Performing Art in Interventional Oncology Therapy
Robert L. Bard | Mar 14, 2017
Sylvester Comprehensive Cancer Center at the University of Miami uses imaging equipment from Siemens Healthineers to support its interventional oncology division and provide more accurate diagnosis and specialized treatments. New imaging technologies allow specialists Govindarajan Narayanan, MD, Riccardo Lencioni, MD, and their team to provide successful, less invasive therapies.
Photos: Jock Fistick
Imaging has the key role in oncology
Staffed with clinicians specializing across the entire spectrum of procedures, the Department of Interventional Radiology (IR) at the University of Miami Miller School of Medicine is a well-known and respected institution. Sylvester Comprehensive Cancer Center, part of UHealth – the University of Miami Health System, is a center of excellence for cancer treatment and research that provides the full scope of available treatment models. The IR department at the Miller School of Medicine relies on a fleet of highend Siemens Healthineers equipment to cater for a high volume of patients and support highly proficient clinical staff. Leading this operation is Govindarajan Narayanan, MD, Chairman of Interventional Radiology at Sylvester Comprehensive Cancer Center, in a unique collaboration with Riccardo Lencioni, MD, FSIR, EBIR, Vice-Chair of Clinical and Translational Research at Sylvester.
Lencioni is a world-renowned interventional oncologist from the University of Pisa in Italy. He is considered one of the pioneers in interventional oncology and was greatly involved in defining the field. He served for six years as Chairman of the European Conference of Interventional Oncology (ECIO) and later the World Conference of Interventional Oncology (WCIO). Lencioni explains that the full name for this field as proposed years ago was in fact “image-guided interventional oncology” and later came to be known simply as interventional oncology; Lencioni, however, still stresses the “key role of imaging in oncology.”
Individualized treatment for every patient
Narayanan was inspired by Lencioni’s innovations and successes with less invasive treatments for liver cancer. Sylvester was fortunate enough to lure Lencioni to the United States to help expand the treatment options for its patients. Convincing Lencioni to join the division at Sylvester is just one of Narayanan’s recent successes. Since Lencioni’s appointment, the program has grown from a team of just four to 16 interventional radiologists and now ranks among the largest fellowship programs in the country. Narayanan explains, “Our program is unique in that you get general IR, the entire gamut, along with trauma and a very high-quality interventional oncology program. Most sites in the country are for one or the other.”
Narayanan continues, “We deliberately built the program from the initial stages to offer all transcatheter and ablation options available”. The most common procedures of these are transarterial chemoembolization (TACE), radioembolization (Y90), along with irreversible electroporation (IRE), microwave (MWA), radiofrequency (RFA), and cryoablations. Sylvester Comprehensive Cancer Center not only has the equipment to perform all procedures currently offered, they also offer skilled specialists who routinely perform these procedures as well as engaging in research. Therefore, as Narayanan says: “A patient here is given a treatment option based on what we think is the best choice for them, not based on what we are best at.”
Radiopaque beads and syngo DynaCT
While TACE has been around for over 30 years, a dedicated embolic particle for TACE was only introduced 10 years ago. “The introduction of drug-eluting beads basically revolutionized the treatment of some tumors, particularly primary and metastatic liver cancer,” Lencioni explains. However, unlike Lipiodol used for conventional TACE, the drug-eluting beads themselves are not visible on X-ray. This means that during the procedure, the treating physician has only indirect feedback on the extent of embolization and exact location of the delivered drug. The team at Sylvester Comprehensive Cancer Center is one of the first globally to use a new type of embolic beads, which are radiopaque. The visibility of these new radiopaque beads during the embolization procedure enables real-time adjustments to optimize patient treatment. “During the procedure, you have feedback that was not available with the standard beads,” Lencioni explains.
The new bead technology works in concert with cone beam computed tomography (CBCT) and Narayanan depends on the Siemens application syngo DynaCT. “In the past, we relied solely on conventional angiography where you see images without the cross-sectional 3D view and a lot of times you don’t get the entire information,” says Narayanan. “Vascular anatomy of the tumor is usually the most important aspect and it determines whether your procedure is going to be successful or not. So if you have the option of additional information which otherwise may have been missed, it improves your outcome. syngo DynaCT gives you an extra layer of information which initially was not available with conventional angiography,” he explains. Lencioni adds, “during the procedure you have feedback that was not available with the standard beads, and we have already seen how in action this translates into fine tunings, adjustment in the position of the catheter, going more distal or proximal. This becomes a truly ‘manicured’ embolization.”
