Brain Tumor Board Takes Team Approach

The scenarios are staggering.

A previously healthy man in his 40s develops leg weakness. Doctors suspect a stroke until a follow-up magnetic resonance image scan shows two large and likely connected masses in his brain.

An 18-year-old has had glioblastoma multiforme, the most common and malignant brain tumor in adults, for more than 18 months. Most patients die within a year of diagnosis of this aggressive tumor that attacks the glia or support cells of the brain. With surgery, Gamma Knife treatments, radiation and chemotherapy, this young man and his doctors have negotiated a one-year truce with the tumor. The question for the group of experts gathered on a recent Friday morning is what’s next.

“Every case that we present here is for management decisions,” says Dr. Alfredo D. Voloschin, neuro-oncologist at the Medical College of Georgia. He runs down the list of five patients presented at the Brain Tumor Board meeting recently, all in their 40s except the 18-year-old. There are more experts gathered than there are patients to discuss: Dr. Voloschin, neurosurgeons Mark Lee and John Vender; neuropathologist Richard B. Hessler; neuroradiology fellow Ajay Panchooy sitting in for Dr. Ramon E. Figueroa; radiation oncologists John T. Barrett and  W. Chris Sheils; the omnipresent residents and students.

“It’s fantastic,” Dr. Lee, chair of the Department of Neurosurgery, says after the meeting. “This is what all tumor programs do: have a multidisciplinary conference with different areas of expertise and it all comes together for the right plan for the patient.”

Dr. Lee had just this in mind when he recruited Dr. Voloschin last August as the first MCG neurologist to have a primary appointment in neurosurgery. The new subspecialist -- who recently completed clinical research and clinical fellowships in neuro-oncology at Massachusetts General Hospital/Harvard Medical School and a neurology residency at the University of Miami -- is a critical player in neurosurgery’s expansion into tumor treatment.

“When you think about brain surgery, what do you think about? Brain tumors,” says Dr. Lee. “One of our flagship programs needs to be in cancer.”

Dr. Lee works with Dr. Voloschin and the others to treat patients before and after surgery. The department is recruiting a surgical neuro-oncologist to join the brain tumor team, further advancing patient care and clinical trials. Next will be a basic scientist in neuro-oncology to help develop new   brain tumor treatments. Recently operational is the MCG Department of Pathology’s molecular neuro-oncology lab where cutting-edge tests are assessing chromosomal changes in tumor samples obtained on biopsy to better assess a patient’s prognosis and treatment.

Dr. Voloschin says being the only neurologist in a department of brain surgeons -- he also has a joint appointment in the MCG Department of Neurology -- is ideal. “It goes to exactly what we are building,” says the man who initially chose neurology, “because it’s full of mysteries and has many difficult to diagnose problems … so it’s an obvious area for research and understanding the unknown.”

Then he found a mystery that slightly altered his plan.

That mystery, called paraneoplastic neurologic syndromes, or PNS, oddly has nothing to do with brain tumors but plenty to do with what can happen when neurology and oncology meet.

PNS is an autoimmune process in which the neurological system gets caught in the friendly fire of the immune system trying to fight a small, asymptomatic cancer, says Dr. Voloschin.

The aggressive immune response causes a rapid    onset of a wide spectrum of symptoms, such as forgetfulness, numbness or tingling, difficulty walking, uncontrolled movement of   the eyes or limbs, even anxiety. PNS is often misdiagnosed as anything from multiple sclerosis to Alzheimer’s to   any number of purely neurological problems.

Properly diagnosed, the syndromes are an early warning system of cancer.  Sometimes the neurological symptoms improve or even disappear when the cancer is treated. Often, short-term use of high-dose steroids may be needed to squelch the neurological attack. Sometimes the damage is permanent, for instance when the target is the cerebellum that helps control coordination and movement.

People who have PNS are likely among the some 10 percent of cancer patients who usually do better than their peers, says Dr. Voloschin.

In their body’s aggressive cancer fighting-response, he is looking for clues that may help many more patients do better.

“If you have two patients who are the same age, same type of cancer, everything the same medically speaking, one may still do much better than the other. We don’t know why. Every (theory) is valid because we don’t know the answer.”

Cancers associated with PNS include small cell lung cancer, breast and ovarian cancer, Hodgkin’s disease, colon cancer, testicular cancer and, less frequently, melanoma   and malignant thymoma, among others.

PNS happens when the immune system identifies a target, called an antigen, on a cancer. “When the immune system detects and attacks the cancer, it does a cross reaction, if you will, some sort of friendly fire, attacking the brain and other parts of the nervous system as well,” Dr. Voloschin says.

