The new

“The generosity and foresight of the Cayton Goldrich Family Foundation gave us the resources to conduct outreach and coordinate care for these patients,” said Cristina Ferrone, MD, chair of the Jim and Eleanor Randall Department of Surgery at Cedars-Sinai. “By bringing together our dedicated physicians and recruiting top talent from around the country, we are making this centralized BRCA center unlike any other.”

Individuals of Ashkenazi Jewish descent, and those with family history of breast, ovarian, prostate or pancreatic cancer, or people who have been diagnosed with one of these cancers, should be screened for BRCA1 and BRCA2 mutations, Ferrone said.

Cancer Screenings

“This center will provide every relevant service: comprehensive risk assessment, state-of-the-art surveillance, prevention strategies, clinical trials, and access to the latest scientific discoveries,” said Farin Amersi, MD, a surgical oncologist who treats patients with BRCA mutations. “More importantly, it will create a true home for patients and families facing hereditary cancer risk.” 

A patient’s first visit to the center begins with genetic counseling to help patients understand their unique cancer risk. For women, the initial visit also includes a breast MRI or mammogram, and a pelvic ultrasound and blood test to screen for ovarian cancer. Men undergo imaging to screen for breast cancer and an exam and blood test to screen for prostate cancer. For pancreatic cancer, both men and women may have abdominal imaging and discuss the possibility of endoscopy screening, depending on their individual risk.

“At many other institutions, patients diagnosed with a BRCA mutation have to make appointments for each of these screenings separately, with different physicians,” Amersi said. “Our patients will have all their screenings—and receive their test results—in one visit. This will help relieve the anxiety of juggling multiple appointments and waiting to learn the results of these tests.”

The process condenses what could be eight to 12 different appointments into a single day, Ferrone said.

“For patients with BRCA mutations, these screenings are repeated every six to 12 months, so you can imagine how disruptive separate appointments are for patients, many of whom work and have families,” Ferrone said.

Based on their test results, patients meet with a team of specialists about the best path forward, taking into account the patient’s age, fertility goals and individual cancer risk.

Preventive Treatment

For breast and ovarian cancer prevention, patients and their care team discuss the need and timing for possible preemptive surgery.

BRCA1 and BRCA2 mutations have slightly different risks associated with them, said Marla Scott, MD, a gynecologic oncologist.

“People with BRCA1 mutations have roughly a 40% higher risk for gynecologic cancers, and are a younger average age when cancer tends to appear,” Scott said. “This means we have a discussion about removing the fallopian tubes and ovaries, as well as consideration for hysterectomy and mastectomy, between ages 35 and 40.”

A reproductive endocrinologist is on-site to discuss fertility preservation—including egg and embryo freezing and in-vitro testing and fertilization—as well as hormone replacement options to manage symptoms of surgically-induced menopause, Scott said.

For people with BRCA2 mutations, there is a slightly lower increased risk of gynecologic cancer, and age of cancer onset tends to be about 10 years later, allowing doctors to delay preventive surgeries, Scott said.

“With the exception of regular breast exams, patients may get to ‘graduate’ out of further screening for gynecologic cancers if they have a risk-reducing surgery and show no signs of cancer,” Scott said.

Scott added that while managing cancer risk can be challenging for people with a BRCA mutation, having a place they can go for guidance is empowering. The hope, Ferrone said, is that community outreach efforts will bring these benefits to even more patients.

“We are incredibly fortunate to be able to offer free genetic testing in high-risk populations in the near future,” Ferrone said. “This will help us identify more at-risk patients and get them enrolled in the appropriate programs to help them manage their risk and preserve their health.”

Cedars-Sinai Health Sciences University is advancing groundbreaking research and educating future leaders in medicine, biomedical sciences and allied health sciences. Learn more about the university.

The findings, published in JAMA Surgery, provide a framework to better manage ongoing follow-up care of patients whose cancer has not spread to their lymph nodes and who have had their tumors surgically removed.

“We now have a way to identify patients whose higher risk of recurrence may have been previously overlooked,” said Cristina R. Ferrone, MD, chair of the Jim and Eleanor Randall Department of Surgery at Cedars-Sinai and corresponding author of the study. “This gives us the opportunity to change the way we care for this patient population in a meaningful way.”

Pancreatic neuroendocrine tumors are a less common and typically less aggressive form of pancreatic cancer. Patients whose cancer has not spread to the lymph nodes or outside the pancreas have a 91% five-year relative survival rate following surgical treatment, according to the American Cancer Society. However, the Cedars-Sinai study identified a distinct subset of those patients who remain at high risk for their cancer to return.

