Additional Info
- Audio Fileuab/ua237.mp3
- DoctorsCasp, Aaron
- Featured SpeakerAaron Casp, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5639
- Guest BioAaron Casp, MD Specialties include Orthopedic Sports Medicine and Orthopedic Surgery.
Learn more about Aaron Casp, MD
Release Date: April 4, 2022
Expiration Date: April 3, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Faculty:
Aaron J. Casp, MD
Assistant Professor, Orthopedic Sports Medicine & Orthopedic Surgery
Dr. Casp has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole. And today I hope you'll join us, as we explore hip arthroscopy, a new frontier in treating hip pain. Joining me is Dr. Aaron Casp. He's an Assistant Professor, an Orthopedic Surgeon, and an Orthopedic Sports Medicine Specialist at UAB Medicine. Dr. Casp, thank you for joining us as a repeat guest today. I'd like you to start by telling us about hip arthroscopy, as it's relatively new and expanding field to treat hip impingement and groin pain in young active individuals. What had been the options for treatment? How has it evolved now?
Aaron Casp, MD (Guest): Sure. Previously, in years past, people had just attributed people with groin pain or hip pain as, oh, you strained a hip flexer or something along those lines and sort of didn't think of it as anything that needed to be intervened upon. More recently, as we've learned a little bit more about hip anatomy and hip biomechanics, we've realized that people are actually having some signs of impingement and you can actually tear a structure around your hip called the labrum, and then, that labrul tear can lead to small mechanical changes in your hip and can actually lead to early arthritis and early degenerative changes.
So, when people were initially sort of brushed off a little bit about what their hip was doing, it could have been doing some long term damage to their hip. And more recently as technology and techniques have evolved a little bit, people are actually able to intervene upon these labrul tears and this hip impingement.
In early years, it was open surgery where it was called a open surgical hip dislocation, which is about as morbid as it sounds, you make a big incision and dislocate the hip and have a long, massive painful recovery from this big open incision. But now we're able to do almost everything arthroscopically.
Host: So for other providers that may not see hip labrum tears very often or may not recognize as you say things we learn, right? How does that happen in younger people that can cause significant pinching pain with deep flexion, prolonged running, sitting, tell us a little bit about the most common causes that would necessitate the need for arthroscopy in the hip.
Dr. Casp: Yeah. So, labral tear can happen in a few different ways. I sort of split them up in my head in kind of two main ways. One is a hyperflexible patient that has a labrum tear. And that could be someone like a dancer or a cheerleader or someone who uses a lot of high hip flexion angles as part of their activities and that usually creates a labral tear that is a little more acute in nature. By that I mean, they did it and then they started having hip pain afterwards. The other one is a little bit more of an overuse type labral tear, and that's runners or sort of more endurance athletes.
And while they still have pain with high hip flexion angles or deep squatting, it was more of a sort of prolonged wear and tear type injury for them. And so I get a lot of questions like how did this happen? Well, there are a number of ways it can happen and a number of different mechanisms. Some of them being either sort of more acute, like I talked about, or sort of more wear and tear, and sometimes they're a little bit of a combination of both.
Host: So then tell us the goal as far as intervening before, especially for young people, dr. Casp before degenerative changes in hip, arthritis begin to set in, prolonging the health of the joint is really essential. So what are the clinical indications for the procedure we're talking about today?
Dr. Casp: The main clinical indications are what we call a symptomatic labral tear. What does that mean? Well, there are a lot of people that if you got an MRI or imaged their hip, with no symptoms, they would have some evidence of a small labral tear. Those are the people that don't need surgery or need intervention. But there are a subset of people who have a labral tear that is quite symptomatic. And what do they look like? Oftentimes they look like they have deep seated groin pain, kind of in the front of their hip. Sometimes it radiates almost through their hip and oftentimes people sort of grab the side of their hip in a, in a C shape with their hand and say the pain is in there.
It mainly bothers people, like I said, with some deep squatting activities or prolonged running and oftentimes people get very sore when going from sitting to standing or after they've been in a car for a long period of time. And so the people that do the best are, you know, healthy, active individuals who have this labrum tear on imaging, but also don't have any current arthritis. By that I mean, their cartilage is still in good enough shape that if you repair the labrum, you're preserving an otherwise healthy joint. And the goal is to prolong the health of the joint and reestablish the labral suction seal that it creates and stabilize the hip and give people back their activities that they want to do.
Host: So speak about patient selection for whom this procedure is indicated. As we said at the beginning, it's relatively new. Tell us a little bit about the procedure itself for other providers that are looking to refer their patients to you. Tell us are you using robotics? What's the procedure itself like.
Dr. Casp: So the procedure sort of starts before we even get into the operating room, looking at the imaging. I have a very particular set of x-rays and MRI that I get to evaluate the entire anatomy of the hip. So there's a reason that this labrum tore, and it's usually because the head of the femur has impinged on the acetabulum or the socket and in between those two is the labrum.
So it's gotten pinched and torn. So if you can look at the bony anatomy, you can see whether or not somebody has a little bit of a bony deformity on their hip that would put them at risk for this labrum tear. And then the MRI confirms any cartilage or labrum damage. And then the procedure itself, is mainly for people who have these symptomatic labral tears in otherwise healthy joint and want to get back to their painfreeactivities.
The procedure is all outpatient. So it's a come in and go home same day kind of procedure. The procedure itself, uses two or three small poke holes in the skin using all arthroscopic techniques. By that I mean, small four or five millimeter camera and some four or five millimeter instruments. And the labrum is then reattached or repaired back up onto the socket to where it should be. And then any bony impinging lesions or bony deformity that caused the issue to begin with are sort of shaved down according to the imaging and the template from the preoperative imaging. So the overall goal is to make this a very thorough one and done surgery. So not only does the labrum get repaired, but any cause of the labral tear, any cause of the impingement is then shaved away back to a more sort of normal bony anatomy.
Host: Dr. Casp we've been doing knee arthroscopies for a long time. Why is this new?
Dr. Casp: The hip is particularly difficult to get access to for a number of reasons. Number one, there's a lot of soft tissue around the hip joint itself. Even in the skinniest person, you have all of your gluteal muscles, you have your hip flexor muscles and your thigh muscles that sort of get in the way. The other reason is that the hip is a very deep ball and socket joint. So in order to get access to the joint, you have to have a specific traction type table to distract the hip joint, to get in and work in that area. So, both the improvement of arthroscopic tools, as well as the improvement in techniques and ability and specialized OR tables in order to access the hip have made this a little bit slower on the playing field as far as an option goes to treat hip pain.
Host: And how have been your outcomes? Does the repair hold? What have you seen with your patients?
Dr. Casp: I think it's mainly because of very sort of strict selection criteria, but a lot of my patients are back and doing some of the things that they really enjoy doing, hiking, playing sports, and running. And so, the overall outcomes are very good, but even though I repair the labrum back, that's using some small anchors and some stitches, the labrum still has to heal there. So overall it heals very well, and reliably, so, but you have to allow it to heal. So the recovery, is just very slow initially, cuz you have to allow that labrum to heal there if you want the most optimal outcome.
Host: And do you have any final thoughts for other providers that are looking to add this to their armamentarium of available therapies, or to refer to the specialists at UAB Medicine? What would you like to tell them about hip arthroscopy, the new frontier in treating hip pain.
Dr. Casp: I think that hip arthroscopy is definitely an emerging field. And I think we'll see a lot more hip preservation and surgeries to prevent hip arthritis going forward. As far as adding this to their armamentarium, there's a fairly steep learning curve to learning hip arthroscopy. Again, it's a little bit different than a knee arthroscopy. But I think getting exposed to hip arthroscopy and of being able to evaluate your patient's hips, doing a good hip exam is very important, for understanding what's going on with your patients. So I think listen to them and then if you are not quite sure, I'm always happy to discuss with any provider in the area or any provider across the country that has any questions.
Host: Thank you so much, Dr. Casp for joining us, telling us about this procedure, the learning curve, technical considerations, everything you've shared with us today. A physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST, or you can visit our website at UABmedicine.org/physician.
That concludes this episode of UAB Med Cast. For more updates on the latest medical advancements, breakthroughs and research, follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua234.mp3
- DoctorsMomaya, Amit;Casp, Aaron;Brabston, Eugene
- Featured SpeakerAmit Momaya, MD | Aaron Casp, MD | Eugene Brabston, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5629
- Guest BioDr. Amit Momaya is a sports medicine surgeon and serves as section head of the sports medicine division within the Department of Orthopedic Surgery at the University of Alabama at Birmingham.
Learn more about Dr. Amit Momaya
Aaron Casp, MD specialties include Orthopedic Sports Medicine, Orthopedic Surgery.
Learn more about Aaron Casp, MD
Eugene Brabston, MD Specialties include Orthopedic Surgery.
Learn more about Eugene Brabston, MD
Release Date: March 24, 2022
Expiration Date: March 23, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Speaker:
Eugene Brabston, MD
Assistant Professor in Orthopedic Surgery
Amit Momaya, MD
Associate Professor in Orthopedic Sports Medicine & Orthopedic Surgery
Aaron Casp, MD
Assistant Professor in Orthopedic Sports Medicine & Orthopedic Surgery
Drs. Brabston, Momaya & Casp have no relevant financial relationships with ineligible companies to disclose. Also, no other speakers, planners or content reviewers (Ronan O'Beirne, EdD, & Katelyn Hiden) have any relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - Transcriptionua234
Welcome to UAB MedCast, a continuing education podcast for medical professionals. Providing knowledge that is moving medicine forward. Here's Melanie Cole.
Melanie Cole: A massive and irreparable rotator cuff tear is a diagnosis that no patient, especially an active patient, wants to receive. Now, orthopedic physicians at UAB Medicine offer a new procedure that has the ability to bring relief for patients with a massive rotator cuff tear previously deemed irreparable.
Welcome to UAB Med Cast. I'm Melanie Cole. Joining me in this panel are Dr. Amit Momaya, he's the Chief of Sports Medicine; Dr. Aaron Casp, he's an assistant professor and an orthopedic surgeon and an orthopedic sports medicine specialist; and Dr. Eugene Brabston, he's an assistant professor and an orthopedic surgeon. They're all with UAB Medicine.
Gentlemen, thank you so much for joining us today. And Dr. Momaya, I'd like to start with you and traditionally rotator cuff repairs have a high failure rate proportional to the tear size. What have you learned about rotator cuff injuries in the last decade or so, and any patient-specific factors that influence healing rates? Speak to us about that for just a minute.
Dr. Amit Momaya: Sure. Rotator cuffs continue to be an issue with many patients, especially a growing population as we age. And the failure rates are higher than we would like. A lot of times rotator cuffs become massive and some factors involve the lack of healing include age of the patient. The older the patient is, oftentimes the more difficult it becomes to achieve healing. Also, the size of the rotator cuff often is predictive if it's going to heal or not, in addition to some muscle atrophy or wasting away where sometimes fat can be embedded into the muscle belly, and that can lead to lack of healing after repair. And so, you know, one of the things we've looked at closely is looking at some of these tears that become so massive and deemed irreparable. And those are very challenging patients to deal with from a surgical technique and from a healing perspective.
Melanie Cole: Dr. Casp, I'd like you to tell us about the subacromial balloon space or procedure for relief of those rotator cuff tears that Dr. Momaya was just speaking about.
Dr. Aaron Casp: Sure. Yeah. You know, as Dr. Momaya had mentioned, having a massive and irreparable rotator cuff tear is a challenging problem. And previously, the solution was not very good kind of frankly. It would require cadaver graft and several anchors and a long surgery and still their outcomes were not as favorable as we had liked.
The subacromial balloon spacer puts a bioabsorbable, biocompatible, saline-filled balloon into the subacromial space, which is where the rotator cuff tendons used to live. And what it does is it essentially keeps the humeral head or the ball and of the ball and socket joint of the shoulder in place, so your shoulder can function. Basically, it pushes down on the humeral head and keeps the joint centered, so the rest of the muscles can take over and function appropriately where the rotator cuff used to.
Dr. Eugene Brabston: And I completely agree with that, Aaron. And in terms of that big important part of why this surgery actually works, we think that it works by rebalancing the shoulder. When you actually have an irreparable rotator cuff tear, somehow you lose the balancing of the ball and the socket. And that's where a lot of folks get pain as well as inability to get their arm up over their head as well as dysfunction. So the thought about the spacer is in a way it rebalances the shoulder. So over time, and we don't know if it's scar tissue, if it's these rotator cuff muscles that are still attached, somehow the shoulder relearns how to function. We know that it does very well in terms of improving pain and also improving function. But we have to be very careful in terms of who we select this surgery for.
Melanie Cole: So then along those lines, Dr. Brabston, one thing I found interesting is that this spacer is designed to restore more normal acromial humeral interval to allow for that normal shoulder kinematics. Do you feel it works more as a biological spacer or cushion? Or is it helping to restore a more normal shoulder biomechanics? Tell us a little bit about that and why patient selection is so important. Tell us about patient selection.
Dr. Eugene Brabston: That's a really good question. And the short answer is we don't exactly understand how it works. I think it's probably both of those items in terms of physically distancing the humeral head from the acromion and, in addition, kind of rebalancing it over time. So the initial thought is that you put it in and what it does is it does provide a space. You know, if the humeral head can't hold itself down, then this is actually a biological way to do that. So it provides that space initially, and then over time, the muscles and essentially, you know, the way that you're functioning that shoulder, you relearn how to hold the humeral head down.
In terms of some of the indications, we know that this does do better in certain kinds of tear patterns. So for instance, if you have a really big tear that extends all the way to the front of the shoulder and actually extends to a muscle called the subscapularis, this is probably not the best surgery. In addition, we also know that if folks have arthritis or wear and tear changes of the actual cartilage in the joint, this probably is not great solution for them either. But in terms of, you know, age, ages typically for this kind of a procedure, we're doing this in younger patients, as opposed to patients that we would do in a replacement surgery. And I don't think we quite have hit the upper limit of what is oldest that we can do this procedure in and I think that time will tell.
Melanie Cole: Dr. Momaya, what about the balloon itself? Tell other providers what this material is and how long it's expected to last.
Dr. Amit Momaya: Sure. The actual spacer material is a biodegradable polymer. It's a polymer that's commonly found in a lot of other medical devices. It's not necessarily novel in that respect. But overall, in terms of how long it lasts, you know, the actual balloon is thought to deflate approximately three months after implantation, but it actually degrades over a period of years. Now, we've looked at studies where we're looking at MRIs after someone has received this, the actual material likely incorporates into scar tissue. So we see a spacer effect probably much longer than that. And one of the things that you had mentioned was the acromial humeral interval, which is a space between the roof and the ball. And one would think that if you were to have a device that degrades in a relatively short period of time, let's say within a year or so, that space would not be maintained beyond that.
UAB, we were the first in the United States to perform a systematic review looking at 200 patients that received this type of treatment. And we found that actually beyond one year, going on to two to three years, the space was actually maintained to a certain level, which was somewhat of a surprising finding. But overall, the spacer is biodegradable and likely forms a little bit of scar tissue. And again, as Dr Brabston mentioned, it retrains the muscles and restores what we call a force couples in that area to allow the shoulder to function better.
Melanie Cole: Very cool. The technology now that you're using at UAB is really amazing. And this is a big problem. It affects a lot of people. And Dr. Casp, as you're speaking to other providers that are looking to the experts at UAB for the procedure itself, is there a learning curve? Are there any tips and tricks, technical considerations you'd like to share with other providers that are looking to add this to their armamentarium of therapies?
