The authors review methods for image-guided diagnosis and therapy that increase precision in the detection, characterization, and localization of many forms of cancer to achieve optimal target definition and complete resection or ablation. A new model of translational, clinical, image-guided therapy research is presented, and the Advanced Multimodality Image-Guided Operating (AMIGO) suite is described. AMIGO was conceived and designed to allow for the full integration of imaging in cancer diagnosis and treatment. Examples are drawn from over 500 procedures performed on brain, neck, spine, thorax (breast, lung), and pelvis (prostate and gynecologic) areas and are used to describe how they address some of the many challenges of treating brain, prostate, and lung tumors.
BACKGROUND: The rate of reexcision in breast-conserving surgery remains high, leading to delay in initiation of adjuvant therapy, increased cost, increased complications, and negative psychological impact to the patient.1 (-) 3 We initiated a phase 1 clinical trial to determine the feasibility of the use of intraoperative magnetic resonance imaging (MRI) to assess margins in the advanced multimodal image-guided operating (AMIGO) suite. METHODS: All patients received contrast-enhanced three-dimensional MRI while under general anesthesia in the supine position, followed by standard BCT with or without wire guidance and sentinel node biopsy. Additional margin reexcision was performed of suspicious margins and correlated to final pathology (Fig. 1). Feasibility was assessed via two components: demonstration of safety and sterility and acceptable duration of the operation and imaging; and adequacy of intraoperative MRI imaging for interpretation and its comparison to final pathology. Fig. 1 Schema of AMIGO trial RESULTS: Eight patients (mean age 48.5 years), 4 with stage I breast cancer and 4 with stage II breast cancer, were recruited. All patients underwent successful BCT in the AMIGO suite with no AMIGO-specific complications or break in sterility during surgery. The mean operative time was 113 min (range 93-146 min). CONCLUSIONS: Our experience with AMIGO suggests that it is feasible to use intraoperative MRI imaging to evaluate margin assessment in real time. Further research is required to identify modalities that will lead to a reduction in reexcision in breast cancer therapy.
Real-time imaging of a patient's body is guiding surgeons and radiologists past healthy tissue to the diseased cells.
In the early 1990s, Jolesz pioneered the use of MRI in operations, taking scans during brain surgery for the first time. When this was successful, it became clear that the best way to guide treatment would be to combine as many forms of imaging as possible, says Jolesz. In September 2011, a grant from the US National Institutes of Health led to the Advanced Multimodality Image Guided Operating (AMIGO) suite — a three-room operating suite that includes an MRI scanner, a CT and positron emission tomography (PET) scanner, and an advanced three-dimensional ultrasound and navigation system.
Researchers are exploring how to combine the resources at AMIGO to refine treatments. Imaging during surgery can address the problem of overtreating early-stage tumours, such as those found during routine lung CT scans on smokers. Small lumps are difficult to locate so surgeons may end up removing large pieces of lung tissue that will never grow back, says Raphael Bueno, a thoracic surgeon at Brigham and Women's Hospital. As part of an ongoing clinical trial, Bueno has devised a method to use a CT scan to guide the placement of a small hook-like device in the lesion. The hook is attached to surgical thread that reaches out of the lung. During surgery the thread acts as a guide, allowing Bueno to snip out only the affected tissue.