Big Ideas: Local doctors and scientists pursue innovation

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Antoine Louveau, a postdoctoral fellow in the neuroscience department at the University of Virginia, found that the brain and lymphatic system are connected, a discovery that could lead to new treatments for diseases such as Alzheimer’s. Photo: Jackson Smith Antoine Louveau, a postdoctoral fellow in the neuroscience department at the University of Virginia, found that the brain and lymphatic system are connected, a discovery that could lead to new treatments for diseases such as Alzheimer’s. Photo: Jackson Smith

Innovations surrounding our health—both personal and global—are happening every day. Whether it’s the invention of a new technology or the discovery of how a disease works on a molecular level, every advancement puts us one step closer toward enjoying a collective healthier life. In this issue you’ll meet a scientist who is working to understand the exact effects exercise has on diseases, as well as a man who invented a way for ceramic tablets to be used as water purifiers in underdeveloped countries. You’ll also learn what types of cancers two local centers are known for treating, as well as what’s on the horizon for the disease–both in terms of treatment and a potential cure. ν These pioneering men and women are at the forefront of health and are employing groundbreaking strategies to ensure better lives.

A new connection: Neurological discovery overturns textbooks

Neurologists now know that the lymphatic system stems into the brain, rather than stopping at the neck. Image: Courtesy University of Virginia School of Medicine
Neurologists now know that the lymphatic system stems into the brain, rather than stopping at the neck. Image: Courtesy University of Virginia School of Medicine

Researchers at the University of Virginia’s School of Medicine have made a discovery that could change the treatment of neurological diseases such as Alzheimer’s disease, multiple sclerosis and autism.

The discovery involves the presence of the lymphatic system—the network of vessels that serves as a connection between tissues and the bloodstream and removes dead blood cells and other waste—in the brain, thus connecting the brain to the immune system, and overturning the teaching in decades-old medical textbooks.

“That makes us revisit the way we think of the brain as scientists,” says 29-year-old Antoine Louveau, a postdoctoral fellow in the neuroscience department. Louveau works under Dr. Jonathan Kipnis, the director of UVA’s Center for Brain Immunology and Glia.

Louveau discovered the vessels after he mounted a mouse’s meninges (the membranes covering the brain) on a slide to examine them under a high-powered microscope. He then noticed vessel-like patterns in the immune cells on his slide and tested for lymphatic vessels.

His findings were published online in a June issue of Nature and have received massive national attention, including a nomination for Science magazine’s Breakthrough of the Year.

According to Louveau, this breakthrough that shows a route between the immune system and the brain is leading scientists to question whether a disruption to the pathway could be involved in neurological disorders that are associated with immune system dysfunction, like Alzheimer’s. The discovery is significant because doctors may now be able to find new ways to treat illnesses.

With Alzheimer’s, for instance, Louveau says “you have a problem with immune systems and it can reach the brain,” so in the future, doctors may be able to target the issue in the meningeal vessel in the brain “and find new treatments that we never thought of,” he says, or “by manipulating the vessels, see if we can change the outcome of the disease.”

As for making such an important discovery that will change what’s been written in all science textbooks, Louveau has set the bar high.

“It’s pretty exciting because this is the kind of thing that’s going to happen maybe once in my life,” he says. “Now I have to live up to the expectation and still be able to do great science.”

In good company

Although the genome editing system called CRISPR ultimately earned Science’s 2015 Breakthrough of the Year award, as one of 10 finalists Louveau’s medical textbook-changing discovery was named among some of the top scientific advancements of the year.

Finalists included:

• Missions to dwarf planets Pluto and Ceres

• Studies of the DNA of Kennewick Man, one of the oldest skeletons ever found in the Americas

• The discovery of fossils of a new human species in a South African cave

• The confirmation of deep plumes of hot rock rising from the bottom of Earth’s mantle

• An effective vaccine against ebola

• Engineered yeast that produces painkilling opioids

• An experiment that showed the quantum phenomenon entanglement exists, in which one particle a large distance away can influence another particle

• An effort to replicate key findings in psychology discovered that the findings in only 39 percent of 100 prominent psychology papers could be reproduced

Improving quality of life: Neurosurgeon believes focused ultrasound has many possibilities

