem posed by these small, scirrhous, fibrotic, scar-like tumors. PCLE, by providing 1,000-times magnification, allows the endoscopists to conduct an “optical biopsy” in real time, on live tissue. After intravenously injecting fluorescein to provide contrast, the tumor cells fluoresce, and within minutes, physicians can see the living cells almost with the same clarity and magnification as on a microscope slide.

“Three concentric scopes allow me to get into the bile duct through the intestines and examine a potentially malignant bile duct stricture,” Dr. Stavropoulos says. “A cholangioscope is inserted through the endoscope and into the bile duct until the stricture is visualized, and then the tiny probe that constitutes the confo-cal microscope is inserted through the cholangioscope. We can then scan the stricture to determine whether it is benign or malignant.”

The technology can also be used to examine mucinous cysts found in the pan-creas. In pancreatic cysts, a conventional biopsy is not possible; thus an optical biopsy is desirable. By inserting a needle through the wall of the stomach or duodenum into the cyst under EUS guidance and inserting the PCLE probe via the needle

into the cyst, physicians can examine the cyst wall at high magnification.

Only mucinous pan-creatic cysts can develop into pancreatic cancers. PCLE technology can be used to determine whether a pancreatic cyst is mucinous with a very high degree of accuracy. This examination may help healthcare providers decide whether to proceed with surgical resection or continued surveillance.

Plans for TreatmentAfter completing the diagnostic

phase, physicians present patients to the multidisciplinary conference to discuss treatment possibilities. Director of Winthrop-University Hospital’s Pancreas Program, John Allendorf, MD, Vice Chairman, Department of Surgery; Chief, Surgical Oncology; Director, Endocrine Surgery, explains that GI and hepatobiliary cancers can be extremely difficult to treat, and they require multidisciplinary expertise to construct efficacious treatment plans.

Stavros Stavropoulos, MD, Director of Endoscopy and Director of the Program in Advanced GI Endoscopy at Winthrop-University Hospital, demonstrates the scanning laser of the confocal endomicroscopy probe — the miniaturized microscope that allows real-time examination of live cells of tumors of the gastrointestinal tract at 1,000-times magnification.

HITTING THE PAVEMENT FOR A CUREOn Oct. 13, Winthrop-University Hospital sponsored the Lustgarten Foundation’s Long Island Pancreatic Cancer Research Walk. Participants raised more than $1.1 million.

RADIATION’S ROLE IN GASTROINTESTINAL (GI) MALIGNANCYRADIOTHERAPY’S ROLE IN the successful treatment of GI malignancies is controversial. A

mainstay in the United States, the modality’s efficacy hasn’t had the same support in Europe.

John Allendorf, MD, Vice Chairman, Department of Surgery; Chief, Surgical Oncology; Director,

Endocrine Surgery and Pancreas Program, explains that, while the jury may be out on the efficacy

of local radiotherapy as a primary treatment, radiation oncologists can play an important role

following surgical excision of a malignancy.

“If a tumor is close to the margins of what the surgeon removed — or at the margins — we

think there will be a high chance the patient will fail treatment and develop recurrent local

disease,” Dr. Allendorf says. “When this happens, we recommend radiotherapy. Additionally,

radiotherapy is helpful in palliating local symptoms, as well as stopping the oozing and

bleeding of tumors in the GI tract.”

CONFIRMING METASTATIC DISEASEWhen physicians suspect pancreatic cancer results from metastatic liver disease, interventional

radiologists can biopsy liver lesions to confirm their suspicions and then treat inoperable liver

tumors — as well as colorectal and neuroendocrine tumors — with an array of modalities, including,

radiofrequency ablation and radiofrequency embolization.

“When you bring all these disciplines together, you get varied perspectives on the treatments we’re able to offer and what the best course of action is for each individual patient,” Dr. Allendorf says. “The right thing to do for most of these patients is often not straightforward, so it’s good to hear colleagues’ perspectives in order to come up with a consensus plan for care.”

The key to successful treatment of pancreatic cancer is its operability, and Dr. Allendorf notes that surgical resection is critical for providing best outcomes. But patients whose cancer is surgically amenable are in the minority.

“Less than 20 percent of patients are considered to have operable tumors by traditional criteria, which means the tumor doesn’t involve any local blood vessels,” Dr. Allendorf says. “We can operate on these patients using standard surgical techniques, but the problem is that for every patient coming to my office with operable tumors, there are two who come with locally advanced tumors, meaning they involve local blood vessels and are inoperable by traditional criteria.”

For approximately 75 percent of patients with such tumors, Dr. Allendorf provides surgical intervention to resect and reconstruct tumor-involved ves-sels, which can include the portal vein, superior mesenteric vein, and sometimes the hepatic artery. The

remaining 25 percent, whose tumors aren’t amenable to such surgical downstaging, can glean similar benefits from Dr. Allendorf’s medical oncology colleagues, who provide a variety of therapies to reduce the tumor’s size to surgical operability and can even treat metastatic disease that traditionally has a lethal prognosis.

Downsizing Tumor ThreatsTo provide such innovative therapies,

Winthrop-University Hospital relies on nine experienced oncologists who incorporate their expertise and knowledge of treating other cancers into effective chemotherapy and biologic therapies.

