Innovative Minimally Invasive Technology in the Hands of Cancer Specialists Fosters Better Care for Florida and Beyond
More than 25 years ago, when Rep. H. Lee Moffitt shared his vision with the Florida Legislature to improve its cancer services for our citizens and create a cancer-only center of excellence in Tampa, he could not have imagined how far his dream would come. As one of the fastest growing cancer centers in the nation, Moffitt has recruited some of the most accomplished clinicians and scientists sharing a common goal to contribute to the prevention and cure of cancer.
Rep. Moffitt could not have envisioned that the cancer center would so quickly grow beyond its original hospital and outpatient clinics on the University of South Florida campus to include a dedicated research facility with more than 300 scientists, an outpatient center at International Plaza near Tampa International Airport, and several research and administrative buildings being planned.
As the third busiest cancer center by patient volume in the United States, Moffitt embraces the constant challenge of increased patient demand as our population grows and matures. Developing and implementing cutting-edge technologies and innovative approaches to cancer treatment allows Moffitt to thrive while promoting systematic efficiency and improving the tools needed to help doctors meet the complex needs of cancer patients. Moffitt is strategically positioned to lead the fight against cancer while providing for a brighter and more hopeful future emphasizing quality of care more than ever before.
Advances in Radiology: Better ways to see, isolate and treat cancer
Moffitt’s Department of Diagnostic Imaging employs state-of-the-art technology, novel research in the field of tumor imaging and a subspecialized multidisciplinary team approach to provide the highest level of quality. The department is equipped with the latest generation multidectector CT scanners, high-field MRI scanners, and 4D PET/CT scanners, in addition to diagnostic radiography, ultrasound, interventional radiology, and nuclear medicine.
“Moffitt’s research in diffusion-weighted MRI, molecular imaging and radiomics will help define the individualized, patient-specific imaging strategies of tomorrow,” said Jamie T. Caracciolo, M.D., MBA, assistant member of Diagnostic Imaging and section head of Musculoskeletal Imaging. “Radiomics, or the evaluation of heterogeneous tumors on a pixel by pixel basis, is an innovative area of research with promising implications for treatment efficacy in the future.”
At the heart of the mission to contribute to the prevention and cure of cancer, Moffitt is organized around specific types of tumors such as thoracic oncology, neuro-oncology and women’s oncology, to name a few. The subspecialty-trained, board-certified radiologists work closely with other cancer professionals to apply their specific areas of imaging expertise to cancer treatment.
For example, a woman with breast cancer treated at Moffitt will have her films interpreted by a radiologist who specializes in breast imaging. The radiologists participate in weekly multidisciplinary tumor board meetings to discuss imaging findings and formulate a treatment plan with the surgical and radiation oncologists, among many others. This collaboration between the clinician who has examined the patient and the doctor who has seen the cancer yields a comprehensive level of care.
The patient also has the option of having her mammogram performed on the new MicroDose mammography unit, which delivers 50 percent less radiation with improved diagnostic accuracy over standard units. Moffitt was the first academic medical center to acquire this technology, which is available at only a few centers in the United States.
“This state-of-the-art, cutting-edge technology for women with cancer or being screened for cancer is highly significant,” said Chris Flowers, director of Breast Imaging and Research.
MicroDose mammograms are available at the new outpatient location next to International Plaza, where patients check in for their initial visit once and then are given a “Care Pass,” a wristband device that enables patient tracking within the building. The Care Pass assists the staff in enhancing the patient experience.
“We know waiting can increase an already stressful situation for a patient, so our new facility was designed to streamline care by increasing efficiency,” said Nancy Ziel, administrative director of Satellite Operations.