Dr. Jeff Elias originally set out to become a neurologist like his father, but the pull toward stereotactic neurosurgery, precise techniques to stimulate or lesion areas of the brain, was too strong. Since coming to UVA in 2001, his focus has been on treating neurologic disorders such as tremors, Parkinson’s disease and epilepsy. Photo: Jackson Smith/ UVA Health System
Dr. Jeff Elias originally set out to become a neurologist like his father, but the pull toward stereotactic neurosurgery, precise techniques to stimulate or lesion areas of the brain, was too strong. Since coming to UVA in 2001, his focus has been on treating neurologic disorders such as tremors, Parkinson’s disease and epilepsy. Photo: Jackson Smith/ UVA Health System

Not only is neurosurgeon Dr. Jeff Elias helping people, in some cases he’s seeing the effects of the treatments immediately.

Elias, a professor of neurological surgery and director of stereotactic and functional neurosurgery at the University of Virginia School of Medicine, has targeted his current research on the use of focused ultrasound, which is the therapeutic use of sound waves directed at a specific location, to treat brain disorders. His pilot study on using the technology to treat patients with essential tremors, the results of which were recently profiled in the New England Journal of Medicine, is believed to be the first study to use this therapy intracranially.

“People have been interested in ultrasound in the brain for 50 years,” Elias says. “The problem has always been getting sound waves through the skull. There have been some real awesome technological advances in the past decade or so that have allowed ultrasound to be transmitted through the skull, not just transmitted but really focused precisely so that we can do a treatment deep inside the brain within a millimeter or two of precision.”

Although most people think of research being done in a lab, Elias, along with his fellow neurologists, neurosurgeons and radiation oncologists at the Focused Ultrasound Surgery Center, are able to conduct research in a clinical setting. The center, the brainchild of Dr. Neal Kassell, combines the use of MRI with focused ultrasound treatment so doctors can monitor the effects in real time. It’s a partnership between UVA, InSightec Ltd., the company that makes ExAblate Neuro, the focused ultrasound device used in Elias’ clinical trial, and the Focused Ultrasound Surgery Foundation, a local nonprofit Kassell also founded.

Elias chose to focus first on treating essential tremor (tremor of the hands), because although the disease, caused by brain tumors, is technically labeled benign, it can be disabling. Patients lose their ability to feed themselves, brush their teeth, write a check—everyday tasks most people take for granted. In addition, the typical treatment options for essential tremor include drilling a hole in the skull and using a probe to implant a pacemaker-like device for deep-brain stimulation or using a Gamma Knife to deliver precise radiation treatments. Although both treatments are effective and are used to treat a variety of brain tumors, some patients feel they are too invasive.

“We really like the ability to be able to monitor the patient while we’re delivering some of the treatment,” he says. “That was a powerful concept: Deliver the treatment, then image it or view it on an MRI, then check the patient [to see if the hand tremors have decreased]—all at once.”

The average tremor reduction for the group of 15 patients was 75 percent, which demonstrated that the technology is not only precise, but it can safely deliver the treatment while monitoring the patient. Elias used the results from this pilot study (completed in 2011) to conduct a phase 3 international randomized controlled clinical trial. Seventy-six patients in eight centers around the world just finished their last treatments and researchers are now tabulating the results. Elias is optimistic this treatment could be approved by the U.S. Food and Drug Administration as a less invasive option for essential tremor patients.

Since the center treated its first patient in February 2011, Elias has seen an explosion in the field—both in terms of interest from researchers, doctors and patients to advances in technology surrounding the focused ultrasound treatment. Two FDA-approved focused ultrasound treatments doctors at the center are using target uterine fibroids and relieve cancer-related pain from bone metastases.

“I think it’s going to be a major technology that’s going to creep into a lot of fields of medicine, not just brain treatments,” Elias says. “The ability to use ultrasound to open up the circulation or bloodstream and deliver drugs or genes is a whole other treatment strategy besides ablating an abnormal circuit in the brain or tumor.”

The clinic, which has treated patients from around the world, is already using a second-generation MRI system—much like the iPhone receives an upgrade every year, so do their machines, he says.