Dr. Aaron Casp: Absolutely. You know, I think the biggest benefit and beauty of this procedure is that it's very simple. Just like any new procedure, there's a little bit of a learning curve. But if you can put an arthroscope into a shoulder and do some procedures, you can certainly do this procedure. It uses the standard arthroscopic portals. It doesn't necessarily require any additional procedures beforehand, though most people are doing some amount of getting rid of some scar tissue or taking a little bit of the underside of the acromion so it doesn't pinch or impinge on any of the structures. And then, there's really just one implant, one thing that comes essentially out of the box. You measure the size that you're supposed to use, and there's measuring device that comes with it. And then you know the size and then you insert the implant and then basically remove the sheath, fill it up with saline to the appropriate amount. And then, you'd close the balloon and that's pretty much it.
Compared to the previous procedure, which was what we called a superior capsular reconstruction, this takes a fraction of the time, maybe 10 minutes, whereas the previous procedure could take a couple hours. So it's very fast, very time-conserving and very simple and easy to use.
Melanie Cole: Nice. And Dr. Brabston, I'd like you to tell us about the patient experience and the outcomes that you've seen and post-surgical shoulder function. Has there been a need for revision surgery? What's the recovery like? What's the range of motion like? Tell us a little bit about your outcomes.
Dr. Eugene Brabston: Sure. You know, in terms of that procedure, I think one of the most amazing things is how patients get such a significant relief of pain so quickly after surgery. And, you know, we don't quite understand if that's because of the spacer itself or the surgery, whenever we're doing the arthroscopy, when we go in with a scope, obviously we try to clean any scar tissue out, any bursitis or inflammatory tissue in that area. But we're kind of surprised at how well patients do immediately after surgery. You know, a lot of them will come back and say that their pain is significantly better, which even for a regular rotator cuff tear, whenever you're repairing those, it's variable in terms of how much pain relief patients get immediately after surgery.
In terms of kind of what we do with these patients, usually we treat them in a sling for several weeks' time to really kind of let things calm down after surgery. And then after, you know, somewhere in the range of four to six weeks, we initiate physical therapy, starting to work on motion. And the big idea with motion is obviously getting the motion back that they may have lost over time and then retraining those muscles that are still attached to actually do the work.
You know, in terms of kind of long-term outcomes, you know, we're still following up on that. And it's something that patients in terms of range of motion and pain control, they're doing exceptionally well with that. I think we're kind of waiting time-wise to really see strength-wise how much strength they're able to get back over time. And that's something that obviously takes a long period of time after a surgery to really retrain those muscles that are still attached to get strength.
Dr. Aaron Casp: I'd like to add just that, because you're not really relying on something to heal or scar in as much as big, massive rotator cuff repair or superior capsular reconstruction, you can be a little bit more aggressive with range of motion. And these patients are getting their motion back a little faster because you don't have to slow them down as much because you're not relying on as much bone to tendon healing as in an actual repair.
Dr. Amit Momaya: And just to piggyback on what Dr. Brabston said, you know, one of the things with the longer-term-- you know, when we're still in the short to midterm outcome range for this, but some of the averages that we've seen in terms of elevation of the arm is approximately 165 degrees of elevation and about 35 degrees of external rotation, which honestly, those are figures that are very respectable and favorable for a normal shoulder rotator cuff repair. And so, the outcomes have been positive and surprisingly better than expected.
Melanie Cole: It's very impressive. Such a fascinating technique. And I'd like to give you each a chance for a final thought. Dr. Momaya, are there any comparison studies, as we're talking about these outcomes and what we're hoping to see as you all perform more of these, and I'd like you all to come back and update us as we find out more, have you seen whether this treatment is for untouched shoulders? Is it revision? Have we done it on revision yet? I'd like your final thoughts on where you see this going, where you see the best uses for this.
Dr. Amit Momaya: Sure. It's been used in a lot of different settings. There has been one randomized controlled trial, comparing it to partial repair in a shoulder. And oftentimes, when someone has a massively irreparable rotator cuff, it most likely has been operated on before, but not necessarily. Where I see this going in the future, I think this is going to be ultimately either used for the shoulder that has an irreparable rotator cuff or, even better idea, I think is an augment to what we're already doing to help offload the forces across either we've repaired something, or we've done a partial repair. And I think that's going to be its greatest use, is to actually augment. And I can envision different sizes of the balloons and different techniques for when we're augmenting the procedures we're already doing to obtain better healing and function.
Melanie Cole: It's a great point. Dr. Casp, tell us about the multidisciplinary team. How do you all work together for these patients?
Dr. Aaron Casp: Yeah, I think that's just as important, if not more important than the actual surgery or the technology itself. Dr. Brabston, Dr. Momaya and I all run our patients by each other every week. We have a scheduled time where we can bounce ideas off each other and get sort of some input from our colleagues. We also work very closely with our physical therapists. And I always like to say that, you know, our physical therapist network is probably more important than anything that I could possibly do considering they see the patients more often, they are responsible for getting them strong, getting them back and sort of coaching them along in their recovery process.
We also have large team of non-operative sports medicine physicians here at UAB who see the patients oftentimes before we do, whenever they're starting to come in for shoulder pain or if they need injections. And eventually, if their condition worsens or if they need some extra help, they'll send them to us for further possible surgical evaluation. So you know, it really is a team here at UAB. And, you know, it goes from everybody they see at the front desk to us as the surgeons all the way to the outpatient physical therapist providers. And so we rely heavily on everybody here.
Melanie Cole: And Dr. Brabston, final thoughts, what you'd like other providers to take away from what you're doing at UAB Medicine and when you feel it's important that they refer.
Dr. Eugene Brabston: That's a really good question. So obviously, you know, we all kind of work here because we do like teaching, we like the research, we like being on the edge of innovation. And working at UAB really provides all of us that opportunity. So, you know, from our standpoint, we want to educate. We want to educate community. We want to educate community surgeons. And so we welcome any kind of questions, we welcome interest in this. And I think that long-term, you're going to see this procedure really kind of blossom and spread out in the community. And the good news is, you know, we obviously need to have a lot more outcomes to be able to follow the more that it's being done. But, it is something that, you know, we're here available for complicated issues, straightforward issues. And we just really want to be a national, if not international, institution to really promote our care and our service and really making patients better.
Melanie Cole: Thank you all so much for joining us and telling us about this innovation that you are doing at UAB Medicine for rotator cuff tears. A physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or you can always visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. For updates on the latest medical advancements, breakthroughs and research, follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua221.mp3
- DoctorsBhatt, Surya
- Featured SpeakerSurya Bhatt, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5609
- Guest BioDr. Bhatt completed his medical degree at Mysore Medical College in India, followed by an Internal Medicine residency and chief residency at the All India Institute of Medical Sciences (AIIMS) in New Delhi, India.
Learn more about Surya Bhatt, MD
Release Date: March 16, 2022
Expiration Date: March 15, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Speaker:
Surya P. Bhatt, MD
Medical Director, Pulmonary Function and Exercise Physiology Lab
Dr. Bhatt has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole, and I invite you to listen as we explore endobronchial valves for severe emphysema. Joining me is Dr. Surya Bhatt. He's an Associate Professor of Medicine in the Division of Pulmonary, Allergy and Critical Care at UAB Medicine. Dr. Bhatt, it's a pleasure to have you join us today. As we get started, can you tell us the idea behind lung volume reduction procedures? What is bronchoscopic lung volume reduction?
Surya Bhatt, MD (Guest): Sure. Lung volume reduction is a procedure that's intended for alleviating respiratory burden mainly in the form of symptoms of shortness of breath. Many patients with COPD, especially those with severe emphysema, develop significant air trapping. And this causes a reduction in their inspiratory capacity, meaning the ability to take a bigger breath and thus causing shortness of breath.
Lung volume reduction is a procedure in which we can deflate more effected lobes compared to non-affected lobes and hence reduce air trapping and hence significantly increase the inspiratory capacity. And this also leads to an improvement in lung function and an improvement in symptoms. Bronchoscopic lung volume reduction is a relatively new procedure. It's been around for about 13 to 14 years, but it's an advance over the previously mainstream lung volume process of performing it surgically. So, now we can perform this bronchoscopically by placing one way valves and effecting lobar deflation.
Host: And it leads to substantial improvements in lung function, symptoms, and certainly quality of life. Yes. But one of the most important things, discussing a bit is patient selection and how that has changed over the years. Can you speak about who's eligible and really who this procedure is indicated for?
Dr. Bhatt: Yes. This is it's very important to select the right patient for this procedure. When surgical procedures were introduced, it was predominantly targeting upper lobe emphysema, and it did not matter if there were intact fissures between the lobes or not. Whereas with bronchoscopic lung volume procedures, we have gradually seen an evolution of the inclusion criteria so much so that we can now actually target any of the lobes in the lung, either the upper or the lower, but the biggest criteria is that the fissure or the partition between the lobes has to be intact. If there is any breakage in the fissures or collateral ventilation, then this procedure is not going to be successful. Using the left upper lobe as an example, if the left upper lobe is targeted for deflation, but the oblique fissure on the left side has collaterals then air can leak from the lower lobe into the upper lobe and the procedure will not succeed. So, it is very important to identify patients with a significant amount of destruction in the target lobe. And also make sure that the fissures are intact. Also the patients who get more benefit are those who have what is called heterogeneous emphysema. Meaning emphysema is more in the target lobe, but there is a relatively healthy lobe on the same side, which can then expand and take over the role of the deflated lobe.
Host: So then what studies are needed to assess for candidacy and tell us a little bit about the tests required to select patients.
Dr. Bhatt: The most important is spirometry or lung function testing. So, patients should have severe enough lung disease. So that FEV1 should be between 15 to 45% predicted. And then it is important to confirm air trapping and hyperinflation. So, this is preferably done using a body plethysmograph and the total lung capacity should be at least 100% predicted or more.
And air trapping as defined by residual volume should be greater than at least 175% predicted. And then the oxygen transfer, which is determined by the diffusing capacity of carbon monoxide should be at least 20% predicted. And we also want to select patients who are not so good that they don't really benefit from this procedure, but are also not so sick that they may have more complications.
So we want to identify patients who have a six minute walk distance between 100 and 450 meters. And we also want to make sure that they do not have chronic respiratory failure. For example, they should not have a carbon dioxide on their blood gas of greater than 15 millimeter mercury.
Host: Well, then tell us a little bit about what the procedure involves Dr. Bhatt, and what are the potential downsides? Are there any complications you'd like to share?
Dr. Bhatt: Sure. The procedure itself is relatively simple. It can be done under conscious sedation or under general anesthesia. At our sidte, we prefer to do it under general anesthesia. It's a bronchoscopic procedure, meaning the patient is first made sleepy either with conscious sedation or general anesthesia, and then the bronchoscope is introduced into the lungs.
And the first step is to confirm that there are no collaterals. So we use something called a Chartis system where we inflate a balloon to deflate the target lobe temporarily. And the balloon has a central conduit in which there is a one-way sensing mechanism to see if air continues to come out of the target lobe. After awhile, if it stops coming out, that is confirmation that there are no collaterals, at which point we can proceed with the more permanent valves. So, we take out the temporary balloon and then we introduce valves into segments of the lobe. Usually depending on the size of the lobe, we may need anywhere between three to five valves. And these do not require any stitches. They are held by the tensile expansile force of the valves and they stay in place once they're inserted without any stitches.
Host: So do they ever need to be adjusted?
Dr. Bhatt: Sometimes they may need to be. And also there are some potential complications that we may encounter. Some are expected. Some may not be expected. The expected complications are one in four people get a pneumothorax or collapse of the entire lung, which can be treated with a chest tube. Some people get hemoptysis. That is seen in about 5% of patients. In about five to 10% of patients, there may be movement of the valve either by coughing or over time, it can migrate requiring repositioning of the valve in about five to 10% of the patients.
Host: What's been the experience Dr. Bhatt of patients to date with this treatment?
Dr. Bhatt: It depends on selection of the patients. So if we, in patients who have heterogeneous emphysema, meaning at least a 15% difference in the emphysema scores between the target and the non-target lobe, most patients can expect to achieve a 15 to 20% improvement in their lung function, or at least a 350 to 500 mil decrease in their residual volume, which is directly correlated with how they feel.
So in about half to two thirds of patients, I think feel considerably better. We also perform this procedure in people with what is called homogenous emphysema, meaning the amount of emphysema difference between the target and the non target lobe may not be 15%. It could be less than that. Those patients usually benefit, but they do not benefit to the same extent. They may get a 10 to 12% improvement in their FEV1.
Host: Where do you see this going now Dr. Bhatt? Because it's such an interesting procedure. You describe it so well, what do you see happening in the next 10 years in this, in this area?
Dr. Bhatt: I think this is a really exciting technology and very beneficial for patients with less morbidity compared to surgery. I think it is our role to identify the right people for this procedure, because we want to make sure that patients get the maximum benefit, given that there are some side effects and complications related to the procedure.
So we want to maximize the benefit, but reduce the risk. And also there are steps to try and identify patients better. We do need CT scans to identify if the fissure's are in intact. We do have the balloon procedure to confirm that the fissure's in intact, but in those in whom the fissures are not intact, we do need alternative procedures because valves will not work in them the way they are designed now.
There are attempts to try and seal the fissures either surgically or otherwise. There are also previous trials, which were not successful, but are being modified wherein, scarring agents were used so that you can actually achieve lung deflation bronchoscopically in other ways. And not just by placing one way valves.
Host: Wow. It's such an exciting time, really in your field. In summary, Doctor, let other physicians know what you'd like them to know about endobronchial valves for severe emphysema. And when you feel it's important that they refer their patients, so they know their patients are getting the best care at UAB Medicine.
Dr. Bhatt: I think any patient with significant symptom burden who are not responding to usual therapy in the form of bronchodilators and pulmonary rehabilitation and if they have stage three or stage four COPD by gold criteria, I think that's the time to think about whether they may be candidates for this procedure.
And we would suggest referring those kinds of patients to us for evaluation.
Host: Thank you so much, Dr. Bhatt for joining us. A physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST, or you can always visit our website at UABmedicine.org/physician. That concludes this episode of UAB Med Cast. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua235.mp3
- DoctorsKase, Michael
- Featured SpeakerMichael Kase, DMD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5624
- Guest BioDr. Kase was raised in Park Ridge, IL, and graduated from Marquette University. He completed his Doctorate of Medicine in Dentistry at the Maurice H. Kornberg School of Dentistry at Temple University. Afterwards, he proceeded to obtain certificates in prosthodontics at the Birmingham VA Prosthodontics Clinic as well as at the University of Alabama at Birmingham School of Dentistry. He also received his certificate in maxillofacial prosthodontics and dental oncology at the Memorial Sloan-Kettering Cancer Center in New York. Currently, Dr. Kase serves as a maxillofacial prosthodontist at UAB, he is an assistant professor at UAB’s Health Science Foundation and as well as the School of Dentistry.
Learn more about Michael Kase, DMD
Release Date: March 23, 2022
Expiration Date: March 22, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Speaker:
Michael Kase, DMD
Assistant Director of the Advanced Education in Maxillofacial Prosthodontics and Dental Oncology Fellowship
Dr. Kase has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole, and I invite you to join us as we look at maxillofacial prosthetics practice in profile.
