A parent’s worst nightmare

14-year-old Spencer’s eye became reddish and tearing for more than a week; and this strange blockage was protruding from his nose. Despite repeated efforts, it would not come out.

That’s when Spencer’s mom, Ellen, knew he needed help and they would ultimately end up in CHEO’s emergency department. Doctors ordered a CT scan. It was around midnight; Ellen recalls when the results came in.

“A gravely concerned looking doctor asked me, ‘Did you know that Spencer has a tumour in his head?’”

It was not the news any parent wants to hear. 

The growth, which was protruding from Spencer’s nose, was biopsied. While benign, that tumour was resulting in the quick deterioration of Spencer’s health. When Ellen asked to see the CT scan, she recalls searching the picture for a grape or golf ball sized image attached to a nose growth.  

“I didn’t see any and asked where it was.  ‘It’s the grey area’, the doctor said.” 

The grey area was over half of his face. 

“I didn’t even want to think about what his face would end up looking like after all the cutting they’d have to do to remove so much material, but I had to ask.” 

The doctor revealed the tumour was larger than any he had ever worked with. It was for that reason and the fact it was reaching up to the floor of the brain, he told Spencer’s parents they couldn’t perform the surgery. 

This type of tumour would need a specialized team of an ear, nose and throat doctor along with a neurosurgeon working together.  Ellen recalls thinking she would take her son anywhere in the country to get the help he needed.

Specialized care at The Ottawa Hospital

However, the specialized care was nearby at The Ottawa Hospital. A highly skilled team would perform minimally invasive surgery and remove the tumour through Spencer’s nose.

Just over a week later, with his condition worsening, Spencer was to be admitted to The Ottawa Hospital. He had another CT, an MRI, and the specialized team was monitoring his optic nerve behind his bulging eye to ensure it wasn’t being severed by the growing tumour.

Two days later Spencer underwent a 4-hour surgery, which helped stop 80% of the blood flow feeding the tumour. The remaining 20% would maintain blood flow to his brain.

The next day the highly skilled team, which included Drs. Fahad Alkherayf and Shaun Kilty performed an eight-hour surgery. With expert precision, and state-of-the-art technology, they would remove the large tumour from Spencer’s face and base layer of the brain. They also rebuilt that layer to prevent the fluids that protect the brain from leaking out.   

This minimally invasive surgery, removing the tumour and rebuilding the layer, was performed through Spencer’s nose by Dr. Alkherayf who has the greatest number of surgical hours of training for this procedure in Canada. 

A Canadian Medical First

In order to rebuild the brain layer, 3D printing technology also aided doctors during the surgery. Ellen says it’s remarkable. “It’s really pretty cool the advancements which have been made to help patients in our community.”  In 2016, The Ottawa Hospital became the first hospital in Canada to have an integrated medical 3D printer.

Ellen says her initial concerns of recovery completely faded thanks to this minimally invasive technique. “It was incredible. Spencer was home again only three days after surgery!” 

When she thinks back to the fear of the initial diagnosis to where Spencer is today, back at school and active, several thoughts comes to mind. 

“I was immensely grateful to God and The Ottawa Hospital, and I truly feel that we were in the best hands.”

The Ottawa Hospital is a leading academic health, research, and learning hospital proudly affiliated with the University of Ottawa.

The “seeds” are one millimetre by three millimetres, a third the size of a grain of rice, and made of platinum. These tiny seeds, created by researchers at The Ottawa Hospital, improve the CyberKnife robot’s accuracy in detecting and delivering precise doses of radiation to tumours in the brain and body.

CyberKnife uses X-rays and complex precision software to track and focus radiation directly to the tumour. With accuracy of less than a millimetre, there is virtually no radiation spill over to normal tissue. As a result, patients have much better responses to this type of treatment compared with traditional radiation where a larger area is targeted.

