So my situation has done a very abrupt about face towards a much more positive direction compared to last week's blog post. Due to the benevolence of Dr. Min, I was introduced to Dr. Bradley B. Pua, an interventional radiologist at New York Presbyterian Hospital and Weill Cornell Medical Center. Dr. Pua specializes in ablation of tumors in the lung among other image guided procedures and is also the director of the lung cancer screening program at the hospital. I met with Dr. Pua last Friday afternoon, and he wasted no time in developing a comprehensive weekly schedule allowing me to shadow his own procedures, thoracic surgeons such as Dr. Port, the coordinator for the lung cancer screening program, Brooke, the hospital's smoking cessation counselor, Katherine, chest radiologists such as Dr. Alan Legasto, and pathologists including Dr. Narula. I've seen all of these individuals in varying amounts this week and am already gaining invaluable insight into the complexities of treating and preventing lung disease.
On Tuesday, I observed a thermal ablation of metastatic adenocystic carcinoma in a 41 year old male who had originally had head and neck cancer (the primary tumor was already removed). Dr. Pua briefly reviewed the CT images of the patient's lungs with me and pointed out the the white masses (correlating to high density) that were not connected to other structures, a very basic way to identify a tumor (I will go into further depth on identifying lung cancer in CT images when I get to my shadowing experience from Thursday). We then went into the control room where 16 (I counted) people were crammed into a space roughly the size of my dorm room. I felt bad literally wasting space where other people who serve critical roles or have more qualification for their fascination were being hit by doors as people funneled in and out. However, Dr. Pua said it was alright that I remained and handing me a hairnet and mask, said that I could be in the procedure room while the CT scan wasn't running. The other golden rule was to not touch anything that was blue in the room, namely the gowns or the table where various tubs and color-coded syringes were meticulously arranged. Today was a particularly interesting procedure since the company that produces the ablation antennas that Dr. Pua uses had two employees present. This was because Dr. Pua was testing surgery planning software they had developed to determine the amount of energy required to successfully ablate a desired region. Dr. Pua had explained that it is critical that adequate margins (≥1 cm) be obtained since micrometastases are present up to 5 mm away from the tumor. Thus, one can immediately recognize the utility of such software if it works consistently as intended. Anyhow, Dr. Pua jumped back and forth between the control room and procedure room several times to correctly position the antenna between CT scans. I didn't really get to see the insertion of the antenna up close since it was done close to the CT scanner and there was a lot of equipment I didn't want to accidentally bump into. I figure that on a less hectic day, I could witness this part more in depth. Ablation was performed based on the recommendations from the software, and the margins seemed to be less than what was desirable. This may be due to the nature of the program which uses pre-clinical data from a porcine model to calculate the amount of energy required to ablate a desired region. Since this model was ablating non-pathological lung tissue, it might not possible for the pre-clinical data to be directly correlated to provide desired clinical outcomes. To make things more interesting, there was another factor that could have contributed in this result. The tumor was near the pleura and in order to capture the tumor the ablation region while avoiding ablating outside of the lung tissue, Dr. Pua inserted the antenna on an angle and skewed away from the edge of the lung tissue.
A very strict protocol was being followed to test the antennas and software so I had a fast-paced day following the patient after the ablation was performed to the OR for wedge resection. Video-assisted thoracic surgery is an amazing sight. The dexterity of the surgeon using tools inserted into a portal in the patient's side is astounding. A clamp-like tool actually closes onto the tissue to be resected and seals the lung with staples all at once. Then, another rod-like tool is inserted into the patient's side and a trigger is pulled to reveal a fishing-net-like extension that neatly collects the resected tissue so it can be extracted from the portal. I still need to look into the particulars of the procedure since this was not the environment for intensive question asking. Additionally, there was a time crunch to get the resected tissue up to the 10th floor for pathology to prepare the samples for histological analysis. The tissue was cut, stained to show the face the cuts were made on, and half was frozen in liquid nitrogen while the other half was put in paraformaldehyde. This process had to be done within a half an hour as prescribed by the trial's protocol so the nurse was a little flustered. All in all, I had an excellent "first" day and took in a lot of interesting interplay between medicine, engineering, and research.
