Advanced Multimodality Image-guided Operating Research Articles

Multimodal Intraoperative Image-Driven Surgery for Skull Base Chordomas and Chondrosarcomas.

Simple SummaryAchieving gross total resection during the first surgical intervention is particularly important for chondrosarcomas and chordomas, as recurrences are frequently impossible to resect due to post-surgical and post-radiation scarring and vascular fragility. Despite overall survival and progression-free survival being strongly dictated by gross total resection, it is reportedly achieved in less than 70% of patients. While the individual utility of several imaging modalities such as intraoperative CT, MRI, ultrasound, endoscopy, fluoroscopy and neuronavigation has already been demonstrated in previous literature; our case series highlights the importance and methodology of their simultaneous, real-time integration in the Advanced Multimodality Image-Guided Operating (AMIGO) suite at our institution to maximize of resection and mitigate complications.Given the difficulty and importance of achieving maximal resection in chordomas and chondrosarcomas, all available tools offered by modern neurosurgery are to be deployed for planning and resection of these complex lesions. As demonstrated by the review of our series of skull base chordoma and chondrosarcoma resections in the Advanced Multimodality Image-Guided Operating (AMIGO) suite, as well as by the recently published literature, we describe the use of advanced multimodality intraoperative imaging and neuronavigation as pivotal to successful radical resection of these skull base lesions while preventing and managing eventual complications.

MO-DE-202-03: Image-Guided Surgery and Interventions in the Advanced Multimodality Image-Guided Operating (AMIGO) Suite

At least three major trends in surgical intervention have emerged over the last decade: a move toward more minimally invasive (or non-invasive) approach to the surgical target; the development of high-precision treatment delivery techniques; and the increasing role of multi-modality intraoperative imaging in support of such procedures. This symposium includes invited presentations on recent advances in each of these areas and the emerging role for medical physics research in the development and translation of high-precision interventional techniques. The four speakers are: (1)Keyvan Farahani, “Image-guided focused ultrasound surgery and therapy” (2)Jeffrey H. Siewerdsen, “Advances in image registration and reconstruction for image-guided neurosurgery” (3)Tina Kapur, “Image-guided surgery and interventions in the advanced multimodality image-guided operating (AMIGO) suite” (4)Raj Shekhar, “Multimodality image-guided interventions: Multimodality for the rest of us” Learning Objectives: 1.Understand the principles and applications of HIFU in surgical ablation. 2.Learn about recent advances in 3D–2D and 3D deformable image registration in support of surgical safety and precision. 3.Learn about recent advances in model-based 3D image reconstruction in application to intraoperative 3D imaging. 4.Understand the multi-modality imaging technologies and clinical applications investigated in the AMIGO suite. 5.Understand the emerging need and techniques to implement multi-modality image guidance in surgical applications such as neurosurgery, orthopaedic surgery, vascular surgery, and interventional radiology. Research supported by the NIH and Siemens Healthcare.; J. Siewerdsen; Grant Support - National Institutes of Health; Grant Support - Siemens Healthcare; Grant Support - Carestream Health; Advisory Board - Carestream Health; Licensing Agreement - Carestream Health; Licensing Agreement - Elekta Oncology.; T. Kapur, P41EB015898; R. Shekhar, Funding: R42CA137886 and R41CA192504 Disclosure and CoI: IGI Technologies, small-business partner on the grants

MO-DE-202-00: Image-Guided Interventions: Advances in Intraoperative Imaging, Guidance, and An Emerging Role for Medical Physics in Surgery