“The sky’s the limit on how much technology can advance,” he says. “With MRI it’s almost like every year we can see things we couldn’t see last year. So we’re definitely not looking at the best images of the brain right now in 2016. Next year it will be even better; who knows what we’ll see in five years.”

Focused research

Dr. Jeff Elias is not only studying essential tremor treatment with focused ultrasound. He’s currently conducting several pilot studies with Parkinson’s disease patients, exploring which types of Parkinson’s symptoms respond to that type of treatment. Because Parkinson’s is such a complex disease and can be more disabling than essential tremor, Elias thought it was a perfect second step after the initial essential tremor pilot study. And the next brain-related disease Elias wants to study with focused ultrasound is epilepsy.

“Focused ultrasound, in my opinion, would be a great treatment option for some Parkinson’s patients, but I always caution people it’s not going to be a cure,” he says. “Some day it will get cured and we might not necessarily need this type of treatment, so it’s more of a palliative procedure or a symptom-management technique than a cure.”

See one patient’s results after just one sound waves treatment for essential tremor, here.

Get moving: Exercise promotes disease prevention

Zhen Yan, Ph.D., is the director of the Center for Skeletal Muscle Research at UVA’s Robert M. Berne Cardiovascular Research Center. His lab discovered that a single bout of endurance exercise promotes stem cell activity in maintaining muscle mass. Photo: Jackson Smith
Zhen Yan, Ph.D., is the director of the Center for Skeletal Muscle Research at UVA’s Robert M. Berne Cardiovascular Research Center. His lab discovered that a single bout of endurance exercise promotes stem cell activity in maintaining muscle mass. Photo: Jackson Smith

It’s universally accepted that exercise is good for the body.

We know it has a number of benefits on our general wellness, but Zhen Yan, Ph.D., has uncovered some effects that are not as widely known. His research investigating the impact of exercise on health has resulted in discoveries that may answer questions about helping to prevent chronic diseases, including cancer.

Yan, an associate professor at the University of Virginia School of Medicine as well as the director of the Center for Skeletal Muscle Research at UVA’s Robert M. Berne Cardiovascular Research Center, uses animal models of exercise combined with molecular genetic imaging to determine how the mechanics of muscle function during exercise result in effective intervention against chronic diseases.

“In addition to numerous findings by fine scientists in the field, we have obtained first-hand experience and findings of benefits of exercise,” Yan says. The mouse models and imaging technologies revealed that “exercise-induced antioxidant protein expression helps prevent heart failure [and] diabetes.”

Yan aims to collaborate with educators, scientists and doctors alike in taking advantage of advances in science and technology to maximize what he refers to as “healthspan,” the time in our lives when we are free of major diseases.

“We need to take holistic, multidisciplinary approaches to take care of ourselves across the whole lifespan, focusing more on healthspan (prevention of disease),” he says. “Specifically, I am working with a fantastic group of faculty at UVA in establishing a pan-university institute to tackle this question.”

With overwhelming evidence that regular exercise is beneficial in so many ways for the body, it’s difficult to deny its necessity in everyday life. And studies from the Yan Lab indicate that every singular instance of exercise helps.

While Yan reveals that “Lifelong exercise reduces inflammation and promotes insulin sensitivity,” he also says that “a single bout of endurance exercise promotes stem cell activity in maintaining muscle mass.”

The lab has also gathered results that might encourage expectant mothers to get active. Not only is exercise good for the mother’s health, these studies suggest that the unborn child could benefit in a major way.

“Exercise during pregnancy mitigates the negative epigenetic impacts from obese pregnancy to the offspring, reducing their risk in developing diabetes,” says Yan. While there is still work to be done in investigating the mechanical details of how maternal exercise helps to prevent transmission of disease, conceivably, exercise could disrupt the passage of disease from mother to child.

Looking toward the future, Yan talks about some work still under development in his laboratory and other labs across the UVA Grounds. “I am extremely excited about the possibility to address the questions with regard to the impact of exercise in prevention of cancer and Alzheimer’s disease,” he says.

Madi-makers: New technology provides clean water for all

Jim Smith, inventor of MadiDrops, water-purifying tablets, hopes production of the product will increase to several million a year. Photo: Amy Jackson
Jim Smith, inventor of MadiDrops, water-purifying tablets, hopes production of the product will increase to several million a year. Photo: Amy Jackson

The South African word for water is madi, which explains why the invention of a palm-sized ceramic tablet that could revolutionize the quality of water in underdeveloped countries around the world carries the foreign word in its name.

