Surgeon's smart knife detects cancer cells in tumor operations

When surgeons remove tumor tissue they try to leave a "margin" of healthy tissue to ensure all the cancer is removed. Sometimes this means the patient has to remain under general anaesthetic for another 30 minutes or so while tissue samples are sent for analysis to check if the margin is clear. Even then, it is still possible that some cancerous tissue remains, and the patient has to undergo further surgery to remove it.
Now, a new technique based on an "intelligent knife," called the "iKnife," promises to remove the need for lab analysis and the accompanying delay, and it also helps avoid repeat surgeries.
The iKnife sniffs the "smoke" created by the electrosurgical removal of cancerous tissue and tells the surgeon almost immediately if the tissue it has come from is healthy or cancerous.
This first study appears online this week in Science Translational Medicine, in which the iKnife is tested in the operating room.
In tissue samples from 91 patients, researchers at Imperial College London using the iKnife achieved 100% accuracy in diagnosing whether the samples were cancerous or not.
Study author Dr. Zoltan Takats is the inventor of the iKnife. Asked if his new surgical tool would be confined to use in only certain types of cancer, he told Medical News Today:

"It is a generally applicable tool, we believe it will be useful for many different types of cancer surgeries."

On the question of cost-effectiveness, Dr. Takats told us:

"We believe that it will be a cost-saver - due to elimination of intraoperative histology, shorter intervention times and lower rate of re-operations."

iKnife combines electrosurgery with new mass spectrometry techniques

The iKnife is a combination of an established technology called electrosurgery that was invented in the 1920s and a new technology that is still emerging, called rapid evaporative ionization mass spectrometry (REIMS).
In electrosurgery, the surgeon's knife delivers an electric current that heats the target tissue and cuts through it while causing minimum loss of blood.
The heat from the current vaporizes the tissue, which gives off a smoke that is normally sucked away with an extractor.
The mass spectrometer technology behind REIMS almost instantly identifies the chemicals present in human tissue by analyzing the smoke that is released during electrosurgery.
Cells produce thousands of metabolites in various concentrations, depeding on their cell type. So once the REIMS technology is primed with the profiles of healthy and cancerous cells, it can rapidly use these to screen the sample of smoke and inform the surgeon whether it is from a tumor or healthy tissue.

The iKnife device "sniffs" smoke created when cancerous tissue is surgically removed, and it then determines whether the tissue is cancerous or healthy. Photo: Imperial College London

iKnife relies on a library of chemical profiles

In the first stage of the study, the researchers created a reference library of chemical profiles consisting of both healthy and cancerous tissue types for the iKnife. They collected samples from surgery patients, taking note of the characteristics of thousands of cancerous and non-cancerous tissues, including brain, lung, breast, stomach, colon and liver tumors.
In the second stage of the study, the team transferred the technology to the operating room and tested it on 91 patients. In all cases, the iKnife correctly identified the tissue type. The results were confirmed with lab tests on the samples after surgery.

Results delivered in under 3 seconds

By comparing the chemical profile of the tissue it is sampling to the reference library, the iKnife can deliver a result in under 3 seconds, say the researchers.
But for this study, the surgeons carrying out the procedures were not allowed to see the nearly instant readings from the iKnife.
The researchers now hope to run a clinical trial that tests whether giving surgeons access to iKnife readings during operations improves outcomes for patients.
Dr. Takats says in a statement:
"These results provide compelling evidence that the iKnife can be applied in a wide range of cancer surgery procedures."
As the technology delivers almost instant results, it allows "surgeons to carry out procedures with a level of accuracy that hasn't been possible before", he adds, noting that they "believe it has the potential to reduce tumor recurrence rates and enable more patients to survive."

Other applications: "Is this beef or horsemeat?"

Although this latest study uses the iKnife to test cancerous tissue, Takats says there is no reason why it couldn't also be used to test for other features, such as whether there is an adequate blood supply, or to identify types of bacteria in the tissue.
Dr. Takats says he has already used the iKnife to distinguish horsemeat from beef.
He first raised the idea of combining electrosurgery with REIMS from real-time identification of tumor tissues in a paper published in 2009.
Funds from the National Institute for Health Research (NIHR) Imperial Biomedical Research Centre, the European Research Council and the Hungarian National Office for Research and Technology helped finance the study

Breast Cancer Rates Increase Among Young Women

here has been a small increase in the incidence of advanced stage breast cancer among women 25 to 39 years old, according to a recent study in JAMA.

