Banner MD Anderson Rounds - January 2013

A PUBLICATION FOR COMMUNITY PHYSICIANS

JANUARY 2013

Integrated approaches

First look at Banner MD Anderson Cancer Center’s new head and neck cancer and stem cell transplant programs

BY JAKE POINIER

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ith the arrival of 2013, Banner MD Anderson Cancer Center in Gilbert will be expanding its world-class offerings in two key areas: Head and neck cancer surgeries and oncology, and stem cell transplantation. While the programs are different from a medical perspective, they have one essential element in common: integrated teams with national expertise in their respective fields.

“Integration is one of the important things that makes the Banner MD Anderson approach different,” says head and neck surgeon Thomas D. Shellenberger, M.D., who has helped start up the program. He has been both at The University of Texas MD Anderson Cancer Center and MD Anderson Cancer Center Orlando for a decade, where he headed up the creation of their head and neck program. “Relative to other cancers, head and neck cancer requires numerous disciplines and subspecialties in addition to radiation oncology, medical oncology, and surgery in order to be successful.”

For example, Dr. Shellenberger cites speech pathology, dental oncology, and nutritional consultation, as well as collaboration with plastic and reconstructive surgeons. “It’s not just about curing the cancer, but how can we help patients retain maximum quality of life,” he says.

Thomas D. Shellenberger M.D. and Klaus Wagner M.D.

INSIDE 2 Stem cell program, transplant options

6 What’s happening at Banner MD Anderson

3 Changing the surgical landscape

7 Rare pregnancy cancer is curable

4 Meet Drs. Craft and Tan

8 Banner MD Anderson physicians

5 New hope for pancreatic cancer patients

Javier Munoz M.D., and Gorgun Akpek M.D., M.H.S.

HEAD AND NECK CANCER Klaus Wagner, M.D., the team’s medical oncologist, notes an increasing prevalence of head and neck cancer. “In the past, these types of tumors were smoking and alcohol related,” he says. “We’re seeing more head and neck cases that are HPV related, and we’re also seeing them in younger patients.”

The head and neck program will be increasing its capabilities in the coming year, including the addition of robotic surgery. On the oncology side, Dr. Wagner will be adding state-of-the-art diagnostic imaging as well as multimodality therapies such as monoclonal antibodies.

“Cetuximab can be a good alternative to chemotherapy, with fewer side effects, or as a synergizer with radiation, particularly for those who have tolerance issues with chemotherapy,” he said.

It’s not just about curing the cancer, but how can we help patients retain maximum quality of life.

“We will be studying treatment regimens to determine which ones lead to improved outcomes, with specific strategies to objectively study quality indicators in a prospective way to chart the course of how the program develops. The head and neck program at MD Anderson Houston is a world leader, and our task is to follow that lead and meet that high standard.”

STEM CELL TRANSPLANT PROGRAM The launch of the Stem Cell Transplant program offers new hope for Arizonans with leukemia, lymphoma, multiple myeloma, myelodysplastic syndrome, and other hematologic and bone marrow failure disorders. Heading up the program is Gorgun Akpek, M.D., M.H.S., a nationally recognized stem cell transplant physician whose background includes work with the Bone Marrow Transplantation program at Johns Hopkins University and the University of Maryland Greenebaum Cancer Center, an NCI-designated cancer center.

“I’m excited to translate my experience and background into building a program in a timely fashion and providing the best transplant care in Arizona,” Akpek says. “We’re currently in the process of aligning our guidelines and standard operating procedures with MD Anderson, since we have very similar treatment goals and care sets.”

Akpek expects to announce trans-

plant activities starting in January or February, and is in the process of hiring two additional transplant physicians. The program will start with autologous transplants, using a patient’s own stem cells.

Allogeneic transplants, using cells from a related or matched donor, are expected to be added by summer 2013.

TRANSPLANT OPTIONS The upper age for eligibility is expected to be 75 for autologous transplants and 70 for allogeneic transplants, with the possibility of increasing those ages in the future.

