Interventional Gastroenterologist Creates New Endoscopic Approach for Pancreatic Cancer Survivor

Interventional Gastroenterologist Creates New Endoscopic Approach for Pancreatic Cancer Survivor An innovative endoscopic technique resolved a unique problem for pancreatic cancer survivor Andy Chaloupka

In the winter of 2012, a decade after first being treated for pancreatic cancer, 52-year-old Andy Chaloupka met with interventional gastroenterologist Uzma Siddiqui, MD, to discuss a complex problem -- one Siddiqui and her colleagues had never seen before.

Uzma Siddiqui, MD Uzma Siddiqui, MD

When Chaloupka was diagnosed with acinar cell carcinoma (a rare type of pancreatic cancer) in 2002, University of Chicago Medicine surgeons removed the narrow end, or tail, of his pancreas. After the cancer came back a year later, gastrointestinal oncologists here treated him with radiation and chemotherapy.

The recurrent tumor, located in the top, or head, of the pancreas, caused an obstruction of Chaloupka’s bile duct. Physicians performed an endoscopic procedure to insert an expandable metal mesh tube, called a stent, to open the blocked duct. At the time, widening bile ducts with uncoated metal stents as a measure to relieve jaundice (blockage of the bile duct) was the standard of care for patients who had metastatic disease and who were not expected to survive their cancer. Because tissue eventually grows into the mesh, these stents are considered permanent. Chaloupka’s stent functioned well for two years, but it eventually became obstructed and physicians placed a second metal stent inside the first one.

Chaloupka said he "feels lucky to get the best care in the city, if not the region."

"We didn't talk about these stents being palliative at the time, but I understood they were meant to be there only as long as I was here," Chaloupka said.

But for Chaloupka, the aggressive radiation and chemotherapy treatment brought his cancer into long-term remission. He stopped getting regular follow-up scans several years ago. Feeling “100 percent,” he works as a solutions marketing manager in Tinley Park and crews on sailboats racing off of Chicago’s Belmont Harbor.

A Unique Problem, A Creative Strategy

In February 2012, Chaloupka sought help from Siddiqui, an expert in interventional endoscopy, when he suffered from cholangitis -- an infection of the bile duct that causes fever, jaundice and abdominal pain.

"Although Mr. Chaloupka’s cancer was cured, he was dealing with a complication of the initial treatment," Siddiqui said. "The metal stents were no longer doing their job." Because scar tissue enveloped the stent, surgery would be difficult and highly complex.

Eugene Choi, MD Eugene Choi, MD

Soon after meeting with Chaloupka, Siddiqui conferred with Eugene Choi, MD, a surgical oncologist specializing in gastrointestinal cancers. Choi presented the case to the gastrointestinal tumor board, a weekly meeting bringing together experts in surgery, medical oncology, gastroenterology, radiology, and pathology. This multidisciplinary team reached the consensus that treating Chaloupka endoscopically offered the safest and best course of action.

Siddiqui devised a variation of the same technique (endoscopic retrograde cholangiopancreatography or ERCP) that was used to insert Chaloupka’s original stent. Guided by real-time X-ray, she maneuvered a specially equipped endoscope to stretch the mesh tube, drain the bile duct, and insert temporary plastic stents to reopen the tube. In addition, she used a special laser through the endoscope to burn holes into the bottom of the old stent, which had penetrated surrounding tissue and closed up the opening to the bile duct.

"No one else has seen a patient who survived a recurrence of pancreatic cancer and lived this long with a metal stent," Siddiqui said.

For now, Siddiqui repeats the outpatient ERCP procedure every three months, replacing the plastic stents and gradually burning more sections of the metal mesh in order to increase access to the bile duct. Meanwhile, she looks for other options to treat the condition, frequently discussing the case with colleagues here at the Center for Endoscopic Research and Therapeutics and also around the country.

"No one else has seen a patient who survived a recurrence of pancreatic cancer and lived this long with a metal stent," she said, "I hope that innovation and new technology will eventually bring about an easier, more permanent solution."

In the meantime, Chaloupka says he doesn’t mind having the regular endoscopic treatment, explaining that he looks forward to coming to the medical center because he finds it reassuring. "The staff are positive and warm and they always make it comfortable for me," said Chaloupka, adding that he "feels lucky to get the best care in the city, if not the region."

December 2012