First Liver Cancer Patient Treatment Using Epione Robot in the US: An Interview with Govindarajan Narayanan, MD

An Interview With Govindarajan Narayanan, MD

Welcome to IOL Radio, the podcast for IO Learning, a digital publication that covers the latest advancements in interventional oncology. In this episode, we are joined by Dr Govindarajan Narayanan, Chief of Interventional Oncology at Miami Cancer Institute and a vascular interventional radiologist with Miami Cardiac & Vascular Institute. Dr Narayanan discusses his recent outstanding achievement of successfully treating the first patient in the United States with a liver tumor using Quantum Surgical’s Epione robot. 

This episode is also available on Spotify and Apple Podcasts!

Samantha Hager:

Tell us a bit about your experience, impact on IO, and current roles at the Miami Cancer Institute and Miami Cardiac and Vascular Institute.

Dr Govindarajan Narayanan:

My name is Raj Narayanan. I'm currently the Chief of Interventional Oncology for the Miami Cancer Institute and I'm an interventional radiologist at the Miami Cardiac and Vascular Institute. I've been involved with interventional oncology since as early as 2005, back from my days at the University of Miami and where we worked at the Sylvester Comprehensive Cancer Center. I switched to predominantly IO probably around 2009, 2010. Been doing mostly interventional oncology since then. Been in practice since 2000, so that's about 20 plus years. So you wanted to know what is my role or what do I do in IO?

Samantha Hager:

Yeah, you can elaborate on both. We would love to-

Dr Govindarajan Narayanan:

Okay, sure. So my areas of interest and focus involve liver directed therapies for primary and metastatic liver cancer. I pioneered the technique to ablate pancreatic cancer without surgery using IRE. Started using different ablated modalities back in 2000, starting with RFA, and currently I use all different ablated modalities and transarterial techniques to treat primary and metastatic cancers. But like you said, my main areas of focus involved pancreatic cancer, colorectal mets to the liver, and primary liver cancer.

Samantha Hager:

Wow, that's really impressive.

Dr Govindarajan Narayanan:

Thank you.

Samantha Hager:

As stated in our intro, you recently treated a patient at Baptist Health South Florida for liver cancer using the Quantum Surgical Epione robot. Can you explain the patient case, the process of that, and what it means for you to be the first physician to utilize this revolutionary tech in the United States for liver cancer treatment?

Dr Govindarajan Narayanan:

Sure. So the patient who was treated, the first patient and almost 20 after that, we're now up to I think 20 patients, are all patients who would've received their ablation treatment with or without the Epione robotic system. So we would've done it the way we've traditionally done ablations, which is we would plan the trajectory, get the patient ready on the table, and then start advancing the needle from the skin to the target. Depending on what kind of modality we use. It could be a single needle for microwave or it could be multiple needles for cryo or IRE. And then we would constantly make adjustments to the trajectory of the needle using our training and experience with cross-sectional imaging. So we make the adjustments to either go more anterior, more posterior towards the head, towards the feet. So all these adjustments will be made little by little as we advance. Every time we move the needle, we use what we call a CT fluoroscopy to take a picture, which involves obviously radiation to the patient. And of course we wear protection, but we're still in the room.

And what Epione has done is it's taken away the need for all these multiple adjustments. To start with, even though it's called a robotic device, there are more pieces to it and we'll talk a little bit about that in the next few minutes. But to start with the robotic aspect of it, it helps you plan your trajectory, number one. But once you've planned and everything is set up and the robotic arm moves into position and holds the position just above the skin surface, so then you advance the needle from skin to target with a single push without the need for a multiple check scans, without the need for exposing the patient to more radiation and the physician.

So the first case, obviously it was very precise and I felt comfortable about the technology because a good friend of mine in France, Professor De Baere, has used it in over 100 plus cases and he's the one who got me interested in the technology. And since that particular patient, like I said, we've done about 20 and the accuracy has been fantastic. It gets you from start to finish pretty much with one push. So that is where I think [inaudible 00:07:28] very, very early in our experience but even with these 20 treatments, I can say that the accuracy has been remarkable for a robotic device and it's definitely significantly reduced the radiation exposure to the patient and to the physician. So we don't need that many check scans.

