Building on Excellence: Cutting-Edge Technologies Available

Building on Excellence: Cutting-Edge Technologies Available
Nathalie Agar, PhD, uses mass spectrometry technology to analyze and identify tissue content.

This story was originally published in BWH Clinical and Research News.

When the Brigham Building for the Future opens this fall, clinicians and researchers will have access to advanced tools and opportunities to collaborate and push the boundaries of discovery in ways that have never been possible before.

“The BBF will be a one-stop shop, with multidisciplinary experts within arm’s reach and top-of-the-line imaging technologies, interventional procedures and clinical evaluation,” said Stacy Smith, MD, chief of the Division of Musculoskeletal Imaging and Intervention in the Department of Radiology. “It will allow for the stimulation of new ideas through constant interaction with other clinicians and researchers, as well as patients. The fusion of these minds will lead to new investigations and research collaborations that will help us in caring for our patients and the curing of disease.”

Smith says that this access to multidisciplinary experts and technologies will improve BWH’s Musculoskeletal Center and many other clinical centers’ ability to diagnose, further evaluate and even cure patients coming through our doors.

Next-Generation Imaging

One of the BBF’s major innovations are its state-of-the-art imaging technologies, which will be housed in two locations—within the Radiology Department on the Musculoskeletal floor and within Radiology on the lower level of the building. The imaging facility on the lower level will be comprised of a CT scanner and five highly configured MRI machines—three top-of-the-line 3 Tesla (3.0T MRI) scanners, one 1.5 Tesla (1.5T MRI) and a 7 Tesla (7.0T MRI), which is one of the most powerful commercially available MRI machines in the world (due to arrive in summer 2017). Two of the 3.0T MRIs will be Siemens’ newest model, the Magnetom Prisma—the first at BWH and the most advanced clinical MRI scanner available. The Prisma has the capability to perform advanced imaging that was previously only available on research scanners. This imaging can help demonstrate the anatomy of white matter in individual patients, information that might be helpful for diagnosis and for planning treatments including neurosurgery.

These technologies will be delivered, installed and calibrated in the BBF beginning in early July. Together with an extensive array of X-Ray, fluoroscopy and ultrasound technologies—including dedicated Musculoskeletal Ultrasound located on the Musculoskeletal floor—this impressive fleet of non-invasive medical imaging devices will streamline and improve patient care and support Brigham’s research mission to translate promising medical and scientific advances to the clinic.

The 7.0T is one of only a few of its kind available to clinicians and researchers and will allow them to visualize critical structures and pathologies that until now were not visible by MRI. Seeing these structures and pathologies will help clinicians differentiate between different diseases or conditions in which symptoms may be similar and, in turn, choose the best treatment option for patients. BWH’s 7.0T will be the first to be installed in a clinical setting in North America. The machine will be used exclusively for clinical research for approximately the first year after the BBF opens. Steven E. Seltzer, MD, outgoing chair of the Department of Radiology, says that he and many others are hopeful that the 7.0T will be FDA-approved for use in clinical care soon after that.

Once approved, the 7.0T may also help clinicians more precisely diagnose many neurological and musculoskeletal conditions, in some cases localizing small areas of pathology that can be treated effectively. This information can help clinicians make decisions about treatment, for example, assisting them in deciding whether or not to operate or use a certain drug, and allowing them to discriminate between two treatment choices or monitor the effectiveness of a course of treatment.

In April, the Department of Radiology hosted a workshop to discuss the 7.0T and the new imaging facility’s other technologies. The workshop was attended by dozens of clinicians and researchers from across the hospital, all of whom were eager to learn more and share their ideas for applications and collaboration. The department has sponsored six related projects in the neurosciences and will seek a second round of proposals in the near future.

“We anticipate that the new technology could be a game changer in multiple sclerosis (MS) and traumatic brain injury,” said Srinivasan Mukundan, MD, PhD, of the Department of Radiology. “The 7.0T will provide the ability to help diagnose neurodegenerative diseases and will provide new insights into traumatic brain injury. Although it will impact many areas in the neurosciences, two areas where we expect to see a great impact—MS and brain injury—are also major areas of focus for the Ann Romney Center.”

On the musculoskeletal side, the 7.0T will provide new insights in cartilage, fascia and muscle research, providing a much higher degree of evaluation of these structures that is not possible with other MRI technology. With this additional information, Smith expects improved diagnosis and treatment of disease in these areas on the clinical side, as well as the development of new therapies from research and collaborative efforts.

Better Images to Combat Brain Cancer

Even investigators who are not physically moving to the BBF stand to gain from the imaging facility’s offerings. Alexander Lin, PhD, anticipates that he and others in the research community will benefit greatly from the new imaging facility, which will be accessible to clinicians and researchers across the hospital, and that he will be working in it often. He expects the facility will provide a platform for even more collaboration across BWH’s distributed campus.

