With his abdomen covered in tiny tumors, Todd Painter was given mere months to live. Then a Hopkins team intervened with a hot new approach.

Todd Painter wasn’t quite ready to wrap things up. At just 33 and at a robust 205 pounds, the former competitive wrestler had been cancer-free for a year. The last bout cost him most of his colon, and he’d struck back with a strict regimen of diet and exercise.

But the monster had returned in a new form, his oncologist told him in September of 2008. It was now raging throughout his abdomen, just beneath the skin surface, gelatinous little tumors blooming like spring dandelions in an uncut field.

The tumors’ numbers were “too many to count,” the oncologist told Painter and his wife. They were in his spleen, his bladder, his kidneys, maybe even his liver. The doctor gave him up to nine months, tops. “There’s not much we can do.”

The new cancer was a form of peritoneal surface malignancy, often seen in the mesothelioma cases suffered by asbestos workers but also stemming from cancers that start in other abdominal organs, such as the colon or appendix. It is notoriously resistant to treatment because of its extent—and the insidious way it weaves through the thin membrane of peritoneum that wraps around the abdomen and its internal organs.

It afflicts 1 in 10,000 annually in the United States. Until recently, few surgeons have been willing to take on such cases, leaving them in the hands of oncologists. But even the best nonsurgical approaches have been able to sustain few such patients for more than several years after diagnosis.

Over a sober dinner outing that evening, Todd unwaveringly told his young wife, Marina, that he was not going to die, leaving behind both her and their then 2-year-old daughter, Sasha. “I’ll accept it if I have to,” he told Marina. “But first, let’s find another way.”

As the couple geared up for their quest, larger fates intervened. Marina got hired as an accountant at Johns Hopkins, where she quickly made contact with innovative oncologist Luis Diaz and outlined the crisis. Diaz agreed it was premature to surrender, and vowed to join the cause. “We’re Hopkins,” he told her. “We’ll find a way.”
After a rapid series of work-ups, Diaz recognized Painter’s cancer as potentially eligible for a growing mode of treatment that at least two of his Hopkins colleagues, Nita Ahuja and Barish Edil, had chosen to master.

Not every patient was a candidate for the latest surgical approach. Could Painter handle a 14-hour operation that would peak with hot chemotherapy fluids flooding his belly at 105 degrees? After meeting with Painter, Ahuja was swayed by his fiery display of stamina. “Let’s do this,” she said. She slotted the surgery for January 30, 2009.

One of the key parts of the procedure involved a process called hyperthermic intraperitoneal chemotherapy, better known as HIPEC, which a number of medical centers around the country have been using for five years or more. The novel approach has been considered risky, earning mixed outcomes and doubts among oncologists.

But Edil and Ahuja were confident that Hopkins’ hallmark multidisciplinary approach could improve outcomes. And by the time Todd Painter came along, the treatment group was hitting its stride.

That would come in handy. When they began assessing Painter’s latest CT scans on the Friday morning of his surgery, Ahuja told both Todd and Marina that it looked worse than anticipated. They’d have to remove his spleen, some of the liver, and then scrape tumors away from his bladder, pancreas, diaphragm and small intestines. And, if Todd could survive all of that, he’d also likely be wearing a colostomy bag for the rest of his life.
If they couldn’t remove at least 95 percent of the cancerous tissue in what amounted to a de-bulking process, Ahuja said, they would close Todd up and suspend the HIPEC phase.

Braced, Todd Painter was not turning back now. “Let’s go,” he said.

Preparations lingered, delaying the first incision until early afternoon. Painstakingly, the surgeons tag-teamed on stripping away Painter’s peritoneal membrane and then began teasing away the gelatinous tumors. Hours later, and against expectations, their cytoreduction process appeared to achieve its goal. They’d reduced the masses by about 99 percent. This patient was now eligible for the HIPEC treatment.

The team temporarily closed Painter’s abdominal incision, deploying large-capacity intra-abdominal tubes to unleash a bolus of heated chemotherapy fluids into the cavity for about 90 minutes, rocking him from side to side to ensure saturation of the abdominal organs. The heat is known to accelerate the fluid’s penetration of abdominal tissues, and the vigorous motion ensures its thorough contact with all of the targeted organs.

Outside in the surgical waiting room, Marina Painter’s pacing sped up some time after 6 p.m., when a circulating nurse confirmed the HIPEC plan was in motion. When an exhausted Ahuja finally emerged from the O.R. near 1 a.m., she reported that the procedure “went much better than we’d anticipated.” The spleen came out. They scraped tumors off the liver and pancreas. They performed a marathon of tedious surgical purging of the abdomen’s fatty tissues, prising away every vestige of the cruel malignancies. Todd responded well to the HIPEC. There was real hope.

When Marina and two of Todd’s best friends entered the ICU at 3 a.m., they were shocked at his ghost-white skin. His eyes were swollen shut, which they took as an indicator of lingering deep sedation. Still, the trio uttered a few words of encouragement before turning to leave.

Then Marina noticed Todd’s index finger was tapping. She thought it was a nerve thing. Wait, said one of Todd’s friends. “Todd, are you trying to spell something?”
With Todd’s finger suddenly tapping with excitement, Marina and the two friends pressed close. Slowly but surely, Todd traced the letters “C,” “H,” “E,” and then “M” before Marina interjected. “Yes, honey. They did the chemo.”

Todd took a deep breath and started tracing again, spelling out the word “BAG.”

“No, honey, you don’t have a colostomy bag.” Tears streamed down Todd Painter’s cheeks.

Since Edil and Ahuja teamed up to provide HIPEC treatment for surface malignancies in early 2008, pulling in nearly 20 colleague specialists, they have successfully treated more than 30 patients. All are still alive and doing well, says Ahuja.

She thinks of Painter’s case as a model, and adds that her group’s growing string of successes has given them confidence to expand their work further into appendiceal cancers and others that afflict areas of the upper abdomen. Their typical patients, says Ahuja, “are people who are very sick and don’t have a lot of options.” Though she says her group is shy of using words like “cure,” they occasionally are willing to declare patients like Todd Painter “free of disease.”

For the Painters, the long road to recovery was marked with a post-surgical infection, and then by a full six months of healing before he began to feel normal again.
Though he was spared the colostomy bag, Todd Painter had been told that his many rounds of chemotherapy and radiation had likely knocked out his ability to father a second child. “They told me my chances of being a father again were somewhere between slim and none,” he said with a smile this past June. “Well, Marina’s about to have our second baby, so I’d say ‘Slim has just left the building.’”

Dr. Ahuja is an Associate Professor of Surgery and Oncology at Johns Hopkins University. She is the Chief of Section on Gastrointestinal Oncology and Mixed Tumors. She serves as the Director of the Peritoneal Surface Malignancies program and the soft tissue sarcoma programs. Dr. Ahuja is internationally reknowned for her expertises in the management of complex gastrointestinal malignancies including Peritoneal Surface Malignancies, Colorectal cancer, Appendix cancer, Gastric cancer, Pancreatic cancer and retroperitoneal sarcomas. Dr. Ahuja completed her surgical training at Johns Hopkins University including a general surgery residency followed by a fellowship in Surgical Oncology. Dr. Ahuja serves on multiple editorial boards and national committees on management of cancers. She has written hundreds of papers, expert commentaries and has published several books on managements of colorectal cancer, pancreas cancer and sarcomas. She also runs a research laboratory focused on the development of novel cancer therapies as well as early detection of colorectal and pancreas cancers. She has multiple ongoing clinical cancer trials focused on treatmenet of advanced cancers in colorectal and pancreas cancers.

By: Ramsey Flyn