PET/CT is a hybrid imaging system that combines the precise diagnostic functionality of assessing physiological functions (PET) with the anatomical assessment of various organs (CT). This combination with the scanner’s leading-edge digital PET detectors and quicker processing power, mean that image quality is enhanced and that diseases are detected with higher sensitivity (earlier) and specificity (more accurate).

“This is truly the only one of its kind in the hospital,” says Henry Sinn, Sunnybrook’s medical imaging director, who adds that there are just a handful of PET/CT scanners throughout the province. “It allows us to expand our imaging capacity at Sunnybrook, and patients are getting better service because the scanning is much faster.”

While this new scanner has and will continue to lead to exciting improvements, acquiring this equipment and creating the significant infrastructure needed to house it was no easy task.

Strong support and collaboration by Cancer Care Ontario (CCO), Sunnybrook senior leadership, corporate planning & development, and the flexibility from the medical imaging and oncology teams, were all needed before this new PET/CT scanner could call Sunnybrook home.

“We had to do a lot of re-configurations of existing space and functions, meaning we had to move people and services. It was a very complex project,” says Henry. But through thoughtful design, careful phasing, strong teamwork and dedication, he says, “We came out successful.”

This collaborative achievement is expected to have widespread and innovational impacts because, unlike older, similar scanners whose applications are solely in oncology, this new scanner can also be used for cardiac, neurological and research purposes.

Knowing the work that went in to acquiring the PET/CT scanner and knowing that it will help Team Sunnybrook invent the future of health care, Henry says, “It is a milestone investment well aligned with Sunnybrook’s strategic directions, particularly in precise and personalized treatments. It feels very good.”

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Sunnybrook researchers are leading the way in cancer treatment with the Elekta Unity MR-Linac. The revolutionary new machine combines high-resolution MRI and radiation, delivering greater precision and new hope for patients.

Sunnybrook took a step toward the future in August 2019 when the first patient in Canada received treatment on the Elekta Unity MR-Linac, the first machine in the world to combine radiation and high-resolution magnetic resonance imaging (MRI). The team directed a beam of radiation precisely at a glioblastoma, the most common and aggressive type of brain tumour, and watched it strike the tumour in real time. It was a feat that would have been impossible in the past, because doctors could only plan treatment based on images taken before radiation treatment began.

With the Elekta Unity MR-Linac, the team at the Odette Cancer Centre can target a tumour and monitor its response to radiation with unprecedented accuracy – even as that tumour moves inside the body.

The moment that first patient was treated on the Elekta Unity MR-Linac was one of personal and professional pride for Mikki Campbell, a radiation therapist and manager of strategic initiatives at Sunnybrook, who has been involved in the Elekta Unity MR-Linac project since it started in 2013. It was also bittersweet.

“I really wanted to call my dad and tell him, ‘Dad, we did it,’” Mikki says.

From tragedy to inspiration

Mikki was just seven years old when her 32-year-old father Ronnie was diagnosed with glioblastoma on Canada Day weekend.

With no MRI at their hospital in Sudbury, Ont., Mikki’s parents flew back and forth to Ottawa for imaging tests.

“I’m not sure how they did it. My little sister was three. We didn’t really understand what was going on,” Mikki says.

During this time, Mikki’s parents explained that her father would need radiation treatments to treat his brain tumour.

Mikki Campbell (right) gets a hug from medical radiation therapist Anne Carty after witnessing the first patient receive treatment. (Photography by Kevin Van Paassen)

“When my dad realized he was coming close to the end, it was really hard for him to go in for radiation,” Mikki recalls. “But he had an outstanding radiation therapist who he’d tell me about.”

Mikki’s dad died just a few months after his diagnosis, in November 1992. Though she was still a child, Mikki decided then she’d become a radiation therapist, a job she thought “would be neat to help patients and families get through a really challenging time.”

As Mikki embarked on her career, she met Dr. Arjun Sahgal, a radiation oncologist specializing in brain and spinal tumours and head of Sunnybrook’s Cancer Ablation Therapy Program, who was joining a global group to develop new radiation technology. Sunnybrook was one of seven health sciences centres in an international consortium with Elekta to develop the Elekta Unity MR-Linac and bring it into clinical use.

“As Dr. Sahgal explained the [Elekta Unity MR-Linac] to me, I got excited by the opportunity. It really fit with what I thought of as my purpose – to improve the care for these patients and their families,” Mikki says. “It was easy for me to jump on board.”

Since then, Dr. Sahgal, Mikki and a talented team at Sunnybrook have been involved in the Elekta Unity MR-Linac’s development every step of the way.

A major feat of engineering

The Elekta Unity MR-Linac is an MRI machine capable of running diagnostic imaging sequences to look at how tumours behave and metabolize. It’s combined with a linear accelerator, which delivers radiation by accelerating electrons to a very high speed. The resulting beams of radiation destroy cancer cells, while leaving the surrounding tissue untouched.

“If you asked me 10 years ago if we’d ever have a radiation machine with an MRI built into it, I would have said, ‘You’re crazy. That’s not possible,’” says Sunnybrook radiation oncologist and specialist in prostate and breast cancer Dr. Danny Vesprini. “You can’t have a machine that produces electrons, which are negatively charged, in a magnet. But here we are.”

