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A Better Kind of Brain Surgeryby Sunni Hosemann with reporting by Dawn Chalaire and Dianne Witter The human brain is an especially bad place for a tumor. Surgically navigating this vulnerable terrain, completely removing a tumor, and leaving without damaging key structures only a few millimeters away requires extraordinary precision and skill. An extremely high-tech road map doesn’t hurt, either. Such is the thinking behind BrainSUITE, The University of Texas M. D. Anderson Cancer Center’s new, $9.2 million system of advanced imaging technologies brought together in a sophisticated new operating room. The equipment is designed to give surgeons better information intraoperatively to help them completely and safely remove complex, hard-to-access brain tumors, with advanced surgical and diagnostic tools combined in one room. “Precision in resection is key because survival in patients with brain tumors parallels the percentage of tumor successfully resected,” points out Raymond Sawaya, M.D., a professor and chair of the Department of Neurosurgery at M. D. Anderson Cancer Center. “Even among patients with glioblastoma, the most malignant of brain tumors, we see a subset of these patients still alive 7 or 8 years later—these are patients whose resection was complete.” An image-guided surgical system The BrainSUITE is anchored by two core pieces of equipment: a high-intensity intraoperative wide-bore magnetic resonance imaging (MRI) scanner and an integrated image-guided surgical system. The new 1.5-Tesla MRI scanner is more powerful than previous intraoperative MRI magnets of 0.2 Tesla in magnetic strength. Its special wide-bore opening will accommodate a patient placed on his or her side, whereas most scanners require the patient to be lying flat. Therefore, a patient who has a brain tumor that must be accessed from the side of the head, which is inaccessible in most other intraoperative MRIs, can now undergo surgery in the BrainSUITE. These features, along with a special pivoting operating table, allow for scanning to be done periodically during surgery with minimal intrusion, providing the surgeon with much more accurate and up-to-date information during the procedure. The image-guided surgical system of ceiling-mounted cameras and fiber-optic wiring incorporated in the BrainSUITE provides the surgeon with continually updated images on huge monitoring screens during the procedure. This is important because the surgical field changes during surgery: when tumor tissue is removed, the remaining tissue shifts. According to Dr. Sawaya, this movement of tissue within the surgical field isn’t a problem in many kinds of surgical procedures, but during brain surgery—particularly surgery for large, deep tumors—it can be significantly disorienting for the surgeon. According to Jeffrey Weinberg, M.D., an assistant professor in the Department of Neurosurgery and the medical director of the BrainSUITE, besides ultrasonography, other methods currently used for image guidance during brain surgery do not account for that shift. Instead, surgeons rely on a preoperative MRI and use ultrasonography intraoperatively.
Typically in brain surgery, radiologic markers are placed on the patient’s forehead the day before surgery, and the patient undergoes a preoperative MRI scan. In the operating room on the day of surgery, after the induction of anesthesia, the head is fixed in place, and the markers are registered to the preoperative image. During the procedure, the surgeon compares his or her impression of the operative field with the preoperative image from the day before to make judgments about shift, about the extent of tumor removed, and about the location of critical structures that sit only millimeters away. “Now, with the BrainSUITE, our surgeons will have coordinated access to more real-time information more quickly than ever before, and that will translate into better patient outcomes,” Dr. Sawaya added. The magnetic field One unique challenge of doing surgery in the BrainSUITE is working near a powerful magnetic field. A 1.5-Tesla MRI scanner, such as the one in the BrainSUITE, contains a magnet so strong that objects drawn to it can become dangerous projectiles. Surgeons, neuroanesthesiologists, and others caring for patients in the BrainSUITE must ensure that the equipment they use is compatible with the MRI or out of range of its strong magnetic force. Patients are prescreened for any metallic objects or implants that might be attracted to the magnet as well. “Everything that we normally tell people not to do in the MRI environment, we are going to do in the BrainSUITE, including bringing in equipment and surgical instruments that contain ferrous material,” said David Ferson, M.D., who heads the Section of Neuroanesthesia at M. D. Anderson. “However, the key is not to allow any of these objects to come close to or cross the 5-Gauss line, at which point they could become projectiles. This will require tremendous coordination, attention to detail, and teamwork by all the operating room personnel.” Safety and accuracy The BrainSUITE’s design will allow neurosurgeons to remove brain tumors more safely than ever before because the MRI scans will enable surgeons to more precisely locate—and circumnavigate—critical structures of the brain like the optic nerve and the brain stem. “This will reduce the possibility of neurological deficit that can negatively impact a patient’s quality of life after surgery,” said Dr. Weinberg. With BrainSUITE technologies, surgeons, patients, and families anxiously waiting for information don’t have to wait for postoperative imaging to learn whether the tumor was successfully removed. Since all imaging is performed in the operating room under the supervision of a neuroradiologist, the surgeon has information about the procedure’s success right away. Because there is no waiting to learn if the tumor was completely resected, the number of repeat surgeries, with their attendant risks and costs, is expected to decline. Not every patient needs the sophisticated technology afforded by the BrainSUITE, but “it’s important for an institution like M. D. Anderson to have this capability,” Dr. Weinberg said. At M. D. Anderson, almost 1,000 brain tumor surgeries are performed every year—more than at any other hospital in the nation. And for the most part, those surgeries involve large, deep tumors that represent a high degree of complexity. Even among M. D. Anderson patients with brain tumors, Dr. Weinberg estimates that only about half will require surgery in the BrainSUITE. For those that do, however, a surgeon can emerge from surgery to meet the family with more than a guess about how much of the tumor was removed.
For more information on this topic or for questions about M. D. Anderson’s treatments, programs, or services, call askMDAnderson at (877) MDA-6789. Other articles in OncoLog, May 2006 issue:
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