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Incision-less procedure saves esophageal cancer patient’s life

February 12, 2021 | Valerie Elwell

Patrick Aurignac is grateful for his care at UCI Health and for Dr. Jason Samarasena, whose "focus on earlier detection and minimally-invasive treatments gave me a great outcome. I'm able to continue living a normal life."

Troubled by bouts of rapid and irregular heart rhythms, Patrick Aurignac's cardiologist ordered a CT scan to take a closer look. The radiologist spotted a lesion-like growth in his esophagus. Aurignac was sent immediately to a gastroenterologist. An endoscopy revealed high-grade dysplasia, a mass of precancerous cells. A biopsy was ordered.

On Christmas Eve of 2019, the gastroenterologist confirmed that the growth appeared to be precancerous. “We won’t be sure until after we get the pathology report, but it doesn’t look like cancer," he told Aurignac. "It’s still something we need to be concerned about, but have a good new year. You’re going to be fine.”

A week later, while driving home to San Luis Obispo after attending a Los Angeles Lakers’ game with his two sons to celebrate his 53rd birthday, the doctor called to say that the lesion was far more serious than he'd thought. “Patrick, I’ve never seen anything like this that wasn’t cancerous.”

Aurignac was stunned. “How could this happen? I had never even smoked. I had to live with that news for four or five days because of the holidays.”

Searching for answers

After many sleepless nights, he met again in early January with the gastroenterologist, who advised him to take an over-the-counter heartburn medication for a month to reduce the inflammation in his esophagus so they could take another look.

A real estate developer, Aurignac is not one to wait around. “I said to myself — no, I’m going to figure this thing out — and I started calling the top cancer hospitals in the country to get a second opinion.”

The two cancer centers he contacted couldn’t see him until March, but he booked the appointments anyway. A few days later, while staying at a hotel in Newport Beach, a magazine headline — Top Docs of Orange County — grabbed Aurignac’s attention.

As he read the article, he noticed UCI Health interventional gastroenterologist Dr. Jason Samarasena, who was listed as an expert in advanced endoscopic techniques to treat esophageal diseases, including cancer — and he had a 5-star rating.

“I thought, this is perfect! I’m in Newport. He’s just up the road. This is the guy!” recounts Aurignac.

The next day, he emailed Samarasena and within two hours had a response asking him to come in a few days later.

Aurignac jumped at the chance. Samarasena, director of advanced endoscopic imaging at the UCI Health Digestive Health Institute, scheduled him for a Cellvizio® confocal laser endomicroscopy to get a more targeted, accurate diagnosis of cells, lesions and tumors than the earlier endoscopy.

See Samarasena and Aurignac describe his journey to health ›

Early detection is key

Once he had those results in hand, Samarasena determined that Aurignac did indeed have esophageal cancer, but he said the tumor was superficial enough to do a minimally-invasive outpatient procedure called esophageal submucosal dissection (ESD).

Patients diagnosed with esophageal cancer usually undergo an esophagectomy, a life-altering surgery that involves removal of all or part of the esophagus, part of the stomach and nearby lymph nodes to prevent any residual cancer cells from spreading to other parts of the body. The remaining portion of the stomach is then connected to what is left of the esophagus.

With ESD, however, the patient is given general anesthesia and an endoscope is passed through the mouth and into the esophagus. The physician injects fluid into the layer beneath the mucus lining, called the submucosa, to float the tumor away from the esophageal wall, then cuts underneath the tumor to remove it in one piece, ensuring that all the cancer is gone.

“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,” says Samarasena, who is one of only a handful of U.S. gastroenterologists trained in the procedure.

Awaiting the pathology report

Immensely relieved that he could avoid an esophagectomy, Aurignac had the ESD procedure on Jan. 31, 2020, and it went off without a hitch.

Samarasena told his patient that he was pretty confident he’d removed the entire tumor, but wouldn’t know for sure until he received the pathologist’s report. If the tumor had penetrated deeper into the submucosal layer or if cancer cells had spread to nearby lymph nodes, Aurignac would still need an esophagectomy.

A few days later, Samarasena called with the results, saying, “Patrick, we just barely got it in the nick of time. It wasn’t too deep and there is no lymphatic involvement.”

