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Saving a Life Against the Odds

Rimas V. Lukas, MD Neuro-Oncology

Roger Stupp, MD Neuro-Oncology

Craig M. Horbinski, MD Neuropathology

Borislav A. Alexiev, MD Pathology

Jean-Paul Wolinsky, MD Spine Surgery

Sabine B. Sobek, MD Hospital Medicine

Gregory A. Dumanian, MD Plastic Surgery

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MEETING OF THE MINDS

As members of the Northwestern Medicine Neuro-Oncology tumor board, Rimas Lukas, MD, and Roger Stupp, MD, regularly consult with their colleagues on cases like Jeff’s. The board — consisting of internationally renowned neurological oncologists, pathologists, surgeons, radiologists and other hospital staff — meets weekly to review cases and scans to form the best diagnosis and treatment plans for patients who need complex care.

We believe that the tumor board’s review of complex cases helps Northwestern Medicine elevate patient care to the next level.
–Rimas Lukas, MD

Often the scene of inquiry and debate, insight shared at these gatherings strengthens treatment throughout the Neurology and Neurosurgery units. From providing surgical consultation to advising on radiation therapy, even when Dr. Lukas and Dr. Stupp never directly treat a patient like Jeff, they help influence and navigate that patient’s care plan.

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SAVING A SUPERHIGHWAY

Chordomas are slow-growing tumors, which means it can take months or years for them to become identifiable. But what Dr. Wolinsky saw in Jeff’s scans convinced him that it was a chordoma beyond a shadow of a doubt. Wrapped around three vertebrae was a soft-tissue sarcoma — a cancerous tumor that forms near connective tissue — threatening to metastasize, or spread to other parts of the body. In certain scenarios, specialists will monitor a growth to see whether it continues growing or risks encroaching on surrounding tissue, but Jeff’s had already spread across a dangerous amount of his spine. Slowly, over the course of a 14-hour surgery, Dr. Wolinsky and his team went to work.

Your best shot is the first shot. Getting it out in one piece gives a patient the best chance for disease-free survival or a cure.
–Jean-Paul Wolinsky, MD

The procedure, better known as a “thoracic spondylectomy,” began with the removal of the three vertebrae (nearly 6 inches) from Jeff’s spine. In place of the vertebrae, Dr. Wolinksy inserted metal rods and a cage to reconstruct the spine, as well as to prevent any neurological damage. For periods of time during surgery, Jeff’s spinal cord was totally exposed, basically floating in his body, as his chordoma was excised. Finally, as he had done more than 100 times before, Dr. Wolinsky confirmed that Jeff’s mass had been removed.

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CLOSING THE BOOK

Still, Jeff’s journey was far from over. Due to the size and location of Jeff’s surgical incision, Plastic Surgeon Gregory Dumanian, MD, was brought on to the team to close up the wound. Observing Dr. Wolinsky’s work in the OR allowed Dr. Dumanian to plan exactly which tissue would be grafted to ensure coverage and future mobility.

The process of closing the wound takes many things into account: what’s missing, how much tension is acceptable at the wound site and so on. We have to find our closure through parallel problem-solving.
–Gregory Dumanian, MD

In what’s called a “prophylactic closure,” Dr. Dumanian stitched the wound closed using muscle tissue from the back and shoulder. Finally out of surgery, Jeff began a slow, careful period of physical therapy, closely supervised by Dr. Dumanian to ensure proper healing. Meanwhile, Sabine Sobek, MD, and the perioperative team monitored Jeff’s post-surgery care and pain management. This multidisciplinary team approach led to a successful outcome as Jeff is now back at work and living a physically active lifestyle, despite a large section of his spine having been replaced with a metal cage.

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FINDING MOLECULAR CLUES

The only way to definitively diagnose a chordoma is to view its cells under a microscope. However, due to the “flowering” nature of chordomas, taking a biopsy of Jeff’s tumor before operation would have been incredibly risky due to the threat of spilling rogue cells. Thus, after surgery, once Jeff’s mass was removed, it was entrusted to Soft Tissue Pathologist Borislav Alexiev, MD, and Surgical Neuropathologist Craig Horbinski, MD, director of the Northwestern University Nervous System Tumor Bank, for complete analysis.

Pathology plays ‘umpire’ in the world of tumors. It’s not until we view a tumor under the microscope, and perform our genetic testing, that we can make our final call.
–Craig Horbinski, MD

The Nervous System Tumor Bank is funded by a highly competitive Specialized Program of Research Excellence (SPORE) grant from the National Cancer Institute (NCI) to advance research and improve outcomes for patients like Jeff. It functions as part of the Robert H. Lurie Comprehensive Cancer Center of Northwestern University, one of just six programs in the nation with a Brain SPORE.

Finally able to view Jeff’s cells up close, Dr. Horbinski and Dr. Alexiev found a significant expression of brachyury, a protein highly indicative of a chordoma. Since 2014, the Northwestern University Nervous System Tumor Bank has collected more than 2,300 biospecimens from donors for medical research. And now, after finally being removed, Jeff’s chordoma is powering research that might one day help researchers tackle cancer at its roots.

The two words that would characterize our team, specifically in the brain tumor and spinal tumor setting, would be ‘respect’ and ‘trust.’ At Northwestern Medicine, there is a freedom to be honest when something is difficult, because everybody recognizes that medicine is challenging.
–Craig Horbinski, MD
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