The transplant program will work in concert with Javier Munoz, M.D., staff physician in hematology and oncology who has trained at MD Anderson Houston, and handles patients with hematological malignancies including lymphomas, many of whom eventually need transplants. “Lymphoma is a heterogeneous disease, and there are multiple variables that determine which patients will truly benefit from a particular treatment including targeted therapy with monoclonal antibodies or antibody-drug conjugates,” said Munoz.

“We formed a hematology tumor board in which different specialists review cases in a multidisciplinary fashion to tailor the best treatment regimen for each patient.”

Optimally, physicians should refer patients to Akpek for a transplant consultation early in the course of the disease.

“Most of the time we are a last resort, after many treatments and after the disease becomes resistant,” he says. “Even if a patient doesn’t meet the criteria, the earlier the referral the better.”

— Thomas D. Shellenberger, M.D.

Finally, the program will be launching prospective research trials in 2013.

“Head and neck cancers really don’t form one disease but a group of diseases that are individually rare, so there’s a lot of heterogeneity,” Dr. Shellenberger says.

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DID YOU KNOW? According to the American Cancer Society, more than 52,000 men and women in the U.S. were diagnosed with head and neck cancers in 2012.

DID YOU KNOW? MD Anderson Houston is one of the largest centers in the world for stem cell transplants — performing more than 865 procedures for adults and children each year, more than any other center in the nation.

Changing the surgical landscape

New era in autologous breast reconstruction comes to Banner MD Anderson Cancer Center

BY DEBRA GELBART

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wo plastic surgeons at Banner MD Anderson Cancer Center in Gilbert recently began perform-

ing the latest in autologous breast reconstruction surgery for cancer patients.

Unlike a TRAM flap that depends on the rectus for a blood supply when the tissue is relocated, the Deep Inferior Epigastric Perforator (DIEP) reconnects abdominal skin and fat to the internal mammary artery. The rectus is left intact.

A by-product of the procedure is improved abdominal contour, which engenders increased patient satisfaction.

GIVING PATIENTS MORE OPTIONS “The DIEP has not been widely available before now,” said reconstructive surgeon Benny Tan, M.D. “We want to give more patients an opportunity to choose this approach to breast reconstruction.” He and reconstructive surgeon Randall Craft, M.D. typically perform the surgery together.

Both practice in Banner MD Anderson’s Division of Surgical Oncology as plastic and reconstructive surgeons. Unilateral reconstruction takes between six and eight hours; bilateral reconstruction can take up to 12 hours.

With a traditional TRAM flap, the surgical impact on the rectus often results in bulging of the abdomen, hernias or weakness, Drs. Tan and Craft said. “But by leaving the rectus intact,” Dr. Craft said, “we can often give patients a better quality of life.”

NO AUTOMATIC AGE RESTRICTION Not all patients are candidates for the DIEP, Dr. Tan said, explaining that sometimes a patient’s vessels are too small to accommodate the reattached tissue. “Although there is no age cutoff,” he said “a patient must be physiologically fit enough BannerMDAnderson.com

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to endure a six-to-12-hour surgery, depending on whether the reconstruction is unilateral or bilateral.”

A patient can’t be morbidly obese or especially thin. Her ideal BMI is between 25 and 35, he said, so that she has enough abdominal tissue to be used for the reconstruction. And, ideally, she has not had previous abdominal surgery, although a Csection or a previous hernia surgery or laparoscopic cholecystectomy, for example, would not preclude a DIEP. The post-surgical hospital stay is typically four to seven days.

This procedure is well-suited for a patient who has undergone radiation therapy, Dr. Craft said.

Susan Brown*, 50, of Chandler, had been a radiation therapy patient, so she wasn’t a good candidate for implant surgery. She was referred to Dr. Craft for the DIEP. “I would tell other breast cancer patients to strongly consider this procedure,” Brown said. “It’s tough, because of the length of the surgery, but it’s well worth it. I am so grateful to have a natural-looking and natural-feeling breast again and I really like knowing I won’t need another surgery in 10 years like I would with an implant.”

For patients who are not good candidates for the DIEP, Drs. Craft and Tan perform autologous breast reconstruction options, including the latissimus dorsi flap, TRAM flaps and implant reconstruction.

