Additional Info
- Audio Fileuf_health_shands/ufhs090.mp3
- DoctorsHoh, Brian;Khanna, Anna
- Featured SpeakerBrian Hoh, MD, MBA, FACS, FAHA, FAANS | Anna Khanna, M.D.
- Guest BioMy name is Brian Hoh, MD, MBA, and I am chair of the UF Department of Neurosurgery. I specialize in the treatment of brain aneurysms, arteriovenous malformations, ischemic and hemorrhagic stroke, cavernous malformations, carotid stenosis, moyamoya disease, hydrocephalus, Chiari malformation, brain cysts and brain tumors, including meningiomas, glioblastoma and astrocytomas.
I joined the UF Department of Neurosurgery in 2006. Before that, I graduated with a bachelor’s degree from Stanford University and a medical degree from Columbia University. I completed my internship in surgery, residency in neurosurgery, and fellowship in endovascular neurosurgery and interventional neuroradiology at Harvard University’s teaching hospital, Massachusetts General Hospital. I later attended UF business school and graduated with an MBA in 2019.
In addition to taking care of patients, I conduct NIH-funded laboratory and clinical research to improve biomedical advances in care. My laboratory investigates the biological mechanisms of brain aneurysm formation and rupture, innovative tissue engineering technology to improve the treatment of brain aneurysms, and the pathophysiology of acute neural injury and delayed cerebral ischemia after subarachnoid hemorrhage.
The NIH awarded me a $38 million grant to lead a large national clinical trial, Comparison of Anticoagulation and anti-Platelet Therapies for Intracranial Vascular Atherostenosis (CAPTIVA). With CAPTIVA, we are investigating rivaroxaban or ticagrelor versus clopidogrel for preventing stroke in patients with symptomatic 70% or greater intracranial atherosclerotic stenosis.
As a national leader in neurosurgery, I have served as president of the Congress of Neurological Surgeons, chair of the Joint American Association of Neurological Surgeons/Congress of Neurosurgical Surgeons Cerebrovascular Section, co-chair of the editorial board of the Journal of Neurosurgery and a past member of the editorial board of World Neurosurgery.
In my free time, I enjoy spending time with my family, rooting for the Gators and playing golf.
Anna Khanna, MD, an assistant professor of neurology at the University of Florida College of Medicine and is a key member of the only comprehensive stroke program in north central Florida.
Dr. Khanna earned her B.A. in biological sciences from Rutgers University and her MD at Ross University School of Medicine. She completed her preliminary internal medicine residency year at the University of Medicine and Dentistry of New Jersey in 1999 and remained there to complete her neurology residency in 2002. Dr. Khanna became a stroke fellow there, and through its active vascular program, used both medical and endovascular therapies for the treatment of stroke. She completed her fellowship in 2003. She remained on faculty as an assistant professor, stroke program director and a mentor to medical students and residents. Dr. Khanna played an integral role in the community outreach for stroke education and traveled extensively to educate the public. As director of the outpatient stroke clinic and the resident clinic, Dr. Khanna introduced a comprehensive vascular ultrasound examination in the outpatient setting. - HostsMelanie Cole, MS
Additional Info
- Audio Fileuf_health_shands/ufhs087.mp3
- DoctorsSayour, Elias
- Featured SpeakerElias Sayour, M.D., Ph.D
- Guest BioElias Sayour, MD, PhD, is an assistant professor in the UF departments of neurosurgery and pediatrics at the University of Florida. He is also a principal investigator of the ribonucleic acid engineering laboratory at the Preston A. Wells, Jr. Center for Brain Tumor Therapy. He received his bachelor’s degree from Fordham University, his medical degree from the University of Buffalo and his doctorate from Duke University.
He completed his residency in pediatrics at Cohen’s Children’s Medical Center in New York and his fellowship at Duke University Medical Center. During his fellowship training, he completed a two-year National Institutes of Health research fellowship in cancer biology and developmental therapeutics. His primary research focus is developing tumor RNA loaded nanocarriers to re-direct host immunity against pediatric brain tumors.
Dr. Sayour is an NIH-funded investigator focused on on developing new nanotech vaccines to reprogram the immune system against cancer cells. He is investigating the use of personalized nanoparticles small enough to deliver essential information to the immune system educating it reject pediatric cancer. Currently his group is investigating the safety and efficacy of this novel vaccine formulation in canines with malignant brain tumors before translation into dedicated human studies.
Dr. Sayour’s work has been nationally recognized by the American Society of Pediatric Hematology-Oncology, National Institutes of Health, and U.S. Department of Defense. He has been the recipient of the Hyundai Hope on Wheels Hope Award, St. Baldrick’s Scholar Award, and the American Brain Tumor Association Discovery Award.
Dr. Sayour is board-certified in general pediatrics and pediatric hematology-oncology.
He has presented his work at several national meetings and is a member of the Children’s Oncology Group, Society of Neuro-Oncology and the American Society of Pediatric Hematology-Oncology. - TranscriptionMelanie Cole (host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And joining me today is Dr. Elias Sayour. He's an Associate Professor of Neurosurgery and Pediatrics, the principal investigator of the RNA Engineering Laboratory at the Preston A. Wells Jr. Center for Brain Tumor Therapy and the Pediatric Cancer Immunotherapy Initiative at the University of Florida College of Medicine. He's here to highlight pediatric brain tumors.
Dr. Sayour, thank you so much for joining us today. I'd like you to start by telling us a little bit about the prevalence of pediatric brain tumors and how the treatments have evolved over the years. Tell us a little bit about what has been the thought previously and what are we looking at and doing now?
Dr. Elias Sayour Sayour: Well, thank you, Melanie, for having me. It's an honor and a privilege to be here and speaking to you all. So, pediatric brain tumors are really one of the most common cancers that children are diagnosed with. About 10,000 children in the United States under age 15 will be diagnosed with cancer in the United States. And in many ways, because we've gotten so good at curing other cancers, primarily leukemia, which is the most common childhood cancer, the brain tumors are now the number one cause of cancer death in children. And so, we have a bit of work to do to improve those outcomes.
And pediatric brain tumors really have been difficult to manage in large part because of the blood-brain barrier, which is difficult to get therapies past. And so, the mainstay of therapy has largely been surgery, radiation, which can be a challenge sometimes for children because of the developing brain. We tend not to want to radiate children who are less than three years of age. And so, chemotherapy has largely overtaken radiation as a primary way of managing a lot of these tumors, the malignant brain tumors that is, to help ameliorate some of the effects and buy time really for radiation and other therapies as they grow up.
Melanie Cole (host): Well, I'd like you to speak about how it presents clinically if pediatricians might be the first providers, if a child is having some of these signs and symptoms. I'd like you to speak about those. And then, you can get into classification, how it really is diagnosed.
Dr. Elias Sayour Sayour: So, signs and symptoms, children with a malignant brain tumor can present with different signs and symptoms. This really depends on where the tumor is. So if we could divide the brain into two portions, an upper portion and a lower portion. The upper portion of the brain, if there's a tumor there, a child could present with a seizure. The lower part of the brain, a child could present with the eyes could start to deviate perhaps to one side or another. For brain tumors in children, other signs could include imbalance. This can especially be true if there's a tumor in the lower part of the brain.
Other signs include nausea, vomiting, certainly morning nausea, any sort of imbalance, uncoordination. All of those things could be concerning. It's really the constellation of symptoms that a child could present with that would make one a little concerned about something like this. And that would warrant imaging.
I think some of the followup questions you asked were regarding classification, if I understood that correctly. In terms of classification, we used to refer to these as either benign or malignant. I don't like the term benign because benign, really, it has this connotation that it's not a big deal. And certainly, if you have a benign brain tumor in an area that cannot be removed surgically, that could be problematic. But in general, we have referred to these as benign or malignant.
And by benign, the most common ones tend to be what we call low-grade gliomas. The bulk of these are a disease called juvenile pilocytic astrocytoma. And those can be resected and it can be fully resected, a child can just be monitored to make sure it doesn't recur. But oftentimes, these low-grade gliomas, they arise in regions that you can't resect, especially if it's in the brainstem or the middle part of the brain, that could be very challenging. And so, they're very slow-growing and so often, we can treat them with chemotherapy to try to melt them away. Targeted therapies are becoming more and more common where we would find a target that's present on a patient's tumor and then go after it with a small molecule inhibitor that just specific to that patient's individual target. Sometimes that helps for these slow-growing tumors.
This is in contrast to what we refer to the malignant tumors. These tumors they're not slow-growing. They can be highly invasive. They can invade the architecture of the brain causing a lot of damage. And these tumors require a bit more aggressive management. These include diseases like medulloblastoma. Medulloblastoma is the most common malignant brain tumor in children. Other malignant brain tumors include rhabdoid tumor, neuroectodermal tumors, appendamomas, malignant gliomas, which includes the dreaded diffuse intrinsic pontine glioma, which is a very, very difficult tumor to manage.
And so without getting into each and every one of these, the management is largely surgical, if surgery is an option. Unfortunately, for the diffuse intrinsic pontine glioma, these are usually inoperable. The most you could do is biopsy because these tumors are located in the brainstem. And the brainstem, it controls breathing, so you can't do full resections when these are arising from within the brainstem. Other tumors such as medulloblastoma, rhabdoid tumor, primitive neuroectodermal tumors, those tend to be managed with chemotherapy, radiation as well. Again, we would try to defer radiation into children who are three years or older to prevent some of the deleterious effects on growing brains. But those, again, are radiation, chemotherapy, surgical management. Appendamomas, that often can be treated with surgery, radiation, sometimes chemotherapy in the younger children. And the malignant gliomas outside of DIPG, it's surgical, radiation as well.
And it's interesting, chemotherapy has been tried for a lot of these malignant gliomas in children. And it's still not clear whether there are really good backbone chemotherapeutic regimens to really improve outcomes. Certainly, the drug of choice in adult malignant glioma like glioblastoma, temozolomide has yet really to be proven to have the same effectiveness in childhood high-grade glioblastomas.
So, I hope that gives a little bit of an overview of our tumors and the management that we have for them.
Melanie Cole (host): Well, it certainly does and thank you so much for that. And I'm glad that you brought up the difference between glioblastomas in adults and gliomas in children. And as you've spoken about management strategies, Dr. Sayour, and some of the challenges to treating these in children and for developing effective therapies in clinical trials, I'd like you to speak about some of the novel treatments and what you're doing at UF Health Shands Hospital. Tell us a little bit about immunotherapies. I know that they've been looked at for adults, but what about for children? And if they have, how have been the results?
Dr. Elias Sayour Sayour: Thank you for that question. So, as I mentioned at the intro, because we've gotten better at treating other cancers, brain tumors are now the leading cause of death from cancer in children. And so, we really do need new therapies. We are starting to see some newer regimens arise. This is some of the targeted therapies that we're employing in low-grade gliomas. Certainly, we're trying to adapt this to some of the higher grade gliomas and hoping for therapeutic effect.
Here at UF Health Shands Hospital, we have a particular interest in immunotherapy. Immunotherapy is largely the ability to recruit the immune system to fight on a patient's behalf and kill their own cancer. The challenge, of course, with immunotherapy is what to target. Sometimes that isn't clear. A lot of these cancers, especially in children, unlike adult cancers, these tend to be more developmental tumors, meaning genes that during development that are supposed to turn off, turn back on and can lead to some of these tumors that we just discussed. And so, that doesn't really look foreign to the immune system. And so, being able to stimulate an immune response can be a challenge.
But here at the University of Florida UF Health Shands, we've really come up with some novel methods to do just that, to actually sensitize a response against a patient's individual tumor. And we use really the RNA technology that people now all over the world are familiar with in light of the COVID-19 vaccines. We take RNA, which is just information. Really that's all RNA is, is it's information, but we take it from a patient's tumor and we can load it into a vaccine using lipid particles, lipid nanoparticles. We can actually take the master cells from the patient, the master immune cells called dendritic cells, and we can load that personalized information from a patient's tumor in the form of RNA into their master cells, those dendritic cells, and give that as a vaccine. We can also take the patient's other immune cells called T-cells, which are the army members and basically educate them outside the patient's body and return them to fight the tumor.
So, we have trials for each of these things right now in children with malignant brain tumors, dendritic cell vaccines, T-cell therapies, mRNA vaccines using lipid particles. And there have been cases of patients who have had some pretty remarkable responses to these interventions and we are hoping to learn from those patients in terms of why those patients had such a good outcome to really broaden the impact of this work to other people.
Melanie Cole (host): This is a fascinating topic and such a hopeful time in your field, Dr. Sayour. As we wrap up, I'd like you to speak to other providers about when you feel it's important that they refer to the specialists at UF Health Shands Hospital, what sets you apart, really makes you unique, and anything else you'd like the key takeaway to be. Whether it's precision medicine and gene sequencing, whatever you would like to speak about, summarize that for us.
Dr. Elias Sayour Sayour: Yeah. Thank you for that question. I think that a child with a brain tumor really mandates multidisciplinary care, multidisciplinary expertise. We have that here at UF Health Shands Hospital. That doesn't just entail a surgical intervention or radiation. It really mandates, especially for many of these malignant tumors, innovative approaches, whether it's a new clinical trial, whether it's consortias. We're a part of pediatric consortias that include the Pacific Pediatric Neuro-Oncology Consortium, the Pediatric Brain Tumor Consortium. And those consortiums allow us to reach out to regional experts, allow us to offer the latest and greatest clinical trials for some of these diseases.
For some of these tumors like glioblastoma in a child, or diffuse pontine glioma in a child, really, clinical trial is a standard of care. It really is. Because these diseases are so refractory, these are really standard approaches for management of children. And so, being at a place that can offer not just one, but several different trials and have experts kind of identify what might be the best trial for a particular child, I think is critical. And all these cancers are different, even if they have the same name, diffuse pontine glioma, glioblastoma. Each person's tumor is different and it is personalized to them. And so, being at a place that can understand the personalization of an individual's tumor, come up with therapies that are personalized and trial options that are unique to that individual really mandates that you have a portfolio of different trials with a network of connections to national experts that can be offered to patients and families in a way that's best for them and their individual tumor. And that's the kind of expertise that we have here that we can offer our patients. And certainly, I think that this is a responsibility we have to all of our region in North Central Florida. But because of the expertise here, we draw patients nationally and internationally.