Searching for a predictor
Currently, the first indication of tumor response comes only weeks after the intervention, in the patient’s followup imaging results. Lencioni found that there was room for improvement: “With the current protocols, basically, you often wait for the tumor to send a signal of activity and follow the tumor. We are not first; the tumor is ahead. Then, we try to deal with it. This may not be the best way to treat the cancer: You want to be ahead of the tumor, rather than behind it.” He continues: “The way to be ahead is to understand that because you didn’t get a particular feeder, this indicates that the tumor will reoccur.”
Combining syngo DynaCT with radiopaque beads could make it possible to look deeper into the state of the tumor immediately after treatment and identify predictors of tumor recurrence at that time. Lencioni, who developed the currently adopted follow-up criteria known as the modified RECIST (mRECIST) criteria, envisions a potential change: “The mRECIST criteria have been supported by several studies including meta-analysis. It’s ok, but the tumor is still ahead of us. If we want it to be the other wayaround, we need to change the paradigm. So, if we were truly able to predict the outcome based on information that wasn’t available before, even the mRECIST criteria, which I developed, could become obsolete. Of course, this is something that we first need to understand. But this is the area we are currently focusing on.”
Beyond cancer treatment
Research opportunities go beyond cancer as Sylvester Comprehensive Cancer Center also operates a prostate artery embolization (PAE) program led by Shivank Bathia, MD. This relatively new procedure is clinically beneficial for patients with benign enlargement of the prostate, a condition from which many men suffer but one without sufficient treatment options. PAE involves stopping blood flow to the prostate, thus positioning of the catheters is vital. Narayanan emphasizes: “Precision is of paramount importance here because if the particles get to other branches that feed the bladder or the rectum, you could have disastrous complications.”
To tackle such procedures with confidence requires having the right set of tools at hand. Narayanan explains using a simple analogy: “The driver (interventionalist) has to have good knowledge of the anatomy but the car that you drive, or the machine that you use needs to be a highquality machine that gives you excellent images and resolution.” In addition, he relies on helpful software applications for both 2D and 3D guidance, such as syngo Embolization Guidance to plot the vessel path on the syngo DynaCT images and overlay it with the fluoroscopy images for real-time guidance during the catheterization. He is also particularly pleased with the ability to overlay reference images with contrast for 2D guidance using the Overlay Reference functionality, known by many users as “Fluoro fade.” “These are all additional tools that are available to make your catheterization better, easier, and give you a higher level of precision and control,” he says.
Narayanan stresses the need for good driving skills to get the most out of the equipment: “Without a good driver, the car is not nearly as useful. The equipment alone is not enough.” Narayanan is leading efforts to make specialty training mandatory, providing his technicians with a week of Siemens Healthineers training to become “super users” of the system. He explains that many institutions put money up front for the capital investments but shy away from training because it is often viewed as an “add-on.” However, Narayanan firmly believes this investment in training is critical for the best results. Quality, innovations, and the solid service back-up which minimizes downtime are important factors that led to the decision to install Siemens Healthineers equipment at Sylvester Comprehensive Cancer Center. “Siemens has provided cutting-edge technology. There’s stability and reliability,” Narayanan concludes.
The union of man, machine, and medicine is being optimized at the University of Miami. Interventional radiologists’ cutting-edge treatments and research along with the optimal use of Siemens Healthineers imaging equipment by well-trained technicians provide a synergistic approach with an eye toward innovation. With the current setup, Sylvester Comprehensive Cancer Center patients and the entire region served by UHealth are benefiting from these innovations – now and for the foreseeable future.
For a dedicated patient example of radiopaque beads during a TACE procedure at Sylvester Comprehensive Cancer Center at the University of Miami read the clinical case report 0.9 MB.
About the Author
Robert L. Bard is a freelance medical writer who specializes in clinical cardiology, heart failure and exercise, and imaging. Bard also conducts clinical research at the University of Michigan’s Division ofCardiovascular Medicine.
The statements by Siemens’ customers described herein are based on results that were achieved in the customer's unique setting. Since there is no "typical" hospital and many variables exist (e.g., hospital size, case mix, level of IT adoption) there can be no guarantee that other customers will achieve the same results.