Drs. Craft and Tan estimate that between 25 and 40 percent of all breast reconstruction patients ultimately will choose the DIEP for their breast reconstruction. Even if they are good candidates for the procedure, however, some patients will opt for implant surgery or another autologous reconstruction surgery because of the complexity of the DIEP. * Not patient’s real name.

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Doctors well-trained, skilled in performing DIEP Randall Craft, M.D. became interested in the Deep Inferior Epigastric Perforator (DIEP) procedure while he was a surgical resident in the Harvard Plastic Surgery Combined Residency Program in Boston, Mass. “They did a high volume of these in the Harvard system,” he said, “and I was able to learn a lot about the procedure.

Since then, I’ve published a lot about it in the medical literature.”

Dr. Craft, who is board-certified in surgery, said he’s always “been drawn to the creativity of plastics. “There’s nothing routine about it, and I like the reconstructive aspects of this type of surgery.” Most of his patients undergo breast reconstruction, but he also performs reconstructive surgery on any part of the body affected by cancer.

After graduating from medical school at The Ohio State University College of Medicine in Columbus, he completed his general surgery residency at Mayo Clinic Arizona before beginning his plastic surgery residency at Harvard. He also completed a combined research and clinical fellowship at the Bernard O’Brien Institute of Microsurgery in Melbourne, Australia.

Dr. Craft said the most rewarding aspect of performing the DIEP is “providing an opportunity for women to have their sense of self restored,” he said, “without having a foreign body inside them. “The DIEP preserves the symmetry of the chest and patients are typically quite happy with the outcome.”

Benny Tan, M.D. was born and raised in Singapore. At 21, he went to Ireland to attend medical school. After graduation and a general surgery and orthopedic surgery residency, he came to the United States and completed a three-year general surgery residency at Johns Hopkins Hospital in Baltimore, followed by two years of a general surgery residency at Massachusetts General Hospital in Boston. He then completed an orthopedic hand and microsurgery fellowship at Jackson Memorial Hospital in Miami, Fla., followed by a plastic surgery residency at the Cleveland Clinic Florida in Weston, Fla. He is board certified in plastic surgery and general surgery.

“I performed many types of reconstructive surgery,” Dr. Tan said, “but I gravitated toward breast reconstruction because the patients are so appreciative when we’re able to give them back their normal life.”

He said he began performing the DIEP procedure at Banner MD Anderson because of patient demand. Like Dr. Craft, Dr. Tan also performs implant- and autologousbased breast reconstruction.

Dr. Tan noted that DIEP patients also appreciate the extra benefit of the tummy tuck that comes with the procedure. He said both the chest and abdominal scars are well-tolerated by patients. “They also like that their abdominal contour is improved,” he said. “It’s a change most patients are very happy with.”

Contact Drs. Tan and Craft at 480-256-3609.

New hope

for pancreatic cancer patients Cancer clinical trials open at Banner MD Anderson Cancer Center

BY BETH LIPHAM

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nnovative treatments and a brighter sense of hope are on the horizon for pancreatic cancer patients as Banner MD Anderson Cancer Center in Gilbert begins a series of clinical trials.

Pancreatic cancer is one of the deadliest cancers of our time, with approximately 42,000 new cases diagnosed annually in the United States resulting in 35,000 deaths. Diagnosing pancreatic cancer is difficult because symptoms such as low back pain, indigestion and gastrointestinal complaints could be mistaken for other common conditions such as peptic ulcer, gastritis or arthritis. Unfortunately, once detected, pancreatic cancer is often advanced and not curable. Only 20 percent of patients are candidates for surgery, and only 20 percent of those that have surgery survive up to 5 years after diagnosis.

research efforts with some more recent studies showing promise,” Dragovich says. “A combination regimen called FOLFIRINOX, for the first time extended the survival of patients with metastatic pancreatic cancer to beyond 11 months. This is now accepted as a good option for some patients (those with a good performance status). And adding a new drug, nab-paclitaxel (Abraxane), to the current standard therapy (gemcitabine) also appears to extend survival of patients with metastatic disease.