A MadiDrop is a porous tablet, or drop, that can be used for six months and is designed to release silver ions that purify water. Just one drop can disinfect about 500 gallons of contaminated H2O.

Jim Smith, a University of Virginia civil and environmental engineer and creator of MadiDrops, says he did not invent the ceramic water filter—rather, it was “developed by a lot of people over a long period of time,” and he is making them more accessible to those who need them.

Ceramic filters, which have silver in them, are pot-shaped and are made with clay, soy dust and water. Over the last five years, Smith has worked with PureMadi, a UVA faculty and student-based interdisciplinary collaboration that aims to prevent waterborne diseases through innovative point-of-use water treatment technology by using these filters.

“Our claim to fame is that we largely demonstrated their effectiveness of improving water quality and water health,” he says, but adds that everything accomplished by PureMadi was accompanied by a list of limitations. Because ceramic filters are expensive, large, heavy, fragile and difficult to transport, Smith says those behind PureMadi found that they were limited to teaching people around the world how to make and sell the filters locally, rather than mass producing them. He says this was the driving motivation behind his next big idea.

One MadiDrop tablet can purify 500 gallons of contaminated water. Photo: Amy Jackson
One MadiDrop tablet can purify 500 gallons of contaminated water. Photo: Amy Jackson

“What if we just had a ceramic tablet to drop into a water sample and have it passively release silver ions into the water,” Smith says. Thus the MadiDrop was born, and Smith led the crew in developing and testing it.

While the original filters cost $30 each to produce, Smith says MadiDrops will only cost between $5 and $10, and one drop can treat up to 20 liters of water per day for sixth months.

Though MadiDrops aren’t on the market yet, they will be soon. Developers are currently in the process of pilot testing the drops and Smith says 10 to 12 pilot studies between different organizations and countries will begin in the next couple months. (The product has already been tested in UVA labs, South Africa and Tanzania). Based on feedback, he says they’ll be able to start producing the drops on a large scale.

Developers will be capable of producing between 150,000 and 200,000 MadiDrops per year at a new production facility on Avon Street Extended. But Smith hopes to eventually ramp up production.

“Our goal is to produce several million a year,” Smith says, adding that they hope to eventually build a new production facility. “It’s a relatively simple process to manufacture—that’s one of the reasons we think we can keep the price low.”

MadiDrops have been tested in University of Virginia labs, South Africa and Tanzania. Photo: Amy Jackson
MadiDrops have been tested in University of Virginia labs, South Africa and Tanzania. Photo courtesy: Jay Seals

In April, Smith was the co-recipient of the 2015 Edlich-Henderson Innovator of the Year Award, presented by UVA’s Licensing & Ventures Group, but he says that was never a goal for the project.

“I received a call congratulating me that I’d won it,” he says. “I didn’t realize that I was even nominated or considered for the award.”

Says Smith, the recognition is “very exciting” and he’s grateful for the people who believed that the MadiDrop is a significant new technology, which will be able to provide “two thousand liters of safe water in your pocket” to people in countries all over the world.

Cancer centers: Local research and therapies focus on targeted treatments

Cancer. A heavy word, the disease is the second most common cause of death in the United States, behind only heart disease. It was expected to claim the lives of 589,430 Americans in 2015, and it accounts for nearly one out of every four deaths, according to cancer.org.

In his January State of the Union address, President Barack Obama said Vice President Joe Biden worked with Congress on his “moonshot” to cure cancer by giving scientists at the National Institutes of Health the most resources they have had in more than a decade.

“For the loved ones we’ve all lost, for the families that we can still save, let’s make America the country that cures cancer once and for all,” the president said.

With 41,000 Virginians expected to have been diagnosed with cancer in 2015, we unfortunately know all too well the realities of this disease. However, local doctors are making strides in terms of both research and treatments to hopefully, one day, cure cancer.

