Someone once asked me, “You had surgery to remove your liver tumor, why didn't you have the percutaneous cryo-ablation?” This question had a good point. My tumor was suitable for cryotherapy, it was situated on the left hepatic lobe and the size was less than five centimeters. In retrospect, if I had received cyrotherapy the postoperative recovery time would not have been so long and I would still have my left hepatic liver lobe. So far, I often feel tired, especially after exercising, perhaps because the left hepatic lobe was removed consequently the number of my liver cells and the hepatic functional reserve have both been reduced.
I was very envious of an old friend Zhao in Shenzhen, he was a chief gastroenterologist. Three years ago he called me and told me he had a liver tumor and was preparing to come to our hospital for cryotherapy. He sounded relaxed as if he were not the patient. The next day he arrived with his wife, it looked as if he had driven to our hospital. I asked him, “Are any others accompanying you?” He responded “Everyone is busy, there is no need to bother them with this trivial matter!” I looked at his CT film and found a three centimeter low-density area on the right hepatic lobe. On the second day we began his treatment. I especially supervised the operating procedure, he was
administered a light anesthesia similar to the one they give patients for a painless gastroscopy. Under the guidance of an ultrasound a biopsy was taken, four tissue samples were removed by the surgeon. I suggested he take another two samples, maybe this was fate as these last two tissue samples showed cancer cells, treating patients can be so dramatic! As the old friend made it clear beforehand, no matter what the biopsy results were he wanted us to freeze the tumor first. Judging from our experience, we assessed that the tumor was most likely malignant. Under ultrasound guidance, four cryoprobes were inserted into the center and periphery of the tumor. After ten minutes the frozen area extended at least one centimeter over the tumor, followed by rewarming and freezing again. The whole procedure was completed in less than one hour. He was discharged from the hospital three days after the surgery and returned to his hometown in Qinghai to recuperate for a few days. Since then he often called and greeted me during important festivals. On the 15th of September in 2012, the Shenzhen Medical Society of Gastroenterology held an academic conference, I was invited to give a lecture there. Zhao also attended the conference, I saw him talking and laughing cheerfully with his colleagues.
Seeing Mr. Zhao full of radiance, looking so energetic and vigorous made me feel deeply pleased but also very envious. We both had suffered from liver cancer, the tumor sizes were similar. The difference was that Mr. Zhao suffered from hepatocellular carcinoma whilst I had cholangiocarcinoma, this was a microscopic distinction. But there were no differences in clinical manifestations and treatment principles. Both of us are engaged in liver diseases, liver cancer is part of our specialist territory. But he was tougher and more optimistic than me. His treatment was quite simple whilst my surgery was complicated and involved many people’s attention, followed by postoperation physical and mental suffering. If the treatment methods are different, the consequential results have a world of difference. Mr. Zhao had not practiced cryrotherapy yet he firmly believed in it. Yet whilst I was considered to be China's earliest pioneer-expert of applying cryotherapy, I was still obsessed with the traditional methods. Thinking of this, I cannot avoid feeling guilty.
In recent decades, Japan has had a fierce debate on “Organ Preservation,” advocating when using the surgical method for treating cancer surgeons should try and conserve the organ as much as possible. For instance, surgeons should avoid a total gastrectomy when treating gastric cancer. When treating breast cancer, surgeons should try their best to manage “breastconserving surgery,” and for lung cancer, pneumonectomy should be avoided as much as possible. The Japanese medical community has debated whether or not surgery was appropriate for two Imperial Mikados.
In 1987, on the Emperor Showa’s birthday, he vomited after eating. Later he was diagnosed with pancreatic head cancer causing duodenal obstruction. In September of the same year he received the duodenojejunostomy. This comprises of connecting the upper duodenum and jejunum (shortcut surgery), which enabled the food eaten to pass directly into the small intestine without going through the obstruction site. They did not do much with the pancreatic tumor itself. After the surgery the emperor could eat as before and resume work. One year and four months later the emperor died of tumor progression and hemorrhoea. It was discovered during a routine physical medical exam that the second emperor, the incumbent Emperor Heisei’s PSA (the associated prostrate antigen) in the blood had risen up. He had a biopsy which was positive for prostate cancer. On January 2003, he accepted the radical prostatectomy. Postoperative pathological examination proved a localized well-differentiated adenocarcinoma (Stage B). The postoperative recovery went smoothly and he returned to work.