“The complete results from this trial will be presented at a national oncology meeting (ASCO GI Symposium) in January,” say Dragovich, who participated as an investigator in this trial.

“These are incremental but significant improvements for our patients.”

RESULTS ARE ENCOURAGING PATIENT ACCESS Tomislav Dragovich M.D., division chief of Medical Oncology and Hematology, feels patients with this deadly disease should be offered access to clinical trials because standard therapies are just not good enough.

Current research focuses on breaking down the complex genetic code of pancreatic cancer and finding new anti-cancer drugs (“targeted therapies”) for pancreatic cancer.

“We are just beginning to see the fruition of years of continued

The Banner MD Anderson team is encouraged by the pace of new research concepts introduced for patients with pancreatic cancer. Some of the research treatments are now available at Banner MD Anderson. Dragovich is the principal investigator on two such trials for patients in whom the standard treatment has failed.

The first trial investigates an anti-cancer drug called MM398. This is a chemotherapy drug packaged in nano-liposomes, which coat the drug to allow for better penetration inside

Tomislav Dragovich M.D. pancreatic cancer tissue.

The second trial is a radio-immunotherapy trial. It exploits a novel approach where antibodies are tagged with a radioactive head that links to a protein (PAM4) on the surface of the pancreatic cell much like a “lock and key” system. “The antibody attaches to the cancer cell and unloads the radiation to selectively target and kill cancer cells,” Dragovich says.

While these are promising and intriguing concepts, they still need to be proven in clinical trials. “We are proud to offer state-of-the art treatment but also to go beyond that and provide access to clinical trials to patients suffering from this disease. We are encouraged with some recent results generated by clinical trials,” he says.

To refer a patient, contact Banner MD Anderson Cancer Center at 480-256-3433. To learn more about pancreatic cancer therapy, read Dragovich’s recent review online at emedicine.medscape.com/ article/280605-treatment. He can be reached at 480-256-3335.

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What’s happening at

Banner MD Anderson Cancer Center

BY DR. EDGARDO RIVERA, MEDICAL DIRECTOR

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he start of a new year is a time to consider our personal and professional goals, to reflect and to dream.

Our patients will resolve to live better and to fight their cancer, and it is our privilege to stand by them and arm them with the tools to survive and thrive.

One reason we’re so successful at Banner MD Anderson Cancer Center in Gilbert is because of our focus on the continuum of care.

We are not isolated providers.

We are a team that works together.

Physicians, nurses, researchers, pharmacists and staff are all essential, because without this team approach to cancer care, the quality of care suffers.

From the very first diagnostic test to treatment and beyond, excellent communication is critical to providing outstanding care along the continuum. One place we see this working very well is with our gynecologic oncology program, led by Diljeet Singh, M.D. In the past, the Valley has been traditionally underserved in this area. But with this program and our experienced gynecologic oncologists, we are changing that. The presence of large specialty medical centers like ours helps to ensure that patients can experience the continuum of care — working with the same team from

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diagnosis through survivorship. Plus, with the growth of the gynecologic oncology program, we also expect to bring more clinical trials to the Valley.

As we look ahead to this year, I’m also excited to see the Banner MD Anderson Stem Cell Transplant program continue to grow and evolve under the leadership of Gorgun Akpek, M.D. It’s a tremendous step forward to be able to offer this to patients with leukemia, lymphoma, multiple myeloma and other hematologic conditions stem cell transplantation as part of their treatment.

I’m also eager to watch as our head and neck program, led by Thomas Shellenberger, M.D.,

continues to grow as well. In fact, this March, we expect to see another surgeon join the team, which already includes talented radiation and medical oncologists, allowing us to offer a full range of care.

This year promises to be an exciting one, and each and every one of you plays a critical role in the continuum of care and the quality of care we as a team provide. Thank you for all you do, and I look forward to building on our successes in 2013!

Sincerely, Edgardo Rivera, M.D. Medical Director

Rare pregnancy cancer

is curable

Choriocarcinoma occurs in 2 of 1,000 pregnancies

BY BRIAN SODOMA

here are plenty of concerns for a mother to be. Unfortunately there are also those rare instances when thinking about cribs and diapers is suddenly cancelled out by cancer treatment.

