I'm Dr. Eric Anderson, I am
director of interventional pulmonology at MedStar Georgetown University Hospital.
I see a variety of patients from patients who need counseling on smoking cessation,
patients who are at risk for developing lung cancer,
those who have smoked cigarettes for a long period of time.
And I also spend a lot of my time doing diagnosis and staging of patients
who have been found to have lung cancer or an abnormal C.T.
scan of the chest that may demonstrate
a lung nodule or enlarged lymph nodes in the middle of the chest.
I decided to go into pulmonary critical care medicine
because of the multiple types of activities we can do each day,
the multiple types of patients
we can take care of, whether it's the critically ill in the ICU
or the outpatient patients who have continuity
for a long period of time, helping them make it through their problems.
There hasn't been any great movement
in the survival of these patients for a very long time.
And now we're finally on the cutting edge of changing things.
We are now being able to detect patients with lung cancer screening,
CT scans at earlier stage disease. Stages
where the survival is much better.
We also have technology that has moved
great leaps and bounds to help get the diagnosis for our patients.
And we have even better technology now
for the treatments. We have better radiation techniques,
and now we have medications that can help patients with lung cancer
survive longer, including patients who has stage four or metastatic disease.
You want to come to MedStar Georgetown University Hospital because we have
techniques in interventional pulmonology that will allow us to get you a diagnosis
the first time. We have a team of experts who specialize in lung cancer only.
We have thoracic surgeons
who can use robotic surgery with minimally invasive techniques.
We have radiation techniques that only Georgetown will have.
We have proton therapy and we have CyberKnife
radiation as options for treatment for lung cancer.
And we have dedicated medical oncologists who are here to take care of your lung
cancer with medications, whether it be drug therapy, like chemotherapy,
immunotherapy or molecular targeted therapies.
Lung cancer is the beast of all the cancers.
Lung cancer is a cancer that starts in the lung
and quickly spreads to other places in the body.
The unfortunate part about lung cancer is that there are no pain fibers
inside the lung.
So people cannot feel this until it becomes an advanced disease,
until it invades into a structure that causes pain, or until it spreads
to some other part of the body where it starts causing symptoms.
Lung cancer is the big killer of cancers out there.
There are more deaths from lung cancer than prostate cancer, breast
cancer, pancreatic cancer and colon cancer combined in the U.S. every year.
Millimeters matter in the diagnosis of lung cancer. We know that only a few patients
are lucky enough to present to us with an early stage lung cancer, one
which is potentially curable with surgery alone.
Patients who have tumor sizes that are smaller
than one centimeter are hardly ever discovered.
But with lung cancer screening CT scans,
we now can find smaller nodules in the lungs.
And when we see them, we can find them, if they're cancer or not, by doing a biopsy.
If it turns out to be cancer and we find it at its earliest stage,
the survival may be as good as 90 percent if something is less than one centimeter.
When it goes to one to two centimeters, that survival drops to 80 percent.
And if it goes two to three centimeters, the survival drops to 70
percent. Millimeters matter and the diagnosis of lung cancer.
Our job is to try to figure out
what your lung nodule is as soon as possible,
so that we have the best chance for a good outcome.
Lung cancer is always a serious problem.
We need to diagnose it as soon as possible without delay.
We need to figure out if it has spread.
What is the stage of the disease?
Has it already moved to lymph nodes or has it moved outside of the chest?
Each time we find it spread to somewhere else, it means
that the treatment is going to be harder and the survival is less.
It's important that we figure this out as soon as we can.
Lung cancer is diagnosed usually on a CT scan.
We often have to do a PET scan to help figure out where it has spread to.
You need a biopsy to figure out if you have lung cancer.
We need a biopsy of potentially the spot itself,
but also the lymph nodes in the middle of the chest.
Because lung cancer typically spreads to the lymph nodes first.
Once it's spread to the lymph nodes
on the side of the tumor, it may spread to the other side.
And then frequently it spreads outside of the chest to someplace else in the body.
We may have to biopsy an organ outside of the lungs
if there has been spread to the liver or to bone or somewhere else.