Radiation oncologist Dr. Danny Vesprini and radiation therapist Susana Sabaratram monitor how the patient’s tumour is responding to treatment. (Photography by Kevin Van Paassen)

Normally, a magnetic field would cause the electrons in the linear accelerator to reverse course and start bending backward, Dr. Sahgal explains. But the Elekta Unity MR-Linac is able to mitigate that issue through software and advanced computing, allowing radiation to be delivered in a highfield- strength MRI. “That’s a major engineering feat,” he says.

The one-two punch of imaging and radiation allows doctors to precisely monitor how a tumour is responding to treatment day by day and make the tiniest of adjustments in where to aim the radiation.

“If you asked me 10 years ago if we’d ever have a radiation machine with an MRI built into it, I would have said, ‘You’re crazy. That’s not possible.’”
– Dr. Danny Vesprini, Sunnybrook radiation oncologist

In November 2019, Sunnybrook treated its first patient with prostate cancer on the Elekta Unity MR-Linac. Dr. Vesprini said it was like his eyes had been opened.

“We are already very precise with prostate radiation on a regular linear accelerator,” he said. “But now, this imaging allows us to really see what we are doing; we are planning the treatment based on what we see each day, and by doing that, we can decrease the radiation to the surrounding tissue.”

In Canada, the Elekta Unity MR-Linac is Health Canada approved but still under evaluation, meaning that all patients treated on it at Sunnybrook are part of clinical trials. The first trials involve patients with brain tumours, to be followed by patients with prostate and pancreatic cancers, Dr. Sahgal says.

“The challenge will be to prove that treating with [this] technology is better than our current standard of care,” says Dr. Sahgal.

The team is working closely with researchers, who will use the daily MRIs to look at the metabolism – the cell death or growth – of each tumour and determine how the tumour responds to the radiation.

“By studying this data, in the future we will be able to predict which tumour will respond to treatment, and which will not, so that we can truly personalize treatment,” Dr. Sahgal says.

This is particularly important for patients with brain tumours, he says, because there has been little advancement in treatment options for these cancers in many years.

Mikki as a baby with her father Ronnie.

“This is giving us all some hope,” he says.

Excitement ahead

Mikki says she’s excited for the Elekta Unity MR-Linac’s precision therapy to one day become available to more patients and families. She’ll never forget the day she witnessed the first patient receive treatment.

“From seeing my parents fly hours away to get an MRI, to having one built right into the radiation-treatment device – it was overwhelming,” she says. “I was speechless. I had to step out for a moment and call my mom. We shed some tears together.”

When Mikki went home that night, she sat down with her sons, who are aged nine and 11 years.

“I told them what their mom did that day at work, and what that means for people in Canada and around the world,” Mikki says. “My eldest said, ‘Mom, you did this for Grandpa Ronnie.’ And I did. We did.”

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In reality, having an MRI is good for patients, not ratings, meaning it’s typically routine and drama-free. MRI stands for magnetic resonance imaging, technology that uses a magnetic field and radio waves to scan the body and produce detailed images. It’s used for everything from back pain to sprained ankles, helping to either detect a problem or figure out the extent of an injury.

Sunnybrook’s three MRI machines scan more than 16,000 patients every year. And for the vast majority, it’s a matter of, “bring your health card, lay down here and keep still for a moment”. You’ll be screened in advance to check for any implanted devices that could inhibit the test. (Unlike certain House scenes would suggest, the MRI magnet won’t rip pacemakers out of your chest, but may in reality interfere with their functioning or placement). It’s best to come to the hospital bling-free, so leave your jewellery and zipper-ladden clothing at home. And if you are having a pelvic or abdominal scan, don’t drink for 4 to 6 hours before your MRI. That’s about it.

The length of the test itself varies, from about 15 minutes to over one hour. And while it would be nice to use this time for rest and reflection, the loud banging noise emitted by the machine makes that hard to do. You will be offered earplugs beforehand, and that definitely helps.

You may also want to talk to your family doctor before coming in about getting a prescription for oral sedation, especially if you find yourself anxious in small spaces. It won’t put you to sleep, but will relax you. Kind of like sitting down to watch your favorite TV show…

Learn more about medical imaging at Sunnybrook

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First step: confirm your appointment. Then, make sure you don’t eat for 3 hours before your scan. The good news is, you can drink as many clear fluids as you want! In fact, before your scan, you’ll most likely be asked to drink a cup of water infused with a special contrast agent. Basically, that’s a dye that will make your inner organs easier to see. And drinking plenty of fluids before and after your scan will help that dye work its way out of your system.

It’s important to also leave yourself lots of time. Besides traffic and parking delays, you may also need additional blood work before you scan is done. That might delay things by 90 minutes, so make sure you have plenty of coin in the parking meter! It may seem like a pain, but the results from the blood work will help the technologist figure out which dye is safest for your body.

After that, it’s off to the change room and in to the infamous hospital gown. Some people may also require an IV if it’s determined that they need a special kind of dye. Now here’s the weird part: you will get a metallic taste in your mouth, and will feel like you’ve just urinated. You haven’t, and this is completely normal. These sensations also pass quickly.

When you scan is done, it’s a good idea to sit for a few minutes to make sure you are OK. After that, drink plenty of clear fluids and eat what you like. Donut anyone?

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