That’s the case with the rare but curable Choriocarcinoma, a type of Gestational Trophoblastic Neoplasia (GTN).

15 choriocarcinoma cases in his career.

GTN occurs in about 2 in 1,000 pregnancies, with choriocarcinoma being only a small fraction of GTN cases. In all cases of GTN, the pregnancy is nonviable.

But the good news is that most women can conceive again after treatment. There is no prevention strategy for choriocarcinoma. More than anything, the condition seems to be a case of bad luck.

ABNORMAL ACTIVITY

SEEING THE MARKERS

GTN occurs when placental tissue grows abnormally during a pregnancy.

The most common type of GTN is a hydatidiform mole, also known as a molar pregnancy. In rare cases, molar pregnancies can become malignant, leading to choriocarcinoma.

“The good thing is [choriocarcinoma] is very sensitive to chemotherapy. Even stage three can be cured,” says Dr. Matthew Schlumbrecht, a gynecologic cancer specialist at Banner MD Anderson Cancer Center in Gilbert who has seen about

Doctors are usually tipped off to the condition during an ultrasound, which will reveal abnormal tissue in the uterus. A blood test showing high hCG (beta human chorionic gonadotropin) levels is the biggest clue. Abnormal vaginal bleeding, pelvic pain, and an abnormal uterine size can also be present. During treatment, βhCG levels are monitored closely as a sign that the condition is receding. Though rare, GTN can recur after initial diagnosis, so it is important that patients follow up closely with their doctors.

Those at greatest risk for the condition are Asian women, folate-deficient women, and those having babies at the extremes of child-bearing age, either under 20 or over 45 years. Obstetrician/gynecologists are well-trained at detecting the disease, according to Schlumbrecht, who also said only a small number of patients with GTN even require chemotherapy.

“Most patients end up doing really, really well with this,” he says.

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The good thing is [choriocarcinoma] is very sensitive to chemotherapy. Even stage three can be cured.

— Dr. Matthew Schlumbrecht

Meet Dr. Matthew Schlumbrecht Going into medicine was an easy choice for someone like Dr. Matthew Schlumbrecht. The gynecological cancer specialist at Banner MD Anderson in Gilbert was driven by the intellectual challenge and a desire to help others.

Today, Schlumbrecht finds great intellectual challenge specializing in malignancies of the female genital tract. He has been awarded The University of Texas MD Anderson’s Jesse H. Jones Fellowship Award for excellence and unique contributions to cancer education and has also won MD Anderson’s Gynecologic Oncology Fellow of the Year recognition.

Schlumbrecht is also working on doctorfocused cancer survivorship research.

He has conducted numerous surveys of primary care physicians, internists and those in other disciplines, asking them to assess their strengths and weaknesses in working with cancer survivors.

By 2020, there will be some 20 million cancer survivors in the U.S. After successful treatment, these patients must then use these primary care physicians, internists and other disciplines for their health care needs instead of their oncologists, a transition, Schlumbrecht says, that can be difficult.

“There’s a lot of anxiety for patients leaving their oncologist. It’s a much more complicated problem than one would think,” he said.

He is also working to establish a robotic surgery database for the surgery division at Banner MD Anderson to conduct research in the rapidly growing field of minimally invasive surgery. Partnered with MD Anderson’s Houston facility, the data from such a venture will aid in tracking patient outcomes from new surgical approaches.

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Banner MD Anderson Cancer Center Physicians

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DIAGNOSTIC IMAGING SECTION Donald Schomer, M.D. Division Chief CAQ Neuroradiology Oncologic diseases of the brain, spine, head and neck

anner MD Anderson Cancer Center in Gilbert physicians are highly specialized in their fields of expertise. Below is a listing of physicians currently on our full time staff.

Physicians continue to join Banner MD Anderson, so this list will continue to evolve.

To make a referral to a physician on our staff, please call 480-256-3433. To contact a member of medical staff, call 480-256-6444 and ask for the physician to be paged.

