An interview with Ernest U. “Chappie” Conrad III, M.D., F.A.C.S.

Dr. Conrad received his medical degree from the University of Virginia after graduating from Washington and Lee University in Lexington, Virginia. He completed his orthopaedic training at the Hospital for Special Surgery and served as a fellow in orthopaedic oncology for Dr. William Enneking at the University of Florida, and also as a fellow in pediatric orthopaedics for Dr. Mercer Rang at the Hospital for Sick Children in Toronto, Ontario. 

Dr. Conrad, ranked as a "Top Doctor" in the category of "Pediatric Orthopaedics" according to Seattle Magazine (September 2007), founded the Sarcoma Service at the University of Washington and at Children’s Hospital and Regional Medical Center.  Both of these services are multidisciplinary and include comprehensive services to sarcoma patients, with a particular interest in defining chemotherapeutic risks for patients with high-grade tumors. 

Dr. Conrad’s surgical interests include extremity limb salvage, pelvic resections for malignancies, and surgery for soft-tissue sarcomas.  His work with allograft transplantation and implant design has resulted in many advances in limb-sparing procedures.

Dr. Conrad’s research interests include the use of metabolic imaging (as in positron emission tomography, or PET, scans) for high-grade sarcomas, the assessment of allograft healing, the description of clinical outcomes, and population studies that describe the occurrences of sarcomas in adult and children. 

What do you most enjoy about your work?

Being a sarcoma specialist is a demanding job that requires delivering care for high-grade tumor patients in an urgent and emotional setting.  The challenge of and interest in delivering multidisciplinary care allows me to participate in not only the pathologic evaluation of patients, but their responses to chemotherapy, the assessment of their responses to metabolic imaging, and the results of complex and challenging surgical procedures such as bony pelvic transplants and extremity limb-sparing procedures.  For sarcoma patients, all of the disciplines involved in delivering care—orthopaedic surgery, nuclear medicine, medical oncology, radiation oncology, surgical pathology, et cetera—have made dramatic progress in the past ten to 15 years.  Patient survival has improved dramatically over that same period of time.  The rewards for this demanding practice are enormous in terms of improving each patient’s quality of life and improving survival in those patients with high-grade tumors.

What is your treatment philosophy?

My treatment philosophy for the Sarcoma Service is to deliver the best care to all patients while learning from each patient.  While each patient is different, and treatment varies from patient to patient, all patients want excellent and caring treatment and want a responsive treatment team.  The Sarcoma Service at UW Medicine/Seattle Cancer Care Alliance and at Children’s Hospital and Regional Medical Center is designed to respond to patients’ immediate needs and to plan for their eventual post-treatment rehabilitation.   We are very proud of this service that encompasses careful treatment communication through weekly clinics and conferences attended by all disciplines, especially medical oncology, orthopaedic surgery, nuclear medicine, et cetera.  In addition, we hold a monthly research protocol meeting and maintain a dedicated Sarcobase tumor registry that coordinates care of and tracks the outcomes for all patients, regardless of their treatment protocol.  

What are your interests outside of medicine?

My activities outside of medicine are completely occupied by my family.  I have three children, two of whom are now in college and one of whom is finishing high school.  When I am not practicing, I give them and my wife, the time and attention they all so richly deserve.

What is the focus of your teaching efforts?

I am focused primarily on the education of orthopaedic residents and post-doctoral “fellows” through our Advance Clinical Experience (ACE) program, with particular emphasis on diagnostic challenges of tumors in the musculoskeletal system, in addition to teaching medical students the basics of orthopaedic surgical practice and basic oncology.  Once each year, we hold a two-day, intensive review of orthopaedic pathology.  In addition, we have a yearly teaching protocol that is directed by my partner and long-term colleague, Dr. Howard A. Chansky.  In the operating room, students, residents and ACEs participate at levels appropriate to their standing in patient care under direct supervision. 

On the national level, I am involved in education through the Musculoskeletal Tumor Society and the American Academy of Orthopaedic Surgeons. 

What do your most recent research efforts focus on?

My research efforts are inseparable from my clinical efforts, and are detailed below. 

What is the focus of your clinical efforts?

Our most recent, significant clinical project is assessing the histologic grade and potential therapeutic response of a patient’s tumor by using a metabolic-imaging technique called positron emission tomography (or PET) scanning.  It has been an enormously successful program for us in two ways.  First, we are able to recognize those adult and pediatric patients who are at high risk by more accurately determining the grade of their tumors before treatment starts.  This pretreatment assessment helps in planning how to attack the tumor over the entire course of treatment.  In tumors assessed by PET scan, there is a correlation between a high rate of uptake of the radiopharmaceutical used in the scan and a tumor having a high-grade histologic makeup.  Knowing that in advance allows us to better custom tailor the proper treatment protocol.  For example, a patient with a high-grade, soft-tissue tumor that demonstrates a high standardized uptake value (we call this an SUV rate) on PET scan would be likely to be placed on a treatment protocol that included multiple cycles of preoperative chemotherapy, followed by definitive surgical resection, followed by one to two cycles of postoperative chemotherapy, and possible postoperative radiation therapy.  A patient whose tumor proved to be low-grade on PET scan would be likely to need only surgical resection, with or without postoperative radiation therapy. 

The second treatment advantage to PET scanning is that we can assess a patient’s response to presurgical treatment.  After the patient has finished his or her preoperative chemotherapy, a second PET scan is done and the two studies are compared.  Again, there is a correlation between a tumor that shows a marked decrease in SUV on the second PET scan and a good response to the preoperative treatment.  This response, which amounts to destruction of a large portion of the tumor, then makes the surgical phase of treatment much more likely to succeed.

