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Curing esophageal cancer without surgery

October 10, 2019 | UCI Health
esophageal cancer survivor alwyn kong and his dog shaggy
Esophageal cancer survivor Alwyn Kong with his dog, Shaggy.

When Alwyn Kong, 59, learned he had esophageal cancer, the stunned Foothill Ranch man was faced with a grim picture of the next few months of his life.

He would undergo two operations:

  • The first would include inserting a feeding tube into his stomach to provide nutrition over the challenging weeks ahead.
  • During the second operation, doctors would insert instruments into the abdomen to remove the tumor as well as part of the esophagus and upper stomach, with the surgeon bringing the upper stomach into the chest area to connect it with what remained of the esophagus.

“Even the amazing esophageal cancer surgeons at UCI say the only thing worse than having esophageal cancer is having esophageal cancer surgery,” says UCI Health gastroenterologist Dr. Jason Samarasena, associate professor of medicine at the UCI School of Medicine.

That Kong woke up from his surgery in late June 2018 without a single incision on his body, no feeding tube, his tumor gone and his stomach where it belongs is a testament to the wonders of medicine and the immense talent of the medical team at the UCI Health Digestive Health Institute (DHI).

uci health gastrointestinal surgeon dr. jason samarasena and alwyn kongRemoving tumors without cutting

Not content with the status quo, the digestive disease team at Orange County’s only academic medical center has, over the past several years, mastered a challenging procedure called endoscopic submucosal dissection (ESD), which allows them to remove some types of digestive tract tumors through the mouth.

“At the time I was diagnosed, they had to give me the worst-case scenarios,” Kong recalls. “It was a horrific rundown of what the procedure looked like. After the surgery, I realized I just avoided something unbelievable.”

The CDDC has been striving to avoid “worst-case scenarios” since its founding in 1993, says DHI Director Dr. Kenneth Chang, an endoscopic gastroenterologist and a professor at the UCI School of Medicine. The center provides care for benign and cancerous tumors of the colon, rectum, stomach, pancreas and esophagus, as well as treatment for gastrointestinal reflux disease (GERD) and a precancerous condition caused by GERD called Barrett’s esophagus.

A major focus is performing minimally invasive treatments whenever possible.

“We have the first and only endowed chair in the country that is devoted to treating cancer with endoscopy,” Chang says. “Care at DHI starts with a passion, a philosophy and that focus. Gastrointestinal oncology has always been central to our origins.”

Concerns about acid reflux medications

Being diagnosed with a gastrointestinal cancer was not what Kong expected when he saw his gastroenterologist in June 2018 for a routine colonoscopy. It had been a difficult time for the human resources executive. His adopted son had recently died after a seven-year battle with lung cancer. Kong’s mother died suddenly a month later.

When Kong went in for his colonoscopy, his doctor suggested he also undergo an upper-GI endoscopy, a procedure in which the doctor inserts a camera through the mouth into the esophagus to look at the health of the esophageal lining. The physician was concerned because Kong had been taking medication for acid reflux, which can cause inflammation and damage to the esophageal lining.

“I kept telling him, ‘I feel fine,’” Kong recalls. “But he said he would do it during the colonoscopy, and I wouldn’t feel a thing. Finally I said, ‘Yeah, you’re right.’ It was the craziest thing; I had no symptoms so I almost didn’t do it.”

The results, including a biopsy, showed a small malignant tumor deep in the esophagus. Kong’s doctor promptly referred him to UCI Health surgeon Ninh T. Nguyen, MD. Nguyen described the typical esophageal cancer surgery to the stunned Kong.

“I felt overwhelmed,” Kong says of the diagnosis. “I was trying to process everything. It was going in one ear and out the other. I felt good that the doctors were trying to be slow and patient, but the emotional side takes over. I really just sat there dumbfounded.”

Reputation for innovation comes into play

Pre-surgical tests were ordered, including an endoscopic ultrasound conducted by Samarasena, to determine the tumor’s size and precise location. That’s when the CDDC’s reputation for innovation became a reality for Kong.

