Medical Update (2004)

Volume1/2004_Winterupdate University of Utah Health System Winter 2004 W H A T ' S I N S I DE Teen's Torturous Headaches Stop with Neurosurgery page 4 Patient with Low Back Paiu Finds Relief page 6 Continuing Medical Education Schedule page 8 Korean War Veteran Beats Prostate Cancer with Aid of New Radiation Treatment By Phil Sahm Harrison Stufflebeam's laughter could warm a winter night. Stufflebeam, who slyly gives his age as " three- quarters of a century," laughs readily as he looks back on more than seven decades. He doesn't dwell on diffi-cult times, but it's fair to say the retired truck driver has seen his share of life's fortunes, both good and bad. As a youth in Oklahoma, he helped his family through the Dust Bowl days by hunting quail, squirrels, and rabbit with nothing but rocks to throw at them. As a young man, he drove a truck on the front lines of the Korean War- in easy firing range of enemy soldiers- without being shot at even once. Such experiences would last many people for a lifetime- and provide some good stories to tell as the years go by. But in 2001 Stufflebeam learned he had another challenging chapter ahead- prostate cancer. With the resolve that saw him through the Great Depression and Korean War, he faced the disease head- on with Intensity Modulated Radiation Therapy ( IMRT)- offered at the University of Utah Hospitals & continued on page 2 Dennis C. Shrieve, M. D., Ph. D., ( seated) professor and chair of the U medical school's Department of Radiation Oncology, and radiation physicist Richard Chern, Ph. D., assistant professor of radiation oncology, are part of the team that gives IMRT to cancer patients. New Radiation Therapy Helps Treat Prostate Cancer ... continuedfrom cover Clinics. Stufflebeam was the first prostate cancer patient to undergo IMRT at the U. Benefits of IMRT IMRT bombards tumors with varying intensities of radiation to maximize the dose to cancerous cells and minimize or eliminate the dose to surrounding healthy tissue, according to Dennis C. Shrieve, M. D., Ph. D., professor and chair of the Department of Radiation Oncology at the U School of Medicine. " IMRT allows us to deliver radiation much more accurately and at the optimum dose," Shrieve said. " Most patients with prostate, or head and neck cancer could benefit from this therapy." Three months after undergoing IMRT, Stufflebeam's tumor had shrunk markedly, and at a year, it was gone. Today, Stufflebeam and his wife, Ravenna, enjoy retirement in their comfortable home under the commanding view of Mount Timpanogos in Orem, Utah. After 53 years hauling thousands of tons of rock and dirt at construction projects, including the mammoth rebuilding ol Interstate 15 in Salt Lake County, Stufflebeam now spends his days engraving wood and glass, doing church work, and living at his own pace. " It's been a good life," he said. " I've been blessed by the Lord many times." A soft drawl hints at his Arkansas birth and Southern upbringing. A puff of white- gray hair, red plaid shirt, and sus-penders give him a neigh-borly look. But behind the easy manner lies some toughness. His doctor had diag-nosed prostate cancer after tracking his PSA ( prostate specific antigen) level, which when elevated often indicates cancer. When a tumor was confirmed, Stufflebeam weighed his options and made an appoint-ment with Shrieve. After meeting Stufflebeam and examining images of the tumor, Shrieve and three colleagues decided IMRT was a good option because the tumor was small and slow- growing. Radiation Treatment In early September 2001, Stufflebeam began radiation treatment, driving with his wife from Orem to Salt Lake City and back five days a week for more than eight weeks. " I'm sure glad my car gets good gas mileage," he said. For his first 25 treatments, Stufflebeam received standard external- beam therapy in which a machine directs a constant intensity of radiation at the tumor and surrounding tissue. But for the last 18 treatments he received IMRT. 2 " IMRT delivers radiation much more accurately and at the optimum dose." Whether by luck, disposition, or both, Stufflebeam has managed to squeak through life's rough spots in pretty good fashion. As he transported logs for building U. S. Army bunkers on the 38th Parallel in Korea, Stufflebeam managed to occasion-ally forgo the fine military