Dr. Matthew Goodwin discusses spinal tumor research and the evolution of the modern patient

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Matthew Goodwin, MD, PhD, is an assistant professor of orthopedic surgery and neurological surgery at Barnes-Jewish Hospital/Washington University in St. Louis.

His practice focuses on spinal tumors including metastatic and primary cancers of the spine, benign-aggressive lesions of the spine and other noncancerous lesions requiring surgical treatment.

Here, Dr. Goodwin discusses his spinal tumor research, what surprises him about today's patient and goals for the future.

Note: Responses are edited for style and clarity.

Question: What spine research are you currently engaging in? 

Dr. Matthew Goodwin: My main clinical interest is spinal tumors, and that carries over into my lab as well. Currently, my work involves how the metabolism of different tissues are affected by the immediate microenvironment. This has come to light for me in the context of spinal tumors but has important applications to other spine settings as well, including the profound influence of the microenvironment on intervertebral discs and on the spinal cord during spinal cord injury.

In tumor metabolism, lactate has played a fascinating role in this regard. I have been studying lactate metabolism for about 15 years and it remains a widely misunderstood topic. As a few small examples, many people think of lactate as a waste product or byproduct of low oxygen or low perfusion. In reality, lactate is a metabolite that is shuttled between tissues of the body; it is the way whole-body metabolism is coordinated. Multiple unique metabolic details make this possible. 

For example, the enzyme that forms lactate is the fastest enzyme in metabolism, assuring lactate is always made. The transporters that move lactate across cell membranes are diffusion driven, assuring there is always movement down concentration gradients and into cells that need it, where lactate is taken up, converted to pyruvate and oxidized as fuel. It is unique in how easily it allows carbon to be moved throughout the body. For example, during times of stress and trauma, catecholamines bind muscle cells throughout the body, signaling muscle glycogen to be broken down to lactate and released into the blood, where it circulates to tissues in need of fuel. Otherwise that muscle glycogen is inaccessible by other tissues of the body. Much of this is not appreciated by some researchers or clinicians, in part because no one studies whole animals anymore. 

Q: What area of research particularly captures your interest? 

MG: In cancer research, there are thousands of studies on cells in culture, but most of these results are not very meaningful because the tumor microenvironment has such a profound impact on how tumors behave. This is my main area of study. In particular, tumors of the spine are of interest because the stakes are high. The margins are tight, you need every millimeter you can get, and being able to perform a clean en bloc resection with negative margins is literally life or death for many of these patients.  

There is wide misunderstanding about what fuels tumors use and how their unique metabolism can be targeted. My lab has an advantage in looking at this because of my background studying lactate metabolism, so hopefully we can continue making progress in this area. We already have ways of targeting lactate pathways but understanding them in the context of the whole animal is critical now, and key to moving us toward clinical trials.

Washington University is a special place in that we have this incredible basic science support system and our clinical volume continues to grow exponentially. I think a lot of this has to do with how our culture fits today's patient, who want to be seen by a provider who is on the cutting edge of the science but is also providing excellence in clinical care. They want a provider who is pushing the limits in the field but not trying out new, untested products on them. 

Q: How do you see the spine field progressing in the near future?

MG: I think we will continue to see the growth of specialty centers like Washington University around the country as patients continue to become their own advocates and are able to read about their choices of specialists online before deciding where to go. Often it is not even the specialist that the patient is traveling for, but rather the specialist's team that repeatedly performs the procedure. I am always amazed by how many patients show up to meet me who have read my bio online and have very specific questions. I also think we are going to dramatically improve how we predict and track patient mortality and patient reported outcomes. Machine learning will be a key part of this.  

Q: How important is having mentors in your practice?

MG: I am lucky in that I've had tremendous spine mentors at each step of my career. As a resident at Utah, Drs. Brodke, Lawrence and Spiker took me under their wing to teach me spine. As a fellow under Dr.Sciubba, learning spine tumors was like drinking from a fire hose. I learned things I didn't even realize I did until I got on my own and was placed in tough situations. Now, my department is built by giants in spine surgery — Drs. Bridwell, Lenke and Riew. That legacy is not lost on me. I think one thing all young spine surgeons fear is they won’t have a solid team to run cases by and get feedback on. In many ways my day-to-day is the opposite — there is so much spine knowledge in this department I sometimes worry I'm not taking as much advantage of it as I should be.

Q: What strategies are you implementing to enhance your practice? What are your short-term goals?

MG: As an aspiring surgeon-scientist early in my career, I am constantly trying to strike that balance of being successful in both surgery and science without sacrificing quality in either. My goals center around that focus and learning to use each to enrich the other. Having great mentors has been key —  Kevin Jones, MD, taught me a lot about this at the University of Utah in Salt Lake City, and my department chair here, Regis O'Keefe, MD, PhD, has been very successful in doing that. He created an atmosphere where science and surgery complement each other, rather than getting in the way of each other. Figuring out a way to balance excellence in science and surgery while also getting time to be with my wife and two kids will be the challenge over the next several years.

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