John Chang, M.D., PhD Advanced MR and CT imaging of gastrointestinal and genitourinary systems; imaging guided biopsies

HEMATOLOGY & MEDICAL ONCOLOGY SECTION

Klaus Wagner, M.D., PhD Thoracic and Head & Neck Cancers

Tomislav Dragovich, M.D., PhD, Division Chief Digestive tract cancers including colorectal, esophageal, stomach, pancreatic, hepatobiliary

Bryan Wong, M.D. Genitourinary cancers

Harvinder Maan, M.D. CAQ Neuroradiology Director of Neuroradiology Neuroradiology and interventional spine procedures

Gorgun Akpek, M.D., M.H.S. Director of Stem Cell Transplantation and Cellular Therapy program

Judith K. Wolf, M.D. Division Chief Gynecologic oncology

Diljeet Singh, M.D. Program Director, Gynecologic Oncology; Program Director, Cancer Prevention & Integrative Medicine

Shakeela Bahadur, M.D. Lung, colorectal, breast cancers

Stephanie Byrum, M.D. Breast surgery

Benny Tan, M.D.

Mary Cianfrocca, D.O. Breast Cancer Program Director

Al Chen, M.D. General Surgery

Farshid Dayyani, M.D., PhD Genitourinary and Gastrointestinal cancers Jade Homsi, M.D. Melanoma, sarcoma, immunotherapy

Randall Craft, M.D. Full spectrum of both implant-based and autologous breast reconstruction, comprehensive plastic and reconstructive options for all areas of the body

H. Uwe Klueppelberg, M.D., PhD Multiple myeloma and other plasma cell disorders, lymphomas, myelodysplastic syndrome, brain cancers, head and neck cancers, thoracic cancers

Mark Gimbel, M.D. Melanoma, sarcoma, cancer of the stomach, small bowel, colon and rectum, thyroid, pancreas, liver and other rare cancers

Javier Munoz, M.D.

Matthew Schlumbrecht, M.D., M.P.H. Gynecologic oncology; gestational trophoblastic disease; a variety of surgical techniques including radical abdominopelvic exploration and minimally invasive procedures.

Lymphoma and other blood cancers Edgardo Rivera, M.D. Medical Director Breast cancer Kerry Tobias, DO Pain management, palliative medicine, physical medicine, rehabilitation

ONCOLOGY SURGERY SECTION

Rob Schuster, M.D. General surgery

Thomas Shellenberger, M.D.

Recurrent thyroid cancers, cancers of the oral cavity, oropharynx, and larynx, salivary gland cancers, advanced skin cancers and melanoma of the head and neck, complications from treatment of head and neck cancer.

Plastic and reconstruction surgeon Breast cancer reconstruction and most forms of cancer reconstruction

RADIATION ONCOLOGY SECTION Matthew Callister, M.D. Division Chief Gastrointestinal, skin, sarcomas and head and neck cancers Dan Chamberlain, M.D. Thoracic and head and neck malignancies, and body radiosurgery Emily Grade, M.D. Breast treatment including partial breast brachytherapy, prostate brachytherapy, gynecological and thyroid cancers Terence Roberts, M.D., J.D. Brain, lung and prostate tumors; stereotactic radiosurgery; partial breast brachytherapy

Vilert Loving, M.D. Breast imaging and intervention

Rizvan Mirza, M.D. Abdominal and pelvic magnetic resonance imaging Susan Passalaqua, M.D. Director of Nuclear Medicine and Molecular Imaging Oncologic imaging, nuclear medicine, radiology, PET/CT Andrew Price, M.D., C.A.Q. Interventional radiology, including percutaneous tumor ablation, chemoembolization, and radioembolization David Russell, M.D., F.A.C.P. Breast imaging and intervention

CRITICAL CARE SECTION Shiva Birdi, M.D., Division Chief Jijo John, M.D. Deven S. Kothari, M.D. Dean Prater, M.D. Ravindra Gudavalli, M.D.

INTERNAL MEDICINE SECTION Nikunj Doshi, D.O., Division Chief Shefali Birdi, M.D. David Edwards, M.D. Ronald Servi, D.O.

PATHOLOGY SECTION Kevin McCabe, D.O. Division Chief