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Dying cancer cells make remaining glioblastoma cells more aggressive and therapy-resistant

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Ichiro Nakano, M.D., Ph.D.

A surprising form of cell-to-cell communication in glioblastoma promotes global changes in recipient cells, including aggressiveness, motility, and resistance to radiation or chemotherapy.

Paradoxically, the sending cells in this signaling are glioblastoma cells that are undergoing programmed cell death, or apoptosis, according to research by a team at institutes in the United States, Russia and South Korea.

The dying cancer cells send their signals by means of extracellular vesicles induced and released during apoptosis. These vesicles — small, membrane-bound blobs known as exosomes — carry components that alter RNA splicing in the recipient glioblastoma cells, and this altered splicing promotes therapy resistance and aggressive migration.

This mechanism thus becomes a possible target for new therapies to treat glioblastoma, a primary brain cancer, and the mechanism may apply to other cancer types as well.

“Clinically, our data may provide the rationale to the molecular targeting of RNA splicing events or specific splicing factors for novel cancer therapies,” said Ichiro Nakano, M.D., Ph.D., leader of the international study being published in Cancer Cell. “This may lead to decreased acquisition of therapy resistance, as well as reduction in the migration of cancer cells.”

Nakano is an academic neurosurgeon at the University of Alabama at Birmingham who conducts both brain tumor translational research and clinical brain tumor surgery. He is professor of neurosurgery in the UAB School of Medicine and a senior scientist for the UAB Comprehensive Cancer Center.

Glioblastoma exhibits invasive behavior, abrupt growth and poor patient survival. As the number of the cancer cells rapidly increases, abundant apoptotic tumor cells are intermingled with neighboring proliferating tumor cells. The apoptotic cells can account for up to 70 percent of the tumor cell population.

The discovery of this unusual cell-to-cell communication began with a simple experiment — injecting a combination of lethally irradiated human glioblastoma cells, which makes them apoptotic, and “healthy” glioblastoma cells into a mouse xenograft model. This combination led to much more aggressive tumor growth, as seen in brain scans, compared to “healthy” glioblastoma cells or irradiated glioblastoma cells alone. The combination was also more therapy-resistant.

The UAB researchers and colleagues found that, after induction of apoptosis, glioblastoma cells shed significantly higher numbers of exosomes with larger average sizes.

Those apoptotic exosomes, when combined with “healthy” glioblastoma cells, significantly increased tumor growth in the xenograft model and cell motility in bench experiments. Also, while the “healthy” glioblastoma cells alone had a clear border between the tumor and adjacent normal tissue in the xenograft, the glioblastoma cells co-injected with apoptotic exosomes invaded into adjacent brain tissue. Exosomes shed by non-apoptotic cells did not have these effects.

To discover the mechanism underlying these changes, the researchers looked at what was inside the apoptotic exosomes. The vesicles were enriched with spliceosomal proteins and several U snRNAs — parts of the cellular machinery that remove introns from pre-messenger RNA.

These are normally confined to the nuclei of cells; but the Nakano team found that, as the glioblastoma cells underwent apoptosis, the spliceosomal proteins were transported out of the nucleus to the cell cytoplasm, where they could be packaged into vesicles for release.

Glioblastoma cell subtypes include the proneural subtypes and the mesenchymal subtype. Recent data have shown that, after therapy, glioblastoma cells shift from the less aggressive proneural subtype to the more aggressive and therapy-resistant mesenchymal subtype. The researchers found that apoptotic exosomes induced substantial alternate RNA splicing in recipient cells that resembled the splicing patterns found in the mesenchymal glioblastoma subtype.

Part of this was caused by the splicing factor RBM11, which is encapsulated in the vesicles. The researchers found that exogenous RBM11 caused upregulation of endogenous RBM11 in the recipient cells and activated glycolysis. Overexpression of RBM11 increased the migration of glioblastoma cells.

They also found that RBM11 altered RNA splicing to produce an isoform of the protein cyclinD1 that promotes DNA repair and an isoform of the protein MDM4 that has significantly higher anti-apoptotic activity. These changes can make the cells more therapy-resistant.

Examination of the Cancer Genome Atlas database showed that elevated expression of those two isoforms is associated with poor prognoses for glioblastoma patients.

