Ways of Seeing

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.”

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.”

What’s Next?

“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.”

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?’”