Ryan - Week 5

It's crazy to think that we only have two more weeks left in NYC but I guess time flies when you're having fun. This week in the OR, I saw Dr. Boockvar and Dr. Huang perform a pituitary endoscopy and adenoma resection on a middle aged man. The surgery was pretty textbook and everything went well. Then Liz and I went downstairs to the food court so she could grab something to eat before the next operation. However, when we got up to the OR room, the operation was cancelled because when the anesthesiologists were prepping the patient, they recorded a concerning heart rhythm. Therefore, the doctors all decided that the surgery (a craniotomy and resection of a glioblastoma multiforme, or GBM, tumor) should be postponed for two days so that cardiology could clear her. So instead, Liz and I went next door to see Dr. Schwartz perform a left temporal craniotomy and language mapping study on an awake man; by far the coolest surgery I've seen yet in NYC. A neurologist was making the man read from slides to monitor his ability to read (speed and comprehension) while Dr. Schwartz applied stimulation to different regions of his exposed brain. This method of testing the man’s language skills allowed Dr. Schwartz to identify which part of the man’s brain was healthy, normal tissue (stimulation hindered his reading ability because this tissue conducts electrical signals) and which part was tumor tissue (stimulation did not affect reading ability because this tissue does not conduct electrical signals). After mapping out the area, Dr. Schwartz proceeded to resect the brain tumor, which turned out to be malignant GBM. Since the patient had to be able to talk during the procedure, he could not be intubated or given general anesthesia and therefore the anesthesiologists had to watch him very closely and make sure that his local anesthesia didn’t fall below a certain concentration or he’d pass out or vomit. So throughout the surgery, they had to keep him talking and letting them know when the pain was getting to be too much. Looking at his brain and hearing him talking made me pretty nervous but he seemed to be comfortable enough because he actually cracked a couple jokes and talked to exhaustion about being a pastry chef. Then, once the surgeons closed him up, he seemed fine and was really happy that the surgery went well. Everyone in the room (there were a ton of people watching this procedure) was really impressed by the operation and by the patient’s ability to go through something like this and be as cheery as he was. I also saw Dr. Boockvar perform another craniotomy case where he resected a left temporal GBM tumor from an old lady. The surgery went well despite surgical pathology telling us that the mass in her head is GBM. Following surgery, Dr. Boockvar brought me with him to go notify the family that surgery went well and that their grandmother does indeed have brain cancer. As of right now though, we don’t know the exact grade of the tumor, so Dr. Boockvar advised the family not to go and search “GBM” on the internet and get themselves all worked up until we know the whole picture. As a side note, the World Health Organization (WHO) tumor grade scale indicates the level of malignancy based on the tumor’s mitotic index (growth rate), vascularity (blood supply), presence of a necrotic center (dead cells), invasive potential (tumor border distinctness), and similarity to normal cells of the afflicted organ. There are four grades associated with this scale. Grade I tumors are the least malignant because they grow slowly and appear most like normal cells, therefore surgery alone may be effective in treating the patient. Grade II tumors grow slightly faster, have a slightly abnormal appearance, and may invade the surrounding normal tissue, which poses a risk for tumor recurrence following surgery and requires follow-up chemo/radiotherapy. Grade III tumors are malignant, contain actively reproducing abnormal cells that invade surrounding normal tissue, and frequently recur after surgery. Grade IV tumors are the most malignant, contain rapidly reproducing abnormal cells that invade wide areas of the surrounding normal tissue, possess a necrotic center, and recruit new blood vessel ingrowth to support their rapid growth. That being said, Dr. Boockvar is hoping that the GBM for this patient is low grade so that he can aggressively treat it and thereby try to maximize the patient’s longevity. Meeting with the family was a good experience to watch Dr. Boockvar break the news to the family members that their grandmother/mom has a brain tumor and see how he handles their response. I personally feel that he has a great bedside manner with patients and their families and I’m not the only one to think so. Patients and their family members have mentioned to me that they think he’s a fantastic doctor and how they went out of their way to seek him out. Dr. Schwartz had another pituitary adenoma endoscopy this week and when he walked into the OR, he and the ENT (ear, nose, and throat) surgeon quickly discussed the case and went through surgical “timeout.” As the ENT started, Dr. Schwartz went on rounds to check up on a few patients and invited me to come with. While walking around, he and I discussed my work on investigating narrow band imaging (NBI) endoscopes and the potential for using one of gastroenterology’s NBI endoscopes for a pituitary endoscopy. Of the three patients we saw, two were surgery follow-ups that went pretty easily and one was a surgical prep where the grandmother had a brain tumor in her language center and was therefore misplacing or having trouble finding the right words. Then back in surgery, Dr. Schwartz used the 3D endoscope again to resect the middle-aged woman’s pituitary adenoma.

