Innovations in the OR
Surgeon scientists are testing unconventional therapies in the operating room
A cadre of elite surgeons is making a mark as pioneering researchers at MD Anderson. In the operating room, they’re not just excising tumors, they’re testing innovative therapies to stop cancer in its tracks.
The surgeons you’re about to meet have dedicated their careers to curing and preventing cancer, often through less-invasive procedures. Curiosity spurs their motivation: Can doing less to patients — or something dramatically different — allow doctors to manage their disease and return them to a reasonable quality of life?
To get answers, their patients have enrolled in clinical trials that unfold in the operating room and are often over in just minutes or hours.
Robotic surgery or radiation?
Neil Gross, M.D., associate professor of Head and Neck Surgery, wants to know how well patients regain normal function after treatment for cancers affecting the back of the throat, the base of the tongue or the tonsils — an area known as the oropharynx. He’s comparing patients who had surgery to those who had radiation.
It’s an especially timely question, because these cancers, called oropharyngeal cancers, are up 225% since the late 1980s. Researchers associate this rise with the spread of the human papillomavirus (HPV) — the most common sexually transmitted virus in the United States.
Radiation and chemotherapy traditionally have been used to treat oral cancers, and patients’ prognoses are generally good, Gross says. But long-term side effects of radiation include scarring, tightness in the throat, trouble swallowing and loss of saliva.
Before 2009, surgery wasn’t a commonly used option because it meant splitting the jaw to access the cancer. That’s when the Food and Drug Administration approved the use of robotic surgery for head and neck cancers.
Gross became one of the first surgeons to perform the less-invasive surgery.
In his latest study, Gross is collecting data from patients who’ve undergone either robotic surgery or radiation to treat early-stage oropharyngeal cancer. Participants wear a Fitbit-style band that tracks their daily activity and provides Gross with a better understanding of the impact various treatments have on patients’ quality of life.
NEIL GROSS WAS AN EARLY ADOPTER OF ROBOTIC SURGERY TO TREAT
HEAD AND NECK CANCERS.
“Operative robotic technology has improved. So now we can access these areas surgically that we couldn’t access very well before,” he says. “My hope is to offer patients as many options as possible and then help them choose the best treatment.”
A less-disruptive surgery for endometrial cancer
Women who have advanced or difficult-to-treat cancer in the lining of the uterus face the dangerous risk of the cancer spreading from the uterus to the lymph system in the pelvic and abdominal area.
To determine if this has happened, doctors typically remove all the lymph nodes in that region at the time of initial staging surgery. However, the surgery can cause complications for women who are obese, and for those who have diabetes or high blood pressure.
Pamela Soliman, M.D., associate professor of Gynecologic Oncology and Reproductive Medicine, is leading a study to pinpoint precisely which lymph nodes are the most likely to be invaded by cancer of the endometrium — the lining of the uterus.
In the operating room, participants undergo sentinel lymph node mapping followed by a full lymph node dissection, the current standard of care. Early findings suggest that in the future, surgeons may need to remove only patients’ sentinel nodes — the first few lymph nodes into which a tumor drains — as opposed to all their lymph nodes in the affected region.
This shift away from complete lymph node removal has been proven when treating melanoma, breast cancer and vulva cancer, Soliman says.
“It’s a little more challenging in endometrial cancer because the lymphatic drainage in the uterus appears to be multi-channeled. It doesn’t follow one pattern,” she says. “But, at least so far, we’ve had a good accuracy rate.”
Smart bombing brain tumors
For some patients of Frederick Lang, M.D., getting a virus is just what they need.
The Neurosurgery professor is working to wipe out brain tumors using an active and highly virulent adenovirus — the kind that causes the common cold.
“We go to the operating room and inject the virus into the tumor for 10-15 minutes,” says Lang. “The patient theoretically doesn’t have to do anything more. There’s no chemotherapy after it.”
The virus has been engineered to multiply and attack cancer cells while leaving healthy cells alone. In some patients, it even alerts the immune system to fight the tumor, a concept called antigen spread.
In a recent clinical study, the virus — combined with antigen spread — completely eliminated glioblastomas in three of Lang’s patients. Although the tumors later returned, the patients lived three to four years longer than what’s typical. Other patients in the study lived an average of nine months longer.
For Lang, the question now becomes: How do we create antigen spread in everyone?
Juan Fueyo-Margareto, M.D., professor of Neuro-Oncology, and Candelaria Gomez-Manzano, M.D., associate professor of Neuro-Oncology, may have the answer.
The duo created the amped-up adenovirus used in Lang’s clinical trials. Now, they’re using discoveries by James Allison, Ph.D., chair of Immunology, to further modify the virus to prompt an immune response.
“If we can make the virus activate the immune system the way we want, then we’ve got the solution all packaged in the virus,” Lang says.
For more on this approach, see “Unleashing the cold virus to kill cancer”.
When less is more
Kelly Hunt, M.D., ad interim chair of Breast Surgical Oncology, envisions a future where some breast cancer patients avoid surgery altogether.“
That’s where the field is going,” she says, pointing out the evolution from pre-1970s radical mastectomies to today’s breast-conserving therapies.
Hunt helped lead a study that confirmed women with early-stage breast cancer don’t need to undergo aggressive lymph node removal to stop the cancer’s spread. The study led to a new standard of care for breast cancer patients worldwide.
“We’re now starting to look at the same paradigm in women with more advanced breast cancers,” Hunt says.
Along with physician researchers like Henry Kuerer, M.D., Ph.D., and Abigail Caudle, M.D., in her department, Hunt is offering candidate patients who have advanced breast cancer the option of removing fewer lymph nodes.
“Because the standard treatment has been performed for so many years, it’s hard for physicians and patients to accept that you’re going to take something away and do something less radical and still get the same outcomes,” Hunt says. “That’s why trials are needed to prove this had to be done.”