“I think it’s a noble goal to try to eradicate cancer, and it’s quite conceivable (that) the combination of radiation, chemotherapy, targeted therapy and immune therapy will produce a climate in which we will eliminate cancer from our patients and say, ‘You’re disease free,’ with the kind of certitude we’d like to have,” says Dr. John Lazo, associate director for basic science at the University of Virginia Health System Cancer Center.

University of Virginia Health System—Cancer Center

Dr. John Lazo, associate director for basic science of the University of Virginia Health System Cancer Center, says there have been remarkable advancements in the cancer research community in the last five years. Photo: Amy Jackson
Dr. John Lazo, associate director for basic science of the University of Virginia Health System Cancer Center, says there have been remarkable advancements in the cancer research community in the last five years. Photo: Amy Jackson

The UVA Cancer Center is one of more than 60 National Cancer Institute-designated cancer centers in the country. It is more than 32 years old—one of the earliest ones, and it’s dedicated to fundamental research that provides insight into cancer—both cause and treatments. One of its strategic goals is to become a comprehensive cancer center, which includes incorporating population science and understanding why certain diseases are overrepresented in some areas. There are currently no comprehensive cancer centers in Virginia.

Lazo has seen a huge shift in the last decade and a half in regard to targeted therapy, which is directed toward the things that cause cancer. He says that’s in contrast to when he was a medical student and cytotoxin drugs, which stopped cells from dividing, were mainly administered. He says UVA’s cancer center had a hand in identifying the first and second generation, and now the third generation, of targeted therapies, because its employees were interested in how cells talk to each other. There are different “religions” of the cause of cancer, including faulty cell signaling (cells talking to each other), a screwed up immune system and genetics. The center’s focus and some of its most innovative work concerns cell signaling, immunology/immuno therapy, genetics and epigenetics, imaging and creating better models for cancer.

“What’s really exciting and frustrating is we know so much more about this disease (cancer) we didn’t know before,” Lazo says. “The cancer research community has the possibility of making some remarkable advancements—we’ve seen it in the last five years.”

A notable discovery in the last year has been a major change in how to harness the immune system so that it is able to destroy the cancer, Lazo says. Many of the cytotoxic drugs wrecked the immune system and were immunosuppresent—they were challenging the system that doctors are now trying to boost. Lazo says UVA doctors are at the forefront of immune oncology drugs.

Epigenetics has to do with a substance that doesn’t change your genes, just how they are read, and is something that is reversible. UVA researchers have focused on a group of drugs called epigenetic modifiers, which “have changed the way in which we approach cancer,” Lazo says.

Another theory of the cause of cancer is a disease of cells failing to differentiate, the process in which STEM cells become hair follicles, blood cells, heart cells, etc., and then stop dividing. Dr. Tom Loughran, UVA Cancer Center director, is at the forefront of studying the factors that prevent blood cells from differentiating and becoming white blood cells or other types of cells, Lazo says.

Researchers are also devising ways to improve models for cancer, the way in which cancer is studied. The historic way of studying cancer is to take tumor cells, put them on a plastic dish and incubate them with pink media and protein and study how they grow on the plastic or to put the cells in a mouse that may be eventually cured, only to find the same effect isn’t replicated in humans. Jennifer Munson, a biomedical engineer, is creating lawns, or surfaces that simulate the environment of a real tumor. Other researchers are taking cancer directly from a patient and putting it in an immuno-compromised mouse to understand the biology of that particular tumor. The goal, Lazo says, is to understand the way particular tumor types (ovarian, pancreatic, etc.) respond to certain treatments, a term called precision medicine.

Dr. John Lazo 01
Photo: Amy Jackson

Another innovation of the cancer center is its promotion of teams—between researchers, doctors, surgeons and even chemical engineers. Gone are the days of a scientist alone in a lab waiting for that eureka moment.

“The cancer center has been really trying hard to build team science that would lead to the translation of whatever we’re doing: better diagnostic, better imaging system, better biomarker, better drug or [a] better way to prevent cancer,” Lazo says.

One team is that of Dr. Jim Larner, head of radiation oncology, and David Brautigan, Ph.D., who studies cell signaling. The most common targeted therapy in cancer is radiation, which works well if the disease is local, meaning it hasn’t spread. There are also types of tumors that are highly resistant to radiation, such as a glioblastoma, an aggressive brain cancer. Brautigan has been studying why that resistance occurs, the biology of it, to help produce better compounds. Other researchers at UVA are developing improved delivery methods of drugs, such as how to get drugs between the blood-brain barrier for brain tumors.

