For more than 120 years, Roswell Park Comprehensive Cancer Center in Buffalo, New York, has provided focused, comprehensive, and multidisciplinary care for cancer patients. Our focus has always been squarely on cancer – treating it, studying it, and training physicians and surgeons on how to do it better. Innovation in cancer care is at the heart of our practice. We strive to create new and better medical, surgical, and radiation oncology approaches across specialties to improve patient care and outcomes.
In this video, John M. Kane III, MD, FACS, chair of Surgical Oncology and Chief of the Melanoma/Sarcoma Service at Roswell Park, discusses some of the unique aspects of surgical oncology offered at the center and recent innovations in techniques.
Robot-assisted and minimally invasive surgical techniques for pancreatic cancers and upper GI malignancies are one of the specialties at Roswell Park experiencing innovative new approaches in recent years, including a unique robot-assisted approach to esophagectomy pioneered by our surgical teams.
Dr. Kane also discusses the long history and advances in technique and application of cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) for a growing range of cancer types, coupled with new research working to improve clinical outcomes.
Additionally, in this video, Dr. Kane explains new clinical trials in extremity melanoma and sarcoma surgery led by Roswell Park investigators, including work in isolated limb perfusion and infusion in sarcoma, and a novel therapeutic agent called CDL-137 being studied in treating advanced extremity melanoma and sarcoma.
Recent work in robot-assisted colorectal cancer and surgical procedural innovations is also covered in Dr. Kane's discussion, including advances in treatment approaches for certain rectal cancer patients who may avoid surgery after neoadjuvant chemotherapy.
historically our department has been very strong in the upper gi malignancies. Pancreas cancer and also esophagus and esophageal gastric cancer. Many of our faculty on the esophageal gastric side have really developed a unique expertise and minimally invasive ISAF ejecta me. This was initially based on a laparoscopic approach um and have some of the largest series in the country in terms of treating these patients with well defined clinical pathways. But over the last couple of years we've really ramped up our robotic pancreas program where a significant number of both our distal pancreas cancers as well as our pancreatic head and other um associated ambulatory duodenal malignancies are being treated with a robotic approach. They then took that robotic approach and extrapolated it into the esophageal realm. And so they've developed a very unique technique with a robotic assisted um soft ejecta. Me, it's basically kind of a modified Ivor Lewis with a stapled side to side anastomosis. And because we have such a large experience with esophagus cancer. We've recently been comparing that outcome to the outcome with more traditional laparoscopic approach. Probably have done about 80 patients by the robotic approach to this point. And some of the primary findings have been very interesting. Um the first has been that there's been a decrease in grade two or higher complications. So clearly the robotic approach has been beneficial from a patient recovery standpoint. There's been a trend that's pretty significant to decrease the systematic leaks. A lot of these patients have had neo adjuvant chemo radiation. You've got this anastomosis with your gastro conduit with a robotic approach. And doing it this way. We're seeing leak rates as low as 3%. And this is actually translated into a decrease in length of stay by about one day. You know we have this experience with robotics and other gi malignancies by kind of taking an area that we already had some strengthen with laproscopic, minimally invasive soft ejecta. Me we've now moved into the robotic realm And think it's something that's very unique and beneficial to that patient population. So one of the things that has been part of my career and actually part of the department for a long time is slightly reductive surgery and hypothermic intraperitoneal chemo perfusion or high peck. We have had a high packed program here at Roswell Park since 2002 when I came here. And over time it's become very robust. I know that there's a lot of places that have high peck programs but I think ours is unique from several aspects. The first is that we currently have four surgeons that do I pack not only have we really focused on the clinical aspect, we probably approaching almost 400 patients. Um since its inception we've also expanded the indications for another. Do we do appendices? Colorectal, we have mesothelioma patients we've combined with our gynecologic oncology service and we've done patients with recurrent or refractory ovarian cancer and then some other rare peritoneal malignancies. Um Desmond, plastic small round cell tumors in the pediatric population. There's now several surgeons dr skits key has been doing it for several years. Doctor man and we've recently added dr O'brien really because there's such a high clinical volume, this is a technique that developed without really having a lot of pre clinical data. And so dr skits key in the lab really took it upon himself to try to define some of these variables for cider reduction, high pecking the outcome. We can look at time, temperature, drug dose, ng, we can look at different