Alexander Hindenburg, MD, FACP, attending physician in the Division of Oncology and Hematology in the Department of Medicine at Winthrop-University Hospital, explains that neoadjuvant chemotherapy before surgical intervention offers great promise, but suc-cessful implementation requires adept skill.

“We offer innovative, personalized thera-pies, and we monitor patients’ responses early, rather than later on,” Dr. Hindenburg explains. “Many of these cancers are hard to treat, so if you administer a blanket regimen and do not monitor patients carefully for

early response or progression, you might lose a substantial number of patients due to the disease’s inherent resistance to treatments. You have to be nimble at changing regimens when appropriate.”

Neoadjuvant chemotherapy and radiation can be administered for five or six months in an effort to shrink the tumor and make it surgically operable. Once treatment regi-mens conclude, physicians present patients at the multidisciplinary conference a second time, where surgeons determine whether surgical resection can be achieved. One of the chief goals of surgery is to remove the entire tumor and achieve negative mar-gins — a section of normal tissue around the resected tumor, indicating all diseased tissue has been removed — and neoadjuvant chemotherapy greatly improves the prospect of successfully achieving this goal.

Adjuvant chemotherapy regimens may be administered — sometimes in concert with radiation — following successful surgical resection to eliminate residual traces of malignancy that could grow and metastasize.

Metastatic disease is not surgically treat-able, and for this, oncologists are involved in investigational protocols involving biological therapies which aim to recontextualize the cancer to a manageable, chronic disease.

Close-up of the confocal endomicroscopy probe, a major technological breakthrough that has been described as the “world’s smallest microscope”

Dr. Stavropoulos, assisted by Scelven Edwards, GI Tech, uses probe-based confocal endomicroscopy.

Coordinated CarePatients are treated by a dynamic team

of oncology nurses and other clinical professionals in the Hospital’s new state-of-the-art Adult Oncology and Hematology Infusion Center, which offers the most innovative cancer treatments and therapies in a beautifully appointed and comfortable atmosphere. With 34 infusion chairs situ-ated in an open, comfortable setting, the Center is also equipped with an on-site pharmacy. Along the way, a specialized nurse navigator coordinates care to make the overall medical process experience more understandable, manageable and patient-centered.

Surgery for Benign ConditionsFor a broad swath of the patient

population, downstaging is unnecessary because they present with less aggres-sive, benign tumors. Although bereft of the threat inherent in metastatic growths, these tumors may require surgical intervention. Surgeons at Winthrop-University Hospital offer pancreas-sparing surgical procedures to remove these tumors and avoid post-operative complications typically related to removing portions of the organ.

The pancreas houses evenly distrib-uted cells that produce insulin and control blood sugar. It also generates digestive enzymes that afford proper digestion and effectively break down fats and proteins in food. Surgery to remove any part of the pancreas can greatly disrupt its functionality and can result in diabetes or pancreatic insufficiency.

Dr. Allendorf offers two pancreas-sparing techniques to avoid either complication. Enucleation allows surgeons to remove the tumor without compromising any normal pancreas tissue. Surgeons sew the surgical site so that, as far as normal pancreatic tissue is concerned, nothing ever happened.

Central pancreatectomy also spares as much normal pancreas as possible, and can be offered to patients with tumors located in the neck of the pan-creas. Traditional surgical methods don’t effectively reduce the amount of

pancreatic tissue removed in these situations.

“Standard surgery removes the entire tail of the pan-creas to get the tumor out,” Dr. Allendorf says. “To spare the parenchyma, we take out the center of the pancreas and then reconstruct the tail, which means we have to sew it into a loop of bowel or into the stomach so the digestive enzymes made by that piece of the pancreas have somewhere to drain.”

W h i le a t Colu mbi a University Medical Center, Dr. Allendorf investigated these methods and found that removing the tail of the pancreas resulted in postoperative diabetes for approximately 25 percent of patients, while those who underwent central pancreatectomy only faced a 2 percent chance of developing the disease.

Winthrop-University Hospita l surgeons also offer robot-assisted laparoscopic methods for distal pan-createctomy, which has previously been performed laparoscopically, but because parts of the pancreas are hard to reach and operate on with laparoscopic meth-ods, sometimes surgeons had to convert to open procedures. Increased articu-lation provided by the robot-assisted platform reduces the conversion rate and avails a minimally invasive surgical option for those patients whose choice was previously limited to open surgery.

One and DoneWhile minimally invasive surgical tech-

niques allay many complications associated with open surgeries, Dr. Stavropoulos’ expertise allows him to offer another state-of-the-art endoscopic technique to remove a variety of precancerous tumors. Most commonly, he treats patients with GI stromal tumors (GISTs) originating from deep-seated cells in the stomach musculature. If GISTs progress to cancer, they do so in a much slower fashion than adenocarcinomas. Nevertheless, these

cancers do spread and can be fatal, so they require attention.