On Wednesday, I shadowed Brooke Crawford, RN, the coordinator for the lung cancer screening program at New York Presbyterian Hospital. Brooke is, in one word, amazing; she's very laid-back and approachable but at the same time, she possesses an intensity and passion for her work and the policy that shapes it. She explained the premise of the screening program, that until recently, there was not an effective method to screen for lung cancer since X-ray is not very specific and can produce false positives. A study called the National Lung Screening Trial (NLST) compared low-dose helical computed tomography (LDCT) and chest X-ray and released results in late 2010 supporting the use of LDCT for screening in an at-risk population, heavy or former heavy smokers ages 55-74. Results showed annual screening over 3 years in the at-risk population reduced lung cancer attributed mortality by 20%. Based on the compelling results of this study, the U.S. Preventative Services Task Force (USPSTF) gave annual screening with LDCT for those 55-80 years old with a 30 pack-year smoking history who currently smoke or have quit within the last 15 years a B grade. The B grade means that "there is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial" (Source: USPSTF). I'm sure I will have more interesting tidbits on the policy that shapes this to include later but for now, I'd say that's sufficient. Anyhow, this week was rather slow for the program so I only got to watch a shared-decision consultation with one patient. I'm sure next week I'll see some more.
Thursday, I met with Dr. Legasto, a chest radiologist who gave me a fantastic first exposure to his world of clinical imaging. This section will be rather difficult to convey since it's true a picture is worth a thousand words; however, I will do my best! Dr. Legasto immediately launched into viewing images with abnormalities that the inexperienced eye would be inclined to proclaim as cancer but were in reality infection or fungus. He then showed me images that actually contained tumors and noted the primary markers to identify a tumor in a CT scan, architectural distortion and internal cystic changes. We looked at mucinous adenocarcinoma, squamous cell carcinoma, small cell carcinoma, and Kaposi's sarcoma, and Dr. Legasto provided a short description on characteristics of each. I was particularly struck by Kaposi's sarcoma, which looks like pneumonia on the scan, and by small cell carcinoma, which can in some cases have no lung component, instead being present in the lymph nodes and then metastasizing to the brain. Dr. Legasto explained how different waiting periods (4-6 weeks minimum) are given based on the characteristics of the possible tumor on the CT scan because time is essential in determining whether the abnormality is infection or not. However, the clientele of the Upper Eastside doesn't take kindly to waiting for things, and I guess one patient actually demanded a lobectomy immediately follow a suspicious scan. It did in fact end up being lung cancer, but the immediacy of her intervention was overblown because the situation wouldn't have changed drastically if she had waited. Anecdotes aside, I learned that chest radiologists still have to perform a comprehensive work ups on their patients and often, imaging is performed for one particular reason when something abnormal is seen in a completely different place that requires further attention. The final exciting episode of the week was when Dr. Legasto was reviewing a patient with a congenital defect that caused tightening of the aorta. Measurements were needed to plan for surgery to add a stent to the constriction. The constriction was so difficult to see that Dr. Legasto utilized medical reconstruction software to change the viewing plane of the CT scan images. After this alteration, he pointed out the constriction; it was amazing that any blood could actually be flowing through the almost imperceptible slit. Unfortunately, I didn't get to see the conversation with the clinician who wanted the measurements since he was going to stop by on another day.
The reason for this week's post title "A little close to home" is that this week has had an unexpected effect on me and my conversations with my family. I regularly talk to my mom and my grandma about my classes and research since they're both involved in the medical field, my mom being a unit clerk in a small town ER and my grandma being a retired nurse. Both of them are also smokers, along with many of my other relatives. In talking to my mom this week, she mentioned maybe she'd try and quit (precontemplation phase of the transtheoretical model as I've learned this week!). It's a testament to the power of nicotine addiction that so many people are aware of the negative consequences of smoking but still only about 7% of smokers who intend to quit each year successfully remain abstinent. My grandparents are some of the most strong-willed people I know and even they haven't been able to successfully quit despite several dedicated attempts. I think it is imperative to the improvement of healthcare worldwide that better therapies and treatments can be developed to help smokers quit, and I admire the work being done at the Lung Cancer Screening Program to deliver comprehensive care to this at-risk population.
No comments:
Post a Comment