“Because CyberKnife delivers a high dose, it’s considered similar to surgery without using a scalpel, so no blood loss, no pain, no ICU stay, or recovery time,” said Dr. Vimoj Nair, one of the radiation oncologists trained to prescribe CyberKnife treatment.

Ninety percent of CyberKnife treatments are for malignant or benign brain tumours, but CyberKnife’s image guidance system can also treat tumours in organs that move constantly, such as the lungs, kidneys, liver, prostate gland, and lymph nodes. It can precisely align the radiation beam to the tumour even when it moves. But radiation oncologists and researchers at The Ottawa Hospital are refining techniques to further enhance the performance of this state-of-the-art technology to improve patients’ outcomes. These techniques are ultimately changing radiosurgery practice.

“One unique thing that the CyberKnife research team at The Ottawa Hospital has come up with are in-house designed platinum MRI-compatible seeds that can be implanted around the moving tumour,” said Dr. Nair, who is also a clinician investigator at The Ottawa Hospital and an assistant professor at University of Ottawa. “We can see the tumour and the seeds better on the MRI, and the CyberKnife software can detect and track the motion of the tumour with the help of these seeds. The robotic arm of the CyberKnife matches the target motion to treat the tumour more accurately while the patient breaths normally.”

The Ottawa Hospital is one of the first centres in North America to use these platinum seeds. In the past, oncologists used tiny gold seeds, but they were difficult to see in the MRI sequences used to view the tumour. This made the treatment planning less accurate. Dr. Janos Szanto, medical physicist, and Dr. Len Avruch, radiologist (now retired), were the initial brains who took platinum wire (otherwise destined to be jewelry), cut it into minute pieces, and then put through a sterilization process to ensure the seeds were appropriate for insertion into the human body. It worked. They were visible to the naked eye, more visible in an MRI than the gold seeds, and could be detected by CyberKnife.

“The benefit of this technique is we see both our target and seeds more clearly together, which provides the best use of advanced imaging and improves the accuracy,” said Dr. Nair, who called the discovery novel research and application that positions The Ottawa Hospital very favourably on the world stage.

Dr. Nair was the first author on the research paper published about the platinum seeds. He said that researchers and clinicians are continually sharing innovative CyberKnife techniques they’ve developed, like this one, at conferences and with other health centres across Canada and globally. In September 2018, he gave presentations on The Ottawa Hospital practices on clinical uses of CyberKnife at a conference in India.

“We can see the tumour and the seeds better on the MRI, and the CyberKnife software can detect and track the motion of the tumour with the help of these seeds.”

Read more about the history of the community-funded CyberKnife at The Ottawa Hospital.

The Ottawa Hospital is a leading academic health, research, and learning hospital proudly affiliated with the University of Ottawa.

The uterus fits in the palm of Dr. Sony Singh’s hand. The large pink lumps inside the clear, plastic 3D-printed model are fibroids, or tumours, and there are more than 50 of them. To ensure his patient could carry a child in the future, Dr. Singh had to do something that had never been done before.

Maureen had suffered for years with abdominal pain. Over the past six years, she was told by five doctors that she had so many fibroids in her uterus, her only option was to have a hysterectomy – complete removal of her womb. She refused this option.

“I will die with my womb. Nobody will touch it,” said Maureen (who did not want her last name used).

She was referred to the Shirley E. Greenberg Women’s Health Centre at The Ottawa Hospital, where she saw the Minimally Invasive Gynecology team of doctors and nurses. Dr. Singh, a surgeon and the Elaine Jolly Research Chair in Surgical Gynecology, told Maureen he could remove all the fibroids, and she would not need a hysterectomy.

“Maureen had close to 50 fibroids and we wanted to make sure her uterus was able to carry a baby in the future and function normally,” said Dr. Singh. “But we needed help to plan the complicated surgery to remove them.”

Dr. Teresa Flaxman, Research Associate at The Ottawa Hospital, said it was difficult to see tumours in the patient’s uterus on an MRI. So, she contacted the hospital’s 3D Printing Lab. She had heard how 3D-printed models were helping orthopaedic surgeons see exactly what they were operating on, so they could better plan the surgery.