The surgeries were discussed by the Japanese medical community and they decided in regards to the first emperor the “shortcut” surgery was the best option as it’s hard to diagnose pancreatic cancer in the early stages. Even with “early stage” pancreatic cancer patients who choose to have the “Whipple surgery” the prognosis is not necessarily better than those nonsurgical methods. Furthermore, this surgery involves cutting the whole pancreas, the bile duct, the gastrointestinal duct and the spleen. After the surgery patients may have a poorer quality of life even suffering with great pain of the disease, people are usual afraid of death, for a living dog is better than a dead lion.
Patients who undergo the ‘shortcut’ surgery could recover quickly and “live happily” before they die. But for the second emperor, it was wrong for him to receive the prostatectomy because prostate cancer develops slowly, regular observation is more appropriate as the disease may not progress for 5-10 years. In 2002, the “New England Journal of Medicine” published the results of a study. The study was a randomized controlled clinical trial in Northern Europe. 695 cases of localized high-grade prostate cancer patients were divided into two groups, one group received radical surgery, and the other group was just under observation. The follow-up visit of these cases was as long as 12 years. The results showed that the total mortality of both groups of patients was the same and the average life expectancy of two groups of patients was similar.
I personally don’t approve of the above discussions. Regarding the first emperor, I would not recommend receiving a radical resection, but to simply perform a “shortcut” surgery would not be enough. Currently, under CT scanning guidance a partial percutaneous ablation (cryosurgery or radioactive seed implantation) could eliminate or substantially reduce the pancreatic tumor. Even in regards to the ‘shortcut’ surgery, it is not necessary to involve the opening of the abdominal cavity, it could be completed under the guidance of a laparoscopic or gastrointestinal endoscope. Japan at that stage had not yet carried out pancreatic percutaneous ablation treatment. With
reference to the second emperor, a radical prostatectomy or close observation is not necessarily the most advisable treatment plan. The ultrasound-guided percutaneous cryosurgery or 125 iodine seed implantation therapy has already become routine treatment, which can be undergone in the case of tiny wounds. Now Japan has rich experience in applying cryotherapy for prostate cancer.
Of course there is no need to blame the Japanese medical group. After all treatments for dignitaries and general patients differ, traditional treatments cannot be blamed. Although dignitaries may receive treatment with the highest amount of priority, it's not necessarily the best treatment.
In terms of cancer treatment and which is more preferable, surgical resection or local ablation? Do you have the surgery that will damage organs or the minimally invasive treatment that aims to preserve all or most organs? Certainly considering the patient’s treatment as a whole is important. So far I have been regretful of an Indonesian friend’s death. He was a very kind hearted Chinese entrepreneur, eight years older than myself and one of Indonesia's largest automobile dealers. He also established several hospitals, which he would jokingly
refer to this as him doing a good deed for his own salvation.
One of his hospitals has a long-term cooperative relationship with our hospital. About seven to eight years ago he suffered from liver cancer and underwent an operation in Japan. Two years later the tumor recurred and he received local radio frequency ablation in Japan. Two years ago he had a second recurrence, the tumor on his liver was about two to three centimeters. I suggested he come to our hospital and have cryoablation. He booked his ticket and I helped book him a room at our hospital and gathered experts to discuss his condition and treatments. A week passed and he called me to tell me he needed to delay his schedule. Another week passed and he said he had not prepared himself yet. After a few days, we heard from Indonesian news that he had gone to Japan. After another few days we heard via Japanese news that he had undergone surgery in Japan to remove the liver tumor. Another two weeks passed and I received an urgent call from Indonesia saying he had a high fever, cough and had been admitted into a hospital in Singapore and asked me if I had a good plan. It turned out that he had pulmonary fungal infections. A few days later this famous Indonesian entrepreneur passed away. Before he died he
subsidized ten thousand cataract patients and entrusted the Indonesian International Daily to follow up on this.
All men will die no matter how great they are, but it seemed that this friend should not have left this world so quickly. If he had received the percutaneous cryosurgery as we suggested, it would have been possible to avoid his tragic ending.
