July 8, 2002
Nutritional Therapy for Primary Peritoneal Cancer: A Case Study
Guisseppi A. Forgionne, PhD
Figure 3 - Patient's Pathology Report
Table 2 - Patient's Imaging Study Results
Table 3 - Patient's CA-125 Test Results
Nutritional Therapy for Primary Peritoneal Cancer: A Case Study - Alternative Therapy
Nutritional Therapy for Primary Peritoneal Cancer: A Case Study - References
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The theories are being tested on an elderly woman diagnosed with primary peritoneal Stage 111A, Grade 3, papillary serous carcinoma expressing in the left ovary and omentum. This woman refused postsurgical chemotherapy, instead opting for a nutitional therapy regime. The regime has continued since the surgery.
At the time of her diagnosis, the patient was an 89 year old female in relatively good health. In the past, she had gastrointestinal (gall bladder and ulcer) disease, hypertension, arithritis, pneumonia as a complication of surgery, Carpal Tunnel Syndrome, and sepsis arising from a urinary tract infection.
The gall bladder disorder required surgery to remove the infected organ and various postoperative procedures to clear stones that remained in her bile duct. The ulcer was not of bacterial origin and has been treated continuously with Prevacid. None of the preoperative or postoperative examinations showed any evidence of malignancies in the gastrointestinal system. The Carpal Tunnel Syndrome was surgically treated.
Her hypertension has defied treatments through a variety of conventional medications. The hypertension has responded to a nutritional regime of 550 mg of potassium, 500 mg of calcium, and 400 mg of magnesium per day. This regime was started approximately 6 months after the cancer surgery, when her hypertension again failed to respond to conventional medications, and continues to this date.
In October of 1999, the patient began experiencing severe back pain in the left kidney area. Examinations and tests by emergency room physicians revealed a kidney stone that was small enough to pass on its own after about 10 days. A followup examination, including ultrasound, by the patient's urologist revealed no remaining kidney stone but a pelvic mass in the area of the left ovary. The mass was thought to be a fibroid, and no other treatment was prescribed.
The patient began to feel progressively ill through the remainder of 1999 and the beginning of 2000. She had abdominal pain, general weakness, and she was tired all the time. Her family physician referred her to a gynecologist, and the gynecologist ordered CA-125 (and other experimental) blood tests and a CT scan. These tests were performed in May of 2000.
The CA-125 test came back extremely elevated to a level of 1040, and the CAT scan indicated that the pelvic mass had grown considerably since the Fall of 1999 and appeared solid. Based on these test results and physical examination, the gynecologist recommended surgical removal of the uterus, Fallopian tubes, ovaries, and, if necessary, the omentum and lymph nodes. This surgery was performed on July 6, 2000. All of the recommended organs, except the lymph nodes (which appeared normal to the surgeons) were removed during the surgery. The surgery was successful but revealed a cancerous left ovary with some mastastasis to the omentum.
Resected tissue and abdominal fluids were examined pathologically. Figure 3 - Patient's Pathology Report summarizes the pathology report.
Figure 3 Patient's Pathology Report
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SURGICAL PATHOLOGY (7/7/00)
A.Mesosalpinx, including paratubal cyst: Papillary serous carcinoma, poorly differentiated.
B.Fallopian tube, left: Salpingitis, chronic, benign.
C.Ovary, left: Atrophy, physiologic, benign.
- 2.Hysterectomy and right salpingo-oophorectomy:
A.Cervix uteri: No pathologic diagnosis.
B.Corpus uteri: Basal endometrium with atrophy and polyp, endometrial, benign.
C.Anterior myometrium: Leiomyoma, benign.
D.Right ovary, serosa: Adhesions, fibrovascular, benign.
E.Fallopian tube, right: No pathological diagnosis.
F.Mesosalpinx, right: Cyst, paratubal and fibrovascular adhesions, benign.
