My name is Mike Fadu. I'm a cancer rehab doc and medical director of cancer rehab down at UT Southwestern in Dallas. I've been in practice for about five years and I do a mix of outpatient work for cancer rehab and I do full-time cancer rehab. It's the only population I see. So we've been trying to do a little bit more intros for these meetings. So that way people that are new to the meeting or especially some of the trainees that hop on can kind of start to get a sense for who's who and also get a chance to show your face and network a little bit. So today our presentation is gonna be by Dr. Jessica Casey. First, let me actually introduce my co-leaders and chairs of this tumor board. I don't wanna forget anybody, but Jessica Chang, Brian Fricke, and new to this year, Eileen Slavin, are our co-leaders and definitely the better part of this than I am. So usually this is a case-based series that is often led by the cancer rehab fellows. So we give them an opportunity to present and network, but also to kind of dip their toes into some of the academic work. And so today we have Dr. Jessica Casey, who's coming to us from MedStar, I believe. Is that right? Yes, okay. Yes, that's right. She's gonna give us a topic of a interesting case of a head and neck cancer patient. So I will stop screen share. All right, can everybody see my screen? Yes. Okay, cool. All right, let me know if we're ready to get started. We're ready. All right, awesome. Okay, so I have a patient here. He had a pain and weakness and he's a head and neck cancer patient. And just as we go along with this case, if you can just kind of think in the back of your mind, if you have any other differential diagnosis that might help us out in helping him out. And then just kind of have your thinking cap and see if there's any other interventions that you might think that might be helpful for him. All right, so let's see if I can start going through these. Okay, there we go. All right, so general, he's a 45-year-old male with a history, and he's 45 now, with a history of oral cancer. And more specifically on the right lateral base of his tongue, he had a squamous cell carcinoma. And according to the American Joint Committee on Cancer, it was a T1 and 2B, M0, so it was a stage 4A cancer. And that was diagnosed in November, 2017. He was treated from December, 2017 to February, 2018 and had radiation to the right side of the neck and chemotherapy, specifically cisplatin. Immediately following the radiation, he had some tightness of his right neck, jaw stiffness, and somewhat frequent locking, he said. And two years after the radiation, he began having some constant numbness and tingling of his right up extremity digits. All of them, he would say that he had it, but especially in his thumb. And then also, very specific, but he would actually press on his right scalene muscle and it would produce neuropathic pain, shooting down his right upper extremity. Five years after radiation, he also noticed weakness. And he said with bench pressing. So just in his right arm, he said just in general with bench pressing, either going up or coming back down. And so with the flexion or extension of his elbow, he would have that weakness. Also, he had slight hand weakness as well in his right hand. These are the imaging and studies that were done. So the EMG was done at an outside location and it was considered normal. But in the notes, when we actually looked at the whole report, he had all sensory nerve in the right median ulnar radial and the lateral antebrachial cutaneous nerves. All the amplitudes were decreased compared to the left. And all the motor nerves were fine. So it was just the sensory nerve amplitudes that were decreased. And then the MRI of the cervical spine, you can see there of things going on there. And the MRI of his right brachial plexus also done it in May, 2023. He had diffuse thickening as a non-normality of the right plexus concerning for post-radiation changes. And then more specifically in there, when I looked at it, because he had this also done at an outside location, it said basically just thickening of C5 through T1. So treatments that he had tried for all the symptoms essentially. Gabapentin, he tried one month and not liked the effects nor felt it helped. He also tried physical therapy, obviously with stretches, strengthening shoulder girdle, muscle strengthening, all that. And he said that it was kind of helpful, although it did not relieve it. And then no jaw opening device was used because he had no limitations with his jaw opening. He also tried a hyperbaric chamber therapy times three, and that was completed in November, 2023. And he didn't find that very helpful. And then vitamin E and pitoxifilin he tried for a year and he didn't find that very helpful. So he wanted just to discontinue that. And then most recently, actually just a couple of weeks ago, we tried Xeomin. The time prior to that, it was just in the middle scalene and the SEM that was injected. But just most recently, we tried to do more of the right anterior, mid and posterior scalenes along with the SEM that Dr. Wazowski and I tried to do for him. And he said with the last Xeomin injections that it didn't help with the weakness per se, but it just kind of helped with that shooting