Synergy: Optimizing outcomes through teamwork
The patient, a 61-year old female, was having her chronic back and sacroiliac pain managed successfully by The Montana Center for Wellness and Pain Management. During a routine follow-up she began to complain of a new pain different in type, intensity and location. She described it as knife-like and radiating from between her shoulder blades around her rib cage to just below her breast on the right. To investigate this new and progressive complaint an MRI of the thoracic spine was ordered. The MRI revealed a posterior chest lesion centered at T6. A CT of the chest, abdomen and pelvis demonstrated this was a solitary soft tissue mass spanning the posterior right T6 and T7 ribs with lytic boney changes. She subsequently underwent a CT-guided needle biopsy. The pathology was reported as spindle cell sarcoma. This pathology is best treated with radical resection including, if possible, margins (a portion of normal tissue) free of tumor. The patient was seen in consultation by the hematology and oncology services who recommended she have surgery. She was then referred to thoracic surgery.
The thoracic surgeon assembled a comprehensive surgical team. To be successful, and to include in the resection the appropriate tissue margins, there would be significant soft tissue loss (requiring reconstruction) and the release of the tumor from its spinal cord tethering roots. The team consisted of a thoracic surgeon, a neurological surgeon, and an oncological surgeon familiar with large-volume soft tissue reconstruction. The operative procedure included a complex posterior chest wall resection, three level costotransversectomy with isolation and section of the T5, 6 and 7 nerve roots and a final latissimus muscle flap rotation (with skin paddle) for closure. After six hours in the operating room the tumor was out and the wound was closed. The extent of resection can be seen on the postoperative chest x-ray. The patient’s postoperative course was complicated by significant pain management challenges. These challenges were mitigated through the multimodality pain management resources of The Montana Center.
The patient’s case was then discussed at the multidisciplinary tumor board/cancer conference. This weekly conference consists of surgeons, radiation oncologists, medical oncologists, radiologists, pathologists, social workers, genetic counsellors, clinical research nursing, and a spectrum of ancillary oncology therapy and support personnel. In light of the nature of the pathology and extent of resection the course of action was serial imaging. Serial imaging eventually lead to radiation therapy for long-term durable control.
This patient’s journey to health required teamwork, talent, experience, and expertise working together to optimize the outcome. The members of the interventional team included:
- Thoracic surgeon
- Surgical oncologist
- Neurological surgeon
- Pain management specialist
- Medical oncologist
- Radiation oncologist
- Interventional radiologist
- Diagnostic radiologist
- Primary care physician
(pictured above: TC Origitano, MD; John Federico, MD; David Sheldon, MD)
By Thomas Origitano, MD, PhD, FAANS, FACS