Finally, the Nakano-led team looked at paired glioblastoma specimens of primary and recurrent tumors from matched patients. In most of the 43 pairs of matched samples, the RBM11 protein levels were substantially higher in the recurrent glioblastoma compared to the original, untreated tumors. In two other patient cohorts, they found that the higher RBM11 levels correlated with poor post-surgical survival for glioma patients.

Beside Nakano, co-authors of the paper, “Apoptotic cell-derived extracellular vesicles promote malignancy of glioblastoma via intercellular transfer of splicing factors,” are Marat S. Pavlyukov, Hai Yu, Soniya Bastola, Mutsuko Minata, Suojun Zhang, Jia Wang, Svetlana Komarova, Jun Wang, Shinobu Yamaguchi and Heba Allah Alsheikh, UAB Department of Neurosurgery; Victoria O. Shender, Ksenia Anufrieva, Nadezhda V. Antipova, Georgij P. Arapidi, Vadim Govorun, Nikolay B. Pestov and Mikhail I. Shakhparonov, the Shemyakin-Ovchinnikov Institute of Bioorganic Chemistry, Moscow, Russia; Yeri Lee, Yong Jae Shin and Do-Hyun Nam, Sungkyunkwan University School of Medicine, Seoul, Korea; Ahmed Mohyeldin, Junfeng Shi and L. James Lee, Ohio State University, Columbus, Ohio; Dongquan Chen, UAB Division of Preventive Medicine; Sung-Hak Kim, Chonnam National University, Gwangju, Korea; and Evgeniy G. Evtushenko, Lomonosov Moscow State University, Moscow, Russia.

This work was supported by NIH grants NS083767, NS087913, CA183991 and CA201402; Russian Foundation for Basic Research grants 16-04-01414, 16-04-01209 and 17-29-06056; and Russian Science Foundation grants 17-75-20205 and 16-14-10335; and by the Scholarships of the President of the Russian Federation SP-4811.2018.4.

At UAB, Nakano surgically cares for brain tumor patients. For any questions about his clinical program, call 205-996-2098 during working hours or 205-572-9703 at night or on weekends.

“This career move saved my life”

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Powell noticed a tiny nodule near the hook of her jaw that had not been there before.

After an eight-year struggle to figure out why a lump formed under her jaw, to say Valerie Powell believes all things work together for good is an understatement.

In 2009, Powell, program coordinator in the University of Alabama at Birmingham’s Department of Radiation Oncology, noticed a tiny nodule near the hook of her jaw that had not been there before. She assumed it must be a side effect of the several Novocain shots she received at the dentist for a cavity filling. After calling her doctor, Powell received regular CT scans, which provided no further insight.

After six years, Powell’s mother was diagnosed with breast cancer, which led to Powell’s wanting another CT scan for her nodule.

“I figured after Mom’s diagnosis and the fact this little nodule had obviously gotten angrier in size and tenderness that I should check on things again,” she said.

Her doctors determined that she had an extra piece in her parotid gland and advised her not to worry.

Things began to change for Powell after she landed her program coordinator job in UAB Radiation Oncology in March 2017. She started researching oncology protocols as part of her duties, and the first protocol she reviewed was a salivary gland tumor study, which persuaded her to try another CT scan from a different clinic, which also proved to be inconclusive. She also received an MRI, which showed the same results.

Powell knew something was wrong and demanded answers.

“I was pretty frustrated, so I emailed one of our radiation oncologists at UAB and explained that two doctors at a different local hospital were unable to figure out what it was,” she said. “I asked if he could take a look at my scans.”

valerie powell carroll

Valerie and William Carroll, M.D.

Soon after, Powell found herself scheduling an appointment with Department of Otolaryngology Chair and Comprehensive Cancer Center Senior Scientist William Carroll, M.D. The nodule in question was diagnosed as pleomorphic adenoma — a common benign salivary gland tumor.

“We scheduled surgery to remove the tumor because Dr. Carroll said he would remove it no matter what if I were his family member,” she said. “From the moment I met Dr. Carroll, he did feel like family. He’s always been patient and understanding, and he’s always done his absolute best to make sure I left his office confident and comfortable with the care I was receiving, and I would say that that’s hard to find.”

After the tumor was removed and pathology tests returned, it was determined that the tumor wasn’t actually benign; it was malignant.

