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Amigo Innovative Breast Cancer Surgery

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BOSTON (Ivanhoe Newswire) - Undergoing any surgery can be difficult, but having to go back again can be unnerving. Now, a world class operating suite is sparing some patients a second trip under the knife.

"I've never been in a hospital, I've never had surgery, I've never had anesthesia so I was really nervous," Jane Davis, Breast Cancer Patient, told Ivanhoe.

Jane Davis would've been part of the 40 percent of U.S. women to undergo a second surgery, but the AMIGO allowed her doctor to take an MRI during her lumpectomy; to make sure he had cancer free margins.

"An MRI machine comes in from the ceiling and then looks at the area that I removed to see if I removed the tumor in its entirety," Doctor Mehra Golshan, MD, at Brigham and Women's Hospital, told Ivanhoe.

The three room O.R. suite has an electronically controlled operating table mounted with an MRI compatible anesthesia delivery system and other advanced mobile imaging devices. Next door is a PET and CT room that scans the entire body.

"There is no other operating room where you can actually use an MRI or Pet Scan at the same time," Doctor Golshan explained.

Surgical teams can view all of the patients' images on large LCD monitors making surgeries more precise. The AMIGO is also used for other treatments that include brain surgery, radiation treatment for prostate cancer and gynecological tumors.

RESEARCH SUMMARY

BACKGROUND: Breast cancer is the second most common cancer among American women. About 1 in 8 (12 percent) women in the US will develop invasive breast cancer during their lifetime.  The American Cancer Society estimated that in 2012 approximately 226,870 new cases of invasive breast cancer will be diagnosed in women in the US. (SOURCE:http://breastcancersurgery.com/about-breast-cancer/)

RISK FACTORS: Factors that are associated with an increased risk of breast cancer include:

  • Radiation exposure - If you received radiation treatments to your chest as a child or young adult, your risk of breast cancer is increased.
  • Beginning your period at a younger age. Beginning your period before age 12 increases your risk of breast cancer.
  • Having your first child at an older age. Women who give birth to their first child after age 35 may have an increased risk of breast cancer.
  • Having never been pregnant. Women who have never been pregnant have a greater risk of breast cancer than do women who have had one or more pregnancies.

(SOURCE: www.mayoclinic.com/health/breast-cancer)

LATEST TECHNOLOGY: Up to 40 percent of women in the U.S. who undergo a lumpectomy to remove a breast tumor require a second surgery. That's because surgeons often are unable to microscopically remove the entire tumor during the first surgery. Dr. Mehra Golshan, Director of Breast Surgical Services, at the Brigham and Women's Hospital, is changing all of that with the Advanced Multimodality Image Guided Operating (AMIGO). "Using contrast MRI, an image is taken of the breast before the surgery and then again after the tumor is removed. We then use the images to ensure the entire tumor is removed, with clear margins, before the patient leaves the operating room," said Dr. Golshan. The idea may be simple but the technology is one of a kind. "I am hopeful this innovative procedure will help create a platform for tests and studies that could be done in the operating room to eliminate repeat procedures for breast cancer patients and allow patients to shift their focus to healing and living their lives," said Golshan. (SOURCE:http://healthhub.brighamandwomens.org/reducing-repeat-surgeries-after-breast-cancer)

INTERVIEW

Mehra Golshan, MD, Director of Breast Surgical Services, at the Brigham and Women's Hospital, talks about a new treatment option for breast cancer.

The study you are involved in, what is it about?  

Dr. Golshan: Women who are newly diagnosed with breast cancer in the United States are either offered either what is called a mastectomy, which is removal of the entire breast or what is called breast conserving therapy or lumpectomy; where you remove the tumor with a rim of normal tissue and then you follow it with radiation.  When you do a lumpectomy, the challenge is to remove the entire tumor and leave a woman with a cosmetically acceptable result.  What ends up happening in the United States is about 40 percent of the time women have to come back for a second operation to get what is called clear margins or normal tissue.  In this study, we are using what is called, AMIGO, which stands for Advanced Multimodality Image-Guided Operating Suite at the Brigham and Women's Hospital. When I perform a lumpectomy we remove the tumor and temporarily close, then, a MRI machine comes in from the ceiling and then looks at the area that I have removed to see if I have removed the tumor in its entirety and if there are any abnormalities that are identified, I can, while she is under anesthesia, target those areas and remove them. 