Melanie Cole (host): Well, you certainly do, and I can hear your passion and compassion in your voice, Dr. Sayour. Thank you so much for joining us today and sharing your incredible expertise and the exciting advancements in the field.
To learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org. And to refer your patient or to listen to more podcasts from our experts, you can always visit ufhealth.org/medmatters. That concludes today's episode of UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Thanks so much for joining us today. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs089.mp3
- DoctorsQumseya, Bashar
- Featured SpeakerBashar Qumseya, MD, MPH, FASGE
- Guest BioHere at the University of Florida Division of Gastroenterology, Hepatology & Nutrition, we constantly push the limit and our knowledge to provide minimally invasive procedures that can save patients’ lives. As an associate professor within our department, I treat patients for gastroesophageal reflux diseases, Barrett’s esophagus, esophageal and gastrointestinal cancers, pancreas and biliary diseases, obesity and screening colonoscopy.
It all started at Beloit College, where I obtained my Bachelor of Science in biochemistry, was inducted into Phi Beta Kappa and graduated summa cum laude with several awards. I attended medical school at St. George’s University, where I graduated with magna cum laude and was inducted into Iota Epsilon Alpha Medical Honor Society. I completed my residency in internal medicine from the Medical College of Wisconsin in Milwaukee. Thereafter, I completed two fellowships from Mayo Clinic College of Medicine, one in gastroenterology and one in advanced endoscopy. Additionally, I obtained a Master of Public Health from Harvard School of Public Health.
Since 2015, I have been a member of the Standards of Practice Committee at the American Society for Gastrointestinal Endoscopy, where I currently serve as the chair. Through my role, I am developing and publishing clinical practice guidelines, which set the standards for clinical practice in gastroenterology in the U.S. and throughout the world.
My research interests are focused on Barrett's esophagus, reflux, obesity and systematic reviews. I have over 100 publications, including peer-reviewed manuscripts, clinical guidelines, book chapters and meeting abstracts that have been featured in high-impact medical journals and national news outlets.
When I’m not practicing at UF Health Shands Hospital, I enjoy spending time with my family. I also enjoy gardening and playing guitar. - TranscriptionMelanie Cole (Host): Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Joining me today is Dr. Bashar Qumseya. He's an associate professor of medicine and the chief of endoscopy at UF Health Shands Hospital. He's also the chair of the Standards of Practice Committee of the American Society of Gastrointestinal Endoscopy. He's here to highlight gerd for us. Dr. Qumseya, it's a pleasure to have you join us. This is such a huge problem in this country, and we're learning more it seems just all the time. Speak a little bit about gerd. What do we know about it now that maybe we did not know 10 years ago?
Dr Bashar Qumseya: Thank you Melanie, and thank you for having me today. I'm happy to be here today to talk about, a very important topic that is near and dear to my heart because I've been researching Barretts which is a condition that relates specifically to acid reflux disease. So acid reflux happens when you have stomach content that reflux up through the, GE junction into the esophagus. It is a very common condition and most people, including many of our physicians would have experienced personally acid reflux. The vast majority of the US population have experienced acid reflux, and about 30, even 40% have it on a frequent basis more than once a week.
And so this is a very prevalent condition that affects people's lives very significantly, and it is also very costly condition. The most common kind of medication that are used over the counter to treat acid reflux called PPIs are used on a daily basis by millions of Americans, and we spent billions of dollars. Annually in the US in treatment of acid reflux disease. So what we now know, to go back to your question, Melanie, that we didn't know before, we now have a better understanding of the mechanism of the flap valve and the GE junction that helps prevent acid reflux normally. And how disruption in that mechanism can result in acid reflux.
And furthermore, and most importantly, we now have some non-invasive ways in which we can reconstruct that mechanism of the flap valve to prevent acid reflux and make patients feel a lot better, decrease their dependency on PPIs and decrease regurgitation and some of the sequela of having acid reflux.
Melanie Cole (Host): Now you've mentioned a few. Dr. Qumseya, Barretts, so I'd like you to explain a little bit about some of the complications of untreated reflux, but also the presentation both typical and atypical, because sometimes this is silent. Sometimes people do not know that they have it. It's not always that feeling of heartburn or burping. It's not always those things. So I'd like you to speak a little bit about how it most commonly presents what you see, and if it's left untreated because it might be silent. What are some of those complications?
Dr Bashar Qumseya: So when you have acid reflux, it triggers pain nerves in your esophagus. So you end up having pain and most people refer to that as heartburn. And they present to their primary care providers, usually who is the first, person to see this, with this acid reflux, they might already have gone over the counter and taken medication. So this is the most common presentation. Now what happens is your body does not like to be in pain. So over time, if you have acid reflux, you may develop this change in the lining of the esophagus called Barrett's esophagus.
So Barrett's esophagus, as we all know, is a change from the squamous, kilometer, epithelium of the esophagus, into an intestinal metaplasia. So intestinal metaplasia is where you have a change in the lining of the esophagus. And this change in the lining of the esophagus is actually protective of pain. So patients who have better esophagus experience, less heartburn than patients who don't have it, and that's why people have it, is because your body does not like to have pain.
The problem with Barrett's Esophagus is that it is a risk factor for esophageal adenocarcinoma. So we have looked at the data and for example, the one Florida database, and we've seen that the prevalence of Barrett's esophagus has been increasing dramatically in recent years. And national data showed the same that the incidence of Barrett's Esophagus and esophageal adenocarcinoma have been increasing dramatically over the last 50 years, although most recent data is showing a plateau.
So we may have peaked at this point, but for the last four or five decades we've seen dramatic increases in Barrett Esophagus incidents and prevalence, and in esophageal adenocarcinoma incidents and prevalence. And this may be related to the epidemic of obesity that we have and how obesity is linked to people having Barrett esophagus and acid reflux as well. So that lot of patients who have silent acid reflux may have in fact Barrett's esophagus, and that's why they do not feel the acid reflux. So it's important to know about this.
Now, there are atypical presentations, as you said, of acid reflux. For example, not everybody feels heartburn, but some people may present with cough. Some people may present with chest pain, which is atypical chest pain. They have a chest pain. They feel like they're having a heart attack. They go, they have cardiac workup. They may get a stress test. they may even present to the emergency department for this, and they tell them, no, it's your acid reflux. They may have hoarseness, so they go and see the ENT and they do a procedure or they look at their, vocal cords and they say, yep, you need to see a gastroenterologist.
So there's a lot of atypical presentations. Sometimes patients can present with asthma and acid reflux or silent acid reflux has also been linked to cases of, pulmonary fibrosis where patients actually end up having to undergo lung trans. Because they have undetected acid reflux that needs to be treated. So there are a lot of ways that, acid reflux can present and patients who have acid reflux need to be treated to prevent these, downstream sequela that we've been talking about.
Melanie Cole (Host): So you mentioned PPIs as one of the first line treatments and how many millions of people are on them, and studies have come out that have always, for a while raised concern about these medications. I'd like you to speak about that briefly. And then for gerd, that's refractory to medications, some of the surgical indication treatment options that are out there because it really is such a huge problem. And even do you think Dr. Qumseya, as we speak about screening diagnosis for colonoscopy, should this be treated that way as well? Should there be a screening option that's done for people that might be more at risk?
Dr Bashar Qumseya: So let's start with the PPI adverse events. These have gained a lot of national attention. PPIs are very safe medications and we have been using them for many, many years. They work really, really good. However, they are not risk free. And the main risk factors of taking long-term PPIs, meaning patients. They come to you in their twenties, in their thirties, in their forties, and they're gonna live for another 20, 30, 40 years. So you cannot keep them on PPIs forever because what we're doing is, we are suppressing the acid, obviously in the stomach, and you need the acid in the stomach for a lot of stuff, including for digestion, absorption of various, vitamins.
So a lot of patients who are on long-term PPIs can have vitamin D deficiency. They can have osteoporosis, which is probably one of the most important risk factors from chronic PPI use. The acid in the stomach works as a first line to prevent infection. So, For example, studies have linked acid suppression by PPIs to maybe increased covid infections, increased risk of, pneumonias, increased risk of c diff infections. And there are a lot of other adverse events. There are a lot of studies that looked at the prevalence of these adverse events in PPIs.
And overall, they're very, very low. But more importantly, also, a lot of patients do not wanna be on these medications forever because they come to me and they say like, if I miss the medication once, I'm gonna be miserable. And I don't, you know, I'm young, I'm 40, I'm 50. I do not wanna do this the rest of my life. Be dependent on a medication that I also know is not great for me in the long term. PPIs are very effective. By treating patients on them for many, many years is probably not the right choice. However, we'd have had surgical options for patients with acid reflux.
They're called fundoplications and they come in various forms, this fundoplication, dual fundoplication to pay. And there are different forms of fundoplication where the surgeon, perhaps the fundus of the stomach, are on esophagus and fixes a hernia. Now, this is an invasive procedure. Many patients do not want to have it, and a lot of patients who had the Procedure had experienced adverse events, mainly they cannot burp, they cannot throw up, which is very bothersome. Many patients who come to me are aware of people who've had these procedures and had adverse events from that.
So a very small minority of patients with acid reflux have in fact gotten fundoplication, but until recently we really didn't have anything else to offer them. More recently, now we are starting to, provide this procedure called transoral Ingenless fundoplication, which is a good option that is less invasive than having surgery and works good. and we can talk about that a little bit more. But I do wanna address your other question before we talk about the tif, which is screening for patients who have acid reflux. In fact, there are already guidelines on this.
I was actually the first author on the guideline by the American Society of the Gastrointestinal Endoscopy, and we looked at the evidence for this extensively. There's clear evidence that if you have multiple risk factors, acid reflux for Barrett's esophagus, then screening by various methods. Most commonly endoscopy is indicated and there are recommendations from all major GI societies within the US and outside of the US recommending screening for Barrett's Esophagus and esophageal cancer in patients who have multiple risk. However, compliance with these guidelines is minimal.
We see, for example, I looked at this data in the One Florida database, which has over 9 million patients in this state of Florida, and we found that most patients who have four or more risk factors for esophageal cancer, they have reflux, they have obesity. They are white traits, they are male gender, they smoke, and go on. These patients, only about 20 to 30% ever had an endoscopy in their life. So we're talking about patients who have many risk factors. And they are getting colonoscopies, but they're not getting endoscopies. So we're trying to raise awareness about this, and I'm glad you brought this up.
There are guidelines about this. People should be getting screening if they have risk factors. So I encourage primary providers all the time. If you have patients that meet these criteria and they're due for a colonoscopy, this would be a perfect time to have an endoscopy. At the same time, if they have these other risk factors that I was talking about.
Melanie Cole (Host): Wow, that is so interesting that you are one of the people that started this initiative because I've been wondering for so long about that. And so before we wrap up, Dr. Qumseya, I'd like you to just speak about some of those advances briefly that are, available now and these procedures for GERD that are really helping to increase the quality of life and decrease some of the sequela of GERD.
Dr Bashar Qumseya: Exactly. So this is what we started talking about. One of the procedures that we're very excited about offering here at the University of Florida Health Shands Hospital is called the Transoral Ingenless Fundoplication. So in this procedure, a patient, goes endoscopy and after, we've done workup before to make sure that they're the right candidate. Mainly that we confirm that they have acid reflux by pH testing, and we also do a motility test to make sure they don't have an issue with the movement of the esophagus. And then we check for the size of a hiatal hernia.
That's key because if they have more than two centimeters of varial hernia. We cannot do this procedure alone, we'll have to do it alongside the surgery. So for patients who have confirmed acid reflux and do not have a large hiatal hernia, the stiff procedure is an excellent option. We bring the patient in, this is done under general anesthesia, but again is incisionless. So we go through the esophagus with this device, and we create a fundoplication. Without making any incisions, the patients go home the same day.
It is an outpatient procedure. We keep them on a diet for about five to six weeks and then they can go back to the regular diet. And about 80% of them are able to get off of the PPIs, and 80 to 90% of them have excellent results in terms of decrease in their regurgit. And decrease in acid reflux. And we confirm these results. There is a lot of trials on this, but here at our center we confirm the acid improvement by doing a pH test before and a pH test after to make sure they have responded well. These patients who have this procedure and about 80 to 90% of the time, it is very successful.
They come to me, and we have changed their life dramatically. They can now eat the kind of foods that they like. They can have a pizza, they can go to a restaurant, they can lay flat in the bed without having to be propped up because they're having to regurgitate all their, food, overnight or stomach juices. So they have excellent improvement in their quality of life, and they're very satisfied and they are off of the PPIs. So this was not an option maybe 10 years ago. More and more this is becoming an option. Now for patients who have a hernia as well, which is also a lot of patients with reflux have a hiatal hernia.
We also do this procedure alongside with the surgeon, so we have partnered with one of our excellent surgeons here, Dr. Masio Mansour, and he sees them in the clinic as well. After I have assessed the patients and then we take them to the OR where he does the hernia repair, I then come in and do. Transoral incision, less fundoplications. We admit the patient overnight and we send them home and they also do very well because we fix the hernia and now we fix the acid reflux and they do amazingly well. Our patients also have excellent, profile in terms of adverse events for this procedure.
Most patients never have any dysphagia. Or difficulty swallowing because the TIF procedure that we use is a rather big device. It's 60 French, which is as big as you can get in the esophagus. And so dysphagia is not an issue for our patients, which used to be an issue for other patients who have the surgical approach. And gas bloat is not an issue. Up to 70% of patients who have the surgical approach can have something called gas bloat, or they feel bloated and they can't burp. But with the TIF population, the studies have shown this to be less than 3%, which is amazing.
So overall, a very successful procedure for the right candidate. If somebody has acid reflux that either of you do not wanna be on PPIs forever, or they are still symptomatic, despite being on PPIs, referring them to us, will do the full workup for them and we will offer them the best treatment option and they can do very, very.