“I was flooded with questions in my head like ‘Why did a CT, an MRI and a needle biopsy all confirm that my tumor was benign when it was in fact cancerous,’” Powell said. “Why was this happening to me at 28 when I’ve barely been married two and a half years, and why had no one paid more attention to this knot in my neck for the last seven years since it had shown up?”

valerie powell heels

Powell only had to take a few steps from her office to her radiation treatment.

The more she thought about it, Powell says, her faith reassured her that things worked out the way they were supposed to.

“I was supposed to go into surgery knowing it was benign because my little heart couldn’t have handled going into surgery knowing that I had let something dangerous live inside of me for that long,” she said. “God knew I needed the excitement of getting it out to carry me into that operating room with peace and a feeling of security.”

In September of 2017, Powell began seeing Sharon Spencer, M.D., professor in the Department of Radiation Oncology and senior scientist with the Comprehensive Cancer Center, for her radiation treatments. It was a familiar setting for Powell since she walked the path every day to her office, which resides just a few steps from patient care areas. She worked closely with Spencer in the months leading up to her diagnosis and treatment.

“This was kind of a neat plot twist in the workplace because I showed up to see Dr. Spencer as a patient instead of needing her signature,” Powell said.

After six weeks of daily radiation, Powell’s co-workers threw her a party to celebrate her final day of treatment.

“When I saw 50-plus people crammed in our break room yelling congrats at me, I lost it,” Powell said. “People from every single department — physicians, residents, billing, check-in, dosimetry, therapy, social work, administration and physics. They had all come for me, and right in the middle was my precious husband, K.T., my parents and my brother.”

Powell credits many people — at work and at home — who helped dry her tears, listened to her worries, and saw how the effects of radiation affected her physically and mentally. She says it was a hard road, but it was exactly where she was supposed to be.

“This was the road that led me to the career I never knew I needed,” she said, “and the career move that saved my life.”

Powell hopes to empower cancer patients and survivors through her blog where she documented her treatment and recovery. Click here to follow her journey.

Nation’s top cancer centers to endorse elimination of HPV-related cancers

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Michael Birrer, M.D., Ph.D.

Nearly 80 million Americans — one out of every four people — are infected with the human papillomavirus, and more than 31,000 will be diagnosed with an HPV-related cancer this year. Despite the availability of a vaccine to prevent the infections that cause these cancers, HPV vaccination remains low in the United States.

The UAB Comprehensive Cancer Center has partnered with 69 other National Cancer Institute-designated cancer centers to issue a statement urging for increased HPV vaccination and screening to eliminate HPV-related cancers, starting with cervical cancer. These institutions collectively recognize insufficient vaccination as a public health threat and call upon the nations’ health care providers, parents and adolescents to take advantage of this rare opportunity to eliminate several different types of cancer in men and women.

“We have the opportunity to eliminate multiple HPV-related cancers beginning with cervical cancer,” said Michael Birrer, M.D., Ph.D., director of the UAB Comprehensive Cancer Center. “To accomplish this goal, we need to utilize our most important tool — HPV vaccination. We hope our collective action as NCI-designated cancer centers will educate and motivate the public and highlight this tremendous opportunity we have to eliminate a preventable cancer.”

Vaccination rates remain significantly lower than other recommended adolescent vaccines in the United States. According 2016 data from the Centers for Disease Control, less than 50 percent of girls and 38 percent of boys completed the recommended vaccine series. Research shows there are a number of barriers to overcome to improve vaccination rates, including a lack of strong recommendations from physicians, and parents’ not being properly informed that this vaccine protects against several types of cancer in men and women. HPV causes multiple cancers, including cervical, anal, oropharyngeal (middle throat) and other genital cancers.

warner huh

Warner Huh, M.D.

Warner Huh, M.D.UAB has been at the forefront of conducting groundbreaking cancer research, especially in developing the HPV vaccine. Warner Huh, M.D., director of the UAB Division of Gynecologic Oncology and senior medical officer for the cancer service line at the UAB Comprehensive Cancer Center, has tested several HPV vaccines. He was one of the first to test Gardasil, the first U.S. Food and Drug Administration-approved vaccine for the prevention of cervical cancer and genital warts. Huh was a lead author with a multinational study of a new nine-valent HPV vaccine that has even further potential to dramatically reduce rates of cervical cancer and perhaps eliminate cervical cancer screening altogether.

“There is no question that the vaccine works,” Huh said. “We now have a second-generation vaccine that protects against 90 percent of the HPV that are associated with cervical cancer. This vaccine can literally eradicate the majority of cervical cancer, if given widely and appropriately.

