In November 2018, the Minimally Invasive GI Surgery team at Cedars-Sinai was approached by Youram Nassir, MD, a referring oncologist, to look into a challenging and complex case of a male patient in his early 50s who had been diagnosed with stage 4 stomach cancer.

Miguel A. Burch, MD, chief of Minimally Invasive GI Surgery at Cedars-Sinai, presented the case to the upper GI tumor board, which included pathologist Kevin M. Waters, MD, oncologist Jun Gong, MD, and radiation oncologist Robert S. Reznik, MD.

"The referring physician asked if we would ever consider surgery on this gentleman," Burch says. "Normally stage 4 gastric cancer is not curable, and surgery has been avoided in the past."

Gastric cancer remains one of the deadliest cancers worldwide. In the U.S., roughly 40% of all stomach cancers are diagnosed at stage 4, and the five-year survival rate for patients diagnosed with stage 4 gastric cancer is only 5%.

Unknown to the referring oncologist at the time, the GI surgery team at Cedars-Sinai was already well-versed on recent research out of Germany that identified a highly selected group of patients that could enjoy a significant benefit from surgery.

The 2017 study, published in JAMA Oncology and funded by the German Research Foundation, was the first prospective study to evaluate neoadjuvant chemotherapy with FLOT, followed by surgery in patients with low-volume metastatic disease in gastric and gastroesophageal junction cancer. The authors concluded that patients with limited metastatic disease who received FLOT neoadjuvant chemotherapy and proceeded to surgery showed a favorable survival advantage, with median survival rising to 33 months.

"This was a multidisciplinary decision from our tumor board," Burch says. "We looked at the case carefully and started finding factors that made surgery seem more plausible, so that we could offer the patient options."

Read: The Newfound Impact of a Shortened Esophagus for Hiatal Hernia Patients

The decision to do the surgery was tough for both the GI Surgery team and the patient, who would have to stop undergoing chemotherapy for three months before the operation could occur. 

"This was a big ask," Burch says. "When we discussed with him the possibility of surgery, he had sort of felt like chemotherapy had been keeping him alive for six months. It was a nerve-racking decision for him to trust us to come off chemotherapy for three months. To basically say to him, 'If your tumor doesn't progress, you have a shot at getting this thing removed.'"

The patient underwent a minimally invasive gastrectomy with a brief hospital stay and quickly returned to his baseline—ready for the likelihood of additional chemotherapy after discharge. After surgery, the pathology team ran molecular profiling of the tumor and found that the patient had medullary carcinoma of the stomach, a very rare subtype of gastric cancer.

With gastric medullary carcinoma, the cancer is not very chemo-sensitive, explains Burch. Rather, this type of gastric cancer would be responsive to immunotherapies.

"With a surgical specimen instead of just biopsies, for the first time the cancer was able to be looked at in its entirety," Burch says. "The results of that were a total surprise—that he had this extraordinarily rare tumor that would be responsive to new therapies."

A year after surgery, the patient is in remission without any evidence of tumor and "doing great," Burch says. "He has a normal quality of life."

Burch says the collaboration and dedication among the referring oncologist, the Minimally Invasive GI Surgery team and the upper GI tumor board at Cedars-Sinai led to the remarkable results of this particular case.

"We took a patient who normally would be advised to consider end of life options, like hospice, and gave him a shot at a long-term survival," Burch says. "All aspects of this patient's surgery and treatment required an immense attention to detail, exceptional operative care and working collaboratively with the physicians who referred the patient to Cedars-Sinai and now care for him in the community."

Burch says the culture at Cedars-Sinai, one of taking complex problems and solving them in teams, was instrumental in the successful outcome of this surgery.

"The stakes of this case were incredibly high," Burch says. "It's a testament to everyone involved—not just the surgeons, but the radiation and medical oncologists, the pathologists, everyone—that we were able to give this patient a chance at a prolonged survival."

More on the Surgery Program at Cedars-Sinai.