Health Care Quarterly:

Patient Success Profile: Ernest Williams

Ernest Williams was found to have mucosal-duodenal-melanoma, an extremely aggressive and lethal form of cancer. Most people think of melanoma only in relation to skin cancer.

Skin and the sun” are the first words that likely come to mind when melanoma — the most lethal form of skin cancer — is mentioned. Sunscreen application and tanning bed avoidance remain the primary preventions of this cancer.

But, there is more to this disease, including rare non-skin variants.

In 2016, according to the American Cancer Society, more than 75,000 Americans will be diagnosed with melanoma and more than 10,000 Americans will die from the disease. Within these statistics, only a handful are identified as starting somewhere other than the skin, such as palms and plants, the vulva, esophagus and, to a lesser extent, various areas of the gastrointestinal tract.

So is the case with 53-year-old Summerlin resident Ernest Williams. In 2015, Williams had what was suspected to be peptic ulcer disease. It turned out to be an aggressive cancer of the duodenum (in the small intestine), prompting an immediate consultation with medical oncology for treatment. Upon later discovery, it turned out to be an even rarer form of cancer of the bowels — mucosal-duodenal-melanoma, an extremely aggressive and lethal form of cancer, particularly when it has already spread.

Williams’ battle with melanoma began with what he thought was the flu. He typically wasn’t one to get sick, but he took action when unusual symptoms began to add up — he was experiencing severe stomach pain, lost five or 10 pounds seemingly at random and felt tired all the time. A couple rounds of antibiotics did not help, and things got worse.

An ultrasound of the liver showed it was packed with tumors. He was referred to a gastroenterologist, who revealed that the duodenum, the first part of the small bowel, harbored a malignant-appearing ulcer, presumably a cancer of the lining of the bowel (or “adenocarcinoma”) that spread to the liver.

A pathologist at Comprehensive Cancer Centers of Nevada revealed that Williams had mucosal-associated melanoma, an even rarer variant of cancer of the duodenum. The cancer had also spread to the lymph nodes and liver, replacing 80 percent of the healthy liver.

Williams arrived at CCCN just days after groundbreaking clinical research data demonstrated the superiority of combining two immunotherapy drugs rather than one in the treatment of melanoma. He received a combination of Ipilimumab and Nivolumab. He took this combination of drugs for four doses before he continued to receive the single-agent Nivolumab, with dramatic clinical and radiographic responses. Not only did his blood markers normalize, but he gained most of the weight he had lost and went back to work full time.

Each of the immunotherapy drugs essentially boosts the body’s immune system to treat melanoma and ultimately the Food and Drug Administration approved this combination thereafter. Both Nivolumab and Ipilimumab are monoclonal antibodies that target the ON/OFF switch of the immune cells, although referred to as “checkpoint molecules”. The drugs are engineered to lift the immune cells’ suppression of normal function, imposed by the cancer to inflict on the body to tolerate it. Hence, these drugs allow an immune function “awakening” to complete fighting the malignant intruder cells. Where Ipilimumab is solely being used for melanoma treatments, Nivolumab as a single agent is currently commercially available, used to fight advanced melanoma and to prevent recurrence of certain cases of early melanoma. Additionally, it is used for advanced renal cell carcinoma, non-small cell lung cancer and classic Hodgkins lymphomas. As of today, there are drugs on the U.S. market that belong to the class of immune checkpoint inhibitors, some to treat melanoma and lung cancer (Pembrolizumab), and others to treat bladder cancer (Atezolizumba).

During his initial treatments, Williams only noted mild tiredness as a side effect and his organs were spared any side effects.

By January 2016, his scans showed resolution of cancer in his lymph nodes and significant shrinkage of his cancer in the liver by half. By June, his cancer in the duodenum had resolved and he had minimal residual cancer in the liver. Although he is not completely cancer-free yet, the treatment definitely allowed him to recover, return to work and re-start his gym routine. Hopefully the treatment will carry on to eradicate what is left of the disease and render him cancer free soon.

What started as a rare case of melanoma has evolved in to a case study for what is possible in the realm of cancer treatment. With immunotherapy — and its recent advances, current clinical trials and discoveries just over the horizon — patients like Williams can have real hope.

Dr. Fadi Braiteh is a medical oncologist and director of the Translational Oncology Program (TOP) — Phase I and GI Malignancies Program for Comprehensive Cancer Centers of Nevada (CCCN). He is also a clinical associate professor at University of Nevada School of Medicine.

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