Joining me is Dr. Michael Kase. He's an Assistant Director of the Advanced Education in Maxillofacial Prosthodontics and Dental Oncology Fellowship at UAB Medicine. Dr. Kase, it's a pleasure to have you join us again. This time we're talking about specifically your field. Can you tell us a little bit about the subspecialty of maxillofacial prosthetics and dental oncology? Tell us about this exciting field.
Michael Kase, DMD (Guest): Sure. Well, thanks for having me again. I really enjoy being on these interviews with you. So the subspecialty of maxillofacial prosthetics and dental oncology is again, it's the subspecialty of dentistry. So we go through, you know, four years of dental school, but then you have to do a three-year residency in graduate prosthodontics and people always ask me, well, what's that? So the best way I can explain it would be your general dentist might do two or three crowns, a prosthodontist they'll do 28 crowns. So it's a full mouth rehabilitation. So you have to get that fundamental knowledge in your system before you can move on and then do the subspecialty fellowship, which is a one-year program.
And that's for maxillofacial prosthetics and dental oncology is usually combined in it because to treat all these patients in the maxillofacial prosthodontic world, the dental oncology side of things, you can't separate it from each other. It's just kind of inherent. And basically what maxillofacial prosthetics is is, replacing parts of the body that are lost to cancer, to traumatic events, or even congenital aspects of certain syndromes.
So we make eyes, we make ears, we make noses, we make interoral prosthetics called obturators, which essentially plug a hole or obdurate what might be between the oral cavity and the nasal cavity. So patients can eat without food or drink coming out their nose and speak intelligibly as well. So that's the biggest outline I can give of the prosthetic side of things.
And we do even branch into other things such as fingers or if patients have defects in their neck, we might make a prosthesis that plugs the hole in the neck. I believe this coming week or so we have a patient coming in that needs a toe. So we make all sorts of prosthetics. And then the dental oncology side of it is going to be treatment and management of patients that are undergoing therapies such as radiation or medical oncology or IV bisphosphonate drugs, such as that. So we see a wide array of patients.
Host: Well, you certainly do. And I'd like you to expand just a bit because it fascinates me that you do, there is so much, it's so comprehensive from speech pathology and head and neck cancers and didactic training and oncology and dentistry, as you said, and prosthetics, I mean, really there's so very much. Tell us a little bit about, is it a crowded field, Dr. Kase?
Dr. Kase: No, it's not. It is a very, very small number of people. And I always like to say that once you're in this field, you pretty much know everybody because I would have to say in the entire country, there's probably 200 people that are trained to do this. And I would honestly say that probably a third of that actually do the practicing.
A lot of people might do this fellowship and go into purely academics. Or they might do this training and then go into private practice and do an obturator here and there, just in case it comes across their table. But as far as people that practice in this manner, like I do, probably about a third of those that greater pool of 200.
So it's a very, very small number of people. I am the only one, essentially the only one in the state that does this in Alabama here. We have Dr. Sudi as well, who works with me in the dental school, but, he's kind of at retirement state. So it's pretty much myself and the fellow that do all the work here for all these patients in the state of Alabama.
Host: Well, you're a busy man. So one of the things I personally know about you having interviewed you is the way you work so well with other subspecialties. And then there's a lot of them. We've done panel interviews with oral surgeons and medical oncologists. And tell us a little bit about what that's like for you working with such a broad range of other subspecialties and how important that multidisciplinary approach and the multimodal approach that you use for many of the procedures that you tackle.
Dr. Kase: Just right off the bat, I'll say that I love it. I love working with everybody here at UAB. Everybody that I work with every, every department is just wonderful and excellent clinicians and just great people to begin with. So it makes my day better just working with everybody that I work with, but it's also very, very comprehensive for the patient.
I mean, instead of patients having to go from one hospital to the other hospital, seeing a private practitioner outside; they get everything done in-house, at UAB. So the patient comes through and whether it comes through our oral oncology department and oral surgery, or through ENT they'll see the surgeons first and we'll kind of triage the patient and figure out what they need.
And then everybody involved in the treatment ends up seeing the patient beforehand. So we get this huge comprehensive treatment plan, and that's just hugely beneficial for the patient. So, you know, the patient needs radiation. They come see me for a pre radiation evaluation. If the patient is going to have maxillectomy, they come see me for impressions for an obturator prosthesis, or if they are going to need an auriculectomy, they'll come see me for evaluation for an ear prosthesis and, and so forth.
And then it gets even more intricate because the different surgeons I work with all do different aspects of the care. So some may place implants in the mouth, some may place implants in the temporal bone. So, this multi-disciplinary approach we have is just hugely beneficial to the patient, for the efficient yet comprehensive workflow.
Host: And it's quite obvious that you do love it. And I hear you talk about the people that you work with. So really what an interesting field that you're in, what do you personally offer these patients in terms of care. Can you tell us a little bit about your practice within maxillofacial prosthetics and dental oncology at your office? Tell us about your team and what you're doing special to go above and beyond.
Dr. Kase: Well, I believe in some of the other podcasts I've done with you, we've discussed the multidisciplinary clinic I have with Dr. Moreland and Dr. Yang and Christina, our PA. That's one way where we work together and kind of a microcosm of the last comment I made regarding greater UAB, we see the patient and offer this comprehensive care model where they get their treatment plan ahead of the therapy and they know what to expect as they go through it.
But I also get patients come to me they may be from an outside hospital, somewhere up in Huntsville, or I see patients from Georgia, from Mississippi, from, from Florida that need my care. So they may come to me after having surgery and then I have to kind of get them up to speed in terms of, the prosthetics they need.
So if they come to me after having had a maxillectomy, well, then I have to get them an obturator prosthesis to help them with their speech, their swallowing, and function to get them back to a more normal state. But we also do a lot of treatment planning. So the patient comes in let's say they have their ear removed an auriculectomy.
Well, we talk to the patient about the different ways we can have an auricular or an ear prosthesis, retain itself to the patient, whether it's adhesive or using dental or other forms of implants to help with the retention. And at that point, then we start working with the surgeons and we plan things out appropriately to get the best results.
I may see patients from my friends in speech pathology, and they may send me patients for prosthetics, such as palatal augmentation prosthesis, or a palatal lift prosthesis. Basically their prosthetics to help with speech and swallowing and due to non-function or a lack of anatomy in the soft palatal region.
So I work very closely with them. I'll make the prosthesis, and then I usually send them back to see speech path and then they'll evaluate the patient from their end. And we'll kind of work together to determine what needs to be done with the prothesis to optimize the patient's outcome.
Host: Such a comprehensive and intricate nature of your job, Dr. Kase as we get ready to wrap up, I'd like you to tell referring physicians what you would like them to know in terms of maxillofacial prosthetics, and dental oncology practice, and what is really exciting in your field right now, what's really getting you jived and, and something that you see coming in the horizon that you say, oh, I'm so really glad to be in this field because that's going to be awesome.
Dr. Kase: Well, what I would tell any physician that might be listening to this is I might be able to help you. It sounds pretty, uh, broad spectrum, but every once in a while we get a patient that's kind of a last ditch effort to see if we can help them. And we end up being able to help them, whether it's a patient that suffered third degree burns across their head and neck region, their whole body. And we need to make a prothesis that stretches their mouth to allow their mouth to open again so they can fit in something larger than a baby spoons to feed themselves. Or again, a patient might need a finger or a toe things like that are aspects of care that we can help with that well you might not think a dentist can do.
So if you ever run into any brick wall, and you're just wondering if there's something that might be able to be done, I might be able to help you. As far as what gets me excited is probably how we're involving technology in our care. Just yesterday, we had a patient for a jaw in a day procedure, and I'm not sure if Dr. Moreland had mentioned this in one of our previous podcasts, but essentially in, one day we take the patient to the OR, one of the surgeons will do the mandibularectomy and take part of the lower jaw out with the tumor. And then the other surgeon will do the fibula free flap reconstruction, but at the same time, place dental implants into the leg bone while it's still attached to the vasculature in the leg.
And then my team, the prosthetics team comes in there and we deliver, essentially we deliver teeth to the leg and then once everything's in place, we bring all of that up to the mouth. And then the microvascular team comes in and finishes the reanastomosis of the vessels. And the patient goes to sleep with teeth and wakes up with the prosthesis. And that's pretty exciting to me.
Host: Well, wow. It certainly is to me. Absolutely fanscinating. And do you just have any final thoughts for other providers on this exciting field that you're in?
Dr. Kase: I'm just happy to be here and happy to help. So don't be shy and reach out to me and see if I can help, because there's a good chance, I probably can.
Host: Excellent. Excellently said. What a great podcast. Such great information, Dr. Kase what a great guest you are. Thank you so much for joining us today. And a physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST or by visiting our website at UABmedicine.org/physician. That concludes this episode of UAB Med Cast. For updates on the latest medical advancements, breakthroughs and research, follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua232.mp3
- DoctorsKase, Michael;Snider, James;Willey, Christopher
- Featured SpeakerMichael Kase, DMD | James Snider, III MD | Christopher D. Willey, MD, PhD
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5562
- Guest BioDr. Kase was raised in Park Ridge, IL, and graduated from Marquette University. He completed his Doctorate of Medicine in Dentistry at the Maurice H. Kornberg School of Dentistry at Temple University. Afterwards, he proceeded to obtain certificates in prosthodontics at the Birmingham VA Prosthodontics Clinic as well as at the University of Alabama at Birmingham School of Dentistry.
Learn more about Michael Kase, DMD
James Snider, III MD is an Assistant Professor.
Learn more about James Snider, III MD
Christopher Willey, MD is an Associate Professor, Director of UAB Kinome Core.
Learn more about Christopher Willey, MD
Release Date: March 2, 2022
Expiration Date: March 1, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Faculty:
Christopher D. Willey, MD, PhD
Associate Professor, Director of UAB Kinome Core
Michael T. Kase, DMD
Assistant Professor, Dental Oncology
James W. Snider, III, MD
Assistant Professor, Radiation Oncology
Dr. Willey has the following financial relationships with ineligible companies:
Grants/Research Support/Grants Pending - AACR Novocure, Tactile Medical, Varian, Mureva
Consulting Fee - LifeNet Health
Honorarium - Novocure, ACRO, Varian
Board Membership - American Cancer Society
Support for Travel to Meetings or Other Purposes - AACR
Dr. Snider has the following financial relationships with ineligible companies:
Consulting Fee; Honorarium; Support for Travel to Meetings or Other Purposes; Payment for Development of Educational Presentations; Payment for Lectures, Including Service on Speakers Bureaus - Varian Medical Systems/Siemens
Other - Hefei Ion Medical Center, Russian ONE Conference
All relevant financial relationships have been mitigated. Dr. Willey and Snider does not intend to discuss the off-label use of a product. Dr. Kase nor any other speakers, planners or content reviewers (Ronan O'Beirne, EdD and Katelyn Hiden), have any relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole, and I invite you to listen as we discuss radiation therapy for oral cancer. Joining me in this thought leader panel today is Dr. Michael Kase. He's an Assistant Director of the Advanced Education in Maxillofacial Prosthodontics and Dental Oncology Fellowship. Dr. James Snider. He's a Radiation Oncologist and an Associate Professor and Dr. Christopher Willey, he's a Hale Stephens ROAR Endowed Professor for Distinctive Radiation Research and a Radiation Oncologist.
And they're all at UAB Medicine. Doctors, thank you so much for joining us today, Dr. Willey, I'd like to start with you. Can you tell us what oral cancers we're discussing here today? The current standard of care. Do the current therapies have a measurable effect on the course of the disease? Speak a little bit, just give us a broad overview of oral cancers.
Christopher D. Willey, MD, PhD (Guest): Sure. The main idea for oral cancers are basically the front part of the mouth. So, the very visible, the very sensitive part of the mouth that patients may become aware of eating food, seeing a dentist, seeing a primary care provider. Basically the areas we're talking about are areas along the lip, along the gum lines, both top and bottom, and really the tongue and the floor of mouth.
So, basically the area between where the gum and the tongue meet. And so, in general, really like for a lot of cancers, oral cancer is managed by really three major modalities and those include surgery, radiation treatment, and potentially chemotherapy. And so, in general, surgery, if possible is, the first step. And then that is typically followed by radiation and chemotherapy. A lot of it depends on when we diagnose it and that's basically called the stage. That's knowing where the tumor is when the disease is found. And then the management is usually based on many factors, which include some factors related to the patient themselves, and then some factors related to the extent of the disease and the available treatment.
So, I would say that's the big thing. But the idea is that surgery, is typically used to try to remove as much as possible, involves any potential reconstruction of the area. And then, radiation is used to essentially mop up after the surgery, often where you get, high risk factors, that can be hopefully controlled by radiation to the tumor bed, with or without chemotherapy based on, really the level of risk for the tumor coming back in that patient.
Host: Thank you so much for that, Dr. Willey and Dr. Snider, can you speak a little bit about how radiation for oral cancer affects the mouth, some of the side effects and how does it really, because I think this is one of the bigger issues in oral cancers. How does it affect the quality of life for the patient?
James Snider, III MD (Guest): Sure. I think radiation therapy to the head and neck is one of the more sophisticated things we do as Radiation Oncologists. And certainly is one that comes with a high payoff. Often these patients can be cured of their cancers and can do very well long-term, but the side effects of therapy can be relatively severe.
Most patients come to us, having had a big surgery to the front of their mouth, like Dr. Willey has stated. And certainly that's a very sensitive area, like he stated as. And then we're telling them that they're going to get six, seven weeks of radiation therapy, of daily treatments Monday through Friday, that are small treatments, small doses of radiation that add up to a total dose we want to get to, by the end. You know, each treatment is not something that the patient particularly feels, it's such a small dose of radiation. But as they start to build, as they get more and more dose throughout the course of radiotherapy, they certainly feel side effects. The most common side effects are taste changes, dry mouth, pain with swallowing and pain in the mouth. Some ulcer formation that we call mucositis. Most of these are short-lived and they will heal after the course of radiotherapy. Some of the side effects like dry mouth can be long-term and some of the effects on the bone in the mouth, and especially the dentition can be long-term.
And so that's why it's particularly important as patients go through this rigorous course of radiation and sometimes chemotherapy after they've had a major surgery, that they see a multidisciplinary team that is highly integrated and work together closely about making sure each of the steps is kind of checked off in the right order and that all the boxes are filled by the time we get to the end of the course of therapy. And that's why one of the most important steps we take is making sure that their teeth and dentition and oral health is well taken care of both upfront before we do the radiation therapy, as well as outback.
And that's why we work with people like Dr. Kase who I know can speak to after this, a lot of, sort of how we screen patients for their dental, before a course of radiotherapy and then how we follow them long-term and take care of their dentition and their jaw and the bones in their mouth long-term after a course of radiotherapy to the head and neck.
Host: Well, that leads very well into Dr. Kase. So, does the patient see a dentist before or even after radiation treatment, throughout that treatment course? Is this a general dentist that evaluates the patient? Do they need a specialist? Explain a little bit about your role in this topic.
Michael Kase, DMD (Guest): Sure. All those points are fantastic that Dr. Willey and Dr. Snider have made. First, I'm just going to emphasize a little about some of those side effects that that they mentioned just a little bit more depth from my perspective. So, they mentioned the dry mouth, the xerostomia, the hyposalivation.,Well, that has big problems for the patient because they lose the protective elements those of us who have not had head neck radiation have. So the mechanical ability to use the saliva, to wash stuff away from our teeth. The enzymes that we have on our teeth that protect or have in our saliva that protect the teeth tend to be decreased. So, all that leads to this increased chance of cavities and increased rate of progression of these cavities.