cuisine and dine on pheasant. The game bird was abundant in the area, so Stufflebeam sometimes shot two or three and the company cook made a meal on the sly for both of them. He went through the rigors of radiation therapy in similar style. Most people who undergo the treatment experience side effects that range from diarrhea to radiation burns. Stufflebeam suffered no ill effects. " I kept asking the nurses if the machine was working," he said. Radiation therapy stops cancer by killing cells to prevent tumors from growing. In conventional radiation therapy, the same level of radiation strikes both tumors and healthy sur-rounding tissue. With IMRT, Shrieve and his colleagues at the U direct up to 50 radiation beams of varying intensity at tumors. For glands such as the prostate, this means a tumor can be attacked from 360 degrees with optimum doses of radiation beamed at the cancer while healthy tissue is spared. For conventional therapy, the radiation beam direction and shape are preset, and then the dosage to the tumor is computed. With IMRT, radiation oncologists first calculate how much radiation is needed to kill the tumor. A computer then uses mathematical algorithms to determine the beam configuration for the precise radiation dose that strikes the tumor while avoiding surrounding tissue. IMRT costs more and takes longer to plan than conven-tional radiation therapy, and Shrieve estimates up to 15 percent of all cancer patients can benefit from it. At the U, Shrieve and a team of four other board- certified radiation oncologists specialize in IMRT and other therapies. Four dosimetrists ( who operate the linear accelerators that dispense radiation) and four medical physicists also work in IMRT. Advances in Radiology Along with better ways to attack tumors, radiation therapy has gained from major advances in radiology the past 30 years, according to Shrieve. More sophisti-cated imaging techniques and computers now allow physicians to see into the human body with clarity almost unimagined a few decades ago. Imaging has become computerized information, and with CT scans ( computed tomography) and MRI ( magnetic resonance imaging), radiation oncologists can see precisely where tumors are located. Tumors do not remain stationary in the body, but new radiation therapy devices, such as the U of U's Novalis, help physicians track a tumor's location daily, allowing them to use higher doses of radiation without increasing the risk to surrounding tissues. Studies have shown there's a better outcome against prostate cancer when higher doses of radiation are used. For patients such as Stufflebeam, these advances provide longer, richer lives- and that's not something he's taking for granted. A couple of weeks after finishing IMRT, Stufflebeam signed up for a course in wood engraving- and found a new passion in life. With a used dental drill he bought, Stufflebeam now spends much of his time in a small but well- equipped shop at his house, fashioning salt and pepper shakers, engraving small jewelry boxes, and creating whatever else strikes his fancy. He engraves eagles, flowers, and other images on everything from wooden clocks to mirrors. Some of his pieces even sell- and two particular images never go out of style: the King and the Duke. " Anything with Elvis or John Wayne on it always sells," Stufflebeam said. After successful IMRT treatment, Harrison Stufflebeam took up wood engraving, which he enjoys doing in his workshop. © For more information, call the Department of Radiation Oncology, ( 801) 581- 23%. University of Utah Hospitals & Clinics referral and consultation: I - 8 I - 5 8 1 - 2 8 9 7 in Utah, I - 8 6 6 - 8 5 O - 8 8 6 3 ( toll free) outside Utah Teen's Torturous Headaches Finally Stop with Neurosurgery By Cindy Fazzi For as long as 16- year- old Temria Airmet can remember, she never had any headaches until Jan. 12, 2001. And boy, did she ever have one then. Temria woke up sobbing in the middle of the night because of excruciating pain. " I kept thinking, did I hit my head? Why is this happening?" she said. Temria's mother, Tiffani Airmet, asked her to rate the pain on a scale of one to 10. Temria's answer: a whopping 25. " It scared us so much that we rushed her to a hospital," said Tiffani. It was the beginning of 2 1/ 2 years of Temria's torturous battle with headaches. Her family's