Moving forward, what are all the other advantages that this device brings to the table? So about three weeks into our experience, we got the multi-needle planning software installed in the machine. So now for technology like IRE or cryo where you need multiple needles, you can plan all of them using the robot. And in fact, if you put the dimensions of the tumor and you come up with the trajectory or the pattern of needle placement, let's say you want to put one on top, one at the bottom and two in the middle and there are pre-configured shapes in the robot, you click on one of them, it automatically picks the sites on the skin without you having to do it manually.

And then it also gives you the path to take so that the robot doesn't hit the needle that's already in position. So it's pretty smart, it guides you as to which one should go first and then you follow it with the others. So you can do multi-needle planning now and placement, which we've done. We've done three of those. Then it also allows you to fuse images from the patient's MRI that was done earlier, if you're not able to see it adequately on the CT on the day-of, you can now bring the patient's MR. Usually we're able to see the tumors on MRI much better than sometimes on CT. So it allows you to fuse the MR images onto CT, which is another advantage or another capability of the device.

And finally it allows you to get to how your ablation zone's going to look even before you start. And B, you now can get post ablation confirmation as to how your ablation went in the patient. In the past we've relied on, say if the tumor lights up with contrast, you finish the ablation and you see the contrast enhancement disappear and so then you say, "Okay, I think I got it." And then you look for a margin, you want to see if the ablation zone is bigger than the actual tumor itself. So not very sophisticated methods, but that's how we've been dealing with ablation confirmation. There's work happening in this space, but we're still not reached a point where we can say we do this in a really sophisticated fashion.

But I think this allows us, as we continue to use the technology, gather more data and validate the software, I think it will help us change the way you plan, perform the ablation, and confirm the ablation. So all three I think will change when [inaudible 00:10:55] mainstream. In addition, the time taken obviously is a lot less because we're just going with one push from skin to target so that saves a significant amount of time so that could potentially improve the throughput in the CT [inaudible] whereby you can treat more patients than what you traditionally did. So I think that's the whole package for that device. But for that particular patient that we did, the first patient, everything went perfectly. Patient had a pretty uneventful recovery the next day and went home. Again, the benefits of having used the technology would be the accuracy and the less amount of radiation that the patient got.

Samantha Hager:

Wow, that's very impressive. It's so amazing to see some of this technology in action and helping to help with throughput and helping with so many different elements of IO and with care. So that's very impressive. 

Dr Govindarajan Narayanan:

I think one of the other part of the question was how did it feel to be the first in the country?

Samantha Hager:

Yeah.

Dr Govindarajan Narayanan:

It was a great feeling to be the first to do it. But I think while being first feels good, I think the work that needs to be done is to stick with the technology and try to learn through the learning curve that is involved. Sometimes what happens is physicians, I'm not talking about IR, in general, is you do something and one or two things don't go right and then we stop using. We feel like the technology is not the best. But I think it's important if you commit to something, to see it through, to really go in depth and try to understand the pros and cons. And I think I can say in one month, we've definitely come a long way from where we started, even with IRE with the multiple needle cases. From the first case to the third case, we could see that there was a difference in how we approached the workflow and how we could get in and out. So we are excited to be the first, and I want to thank both Epione for the partnership and our Baptist South Florida team, our administration for believing in us in bringing the technology in. So that's exciting.

Samantha Hager:

Absolutely. And I'm sure that a lot of this technology, if more physicians are going to take it on, then they'll be able to take some of that data, quantum surgical, and come out with new iterations of that robot. So any issues that we are facing now, they won't be facing in the future thanks to physicians giving their own opinions. Correct?

