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Episode 10 - Interventional radiology and palliative care - Tom Sullivan, MD
25 Plays1 month ago
Today I’m joined by Tom Sullivan, MD. Dr. Sullivan is an interventional radiologist at Atrium Health Wake Forest Baptist Medical Center, who specializes in multiple methods for treating painful metastatic disease, in addition to his general interventional radiology practice. We discuss some of the techniques he uses to treat metastatic cancer pain, particularly for bony metastases, and patients who can benefit from these types of treatments. We also explore enjoyment and inspiration he finds in his work, allowing him to reduce the pain associated with metastatic cancer, and improve the quality of life of his patients.
This podcast was previously released in November 2023
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Transcript
Introduction to Pallium Podcast
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This is the Pallium Podcast, a production of pallium.org at the intersection of palliative and emergency medicine.
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I'm your host, Justin Bruton.
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Today on the Pallium Podcast, I'm joined by Dr. Thomas Sullivan.
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Dr. Sullivan is an interventional radiologist and assistant professor of radiology at the Wake Forest School of Medicine.
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Tom, thank you for joining me today.
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Glad to be here.
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Thanks for having me.
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This is exciting.
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I was really excited after you came several months ago to talk with the palliative care team and you mentioned to us a procedure that you do to try to treat pain from spinal metastasis.
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And I thought this was a really interesting concept, the idea that interventional radiology can be used for palliative care.
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And just as a disclosure, this video is not sponsored by any of the manufacturers that make any of the devices that Dr. Sullivan uses.
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But it's more really just to kind of get information out there about ways that we can better treat this patient population.
Inspiration and Development of Techniques
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So the first thing I wanted to ask you is how did you get interested in treating people with with spine metastasis pain?
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Well, it goes back to when I was a fellow as a fellow at the University of Miami, and we had this
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One of my faculty, a guy named Esam Kabley, who we referred to him as a bit of a mad scientist.
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And so we would scrub in on his cases and do spine procedures with him.
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And he was one of those guys that was just willing to try anything.
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And this is before a lot of the major data in RFA of the spine came out.
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This was 2018, 2019.
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So we're very new.
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But he was looking at spinal instability scores and opioid use and the use of spinal cord.
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rfa and spinal augmentation and we ended up presenting our presenting our data at our annual meeting at the society of interventional radiology and um and ever since then it really and it really started to take off there's a group in atlanta that's that wrote a actually one of the abstracts of the year for sr called the opus one study and that really kind of helped us gain some momentum and get us going but as a fellow we would scrub these cases
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And we put these needles in people's spines.
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It was wild because then they would get better.
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And I mean, the cases were a little bit long and a little bit torturous for his fellows because he would just, I mean, we were just kind of watching him or whatever.
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And like, oh my God, we're putting needles in people's spines and then burning them.
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And aren't we going to, aren't we going to hit the spinal cord or cause a CSF leak or some kind of something horrible?
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And actually it's, it's, it's just an addition to a procedure that's been tried and true for almost 30 years, years called kyphoplasty.
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And if you have the skill set to do a kyphoplasty, you can generally do an RFA of a spine met.
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So that's kind of how I got started.
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Tell us a little bit about kind of how the procedure works and what kind of patients this can be helpful for.
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So we're in the NCCN guidelines for stage four spinal metastases.
Radiofrequency Ablation Procedure Explained
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And so that means anyone with
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spinal metastases is eligible.
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And we love it because we like to be partners with radiation oncology.
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So we don't preclude EBRT or SBRT.
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And so you can still have radiation
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And you can still have, you can do it before or after.
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The results are similar.
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And it's actually pretty well validated by a couple different studies that we can cite.
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And so these are patients with painful spinal or vertuospinal mets or anywhere in the axial or appendicular skeleton.
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And what we do is we put needles into the lesion and we apply radiofrequency ablation, which is generally heat.
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It's actually from a microwave and it just causes local heat.
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And we monitor that heat and make sure that it doesn't travel posteriorly.
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We're actually able to very carefully control where that heat goes
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And then typically in the spine, we will then do our vertebral body augmentation, which is a balloon and then cement.
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And generally, people are better within 12 to 24 hours.
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Once in a while, you get a little bit of inflammation.
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People with larger lesions will typically mitigate some of the inflammation with the solumedrol.
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But they generally do really well.
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And what what are some of the how quickly from the time, let's say that somebody has a patient that they want to have consideration for this procedure for?
