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Advent of Hybrid OR Signals Paradigm Shift in Lung Cancer Surgery

Holt, Chuck

doi: 10.1097/01.COT.0000552831.05496.37
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One in four cancer deaths are attributable to lung cancer, which is more than breast, prostate, and colon cancers combined, according to the American Cancer Society. One major contributor to the high mortality rate has been the challenge of diagnosing lesions in the lungs.

Early diagnosis and treatment, however, is essential to a positive outcome for patients with lung cancer, who typically endure a series of visits to multiple providers over several weeks before receiving a diagnosis and beginning treatment. Studies show treatment delayed by more than 8 weeks in patients with stage I lung cancers results in increased mortality (Ann Thorac Surg 2015;99:1906-1912).

“When somebody gets worked up for lung cancer, often it takes quite a complicated route,” noted Carsten Schroeder, MD, PhD, a thoracic surgeon at Augusta University Health (AUH) Georgia Cancer Center.

Patients typically will have been seen by pulmonologist for a bronchoscopy, as well as an interventional radiologist, not to mention their primary care provider and trips to the lab, prior to receiving a diagnosis of lung cancer from a thoracic surgeon. “The patients are sometimes 4, 6, and even 8 weeks down the road, just going from one to the next appointment, before they are ready to start treatment.”

Enter the hybrid operating room, which combines the capabilities of the catheterization lab and a traditional OR. Although intended for vascular surgery, Schroeder saw an opportunity to streamline the diagnosis and improve outcomes for patients with lung cancer by utilizing the cutting-edge imaging technology.

The new $2.6 million hybrid OR, which opened in 2017 at AUH, can be used to not only pinpoint lung nodules, even those smaller than a centimeter, but also to perform a percutaneous biopsy, diagnose and stage the tumor, and then, if the patient consents, to remove it—all in the same setting and on the same day.

Specifically, Schroeder uses the hybrid OR's cone-beam CT imaging to perform CT-augmented navigational bronchoscopy to locate tumors, CT-guided percutaneous biopsy to determine if they are malignant and/or place metal fiducial markers to help ensure the mass displayed on a large digital monitor is removed entirely via resection using image-guided video-assisted thoracic surgery (iVATS).

The fully equipped angiography facilities at AUH feature a ceiling mounted C-arm, which can also be used to perform a high-quality, tabletop, cone-beam CT scan. The ceiling-mounted C-arm rotates above and around the patient, who is asleep on the specialized operating table, to generate a cone-beam CT scan. The 3D images generated during the rotation are displayed on a large LED monitor attached to the workstation, providing CT scan analysis, processing, and procedure guidance (Innovations 2018;13(5):372-377).

“The hybrid OR basically is a very sophisticated fluoroscopy unit with 3D processing and a CT overlay on the table, which knows where the patient is positioned,” Schroeder explained. “It is very much like a video game where you can put metal dots in different spatial areas, inside of which will be the tumor or whatever you want to target and also to place the markers in areas that you otherwise wouldn't be able to get to in the traditional operating room setting.”

As such, the addition of the hybrid OR to the “armamentarium” of thoracic surgeons is “a paradigm shift” in the fight against lung cancer, Schroeder contends.

“I am doing more and more of these procedures, and my thought process has changed,” he told Oncology Times. “Two years ago, if you had come to my office with a very small lung nodule, I would have had to tell you that we may have to wait 6 months to 1 year to do the surgery, because we could not even biopsy it until it grew bigger. Now, we can diagnose the nodule, do the staging, and provide the curative treatment all in the same setting, in the same day.”

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By the Numbers

Findings from data Schroeder and colleagues collected on the first few dozen patients who underwent the streamlined same-day workup paradigm—diagnosis, staging and treatment—were published this summer (Innovations 2018;13(5):372-377). In addition to reduced time between diagnosis and curative treatment, the study's results show decreased upstaging, improved survival rates, and better detection and resection of smaller and deeper lesions in the lungs.