Which all lead to big problems if they're unchecked, which kind of leads us into that next question that you had involving, when do these patients see me and generally that we want it to have happened as soon as they seen the radiation oncologist, or as soon as they know they're going to need radiation. Sometimes that can occur even at the surgical visit that the surgeons can pretty much assume or know that if the cancer is advanced to a certain point, they're going to need radiation.
So, if I could even see them before, surgery, that offers the best opportunity to help them out and streamline their care. Because as Dr. Snider alluded to, the patients have this very large risk of something called osteoradionecrosis, which is essentially dead bone and that can be, extraordinarily life changing even after the cancer therapy and we try and avoid that as much as possible. So, if the patient tends to need teeth extracted, we like to do that at the time of surgery. And definitely before the radiation. As far as a specialist, I tend to believe they need to see a specialist. I did a whole fellowship in this material. So, I'm very well versed in all this information. And if the patient doesn't get the right information, the rest of their life can be severely affected by it. So, they need to see a specialist before the radiation. And at times after it's all completed as well, but once they get back to the routine care, they can see their general dentist.
Then I always offer my contact information, to help them out with information if they have any questions.
Host: Can you expand a little bit Dr. Kase on, you mentioned extraction, is this necessary in all cases? Why is. that?
Dr. Kase: It's not necessary in all cases. More frequently than not. THe problem relates to the side-effect I mentioned previously called osteoradionecrosis oftentimes just called ORN. And the reason this is important is, the patient, once they've had radiation, especially to the effected area, they cannot have extractions anymore due to this risk of osteoradionecrosis. And what happens and unfortunately, we see it more than we like, is the patient either doesn't hear this information or forgets, and then five years down the road, when all else is well, they have a tooth that goes bad. The tooth needs to be extracted and the bone does not heal. The bone dies. And then the patient has to have another big surgery to fix that problem.
And that's not something we want the patient to have to go through. So, if we can get the teeth that are questionable out before the radiation, the patient is in a much, much better situation for their future.
Host: What a great point to note for other providers, Dr. Kase. So, Dr. Willey, let's speak about the latest radiation techniques. Evaluate for us the currently available radio therapeutic modalities that are available for oral cancer and any that have really changed the landscape for you. Any that you find really exciting right now for your diagnostic and therapeutic capabilities.
Dr. Willey: I guess historically there have been predominantly what we call external beam, which is like the general category of a therapy that comes from outside of the patient, shining on them. So, typically x-rays and proton therapy, which, we will talk about a good bit. The other approach has been more of a brachy therapy, which is basically stands for short therapy. And that's implantable radiation, typically utilizing a needle. I would say that's kind of fallen out of favor a good bit because it's, fairly difficult. And really more of a rare one-off type of therapy, at least certainly where we practice.
So in general, this external beam radiation is the key. And so, really what has changed how we utilize this is our ability to really focus the radiation and sculpt it individually to the patient. And so, every patient is different. And so every therapy we do is customized for our patients. And so we, utilize basically 3D imaging information from a CAT scan, when the patient is immobilized inside of a mask. This is, done through what's called the planning session. And once we have that information in the computer, we can design a custom therapy to them and, and we use computer optimization to optimize, really something that even a human really can't do as well as a computer can and design a treatment that really maximizes dose to the intended target and then, reduces the dose, dramatically to the areas we want to avoid. And once again, an ounce of prevention is worth a pound of cure. So, it's critical that the patient gets any of their teeth taken care of prior to radiation.
And so we don't want to design a custom made plan for the patient, then they get a tooth removed or something happens that changes their anatomy. In terms of things that are very exciting for us, really, I think, Dr. Snider will be best able to discuss since he really leads this program for us. It's really our proton therapy, which is a particle based therapy and has some very special physics that allows the dose to essentially stop on a dime, as compared to x-ray therapy, which does have what we call entrance and exit dose as it passes through tissue. So, proton therapy has allowed us to really spare, basically more far away target tissue and normal tissue, on the other side of what we're trying to hit with our therapy.
And so, that particle based therapy, is very specialized. We have the only center in the state of Alabama, but, Dr. Snider, really leads that effort. And I think he probably, could expound on that a good bit.
Dr. Snider: Yeah, I appreciate it Dr. Willey. I, think, the proton center here at UAB or Proton International at UAB Proton Center is a very unique center. There's only 30, some odd proton centers in the United States and only a handful more around the world. It does deliver what, is kind of our newest, latest and greatest as far as a new modality of radiation therapy that has changed our game to some extent. As Dr. Willey alluded to protons, do something different inside our body, x-rays go in one side of us and out the other, which means they have both entrance and exit dose. Whereas, and I always liken it to, if we're shining x-rays onto a patient it's like shining a hundred flashlights onto their tumor. Unfortunately the light passes through the tumor and onto the other side of them with each flashlight. Now it's very bright where all the flashlights meet, but around in all their normal tissues, in the rest of their mouth, in their salivary glands, on the other side, in tissues that we're not trying to target, there's some dose of radiation that's being deposited by just trying to get our dose into the patient.
In proton therapy instead, the dose goes to a certain depth inside the patient and stops and where it stops or where the particle actually stops inside the body is where it delivers almost all of its dose along its path. And so I always tell patients, I liken it to almost like a light saber in star wars. It goes to a certain depth and just stops, and that allows us to more finely target our radiation inside the human body and reduce the exposure of the rest of the normal human body to radiation therapy. Which can therefore reduce the side effects associated with what is a fairly rigorous course of radiation therapy to the head and neck region. For patients with oral cavity cancers, that means sometimes reduced dose to salivary glands, reduced dose to the other side of their body if we only need to treat one side of their oral cavity, reduced dose to their swallowing tissues or their voicebox tissues or their swallowing tube called their esophagus. All those things can make what is a tough course of radiotherapy, less severe them and as the Associate Medical Director of this center at UAB, it's been my pleasure to bring that here.
We only opened that center in 2020 with the technology that I was very familiar with in my last job in Maryland. And we got that center up and running and now we're at capacity most of the time treating as many patients as we can. And over half of our patients in the center, are normally head neck cancer patients, often oral cavities or, oropharynx, the back of the throat cancers. Or nasopharynx or nasal cavity tumors, all things around the oral cavity that we treat with radiation very frequently, either instead of surgery or with a surgery as we do in the oral cavity. But it's really changed our game as radiation oncologists, about how much we can spare and how little damage we can cause to a patient while still giving them adequate radiation therapy.
Host: Dr. Snider, is there an optimal surgery to radiotherapy interval that you work with patients? Because I understand that these things, you know, as you've said can cause complications. Is there something you'd like to let other providers know about what you use as those clinical indicators for when it's time to start and a little patient selection.
Dr. Snider: Yes, Ma'am and I think one of the things that I would, maybe expound upon that Dr. Kase mentioned, and reinforce, and maybe use a little bit stronger words than he did is that I wouldn't just recommend, but instead I, strongly recommend that patients see somebody who's trained, especially for their dental care, who's trained specifically in looking at this issue around radiation therapy and things like that. And to speak to that timeline. I think that, that's very important about the dental timeline as well. That's one of our biggest holdups that we can run into between surgery and radiation is if we don't have an integrated team, this multidisciplinary team that can quickly act on a patient and do what needs to be done for their dental care to get them to radiation therapy, it can often delay their care overall.
And there is a critical what we call package time. That's a term that we use, but basically it means time from when they get their surgery to when they complete their radiation, that, that package of therapy needs to be completed in a certain period of time to give them the best chance at a great oncologic or cancer outcome, as well as a side effect profile and toxicity outcome.
And normally we want that timeline from surgery to radiation to be at or under about six weeks, which means there's a lot that has to happen in that six weeks. And if you don't have a team, that's all on the same page, that does this regularly, that does it with a lot of head neck patients that timeline could get protracted in a way that we don't want it to be. From surgery, they need to start healing. They need to see their surgeon post-op and make sure they're healing correctly. There can always be little revisions, like little wash outs and things like that, that need to be done. They need to see the radiation oncologist.
They might need to see the medical oncologist about chemotherapy. They need to see Dr. Kase or somebody from our prosthodontics team or oral surgery team to talk about extractions, if they are need it or dental work, if they need it. That dental work needs to be done, then we need to do the CT simulation or planning process that Dr. Willey mentioned for radiation therapy, where we make a mask and custom molded pillow for the patient that they'll lay in every day for treatment, they need to do their CAT scan for treatment planning for radiation. Then we have to plan the radiation, which in the case of something like proton therapy, that means we're taking a subatomic particle speeding up two thirds the speed of light, shooting it up a story in a building back down a story in a building through a 300 ton machine and landing it in the patient within a two to three millimeter space.
If we're doing that, that takes a lot of planning. It takes a lot of people and it takes a lot of work. And so having all those steps laid out by a team that does it every day, that is used to doing it in a concerted fashion, that everybody knows, it's almost like a dance and everybody knows their next step. And everybody has to know that next step for the patient. Otherwise the whole dance falls apart.
And so, for us having this multi-disciplinary team and working with Dr. Kase and his ilk, they're very ready to take our patients and know what we want from him. Know what we're asking him every time we send him a patient and can manage them quickly and expeditiously is highly important.
Host: Dr. Kase, would you like to expand a little bit on what Dr. Snider and by the way, Dr. Snider, what an excellent explanation. That was fascinating, really. Dr. Kase, speak to this just a little bit in your role in this setting this interval, and any interventions that happen during this time that you'd like to mention.
Dr. Kase: It kind of relates back to my previous statements in that it's best for me to see the patient as early as possible because these interventions that are mainly I'm referring to the extractions need to be done as soon as possible. So, if this happens at the time of surgery, when there's that hypothetical six week window where the extraction sites will be healed up much sooner than the large surgery the patient had.
So, the rate limiting step does not have to be the extractions. Whereas if an outside institution sends me a patient that has had surgery and seen radiation oncology, and now I have to see the patient, we have to evaluate them. They need extractions. And once those extractions occur, it's generally, 10 days, 14 days before it's healed enough to move forward with the simulation. So, that can delay time, a lot more than if we see the patient as Dr. Snider said, this well-orchestrated dance well before the surgery, so we could plan everything to happen at the same time.
Host: I'd like to give you each a chance for a final thought before we end this very informative podcast. So, Dr. Snider, why don't you start? I'd like you to please just tell other providers what you would like them to know about this multidisciplinary team that you've got, this approach that you described and how it really helps with your clinical decision making.
Dr. Snider: I think the proof is in the pudding for us. We can say all we want that we think having a concerted team and a multidisciplinary team in one place matters, but instead I think in the head and neck space in particular, in cancers of the head and neck region, time and time again, we've seen clinical trials, large clinical trials with thousands of patients who are being treated for head and neck cancer. And they show over and over again, one of the most important prognostic factors for how they will do both from a cancer standpoint, as well as from a toxicity and side effect management standpoint with their therapy, that multidisciplinary teams at major academic facilities, like UAB make a difference for these patients. Whether it's the timing or how concerted their efforts are, people that are trained in looking at things like oral health, like Dr. Kase are, whatever it is, there's magic in that mixture and magic in that recipe, and I think that's what we try to be here, for the head and neck team at UAB is one team that works closely together, that understands the calling that is in front of us, which is that these patients go through a very severe course of therapy that has a lot of side effects, but can be managed appropriately and get them to the other side of that with a very good long-term prognosis, if we dot all our I's and cross all our T's correctly and in a concerted fashion with the right timing and all those things for the patients. So that's, I think I hope the difference that we offer at UAB, not just technologies. And we do have fancy things like protons and so on and so forth. But I think the biggest thing we offer is this one team mentality around head and neck and understanding that, hey, patients are going to flow into this system.
We're going to take care of them from A to Z and make sure all the steps are done in the right order, on the right timing, to make sure they have the best chance at a great outcome, both from a cancer standpoint, as well as from a side effect of therapy. And long-term that their quality of life is as good as possible after this rigorous course of therapy for head and neck cancer.
Host: What an elegant description. And as you describe it as this dance and this multidisciplinary approach is just so important. Dr. Kase, I'd like you to go next and speak to other providers and specifically even to other maxillofacial prosthedontists or dentists about what you'd like them to know about their role in this, and even referral to you at UAB.
Dr. Kase: Well, I would just like to emphasize to any of the dentists out there that might be listening to this, that it's okay to not know all this information. And that's what I'm here for is to take the patients that they may have and guide them the appropriate way. But I'm also going to send the patient right back to them for the care afterwards. So, all the information that I have, I'm happy to talk to them about. I'm happy to discuss patient care with them. And that's usually what happens is I always give the patient my card and tell them to have their local dentist talk to me in the future if they ever have any questions. And that usually ends up taking the decreased risk for these big problems like osteoradionecrosis that are decreased because of our multidisciplinary care and decreasing it even further because we try and send this information into the community as best we can.
Host: Dr. Willey, last word to you, as you represent different specialties, all focused on treating oral cancer for the most part, different specialties. I just would like you to kind of summarize your combined clinic and why this is so important for the patients. They don't have to go to 8 million different places and how you all work together. And when you feel it's important to refer to the specialists at UAB Medicine.
Dr. Willey: I think a great way to finish this up, so, a lot of times when I'm talking to patients or even friends or people who just want to find out about this newly diagnosed head and neck cancer and how to manage it. I think the one thing that I, tend to bring up first is, really, we have amazing surgical specialists here. Okay. So, we have a huge catchment area because we have some of the highest volume surgeons, particularly the maxillofacial group, our ENT group is outstanding. And so really, a national leader and certainly regional leader. And so a lot of get introduced to the Cancer Center and UAB, actually through the surgical providers.
And we have an outstanding relationship with them, all of us. And so we consistently meet, a lot of us actually do research together as something we haven't talked about today is that, we actually have a number of clinical trials that are looking at what's the next best thing. Can we improve outcomes for patients through new research and we have some research that's geared just towards quality of life and just the toxicity that our therapies produce. So, a lot of those are multidisciplinary as well. And so once you're plugged into the UAB system, you're really connected to all these specialists, who meet regularly, who really come up with consensus best care plans for these patients. And it also involves obviously maxillofacial group, the prosthodontists. And so another thing we didn't really have time to talk about is not only, we're talking about teeth and management of that, but sometimes patients will have resections, have holes, let's say they have a pallet defects, something like that.
You're having Dr. Kase create prosthetics that allow the patient to eat, to talk, to communicate much better and all those things are really part of the care, not just the cancer control. On the radiation side, we have a very large group. And we have a lot of experience. We have a lot of providers that really tackle head and neck as their main gig.
And so, really all those things pulled together, when you get plugged in and then, certainly on the medical oncology team, we have a lot of experience Dr. Nabell, really leads that effort and so I think all together, we really want to attack this in a comprehensive manner because, in terms of side effects and difficulties to get through the care, this is really, I call the top three of radiation oncology in terms of most difficult. In fact, where I trained, the main head and neck provider used to tell patients, I'm going to take you to hell and back. And so be able to embark on a course, such as that, you really want a group that's able to tackle all aspects and all facets. We have had a neck cancer support team. We have really, providers that are even mainly focused on the supportive care management. And so all those things really come into play to get a patient through such a difficult course. And so I think with that, I would just say, we're willing and able to handle the head and neck cancer cases that, the people of Alabama are faced with.