The multi-institutional study analyzed data from 770 patients across five high-volume institutions and found approximately 10% of patients without lymph node involvement would eventually experience a recurrence of their cancer, most commonly in the liver. This data allowed investigators to develop a 13-point risk score by identifying four key factors that predict a higher risk of recurrence: male sex, a tumor size of 3 centimeters or larger, World Health Organization grade of 2 or higher, and whether cancer cells had entered the blood or lymph vessels, called lymphovascular invasion.

By using the newly created risk score to stratify patients into low-, moderate- and high-risk groups, investigators say they can better predict which patients should receive more frequent and intensive monitoring.

“The current guidelines leave clinicians with a ‘one-size-fits-all’ approach, but it’s clear from our research that not all patients require the same intensity of surveillance,” Ferrone said. “The results address a critical gap in current practice and will hopefully influence future guideline development for well-managed, individualized and cost-effective care.”

Shlomo Melmed, MB, ChB, Cedars-Sinai’s dean of the Medical Faculty and executive vice president of Medicine and Health Sciences, who was not involved in the study, said the new risk score could help physicians and patients around the world.

“The exciting research outcomes of Dr. Ferrone and team will have a significant impact on enhancing the care and management of all patients with neuroendocrine tumors,” Melmed said.  

Additional Cedars-Sinai authors include Shahrzad Arya, MD; Liti Zhang, MD; Alexandra Gangi, MD; Andrew E. Hendifar, MD, MPH; Giulia Cattaneo, PhD; Luigi Liguori, MD; Arsen Osipov, MD; Nicholas N. Nissen, MD; and Kambiz Kosari, MD

Other authors include Marco Ventin, MD; Carlos Fernandez del-Castillo, MD; Motaz Qadan, MD, PhD; Francesco Sabbatino, MD, PhD; Keith D. Lillemoe, MD; Alice C. Wei, MD, MSc; Jin He, MD, PhD; and Amer H. Zureikat, MD

Cedars-Sinai Health Sciences University is advancing groundbreaking research and educating future leaders in medicine, biomedical sciences and allied health sciences. Learn more about the university.

Widely known as a pioneer in robot-assisted colorectal surgery, Pigazzi performed the world’s first robot-assisted tumor removal for rectal cancer more than 20 years ago. He has continued to advance the colorectal surgery field with his expertise in robot-assisted, laparoscopic and open surgical techniques to treat complex colorectal conditions such as recurrent and metastatic colorectal cancer.

Pigazzi brings to Cedars-Sinai a rich history of surgical leadership. Most recently, Pigazzi was division director of Colorectal Surgery at New York-Presbyterian/Weill Cornell Medical Center. He also was executive director for Surgical Services, vice chair of Clinical Network, and professor in the Department of Surgery at City of Hope Orange County.

In his new role at Cedars-Sinai, Pigazzi will concentrate on developing the academic colorectal practice, opening novel clinical trials and advancing translational research.

“Cedars-Sinai’s new Faculty Division of Colorectal Surgery will continue to build best-in-class, patient-centered care by staying on the forefront of the latest surgical techniques, clinical trials and clinical practices,” said Cristina Ferrone, MD, chair of the Department of Surgery at Cedars-Sinai. “Under Dr. Pigazzi’s esteemed leadership, we will also enrich our training programs as we develop the colorectal surgical leaders of tomorrow.”

In addition to his clinical practice, Pigazzi is involved in many significant research initiatives, including a translational research effort investigating the role dietary sugars play in the development of colorectal cancer. His extensive publication record includes more than 150 peer-reviewed articles and 16 book chapters. 

“Dr. Pigazzi’s innovative clinical work and research discovery for colorectal cancer aligns perfectly with our commitment to providing leading-edge expertise and care for our Cedars-Sinai Cancer patients,” said Robert Figlin, MD, interim director of Cedars-Sinai Cancer.  

Pigazzi earned both his medical and doctoral degrees at Boston University School of Medicine. He then completed his general surgery residency at New York-Presbyterian/Weill Cornell Medical College, followed by advanced fellowship training in minimally invasive surgery at Hackensack University Medical Center and in colorectal surgery at the University of California, Irvine.

“I’m grateful for the opportunity to bring my passion to this leadership role in the Department of Surgery at Cedars-Sinai,” Pigazzi said. “I look forward to growing the division to be the best in the region in terms of clinical, research and academic excellence.”

Read more on the Cedars-Sinai Blog: Taking the Fear Out of Colon Cancer Screening

A CT scan at Pulido’s community hospital revealed a large tumor on Pulido’s right ovary—roughly the size of a small basketball. Surgeons removed the cancerous mass, only to discover a smaller tumor on the left ovary, which was removed three months later. Believing the worst was behind her, Pulido returned to work.

