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Remote Seed Implant Guidance for Breast Cancer Surgery > Breast Cancer Incidence > Deep Inspiration Breath Hold (DIBH) for Breast Cancer
Dr Lyn Oliver AM PhD
Consultant Medical Physicist
Literature Review
Information for Patients and Profession
This is a scientific and technically based article. It is not intended to provide medical advice and is for information only.
If you have any health problems or questions related to your health, then please consult your doctor.
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Better Healthcare Technology for Surgery
Media Release, 2016
Dr Samuel Achilefu PhD
Introduction
The Washington University news announced that the professor of radiology, Dr. Samuel Achilefu PhD, had invented ‘cancer goggles’. They said: “New hi-tech goggles that allow doctors to see cancer cells during surgery will be tested in clinical trials at hospitals across the country” . The short report referred to a Fox2now media release televised in February, 2016.
New ‘Cancer Goggles’ help surgeons spot malignant tumours
The procedure was described as: “requiring the patient to have a bio-luminescent marker injected about one hour before the operation. The marker ‘dye’ attaches to the cancer cells. The surgeon wears the specially designed goggles during the operation and sees the malignant tumour cells glow when a near infrared light is beamed onto the patient.”
Looking to the Future
Despite it taking almost ten years to research and develop the ‘cancer goggles’ for real-time, image-guided oncological surgery, there’s now great optimism that the goggle imaging technique combined with suitable biomarkers could assist surgeons with other types of oncological surgery.
In an interview held with Professor Achilefu and Innovation City interviewers, he provides his impressions on where the future may be for the use of cancer goggles and biomarkers:
To Hear Dr Achilefu’s Vision ⇒ Dr Achilefu at Innovation City
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Literature Review: Progress
Real-Time, Image-Guided Oncological Surgery
It’s standard practice that, at the end of an operation to remove a breast tumour, the surgeon takes samples from around the resection site. This is sent to pathology after the patient has left surgery. The pathology request is to check that there’s no residual cancer left in the breast tissue surrounding where the tumour was removed,. McLaughlin (McLaughlin, 2013) reported that the pathology tests indicated incomplete tumour resection in an undesirable 20 to 25 percent of cases who would then need a repeat operation.
Based on every individual case, the surgeon will advise the patient whether there should be any radiation therapy and/or chemotherapy as follow-up treatment to complement breast cancer surgery.
To reduce the number of patient revisits to surgery and to provide a better treatment protocol and outcome, surgeons need a better, more reliable means of helping the surgeon to assess the extent of tumour spread and decide how much margin to allow when removing the breast cancer.
The Surgical Procedure
There are excellent imaging methods of X-ray mammography, ultrasound or CT, MRI, PET , SPECT Scans to detect cancer and diagnose the extent of the disease. A tracer wire can be inserted at depth in the breast and a mark placed at the surface of the breast with the aid of imaging. This provides the surgeon some indication of the lump location .
But the use of imaging facilities during surgery in the operating theatre, are either impractical or unsuitable to use (2, Mondal SB et al.).
The surgeon removes the tumour mass plus any suspected surrounding tissue that may be involved, but retains as much as possible, the normal unaffected breast tissue.
How does the surgeon decide what is a suitable margin around the tumour?
The surgeon mainly relies on sight and touch to determine the tumour’s position, size and extremity. The excision boundary for small tumour nodules or diffusely dispersed tumours is not easy to determine. The final decision on the size of the margin to remove, is decided by the surgeon during the operation.
Marker clips are inserted and pathology samples are taken from the excision boundary tissues for pathology tests are arranged. Pathology results are sent to the surgeon after the patient has left the operating theatre. The difficulty in identifying microscopic cancer cells in this region during the operation has meant that some patients, diagnosed as having cancer cells in their pathology samples, require repeat surgery.
Surgeons have, for many years, wanted a workable method that can provide them real-time image-guided surgery.
Image-Guided Goggles
Scientists and biomedical engineer researchers at the Washington University have been working with surgeons for almost 10 years to develop a suitable image-guided surgery technique. The end goal in this research was to label the cancer cells with some form of fluorescent biomarker that the surgeons could see whilst they operated. This was when the ‘cancer goggles’ were first considered.
Prototype Goggle, 2011
The first hands-free prototype goggle was described in 2011 (3, Liu Y et al). It was actually a monocle arrangement.
The Lui method was able to:
- detect non-obvious small tumour lesions; and
- guide biopsy resection by remote telemedical signals.
As shown in Figure 1, surgeons used one naked eye to view the operation site and the other eye viewed the operation site through a monocle type goggle to view the fluorescent labelled cells.
It was designed to be a low cost, small sized instrument, that developing countries or remote and rural areas could afford. Image quality was automatically controlled and it had adequate sensitivity. It was relatively easy for the surgeon to use.
Disadvantages:
- The procedure was limited to a 2-D planar image and could not be obtained in real time.
- It was not suitable for large animals or patient studies.
- Using the ‘goggle’ on just one eye limited the surgeon’s perception of depth.
- The procedure had to be improved for the procedure to be compatible with normal patient operating theatre work.
Real-Time Image-Guided Goggles, 2014
Early-stage experimental fluorescence image-guided goggles were trialled clinically in 2014 at Washington University, St Louis. The 2011 google design improved wearability and video image display. It could detect colour and fluorescent light signals from the operating site in the patient by using a very small camera. It had fast processing and real-time superimposed images displayed on the surgeon’s head mounted display. The goggles assisted the surgeon to image-guide the breast operation without disruption or break the normal surgical workflow (Fig. 2).
