James Bowman wanted to know his choices. When he learned last summer that his colon cancer had spread extensively in his liver, he sought opinions in Rochester, New York City, Chicago and Texas.
Because every segment of his liver was riddled with tumors, conventional liver surgery was not an option. It wouldn’t leave him with enough healthy liver to survive.
He could get chemotherapy to try to control the cancer, but that would buy him only months to a few years.
“My journey was going to be on a narrow path,” Bowman, 71, of Penfield, recalls. “I was not going to have a wide range of options.”
Richard Dunne, M.D., his medical oncologist at Wilmot Cancer Institute, and liver surgeon Roberto Hernandez-Alejandro, M.D., UR Medicine’s chief of Solid Organ Transplantation, saw another possibility for Bowman — aggressive chemotherapy to prevent his cancer from spreading further and a relatively new operation known as ALPPS, or associating liver partition and portal vein ligation for staged hepatectomy.
At the time, fewer than 1,000 people in the world had undergone this high-risk procedure, and Hernandez-Alejandro, one of the only surgeons in North America who can perform ALPPS successfully, had done 38 of these operations with good results.
Despite its serious risks, ALPPS held the promise of more time, better quality of life and a potential cure for Bowman, who was otherwise in good health. His choice became clear: “In life or in death, this was the way I was going to go.”
“I had one year, maybe,” he says, recalling his initial prognosis. “Now, I have hope and time.”
An innovative procedure
Colorectal cancer is the third most common cancer diagnosed among men and women in the United States. About half of those cancers spread to the liver, the largest organ inside the body. The liver is responsible for several essential functions, including the breakdown and absorption of nutrients and filtering toxic substances from the blood. If the liver is unable to function properly, it can be fatal.
“If you can control the disease in the liver, you can affect overall survival,” says David Linehan, M.D., chair of Surgery and Wilmot’s co-director of clinical operations.
When colorectal cancer has spread to the liver, surgery is the only avenue for potential cure. Until now, if the cancer had spread throughout the liver, removing the tumors would not be possible.
“Normally, we couldn’t take these patients into the operating room because if we remove all of the cancer, we leave only a very small portion of liver, and they would die of liver failure,” Hernandez-Alejandro says.
The ALPPS procedure, however, stimulates the liver’s unique ability to regenerate itself and accelerates that process, helping to offset the removal of the cancer.
“ALPPS is the most innovative advance in liver surgery over the last decade,” says Hernandez-Alejandro, who has been doing the procedure for five years. The procedure was developed in Germany several years ago, and surgeons elsewhere have been slowly adopting it.
In this two-stage operation, the large, diseased section of liver is separated from a small healthier portion. The surgeon diverts the majority of the liver’s blood supply to that small portion, triggering the rapid regeneration of the organ. Although separated, both sections remain in the body for seven to 10 days. In that period, the smaller section of liver grows rapidly and can almost double its size, a process called hypertrophy. Meanwhile, the diseased liver continues to function, preventing liver failure.
Once the healthy liver is large enough to take over, the patient returns to the operating room, and the diseased part is removed. That healthy portion of liver will continue to grow, though more slowly. After three to four months, it will reach about 70 percent of its original size and function at close to normal capacity.
The ALPPS procedure requires close collaboration with a patient’s medical oncology team. Patients at Wilmot undergo a course of chemotherapy prior to this surgery to control the cancer where it is, prevent it from spreading further and sometimes to shrink the size of the tumor. But it’s a delicate balance, as chemo can cause liver damage, and patients need as much healthy liver as possible to undergo ALPPS.
“We try to choose those regimens that may have less effect on the liver,” Dunne says. “In recent years, we’ve seen the effectiveness of chemotherapy improve with the use of targeted antibodies. Better response rates have allowed patients to undergo surgical resection and give more patients a hope for cure. The ALPPS procedure takes this one step further, as it presents opportunities for surgery in patients in whom we previously thought surgery was not possible.”
Not by chance
In August, Dunne presented Bowman’s case to his colleagues at Wilmot’s weekly tumor board conference. Experts from pathology, radiology, surgery, medical oncology and radiation oncology reviewed Bowman’s diagnosis and debated the possibilities for treatment.
Hernandez-Alejandro, who had come to Rochester just a few months before, saw the scans of Bowman’s liver and recognized him as a potential candidate for ALPPS. The cancer was quite advanced, and Hernandez-Alejandro needed to see that it responded to chemotherapy before he would operate.
Dunne called Bowman right after the meeting to explain that ALPPS was an option, and Bowman knew this was what he had to do.
“It was very clear to me that this was God’s providence,” says Bowman, who has strong faith. “Providence means that the hand of God is in the glove of human events. Our meeting was not by chance.”
He started chemotherapy the following week. After four rounds, Bowman and his wife Ruby met Hernandez-Alejandro, and they felt an immediate connection.
The Bowmans appreciated Hernandez-Alejandro’s candor about his experience, the risks and benefits of ALPPS, and what life after the procedure could hold. The surgeon was impressed by Bowman’s passion for life and motivation.
“Don’t give me any false hopes here,” Bowman told him. “I just need to live with what’s real.”