Melanie Cole (Host): Thank you so much. What an informative episode This was Dr. Qumseya. Thank you for joining us and really sharing your incredible expertise. To learn more about this in other healthcare topics at UF Health Shands Hospital, please visit innovation.Ufhealth.org or to refer your patient or to listen to more podcasts from our experts, please visit UFhealth.org/medmatters. That concludes today's episode of UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Thanks so much for joining us today. - Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs088.mp3
- DoctorsQumseya, Bashar
- Featured SpeakerBashar Qumseya, MD, MPH, FASGE
- Guest BioHere at the University of Florida Division of Gastroenterology, Hepatology & Nutrition, we constantly push the limit and our knowledge to provide minimally invasive procedures that can save patients’ lives. As an associate professor within our department, I treat patients for gastroesophageal reflux diseases, Barrett’s esophagus, esophageal and gastrointestinal cancers, pancreas and biliary diseases, obesity and screening colonoscopy.
It all started at Beloit College, where I obtained my Bachelor of Science in biochemistry, was inducted into Phi Beta Kappa and graduated summa cum laude with several awards. I attended medical school at St. George’s University, where I graduated with magna cum laude and was inducted into Iota Epsilon Alpha Medical Honor Society. I completed my residency in internal medicine from the Medical College of Wisconsin in Milwaukee. Thereafter, I completed two fellowships from Mayo Clinic College of Medicine, one in gastroenterology and one in advanced endoscopy. Additionally, I obtained a Master of Public Health from Harvard School of Public Health.
Since 2015, I have been a member of the Standards of Practice Committee at the American Society for Gastrointestinal Endoscopy, where I currently serve as the chair. Through my role, I am developing and publishing clinical practice guidelines, which set the standards for clinical practice in gastroenterology in the U.S. and throughout the world.
My research interests are focused on Barrett's esophagus, reflux, obesity and systematic reviews. I have over 100 publications, including peer-reviewed manuscripts, clinical guidelines, book chapters and meeting abstracts that have been featured in high-impact medical journals and national news outlets.
When I’m not practicing at UF Health Shands Hospital, I enjoy spending time with my family. I also enjoy gardening and playing guitar. - TranscriptionPreroll: The University of Florida College of Medicine is accredited by the Accreditation Council for continuing medical education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA category one. Credit physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Joining me today is Dr. Bashar Qumseya. He's an associate professor of medicine and the chief of endoscopy at UF Health Shands Hospital. He's also the Chair of Standards of Practice Committee of the American Society of Gastrointestinal Endoscopy. He's here to high. Endoscopic sleeve gastroplasty, a non-surgical approach to the management of obesity. Dr. Qumseya it's a pleasure to have you with us as we get started with this topic. Can you define obesity for us just a little bit? Speak about the prevalence and what you've been seeing in the trends. We know this is an ongoing and increasing epidemic in our country. Speak about that for just a minute.
Dr Bashar Qumseya: Thank you so much, Melanie, for the introduction and yes, obesity is defined as body mass index, or bmi of more than 30, which is a calculation based on, someone's weight and height. So basically how much you weigh compared to your height. So body mass Index over 30 is defined as obesity and unfortunately, as you mentioned, obesity rates have been increasing throughout our, community, and in Florida and nationally as well. In fact, we looked at the state of Florida through one of our databases called the One Florida Database.
And we found that among adults, the rates of obesity have continued to increase, reaching about 40 or 42% of, the overall adult population in the United States and in the state of Florida, which is a very alarming rate. And it does appear to be, going up still more so we have not reached the peak of this, epidemic of obesity. And it is a disease that have far-reaching effects on our population, on its health and, on, the economics of the country as well.
Melanie Cole (Host): One of the things, I'm an exercise physiologist, Dr. Qumseya and one of the things that I've noticed is when you say far-reaching effects, and we're gonna talk about the sequela of untreated obesity as we look at our children that are starting with obesity very, very young. Now, when we talk about sequela, we're seeing young children with type two diabetes and high blood pressure and heart issues all the way up into their older years. Speak a little bit about what you have seen doing what you do for a living as far as kids all the way up through to adults because of this epidemic that we are seeing.
Dr Bashar Qumseya: Exactly. So the rates of increase of obesity, do start at a young age. And in fact, we used the One Florida database and we looked at this and we found that the rates of obesity was increasing at younger ages more than middle-aged and more than older aged patients. And so we think that the younger patients and the younger individuals who are getting obesity now, 10, 15, 20 years later, we do find sequela of that in terms of, acid reflux disease, Barrett esophagus, which is a condition that predisposes patients to esophageal cancer and other forms of cancer.
So obesity at early ages does seem to set up patients to have chronic diseases. Also, coronary artery disease, diabetes, fat, liver, and many kinds of cancer. And so the effect of obesity take many years to show and it starts in children. And usually when they are in their thirties and forties, you're seeing a lot of these downstream effects. They can start having, diabetes and fat liver at a much younger age, but a lot of the chronic diseases appear to develop many decades later, which is why it's really important to try to treat obesity as, early as possible to prevent the sequela from happening many years later.
Melanie Cole (Host): I agree with you completely. So I'd like you to speak a little bit about endoscopic sleeve gastroplasty, outline some of those recent advances to management of patients with obesity and tell us about that and how it differs from what we've been hearing about for years, which is bypass and gastrectomy. Tell us a little bit about this procedure.
Dr Bashar Qumseya: So we're very excited about being able to offer this procedure here at UF Health Shands Hospital. And so let me just tell you about the treatment of obesity to set the stage. So obesity, as we said, is very prevalent nowadays and most people know about lifestyle changes. These are changing your diet, going on many diets, trying to exercise more. Those are really good interventions to do, but unfortunately, they do not work very well. Most patients who try these do not, in fact, lose a lot of weight, and if they lose weight, they seem to gain it. The next option, for people who want to do something else is obviously medication. So there are a lot of medications and now more medications coming on the market that treat obesity.
And those can be effective when taken appropriately. But they also do have some side effects and they can be costly and many patients don't have a lot of success long term with these medications. And the third option that traditionally has been available is the surgical option, which is the gastric bypass, the sleeve gastrectomy. And other interventions. And these are, very good interventions in the sense that they can result in a lot of weight gain, but only about 3% of patients who qualify to have these kind of procedures ever have them. And the reason being is these are obviously, are invasive procedures. They involve you having to undergo a surgery.
And alter your anatomy. And this is not appealing to the vast majority of patients with obesity who would like to avoid invasive procedures. So in these three things that I said, lifestyle, medical management, and surgical. Now we have a fourth option, which is endoscopic management, which is, a very exciting option. The reason it's exciting is that it is non-invasive. It does not involve any kind of surgery. There is no cutting on the patient. There's no real change in the anatomy. It is also reversible. Meaning, we're not cutting part of your stomach. We're not bypassing your stomach. Rather, we are using an endoscopic device that fits on the tip of the scope.
We pass the scope into the stomach and then we use a suturing device, basically a needle to suture the stomach to make it smaller, so we'll reduce the size of the stomach. In doing so, when you eat, you cannot eat as much, and also you have delayed gastric emptying, so the food sits in your stomach for a longer time, so you feel full for a longer. And therefore you eat less and you lose weight. So this is a very exciting option because like I said, it is a non-invasive, it is endoscopic, it is reversible. These sutures can be cut and it is very, very well tolerated.
We have now randomized control trial that was published in last August showing that only 2% of patients have any, serious adverse events. So the vast majority of patients have no adverse events, and in our practice, we have not experienced any severe adverse events. The most common adverse event being nausea and vomiting, but those can be very well controlled with medications. And most of our patients are able to go back to work within a few days from having this procedure and being on a diet. So it is very exciting era for us to be in because now we have another option, which is really efficacious.
Patients can lose 15 to 20% of their total body weight and, not have, an invasive procedure. And finally, Get to the stage where they can improve their comorbidities, they can decrease their insulin dependence. They can improve their hyperlipidemia. They can have improvement in hypertension, fat liver disease improvement. and generally patients who lose weight and have been through our program feel a lot better than they did before. They can walk more they can travel more, they can exercise, they can hike, they can do a lot of activities that they were limited from when they had obesity.
Melanie Cole (Host): Wow, what an exciting time in your field and you're right about how many people don't want to do the big major surgeries of bariatrics, bypass, and gastrectomy, because as you said, they are major surgeries now, is this contraindicated for anyone? Can you speak about patient selection? Are there any endoscopic or esophageal issues that would preclude somebody from having this type of surgery? Even something like gerd? Would any of these things preclude somebody? Are there contraindications?
Dr Bashar Qumseya: Yes. So there are obviously some contraindications to having any procedure. So for example, you cannot have this procedure if you've had major abdominal surgery, you've had altered anatomy, in your stomach, then you cannot have that. Although, this is still an option, although it's not called endoscopic sleeve, but we can still do redo procedures for patients who had existing gastric bypass or had a sleeve gastrectomy surgically, but have regained some of the weight so that it is still an option to do endoscopic suturing for them and they lose a lot of weight.
But other contraindications could be, for example, pregnancy, really old age, somebody with cirrhosis of the liver, somebody with, recent heart attacks. So a lot of things that would prevent you normally from undergoing a medical procedure would be contraindicated. As far as esophageal reflux is not a contraindication, in fact there's a plethora of data now, which I have also personally published about that the surgical counterpart of this, which is the surgical sleeve, that patients have really bad acid reflux after that. There is a lot of data about that now.
And we looked at this in the randomized control trials and the data does not show that that is the case with, endoscopic sleeve because we do not do the same thing, even though it is called a sleeve. It does not resemble a lot the surgical sleeve. In that sense that we leave the fundus, which is part of the stomach that stays intact in our procedure. And this is where a lot of the accommodation of the stomach exists. And this is where, a lot of the acid prevention mechanism of the stomach is. And so we leave that intact.
So we believe that our patients do not have worsening reflux, after this, although we are also looking at this in our center prospectively, where acid pH testing and esophagus before the procedure and six months after. And then hopefully we'll get this data published. But that having acid reflux is not a contraindication, to having this procedure. So really, if somebody is medically fit to have a procedure, doesn't have any contraindications or comorbidities in general to have anesthesia and undergo procedure, they can be good candidates.
We also test patients for esophageal dysmotility. And make sure that their esophagus contraction is fine. If somebody already has a lot of abdominal symptoms, like have existing nausea and vomiting, this may not be a good, procedure for them because, if your stomach is smaller and you have delayed gastric emptying already, this may be a problem. So patients who have something called gastroparesis, I'm not also a good candidate for this, but we have a good screening process in which we have our patients go through the screening process.
We also look for psychological contraindications, and so we have them sees psychologist, for clearance. We have them see anesthesia for clearance, and then we have them work with the dietician. Part of our program, we have to work with the dietician, before the procedure, and then for six months, at least after the procedure, to continue to have counseling on calorie counting. And exercise and diet because any procedure that you can have for obesity if patients do go back to a lifestyle that they used to before, they can gain the weight back even if you do a gastric bypass.
So what I tell my patients is, I'm gonna do 20% of the work for you. You are gonna lose weight, but I'm not gonna be home with you. But we're gonna give you the resources so that when you are at home, you continue to make the right choices. You continue to eat a healthy diet, you continue to be more active and burn more calories than you take in. And that's how you lose weight. And we've had great success with that. And we are convinced that patients who follow the process do very.
Melanie Cole (Host): Well, thank you so much Dr. Qumseya. As we wrap up, I'd like you to let other providers know about endoscopic suturing and this endoscopic sleeve gastroplasty that you're doing at UF Health Shands hospital and really how your outcomes have been. What have you've been seeing with your patients and when do you feel is the right time for them to refer their patients to you for counseling?
Dr Bashar Qumseya: If you have a patient who has obesity, BMI more than 30, or the patient want to do something about it. Frequently, since many of our patients are obese, they come to us for other reasons. They come to us for acid reflux. They come to us for abdominal pain. They come to us for screening colonoscopy. They come for a lot of other things because people have gotten used to obesity. So anytime you have a patient encounter, I would encourage you to look at the patient's BMI and to have a discussion with them. Saying, you know, I've noticed that your weight is above what's recommended for your, age and, your height.
And would you be interested in finding out, about how to help you lose weight? And nine out of 10 times the patients, do wanna talk about it and, do wanna do something about it. For our procedure, they don't have to have failed other stuff, although most patients have tried diet and exercise most of their life. And, part of our program, we can refer them to a program to get medications for this. So our goal is not to, bring the patient and do the procedure for them. We really are hoping to provide them with the best answers.
Some patients are more suitable for surgery and for these patients, we refer them to surgeons and we have an excellent bariatric program here. And some are more suitable for medications. And we have, an endocrine program for obesity that, we, collaborate with in our program. And so we work together with all of these providers. And our goal is to provide the patient with the best care that is suitable for them. I think endoscopic sleeve is an important consideration. It's a lot less invasive and a lot of patients. Would be really excited to know about it. So if you have anybody who's dealing with obesity, I encourage you to to have this discussion with them.
We, as physicians know that when we improve obesity, we can decrease risk for coronary artery disease. We can improve diabetes, we can improve hypertension, obstructive sleep apnea, fat liver disease, cirrhosis, resulting from fatty liver, and decreased risk of many cancers. And our patients deserve to know about these options. These options are, many patients are not aware of them. So talking to your patients about weight loss is key, and if they are interested in having something done, we see them for a clinic consult. We explain the procedure for them.
We offer them the option, the surgical option, the medical options, the lifestyle options, and sometimes it's more than once. Many, many patients are obviously on medical management and have an endoscopic. and continue to have lifestyle changes. So attacking this problem from, multiple, points of view can help us achieve the best results for our patients. We encourage you to refer your patients and also to give us a call or send me an email and I'll be more than happy to have a discussion with you about what our program is and, how we can serve you and your patient.
Melanie Cole (Host): Thank you so much, Dr. Qumseya what an interest. C and thank you for all of this information. To learn more about this in other healthcare topics at UF Health Shands Hospital, please visit innovation.Ufhealth.org and to refer your patient or to listen to more podcasts from our experts, you can always visit UFhealth.org/medmatters. That concludes today's episode of UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs086.mp3
- DoctorsGhiaseddin, Ashley
- Featured SpeakerAshley Ghiaseddin, M.D.