Most patients end up needing a bronchoscopy:
a camera placed down inside the airway with a patient completely asleep.
We use the camera to go sample the lymph nodes
in the middle of the chest using a special ultrasound camera.
And we use a robot to biopsy the peripheral lung nodule.
Lung cancer patients typically have no symptoms when their tumor is small.
The only way we're going to change the survival of lung
cancer is if we can detect it early.
Lung cancer detection early means doing CT scans on patients who are at high risk.
High-risk patients include patients who have smoked
20 years of one pack a day or more, age 50 to 80,
and someone who's a current smoker or someone who has stopped
smoking within the past 15 years.
This represents the patients at highest risk of developing lung cancer.
And these are the patients who should get a CAT scan of the chest
once a year to see if they might have
an early stage tumor. Finding on the CAT scan before
it has a chance to cause symptoms and spread someplace else:
that's the key to survival with lung cancer.
Patients who meet criteria for lung cancer screening
should have a CT scan of the chest done once a year.
You can do that by contacting our nurse practitioner who will help arrange
for the CT scan, screen you to make sure that you meet all the criteria,
covered by insurance as well.
And then she'll arrange for a day when you can come in for this CT scan
and you'll get the results within 24 hours.
If your CT scan turns out to be normal, then you're good for another year.
CT scans frequently find lung nodules.
They may be found on purpose with a lung cancer screening CT scan
or they may be found when somebody comes to the emergency room and has a CT
scan done for an unrelated reason, perhaps chest pain or something else.
Lung nodules are small spots in the lung.
And we know there are many causes for lung nodules.
Most times it's not cancer,
but two percent of the time we do CT scans and find lung nodules,
they are cancer.
Our job as interventional pulmonologists is to figure out which ones are cancer
and which ones are the benign spots that don't need any further workup.
A bronchoscopy is a small camera
that is placed down through the windpipe into the lungs.
Through this same procedure, we can put in a specialized bronchoscope
that has an ultrasound on it
that lets us see through the walls of the trachea and the large airways.
That's where the lymph nodes are in the middle of the chest.
We can place a small needle through the bronchoscope
and sample these lymph nodes that are beside the airway in real time
using the end of bronchial ultrasound.
During bronchoscopy,
we can sample multiple lymph nodes using the end of bronchial ultrasound.
It's very safe to patients, with a very high yield.
We can diagnose what's going on with your lymph nodes with an accuracy
around 90 to 95 percent of each of the lymph nodes that we biopsy.
The iron robot is a unique
tool for MedStar Georgetown University Hospital.
We were one of the first sites in the United States to have
this commercially available to us for a better chance
of getting a diagnosis of a peripheral lung nodule.
The iron robot is a fancy bronchoscopy
where the robot is placed to push the scope through the airway.
The bronchoscopist will guide the bronchoscope
through the airway using a mouse pad with a trackball on it.
Much like the video games you used in the past.
Here we're using it for medical purposes
to make a more accurate pathway to get to the target in the lung.
Lung nodules can show up anywhere in the lungs, and it's challenging
sometimes to get close to the nodules through the airways.
The ION robot provides several advances
that allow us to more accurately biopsy spots in the long.
The first advance is that the technology involves
a computer recreation of the airways
that allows us to plan ahead of time
which pathway we're going to go down to get to the target.
The second advantage is that this machine will allow us
to get very close to the target and point directly at the target.
Of course, the benefit of doing a bronchoscopy biopsy over a CT-guided
biopsy is there's less complications.
The third part of bronchoscopy with the ION robot that makes it unique
is the ability to stay fixed and firm, yet flexible.
We can turn it through the different airways,
and once we've got it facing the target, we can lock it into position, allowing us
to do multiple biopsies through different techniques to get to our target.
The first step of ION robot is to get a CT
scan done at our hospital with very fine resolution cuts.
That CT scan is put into our
planning software, and we can create with the technology
from the computer, a pathway towards the target.
Once we've chosen the correct target,
we take that information and put it into the robot.
During the bronchoscopy,
the iron robot is connected to the endotracheal tube
that the anesthesiologist has placed for general anesthesia.
