New procedures, devices, guidelines
Advanced Care for Bone Cancer Patients
Even though he is a surgeon, Francis Lee, M.D., Ph.D., associate professor of orthopedic surgery, vice chair for research, and director of the Center for Orthopedic Research, has an unusual approach to the treatment of inflammatory bone loss and bone cancers.
By Christine Hsieh
“I try to avoid surgery,” he says. “I want to treat bone cancer with drugs.” Dr. Lee spends about 60 percent of his time caring for patients and the other 40 percent in the lab performing the research that may lead to the development of new drug treatments.
As a physician-scientist with extensive experience in pediatric orthopedics and orthopedic oncology, Dr. Lee sees many patients with benign or malignant tumors of bone and connective tissues. One day he may perform joint replacement surgery, another he may remove a patient’s massive tumor. It is this work that informs and inspires his research focus. “All of my research stems from a strong desire to provide the best care for my patients. I can do a perfect reconstruction after a sarcoma resection, for example, only to see it fail when the bone melts away, so I want to find better ways to preserve bone mass.”
To seek better ways he investigates the inflammatory processes of bone cells. For example, a successful hip replacement often requires an additional surgical revision after five to 10 years, not because the artificial joint itself needs fixing, but because the surrounding bone has worn away. Though small wear particles may be invisible to the naked eye, the immune system reacts to them strongly. Osteoblasts and macrophages induce inflammation, which in turn triggers the bone resorption process.
“A tremendous amount of wear particles are generated by replacements,” Dr. Lee says. “I’m looking at how biomaterials and physical force cause wear and tear on bone cells with the goal of reducing inflammation and bone loss.”
On the clinical side, Dr. Lee reduces surgeries for his young osteosarcoma patients by using a relatively new type of prosthesis to replace diseased bone. With this implant, approved by the FDA in 2002, an electromagnetic force applied to the leg by a handheld device releases a mechanism inside the prosthesis that allows it be lengthened from outside, without surgery. “Many bone cancers typically occur in children or young teenagers whose growth is affected after surgery for tumor removal because growth plates are often removed,” he says. “Sometimes there can be up as much as a two- to three-inch leg length discrepancy after surgery, so further surgery is usually necessary to equalize leg length.” The expandable prosthesis lessens the number of surgeries required, thus lowering the risk of complications not to mention the favorable reduction of emotional trauma and scars in this age group.
Working with support from the NIH Dr. Lee is one of only a handful or orthopedic surgeons with a coveted R01 grant he continues to push boundaries both in the OR and in the lab. Dr. Lee has been mentoring both medical students and residents who have obtained pre- and postdoctoral grants. A desperate need for orthopedic surgeon-scientists exists, Dr. Lee says, and this mentoring aims to help fill the gap. “Orthopedic oncology is a specialty that requires training in orthopedic surgery but also a deep understanding of biology in general. Because of the current difficult funding environment, clinician-scientists are disappearing but translational research is absolutely necessary if we are to bring the best possible care to patients.”
Information about the work of Dr. Lee and the Center for Orthopedic Research can be found at www.cumc.columbia.edu/dept/ortho/cor/cor.html.
Cognitive Behavior Therapy for Schizophrenia
By Susan Conova
Like many sedentary 40-somethings, Sara* had legs that were sore a few days after starting a new exercise routine walking a few blocks around her neighborhood. Sara, who was diagnosed with schizophrenia in her early 30s, was convinced that the pain she felt after a walk was caused by the voices she hears almost constantly, despite medications. The voices were threatening her if she did not quit. Consequently, she considered discontinuing her daily walks.
“It turns out she had been walking without sneakers or water,” says her therapist, David Kimhy, Ph.D., assistant professor of clinical psychology in the Department of Psychiatry. “I suggested that the pain was caused by cramps rather than her voices and that we should try an experiment to test this hypothesis: She should change her shoes, walk more slowly, drink more water, and see what happens.”
Sara tried, and the pain went away. “It showed Sara that the voices were not omnipotent and that she could face their threats and win. And once you realize that you have control over the voices in one part of your life, you may be able to gain control over them in other parts as well.”
