In 2009, Brett Johnson was a healthy 47-year-old enjoying his life as a singer, teacher, and pianist when he began to suffer from nagging headaches.
As a precaution, his physician ordered an MRI (magnetic resonance imaging) scan of his brain. When the test revealed a cancerous tumor, Johnson recalls feeling shocked, then devastated. On a scale of I–IV, where IV is the most serious, the tumor ranked a Grade III. Johnson’s distress was compounded when he learned the tumor—called an oligodendroglioma—was located in an area of the brain associated with creativity and emotion.
“Creativity is my whole life and career,” Johnson says. “I thought, ‘Please, not that.’”
Within three weeks of his diagnosis, Johnson’s tumor was removed by neurosurgeon Alexandra Golby, MD, at Brigham and Women’s Hospital (BWH). After two months of oral chemotherapy and 33 sessions of radiation, physicians told Johnson that while some cancer cells would always be there, his cancer was stable.
“I was so grateful and happy to have my life back,” says Johnson, who resumed his career with no negative effects on his creative abilities.
Part of Johnson’s new routine meant having follow-up MRIs for the rest of his life. In 2012, something new appeared on a scan. Johnson’s care team could not tell if it was new tumor growth or scar tissue, so they recommended a second surgery.
A Vision for Image-Guided Procedures
In the three years between Johnson’s surgeries, BWH opened the Advanced Multimodality Image Guided Operating (AMIGO) suite, designed to guide complex treatments and procedures with navigation tools and imaging technologies including MRI, CT (computed tomography), PET (positron emission tomography), fluoroscopy, angiography, and ultrasound (see Radiology 101).
“Second only to my wedding day, my second surgery was the most profound day of my life,” Johnson says. “Dr. Golby explained that AMIGO would allow her to use imaging during surgery, which would help her be much more precise.”
“With the naked eye, a tumor looks nearly identical to the brain,” says Golby, BWH’s director of image-guided neurosurgery. “The most dangerous part is when you’re trying to remove the last 10 to 15 percent of the tumor, at the very edges. AMIGO gives us images during surgery, which helps us accomplish a more complete removal without damaging healthy tissue surrounding the tumor.”
The results of Johnson’s surgery in AMIGO were encouraging. Golby found scar tissue—no new cancer growth.
AMIGO was the brainchild of the late Ferenc Jolesz, MD, a BWH radiologist whose peers and students called him the father of modern day image-guided therapy. Since its opening in 2011, AMIGO has hosted more than 1,200 procedures for the brain, head, neck, spine, lungs, abdomen, and pelvis. The suite also doubles as a translational research lab and is the centerpiece of the National Center for Image Guided Therapy, funded by the U.S. National Institutes of Health, based at BWH, and led by Clare Tempany-Afdhal, MB, BAO, BCh.
Detecting Disease Earlier
In the 10 years it took to design and build AMIGO, advances in equipment and techniques improved radiologists’ abilities to diagnose a variety of medical conditions.
Last January, Lisette Mancini’s rising cholesterol and family history of heart problems prompted her primary care physician to refer her to BWH’s Heart & Vascular Center, where she saw Ron Blankstein, MD, a preventive cardiologist and the director of the Cardiac Computed Tomography (CT) service.
While a treadmill stress test showed no restriction of blood flow through the arteries of Mancini’s heart, a CT test that detects calcium buildup in the arteries confirmed the presence of coronary heart disease for the 58-year-old.
At Blankstein’s direction, Mancini began taking statin medications immediately and adopted a mostly plant-based diet.
“In five months, my cholesterol went from 328 to 186 and I cut my blood pressure medicine in half,” Mancini says. “Dr. Blankstein saved my life.”
“My goal is to catch heart disease before it causes problems,” Blankstein says. “If we can use imaging technology to identify it early and start therapies, like we did with Lisette, we can reduce people’s chances of heart attacks and strokes.”
If we can use imaging technology to identify [heart disease] early and start therapies, like we did with Lisette, we can reduce people’s chances of heart attacks and strokes.
