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  • I want to talk to you

    我想跟各位談談

  • about one of the biggest myths in medicine,

    醫學界最大的迷思之一

  • and that is the idea

    這個迷思就是

  • that all we need are more medical breakthroughs

    只要我們在醫學界有更多的突破

  • and then all of our problems will be solved.

    一切問題就能迎刃而解

  • Our society loves to romanticize

    世人喜歡把這種事想得浪漫

  • the idea of the single, solo inventor

    某位發明家隻身奮鬥

  • who, working late in the lab one night,

    某晚在實驗室工作到很晚

  • makes an earthshaking discovery,

    有了驚為天人的發現

  • and voila, overnight everything's changed.

    突然,一夕之間全都變得不一樣了

  • That's a very appealing picture,

    這樣的畫面非常吸引人

  • however, it's just not true.

    然而,實情並非如此

  • In fact, medicine today is a team sport.

    實際上,現今的醫學是種團隊運動

  • And in many ways,

    很多方面來說

  • it always has been.

    一直都是如此

  • I'd like to share with you a story

    我想和大家分享一則故事

  • about how I've experienced this very dramatically

    這故事是我在工作上

  • in my own work.

    親身經歷的戲劇化改變

  • I'm a surgeon,

    我是名外科醫生

  • and we surgeons have always had

    身為外科醫生

  • this special relationship with light.

    我們和光線有種奇妙的關係

  • When I make an incision inside a patient's body, it's dark.

    當我動刀切入病患的身體時,裡頭是暗的

  • We need to shine light to see what we're doing.

    我們要打光才能知道我們正在進行什麼動作

  • And this is why, traditionally,

    這就是為什麼傳統上

  • surgeries have always started so early in the morning --

    手術都在一大早的時候進行

  • to take advantage of daylight hours.

    以便利用白天的光線

  • And if you look at historical pictures

    假如你看看歷史照片

  • of the early operating rooms,

    早期的手術室

  • they have been on top of buildings.

    都位在建築物的頂樓

  • For example, this is the oldest operating room in the Western world,

    例如:這張是西方世界最早的手術室

  • in London,

    位在倫敦

  • where the operating room

    這間手術室

  • is actually on top of a church

    位在教堂的頂樓

  • with a skylight coming in.

    上頭有日光照進來

  • And then this is a picture

    再來這張照片是

  • of one of the most famous hospitals in America.

    美國最有名的醫院之一

  • This is Mass General in Boston.

    這是波士頓的麻省總醫院

  • And do you know where the operating room is?

    你知道手術室在哪嗎?

  • Here it is

    在這裡

  • on the top of the building

    醫院的頂樓

  • with plenty of windows to let light in.

    上面開了很多窗戶引進光線

  • So nowadays in the operating room,

    現今的手術室

  • we no longer need to use sunlight.

    不再需要利用陽光

  • And because we no longer need to use sunlight,

    因為我們不需要利用陽光

  • we have very specialized lights

    我們有特製的燈光

  • that are made for the operating room.

    專為手術室打造的燈

  • We have an opportunity

    我們有機會

  • to bring in other kinds of lights --

    引進其他種類的光線

  • lights that can allow us to see

    這種光線可以讓我們看見

  • what we currently don't see.

    目前我們看不到的地方

  • And this is what I think

    這種光線就是

  • is the magic of fluorescence.

    神奇的螢光

  • So let me back up a little bit.

    我先把話題拉回以前

  • When we are in medical school,

    當我們在醫學院的時候

  • we learn our anatomy from illustrations such as this

    我們透過插圖學習解剖學,就像這張

  • where everything's color-coded.

    各部位都用色彩區分

  • Nerves are yellow, arteries are red,

    神經是黃的,動脈是紅的

  • veins are blue.

    靜脈是藍的

  • That's so easy anybody could become a surgeon, right?

    很簡單,每個人都可以當外科醫生,對吧?

  • However, when we have a real patient on the table,

    然而,當我們在看手術台上的實體病人時

  • this is the same neck dissection --

    這是相同的頸部解剖面

  • not so easy to tell the difference

    不太易區分

  • between different structures.

