Medical breakthrough a boon for cancer care

Revolutionary imaging and treatment technology begins patient trials

Story of Sharon Basaraba

X-rays show dense matter in the body, such as broken bones and solid tumors. But X-rays of tumors in soft tissues, like those in the lungs, breast, or prostate, are often fuzzy and blurry.

Magnetic resonance imaging (MR) improves the ability to see cancerous tumors clearly. However, once the target has been identified, a new problem arises when moving patients from an MR machine to a linear accelerator (linac) for X-ray exposure, as tumors in soft tissue often shift during movement.

The medical physicist Dr. Gino Fallone thought of combining the two technologies – MR and a linac delivering therapeutic radiation – to track and treat a tumor in real time. Radiation is capable of destroying cancer while MR offers improved visibility.

However, the combination was generally thought to be impossible. The opposing technologies could interact or compete with dangerous effects.

“These technologies are ‘allergic’ to each other. The devices must be installed at least 10 meters apart in a treatment center because one interferes with the operation of the other,” says Fallone, Professor and Director, Medical Physics, Department of Oncology, University of Alberta and Director, Medical Physics, Cross Cancer Institutes.

The magnetic field of the MR impedes the generation of X-rays and the linear accelerator in turn affects the operation of the MR.

“The result? No effective radiation, no working image of the tumor,” he says.

Despite these challenges, the concept of a hybrid machine stuck with Dr. Fallone and in the years that followed—with competitive grant support from the Alberta Cancer Foundation (ACF), Alberta Health Services (AHS), Alberta Innovates, and others—led him to Linac MR development at the Cross Cancer Institute (CCI) in Edmonton.

The Linac MR is currently undergoing clinical trials after being certified and licensed by the Canadian Nuclear Safety Commission in 2021 and 2022.

Trials will continue until the linac is available as a standard of care, which the team hopes will be within the next five years.

The Linac MR was marketed as the Aurora-RT and cleared for sale in the US by the US Food and Drug Administration in May 2022. Regulatory approval for sale in Canada is imminent.

According to Fallone, for all its strengths as a signature cancer treatment, radiation therapy has historically presented a unique challenge: “You have to know exactly where you want that beam to go.”

“For 50 years, that was the holy grail of radiation therapy – getting it in exactly the right place. This is crucial to protect healthy tissue from the harmful effects of radiation.”

But any movement, and the tumor can shift. “Standing up, walking, and even lying down inside the linac device can cause the tumor to move, even slightly. It’s not exactly where it was a few moments ago,” Fallone adds. “By breathing regularly, the lungs, stomach, liver and pancreas move and displace the tumour. Prostate tumors can also be easily displaced by other processes.”

To accommodate a mobile tumor and minimize damage to surrounding healthy tissue, radiation doses are lowered while the beam is widened in each treatment session.

Fallone and his team began working on their idea of ​​combining MR imaging and radiation, and in 2008 they had the world’s first working prototype and published their landmark paper in Medical Physics one year later.

Over the next few years the development process continued with a number of worldwide patents being awarded to AHS. Refinements to the modular design allow it to be assembled and installed in an existing clinic, as well as rotated around patients of different sizes and treating tumors anywhere in the body.

“As researchers, we dream of a new technology that has the potential to make a big difference in the treatment of cancer,” says Dr. Nawaid Usmani, Professor of Radiation Oncology and University of Alberta. He is leading the clinical trials of the Aurora-RT under a program titled Northern LIGHTS. So far, 38 patients have been included in the studies at the CCI, currently the only study center.

“Not only will the hybrid design give us live MRI imaging, allowing us to see and treat more types of soft tissue tumors clearly, but we can also confidently increase the radiation dose because the tumors are so much more visible.”

The new technology also offers better treatment and can be performed in less time. “We can potentially reduce the number of treatment sessions to five, compared to 39 sessions 15 years ago,” says Usmani. “For patients from Grande Prairie or Yellowknife who are being treated far from home, that’s huge.”

Len Friedenberg, one of Usmani’s patients, lives in rural Alberta near Edmonton. In 2021, Usmani asked if Friedenberg would be interested in helping test the new technology. “You didn’t use the image as a diagnostic tool. It was more about confirming that it was working as it should,” says Friedenberg. “I’ve had MRIs and it wasn’t much different from my perspective as a patient.”

However, as an Albertan with a background in engineering and imaging, he is excited to see what the opportunity means for other Albertans. “It’s very interesting.”

David Dyer, executive director of the CCI, agrees. “It’s wonderful to be able to expand the use of radiation therapy to things that we couldn’t treat years ago. It’s a real tribute to the expertise here at AHS and the University of Alberta.”

For his scientific contributions, Fallone was knighted by the President and Prime Minister of Italy, his birthplace. In 2021 he was awarded the Canadian Organization of Medical Physicists Gold Medal and the first Alberta Lifetime Contribution Award in Cancer Research.