Radiology has seen a recent explosion of novel technologies and imaging techniques that has revolutionized the ability to define the extent of disease, allowing for more focused and targeted cancer therapy. This has certainly been the case at Moffitt. The cancer center offers 4D PET/CT scanning, a fused PET scan and CT scan, which also demonstrates patient breathing motion displayed in a dynamic cine clip. This allows the radiologist to identify hypermetabolic tumors as they change position with patient respiration. Research conducted by the Moffitt PET/CT committee has shown that motion may allow for identification of additional sites of disease that were not previously seen with standard PET/CT imaging. This is particularly important in cases of lung cancer where motion can reveal, or obscure, small lymph nodes that may change the patient’s stage and treatment.
The radiation oncologists at Moffitt work closely with the radiologists utilizing 4D PET/CT to more precisely define tumors during end-expiration with minimal respiratory motion. More accurately defining and isolating tumors with 4D PET/CT allows for delivery of more focused radiation therapy directly to the tumor via stereotactic ablative radiotherapy (SABR). SABR is a technology that delivers an extremely high dose to the tumor itself while limiting exposure to surrounding structures and can be delivered in synchrony with a specific breathing phase.
Moffitt also employs a skilled group of interventional radiologists who perform minimally invasive procedures to treat cancer. In addition to standard interventional procedures, the interventional radiologists have been performing hepatic radioembolization since 2009, and Moffitt has quickly become one of the most active centers in the United States performing this procedure, with more than 300 performed in the past few years. The success of this procedure is based on the fact that most hepatic tumors preferentially derive blood supply from the hepatic artery rather than the portal vein due to neo-vascularization. Following selection of appropriate candidates at the multidisciplinary tumor board, this outpatient procedure is performed through a small catheter placed into the femoral artery and advanced into the hepatic artery. In conjunction with radiation oncology, the interventional radiologist defines the site of disease and dose to be administered. Millions of radioactive spheres are then delivered through the hepatic artery directly to the tumor to irradiate it from the inside out. This treatment may be palliative or utilized to shrink tumors before surgical resection.
Innovation and research are central to the mission of Moffitt and the Department of Diagnostic Imaging. Radiologists, physicists, graduate students from USF, the Department of Mathematical Oncology, and researchers around the world collaborate in the pursuit of groundbreaking quantitative imaging techniques.
Radiation Oncology: Technological advances lead to higher efficacy with decreased side effects
Recent advances in technology have dramatically improved patient outcomes in radiation oncology. These techniques allow a higher dose to be delivered to the tumor with a lower dose to normal tissues, translating to higher cure rates and less toxicity. Although physicians have had the ability to determine the extent of disease in three planes, it was only recently that 4D imaging and placement of radio-opaque markers called fiducial markers have been integrated into radiation treatment planning. At Moffitt, fiducial markers may be placed by interventional radiologists, endoscopic oncologists, and in the prostate gland, by radiation oncologists. These advances in pre-treatment planning allow the radiation oncologist to better localize the tumor on a daily basis.
SABR: Stereotactic Ablative Radiation Therapy
In the 1990s, patients with early stage lung cancer who were not candidates for surgery faced a six- to seven-week course of radiation with limited likelihood of cure, with most series reporting less than 30 percent long-term survival. Stereotactic ablative radiation therapy has since emerged as a much better treatment option offering patients a higher chance of cure in one week or less with this noninvasive technology. The key is being able to precisely identify the extent of the cancer and then delivering “pinpoint” radiation to the target. This is now possible with the implementation of 4D PET/CT scanning at the time of treatment planning, which depicts the extent of respiratory-associated tumor motion. Strategies to deliver targeted radiation directly to the tumor at the point of least respiratory motion can then be implemented with the added benefit of exposing as little of the patient’s normal healthy lung tissue as possible.
At Moffitt, more than 400 lung cancer patients have been treated with SABR with high rates of tumor control and minimal toxicity. This technology has since been integrated into the treatment of many other cancers. For example, patients at Moffitt with inoperable pancreatic cancer often receive chemotherapy followed by SABR. High rates of conversion to surgical resection with negative margins have been reported; in fact, three patients treated with this technique had no residual pancreatic cancer at surgery.