pain. And if you press on it, it wasn't as bad. And we also had referred him to the pain people to our colleagues to get a right inner scalene nerve block, which he got done once. And then just a review of the case and kind of like a background of the case for what we did for this. This is brand new to me. I had never Botox the scalene muscles prior to fellowship. So I thought it was kind of interesting to do. And just to see the structures here again, obviously the SEM that comes across, but behind that is obviously the anterior, mid and posterior scalene. And the brachial plexus coming just right in between the anterior and the mid. And then obviously all the vasculature coming anterior to the anterior scalene muscle. So it's all a lot of things going on right there. And the approach that we take and that I have learned is essentially if we take the probe and kind of go up and down the SEM and longitudinal first, and then kind of do a 90 degree and go a little bit posterior, that's when you really start seeing the SEM thin out. And then on here, it's a beautiful picture that I thought was good because as the SEM thins out, that's when you really start visualizing the anterior and then right in between you start seeing what on this image is yellow. And that's the bundle of grapes, if you will. And that's the brachial plexus. And then behind that, that's the mid scalene. And then behind that and actually deeper, so more posterior and deeper would be that posterior scalene muscle. But the approach we take is similar to this because you want to kind of come from that posterior to anterior approach. And then graze right over that brachial plexus to get to that anterior scalene, then back off and then you go more into that mid scalene and then you back off and then you can go into that posterior scalene. So the plan so far that we have, we have referred him to plastic surgery to discuss a possible brachial plexus neuralysis of what we think is the radiation induced fibrotic tissue or the radiation induced fibrosis that was likely the concern here. Maybe for a repeat inner scalene block, which I think they're trying to approve with insurance right now. Repeat Botox injections, if you thought that was helpful, we haven't done follow-up as of yet. And of course, PT because we're PM&R. Yeah, any questions, concerns? And then to add it, I just, I'm a Dodger fan. So I'm very excited right now. And that's my little boy when we took him to the Dodger game earlier this year when we were in Minneapolis. Thank you, Dr. Casey. I think that's a really interesting case and something that you'll definitely see if you treat the head and neck cancer population. I think we have some questions. Yeah. Dr. Sean Smith has raised his hand. Hi. Yes, Dr. Smith. Hi, thanks for presenting that, Jessica. So I have a question. So the potential neuralysis you're referring this patient to plastic surgery for is because of like the tingling and pain part of things to just kind of like, do they do like a cryo ablation or do you know how that works? No, I'm not sure how that works actually. I wanted to actually ask more about it, but from what I understand is that they might be able to take away kind of some of that scar tissue maybe too that they think is impinging on the brachial plexus. That might help with the pain, I'm guessing, especially, you know, since we all know that radiation induced fibrosis is not just necessarily like five years into it the way he started feeling those symptoms, but can last even up to 10 years or longer. But so maybe it'll help with the pain, but I think from what I've read and I have learned even throughout residency, usually a muscle, if it's not innervated, you know, which I'm guessing, you know, it was a brachial plexopathy that was happening likely upper trunk that was happening here. And if it's not innervated by 18 months, then it's usually the muscle just kind of doesn't receive that again. So as far as plastic surgery goes, I don't think that they necessarily would be able to do like a nerve transfer per se to like help it out, but at least maybe just kind of taking out some of that scar tissue and that neural lysis might help, but exactly what they do, I don't know. And I'm very interested. I would actually be very curious to go out and see what those procedures too. Yeah, if you find out, let me know. I wasn't putting you on the spot. Like I knew, that's not cool. I will say one thing about scar tissue. So the patient tried contoxaphylene and vitamin E for a year and like stopped it because he didn't think it did anything. You do and others heard me like rant about this, but like, so, I mean, those drugs are supposed to prevent fibrosis from worsening. And in some cases it has like reduced some soft tissue fibrosis. But so, I mean, I'm not surprised that he might not have seen a benefit, but I would have encouraged the patient to take it longer. And the other reason is the patients in the studies who they take it, there was like sort of two subsets, people who took it for six months and people who took it for two years. And the people that took it after six months and stopped it because they were like, man, it doesn't matter, actually got a rebound fibrosis where it got a lot worse. And so it can really worsen