    不同組織的差異

  • We heard over the last couple days

    過去幾天我們聽說

  • what an urgent problem

    癌症至今仍是

  • cancer still is in our society,

    我們所面臨的迫切問題

  • what a pressing need it is

    我們有急迫的需求

  • for us to not have

    不希望隨時會有人

  • one person die every minute.

    因為癌症而死

  • Well if cancer can be caught early,

    假如能夠早期發現癌症

  • enough such that someone can have their cancer taken out,

    在最初時就透過手術

  • excised with surgery,

    把腫瘤移除

  • I don't care if it has this gene or that gene,

    我不管是有這個基因或那個基因

  • or if it has this protein or that protein,

    或者有這種蛋白質或那種蛋白質

  • it's in the jar.

    反正都丟到罐子了

  • It's done, it's out, you're cured of cancer.

    手術完成,切除了,癌症治好了

  • This is how we excise cancers.

    這是我們移除腫瘤手術的照片

  • We do our best, based upon our training

    我們盡最大能力,依據過去的訓練

  • and the way the cancer looks and the way it feels

    還有腫瘤的樣貌和感覺

  • and its relationship to other structures and all of our experience,

    以及腫瘤與其他組織的關聯,還有過去的經驗

  • we say, you know what, the cancer's gone.

    我們說,你知道嗎,腫瘤清除了

  • We've made a good job. We've taken it out.

    很好,我們把腫瘤移除了

  • That's what the surgeon is saying in the operating room

    外科醫生在手術室都會這樣說

  • when the patient's on the table.

    當患者還在手術台上時

  • But then we actually don't know that it's all out.

    可是我們其實不確定腫瘤是否都移除了

  • We actually have to take samples from the surgical bed,

    我們必須從腫瘤床採取樣本

  • what's left behind in the patient,

    以了解患者體內是否殘存腫瘤

  • and then send those bits to the pathology lab.

    然後把樣本送到病理實驗室

  • In the meanwhile, the patient's on the operating room table.

    這時,患者仍然躺在手術台上

  • The nurses, anesthesiologist, the surgeon,

    護士、麻醉師、外科醫生

  • all the assistants are waiting around.

    所有的助理都在等候

  • And we wait.

    我們就這樣等著

  • The pathologist takes that sample,

    病理師把樣本拿去

  • freezes it, cuts it, looks in the microscope one by one

    冷凍、切開,一片片放在顯微鏡下觀察

  • and then calls back into the room.

    然後回覆手術室

  • And that may be 20 minutes later per piece.

    每件樣本大概要花20分鐘

  • So if you've sent three specimens,

    所以假如你送三件樣本

  • it's an hour later.

    要等上一小時

  • And very often they say,

    通常他們會說

  • "You know what, points A and B are okay,

    「你知道嗎,A點和B點都沒問題,

  • but point C, you still have some residual cancer there.

    但是C點仍然殘留些許的腫瘤,

  • Please go cut that piece out."

    請把殘留的腫瘤切除。」

  • So we go back and we do that again, and again.

    所以我們就回去一次又一次再做手術

  • And this whole process:

    這就是整個過程

  • "Okay you're done.

    「好了,完成了,

  • We think the entire tumor is out."

    我們認為腫瘤已經切除了。」

  • But very often several days later,

    但通常幾天以後

  • the patient's gone home,

    病患回家了

  • we get a phone call:

    我們接到電話說:

  • "I'm sorry,

    「抱歉,

  • once we looked at the final pathology,

    我們看了最後的病理報告

  • once we looked at the final specimen,

    我們看了最後的樣本

  • we actually found that there's a couple other spots

    我們發現有些其他的點

  • where the margins are positive.

    邊緣呈現陽性反應

  • There's still cancer in your patient."

    患者的體內仍有腫瘤。」

  • So now you're faced with telling your patient, first of all,

    所以首先要面對的是告訴患者

  • that they may need another surgery,

    可能要再進行一次手術

  • or that they need additional therapy

    或者額外的治療

  • such as radiation or chemotherapy.

    像是放射線治療或化療

  • So wouldn't it be better

    如果我們能夠知道

  • if we could really tell,

    如果可以在手術時就知道

  • if the surgeon could really tell,

    腫瘤是否仍然存在

  • whether or not there's still cancer on the surgical field?

    這樣是不是更好?