And we really have an outstanding group that I love to work with everyday.
Host: Thank you gentlemen, for joining us today. What an interesting and so informative podcast. Thank you all for joining us and sharing your expertise. And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website at UABmedicine.org/physician. That concludes this episode of UAB Med Cast.
Please always remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua233.mp3
- DoctorsMorlandt, Anthony;Kase, Michael;Cyriac, Christina
- Featured SpeakerAnthony Morlandt, MD, DDS, FACS | Michael Kase, DMD | Christina Cyriac, PA-C
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5557
- Guest BioDr. Morlandt was born and raised in Floresville, Texas and graduated from Baylor University. He completed his DDS magna cum laude at the University of Texas Health Sciences Center in San Antonio, Texas, and received his MD and internship and residency in Oral and Maxillofacial Surgery from the University of Alabama School of Medicine.
Learn more about Anthony Morlandt, MD, DDS
Dr. Kase was raised in Park Ridge, IL, and graduated from Marquette University. He completed his Doctorate of Medicine in Dentistry at the Maurice H. Kornberg School of Dentistry at Temple University.
Learn more about Michael Kase, DMD
Christina Cyriac, PA-C Specialties include Oral and Maxillofacial Surgery.
Christina Cyriac, PA-C Learn more about Michael Kase, DMD
Release Date: February 14, 2022
Expiration Date: February 13, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Faculty:
Anthony Morlandt, MD, DDS
Associate Professor, Head and Neck Surgery
Michael T. Kase, DMD
Assistant Professor, Dental Oncology
Christina Cyriac, PA-C
Adv. Pract. Provider, Oral Surgery,
Drs. Morlandt, Kase and Ms. Cyriac have no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionWelcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.
Melanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole, and I invite you to join us as we discussed the UAB Oral Oncology Multidisciplinary Clinic. In this thought leader panel today, I have Dr. Anthony Morlandt. He's a head and neck surgeon, Head and Neck Surgical Oncology and Oral and Maxillofacial Surgery and he's also an associate professor. Dr. Michael Kase is a specialist in maxillofacial prosthodontics and the Assistant Director of the Advanced Education in Maxillofacial Prosthetics and Dental Oncology Fellowship. And Christina Cyriac, she's a physician assistant specializing in head and neck oncology. They're all with UAB Medicine.
Thank you all for being with us. I love when I do a podcast on the multidisciplinary approach, because this is the way medicine is advancing so greatly. Dr. Morlandt, I'd like to start with you and as we set the table here, can you tell us a little bit about oral cancer and why this care management model is a bit challenging for clinicians?
Dr Anthony Morlandt: Thanks so much, Melanie, and it's good to be with you again. Oral cancer is like I think just about every other type of human cancer in terms of its diagnosis and treatment in the sense that it requires not just one type of specialist, not just one type of practice, but a multitude of specialists from many backgrounds, many types of backgrounds. So our O'Neal Comprehensive Cancer Center here at UAB is widely known for incorporating leaders and specialists from many disciplines, whether it's medical oncology to deliver chemotherapy and immunotherapy or radiation oncology, and that couples in with our new Proton Therapy Center or the various surgical specialties. And then we have a number of additional services, ancillary type services, such as supportive care, speech-language pathology, physical therapy, occupational therapy, and an entire army of individuals to help manage patient's complex diseases.
I think one of the greatest reasons we have a very complex care model is because of the opportunities for cancer patients to live with a high quality of life and excellent survival is available now. And we can offer that here at UAB. In the past, I think for many cancers like oral cancer, the prognosis was dismal. Patients didn't have much of a chance of survival or a chance to have a reasonable quality of life, and so the treatment in a sense was simpler. But now, the treatments are complex because there's so much more to offer our patients.
Melanie Cole (Host): Dr. Morlandt, what type of patients are referred to the clinic and from where do these referrals come?
Dr Anthony Morlandt: Well, geographically, they come from all over the southeast. We're one of the largest head and neck cancer programs in the southeast. But we have not only the oral oncology clinic here at UAB, but we also have the otolaryngology service and we have a plastic and reconstructive surgery service as well. And so patients who end up in our clinics come from all of those disciplines and more. They may come first from a general dentist's office with a mouth tumor, that's then biopsied by an oral surgeon or an ear, nose and throat doctor or even a general surgeon or dermatologist, we see those too. And then they make their way into our clinics. So we're happy to see patients from any background or any discipline as far as the source of their referring doctor and we work with all types.
Melanie Cole (Host): Very well said. And so Dr. Kase, has this introduction of therapy involving multiple subspecialists and that utilization of a multidisciplinary team been really ideal for managing these complex patients? As Dr. Moreland said, head and neck cancer can really be devastating for a person's quality of life. Can you speak a little bit about the clinic itself and really how does it work as this multidisciplinary team?
Dr Michael Kase: Our clinic is very specialized related to oral oncology and the oral cavity. So, we tend to dedicate one clinic session a week for this multidisciplinary aspect where all aspects of our team end up seeing the patient. So we have the ablative surgeon, the reconstructive surgeon and myself, the prosthetic aspect, so we can develop this treatment plan where the patient will know exactly what's going to happen and everything that we're going to do to help this patient out as they go through everything.
Melanie Cole (Host): So, Christina, onto you, you're all representing different specialties here. And I imagine you work very, very closely with the patients. What are some of the effects of this type of cancer treatment for oral cancers? How does it affect the daily lives of patients, their families? And what are you finding the largest benefits of this multidisciplinary approach?
Christina Cyriac: So I'd first like to say that the multidisciplinary approach to cancer care and treatment is that a lot of our patients do not live in the Birmingham area, so they travel from all over the Southeast. So allowing them to see both the ablative surgeon, the reconstructive surgeon, as well as prosthodontist all in one day, limits their travel and strain coming to UAB for treatment. If you can imagine having to come back for three different appointments and living maybe four or five hours away, it has a lot of strain on not only the patient, but the family and the support system.
By combining these visits within our Oral Oncology Multidisciplinary Clinic, it allows our patients and families to only have to travel for one visit. This not only helps the patient, but also the families be there for the visit. As you can imagine, we are compassionate in understanding that our families work and have difficulty traveling to Birmingham if they do not live locally. And so patients are able to have the support they need during the clinic session.
Dr Michael Kase: I wanted to echo Christina's point there about how hugely beneficial it is to have all of us there, so the patient that drives from Mobile to Birmingham, that they get to see us all at the same time, in a matter of four or five hours, rather than it being protracted across two to three weeks. And not only does that benefit the patient, but it benefits us as providers because, now, instead of relying on notes being faxed over, instead of relying on other outside institutions telling us things about the patient and their treatment, we have it all in-house. So the communication is right here and we can all move forward cohesively and give the patient the best outcome possible.
Dr Anthony Morlandt: That's so true, Mike. And I think when patients have a diagnosis of cancer, it's scary and they want to be able to tell their family members, they want to tell the referring doctor what they learned at UAB. And so, what we really aim to do is send that patient home with some confidence and some comfort about the next steps moving forward. And so by giving them as much information as possible from our unified voice, our unified cancer treatment algorithm, I think it helps, I think it helps manage the burden of the psychological struggle that patients go through with a new diagnosis of head and neck cancer.
Melanie Cole (Host): What an excellent model of care this is. Really, you are leaders in the field. Christina, what does this clinic do that makes it unique? At UAB, you work with these families, what are they saying to you about this type of multidisciplinary care and what you're doing to go above and beyond? Because obviously, compassion and passion for your job is obvious here, so speak about what that means to patients, what they've said to you.
Christina Cyriac: We provide high quality and compassionate care here at UAB in our oral oncology clinic. I personally treat every patient as if they were one of my own family and want to provide the care I would want to receive in the time of a diagnosis of something like cancer.
One of the unique things we have here at UAB is we have developed a head and neck cancer support group. This support group is not only available for patients but families. We meet six times a year, both in person and via Zoom. With the COVID pandemic ever evolving, right now we're only meeting via Zoom, but this makes it easier for our patients and family members to get involved and get in touch with other patients who are also going through this. When you're first diagnosed with oral cancer, you have those initial steps to get through, what is my diagnosis and my prognosis and what treatment options are available to me?
Once a patient comes through our clinic and understands their different treatment options and opts to go forward with surgery, they then have the treatment side effects and sometimes adjuvant treatment that they have to undergo. The support group allows patients to discuss different tips and tricks and just have overall support through the cancer diagnosis.
Melanie Cole (Host): Dr. Kase, as Christina is talking about working with the patients, I imagine with any cancer, of course, the fears of the medical and the financial side, not to mention the devastating effects that an oral cancer can have on someone's appearance and ability to swallow, eat, speak, all of those things. In your role in this multidisciplinary team, does medical insurance cover the dental aspects of multispecialty oral cancer care? What about high cost implants? You and I have done other podcasts on implants and radiation therapy. Tell us a little bit about where insurance comes in for your part in this care.
Dr Michael Kase: Well, I will definitely say that our team has dedicated billing professionals that help give the patient all the information they need in terms of what is covered or is not covered. And in my opinion, our staff does the best job possible. And if there's a way to get it covered, they'll get it covered. But speaking on regards to what I do, the prosthetics, I will say that, again, with the help of our staff, more often than not, we get these prosthetics covered due to the fact that they relate specifically to a medical problem. So it's not just a denture, it's an obturator. It's not just a lower denture, it's a mandibular resection prosthesis. So it all pertains to the surgery and the reconstruction that Dr. Morlandt or Dr. Ying do that help rehabilitate the patient. So there is definitely a role for medical insurance in all of this and we usually find a really good way of getting it covered.
Melanie Cole (Host): As we work our way through this really important podcast, I'd like to give you all a chance for some final thoughts. And Christina, I would like to start with you. If you were to think of your patients, what do you find are the most important issues to patients and families as they navigate that cancer care and how you help them? And remember, this is for your referring physicians, so they are looking to the specialists at UAB Medicine. How are you helping them navigate this confusing and scary world of oral cancer?
Christina Cyriac: So here at UAB and specifically in our clinic, we help the patients navigate through their cancer journey throughout a multitude of ways. We have a clinical care coordinator, who helps patients as well as a patient portal. Patients are available to send us their questions and concerns and we get back to them just as quickly as we can. So our patients through their care here at UAB have access to our head and neck cancer support group, our supportive care department, which helps link up the patients with physical therapists, lymphedema therapists, speech-language pathologists. We help our patients with any of the other appointments and referrals they need. We're also available to answer any referring physician's questions in regards to if any staging CT scans need to be done prior to an appointment, we can help them arrange those as well.
Melanie Cole (Host): Dr. Kase, next to you, do you have a vision for this program? If you were to say about this care model and the way that it improves the way that patients receive their care, as you're speaking to other physicians that maybe want to simulate this type of care model, tell them what you would like them to know about how well it's working and how great you all work together.
Dr Michael Kase: Well, I think first of all, what makes it work so well is the people we have, like our team is I can't say enough good things about our team. Everybody on our team is outstanding and I'm privileged to work with them every single day, so, number one, that makes a huge difference in the character and integrity of the people you have as well as their skillset. But secondly, I would say the best advice in terms a vision for this program, is if you're wanting to emulate, it would be plan ahead because we're growing so fast. We need to make room for ourselves as we grow. And that's a good thing because then we have the ability to take care of all these patients, this influx of patients that we have. But, as we grow, we need physical space, we need more faculty, we need all of the supporting staff to help us too, so always plan for the ability to help more people.
Melanie Cole (Host): Dr. Morlandt, last question to you. As we wrap up, what would you like referring physicians to know about the special care that oral cancer patients are receiving at the UAB Oral Oncology Multidisciplinary Clinic and what you would like them to know about communication with the referring physicians, anything you'd like to wrap this up for us?
Dr Anthony Morlandt: Well, thank you. I really would like referring clinics, physicians, cancer centers to know that the reputation that UAB has enjoyed for many years hasn't changed. In fact, if anything, with our outstanding leadership and the great resources that have been put into the O'Neal Cancer Center, if anything, it's enhanced. We use the latest technology, state-of-the-art care. We have 3D imaging. We use surgical navigation in our small neck of the woods surgically. We use 3D printing to give a very patient-specific individualized outcome. And that's just the beginning.
So I just want anyone in the community who'd like to work with us and send us our patients, I'd like them to know that we appreciate your referrals. We appreciate the show of trust you've placed in us. And, for many years, we've been very fortunate to work with you and we'll continue to do so.
Melanie Cole (Host): Thank you all so much for joining us today, and such an informative podcast and such a great care model. Thank you again. And a physician can refer a patient to the UAB Medicine Oral Oncology Multidisciplinary Clinic by calling the mist line at 1-800-UAB-MIST or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. Please remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. Thank you so much for joining us today. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua230.mp3
- DoctorsKase, Michael;Morlandt, Anthony
- Featured SpeakerMichael Kase, DMD | Anthony Morlandt, MD, DDS, FACS
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5549
- Guest BioDr. Kase was raised in Park Ridge, IL, and graduated from Marquette University. He completed his Doctorate of Medicine in Dentistry at the Maurice H. Kornberg School of Dentistry at Temple University. Afterwards, he proceeded to obtain certificates in prosthodontics at the Birmingham VA Prosthodontics Clinic as well as at the University of Alabama at Birmingham School of Dentistry.
Learn more about Dr. Kase
Dr. Morlandt was born and raised in Floresville, Texas and graduated from Baylor University. He completed his DDS magna cum laude at the University of Texas Health Sciences Center in San Antonio, Texas, and received his MD and internship and residency in Oral and Maxillofacial Surgery from the University of Alabama School of Medicine.
Learn more about Dr. Morlandt
Release Date: February 14, 2022
Expiration Date: February 13, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Faculty:
Anthony Morlandt, MD, DDS
Associate Professor, Head and Neck Surgery
Michael T. Kase, DMD
Assistant Professor, Dental Oncology
Drs. Morlandt and Kase have no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole, and I invite you to listen as we examine the immense value of dental implants for the oral cancer patient. Joining me in this physician round table panel today is Dr. Michael Kase. He's a Maxillofacial Prosthodontist and the Assistant Director of the Advanced Education in Maxillofacial Prosthetics and Dental Oncology Fellowship. And Dr. Anthony Morlandt. He's a Head and Neck Surgeon, Head and Neck Surgical Oncology and Oral and Maxillofacial Surgery. And he's also an Associate Professor at UAB Medcine.
Doctors, I'm so glad to have you join us today. And Dr. Morlandt, I'd like to start with you. If you would set the table for us a little bit about the prevalence of oral cancer and what you're seeing in the trends.
Anthony Morlandt, MD, DDS, FACS (Guest): Well, thank you so much. I appreciate the chance to talk with you, Melanie, and provide this Med Cast for our physician and dental colleagues. Dental implants they're certainly not new. They've been around since the 1960s and 70s, when an orthopedic surgeon and researcher named Per-Ingvar Brånemark, based in Sweden, began to investigate the use of a titanium screw placed directly into bone.
And because of the unique property of titanium and that it has a very thin dioxide layer on the surface that's almost completely biocompatible, that unique property makes these implants integrate into the bone. And so similar to other orthopedic implants, they can't be unscrewed, and these are permanent fixtures.