symptoms and be dangerous. So I counsel all my patients to take this for two years as long as it doesn't cause like nausea or a headache or some side effect you can't live with or else it could actually get worse. So he might've also got some more benefit who took it for two years, but after that it seemed like the curve of benefits sort of burned out. So you can sort of stop it safely and probably there's not a huge benefit to extending it. Yeah, I usually tell people in my patient population that people don't usually see a benefit. So they have told me they've stopped and then they notice worsening. And that's kind of how I frame it and being like, hey, you may not notice, but most of the people do tell me that they notice after they stop. So give it a full try and then we'll kind of reassess. But it is hard. I can understand like if you're not seeing something, it's a similar kind of thing of like, well, I don't know my blood pressure is high. Why would I take this medicine? You know, it's kind of hard. Right? Yeah, I tell them it's like Lipitor or something like you won't know it's doing anything, but it's probably healthy. Yeah. Are you using the vitamin E and Pentoxyphalline for like suspected radiation induced nerve injuries, like someone got radiated to the pelvis and maybe is causing weakness with her femoral nerve, for example, would you use vitamin E and Pentoxyphalline to help with that potentially? Not just like skin changes. As far as I'm concerned, from what I've read and understand vitamin E is that it helps with with radiation induced fibrosis and like Dr. Smith was saying in helping prevent it or further worsening of it. So I feel like even in pelvic cancer patients, it would be helpful as well, as long as they don't stop it early. And of note, this patient did stop his vitamin E and Pentoxyphalline prior to seeing us so he was at another institution up north before coming to see us. I'd like to say to that, to answer your question, I haven't seen any studies specifically looking at that most of the studies that have looked at more of the breast and head and neck patients for Pentoxyphalline and vitamin E. But, you know, at the end of the day, the alternative answer is we don't have much and they're relatively, you know, well tolerated and fairly low risk medications. Although, sometimes depending if you talk to the radiation oncologist, some of them, they might not want you to do the vitamin E portion within six months or a year after radiation. I think because they're trying to probably do some of that inflammatory response to cocaine cells, I'm not real sure, but the ones at my institution, one in particular, usually wants you to wait for the vitamin E portion if it's if it's fairly early after treatment, but later on down the road, they're fine with it. Dr. Begley, do you have your hand up? I do. Thanks so much. So not in the cancer world, but in the rest of the world, it's really curious that decreased sensory amplitudes that were diffused was assumed to be a brachial plexopathy. So I would argue one possibility true, true and unrelated, right, like sensory neuropathy from the cancer or from the cancer treatments. Did anybody look downstream at the biceps? Just like shoulder MRI, like you've tried all these other things, which I think are great and super interesting case. Thanks for sharing. But are we sure this is an upper trunk brachial plexopathy with diffused decreased sensory amplitudes? And it sounds like you don't have all the EMG data. And maybe it wasn't the best EMG if it was read as normal, and it wasn't normal. But what do you think about looking at the shoulder? That might be interesting. Absolutely. And funny enough with this gentleman, he does not look like he has atrophy even on strength exam. I mean, he looks like he's a UFC guy. He's, he works out all the time. He's a health instructor, a PE coach. So he's working out constantly. So it's not something that even in strength exam that I could see that, like, I didn't see any atrophy, any blaring atrophy or, or weakness on exam, but, but maybe imaging would capture that, that stuff that we couldn't necessarily see so far, with the diagnostics that we've done or on my exam. It's a good thought. Dr. Case, I'm also curious. Did this, did this gentleman have a neck dissection? No, he did not have a neck dissection. Has anybody taken his shirt off and looked at his scapular motion? Yes, I actually did look at his scapular motion, just because, since I just took boards and saw that scapular thoracic motion is very, is about one third of all glenohumeral joint and shoulder movement. Anyway, so that's why it was fresh in my mind. And I looked at it, and I didn't think that he necessarily had any scapular dyskinesia present. That's just another good thought is there could be a red herring. He's simply mentioned weakness with bench pressing. And people that rehab well understand the scapular biomechanics, but also bodybuilders, they don't understand, that's like, minute detail, but they've kind of figured this out is you have to basically stack your shoulder blades in order to stabilize your scapular base. So that way you create can create more force and pressure with your push. And obviously, with this population, they're usually at risk for