Samarasena also said the patient had Barrett’s esophagus, essentially precancerous cells damaged by repeated exposure to stomach acid. It usually develops after years of gastroesophageal reflux (GERD), commonly known as heartburn.

“I had no idea that my esophageal cancer started with acid reflux," Aurignac says. "Mine is called silent reflux. It was happening at night while I slept.”

Another change in diagnosis

A few days later, Samarasena called again, this time to say the pathology team on further analysis determined that the tumor had penetrated deeper into the esophageal wall than they had originally thought. There was a 40% chance that it would metastasize. Unfortunately, he said, he had to recommend an esophagectomy.

Aurignac was adamant: “No way, I’m not doing it. I’ll take the risk. If we see something during my follow-up visits or involvement in the lymph nodes, I’ll reconsider it then."

He still had his March cancer center appointments, so he informed the gastroenterologist that he would be getting a second opinion. 

“I was really impressed that Dr. Samarasena didn’t hesitate and provided all my lab work and slides to take with me," Aurignac says.

"He was patient and methodical. He really wanted the best outcome for me.”

Barrett’s makes diagnosis difficult

Determining precisely how deep a tumor penetrates the esophagus is one of the most important indicators when diagnosing esophageal cancer.

Unlike other regions of the gastrointestinal tract, precancerous Barrett’s cells make accurate staging difficult because they can create a duplicate layer of mucosal tissue that looks like the deeper, more serious submucosal invasion on scans.

At his appointment in New York City, the cancer center's top-ranked esophageal surgeon thought Aurignac’s tumor had only penetrated the duplicated mucosa with an 8% to 10% chance of metastasis. The hospital tumor review board disagreed, finding that it had reached deep into the submucosal layer and that an esophagectomy was needed.

They scheduled his surgery for April 2 and Aurignac flew home on March 15.

Then COVID-19 hit and the whole world shut down. “Naturally, I was not going to fly back to New York City for surgery with the surge going on,” he says.

A third opinion

Aurignac was able to reach the Texas doctor he had an appointment with, explaining his situation by email. The cancer specialist promised to review Aurignac's scans. UCI Health even helped expedite sending the New York City hospital's medical records to Texas within the week.

Three Texas pathologists agreed that Aurignac's tumor had been excised from duplicated mucosa. Via a telemedicine consultation, the Texas cancer surgeon advised Aurignac against the esophagectomy.

“I was so relieved,” Aurignac recalls. “I recorded the conversation and sent it to Dr. Samarasena immediately. He thanked me for the tape and said he would send my slides to the top pathologist in the United States."

That pathologist also confirmed without a doubt that the tumor had been in the duplicated mucosa with no lymphatic involvement and that there was no reason to do an esophagectomy. Aurignac was thrilled by the news.

Cleared of the cancer, Aurignac still comes from San Luis Obispo to UCI Medical Center in Orange every three months for treatment of Barrett's disease. He undergoes radiofrequency ablation (RFA) to remove the precancerous Barrett’s cells and has additional tests to monitor his condition.

When Aurignac finishes RFA treatments in May, he'll be monitored every six months for the next two years, then once a year for the rest of his life. He’ll also continue taking heartburn medication twice a day to reduce acid levels and inflammation. The irregular heart beats — atrial fibrillation — he used to experience three times a week have become a rarity.

Stop-at-Nothing care

Aurignac is amazed by the care he’s received at UCI Health and has only praise for Samarasena. “He’s been a good captain of my ship and I feel like I can confide in him. He was available at all times and made me a priority. The whole team made me feel like family.”

He also appreciates that Samarasena and the DHI team are at the forefront of efforts to find the latest methods to prevent, detect and remove esophageal cancer at its earliest, most treatable stage.

“We are getting so good at treating Barrett’s esophagus and early esophageal cancer that when someone comes to me and it’s diagnosed too late or is too deep into the wall, it really breaks my heart,” says Samarasena.

If it were up to him, early testing for esophageal diseases would become as routine as colonoscopies are today — catching benign and precancerous polyps before they can become colon cancer.

“Dr. Samarsena's focus on early detection and minimally-invasive treatments gave me a great outcome," Aurignac says. "I'm able to continue living a normal life.”

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