‘It’s like GPS in the OR.’ Guided by a 3D model of Ricardo Parker’s foot, doctors at SCCA treat his rare sarcoma and avoid amputation
Fifteen years ago, Ricardo Parker asked his doctor about a small painless lump that was barely visible on his left foot. “It’s nothing,” the doctor told him. A few years later, noticing it was getting larger, Parker consulted a different doctor. Again, he was reassured and told there was no need to worry.
Fast forward to 2019, and it was starting to hurt to walk. “I had been healthy all my life, I’d never been to the hospital, I don’t take any medications,” says Parker. But the lump had grown to the size of a golf ball. A community nurse practitioner, Megan Murray, referred him to UW Medicine, which sent him to Dr. Matthew Thompson at Seattle Cancer Care Alliance (SCCA) in the fall of 2019.
“It never crossed my mind that it could be cancer,” says Parker, who is 45. But two days before Christmas, a biopsy confirmed that the lump was indeed malignant, a rare sarcoma called epithelioid hemangioendothelioma.
Epithelioid hemangioendothelioma is an extremely unusual type of vascular tumor that invades the epithelial cells, which line the inside of blood vessels. These tumors typically grow slowly over years, until they get large enough to begin causing pain.
Parker, originally from Brazil, considers himself fortunate to have landed at SCCA. “It wasn't until I came to SCCA that I really got noticed and then got the right diagnosis, and received proper treatment,” says Parker. “It likely saved my life. When I met with Dr. Thompson, it was the first time I felt someone knew what I had and cared to treat me.”
Yet back in Brazil, Parker’s parents worried. Before he started treatment, they asked if he'd consider going back to his native country, where they have universal health care. He declined, assuring them that he was being treated at “one of the most notable and important cancer clinics in the world, which also has a cancer research institute as part of it.”
When Parker arrived at SCCA, a multidisciplinary team reviewed his case given the unusual nature of his tumor. After a biopsy, the team recommended radiation therapy followed by surgery. Parker was relieved to have a plan in place. “Just think of meeting doctors who don't even know what they are talking about, to then meeting a doctor that not only knows what you're dealing with but has a great deal of confidence in the call he's making,” says Parker. “Dr. Thompson had two different kinds of cancer in mind, and the biopsy was merely a way to determine which one it was.”
The tumor, by then the size of a plum and situated in Parker’s midfoot, just below his ankle, had completely destroyed portions of bone. That made surgery tricky. “It was challenging because complete removal of the tumor would require removal of a large portion of the bony architecture of the midfoot, leaving the foot structurally unable to bear a normal load during walking,” says Dr. Thompson.
The solution? Because of the rarity of the tumor and where it was located, the team used a 3D printer to print a model of Parker’s foot, complete with the tumor embedded. That enabled them to do a so-called trial run, relying on the 3D model of Parker’s foot to simulate his surgery. The day before surgery, Dr. Thompson took the model into the operating room and performed a practice surgery using computer-assisted navigation. “It’s like GPS in the OR,” says Dr. Thompson. “We take images of his anatomy and upload to them to a computer program, then use that program to navigate our surgical instruments to ensure our cuts accurately follow our preoperative plan.”
Simulating the surgery ahead of time allowed the team to confirm that its plan was on track to achieve negative margins—removing the entire tumor plus a bit of surrounding healthy tissue to be certain all tumor cells were eradicated—and achieve the outcome that Parker hoped for: vanquishing the cancer while achieving a lasting cure and maximizing his ability to walk.
Yet even with the 3D visual aid, the surgery remained complicated. Amputation would have been a more straightforward approach, but Parker was adamant about preserving his foot. “Amputation would have felt like the end of life for me,” says Parker. “What's really remarkable is that the doctors agreed to go with the much more complex and costly procedure. The doctors at SCCA empower the patient in the choices they make regarding their health.”
Dr. Thompson didn’t flinch at the challenge. “It was a really rare one-of-a-kind surgery intended as a limb salvage measure,” says Dr. Thompson. “We needed to remove the entire tumor with negative margins, while sparing enough of his foot to allow advanced reconstruction that would eventually allow him to walk. We used the 3D-printed model and computer-assisted navigation to ensure we got it right.”
Dr. Thompson worked with Dr. Otway Louie, a plastic surgeon, to do what’s known as a free vascularized fibula graft, taking the middle section of Parker’s fibula bone—a portion of the bone that isn’t weight-bearing and isn't critical to the functioning of the knee or ankle joint—and reconnecting it to a new blood supply in the foot. Then they reconstructed the bones of the foot in the hole that remained after removing Parker’s tumor. The delicate, highly technical surgery lasted 20 hours.
In the months afterward, Parker has taken things one step at a time—a phrase he’s borrowed from Dr. Louie, who would say it when he came into Parker’s hospital room. “To reassure me, he'd say, ‘We take it one step at a time,’ then give a big smile before leaving the room. I like that line because it serves as a pun. I've literally had to take it one step at a time —a very humbling experience when I actually used to be a great (non-professional) soccer player.”
Recovery wasn’t easy. Parker experienced problems healing and needed additional plastic surgeries. But he is thrilled to have retained his foot. "Ricardo is very optimistic, energetic, and resilient,” says Dr. Thompson. “Given the taxing nature of his recovery, we have all been impressed by his stamina and stoicism.”
Those obstacles on the road to healing offered him insight that he needed to slow down the breakneck pace he was keeping as he worked to build a company. He has since pulled back and is focused now on translating the perspectives he gained during his experience with cancer into gratitude that his cancer was finally diagnosed and treated.
“I had a spectacular experience at SCCA,” he says. “I don't know how to word this because I know it sounds weird, but I'd like for patients to know that cancer treatment doesn't need to be grueling and excruciating. I had a terrific time, in more than one way. It was a spiritual journey for me, I learned so much about the medical field first-hand, I was treated extremely well by everyone, and I was in the presence of what I consider some of the best people on this planet.”
To keep tabs on how he’s doing, Parker will have ongoing surveillance every six months. After five years, he’ll move to annual scans. Epithelioid hemangioepithelioma has up to a 30% chance of metastasis so regular monitoring is essential.
A year out from surgery, Parker is still learning to walk and praises the on-site physical therapy at SCCA. His doctors, his physical therapists and his own sheer will are moving him closer toward his goal: playing soccer with his daughter, who turned 11 at the end of June. “Every day, I try to push myself a little bit while being grateful for where I am,” he says. “I take it one step at a time."