Vadim Gushchin, MD, Director of Surgical Oncology at Mercy Medical Center talks about signet ring cell carcinoma and how it is being treated.
Interview conducted by Ivanhoe Broadcast News in March 2019.
I wanted to talk today about signet ring carcinoma. It’s something that a lot of people might not have heard of. What is it?
GUSHCHIN: Signet ring cell carcinoma can develop in any. Any organ. For example in the stomach, in the colon, in the appendix, in the rectum and for a clinician it typically means that it’s very difficult to treat. It spreads to other organs very early on. And the results of treatment are not that great typically.
This is a carcinoma that is mostly in the abdominal region and organs.
GUSHCHIN: Well there are a few other rare instances of signet ring cell carcinoma but typically it comes from the GI tract.
What makes it so difficult to treat?
GUSHCHIN: It is an aggressive tumor. Typically, it consists of very immature cells. That spread to the lymph nodes and to other places. Where the tumor is too small to be diagnosed and too small to cause any symptoms. For example, by the time a typical diagnosis of signet ring cell carcinoma of the stomach is made the entire stomach is engulfed in the tumor and that’s the reason the prognosis of this patient is very poor.
You said no symptoms or very few symptoms?
GUSHCHIN: Correct and this is probably because the tumor metastasizes when it’s still small.
Is this a common cancer?
GUSHCHIN: Well it really depends where the tumor starts. It is relatively common for the stomach. Approximately 20 to 40 percent of all gastric cancers may be diagnosed as signet ring cell. In colon cancer it’s a rarer malignancy. I would estimate it is about 10 percent of all cancers. So it’s not a histological diagnosis. A topical diagnosis but histological analysis.
It might sound like an odd question but why the name signet ring cell?
GUSHCHIN: Because it looks like a signet as a ring. Typically the appearance is produced by musin that is collected inside the cell and it kind of pushes the nucleus to the side and looks like a ring.
How is it diagnosed?
GUSHCHIN: Well it really depends where the tumor starts from. For example. In the patient that you got to know today, he did not have any symptoms. It was diagnosed on a colonoscopy as a small tumor of the appendix. It’s a really uncommon pattern of diagnosis. If it develops in the stomach patients may have indigestion or bleeding in the stomach.
What are the treatments? Does it depend upon the stage at which it’s at?
GUSHCHIN: So yes, the treatments depend upon the location where the tumor starts. And on the stage of the tumor. We suspect that in tumors with this histology the story is much more advanced than it looks at the beginning. We kind of assume the worst case scenario. Just by looking at the histology for example if we see a small tumor in the stomach and it has histology of a signet ring cell, we suspect that it has metastasized, and we’ve tried to prove ourselves wrong. So we do. Different types of biopsy, laproscopy to make sure that we are wrong in this case.
So there is surgical treatment usually?
GUSHCHIN: Surgeons typically have very bad luck with signet ring cell carcinomas. For example if you look for articles on surgical treatment of signet cell carcinoma of the appendix, there are very few publications you come across. Our center is known for a more aggressive approach. We relatively commonly operate on patients with these tumors. If the tumor starts in the appendix. I know that some of my colleagues do not share this approach and for good reason because a lot of serious patients treated surgically with this tumor show very poor survival. If we are very careful in selecting patients and reasonable in our surgical approach we personally achieve 30 to 40 percent five year survival. That means three out of 10 patients will survive for four or five years. Not so great. And it’s a matter of personal take on the matter. So that’s probably why we’re criticized.
What kind of a role does HIPEC play in the treatment?
GUSHCHIN: As I told you these tumors typically spread early on and they typically present with advanced disease. For example, signet ring cell. Tumors of the appendix spread on the surfaces of the bowel pretty commonly and that’s where the technique of site reduction surgery with HIPEC becomes very handy. And again this is a very aggressive treatment. The tumor is very difficult to treat and we think that the treatment matches the enemy.
Can you tell me a little bit about Mr. Gibbs?
GUSHCHIN: He’s a lovely person. I like him a lot. I remember him very well. He and his wife came to me very scared. They did not anticipate that he had a real problem. He had a colonoscopy. Possibly for small pain. I don’t remember the details but he didn’t have too many symptoms as far as I recall. And a colonoscopy showed a tumor. Because of the histology I suspected that there is much more than meets the eye. And unfortunately I was correct. We did surgery and found that the tumor had spread to many many more regions of the abdomen. That was obvious on the C.T. scan, on physical exam, and on other imaging studies. He had surgery and had a couple of pieces of bowel removed. And he had HIPEC. I have had a very guarded enthusiasm about his prospects and when we talked after the surgery he asked me ‘so what do you think my chances are.’ And I said the majority of patients tumors have recurred. And if that happens, the majority of recurrences happen in the first two years. And he said huh. Why don’t I take it easy for the first two years and spend more time with the family. He was extremely rational and he used this information about the biology of the tumor that we all present at meetings. He used it very wisely to his to guide his lifestyle. And he started charity work and he was active with the church. And he said well if I pass the two year mark I’ll feel better about myself. And I don’t know if he told you but he became an Iron Man. I never tried it myself. I’m pretty impressed with that. He takes his life one day at a time. And I’m very impressed by him. Very impressed.
Is he is approaching the two-year mark?
GUSHCHIN: He’s past. So far, no sign of recurrence. Last time when we saw each other, he was a little bit I would say cocky about this, and said why don’t we take the port out for patients who undergo this treatment and undergo chemotherapy after the surgery. Taking the port out is kind of is a sign that they’re doing well. And they are confident that the worst is behind them. So they don’t need to go back on the chemotherapy. And I’m typically very on the pessimistic and cautious side but we had a friendly conversation about that, very frank. He’s very open about that. And took the port out. So he’s enjoying his ‘my cancer story is behind me’ time. I surely wish him the best. I still have cautious thoughts in the back of my mind, but he’s doing very well so far.
How often will he be followed then? Every six months?
GUSHCHIN: We typically follow patients like that every six months. As time progresses and the probability of it goes down, we do imaging studies less frequently. And we see patients less frequently. But we never lose them from our side. We try not to.
Is there anything I didn’t ask you that you would want people to know about this type of cancer and the treatment?
GUSHCHIN: I would say that so far we do not have a magic treatment for these patients. I certainly don’t want your viewers to come from this interview with an idea that oh this doctor does amazing treatment surgery in HIPEC that cures everyone. No. It’s far from the truth. Our approach in research for example is to select these few patients who would benefit from this treatment and not to harm the rest. And that’s the key to our research: which patients would benefit, the patients with lymph nodes not involved with the tumor which is somewhat difficult to know before the surgery. The surgery patients with less amounts of tumor outside the organ. Will score the amount of tumor and patients under a certain score that would benefit more from it. But sometimes we become over optimistic, sometimes we have to hold ourselves back but we never stop looking for answers.
And just one more question on Mr. Gibbs, was it a certain stage of cancer when he was diagnosed?
GUSHCHIN: He was diagnosed with stage four appendix cancer.
So it had spread.
GUSHCHIN: It spread to many. Many organs. On top of many organs in the abdomen.
END OF INTERVIEW
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