In 2016, thanks to a donor’s generosity, The Ottawa Hospital acquired a medical 3D printer that uses acrylics and plastics to create exact replicas of patients’ bones and organs from a CT scan or MRI. With the opening of the 3D Printing Lab in February 2017, the hospital became the first in Canada to have an integrated medical 3D-printing program for pre-surgical planning and education.

Dr. Adnan Sheikh, Director of The Ottawa Hospital’s 3D Printing Program, said the Department of Orthopaedics is one of the main users of the lab, which prints models for orthopaedic oncology surgeons to plan operations in advance, reducing surgery times and costs.

“3D printing is revolutionizing the way we look at anatomy,” said Orthopaedic Surgeon and Oncologist Dr. Joel Werier, who has used 3D-printed models of his patients’ hips and bones since the lab opened. “It adds another perspective to how we view tumours, how we plan our surgery techniques, and our ability to offer precision surgery.”

Bones are relatively easy to create from CT scans and MRIs, said Dr. Flaxman. However, soft tissues, such as uterine tissue, is harder to identify, and a model hadn’t been made of one before.

“We’re going to be one of the first hospitals internationally to study how we can provide this improved care by using 3D-printed models in planning surgery for women’s health.”

Dr. Flaxman and other researchers from the Women’s Health Centre worked with Waleed Althobaity and Olivier Miguel at the 3D Printing Lab to create 3D images from an MRI of Maureen’s uterus. Then the lab printed a model that allowed them to see exactly where the fibroids and the lining of the uterus were located.

“This was a very challenging case,” said Dr. Sheikh. “The multiple fibroids within the uterine cavity made it very difficult to print, and we had to identify each one of them, in order to replicate the exact anatomy on a 3D-printed model. We used a softer, flexible material to create the model that was more consistent with uterine tissue.”

The model took 14 hours to print. Although the model was scaled to eight times smaller than her actual uterus, her fibroid-filled uterus was 20 times bigger than normal. Having a 3D-printed model was a huge asset to the gynecological surgery team, which included surgeons Drs. Singh and Innie Chen.

“This model helped to provide a good visual aspect. To have a model in my hands during surgery was incredible,” said Dr. Singh. “At the same time, we also had 3D images that I could look at on a TV screen in the operating room. It seems very futuristic, but in the operating room I was able to turn the image of the uterus at any angle or degree that I wanted, so I could see it from different perspectives, which helped during surgery.”

A picture might be worth a thousand words, but a 3D version is worth a million words. The 3D-printed models are not only helping surgeons, but also helping patients like Maureen understand their illness and prepare for their surgery. For patients, seeing a 3D model of the problem inside their bodies makes it tangible and real.

“Just before my surgery, Dr. Singh brought the model to me,” said Maureen. “He explained how he could use it in the surgery to see where the fibroids are, and he asked my permission to use it during the operation.”

She agreed, knowing that it would help other women suffering similar experiences. Dr. Singh successfully removed the fibroids, sparing Maureen from having a hysterectomy.

“We wanted to save her uterus in hopes that she can carry a pregnancy in the future, which wasn’t a hope for her up until this point,” said Dr. Singh.

“By working together with the 3D Printing Lab at The Ottawa Hospital, we’re going to be one of the first hospitals internationally to study how we can provide this improved care by using 3D-printed models in planning surgery for women’s health,” said Dr. Flaxman.

Dr. Sheikh said that, since the success of this first use of a 3D-printed model for gynecological surgery, the 3D Printing Lab is already working on a couple of other similar projects with the Minimally Invasive Gynecology team to offer other women alternatives to major surgery in the future.

Maureen was so grateful the gynecology team was able to spare her uterus, that she donated to the Gratitude Award Program to thank them.

The Ottawa Hospital is a leading academic health, research, and learning hospital proudly affiliated with the University of Ottawa.