“We need health care providers to stand with us and recommend the HPV vaccine. Parents can join with us by asking their doctors about the vaccination.”

HPV experts from the nation’s top cancer centers, including the UAB Comprehensive Cancer Center, along with partners from the NCI, CDC and the American Cancer Society, are meeting June 7-8 in Salt Lake City to discuss a path forward to eliminating cancers caused by HPV, including ways to reduce barriers to vaccination, as well as share education and training strategies to improve vaccination rates.

“In addition to being at the forefront of research, the UAB Cancer Center along with multiple stakeholders across the state established the Alabama HPV Vaccination Coalition, which has been a model for other states across the country,” said Isabel Scarinci, Ph.D., professor in the UAB Division of Preventive Medicine and associate director for Globalization and Cancer at the UAB Comprehensive Cancer Center.

“This movement is no longer just in the hands of the medical community, as cervical cancer screening and vaccination discoveries are already in existence,” she said. “There are many socio-economic and cultural reasons that stand in the way of adherence. But I am optimistic that we can legitimately move the needle as the scientific, public and private sectors combine efforts and expertise, with Alabama’s being one of the leaders in this effort.”

This is the third year that all NCI-designated cancer centers have come together to issue a national call to action. All 70 cancer centers unanimously share the goal of sending a powerful message to parents, adolescents and health care providers about the importance of HPV vaccination for the elimination of HPV-related cancers.

Novel procedure shortens stay for melanoma patients

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Carlo Contreras, M.D.

Lisa Chappell enjoys the summer sun, spending time outside and relaxing on the Coosa River at her Gadsden residence. Now, after being diagnosed with melanoma in 2015, she is much more cautious about her outdoor habits.

Chappell noticed a mole on her upper thigh had changed color and immediately visited her dermatologist. She was quickly advised to visit doctors at the University of Alabama at Birmingham, where she met with Carlo Contreras, M.D., assistant professor in the Division of Surgical Oncology and associate scientist with the UAB Comprehensive Cancer Center. Chappell met all the criteria for persons who are at risk for developing melanoma — red hair, light skin tone and chronic sun exposure.

“I was scared because I have a history of cancer in my family,” Chappell said.

Melanoma is highly capable of spreading and can be deadly rapidly if not treated.

Skin moles are very common, and fortunately the vast majority of skin moles do not transform into melanoma. Melanoma often appears as an enlarging skin mole, either flat or raised. Moles containing melanoma are usually darkly pigmented, but can take on a variety of colors. In addition to rapid growth, moles with an asymmetrical shape or irregular borders are also concerning. Overall, new or changing moles should be examined by a dermatologist, surgeon or primary care physician.

Chappell and her husband David

C. Blake Phillips, M.D., an assistant professor in the UAB Department of Dermatology, did not treat Chappell, but says anyone with areas of concern on their skin should see a dermatologist.

“You should see a doctor if you are concerned that a lesion is changing, is newly symptomatic or is non-healing,” Phillips said. “If you have a first-degree relative with melanoma or you have many dark moles, it’s a good idea to have a baseline skin exam by a dermatologist.”

Chappell’s mole was removed, and after testing, results showed that the melanoma had unfortunately spread to her lymph nodes. Contreras suggested a minimally invasive type of lymph node removal for her melanoma in the groin and in the pelvis. This unique operation is one Contreras developed at UAB’s Comprehensive Cancer Center and is not offered anywhere else in Alabama.

“The traditional operation for Lisa would have involved about a 12-inch incision that starts in the abdomen, goes over the groin and ends in the upper part of the thigh,” Contreras said. “The traditional operation usually involves a three- or four-day hospital stay and a considerable recovery period of several weeks at home.”

Contreras’ minimally invasive approach uses six small, laparoscopic incisions, and patients can usually go home the next morning. The recovery at home is much quicker, meaning patients can get back to doing the things they love earlier, or they can start chemotherapy earlier if that is part of their regimen.

“The recovery was great for me,” Chappell said. “I was only in the hospital for one night. I don’t like to take pain pills, and this procedure didn’t really leave me all that sore.”

Chappell says she now takes all the necessary precautions — like wearing sunscreen with a SPF value of 30 or higher every day and wearing a hat and sunglasses — to ensure she doesn’t have to have another scare.

“I still love relaxing by the river, but now I always reapply sunscreen and make sure I’m doing things the right way,” she said.