Dr Govindarajan Narayanan:

Yeah. Absolutely. I would not have jumped in with the level of trust and confidence I had if not for Thierry's experience. I would've been a little more skeptical. I would not have pushed my first case from skin to target with one push. I would've said, "Okay, let's do three, four scans and confirm it." But when I hear from him, somebody who's so experienced and who's been somebody who I've looked up to, I hear from him then with the 100 cases under their belt and he said, "Okay, there is a learning curve. You're going to learn a bunch of things on your own. There's workflow things, which you have to adapt to your practice." But as far as accuracy goes, he was very happy. And so far that's been my experience too. So yes, early adopters, we do stuff and learn along the way, which I'm sure will benefit all the people who go after us. Yes.

Samantha Hager:

Nice. So in regards to this procedure, you stated this robotic assisted equipment is going to change the way we deliver effective treatments to our patients for cancerous tumors. How do you believe this technology will impact IO and cancer treatment now and in the future?

Dr Govindarajan Narayanan:

Okay, so ablation in general, you have those who do this once in a while and those like me who do this four or five times a week. So just like with any other procedure, the more you do, the more challenging procedures you do, you're going to get better and better at it. And so you would approach tumors and locations which are difficult to reach, where you might have to start off plane and then get into a different plane. In other words, you would start at the lower level, go higher in the liver, or start anterior, go posterior. So you make all these adjustments in your head. So as an experienced person doing it, you've been doing it for such a long time that this is something that you don't think too much about. Whereas somebody who's coming fresh out of fellowship may not venture into taking these complex cases.

To give you an idea, every one of our trainees has used the robot now and they have done cases with me, which, without the robot, they would've probably not touched it because of the location, but they were able to push it from skin to target just like how an experienced person would do it without the robot and get it to the destination. Which is why I said it has the potential to change how we do this in future because it neutralizes everything or equalizes it. Is it good or bad? I don't know. But somebody who's not done a lot of these may be more comfortable taking on more challenging cases once you have the assistance of the robot.

But even without that in the picture, the fact that you are able to go from skin to target with one push completely changes how we've done business. Whether you're experienced, you're not experienced unless somebody's using ultrasound where they can watch and they can push the needle in real time, anyone who's using CT typically would rely on scans, what we call is check scans. So you're changing that going from one to destination, skin to destination. That's one. Two, reduction in radiation. Three, increase in your throughput. And then four, being able to plan multiple needles simultaneously.

And last but not least, when we were doing planning before the robot, we used the old grid on the patient, scan with the grid, mark on the skin, find out which number and alphabet it corresponds to, it's like Battleship, and then get the coordinates on the skin, and then prep around it. And sometimes when they put the Betadine or the chlorhexidine, it'll wipe out the ink mark and now you're searching for where you're supposed to put the needle in. Everything is out of the door now because you just get the scan, send it to the robot, and you plan everything on the robot.

So there's nothing on the scan page, nothing that's marked. The robot just takes you there and marks it so then you move from there. So the workflow is completely changed and all of the other things that we spoke about. So that's why I feel that as this becomes more mainstream, it will change how we do ablations. To give you an analogy, back when I trained 23 years ago, as fellows, we used palpation with our fingers to feel the artery and we went in with the needle feeling the pulsation. Today, you go to any training program, the trainees have not gotten access without an ultrasound. That's all they know, is how to get into the artery with an ultrasound because that's become mainstream. And when I do it with my fingers and pulsation, they look at me like, "How did you do this?"

So things like that. So when technology evolves and the way we do procedures evolve, and I feel like this is the beginning, over the last few years, last decade, we've had numerous navigation systems which help you go from point A to point B. It does part of what this robotic arm does, but this robotic arm combines a lot more than just help you navigate. So that's why I think it is going to change moving forward. We're in the beginning now. There are two more, I think, institutions coming on board very soon. But I think it'll be some time before it becomes mainstream. But I think the change may not take that long of a time.