IMRT/IGRT: Intensity Modulated Radiation Therapy with Image Guided Radiation Therapy
Not all patients are candidates for short course radiation therapies. Patients with head and neck cancer, for instance, receive a seven-week course of combined chemotherapy and radiation therapy. Prior to the modern era in radiation oncology, large radiation fields were used to treat these cancers with limited ability to spare normal tissue. Patients routinely developed the permanent loss of salivary function but no longer. Current practice has recently evolved to include Intensity Modulated Radiation Therapy, or IMRT, a technique whereby each radiation beam can be divided into individual beamlets, which increases precise delivery of higher doses. Many machines at Moffitt are capable of IMRT delivery and are used in conjunction with Image Guided Radiation Therapy, IGRT. These techniques allow the radiation therapists to verify the patient’s position with images generated on the treatment machine. This capability allows physicians to use narrower margins, reducing toxicity, ensuring that the intended target is irradiated.
Brachytherapy: Internal Radiation Minimizes Exposure of Normal Tissues
At Moffitt, there are physicians who specialize in internal radiation delivery termed brachytherapy. New technology has now expanded beyond the “traditional” permanent seed implant. Modern options include the ability to use catheters placed in the patient’s body cavity or tissues adjacent to the tumor that are then connected to a robotlike device called a remote afterloader. Radioactive seeds travel from the robot up the catheter into the patient, dwell for an average of 10 to 15 minutes, and then retract back out through the catheter. This outpatient procedure, termed High Dose Rate (HDR) brachytherapy, is an important tool in the management of patients with many different cancer types such as soft tissue sarcomas and prostate cancers.
In addition, Moffitt has increased internal treatment options available for women with breast cancer. Instead of the usual six-week course of treatment, women who are candidates are offered a single fraction of internal radiation delivered at the time of lumpectomy. This approach, called Intrabeam, is well tolerated and appreciated by patients.
“These advances are revolutionizing how internal radiation can be given so that patients have more chances for cure with an emphasis on quality of life,” said Matthew Biagioli, M.D., Moffitt’s Brachytherapy service chief.
Radiopharmaceuticals: Liquid Radiation Improves Outcomes
At Moffitt, new research led by Dr. Michael Tomblyn has broadened the indications of novel radiopharmaceuticals in the treatment of patients with cancers that have failed traditional therapies. These micro-particles injected into the bloodstream locally deliver radiation directly to sites of disease and can be administered on an outpatient basis. Certain radiopharmaceuticals are indicated in patients with lymphoma and bone metastases, with growing potential for a wider range of clinical applications in the near future. For example, a new alpha-emitting radiopharmaceutical has recently been shown in clinical trials to improve overall survival in men with hormone-refractory metastatic prostate cancer.
Personalized cancer care tailored to each patient is a major focus of Moffitt, as no two cancers are the same. Moffitt’s Total Cancer Care® program has been dedicated to this approach.
“I have to remind patients that it is about the Moffitt team, not the machine,” said Richard Wilder, M.D., program leader for Radiation Oncology. “At Moffitt, we really are able to personalize the right treatment machine and technique for the right patient.”
Selecting an appropriate radiation delivery system for each patient’s particular disease is truly a key objective of Moffitt’s radiation oncologists. With six types of external radiation machines available and a range of treatment techniques, several options exist for every individual’s treatment plan.
In the not too distant future, patients’ tumors and genetics may be identified before therapy to determine how sensitive their cancer cells may be to different radiation therapies. Moffitt physician-scientist Javier Torres-Roca, M.D., has designed a test to do just this. He has patented his techniques and partnered with Moffitt to bring this technology to market in the next few years.
Innovative technologies and novel research being performed at Moffitt continue to revolutionize the fields of radiology and radiation oncology in the continuous battle to contribute to the prevention and cure of cancer. At Moffitt, the future is indeed becoming brighter.
By Sarah Hoffe, MD
Moffitt Cancer Center
12902 Magnolia Drive
Tampa FL 33612
Referring Physician Line:
(813) 745-3980 or 1-888-860-2778