Managing Patient Expectations in Palliative Care
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What's the time frame in trying to get follow up and evaluate them to getting the procedure done to getting relief?
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Like, what does that look like?
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Well, anytime you see someone in palliative care, I'm sure as anyone knows in this audience, you have to manage expectations.
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And I would never go into a consult.
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And so I see everybody in clinic because I want to get to know them and I kind of want to set expectations and we want to have goals.
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And those goals have to be, of course, in line with those of our furs and whatever issue it is.
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And a lot of it is actually side effects from opiates.
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And one of my major goals and one of my follow-up markers is opioid usage.
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And as we all know, these medications work, but they are a little bit dirty.
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And any time we can kind of turn that dial down, you have somebody that's on an 80 milligram a day regimen, 100 milligram regimen a day,
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100 milligram regimen a day.
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And if we can get that down into the teens, that's a win for me.
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And do you, well, one thing that that brings up, because those of us who manage pain with opiates know that if you do things that modify the pain, then there can be a need to really modify the opiates.
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So what are some, how do you manage that whole transition of treating the pain, getting the actual pain down with the procedure, and then also having to adjust the pain medicine accordingly?
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Right.
Patient Story: Impact of Vertebral Body Augmentation
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But we have great partners here at Wake, and we generally work hand-in-hand very closely, but because obviously you don't want to overdose anybody and then you have rebound effect.
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We typically will look at their PRN usage first.
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So most of our patients are on a long-acting regimen, but with the PRNs.
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And what we do is the trend that we typically see is that PRN need goes down.
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And so they'll be getting their 15-eroxy four times a day, and that kind of goes down to two.
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And that's what we watch.
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And then as a team, we'll adjust the long-acting together as well.
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What are some of the things you've had patients say to you after they get this done and feel the results of this?
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What is some of the feedback you get?
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So one of my favorite stories is, so I used to be the division director of Mount Sinai, Chicago, which is a safety net hospital on the South side of Chicago.
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And I took the job because I'm a crazy altruist and I wanted to address this population that has essentially ignored.
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And so I did it for two years.
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And one of the reasons that
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I made a switch to academics was, um, was I wanted a bigger microphone was because of this patient.
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Um,
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And I'll never forget him.
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He, the 56 year old guy with metastatic lung cancer to T5, seven and nine.
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And he was almost bed bound.
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He was able to get up and walk with a walker with a lot of supervision, but he was on a lot of, he was on like 120, 130 milligrams a day.
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And I actually was, and this was private practice, so I was reading Spine MR. And I read his MRI, and I called his oncologist, and I said, hey, you know what, I think I can fix this.
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Can I see him in clinic?
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And she said, sure, no problem.
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We'd love to have your input.
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He's maxed out on grays.
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Radiation oncologist doesn't really have anything else to offer him.
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But we but he had catruda and had a great response in his lungs.
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And so he was so we actually had some time.
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And we brought him in.
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We did vertebral body augmentation on our body.
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very limited South side equipment.
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And it took a long time.
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My texts wanted to kill me.
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And it was a, it was a, it was a long, it was a three to four hour procedure that could have been a lot shorter if we had the nice stuff we have here awake.
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Um, but, uh, with, you know, anesthesia, we put him to sleep and, uh, he got up and stayed the night where he, he stayed the night with us.
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The next day he was walking.
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Wow.
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And the spine and the pain in his spine was gone for the, for the remainder of his life.
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He actually ended up dying in the hospital six months later with a, with a liver metastasis.
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And, um, and, you know, I actually visited him when he was, when he, when he was, when he was on near the end, um, at his hospital bed and we had a, we had a great conversation and he
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And he thanked me for giving him six months of his life back.
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And after that, I was like, okay, this is, you know, this is an important mission.
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And this is, this is something that we really have to have to make sure that people know about and have access to.
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And so that's kind of become a major area of academic and clinical interest for me is, is trying to see these patients and, and,
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and offer something else in addition to radiation and opioids.
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That is a that is an awesome story.
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I'm not kidding.
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I got chills while you were while you were saying that story.
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And first time first time hearing you relay that.
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And that's really a couple of things.
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One, I think it's amazing that you were sitting there reading his films and actually were able to see something, not just not just identify the pathology, but say, I can do something about that, because that's one of the things I think is physicians that that energizes us is finding something that we can do, but not just for the sake of doing it.