Doctors in the Division of Surgical Oncology are committed to providing personalized, comprehensive care for patients with a broad array of benign and malignant tumors, often working in collaboration with other departments across UAB’s medical campus to guide patients through the surgical decision-making process and provide innovative, advanced diagnostic and therapeutic options.

Softball player’s resilient spirit recognized through ovarian cancer treatment

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Mississippi State freshman outfielder Alex Wilcox

When watching the Mississippi State softball team take the field this spring, it would be tough to tell that freshman outfielder Alex Wilcox is actively undergoing chemotherapy treatment. The 18-year-old Brantley, Alabama, native has been battling ovarian cancer since December 2015, juggling her Division I softball commitments and chemotherapy regimens at the University of Alabama at Birmingham with unmatched resiliency.

It started when Wilcox, a junior in high school at the time, felt abnormal pain in her side. She chalked it up to appendicitis; but after being rushed to the nearest emergency room, she and her family knew something was not right. Their suspicions were confirmed when the pain Wilcox was experiencing was diagnosed as ovarian cancer, specifically granulosa cell tumor of the ovary.

“You hear people say this, but you never think something like that will happen to you,” Wilcox said. “I had heard a lot about other cancers over my lifetime; but I didn’t know much about ovarian cancer at all, let alone that it could develop in girls my age.”

After she was referred to UAB’s Division of Gynecologic Oncology, Wilcox’s care and treatment plan began with a surgery to remove her tumor, and rounds of chemotherapy and surgeries to follow. All the while, Wilcox was still making strides on the softball field, inking her commitment to the Mississippi State softball team in fall of 2016 while in the throes of intense treatment.

Now, two years after her initial diagnosis, Wilcox is living out her dream by taking the field each week with the Bulldogs in Starkville. Her treatment has been personalized to enable her to compete if she is up to it, but her care team at UAB credits her ability to play to her unparalleled tenacity.

The Mississippi State Bulldogs have donned teal uniforms all season in support of Wilcox, right, while raising awareness about ovarian cancer with their fans.

“What Alex has gone through is nothing short of remarkable, and she is surrounded by teams both here at UAB and at Mississippi State that are working to keep her healthy and able to live out her dream of competing at the highest level,” said Warner K. Huh, M.D., director of UAB’s Division of Gynecology Oncology and Wilcox’s oncologist. “Her involvement as an athlete has given us tangible goals to meet, but her drive and spirit are really what have made the difference. I’ve never worked with a patient before who has the type of bravery and patience that Alex has.”

While ovarian cancer tends to be uncommon in young women and teenagers, Wilcox’s particular cancer is incredibly rare.

According to the American Cancer Society, 22,240 women will be diagnosed with ovarian cancer in 2018. Ovarian cancer is often known as the “silent killer,” as many of its symptoms tend to be ones that women experience as nonspecific symptoms or with menstruation, but Huh wants women to understand that paying attention to their own bodies can be the best detector.

“Women may experience symptoms like bloating, cramping or nausea regularly; but it’s when it turns chronic that there is an indicator that something is not right. Women are the only ones who can judge their symptoms and know when they are experiencing a legitimate bodily change, so we encourage them to always speak up and seek clinical advice if something doesn’t appear right — it could be what saves their life.”

For Wilcox, going through her cancer at this phase in her life has not been easy; but having strong teams behind her has made all the difference. The softball team at Mississippi State has even launched a campaign in her honor appropriately titled “No One Fights Alone,” wearing special teal team jerseys each week to shed light on ovarian cancer and in support of her fight, a campaign that her care team at UAB have also rallied behind.

“Since day one of treatment, my care team at UAB has shot everything to me straight and outlined how we are going to work through this together, just as my teammates have supported me during this time on and off the field,” Wilcox said. “Whether I’ve been able to play or had to watch from the sidelines, all of my teams have made the difference and made me realize that I really am not fighting this alone.”

Local eighth-grader gets hands-on experience on her two passions — robotics and surgery

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When Cieasha Jones, 13, attended Wednesday’s 10,000th robotic surgery milestone event at the University of Alabama at Birmingham, she had no idea she would have the opportunity to experience one-on-one simulated surgical training with renowned UAB surgeons.