And so because of that unique biomechanical property, these can actually be used to support the immense chewing forces that are generated during massification. And the implant itself, as many of you may be aware, involves a screw, a titanium screw that's actually threaded into the maxilla or the mandible that has to be placed to precisely because the next phase called the abutment actually comes through the soft tissue into the mouth; and is the platform for the actual dental restoration. The dental restoration is something made by a dentist or a prosthodontist, someone like Dr. Kase, with his expertise and that restoration can take the form of a porcelain or metallic or even acrylic or plastic based tooth shaped structure. It can be removable or screwed in and fixed.
And for the average patient who loses a tooth, it's truly the Cadillac or the state-of-the-art treatment in 2022. For the cancer patient, someone who's had radiation therapy, who's had major surgery, including reconstructive surgery using microvascular free flaps, dental implants are absolutely essential.
Without a dental implant, these patients cannot retain a denture. They don't have enough saliva because of dry mouth, xerostomia from radiation therapy. They don't have enough saliva to retain a denture normally. So, they're stuck using adhesives or just going without teeth. And the literature tells us that, that is a significant detriment to a patient's quality of life after suffering through oral cancer. So it's not a short answer, but dental implants are important and certainly state-of-the-art.
Host: Wow. Really fascinating information Dr. Morlandt. And Dr. Kase, how is the oral rehabilitation of a patient with oral cancer such a challenge for clinicians, as Dr. Morlandt has just gone through some of the options available. Speak a little bit about some of the challenges, and you can even speak about the optimal timing of this implant placement regarding survival rates and the oral cancer patient.
Michael Kase, DMD (Guest): Well, the challenge is associated with any implant prosthesis with one of these cancer patients is, very difficult to manage. There's things such as the xerostomia, the lack of saliva, the inability to open the mouth, the trismus, things like that, which just inhibit my access to get into these implants.
And once I'm able to access the implants, then we have to worry about things such as how the tissue is going to behave after these large procedures that Dr. Morlandt or Dr. Yang do, where they are essentially transforming the entire jaw with a different bone from a different part of the body.
So, the tissue essentially doesn't know how to react. It overreacts. And then we're left trying to manage this tissue to get it to a point where it's predictable and we can move forward and make some sort of prosthesis, whether it's fixed or removable. And varying other options that we have sometimes that involves tissue splints, or tissue conditioning, stuff like that, splints that get screwed down, splints that the patient can take out, anything to manage that area, to give us enough space where we can make the eventual prosthesis.
As far as failure rates, that's where we run into things related a lot to potential for radiation therapy and the osteoradionecrosis, which may occur. So, generally we like to place these implants before any radiation occurs. So, optimal timeline would be at the time of surgery, of course, but sometimes that can't be done.
So we got to try and get it in before the radiation begins or we got to plan it very, very, very carefully, so we don't end up in tissue that has been radiated. But there is slew of problems and challenges that come with all these patients. But as a team, we work together, overcome them and, give the patient prosthetics that help them function and have a much improved quality of life.
Dr. Morlandt: I'd also like to add to what Dr. Kase said. The ideal time to place these implants, however, is not after the radiation. And so what a lot of major academic centers struggle with, is when the patient comes in and has their initial surgery, let's say to remove cancer of the tongue or cancer of the upper or lower jaw, that patient may have reconstructive surgery, but then go on to receive radiation without ever having their dental implants placed.
And unfortunately that then renders that patient essentially unable to ever receive a prosthetic. And unable to ever have proper oral function and that impacts nutrition and it impacts their psychosocial performance and their quality of life. And so what we've really tried to do at UAB is with a fantastic team in MSO, a fantastic team in our billing and compliance office, is work with the dental insurance carriers and even medical insurance carriers before the patient ever has their major cancer surgery.
And that way we can place the implants the same day as they're having their major oral surgery, before they've ever received radiation. So dramatically lowers the risk of implant failure, and it makes that patient wake up from their operation feeling whole and that hasn't been done in the past. And we're seeing that there is quite a bit of benefit just changing that order, making those initial extra steps happen.
Host: Dr. Morlandt, can you speak a little bit about patient selection? And how, or when you might use each of these options that you've mentioned today? Are you working with the patient and we've talked about your multidisciplinary team, and we're going to talk about that a little bit more coming up, but can you speak a little bit about patient selection for these?
Dr. Morlandt: Every patient who comes to UAB with a new diagnosis of oral cancer should be seen by a dentist. Many of them do come from an existing general dentist and maybe an oral maxillofacial surgeon or an ear nose and throat surgeon performs the biopsy. But regardless of how they come to us, they need to be managed by a general dentist.
So, by collaborating with that general dentist, we can understand if they've been a patient with good long-term compliance. If these are patients who only go to the dentist once in a great while when they have pain or infection, these may not be ones who can tolerate a complex elegant state-of-the-art implant-based restorative plan.
So, the greatest contributor to success for some of the things we can offer, is maintenance and oral hygiene and having good follow-up from a local general dentist. So, that probably is the greatest factor in patient selection. And then we have some patients who we really are looking for them to have realistic expectations after a devastating injury.
Even if it's a surgically created injury or radiation induced injury, both necessary to treat their cancer. After an injury like this, they need to understand that there will be permanent changes to speech and chewing and swallowing. There may be permanent limitations in mouth opening, and though we can overcome a lot of that; we want to have a patient who understands these are all attempts to make them whole, but never will be quite the same as their pre-surgical state. And so there's a good bit of psychology. There's a good bit of just managing expectations before we ever take that patient to surgery. And think that's really important.
Dr. Kase: Yes, I would like to echo what Dr. Morlandt just said is that's probably one of the single most important things we need to worry about with these patients. Selection is definitely management of expectations. Just a simple number to throw out there is for a non oncologic patient that's just getting your standard complete dentures, I always have the conversation with them to say, you know, all of your teeth are no longer there. So, your chewing function is going to be inhibited. And I try and explain that even with the best fitting dentures, you're only going to get about 60 to 70% chewing efficacy as you would with your normal teeth. So, you can imagine that these patients that undergo so much surgery, so much radiation, or chemotherapy, all the comorbidities they have along with it; the problems that are inherent to a prosthetic with them is going to be pretty great. So, as long as you manage their expectations, you can kind of tailor the appropriate treatment to them, and the echo is his first comment about managing the tissues with the general dentist, that also plays a huge role in how we decide things. Because if you make a really large restoration on a patient's lower jaw after a fibula free flap reconstruction and all this tissue change and management and they can't clean underneath it; well, there's really no point in having done that because it's probably going to end up with it poor results. So, in that case, we probably want to move to something that's more removable that allows the patient to clean things a lot better.
Dr. Morlandt: Mike, let me ask you a question. Have you noticed in your experience that regardless of someone's background, they come in with the expectation, with the knowledge, the understanding that implants are available. What I've noticed in the past 10 years of doing this is, patients now expect to have dental implants. They know they're available, they know they're state-of-the-art and they find ways to make it happen. It's a little different than what it used to be. People would come in and say, geez, I'm just happy to survive this oral cancer. Please help me. But now I think people are living longer. We have proton therapy. We have immunotherapy, we have all of these outstanding adjuvant treatment modalities. And patients want the best. When they come to UAB, we can offer that. I'm happy and proud of our work to be able to do that.
Dr. Kase: I agree. I think that's definitely a part what makes UAB so special is that we have this team that has made these dental and osseous implants a part of our protocol that patients do come here and they expect that they can get that. Whereas we see patients come in from outside institutions that don't have a team such as ours and they had no idea it was even a possibility. So, it's a good thing in that implants are becoming more available and more widespread known, but it's also a very good thing that UAB is leading the way and making that an option for even these oncologic patients.
Host: Well, it certainly shows the benefits of your comprehensive care model and the ability to cut down time from pre-op to getting that prosthesis and from there on treatment. So, I'd like to give you each a chance for a final thought and Dr. Kase, I'd like to just start with you here. The elements that make up your team, because as we're really finding more involvement of multiple sub-specialists and the utilization of this multidisciplinary team; how ideal has this been for managing these complex patients and given the complexity and with these treatment algorithms, more options in your armamentarium? Can you speak about who's in charge of guiding patient care and really a little bit about why this multidisciplinary approach is so ideal for these patients?
Dr. Kase: Certainly. Well, the simple word would be time. Having this multidisciplinary approach with Dr. Morlandt and Dr. Yang and myself as three main practitioners, it allows us to all see the patient at once, on the same day. We essentially can develop a treatment plan right there, and we can get the balls rolling right away rather than the patient needing to come back or go to a different site or even a different institution. So, having two microvascular head and neck surgeons and a maxillofacial prosthodontist, as the practitioner, all being able to see the patient at once is a huge, huge plus the patient. And then, just because we're the practitioners, it doesn't mean we don't have amazing members of our team that do so much, like our PAs, the nursing staff, even the residents and fellows that we have. They all contribute so much and really help us push the boundaries, allowing for technology to come into play. So, that even speeds things up even more, whereas a patient that comes in that ultimately needs a segmental mandibulectomy and a fibula free flap reconstruction, from the time they come in, until the time they would get teeth, historically, it would take close to a year and a half. In some cases we could do it in about six months. So, this multidisciplinary approach really cuts down on time. And I think that's probably the optimal benefit for these patients, as well as getting them the best function and aesthetic outcome as possible.
Host: Dr. Morlandt, last word to you, as we're speaking about the immense value, as you've spoken about today, both of you, of dental implants for the oral cancer patient. I'd like you to speak to other providers about first of all, when you feel it's important they refer to the incredible specialists at UAB Medicine and how it really can help their patients with the overall outcome of the patient experience, improved retention, adherence, compliance, psychosocial, confidence. I mean, there is a lot, this is a complex issue. Can you wrap it up for us with really your final thoughts on this topic?
Dr. Morlandt: It's important to remember, I think Melanie, that oral cancer is too complex for any one type of doctor to manage. And that's true for almost every type of cancer, breast, colorectal, lung, in most cases we're using the team approach. We are very blessed in Alabama to have extremely strong and well-trained community-based practitioners. And we work with all of them. We work with general dentists, oral surgeons, ear, nose, and throat, radiation oncology, medical oncology, speech pathology, that the entire gamut.
So, one thing we offer is certainly for the surgical aspect of the care, when the patient comes to us, we can have that patient mentally and psychologically ready for the next phase in their cancer treatment, which for head and neck, cause usually radiation therapy. And in some cases, chemotherapy or immunotherapy, we can have that patient ready for the next phase when they leave UAB. The challenge that this is really a marathon event for most people who aren't having care at a major medical center like ours, at least in the surgical and dental arenas. They are going from office to office and having months and months of treatment.
And it's exhausting. It's psychologically exhausting and it's financially taxing for the patient to be sort of stretched out. And so what we've tried to do is compress that treatment plan into a very efficient, very well-run operated system that then allows the patient to get on with their treatment and get on with survival.
I think that's what we offer. It's an exciting time. And of course, we're very fortunate to have all of the 3D-based planning and surgical navigation and technology here at the institution. We've been very well supported by the institution to put all of these things in place in the clinic and the operating room, on the floor, for our inpatients. So we're fortunate to be able to offer that to our, community-based providers.
Host: Well, you certainly are. And thank you both so much for sharing your incredible expertise and experience. And I hope that you'll come back on because we didn't even get into the technology involved. And as you said, this is such an exciting time to be in your field and the technology is advancing ever rapidly.
Come back on and let's speak about some of that. And thank you again for joining us. A physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST. Or by visiting our website at uabmedicine.org/physician. That concludes this episode of the UAB Med Cast. Please remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole.
Additional Info
- Audio Fileuab/ua231.mp3
- DoctorsRosenthal, Richard
- Featured SpeakerRichard Rosenthal, MD
- CME SeriesQuality and Outcomes
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5513
- Guest BioDr. Rosenthal received his BA in Zoology from The University of Texas at Austin and MD from UAB Medical School. He trained in Internal Medicine at Carolinas Medical Center. He completed his Endocrinology Fellowship at UAB. Dr. Rosenthal is a Professor of Medicine in the Division of Endocrinology, Diabetes, and Metabolism and has served as clinic director from 1999 to 2011.
Learn more about Richard Rosenthal, MD
Release Date: January 25, 2022
Expiration Date: January 24, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no relevant financial relationships with ineligible companies to disclose.
Speaker:
Richard S. Rosenthal, MD
Associate Professor in Endocrinology
Dr. Rosenthal has no relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB Med Cast. I'm Melanie Cole. And today we're discussing thyroid disease. Joining me is Dr. Richard Rosenthal. He's an Endocrinologist at UAB Medicine. Dr. Rosenthal, I'm so glad to have you with us today. This is a pretty prevalent situation we're seeing now. Can you tell us a little bit about thyroid disease and what are the different types that you see most commonly?
Richard Rosenthal, MD (Guest): Well good morning. Thank you for having me speak on this very important topic. Thyroid disease is very common. In the general practice population, we get lots of patients who come see us for various thyroid disorders, whether it be hypothyroidism or hyperthyroidism. With the advent of increased imaging over the years, we also see a lot of people who develop nodules in the thyroid gland that need to be addressed.
Host: So, what are some common conditions and factors? Can you speak a little bit about the etiology and any risk factors that you can identify for us? Is there a genetic component? Tell us a little bit about this.
Dr. Rosenthal: Well, thyroid disease tends to be a little bit more prevalent in certain populations. Patients who have other autoimmune disorders, patients who have a family history of thyroid disease. It's also very common in patients in the postpartum period. A lot of women who are pregnant or have just delivered baby may also develop some thyroid dysfunction.
And we also see patients who present with a condition called Graves disease, where their thyroid is hyperfunctioning or overactive, and they need therapy for that condition.
Host: Well, then how does it present Dr. Rosenthal? Is it found incidentally? Are there some symptoms and signs? Are people supposed to see their primary care provider, if they've gained weight or have fatigue? Tell us a little bit about the presentation and really diagnosis for us.
Dr. Rosenthal: Well, a lot of patients who present to a primary care office may have various signs or symptoms. They may have fatigue or weight gain, dry skin, constipation. And these are very common presenting signs of hypothyroidism, which is an underactive thyroid condition. A very common word that we see used for this is Hashimoto's thyroiditis, which is an inflammatory condition of the thyroid. You develop white blood cells that infiltrate the thyroid and cause it to not function as properly. Women account for about 95% of the cases of an underactive thyroid, when it's related to this autoimmune condition. And patients may also be asymptomatic. They may just have a slightly enlarged thyroid gland. And where we get involved as an Endocrinologist, is the primary care provider checks a blood test called a TSH level or a serum thyrotropin level. And that level is sometimes elevated. And an internist may either start that patient on therapy or refer them to us as an Endocrinologist to complete the evaluation and work up.
Host: And what's involved in that evaluation and work up? And you can speak about any imaging or radiologic technology that's really advanced and augmented your abilities for detection and therapy.
Dr. Rosenthal: Well in hypothyroidism, the TSH value is elevated. And that's the first thing you need to do to, to check someone's thyroid condition. Because if it's elevated, you want to go ahead and feel their thyroid gland. And a lot of times we think of a thyroid gland as being about 20 grams and we make an assessment of the size of the gland. Sometimes we need to go ahead and order a thyroid ultrasound. The patient may have a nodule that we detect on our physical examination. They may also present with signs and symptoms of compression of the thyroid gland into other organs, mainly the esophagus or trachea. So, if patients are having problems swallowing, we call that dysphasia. Or they're having problems with hoarseness where the gland may be affecting their trachea, that also leads to additional imaging, most commonly the ultrasound, but sometimes we do need to do a CAT scan of the neck to see if there's any impingement of those organs. The other tests we also order are called antithyroid antibodies. They're present in a high titer in about 70 to 80% of these patients.
