James Brugarolas, MD, PhD, Director of the Kidney Cancer Program at UT Southwestern Medical Center talks about a seven minute MRI.
Interview conducted by Ivanhoe Broadcast News in May 2018.
You were talking a little bit about Joe, describe the miracle or what’s amazing to you about Joe’s story.
Dr. Brugarolas: He came for the surgery and it was a large tumor (6 in) that was invading the diaphragm. That was back in July of 2015. 5 days after the surgery, he wasn’t feeling his legs and we got really worried. We found a metastasis in his spinal cord. He had emergency surgery. And then, less than 3 months later, he had 10 brain metastases. A tough case. He received radiosurgery in September. And then more brain metastases that were treated again in January. He started immunotherapy in early 2016. Joe had received preop axitinib to try to shrink the cancer, and now received nivolumab. This was the first checkpoint inhibitor that the FDA approved for kidney cancer.
Tell me again what is amazing you could find with Joe’s story.
Dr. Brugarolas: What’s amazing about Joe’s story is the fact that he presented with a very advanced tumor requiring a very complex surgery. And had additional treatment within a few weeks for a metastasis in the spinal cord as well as ten brain metastases. And three years later he’s around. That’s quite amazing and I think it’s a testament to the teamwork at UT Southwestern’s Kidney Cancer Program. We have outstanding surgeons both urological and neurosurgeons, and outstanding radiation oncologists that have worked with Joe through this date. This is due also to the advancements in drug treatments for patients with kidney cancer and in particular to immunotherapy. Joe was one of the first patients to receive immunotherapy after the approval of nivolumab. And that has had a significant impact on his cancer.
What is the significance of the MRI, these new advancements and these shorter, quicker and perhaps more complete MRIs, would you talk about that and how significant that has been?
Dr. Brugarolas: Patients with kidney cancer tend to be followed with CT scans. We do MRIs to image the brain as well as the spine. And we also do MRIs of particular bones where we suspect a metastasis. However, MRIs take a long time and we don’t have a way to image all of the bones in the body quickly. So Dr. Madhuranthakam at UT Southwestern has developed a protocol that scans the whole body in seven minutes that we call DETECT. With that protocol we can find metastases that are ordinarily missed with other forms of imaging and do that quickly.
Did this approach with the MRI help Joe?
Dr. Brugarolas: It has. Joe was one of the few patients that volunteered to participate in the clinical trial that tested the new MRI protocol. When we tried DETECT on him, we found metastases that had been missed. In fact, there was one metastases that undetected may have caused a bad fracture with all the associated problems.
You treat these metastases with what, radiation?
Dr. Brugarolas: The treatment of bone metastases typically involves radiation. However, kidney cancer does not respond well to standard radiation. Thus, at the UT Southwestern Kidney Cancer Program, we use almost exclusively a new form of radiation, called stereotactic radiation. We do high doses of radiation over a few treatments. Our results show that we have control rates over ninety percent of one year.
What if you did not have these advanced tools what would Joe’s situation be today?
Dr. Brugarolas: Just to put it in context of the statistics, the life expectancy of patients with brain metastases is measured in months. Joe presented with over ten brain metastases and that was already three years ago. Not only that, he also had a metastasis in his spinal cord. This requires very substantial skill with minimal room for error. Making a mistake during the removal of a metastasis in the spinal cord can make somebody paraplegic. Joe has benefited, as I was saying before, from the skill of our surgeons and from new treatments that were not available just a few years ago. And of course our radiation oncologists being able to deliver the highly focused radiation has been quite helpful for controlling the brain and bone metastases.
How do you feel about Joe’s future, he’s sixty four years old and he sounds like he’s already pretty much outlived the competition.
Dr. Brugarolas: Joe went from a single agent immunotherapy to a combination of immunotherapy drugs and then cabozantinib. Since he started, he has undergone multiple surgeries, including brain and hip surgery, as well as extensive stereotactic radiation, including multiple rounds to the brain. He wants to fight and we will fight with him and leverage every opportunity we have to help him.
I know this must bring you a lot of satisfaction to bring a lot of joy to this nice couple.
Dr. Brugarolas: Yeah… However, being a physician and taking care of patients with metastatic kidney cancer is also hard. It is a disease that is largely incurable and that makes it difficult. It is exciting to see the progress that we are making, though, but it is not enough. When I chose to work on kidney cancer, there was only one drug available. And today, we have over a dozen drugs. My goal is not only to help patients by caring for them, but also make discoveries leading to new treatments.
And you have been part of this development?
Dr. Brugarolas: I like to think so. Discoveries that we made in the laboratory implicated the mTOR pathway in kidney cancer and today two drugs are approved by the FDA that block the pathway. It’s exciting to see that the advances in fundamental research are laying the foundation for new drugs and providing new hope for patients.
Now are you a medical doctor and a PhD?
Dr. Brugarolas: Yeap. Got a PhD from MIT.
So you do some of the research as well. You work beyond the patient care to the research?
Dr. Brugarolas: Right. I oversee one of two specialized programs for research excellence or SPOREs in kidney cancer in the country. These SPOREs are a flagship of the National Cancer Institute. One is at Harvard and the other one at UT Southwestern. Research at UT Southwestern for the last two decades has led to a new drug, completely different from any other drug we have, and that is really exciting.
A few years ago none of this would have been possible, is that fair to say? That it’s all developed within the last what?
Dr. Brugarolas: Decade and a half.
Joe’s doing okay?
Dr. Brugarolas: It takes a lot of courage to deal with cancer and an incredibly supportive environment and Joe has that. Joe has been fighting cancer now for over three years and he’s had multiple surgeries, extensive radiation, and he’s had to deal with side effects from medications. He has had to cope with problems associated with cancer progression, including pain from the metastases going to the bone and functional limitations. It takes a special kind of person to choose to fight the cancer the way he is doing it. He is passionate about life. And also he’s fortunate to have his wife Anita who’s been incredibly supportive, and who really has developed a very sophisticated understanding of kidney cancer and its treatment. She has been there for Joe throughout all of it. And there have been rough patches. After one of the brain surgeries Joe’s moods changed… what he would say and how he reacted to things… it was really hard. And she was there with him.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
For more information, please see: www.utsouthwestern.edu/kidneycancer
If you would like more information, please contact:
Avery Anderson, UT Southwestern, Dir Communications
214-648-5027
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