Mentors and Protégés: Conversations on Career and Craft With Robert J. Lewandowski, MD, FSIR
Adam Sucher, DO, talks with Dr. Lewandowski about his work in early interventional oncology and IVC filters, how to meld clinical and research interests, balancing competing priorities, and more.
Can you share some background about yourself and where you did your training?
I am from the Detroit, Michigan, area. Growing up, no one in my family was in medicine. When I started my path into medicine, I thought I was going to be an orthopedic surgeon. I went to the University of Michigan in Ann Arbor, Michigan, where I received my degree in mechanical engineering. I did some research in orthopedic surgery and decided to attend medical school at Michigan State University (MSU). I had an interest in surgery at MSU, but after completing some electives in orthopedic surgery, I realized it wasn’t for me. I decided to go into a preliminary surgery year at Virginia Mason in Seattle, Washington, which was a fantastic place to train. That program was built as an apprenticeship. As an intern, I was able to spend time with the attending physicians and senior residents who provided the opportunity to be involved in many areas of medicine. Ultimately, I decided to pursue radiology to get involved with interventional radiology (IR). I returned to the Detroit area and completed my residency at William Beaumont Hospital in Royal Oak, Michigan. There, I met one of my mentors, Dr. Riad Salem. While I was in residency, he moved on to Northwestern University in Chicago, Illinois, which is where I opted to do my fellowship training.
What was your pathway into IR, and what made you consider it? What was your first experience with the subspecialty?
When I was younger, I was interested in sports, which prompted me to study mechanical engineering. Ultimately, I started gravitating toward the medical sciences and realized I wanted to be a physician. Although I liked engineering and enjoyed problem solving, I knew a career in medicine was more of a natural fit for me. I did some really interesting orthopedic surgery research at the University of Michigan on the Ilizarov procedure—more commonly referred to as distraction osteogenesis—which helped with leg length discrepancy. At that point, I thought that would be my career. When I finally started doing electives as a fourth-year medical student, I realized I was not as passionate about orthopedic surgery, which was kind of disheartening because I had spent so much time in the field. I wanted to be passionate about my career choice, and orthopedic surgery just didn’t provide that for me. My last rotation of medical school was in IR, which introduced me to central line procedures. Fast forward to my time at Virginia Mason, I did a lot of work with the vascular surgeons, who were amazing and taught me a great deal. I also enjoyed the work they were doing. This was an early time for endovascular procedures, and I was lucky enough to take part in their first endovascular abdominal aortic aneurysm repair. An IR physician took part in that procedure as well. The senior IR resident gave me a lot of insight into IR as a specialty, which ultimately prompted me to go into the field. After starting my career at William Beaumont, Dr. Salem was gracious enough to let me assist with his work in interventional oncology during its early stages.
What were your early interactions with Dr. Salem, particularly regarding your work in early interventional oncology?
Dr. Salem and I have been working together for the past 18 years as colleagues and friends. He started his career in interventional oncology, dating back to his fellowship at the University of Pennsylvania with Dr. Michael C. Soulen, and a lot of Dr. Salem’s background knowledge in oncology stems from that experience. After he started working at William Beaumont in 2001, Dr. Salem began building his own oncology practices. Interventional oncology was very new at this time. Dr. Salem had spent a lot of time during his fellowship training performing chemoembolization procedures, and treatment with yttrium-90 (Y-90) was just beginning. I learned a lot from him about oncology and interventional oncology during that time of my career.
What was the inspiration for your research on Y-90 and radiation segmentectomy?