“The easiest thing is not to do the surgery,” Hernandez-Alejandro tells his ALPPS patients. “The other thing is to do this surgery. There’s a small chance of being cured and a good chance of surviving for more time with better quality of life. There’s also a small chance of dying and a chance that your cancer will come back. The only way to know is to go through this procedure, but you have to be prepared. I am prepared.”
He told Bowman to be strong, to be a warrior, to eat healthy. Bowman began to focus on building his strength before surgery. He and his wife met with the team at Wilmot’s PEAK Lab, where clinical exercise physiologist Michelle Porto created a personalized plan, and they also met with Joanna Lipp, one of Wilmot’s specialized registered dietitians.
“You just do what you have to do,” Bowman says. “You rely on your faith and people you can trust.”
He underwent the first stage of his surgery on Nov. 30. In the six-hour operation, Hernandez-Alejandro separated 85 percent of Bowman’s liver from a very small healthy remnant. That remnant, about the size of a medium apple, was one of the smallest that Hernandez-Alejandro had ever worked with. It was less than half the volume of liver that Bowman would need to survive.
In the waiting room, Bowman’s wife Ruby prayed, “Save this one good man.”
“It was not just a prayer,” she says. “I was challenging God.”
After the operation, Hernandez-Alejandro told her that he was confident, but that he was also concerned about the small size of the liver.
A few days later, Hernandez-Alejandro visited Bowman in the hospital. He was impressed to see his patient using his computer, and he knew that Bowman’s liver was growing stronger. Liver failure would have left him too weak and confused even to send an email.
In just over a week, Bowman’s apple-sized liver doubled in size, and on Dec. 12, Hernandez-Alejandro completed the second half of the operation.
Bowman went home eight days later.
“I just knew I was going to be OK,” he says.
Serious risks, major rewards
Because of its complexity and risks, ALPPS is appropriate only for certain patients with metastatic colorectal cancer. They have to be well enough for surgery and have no background of liver disease such as hepatitis or cirrhosis. A small portion of the left side of their liver must be free of cancer and have an independent blood supply. Their cancer should also be responsive to chemotherapy.
The skill and experience of the surgeon are the key factors in the success of ALPPS. Because it is so technically challenging and still new, very few centers in the United States offer the procedure. Wilmot is one of the only places in the country to offer ALPPS.
“This type of complex and risky surgery really needs to be done by expert surgeons in centers with the highest level of expertise,” Linehan says. “To my knowledge, Dr. Hernandez-Alejandro has the largest experience in North America with the ALPPS procedure, and his results are outstanding.”
Serious, sometimes fatal, complications of ALPPS include bile leaks and sepsis. About 12 to 15 percent of those who have undergone ALPPS worldwide have died within three months of surgery. Hernandez-Alejandro’s patients experience relatively few complications, and so far, none have died within 90 days of surgery.
“Without this surgery, the majority of these patients would die within a year or perhaps year and a half,” Hernandez-Alejandro says. “With it, more than 50 percent are alive at three years, and those who do not reach the three years have extended their survival with better quality of life.”
Some ALPPS patients see their cancers return, but with close follow-up, these metastatic tumors are often found early. Depending on the tumors’ size and location, surgery may still be possible.
“If the cancer comes back, it’s like resetting the clock,” he explains, because patients have options that would not be available if they had not undergone the procedure.
Even if the cancer does not return, patients may undergo chemotherapy following surgery, though there is no guarantee that after ALPPS they will be able to tolerate it with a smaller liver.
The high rate of major complications, the likelihood of the cancer’s recurrence and the potentially limited options for additional treatment make ALPPS controversial among oncologists. Others, however, contend that patients with advanced cancer should keep all their options on the table, especially with the growing evidence of the procedure’s benefits.
“It’s a very aggressive approach,” medical oncologist Dunne says. “Without surgery, most of these patients would be on and off chemotherapy for the rest of their lives. Even if their cancer recurs, these patients live longer. The surgery gives them an option potentially for additional time off chemotherapy, and with that, their quality of life is improved.”
Although relatively few people have undergone ALPPS, Hernandez-Alejandro and his colleagues around the world are studying what life is like after surgery for their patients. In addition to long-term clinical and oncological outcomes, they are looking at emotional well-being, social functioning and overall health status. They have so far found that ALPPS patients report their quality of life to be similar to that reported in surveys of the general population.
“A lot of them are retired and want to enjoy life with their families. They want to play golf and go to their grandchildren’s weddings,” Hernandez-Alejandro says. “ALPPS, when indicated, can offer this to patients. A few years ago, we couldn’t have imagined offering them surgery.”
Hope for 10 more years
For Bowman, life after ALPPS includes plans to spend a month in Akron with his young granddaughters. Once he’s finished with his post-surgery chemotherapy, he’ll get to see their recitals and once again be their “G-Daddy,” as they call him. He and Ruby are planning a trip to Bermuda, where they have extended family, and he’ll soon be back at church, where he is an organist.
“And maybe in 2018, we can take that trip to Europe that we put off,” Ruby says.
“I’m still challenging God,” she adds. “I want 10 more years.”
“I don’t know what my course will be, but this has given me hope and time,” Bowman says.
“We appreciate every sunset, every sunrise and every noon-day in a new kind of way. It has a whole different texture and richness.”