3.Omentum, infracolic omentectomy, peritoneum and adipose tissue: Adenocarcinoma, metastatic, poorly differentaited on surface and with invasion.
1. Best demonstrated in slides "1C" and "1J1" is a mass of papillary fronds covered by a complex, variably dense collection of poorly oriented, pleomorphic malignant cells which raely form small acinar groups. This tumor is present within and is confluent with a benign epithelial lining consistent with a paratubal cyst. The tumor is clearly demarcated from the benign, atrophic left ovary and from the dilated, chronically inflamed left fallopian tube. No definite peritoneal invasion is seen at this point but specimen #3 demonstrates an omental peritoneal invasive metastasis of an identical adenocarcinoma. No other focus of malignancy is seen in the submitted specimens. (A microscopic adhesion to the transverse colonic mesocolon was described by the operating surgeon but is not identifiable in the available samples.)
Despite focal tumor necrosis, the appropriate CK7 tumor cell decoration without CK 20 or CEA decoration (in association with appropriate vimentin staining of benign stroma) along with a report of an unremarkable intraoperative colonic palpation and with markedly elevated serum CA125 and moderately elevated serum NB/70K marks this as a primary adenocarcinoma arising in the left mesosalpink, either from a peritoneal or a partubal surface epithelial origin.
Patient's Pathology Report (Continued)
Based on the pathological results, then, the patient was diagnosed with Stage IIIA, Grade 3 papillary serous carcinoma. Since the origin of the disease was believed to be in the peritoneal cavity, rather than the ovaries, the disease was also diagnosed as primary peritoneal cancer.
As Figure 3 - Patient's Pathology Report indicates, the patient's left ovary expressed a Grade 3 papillary serous carcinoma. It also shows that the patient's omentum also expressed the same malignancy. Hence, the cancer was characterized as a Stage IIIA disease.
The patient spent five days in the hospital and then another several weeks at home with visting nurses recovering from the surgery. The recovery was relatively uneventual and rapid. Postoperative followups were completed at the offices of the gynecologist and the second operating physician, a gynecological oncologist.
On the followup visit with the gynecological oncologist, the patient was informed about the severity of her illness. She was also told that, since the cancer most likely originated in the peritoneal cavity and had spread to the omentum, there were likely to be cancerous cells remaining in the peritoneal cavity, even though the mass and corresponding cancerous tissue were completely removed. Without further conventional treatment, the gynecological onocologist believed that the cancer would return soon and in a severe form. No specific time period was identified, but the implication was that the remanifestation would be relatively soon.
The gynecological oncologist recommended traditional 6-round chemotherapy with paclitaxel and cisplatin. The patient was opposed to this treatment, but said that she would take and examine the the literature offered by the oncologist. After examining the available information, the patient decided against chemotherapy. Instead, she requested alternative, and if necessary experimental, treatments that would have less severe side effects and a better potential for a cure, rather than a delay in recurrence of the disease. None were available for which the patient qualified or which offered reasonable promise of success.
Additional consultations with the oncologist, the family physician, the gynecologist, and a referred John Hopkins oncologist did not convince the patient to accept chemotherapy. The Johns Hopkins oncologist was most candid in her consultation, indicating that: (a) the cancer could return in months or possibly years and (b) the patient's refusal of chemotherapy was a reasonable decision given the person's age. The Johns Hopkins oncologist, however, gave the distinct impression that the cancer would most likely return within a year. All physicians noted that the cancer would be fatal when it returned.
The patient did not give up hope and through an intermediary began searching for reasonable alternative treatments for her form of cancer. The intermediary's search revealed the independent treatments of wheat grass, coenzyme Q-10, and bovine cartilage.
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Wheat grass, coenzyme Q-10, and bovine cartilage theoretically offer systematic attacks on cancer. Each, however, has a somewhat different mechanism of attack. Moreover, there may be synergistic effects from combining the mechanisms of attack. For these reasons, it was hypothesized that a nutritional regime involving all three ingredients may be effective in treating primary peritoneal cancer.