Ron Blankstein, MD
Expanding Non-Invasive Therapies
For Brett Johnson, an MRI during surgery gave his doctors a clear answer in a time of uncertainty. For Lisette Mancini, a CT scan provided an early warning system to help improve her heart health. A different imaging device changed Sharon Samuels’ life.
At 72, Samuels is among approximately 10 million people in the United States living with essential tremor, a movement disorder that causes uncontrollable shaking, typically in the hands or legs. Samuels’ hands first began shaking when she was a teenager, but in recent years, her tremors began interfering with everyday tasks.
“I couldn’t write anything because it came out scribbly,” she says. “I would try to dial a phone number and my finger kept going. Eating at a restaurant was embarrassing because people would be looking at me. It’s frustrating. You can get depressed very easily with this.”
When medication provided little relief, Samuels enrolled in a clinical trial at BWH, one of 13 sites worldwide studying MRI-guided focused ultrasound for the condition.
The trial required Samuels to lie awake inside an MRI machine wearing a special helmet, designed and tested by BWH researchers. Using a separate device, a neurosurgeon, medical physicist, and radiologist focused the output from nearly 1,000 ultrasound waves at an area measuring only a few millimeters in the thalamus of her brain.
“When it was over and they wheeled me out, my hand was straight and still as a stick,” she says. “My family was so excited they were crying. They were so happy to see it because they know how much I’ve struggled. Now, I can sign my own name. I can brush my teeth normally, put on makeup, everyday things your hands do for you.”
“This is not diagnostic ultrasound that we’re used to seeing for pictures of babies in utero,” says Tempany-Afdhal. “With techniques developed by BWH researchers, therapeutic ultrasound uses sound waves to generate heat and burn tissue. The MRI scanner shows us when it reaches the right temperature.”
While this experimental procedure has caused side effects in some patients in the trial, Samuels has not experienced any. It’s too early for scientists to know if the treatment’s effects are permanent. Still, Samuels is eager to receive treatment for her other hand.
The U.S. Food and Drug Administration recently approved the treatment for essential tremor, prompting researchers at BWH to begin planning a new trial to target tremors caused by Parkinson’s disease.
Additionally, Tempany-Afdhal and Adam Kibel, MD, chief of the Division of Urology, have launched a clinical trial to use focused ultrasound in treating prostate cancer, building on BWH’s earlier work improving prostate cancer biopsy using MRI technology.
“The Brigham’s biopsy program has led to worldwide changes in how prostate cancer is diagnosed,” she says. “Now we want to change how it’s treated.”
Some of the most common imaging technologies include:
Low doses of electromagnetic radiation show structures inside the body. Bones display as white, fat and muscle are shades of gray, and air in the lungs appears black.
Uses: Identifies broken bones, pneumonia, breast cancer (mammography), or problems with the blood or lymph vessels (angiography).
(Radiation waves also are used in high doses to treat cancer.)
Computed Tomography (CT)
Sometimes called CAT (computerized axial tomography), this machine uses multiple X-ray images obtained at different angles to create 3-D cross-sectional views of areas such as the head, spine, chest, and abdomen.
Uses: Identifies hemorrhage, stroke, fractures, osteoporosis, and abnormalities such as tumors or infections. Also can be used to guide procedures.
An X-ray imaging technique to observe form and movement of internal structures of the body, such as joints, organs, and entire systems.
Uses: Diagnoses diseases, determines how to align broken bones, visualizes blood vessels, and creates real-time images during procedures.
Magnetic Resonance Imaging (MRI)
Strong magnetic fields and radio waves interact with water in the body to produce an image of the body without radiation or use of X-rays.
Uses: Detects tumors, bleeding or swelling, damage to all body parts, brain, bones, or soft tissues, and provides information on glands, organs, and joints. Also guides procedures.
Positron Emission Tomography (PET)
A special radioactive tracer is injected into the body and absorbed by organs and tissues, showing how they are working. PET scans detect abnormal masses and measure blood flow, oxygen use, and how the body processes sugar.