We expect to expand this program further through ongoing National Institutes of Health funding under the direction of Dr. Janet Eary, Professor of Nuclear Medicine.  We have presented the results of this groundbreaking research in multiple papers and through scientific exhibits at the American Academy of Orthopaedic Surgeons in 2004 and 2005.

We are also interested in improving the limb-salvage results for patients with bony malignancies whose limbs have been reconstructed with either transplanted bone or with metallic implants.  We have developed an implant registry and an allograft transplant project to further those programs and consider these to be extremely important projects in the effort to minimize the revision-surgery rate for these complicated reconstruction techniques.  We further use PET scanning techniques for the assessment of bony healing in those patients who have received allograft transplants and in assessing high-risk pediatric patients being treated for Ewing’s sarcoma and osteosarcoma. 

Allograft transplantation research through the Northwest Tissue Center, http://www.nwtc.org, assesses all patients who undergo limb-salvage surgery, specifically for those patients who develop rejection phenomena.  Almost half of those patients suffer delayed healing because of a reaction to their bone allografts and need careful follow-up.

Sarcobase is a dedicated sarcoma patient registry that defines the occurrence of sarcomas in our adult and pediatric population.  This has been in existence for three years and is defining the scope of our practice at both the regional and national levels.  Recently recognized by the international Connective Tissue Oncology Society for discussion at their annual meeting (Fall 2004), this registry is a valuable part of patient education and tracking.  We hope and expect this tool will help us with patient support.  We also expect that Sarcobase will help define and track the growing incidence of these unusual tumors, most of which have been treated at centers that do not have a specialized interest in sarcoma treatment protocols, leading to diagnostic variances that affect patient care.

• Conrad EU, Section Editor, Soft-tissue tumors, in Menendez (editor) Orthopaedic Knowledge Update, American Academy of Orthopaedic Surgeons, Chicago 2001.
• Conrad EU: Multimodality Management of Malignant Soft-Tissue Tumors, Chapter 28, in Menendez (editor) Orthopaedic Knowledge Update, American Academy of Orthopaedic Surgeons, Chicago 2001.
• Eary JF, O’Sullivan F, Powitan Y, Chandhury KR, Vernon C, Bruckner JD, Conrad EU:  Sarcoma tumor FDG uptake measured by PET and patient outcome:  a retrospective analysis.  Eur J Nucl Med Mol Imaging, 29(9): 1149–1154, 2002.
• Rajendran JG, Wilson DC, Conrad EU, Peterson LM, Bruckner JD, Rasey JS, Chin LK, Hofstrand PD, Grierson JR, Eary JF nd Krohn KA: [F-18]FMISO and [F-18]FDG PET imaging in soft tissue sarcomas:  Correlation of hypoxia, metabolism and VEGF expression.  Eur J Nucl Med Mol Imaging, 30(5): 695–704, 2003.
• Newkirk L, Vater Y, Oxorn D, Mulligan M, and Conrad E:  Intraoperative TEE for the management of pulomary tumor embolism during chondroblastic osteosarcoma resection, Can J Anesth, 50(9): 886–90, 2003.
• Vernon CB, Eary JF, Rubin BP, Conrad EU 3rd, and Schuetze S:  FDG PET imaging guided re-evaluation of histopathologic response in a patient with high-grade sarcoma, Skeletal Radiol, 32(3): 139–42, 2003.
• Van Boerum DH, Randall RL, Mohr RA, Conrad EU, Bachus KN:  Rotational stability of a modified step-cut for use in intercalary allografts, J Bone Joint Surg Am, 85-A(6): 1073-8, 2003.
• Chansky HA, Barahmand-pour F, Mei Q, Kahn-Farooqi W, Zielinska-Kwiatkowska A, Blackburn M, Chansky K, Conrad III EU, Bruckner JD, Greenlee TK and Yang L:  Targeting of EWS/FLI-1 by RNA interference attenuates the tumor phenotype of Ewing’s sarcoma cells in vitro, JOR, 2003.
• Morgan H and Conrad EU: Limb Salvage and Spinal Surgery for Childhood Cancer: Surgical Treatment of Childhood Extremity and Spinal Tumors, pp 293–303, in Green (ed.) Late Effects of Childhood Cancer, Edward Arnold Publishers, Ltd., London, 2004.
• Brenner W, Vernon C, Muzi M, Mankoff D, Link JM, Conrad EU and Eary JF:  Comparison of different quantitative approaches to 18F-fluoride PET scans.  J Nuc Med, in press 2004.
• Brenner W, Conrad EU, and Eary JF:  FDG PET imaging for grading and prediction of outcome in chondrosarcoma  patients, Eur J Nuc Med Mol Imaging, 31(2): 189–195, 2004.
• Randall RL, Bruckner JD, Papenhausen MD, Thurman T, and Conrad EU 3rd: Errors in Diagnosis and Margin Determination of Soft Tissue Sarcomas Initially Treated at Non-Tertiary Centers, Orthopaedics, 27(2): 209–12, 2004.
• Beaulieu S, Rubin B, Djang D, Conrad E, Turcotte E, and Eary JF:  Positron emission tomography of schwannomas: emphasizing its potential in preoperative planning.  Am J Radiol, 182: 971–974, 2004.
• Brenner W, Vernon C, Muzi M, Mankoff DA, Link JM, Conard EU, and Eary JF:  Comparison of different quantitative approaches to F-18-fluoride PET scans.  J Nuc Med, in press 2004.
• Randall RL, Conrad EU3rd:  Sacral resection and reconstruction for tumor and tumor-like conditions, Orthopedics,  in press 2004.
• Conrad EU, Editor, Basic Orthopaedic Oncology, Thieme Publishing, New York, in progress 2004; in press 2005.

University of Washington
Orthopaedics and Sports Medicine
Box 356500
Seattle, WA  98195-6500
chappiec@u.washington.edu

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