Host: So, then speak about first-line treatment. Now you've mainly been mentioning hypothyroidism, but what about hyperthyroidism? Speak a little bit about first-line treatments that you would try in either situation with a patient, Dr. Rosenthal.
Dr. Rosenthal: For hypothyroidism, the first thing is to place them on thyroid hormone supplementation. We give them a hormone called thyroxin or serum T4, that is commonly a generic form of that medication is levothyroxin sodium and we follow their thyroid levels and we repeat their thyroid levels in six to eight weeks. That's the amount of time it takes for the pituitary thyroid access to normalize, to see if we need to make further adjustments. On the flip side of things, patients with hyperthyroidism also present with tremulousness, heart racing, weight loss, fatigue, irregular menstrual cycles. And just like we check a serum thyrotropin level for hypothyroidism, we also check it for hyperthyroidism. And in that situation, the TSH value is low or suppressed. When we see a suppressed TSH, the test we like to order in that situation is a nuclear thyroid scan and uptake. The reason we order a thyroid scan and uptake is it helps us differentiate for the cause of hyperthyroidism. Is it an inflammatory problem with the thyroid? Or is it an endogenous problem with the thyroid where antibodies may be causing the thyroid gland to work harder than it needs to?
Host: When is surgical intervention necessary?
Dr. Rosenthal: There's different forms of therapy for hyperthyroidism, when it's endogenous. The most common thing we consider is putting patients on antithyroid medications. They may also need I-131 therapy. And as you mentioned, surgery is also an option. We tend to reserve surgery for patients that have a large gland, patients whose hyperthyroid signs and symptoms are uncontrollable with medication or those that have compressive symptoms from their thyroid condition, that may cause trouble swallowing or hoarseness. We also consider surgery for patients who have thyroid eye disease and in some of our younger patients.
Host: That's really interesting. So, Dr. Rosenthal, what about nodules? You mentioned it just briefly before. Tell us a little bit about the difference with how those might be treated. Do you see these vert often?
Dr. Rosenthal: Nodules are very commonly seen because primary care providers tend to order imaging of the thyroid gland. And when you image a thyroid gland, lots of little nodules can be found. Our job as an Endocrinologist it's to make a determination of which nodules need to be biopsied and which nodules can be followed. In general about 95% of these nodules end up being benign. So, we feel pretty good when we see nodules. However, sometimes when we do a fine needle aspiration biopsy of one of these nodules, we will detect thyroid cancer, which needs additional treatment. That treatment includes referring to a surgeon to either removing one of the thyroid lobes or both of the thyroid lobes, and then there's additional treatment that may need to be considered mainly in the form of I-131 therapy to ablate any kind of remaining thyroid tissue.
Host: Well, you mentioned now surgery and primary care providers. Is a multidisciplinary approach really important for these patients? What types of providers are involved in sometimes what could be considered complex situations?
Dr. Rosenthal: As an Endocrinologist, we feel pretty comfortable seeing these patients ourselves and making the determination of whether they need to see a surgeon or not. There are multidisciplinary clinics using surgeons as well as Endocrinologists. However, that's not a necessity in all situations. These patients can initially be managed just by the Endocrinologist and if they feel a biopsy is concerning and they need surgery, a direct referral to a thyroid surgeon is quite appropriate.
Host: So Dr. Rosenthal, do you see anything exciting? What's exciting in this field for thyroid disorders? Is there exciting medications on the horizon? Any research that you'd like to share with other providers?
Dr. Rosenthal: One of the things that's exciting about the management of thyroid diseases from a hypothyroidism perspective is there's various treatment options. Mainly in the forms of thyroid medications. We tend to use generic thyroid medications, however, in the last five years or so, we've seen different versions of thyroid medication, name brand versions that may be a little more pure, a little bit more tolerable for patients. However, in general, hypothyroidism is pretty standard in the treatment of the disease. The most exciting thing we've seen in the management of thyroid disease is more on the thyroid eye disease. There's been a new treatment out to manage these patients.
It's mainly prescribed by ophthalmologists. However, patients don't have to have surgery as much for their thyroid eye disease. The most important thing to manage the hyperthyroid is to treat the underlying condition, which is either getting them on thyroid medications, giving them I-131 therapy or surgery to see if the thyroid eye disease resolves.
Otherwise, they may need additional treatment from the ophthalmologist or with one of these newer infusion therapies for thyroid eye disease. As far as the thyroid nodules, the most exciting thing about that disease is most people live normal lives with thyroid cancer. If they are noted to have thyroid cancer on a thyroid biopsy, they need a surgery in the form of either a lobectomy or a thyroidectomy, and then the radioactive iodine is also a potential treatment option.
Host: So, do you have any final thoughts about referral to the specialists at UAB Medicine and when you feel it's important that they look to you and send their patients onto you for further treatment?
Dr. Rosenthal: Well, I believe that treating thyroid disease is something that is very standard. One of the things we like to do is if you detect a thyroid issue, go ahead and make the referral, after you order blood work. I tend to encourage patients not to do too many imaging studies that are unnecessary in the management of thyroid disease.
And one of the rules of thumb that I've always considered is that if you feel a thyroid gland that's abnormal, the first thing you need to do is just order a TSH. And if that TSH's value is normal, you feel pretty comfortable that the only additional tests they would need at that time would be a thyroid ultrasound.
On the flip side, if the TSH value is suppressed or elevated, that's when you want to consider referring on to an Endocrinologist to determine the next step in the process of the management of this disease. The other thing I would leave you with is also thinking about thyroid disease and pregnancy. It's very common to see thyroid abnormalities. You want to make sure that your pregnant patients are properly replaced because the treatment options are a little bit different. They need a little bit more medication as they progress through pregnancy. They also may develop thyroid abnormalities in the postpartum period.
And lastly, we've seen a little bit more inflammation of the thyroid. A A condition we call subacute thyroiditis with all kinds of viruses, including the recent COVID virus or Coronavirus that we've seen during the pandemic.
Host: Thank you so much, Dr. Rosenthal. Excellent summary and a very important, very informative podcast. Thank you so much for joining us today. A physician can refer a patient to UAB Medicine by calling the mist line at 1-800-UAB-MIST, or you can always visit our website at UABmedicine.org/physicians. That concludes this episode of UAB Med Cast.
Please always remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua227.mp3
- DoctorsEudailey, Kyle
- Featured SpeakerKyle Eudailey, MD
- CME SeriesClinical Skill
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5476
- Guest BioKyle Eudailey, MD, is a cardiothoracic surgeon with expertise in complex aortic surgery, aortic valve repair, and endovascular and interventional techniques in aortic stenting.
Learn more about Kyle Eudailey, MD
Release Date: January 5, 2022
Expiration Date: January 4, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Faculty:
Kyle W. Eudailey, MD
Assistant Professor in Cardiac Surgery, Cardiothoracic Surgery, Thoracic Surgery
Dr. Eudailey has disclosed the following financial relationships with ineligible companies:
Consulting Fee - Edwards Lifesciences, CryoLife, Medtronic Inc., Terumo Corp.
All relevant financial relationships have been mitigated. Dr. Eudailey does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers (Ronan O'Beirne, EdD and Katelyn Hiden), have any relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole. And today, we're exploring bicuspid valve disease. Joining me is Dr. Kyle Eudailey. He's an assistant professor and a cardiothoracic surgeon with expertise in complex aortic surgery at UAB Medicine.
Dr. Eudailey, it's a pleasure to have you join us again today. So help us to understand the epidemiology and clinical features of the bicuspid aortic valve and this disease. Is there a heritable component? Speak a little bit about it.
Dr. Kyle Eudailey: Sure. Well, nice to chat with you again, Melanie. Appreciate you having me. So the bicuspid valve, I guess really first it's important to define a few things, right? So, the aortic valve, obviously last valve to leave your heart, intimately connected with the aorta, which is the largest blood vessel in your body. And so that will kind of become important later on in our discussions about treatment. So it's important to know that the aortic valve and the aorta are kind of intimately connected specifically at the aortic root by the heart.
Bicuspid aortic valve disease is really a hereditary or congenital heart defect. And it's actually probably the most common congenital heart defect. It basically exists somewhere between 1% to 2% of the entire population. So if you think about that 1% to 2% of all people, there's a lot of bicuspid valve disease out there. And so it's a relatively common disease pathology or valve pathology that we come across.
Essentially, what it means is the aortic valve normally has three leaflets. It's a tri-leaflet valve. If you look at that valve en face or in cross-section, it looks like a peace sign or a Mercedes-Benz sign. And, in terms of when you have a bicuspid valve, it simply means that you have two leaflets instead of three. That can come in a couple of different flavors, but the vast majority of them are a simple fusion of two of the leaflets together.
And what that does is it sets up the valve for complications throughout the lifetime of the valve. But that's the kind of gist of sort of what we're looking at in terms of when we talk about bicuspid aortic valve disease, we're really just talking about a two-leaflet valve of the aortic valve as opposed to a three.
Melanie Cole (Host): So when is diagnosis usually made? Since this is congenital, is this something we know from in utero or when a child is little or is this usually found in adults? Tell us a little bit about diagnosis.
Dr. Kyle Eudailey: Yeah. So, diagnosis, it can be at any time in a person's life or the valve's life. As I said, 1% to 2% of people have this. And so a lot of people live a normal life and never know that they have a bicuspid valve. Many will remain asymptomatic. If we look though at sort of the lifetime of bicuspid valves, probably 50% of people will ultimately have some complication regarding their valve or have some intervention in regards to their valve over their lifetime. And so really, the diagnosis comes about when there are symptoms or complications of bicuspid valve disease.
So the important thing to understand is that really is associated with valve dysfunction or if there's any sort of associated aneurysmal disease. And the symptoms that you have are based upon ultimately the type of valve failure that you have or our mode of failure. And so if we look at really the most common ways that these valves failed, there's really kind of three ways that we ultimately end up figuring out that somebody has a bicuspid valve or figuring out that they have symptoms from a bicuspid valve.
So probably the most common is what we call aortic stenosis. Aortic stenosis is a stricture of the aortic valve or calcification of the aortic valve. And what happens is the valve itself basically gets stiff and doesn't open as well. This is something that usually presents later in life. And so this is something that we typically see in people who are between 50 and 70 with bicuspid valves and basically the valve itself gets stiff and calcified. And what it does is it makes it to where it's harder for the heart to pump blood through that valve.
The most common symptoms are the symptoms associated with valve dysfunction, which is trouble breathing, dyspnea on exertion, fatigue, worsening exercise tolerance. Sometimes it can be associated with some chest discomfort or syncope, you know, passing out. And this is really probably the most common way in which we pick up bicuspid valve disease. So this is the vast majority of bicuspid patients.
The other ways in which we see bicuspid valves or see the symptoms or complications really or the other modes of failure, so aortic regurgitation or aortic insufficiency is basically a failure of the valve to coapt or basically means that the valve itself is leaky. And so this is something we see probably in about 10% of bicuspid patients. And this is usually seen in the younger years. So people with bicuspid valve disease, they could be teens, 20s, 30s. And what we often see are the signs of when you have a severe leaky valve. And often that means, again, decreased exercise tolerance, getting more short of breath. But typically, these people have other symptoms like palpitations or heart racing. And this is again secondary to the valve leaflets being a little extra floppy, so kind of different than the aortic stenosis patients.
And then, finally, we have patients who have aneurysmal disease and that means that you have some associated aneurysm of the aorta with the bicuspid valve. And these people can often be asymptomatic. This is typically picked up serendipitously or by some other tests for some other medical procedure. But if we look at all patients with bicuspid valve disease, probably 50% of them have some sort of associated aneurysmal disease, either of the ascending aorta or the aortic root.
And so any one of these three major pathologies of the valve can result in either symptoms or complications that ultimately lead us to heading down the pathway of treatment or setting up a surveillance program in terms of keeping an eye on something or management.
Melanie Cole (Host): Thank you so much for that comprehensive answer, Dr. Eudaily, and we're going to get into patient selection for valve repair. Before we do that, you're speaking to other clinicians, what is the importance if this is diagnosed and identified of other family members being evaluated by a physician? And how does your program identify those family members who are affected? What would you like to tell other providers about the importance of that identification for a hereditary bicuspid valve disease?
Dr. Kyle Eudailey: Sure. I think that's probably the best question that can be disseminated in a podcast, right? And it's something that's been evolving and we sort of have a better understanding of. The thing that we need to understand is that bicuspid valve disease has a genetic component. Some bicuspid valve disease can be sporadic. But we do know that the majority of bicuspid valve disease has some autosomal dominant component. And so autosomal dominant, for clinicians, we know that that usually means direct one-to-one inheritance. But the kind of complicating factor about bicuspid valve disease is that there's incomplete penetrance, right? So the heritability, it's not clear, meaning that the genes can be passed on, but it doesn't necessitate that a bicuspid valve is going to end up being present.
So, ultimately what does that mean? It means that if you have a patient who has bicuspid valve disease, really all of their first relatives should be screened for bicuspid valve disease. And so the big takeaway is that kind of point right there. And if you look at population studies or if you look at genetic studies, basically, it comes down to about 10% of first-degree relatives have a bicuspid aortic valve. So if you yourself have a bicuspid aortic valve, 10% of your first-degree relatives will actually ultimately end up having a bicuspid valve. That's a fair number of people, even if you think about how prevalent it is. Like I said, it's important that screening is kind of really considered.
And so what is screening, right? So, screening for all first-degree relatives, specifically, when we talk about screening, we mean a transthoracic echo. So were talking about echocardiography. We're doing ultrasound of the heart, specifically focusing on good views of the aortic valve as well as good views of the ascending aorta and aortic root, because what we want is a screening process to pick up not just valve disease, but also aneurysm disease. And the nice thing about echocardiography is it's a non-invasive screening method and so it doesn't require radiation or it doesn't require contrast. And the big important takeaway is this is actually an AHA or American Heart Association guideline for screening, which like I said, is first-degree relatives specifically should get a TTE or transthoracic echo.
Melanie Cole (Host): That is a key component as a takeaway message for this podcast and an important point that you made. So, what about patient selection? Because not everybody's an optimal patient for aortic valve repair, correct? If somebody is younger, you mentioned earlier aortic regurgitation, but not necessarily valve repair in these patients. Speak about how you decide and how you discuss and work with the patients and a multidisciplinary team to figure out who are the best candidates.
Dr. Kyle Eudailey: I think you hit the nail on the head there in that it's always a discussion, right? And ultimately options for intervention depend upon whether or not the patient with a bicuspid aortic valve requires a valve intervention, repair of aorta or both, right? So, sometimes it's an isolated valve intervention. Sometimes it's an isolated aortic aneurysm intervention. Sometimes it's both. And so the combinations of how we treat those patients, there's really a lot. And so I'm going to try to break it down based upon the specific pathology. But everybody's different and everybody's a little bit unique in terms of their risks and benefits of what we are able to offer.