Uses: Detects cancer and problems with the heart, brain, and central nervous system. Also guides procedures.
Detects cancer and problems with the heart, brain, and central nervous system. Also guides procedures.
Uses: Low-power ultrasound can identify causes of pain, swelling, and infection, view a fetus in the womb, treat pain caused by conditions such as tendonitis, and guide procedures. High-power ultrasound can remove cataracts, heal bone fractures, and burn and destroy tissues such as uterine fibroids or brain lesions responsible for conditions such as essential tremor.
“The role of the imaging specialist used to be, ‘Read the picture and tell me what it shows,’” says Marcelo DiCarli, MD, chief of the Division of Nuclear Medicine and Molecular Imaging and director of cardiovascular imaging. “Now that we’re embedding imaging specialists in the clinics, radiologists can better guide clinicians on diagnosis as well as treatment decisions.”
Now that we’re embedding imaging specialists in the clinics, radiologists can better guide clinicians on diagnosis as well as treatment decisions.
Marcelo DiCarli, MD
To facilitate these conversations, radiology staff and equipment are located near clinics throughout the hospital, rather than in a central imaging area. This approach continues in its newest building.
“The Building for Transformative Medicine was designed to bring multiple specialists together in one space, often on the same floor, so radiologists and those in the neurosciences, orthopaedics, rheumatology, and immunology are working collaboratively from the beginning of the care process to make the right decision for each patient,” says Giles Boland, MD, chair of the Department of Radiology.
As imaging technologies improve, care teams can see anatomical structures—such as bones, ligaments, and nerves—more clearly. They can also pick up clues about processes happening in the body that were not discernable before.
“Through molecular imaging, we can now see and measure tiny quantities of specific molecules that help identify conditions such as heart disease or cancer, which help us to detect disease earlier and, more importantly, individualize treatment options for patients,” says DiCarli.
“As we continue to think of new ways to improve imaging—and improve diagnosis and treatment—we always face challenges,” DiCarli adds. “But this is a place where we have almost unlimited opportunities to turn big ideas into new approaches. A thousand years from now, we’ll still be trying to perfect medicine. We will never be done. Instead we say, ‘What are we going to do next?’”
A Closer Look
The Building for Transformative Medicine at BWH includes a new fleet of imaging equipment, such as X-ray, fluoroscopy, ultrasound, CT, and MRIs of varying field strengths, including one 1.5 Tesla and three 3.0 Tesla (3.0T) scanners.
In 2017, BWH will receive the newest generation ultra high field 7.0 Tesla (7.0T) MRI scanner. Initially, BWH researchers will use it to study disease while the hospital waits for approval from the U.S. Food and Drug Administration for clinical use. Older models of 7.0T MRI scanners are restricted for research only.
“The Building for Transformative Medicine represents an ideal location to translate 7.0T MRI clinical research into cutting-edge clinical care for patients,” says Srinivasan Mukundan Jr., MD, PhD, chief of the Division of Neuroradiology.
“It could be a game changer in several ways,” he adds. “For example, multiple sclerosis can be difficult to diagnose. We can identify grey and white matter lesions containing central veins in the brain much more readily with 7.0T than 3.0T. And when we see this, the diagnosis can be confirmed. Similarly, in traumatic brain injury, 7.0T can show subtle brain microhemorrhages.”
The 7.0T MRI will also provide better identification of cartilage disease, meniscal tears, bone and soft tissue lesions, and issues involving nerves and connective tissue, notes Stacy Smith, MD, chief of the Division of Musculoskeletal Imaging and Intervention.
“When people think of chronic low back pain, they’re often evaluating the structures inside a person’s spine, including nerves, joints, and disc spaces,” says Smith. “One hypothesis is the tissue that surround the muscle—called the fascia—may be inflamed. A 7.0T MRI can show these areas even better than the previous technology, helping to further identify the potential cause of this type of chronic pain that affects so many individuals worldwide.”