To help Sara, Dr. Kimhy uses CBT cognitive behavior therapy a talking technique rarely used in the United States for schizophrenia. CBT, which has been around for more than 50 years, is used most commonly to treat depression and anxiety. Fifteen years ago, therapists in the United Kingdom revived and adapted the use of CBT for schizophrenia. It is standard practice there but only now starting to trickle into use in the United States. Dr. Kimhy is one of a handful of psychologists in the country who are trained to use CBT with schizophrenia patients.
CBT is based on the idea that thoughts cause feelings and behaviors, not external factors, such as people, situations, and events. “It’s not what actually happens that influences our feelings or behavior,” says Dr. Kimhy, “It’s how we interpret the experience. If I see a friend down the hall but he doesn’t say ‘Hi’ when I wave, I may believe that he doesn’t like me anymore so I become sad and anxious. Alternatively, I can consider the idea that he’s preoccupied or that he didn’t see me. As a consequence my feelings aren’t as negative.” Many individuals with schizophrenia have difficulties correctly perceiving and interpreting social and other situations or coming up with alternative explanations for events, resulting in increased stress.
In CBT, patients are encouraged to deal with their hallucinations and delusional beliefs by coming up with alternative explanations to these experiences. With the help of their therapists, they collaboratively design real-life experiments to test their validity. Such exercises and experiments allow patients to develop alternative, more reality-based ways to understand and attribute their symptoms. As a result, they experience less stress, even if the hallucinations never go away. “Hallucinations feel very real to people, and it is hard to function with them,” Dr. Kimhy says. “When medication doesn’t help, people may become depressed and hopeless about changing their condition, and as a result far too many patients disconnect from life.”
To help patients, Dr. Kimhy often starts with a minor challenge to the patient’s expectations about their hallucinations and delusional beliefs. The patient gets a sense of accomplishment in dealing with symptoms and uses it as a foundation for further exploration. When she first came to Dr. Kimhy, due to her threatening voices Sara spent most of her days watching television or sleeping, venturing outside only for weekly meetings with doctors. In the year since she did her exercise experiment with Dr. Kimhy, she started attending group therapy, working part time at a bookstore, and is considering taking some courses despite continuing to experience daily auditory hallucinations.
“When I first came to Dr. Kimhy, I wanted to feel better, but I didn’t know how to do that. It was so hard to get out of bed,” Sara says. “Walking gave me more energy and the voices faded into the background. Now I take more pleasure in things like cooking. I still have days when I’m down, but in general, I feel happier. He has helped me overcome things I thought I couldn’t.”
Dr. Kimhy hopes CBT may help minimize the need for hospitalizations for patients with schizophrenia. Many schizophrenia researchers believe that stressful experiences often precede the type of psychotic episodes that require hospitalization. Dr. Kimhy is currently enrolling patients in an NIMH-funded clinical trial to test whether patients who have completed CBT are better at handling daily stressors than patients who receive standard psychiatric treatment. Heart monitors worn by participants will measure heart rate and the patients will record their feelings on handheld computers in one of the first studies to measure stress in real time during the flow of daily functioning.
Studies are still needed to determine which patients will benefit most from CBT, Dr. Kimhy says. “I think there is a large group of patients out there like Sara, who still hear voices or have other psychotic symptoms despite adhering to their medications, who can benefit greatly and begin to enjoy a fuller life.”
*not her real name
For more information about CBT for schizophrenia or the clinical trial, contact Dr. David Kimhy at 212-543-6817 or firstname.lastname@example.org.
Minimally Invasive Surgery: From Stomach Reduction to Tumor Removal
By Christine Hsieh
P&S surgeons are increasingly using minimally invasive techniques and finding that in many cases they can often achieve even better outcomes than with traditional operations that require large incisions.
In August 2008, bariatric surgeons Marc Bessler, M.D., assistant clinical professor of surgery, Daniel Davis, M.D., assistant professor of surgery, and Peter Stevens’87, assistant professor of clinical medicine, performed a stomach stapling without making a single external incision. The patient awoke a few hours later with some postoperative discomfort from the endolumenal surgery, but hardly any pain. Her major complaint? A slightly sore throat from the tube that had been inserted in her esophagus so that thesize of her stomach could be reduced with staples from the inside. This minimally invasive procedure spared the patient several days of inpatient recuperation and weeks of restricted activity that usually follows traditional surgery.