At least three major trends in surgical intervention have emerged over the last decade: a move toward more minimally invasive (or non-invasive) approach to the surgical target; the development of high-precision treatment delivery techniques; and the increasing role of multi-modality intraoperative imaging in support of such procedures. This symposium includes invited presentations on recent advances in each of these areas and the emerging role for medical physics research in the development and translation of high-precision interventional techniques. The four speakers are: (1)Keyvan Farahani, “Image-guided focused ultrasound surgery and therapy” (2)Jeffrey H. Siewerdsen, “Advances in image registration and reconstruction for image-guided neurosurgery” (3)Tina Kapur, “Image-guided surgery and interventions in the advanced multimodality image-guided operating (AMIGO) suite” (4)Raj Shekhar, “Multimodality image-guided interventions: Multimodality for the rest of us” Learning Objectives: 1.Understand the principles and applications of HIFU in surgical ablation. 2.Learn about recent advances in 3D–2D and 3D deformable image registration in support of surgical safety and precision. 3.Learn about recent advances in model-based 3D image reconstruction in application to intraoperative 3D imaging. 4.Understand the multi-modality imaging technologies and clinical applications investigated in the AMIGO suite. 5.Understand the emerging need and techniques to implement multi-modality image guidance in surgical applications such as neurosurgery, orthopaedic surgery, vascular surgery, and interventional radiology. Research supported by the NIH and Siemens Healthcare.; J. Siewerdsen; Grant Support - National Institutes of Health; Grant Support - Siemens Healthcare; Grant Support - Carestream Health; Advisory Board - Carestream Health; Licensing Agreement - Carestream Health; Licensing Agreement - Elekta Oncology.; T. Kapur, P41EB015898; R. Shekhar, Funding: R42CA137886 and R41CA192504 Disclosure and CoI: IGI Technologies, small-business partner on the grants

MO-DE-202-04: Multimodality Image-Guided Surgery and Intervention: For the Rest of Us

At least three major trends in surgical intervention have emerged over the last decade: a move toward more minimally invasive (or non-invasive) approach to the surgical target; the development of high-precision treatment delivery techniques; and the increasing role of multi-modality intraoperative imaging in support of such procedures. This symposium includes invited presentations on recent advances in each of these areas and the emerging role for medical physics research in the development and translation of high-precision interventional techniques. The four speakers are: (1)Keyvan Farahani, “Image-guided focused ultrasound surgery and therapy” (2)Jeffrey H. Siewerdsen, “Advances in image registration and reconstruction for image-guided neurosurgery” (3)Tina Kapur, “Image-guided surgery and interventions in the advanced multimodality image-guided operating (AMIGO) suite” (4)Raj Shekhar, “Multimodality image-guided interventions: Multimodality for the rest of us” Learning Objectives: 1.Understand the principles and applications of HIFU in surgical ablation. 2.Learn about recent advances in 3D–2D and 3D deformable image registration in support of surgical safety and precision. 3.Learn about recent advances in model-based 3D image reconstruction in application to intraoperative 3D imaging. 4.Understand the multi-modality imaging technologies and clinical applications investigated in the AMIGO suite. 5.Understand the emerging need and techniques to implement multi-modality image guidance in surgical applications such as neurosurgery, orthopaedic surgery, vascular surgery, and interventional radiology. Research supported by the NIH and Siemens Healthcare.; J. Siewerdsen; Grant Support - National Institutes of Health; Grant Support - Siemens Healthcare; Grant Support - Carestream Health; Advisory Board - Carestream Health; Licensing Agreement - Carestream Health; Licensing Agreement - Elekta Oncology.; T. Kapur, P41EB015898; R. Shekhar, Funding: R42CA137886 and R41CA192504 Disclosure and CoI: IGI Technologies, small-business partner on the grants