So you touched upon valve repair, which is probably the most technically challenging and something that's probably unique to UAB. Valve repair, really this comes down to aortic regurgitation, right? So, aortic regurgitation, obviously like we've mentioned is when the valve is leaky or floppy. The valve at this point doesn't really have heavy calcification in regurgitation. And typically, this is what we see in younger patients. So the issue here is we have younger patient population and if we are considering intervening on the valve, really we're trying to think about the lifetime management of the valve. So particularly in patients who are in their 20s, 30s, 40s, they have a life expectancy of 30 to 50 years and really, we need to find a solution for them for that long of time.
The issue with valve replacement in these people is that tissue valves just don't last that long. These are valves that are made of cow tissue and pig tissue. Unfortunately, these valves actually fail sooner in younger patients. And so, typically, in young patients, a tissue valve may not last more than seven to ten years, honestly. And so that's really not a great solution. So the only other option for those patients for replacement is a mechanical valve. The trouble with a mechanical valve is that they're then bound to anticoagulation for the remainder of their life.
So in a lot of these patients, as long as the valve has decent tissue, and it's not too calcified, we're actually able to provide an aortic valve repair using the natural tissue. And what this does is it gets the intended result where you have a functional valve that it works well. You are able to do it with natural tissue and often you can have a longevity or the valve will last longer than a tissue valve and honestly, in a lot of cases, as long as the mechanical valve, except you do not have to take blood thinner. That's a real win for younger patients. And like I said, that's something that can really only be achieved in places where valve repair is done often, and that's high-volume valve centers or valve referral centers.
The next pathology we're going to talk about is aortic stenosis. This is something that we know a lot more about or treat more often, partly because we see aortic stenosis with normal tri-leaflet valves. But that being said, aortic stenosis with bicuspid valves is just slightly different in terms of how we treat it. Really the option for this is aortic valve replacement. Again, this is a little bit easier to deal with because often these patients are in their 50s and 60s. That being said, in your 50s and 60s, you still may have 30 years ahead of you in terms of life expectancy. And so we have to have some of these same conversations about tissue valves versus mechanical valves. But for this population, really replacing the valve is the best option.
Now, in the aortic stenosis population, we have to consider the classic surgical aortic valve replacement verse the newer transcatheter valve replacements. This is kind of interesting topic because transcatheter aortic valves, these are valves that are placed in through the leg and that are done through endovascular techniques. This is the sort of standard of care for tricuspid aortic stenosis. But there's this ultimate question about, do we treat bicuspid valves using transcatheter techniques?
At this point, the important thing to know is that in all of the pivotal trials that approved transcatheter valves for use, bicuspid valve patients were excluded. We do have some larger observational studies where transcatheter valves have been used on bicuspid valve patients. And we do know that it's possible to use them on bicuspid valve patients, but these are typically older bicuspid valve patients. So these are people in their 70s, 80s, which is probably a slightly different flavor than the people who get aortic stenosis in their 50s and 60s.
At this time, I would say again, the best thing is for people to be evaluated at a high-volume valve center. And that's because what that allows is multidisciplinary teams sort of make the best decision regarding how to best treat the valve. We do know that bicuspid valves often are more calcified or sort of more heavily calcified than tricuspid aortic valve stenosis. And so for those reasons, we still believe that in younger patients, an open surgical valve replacement is really the best option. The other reason for that is, when that tissue valve fails, those people are set up for success because they can get a transcatheter valve inside of their surgically replaced valve. And so they are set up for sort of this long-term success of their valve, where you have a surgical valve replacement, and then you have what's called a valve-in-valve TAVR in the future. Now, this is still an area of study where we're kind of trying to figure out if we can move the needle and treat younger patients with transcatheter valves. But at this time, we still lean a little bit towards surgical valve replacement in younger bicuspid valve aortic stenosis patients.
The sort of final option for treatment that I had mentioned is patients who have an associated aneurysm or aneurysmal disease, and that can come with a valve problem or without a valve problem. If you have a valve problem and you have an aneurysm, you're not a candidate for any of the transcatheter therapies. If you have an aneurysm and you don't have any valve disease, meaning you have bicuspid valve, but it's working very well, then your indication for treatment is really dictated by your aneurysm. And that's a whole different discussion, but basically what we do is we kind of decide what's the risk-benefit of either continuing surveillance imaging, meaning just keeping an eye on your aneurysm first and intervention. And ultimately, we make a decision about what's the lowest risk option, meaning is it less risky to prophylactically treat the aneurysm and replace that? Or is it less risky to just keep an eye on it and continue with continued surveillance imaging or repeat scanning or ultrasound imaging?
So, as you can see, it can get complicated quick, and that's because you have to put together all the different pieces of bicuspid valve disease and the associated lesions that come with it, which most notably are usually aneurysmal disease.
Melanie Cole (Host): Well, you made it very clear and your indications were really understandable. You're a great educator, Dr. Eudaily. No, truly you are. And for other clinicians, this was all excellent patient selection information and complications. So as we wrap up, any game-changers that you would like to mention? And I'd also like you to just let other clinicians know when you feel it's important to refer to a high-volume valve center, as you said, like UAB Medicine.
Dr. Kyle Eudailey: I think the big thing is if a bicuspid valve is identified, it's important to set up the screening of the first-degree relatives. I think that's kind of probably the biggest takeaway for physicians. But I also think that if somebody has a bicuspid valve and there's any concern for an associated aneurysmal component, it's reasonable for them to be bumped up to a cardiologist or even a cardiothoracic surgeon in order to set up a plan of how to monitor this moving forward.
Obviously, I'm a cardiothoracic surgeon. I think the biggest thing for me is I always tell people, just because you're sending somebody to a surgeon, it doesn't mean that they're going to get surgery, meaning that part of what I do in my clinic is I see a lot of aneurysmal patients and so what we do is we set up a plan of how to continue surveillance, how are we going to move forward. And we also discuss with patients what are the triggers as to when we would consider surgery or what ultimately means we're going to undergo surgery.
And so, getting a plan earlier in the patient's course is really important and understanding that just because you're sending somebody to either a cardiologist or a surgeon, doesn't necessarily mean that you're committing them to an intervention, which is really the other important thing.
Melanie Cole (Host): Well, it is. All of this information is fantastic. And I'd like you to come on with us again and talk about some of the specifics of those various repairs that you were discussing earlier.
Dr. Kyle Eudailey: One more public service announcement is that anybody who has a bicuspid aortic valve, even if it's functioning well, is actually at slightly higher risk of getting an aortic valve infection or what's called infective endocarditis. And so we actually recommend usually that these people have prophylactic antibiotics before dental work and things like that, which is important for primary care people and for cardiologists to know about their patients who have bicuspid valve disease.
Melanie Cole (Host): That's an excellent message to let them know. So thank you so much.
And a physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or by visiting our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. Please remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuab/ua229.mp3
- DoctorsBeck, Adam
- Featured SpeakerAdam Beck, MD
- CME SeriesMedical Innovations
- Post Test URLhttps://cmecourses.som.uab.edu/mod/quiz/view.php?id=5467
- Guest BioDr. Beck earned his medical degree from the UAB School of Medicine, and then completed his general surgery residency training and a surgical oncology research fellowship at the University of Texas-Southwestern Medical Center. He trained in vascular surgery at the Dartmouth-Hitchcock Medical Center and then completed a fellowship in advanced endovascular techniques, including branched and fenestrated endografts for aortic aneurysmal disease, at the University Medical Center of Groningen in The Netherlands.
Learn more about Adam Beck, MD
Release Date: January 4, 2022
Expiration Date: January 3, 2025
Disclosure Information:
Planners:
Ronan O’Beirne, EdD, MBA
Director, UAB Continuing Medical Education
Katelyn Hiden
Physician Marketing Manager, UAB Health System
The planners have no commercial affiliations to disclose.
Faculty:
Adam W. Beck, MD, FACS
Director, Division of Vascular Surgery and Endovascular Therapy
Dr. Beck has disclosed the following financial relationships with ineligible companies:
Grants/Research Support/Grants Pending - Cook Medical, Medtronic Inc., W.L. Gore & Associates, Terumo Corp.
Consulting Fee - Cook Medical, CryoLife, Medtronic Inc., Terumo Corp., Philips
All relevant financial relationships have been mitigated. Dr. Beck does not intend to discuss the off-label use of a product. No other speakers, planners or content reviewers (Ronan O'Beirne, EdD and Katelyn Hiden), have any relevant financial relationships with ineligible companies to disclose.
There is no commercial support for this activity. - TranscriptionMelanie Cole (Host): Welcome to UAB MedCast. I'm Melanie Cole, and I invite you to listen as we explore non-fluoroscopic imaging for endovascular surgery. Joining me is Dr. Adam Beck. He's a professor and Director of the Division of Vascular Surgery and Endovascular Therapy at UAB Medicine. Dr. Beck, it's a pleasure to have you join us again today for this very interesting topic. And due to its 2D nature and the high radiation exposure associated with its use, fluoroscopy has really been deemed an imperfect solution to endovascular surgery's need for intraoperative imaging. Can you tell us a little bit about that and the evolution?
Dr Adam Beck: Sure. Thank you for having me. Fluoroscopic imaging is really the only thing that we've had for decades now to perform endovascular procedures. And unfortunately, even though it's a pretty good way to do these procedures, unfortunately, the radiation that we receive as healthcare providers and the radiation to the patients give us some risk from the procedure that really you can't get rid of despite wearing lead in the operating rooms. The lead itself that we use to protect ourselves actually can cause some occupational hazard. It can cause problems with your back or your neck and, when you go home at night, your back hurts because you've been wearing 15 to 30 pounds of lead throughout the day. And there's actually been some changes that have been seen in people's circulating white blood cells just after doing some fluoroscopic imaging. And so there are a number of companies that are trying to look for ways to navigate the vasculature without having to use fluoroscopy or radiation. And one of these is something that we're going to talk about today.
Melanie Cole (Host): Well, then let's talk about that. So UAB Medicine is one of the first in the world to introduce non-fluoroscopic imaging, an innovation that you have called one of the most transformative technologies you've seen. So tell us about this exciting advancement, Dr. Beck.
Dr Adam Beck: So this particular technology is very new. It was just FDA approved this past year. We are one of the first six institutions in the whole world that have had access to it. So we were the third in the United States. What it is is basically a fiberoptic technology that is built into some catheters and wires that allow us to navigate the vasculature and can see where the fiberoptic wires and catheters are on a screen in front of us, similar to fluoroscopy without having to perform fluoroscopy. And so it's actually overlaid upon a three-dimensional image of the patient's arterial anatomy that is imported from a preoperative CT that is done in preparation for the procedure.
The technology is in its first generation. And so there are a lot of exciting things that are going to come in the future. Right now, we have some navigational catheters and wires that we can use along with it. But, in the future, it will become much more expansive and useful in more than just endovascular procedures.
But, right now, we're using it primarily for complex minimally invasive aortic repair for aneurysms that involve the portion of the aorta that has branches to the intestines and kidneys. These aneurysms are called thoracoabdominal aneurysms because of the location into the chest or thorax and the abdomen.
Melanie Cole (Host): Well, thank you for telling us the procedure that you found this to be most beneficial for at this point. Can you give us any studies that have demonstrated that the application of force reduces fluoroscopy time and dose? Tell us about some of the studies that are out there.
Dr Adam Beck: There are some very early studies that have been done very recently. The first institutions that had access to this are in Europe where it was approved earlier and the physicians who participated in the initial development are located. It is without question a way to decrease the amount of fluoroscopy. It doesn't necessarily decrease the time of the operation right now because we're learning how to use it. But most importantly, it decreases the fluoroscopy dose. It also decreases the manipulation that's required of the catheters and wires. And that is a little hard to describe, but the manipulation of those catheters and wires inside the blood vessels can cause injury to the blood vessels or it can dislodge plaques inside of the blood vessels that can go into the kidneys or down the legs and it reduces those complications that can occur as well. We are working on multiple papers that are looking at this very issue. As our experience grows in the United States and Europe, we'll have a lot more data for publication in the future..
Melanie Cole (Host): Dr. Beck, you mentioned the relevance to the staff and physicians certainly occupationally, as you mentioned, wearing the lead all day. But what about the patients? What have they been saying about this? And tell us about some of the outcomes that you've seen.
Dr Adam Beck: Well, we're early in our experience here, but our patients don't really see it, so they don't know much about it. I show this to them and show them the 3D overlay imaging that we do, and they think it's pretty cool, but it is a pretty complicated subject. So it's a lot to take in. But, just like, lasers and robots, this is an exciting new technology. And most of our patients are pretty savvy these days and have done a lot of research before they get to us. And so they're really interested in seeing the new technology. It just kind of blows your mind a little bit that you can see things inside your body without radiation since we're so used to that.
Melanie Cole (Host): Is there a learning curve involved in using this technology?
Dr Adam Beck: There is, but it's not bad because most of the setup of the equipment in the operating room is done by our radiology techs and our nurses. And we already do a lot of 3D overlay imaging in our OR and it's essentially an adjunct to that 3D overlay imaging that we've been very used to using. And so it's a pretty easy system to use, believe it or not. And it kind of hooks into the equipment that we've already used and the computers that we've used in the past. And so, it's fairly simple. The act of using it from my end and using it inside the body, the catheters and wires are very similar to catheters and wires that I've used my whole career. So it makes it pretty easy to use as well.
Melanie Cole (Host): Then Dr. Beck, you mentioned just briefly before, but where do you see this technology going in terms of potential to improve device visualization in other endovascular interventions? What do you see happening with this?
Dr Adam Beck: Well, I think it's going to expand into any kind of procedure where a catheter and wire is used, especially intraarterial procedures. I could see it being used for chemoembolizations for cancer in the liver in particular. I can see it being used for intercranial interventions for aneurysms or arterial venous malformations or anything that's transarterial. Coronary interventions, this would decrease the radiation to our cardiology colleagues significantly once they start using it in the heart. We can use it for lower extremity interventions.
There's a lot of refinement and changes to the catheters and wires that'll need to be done over the coming years to make it applicable to these more common procedures that are done. And then I think there's going to be some really exciting advancements that'll happen as this is blended with some of the really neat 3D imaging that we're doing. There are companies that are working on virtual reality imaging where you can wear goggles on your face and look at the patient and see the inside of the patient basically in virtual reality, and be able to see these catheters and wires moving inside of the patient without even having to look up on a screen. It would almost feel like you're looking inside the patient at your wires. These are things that people are working on. Right now, it seems like science fiction, but I think in 20 years, it'll be fairly commonplace.
Melanie Cole (Host): And I would love for you to come back and tell us as these advancements are made and UAB Medicine is certainly at the forefront of these technologies and research. So wrap it up for us, for other providers, what would you like them to know about referral for non-fluoroscopic imaging for endovascular surgery and why they should look to the experts at UAB Medicine?
Dr Adam Beck: This is obviously exciting technology. And I think the fact that UAB had the foresight to invest in us and be one of the first centers in the world to have this technology is a really great indication of how cutting edge this institution is. And I hope that people will recognize that and will send their patients with complex vascular surgical problems, especially aortic problems to us. I think we've got a really great referral practice now, but our referral practice stretches well outside of the southeast, and we'd like to continue to see it stretch further. And I think these are things that are indications of why people should send their patients to UAB for their care.
Melanie Cole (Host): I agree with you. It's very exciting, incredible technology. And thank you so much for sharing it with us today. A physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST or you can visit our website at uabmedicine.org/physician. That concludes this episode of UAB MedCast. Please always remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I'm Melanie Cole. - HostsMelanie Cole, MS
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