TMC PULSE

t m c » p u l s e | n o v e m b e r 2 0 1 7 26 "If the patient goes to a surgeon, they will look at the nodules that are on the sur- face, but they won't realize that, underneath the skin, there may be other nodules that you cannot see," Torres said. "Whenever they resect the margins of the specimen, it may have some tumor cells that were left behind." Torres and Jesse Selber, M.D., a recon- structive plastic surgeon at MD Anderson, devised a plan to first surgically remove the diseased flesh and then perform an autol- ogous microvascular reconstruction—they hoped to transfer skin, muscle and tissue from Marian's abdomen and thighs to cover the excision. Unfortunately, Marian's petite 5-foot, 115-pound frame was an issue. There simply wasn't enough of Marian to go around. She had previous surgery on her abdomen, rendering the small amount of tissue there unusable. "Because [Marian's tumor] had recurred several times and had grown to epic pro- portions, it outstripped most reconstructive tools we normally use to perform cancer reconstruction," Selber said. The "suboptimal" alternative was to use muscle and skin from multiple parts of Marian's body and patch them together like a quilt to cover the hole from the resection, but there was a high risk of chronic wound and pain management for years to come, Selber explained. This option sounded bleak, but Marian's twin was determined to help her sister. "Just use me," Mary Jane told the doctor. Selber had heard that offer many times before: A patient's loved one often vol- unteers his or her own tissue for transplant. Although it's a noble and altruistic offer, it is rarely feasible because transferring tissue between two indi- viduals requires immu- nosuppression, which is considered too risky in cancer patients. Selber took a longer look at the two women. "How are you two related?" he asked. "Well, I'm her identical twin," Mary Jane responded. Selber raised his eyebrows. The sisters certainly didn't look like identical twins. Mary Jane is taller and broader than Marian, with a larger body and head. She stands at 5'4.5" and, at the time, weighed 44 pounds more than Marian. It wasn't the first time someone doubted they were twins. By the time Mary Jane entered college, she had grown an addi- tional 4.5 inches beyond her sister and continued to gain weight. For 10 years, doc- tors couldn't explain what was causing the mysterious changes in her body. Eventually, Mary Jane was diagnosed with acromegaly, a tumor in her pituitary gland that caused her to produce excessive growth hormone. She went on steroid medication and had the tumor removed, but by then, her appearance and size had already dramatically changed to the point where she and Marian no longer looked like identical twins. When Selber heard this, he realized a rare and unique opportunity had presented itself. If he could confirm that Marian and Mary Jane were, indeed, identical, Mary Jane's larger build might actually provide Selber with enough tissue from her abdomen to recon- struct the hole in Marian's back. Selber ordered genetic tests that would determine if the sisters were 100 percent identical and a match for transplant. He enlisted the help of transplant surgery veteran Osama Gaber, M.D., director of the Houston Methodist J.C. Walter Jr. Transplant Center, to run further immu- nological tests. Gaber and Selber had collaborated two years earlier to perform the world's first skull-scalp-kidney-pancreas transplant. Confirming an identical match was crit- ical to the success of the surgery. Typically, a transplant recipient would be placed on immunosuppressive medication to pre- vent the rejection of the new organ. But with the high recurrence rate of Marian's tumor, the doctors couldn't risk weakening her immune system. If they were identical twins, there was a chance immunosuppres- sion wouldn't be necessary. The doctors found that not only were the twins identical on six of the human leuko- cyte antigens usually measured, but they were a match on all 10. "They were completely identical," Gaber said. But the twins didn't need genetic tests to prove they were one. Their kinship ran deeper than the flesh and bone of their bodies or matching DNA on a lab report. Except for six years in their late 20s, Marian and Mary Jane have lived together their entire lives. Neither ever married or had children. They have each other, and that's all they need. "We get along really well. It seems silly to force a separation. If we lived in separate houses, we would always be at each other's house," Marian said. "It's just nice to have your best friend around all the time." "'Good friendship is one soul in two bodies,'" Mary Jane said, quoting Aristotle. "That's us." What is life without quality? Before the doctors could proceed with the surgery, Gaber put the twins through the routine process of consent. He had to make sure they understood all the risks and benefits. Although he, Selber and Torres supported the surgery, they had to make sure the twins knew every possible complication that could arise and all the challenges they might face. There was a chance the tumor could recur. The surgery might not completely relieve Marian of the neuropathic pain caused by the radiation. And Marian's mobility and strength might Keila Torres, M.D., Ph.D., is a sarcoma specialist and assistant professor in the department of surgical oncology at The University of Texas MD Anderson Cancer Center. Osama Gaber, M.D., is director of the Houston Methodist J.C. Walter Jr. Transplant Center. Credit: The University of Texas MD Anderson Cancer Center

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