Update: Sadly, Ida Chen passed away on November 6, 2019. The following story was written earlier this year, after Ida had undergone fluorescence-guided surgery at The Ottawa Hospital.

Symptoms strike and reveal shocking brain cancer diagnosis

While out on a bike ride enjoying the warmth of Palm Beach, Florida, in December 2016, Ida Chen noticed something was wrong with one of her legs. She had experienced some minor symptoms in the weeks prior, but suddenly, her right leg stopped working. Unable to balance, she fell and couldn’t continue her ride.

The fall left her stunned. “After I fell, I could walk. It wasn’t a permanent issue,” said Ida. However, a gash in her leg sent her to a walk-in clinic near where she and her husband, Clarence Byrd, have their vacation property.

When Ida recounted what happened to the doctor, he assured her there wasn’t an infection in the leg but he was deeply concerned about what had led to the fall. He advised her to contact a neurologist.

The neurologist scheduled an MRI, which revealed Ida had a 4 cm sized tumour in her brain which had features concerning for a malignancy. Recognizing that she may not survive a trip back to Canada for surgery, the neurologist contacted a neurosurgeon at the University of Miami Hospital who performed surgery only days later. Ida’s tumour was identified as a glioblastoma multiforme, an aggressive form of brain cancer. Unfortunately, not all the tumor could be completely removed, with 25% left behind due to the involvement of the tumor with the motor control areas for Ida’s leg.

Glioblastoma multiforme – brain cancer

For Clarence, it was hard news to absorb.

“It’s a particularly nasty cancer because it has fuzzy edges and they have trouble ensuring they get all of it.” Clarence Byrd, Ida’s husband

Ida advised her Ottawa doctor of the situation. Despite the fact that it was Christmastime, Dr. Lisa Lezack of the University of Ottawa Health Services made great efforts to ensure that when Ida returned to Canada, she would get prompt treatment.

Once back in Canada in early January, Ida was scheduled for radiation and chemotherapy. However, a new MRI showed that the tumour had returned to almost 100 percent of its original size.

Once again, just weeks after her first surgery, Ida was wheeled into the operating room, this time at The Ottawa Hospital under the care of neurosurgeon Dr. John Sinclair. It was a seven-hour surgery, followed by six weeks of radiation treatment and chemotherapy.

Ida’s initial prognosis was 12 – 15 months to live. Eighteen months after her diagnosis she had surpassed the odds, but the cancer was back, and she needed another surgery – her third in less than two years. This time, Dr. Sinclair had access to a revolutionary microscope, which was on loan to The Ottawa Hospital.

Ida, at home, enjoying every moment she gets to play piano.
Ida, at home, enjoying every moment she gets to play piano.

Illuminating cancer

Dr. Sinclair had traveled to Switzerland to receive training for fluorescence-guided brain surgery and was able to perform such surgery in the context of a trial using a microscope on loan to The Ottawa Hospital. The technique requires patients to drink a liquid containing 5-aminolevulinic acid (5-ALA) several hours before surgery. 5-ALA concentrates in the cancerous tissue and not in normal brain tissue. As a result, malignant gliomas “glow” a fluorescent pink color under a special blue wavelength of light generated by the microscope while the normal brain tissue does not fluoresce. This permits surgeons to achieve a complete resection of a tumour in many more patients, with recent studies demonstrating that this can now be achieved in 70% of surgeries as opposed to the previous 30% average.

“Seeing the brilliantly coloured tumours helps neurosurgeons remove more of the cancerous cells,” said Dr. Sinclair. “It’s like turning on the lights. You can actually see the difference between the tumour and the brain tissue. It’s dramatic.”

Added Dr. Sinclair, “Survival and quality of life are both dramatically impacted by this technology.”

In later discussions with Dr. Sinclair, it was clear that, without the use of the microscope Ida would have lost the use of her right leg. Ida explained, “He would have had to take out more of my brain matter and disable me to be sure he had all of the cancer cells.” She also learned that, because the microscope was available for a limited time on loan from the manufacturer, she was one of only ten people in Canada who benefited from the loan of the microscope.

Shortly after Ida’s surgery, a fundraising campaign was initiated to acquire a permanent microscope for Fluorescence Guided Surgery at The Ottawa Hospital. Recognizing how vital this piece of equipment was, Ida and Clarence made a substantial contribution towards its purchase. Dr. Sinclair performed the first surgery with the new microscope on August 26th.