In the study, seven patients (28%) underwent the same-day surgical procedure, receiving their pathology results on-site; six patients received a wedge resection; and one received a lobectomy. Eight patients who underwent hybrid OR bronchoscopy and biopsy but elected to undergo surgical resection at a later date (Innovations 2018;13(5):372-377).

“It can be difficult for patients to develop that level of trust, where they are willing to go from having just undergone a diagnosis of lung cancer to surgical resection in one day. Some patients want to think about it,” explained Schroeder, adding that the data collection is part of a clinical trial with an ongoing registry. “We began with 11 patients with a 92 percent diagnosis on first run. Now, we are at 21 patients with 95 percent diagnosed on the first run, and then were treated with surgical resection in the same day.”

The findings by Schroeder, et al, are helping spark interest in the hybrid OR technique nationwide, particularly in conjunction with the 3D navigational systems that help direct the surgeon to the lesion in the lung, said Osita Onugha, MD, thoracic surgeon and Director of the Thoracic Surgery Research and Surgical Innovation Lab at John Wayne Cancer Institute at Providence Saint John's Health Center in Santa Monica, Calif.

Like Schroeder at AUH, Onugha and colleagues see the combination of navigational bronchoscopy, percutaneous biopsy (or percutaneous wire localization), and iVATS as increasing OR efficiency and speed of diagnosis for lung cancer lesions.

“In fact, we are currently evaluating our data on our first 13 patients to look at efficiency and decreased cost when compared to traditional techniques,” Onugha told Oncology Times. “There is tremendous promise in the use of a hybrid OR and 3D navigation to improve efficiency, decrease cost, and save time in the diagnosis and surgical treatment of lung cancer.”

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Purposefully Repurposed

Back at AUH, Schroeder said another benefit of the hybrid OR for thoracic surgeons and their patients is that the nursing staff, radiology technicians, and other clinicians have already been trained to work in that setting, which is great for the healthcare organization's bottom line.

“The beauty of the hybrid OR is that was already set up for the vascular surgeon. So, the use of the hybrid OR is a common thing: it is a versatile technology that can be used for various specialties,” said Schroeder, adding that the lung cancer procedures were scheduled during normal working hours and at times when the hybrid OR was not otherwise in use, thereby repurposing the expensive imaging technology.

“They had already made a business plan for vascular surgery within the hybrid OR, but it was not expected that I would be coming in to use it diagnose and treat lung nodules,” he noted.

That left the biggest learning curve to surmount for Schroeder, who completed training at a hands-on lab in Cleveland. Here, Schroeder was able to get comfortable enough with the hybrid OR technology that he does not always need a radiology tech to be available because he has been properly trained to run it himself. “Proper training is essential for the thoracic surgeon to use the hybrid OR properly,” he emphasized, quipping, “It can be difficult to teach an old dog some new tricks.

“I am actually one of the few thoracic surgeons who can use all of the tools that the hybrid OR supplies for lung treatment,” Schroeder added, in all seriousness. “I do the special navigational bronchoscopy enhanced by the hybrid OR; I put in a needle and biopsy the lung nodule like an interventional radiologist would; and then, if the patient is comfortable with having the [surgical] procedure done in the same day, I go ahead and do the resection in the setting like a classical cancer operation.”

Surgical oncologists at Harvard University's Brigham and Women's hospital in Boston pioneered the idea of using the hybrid OR for treating lung cancer about 3 years ago, Schroeder noted, “We were kind of the first to put it all together—not only localizing tumors, but also to doing the whole workup, meaning getting to a diagnosis, staging, and curative treatment all in one setting in the same day.”

Now, Schroeder is excited to find out just how big of a role the hybrid OR will play in improving outcomes for patients with lung cancer while reducing costs over the long term. Already, he is convinced, along with his colleagues, that training in the hybrid OR should be part of the standard curriculum for thoracic surgery residency. “I like to think that I am a technologically savvy person, but even I did not know all that one can do with this technology,” he admited. “I did not realize its full potential.”

Chuck Holt is a contributing writer.

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