Dana-Farber / Brigham and Women's Cancer Center

Advanced Multimodality Image-Guided Operating Suite Enhances Neurosurgical Procedures and Enables New Interventions

amigo operating suite

The AMIGO Suite is the nation's first 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, including 3T MRI, PET/CT, fluoroscopy, and ultrasound.

Neurosurgeons Alexandra J. Golby, MD, Director of Image-guided Neurosurgery, and Edward R. Laws, MD, FACS, Director of the Pituitary/Neuroendocrine Program, are treating complex primary brain tumors and pituitary tumors in the new Advanced Multimodality Image-Guided Operating (AMIGO) Suite. Part of the National Center for Image-Guided Therapy at Brigham and Women’s Hospital, the AMIGO Suite is designed to facilitate the introduction of new image-guided therapies and enhance current image-guided techniques.

“AMIGO represents the latest advance in our extensive history in image-guided neurosurgery,” said Dr. Golby. “We designed this suite based on our experience in this field, with specific capabilities that will enable us to initiate the next-generation of neurosurgical interventions.”

Built with support from the NIH and Brigham and Women’s Hospital as a medical and surgical research environment, AMIGO’s design optimizes surgical guidance and supports intra-operative decision-making among cross-disciplinary neurosurgical teams, including neurosurgeons, neuroradiologists, neuropathologists, and other specialists. Current procedures include individualized treatment for patients with brain tumors using intra-operative MRI-assisted craniotomy and biopsy and minimally invasive treatment with interstitial laser ablation, endoscopic pituitary surgery, and anterior skull base surgery. AMIGO’s capabilities also will facilitate future minimally invasive approaches, including robotic surgery.

“Performing endoscopic pituitary surgery in AMIGO enables us to achieve more complete tumor excisions and restoration of impaired vision, while still preserving normal pituitary function,” said Dr. Laws. “With high-resolution intra-operative MR imaging, we also are able to confirm success of the procedure and rule out any complications while in the operating room.”

Pre- and post-op AMIGO images

Pre- and post-op AMIGO images of a growth hormone secreting benign pituitary tumor (yellow arrow). The postoperative image clearly shows tumor removal and decompression of the optic nerves and optic chiasm (arrowheads).

Case Study: Pituitary surgery, imaging in AMIGO

A 38-year-old male patient presented with headaches and newly-diagnosed acromegaly. Imaging demonstrated a large macroadenoma with mild optic chiasm compression. Pre-operative endocrine labs showed GH:1.3 ng/ml; IGF-1:802 ng/ml; Prolactin:24 ng/ml; Cortisol:8.4 ug/dL. Visual fields were full, acuity was 20/20, and optic discs were sharp and without pallor. During endoscopic pituitary surgery, performed in AMIGO by Dr. Laws, dynamic pituitary imaging was helpful to discern hematoma from residual tumor. Initial and repeat primary tumor resection pathology confirmed pituitary adenoma with scarce HGH expression.

Case Study: MR identifies residual tumor for complete resection

A 43-year-old male golf professional presented with low-grade glioma recurrence in the motor cortex. The original glioma was resected at BWH in 1999 using intra-operative MR guidance.  Since that time, he has performed well, continuing to work with some intermittent partial seizures. The team’s goal was to provide a safe, yet maximal resection of his tumor, recognizing the importance of his motor function to his livelihood. Preoperative structural and functional MRI images were obtained, as well as diffusion tensor imaging (DTI) with tractography to define the relationship of the tumor to adjacent motor elements including cortical areas and the cortico-spinal tracts. He underwent an awake craniotomy, performed by Dr. Golby in the AMIGO suite, which confirmed the findings of the preoperative functional MRI and tractography with electrophysiological mapping. After an initial resection, intra-operative MR demonstrated a small area of residual tumor. In addition, intra-operative DTI demonstrated the intra-operative configuration and position of the cortico-spinal tracts. The intra-operative MR images were used to localize the area of residual tumor and achieve a radiographically complete resection. The patient tolerated the procedure well and was discharged on the second post-operative day free of neurologic deficit.

MIGO images
This image shows the proximity of the tumor to the motor areas. Close cropped fMRI on T2 show foot, hand, and face activations (in purple, blue and orange) as well as the 3D segmented tumor. Pre-op DTI shows the tumor surrounded by the white matter tracts, including one area where the tract goes through part of the tumor. Intra-operative T2 weighted MRI shows small residual tumor marked in orange with reference to original tumor size marked in green. Post-op T2 shows a near gross total resection.

Future AMIGO Neurosurgical Endeavors

Dr. Golby is collaborating with researchers to develop intraoperative probes and imaging advances for future use in AMIGO, including:

  • Researcher Nathalie Agar, PhD, Director of Neurosurgical Treatments, is working on a mass spectrometric probe for intra-operative use. Tissue analysis using this technology is compared with histopathological analysis and imaging to validate results;
  • A beta probe under development is designed to identify residual tumor. A cyclotron at Brigham and Women’s Hospital will be helpful in developing a radioisotope tracer to be used with this probe and the PET-CT scanner in AMIGO;
  • Development and validation of multi-modality image fusion, non-rigid image deformation, and coregistration. This will maximize intraoperative information, updated as the procedure progresses.

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