National Center for Image Guided Therapy

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Advanced Multimodality Image Guided Operating (AMIGO) Suite

Image-guided Therapy

Imaging has become essential not only for the detection and monitoring of disease but also for improving the outcome of therapy. The overall goal of Image Guided Therapy (IGT) is to help the physician improve the efficacy and reduce the morbidity of minimally invasive procedures by providing intra-operative imagebased anatomic and physiologic information in real-time. Traditional surgery is based on hand-eye coordination; IGT advances this concept by enhancing what the eye can see with multimodal imaging, and what the hand can do with robotic and therapy devices. IGT integrates therapy with intra-operative imaging and transforms invasive procedures into reduced-risk minimally invasive or non-invasive ones. In IGT, pre-operative and real-time intra-operative image information is displayed, and the technologies for imaging, guidance, and therapy are all integrated within complex therapy delivery systems. In addition, multimodal imaging guides therapies using comprehensive information derived from the different physical and biological characteristics of the tissues in ways that a single imaging modality cannot. Through this fusion of data from various imaging sources, compensations are made for any weakness of an individual modality.

The History of Image-guided Therapy at Brigham and Women’s Hospital

The BWH began its IGT program in 1991. Since then, it has become an internationally recognized pioneer in real-time intra-operative MRI-guided therapy. Using the well-known “double-doughnut” system, BWH teams performed over 3,000 surgical and interventional procedures. By 1994 the BWH IGT Program introduced non-vasive MRI-guided ocused ultrasound surgery. Constructed in 2009, AMIGO continues these pioneering efforts with multimodal image guidance.

MRT 1991	Focused Ultrasound Surgery 1994	AMIGO 2009

AMIGO

The Advanced Multimodality Image Guided Operating (AMIGO) Suite is an innovative surgical and interventional suite that is the clinical arm of the National Center for Image Guided Therapy (NCIGT) at the Brigham and Women’s Hospital and Harvard Medical School. AMIGO is a highly integrated, 5,700 square foot suite featuring three sterile procedure rooms in which a multidisciplinary team treats patients with the benefit of intra-operative imaging. In AMIGO, real-time anatomical imaging modalities like x-ray and ultrasound are combined with CT and MRI cross sectional digital imaging systems. AMIGO also takes advantage of the most of advanced molecular imaging technologies, such as beta probes, PET/CT, and optical imaging to provide molecular image guided therapy. The use of multiple molecular probes increases the sensitivity and specificity of cancer detection by improving the ability to define tumor margins to more completely excise or thermally ablate tumors. In addition to these multiple imaging modalities, AMIGO has guidance or navigational devices that help physicians localize tumors or other targeted abnormalities that are identified on images but that may not be visible to the naked eye. AMIGO enables co-operation and collaboration between interdisciplinary teams of surgeons, interventional radiologists, imaging physicists, computer scientists, biomedical engineers, nurses and technologists in their common goal of delivering the best therapy to patients in a friendly environment.

MR Room The Magnetic Resonance Imaging (MRI) room of AMIGO includes a high-performance General Electric 3 Tesla 750 MR scanner that will be used to image patients before, during, and after therapy. This room is fully outfitted with MRI-compatible materials and devices, including a surgical table with MR-compatible table top, transfer board, and transmobile table that, along with the entire anesthesia and patient-monitoring set up, are used to move the patient safely and efficiently between the MRI, PET/CT, and the operating room. MRI, due to its exceptional ability to provide detailed anatomical, functional, and metabolic information, is now a proven modality for intra-operative guidance of brain tumor resection, and we will extend similar image-guidance principles to the excision of breast cancer, prostate cancer, and other malignancies. Initial procedures that will use the MRI in AMIGO include biopsies, needle insertion-based procedures such as prostate brachytherapy, laser ablation of brain tumors, percutaneous ablations of soft tissue tumors using freezing or heating technologies, and cerebro-vascular and endo-vascular interventions including x-ray and MRI-guided cardiac ablations to prevent arrhythmias.	Operating Room The center of the AMIGO suite, the operating room (OR), is outfitted with a state-of-the-art, electronically controlled Maquet 1150 operating table mounted with MRI-compatible anesthesia, and surrounded by state-of-the-art major mobile imaging modalities and therapy devices including: BrainLab and GE surgical navigation systems, a GE 9900 Mobile X-ray C-arm, a GE 3D ultrasound, and a near-infrared imaging system. All images and data pertinent to the procedure are collected using video integration technology, prioritized, and then displayed on large LCD monitors that cover the walls of all the three rooms in the suite. Procedures performed in this room will include open surgeries of the brain and breast, cerebro-vascular and endo-vascular interventions, spine surgery, skull base surgery, and endoscopic and laparoscopic surgeries. Endoscopic procedures enhanced with imaging modalities and navigation are introduced for the first time in the OR. Above all, AMIGO will provide a sophisticated infrastructure that will lead to disruptive changes in current procedural paradigms of surgery and interventional radiology.	PET/CT Room Positron Emission Tomography (PET) elucidates metabolic activity and promises to be the method of choice for the introduction of molecular imaging agents into therapy. Within the PET/CT room that houses a GE Discovery PET/CT scanner, researchers will test novel molecular imaging agents (under research protocols) to image the extent of cancer before and after therapy. The inclusion of PET imaging into the suite, along with the use of short half-life isotopes made in the BWH’s cyclotron, is one of the most innovative features of AMIGO. Using this technology, physicians can localize and target viable tumor tissue before the procedures and verify the complete removal or destruction of tumors by depicting any residual cancer tissue before concluding the procedure. The combined use of MRI and CT with PET enables clinicians to integrate anatomical, functional, and metabolic information to guide their decision making during tumor resections and percutaneous thermal ablations.