histology, ease. And so we've really tried to put the science behind what we do clinically. Some of our faculty that are involved in high peck have done international surveys of high tech surgeons looking at variables that they think are important patient selection. We did a big patient experience project where we focused on patients and you know sort of asked them what were your expectations? Was this what you thought it was going to be? How could we make the process better. We've also focused on improving the, you know, the outcomes and the time the patients in the hospital. We've developed Iran's pathways. We've published on some novel ideas like inter operative fluid restriction to you know, decrease postoperative complications and improve length of stay along those lines. The payers have been very happy to, you know, this is something that is a very unique patient population by being very transparent with our outcomes and expectations are local. Players have almost never denied us doing cider reduction high pick because they know that we really have a good high quality program but that's not the only things that we do in the department. And I think as a tertiary, you know en ci cancer center, we're always trying to come up with new and better treatments historically. We've also had a very robust melanoma and sarcoma service. And for those of you that treat those diseases, we know that some patients with extremity sarcomas develop recurrent disease or present with locally advanced disease where you may not have a limb salvage option. And you know, amputation is the only surgical choice at that time in terms of melanoma, we have a lot of patients that develop extensive in Transit disease. Um you know, so it's no longer surgically respectable. Sometimes that does not respond to our current immuno therapies or targeted therapies from some of our pre clinical laboratory work. We have a unique agent called CBL 1 37 and that is kind of a novel agent that has a unique molecular target called fact. And so when you deliver this agent and it interacts with fact, you get don regulation of NF kappa B. You get done regulation of heat shock factor one and you get activation of P 53. So these all lead to decrease cancer proliferation suppression of tumor growth. Um what's interesting is it has a first pass effect. And so there's very minimal toxicity. So dr skits kie has developed a phase one trial where we're doing inter arterial CBL for patients with advanced extremity in transit melanoma or sarcoma. We've already gone through the rapid dose escalation phase and as expected we've seen zero toxicity. This is essentially non toxic. It's essentially a 15 minute intra arterial infusion. It's catheters placed by interventional radiology. It's essentially an overnight stay 23 hour observation for the patient in the hospital, mainly for some correlative studies in laboratory work. And we've seen some early responses. So this is a trial that's actually currently open. It's open to anybody in the United States. Um It is an en ci clinical trial but this is really something that could be very promising for patients with advanced extremity melanoma or sarcoma is where we may be able to get control of their disease without amputation or other extensive treatments as we all know. It's very important to provide outstanding clinical care and also come up with new treatment options for patients with cancer. But the quality of life of the patients is also very important. And so within the department we really focused on that much like our upper G. I forgot service where there's a big emphasis on robotic surgery and the colorectal department led by dr knockin. We probably have one of the largest experiences in the region with robotic colorectal surgery. We're now probably reaching 500 plus patients from that standpoint. That's important. And that's good. But the flip side of that, as we all know, is with rectal cancer patients that get multi modality therapy. Some patients actually get a clinical, complete response by the rectal cancer from the neo adjuvant chemo radiation. And historically the treatment algorithm has still been to take those patients to the operating room and do the rectal resection. Um Oftentimes with the patient being left with a permanent colostomy. So DR Nurcan has really started to focus on identifying which patients may benefit from a non operative watch and wait approach. So we've now been doing that for about 10 years. So some of the first patients literally have 10 years of follow up, we're probably approaching over 100 patients. What we've seen is only about 25% of the patients will ultimately need some sort of surgical treatment for the primary rectal cancer. Either prostatectomy, transitional excisions, something like that. It's very structured, very rigorous. You know, clearly we want the patients to have the safest outcome possible. But we're really starting to learn a little bit more about rectal cancer and which patients may not need to undergo completion surgery after their neo adjuvant therapy. And so if you're one of those patients, you know, your quality of life is clearly much better if your neo adjuvant therapy led to a complete response and you didn't need surgery versus needing to go to surgical resection. So that's been very promising. A lot of very happy patients in our area with rectal cancer that have just continued to have surveillance. You know, sigmoidoscopy is colonoscopies but have not needed surgery.