Using the scientific theories and the few reported studies as a basis, a nutritional regime was devised that involved 100 mg of coenzyme Q-10, 2 grams of whaet grass, and 9 grams of bovine cartilage per day. The wheat grass was initiated within 1 week of surgery. As the other ingredients became known, they were added to the regime. One hundred miligrams of coenzyme Q-10 was added to the regime 1 week after the wheat grass, and 9 grams of the bovine cartilage followed 2 weeks later. By the end of the first month from surgery, then, the patient was receiving all three components of the nutritional therapy. For economic reasons, the Q-10 dosage was increased to 150 mg per day approximately 9 months into the regime.
Patient General Health Progression
The patient has shown continuous improvement in her general health since the nutritional regime has been implemented. She feels stronger, is not usually tired, and is in good spirits. Her body weight has increased from a low of 111 pounds after the surgery to a high of 124 pounds, and she has maintained her weight at about 120 pounds for the past several months.
The patient's appetite, bowel movements, and all main organ functions have been normal since her surgery. She also generally has experienced no pain in the pelvic or abdominal areas. The patient also is able to work around the house and yard at levels of performance experienced when she was about 5 or 6 years younger. She has experienced no adverse effects from the nutritional regime.
During the month of July of 2001, the patient did experience a health problem. She began having back pain in the left shoulder blade and throughout the spine. A CT scan, MRI, various X-rays, and an Ultrasound revealed advanced arthritis (a longtime problem), mild to moderate spinal stenosis, and mild osteoporosis. Table 2 summarizes the test results. After receiving a steroid injection in the epidural space, the pain was eliminated, and the patient returned to a normal, healthy life. Apparently, the source of the pain was the inflammation that normally accompanies the arthritic and stenotic conditions.
Clinical Test Results
As Table 2 - Patient's Imaging Study Results shows, the July, 2001 CT scan also revealed a small hypodensity in the left kidney. On the recommendation of the radiologist, a followup ultrasound was done, and this test
No acute cardiopulmonary findings; Advanced osseous demineralization with multiple insufficiency insufficiency compressions throughout the dorsal spine; Advanced osseous demineralization and moderate degenerative changes of the left shoulder.
CT Scan of the Abdomen and Pelvis
- - 1 cm focal hypodensity within the aspect of the left kidney, which is a new finding. This most likely reflects a simple cyst in a patient of this age, but the possibility of a small renal cell cancer cannot be excluded. Further evaluation is recommended with an ultrasound of the kidneys. If this proves solid, then a dedicated CT of the kidneys would be recommended.
- Stable cysts involving the right kidney.
- Postoperative changes of the pelvis, with no evidence of cancer reoccurrence.
- Sigmoid diverticulosis
- Stable right inguinal hernia.
MRI of Lumbar Spine
There are degenerative changes at all lumbar disc levels. There is mild to moderate spinal stenosis at the L2-L3 level, moderate spinal stenosis at the L3-L4 level, and mild spinal stenosis at the L4-L5 level. There is narrowing of the neural foramina bilaterally at these levels, but no gross root compression is shown within the neural formina. No malignant bony neoplasm, osteomyelitis, or acute compression fracture is shown in the lumbar spine.
Questioned in the biliary tree; abdominal film will be obtained for further assessment. Right lower pole renal cortical cysts and small parapelvic cysts. The lesion described on the recent CT scan in the left kidney is felt most likely to represent a left renal cyst. A few internal echoes probably artifactual. A follow-up study with CT or ultrasound is suggested in 6 months for reassessment. Surgical absence of the utuerus. No pelvic mass is seen.
Specifically no air is seen in the biliary tree. There are numerous costochondral cartilage calcifications projected over the upper abdomen and also residual barium in presumed divertcula. No obstructive pattern was seen. There are extensive degenerative changes of the spine.