“He saved my life.”

Thanks to the revolutionary care she received right here at home, Ida is enjoying a normal life style. “The Ottawa Hospital has given her outstanding service. Dr. Sinclair in particular has been very impressive,” said Clarence.

Ida is quick to add, “He saved my life. Twice.”

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

A bystander only sees neurosurgeon Dr. Adam Sachs wearing large goggles, looking at the air between the two wands he moves back and forth in front of him. What Dr. Sachs sees is a three-dimensional image of a patient’s brain, with its electrical activity superimposed. This isn’t a video game. It’s the cutting-edge of deep brain stimulation and neurosurgery technology.

Wearing virtual reality goggles, Dr. Sachs can view an accurate, computer-generated 3-D image of a patient’s brain with Parkinson’s disease, created using the patient’s own MRIs. The patients’ brain activity recorded from microelectrodes can be visualized in this virtual world. With the two wands, or joysticks, he can move the three-dimensional brain around, seeing it from all angles. He can also remove layers of the brain to look inside at the exact spot where he will place a DBS electrode during deep brain stimulation (DBS) surgery. He is hoping to soon use this technology in the operating room.

Dr. Adam Sachs
Neurosurgeon Dr. Adam Sachs is planning to use 3D virtual reality in his deep brain surgery for patients with Parkinson’s.

This medical 3-D virtual reality system was developed at The Ottawa Hospital, and is expected to be the first of its kind in the world to be used for deep brain stimulation surgery. Drs. Justin Sutherland and Daniel La Russa are clinical medical physicists in the hospital’s radiation oncology department. The two used their imaging expertise to develop a virtual reality system that combines a patient’s MRIs and CT scans to create a 3-D image of a patient’s organ or body part to give surgeons a detailed, accurate representation of the surgical area.

Historically, medical virtual reality programs were used by patients mainly for rehabilitation. Patients would wear VR-goggles to help relearn how to move through and cope with different environments. Until recently, the technology wasn’t good enough to create images of organs or tissue that could be used by clinicians in a manner that improves on current practice.

“What we are trying to do in our virtual reality lab is come up with new ways to leverage technology to help doctors and nurses, or any medical professional, do what they do better.  And how better than with 3-D visualization,” said Dr. Sutherland who is also an assistant professor in the University of Ottawa’s Department of Radiology. “We think the technology has only reached that point now. We’re now at a place where we want to pursue the avenue of clinicians-as-users.”

“Nowhere else in the world are they using virtual reality in this fashion.”

One Ottawa Hospital surgeon interested in using 3-D virtual reality was Dr. Sachs, who performs deep brain stimulation surgery for people with Parkinson’s. During this procedure, a microelectrode, no wider than a human hair, is implanted into a very specific area of the brain. The microelectrode then records activity from and stimulates that part of the brain and alleviates some of the patient’s symptoms, such as tremors and akinesia or the loss of ability to move their muscles voluntarily. The virtual reality system allows the electrical activity, stimulation effects and the MRI to be visualized together.

“In deep brain stimulation surgery, because the target is very small and in the middle of the brain this leaves the surgeon with the problem of how to visualize the person’s brain to understand the area and where to put the electrode,” said Dr. Sachs.

Dr. Adam Sachs holding 3D virtual reality wands.
Neurosurgeon Dr. Adam Sachs uses virtual reality wands to manipulate a 3D image of the brain.

He said neurosurgeons use MRIs and brain atlases to get a mental image of what the patient’s brain looks like. The problem is these atlases are maps created from many different people’s brains, but each patient’s brain is unique. As well, the brain atlases are only two-dimensional, while the brain is three-dimensional. This makes it difficult to place the microelectrode in the exact spot in the patient’s brain where it will have the best chance of halting or reducing the Parkinson’s tremors.

Dr. Chadwick Boulay, a senior research associate in the neuroscience program, understands the challenges faced by neurosurgeons when implanting an electrode at the optimal position in the brain. When Dr. Boulay learned about the 3-D virtual reality technology being developed at The Ottawa Hospital, he realized the potential this had for increasing the accuracy of deep brain stimulation surgery. He and Dr. Sachs worked with Drs. Sutherland and La Russa to develop a virtual reality program that would enable them to see the patient’s brain in three dimensions.