- Guest BioMy name is Ashley Ghiaseddin, MD, and I’m a neuro-oncologist and chief of the division of neuro-oncology in UF’s Department of Neurosurgery. I specialize in brain cancer treatment, using targeted methods including chemotherapy, immunotherapy and precision medicine for patients with malignant brain tumors, such as glioblastoma.
I graduated with a bachelor’s degree in science and business from the University of Notre Dame and completed my medical degree at the University of Toledo. I went on to complete my residency at Indiana University and a neuro-oncology fellowship at Duke University.
I am a member of the Preston A. Wells Jr. Center for Brain Tumor Therapy, where I collaborate with an interdisciplinary team of experts dedicated to delivering patient-centered care and discovering better treatments for brain tumors.
In addition to taking care of patients, I conduct research into novel immunotherapy approaches to treat brain cancer and improve outcomes for patients. I am also interested in population-based studies involving glioblastoma and identifying ways to improve quality of life for patients and caregivers.
I am a leader in the neuro-oncology section of the American Academy of Neurology, and I am a member of the Society for Neuro-Oncology and the American Society of Clinical Oncology.
In my free time, I enjoy spending time with my family, walking, traveling and exploring Florida. - TranscriptionMelanie Cole: Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole, and joining me today is Dr. Ashley Ghiaseddin. He's the chief in the division of Neuro-Oncology at the University of Florida College of Medicine in the Department of Neurosurgery, and he practices at UF Health Shands Hospital. He's here to highlight treatment strategies for malignant gliomas. Dr. Ghiaseddin, it's such a pleasure to have you join us today. I'd like you to start by telling us a little bit about the state of therapies for brain tumors as it has been practiced for the last 20 years or so. How has that evolved?
Dr. Ashley Ghiaseddin: Yeah. Thank you so much for having me, Melanie, and I'm happy to be here today to discuss, treatment therapies in malignant gliomas and where we've been, where we're going, in this, current field and what the environment has been like. I would say that early on, we had been treating, let's say before 2005 patients, who were diagnosed with a malignant glioma, specifically glioblastoma, which is a grade four malignant brain cancer. Patients were treated with surgical resection if they were able to have surgery, followed by radiation therapy. There were several different chemotherapies that were used, but that was not actually a standard of treatment.
It was something that was added and some of those treatments included, nitrous, ureas, such as, lomustine, as well as other options that providers may have given to patients, but really the backbone of treatment with surgical resection and radiation. Then in 2005, temozolomide, which is a DNA al alternating chemotherapy was Really brought on as a standard following a 2005, large study that looked at patients who were treated with radiation, after surgical resection versus the addition of temozolomide to their radiation therapy followed by additional cycles of temozolomide chemotherapy.
That did show a survival benefit. And following that, it really became the standard. Now, the difficult thing has been since 2005. There has been very little development in additional treatments for patients until several years ago the addition of Optune tumor treating fields as a additional option with temozolomide therapy, after they finished chemoradiation has shown a small yet Still important survival benefit for patients. And that is another option that is, offered to patients. Now, in addition to the temozolomide chemotherapy upfront.
Because of that, what you will see much of the time is clinical trial enrollment for patients who have newly diagnosed glioblastomas, as well as in the recurrent setting when the cancer is growing back. So this is always something that we consider for patients if there are clinical trials available. at our institution or around the country. If there are trials available, patients will seek those out. But if we're using just the standard of care and what's been really developed over the past, I'd like to say 17 years, almost since 2005 when chemotherapy, temozolomide was added. We really look at the addition of Optune, a tumor treating field.
Melanie Cole: Well, thank you for that. Then, Doctor, can you please speak a little bit about advances in radiologic imaging that have been instrumental in finding these tumors? And while you're doing that, speak a little bit about the development of complementary technologies such as intraoperative MRI and realtime MRI. Entering the fields of neurosurgery and neuro-oncology?
Dr. Ashley Ghiaseddin: Thank you for asking. So, I'll break it up into two parts. Really when it comes to the radio graphic technology that we've been using for patients, that is something that is continuously being looked at, especially when we think about the advent of artificial intelligence coming into the medical setting, and how we can leverage that, to use for patients as we not only look at their initial, diagnostic imaging, but then also tracking patients on their treatment response surveillance, as well as what to do when we see something that looks concerning for disease progression.
The backbone of radiographic imaging has really been, MRI with contrast. And this is, something that's been used, for quite some time where we look at contrasted imaging for patients because malignant gliomas, specifically glioblastomas, they have a heterogeneous ring enhancement, commonly with a necrotic core that is very classic, for glioblastoma. The differential may include things such as tumor, effective multiple sclerosis, or even abscess, but typically the patient's presentation will be able to kind of lead you into the right direction as to, whether or not this is a primary malignant brain tumor.
In addition, we look at other sequences such as T2 and flare imaging, which will assess not only the area of the tumor, but also the surrounding vasogenic edema, which for a primary malignant brain tumor, is a very large area of edema that surrounds the, diffusely infiltrative tumor. And when we look at other options of imaging, frequently people have looked at ADC mapping, which can, show evidence of dense hyper cellularity. We also look at profusion imaging, which although is not validated for use, often it is employed to look at areas of elevated blood volume, which if that is present, may be suggestive of increased cellularity, which you expect to see with tumors.
So that's another option that's being used for patients. When we look at imaging, PET imaging, which. May be familiar with in, neurodegenerative diseases such as Alzheimer's is also something that is an advanced MRI technique available to assist with both diagnosis as well as, treatment changes for patients. And specifically the amino acid PETs have been really the preferred PET tracer, for patients because of higher specific fDG PET is also employed. however, this is a technology that is, limited because of the amount of availability that we see for patients, in centers across the United States.
But I think in the future you'll see PET potentially employed more. and then I, kind of add The talk on artificial intelligence as something that's going to probably be, utilized much more as we kind of move forward in our radiographic techniques. Specifically, I think looking at volumetric studies, three-dimensional spatial technology to really assess. How these tumors look, not only at diagnosis, but even after, immediate surgical resection and during their treatment, which is after radiation, and also, different chemotherapies that they're receiving. Now the second part of the, question, I think was really discussing what we do in terms of surgical management and how that's improving.
And really you can add the imaging. advances, a part of this talk, which is really, the advent and the use of intraoperative MRI for our surgeons, that when they take the patients back to do a, a surgical resection, we know that the greater the amount of tumor that can be removed, the better outcomes that patients will have obviously you have to consider. That you're not resecting areas of eloquent cortex and really minimizing the amount of neurologic deficit that patients may have. But if you are able to achieve a large, safe maximum resection, we know those patients are gonna have better outcomes. So using intraoperative MRI is a useful way.
To assess immediately, real time, the extent of resection so that surgeons can decide while they're still in the OR whether or not a patient needs to have a larger resection and is it safe. Awake cortical mapping is also a new technique that has been utilized now for several years so that patients are actually awake during the surgery. And the surgeons can actually determine whether or not they're getting closer to eloquent cortex or critical structures where further resection will lead to a deleterious outcome, long term. So these are really being, touted as ways for us to have much better outcomes, larger extent of surgical resection.
In addition, when we think of, several other options, we also talk about, fluorescent dye, which is, five amino acid, which is able to visual. malignant tumor tissue. Really the high grade areas of the tumor will, light up when you give this dye. And this also allows the surgeons to really maximize their extent of resection when they're in the OR.
Melanie Cole: An interesting field that you're in and an exciting time with the advancements as you where just discussing. Dr. Ghiaseddin as the advent of gene therapy in the early nineties, raised real expectations for brain tumor therapies in clinical trials in patients with malignant gliomas. Can you tell us a little bit about some of the challenges now of treating these types of brain tumors and the limitation of clinical trials to find new treat?
Dr. Ashley Ghiaseddin: That's an excellent question. When we think about what makes treatment so difficult for malignant brain tumors and specifically glioblastoma clinical trials to date have really been, selective, to identify the patients that we think will, most appropriate for studies. So we look at things like functional status, the amount of, tumor that still remains after a surgical resection. And these things can actually lead to bias and, have, outcomes, for patients that may not be able to, generalize very well to our, real world population.
There are many reasons why we have to do this, and one of them being, the homogeneity of the population that we're treating, which means that when we look at the patients that are being enrolled in a study, they need to look as similar as possible so that we can be able to ensure that the outcome that we are finding isn't due to, variables that we didn't consider. In addition, when you think about treatment outside of just a clinical trial, you run into issues where these tumors are very resistant to therapy. It is difficult for drugs to cross the blood-brain barrier so that you limit the concentration of drug.
It is difficult for us to measure the amount of drug that's been delivered to those patients. So even if we treat a patient, you cannot be completely sure how much drug is actually getting to the tumor. In addition, radiographic challenges make it difficult when certain therapies like radiation or immunotherapy, which can create inflammation. on imaging, it may be difficult to determine what is treatment effect and what is true tumor progression and this sort of challenge is something that we deal with on an everyday basis.
We know that these tumors are very difficult to control so that their progression-free survival, unfortunately, can be somewhere, between six to nine months. And this is, something that challenges us to always think about what is the next therapy we need to be using. Whether that's another surgical resection or tumor treating fields, chemotherapy, targeted therapy based on the molecular markers of the tumor. It makes you always think on your feet and try to plan ahead for those patients so that you're not behind the eight ball, when you're seeing someone with a, progression and looking to have a quick response in terms of the plan moving forward.
Melanie Cole: Well, thank you for speaking also about the barriers to drug and gene delivery challenges that you have seen with this type of condition. So, I'd like you to speak about some of the more novel treatment strategies that you're looking at now, whether they're novel agents that you're using, the cytotoxic agents biologics, tamoxifen, and please tell us how those treatments for malignant gliomas may differ based on a patient's presentation.
Dr. Ashley Ghiaseddin: I'd like to first talk about some of te new technologies that we are using and then get into, medication advances and options that we're considering, for patients that are novel and really I think where the field hopefully is, moving, in the next several. One of those modalities, I alluded to earlier as being one of the new standards in our newly diagnosed patients. And that's tumor treating fields, optune tumor treating fields use low intensity alternating electric field therapy, which disrupts cell division mitosis for these rapidly dividing cells.
So those are the cancer cells. The nerve or muscle tissue are not stimulated. It's treatment that's delivered, via transducer arrays. It's non evasive. You apply it to the shaved scalp, and this is something that is a local treatment, so not systemic. You don't have, the same sort of systemic complica complications.You don't have the same sort of systemic complications that you see with chemotherapies, where you have to monitor, blood counts closely or be worried about, patients, at risk for opportunistic infections because they're immunosuppress. However, you do have to be concerned for skin irritation.
So there can be inflammation of the scalp, and there's preventive care that one would use, when they're using this sort of device. Another option that I think is novel that. Has been used at our institution as well as other large institutions as something called lit, which is laser interstitial thermal therapy, and that is where Hyperthermic laser ablation, is employed to tumors which can lead to a temporary disruption of the Peritumoral blood-brain barrier. We talked about earlier how the blood-brain barrier can limit the effectiveness of certain chemotherapy due to poor penetration, and this limits the treatment options for brain tumors.
Therefore, laser thermal therapy really attacks recurrent tumors in a way to disrupt blood-brain barrier and opens the door to use of drugs that were previously limited by their inability to cross that blood-brain barrier. You increase your therapeutic options. The immune system is really something that we're trying to harness and use to fight cancer. Now, this has been widely successful in lung cancer as well as melanoma, unfortunately, in brain tumors. We haven't had the same sort of success. However, this is something that we're, looking at more closely.
We've had studies, such as Checkmate 143, which looked at nivolumab, a PD1 inhibitor, that was compared to Bevacizumab monotherapy, which is also known as Avastin. And this was, studied in recurrent glioblastoma. There was no improved overall survival. There were more durable responses noted in nivolumab. However, at this point, When we think about immunotherapy in malignant brain tumors, we really think about this in terms of how we can combine this approach to maybe chemotherapy or small molecule therapy, and really need to pay attention to things such as tumor mutational burden and mismatch repair deficiency or microsatellite instability.
As well as PD-L1 expression on tumor tissue. These may be possible predictive biomarkers and help us determine what patients may benefit when we consider the use of immunotherapy. And then I think when you look at targeted therapy options, you wanna look at the molecular alterations in these tumors and where it makes sense to try to use different biologics and treatments to really, offer a precision medicine for patients. There are several options that have been really considered, and it's based on the molecular target. One of the molecular targets that we look at would be BRAV 600 E mutation.
Although it's not, common in glioblastoma, you can find it. Maybe less than 5% of patients combination treatment with a dual BRAF MEK inhibitor, has been used for patients, and that would be something such as dabrafenib plus trametinib. This is a combination that is successful in melanoma. We also look at EGFR amplification, in patients to see if there is a targeted option for that. specifically EGFR V3 amplification. in certain patients we can use, small molecule inhibitors that target that mutation, and that's been also utilized in non-small cell lung.
And then we know that there are new molecular targets that are being investigated and really identified as potential, therapeutic options. Nearly, every several months we learn about a new option that could be, utilized for patients. one of our more recent developments has been a, VEGF receptor. That also, is a multi tyrosine kinase inhibitor, regorafenib. And there was a trial NCT02926222, which was a randomized phase two study comparing regorafenib with lomustine, in patients who had recurrent glioblastoma.
That is another option that's being used for patients. So although we are. Frustrated at times with the difficulty in treating this tumor. I think we are motivated with the amount of research that has shown different molecular targets for us to really attack and different treatment options for these patients. And I think several ongoing trials I think will be able to identify different molecular therapies for us to use for these patients.
Melanie Cole: Such a fascinating subject, Dr. Ghiaseddin. As we wrap up, looking forward to the next 10 years in the field, what do you feel will be some of the most important areas of research and what else would you like providers to know about precision medicine for brain tumors, malignant gliomas, glioblastomas, and why and when you feel it's important that they refer to the specialists at UF Health Shands?
