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James Barber, (C), with his family during their October 2023 visit at UHN’s Toronto General Hospital, where he was recovering from surgery​​​. (Photo: Courtesy James Barber)

By Catherine Danko

For most of his life, James Barber never questioned his symptoms. Severe indigestion and heartburn, he thought, were common side effects of eating a meal.

He never thought of them as precursors to esophageal cancer.

When he started losing weight rapidly and was unable to swallow food, James — who was 44 years old at the time of his diagnosis — sought medical attention for what turned out to be stage three esophageal cancer, which eventually spread to his skull and surrounding tissue resulting in metastasis.

“At that point, I was given only 12 months to live,” says James, who is from Peterborough, Ont. and was referred to UHN’s Toronto General Hospital (TGH) for an esophagectomy and a resection of the brain lesion — two high-risk, potentially life-threatening surgeries — to remove the tumours.

“James is now disease-free, which is not something we can say often about someone with metastatic esophageal cancer,” says Dr. Elliot Wakeam, a staff thoracic surgeon at TGH, who performed James’ esophagectomy.

According to Dr. Wakeam, most metastatic cancer patients are informed that their condition cannot be fully treated. Typically, they are offered palliative chemotherapy, which can alleviate symptoms and enhance quality of life, though it does not offer a complete resolution.

Esophageal cancer is particularly aggressive, with only a 20 per cent survival rate over five years.

“James’ success is really a testament to the esophageal program at UHN,” Dr. Wakeam says.

At UHN, a combination of new drugs used by medical oncologists and innovative clinical trials has allowed surgical teams to successfully perform the “aggressive” surgeries on patients who might not have ever been considered for treatment.

Drs. Jonathan Yeung, (L), and Elliot Wakeam say that a combination of systemic treatments including a clinical trial, investigative drugs and out-of-the-box surgical approaches are unique to UHN. (Photo: UHN)

Dr. Jonathan Yeung, a staff thoracic surgeon at TGH, says that the thoracic surgery clinic has the expertise to do all aspects of an esophagectomy — from “taking out the esophagus and reconstructing it with parts of the stomach, colon or small bowel” — a surgery performed anywhere between 40 to 50 times a year either openly, minimally invasively or robotically.

Thanks to a new clinical trial conducted at TGH, Mount Sinai Hospital and UHN’s Princess Margaret Cancer Centre, some of these surgeries now involve patients whose cancer has spread to other organs, such as James. The trial focuses on surgical candidates who have had a positive response to chemotherapy and radiation and can proceed with the surgeries even if their metastases are limited in scope.

“We want patients to know that even if you have a metastasis, we won’t give up on you,” says Dr. Yeung, who serves as co-investigator on the trial.

The objectives of the trials are to assess overall survival outcomes for patients receiving systemic treatment — primarily with chemoimmunotherapy — followed by surgery. Additionally, the trials aim to evaluate surgical safety, progression-free survival, quality of life and patterns of recurrence.

And, according to Dr. Wakeam, James’ story is one that’s becoming more frequent: young people, predominately male, who have never had medical problems prior are “presenting to hospital with very advanced stages of esophageal cancer and in need of lifesaving, challenging surgeries.”

One similar example is Christopher Pearce, a 44-year-old man who was referred UHN’s Toronto Western Hospital (TWH) for a biopsy after consulting a gastroenterologist when he was having trouble swallowing.

Christopher, who had never struggled with digestive issues before, says he was “caught off guard” by his esophageal cancer diagnosis considering his age and general health. By the time he began receiving chemotherapy at the Princess Margaret, the cancer had metastasized, spreading to his lymph nodes, making him at the time an unlikely candidate for surgery.

It wasn’t until after a tough nine months of chemotherapy and success with clinical trial drugs to eradicate the metastases in his lymph nodes, that Christopher was a surgical candidate, which was when he became a patient of Dr. Wakeam.

“Dr. Wakeam gave me the confidence that my surgery was possible not just because of his knowledge and expertise, but because of his collaboration with the team at UHN,” says Christopher.

