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Pinpointing Cancer in the Far Reaches of the Lungs

For decades, patients with suspicious spots or swollen lymph nodes in their lungs have undergone a bronchoscopy, in which a lighted flexible tube is inserted into the lungs or chest cavity to help surgeons pinpoint the location of the lesion or lymph node and to take a sample to biopsy it.

Trouble is, an estimated two-thirds of lung lesions are outside the reach of a conventional bronchoscope – an instrument that provides safe, painless access to the lungs, but yields an answer only 33 percent of the time.

In those cases, surgeons will often turn to other methods to reach the lesions, including needle aspiration, an often effective procedure, but one that can result in a collapsed lung. Or patients might undergo surgical biopsy, a highly invasive procedure in which an incision is made in the chest cavity.

Now, surgeons at St. Clair Hospital have another option to help them reach so-called "distal" lung lesions, as well as enlarged lymph nodes that might be harboring lymphoma, a cancer of the lymphatic system, a part of the body's built-in defense system that, ironically, is designed to help fight diseases.

The iLogic Inreach system by superDimension provides access to lung targets like lesions or lymph nodes with GPG (Global Positioning Satellite)-like electronic navigation. In essence, it works by effectively extending the reach of a conventional bronchoscope through the use of steerable catheters which are guided by a 3D map of the lungs shown on a high definition screen.

"I think this is the best technology that we have had to date to get a tissue diagnosis of these hard to reach spots," says Richard H. Maley, M.D., a board certified thoracic surgeon at St. Clair Hospital. "As far as diagnosing, this is state-of-the-art," he says, noting that the system provides an answer approximately 80 percent of the time.

On a recent afternoon in a Hospital operating room, Dr. Maley used the iLogic system to obtain a sample from a lymph node in the right lung of 63-year-old Donald Drew of Bridgeville.

Just prior to being put to sleep for the procedure, Donald explains he was diagnosed with Large B-Cell Lymphoma, a cancer in the lymphatic system of his neck, a little over two years ago.

Donald was in remission for about 15 months when a follow-up exam revealed a cancerous nodule on his right lung and an enlarged lymph node in the center of his chest. A biopsy of the lung nodule showed lung cancer, not lymphoma. Perhaps, Donald's oncologist wondered, the lung cancer had spread to the lymph node. But while three chemotherapy treatments for the lung cancer helped shrink the tumor, it had no affect on the enlarged lymph node. In fact, it grew larger.

As Donald is prepped for the procedure in the operating room, Dr. Maley explains that he needs to access the lymph node in the lung to determine if Donald's lymphoma, once confined to his neck, was now also in his chest, or if the lymph node just contained drug resistant lung cancer.

Lymph nodes in the chest, though, are not directly accessible via the windpipe, explains Dr. Maley. "So we're going to use the navaigational system to find the lymph node right outside of the windpipe. Once we find it, I'll use a needle in the catheter to stick it through the windpipe and into the lymph node and extract some cells for biopsy."

Using the iLogic system and a high resolution image of Donald's lungs and chest cavity, which earlier had been captured by a St. Clair CT Technologist using the Hospital's 64 Slice Computed Tomography (CT) Scanner, Dr. Maley steers the catheter toward the lymph node.

Once he collects a sample of the lymph node, it is placed on a sterile microscope slide and examined by a team from the Hospital's Pathology Department who quietly slip into the operating room during the procedure.

Unfortunately, the lymph node biopsy showed the node contained lung cancer cells. Donald is receiving radiation therapy treatments at St. Clair Hospital to kill the drug resistant tumor.

Dr. Maley and fellow St. Clair Hospital physicians Mathew A. VanDeusen, M.D., Stephen G. Basheda, D.O. and Evan R. Restelli, D.O. are the first doctors to use the iLogic Inreach system in Pittsburgh.

For more information on the iLogic Inreach system, you can reach Dr. Richard Maley at (412) 359-6137. You can also learn more by visiting the website of St. Clair Hospital at www.stclair.org

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