I was very fortunate to be taught about and involved with research during my first year of residency. At that time, I didn’t know if my career was going to be as an academic, physician, or researcher. I knew I was passionate and motivated by IR and was lucky to learn about and be exposed to good clinical research early in my career. Dr. Salem and I always strived to produce good clinical data to push the field of radioembolization further. We were fortunate enough to be at Northwestern, an environment that supported us and provided us with patients who were candidates for this emerging therapy. Being in that environment, we believed we had an obligation to present our data so that we could learn and, hopefully, inspire others at different centers to develop additional techniques. Traditionally, radioembolization was a salvage therapy for patients who had advanced disease. In 2008, patients had limited alternative options; it was truly a palliative therapy back then. What we found in our patients was that not only did they tolerate the procedure well (or sometimes better than the other available therapies) but the time to progression of disease was longer. We started thinking more about radiation therapy and decided to look into the idea of ablating with a margin, particularly in patients with peripherally located tumors. At that time, there was a push in medicine to deliver radiation to patients with doses “as low as reasonably achievable.” After performing many of these procedures for palliative or downstaging reasons, our results showed that higher doses could potentially offer curative benefit. We began to experiment with higher dosages and found these benefits to be real and even more helpful than other available therapies, particularly in certain subsets of patients.
Switching gears, you do a lot of work in the realm of inferior vena cava (IVC) filters. What inspires your work with this technology?
I am very proud of the time and energy I’ve spent on IVC filters. I learned a lot with Dr. Salem about the field of oncology, but as a young attending, I also saw IVC filters as a technology that could be greatly improved on. I realized that after IVC filters were placed, I didn’t have a meaningful way to follow up with the patients who had received them. Patients or physicians sometimes contacted us, but I decided in 2008 that I personally wanted to start bringing these patients back. I remember a patient in whom we placed a filter who began having issues with low platelet counts. The hematologist was unable to start anticoagulation, and the patient came back to have the filter removed. I tried to remove it but was unable to do so. The filter had endothelialized and I couldn’t get it out. Nowadays, you can simply use a laser sheath in this type of situation, but back then, it was not an option. Both the patient and I were very disappointed. I had spent a lot of effort trying to get this patient into surgery to have the filter removed. I decided at that point that IR needed to take the problem head-on. I did not want patients to think that we were not taking care of them or following up after filter placement. I went to hospital administration and was able to secure a nurse to help me take on the challenge. It started almost like a virtual clinic, where the nurse would call me after seeing patients before they left the hospital, and I would meet with the nurse to figure out how and when to schedule the patient for filter removal. The process has evolved to become an entire practice that revolves around IVC filter removal. Our filter retrieval rate has now dramatically increased to > 70%, with a technical success rate of 98% to 99%. Patients from all over the United States come to us with complex filter complications that require advanced retrieval techniques. Part of our success revolves around having a team of people who can learn the ancillary techniques required to remove filters in complex situations. The filter practice is something I built from the ground up with a lot of help along the way, and I am really proud of it.
Are there any specific research projects that you’re particularly proud of or that hold special significance?
To name a few, we published an article on our IVC filter clinic in Journal of Vascular and Interventional Radiology that was one of the journal’s top papers of the year.1 It centered on device removal and was published very early on—before the FDA mandate of device removal. I was really happy with the reception it received, and a lot of other physicians used that article as a model for filter removal in their own practice. There was another article on radiation segmentectomy with curative intent that was recently published in Radiology that I thought pushed the envelope.2 Obviously, the data need to be validated at other institutions, but I am particularly excited about this therapy, as I think it offers another option for patients. I’m also excited about the article that Dr. Salem and I published in Gastroenterology regarding radioembolization versus chemoembolization.3 It showed that radioembolization provides a longer time to progression when the techniques are compared on equal footing. Finally, we published an article that analyzed 1,000 patients treated with radioembolization, which I believe shows the collaborative nature between IR and other specialties and how this collaboration positively affects patients and their disease.4 The title of that article was actually provided by the Head of Transplant Surgery, Dr. Michael Abecassis.
Where do you think the future of interventional oncology is headed, and what do you think will be the next big advancement?