Well before the operation, the patient receives an injection of a biomarker substance that can fluoresce when excited by light. The light frequency is described as ‘near the frequency of infra-red’ (referred to as NIR). By the time the operation begins, the contrast agent labelled with a biomarker is selectively taken up more by the cancer cells than the normal cells.
The surgeon wears the goggles whilst he carries out the breast surgery. The goggles shine NIR light onto the patient’s breast tissue as well as white light for the surgeon to see the patient’s breast while the operation proceeds (the NIR light is not visible to the surgeon).
The emitted fluorescence from the tumour site tissues and the reflection of the normal light are detected by a tiny camera mounted on the surgeon’s goggles.
The NIR and white light images are captured by the camera and processed (in real-time) to generate a superimposed image for the surgeon to see as he/she proceeds with the operation. The surgeon, can see the tumour edges demarcated by the biomarker colours that denote cancer cell density.
To test this new goggle design, surgeons at Washington University, St Louis, carried out the pilot operations for breast cancer and melanoma patients. A comparison of the biomarker images with the routine pathology test method, traditional radioactive technetium-99m uptake measurement and blue dye method, confirmed agreement of the results.
This led to the Washington University publicly announcing and providing a media release in February 2016, the success of the project, ‘cancer goggles’ for surgery.
Video Lecture 2018
For a more in-depth video presentation related to Samuel Achilefu and the Washington University research work, click on:
The ‘Cancer Goggles’, 2019
(a) The New Enhanced Imager
A new generation goggle design was reported in the literature last November 2018 (Garcia et al, 4). The imaging sensor uses a new, improved light filter method that has much more sensitivity to capture near-infrared fluorescence (NIR) information . The image is created as a high-resolution pixel array for the surgeon to view. The image has a view of the operation site with an overlay of colours denoting the fluorescing cancer cell density. Examples of a clinical case are shown in this reference.
(b) Biomolecular Pathology
Pogue et al (4, 2018) published a short review in October 2018 on what is needed in future work for molecular-specific fluorescence-guided surgery. Apart from the problem of solving the bottleneck in receiving FDA approvals, there’s a significant need to have on-going research to explore what might be:
- the most suitable fluoresce biomarkers for the different cancer cell types; and
- adequately identify the heterogeneity of microscopic cancer.
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Professional Career
Professor Samuel Achilefu PhD
The background history of Professor Achilefu in his rise to academic level captured the imagination of the public as much as his reported invention for cancer treatment.
Dr Achilefu was born in the northern region of Nigeria in the ’60s. But when the civil war broke out, his family had to move to safety in the eastern region until it ended in 1970.
His first opportunity to progress further in his education came when he won a French Government scholarship to study in France at the University of Nancy. He obtained a PhD in molecular and materials chemistry there and continued post-doctoral research on oxygen transport mechanisms.
He moved to St Louis, USA in 1993 to work at Discovery Research Department, Mallinkrodt Medical Inc. He eventually joined the Mallinkrodt Institute of Radiology at Washington University, School of Medicine in 2001.
This was when he pursued research into the development of molecular imaging probes (or biomarkers) and therapeutic molecules. In conjunction with this work, he is involved in the development of new methods and devices for imaging and treating cancer and other biological devices.
During his career, he received a number of distinguished Awards and Honours, including:
* St Louis Award, St Louis Award Committee 2015
* Best Global Impact Award, We Heart Stl 2015
* Outstanding scientist fellow award, academy of Science – St Louis, MO, USA 2014
* St Louis innovator award, alive magazine 2011
* Fellow, SPIE – International society for optics and photonics 2008
* Achiever Award St Louis science center and blacks in science, MO, USA1998
* Extraordinary performance award, Mallinckrodt, Inc 1995
* Technical Innovation Award, Mallinckrodt Medical, Inc 1991
* French Government Scholar, French Government (1987-1991)
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References
- McLaughlin SA, Surgical management of the breast: breast conservation therapy and mastectomy, Surg Clin North Am. 2013 Apr;93(2):411-28
- Mondal SB, Gao S, Zhu N, Liang R, Gruev V, Achilefu S. Real-time fluorescence image-guided oncologic surgery. Adv Cancer Res. 2014;124:171-211.
- Liu Y, Bauer RE, Akers WJ, Akers WJ, Sudlow G, Liang K, Shen D, Berezin MY, Culver JP, Achilefu S, Hands-free, wireless goggles for near-infrared fluorescence and real-time image-guided surgery, Surgery, May 2011,Volume 149, Issue 5, Pages 689–698
- Garcia M, Edmiston C, York T, Marinov R, Mondal S, Zhu N, Sudlow GP, Akers WJ, Margenthaler J, Achilefu S, Liang R, Zayed MA, Pepino MY and Gruev V, Bio-inspired imager improves sensitivity in near-infrared fluorescence image-guided surgery , Optica. 2018; 5(4): 413–422.
- Pogue BW, Rosenthal EL, Achilefu S, van Dam GM. Perspective review of what is needed for molecular-specific fluorescence-guided surgery. J Biomed Opt. 2018 Oct;23(10):1-9.
Lyn Oliver AM PhD, 28 February 2019
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Remote Seed Implant Guidance for Breast Cancer Surgery > Breast Cancer Incidence > Deep Inspiration Breath Hold (DIBH) for Breast Cancer
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