Dr. Ashley Ghiaseddin: What I want our colleagues, outside of UF to know is although. , it seems like for almost 20 years we've really talked about glioblastoma, malignant brain tumors in terms of surgical resection, radiation, temozolomide, recently using Optum tumor treating fields. There are many new drugs, precision medicine combining with immunotherapy that are coming out. And being, studied in clinical trials as well as utilized really in recurrence at this point, with the advent of next generation sequencing, using Foundation One or Caris, as well as other providers that can really give us a detailed genomic profile of these patients we're able to look at new targeted options for these patients with the hope of improving their survival, controlling the disease.
And as immunotherapy continues to evolve, you will see I think smarter applications of immunotherapy using nanoparticle technology. Combining immunotherapy. So vaccines that may be utilizing nanoparticle technology or RNA technology. And then combining that with a, checkpoint immunotherapy drug. And then, seeing if there molecular targets that we can use, precision medicine, in addition to the immunotherapy, that's where the field is headed. I think you're gonna see much more combinations being used now. We have to be careful and make sure that the combinations are going to still maintain.
Quality of life for patients that they're able to tolerate this and be able to continue doing their activities of daily living. So it certainly is a balancing act, myself and others are very much, committed to ensuring that our patients are not only getting, Improved survival, but also maintaining a, reasonable quality of life so that, the additional time we provide our patients, it's time that they can really spend with their families and loved. Ones and places, specifically, large academic centers like UF Health we are having new clinical trials that are, looking at immunotherapy targeted treat.
But specifically UF Health, we also have been really focused on making sure that we have a multidisciplinary approach to our patients so that they don't just come and see a neuro oncologist. They don't just come and see a neurosurgeon, but they have available options to meet with supportive care specialists, with social workers, with psychologists that are dedicated to treating patients with brain cancers and being able to, provide benefit, and support to not only patients but their caregivers. So research, at our institution not only looks at therapeutics, but also looks at. , the way we support our patients and the way that we improve quality of life.
What are other therapies and modalities we can use, that are not just treatment oriented, but are oriented at improving their functionality. So whether it's psychology, physical therapy, occupational therapy, speech therapy, these are all things that are gonna be extremely important, especially when we think about. Cure for brain cancer, which I hope in my lifetime we will see that. And I think if you do do that, you have to understand that there's going to be a need to really support these patients in survival. And that will be using things like, physical therapy, psychology services and supportive care services that can make sure that, patients live longer and also have quality of life that allows them to go back to their lives.
Melanie Cole: Thank you so much. Dr. Ghiaseddin said that was such an interesting podcast and so informative. Thank you so much for sharing your incredible expertise with us today to learn more about this and. Other healthcare topics at UF Health Shands Hospital, please visit innovation dot uf health.org or to refer your patient and to listen to more podcasts from our experts, you can always visit UFhealth.org/med matters. That concludes today's episode of UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Thanks so much for joining us today. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs085.mp3
- DoctorsFriedman, William A.
- Featured SpeakerWilliam A. Friedman, M.D.
- Guest BioDr. William Alan Friedman was born in Dayton, Ohio on April 25, 1953. He attended high school in Cincinnati, Ohio. He graduated in 1970 as a National Merit Scholar and attended Oberlin College. There he was elected to Phi Beta Kappa before moving on to the Ohio State University College of Medicine. Before graduating summa cum laude from medical school in 1976, he was elected to the Alpha Omega Alpha honor society and received the Maurice B. Rusoff Award for excellence in medicine.
In 1976, Dr. Friedman moved to the University of Florida in Gainesville, Florida. He performed a surgical internship and a neurosurgical residency, from which he graduated in 1982. During residency training he did basic neurophysiology research as an NIH postdoctoral fellow (1 F32 NS0682-02). In 1982, he joined the faculty of the Department of Neurosurgery, as an Assistant Professor. He received an NIH Teacher Investigator Award (NS 00682-02), from July, 1982 - July, 1987, which funded further research into the basic neurophysiology of spinal cord injuries. In addition, this award supported the development of one of the first intraoperative neurophysiology monitoring laboratories, subsequently used to monitor thousands of neurosurgical and orthopedic surgical cases. Dr. Friedman served as Medical Director of the Intraoperative Neurophysiology Service from 1982-1992.
Dr. Friedman was promoted to Associate Professor and received tenure in August, 1987. In August, 1991 he was promoted to Professor. In 1999, he became Chairman of the Department of Neurosurgery. He is the author of more than 300 articles and book chapters and has written a book on radiosurgery. He is a member of numerous professional organizations. Most notably, he is a Past-President of the Congress of Neurological Surgeons, Past President of the Florida Neurosurgical Society, and Past President of the International Stereotactic Radiosurgery Society. He was the Founding Editor of Neurosurgery On Call, the Internet homepage of organized neurosurgery. He was a member of the Shands Hospital Board of Directors for two terms. Dr. Friedman led the Level I Trauma task force which resulted in the establishment of a trauma center at UF Health. He was also the first ACGME Designated Institutional Official (DIO) at UF.
In 1986, Dr. Friedman began collaborative work with Dr. Frank Bova, which led to the development of the University of Florida radiosurgery system. This system was subsequently patented by the University of Florida and licensed to Philips, then Sofamor-Danek, then Varian. The commercial version of the system has become one of the most popular radiosurgical systems worldwide. Drs. Friedman and Bova received the 1990 UF College of Medicine Clinical Research Prize in recognition of this accomplishment. Dr. Friedman is the leader of a multidisciplinary radiosurgery team which has treated over 4500 patients, published more than120 papers and chapters, produced many international meetings, and educated hundreds of visiting physicians. Drs. Bova and Friedman received NIH R01 funding to support their continuing research efforts.
Dr. Friedman is the Director of the Preston Wells Center for Brain Tumor Therapy at the University of Florida. During his tenure as Chair of the Department of Neurosurgery he grew the department’s endowed funds to greater than $45 million, much of which is focused on finding a cure for malignant brain tumors. In recent years, Dr. Friedman also worked hard to elevate the quality metrics of the department and became a frequent national neurosurgical speaker on quality improvement. He was the Honored Guest at the 2021 Congress of Neurological Surgeons meeting in Austin, Texas. He published a medical memoir, “Something Awesome: A Life in Neurosurgery,: in 2021 which became an Amazon neurosurgical best seller.
After almost 20 years in the job, Dr. Friedman stepped down as Chair on July 1, 2018 but continues to run a very busy neurosurgical practice. In his spare time he loves travel, hiking, reading, Civil War history, cooking, and time with friends and family. - TranscriptionThe University of Florida College of Medicine is accredited by the Accreditation Council for continuing medical education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PR a category one. Credit physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Joining me today is Dr. William Friedman. He's a professor in the Department of Neurosurgery at the UF College of Medicine and the director of the Preston Wells Center for Brain Tumor Therapy at the University of Florida. Dr. Friedman practices at UF Health Shands Hospital, and he's here to tell us about diagnosis and treatment of trigeminal neuralgia. Dr. Friedman, welcome to the show. I'm so glad you could join us today. So as we're getting into this topic, I'd like you to describe the different types of facial pain we're discussing here today and the scope of this problem as you see it, the trends. What are we looking at?
Dr William Friedman: Well, we're principally speaking about trigeminal neuralgia. Trigeminal neuralgia is a horribly severe, sharp, stabbing electrical pain that involves one side of the face. It's brought on by touching the face, eating or talking, and can be severe enough that patients seriously consider suicide. It's called the suicide disease. The major treatment for trigeminal neuralgia is medical. It's a drug called carbamazepine, which is remarkably effective at relieving the pain. Unfortunately, over the course of years, the drug becomes less effective until patients have to push the dose up high enough to cause significant side effects, such as sleepiness or dizziness. And at that point, neurosurgery plays a major role.
Melanie Cole (Host): Wow. So it's pretty severe. Do we know what causes it Dr. Friedman? Do we know why some people get it?
Dr William Friedman: Well, the most prevalent theory is that trigeminal neuralgia is caused by a small artery in the back part of the brain, contacting and pulsing against the trigeminal nerve as it comes out of the brain. That's called microvascular decompression, and it was a theory that was popularized years ago by a neurosurgeon at the University of Pittsburgh by the name of Peter Janetta. So the principle procedure that we do for this disease is called a microvascular decompression. It involves making an incision behind the patient's. Removing a piece of bone, about the size of a nickel, and then using the operating microscope to look directly at the trigeminal nerve.
Identify that artery, which is usually the superior cerebellar artery. We dissect that free from a nerve and we place a small sponge in between the nerve and the artery and the sponge is a plastic material. It could either be Avalon or Teflon. That procedure typically takes me about an hour. Most people spend two nights in the hospital and two weeks at home healing up and recuperating. Most of them never have pain again.
Melanie Cole (Host): pretty exciting time in your field when you're talking about these kinds of things. Now, I'd like to step back for just a second, Dr. Friedman, to diagnose these because sometimes the first provider that will see these patients is their primary care provider, and while some of these pains could mimic other symptoms, Are there specific diagnostic criteria for trigeminal neuralgia? Are there other things that mimic those kinds of symptoms that they may present with?
Dr William Friedman: Melanie, this is an extremely important point. So most of these patients will present either to their primary care provider or even more commonly to the dentist because the pain seems to the patient to be coming from their teeth. It's not unusual that patients have multiple dental procedures that fail to relieve the pain before the correct diagnosis is made. So here are the criteria that I use. One, the pain has to be on one side of the face only, and it can't be in other parts of the head besides the face. It's just in the face. Two the pain is intermittent, not constant.
Three, the pain is sharp, stabbing, and electrical. In character four, there are trigger points, and by that I mean that the patient can bring the pain on by touching the face or talking or chewing. And then five, the pain is usually very reliably relieved by tegratol. So if those five criteria apply, the patient almost certainly has trigeminal neuralgia should be treated medically until medicine fails and then referred to a neurosurgeon. Now, there are a number of other diseases that can cause severe facial pain.
In younger women, we tend to see a type of facial pain that is more constant instead of intermittent. And if it's constant for more than 50% of the time, we call that type two trigeminal neuralgia, or a typical trigeminal neuralgia that can still be treated with microvascular decompression or a couple of the other procedures that I'll mention a bit later. But the success rate is lower. Another painful problem of the face. Occursafter a patient develops shingles on the face, typically in the forehead and the eye, and that's called postherpetic neuralgia.
It tends to be a constant severe burning pain, and that is not going to be relieved by most of the typical neurosurgical procedures or drugs. It does require referral to a neurosurgeon who's an expert in facial pain to explore some other options. And finally, Melanie, I'd like to mention that there is a normal physical exam in most of these patients. So the diagnosis is primarily made by history, but there is one test that can be helpful, and that's an MRI scan of the brain incorporating a special sequence called Fiesta or Space T2 imaging, which is very good at showing these little blood vessels in contact with the nerves. So if you're on the fence about whether the patient has trigeminal neuralgia, getting a positive MRI scan for vascular contact can be very helpful.
Melanie Cole (Host): This is so informative. You're laying it out so beautifully. Dr. Friedman, is it understood. That often facial pain syndromes and mood disorders can coexist? And you mentioned this was called sort of the suicide condition, the psychosocial burden of this particular condition and other facial pain conditions. How is this addressed and what do you want other providers to know about multidisciplinary approach working on that psychosocial aspect of this? Because pain is somewhat subjective. However, when it's constant, when it's sharp, when it's severe, these affect the quality of life, as you've said in unbelievable ways.
Dr William Friedman: So you're absolutely right that, any pain disorder can be a life altering disease and certainly trigeminal neuralgia can be as well. I would have to say that this particular pain disorder is fortunately different than many other chronic pain conditions that we see because the operation and the medication are so effective that whatever depression or anxiety the pain is producing frequently, disappear rapidly with complete relief of the pain. So multidisciplinary care is not as frequently needed for trigeminal neuralgia as it is for many other pain disorders.
Melanie Cole (Host): I'm so glad you pointed that out. This is just all such important information. As we get ready to wrap up, is there anything else you'd like to cover as far as facial pain syndromes, anything you feel we missed, and when you feel it's important to refer to the specialists at UF Health Shands Hospital?
Dr William Friedman: Yeah. I just wanna mention that there are two other procedures that we can do surgically. I talked already about my preferred procedure, which is microvascular decompression, but in patients who don't want open surgery or in patients who are too old perhaps or too medically infirm to undergo, prolonged general anesthesia, we do a procedure called radiofrequency lesion. Radiofrequency lesion is an outpatient procedure. We take the patient to the OR. We very briefly anesthetize them with an intravenous injection.
We insert a needle through the face and into the trigeminal nerve, and we burn the nerve, and that leaves the patient feeling exactly like they've been to the dentist and had a Novocaine injection. It's very effective at relieving the pain, but you do have to be willing to accept the numbness. Now, that procedure typically takes about 10 minutes and a patient can go home an hour or two later with no more pain. The third procedure that has become increasingly popular is called radiosurgery.
Radiosurgery is also an outpatient procedure where we focus hundreds of small beams of radiation, about five millimeters in diameter, very small. We focus hundreds of those beams on the trigeminal nerve, and that also can relieve pain without the need for open surgery. But there usually is a six to eight week waiting period for the pain to go away. And a lot of the patients I see can't eat. They can't drink. They can't wait that long. But those are other options that are an important part of the surgical armamentarium in treating this kind of pain.
Now, the point that you mentioned is that way too often, We see these patients after they've been treated too long, either with ineffective medication or with dental care, or a combination, when we could have seen them much earlier and relieve of their pain. So, in my clinic, if we get a call from a patient who has any facial pain, complaint, we see them within a week because we know how bad this pain can be.
Melanie Cole (Host): Thank you, Dr. Friedman for joining us today and sharing your incredible expertise. What an informative episode this was. Thank you again, and to learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.UFhealth.org or to refer your patient and to listen to more podcasts from our experts, you can visit UF health.org/medmatters. That concludes today's episode of UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Thank you so much for joining us. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs083.mp3
- DoctorsToussaint, R. James
- Featured SpeakerR. James Toussaint, M.D.