“This is really exciting,” said Dr. Sachs. “The deep brain stimulation electrodes will be more precisely placed because we’ll be able to integrate accurate images from the patient’s anatomy and visualize it in three dimensions,” said Dr. Sachs.

He anticipates that the resulting precision of the placement of the electrode will improve outcomes for patients with Parkinson’s disease, but this will be confirmed through research. About 15 people undergo deep brain stimulation surgery at The Ottawa Hospital every year.

“We’re excited about working with the Sachs Lab because it is a perfect clinical example of using 3-D visualization to better understand a spatial problem,” said Dr. Sutherland. “In this case, actually seeing a target for deep brain stimulation removes the burden on the surgeons of trying to create a 3-D model in their head.”

Drs. Daniel LaRussa, Justin Sutherland, and Chadwick Boulay
Drs. Daniel LaRussa, Justin Sutherland, and Chadwick Boulay have teamed up to design a 3D virtual reality program for Dr. Adam Sachs’ deep brain stimulation surgery.

Dr. Sutherland foresees that this 3-D virtual reality technology will one day be in every department throughout the hospital. He says the overall system is surprisingly inexpensive, as the computer that runs it and the goggles only cost a few thousand dollars. The possibilities for this technology are endless. He said it has huge potential for education—teaching medical anatomy—and for surgical planning. Dr. Sutherland sees Dr. Sachs’ endorsement of this system as a shining example of how doctors can use this technology to improve what they do.

“Nowhere else in the world are they using virtual reality in this fashion,” said Dr. Sachs.

The Ottawa Hospital is quickly being positioned as leaders in 3-D virtual reality technology and has already gained international attention. Drs. Sutherland and La Russa have given demonstrations and been invited to talk at large medical conferences, and other institutions have contacted them with interest in using this technology.

INNOVATING TODAY. CREATING TOMORROW.

The latest technology, equipment and innovative ideas

Using state-of-the-art technology is how we are able to deliver 21st century health care right here in Ottawa. We believe that if we get the very best tools into the hands of the very best people, together with the help of our community, we can overcome some of health care’s biggest challenges.

Nurse in Emergency Department

At The Ottawa Hospital, we are leaders in innovative thinking and are committed to tackling the world’s most complex health-care issues. We are pushing the boundaries of what has always been done to find new ways forward. When it comes to your health, and the health of your loved ones, we won’t settle for mediocrity.

Innovations thanks to donor support

3-D virtual reality helps neurosurgeon treat Parkinson’s
3-D virtual reality increases neurosurgeon’s accuracy to place electrodes in patients’ brains. Technology expected to be the first of its kind in the world.
CyberKnife destroys inoperable tumours
Radiosurgery treatment for tumours in brain and other organs revolutionized outcomes for patients. The Ottawa Hospital’s CyberKnife is only one of three in Canada.
Platinum seeds planted to transform CyberKnife treatment
Platinum seeds help CyberKnife robot more successfully detect and destroy inoperable tumours, improving outcomes for patients.

Patients don’t need to have a metal halo screwed into their skull when they receive radiation treatment with the CyberKnife. That was one of the appealing factors for neurosurgeon Dr. John Sinclair to bring the radiosurgery robot to The Ottawa Hospital.

With other radiosurgery, patients with brain tumours had to have their head held perfectly still during treatment. A metal frame or “halo” was screwed into their skull and then fastened to the table they’d lie on for treatment.

However, patients do not need to be held still when receiving CyberKnife radiosurgery. The robot uses x-rays and complex precision software to accurately track the tumour. It gives a high dose of radiation to the precise location of the brain tumour while the patient, who is fitted with a custom-made plastic mask, lies on the table.

“CyberKnife has an advantage over regular radiation because it is so much more accurate; its precision is less than a millimetre,” said Dr. Sinclair, Director of Cerebrovascular Surgery at The Ottawa Hospital. “You can give very high doses of radiation right to the lesion [tumour] and get almost no spill over to normal tissue. And as a result, we see greatly improved responses to this type of treatment compared to regular radiation.”