  • I mean, in many ways, the way that we're doing it,

    我的意思是,現階段我們進行手術時

  • we're still operating in the dark.

    很多時候等於在黑暗中動刀

  • So in 2004, during my surgical residency,

    2004年,當我在住院醫師期間

  • I had the great fortune

    我很榮幸

  • to meet Dr. Roger Tsien,

    遇見 Roger Chen 醫師

  • who went on to win the Nobel Prize for chemistry

    後來他在2008年時

  • in 2008.

    獲得諾貝爾化學獎

  • Roger and his team

    Roger和他的團隊

  • were working on a way to detect cancer,

    當時正在研究偵測腫瘤的方法

  • and they had a very clever molecule

    他們後來研發出

  • that they had come up with.

    一種非常神奇的分子

  • The molecule they had developed

    他們研發出的分子

  • had three parts.

    由三個部分構成

  • The main part of it is the blue part, polycation,

    第一部分是藍色的聚陽離子

  • and it's basically very sticky

    這東西很容易附著在

  • to every tissue in your body.

    身體組織上

  • So imagine that you make a solution

    想像一下你製做了一種溶液

  • full of this sticky material

    裡頭都是這種高依附性物質

  • and inject it into the veins of someone who has cancer,

    然後注射到癌症患者的靜脈

  • everything's going to get lit up.

    接著全身各部位開始發亮

  • Nothing will be specific.

    沒有什麼地方不會發亮

  • There's no specificity there.

    看不出任何不同的地方

  • So they added two additional components.

    所以他們添加了兩種成分

  • The first one is a polyanionic segment,

    第一種是聚陰離子

  • which basically acts as a non-stick backing

    具有反依附作用

  • like the back of a sticker.

    就像貼紙下面那張不黏的底紙

  • So when those two are together, the molecule is neutral

    當這兩種物質結合在一起時,分子變成中性

  • and nothing gets stuck down.

    不會附著在組織上

  • And the two pieces are then linked

    當這兩種物質結合在一起時

  • by something that can only be cut

    必須使用特定的分子剪刀

  • if you have the right molecular scissors --

    才能將兩者分開

  • for example, the kind of protease enzymes

    像是腫瘤產生的

  • that tumors make.

    蛋白酵素

  • So here in this situation,

    在這種溶液裡

  • if you make a solution full of this three-part molecule

    假如溶液裡含有這三種成分

  • along with the dye, which is shown in green,

    同時含有綠色染劑

  • and you inject it into the vein

    把這溶液注射到

  • of someone who has cancer,

    癌症患者的靜脈裡

  • normal tissue can't cut it.

    正常組織無法切斷分子鍵

  • The molecule passes through and gets excreted.

    溶液的分子流經組織,然後代謝掉

  • However, in the presence of the tumor,

    然而,當有腫瘤的時後

  • now there are molecular scissors

    裡面就有分子剪刀

  • that can break this molecule apart

    可以把分子分開

  • right there at the cleavable site.

    從可以切開的地方切斷

  • And now, boom,

    接著,蹦

  • the tumor labels itself

    腫瘤發亮了

  • and it gets fluorescent.

    並且發出螢光

  • So here's an example of a nerve

    這邊以神經為例

  • that has tumor surrounding it.

    神經的周遭有腫瘤

  • Can you tell where the tumor is?

    你看得出來腫瘤在哪嗎?

  • I couldn't when I was working on this.

    我在那時候根本看不出來

  • But here it is. It's fluorescent.

    不過現在有了,螢光的地方就是了

  • Now it's green.

    看起來是綠色的

  • See, so every single one in the audience

    在座的每位聽眾

  • now can tell where the cancer is.

    都看得出來腫瘤在哪

  • We can tell in the operating room, in the field,

    我們在手術室能夠以分子般的細微程度

  • at a molecular level,

    判斷腫瘤位置

  • where is the cancer and what the surgeon needs to do

    知道哪邊需要進行手術

  • and how much more work they need to do

    以及需要做到什麼程度

  • to cut that out.

    才能將腫瘤切除

  • And the cool thing about fluorescence

    螢光最炫的地方在於

  • is that it's not only bright,

    螢光不只會發亮

  • it actually can shine through tissue.

    還能穿透組織發亮

  • The light that the fluorescence emits

    螢光所發出光線

  • can go through tissue.