“This type of surgery has always been done through a large, open incision,” says Dr. Bessler, who directs both the Center for Metabolic and Weight Loss Surgery at CUMC and the Minimal Access Surgery Center at New York-Presbyterian. “If you needed your gallbladder out in 1985 you could expect an 812 inch incision because doctors had to literally reach in with their hands and look directly at organs. Minimally invasive surgery has changed all that.”
For the past 20 years or so, laparoscopy was about as minimally invasive as surgery could get. It is still widely used in colon cancer resections, but physicians like Richard Whelan’82, professor of surgery, are using hand-assisted laparoscopy as a way to maximize the benefits of the laparoscopic approach. The hand-assisted technique is used for patients with large tumors or masses and for obese patients who otherwise might receive a standard open operation. In addition, Dr. Whelan and Dr. Stevens perform endoscopic submucosal dissection and resection of large benign colon polyps under laparascopic guidance. Other surgeons are modifying laparoscopic techniques so that only one incision is needed for the scope and instruments. This technique, called single port access surgery, eliminates the visible surgical scar by hiding it in the umbilicus.
Dr. Bessler and Joshua R. Sonett, M.D., professor of clinical surgery, have for several years performed minimally invasive esophagectomies using five half-inch or quarter-inch incisions in the abdomen and a small incision in the neck or chest, as opposed to the older approach that required large incisions in both the chest and abdomen to bring the stomach up into the chest. These esophageal operations are sometimes no longer needed as Charles Lightdale’66, professor of clinical medicine, and Dr. Stevens are now removing small, early stage tumors and premalignant lesions using an endoscopic technique called endoscopic mucosal resection. In addition to the minimally invasive esophagectomies, the thoracic surgical group routinely performs minimally invasive video-assisted thoracic surgery lobectomies for lung cancer and thymectomies for myathenias gravis and thymoma.
Other surgical subspecialties are experimenting with new minimally invasive technologies. A handful of neurosurgeons use a 3-D endoscope in brain surgery. Salvatore M. Caruana, M.D., assistant professor of otolaryngology/head & neck surgery, uses a CO2 laser through an endoscope to remove head and neck cancers transorally. Ketan Badani, M.D., assistant professor of urology and director of urology’s robotic surgery division, is pioneering the use of surgical robotics for partial nephrectomies and other bladder and kidney procedures, in addition to the well established robotic prostatectomy procedure. Robots can be particularly useful for urologists and gynecologists, who must operate in the tight spaces of the deep abdomen and pelvis.
One of the most advanced techniques being explored at CUMC is the use of Natural Orifice Translumenal Endoscopic Surgery, or NOTES. Just weeks before the endolumenal stomach stapling, Dr. Bessler and his team removed a patient’s gallbladder without any external incisions by inserting an endoscope through a small incision behind the woman’s uterus and threading the endoscope and their instruments through the abdominal cavity toward the gallbladder.
Apart from scarless healing, the NOTES approach minimizes damage to surrounding tissues and may significantly decrease recovery time and pain. An external incision requires cutting through muscle, so even small movements can cause sharp pain. Not so with NOTES. “When you cut through the pelvic floor behind the uterus, those muscles don’t have the same pain receptors as the muscles of the abdominal wall,” Dr. Bessler says. “Irritation from the surgery itself might cause some pain, but the hope is that this surgery may be nearly painless because we don’t make external incisions and go through muscle and skin.”
CUMC surgeons are developing training programs for NOTES and endolumenal surgery, while also cognizant of possible drawbacks. “The development of new technology comes with a learning curve, and while some risk is involved in the early stages of that learning curve we are trying to minimize that,” Dr. Bessler says. “Natural orifice surgery is still in the evaluation stages. We need to better understand its advantages and costs before we can offer this on a large scale to patients. But the potential for making surgery pain free, scar free, and recovery free? That’s exciting.”