Dr. John Sinclair leaning against bed in the operating room
Dr. John Sinclair was instrumental in bringing the CyberKnife to The Ottawa Hospital.

Dr. Sinclair was first introduced to the CyberKnife when he did a fellowship at Stanford Medical Center in California. CyberKnife was invented at Stanford, so the neurosurgeon was one of the first to see the benefits of this frameless radiosurgery treatment.

When Dr. Sinclair was recruited to The Ottawa Hospital in 2005, he had hoped to bring this novel technology to patients here. At the time, it was a technology that wasn’t approved by Health Canada. So, Dr. Sinclair and his team made a case for robotic radiosurgery, presenting scientific data that validated its success.

The Ottawa Hospital was eventually one of two health research centres in Ontario allowed to test the CyberKnife. However, there was no government funding available to purchase the machine. The hospital appealed to the community, which pulled together and generously raised the entire $4 million to purchase it. CyberKnife began treating patients at The Ottawa Hospital in September 2010.

“Because it’s delivering a high dose, it’s considered similar to surgery without using a scalpel, so patients experience 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. “So CyberKnife radiosurgery does provide an option where people can be treated with outpatient techniques.”

With regular radiation, the daily doses were lower and patients had to come to the clinic for more radiation treatments overall. Regular radiation treatment could range from five to six weeks. With CyberKnife, radiation is focused precisely on the tumour, allowing larger doses to be given daily, therefore giving the total treatment in one to six days. The hospital’s CyberKnife has gained a reputation for improving treatment of various tumours. Dr. Nair said that because it is one of only three in Canada, patients from British Columbia to the Maritimes are occasionally referred to The Ottawa Hospital for treatment.

“At first, we would treat one tumour,” said Dr. Sinclair. “Now, we treat five or six individual tumours at a time and spare the rest of the brain. We’re sending radiation only to those metastatic tumours. There is a proportion of patients who develop cognitive problems a few months after whole-brain radiation. But with radiosurgery, because we give a higher dose of radiation only to the actual tumours, patients have improved outcomes, and so their quality of life is better.”

This has meant an increase in the number of patients having multiple tumours treated in the same session.

“Treating several tumours at once helps keep the patient’s clinic visits to a minimum,” said Radiation Therapist Julie Gratton, who has worked with CyberKnife since it was installed at The Ottawa Hospital. “Targeting individual tumours rather than treating the whole organ helps spare healthy tissues and reduce side effects.”

The CyberKnife robot
The CyberKnife at The Ottawa Hospital is one of only three in Canada.
Julie Gratton stands in front of the CyberKnife.
Radiation Therapist Julie Gratton has given CyberKnife treatments to patients since 2010.

Until 2017, 1,825 patients had been  treated with the CyberKnife. In 2018, 359 patients received 1,824 CyberKnife treatments. Gratton said that because more tumours are being treated at once in each patient, the number of treatments given per year has increased as expected.

Although 90 percent of CyberKnife treatments are for malignant or benign brain tumours, CyberKnife is also being used to treat tumours in other parts of the body. Because it doesn’t require a frame to keep the area receiving radiation still, CyberKnife’s image guidance system is used to treat tumours in organs that move constantly, such as the lungs, kidneys, liver, prostate gland, and lymph nodes. CyberKnife can precisely align the radiation beam to the tumour even when it moves. The method of tracking tumours in organs and soft tissue has been improved by research at The Ottawa Hospital.

Read more about how our team is increasing the success rate of this already powerful and precise treatment.

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.

Hand holding a grain of rice and platinum seed
Platinum seeds, a third the size of a grain of rice, are improving the accuracy of CyberKnife treatments.

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.

Dr. Vimoj Nair
Radiation oncologist Dr. Vimoj Nair said platinum seeds improve the accuracy of CyberKnife radiosurgery.

“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.

Julie Gratton with patient beside CyberKnife robot
Radiation therapist Julie has delivered CyberKnife treatments since 2010.

“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 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.

Dr. Sony Singh uses 3D printed model for complex surgery.
Holding the 3D printed model of Maureen’s uterus, Dr. Sony Singh examined the MRIs and 3D renderings – the images that appear on the operating room screens that doctors can move to get a 3D view of the surgical area.

“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.

