Child's large tumor leads to a first for South Carolina

November 02, 2017
Dr. Satish Nadig checks Gabe Cade's liver
Dr. Satish Nadig checks Gabe Cade's liver while the 8-year-old boy's mother watches. Photo by Sarah Pack

“What’s up, man? You doing all right?” transplant surgeon Satish Nadig asks.

Gabe Cade, an 8-year-old boy who loves his four-wheeler, basketball and video games, nods. His mom pipes in. “Wonderful, he’s wonderful.”

It’s an amazing conversation, considering how dire Gabe’s situation was about 6 months ago. That’s when his Greenwood, South Carolina, family learned that a rare type of cancer had caused an aggressive tumor about 7 inches long and 5 inches wide on the second-grader’s liver. Five by 7 inches is the size of a lot of printed photos. But Gabe’s tumor wasn’t flat like a photo — it was bulging and growing.

He would become the first child in the state with undifferentiated embryonal cell sarcoma to have a liver transplant, which took place at MUSC Children’s Health. Nadig runs the pediatric abdominal organ transplant program and performed the operation. “This was a very big tumor,” he says. “You could see it through his skin.”

Undifferentiated embryonal cell sarcoma of the liver, or UESL, is so rare that it only occurs in about one in a million people. Unfortunately, Gabe, a Matthews Elementary School student, was one of them. But fortunately, he has an observant mother who raised the alarm in time to treat it.

Hilary Brown first noticed something was off about Gabriel last spring. “For two weeks, he was quiet. He did not play at recess. He came straight home from school and slept on the couch every day.”

Gabe started running a fever. “The doctor thought it was a virus,” Brown said. “We went to the emergency room. They said he was constipated.”

But as she would soon realize, it was much more serious than that.

One of the challenging things about UESL is that some of its symptoms, like the early ones Gabe had, look like other illnesses. The tumor grows unchecked. But Gabe’s mother keep a close watch over him, and one night, when he was lying with his shirt up, she saw a bump on his right side and took immediate action. “We went back to the emergency room. They did an ultrasound, and they saw he had a big mass on his liver.”

Gabe was diagnosed with the life-threatening form of liver cancer, which typically strikes kids between the ages of 5 and 10. While the disease is unusual, it is treatable, Nadig says. “Most kids with this get resected for it.”

Resected means part of the liver is removed. But that wasn’t an option for Gabe. He needed a new liver. And before he could get it, he needed chemotherapy to shrink his tumor. He would get that treatment at a hospital in Greenville, then come to MUSC Children’s Health for a transplant.

But once again, the rarity of Gabe’s disease created a challenge. Doctors knew chemotherapy was the right route for him, but chemo is a nuanced treatment with multiple options in terms of medication, dosage and frequency. The first regimen didn’t work, Nadig says. “The tumor was actually growing.”

It was a shock for Gabe’s family. “I was worried before, but it didn’t really hit me how close we might be to losing him until the ICU, when the first chemo didn’t work,” his mother says.

Nadig, along with Michelle Hudspeth, director of pediatric oncology at MUSC Children’s Health, and their counterparts in Greenville were determined to find the solution. They reached out to colleagues in Pennsylvania who had treated a child with UESL before, and the South Carolina team came up with a new chemotherapy regimen. This time, it worked.

“He started getting better,” Nadig says. “We did a few cycles of chemo, and looked like it was not metastasizing and was shrinking in size, although was huge, still.”

After spending about two months in the Greenville hospital getting chemotherapy, Gabe was well enough for a transplant. At MUSC Children’s Health, gastroenterologist Nagraj Kasi, a specialist in the medical management of pediatric transplant patients, prepared for Gabe’s surgery. Gastroenterologists specialize in disease of the gastrointestinal tract and liver. Kasi’s integral role was another example, Nadig says, of how well equipped MUSC Children’s Health is to handle complex cases.

“We’re a multidisciplinary, comprehensive transplant institute,” Nadig says. “Gabe came from Greenville, where they can get him the chemo but not the transplant or the follow-up. Here, we have the pediatric oncologists, the pediatric transplant surgeon, the pediatric hepatologist, the whole children’s hospital with an intensive care unit, a step-down unit and nurses who are in tune with caring for liver transplant children. The whole system needs to be in place for this to be successful.”

A donor liver was found for Gabe in August, and he had transplant surgery. “A liver transplant is a technically challenging operation,” Nadig says. “You’re around big veins and arteries, and typically patients who need a liver transplant are pretty sick. There’s little margin for error.”

Gabe’s mother describes the moment Nadig told her family how Gabe’s operation went. “When Dr. Nadig came out of the operating room, he was like, ‘Gabe is cancer free!’ Just out loud,” Brown says. “He is one in a million. He cares about his patients, he’s always cheerful and I’ve never met anyone like him.”

Three months later, Gabe has regained the weight he lost and there’s no sign of what he’s been through, apart from scars hidden by his shirt. He stayed out of school for a while to give him time to heal and for his immune system to return to a healthy level. He’ll probably need to take medication for the rest of his life, but his mother is fine with that. “I’m happy he’s here with me.”

Nadig says Gabe reminds him and his colleagues why they became doctors. “The epitome of that is saving a child’s life. There’s no sugarcoating that.”

Gabe’s transplant was possible because somebody agreed to donate his or her liver after death through the nonprofit United Network for Organ Sharing. About 17,000 people are waiting for donated livers in the U.S.