Lung cancer diagnosis and treatment are on the move. New radiotherapy machines, automated image analysis, and single port robotic surgery are just a few of the technological innovations that are reducing lung toxicity, advancing treatment, and improving patient outcomes.
Current radiotherapy approaches can deliver dramatic clinical results, but not without costs.
“Modern radiotherapy (RT) is complex and time consuming,” said Suresh Senan, MRCP, FRCR, PhD, professor of Clinical Experimental Radiotherapy, Amsterdam University Medical Centers, during a WCLC symposium on technology innovations on Sunday, Aug. 7.
“The multidisciplinary approach can take several days, and patients have to wait. Image quality is not ideal and radiotherapy plans are not routinely adapted to changes. New radiotherapy machines promise dramatic improvement, but the subject is a minefield. Every manufacturer claims to have the newest device, but we need to see the clinical results.”
MRI-guided radiotherapy has been a promising technology for at least a decade. MRI-guided RT offers superior imaging of soft tissues compared to X-ray-guided RT with real-time imaging during treatment. The combination of clear visualization of both tumor and nonmalignant tissue and real-time imaging gives clinicians the ability to adapt treatment plans and offers the potential to identify and target specific biological features.
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Improved imaging is just as important to patients, Dr. Senan said. Patients want safer RT delivery, faster initiation of treatment, single-visit treatment, and minimal disruption to and toxicity from systemic agents they might be receiving.
“The need for such machines has become apparent from recent clinical trials,” Dr. Senan added.
He said that three multicenter lung cancer trials of MRI-guided adaptive SABR (stereotactic ablative radiotherapy) for central tumors have clearly demonstrated the advantages compared to more traditional X-ray-guided RT. A 10-year retrospective analysis of MRI-guided SABR for adrenal oligometastases showed similar results to surgical intervention. Multiple publications describe single-visit consultation and SABR delivery as well as single-visit consultation and complex palliation.
These and other technological improvements can help reduce lung toxicity when combining RT with chemotherapy or immunotherapy.
“Preserving lung function is very important in the setting of lung cancer,” said Andrea Bezjak, MD, Professor of Radiation Oncology, University of Toronto Princess Margaret Hospital, Toronto, Canada. “Advances in therapy are leading to more complex manifestations of lung toxicity.”
Patients receiving immunotherapy or immuno-radiotherapy are more likely to develop Grade 3 or higher toxicities than patients receiving RT alone, she noted. Adverse events such as pneumonitis may occur during treatment or months to years later.
Using 4-dimensional computed tomography (4DCT) can better identify and account for respiratory motion to create patient-specific margins to reduce toxicity. Free breathing can be lung sparing compared to the more familiar deep inhale breath hold. And intensity-modulated RT can reduce low-level radiation exposure to healthy tissue.
“We tend to think about 20Gy isodoses, but even 5Gy can contribute to toxicity,” Dr. Bezjak cautioned. “We need to work together to reduce lung toxicity.”
Radiation oncologists may also soon need to work with artificial intelligence (AI). Automated image analysis in lung cancer is on the verge of disrupting the interpretative and subjective image analysis delivered by human clinicians.
“Clinicians who do not use AI will be replaced by those who do,” predicted Philippe Lambin, PhD, Professor and Head of Precision Medicine, Maastricht University, Maastricht, The Netherlands. “It is the integration of the two that is superior.”
Inter-observer variation and intra-observer variation are awkward clinical realities that degrade the utility of even the best lung images, Dr. Lambin said. AI interpretation can reduce variability in interpretation—saving time for both radiologists and radiation oncologists—and provide more accurate and predictive analyses.
Clinical trials using real world data from multiple centers show that AI can evaluate in seconds lung images that require up to 30 minutes for experienced radiologists. Similarly, automated RECIST scoring is more accurate than manual scoring.
“The code we are using is open source and soon we will be offering clinical solutions,” Dr. Lambin said.
Robotic surgery is another growing part of lung cancer treatment, but not all robots are created equal. Most current robots require four or five ports, meaning four or five incisions. The latest iteration, URATS, uniportal pure robotic surgery, requires a single port to accommodate multiple surgical arms.
“We have reported very good outcomes using one port,” said uniport innovator Diego Gonzalez Rivas, MD, Consultant, Shanghai Pulmonary Hospital. “We just need to convince surgeons who are used to using multiple ports.”
He said the single port system offers improved visualization, improved instrumentation, more precise and easier suturing, better lymph node visualization, and dissection with similar postoperative pain levels as multiport procedures.
Dr. Rivas described multiple uniport lung procedures, including lobectomy, lymphadenectomy, segmentectomy, pneumonectomy, sleeve lobectomy, carinal resection, thymectomy and more. Regardless of the procedure, placement of the robotic arm remains the single most important factor.
“Our aim is to reduce risk to our patients,” he said. “That is why we think ‘uniportal.’ When it comes to robotic surgery, less is more.”