Breast cancer is the most common form of malignant tumor in women aged 15 to 39 and accounts for nearly 14% of all cancer cases in men and women in that age group. The risk of a woman developing breast cancer before the age of 40 is 1 in 173, according to a 2008 study.

The authors wrote:

"Young women with breast cancer tend to experience more aggressive disease than older women and have lower survival rates. Given the effect of the disease in young people and a clinical impression that more young women are being diagnosed with advanced disease, we reviewed the national trends in breast cancer incidence in the United States."

The study involved assessing three U.S. National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) registries from 1973-2009, 1992-2009 and 2000-2009. Rebecca H. Johnson, M.D., the leader of the study, and her colleagues obtained information from the registries regarding the incidence of breast cancer, any incidence trends, the survival rate as a function of age, and the extent of the cancer at diagnosis.

The SEER defines localized breast cancer as cancer only found in the breast, regional cancer as cancer that's spread to adjacent organs such as the chest well, and distant cancer as cancer that's spread from one part of the body to another part not directly related to it (in this case the brain and lungs would be an example).

Over the past three to four decades, the incidence of distant breast cancer in young women aged 25 to 39 has gone up steadily, from a rate of 1.53 per 100,000 in 1976 to 2.90 per 100,000 in 2009. This difference translates to an annual increase in incidence of 2.07 percent per year.

The authors added:

"The trajectory of the incidence trend predicts that an increasing number of young women in the United States will present with metastatic breast cancer in an age group that already has the worst prognosis, no recommended routine screening practice, the least health insurance, and the most potential years of life."

The increasing incidence of distant cancer was greatest among women aged 25 to 34 and got progressively smaller in women as they got older, by 5-year age intervals. There was no real increase in the incidence of distant breast cancer in women 55 years old or above. The authors added that: "For young women aged 25 to 39 years, the incidence of distant disease increased in all races/ethnicities assessed since at least 1992, when race/ethnicity became available in the SEER database."

This finding is particularly concerning, considering that young women, between 20 to 34 years of age who develop breast cancer, have the lowest 5-year breast cancer survival rate as a function of age.

Researchers from the Institut Jules Bordet, in Brussels, Belgium, identified that breast cancer in young women is in itself a biologically unique disease, requiring customized management strategies, and is associated with age related biological processes that are independent from other, more common factors, used in prognosis by oncologists.

Young women who are diagnosed with breast cancer often find themselves feeling isolated and alone, given that most medical resources for the disease are designed for women over 50. In addition, a study in the Journal of National Cancer Institute revealed that health-related quality of life is a lot lower in young women with breast cancer - it is linked with weight gain, increased psychological distress and early onset of menopause.

Robotic-Assisted Radical Bladder Surgery Potentially Benefits Bladder Cancer Patients

About 30 percent of the more than 70,000 bladder cancer cases expected in 2012 are muscle invasive. In such cases, radical cystectomy is the preferred treatment. In a pilot trial, a team of investigators assessed the efficacy of open radical cystectomy (ORC) vs. robotic-assisted laparoscopic radical cystectomy (RARC). While there were no significant differences in treatment outcomes, RARC resulted in decreased estimated blood loss and shorter hospital stay compared to ORC. The results are published in the February 2013 issue of The Journal of Urology.

"In the last decade minimally invasive approaches including robotic-assisted approaches have emerged as viable surgical options for many urological malignancies with the promise of decreased morbidity with shorter hospital stays, faster recovery, and less narcotic analgesic requirements," says lead investigator Dipen J. Parekh, MD, Professor and Chairman of the University of Miami Miller School of Medicine's Department of Urology and Director of robotic surgery; formerly at the University of Texas Health Science Center at San Antonio.

The goal of the clinical trial was to provide preliminary data from a single institution's randomized trial that evaluated the benefits of robotic-assisted vs. open surgery in patients with invasive bladder cancer. The trial, conducted between July 2009 and June 2011, involved 47 patients and was performed at the University of Texas Health Science Center at San Antonio. Primary eligibility was based on candidacy for an open or robotic approach at the discretion of the treating surgeon. Forty patients were randomized individually and equally to either an ORC or RARC group using a computer randomization program. Each of the two study groups was similar in distribution of age, gender, race, body mass index, previous surgeries, operative time, postoperative complications, and final pathological stage.

Investigators evaluated five surgery outcome factors: Estimated blood loss, operative time from incision to closure, transfusion requirements, time to return of bowel function, and length of stay.