But her sense of normalcy was short-lived. Within a month, sharp pains returned.

“I was getting the worst shoulder pain I could get on my left side,” Pulido said. “I went back to the emergency room, and they did another CT scan. Then they saw another tumor. It was much bigger than the first one.”

The doctors diagnosed Pulido—just 22 years old— with a rare condition known as growing teratoma syndrome. The condition occurs when tumor tissue continues to grow rapidly and uncontrollably, pressing on vital organs like the heart and lungs.

The third and largest tumor, about 14 centimeters, was located near Pulido’s liver. Doctors recommended chemotherapy to shrink the tumor, but it failed, and the mass kept growing at an alarming rate. The tumor had progressed so much in size that it was pressing up against her right lung, shifting her heart to the far-left side, essentially under Pulido’s armpit.

By May 2024, the tumor had reached 27 centimeters, weighed more than 40 pounds, and left her wheelchair-bound and dependent on oxygen.

Opting for High-Stakes Surgery Despite the Risks

When chemotherapy failed, surgically removing the tumor was the inevitable choice. After multiple surgery delays and six failed attempts to put Pulido under anesthesia, her original care team halted the procedure altogether.

“The doctors came out of the surgery and told my mom they couldn’t move forward with the surgery because I couldn’t go under anesthesia without flatlining,” Pulido said. “They said the next best step for me would be hospice care.”

Still, Pulido and her family refused to give up.

In their last push for hope, her family sought several opinions from various institutions, but ultimately chose to seek care from Cristina Ferrone, MD, chair of the Jim and Eleanor Randall Department of Surgery at Cedars-Sinai.

Ferrone quickly assembled a team of experienced anesthesiologists and 13 surgeons from various specialties, including cardiothoracic and liver transplant teams, to perform the complex surgery.

“The tumor was so large and heavy, and it involved such essential blood vessels that if you injure them, it would be very, very difficult to repair them. And an injury like that could quickly lead to death on the operating room table,” Ferrone said.

Yet, Pulido was willing to take her chances.

“The only one that could decide if I do go or stay on that surgery table would be God,” Pulido said. “And I just had really high hopes and faith that I was going to make it through.”

Awake on the Operating Table

The surgical team included Tyler Gunn, MD, an assistant professor of Cardiac Surgery at Smidt Heart Institute at Cedars-Sinai. During the first half of the surgery, Gunn performed a critical procedure called preoperative extracorporeal membrane oxygenation, or ECMO, using only local anesthesia while Pulido was still awake in order to keep her respiration and heartbeat stable and to stop her from flatlining.

“When someone goes to sleep for surgery, their muscle tone decreases and the blood flow to the heart can decrease as well. And they can have trouble with their blood pressure, breathing and heart rate,” Gunn said.

Furthermore, as Pulido’s heart was unstable, lying flat on the operating table was not an option. To work around this, the team placed Pulido on an incline for the first half of the surgery.

“In my mind, I just kept saying, ‘You got this, just keep fighting, keep pushing,’” Pulido said.

The long, arduous surgery was a success.

“In the end, we spent over 14 hours operating with all of the different teams working together,” Ferrone said. “It’s a testament to the working environment of Cedars-Sinai. It is an incredibly collaborative institution and patient care comes first, no matter what.”

Within a week after the tumor removal, Pulido’s lungs were able to fully expand, and her heart was back in its rightful place. She was able to breathe on her own for the first time in six months. 

From Wheelchair to Walking Down the Aisle

Amid her harrowing healthcare journey, Pulido found a few uplifting moments, including an important life milestone. Last year, during the halftime show on Super Bowl Sunday, her longtime boyfriend, Jeffrey Chavez, who had stood by her through every challenge, surprised her with a proposal.

“He was always there every day with me, whether it was before work, after work, he was there and visiting me all the time at my mom's house,” Pulido said.

For Ferrone, watching Pulido through her demanding recovery process has been incredibly gratifying.

“When she returned to the clinic a month later, the entire staff and I were amazed. Just six weeks earlier, she had been wheeled in, in a wheelchair. Now she walked through the doors,” Ferrone said. “She's an incredibly strong young woman and has a wonderfully supportive family.”

On June 21, a little over a year after her life-changing surgery, Pulido walked down the aisle and tied the knot with Chavez in front of her close family and friends. While Pulido will need to continue to monitor her health closely, the newlywed is hopeful and looks forward to the next phase of life.  

“I feel really good. I feel like a new person. I see the world differently,” Pulido said. “Every day is a positive day.”

Read more on the Cedars-Sinai Blog: Women in Surgery at Cedars-Sinai.