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what you said about him saying he got six months of his life back.
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Like that is so awesome.
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And one of the things I think that gets overlooked a lot of times in palliative care, people think about the opiates, they think about hospice, they think about just the end of life piece.
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They don't think about trying to help people live better.
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It's not just about helping people die better.
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It's about helping people live better.
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So I think that is such an awesome story.
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And for many of us who are interested in this field, it's the same kind of thing that got us excited about that.
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We see suffering and we see it addressed in inadequate ways.
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And like you said, opiates are useful, but if it's not accomplishing the goal of getting the patient up and moving around and being able to function well, then we need other alternatives.
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So that's really, that's a great, that's a great story.
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I think that's, that's awesome.
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And I'm glad that you're taking that experience and using it really to hopefully help impact other patients and help get the word out about what's, what's possible.
Exploring Cryoablation and IR Tools
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So I'm glad you could, you could join us for that.
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Thank you.
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Well, I think that that covers a lot of the things that our listeners would be interested in.
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Certainly, we're going to have people elsewhere that are going to be listening to this.
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In the wake system, if anybody has a patient who is dealing with painful spine mets, what is the process they can go about by trying to make sure that they can get a procedure like this to address their pain along with the other modalities available?
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Well, I'm absolutely available.
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I don't have a full clinic.
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I've only been here a year.
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So we're generally able to get people in pretty quickly.
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The other plug that I want to make is to a couple of my partners and I do cryoablation for soft tissue tumors.
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And we were absolutely thrilled to see Cynthia Emery get promoted a couple of weeks ago to the
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her new role in orthopedic surgery.
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And I think that's going to open a lot of doors for us in interventional radiology because we have a great, great relationship with her and her team and, and starting to see some of these a little bit exotic, soft tissue tumors, extra spinal, extra spinal things.
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And we, we have a lot of tools in our tool shed.
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One of them is cryoablation.
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for soft tissue tumors.
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And cryoablation is a very different technology from radiofrequency ablation because it causes no inflammation and it never hurts.
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Once, like I mentioned, sometimes you get a little bit of a pain flare after a radiofrequency ablation, but cryo is amazing because it just shuts everything down.
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And we're always looking for an opportunity and application for cryo.
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And that's the ice ball.
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That's actually argon gas that uses entropy.
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So as it expands, it forms a minus 20 to minus 40 degree centigrade ice ball, just freezes everything.
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So we're doing a lot.
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I have a case tomorrow where we're doing cryoablation in a lung tumor.
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So we have a lot of very nice tools.
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And you do other interventional radiology procedures, but it sounds like you've really made a focus in treating oncologic issues.
Advocacy and Career Influences
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Yeah, so my partner, Brian Corey, I mentioned this project with him, and he does liver ablation.
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He's our liver specialist.
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And he turned to me and says, well, Tom, all of my encounters are palliative.
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Do I get to go on a podcast?
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Yeah.
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He's our Y90 and microwave ablation guru.
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And he approaches it the same way as all of us.
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And he has a fantastic relationship with the liver oncology group.
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And he's been building his practice for over 20 years.
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And coming into this as faculty to partner with him has been a fantastic opportunity.
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Well, thanks for joining us.
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And it's really, that's one of the reasons I love being here is just a lot of excellent colleagues to interact with and just a way to deal with these issues that are cancer patients and not just cancer patients, but patients with other conditions in a comprehensive manner that we have all the different
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fields that they need to make sure that these problems are addressed.
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And I really appreciate what you shared about how just that patient encounter, how that made such a, it seems like such an impact on your career and your career trajectory.
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And then not just that you're not just a proceduralist that's reading films and finding patients that need your help, which I still think, I think that's fabulous, especially as somebody who works in the emergency room.
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And I'm frequently having to talk to radiologists about things that come across the screen.
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I can fix that.
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But I appreciate the advocacy behind that, that really this isn't just about just doing your day-to-day job.
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It's really about making sure that these patients that are dealing with some really painful conditions and some really debilitating conditions can get some relief and really get that quality of life back for as long as their cancer can be mitigated and they can live, they can at least live with less pain and better function.
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So thanks so much for what you do and thank you for joining me.
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I really enjoyed talking with you today.
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This is a fantastic opportunity.
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Thank you so much.
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Thank you.
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For more information on current topics in the fields of palliative and emergency medicine, please visit pallium.org.