Dana-Farber / Brigham and Women's Cancer Center

Advanced Multimodality Imaging Enables New Interventions

Nation’s first fully integrated Operating Suite

The nation’s first fully integrated operating suite to offer immediate intra-procedural access to an extensive range of advanced imaging modalities, AMIGO’s 5,700-square foot space is divided into three interconnected procedure rooms housing real-time anatomic, functional, and molecular imaging modalities, including MRI, PET/CT, fluoroscopy, and ultrasound.

Specialists at Dana-Farber/Brigham and Women’s Cancer Center are collaborating to employ new image-guided techniques in the Advanced Multimodality Image Guided Operating (AMIGO) suite at Brigham and Women’s Hospital (BWH) in order to advance treatment for many forms of cancer.

AMIGO’s innovative design enables multidisciplinary teams of surgeons, interventional radiologists, radiation oncologists, imaging physicists, computer scientists, biomedical engineers, nurses, and technologists to use multi-modality imaging to efficiently and precisely guide trreatment - before, during, and after the procedure - without the patient or medical team leaving the operating room.

“AMIGO has been highly instrumental in refining and expanding image-guided techniques pioneered at BWH, as well as in introducing entirely new approaches to image-guided therapy for many forms of cancer,” said Clare M. Tempany, MD, Co-Principal Investigator of the National Center for Image-Guided Therapy (NCIGT) at BWH and radiologist at Dana-Farber/Brigham and Women’s Cancer Center.

Cancer therapies under investigation in AMIGO span treatment for malignant and benign tumors of the brain, prostate, breast, kidney, liver, lung, adrenal gland, bone, cervix, uterus, and vagina.

About the Advanced Multimodality Image Guided Operating Suite (AMIGO)

AMIGO is a unique suite of rooms resulting from a long-standing collaboration between Brigham and Women’s Hospital and the National Institutes of Health (NIH). Radiologists Ferenc A. Jolesz, MD, and Clare M. Tempany, MD, are co-principal investigators of the National Center for Image Guided Therapy (NCIGT) at BWH, which is funded by the NIH and the National Institute of Biomedical Engineering, and serve as co-directors of AMIGO. The NCIGT is the NIH’s central resource for all aspects of research into image-guided procedures, and AMIGO is instrumental to advancing the mission of the NCIGT – to provide more effective patient care.

Prostate Cancer Evaluation and Treatment

Several significant areas of investigation in AMIGO are designed to improve evaluation and treatment of prostate cancer. Examples include:

  • MRI-guided prostate biopsy and mapping – This approach enables image-guided targeted biopsy of prostate tissue based on abnormalities seen on 3T multi-parametric MRI. The technique used in AMIGO is an extension of an established MRI-guided prostate biopsy approach pioneered more than a decade ago at BWH. Additional efforts include fusing MR imaging with real-time ultrasound-guided biopsy, a technique that can be more widely adapted in other hospitals;
  • MRI-guided focused ultrasound surgery – Brigham and Women’s Hospital will be among few sites in the nation to participate in an upcoming study of this technique (Focal MR-guided Focused Ultrasound Treatment of Localized Low Risk Prostate Cancer: A Feasibility Study), led by Principal Investigator Clare M. Tempany, MD, in collaboration with Adam S. Kibel, MD, Chief of Urology at BWH and Surgical Director of the Center for Genitourinary Oncology at Dana-Farber/Brigham and Women’s Cancer Center and Jerome P. Richie, MD, Emeritus Chief of Urology at BWH and urologic surgeon in the Center for Genitourinary Oncology. This study is evaluating high-intensity focused ultrasound (HIFU) therapy for patients with localized prostate cancer as an alternative to active surveillance, prostatectomy, or radiation. During this non-invasive approach, focused ultrasound will be used to ablate the tumor, guided by real-time MR imaging to map temperature changes. Expected to open in 2013, the trial is the first in the United States to study MRI-guided focused ultrasound (MRgFUS) therapy for prostate cancer. Enrolled patients will be followed long-term via PSA screening, imaging, and targeted biopsy.

Percutaneous Tumor Ablation

  Percutaneous cryoablation of renal tumor using 3 Tesla MRI guidance CT guidance
Percutaneous cryoablation of renal tumor using 3 Tesla MRI guidance (left) compared with CT guidance (right). Arrows show the “iceball” during the procedures.
  Percutaneous cryoablation of a left rib tumor
Percutaneous cryoablation of a left rib tumor using PET/CT imaging guidance. Arrows show the “iceball” covering the tumor during the procedure.
Kemal Tuncali, MD, Associate Director of the
 
AMIGO suite and interventional radiologist at Dana-Farber/Brigham and Women’s Cancer Center, is performing image-guided ablation of kidney, liver, bone, lung, soft tissue, and adrenal tumors in the AMIGO suite. The approach employed in AMIGO is an enhancement to a long-standing CT-guided percutaneous ablation technique at BWH, including more than 1,000 tumor ablation procedures. Ablative approaches include cryoablation, radiofrequency ablation, and microwave ablation.

