How a urine test may be able to detect some cancers, before surgery

March 10, 2017 Allison Milionis

Thomas Zisfain has always taken preventive health care seriously. When he turned 50, he followed his doctor’s recommendations and had his first colonoscopy. After that, Zisfain had one every five years to be safe.

A resident of Canoga Park, Calif., Zisfain had owned a successful construction company for many years. After shuttering the business during the recession, he spent several years traveling the country in a motor home. Zisfain’s father lived to be 94, his grandfather was even older when he passed away. Zisfain assumed he would have a long life, too.

In 2016, his gastroenterologist, Lucian Jacobs, M.D., suggested he have an upper gastrointestinal endoscopy in addition to his colonoscopy. Because Zisfain, 66, had suffered from excessive acid in his stomach for years, Dr. Jacobs wanted to check the lining of his esophagus and stomach to make sure acid hadn’t caused damage.

An upper gastrointestinal endoscopy is an exam using a flexible scope that has a light and a camera at the end. As the scope slides down the throat and esophagus, and then into the stomach and the first part of the small intestine, a doctor can look for problems, such as ulcers, abnormal growths or inflammation.

Much to Zisfain’s relief, the results of the colonoscopy came back negative. However, the endoscopy revealed a mass on the outer wall of his stomach. The discovery was a complete surprise to Zisfain – he didn’t have any symptoms or any reason to think anything might be wrong.

Zisfain was sent to Providence Saint John’s Health Center for more testing. The mass was a gastrointestinal stromal tumor, or GIST, a rare tumor that grows most often in the stomach and small intestine. It’s usually not malignant, but if it’s not found early, a GIST tumor can start to penetrate the organ it’s attached to, damaging the tissue. There are only 4,000 cases of this tumor treated each year.

Zisfain immediately scheduled surgery with Anton J. Bilchik, M.D., chief of medicine at John Wayne Cancer Institute in Santa Monica, Calif., to have the mass removed.

But then there was another discovery. In images from a CT scan, Dr. Bilchik spotted a larger tumor on one of Zisfain’s kidneys – renal cell carcinoma. Like the GIST tumor on his stomach, this one hadn’t produced any symptoms to warn Zisfain that something was wrong.

“I was fortunate in that I didn’t have symptoms with pain or discomfort. But if I hadn’t followed my colonoscopy routine, and if my gastroenterologist hadn’t recommended the endoscopy, the tumors wouldn’t have been found,” Zisfain says.

Tandem surgery to remove tumors

Dr. Bilchik referred Zisfain to Jennifer A. Linehan, M.D., urologic oncologist at John Wayne Cancer Institute. Dr. Linehan is also a researcher specializing in investigational studies of kidney, bladder and prostate cancers.

In Zisfain’s case, two tumors of unknown origin needed to be removed. Dr. Bilchik was responsible for removing the GIST tumor, and Dr. Linehan was responsible for the kidney tumor.

Rather than schedule two surgeries, both tumor removals took place during one operation.

Dr. Linehan says it’s not unusual for two surgeons to work alongside one another in the operating room. “It does happen often, especially if cancer is [present] in more than one organ system,” she says. “Sometimes it’s a liver mass and a renal mass or a bladder tumor and a colon mass. I always tell the patients it’s better to have four good hands than two.”

Drs. Bilchik and Linehan both used a minimally invasive technique and robotic technology with robotic instruments. Each tumor was nearly 2 inches in length, but the surgeons removed both through tiny incisions no bigger than 1 centimeter.

After surgery, Dr. Bilchik sent tissue from the GIST tumor for genetic testing. The results were telling: The tumor was the result of an unusual genetic mutation. Was there a connection between the GIST and renal tumor? Dr. Linehan believes it’s possible. She says there are well-known genetic mutations consistent with both types of tumors.

The future of testing urine

The minimally invasive surgery performed on Zisfain made it possible for him to recover quickly. But what if surgery wasn’t necessary at all? What if some cancers could be detected without a biopsy?

Dr. Linehan believes the research she’s working on will eventually help detect the nature and origin of tumors, like the ones found in Zisfain, before or possibly without surgery.

Working in collaboration with Drs. Dave Hoon and Selena Lin, Dr. Linehan is developing a urine test to diagnose cancer in the kidney, bladder and prostate. The urine test looks for cell-free circulating DNA, which signals cancer. The test will also help doctors diagnose, monitor cancer treatments and watch for the possible recurrence of cancer.

“We’re still performing investigational studies, looking for cell-free circulating tumor DNA in the urine,” she says. “The small snippets of DNA circulating in the body and then exiting in the urine can be sequenced and matched to a specific tumor type. Now, even if we find a mass by CT scan, we don’t know if it’s cancer until we get a tissue sample. Having the DNA from the urine would take out the guess work.”

Recovered and back to work

Zisfain took time to recover, but he was back to his normal activities within a few weeks. He went back to work part-time managing shopping malls, which allowed him to spend more time with his teenage son.

He’ll need to return for checkups and CT scans every six months for the first year or two. After that he’ll have yearly checkups for at least five years. There’s a small chance the tumors could return, but with regular monitoring Zisfain’s doctors can catch them early. In the future, his doctors may be able to watch for new tumors with the urine test Dr. Linehan and her colleagues are developing.

Zisfain credits his bright future, despite having had two different types of tumors, to regular preventive health care, the proactive approach of his doctors, and the care he received at Providence Saint John’s. “They took really good care of me,” he says. Zisfain was especially impressed that Dr. Linehan stepped in to do surgery days before her wedding and then called to check on him from her honeymoon.

“We think this stuff doesn’t happen to us,” says Zisfain. “It really does change the way you think about things.”

 

Additional resources

Learn about renal cell cancer, the most common type of kidney cancer. 

Get educated on the symptoms of and treatments for prostate cancer.  

Learn about bladder cancer

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