This illustrates that we cannot treat cancerous tumors in isolation, instead treatment should follow a whole-body, integrated approach. If the tumor was removed and the patient died, this would be a failure. If the tumor still remained, or it wasn’t completely removed but the patient survived this would be a success.
Following the development of medical imaging and medical engineering technology, today there are already many mature localized tumor ablation techniques such as cryosurgery, radiofrequency therapy, microwave and so on. The easiest approach of ablation treatment is to inject chemicals such as ethanol and acetic acid. Among all these techniques, cryosurgery and radiofrequency are mainly used. Both therapies have their own merits, in general radiofrequency is used on smaller sized tumors and a distance from the large blood vessels, whilst cryosurgery is suitable for small and larger tumors including those close to large vessels. Another advantage of cryosurgery is that patients will not feel pain during treatment because cryosurgery itself can relieve pain, whilst radiofrequency therapy can cause pain. In recent years, researchers have also found that cryosurgery can enhance the immune function because the dead cancer cells after freezing
will become fragments remaining within the human body, which develop into antigens to stimulate the immune system and have immunological anti-cancer effects. This is why cryotherapy can eliminate the main large tumors but other small or even invisible tumors will successively disappear. There is some opinion that it is not easy for those cancer patients who received cryotherapy to have a recurrence, this has been confirmed in animal experiments.
The superiority of minimally invasive treatments could be confirmed from the following case involving a six year-old girl who lives in the mountainous area of Yingde City. Two years ago, a mass was found on the left of her neck, continually growing larger and causing her to make a wheezing sound on her throat that could be heard during sleep. The examination revealed that the 7*5 cm mass found on the left neck compressed her trachea causing tracheal stenosis. Both ultrasound and CT scans revealed an egg-sized tumor was on the front of the left carotid artery, located by the second to third cervical vertebra which compressed her trachea and extended to the spinal canal with unclear margins. The biopsy revealed it was paraganglioma.
This was a rare benign tumor, although it does not metastasize to other parts of the body as a malignant tumor would, the tumor was in a unique position only a few millimeters from the spinal cord. If the tumor continued to grow it would compress the spinal column causing paraplegia. The tumor adjacent to the trachea had caused compression and narrowing which continued growth would cause suffocation and be life threatening. Surgeons dared not operate, which was understandable as the slightest mistake during surgery would cause spinal cord injury with disastrous consequences.
A previous patient brought her to our hospital. My colleagues gave her a tracheotomy to protect her breathing, then performing cryosurgery under ultrasound guidance a cryoprobe was inserted into the left neck mass. There were no intraoperative or postoperative complications. A six month follow up CT scan showed that the tumor had shrunk and the tracheal condition improved (Fig. 8). Her condition was stable at a further seven-year follow-up check.
We are delighted to have this sort of result. I have always wished to see this lucky girl and in early May 2012, the seventh year that she had been receiving treatments at Fuda Hospital, myself and one of our hospital’s liver cancer patients Mr. Tan Youhao made a special visit to see this child. From Yingde City we travelled by car for forty minutes and drove from the highway to the rural road. Construction plants and bulldozers could be seen along both sides of the road, and trucks were running on the road as if there was no one else present. After a while we arrived at a small village, with several big dogs barking and running around our car. We climbed out the car and carrying fruit passed through a bumpy dirt road to the end of an alley arriving at the girl’s home. An old bow-backed woman who was the girl’s grandmother was killing a chicken. Mr. Tan told me that it was a special treat for us. The girl had not yet returned from school. I walked out of the alley arriving at a vegetable garden, chickens and ducks were scrambling for food. The sky was an azure blue, the air had an earthy smell. Half an hour later she arrived sitting on her father’s motorbike with him driving. She had grown taller, although she looked thin she was energetic, frequently calling me Grandpa Dean and showed me her homework. Her handwriting was very neat, sentences read coherently, I asked her a few questions and she answered very well, roughly checking her nervous system function, everything was normal.
It was getting dark. The family warmly invited us to have dinner with them before leaving. I was born in a rural area and recognized rural people to be simple and honest, there was sincerity in trying to persuade us to stay. We left the fruits we had brought there and quickly left her house. We can only be grateful for their kindness.