    能夠穿透組織

  • So even if the tumor is not right on the surface,

    就算腫瘤不在組織的表面

  • you'll still be able to see it.

    一樣可以看得到

  • In this movie, you can see

    這段影片可以看見

  • that the tumor is green.

    腫瘤呈現綠色

  • There's actually normal muscle on top of it. See that?

    正常肌肉組織在上面,看到沒?

  • And I'm peeling that muscle away.

    我把肌肉剝開

  • But even before I peel that muscle away,

    不過就算還沒把肌肉剝開

  • you saw that there was a tumor underneath.

    仍然看得到底下有腫瘤

  • So that's the beauty of having a tumor

    散發出螢光的腫瘤

  • that's labeled with fluorescent molecules.

    看起來就是這麼漂亮

  • That you can, not only see the margins

    你不只能夠以分子般細微的尺度

  • right there on a molecular level,

    看出腫瘤的範圍

  • but you can see it even if it's not right on the top --

    即使腫瘤的位置不在最上層一樣看得見

  • even if it's beyond your field of view.

    即使有東西阻隔同樣看得到

  • And this works for metastatic lymph nodes also.

    這項技術也可用在轉移性淋巴結

  • Sentinel lymph node dissection

    前哨性淋巴腺摘除術

  • has really changed the way that we manage breast cancer, melanoma.

    改變了我們治療乳癌、黑色素瘤的方式

  • Women used to get

    過去女性為了

  • really debilitating surgeries

    徹底切除腋下淋巴結

  • to excise all of the axillary lymph nodes.

    必須接受非常折人的手術

  • But when sentinel lymph node

    不過按照我們治療

  • came into our treatment protocol,

    前哨性淋巴結的方法

  • the surgeon basically looks for the single node

    外科醫生會先尋找

  • that is the first draining lymph node of the cancer.

    最早形成腫瘤的淋巴結

  • And then if that node has cancer,

    假如這個淋巴結帶有腫瘤

  • the woman would go on to get

    該名女性病患

  • the axillary lymph node dissection.

    必須接受腋下淋巴結切除術

  • So what that means

    也就是說

  • is if the lymph node did not have cancer,

    假如這個淋巴結沒有腫瘤

  • the woman would be saved

    患者就不必接受

  • from having unnecessary surgery.

    不必要的手術

  • But sentinel lymph node, the way that we do it today,

    現今我們執行的前哨性淋巴腺摘除術

  • is kind of like having a road map

    有點像拿著地圖

  • just to know where to go.

    才知道要往哪邊走

  • So if you're driving on the freeway

    就像你在高速公路上開車

  • and you want to know where's the next gas station,

    想要知道下個加油站在哪

  • you have a map to tell you that that gas station is down the road.

    地圖上顯示往前走就到了

  • It doesn't tell you whether or not

    地圖上不會告訴你

  • the gas station has gas.

    加油站有沒有油

  • You have to cut it out, bring it back home,

    你得把油箱帶回家

  • cut it up, look inside

    打開來看

  • and say, "Oh yes, it does have gas."

    然後才知道:「真的耶,裡面有油。」

  • So that takes more time.

    所以這樣太費時了

  • Patients are still on the operating room table.

    患者仍然躺在手術台

  • Anesthesiologists, surgeons are waiting around.

    麻醉師、外科醫生在一旁等候

  • That takes time.

    要等上一會的時間

  • So with our technology, we can tell right away.

    有了這項技術,我們馬上就可以知道結果

  • You see a lot of little, roundish bumps there.

    這裡有一些小小的、圓圓的腫塊

  • Some of these are swollen lymph nodes

    其中有些是腫大的淋巴結

  • that look a little larger than others.

    看起來比其他的要大

  • Who amongst us hasn't had swollen lymph nodes with a cold?

    在座的各位有誰感冒時不會造成淋巴結腫大?

  • That doesn't mean that there's cancer inside.

    腫大的淋巴結未必代表裡面有腫瘤

  • Well with our technology,

    運用我們的技術

  • the surgeon is able to tell immediately

    外科醫生可以馬上知道

  • which nodes have cancer.

    哪個淋巴結有腫瘤

  • I won't go into this very much,

    細節部分不再多講