Another hurdle to cancer treatment is the number of drugs on the market—more than 200 are listed in the National Cancer Institute’s website—and the varying levels of doses and number of combinations in which the drugs can be administered. Lazo says this goes back to UVA’s goal of understanding the fundamentals of cancer, such as creating good models to test these drugs and drug combinations.

“I know people who say we’ll need 1,000 drugs for cancer, not another 10 or 20, because there are so many mutations, so many different ways to go at this,” Lazo says. “The jury’s out on this. I do think the president’s call for ‘Let’s cure cancer’ is going to be exceedingly challenging to do without good fundamental information. That’s where the cancer center is an engine for that.”

The cancer center is known for the treatment of melanoma, leukemias and lymphomas, glioblastoma and pancreatic and ovarian cancer, Lazo says. One of Loughran’s goals is to get stronger in treating the four most common cancers: colorectal, lung, prostate and breast.

The center has also been nationally recognized for its radiation program, which includes using radiation sensitizers that make a tumor respond better to treatment. Dr. Shayna Showalter has been using Precision Breast IORT (inoperative radiation for breast cancer), a very high targeted radiation for early-stage breast cancer, in which a patient only has to have a single dose of radiation during the lumpectomy, as opposed to six weeks of radiation afterward.

“You have here a scientific national park–it’s a jewel,” Lazo says. “It’s a place where people come together, think outside of the box. Will there be great discoveries? I’m sure. Will they change cancer treatment diagnosis? I think so. …There’s huge innovation—we have to innovate.”

At a glance

There are 132 faculty members in the UVA Cancer Center who publish a little more than 400 research papers a year. Those members are in 26 different departments in four different schools at the university: medicine, engineering, nursing and arts and sciences.

The cancer center has five programs: Cancer Cell Signaling, Chemical and Structural Biology, Molecular Genetics
and Epigenetics, Women’s Oncology and Immunology/Immunotherapy. Cancers
it treats include: bone, brain, breast, colorectal, endocrine, esophageal, gastrointestinal, gynecologic, head and neck, hematologic, lung, pancreatic, pediatric, sarcoma, skin and urologic.

Sentara Martha Jefferson Hospital—Phillips Cancer Center

Dr. Cynthia Spaulding, a radiation oncologist at Sentara Martha Jefferson Hospital, and Dr. David Heilbronner have known each other since they attended Venable Elementary. The treatment for Heilbronner’s stage 3B non-small cell lung cancer included chemotherapy and radiation using the Varian TrueBeam radiation system and 4-D CT scans. Photo: Amanda Maglione
Dr. Cynthia Spaulding, a radiation oncologist at Sentara Martha Jefferson Hospital, and Dr. David Heilbronner have known each other since they attended Venable Elementary. The treatment for Heilbronner’s stage 3B non-small cell lung cancer included chemotherapy and radiation using the Varian TrueBeam radiation system and 4-D CT scans. Photo: Amanda Maglione

Faye Satterly, director of cancer services, has worked at Martha Jefferson Hospital since 1984. She was there for the opening of the outpatient infusion center in 1986 and the hospital’s initial cancer center in 1992. When the cancer center opened, it was the first time there was an alternative in town to radiation therapy at the University of Virginia.

She says the center has grown by “leaps and bounds” since its founding; it moved in 2011 with the hospital to its current location on Pantops, and it is a full-service cancer center including surgery and radiation and medical oncology. The hospital merged with Sentara Healthcare in June 2011.

“I’ve been in cancer almost 30 years–most of the time in nursing–and it’s nothing like it was,” she says. “Even when I came on board people were saying, ‘Wow [then]’ and we’re so much more advanced now.”

One way the center is innovating is through targeted radiation. The center is home to a PerfectPitch 6 degrees of freedom couch, which allows a doctor to adjust a patient on six different axes to deliver radiation. The patient’s positioning can be adjusted without the doctor having to re-enter the room, thus resulting in faster and more efficient treatments, Satterly says. Also, says Dr. Cynthia Spaulding, radiation oncologist, cancer patients’ bodies are changing throughout the course of treatment, and the couch allows the doctor to line them up precisely to ensure accuracy within a millimeter for treatment.