Dr. Kazuhiro Yasufuku, Director of the Interventional Thoracic Surgical Program at Toronto General Hospital, University Health Network; Dr. Tom Waddell, thoracic surgeon and Head of the Division of Thoracic Surgery and thoracic surgical fellow Dr. Mauricio Pipkin carefully attach the first of the four robotic arms on to one of the steel ports in the patient’s chest. The robotic arms are docked on to the four ports through which surgical instruments and camera are maneuvered by the surgeon sitting in a console with a monitor and hand controls several feet away from the patient.

​In a Canadian first, thoracic surgeons at TGH used a robotic surgical system to treat early-stage lung cancer by removing the cancer, along with a lobe of the lung. The use of this system improves outcomes after surgery and will expand the numbers of patients who can benefit from this type of minimally invasive surgical treatment.

Dr. Kazuhiro Yasufuku.jpgIn their pioneering work, a team of surgeons led by Dr. Kazuhiro Yasufuku, Director of the Interventional Thoracic Surgical Program at TGH, and Dr. Tom Waddell, thoracic surgeon and Head of the Division of Thoracic Surgery, performed a robotic surgery on a 78-year-old man with a tumour the size of a penny in his lung’s upper right lobe. The surgery was performed at TGH, as part of the Princess Margaret Cancer Program.

“More than 70% of lung cancers have a good chance of being cured, if they are treated early enough, so we have brought together a team of surgeon-scientists, who use and further develop the latest technology to try and change lung cancer’s horrible statistics, ” says Dr. Yasufuku, adding that the future of treatment belongs to robotics since it can incorporate different imaging modalities which will guide surgeons to perform surgery more safely, and possibly more precisely, something that is not possible with other techniques.

Dr. Yasufuku, one of the most internationally respected thoracic surgeons with expertise in minimally invasive thoracic surgery and diagnostic procedures, was recruited from Tokyo, Japan to set up a unique Interventional Thoracic Surgical Program at TGH, which includes the development of novel technology and a surgical suite to improve the current ways of diagnosing and treating lung cancer.

The day after his robotic surgery on October 20, 2011, Stanley Skorpid, 78, was able to get out of bed, and eat cornflakes for breakfast. On the third day, Stanley was impatiently walking the hospital hallways, and on the fifth day, he was glad to be going home. He is now back at work as a concierge, and continues to walk his German shepherd dog, Skor, about one mile to the lake close to his home.

On his second post-operative check-up today, Stanley remains cancer-free. “I’m still here,” he says happily, “I’m feeling good.”

Many centres would not consider surgery for someone of Stanley’s age, points out Dr. Yasufuku, noting that the use of the robotic system contributed to Stanley’s early recovery, along with minimal complications and pain, and a better quality of life.

Surgeons at TGH have since performed six more successful surgeries with the robotic technique on patients with lung cancer. The patients typically have shorter hospital stays, less pain, easier recoveries, less blood loss and scarring than as if they had been operated on with open-incision surgery.

“The robot becomes your hands, it augments what your hands can do,” explains Dr. Yasufuku. “It’s so easy for your hands to move much more finely right inside the patient. They can get in really deep.”

To date, robotic surgery has most often been used for prostate and gynecological surgeries. It is now being used in several U.S. and European centres, and at TGH, as a useful technique in treating lung cancer. Studies in the 2011 Journal of Thoracic and Cardiovascular Surgery have shown that it is a safe procedure, and results in lower morbidity, such as blood loss, risk of infection, lower mortality, shorter hospital stays, and better quality of life than rib-and nerve-sparing thoracotomy.

In 2008, the Muzzo Family Charitable Foundation made a very generous pledge gift of $5,000,000 through the Princess Margaret Hospital Foundation to purchase the Da Vinci robot and to provide related program funding. This gift enabled the robotics program to begin and PMHF and UHN are very grateful to the Muzzo family for their ongoing support and keen interest in the program’s development.

“We are proud to be able to contribute to such a leading edge technology with the potential to directly impact a patient’s recovery in a very difficult time,” said Marc Muzzo.