It was suggested that the hypodensity was a cyst. Table 2 - Patient's Imaging Study Results indicates that this ultrasound, and none of the imaging studies, show any evidence of carcinoma. In particular, the CT scan shows no evidence of a primary peritoneal recurrence. The MRI, ultrasound, and X-rays show no metastasis to any other organs in the patient's body.
At the suggestion of the Johns Hopkins oncologist, and by order of the cooperating family physician, CA-125 tests have been performed at 3 month intervals since about 2 weeks after the surgery. The test results are summarized in Table 3 -Patient's CA-125 Test ResultsTable 3. It is important to note that the 6/9/00 test was performed prior to the cancer surgery, while the other scores are postsurgical.
As Table 3 -Patient's CA-125 Test Resultsillustrates, the patient's CA-125 test scores have remained in the normal range since the surgery. Indeed, they are in the low end of the normal range. While a decline in the CA-125 score after surgery is expected, it is nontypical for active cancer to express a score at the low end of the normal range and to remain there for over 1 year.
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The results suggest that the primary peritoneal cancer is in remission for the studied patient more than 1 year after her surgery. Moreover, the evidence indicates that the primary peritoneal cancer has not metastasized. Since the patient has received no conventional treatment postsurgical, the possibility exists that the nutritional regime has been at least a contributing factor to these positive results. It is also possible that the nutritional regime is an effective postsurgical first line therapy for primary peritoneal cancer. Since there are no adverse effects from the regime, the therapy can be continued indefinitely.
Moderating Factors and Alternative Clinical Explanations
There are potential moderating factors and alternative clinical explanations for the results. It is possible that no cancer cells remained after the surgery. There have been reports of such outcomes. However, these outcomes are unusual.
Another possibility is that the cancer cells remain but are inactive at this time. The primary peritoneal cancer, or a metastic form, then could express itself at a later time. Given the mature nature of the patient's cancer and its rapid development earlier, however, it seems improbable that a recurrence would be delayed beyond a year with no conventional treatment. Moreover, there seems no reason for the inactivity in the cancer.
A third possibility is that the primary peritoneal cancer, or a metastatic form, is present but has yet to be detected by the CA-125 or imaging tests. Second look surgery would be needed to investigate this possibility. However, the patient would neither consent to, nor would a physician likely recommend, this examination. Perhaps new diagnostic tools on the horizon can offer an alternative, and less invasive, mechanism to perform the investigation.
Medical Implications and Future Research Suggestions
Further followup will provide additional evidence about the efficacy of the nutritional regime for cancer treatment of this patient. Even if the results of this followup continue to be encouraging, further studies on other patients will be needed to confirm or refute these findings. Strict controls will be needed to isolate the effects of the nutritional regime on other patients.
Another issue involves the length of treatment. The patient has continued with the nutritional regime, for health maintenance and other reasons. If the regime were discontinued, it is unknown if the cancer would bcome active. Moreover, it is unclear whether the dosages should be maintained, reduced, or increased over time. In short, it is unknown if the nutitional regime has curative, preventative, or control effects. Therefore, research is needed to resolve this issue.
Additional investigations will be challenging. Alternative cancer treatments have not be adequately funded, and future resources may be even more limited. Cancer patients may be reluctant to try unconventional approaches as a first line therapy. Researchers may be reluctant to abandon their current lines of research.
Still, the results from this case offer significant implications for medicine. One implication is that cancer is a nutritional deficiency which can be treated, if not cured, through the elimination of the deficiency. Another implication is that nutrition may be an effective preventative, as well as first line therapy, for cancer. This an implication has been proposed for years, yet rarely tested scientifically. This case suggests that such testing can be cost effective and health beneficial.
Guisseppi A. Forgionne, PhD
Information Systems Department
University Of Maryland Baltimore County
Catonsville, MD 21250