For some cases, like with stereotactic lung radiation for tiny lung cancers, pulmonary surgeon Dr. Chris Willms performs a navigational bronchoscopy, in which he comes down through a tube in the trachea and out to peripheral lung lesions, and puts in fiducial markers, which look like tiny dumbbells. These markers show up on an imaging screen and allow doctors to watch the lesions as the patient breathes, and allows them to give high doses of radiation in just three or four treatments. This targeted radiation is also used on non-operative candidates, such as chronic smokers with bad lungs, who have Stage 1 lung cancer but wouldn’t survive an operation. In those cases, this treatment provides the same cure rate as surgery.

Dr. David Heilbronner, a now-retired orthopedic surgeon, was diagnosed with lung cancer just two weeks after developing a cough in early 2015. An avid non-smoker, Heilbronner said there were no indications typical of lung cancer such as shortness of breath or a violent cough. In fact, that fall before his February diagnosis he was volunteering with his wife, Lynn Valentine, in the medical tent at the IronMan triathlon in Hawaii, not to mention hiking volcanoes while there.

During his appointment to address his cough his general practitioner told him he wanted to administer a chest X-ray “just to be safe.” The doctor called Heilbronner that same night with the news: They had found a mass on his right lung.

Heilbronner, who was diagnosed with stage 3B non-small cell lung cancer, and his doctors opted for aggressive treatment; this type of cancer has a 5 to 10 percent survival rate. Had his tumor only been Stage 1, surgery and complete removal of the tumor would have been an option. The 3B designation meant it had spread to local lymph nodes, and radiation was necessary to treat the entire area.

“It’s pretty abysmal so you go gung ho after it and fight hard,” he says. “I tried to maintain a sense of humor, which I think is important. I tried to maintain a positive attitude, which is crucial. Set goals short and long-term. I found all those not only helped me but helped my family through the process.”

Heilbronner was on familiar ground as he underwent both chemotherapy and radiation treatment at Martha Jefferson—he served as an orthopedic surgeon at Martha Jefferson while operating a solo practice for 20 years, then joined the staff at the hospital in 2012. Beyond that, Heilbronner has known Spaulding since they were children. They both attended Venable Elementary.

“For me personally it was reassuring, comforting (to work with people I knew),” he says. “You get hit with a diagnosis like this, and in my case it was so sudden.”

For Heilbronner’s treatment, Spaulding and her team did a 4-D CT scan, which includes a regular CT scan but also one that went through all the phases of his breathing. Spaulding drew where his tumor was during inspiration and expiration so they wouldn’t miss it during radiation.

Because Heilbronner’s tumor was on his right lung, there was less worry about damage to the heart during radiation but he did experience esophageal pain during the third part of treatment, which made swallowing extremely painful. He said his medical team prepared him for potential side effects during and after the seven and half weeks of daily radiation treatment.

“For David, the thing I was worried about was his normal lung because I didn’t want him to have too much lung radiation because then he would have a chronic cough and shortness of breath,” Spaulding said. “In my job there’s a line. You have to decide what you’re going to do, you can’t wobble about it, and we have to get the dose in but at the same time we don’t want to cause him side effects.”

After undergoing treatment at Martha Jefferson, Heilbronner entered a clinical trial at Indiana University for the drug pembrolizumab, which was approved for the treatment of melanoma. Heilbronner’s trial studies the drug’s effectiveness at preventing the progression or recurrence of cancer. For the yearlong study he flies to Bloomington, Indiana, every three weeks to receive the drug, and he receives a new CT scan every nine weeks.

His most recent scan showed no evidence of a tumor.

“I think after you get through the initial devastation, for a lack of a better term, of being given a diagnosis like this [my advice] is work with your family and physician to figure out what’s best for you, both short and long-term,” says Heilbronner. “I think staying positive and optimistic is hard but it’s important. I think trying to maintain a sense of humor is important. Once upon a time I would have said it’s easier said then done but having been through it, it’s possible to do it. I think when people want to offer help take it, if not for you, for your family. Because the more you can relieve some of the stresses and anxiety for your family, indirectly it relieves some of the stresses on you.”