spinal accessory nerve injuries and things like that. So I'm glad you guys check that because that can be a little bit of a missed thing where people aren't actually looking at the trap. And the fact that they're just winging and that's why they're that's where they're actually experiencing the arm weakness because it's the downstream probably about 15 minutes more. But it's something to always consider in this population. And I have seen isolated myokinias from spinal accessory nerves after radiation to the neck area that would that without a surgery. Got it. Yeah, I saw on the actually read the EMG report even though it's a source. It did. The whole needle study was absolutely normal in all stages because I was seeing if they had any kind of comments to see if they saw any myokinias specifically, but no, nothing. Was the amplitude difference pretty notable? Or was it settled? No, it's pretty notable. More than 50% compared to the contralateral side on some cases. Wow, I'm just so surprised that it was read as normal. It's weird. I know. Dr. Ozatsky and I were kind of giggling at that too. And I don't know how legit this is. But this did come up very recently. A patient of mine who has what I think is a she's a breast cancer patient. So it'd be very unusual, but she has what appears to be a brachial plexopathy. Before she saw me, she's a younger patient, she's getting, you know, arm weakness, she has like diffuse fibrillation that you can see. But I saw that wasn't that as obvious, but she's clearly getting weaker. She had had an EMG that was read as normal because they said it's not there wasn't more but they said this isn't radiation because there's no myokinia. And then she had actually seen a surgeon who had done a thoracic outlet surgery that just made it worse. When I saw her in the time course, everything lined up pretty well. I said I think this is probably a radiation induced plexopathy if I had to guess and I sent her for another EMG. And that EMG actually did show myokinia and did show a better EMG from a better myographer that actually showed the findings we were expecting. That being said, interestingly enough, this particular patient has a very active job that she really wants to keep. And she's been seeking other opinions. So she went to the Mayo Clinic, and she saw a neurologist and a neurosurgeon, they did not see myokinia. And the neurologist thought it was probably maybe still radiation, but they were like, well, if there's no myokinia, maybe it's not. But she saw a neurosurgeon who says at one time, he has seen a isolated CIDP is what he called like a multifocal CIDP in a patient that was supposedly confirmed on nerve biopsy, and started on IVIG, which improvement. So this patient is right now in the middle of you just started IVIG. And she says, it's helping. So I don't know how much that is. I've spoken to some of my neuromuscular colleagues. And I think a lot of people with some of these questionable CIDP diagnosis always feel like the IVIG is helping. And there's kind of no end point to that. But I'm curious, her exam when I saw it was about the same. And it had been about a year since I've seen her, but she said it had gotten worse, and now is improving. So I'm going to see her again in maybe like three or six months, and reexamine her and see if she actually has objective findings. But I've never heard of a multifocal CIDP from radiation. And this neurosurgeon at Mayo said he had seen it one time in his life. So I don't know, like I said, I've never I wasn't able to find any studies or anything on it. But it's just a curiosity, not saying you should go down that route. That's super interesting. How long after her radiation? This is probably at least, at least two years. I'd have to go back and see but I think it was it had been several years. And it was just the arm that was affected? Just one arm. Unfortunately, she's left handed. And I don't want to get too much about her. Her job involves using a gun and she wants to keep that job. And if it doesn't work, she'll probably have to retire. That sucks. Yeah, that's pretty terrible. Yeah, we have a patient on the inpatient floor that was admitted, quote unquote, for chemotherapy induced peripheral neuropathy, and like, debility. And we're all like, what? She's got bowel, bladder, like weakness, and we're just very perplexed. So they finally did an EMG and it was CIDP. And so we're sending her for IVIG because we're like, yeah, no. So that's interesting. That's a that's a word, word to the wise, always keep your radar up for the other stuff and make sure that the diagnosis they're sending to you is the actual diagnosis. Yeah, because I saw somebody was like, personage Turner, and they were thinking it was like, brachial flexopathy. It was just like, oh, you had a vaccine. Did you? You're like, how interesting. Yeah, I run a similar case recently, they sent it for neuropathy, but it might have been a frozen shoulder in the radix. So gotta keep our keep our options open. It was a nice case, Dr. Casey. Thank you. There's a question in the chat about insurance coverage for difficulty getting coverage for pentoxifiline. Dr. Smith, I would echo that sentiment. I've never had any pushback on that. I don't think it's terribly expensive drugs. So my