- Guest BioMy name is R. James Toussaint, M.D., and I am the chief of the foot and ankle division in the department of orthopaedic surgery and sports medicine. As a surgeon, I specialize in the diagnosis and treatment of orthopaedic injuries, with a particular interest in degenerative, traumatic and sports-related foot and ankle disorders.
I earned my bachelor’s degree in economics from the University of Chicago. Then, I graduated with my medical degree from the New York University Grossman School of Medicine. I also pursued a residency in orthopaedic surgery at Harvard Medical School and a fellowship in orthopaedic surgery, with a focus on foot and ankle, at OrthoCarolina Foot and Ankle Institute in Charlotte, North Carolina.
In addition to teaching as a clinical associate professor at the University of Florida College of Medicine, I also practice at the UF Orthopaedics and Sports Medicine Institute. I became an orthopaedic surgeon because I enjoy body’s complex anatomy and I want to help my patients regain their mobility. I am constantly thinking of new ways to treat foot and ankle disorders, and I’ve published research articles about traumatic disorders to provide care in disaster situations. This is important to me, as I have experience treating victims of the 2013 Boston Marathon bombings and providing care in Haiti, my birth country, following the 2010 earthquake.
Something that patients should know about me is that I always consider the spectrum of nonoperative treatments first. But if surgery is necessary, I encourage patients to ask questions and engage in shared decision making so that they feel comfortable with their treatment choice.
Outside of medicine, I enjoy collecting art and visiting art museums, especially UF’s Harn Museum of Art. I used to compete as a collegiate wrestler and I compete in triathlons when time permits. In 2021, I became a co-owner of the North Carolina Courage, one of the clubs in the National Women’s Soccer League. - Transcriptionpreroll: The University of Florida College of Medicine is accredited by the Accreditation Council for continuing medical education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMAP category one. Credit physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Joining me today is Dr. R James Toussaint. He's a clinical associate professor at the University of Florida College of Medicine in the Department of Orthopedic Surgery and Sports Medicine. And he's also the division chief of Foot and Ankle at UF Health Shands Hospital, and he's here to highlight lateral ankle sprains for us today. Dr. Toussaint, it's a pleasure to have you join us. Can you tell us a little bit about lateral ankle sprains, how common they are, and the mechanics involved to contribute to these injuries?
Dr R James Toussaint: So first of all, thank you for having me. It's a pleasure to be on your podcast. I would start off by saying that ankle sprains or lateral, ankle injuries, related to sprains are very common. The incidence is, relatively high, about 30,000 ankle sprains per day, is what you'll see in some of the literature. And about 40% of all athletic injuries, involve an ankle sprain. It's important to know that the most common reason for missed athletic participation is ankle sprains. And ankle sprains. the variety that we're speaking about today involve the low ankle sprain, which is about 90% of all ankle sprains, whereas a high ankle sprain is about maybe one to 10% of all ankle sprains.
The low ankle sprain is, again, the common variety. It usually happens when, the person twists their ankle in an inversion type injury, meaning that the foot goes medial and the rest of the leg goes relatively lateral to that. And the ligaments that are injured would be the ATFL and CFL ligaments. There's another ligament down there called the PTFO, but that's rarely involved,
Melanie Cole (Host): Well, thank you so much for that. So then, Dr. Troussaint, in what sports are you seeing them the most frequently? I'd like you to speak to patients and to other providers and even to coaches so that they can look out for these kinds of injuries.
Dr R James Toussaint: To be fair, just about any, sport can result in an ankle sprain. You're most commonly see them with the indoor court type sports such as volleyball or basketball. But you also see these injuries in dancers or football players, even, baseball players can result in ankle sprains. So again, it's very common.
Melanie Cole (Host): So then let's talk about mechanical instability versus functional instability. I'd like you to speak about clinical history, the characteristics of this type of sprain. Speak about what you do with the patient when this happens?
Dr R James Toussaint: So first the patient would come in complaining of pain with weight bearing. They may or may not be able to weight bear. You'll often see some swelling and bruising, ecchymosis. The ecchymosis may be over the medial or the lateral aspect of the ankle. most commonly the discomfort that they'll, complain about is over the lateral aspect. But because of a contra crew type injury where, let's say the talus abuts the medial maliolis, they may have discomfort even on the medial side of the ankle. Sometimes the patient will experience some catching or popping sensation, and you'll see that, related to recurrent sprains, recurrent instability.
And it's important to distinguish, let's say, the subtle versus the gross instability patterns. Recurrent instability is only in about 20% of patients. Most patients, let's say over 80% of patients will have an isolated ankle sprain that gets adequately rehabbed. But if it's not adequately rehab, then it may result in chronic or recurrent instability. And the chronic or recurrent instability pattern is one in which the ankle, is just not trustworthy anymore. So whereas the patient with the acute variety, will have an ankle sprain and then not have any, further issues.
The chronic or recurrent instability pattern. the patient will have, the loss of ligamentous integrity and that type of patient will then have a scenario whereby small, and low impact activities such as, walking and maybe stepping on a pebble or a tree root will lead to an ankle sprain. And so those are the, issues that you want to address surgically, and I know we'll get to that, a little bit later on. But during my workup, we'll do a history. We'll get an idea of where the location of the discomfort is or duration. Some of the modifiers, things that make it better or worse, the intensity, if they've had any history of trauma, if they have any comorbidities.
Some patients may have ligamentous laxity that puts them at risk for ankle sprains or sprains of any joint. And then, we can move on to the physical exam. So the moment that I walk into the room, I'm already taking a note and taking stock of what I see. I'm looking at the ankle of high foot alignment, and then I'll evaluate the motion of the ankle, the motion of the foot, the alignment of the foot, as I mentioned. Obviously we'll look at the motor and neurovascular exam. We'll find out any focal tenderness. There are some, things that you would do in the physical exam, that are, gonna elicit, instability.
And we will check for ligamentous laxity with an interior drawer exam or a tailored tilt test that's gonna test the ATFL and CFL. And beyond that, we'll get some x-rays. The x-rays tend to be weight bearing films. Sometimes I'll have a stress view and the stress view will look at, the rotation, of the ankle. We'll look at the, width of certain, joints. And then, we may, move on to treatment options. Rarely do you need an MRI, but an MRI can be necessary if the symptoms are chronic or persistent, or if we're looking out for additional pathology.
Melanie Cole (Host): Well, thank you for that. So then start with some non-operative treatment modalities once you've determined what's going on, and you can even speak about the National Athletic Trainers Association's guidelines for treating, and then we'll talk about prevention for sure, Dr. Troussaint, but I'd like you to speak about non-operative first. What might you try conservative measures and then segue into surgical options?
Dr R James Toussaint: The first line treatment, certainly involves non-surgical treatment. So that's the first line option. And that's generally involving rest, ice, compression and elevation. We may consider a short period of immobilization in a cast or a boot. And in some cases that would, even involve non-weight bearing for a week or two as the discomfort subsides. Following this, physical therapy is extremely. You wanna start physical therapy as soon as possible or as early as can be tolerated. Early motion exercises is where we start, and then we can progress through some strengthening. It would certainly involve propioception and activity specific exercises.
For those out there who aren't familiar with proprioception, proprioception involves basically retraining. Your nerves to give you an idea of where your joint or body parts are in space and that helps to prevent further ankle injuries in the future. For high risk activities or for the athletic type out there, you'll, consider an ankle brace, especially once the rehab gets going in an earnest manner. And again, the ankle brace will help limit the risk of, re. I would say, the important takeaway here is that early functional rehab allows for the quickest return to physical activity. The question that I often get is, when can I return to sport?
And that's highly dependent on the grade of the sprain, whether or not there are associated injuries and the compliance with rehab. But as a rule of thumb, a grade one or a grade two type of ankle sprain, the person should be able to get back to activity or sport within the first two weeks, a grade three type of injury, maybe three or four weeks. And if there's a high ankle sprain, although this is not the topic of this talk, but if there's associated high ankle sprain, it's six to eight weeks.
And if the high ankle sprain needed surgery, The athlete isn't getting back to sport until the next season, so it's a season ending injury. Again, prevention is gonna involve bracing, maybe a semi rigid orthosis. Patients that have some sort of malalignment of their foot, the cable, various foot. So the foot with a high arch is not gonna necessarily need an arch support. The arch is already high. I would recommend a brace with a lateral hind foot wedge, and a four foot wedge with a first meta recess. Again, this is a type of orthosis that's going to diminish or another word is to correct deformity or at least accommodate it.
And again, back to physical therapy. Physical therapy is not a, short term thing. I would say it's season long program. And that's gonna involve the strengthening and proprioseptive exercises that we talked about
Melanie Cole (Host): Dr. Troussaint, when would you consider neurovascular compromise if they've done rehabilitation of this lateral ankle sprain? They've done all of that, and you spoke about criteria for return to play, so I'm glad you did that, because then I didn't have to ask you that question, so that was awesome. But when do you consider that something else might have?
Dr R James Toussaint: If over the course of a few months, let's just say six to eight weeks, and the pain persists, then what I would typically do is obtain a more advanced imaging, such as an MRI. With the MRI, I'm looking for additional pathology, and the additional pathology could be tendon injury such as the perineal tendons, and those are located over the lateral aspect of the ankle and HD foot. There may be an associated osteochondral injury where there's, let's just say a defect within the tailor dome or on the tibial poufant. There's also the possibility of a high ankle injury, such as a Sysdomontic injury. Other things to consider are, fractures. So a fracture of the base of the fifth metatarsal or the anterior calkino process.
And so with patients that have persistent discomfort and pain despite physical therapy over the past six to eight weeks, then an MRI is used to rule out some of these additional pathologies. One thing to keep in mind is for patients that have persistent pain, we may also want to consider a stretch neuropraxia. So the stretch neuropraxia involves a stretch injury of the superficial perineal. Because of the mechanism of the injury, the nerve has been stretched and that could lead to burning or pain or even CRPS, over the injured extremity. So these are all things to keep in mind for patients that have, persistent pain and discomfort despite doing everything right non-operatively.
Melanie Cole (Host): Dr. Toussaint this is such an informative podcast, so please wrap up for us. What would you like other providers, patients, coaches, anybody involved with sports that could, you know, or even daily activities that could cause these kinds of ankle sprains prevention summary. What would you like as your final takeaway message?
Dr R James Toussaint: I would love for all of the providers and patients out there to know that, ankle sprains by and large can be treated non-surgically. but for the patient that ends up with persistent pain and discomfort and recurrent instability over the course of, let's say two months from the date of injury. Then an MRI is necessary, and then a referral to an orthopedic surgeon such as myself is the appropriate way to go. And at that point I would review the MRI and determine what type of surgical treatment may be necessary.
Melanie Cole (Host): Thank you so much, Dr. Toussaint, for joining us today and really sharing your incredible expertise. To refer your patient or to listen to more podcasts from our experts, please visit ufhealth.org/medMatters, and that includes today's episode of UF Health Med EdCast with UF Health Shands Hospital. For updates on the latest medical advancements, breakthroughs, and research, please follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs084.mp3
- DoctorsDiBianco, John Michael
- Featured SpeakerJohn Michael DiBianco, M.D.
- Guest BioMy name is John Michael DiBianco, M.D., and I joined the department of urology in 2022. I received my bachelor’s degree in psychology from Trinity College in Hartford, Connecticut and medical degree from Ross University School of Medicine. I completed a general surgery internship and urologic surgery residency at George Washington University School of Medicine & Health Sciences in Washington, D.C. Afterward, I completed a fellowship in endourology at the University of Michigan.
I am now an assistant professor in the department of urology, and my clinical interests include general surgical urology, minimally invasive surgery and specifically the management of kidney stone disease and symptomatic prostate enlargement. My research focus includes quality improvement (QI), the goal of which is to improve the delivery, experience and outcomes of care. I aim to ensure that the choice of treatment is medically appropriate while aligning with the goals of the patient.
In my free time, I enjoy exercising to stay both physically and mentally fit. Additionally, I enjoy movies and experiencing how new movies compare to the classics. - TranscriptionPreroll: The University of Florida College of Medicine is accredited by the Accreditation Council for continuing medical education, ACCME to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMAP category one. Credit physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole, and joining me today is Dr. John Michael DiBianco. He's an assistant professor in the Department of Urology at the University of Florida College of Medicine, and he practices at UF Health Shands Hospital. He's here to talk to us about homeo, laser and new nucleation of the prostate. Dr. DiBianco, thank you so much for joining us today. As lasers have become a real novel way to open the wider channel, improve voiding dynamics, many different techniques have evolved over the years. Can you tell us a little bit about how this has changed the landscape of BPH symptom management and lots? Describe the basics of BPH and explain kind of how this has evolved over the years?
Dr John Michael DiBianco: Thank you for having me, Melanie. It's a really great opportunity. And, you asked me quite the, question here. So might take me a little bit of time, but bear with me please. so bph, I always stress to my patients at the very beginning is that what we're dealing with here is quality of life. This isn't something like a diagnosis or a treatment for prostate cancer or anything like that. Very few patients need, or do I push them to have these sorts of therapies, because it's mostly about how much are they bothered and, is it gonna improve their quality of life?
And so BPH, for lack of a better term, is enlargement of the prostate. And what we're not actually doing is treating the prostate size or that enlargement, what we're really doing is treating symptoms. Yes, in fact that the bigger the prostate is, over time, the more symptoms will evolve and mostly patients will complain of more symptoms the bigger their prostate is. However, I've seen very small prostates cause problems and humongous prostates not cause people, any issues.
So I think that, the BPH term is the common term and the one that we utilize, but it's not the most technically accurate. But, it's currently the one that we utilize nowadays, the biggest thing that we're actually treating is bladder outlet obstruction. And so there are people who have lower urinary tract symptoms but are not obstructed. And there are people who, have bladder outlet Obstruction, but do not really have many symptoms.
And so the nature of treating BPH and bladder all obstruction is just that, we are removing the obstruction and in men, over 50% of people over the age of 50 and 80% of people at the age of 80 and, so on and so forth, who have this diagnosis. For those men, what we're trying to do is remove some of that obstruction, decrease the stress on the bladder, make it easier for urination, to occur and to allow for more complete urination so that they don't have to go to the bathroom so often and are less bothered by their urinary symptoms.