But that is exactly what happened for Cieasha, an eighth-grader at Oak Mountain Middle School. She has aspired to be a surgeon since she was a young girl, but Cieasha also has a passion for robotics. In fact, she is a member of Oak Mountain’s world championship robotics team. When her mother, Cieara Jones, R.N., a nurse in UAB’s Cardiovascular Intensive Care Unit, saw an email about the robotic surgery event at UAB, she thought Cieasha would enjoy attending and learning how her two passions could collide in the real world.

“I checked my email and saw that this event was taking place and thought ‘there’s no harm in going,’” Cieara said. “I’m just trying to find ways to help Cieasha on this journey and thought seeing firsthand what robotic surgery is about would be a neat experience.”

After the event concluded, Cieasha tested the Intuitive Surgical daVinci simulator when Kenneth Kim, M.D., associate professor in the School of Medicine’s Division of Gynecologic Oncology and director of Robotic Surgical Education and Training, struck up a conversation about her passion. From there, he pulled her aside to walk her through individualized simulated training and teach her along the way how robotic surgery works.

“It was amazing [to replicate robotic surgery],” Cieasha said. “I sort of knew that robotics played a role in surgery, but I didn’t realize it had this big an impact. This was a great experience that I never thought I would be able to get.”

With Kim’s assistance, Cieasha was able to use the daVinci surgery simulator to conduct a virtual hysterectomy, with other Department of Surgery surgeons like John Porterfield, M.D., associate professor and director of UAB’s General Surgery Residency Program, watching along and coaching her through the computer-generated procedure.

“It was easy teaching her, as she has an intuitive knack and feel for this and has the hand-eye coordination already,” said Kim, a member of UAB’s Comprehensive Cancer Center. “She is young, but age doesn’t matter if you have the right talent. It’s our job as educators to identify where trainees are and bring them to where they need to be. She already has the hand-eye down, so she has a leg up.”

While Cieasha has many years to go before she can become a surgeon, she is committed and dedicated to her dream. When asked if this experience motivated her even more to pursue a career in medicine, Cieasha replied, “Absolutely. It is set in stone.”

UAB Cancer Center scientists present pioneering research at ASCO national meeting

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A team of physicians and scientists from the UAB Comprehensive Cancer Center will present some of the latest advances in cancer research to more than 32,000 oncology professionals from all over the world during the annual meeting of the American Society of Clinical Oncology in Chicago from June 1-5.

UAB Cancer Center investigators are authors on 56 abstracts accepted by ASCO for the annual meeting. Many UAB presentations will deliver discoveries expanding on the reach of precision medicine. Topics range from new drug combination therapies to investigator initiated pilot studies that show promising outcomes. Cancer Center members who are lead authors include Rebecca Arend M.D., gynecologic oncology; Luciano Costa, M.D., multiple myeloma; Andres Forero, M.D., breast cancer and lymphoma; Ravi Paluri, M.D., gastrointestinal cancers and tumor biology; Erica Stringer-Reasor, M.D.,breast cancer; Grant Williams, M.D. gastrointestinal cancers and outcomes for geriatric cancer survivors; and Eddy Shih-Hsin Yang M.D., Ph.D., precision oncology and tumor profiling.

This year, Smita Bhatia, M.D., MPH, director of the UAB School of Medicine’s Institute for Cancer Outcomes and Survivorship, will be named a Fellow of ASCO. This distinction recognizes ASCO members for their extraordinary volunteer service, dedication, and commitment to ASCO.

Additionally, Gabrielle Rocque, M.D., has been named the chair of the ASCO Quality of Care Committee. She will also serve on the editorial board of ASCO’s Journal of Oncology Practice.

Detailed information on all UAB abstracts is online — search University of Alabama at Birmingham.

UAB leads the nation in robotic surgeries after more than 10,000

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This April, the University of Alabama at Birmingham surpassed the 10,000 robotic surgeries mark, a feat that helps make UAB the leader in robotic surgery volume in the country. For surgeons within UAB Medicine, a collaborative spirit and the willingness to work together across many disciplines helped push the hospital over this incredible milestone and into a new frontier of surgery.

“Surpassing 10,000 robotic surgeries is reflective of a joint commitment made by many surgeons and hospital administrators alike to demonstrate UAB’s mission pillars, from education to innovation, community engagement to patient care,” said Jeffrey Nix, M.D., assistant professor in UAB’s Department of Urology and associate scientist at the UAB Comprehensive Cancer Center. “We are constantly thinking through how as a team we can continue to enhance patient experiences and make innovative strides in our respective fields, which ultimately reflects back on UAB as a leading health care provider.”

