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In 2011, Madeline Pufahl was a busy 15-year-old who played multiple sports and loved riding horses. That year, she was also diagnosed with embryonal sarcoma of the liver, a rare form of childhood cancer. She had surgery and chemotherapy, and doctors considered the West Bend teen cured.

She returned to her previous activities, graduated high school and entered college. But in November 2017, she began experiencing back pain that medication couldn’t help.

“There was only one other time that I had a pain that just kept getting worse,” Madeline said. “That was when I was first diagnosed with cancer.”

She visited the emergency department at a local hospital, where imaging confirmed her fears: Madeline had a tumor in her thoracic spine that had cracked the T7 vertebra, located roughly between her shoulder blades. The tumor was a recurrence of the type of cancer she’d had before.

Madeline returned to the hospital where she was originally treated for cancer and began a regimen of chemotherapy that successfully shrank the tumor. When chemotherapy was complete, she received proton therapy, a precise form of radiation therapy that could target the tumor without harming nearby organs, including her heart.

Spine Tumor Surgery Options

The next step was to select a medical team and surgical approach to remove the fractured vertebra and any remaining tumor cells.

Madeline sought two opinions, including one from an out-of-state hospital. The doctor there recommended using part of a bone from her leg to repair the vertebra and adding rods and pins in the leg and spine. The doctor warned Madeline that to protect her spine, she could not ride her horses or pursue other rigorous outdoor activities. The gravity of the prognosis hit her hard.

“I thought, ‘I can’t become a couch potato in my 20s,’” Madeline said.

She also received an opinion from Brandon Rebholz, MD, an orthopaedic surgeon and Medical College of Wisconsin faculty member who specializes in spine surgery within the Froedtert & MCW health network.

“When you’re thinking about doing this kind of surgery in young people, you take into consideration that person’s quality of life and their aspirations,” Dr. Rebholz said. “One of the important things to Madeline was getting back on a horse.”

Fortunately, the type of surgery he recommended would likely allow her to return to riding once her spine healed. That possibility made her happy.

Innovative Surgical Technique

In September 2018, Dr. Rebholz conducted the 10-hour surgery at Froedtert Hospital. He removed Madeline’s T7 vertebra by cutting it in just two places, a technique designed to keep the cancer cells contained so they would not escape and increase her risk of recurrence. He replaced that vertebra with a supportive plastic and metal “cage” that he attached with screws to the vertebra above and below T7. If all went well, Madeline’s spine would fuse around the cage, providing stability and offering her medical team a clear view to monitor for cancer recurrence.

The surgery was a success.

“Madeline did fantastic after surgery, better than we would expect,” Dr. Rebholz said. Her pain resolved quickly and subsequent X-rays showed her spine was healing and stable. She also did physical therapy at the Froedtert & MCW Hartford Health Center.

At the Clinical Cancer Center at Froedtert Hospital, she also began seeing John Charlson, MD, a medical oncologist and MCW faculty member with expertise in sarcoma. He works with Madeline in a two-part role: ordering periodic surveillance scans that look for a cancer recurrence and monitoring for any late effects of her cancer treatments, such as heart problems.

“She’s doing really well in both regards,” he said. Given that Madeline, now 25, may want to have children someday, Dr. Charlson also referred her to a specialist who could advise her about the impact of chemotherapy and radiation therapy on fertility.

Triumphant Return

As Madeline healed, Dr. Rebholz offered welcome news.

“I decided it was safe for her to start getting back to the activities she loves,” he said. In the spring of 2019, Madeline returned to riding her beloved horses with a gentle ride on Jaxun, the white and brown paint horse she has owned since 2013. She admitted to being a little nervous, but her love for her horses eased the anxiety.

Madeline is currently free of cancer and grateful to her Froedtert & MCW team for making her active life possible.

“I don’t know what I would have done if I couldn’t ride,” she said. “It’s my main source of stress relief. The horses have helped me through a lot of dark times. It gives me a reason to keep going.”

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