And so historically, The treatment options were quite limited for, bladder out obstruction due to BPH or prostate enlargement. The tried intrude classic very effective procedure was a open, simple prostatectomy where we actually made incisions in the skin, in the bladder itself and in the prostate, and removed the blocking tissue with our hands. Sewed everything up and put a large catheter in, and left it in for a few days.
As you can imagine, the downside to that procedure, although incredibly effective, at removing obstruction, was the morbidity, was the pain associated with specifically the blood loss. transfusions for those procedures were quite high, just due to the nature of the prostate and the operation. Then TURP came along. And so TURP trans urethral resection of the prostate is a res receptive therapy where we utilize, electrocautery and loops, these little sort of almost spoon like, devices that we use through a cystoscope. And actually just resect from the urethra outward towards the prosthetic capsule.
And at the same time we cut and cauterize in order to decrease the bleeding and remove the tissue all at the same time. Now, this therapy is, some would argue that it's still the gold standard. I mean, it's been around for a very long period of time. The transfusion rate is much lower than with a simple prostatectomy and those open procedures and we still do it today. In fact, I still do it today on select patients. Downside with TURP is that while it is certainly effective at removing a large amount of tissue for very large prostates, it is been found to not be as effective at removing enough tissue to prevent further bleeding or further symptomatology.
This procedure, some people used to say, oh yeah, we'll do a tur onia and it'll buy you about eight years, eight to 10 years of, Symptom relief, to somebody who's 90 years old. that's probably sounds great. They're probably saying, that's more than enough time for me. This is a disease that affects men of all ages and younger and younger people, particularly who have a family history of it. And I think the idea of undergoing multiple procedures is sometimes not as palatable for a lot of our patients. And so, the idea of trying to figure out is there a way to mimic that simple prostatectomy procedure that enucleation of the entirety of the BPH blocking tissue, without the associated morbidity was kind of, that ideal operation.
And so the development of these high powered lasers has facilitated that outcome. And so, many years ago, utilizing these high powered lasers, we were able to do that procedure, do that simple prostatectomy, but from the inside. And, it's called a laser nucleation of the prostate where we're able to take out the entirety of the BPH tissue from the inside using some of the similar, equipment that we use for TURP and all that kind of stuff. But we do it in a different way where we actually sort of peel the orange from the inside of the rind inward instead of working from the urethra outward.
That way we know that we get the entirety of the BPH tissue. So that there's less likelihood of it growing back, and we can actually pinpoint the blood vessels that supply the prostate and therefore decrease the intraoperative bleeding and the risk of postoperative bleeding as well. So, utilizing these certain lasers, and that can be, classically the way in the United States, at least currently, the most commonly utilized laser is a home laser. So that's where the term whole up came from homeo laser and nucleation of the prostate.
There are other lasers out there like a thum laser, people who utilize that, it's called Dual up, and so on and so forth. So the catchall term that I like to use is laser and nucleation of the prostate. I am particular am trained with, the homeo laser. And so typically perform a homeo laser integration of the pro or whole up. And the high powered lasers themselves are an incredible tool that has helped us do this operation. But in fact, the thing that has facilitated even less morbidity, meaning that potentially being able to remove the catheters much earlier, sometimes the same day, but most of the time the day after, is laser modulation.
Meaning there are ways that we can alter the dynamics and the physics of the laser in order to make it one better for tissue dissection at the very beginning as well as for hemostasis. And so, those are some of the different advances, that we've utilized particularly recently in the last recent years, to kind of help make this operation even more beneficial as well as less morbid for our patients, to get them back on their feet a little bit quicker.
Melanie Cole (Host): That's fascinating, Dr. DiBianco, and thank you for that comprehensive. Answer. So since we know that men don't often seek treatment until their symptoms become quality of life limiting, and you mentioned that this is a symptom management tool, as you have more developing tools in your toolbox and you're quantifying symptom burden for these men. Please speak about patient selection because I think that that's what you were alluding to before, that it's not necessarily for everyone, that everybody doesn't just go right to some sort of surgical intervention. So speak a little bit about patient selection for Whole Up?
Dr John Michael DiBianco: You're absolutely right. Men they're not usually putting themselves first and. Looking to roll into the urologist's office all the time. That is absolutely true that I always tell people we, we typically try to, kick the can as, far as we can until we kind of have to do something. But when you understand the nature of the problem and how common it is, it's really important to understand that for a lot of us, it's just a matter of time. And the longer we wait, the bigger the prostate gland becomes or the, adenoma typically becomes, and potentially the more complicated the procedure becomes.
And then potentially the less options you have. Smaller prostates have a much, wider variation of the available treatment options, than do very large prostate. So, it is a fine balance and it is very difficult to. Catch everybody at that exact moment. when we're talking about patient selection, the AUA, the American Urological Association guidelines, several years ago came out with an updated guideline recommendations for physicians because all these procedures, began to emerge pretty rapidly actually in simultaneously.
The idea of coming up with some sort of framework as which to identify which patients were ideal for which procedures, and first and foremost, understanding what the patient's symptoms are. Are they mild? Are they moderate? Are they severe? That's an initial classification. Understanding the patient quality of life currently, as well as the patient as a whole. Are they very ill? Are they on blood thinners? Do they have, heart disease? All sorts of things that can go into, selecting which operation is the best one. The next one is understanding the procedures themselves in the absence of medication. So, medication's a whole, other topic.
And, and most patients come into the urologist office already on something, whether it's an Alpha blocker or Flomax or Soin, all these different ones that are out there that really do help with symptoms. But Typically that's, a little bit outside of the realm of the urologist nowadays because they are so safe and effective and common in primary care doctor use when they come to the urologist office. Our job is to understand more of the procedural and surgical aspects of all these different options in order to be able to counsel our patients into, which one suits them best in our opinion, and then which one do. Hear, understand and say, yeah, that aligns with my goals that aligns with what I'm thinking of, as far as an outcome.
And so the prostate itself, the goal of the prostate is to sort of store and, act as a conduit for semen and the fluid associated with ejaculation. As well as it assists us in holding back our urine over time. The problem is that we can't get the urine out, well enough because of the obstruction or the blockage. So those muscles and those nerves that hold our urine back don't get utilized very often, especially when we have an enlarged prostate. So what I typically tell my patients is that, when we treat that area, it's gonna take some time for our muscles and those, nerves to kick back into gear and remember what they're supposed to do.
So Not only does it, deal with ejaculation, but it also deals with continents that holding of our urine. So the downsides to any treatment potentially deal with ejaculation and with continence. The balance is always with surgical efficacy, meaning how well does it work, as well as durability, meaning how well does it work, and then how long does that last for versus the side effects. And so side effects can include, short term pain, some bleeding, potentially infection, time with a catheter in your bladder, as well as retrograde ejaculation, which is sort of the ejaculatory problems. And I always stress that it's not the same as erectile dysfunction or erectile function.
Erectile function in BPH therapy, are. Very well correlated, meaning that just as you have surgery on your prostate, for cancer and so forth, that's what people always hear about issues with erectile dysfunction. But in reality, the problem is with the ejaculatory function, meaning that when you have retrograde ejaculation, the semen, the fluid may come out the end of the penis, but it may not, it may also just go back into the bladder because that tissue has been removed and therefore there's no backstop to project it forward.
So that is certainly one of the complications or the potential downside to any BPH surgery as well as incontinence. So the concern about having some short term, meaning the first few months versus long term issues with urinary leakage or incontinence, those are things that are potential downsides. If you put that on one side of the balance, then you have the symptoms that the patient is having. And for every patient it's, different. How much do they weigh the potential downsides versus how bothered are they with their symptoms? And so what we have is we call them less minimally invasive procedures.
And more minimally invasive procedures. Because whole up sounds like a very aggressive procedure, and we are removing a lot of tissue, but there's no incisions, bleeding risk is very low. the risk to injury, to the urethra and the bladder are quite low, especially in comparison to open procedures or laparoscopic procedures and so forth. So we always refer to them as sort of more minimally invasive. So the less minimally invasive procedures have less chance of all those side effects that we talked about, but their efficacy and their durability are lower, and they typically are not well studied or indicated for patients who have very large prostates.
It's typically reserved for small to normal size prostates, maybe a bit of an enlargement. Because we know that the nature of doing less to the prostate may not affect the prostate tissue in such a way that it allows for good flow afterwards, then we move on to more invasive, minimally invasive procedures. And that is more the classic turp. some of the newer. Vaporization procedures of the prostate, and then we're getting into, whole up and so forth. The other categories, like the patient factors, the minimally invasive, the less minimally invasive or missed procedures as they're sometimes referred to, can be done in the office.
They're quick. They have low risks of bleeding, retrograde ejaculation and so forth. the nice thing for some patients, especially those who have concomitant heart failure, lung disease, so forth, they can be done under local without anesthesia. And so from an anesthetic perspective, they're definitely enticing for sicker patients. Patients who are on anticoagulation or who have a high risk of bleeding, There are some procedures that can be done on full anticoagulation. We try not to do them if there's any, we talk to the patient, talk to their cardiologist or whoever has them on the anticoagulation and figure out the exact risk.
But typically they can restart those anticoagulants pretty quickly. And if we have to, we actually can do, what's called photo vaporization of the prostate or whole up on patients who have active platelet or coagulation, at the time of the operation. although studies do show that if you can hold it, then it's definitely safer. But we certainly can do it and that's for sure. and then additionally, we can do pretty much any trans urethral procedure under an epidural or a spinal anesthetic. We just communicate with our anesthesiology colleagues about which we think is safest for the patient and go from there.
Melanie Cole (Host): Wow. Thank you so much for outlining the pros and cons of Whole Up and speaking about the services that you offer, as we wrap up Dr. DiBianco, is there anything else you'd like providers to know about treating patients with BPH and when you feel it's important that they refer to the specialists at UF Health Shands Hospital?
Dr John Michael DiBianco: Absolutely. So thank you again for the opportunity. The biggest thing that I think the most recent guidelines has forced both, primary care doctors as well as, urologists who treat BPH to think about and to at least, keep in the back of our minds is that this is a chronic, progressive disorder, disease, if you will. We know that if somebody's already symptomatic and there's evidence that their prostate is enlarged, that it's not gonna get better with time. So the understanding and the counseling of that is important. Back in the day, we used to just do our rectal exam and figure out, oh yeah, it feels pretty big.
He's got enlargement. Nowadays with the advent of, prostate MRI, we've realized that we're not as good as we think we are. Some of us are, but most of us aren't. And so the idea of obtaining an objective size measurement of the prostate is very important. And so a lot of times patients already have, whether it's a transrectal ultrasound, a CT scan for some other reason, of their pelvis. Or prostate MRI, because they previously may have had an elevated PSA or, something. those are all incredibly valuable for both one surgical planning as well as patient counseling.
A lot of times they don't have that. And that's one of the things that we do, is we will obtain some sort of, imaging study depending on the, patient and so forth. So, we can also do what's called a cystoscopy, where we actually look inside the urethra to understand the prostate anatomy and look for other, pathology that might be going on or contributing to their symptoms. But I definitely recommend that if you have a patient that you're treating for BPH or you've tried some medication, whatever it may be, and they're just not really, benefiting from it.
You may Specifically ask, did anybody in your family have any problems with their prostate or need to have a, procedure on their prostate? great deal of patients will have, you know, my dad had it, my uncle had it, that kind of stuff. And it's actually more familiar than, prostate cancer is. And so it's a really good indication that potentially they might need something down the line. And, I think counseling and patient empowerment and earlier referral is really critical. if you think about it, a guy in his fifties who's got some symptoms already, has already kind of taken some Flomax, still not very happy.
Think about the average life expectancy for him at least another 30 years or so. That's a lot of medication. It's a lot of potentially new medications, a lot of, potentially small, less minimally invasive procedures and so on and so forth. Where you nip that thing in the bud deal with the actual problem at, earlier stage where the bladder is at maximum health, where he's at maximum health, where his pelvic floor muscles are at maximum health. And you can prevent this from ever being a problem that he'll ever has to deal with again.
And so again, some sort of objective imaging, or size assessment of the prostate. As well as, early referral and patient counseling, in order to empower them to understand that this is a real problem that is very, very, very much, able to be dealt with, with pretty minimal side effects if done appropriately.
Melanie Cole (Host): Thank you so much, doctor, for joining us today and sharing your expertise on all of these new advances. What an exciting time to be in your field and to learn more about this and other healthcare topics at UF Health Shands Hospital, please visit innovation.ufhealth.org.
And to refer your patient or to listen to more podcasts from our experts, please visit UFhealth.org/mema. And that concludes today's episode of UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs081.mp3
- DoctorsOladeru, Oluwadamilola (Lola)
- Featured SpeakerOluwadamilola (Lola) Oladeru, M.D.
- Guest BioDr. Oladeru earned her bachelor’s degree in molecular, cellular and developmental biology at Yale University. She then obtained her master’s degree in African studies and medical anthropology from Yale Graduate School of Arts and Sciences with a concentration in global health from Yale Jackson Institute for Global Affairs.
Dr. Oladeru received her medical degree from the Renaissance School of Medicine at Stony Brook University. She completed her internship at NYU Winthrop Hospital, prior to completing her radiation oncology residency training at Massachusetts General Hospital/Brigham & Women’s Hospital - Harvard Radiation Oncology Program. She also earned an MBA from Johns Hopkins University, with a concentration in Healthcare Management and Leading Organizations.
Dr. Oladeru’s research has published more than 50 research papers, presentations, and book chapters. She is the recipient of numerous awards and recognitions, including the Gold Foundation for Humanism in Medicine Honor Society Award in 2015; the Research Recognition Award from Winthrop University Hospital in 2016; and the AAWR Eleanor Montague Distinguished Resident Award in Radiation Oncology in 2020.