The robotic group experienced significantly decreased blood loss, accompanied by a trend toward faster return of bowel function, fewer hospitalizations beyond five days, and fewer transfusions.

"The strength of our study is the prospective randomized nature that eliminates selection biases that may have been present in prior retrospective analyses," says Dr. Parekh. "We also believe that our study demonstrates that a prospective randomized trial comparing traditional open and robotic approaches in bladder cancer is possible."

This investigative team has joined with several institutions nationally to build on its study and has started an advanced randomized clinical trial among multiple institutions to further compare and assess open vs. robotic-assisted radical cystectomy among patients with invasive bladder cancer. It plans to collect intermediate and long-term survival data from these same patients as well as data on quality of life, daily living activities, handgrip strength, and mobility.

Cancer Screening Rates Have Fallen In US

Despite evidence that earlier diagnosis and improved treatment increases survival, rates of people seeking preventive cancer screening have fallen in the US in the last ten years. Failure of leading bodies to agree screening guidelines, plus reductions in workers with insurance cover could be among reasons for the decline, suggest researchers from the University of Miami Miller School of Medicine.
They write about their NIH-funded study in a paper published 27 December in the online open-access journal Frontiers in Cancer Epidemiology.

In the US, although numbers of cancer survivors have gone up as a result of improved diagnosis and treatment, cancer is still one of the most prominent chronic diseases that in 2011 killed more than 570,000 people.

Alongside a fall in rates of advanced cancer diagnoses in the US in the last ten years, has been an increase in the number of cancer survivors returning to work. The researchers suggest, in their background information, that keeping to a cancer screening schedule could be an important factor (as this helps detect secondary tumors early and reduce potentially limiting side effects).

However, their analysis reveals that although cancer survivors tend to show much higher rates of screening adherence, their numbers too have started falling off in the last three years.

Lead author Tainya Clarke, a research associate in the School's Department of Epidemiology and Public Health, says in a statement:

"There is a great need for increased cancer prevention efforts in the US, especially for screening as it is considered one of the most important preventive behaviors and helps decrease the burden of this disease on society in terms of quality of life, the number of lives lost and insurance costs."

"But despite this, our research has shown that adherence rates for cancer screenings have generally declined with severe implications for the health outlook of our society," she adds.

In January 2012, a new report by the Centers for Disease Control and Prevention (CDC) and the National Cancer Institute (NCI) showed that the percentage of people screened for cancer in the US remains below national targets for 2020, with rates lower among Asian and Hispanic Americans than other groups.

The NIH Study Also Looks at Workforce

For this latest study, Clarke and colleagues examined cancer screening adherence rates of the general public and cancer survivors and compared them to government-recommended "Healthy People" screening goals.

They looked at screening rates for colorectal, prostate, breast and cervical cancers. Not only did they compare rates between the general population and cancer survivors, but they also looked at rates among workers.

The data on screening rates came from National Health Interview Surveys conducted between 1997 and 2010 that in total covered nearly 174,400 people aged 18 and over. These annual surveys randomly sample the US population by household, and collect demographic and health information, including cancer history and cancer-related health behaviors such as cancer screening.

The Results

When they analyzed the data, Clarke and colleagues found that the general population did not meet the government's "Healthy People" screening goals for any type of cancer, apart from colorectal cancer (for this cancer, 54% of the general population underwent screening: the government's 2010 goal is 50%).

But among cancer survivors, who have a higher risk for cancer, the pattern was quite different. Their screening rates, for all types of cancer except cervical (this fell to 78% over the last ten years), exceeded the government goals.

However, the researchers also noticed a decline in the number of cancer survivors who went for cancer screening in the last three years.

Disparities Among Workers

The NIH Survey results also enabled the researchers to include data on working adult Americans with and without a history of cancer: including more than 7,500 with a history of cancer (representing 3.8 million working cancer survivors), and over 119,300 workers with no history of cancer (representing more than 100 million).

They found that among survivors, white collar workers on the whole had higher cancer screening rates than blue collar workers.

Clarke says this was a key finding that she hopes will lead to changes in employment policies to eliminate disparities among different groups of the working population of cancer survivors.

She hopes it will also spur researchers to look more closely at factors influencing screening rates so as to design better workplace interventions and encourage more workers in all occupations to take up screening.

She and her colleagues speculate that ongoing disputes over screening guidelines among bodies like the United States Preventive Services Task Force, American Cancer Society and others, plus reductions in rates of workers covered by insurance that have occurred in the past decade, may lie behind the trend.