At UAB, robotic surgery is a cornerstone in many disciplines, including urology, cardiothoracic surgery, gynecologic oncology, general surgery, otolaryngology, head and neck surgery, endocrine surgery, and surgical oncology, as well as women’s reproductive health. Rather than focusing efforts on select specialties, the well-rounded approach promotes cross-collaboration among surgeons and has helped UAB push the envelope with technology to provide patients unmatched minimally invasive, quality surgical care.

“What makes our approach unique is that a patient may need to have rectal surgery, while at the same time part of his bladder may need to be removed,” Nix said. “Instead of having to have two surgeries that require separate and challenging recovery periods, we can complete both in one surgery through minimally invasive methods that speed up recovery time, cause less pain and leave minimal scaring. Across departments, we are constantly communicating and working together to deliver the best care possible.”

In reaching the 10,000 surgeries, UAB surgeons have gone beyond just performance to make lasting impacts on the field and future of robotic surgery. For instance, William Carroll, M.D., chair of UAB’s Department of Otolaryngology and senior scientist at the UAB Comprehensive Cancer Center notes that the department has been pivotal in the support of head and neck cancer robotic surgeries, as data collected at UAB were used by the FDA to grant approval for robotic surgeries of the head and neck specifically. Renowned surgeons like Robert Cerfolio, M.D., former chief of Thoracic Surgery at UAB, have helped to develop guidelines and standards that have and will continue to influence the field as we know it.

Another unique aspect of UAB’s robotic surgery division includes one-of-a-kind training to which only UAB residents have exposure. In noticing that most residents had access to robotic training only once a year if at all, Kenneth Kim, M.D., associate professor in the Division of Gynecologic Oncology, was tasked with revamping the existing robotic surgery training curriculum.

“Surgery in its basic form is a combination of skill and technique, used in a logical fashion to complete a surgery safely and successfully,” Kim said. “It’s critical that, in addition to learning the ‘how’ of procedure basics, residents are learning the ‘how’ in surgical tools and techniques. The how — in conjunction with consistent simulation to training — is what enables residents to become comfortable with and proficient in robotic surgery.”

Kim’s revisions to the gynecologic resident training gave residents one-on-one training sessions with him on a quarterly basis. Through this, he was able to track data over a year’s time and quantifiably show that, with individualized attention, his residents’ skillsets improved tremendously — enough to convince Intuitive Surgical, the maker of the daVinci Surgical System, to provide UAB with its own robotic surgery simulator with updated and exclusive simulation software that will be used to train residents across multiple surgical disciplines.

With a shared mindset that resident education needed to have a strong focus on robotic surgery training, surgeons across many fields have come together to work toward a common goal of advancing curriculum for residents of all years and specialties.

“We pride ourselves on being early adopters and innovators, and knew it was critical to change the theory that robotic surgery should be used exclusively by chief surgeons,” said John Porterfield, M.D., associate professor and director of UAB’s General Surgery Residency Program. “We wanted to give our residents the tools and time to familiarize themselves with the robot and training as often as possible, which has set UAB’s residents apart nationwide in terms of comfort and skill in robotic surgery specific to their fields. We have been able to prove that the extra attention our residents are given has helped UAB lead the way in a responsible manner that ultimately benefits our patients and the quality of care they receive.”

Porterfield also attributes UAB’s success in reaching the 10,000 robotic surgery milestone to the joint relationship between surgeons and hospital administrators.

“We have found a great balance where surgeons and hospital administrators have mutual understandings about each other’s interests so that, ultimately, our patients are the ones who benefit most at the end of the day,” Porterfield said. “The ‘rising tide floats all boats’ mindset has enabled all involved with robotic surgery to leave a legacy and frame groundwork that will continue to leverage UAB’s innovative offerings to patients on a local to international scale.”

UAB surgeons feel a particular responsibility to continue to serve as leaders in the field. Knowing that ongoing research, technological advances and collaborating are keys to success, Nix says working together to meet quantifiable goals and training the next wave of surgeons at the highest level will continue to give UAB a competitive edge.

“At the end of the day, we are committed to increasing surgery volumes while simultaneously increasing positive patient outcomes,” Nix said. “We are confident that our continued successes will keep UAB’s name synonymous with top robotic surgery care, and hope that we can continue to lead by example in our next 10,000 surgeries.”