experience is that that hasn't really been problematic, I would say. But I don't know if anybody in any other state has had more issues. Really great case, Dr. Casey, does anybody else have any other thoughts or comments? Yeah, I think that's a really good question. I think that's a really good question. I think that's a really good question. I think that's a really good question. I think that's a really good question. I think that's a really good question. I think Okay, we'll take that at face value. That's not sharing. Pull back up the gym so the next part of the agenda, we're just going to have anybody that had any ongoing or interesting cases. I checked our email account, we didn't see anybody had sent anything in but if anybody has any update date or ongoing case that they're having challenges with or want like a consensus opinion or you're kind of getting to a place where you want to try something else, you're not sure what the next step is. We do like this to be kind of like a drill to report in the sense that you can get some consensus opinion on challenging cases. So I would open the floor if anybody has anything. question, maybe since we have everyone here. I have a patient who's going under neoadjuvant chemo for breast cancer that I'm doing prehab with. She's a professional gymnast, so very high level athlete. Also has fallen off the trapeze multiple times, lots of orthopedic injuries. And so she tells me that she's been getting VSCO supplementation, specifically Duralane from Canada, because they don't have it in the US, that she thought was better than Synvisc. And she would get this combined with PRP, which she has found helpful in the past. So she's now looking to me to continue the orthopedic care, and so she's overdue for these injections. Not that I don't do PRP, but she's going to ask me again what I think about it in the cancer setting. And so two parts to the question is, any thoughts on PRP or prolotherapy type of injections during active cancer treatment? And also in terms of VSCO, so she has minimal OA from x-ray, AP bilateral standing, but she says most of the OA, or she was supposed to get a knee replacement 10 years ago, was mostly in her patellofemoral region, and there's crap it is. So I got more imaging in her 40s, so I'm a little bit on the fence of if it doesn't show much OA, should I do the injection? And I don't think it'll be that risky as long as her platelets are fine and her white count's fine, but I'm not used to doing VSCO if it barely shows any OA on x-rays. So any comments on that would be appreciated. I have like 87 comments. So Duraline is available in the US, it's the cheaper one, so what you can do is buy and bill. So if you write her a prescription for it, she can get it, and I would highly recommend it from the US than another country. Personally, so I worked in the joint center, so I saw a lot of patients getting joint replacements postponed due to active cancer treatment, and it's always kind of a conversation between the orthopedist and the oncologist. Certainly this patient doesn't need a joint replacement, but as a 49-year-old marathoner, and my work wife is sports medicine, family med, so she does a ton of PRP and VSCO, so we always have these discussions. There shouldn't, you know, technically if you look at the data, although less effective for arthritis, PRP would be safer than VSCO in active untreated cancer, but she has treated cancer, right? Like she's getting neoadjuvant. Yeah. So it shouldn't, as long as her oncologist is okay with it, like I would just check in with them just because I feel like having worked at different institutions, much like I was thinking about in the last case, Dr. Power and I are, I remember talking about a case before in this where her plastic surgeons and neurosurgeons are far more aggressive with nerve procedures than we are up north, or where I was previously up north, so it's just kind of fascinating because I do think the interventions are regional, so that being said, I would check in with her treating oncologists just on their opinion, but like if you look at the hard data, VSCO is more effective than PRP, although recommended against by the AOS, the AOS recommends against VSCO because it's more expensive than cortisone, and it doesn't, you know, it's not the definitive treatment, so surgeons want to do arthroplasty, so the American Academy of Orthopedic Surgeons is going to come out for arthroplasty, and that's why they're endorsing cortisone over VSCO, but there's good data for VSCO for arthritis, probably better data than there is for PRP in arthritis, but like just full-on safety profile because some people have that local inflammatory response to VSCO, if you have an autoimmune, or you're not really sure what kind of treatment the cancer patient is getting, or they're worried about it, PRP would probably be safer, although I think less effective in her situation, and then there's always like she has mild arthritis, does she need either one of those things, like would she be willing to do aquatic therapy, would she be willing to shorten her running stride, like what is she using it for, you know? She swims like 13 hours a week, and that's less than usual, and it gets a little stiff, so wait, so did you say PRP is safer but