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Collaboration in Precision Biopsy Research Aims to Improve Cancer Care Patient Pathways
How academia and industry are working together to improve personalised medicine by fusing real-time ultrasound with CT information to enable fewer, more targeted biopsies
The one-size-fits-all approach to cancer, where everyone with the same type gets the same treatment, is no longer the state of the art. Personalised medicine has enabled a more targeted approach to oncology where the genetic characteristics of a tumour are understood earlier to enable a more targeted and specifically tailored course of treatment. In order to determine the genetic character of lesions, it is necessary to biopsy them. But where there is heterogeneity, knowing that the potentially different genomic elements have been sampled is of course a challenge. Furthermore, because of the invasive nature of these procedures and the potential for patient discomfort, minimising the number of biopsies is always preferred.
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New research, pioneered by Professor Evis Sala from the Department of Radiology at the University of Cambridge and co-lead of the Cancer
Image of the ovary using CT Ultrasound Fusion
Research UK (CRUK) Cambridge Centre’s Advanced Cancer Imaging Programme, was published in European Radiology earlier this year. It offers exciting insights to help push the current boundaries of precision tissue sampling or, indeed, establishes the feasibility of virtual biopsies in the future.
The study focused on a small cohort of ovarian cancer patients due to have ultrasound-guided biopsies prior to starting neoadjuvant chemotherapy. Firstly, a CT scan was performed, from which it was possible to define different habitats within an ovarian lesion. A habitat is a region of tumour that has well defined image characteristics that are different to other zones. Maps visualising these habitats were then superimposed on the CT images, which could be used in conjunction with real time ultrasound Fusion, to guide biopsy procedures. This enabled a more informed and detailed approach to taking biopsy samples to capture a diversity of cells. Dr Stephan Ursprung, Clinical Researcher in Professor Sala’s team at the School of Clinical Medicine at the University of Cambridge explains, “Our work is attempting to solve unmet clinical needs in cancer care. Cancer-care pathways for today’s patients depend on the balance between several factors including, the ability to detect cancer and its treatment response using imaging; to detect molecular treatment targets; and to develop drugs that act upon these targets. A development in one of these areas enables progress in the others.”
He continues, “Clinical practice has moved on from a single approach to cancer treatments, and today individual treatments are tailored to patients, even for the most aggressive cancers. But the big challenge for radiology is how can we sample such a diverse tumour environment and how do we facilitate multi-regional sequencing?”
“Our study looked at ovarian cancer. To tackle the lesion, targeted chemotherapy is usually prescribed to shrink the tumour before the surgery stage. The challenge is to obtain high-quality targeted samples of the cancer to sequence and tailor treatments. To exhaustively biopsy the many regions of the cancer can be cost prohibitive, or is simply not acceptable to the patient. Imaging therefore holds the key to understanding more about the intratumor heterogeneity. “
“Our collaboration with Canon Medical Systems UK and Canon Medical Research Europe has resulted in the successful live fusion of CT and
ultrasound images; enabled improvements in biopsy technique; helped to overcome the challenge of respiratory motion; and, thanks to a dedicated research ultrasound system, it has laid the basis for the success of this and future ultrasound projects. Our next steps will be the implementation of MR ultrasound fusion, translation to other organs and molecular analysis of tissue samples; and comparison to surgical tissue samples. This is evidence of a successful collaboration across disciplines and across departments,” he concludes.
“Academia, clinical practice and industry, working together to explore new procedures and techniques, can help improve the outcomes of cancer care and the quality of life of patients” states Sally Davey, Ultrasound Product Manager at Canon Medical Systems UK. “Our Aplio I Series ultrasound platform, with ‘Smart Fusion’ capability, is being used in the University of Cambridge ovarian cancer study. It enables clinicians to view, simultaneously, images from a previously performed CT scan, alongside real-time Image of segmentation prior to the Fusion procedure ultrasound imaging. The CT scan has a coloured overlay, indicating the different tissue habitats within a lesion. By synchronising these two modes, it is possible to navigate complex anatomy confidently, taking biopsies from different habitats, while keeping the number of tissue samples required, to a minimum. This will help provide the most detailed information possible to make confident cancer treatment decisions.” The study involved researchers from the Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, CRUK Cambridge Centre, and collaborators at Canon Medical. It was facilitated through the CRUK Cambridge Centre Integrated Cancer Medicine programme and funded by Cancer Research UK and The Mark Foundation for Cancer Research.
Sally Davey at Canon Medical concludes, “Smart Fusion has been used in many studies and in clinical practice where CT or MRI images are fused with real time ultrasound, to give the most accurate picture for biopsies. Other exciting projects beyond the ovarian cancer study include renal and liver disease studies, or the use of omniTRAXTM positioning aids. These are single use tracking devices that are attached to the patient during their CT or MRI scan. The omniTRAXTM is then kept in-situ if the biopsy is to take place immediately, or its position marked on the skin for later repositioning. The use of this device aids rapid synchronisation during the Fusion procedure, which is particularly helpful if the patient has to be re-positioned or needs additional CT scans during an interventional procedure. By continuing to work together with many different innovators, clinicians and researchers, we will help answer many of the big questions of research, to make a difference to people’s lives through advanced clinical care.”//
