The Culture of Different MKTG_150064494_2018 Service Line Big Book Full_FIN | Page 20

A Step
Ahead of
Papi’s Cancer
Charity Martinez didn’t see any need for a CT scan. Of course,
she knew there was something going on with her 20-month-old son.
He didn’t sleep well. He’d wake up screaming. He tugged at his left ear.
He vomited more than seemed normal. It was probably some kind of virus.
A mechanism to
understand the tumor
The Neuro-Oncology Program at Children’s
Colorado — one of the largest teams of its kind
in the nation — couldn’t offer a clear prognosis
without a tissue sample. But they had some clues.
Papi’s issues with vomiting and persistent pain had
been ongoing for the better part of a year, and the
MRI showed a low rate of diffusivity — both solid
indicators of a slow-growing mass.
“His brain was compensating remarkably well
considering the tumor’s enormous size,” says
Dr. Hoffman.
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On the other hand, Papi had a worrisome area of
metastasis on his spine.
It wasn’t his brain. She was sure of that.
Everyone else seemed sure of it, too. Their pediatrician sent them
to Children’s Hospital Colorado for the scan “just in case,” and the
radiology tech assured her and her husband, Josh Sr., they’d be out of
there as soon as possible.
But when Josh Jr. — who everyone called Papi — came out, the tech
asked them to wait a few more minutes. An uneasy feeling settled in
Charity’s gut. She could see the tech behind the glass of the control
booth, on the phone. She glanced at her husband. She could tell he
felt it too.
After a moment, the tech walked them back to the atrium and
asked them to wait. They waited for what seemed like forever.
Papi got fussy. Charity was walking him around when pediatric
oncologist Lindsey Hoffman, DO, called them back in. She showed
them the scans.
Papi had a brain tumor the size of a softball. He’d be direct-admitted
for monitoring and more imaging. He’d get steroids to soothe the
inflammation the tumor was causing in his head.
“It hurt me bad,” Josh recalls.
Charity’s mother had passed away after a six-year battle with cancer
earlier that year. She couldn’t believe it was happening to her son. She
called her older sister, a nurse, who tried to reassure her Papi’s tumor
might be benign, but she knew that couldn’t be. Dr. Hoffman was an
oncologist. Oncologists treated cancer.
“There’s less risk if you biopsy first and get an idea of
what you’re dealing with, and in some cases that’s
the best way to go,” says Todd Hankinson, MD, Papi’s
pediatric neurosurgeon. “In this case, our thought
was that we needed to try at the very least to take
out as much of the tumor as we could, just because
it was taking up so much space in his head.”
Cancer
Neurology and
Neurosurgery
Pathology
Since Papi was clinically stable, Drs. Hoffman
and Hankinson made the case for scheduling a
resection the following week. The family agreed.
Then they went home to wait.
Tumor cells with
autophagy level
rendered in brown.
When starved (bottom),
cells increase their use of
autophagy to survive.
Meanwhile, Dr. Hankinson pored over the imaging.
The tumor blanketed the left side of Papi’s brain,
enfolding critical blood vessels, which put him at
risk for stroke. The team couldn’t be sure of the
tumor’s relationship to the pituitary gland or the
optic nerves, but they knew it had spread into the
ventricles, which could put the brain’s ability to
absorb cerebrospinal fluid at risk.
Given the metastasis on Papi’s spine, though, a
100 percent resection wouldn’t be possible. Dr.
Hankinson would take out as much as he could while
minimizing the risk of damage to the brain tissue.
The operation started early in the morning. Dr.
Hankinson cored out the middle of the tumor first,
coaxing it to collapse to get a better idea of where
the normal brain tissue ended and the tumor
tissue began.
Then he handed off a tissue sample to a pathology
technician, who sunk it in liquid nitrogen and
walked it to the pathology lab. Another portion
would later make it across campus to the lab of
Bette Kleinschmidt-DeMasters, MD, Director
of Neuropathology at Children’s Colorado. Dr.
Kleinschmidt-DeMasters would run the molecular
pathology, while another portion of the sample
would go into a biobank started by pediatric
oncologist Nick Foreman, MD, and neurosurgeon
Michael Handler, MD, in 1995.
“Sometimes the removal of a tumor is curative and
sometimes it’s not,” says Dr. Handler. “Mostly it’s
not, which is why it’s critically important for us as
surgeons to get involved in research, to set up a
mechanism to understand these tumors.”
Papi’s resection would not be curative.
The metastasis made sure of that. In many
ways, the team’s work had just begun.
Targeting the genetic
pathways of cancer
After a nine and a half-hour operation, Papi woke
up and wanted a Pepsi.
Charity laughs. “That’s when we knew he was going
to be okay.”
The histology, too, was encouraging: pilocytic
astrocytoma, the least aggressive form of glioma.
The day after Papi went home, the team’s seven
core oncologists and neurosurgeons, along with
a cast of neuropathologists, radiologists and
others, convened to talk through his case — as
they do every week, with every new case and
every relapse.
Low-grade gliomas proliferate via the mitogen-
activated protein kinase — or MAPK — pathway,
a chain of proteins that ferries a signal from the
surface of the cell to the nucleus, which triggers
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