When a routine mammogram identified a small tumour, Rita Nattkemper was given an innovative option to mark its location for the surgery. A radioactive seed, the size of a pinhead, was injected directly into the tumour in her breast.

“All I have to say is it’s a painless procedure to get this radioactive seed in and it helps the doctor with accuracy,” said Rita. “And as he removes the mass, he’ll be removing the seed at the same time.”

For the last 20 years, when a woman had a breast cancer tumour that was too small to feel or be seen in surgery (called a non-palpable tumour), she had to have a wire (known as a harpoon) implanted at the tumour site to locate it for the surgeon. The wire, which stuck out of the woman’s breast, had to be inserted the morning of her surgery. Then, women had to wait uncomfortably for surgery with the wire sticking out of their breast. To add to the discomfort, many women had to fast overnight to prepare for surgery, causing many to faint in the radiology suite at the sight of the wire protruding from their breast.

The procedure also posed other problems.

“Sometimes the wire moved. And sometimes, because of the location of the tumour, the wire might overshoot or undershoot the tumour, so ultimately there was an enormous amount of guess work involved in taking out a breast cancer tumour properly,” said Dr. Carolyn Nessim, surgical oncologist, and clinician-investigator in the Cancer Therapeutics Program at The Ottawa Hospital.

Dr. Nessim, and other breast oncology surgeons, wanted to find a better option.

That was where radioactive seeds came in. Radioactive seeds have been used for many years to treat prostate cancer. Multiple seeds are implanted in the prostate, where they emit radiation and kill the cancer. Then a procedure was developed for breast cancer patients using a radioactive seed to mark the exact location of small breast-cancer tumours. Using a mammogram for guidance, a radiologist places one seed, so tiny it can be safely injected with a needle, inside the tumour. It emits a very small amount of radiation that is picked up in the operating room with a small, handheld Geiger counter. After the piece of breast tissue with the radioactive seed is removed, the seed is separated from the tissue and appropriately disposed of, with every seed being accounted for.

Realizing the benefits of this procedure, The Ottawa Hospital began a radioactive seed program in 2015. One of the main benefits is that the seed can be placed up to a week before surgery, which makes the day of the operation easier for patients. A woman doesn’t have to wait for surgery with a wire sticking out her breast. From a logistical point of view, it’s easier to organize the procedure days in advance, and means more efficiency in the operating room. Dr. Nessim led a research study comparing seeds to wires, which showed the benefit of seeds.

“The results of the radioactive seed program have been uniformly excellent,” said Dr. Erin Cordeiro, breast surgical oncologist and senior clinician-investigator at The Ottawa Hospital. “We did a study that found that radioactive seeds were more cost effective and decreased wait times for patients on the day of surgery when compared to wires. And the patient experience has also been wonderful. Patients are very supportive of this.”

Rita agrees. She said the surgeon and radiologist both explained the procedure and put her at ease about it.

“I felt a minor pinch, and that was all I felt,” Rita said immediately after the procedure. “And the radiologist had the screen turned, so I could see where she put in the needle and left the seed. It was very easy, very quick, and very painless.”

Dr. Cordeiro said women are often concerned about the seed’s radioactivity, but the staff reassures patients the procedure is completely safe. The amount of radiation that is emitted in the week the patient has the implanted seed is less than having two mammograms.

“A woman can continue to hug her children and do everything in life she would normally do,” said Dr. Cordeiro. “No concerns from that point of view. It’s an extremely safe procedure. The vast majority of women have no concerns.”

Over the past year, 355 radioactive seed procedures have been performed at The Ottawa Hospital. Only two patients have refused the seeds and opted for the traditional wire instead.

Because of the program’s radioactive element, there were stringent guidelines around starting the program.

A multidisciplinary team of nuclear medicine, radiation safety experts, radiologists, pathologists, surgeons, technicians, and nurses were involved.

Key members of the team, led by Dr. Nessim, went to the Mayo Clinic in Rochester, N.Y., to learn how to implement the program. They then ran 15 training sessions for staff at The Ottawa Hospital. The radioactive seed program now “runs like a well-oiled machine,” said Dr. Nessim.

The Ottawa Hospital was the third centre in Canada to have a radioactive seed program, and is a leader in the procedure. Other health centres across the country are now adopting it and looking to The Ottawa Hospital for guidance in successfully implementing their program.

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