Her research interests include technological advancements in radiation oncology, high quality radiation treatment delivery, health policy to address inequities in underserved populations, and global radiation oncology. Her clinical focus at UF Health is patient centered treatment of all types and stages of breast cancer. - TranscriptionThe University of Florida College of Medicine is accredited by the Accreditation Council for Continuing Medical Education, ACCME, to provide continuing medical education for physicians. The University of Florida College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA category 1 credit. Physicians should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. And joining me today is Dr. Lola Oladeru. She's an Assistant Professor in the Department of Radiation Oncology at the University of Florida College of Medicine, and she practices at UF Health Shands Hospital. She's here to highlight patient-centered breast radiotherapy fractionation and treatment approach.
Dr. Oladeru, it's a pleasure to have you with us today. I found this so interesting when I was doing my research for this particular topic. So can you tell us right off the bat, what is fraction radiotherapy? How does this practice seek to maximize the destruction of malignant cells while minimizing damage to healthy tissue? Tell us a little bit about fractionation.
Dr Oluwadamilola Oladeru: Thank you very much. So in radiation, we discuss fractions. That's the number of treatments that we account for and plan to deliver our total dose of radiation through. So typically, a radiation is delivered every day during the weekdays. And as you may know, we have sort of evolved in radiation oncology from bringing patients in for multiple weeks at length for radiation. And now, they're coming in for shorter lengths of time to get their radiation complete.
So essentially, what has happened in the past was people would come in typically for breast radiation over five to six weeks. And over the last decade or so, we have done studies to show that it is safe to increase the dose of radiation per fraction, meaning per treatment or per day, and finish the entire course of treatments in a much shorter.
So now, typically, whole breast radiation would be done in four weeks as opposed to five to six weeks, historically. What has now happened and what's going on, and even with COVID, it has accelerated us towards going from standard fractionation, meaning the gentle small dose per day over six weeks to what we call hypofractionation, where it's a little bit more of a dose per day that you finish in four weeks. And now, we're in the realm of ultra-hypofractionation, where we're getting done in just five total treatments, as opposed to 20 treatments. And that trial that sort of introduced us to all of this came from the United Kingdom.
Melanie Cole (Host): Wow. Isn't that interesting? And what a cool time to be in your field. So tell us a little bit about the difference between the many types of fractionation, conventional, hyper, hypo, accelerated palliative. You've touched on a few. Can you just tell us a little bit about how these are different, how you're using these?
Dr Oluwadamilola Oladeru: So the first thing to note is in total, when you look at all of these approaches, the three different types of fractionation schedules, your total biological dose to the breasts, to the tumor, to the target is all equivalent. We're just giving a higher dose per treatment, also known as per fraction. And the patient is completing treatment sooner and also with less side effects.
So what we are doing is for patients who have early stage, low risk, very good prognosis breast cancer, meaning they're T1 to T2 node-negative breast cancer patients, we are offering them the protocol called the FAST protocol. The FAST trial, FAST, was published and they've published their 10-year results in the Journal of Clinical Oncology in 2020, where they compared going through radiation over four weeks to completing it in five days. And they delivered those five days of radiation treatment as once per week. Let's say you come in on a Monday, you'd come every Monday for five consecutive weeks and you'd be done with radiation over five treatments. And what they found when they compared both groups, the ones that came in every day for four weeks to once a week for five total weeks, they found that the outcomes in terms of cancer control was equivalent. But more importantly, they found that the cosmesis, shrinkage, induration, edema, telangiectasias were much lower in the arm that finished quickly, meaning had shorter fractions of five fractions versus the 20 fractions.
And when we're in the peak of the pandemic, where we had an issue of bringing patients in every single day for radiation, it was very important throughout the country to consider the safety of patients being exposed to a very infectious disease during this time and shortening the length of treatment. And so there was a rapid adoption throughout the country of ultra-hypofractionated approach where patients could be done in five treatments as opposed to coming in 20 times.
At UF Health Shands, we have also adopted this because, unfortunately, one of the issues we faced with COVID was the shut down of the hostel where people used to stay for cancer treatment. And so when Hope Lodge, the cancer hostel, was closed down during COVID, it actually has never been reopened. And so our patients who would typically come from Georgia, from Tallahassee, these patients were making very long, expensive trips down here every day. And for us, in our breast cancer team, we are offering those that are coming from very far distances, the option to still get their care here at UF Health Shands, but still complete it in a reasonable time, coming in once a week without compromising their cancer control outcome.
Melanie Cole (Host): So you just mentioned, obviously, patient convenience and you mentioned the FAST study, but what have you seen as far as your outcomes when patients are doing this type of fractionation treatment? And certainly, once a week for five weeks is preferable to every day for four weeks. How have been your outcomes and what have your patients been . About it?
Dr Oluwadamilola Oladeru: Oh, they love it. So typically, with breast radiation, the first week, you don't notice anything. The second week, with the typical four-week approach, second week you start feeling tired. You start noticing changes in the color of the skin of the breast. It will look more red. We call that dermatitis. It increases in appearance of redness as you get closer to the fourth week and final radiation date of 20 total treatments.
When I compare that with the patients who are getting five treatments in total, these patients, they barely have any side effects. They have barely any redness, any soreness, any fatigue, because they're not coming in every day. They're finishing in five total treatments, though it's drawn out over five weeks, but it's only one day a week. So it makes it very easy and convenient for them. And it doesn't feel like a very burdensome chore for them. And in addition, that time in between fractions is giving the normal tissue time to recover and heal. So they received it very well. It's also helped us to keep some of our patients here to be treated UF Health Shands, as opposed to them looking for places to be treated out in the community.
Melanie Cole (Host): What would you like to tell other providers, as we wrap up, about patient-centered breast radiotherapy fractionation as a treatment approach, if they are counseling their patients and referring them to UF Health Shands Hospital? What would you like them to know about telling their patients about this option?
Dr Oluwadamilola Oladeru: So, do not be afraid that a patient did not get adequate radiation if you get a report saying they got five treatments. Because things have evolved in the world of breast radiotherapy, the biological effective dose of radiation delivered over five treatments is calculated to be equivalent to the typical historical way of coming in for four weeks, five weeks or six weeks. And so do not be alarmed when you see that a patient only got five treatments. Things have changed.
Secondly, when patients are asking about where they can get treated and be done sooner without any negative impact on cancer control, we want you to be comfortable knowing that UF Health Shands is a safe place to do that. Because we are giving a higher dose per treatment or per fraction, we are very careful in our delivery, our physics calculation, our radiation planning, our dosimetry, all of that is carefully designed and planned before we deliver such a high dose per treatment.
Melanie Cole (Host): Thank you so much, Dr. Oladeru, for joining us today. Really very interesting. Thank you again. And to refer your patient for patient centered breast radiotherapy, or to listen to more podcasts from our experts, please visit ufhealth.org/medmatters. That concludes today's episode of UF Health MedEd Cast with UF Health Shands Hospital. I'm Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
Additional Info
- Audio Fileuf_health_shands/ufhs080.mp3
- DoctorsOladeru, Oluwadamilola (Lola)
- Featured SpeakerOluwadamilola (Lola) Oladeru, M.D.
- Guest BioDr. Oladeru earned her bachelor’s degree in molecular, cellular and developmental biology at Yale University. She then obtained her master’s degree in African studies and medical anthropology from Yale Graduate School of Arts and Sciences with a concentration in global health from Yale Jackson Institute for Global Affairs.
Dr. Oladeru received her medical degree from the Renaissance School of Medicine at Stony Brook University. She completed her internship at NYU Winthrop Hospital, prior to completing her radiation oncology residency training at Massachusetts General Hospital/Brigham & Women’s Hospital - Harvard Radiation Oncology Program. She also earned an MBA from Johns Hopkins University, with a concentration in Healthcare Management and Leading Organizations.
Dr. Oladeru’s research has published more than 50 research papers, presentations, and book chapters. She is the recipient of numerous awards and recognitions, including the Gold Foundation for Humanism in Medicine Honor Society Award in 2015; the Research Recognition Award from Winthrop University Hospital in 2016; and the AAWR Eleanor Montague Distinguished Resident Award in Radiation Oncology in 2020.
Her research interests include technological advancements in radiation oncology, high quality radiation treatment delivery, health policy to address inequities in underserved populations, and global radiation oncology. Her clinical focus at UF Health is patient centered treatment of all types and stages of breast cancer. - TranscriptionThe University of Florida, College of Medicine is accredited by the accreditation council for continuing medical education, ACCME to provide continuing medical education for physicians. The University of Florida, College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA category one credit physician should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole (Host): Welcome to UF Health Med EdCast with UF Health Shands Hospital. I'm Melanie Cole. Joining me today is Dr. Lola Oladreru. She's an assistant professor in the department of radiation oncology at the University of Florida College of Medicine. She practices at UF health Shands Hospital, and she's here to highlight prone position for breast radiation treatment. Dr. Oladreru, it's a pleasure to have you join us today. Before we get into prone positioning, I'd like you to start with a bit of history of radiotherapy for breast cancer specifically. How has this evolved over the years? What have you seen change in the field? What's exciting?
Dr Oluwadamilola Oladeru: Thank you. So breast radiation has always been a part of breast cancer management and historically, before the introduction of image, guided radiation, things were done using x-ray based technique. And what this meant, for some patients who, and even physicians who trained many decades ago, they might recall seeing lots of patients report burns and scarring from the type of radiation they had during those period of time. And in fact, as a result, also a lot of side effects from radiation.
Including long fibrosis pneumonitis, heart issues, including cardiac related problems from radiation exposure to the heart, but things have changed dramatically in breast radiotherapy. We now use image guidance when we treat patients it's based on CT based planning. In fact, we have now evolved to MR based planning. We also have stereotactic ways of delivering radiation treatment to targeted areas. In some women, they are eligible to get partial breast radiation instead of whole breast radiation.
We have also evolved to be able to monitor the body internal movement, heart motion, wrong motion, when we deliver radiation to the breast. So modern techniques have really caught up to ensuring we're delivering safe, effective yet also minimizing long term risk and toxicities, for our breast cancer patients.
Melanie Cole (Host): You for that excellent description, what an exciting time to be in your field. So let's talk about the benefits of prone positioning for protecting normal tissues, including the lungs and heart during radiation. Tell us a little bit about that and really what it's like for the patient? How did this get started?
Dr Oluwadamilola Oladeru: So the standard way of treating patients is with her laying on her back with arms up over the head, slightly elevated about five to 10 degrees off the table at the head. And that's called the supine position. So the patient is facing up. The radiation is delivered to the patient's chest or breast. With prone position, the patient is lined face down. So the press that we are not treating remains flat on the table while the targeted breast is left to hang and falls down away from the chest.
And so we are able to direct the beam of the radiation to the breast and avoid the chest, reduce exposure to the heart, and reduce exposure to the lung. This is especially helpful for women with larger breasts, because we're able to focus on just the breast tissue being exposed and we're able to get adequate dose that is homogeneous throughout the breast, as opposed to treating larger breasted patients supine. Where we can have very, significant challenges with delivering homogeneous dose across the entire breast when sitting face up.
Melanie Cole (Host): So tell us a little bit then about the factors that make a patient, a candidate for this prone positioning treatment. Is it contraindicated in certain circumstances? And when is it clinically indicated?
Dr Oluwadamilola Oladeru: So it's only indicated for patients who have breast cancer that only requires radiation to the breast. So there are some women who have cancer that has gone to the nodes. If you have positive lymph nodes and you need regional nodal radiation, you can only be treated in these supine facing up position. However, if you only need the breast radiated, you don't need the node radiated, then you are the perfect candidate for a prone position.
In addition to that, a woman who is at least about a B cup would be the appropriate patient for a prone position, because you need the breast to be able to fall down a certain amount of distance away from the chest in order to be the right candidate for prone. So this is very beneficial for larger cup women, any woman whom has back pain and don't want to lay on their back while getting radiation treatment. This is the best type of position, to deliver radiation for these patients.
Melanie Cole (Host): Does weight enter this picture at all? If somebody is obese, is this kind of treatment contraindicated for them?
Dr Oluwadamilola Oladeru: It all depends on how they lay on the table. If they lay in such a position whereby laying on their belly is extremely uncomfortable or the belly fat extends forward so much that the breast cannot fall forward, then no, that patient would not be the right candidate for a prone position. However, even if you meet the weight requirements for the radiation table and we can get the breast to fall down off the table and we can also, put the patient in a patient that's comfortable for him or her, then it's a situation where we would allow for them to be put in a pro position.
Melanie Cole (Host): So have there been studies on the benefits and advantages of prone positioning for breast radiation therapy. Before we wrap up, I'd like you to speak to other providers about why this can protect vital structures and organs. When you feel it's important to refer in any studies that you would like to mention to other providers that can reiterate what we're discussing here today?
Dr Oluwadamilola Oladeru: So there have been several studies published, including very recent ones. The very first one that comes to mind was in JAMA. And that was published in 2012. And that has sort of evolved to it being adopted more in practice and people reporting their outcomes even today. In that study, they had looked at patients, who all had early stage breast cancer, and that meant they did not have positive nodes and didn't need their notes, treated.
And what they found was those who were treated, particularly those with left breast cancers facing down, the amount of heart tissue exposed to radiation reduced by 86%, the amount of lung tissue exposed to radiation reduced by 91% compared to you facing upward. In addition, whenever you treat someone who is facing up, there's no way to avoid the lungs but in patients who are facing down in the prone position, you can completely avoid their lung, in terms of getting radiation exposure to that area.
And even more so for those who have right breast, cancer, this study also showed that they reduce the amount of heart exposure to radiation to almost zero. So the benefit cannot be underestimated with this setting. It has really changed, us being worried about toxicities in the long term for patients who are undergoing, radiation therapy.
Melanie Cole (Host): Real game changer. Thank you so much, Dr. Oladreru for joining us today and to refer your patient for breast radiation treatment, or to listen to more podcasts from our experts, please visit UFhealth.org/medmatters. That concludes today's episode of UF Health Med EdCast with UF Health Shands Hospital. For updates on the latest medical advancements, breakthroughs and research. Please follow us on your social channels. I'm Melanie Cole. - HostsMelanie Cole, MS
- Post Test URLhttps://cme.ufl.edu/mededcast/
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