For doctors wishing to refer patients for robotic surgery consideration, please contact the University Health Network Lung Cancer Rapid Assessment and Management Program (LungRAMP):

TGHRI Senior Scientist and UHN Surgeon-in-Chief Dr. Shaf Keshavjee has been appointed an Officer of the Order of Canada—one of the country’s highest civilian honours. The distinction recognizes outstanding achievements that have improved the lives of Canadians.

Dr. Keshavjee received the distinction for his innovative contributions to thoracic surgery, notably in the development of the Toronto XVIVO System, which has improved lung transplantation worldwide.

The process effectively preserves donor organs and extends the window of time that an organ can be removed from a deceased donor and transplanted into a recipient without tissue deterioration. Specifically, the technology enables lungs to be preserved outside of the body for over 25 hours, improving on existing limits, which require transplantation to occur within 4 hours. Thus, when used, the technology provides more time for donated organs to be matched transported to recipients. Congratulations to Dr. Keshavjee.

Thoracic surgeon Dr. Marc De Perrot, (R), has developed the world’s first pulmonary endarterectomy simulator in an effort to decrease the length of time it takes new surgeons to learn the technique, thereby broadening the pool of specialists who can offer the procedure. (Photo: UHN)​

It resembles something out of a Tim Burton film: raw, red tree-like monsters with what look like angry, twisted branches. But rather than being the stuff of movie nightmares, it’s in fact scar tissue that has been carefully removed from inside the arteries of a patient’s lungs.

The scarring is the result of chronic thromboembolic pulmonary hypertension (CTEPH) when a mass caused by blood clots gets caught in the lungs’ blood vessels and blocks blood flow. The blood clots are caused by an acute pulmonary embolism (PE) – when a blood clot travels from one part of the body into the lungs and gets stuck.

Though a PE can be resolved with blood thinners, CTEPH can develop anywhere from a few months to decades after it occurs. While rare, CTEPH is also under-recognized since its symptoms – shortness of breath, dizziness, fatigue – are similar to other lung diseases and ailments.

Left untreated, individuals with CTEPH can die within three to five years. But a new world-first simulator, developed by Toronto Western Hospital thoracic surgeon Marc De Perrot in partnership with the National Research Council (NRC) and support from a Bayer HYPE innovation grant, is designed to teach a key treatment option for those with CTEPH to more surgeons.

More surgeons will be able to learn the procedure

The simulator will help teach pulmonary endarterectomy (PEA) surgery, which removes scar tissue from the pulmonary arteries in the lungs, to more surgeons, offering the potential of a huge improvement in the quality of life for patients such as Patrick Himmelheber, 37.

When Patrick couldn’t catch his breath during his first recreational hockey game of the season in the fall of 2015, he just thought he had let himself get out of shape over the summer.

“It was the beginning of the season and I got winded as soon as I got on the ice,” recalls Patrick. “I figured I really needed to work on my cardio, but it got to the point that I couldn’t play without getting short of breath and I quit the team.

“It was very weird to be so short of breath because I’m a pretty fit person and exercised regularly,” he continues. “But every time I exerted myself, even to go up the stairs, I couldn’t breathe.”

Scar tissue removed from Patrick Himmelheber’s lungs. The scarring is the result of chronic thromboembolic pulmonary hypertension (CTEPH) when a mass caused by blood clots gets caught in the lungs’ blood vessels and blocks blood flow. (Photo: Courtesy Patrick Himmelheber)

Patrick struggled with his condition for eight months and finally decided to broach the issue with his doctor at Toronto Western Hospital’s Family Health Team. Since he otherwise felt fine and really wanted to underscore the degree to which he was short of breath, he asked Dr. Taylor Ferrier if he could demonstrate by walking up a set of stairs together.

As they walked up the stairs, Patrick’s breathing immediately became laboured, he couldn’t talk and had to stop to catch his breath.