less effective, is that what I heard? That's my very biased opinion from looking at the data in arthritis, like if we're just talking knee arthritis in the absence of cancer, but like I'm coming from like seeing probably 90% sports and arthritis patients, and 10% all outpatient cancer patients, so you guys know I'm like kind of a different bias. I agree with a lot of what you said though, including the regional disparities. Dr. Smith, do you have your hand up? Yeah, I mean Jen could like run circles around me as far as like the evidence for those two things. My only caution would be that PRP will increase serum levels of factors like VEGF and other growth factors, and I would probably, I would not be comfortable doing it in someone getting like neoadjuvant or just still in like active chemo or just after radiation or surgery, like if it can wait, I would wait. Thank you. I would actually echo that, which ironically, Sean trained me, so it's not surprising we think similarly, but just the thought of like the fact that they're pulling something out of their body and putting it in another place, I mean especially, I agree, especially in a neoadjuvant setting, I would just from a medical legal kind of more conservative, I would definitely get full clearance from their oncologist and probably have that documented before I ever considered something like that, because especially like I said, this is an elective process, and if she metastasized later down the road, she said, oh, it's because you did this injection, I would not want to be in that position trying to defend that. Yeah, I completely, I actually wouldn't do it either, but I just agree wholeheartedly with the idea that everything that you said, Dr. Barabao. And for the VSCO part, do you guys do it when there's minimal, oh yeah, I kind of left it at, well, if the insurance approves it and she's willing to do trisinvisc, then, you know, I don't see more good than harm given that it's helped in the past. You need to document Kellgren-Lawrence grade two osteoarthritis for it to be covered by insurance, so I would document that. Like one is like, meh, they don't really have arthritis. And two is like, you're seeing something. So it can be covered for mild arthritis, but its efficacy in mild arthritis is not as good. That being said, the systemic effects of PRP, you know, could get you into trouble in this population that wouldn't get you into trouble in the general population. Oh, if they're after adjuvant chemo and they're on hormone therapy, does that sound better? That's a really good question. So in the spine world, and this is me reaching here, so please everybody chime in and disagree with me, but we know there are estrogen receptors on the facet joints in the back. And so that's why we think females might get menstrual related back pain. We know this from like cutting open rabbits, obviously we don't cut open humans, but it's not well studied, but it would worry me in hormonal cancers, but I have no data to back that up whatsoever. Not VSCO. PRP. Also, if they were in an adjuvant period and they were on like an aromatase inhibitor, you know, that could also be the culprit. So I would consider, you know, rotating AIs, I would consider doing like some other things to maybe see if you could limit the pain or dysfunction just because they might have a aromatase inhibitor arthralgic picture. And if she wants to come swim on the eastern shore of Maryland, I can do her durling. Okay. I'll let her know. I have a case that's kind of ongoing that it's a bit puzzling because it's experimental. So I have a multiple myeloma patient. She's, I think she's in her 60s and she had progressed through several lines of treatment. She got VRD and ARVD and everything. And so she ultimately wound up in a getting CAR T cell therapy. And then after about a year progressed through CAR T cell therapy. So they did an experimental trial with her where they gave her another CAR T cell infusion. And I've never seen that for multiple myeloma. Afterwards, she developed this severe dizziness that we, they thought was part of an ICAN syndrome. And when I met her when she was in the hospital and she was just so dizzy, she wasn't really tolerant of therapy. So we decided that it wasn't, she wouldn't really qualify for any patient rehab state. She could barely tolerate any type of upbringing ability. We tried everything we could to try to get her tolerance. We thought it could be orthostatic. And we did all the stuff for that, but she, she continued to be just very, very dizzy. So we tried to go kind of a slower route. Fast forward. I see her in clinic. We have tried, you know, she's tried steroids. She's tried meclizine. She's tried midrib. She's tried everything to try to get this dizziness under wraps and it just never got better. And then she also started to develop more of an ataxia. So fast forward again, now I've seen her further. She's continued to decline and she's very ataxic. She's got ataxic speech and she's actually been diagnosed with basically a immune-related cerebellar toxicity syndrome that neurologists, including neuro-oncology thinks is permanent from her CAR T treatment. So she lives in the middle of nowhere. She's been trying to get therapy out there and it hasn't been helping