Studying images of the tumor, Samarasena saw an opportunity to use ESD and spare Kong from the traditional surgery because the mass was confined to the submucosal layer of the esophagus and had not penetrated the muscle wall.

“Dr. Sam looked at the data, consulted with the other doctors and called me,” Kong says. “He said he thought I was a good candidate for something experimental. He said, ‘It’s possible we can cure you without cutting you open. What do you think?’ I was scared, but he sounded excited. I could hear the confidence in his voice.”

Embracing innovation

During ESD, the patient is given general anesthesia and the endoscope is passed through the mouth and into the esophagus. The surgeon injects fluid into the submucosa to float the tumor away from the esophageal wall then carefully begins to scoop it out and remove it through the patient’s mouth.

“It’s a relatively new procedure in the United States, but it has been around many years in Japan where the surgery was created to treat stomach cancer,” Samarasena says. “In the U.S., we don’t have much stomach cancer so we’ve never needed the expertise and training programs to learn that skill.”

Organ-sparing procedure

Uses for ESD expanded to other areas of the GI tract. Besides early esophageal cancer — which has increased in incidence in the United States in the past two decades — it can be used for some colon cancers and precancerous colon polyps, Samarasena says.

The first ESD procedure done at UCI was in 2005 when a trainee of Chang’s learned the technique in Japan and brought it back to his mentor. The CDDC now has one of the busiest ESD practices in California, performing the procedure at least once a week.

“This is an organ-sparing procedure that can be applied anywhere there is a GI cancer,” he says.

Cancer 100% gone

An ecstatic Kong went home the day after surgery. Other than a sore throat that made it difficult to eat for a few days, he was as good as new. 

“On day three after surgery, Dr. Sam called and told me pathology confirmed that he had cut all the way around the tumor with clear margins [the tissue around the tumor was cancer-free], and the cancer was 100% gone,” Kong says.

At 5 centimeters by 3 centimeters, it also was larger than they originally thought because almost half the tumor had been obscured by a fold in his esophagus.

Getting at root causes

Kong wasn’t finished with UCI Health, however. Samarasena next delved into the reasons why he may have developed the cancer — gastric reflux — and sought to make sure new tumors wouldn’t form.

A few months later, Kong was treated for Barrett’s esophagus to remove precancerous cells via another endoscopic procedure called radiofrequency ablation to heat and destroy the abnormal tissue.

He has had two more treatments in the last year to remove additional growths and expects to have more checks to remove growths that could become cancer. “I tease Dr. Sam that we’re going to know each other for the rest of our lives,” Kong says with a laugh.

Caring for the whole person

In addition, Samarasena referred him to Dr. Maria Victoria Peralta, a UCI primary care physician, who is addressing Kong’s cardiovascular health, nutrition and psycho-social issues related to the deaths he experienced.

“The level of care I’m getting right now at 59 years old is amazing. I’m so far ahead of things,” says Kong, who’s delighted that he is able to keep up with Shaggy, his late son’s energetic and much beloved dog.

“I know what I’m going to need to focus on in the next 20 years. I’m not afraid to go to the doctor, and I love these people like my own friends.”

More cures, less-aggressive treatments

Meanwhile, ESD surely won’t be the last innovation at the CDDC. As an academic health system with a National Cancer Institute-designated comprehensive cancer center, UCI Health is charged with performing the research and development that leads to more cures, less-aggressive treatments and better quality of life for patients.

“There has been a lot of innovation in the last few years,” Samarasena says.

“This area of minimally invasive detection of GI cancers has been one of the biggest breakthroughs. The scope and instrument technology has gotten more and more refined. We’re able to do things so meticulously. When I finished my training eight years ago, none of this stuff was around.”

ESD still isn’t offered everywhere. But Kong didn’t have to go far to find state-of-the-art care near his Orange County home.

“I knew nothing about UCI Health before this,” he says. “But I have had an amazing experience all the way around. I swear by UCI. No one else is going to touch me.” 

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