MO-DE-202-01: Image-Guided Focused Ultrasound Surgery and Therapy

At least three major trends in surgical intervention have emerged over the last decade: a move toward more minimally invasive (or non-invasive) approach to the surgical target; the development of high-precision treatment delivery techniques; and the increasing role of multi-modality intraoperative imaging in support of such procedures. This symposium includes invited presentations on recent advances in each of these areas and the emerging role for medical physics research in the development and translation of high-precision interventional techniques. The four speakers are: (1) Keyvan Farahani, “Image-guided focused ultrasound surgery and therapy” (2) Jeffrey H. Siewerdsen, “Advances in image registration and reconstruction for image-guided neurosurgery” (3) Tina Kapur, “Image-guided surgery and interventions in the advanced multimodality image-guided operating (AMIGO) suite” (4) Raj Shekhar, “Multimodality image-guided interventions: Multimodality for the rest of us” Learning Objectives: 1. Understand the principles and applications of HIFU in surgical ablation. 2. Learn about recent advances in 3D–2D and 3D deformable image registration in support of surgical safety and precision. 3. Learn about recent advances in model-based 3D image reconstruction in application to intraoperative 3D imaging. 4. Understand the multi-modality imaging technologies and clinical applications investigated in the AMIGO suite. 5. Understand the emerging need and techniques to implement multi-modality image guidance in surgical applications such as neurosurgery, orthopaedic surgery, vascular surgery, and interventional radiology. Research supported by the NIH and Siemens Healthcare.; J. Siewerdsen; Grant Support - National Institutes of Health; Grant Support - Siemens Healthcare; Grant Support - Carestream Health; Advisory Board - Carestream Health; Licensing Agreement - Carestream Health; Licensing Agreement - Elekta Oncology.; T. Kapur, P41EB015898; R. Shekhar, Funding: R42CA137886 and R41CA192504 Disclosure and CoI: IGI Technologies, small-business partner on the grants

MO-DE-202-02: Advances in Image Registration and Reconstruction for Image-Guided Neurosurgery

At least three major trends in surgical intervention have emerged over the last decade: a move toward more minimally invasive (or non-invasive) approach to the surgical target; the development of high-precision treatment delivery techniques; and the increasing role of multi-modality intraoperative imaging in support of such procedures. This symposium includes invited presentations on recent advances in each of these areas and the emerging role for medical physics research in the development and translation of high-precision interventional techniques. The four speakers are: (1) Keyvan Farahani, “Image-guided focused ultrasound surgery and therapy” (2) Jeffrey H. Siewerdsen, “Advances in image registration and reconstruction for image-guided neurosurgery” (3) Tina Kapur, “Image-guided surgery and interventions in the advanced multimodality image-guided operating (AMIGO) suite” (4) Raj Shekhar, “Multimodality image-guided interventions: Multimodality for the rest of us” Learning Objectives: 1. Understand the principles and applications of HIFU in surgical ablation. 2. Learn about recent advances in 3D–2D and 3D deformable image registration in support of surgical safety and precision. 3. Learn about recent advances in model-based 3D image reconstruction in application to intraoperative 3D imaging. 4. Understand the multi-modality imaging technologies and clinical applications investigated in the AMIGO suite. 5. Understand the emerging need and techniques to implement multi-modality image guidance in surgical applications such as neurosurgery, orthopaedic surgery, vascular surgery, and interventional radiology. Research supported by the NIH and Siemens Healthcare.; J. Siewerdsen; Grant Support - National Institutes of Health; Grant Support - Siemens Healthcare; Grant Support - Carestream Health; Advisory Board - Carestream Health; Licensing Agreement - Carestream Health; Licensing Agreement - Elekta Oncology.; T. Kapur, P41EB015898; R. Shekhar, Funding: R42CA137886 and R41CA192504 Disclosure and CoI: IGI Technologies, small-business partner on the grants

The utility of high-resolution intraoperative MRI in endoscopic transsphenoidal surgery for pituitary macroadenomas: early experience in the Advanced Multimodality Image Guided Operating suite

Endoscopic skull base surgery has become increasingly popular among the skull base surgery community, with improved illumination and angled visualization potentially improving tumor resection rates. Intraoperative MRI (iMRI) is used to detect residual disease during the course of the resection. This study is an investigation of the utility of 3-T iMRI in combination with transnasal endoscopy with regard to gross-total resection (GTR) of pituitary macroadenomas. The authors retrospectively reviewed all endoscopic transsphenoidal operations performed in the Advanced Multimodality Image Guided Operating (AMIGO) suite from November 2011 to December 2014. Inclusion criteria were patients harboring presumed pituitary macroadenomas with optic nerve or chiasmal compression and visual loss, operated on by a single surgeon. Of the 27 patients who underwent transsphenoidal resection in the AMIGO suite, 20 patients met the inclusion criteria. The endoscope alone, without the use of iMRI, would have correctly predicted extent of resection in 13 (65%) of 20 cases. Gross-total resection was achieved in 12 patients (60%) prior to MRI. Intraoperative MRI helped convert 1 STR and 4 NTRs to GTRs, increasing the number of GTRs from 12 (60%) to 16 (80%). Despite advances in visualization provided by the endoscope, the incidence of residual disease can potentially place the patient at risk for additional surgery. The authors found that iMRI can be useful in detecting unexpected residual tumor. The cost-effectiveness of this tool is yet to be determined.

