Lung cancer can now be diagnosed and treated simultaneously using a new type of robotic surgery. Margaret Kirkham, 77, a retired career civil servant from Chiswick, west London, was the first patient in the world to undergo the new two-in-one procedure, she tells ADRIAN MONTI.
The patient
A little over two years ago, I suddenly felt out of breath – even having to stop talking mid-sentence to catch my breath. My GP examined me and sent me to the emergency room for tests, including a chest x-ray.
The next morning I was called to come back straight away for a CT scan because it looked like part of my lung had collapsed. I was quite shocked.
A doctor explained that a large mass had been found on my left lung that looked like cancer. Fortunately, they told me, it had not spread.
Margaret Kirkham, 77, was the first patient in the world to be treated with the 2-in-1 method
I was a smoker but had given it up 20 years ago, and even though I was told my cancer was probably not caused by tobacco because of its molecular structure, I still felt guilty.
My tumor was 7 cm by 6 cm by 6 cm: I imagined it as a large, solid rectangle. It couldn’t be surgically removed because it was close to my heart and entangled in the main airways to the lungs. This sounded terrible, but my consultant assured me that the disease was slow growing and could be controlled with treatment.
In April 2022 I started chemotherapy and radiotherapy and it worked quickly, re-inflating my lungs, making breathing much easier.
A scan in July showed that the tumor had shrunk dramatically. Then I received monthly immunotherapy until August last year. By then the original tumor was gone, but there was a small new lump on my left lung. However, it was not safe to undergo further radiotherapy and I could not undergo surgery.
But my advisor said that a new technique is being tried for smaller, hard-to-reach lung tumors. This involved ablation, which uses heat to destroy cancer. I was referred to Professor Pallav Shah, the pulmonologist in charge of the trial.
He explained that I would be given a general anesthetic and then a flexible tube would be passed through my windpipe. Connected to an advanced robotic system, it could navigate deep into my lungs to take a biopsy and then they would use a small ablation instrument to use heat to destroy small cancerous nodules.
After the operation in November I felt fine – and without pain.
It put a smile on my face when I learned that I was the first to undergo this procedure. I had never been first at anything before!
Scans showed that the tumor had been successfully removed and that I was able to live normally again within a week. I am slightly short of breath due to the scar tissue from the ablation and radiation, but that is a small price to pay.
I’m not on any medication and I’m feeling good and positive and I’m making up for lost time – I just went on a painting trip to Cadiz. I am extremely grateful to have taken part in this trial, which will hopefully benefit many others.
The specialist
Professor Pallav Shah is a consultant physician in respiratory health at the Royal Brompton Hospital in London.
Lung cancer is the third most common cancer in Britain, with 40,000 cases diagnosed each year and a very low survival rate. (Only 20 percent of patients live five years or more).
This is because it does not cause any obvious symptoms and is therefore usually picked up at an advanced stage, often during investigations for complaints such as persistent coughing, weight loss or chest pain. But if we can treat tumors smaller than 10 mm, the cure rate is 92 percent.
Currently, most people are diagnosed when the cancerous spot or lump is larger than 30 mm, with a cure rate of 68 percent.
Since April last year, we have been using a groundbreaking robot-assisted system at Royal Brompton, the Ion Endoluminal System. Using a robotic catheter system, it can reach nodules as small as 6 mm.
This allows us to perform a minimally invasive biopsy on any part of the lung, even in places that are normally very difficult to reach in the small bronchioles, or branches, of the airway ‘tree’.
Lung cancer is the third most common cancer in Britain, with 40,000 cases diagnosed each year
We can now also use the Ion System with a new ablation instrument, which uses heat to destroy the cancer, for patients who are not suitable for conventional surgery or radiotherapy.
Currently, a standard lung cancer biopsy involves inserting a needle through the chest wall and into the lung, using a CT scanner for guidance.
This is done under general anesthesia and the results last for a week. There is a risk of lung puncture (this occurs in 25 percent of cases), which can lead to bleeding, clots, strokes and even death. It is not suitable for patients with poor lung function (e.g. patients with severe emphysema) or nodules in a difficult location.
The robotic approach, also performed under general anesthesia, has a less than 10 percent risk of pneumothorax – collapsed lung. We biopsy to check if the lump is cancerous before performing ablation.
First, a CT scan of the lungs is uploaded to the Ion System, creating a highly detailed 3D road map of the inside of the lungs. The system automatically maps out a route to the lump.
An ultra-thin, flexible tube (catheter) is then inserted through the mouth into the patient’s airways, while we monitor the progress on a screen. Once the catheter reaches the nodule, the needle is deployed to collect a tissue sample.
This not only allows us to target smaller nodules more accurately, but also makes the robotic catheter much more flexible than the conventional bronchoscope (a flexible camera used to examine the airways).
The bronchoscope can only reach 65 percent of spots smaller than 20 mm, but the robotic system reaches more than 90 percent of spots smaller than 10 mm.
We can now also treat the patient during the same session.
Margaret was the first patient in the world to have a biopsy and robotic microwave ablation performed in a single 45-minute procedure, saving her a subsequent 30 to 45-minute ablation treatment.
This is thanks to another technological advance: a new type of ablation tool called the MicroBlate Flex, developed by the British company Creo, with a diameter of just 1.8 mm.
This is done via the same robotic catheter used for the biopsy, so that you biopsy and treat exactly the same spot. This would not be possible with standard ablation devices, which must pass through the chest wall.
Margaret’s lung nodule was smaller than 10mm, but we also removed a margin to ensure all cancerous tissue was destroyed. It took three minutes to ablate.
The great thing about microwave energy is that we can repeat it if necessary, which is not the case with radiotherapy, where you can only deliver a certain amount due to tissue damage.
Performing two procedures at once is a game-changer, saving time for both doctors and patients, who also save a delay between biopsy and ablation, during which their cancer continues to grow.
Patients taking part in the trial will stay in overnight, but in the future this should be a daytime procedure. We want to use it to treat small, early cancers in patients who are not candidates for surgery – for example, they may also have heart disease.
Although we have to send biopsy samples taken with the Ion for analysis, which can take a week, we hope in the future to be able to analyze them in a few minutes using AI, so we can ablate right away.
In Margaret’s case, we were already certain that her lump was cancerous (due to previous treatment). Therefore, we immediately performed a biopsy followed by an ablation to demonstrate that the two-in-one technique could be performed successfully.
So far, we have performed the ablation in nine patients without any serious side effects.