search for effective treatment took them to several doctors who tried different treatments, finally culminating in successful surgery in July 2003 at University Hospital. Temria, whose name comes from spelling her last name backward, said the pounding in her head usual-ly started on the right side, moving slowly to the left, and down her neck. When her head hurt, she saw spots and became extremely sensitive to light and sound. Turning on the light in her room or hearing the laughter of her 10- year- old brother, Connor, caused her to scream in pain. " My headache lasted for days, if not weeks," Temria said. " One time it lasted two months." No amount of aspirin or ibuprofen helped. A junior at Skyline High School in Salt Lake City, Temria managed to go to school despite her headaches. Many times, however, her teachers sent her home early. Between 2001 and 2003, Temria had three emer-gency room visits, each one resulting in an overnight hospital stay and brief relief from pain. Each time, the headache came back twice as bad. Temria initially was diagnosed with migraine. Tiffani said the problem with this diagnosis was that her daughter did not respond to any medications that normally relieve migraine. The girl tried them all- from painkillers to blood pressure drugs- but to no avail. Temria was told to avoid any " triggers" for her headaches, which turned out to be just about every-thing. " She cut her hair. She changed her diet. She got her eyes, teeth, and spine checked to find the trigger," recalled Tiffani. " But the headaches didn't go away." As Temria's headaches worsened, more medica-tion was prescribed, and Tiffani, a pharmacy techni-cian, worried about the increased dosage and atten-dant side effects. One time, at a dance performance, Temria suddenly stopped in the middle of a number and just stood there, spaced- out, which bewildered the audience. " I saw Temria change from being a perfectly happy child to a withdrawn person," said Tiffani. She also was baffled to see her daughter lose her hand- eye coordination practically overnight. Temria, who has played Softball most of her life and was part of a travel team coached by her mother, suddenly found herself unable to hit. " I saw spots Gone are the days of terrible headaches for Temria Airmet, who is happily back at dance practice in the Skyline High School gym. 4 when I played," she said. " I just couldn't hit anymore." Just when the Airmet family thought they had reached a dead end in their search for treatment, friends recommended Ronald I. Apfelbaum, M. D., professor of neurosurgery at the University of Utah School of Medicine. Apfelbaum told the family that Temria's headaches had been misdiagnosed. She did not have migraine, but actually had Chiari malformation, a congenital condition in which the posterior cranial fossa is undersized. As a result, the lowest portion of the back of the brain, known as cerebellar tonsils, can become wedged into the upper part of the cervical spine, blocking the flow of cerebrospinal fluid ( CSF) and putting pressure on the brainstem- spinal cord junction. " Symptoms are varied and can be vague, leading to misdi-agnosis at times," said Apfelbaum, who noted that headaches at the base of the skull often can occur with a Chiari malforma-tion. Other symptoms can include problems with coordination, balance, vision, and swallowing. He said since these are non- specific symptoms that can have a multitude of causes, MRI is essential and considered the definitive way to make the diagnosis. When the scan shows this problem, surgery can be helpful and that is what he recom-mended for Temria. " MRI is considered the definitive way to diagnose Chiari malformation." Apfelbaum's recommendation was different from that of Temria's previous doctor, who was aware of her Chiari malfor-mation, but favored treating her headaches with medication. The Airmet family waited six months to see if medication made a difference before finally allowing Temria to undergo the procedure. " It was a scary decision," Tiffani said. " But my daughter was willing to do anything to make the headaches go away." On July 15, 2003, Temria experienced the worst headache she ever had. It happened to be the day of her scheduled surgery at U Hospital. Apfelbaum performed a cranial- cervical decompression, a procedure that removed a small amount