very much. And she's continued to decline functionally. However, her tolerance of it has improved because now that she's like realizing this might not just could initially be just hoped it would go away. Like, you know, most ICANN syndromes do improve. So in this case, she is, as we speak, getting admitted to inpatient rehab. I admitted her from outpatient tomorrow and I'm hoping that a more comprehensive rehab approach can help her. But in this case, this is all experimental and we're flying blind a little bit, but I was curious, has anybody else seen either multiple myeloma or other blood dysprasia or blood malignancy patients getting a second CAR T treatment and having odd neurologic symptoms? I feel like I have seen second CAR T. I can't confirm that. I feel like I've had that thought before. Go ahead, Jessica. Was it a whole new CAR T? Because like, I know that they just approved on like where they don't have to do a whole new CAR T thing, but they could basically take a pill and they could basically turn it off or on for like five times over from what I understand. So was it a whole new CAR T therapy that was given? Do you know? Or am I just... I know one of them was Yaskarta. I'd have to go back and see if it was, I want to say it was a different one, but I'd have to see. Patient on cyclophosphamide? She is not. I mentioned that because we had a severe case of dizziness that was solely attributed to cyclophosphamide and the person was suicidal, actively suicidal. So it got really complicated and then dizziness went away after the cyclophosphamide was stopped for a little bit. And there are other neurologic effects, but I guess not for this case. Is she on steroids at all? She was, she's no longer. Yeah, they gave her tocilizumab. They put her on steroids and everything as part of her initial treatment when they thought she just had eye cancer. And they scan her and saw something of the cerebellum or they're just assuming it's cerebellar ataxia? Yeah, there's some subtle findings in the cerebellum that have been like combed over by neurology like a million times. They think that there's enough there. I've seen that from lymphoma treatment with like, say, tirabine. I have a patient who has really bad ataxia from that. And it also seems now we thought it was going to get better once her treatment was done, but it's persisted, unfortunately. Also treated with steroids and had aggressive actual acute rehab also, unfortunately. she have any vestibular testing done? Yes. She had been evaluated by like ENT neuro, just a peripheral nerve-like neurotoxicity. We'd send her to like vestibular therapy. We tried several different routes for that. And it wasn't like either like a positional dizziness. It was like just dizziness 24-7 at rest. Didn't matter where she turned her head or how she looked. It was just there. And now it's to the point where she's like very dysarthric now. She actually has like ataxic speech. Yeah, it's been pretty rough on her. And all medication side effects were reviewed already. EMG. Pardon? EMG, nerve conduction EMG. I don't think she's had EMG now. What would you be looking for? Well, you mentioned dysarthric. So I was just thinking like maybe some bulbar stuff and sometimes very vaguely just ALS gets kicked off by random stressors. So I'm not sure if that could be part of it or something similar. That didn't occur to me. It's an interesting thought. Yeah, we'll see. I'm curious about how she responds to a more comprehensive rehab approach. Like I said, she lives kind of in the middle of nowhere, so getting her ancillary services has been a challenge as far as quality therapy and stuff. She sees the one PT in town and he doesn't know what to do. I remember you talking about that patient. I feel like we did one of these things like two years ago or something. Is it the same patient, Mike? Yeah. That's wow. I'm still kicking and you're getting into IPR. Yeah, they're pretty desperate at this point, but there's been a while. It actually hadn't been done yet, so I was like, I think it's worth a shot, but it'd be a big yay for rehab if it makes a big difference. Okay, so we're at just under kind of 10 before the hour, so anybody else have any other questions, concerns, comments, anything, any other cases or anything that they've been puzzled or stumped by? This is just a general question. I've seen several patients with a CIPN and especially patients with breast cancer and I've learned in my training about the interaction of like duloxetine and tamoxifen and when I was seeing one of the patients, I'd seen that they had been on duloxetine and tamoxifen simultaneously and I was asking their oncologist about it and they didn't really like think too much of it, so I don't know if that's something that you guys will order duloxetine for patients regardless if they're on tamoxifen or it's just like something, I don't know, what do you guys do in those scenarios? Do you try to avoid it if possible if they're on tamoxifen or do you actually continue with it? I'll tell you, I can tell you what I do, so number one, I try to try something else and see if it's effective and if they're tolerating something else that's effective then I just leave it at that but I'm not afraid of it. I always as a courtesy will just