Real-time Image-guided Video-assisted Thoracic Surgery Procedures Help to Remove Small Lung Cancers Less Invasively
Led by Raphael Bueno, MD, Chief of Thoracic Surgery at Brigham and Women’s Hospital (BWH) and Co-Director of The Lung Center, a multidisciplinary team developed and performed some of the first real-time image-guided video-assisted thoracic surgery (iVATS) wedge resections in the U.S.
Performed in the Advanced Multimodality Image Guided Operating (AMIGO) suite at BWH, iVATS lung resection combines video-assisted thoracic surgery (VATS) with real-time intraoperative computed tomography (CT)-fluoroscopy imaging. VATS is part of the standard of care in excising lung tumors, however, localization of the tumor in the operating room typically relies on previous diagnostic CT imaging and palpation of the lung. Subsequent surgical resection with this approach can result in the removal of more normal functioning surrounding lung tissue than desired to achieve clear margins.
The iVATS procedure is part of an AMIGO clinical trial, developed and led by Dr. Bueno in collaboration with radiologist Ritu R. Gill, MD, MPH, and research scientist Jayender Jagadeesan, PhD, at the national center for image guided therapy (NCIGT), a NIH/NBIB-funded program at BWH and Harvard Medical School, and employs realtime intraoperative CT imaging of the lung combined with video technology to locate and mark the tumor using intraoperative imaging-guidance so that it could be reliably resected with the minimally of lung tissue lost.
With the lung inflated, the tumor is marked with a metallic bar that is positioned using DynaCT guidance through a needle and connected to a suture. This simple device can precisely locate and track the lesion using X-ray (DynaCT) imaging. After the lung is deflated this bar lodges in the tissue, guiding the surgeon to the precise location of the tumor. The iVATS approach is particularly useful in locating small tumors, which can be difficult to palpate and allows limited resections with adequate margins. Since the completion of the first iVATS procedure, a total of 23 patients underwent this procedure in the Advanced Multimodality Image Guided Operating Suite (AMIGO) as part of a now completed clinical trial.
“This application is designed to improve thoracic surgery techniques and lung cancer treatments,” said Dr. Bueno. “While similar approaches have been used in the excision of breast tumors, and metal wires and coils have been used to identify lung nodules, the intraoperative use of these specialized sutures with real-time radiological imaging in the treatment of lung cancer is both innovative and game-changing. It is like moving from using maps to plan a journey to using GPS.”
The AMIGO suite is a fully integrated operating suite, offering immediate real time intra-procedural access to an extensive range of advanced imaging modalities. This facility is part of the National Institutes of Health funded National Center for Image Guided Therapy (NIH P41-NIBIB, Dr. Clare Tempany, Principal Investigator).The 5,700 square foot space is divided into three interconnected procedure rooms housing real-time anatomic, functional, and molecular imaging modalities, including MRI, PET/CT, CT-fluoroscopy, and ultrasound. Specialists at Dana-Farber Brigham Cancer Center are collaborating to introduce novel image-guided techniques in AMIGO in order to advance diagnosis and treatment for many forms of cancer, including malignant tumors of the brain, prostate, kidney, liver, lung, adrenal gland, bone, cervix, vagina, and uterus.
Raphael Bueno, MD Chief of Thoracic Surgery, Co-Director of The Lung Center, Associate Director, AMIGO Suite, Brigham and Women’s Hospital; Thoracic Surgeon, Dana-Farber Brigham Cancer Center
Clare M.C. Tempany, MD Ferenc Jolesz Chair of Radiology Research, Director, National Center for Image Guided Therapy, Director, AMIGO Suite, Brigham and Women’s Hospital; Radiologist, Dana-Farber Brigham Cancer Center