Samantha Hager:

And out of curiosity, just from a patient's perspective, in the future, if this technology is being utilized more often, will this affect the pricing of these kinds of procedures or even their insurance coverage of them?

Dr Govindarajan Narayanan:

I think one thing which I think you touched on a very interesting topic, traditionally, I've always felt that interventional oncologists don't get what is due. We get extraordinarily low reimbursements for many of the complex ablations that we do, even though they're lifesaving, even though they significantly reduce the amount of length of stay in the hospital. In fact, our skills to do these in a minimally invasive fashion and get the patients out safely in some ways has worked against us because it looks like, "Oh, it's very simple and so therefore it only deserves a $500 payment whereas for surgery, let's reimburse it at 10 times that." I'm just throwing a number. I may not be accurate. But it is very common to get reimbursed just $500 for a physician's fee for an ablation. I don't know about the hospital part. But also unlike radiation oncology, we don't get any reimbursement for planning, which is a significant part of the ablation procedure where you sit and you spend time, you plan single needle, multiple needles, all that time that you spend to get that procedure done the right way doesn't get anything. So I badly think we badly need a code for reimbursement for the planning part and hopefully the robot would help with it.

But to answer your question, will this increase the cost? I don't know the answer to that question. The robotic guidance I think deserves reimbursement because like you said, it helps you get from point A to point B accurately and also helps in reducing or almost eliminating the radiation exposure to the physician, very minimal to the patient because you're going to [inaudible 00:22:57] one confirmation scan, then you're going to treat. So I think there are definitely benefits that should be considered. How it's going to play out, I don't know. It all depends on how much data supporting these hypotheses come out. And the more data we have, then we can make a compelling case, at least for the planning part. But the increased cost of the procedure, again, I don't know if that would happen.

Samantha Hager:

So what other applications do you think this technology can be used for in IO in the future?

Dr Govindarajan Narayanan:

I think it's designed specifically for ablations at this point. Unless the price point changes, biopsies may not be an area where it is used. Currently, this particular device is only approved for ablations. But if it does get the okay for biopsies and it truly, like you said, the workflows optimized and you're able to get patients in and out with it, it might enter that space. So that could be potentially another area of involvement. But right now, the way it is, I see it predominantly in the ablation world for planning, treating, and post confirmation.

Samantha Hager:

Okay. And lastly, would you recommend this robotic assisted equipment to other physicians and will you yourself be using it again? Why or why not?

Dr Govindarajan Narayanan:

I've used it 20 times now. I plan to use it a lot more. I plan to use it on every ablation that we do moving forward. We plan to study this in a prospective manner. Hopefully we'll have the approvals for that and we can do retrospective studies and prospective. That is one of our goals to see how we can validate a lot of the claims of the device and see how it plays out in real world experience. Would I recommend it to any other physician? If somebody wants an opinion, I would tell them exactly what I told you, which is we're 20 procedures in so far, this is what we know, and it's been accurate. It saves on radiation, everything else. We have to wait and see and it'll be up to them.

But we've done off plane ablations. I've had fellows push the needles in off plane ablations where it gets you to the destination. We've done multi-needle ablations where it's worked very well. I'm able to put four IRE probes, one after the other without you put one needle, boom, it moves the next part, push. You can either obtain scans in between each one of them, or you could place all four and then just do one scan. So the more and more comfortable you get with it, the more you're going to eliminate the need for all these multiple scans. So if somebody asked me today, I would tell them exactly what we've learned so far. [inaudible 00:26:37] early, but so far looks very promising.

Samantha Hager:

Awesome. Well, thank you very much. I appreciate your time. This has been incredibly enlightening. Once again, congratulations on being the first—

Dr Govindarajan Narayanan:

[inaudible].

Samantha Hager:

And I cannot wait to see what else you accomplish with this technology.

Dr Govindarajan Narayanan:

Thank you. Appreciate it. If you have time, stop by our place sometime and you can see it.

Samantha Hager:

Absolutely. I definitely will.