A particularly interesting experience from this week was my visit to gastroenterology surgery where Taylor, Matt, and I went to see the Da Vinci surgical robot operate. Dr. Scherr from Urologic Oncology used the robot to perform a minimally invasive prostectomy on an older male prostate cancer patient. When we arrived in the OR, the patient was already on the operating table and the robot’s four arms were already penetrating the patient’s abdomen and the endoscope was portraying the patient’s bladder on a large 3D monitor. The surgeons initially approached the patient’s prostate by going down around and cinching off the bottom of the bladder. Next they isolated the prostate and cinched off and cut the vas deferens, urethra, and all the connected arteries and veins. The catheter was then pushed up through the urethra and a balloon in the tip was inflated to stopper the urethra opening to the outside to keep the pressure up inside the abdomen. A probe was then inserted and the tip opened up like a butterfly net which was filled with the prostate and some of the fat that was lining the abdomen and removed through one of the small surgical holes. To close, the surgeons sutured the bottom opening of the bladder to the urethra and put in some stitches to keep everything in place while healing because they had to cut through a lot of supportive tissues and fat to remove the prostate. While the surgeons were busy closing up the minimally invasive cuts in the patient’s body, Taylor, Matt, and I took a peek at the control system for operating the Da Vinci robot, which looked like there were loops for your thumbs and the rest of the control rested in your palm. This type of odd controller system apparently allows super sensitive tracking where when you move your hands, the robot’s hands mimic your every move and rotation.

In clinic this week, I shadowed Dr. Boockvar as he met with a few new patients and several continuing patient checkups. One of the new patients was particularly troubling because she and her parents were very nervous about a slightly bright spot on her cranial MRI. They had been through this with their other daughter, who lost a fight with brain cancer and were extremely nervous that this daughter might have the same prognosis. Dr. Boockvar tried to reassure them that they would do whatever they could to fight this but the only option she has is surgery to remove and identify what this bright spot is. This case is very strange because brain cancer is not a hereditary disease and therefore it’s scary that this family may have struck some seriously bad luck. I really hope that whatever this bright spot is, it isn’t a malignant brain tumor but rather a benign cell mass that can easily be removed, allowing the patient to live long after surgery. Another one of Dr. Boockvar's patients was a woman with a lumbar spinal tumor pressing on her bladder nerves. The orthopedic surgeon she saw prior to coming to Dr. Boockvar wanted to place a titanium cage along her vertebral bodies following the tumor resection but Dr. Boockvar says that’s unnecessary and that this surgeon suggested a cage because that’s his specialty and he wants the operation. She was really happy to hear from Dr. Boockvar that the surgery does not require a cage and that it will be a minimally invasive surgery with only 2-3 nights in the hospital, depending upon how she’s feeling. We also had a checkup with the aspiring nurse student, who shadowed with me, Molly’s Dad and the MRIs show no new growth so his treatment of Avastin is seeming to keep his GBM at bay. I’m glad that the treatment is still able to keep his tumor from growing but eventually, as happens with all GBM patients, the tumor cells will become resistant to Avastin therapy and a new treatment will need to be implemented. Another interesting patient was an old lady with partially repaired scoliosis who is experiencing a debilitating headache on the left side of her head and around her left eye socket and sinus. After looking at the MRIs, which several other doctors had looked at and couldn’t find anything wrong much to the frustration of the patient, Dr. Boockvar said she should get a CT myelogram to see if her pain is from a spinal fluid leak since her brain shows a slight sagging in the skull possibly from a decrease in pressure. This procedure involves injecting a contrast agent into the lumbar spinal fluid and then flipping the patient upside down to let the contrast agent flow into her skull. Then a CT scan will be taken to see where her spinal fluid might possibly be leaking so that they can surgically seal the leak. Hopefully this works out. I can definitely empathize with the patient on how terrible migraines can be.

At the Multidisciplinary Brain Tumor Conference, Liz, Young-hye, and I sat in on the pretty routine discussions of treatment options of the more complex cases of brain cancer. During the weekly update meeting with Dr. Wang and Dr. Frayer, we all went around the conference room again and shared our most interesting experiences for the week and how our projects are going, over pizza. Since last week, I’ve been analyzing the pituitary endoscopy videos from Dr. Schwartz using Matlab. What I’m most excited about though is that I’ve been able to persuade Dr. Schwartz into trying out one of the narrow band filter endoscopes from gastroenterology during one of his pituitary endoscopy surgeries. Hopefully we’ll be able to get that set up next week.