In 2014 the Sentara Martha Jefferson Phillips Cancer Center treated about 850 patients, almost a third of those breast cancer patients. Other high numbers of cancer treated include prostate and colon and rectal.

“Everything is so much more precise: dosage, management of (treatment) side effects,” says Satterly. “Cancer has become a chronic disease, not a death sentence. Even cancers that don’t have cures, you can give people a really nice quality of life for an extended period of time.”

Best practices

In the next month the Sentara Martha Jefferson Phillips Cancer Center will start implementing a non-invasive “frameless” SRT (stereotactic radiotherapy) treatment in which patients with brain tumors will wear an “open mask” (as opposed to a halo frame, which is fixed through the scalp to their skull). The Optical Surface Monitoring System (a highly sensitive motion detector camera system) will watch the patient during treatment to assure there is no patient movement and to alert treatment staff to the slightest motion during treatment.

In addition to new technology, another focus of the center is multidisciplinary cancer conferences each week during which physicians present their cases to their colleagues (including a radiologist and pathologist) to discuss the best course of treatment. The cases in these meetings are unique, ones that require alternatives to the standard courses of treatment.

Patients walk an hour after major hip surgery

Dr. Megan Swanson, a practicing orthopedic surgeon since 2010. Photo: Courtesy of Sentara Martha Jefferson Hospital
Dr. Megan Swanson, a practicing orthopedic surgeon since 2010. Photo: Courtesy of Sentara Martha Jefferson Hospital

Doctors say a new approach to an old procedure has patients recovering from hip replacements quicker and experiencing a less intensive rehabilitation period.

Dr. Megan Swanson, a practicing orthopedic surgeon since 2010, began taking the direct anterior approach to hip replacement in 2014, when she joined Sentara Martha Jefferson Hospital.

She explains that any total hip replacement involves surgically placing a socket, stem and a ball on the end of that stem into the body—a hip, she says, is a ball-and-stem joint.

When doing so, the direct anterior approach requires going through the front of the hip, rather than the back (posterior approach) or the side (anterolateral approach). Swanson compares this to the many ways one could enter a house, and adds that the direct anterior approach would be akin to using the front door.

“The patients will notice that the incision is in the front part of the hip,” Swanson says, “and there should be less pain and a quicker return to walking without a limp.”

In fact, Swanson takes pride in getting her patients up and walking just an hour after their total hip replacement.

“I work very closely with the anesthesiologist so the patient has a good experience in the operating room,” she says. “I really enjoy it when the patient can walk so quickly after surgery. It gives them a comfort level in that hip.”

According to Swanson, patients who receive a posterior or anterolateral hip replacement are often instructed to lay in bed for several hours after the operation, which can cause anxiety. Now, because they are able to move around so quickly, their bodies also reach a normal medical status quicker—blood flows quicker, which lowers the risk for blood clotting, and bowels regulate more rapidly, too.

This muscle-sparing approach does not slice through any muscles or tendons, also allowing patients to heal much faster and feel less pain. But Swanson says that isn’t always a good thing.

“One of the problems with the direct anterior approach is that people do too much on it because they’re not having pain,” she says. By two weeks, patients can walk easily with a cane and, by six weeks, they can do most anything. “But it’s still a major surgery,” she cautions.

Overall, it takes about eight weeks for the stem to in-grow with the bone and for the patient to completely heal, she says.

Dr. John Edwards, another surgeon at Martha Jefferson who also practices the direct anterior approach, says it’s growing in popularity among doctors in America. He says the main innovation in hip replacement surgeries is medication, though.

One of these medications, tranexamic acid, works on blood clots to stabilize them, and Edwards says doctors have found that it makes bleeding less of a problem and blood transfusions are needed less frequently. Tranexamic acid, along with liposomal bupivacaine, are also used to make patients more comfortable while in recovery and during the surgery, respectively.

–Samantha Baars, Sherry Brown and Jessica Luck

This article was changed at 10:02am January 27 to correct the date Sentara Healthcare and Martha Jefferson Hospital merged and the use of Sentara Martha Jefferson Phillips Cancer Center’s frameless SRT treatment. 

This article was changed at 10:56 am February 1 to correct Antoine Louveau’s age.