What is the obvious benefit to the patient?  

Dr. Golshan: It can potentially stop her from coming back a second time for an operation, which can be both physically and emotionally very difficult for a woman to go through. It increases risk of infection with a second operation; there is obviously the cost that is associated with it for the healthcare system, and it often leads to what is called delay in therapy so a woman will have to wait to start chemotherapy or has to wait to start radiation and these delays accumulate.  

What is the difference traditionally in what you would normally do compared to with AMIGO?

Dr. Golshan: Without AMIGO, you either use a mammogram or ultrasound to target the cancer and sometimes a radiologist will put a thin wire next to it for us to remove the cancer at the time of surgery.  The challenge is how much to remove and how can you tell normal tissue from breast cancer tissue and there is no test in pathology that we can do while she is asleep to say that we have removed the cancer in its entirety.  AMIGO allows us to use an MRI at the time of surgery; this helps to ensure that the tumor is completely removed.

How many people so far have participated? 

Dr. Golshan: We have enrolled nine women so far.  This is a very specialized operating room and suite and the operation takes longer than it does in the traditional operating room.  It is what is called a Phase I Clinical Trial so we are looking at what is called feasibility; are we able to do breast surgery inside an MRI, because no one else in the world has been doing this.

And so far?

Dr. Golshan: Everyone has done very well.

How did the idea of all of this come about?

Dr. Golshan: The idea of this dates back probably about 2 decades where one of our radiologists, Dr. Jolesz, developed what is called the MRT, which was the earlier version of AMIGO; where there was an MRI in the operating room, but that MRI was what is called a 0.5 Tesla Magnet. Basically the field of the MRI was not strong enough and the quality of the image was not good enough for breast cancer surgery. So, over the years, we have been working through the National Institutes of Health and National Cancer Institute for funding the new phase with better machines.

Take me through the procedure, how it works?  

Dr. Golshan: A woman comes in and after we deem that she is a candidate and she is interested in proceeding with surgery in AMIGO, on the day of surgery, they come in and they undergo general anesthesia so they go asleep and then they are on the operating room table and we perform an MRI prior to starting surgery; the reason why we do the MRI before is she is lying on her back and we operate on people lying on their back and every woman who gets an MRI outside of AMIGO, they are actually lying on their stomach and the way the breast moves and the cancer moves in its position is very different. Then I perform the surgery like I would in any other operating room in the world. What happens next, is once I am done with that lumpectomy or removing the tumor, I temporarily close the cavity, the area removed, fill it in with saline or salt water and then we take another picture of it while she is asleep and then we look at the margins or the edges of the tumor with another MRI and if anything lights up, I open back up, take that additional tissue and then close again.

When you say if something lights up, how do you determine that?

Dr. Golshan: That MRI is done with and without what is called gadolinium or contrast so there is some dye that is injected and cancers sometimes take up this dye more than normal breast tissue. We look at the interface of normal tissue and cancer and again, cancer tends to become more bright and those little bright spots are the ones that we try to remove.

If you see the bright spot, you can go back in on scene, just reopen the cavity area?

Dr. Golshan: Yes, and take it out while she is asleep as opposed to what usually happens is we close and then we wait a week for the pathology results to come back. Then they call us and tell us you either removed it fully which is great or about 40 percent of the time around the United States, they will say that there is additional cancer there where you would have to come back again.

How cutting edge is this technology would you say? 

Dr. Golshan: MRI is all over the country and around the world, but an MRI in the operating room and along with a PET CT scan, there is really nowhere else that is doing this.

FOR MORE INFORMATION, PLEASE CONTACT:

Tom Langford
Senior Media Relations Specialist
Brigham and Women's Hospital
617-534-1605
tlangford@partners.org

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