Identifying the natural, powerful anti-tumor substance is his goal. Eliminating its misguided attack on the neurological system is his dream.

He suspects cytokines, which modulate the immune response, as the culprits. He’s designed a pilot study comparing the blood and cerebral spinal fluid of cancer patients with and without PNS. Dr. Joseph Dalmau, a PNS expert at the University of Pennsylvania, will help provide cases and control samples. Dr. Helene Rosenberg at the National Institutes of Health, an expert on cytokine assays, will analyze patient samples.

 “All this is extremely preliminary,” he says. “But if we find any correlation, the next step is to go into full basic science research trying to isolate the substance and reproduce the disease in an animal model that we can study,” pulling in the basic scientist Dr. Lee plans for the expanding brain tumor team.

 More immediately, Dr. Voloschin is beginning four clinical trials, including studies to help improve the still-dismal prognosis of the common glioblastoma multiforme. “We are building a stronger team,” he says. “We want to advance the treatment of brain tumors and help patients get back to their lives.”

--Toni Baker

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Student Gives Voice to Victims of Assault

Fatima Cody Stanford wants the silent cries of rape victims to be heard by their physicians.

“Only 10 percent of all rapes are ever reported to the police or anyone else. It has been called the most under-reported crime in the United States,” said the Medical College of Georgia School of Medicine student who has a master   of public health degree in public health policy and management from Emory University.

“We know that one out of three women is sexually assaulted and one out of four women is the victim of a rape, or an attempted rape, at some time in their life,” she said, citing statistics from the National Sexual Violence Resource Center. “Sexual assault also happens to one in six men, typically before they reach age 18, but those are reported even [less frequently] than female cases.”

Fatima, who worked for two years in the Metro Atlanta DeKalb Rape Crisis Center, has developed numerous presentations on sexual assault awareness and served as a literature consultant for the National Center for Victims of Crime. In January, she took her expertise to the American Medical Women’s Association conference to help physicians recognize and treat the physical and emotional wounds of assault victims.

“Women who are the victims of rape are more likely to experience a range of psychological and physical symptoms as a result of the rape -- stress-related illnesses, depression, insomnia, anger, gastrointestinal problems, chronic pain -- and some of those problems can last   for years after the rape,” said Dr. Amy House, assistant professor in the MCG Department of Psychiatry and Health Behavior who specializes in post-traumatic stress disorders.

“Men are much less likely to come forward for help because there is often more shame associated with their sexual assault. Consequently, there is very little research to tell us exactly what their reactions and [symptoms] are,” said Dr. House.

Fatima’s presentation during the Jan. 27-30 conference in Washington, D.C., included statistics about sexual assault and contact information for victims’ advocacy agencies.

For the predominantly female physicians and medical students in attendance, Fatima stressed “that assault is a common issue that happens with both their male and female patients. I want them to know how to handle these patients, how to refer them to support groups and therapy sessions and help them realize that there is life after an assault has occurred.”

The 25-year-old Atlanta native is passionate about the subject, in part because she’s had several friends and acquaintances share their sexual assault experiences.

“I also felt I needed to do this presentation because, prior to medical school, I attended several sexual violence conferences where more than 500 advocates would be in attendance, and often, only one of those was a physician,” said Fatima. “This was disturbing because a lot of times, the physician is the first person a victim will open up to. Physicians need to be educated on how to be advocates for sexual assault survivors.”

--Ellen Gladden

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Dr. Hames, Epidemiology Pioneer, Dies

Dr. Curtis Gordon Hames Sr., a 1944 graduate of the Medical College of Georgia whose epidemiological research revolutionized the understanding of health patterns in the Southeast, died Jan. 6 in Savannah, Ga.

Dr. Hames practiced medicine from 1947-88 in Claxton, Ga., treating as many as 60 patients a day. In the mid-1950s, he began an epidemiologic study of Evans County residents that attracted international attention from the scientific community. The National Institutes of Health funded the Evans County Heart Study from 1958-95, allowing Dr. Hames to become a pioneer researcher studying patients within their environment.

His data led to over 560 published papers in major medical journals worldwide on subjects including heart disease, genetics, cancer, hypertension, stroke, pesticide pollution, neurohormones and psychological determinants of disease, immunology, viruses and the effects of social interaction on disease. It was one of the first studies to show the protective value of HDL cholesterol and the possible impact on the absence of certain trace elements in the diet of coastal residents. The study became the model for many other family practice community-based research projects, including most recently HamesNet, created by the MCG Department of Family Medicine and named in his honor.