Dr. Ferrier suspected PE and first ordered blood work but it came back showing nothing out of the ordinary. He spoke to his peers and the consensus was to do a CT scan to be safe. The scan revealed that Patrick had blood clots in both of his lungs. He was immediately sent to the Emergency Department, put on blood thinners and admitted overnight for observation.

“Later on, my family doctor would tell me that I was lucky to be alive,” says Patrick. “The amount of clotting they found in my lungs would have been detrimental to anyone who hadn’t been as physically active as I was.”

Patrick would need PEA surgery

Once stabilized, patients who experience PE are referred to Toronto General Hospital’s (TGH) CTEPH Clinic for follow-up. Patrick went for his appointment a few days later where he was prescribed a twice daily injected blood thinner for a month and scheduled for further follow-up in the fall.

Patrick went on with his life; travelling, enjoying the summer and spending time with his wife. As his follow-up appointment day approached, he figured it would be a routine formality. But the day before, Patrick’s morning routine was interrupted by sharp pain in his chest.

His wife rushed him to TWH Emergency where he was relieved to hear that he didn’t have any new clots. However, the diagnosis was very concerning: as a result of his earlier PE, necrosis – a side effect of CTEPH – was taking hold of his right lung and a very small part of his lung had died from the lack of blood flow in its arteries.

The chest pain was a result of the scar tissue from the necrosis pushing on his chest, and he would need surgery to remove it. Individuals with CTEPH that is left untreated can die within three to five years.

After a summer of feeling relatively secure about his diagnosis and treatment, Patrick now found himself seated across from a thoracic surgeon with an uncertain future ahead.

Fortunately, the thoracic surgeon in question was Dr. De Perrot, whose surgical expertise focuses on procedures for end-stage lung diseases including CTEPH which is treated via PEA.

A year in development, the visual simulator, pictured here, aims to reduce by six months the training time to learn the PEA procedure. (Photo: Courtesy Bayer)

Less than a month after his consultation with Dr. De Perrot, Patrick underwent asurgery of about eight hours to separate and remove the scar tissue from his lungs’ arteries.

For Patrick, it was happenstance that connected him with Dr. De Perrot – as an existing patient at UHN, he was referred to the appropriate physician who had the specialized expertise and skill to diagnose and treat his condition.

But there is a steep learning curve for thoracic surgeons to learn the PEA procedure that can result in high risk of mortality. Currently, PEA is only offered at a few specialized centres in the world.

“Thoracic surgeons learn PEA by assisting during the procedure,” explains Dr. De Perrot. “Working in a lung’s artery with magnifying glasses is delicate work making the technique difficult to teach – only one surgeon at a time can look through the artery during the procedure to see all the intricate detail.”

As such, learning the procedure can take about two years, making it difficult to more quickly enlarge the pool of surgeons who can offer PEA.

But Dr. De Perrot hopes to change all that. He spent a year developing the visual simulator, which aims to reduce training time for the procedure by six months.

Improved quality of life

The simulator, installed this month in the Temerty-Chang International Centre for Telesimulation and Innovation in Medical Education, will give trainees the opportunity to practice the delicate and complex procedure using a virtual platform in 3-D. It also allows experienced surgeons to train others remotely. The goal is to gather ongoing feedback from trainees to further refine the simulator.

“CTEPH is expected to increase in prevalence over the next 10 years,” says Dr. De Perrot. “With surgery, the five-year survival rate increases to 89 per cent and patients return to full function within a few months, so it is imperative to get more thoracic surgeons trained in this skill set and I’m pleased to be a part of the solution.”

One patient can certainly attest what access to this procedure has done for his quality of life.

Following his surgery, Patrick spent a week in the hospital and was then discharged. He felt an immediate difference as a result of the surgery and is slowly returning to normal life, going back to work on the two-month anniversary of the procedure.

He now also volunteers for the Thoracic Surgery Clinic acting as a point person for patients about to undergo PEA with whom he shares his experience to provide comfort and reassurance so they have an idea of what to expect and can see what recovery looks like.

“I’m still on blood thinners and maybe I will be forever,” he says. “But I am light years away from what I was feeling back in 2015.”​