AMIGO offers high-performance, high-field strength MR imaging and PET/CT imaging during percutaneous ablation of tumors, providing better visualization of tumor margins and surrounding critical structures. This technique enables real-time monitoring during the ablation to achieve complete treatment of the tumor and to reduce risk of injury to nearby critical structures.

MR Imaging in Breast-conserving Surgery

A Phase I breast imaging pilot study in AMIGO, led by Mehra Golshan, MD, Director of Breast Surgical Services at Dana-Farber/Brigham and Women’s Cancer Center in collaboration with radiologist Eva Gombos, MD, is using advanced imaging to help improve surgical outcomes with breast-conserving therapy.

While long-term results of lumpectomy followed by radiation and medical therapies are comparable to mastectomy, for patients undergoing lumpectomy as many as 40 percent of surgical procedures must be repeated to achieve clear margins. In AMIGO, the surgeon receives real-time intraoperative images as the procedure progresses, seeing results of the surgical resection while the patient is in the operating room. Additional tissue can then be resected as needed, without requiring a second surgery. Diagnostic images prior to surgery are taken with patients in the prone position, and visualization of the tumor is optimal (Figure 1). In AMIGO, an MR image is taken just prior to the start of the procedure with the patient in the supine position (Figure 2). This provides the surgeon with a clear view of the tumor location during surgery. After the tumor is removed the breast is temporarily closed and another MRI scan is performed of the cavity boundaries (Figure 3) to check for presence of residual tumor. Further surgery is done for any margins felt to have residual cancer. Initial results from this study are promising.

Figure 1 Figure 2 Figure 3
Figure 1
Figure 2
Figure 3

Interstitial Laser Ablation of Brain Lesions

MRI-guided laser ablation neurosurgery was pioneered by Dr. Jolesz and neurosurgeons at BWH. A new study of this technique in AMIGO, led by Dr. Jolesz in collaboration with Alexandra J. Golby, MD, Director of Image-guided Neurosurgery, Clinical Co-director of the AMIGO suite, and neurosurgeon in the Center for Neuro-Oncology at Dana- Farber/Brigham and Women’s Cancer Center is currently evaluating efficacy of this procedure in patients with recurrent brain metastases. The procedure also is being offered for patients with radiation necrosis.

Interstitial laser ablation is particularly advantageous for reaching lesions deep in the brain that are otherwise difficult to access by other treatment methods. During the procedure, a cooling catheter is inserted into the brain via a stereotactic approach. Placement is confirmed with MR imaging and a laser fiber is passed through the catheter. MR imaging is continuously repeated, and test heating is performed at a low level. Temperature mapping is provided with MR imaging, and ablation is monitored with MR imaging and software outlining damage to the treatment area. Flexibility in positioning of the laser fiber enables surgeons to begin the approach at the middle or the edge of the target area and to reposition the catheter as necessary throughout the procedure.

interstitial laser ablation
MRI-guided interstitial laser ablation enables monitoring of temperature changes before, during, and after treatment.

Brachytherapy for Gynecologic Cancers

MRI-guided brachytherapy for gynecologic tumors is performed in AMIGO by Akila N. Viswanathan, MD, MPH, Director of Gynecologic Radiation Oncology at Dana-Farber/Brigham and Women’s Cancer Center. Dr. Viswanathan was the first in the nation to offer this technique and led the first prospective clinical trial using real-time MRI image-guided brachytherapy (Int J Radiation Oncology Biol Phys, Vol 66, No 1, pp. 91-99, 2006). Suitable for select patients with cervical, vulvar, vaginal, and uterine cancers, including patients with recurrent gynecologic cancer, this approach is performed using real-time MRI guidance.

MRI-guided brachytherapy for gynecologic cancer offers an alternative to surgery and is designed to protect surrounding tissues in the bladder and the rectum, reducing the risks of rectal bleeding and bladder ulceration.

Preliminary T2W image demonstrates 3cm vaginal mass and shows a radiation treatment catheter in good position Radiation Dose
Preliminary T2W image demonstrates 3cm vaginal mass
and shows a radiation treatment catheter in good position.
Final radiation dose covers the entire tumor.


 

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