shoot their oncologist a message. I have not to date that I can recall had an oncologist tell me not to. They're usually pretty unimpressed. I've been told not to actually because they had plans to start tamoxifen that I didn't know about and the patient was super concerned about starting any medication and so that's how that happened for me. But were there any side effects, Evelyn, when you? No, there weren't but I've had it sort of ingrained in my mind to be cautious with it. I thought it was kind of debunked. I thought that there was a theoretical interaction and some pharmacists looked at it and it didn't actually like that. I don't think it's an absolute like contraindication or something. That's good. Do you have that literature? I think that seems to be correct to me as well because I remember like I think I had a discussion with somebody like I think there is like some it does affect the metabolism or something of it but it doesn't seem to have like a real world effect if that makes sense but yeah I could definitely see that that's oncologist specific. I would tell you if an oncologist did tell me no I wouldn't do it but as a courtesy I always just throw that one by them. Great. For those of you that may or may not be paying attention to the chat, there have been some links to articles shared in the chat. So for some of the studies that were mentioned during this meeting, so feel free to kind of peruse that if you haven't been paying attention to the chat if you want a little bit more of the data and to kind of dig into some of the studies and what has been discussed. Yeah, one of the things right now. I think that, yeah, it was more of a concern for like SSRIs too, the loxatine at first. I don't know, I could try it on you more. I remember talking to Wyszocki about this like nine, ten years ago, which is how old I am, but it was, yeah, I think it's probably the same thing. I think I was there because I'm that old too. And same thing, like the oncologists were telling me no, so we just didn't do it. And then we just like never revisited it. Yeah, I think you were. I think Julie Silver was there too. Thanks, I appreciate the articles. I'm convinced now. Well, to be fair, I don't know if it's just my institution or just the landscape now, but I don't see a ton of patients, breast cancer patients, on tamoxifen these days. Yeah, and the risk of arthroparalgia is like 10% of that of AI, so they are, you know, you might not even need to start it. Or maybe they're not getting you because there's lots of that. Yeah, definitely could be a bias there, but yeah, most of them we see. I think it is because I see them, but I'm also like, where I live is like 10 years behind the rest of the world, which is both wonderful and scary. I think it's still the standard for premenopausal estrogen receptor-positive breast cancer. So, I mean, we should be seeing it, but it's still a thing. So Maryland is not behind the times with that. You know, I think some of it, too, might be the age demographic of some of our populations, too. Although I'd imagine Dallas sees everything. Yeah, I've definitely seen people that were on tamoxifen and then got rotated to an AI after. I would say, unfortunately, a lot of my younger patients are triple negative. Yeah, Dr. Marshall, I would agree. I generally do it as a courtesy, but again, they generally haven't cared where I'm from, but I think I would as well. Then also use it as a potential educational piece if there was a philosophical vein where I thought it would help them. I'd say sometimes. I think I'm lucky though. My oncologist generally just let me do what I want. I'm working with an oncology tour, and I'm going to ask her. Yeah, I would definitely be curious. I've also noticed that certain like newer oncologists that are closer to being out of training sometimes have different thoughts and ideas about things than oncologists that have been practicing for a long time. So some of it is just, I mean, we all have our biases and stuff, and even as much as we don't have to admit it, sometimes we just kind of have our things we like to do because we've been doing it for a long time. I've observed that phenomenon as well. I still, I consider myself very much a young career person, an early career physiatrist, but yeah, I've already noticed like I'm quickly becoming a dinosaur. Okay, well, nobody else has anything. I will formally end the meeting. There should be a survey, and if you fill that survey out, that will get you one credit of CME. So moving forward, all cancer-related tumor boards will have CME provided. So shameless plug, shout out to the AAPMNR. Thank you for that. So we're very grateful for their support from us, just not just, you know, meetings and stuff, but also nationally as part of this. You know, they seem to really be trying to help us, which is great. So I think it shows the growth of some of our specialty alone, but also there's some people in this meeting right now that have done a lot of that work to get us to this point. So continue to move forward. It was nice to get credit. Thanks, everybody. Take care.

cancer rehabilitation

Dr. Mike Fadu

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squamous cell carcinoma

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