of the occipital bone at the base of the skull and the lamina of the first cervical verte-bra. Then the dura, the strong membrane covering the brain and spinal cord, was opened and a patch graft sewn to it. This enlarges the space at the cranio- cervical junction and allows free flow of CSF, thus relieving pressure in the area. The procedure is not novel, said Apfelbaum, who has a specialized interest in treating Chiari malformations and related problems at the junction between the skull and spine, such as instability due to congenital or degenerative disease in this region of the body. He also specializes in other conditions involving the posterior cranial fossa, such as trigeminal neural-gia, characterized by severe stabbing pain in the jaw, and hemi-facial spasm, characterized by painless facial muscle twitching. He and other U medical school neurosurgeons perform up to 30 Chiari decompression surgeries every year at University Hospital and Primary Children's Medical Center. Apfelbaum was emphatic: " This is not a miraculous cure for all patients with headaches or vague neurological symp-toms." He said neurosurgical consultation usually is not appropriate unless patients have MRI scans that show this type of problem. In Temria's case, the results of the surgery were immediate. " As soon as I woke up, my headache was gone," said Temria. " It's like it never happened." Her parents wanted to test her, so they opened all the blinds in her hospital room, flooding it with sunlight. Tiffani will never forget her daughter's reaction: " She blurted out,' Wow, Mom, it's pretty out there!'" Temria said recovery from the surgery took time, during which she lost 28 pounds. Other than that, she said she's " normal" again. " When I had the headaches, I wasn't myself," said Temria. " It was hard not only for me, but for my entire family. They suffered as much as I did." Temria has picked up where she left off, working out, going to dance practice, and playing Softball again. And yes, she's batting like her old self again. ® For more information, call the Department of Neurosurgery, ( 801) 581- 6908. University of Utah Hospitals & Clinics referral and consultation: I - 8 O I - 5 8 1 - 2 8 9 7 in Utah, I - 8 6 6 - 8 5 O - 8 8 6 3 ( toll free) outside Utah Patient with Low Back Pain Finds Relief after 29 Years $ W8f s Sujnani Adkoli, M. D., assistant professor of anesthesiology at the University of Utah School of Medicine, and Robert F. Finnegan, M. D., DABPM, director of the University's Pain Management Center, show the new radiofrequency ablation equipment they use for treating low back pain. By Cindy Fazzi The year Larry Lazzarotto's back pain began was the same year President Nixon stepped down in disgrace, Elton John's " Bennie and the Jets'' was a huge hit, and moviegoers lined up to see the disaster flick " Towering Inferno." It was 1974, and Lazzarotto's lower back pain continued off and on for the next 29 years. He did not have any long- lasting relief until August 2003, when he started radiofrequency ablation ( RFA) treatment at the University of Utah Pain Management Center. Lazzarotto, 62 and retired, attributed his bad back to a job with a farm- equipment company. " Back then, I used to move parts weighing up to 1,000 pounds with-out any forklift. That's when it all started," he recalled. The first time Lazzarotto experienced acute pain in his lower back, he ended up in an emergency room in Idaho Falls, Idaho, where he lived until 2002. He was given painkillers and sent home. " I was fine for a while, but the pain came back," he said. That was the pattern for him for the next three decades, during which he saw different doctors and took painkillers, but always, the affliction returned. Lazzarotto eventually quit his job with the farm-equipment company. Later he worked as a technician for an engineering and environmental laboratory run by the Department of Energy, where he remained until his retirement in 2002. Even with the heavy lifting eliminated, Lazzarotto endured a bad back. " When my back used to hurt, I could hardly walk. My left leg would go to sleep. I'd take a painkiller and wait two hours for the pain to go away. It always came back, though," he said. 6 The pain stopped him from doing what he enjoyed the most- fishing- and from performing the simplest of chores, such as vacuuming. On