Ferenc A. Jolesz (1946-2014).

Ferenc A. Jolesz (1946-2014).

Multimodal imaging for improved diagnosis and treatment of cancers.

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. Cancer 2015;121:817-827. © 2014 American Cancer Society.

Mass spectrometry imaging as a tool for surgical decision-making

Surgical teams have available a number of real-time imaging tools to help identify and locate tumor tissue. Mass spectrometry, is proven capable of producing molecular signatures from resected tissue which, in turn, has long promised to aid in determining if all tissue which exhibits tumorous molecular signatures has been removed. A few groups have pioneered the transitioning of mass spectrometry from research lab to surgical suite and among these are Professor Nathalie Agar's team at Brigham And Women's Hospital - Harvard Medical School, who present our Special Feature. Agar's team have sited an ion trap system with DESI ion source into the Advanced Multimodality Image Guided Operating (AMIGO) suite and show that MS information can play a role in surgical decision making.

The Utility of High Resolution Intraoperative MRI in Endoscopic Transsphenoidal Surgery for Pituitary Macroadenomas: Early Experience in the Advanced Multimodality Image-Guided Operating (AMIGO) Suite

Introduction: Maximal extent of resection for pituitary macroadenomas achieves optimal neural decompression, the best chance at endocrine cure, and lowers the rate of recurrence. Many studies have demonstrated the utility of low resolution intraoperative MRI (iMRI) during microscopic transsphenoidal surgery in uncovering residual tumor. Few studies, however, have investigated the utility of high-resolution iMRI in combination with endoscopy with regard to gross total resection. The Advanced Multimodality Image Guided Operating (AMIGO) suite at the Brigham and Women’s Hospital harnesses the power of a high-resolution 3-T iMRI and integrated neuronavigation. We reviewed the experience of our initial 12 cases of pituitary macroadenomas operated on by an endoscopic transsphenoidal approach in the AMIGO suite.

3-T MR-guided brachytherapy for gynecologic malignancies

Gynecologic malignancies are a leading cause of death in women worldwide. Standard treatment for many primary and recurrent gynecologic cancer cases includes external-beam radiation followed by brachytherapy. Magnetic resonance (MR) imaging is beneficial in diagnostic evaluation, in mapping the tumor location to tailor radiation dose and in monitoring the tumor response to treatment. Initial studies of MR guidance in gynecologic brachytherapy demonstrate the ability to optimize tumor coverage and reduce radiation dose to normal tissues, resulting in improved outcomes for patients.In this article, we describe a methodology to aid applicator placement and treatment planning for 3 Tesla (3-T) MR-guided brachytherapy that was developed specifically for gynecologic cancers. This methodology has been used in 18 cases from September 2011 to May 2012 in the Advanced Multimodality Image Guided Operating (AMIGO) suite at Brigham and Women's Hospital. AMIGO comprises state-of-the-art tools for MR imaging, image analysis and treatment planning. An MR sequence using three-dimensional (3D)-balanced steady-state free precession in a 3-T MR scanner was identified as the best sequence for catheter identification with ballooning artifact at the tip. 3D treatment planning was performed using MR images. Items in development include software designed to support virtual needle trajectory planning that uses probabilistic bias correction, graph-based segmentation and image registration algorithms. The results demonstrate that 3-T MR image guidance has a role in gynecologic brachytherapy. These novel developments have the potential to improve targeted treatment to the tumor while sparing the normal tissues.