I think a lot of the advancements have been incremental. Most importantly, I think the trend of interventionalists taking a leading clinician role has made a huge impact on the field of interventional oncology. Knowing the disease processes, systemic therapies, and radiation therapies; understanding the options; and seeing how these combinations work together play a huge role in determining the right therapy for the patient and clinician. Historically, many interventionalists have not been clinically oriented, even though we were warned by Dr. Charles Dotter about the problems with this approach. I’m glad the current training paradigm has a renewed emphasis on the importance of a clinically oriented practice. I hope that with the reinvigoration of clinically oriented training, many of the current trainees and young physicians will be better able to communicate across specialties and advance some of these therapies that haven’t changed a lot in the past 30 or 40 years. We will hopefully be better able to stratify which patients need what therapies and become more specific about how we treat diseases and what we treat them with. Collaboration will play a key role in the future.
What do you think is the single biggest mistake that trainees (student, resident, or fellow) make when they are conducting a research project?
I think a lot of trainees come in motivated to conduct research, but they haven’t necessarily looked into what has previously been published or what is currently going on in the field. It’s really important when framing a question to have a good understanding of what information is already out there. In my opinion, trainees tend to think about big ideas and formulate sweeping questions about those ideas. It’s really important to boil down these thoughts and ask yourself, “What is it that I am really trying to look at here?” Another mistake a lot of trainees make is thinking that research is easy. It requires a lot of time and dedication. You can’t write a good paper in a week. You need to dedicate yourself to the entire process to create a meaningful result. Lastly, it’s important for trainees to find a mentor. I would recommend that all residents, medical students, and even early attendings find a mentor who is willing to help guide them through the process.
How did you find the best way to meld your clinical interests with your research interests?
Everyone’s practice is a little different. Ultimately, I think you need to ask yourself what you do a lot of, what you do well, and what you do differently from other people. You need to have a robust clinical practice to figure out where you fit and what you can do. This process requires you to be pragmatic. When I started at Northwestern, Dr. Salem’s oncology practice had already been running for 2 years. After we had treated several oncology patients, we started to look at the data. Our mind-set was that once we started seeing the outcomes from these patients, we would write the papers.
How do you balance the demands of being a clinician, researcher, and teacher?
Well, I think you missed the most important one: I’m also a husband and a father. I have a 3-year-old and a 5-year-old, and they are my priority at this point. If the day is running late, I get a little grumpy if I can’t tuck them into bed. Early in my career, I didn’t have a family and I could spend a lot of time at work, and I made the most of it. I was highly productive from a relative value unit standpoint, a teaching standpoint, and a research standpoint. I enjoyed all those things, and I now enjoy having a family as well. At some point in my career, I realized how hard it was going to be to maintain those responsibilities, and to some extent, I still try to pay attention to everything, but my focus has definitely changed in some respects. I’ll share my personal belief about how a career should generally unfold. For a few years after the end of training, you are still learning and growing as a clinician and proceduralist. It’s important then to dedicate a lot of time to maturing these skills and performing as many cases as you can. As time progresses, you need to decide whether or not you want to get involved with research—and it’s alright if you decide not to. If you are in an academic environment and decide not to do research, it’s important to dedicate your time to something else, such as education. Whatever you do, try to make it meaningful.
1. Minocha J, Idakoji I, Riaz A, et al. Improving inferior vena cava filter retrieval rates: impact of a dedicated inferior vena cava filter clinic. J Vasc Interv Radiol. 2010;21:1847-1851.
2. Lewandowski RJ, Gabr A, Abouchaleh N, et al. Radiation segmentectomy: potential curative therapy for early hepatocellular carcinoma. Radiology. 2018;287:1050-1058.
3. Salem R, Gordon AC, Mouli S, et al. Y90 radioembolization significantly prolongs time to progression compared with chemoembolization in patients with hepatocellular carcinoma. Gastroenterology. 2016;151:1155-1163.e2.
4. Salem R, Gabr A, Riaz A, et al. Institutional decision to adopt Y90 as primary treatment for hepatocellular carcinoma informed by a 1,000-patient 15-year experience. Hepatology. 2018;68:1429-1440.