The Society of Teachers of Family Medicine established the Curtis G. Hames Research Award in Family Medicine. The award, supported by MCG’s Hames Endowment, is given annually to individuals whose careers exemplify dedication to research in family medicine.

Dr. Hames was an MCG clinical professor of family medicine and a clinical professor in the University of North Carolina School of Public Health Department of Epidemiology. He was a visiting clinical professor in the Medical University of South Carolina Department of Family Medicine, an adjunct professor of family medicine at Mercer Medical School and an adjunct professor in the Georgia Southern University School of Health and Professional Studies.

His honors throughout his career included the Medical Association of Georgia Lamartine Griffin Hardman Cup, the Albert Lasker Special Public Health Award and the John D. MacArthur Foundation Fellowship Award. MCG established the Curtis G. Hames Chair in Family Medicine in his honor, and Georgia Southern University established Curtis G. Hames Scholarships in Nursing.

Dr. Hames received a doctor of science degree from Emory University in 1991 and a doctor of medical science degree from the Medical College of South Carolina in 1996. He was past president of the Georgia Heart Association, a fellow of the American College of Cardiology, a member of the American Medical Association and a trustee of the MCG Foundation, Inc.

Survivors include wife Betty, two sons and a granddaughter.

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Sports Lay Groundwork for Medical Career

This spring, Jill Razor has many balls in the air: planning a wedding, graduating from medical school and starting residency training in ophthalmology.

But Jill’s life has always been about juggling, dribbling and fast breaks toward the goal, so there’s no anxiety in the smiles of this 25-year old Medical College of Georgia student.

Jill became immersed in hoops at an early age. “I think I played in my first game in first grade,” says the fourth-year medical student. “My dad would take me to the gym to work on fundamentals and practice shooting.”

In high school, Jill made several slam dunks in the state record books, scoring over 3,399 points for the Athens Academy Spartans in Athens, Ga. During her sophomore, junior and senior years, the team had an 80-5 record, and she was named to USA Today’s High School All American Honorable Mention list each of those years.

During her senior year in1997, Jill received the Georgia Sports Hall of Fame’s Georgia Female High School Athlete of the Year Award and the Atlanta Journal-Constitution’s Miss High School Basketball - Georgia High School Player of the Year Award.

She was also named to the All-South All-American soccer team in 1997 and the all-state teams in soccer, cross-country and basketball in 1995-96.

And while many find it difficult to juggle athletic and classroom commitments, Jill also sported national academic honors in high school. As a member of National Honor Society and Cum Laude Society, the high school equivalent of Phi Beta Kappa with a 4.0 grade point average, college scholarship offers were plentiful for Jill.

She chose a Division Two school, Rollins College in Winterpark, Fla., instead of a larger school. “I wanted to go where I could put academics first, because I knew my career goal was to be in medical school,” she says.

At Rollins, she continued to excel in both fields, devoting 20 hours a week to practices and weight-training. She garnered two Scholar Athlete of the Year Awards, two academic awards, a single-game scoring record of 41 points and a career record of 2,039 points.

“In college, we had a lot of games on the road and I never asked to [reschedule] a test,” says Jill. “I just studied in advance and learned to work around it all. I was on a full scholarship, so even though basketball was like a job, it was very rewarding. We had a great team and I had a lot of fun.”

Through eight years of competitive basketball, “I never missed a game and only missed one practice with the flu,” says Jill, who graduated from Rollins summa cum laude with a 3.85 grade point average.

She soon found that her discipline and time-management training paid off at MCG.

“When I first started medical school, and I didn’t have sports, it seemed easier because I had a lot more time to study,” she says.

The jock in her couldn’t sit still, and by the second semester at MCG, Jill and two classmates trained for and completed the Lake Shore Marathon in Chicago. From tennis and racquetball with fiancé Bryan Wells (also a fourth-year medical student), to playing quarterback with her intramural powder-puff football team, exercise has been a mainstay of med-school stress relief for Jill.

And she’s still keeping academics first; she was inducted into the Alpha of Georgia chapter of the Alpha Omega Alpha Medical Honor Society last fall and maintains a 4.0 grade point average.

“I think Jill will be a fantastic All-American doctor,” says her faculty mentor, Dr. Dennis Marcus, professor of ophthalmology. “She’s a very gifted individual. She works hard and gets the job done. She’s very compassionate, disciplined and well-organized. (In an essay about choosing ophthalmology as a specialty), she described doing free throws every morning before classes. That concentration and discipline are the talents it takes to do microsurgery on an eyeball. Jill will excel in whatever she chooses to pursue in ophthalmology.”

--Ellen Gladden

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