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Cancer centers add MRIs to ORs, expand proton therapy


Posted on: 04/03/2006

Cancer centers add MRIs to ORs, expand proton therapy

By Kristen Gerencher

Last Updated: 4/3/2006 7:32:00 PM

SAN FRANCISCO (MarketWatch) -- Imagine after undergoing surgery for a brain tumor being able to avoid a second operation because doctors had a way to get real-time images of where the tumor was hiding and moving during the procedure.

Or being able to confine radiation therapy for certain kinds of cancer to the size and shape of the tumor, allowing for reduced side effects and better quality of life.

Several major cancer centers are adding such programs that promise to cut patients' risks and prolong their lives.

The University of Texas M.D. Anderson Cancer Center in Houston and Memorial Sloan-Kettering in New York soon will offer a comprehensive system that allows brain-tumor patients to be rotated into a magnetic resonance imaging machine so doctors can get a more accurate look at how much residual tumor remains before ending surgery. Knowing this may prevent further surgeries and risk to the patient.

M.D. Anderson's Dr. Raymond Sawaya, chair of the neurosurgery department, recently showed visiting health-care journalists around what he said will be the United States' most extensive operating room with an integrated full-strength magnet.

The BrainSuite, which is still under construction, contains a mobile patient table and a wide Siemens (SI) MRI a few feet away that can accommodate patients in more than just the standard face-up or down positions. It has an elaborate image display system and a control room.

After surmounting technical difficulties in lifting and installing the 15,000-pound scanner onto Alkek Hospital's fifth floor, M.D. Anderson plans to open its $9.2 million BrainSuite sometime this spring, Sawaya said.

Its purpose: to maximize the chances of removing brain tumors as completely as possible.

BrainSuite to improve accuracy

While relatively rare, brain tumors can be difficult to remove, especially if they're buried deep or are positioned near the spinal cord. The American Cancer Society estimates there will be 18,820 new brain-cancer cases in 2006, resulting in 12,820 deaths.

Not every patient needs the sophistication of the BrainSuite and not every hospital could or should invest in one, Sawaya said.

But with complex tumors, the brain often shifts during surgery, making MRI pictures taken the day before problematic for guiding the procedure, he said. Surgeons may become disoriented, a risk the new system will address.

"This will reorient the surgery by giving us coordinates," Sawaya said.

The expanded suite also is expected to help with needle biopsies and diagnosis, said Dr. Philip Gutin, chief of the neurosurgical service at Sloan-Kettering, which is targeting its own revamped OR debut, estimated to cost $3.5 million, for later this year.

"Due to the vagaries of surgery, the different positions of the head, the brain...shifts a little bit," Gutin said. "Sometimes the needle misses the actual target. In this setting you can follow your needle down."

Having an MRI in the operating room is likely to improve outcomes for the trickiest cases, he said. "We think it will help us get more complete (removals) the first time around without having to go back for residual" tumor.

Sloan-Kettering hopes to do a couple surgeries a day on patients in all age ranges, which also would ease the load on stand-alone MRIs, Gutin said.

"The very fact we'll be able to do post-op scans in the operating room means it will take some of the tremendous toll off the other scanners," he said.

M.D. Anderson performs 850 to 900 brain-tumor surgeries annually and aims to do 200 in the BrainSuite during its first year, said Dr. Jeffrey Weinberg, an assistant neurology professor at the center.

Of course, just because the system can provide more information and navigational aid doesn't mean it will automatically enable surgeons to get the entire tumor, Sawaya said. "We still have to use judgment."

"Sometimes even with residual tumor we opt not to operate," he said. "You're adding more risk, cost. Patients are going to need radiation anyway."

But some patients' prognoses, especially those with benign tumors, likely will improve, Sawaya said. "I anticipate that patients will live longer."

Gutin agreed. "There is some evidence even with malignant tumors that people live longer with a greater resection."

Proton therapy sizes up tumors

Most Americans have some contact with cancer in their lifetime, either in themselves or a loved one. Though advances in drug and other therapies have reduced some of the death rates, cancer last year surpassed heart disease as the No. 1 killer of Americans under 85, the American Cancer Society said.

X-rays are used to treat about half of all cancer patients, either to attempt a cure or to relieve symptoms, Dr. James Cox, head of the division of radiation oncology at M.D. Anderson Cancer Center, told visiting reporters in March.

In the last 15 years, proton therapy's ability to target tumors has enabled patients with certain kinds of cancer to sidestep some of the toxic side effects of regular radiation treatments, he said.

"You can conform a proton beam much more precisely than you can an X-ray beam and leave out normal tissue," Cox said. "That evolution is what's made proton therapy compelling."

Patients who typically benefit are children, and adults with cancers of the head and neck, prostate, lung and other cancers that require a high dose and are near critical body parts, he said.

Cox took reporters on a tour of M.D. Anderson's $125 million soon-to-open Proton Therapy Center. Wearing hard hats and protective glasses, the group went behind the scenes to see the synchrotron, a long, colorful chain of large Lego-looking compartments that accelerate protons, and then out to the patient treatment rooms, some of which contain 190-ton gantries that rotate around the patient and direct proton beams. Hitachi (HIT) supplies the gantries and linear beam lines while General Electric (GE) makes the center's scanners.

Among the most interesting places was the treatment planning room, where 15 cubicles house the medical dosimetrists who model with three-dimensional imaging tools to calculate the best dose distributions for any given patient.

It is there that experts combine their knowledge to come up with a daily and total dosage plan that aims to avoid vital organs such as the bladder and rectum in a prostate-cancer patient, for example, while taking into account special circumstances such as hip replacement. Such a scenario is on the simpler side of what the center will do, Cox said.

The U.S. has three general proton-therapy centers, the first of which opened in Loma Linda, Calif., in the early 1990s. Massachusetts General Hospital operates another long-standing program. Indiana University's Midwest Proton Radiotherapy Institute opened in 2004.

A handful of others are introducing their own or considering it. The University of Florida is set to open its Proton Therapy Institute in Jacksonville this summer, and Hampton University in Virginia expects to have one in 2009.

Still, proton therapy isn't for everyone, said Dr. Shiv Khandelwal, an assistant professor of radiation oncology at the University of Virginia and medical director of the AMC Cancer Center in Fishersville, Va.

Some radiation oncologists haven't seen a proven advantage for proton therapy in prostate cancer, he said. And many patients who would benefit can't afford to wait on a list for treatment or to travel to a center for a six or seven-week treatment course.

But they soon may have more choices. "If proton therapy were more accessible, I would probably refer patients more often, and maybe opening these other two facilities would help with that," Khandelwal said.

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