top of this, Lazzarotto had another, more serious health problem. His heart was weak and enlarged, requiring a triple bypass in 2000, and ultimately, a heart transplant in 2002. Lazzarotto and his wife, Pat, sold their house in Idaho Falls and moved to Spanish Fork, Utah, to be closer to University Hospital, where he had the heart transplant. While his heart was mending, he asked if anything could be done about his low back pain. He was referred to the Pain Management Center, where he was treated by Sujnani Adkoli, M. D., assistant professor of anesthesiology at the U School of Medicine. When Adkoli suggested radiofrequency ablation therapy, Lazzarotto was more than willing to try it. The RFA equipment consists of an X- ray monitor ( radiofrequency generator) and a needle probe. With the patient lightly sedated, anesthesiolo-gists use the monitor to guide them to the spot that needs treatment and help them determine the amount of stimulus needed. The needle probe attached to the machine transmits radiofrequency waves to the target nerves. The heat generated by RFA stuns the defective nerves temporarily and the pain goes away for a few months. RFA is not novel, but for a long time, it was used primarily by neu-rosurgeons, according to Robert F. Finnegan, M. D., DABPM, associate professor of anesthesiology at the U medical school and director of the Pain Management Center. The technology, however, is now being utilized to treat other areas, including the back and neck. With low back pain, Finnegan said even a nerve that has been removed will eventually regenerate and the pain may return. " In some cases, it is entirely possible to achieve a pain- free state after RFA treatment," said Finnegan. " But for most patients, the pain comes back Larry Lazzarotto works out in his home five times a week as part of therapy for his bad back. and they have to use RFA again." He said the Pain Management Center got its first RFA equipment in July 2003. The center uses it to treat an average of 10 to 15 patients with low back pain every month. " RFA is non- invasive and has minimal complications. So we recommend it early on," said Finnegan. RFA is also used in U Hospital's Physical Medicine and Rehabilitation Clinic. Lazzarotto, who had his first treatment in August, was among the first to use the Pain Management Center's new RFA machine. " The whole thing lasted 30 minutes, and the pain went away just like that," he said. Adkoli said three medial nerves in Lazzarotto's lower back were destroyed using thermal RFA, at 80 degrees Celsius. The other type of RFA, pulse RFA, produces lower temperatures of 42 to 44 degrees Celsius. Adkoli said choosing the right kind of RFA depends on the location of the target nerves. " In Larry's case, we used ther-mal because there was no risk of damaging vital structures," she said. Pulse RFA is normally used in more sensitive areas, such as the neck. Adkoli recommended RFA therapy combined with exercise for Lazzarotto. He noted happily that he doesn't use painkillers as often as before. Most of all, he has resumed doing many things he could not do before because of a bad back. " Dr. Adkoli got me using a treadmill five times a week. She got me hiking and fishing again," he said. Adkoli recommended RFA treatment for Lazzarotto every four to six months. " It is safe for him to do it for the rest of his life," she added. How does Lazzarotto feel about doing the treatment on a regular basis? " I'd do it in a heartbeat. It's the only thing that has worked for my lower back," he said. ® For more information, call the University of Utah Pain Management Center, ( 801) 581- 7246. University of Utah Hospitals & Clinics referral and consultation: I - 8 I - 5 8 1 - 2 8 9 7 in Utah, I - 8 6 6 - 8 5 O - 8 8 6 3 ( toll free) outside Utah U N I V E R S I T Y OF U T A H S C H O O L OF M E D I C I NE C O N T I N U I N G M E D I C A L E D U C A T I ON February 22- 2 45th Annual Obstetrics & Gynecology Update & Current Controversies Park City Marriott Hotel, Park City, Utah Howard T. Sharp, M. D. 18 AMA Category 1 hours Natalie Moore ( 801) 581- 5501 ( phone) ( 801) 585- 5146 ( fax) Natalie. moore@ hsc. utah. edu Advances in Internal Medicine 2004 The Grand Summit Resort Hotel Conference Center, The Canyons, Park City, Utah Contact Perso March 18- 2 Site: Course Directo Credit: Contact Perso Cour