Huh named senior medical officer of cancer service line

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Warner K. Huh, M.D., an internationally respected gynecologic oncologist at UAB Medicine, was appointed senior medical officer for the cancer service line at the UAB Comprehensive Cancer Center.

Michael J. Birrer, M.D., Ph.D., director of the Comprehensive Cancer Center, says “It is a great pleasure to work with Dr. Warner Huh as the physician leader of the UAB cancer service line. Dr. Huh will assist in the design implementation and operation of the cancer service line, which is critical to the future success of the cancer center and the care of our patients.”

Dr. Huh’s appointment is effective immediately. “It’s truly an honor and a privilege to be a part of the leadership team for cancer care at UAB. This institution has a longstanding, rich, and productive history in the area of cancer treatment and research,” Dr. Huh says. “It’s important to remember that UAB was one of the very first NCI Comprehensive Cancer Centers in the U.S. Given the current needs of our patients and the considerable future impact cancer will have on our population, it’s imperative that we continue to grow and develop a world-class cancer program that will provide superlative, compassionate care and serve as the standard bearer for the region.”

Dr. Huh’s new responsibilities will be in addition to his current roles as professor and vice chair of Gynecology; director of the Division of Gynecologic Oncology; the Margaret Cameron Spain Endowed Chair in the Department of Obstetrics and Gynecology; professor in the Department of Surgery; professor in the Department of Epidemiology at the UAB School of Public Health; and senior scientist at the UAB Comprehensive Cancer Center.

The heart of cancer care and survivorship

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From left: Garima Arora, M.D., Carrie Lenneman, M.D., and Riem Hawi, M.D.

Patients who develop cardiac side effects from traditional cancer therapies will now have a new place to receive specialized treatment at the University of Alabama at Birmingham.

The new cardio-oncology program at UAB is the only one of its kind in Birmingham and northeast Alabama. Although the number of cancer survivors continues to grow, cardiovascular disease is the second leading cause of death in survivorship. The cardio-oncology program works closely with UAB oncologists, cancer survivorship programs and cancer rehabilitation specialists to return survivors to a high quality of life and improve the cardiac outcomes.

“Through a detailed history and innovative techniques such as strain echocardiography, cardiac MRI, angiography, nuclear imaging and cardiac biomarkers, we identify cancer patients at high risk for cardiovascular complications and work to minimize potential cardiotoxicity,” said Carrie Lenneman, M.D., associate professor in the Division of Cardiovascular Disease.

Heart disease, cancer and strokes continue to be the highest causes of death in the state of Alabama. Through the use of cardioprotective medications and close monitoring, patients can keep receiving necessary chemotherapeutic agents while minimizing their risk for developing heart disease.

“Heart disease in cancer survivors is the second leading cause of death behind recurrent cancer, thus cardio-oncology programs are well-suited to helping cancer survivors,” said Riem Hawi, M.D., assistant professor in the Division of Cardiovascular Disease.The cardio-oncology program also focuses on cancer survivors with modifiable risk factors or pre-existing cardiac disease. The goal is to provide comprehensive care focused on maintenance or prevention of cardiovascular disease with incorporation of healthy lifestyle factors and medical treatment.

Lenneman says pairing cardiology and oncology is unique, but the need for this program is important.

When a patient is diagnosed with cancer, the patient needs timely coordination or care. The cardio-oncology clinics help facilitate timely cardiac evaluation and cardiovascular diagnostic testing. Lenneman says opening the cardio-oncology clinics has decreased wait times to nine days for cancer patients to see a cardiovascular specialist, with many patients seen the same day to facilitate coordination of multiple visits or out-of-state referrals.

Lenneman says the new clinic is just the first step in helping cancer patients with cardiovascular health needs.

“Down the road, we would like to develop collaborative research in UAB cardio-oncology emphasizing improved cardiovascular surveillance in cancer patients,” Lenneman said. “Additionally, we would like to expand the number of locations we hold clinics and implement telemedicine to decrease the burden of long travel times and coordination of care.”

The clinic is open in the afternoon every Tuesday, Wednesday and Thursday at The Kirklin Clinic and every other Tuesday and Friday morning at the Birmingham VA Hospital. To learn more, visit the official UAB Medicine website.

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Beena Thannickal
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205.975.3967
beenat@uab.edu

 

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