Guidelines published by the National Comprehensive Cancer Network call for surgical removal of GISTs larger than 2 cm, and those between 1 and 2 cm be monitored with yearly endos-copy to ensure they do not progress to malignancy. Dr. Stavropoulos explains that patients undergo surgery or invasive endoscopic surveillance for many tumors which will never progress to malignancy, and he offers endoscopic full-thickness resection (EFTR) to patients whose GIST is smaller than 5 cm.

Alexander Hindenburg, MD, FACP, attending physician in the Division of Oncology and Hematology in the Department of Medicine at Winthrop-University Hospital, consults with a patient.

Winthrop interventional radiologists Jason Hoffman, MD (left), and Nicholas Georgiou, MD

Dr. Hindenburg (center) with some of the nursing staff from Winthrop’s Adult Oncology/Hematology Infusion Center, including (L–R) Diana Pasqua, RN, OCN, Nurse Educator; Irena Kosiorek, RN; Jill Feldman, RN; Lois Bonetti, RN; Doreen Powers, RN; Kelly Coen, RN; and Jaclyn Lyon, RN, OCN

“Instead of permeating anxiety by allowing GISTs to remain under life-long surveillance, I can remove the tumor through patients’ mouths in 45 minutes, and then they never have to worry about it again,” Dr. Stavropoulos says. “If everything goes perfectly in young patients, I can send them home the same day. After we take

it out, we’ll know the mitotic rate and tumor size. Mitotic rate is an important predictor of risk that is not available when the traditional sur-veillance approach is followed.”

The EFTR pro-cedure is possible largely due to the availability of the first full-thickness suture device for endoscopes recently approved by the FDA. Dr. Stavropoulos i n t e n t i o n a l l y perforates the stom-ach — which he notes

was previously anathema for endoscopists — making a hole about the size of a quarter, and removes the underlying muscle along with the attached tumor thus ensuring complete removal of the intact tumor with negative margins. Avoiding the leakage of gastric contents and using prophylactic antibiotics, he quickly closes the hole with the suture device.

“Essentially, I use natural orifice trans-luminal endoscopic surgery techniques to perform via patients’ mouths ‘scarless’ surgi-cal removal of tumors that traditionally have been removed through surgical incisions and surgical resection of often much larger portions of stomach or esophagus than through our approach,” Dr. Stavropoulos says. “The procedure carries the advantages of leaving no scars and reducing recovery times because of its minimally invasive nature. It eliminates the need for even the five incisions through the skin and muscle that are usually done when these tumors are removed laparoscopically.”

One Location for ExcellenceDr. Stavropoulos believes patients

benefit from these innovative techniques thanks largely to Winthrop-University Hospital’s administration — particularly Rich Rivera, the Cancer Institute’s and Department of Medicine’s Vice President for Administration — which allowed for the recruitment of top physicians who were provided with the highly advanced cutting-edge technologies and infrastruc-ture to innovate and lead their fields. The hospital’s commitment to patient care is demonstrated with every leading-edge capability and is manifest in the cancer program’s infrastructure.

Without support from the administra-tion, the team-oriented, patient-focused, disease-based approach to cancer care would be relegated to a number of solo practitioners practicing in disciplinary silos. Instead patients can access a comprehen-sive, multidisciplinary program with all cancer services located in one building, encouraging multidisciplinary interaction and improving patient care.

To learn more about the full breadth of Winthrop-University Hospital’s treatment options, please visit www.winthrop.org. ■

ENDOSCOPIC TREATMENT FOR GASTRIC CANCERAT WINTHROP-UNIVERSITY HOSPITAL, patients with gastric cancers may never have to

face open or laparoscopic surgery. Many centers treat early gastric cancers with surgery

or the newer, endoscopic mucosal resection (EMR) technique. Stavros Stavropoulos, MD,

Director of Endoscopy, Director of the Program in Advanced Endoscopy at Winthrop-

University Hospital, uses endoscopic submucosal dissection (ESD), a technique that

reduces recurrence rates while avoiding the invasiveness of surgery and the problems

associated with EMR, which include harvesting the tumor in multiple, heat-treated pieces

that don’t allow accurate assessment of the tumor’s margins.

“ESD solves the problems posed by other strategies,” Dr. Stavropoulos says. “It allows

complete lesion removal by making a perimeter incision that ensures all the cancer is

contained within the specimen.”

Dr. Stavropoulos has offered ESD to patients with gastric cancers since 2005. He notes

that, despite the modality’s improvement over traditional techniques, many academic

centers don’t offer it because it is technically challenging, more time-intensive and

offers little in the way of reimbursement incentives. Dr. Stavropoulos is one of handful of

physicians in the U.S. that have achieved mastery of the ESD technique and are involved

in providing training and proctoring in ESD at national and international courses. Through

the efforts of the physicians that pioneered this technique in the U.S. and also colleagues

from Asia where the technique was invented about 15 years ago, ESD is finally beginning

to be offered in more than the initial three or four pioneering centers in the United States.

Surveillance can generate anxiety, espe-cially when patients learn the tumor has grown even if the growth rate is minimal, say from 1.5 to 1.7 cm. Although such minimal growth doesn’t require action as it often lies within the margin of error of measure-ment, it frequently evokes fear and worry in a patient.

Reprinted from Long Island MD NEWS