We put our cameras down through that endotracheal tube into the airway
and using the robot, we guide the catheter out to the peripheral nodule.
Once we get there, we can lock this catheter in position
aimed directly at the target, and we can place our needles and our biopsy tools
through the robot directly at the target that we're going for.
The iron robot is more accurate than conventional bronchoscopes.
In the past, the chance of us biopsying a small target
in the periphery of the lung was less than 15 or 20 percent.
And now we move that chance
of getting a diagnosis on a small nodule in the lung
up to 80 percent or more.
The ION robot has multiple ways
of giving us feedback of where the target is.
The display tells us exactly how many millimeters
we are away from the target, from the front edge
of the target to the back edge of the target and to the plural
surface, the lining of the lung beyond that,
allowing us to more safely biopsy directly through the target
in a measured distance and not worry about going too far to hit the plural surface.
It also gives us feedback on which direction we're aiming
and, using this with a radio ultrasound,
we can confirm that
we're right up against the nodule before we start taking those biopsies.
A common question to us is whether the robot is autonomous
and doing this procedure by itself, and the answer to that is no.
The interventional pulmonologist is driving the robot through the airways.
We're using the feedback from the many displays that we have
to figure out which airway to turn each
branch of the airway as we go out to the targets in the periphery.
The robot is a tool that is guided by the interventional pulmonologists.
It does not work by itself.
In the past, getting a diagnosis of a lung nodule
to see if it's lung cancer or not was challenging, it may have required more
than one biopsy. A biopsy from the outside using C.T. guidance,
perhaps a biopsy also from the inside.
Sometimes we even needed surgery to figure out what a small lung nodule is.
The ION robot has allowed us to have a technology
that allows us to get to the periphery and get to these smaller nodules
with a much better chance of getting a diagnosis the first time.
Our hope that the use of ION robotic
bronchoscopy is going to allow us to detect early stage lung cancers.
Lung cancers that may be curable at these earliest stages.
In the past, we may not
have even been able to go try to biopsies because they're too small.
Now we have the possibility of more accurately
biopsy nodules that are less than two centimeters.
And in almost a third of our patients,
we've gone after nodules that are less than one centimeter.
This is the game changer that we've been waiting for,
the ability to biopsy spots that are less than one centimeter.
If we can diagnose a spot that's one centimeter
and send them to surgery, they have a chance of cure of 90 percent.
We need to have more patients show up earlier detection with lung cancer
screening and use technologies such as the ION robot
to biopsy this peripheral nodule to get a diagnosis
when it matters, when it's small, before it has spread to somewhere else.
So, the other possible uses of the ION robot are placing
fiduciary markers in preparation for radiosurgery with CyberKnife.
We've already placed....a third of our patients who've undergone robotic
bronchoscopy, had fiducials inserted.
And we're finding that the accuracy of these markings
are even closer than we were doing before.
Being able to use a robot to get close to the target
and more accurately place gold markers around the target
means that will be more accurate with treating with a CyberKnife radiation.
Finishes are gold markers that we use
by the CyberKnife radiation team to track
the target that they're going after with the treatment, with the radiation.
They don't actually treat the patient, but they mark the targets
so that the radiation team can see the target that they're aiming at.
Gold is an interesting metal.
It's inert and it's easy to see on X-rays.
Where the CyberKnife can't see a target very well in the lung,
because it may be hidden behind the shadows of the heart or somewhere else,
it can see gold very well.
So, we use gold fiduciary markers to tell where the target is
as part of the planning process for radiation treatments with CyberKnife.
The other application for the ION robot may be to mark
small tumors who are in need of resection by the surgeon.
Surgeon often cannot feel small nodules in the lung,
and if we put dye marking around the target,
the surgeon will be able to see the dye when they go to surgery later that
day or the next day.
Use of the ION robot for bronchoscopy is going to be
the standard of care for patients who come in with lung nodules.
We know the chance of us getting a diagnosis with the robot
bronchoscopy is much higher than with our conventional bronchoscope
or even with the previous technologies that we use.
This is the new technology here today.