GPS-like tracking part of advanced cancer care at UPMC Passavant

In 2008, approximately 1.5 million people are expected to be diagnosed with cancer. To treat these patients and those already living with the disease, new imaging technologies, advanced chemotherapy and radiation treatment, and cutting-edge surgical options are being developed every day. This is especially true at UPMC Cancer Center at UPMC Passavant, where patients from Pittsburgh’s northern communities can take advantage of innovative cancer treatments available.

Advanced Cancer Care

“Patients who live north of Pittsburgh gain a lot of confidence from the fact that they can receive state-of-the-art cancer therapy right in their own backyard,” explains Kiran Mehta, MD, co-direct-or, UPMC Cancer Center at UPMC Passavant. “What makes UPMC Passavant special is that although it still has the feel of a community hospital, we also provide advanced tertiary care with technology and clinical expertise.”

Radiation Therapy

At UPMC Cancer Center at UPMC Passavant, patients have local access to intensity-modulated radiation therapy, or IMRT, which allows radiation oncologists to better target treatment by sculpting the contours of irregularly shaped tumors with intense doses of radiation. UPMC Passavant offers 4-D gated radiation therapy, a form of IMRT, which captures the motion of a tumor as a patient breathes, as well as on-board imaging (OBI), which enables the treatment area of a tumor to be adjusted on a daily basis.

“IMRT is the latest and greatest external beam radiation technology available,” says Dr. Mehta. “It allows us to target tumors more precisely while limiting the radiation received by surrounding critical structures.

“OBI allows us to track the response of the tumor during therapy on a daily or weekly basis in order to determine subtle changes in the field,” she adds. “We can then change the positioning of the beam as needed to more consistently treat the disease.”

For the past two years, UPMC Cancer Center at UPMC Passavant has been providing 4-D gated therapy as a way to better target tumors that move during treatment, such as lung tumors. By combining a three-dimensional image with the dimension of time, physicians are better able to select the exact moment to treat a tumor when it is at a specific phase of the respiratory cycle, thus minimizing damage to surrounding structures.

Additionally, because a person’s organs naturally move during radiation, an even newer technology is currently being used at UPMC Passavant to ensure that prostate tumors receive the right amount of radiation. The Calypso 4D Localization System uses tiny, implanted electromagnetic transponders to align the radiation beam during treatment.

“We place three tagged markers in place in the prostate,” explains urologist Daniel Cole, MD. “The radiation therapist can then use these markers to pinpoint the tumor and deliver a very focused, localized dose of radiation. This minimizes damage to the surrounding tissues.”
“It is like a ‘GPS’ for the body because the system can always locate the tumor, even if a person moves during treatment,” adds radiation oncologist Alex Chen, MD, associate professor, University of Pittsburgh School of Medicine, and co-direct-or, UPMC Cancer Center at UPMC
Passavant. “We’ve been using it for the past several months, and it has been extremely reliable. In the future, we’re hoping to use it to treat breast and liver cancers, but at this point, it is only available for prostate tumors.”

Brachytherapy for Prostate and Lung Cancer

For the past six years, patients at UPMC Cancer Center at UPMC Passavant have been able to receive brachytherapy, or seed implantation therapy, for prostate cancer.

“By placing these tiny seeds throughout the prostate, we can provide highly focused, high-intensity radiation to a select group of patients,” explains Dr. Cole, who performs approximately 75 procedures a year in conjunction with Dr. Chen. The cure rates are comparable with patients who undergo surgery.” Brachytherapy can be used alone or in addition to external beam radiation therapy.

Brachytherapy for lung cancer was pioneered by Drs. Chen and Rodney Landreneau, MD, professor of surgery and director of the Comprehensive Lung Center, for use with early-stage lung cancer, utilizing small, radioactive seeds sewn into surgical mesh, to deliver a high dose of radiation directly to the lung tumor.

Drs. Chen and Landreneau were the first thoracic surgery and radiation oncology team to perform intraoperative brachy-therapy to preserve lung function in patients with early-stage lung cancer who could not tolerate lobectomy. To date, they have treated approximately 400 patients with that procedure. “We have the most experience in the world with it,” explains Dr. Landreneau, who adds that with this treatment, the local recurrence rate of lung cancer is one percent, compared to 18 to 20 percent at the national level.

Brachytherapy for Breast Cancer (Partial Breast Irradiation)

After breast-conserving surgery, or a lumpectomy, it is recommended that patients undergo radiation therapy to prevent cancer from recurring. While the current standard of care calls for whole breast radiation for five days a week for six-and-a-half weeks, select patients at UPMC Passavant are taking advantage of a shorter radiation treatment that focuses specifically on the lumpectomy site.

“We know from 30-year studies that if cancer does recur in the breast, it is most likely to recur in the lumpectomy site,” explains Mary Beth Malay, MD, medical director of the Comprehensive Breast Center. “It is very rare to have a new primary cancer occur in the same breast in a different location.”

Partial breast irradiation can be delivered through several formats, the most common of which is mammosite brachytherapy. During this procedure, a balloon catheter is placed in the breast after surgery and a ‘source’ of radioactive material is inserted into the balloon during each outpatient visit. This source is withdrawn after approximately 10 minutes, and the balloon is removed from the breast when the five-day course of radiation is complete.

Going Beyond theStandard of Care

Depending on where in the body a patient’s cancer is located, there are a number of new treatment options available to improve quality of life, even in later-stage cases. UPMC’s surgical oncologists are continually utilizing and even creating new state-of-the-art therapies for cancer patients.

Radiofrequency Ablation and Photodynamic Therapy

For the past three years, UPMC Cancer Center at UPMC Passavant has been offering radiofrequency ablation for select patients with lung cancer and photodynamic therapy for select patients with esophageal or bronchial cancers. “While the best treatment for a patient with early-stage lung cancer is surgical resection, approximately 25 percent of patients who could be cured through this option cannot tolerate the surgery due to COPD or heart conditions,” explains Ghulam Abbas, MD, assistant professor of thoracic surgery. “However, they may be candidates for percutaneous radiofrequency ablation (RFA).”

During RFA, doctors use CT-scan guidance to insert a needle into the lung and then use radiofrequency waves to burn the tumor. Approximately 85 percent of patients respond to this treatment, which can be repeated at a later date should the tumor recur.

Patients who cannot be treated for esophageal cancer with surgery because of other health conditions may be candidates for photodynamic therapy, which can be used as a curative therapy if the cancer is superficial, or a palliative therapy to help a patient breathe or eat. RFA also is utilized to destroy inoperable primary, or metastatic, cancers in the liver. RFA often is performed with minimally invasive techniques, and depending on the setting, patients usually are discharged home the day of or the morning following the procedure.

Chemoperfusion

For patients with abdominally disseminated cancers, surgery combined with chemoperfusion therapy can help patients live longer while also improving quality of life. Used mainly for patients with slow-growing cancers that have not responded well to intravenous chemotherapy, the therapy also can be used for patients who have severe side effects from traditional treatment.
After surgical removal of a tumor, a heated sterile solution containing chemotherapeutic drugs is circulated throughout a patient’s abdominal cavity. “Through this procedure, we can treat residual microscopic deposits of cancer that weren’t removed during surgery,” says Steven Ahrendt, MD, associate professor of surgery, UPMC.

“In the right clinical setting, hyperthermic intraperitonial chemotherapy (HIPEC) can provide big benefits for patients,” says Dr. Ahrendt. “We often treat patients who have been told that not much can be done for them, yet after this treatment they are able to return to their baseline precancerous status and function well for another year or two. We greatly exceed the expectations that they’ve been given.”

Laparoscopic Liver Resection for Cancer

For patients with primary or metastatic liver cancers, surgical resection offers the best chance for cure or long-term survival. “We have performed more than 100 liver operations at UPMC Passavant in the past three years, and many of these cases are now being done with minimally invasive surgery,” says David Geller, MD, professor of surgery, and co-director, UPMC Liver Cancer Center. “Patients typically have three to four Band-Aid-sized incisions, and usually are home from the hospital two to three days after the operation,” says Dr. Geller. “They have much less pain with smaller scars and can return to normal function very quickly.”

TACE (Transarterial Chemoembolization) and Radiofrequency Ablation

For patients with inoperable liver cancers, transarterial chemoembolization may be recommended. Chemoembolization is the process of injecting chemotherapy drugs directly into the hepatic artery that supplies blood to the tumor in the liver. Since the chemotherapeutic drugs are injected directly at the tumor site, patients can receive larger doses than standard chemotherapy, with less overall side-effects. “In the past year, we have treated nearly 20 patients at UPMC Passavant with this approach,” says Dr. Geller, “and we continually evaluate new patients for this treatment.”
Imaging Services

UPMC Passavant offers an onsite 64-slice PET/CT machine that enables doctors to precisely pinpoint and better identify the nature of abnormal cell activity. In addition to reducing patient scanning time, the PET/CT scanner improves tumor detection and localization; provides physicians with a better assessment of the tumor’s response to therapy; helps improve therapy planning, and allows for more precise staging of the disease.

“We use the PET/CT scanner in multiple ways with oncology patients,” explains Karen Barkey, MD, assistant chief, Radiology, UPMC Passavant.

“We may use it for an initial stage diagnosis to determine if a lesion seen on a CT scan or x-ray is a tumor, or to follow a patient after intervention to see if a tumor has become less active and is responding to treatment.”

“In certain tumors, what a CT scan alone may show might lag behind the actual tumor response,” says Dr. Barkey. “The advantage of a PET scan is that it shows how a tumor is utilizing glucose, which measures how active the tumor is. We get an earlier idea of how the tumor is reacting to radiation and chemotherapy.” Even when an abnormal growth is not yet visible on a CT scan, it can be seen through a PET scan.

The future of cancer care

The collaboration of medical and radiation oncologists — including Theodore Crandall, MD; Robert Gluckman, MD; Alex Chen, MD; Kiran Mehta, MD; Jennifer Osborn, MD; and Kiran Rajasenan, MD — and UPMC Cancer Centers’ surgical oncologists offers patients the most comprehensive approach, combining innovative drug therapies, state-of-the-art technologies, and the latest surgical options to battle cancer. Through this multidisciplinary approach, the team of cancer specialists at UPMC Passavant hopes to improve outcomes and long-term survival rates for people diagnosed with cancer.