“The BBF is going to open up all kinds of opportunities,” said Lin. “What differentiates the Brigham from other institutions with the 7.0T is that we are clinically focused. One of the goals of bringing the 7.0T to BWH is building collaborations between Radiology and many other departments including Neurology, Surgery and all different walks throughout the Brigham to get more people to use this cutting-edge resource.”

As director of the Department of Radiology’s Center for Clinical Spectroscopy, Lin and his team are working to create noninvasive, diagnostic methods that measure chemicals in the brain to better understand how to identify and treat brain cancer. He says that most spectroscopy is done using a standard MRI scanner, but the 7.0T will provide them with much more detailed images of metabolic pathways in the brain.

“We’ll be going from a 3.0T MRI to a 7.0T, which is more than double the strength,” said Lin. “The higher field strength means a better signal and higher-resolution images that will allow us to obtain more information than we can today.”

Currently, Lin’s team takes what he calls a fairly large “virtual biopsy” of an 8-cubic-centimeter region of an image to ascertain the molecular makeup of a tumor. However, with the increased field strength of the 7.0T, the team will be able to obtain much more information from a smaller region, which is ultimately better for patients, as it provides greater specificity and allows for earlier diagnosis.

Such information as the chemicals produced by a tumor can also give researchers and clinicians insight into tumor recurrence. For example, in cancer patients treated with radiation therapy, it can be difficult to tell if vascular changes occurring in the brain are the result of tumor re-growth or the immune response to radiation. Being able to measure the chemicals produced by specific genetic mutations in tumors will help a patient’s care team better understand these vascular changes and how to alter treatment if needed.

“With the 7.0T, we will also see an increase in spectral resolution, which allows us to detect more chemicals,” said Lin. “As spectral resolution increases, chemicals that might have overlapped at lower field strengths become differentiated and more easily measured. With these additional chemical measurements, we’ll be able to target and follow chemical changes that we could not see before.” Being able to see and track a greater number of chemicals will help lead to more precise diagnoses, Lin says.

Since the team can measure certain chemicals in the brain without having to perform surgery or give radioactive material to a patient, another benefit of the new technology to patients is treatment monitoring.

“Our cancer patients can come in as frequently as every other week to receive follow-up for their tumors,” said Lin. “We can see the progression of outcome in treatment by continuously measuring the chemistry of the tumor over time.”

Bringing Mass Spectrometry to the BBF

A close relative of spectroscopy is mass spectrometry imaging. Unlike noninvasive spectroscopy, which doesn’t require a tissue sample, mass spectrometry analyzes the mass of chemicals in tissue samples to identify tissue content.

Nathalie Agar, PhD, director of the Surgical Molecular Imaging Laboratory in BWH’s Department of Neurosurgery and also part of the Department of Radiology, is using this technology for several different research applications, including mapping metabolites to guide brain tumor surgery, analyzing breast cancer margins and evaluating pituitary adenomas for real-time tumor delineation.

She’s also in the Operating Room, providing tissue analysis during surgery. As surgeons remove sections of tumor tissue during procedures in the Advanced Multimodality Image Guided Operating (AMIGO) suite, Agar and her team are beside them performing biochemical analysis of these tissues by using different mass spectrometer interfaces. The information she provides helps surgeons see tumor margins during surgery in real time, reducing the likelihood that parts of the tumor will be left behind.

Agar’s laboratory, which is currently based at 221 Longwood Ave., will move over to the BBF this fall. The team’s existing mass spectrometers and a new high-power mass spectrometer will join them in the new space. Agar and her team currently spend considerable time traveling between 221 Longwood, AMIGO, the New Research Building at Harvard Medical School and other areas to collaborate with colleagues. Having the laboratory in the same building as the new imaging facility and merely a few floors above other research labs and outpatient clinical space—and interconnected to the Shapiro Center and rest of the hospital—will not only save them travel time, but it will make collaborating with neurosurgery, neuropathology and multidisciplinary colleagues more streamlined.

“We’re excited to bring our instruments closer and closer to surgical pathology and to patients,” said Agar.

Agar is careful to note that there is a distinction between analyzing patient tissue samples and converting the analyses into information that can help surgeons make decisions during surgery, such as information about surgical margins and diagnosis. After many years of validation, together with neurosurgeon Alexandra Golby, MD, and neuropathologist Sandro Santagata, MD, PhD, the team is in the process of adapting its research protocol to finally clinically implement the first real-time analysis of a well-validated brain tumor biomarker.

Patient-Centered Care

Andrew Menard, JD, director of Business Development for the Department of Radiology, is part of a team that is overseeing the extensive imaging project and relations in the new facility. His team anticipates that delivery and installation will begin on Thursday, July 7, and continue each weekend through the end of July.

The imaging facility at the BBF will house equipment specifically selected to best serve the needs of the patient populations that will be seen in the new building, including patients with MS and those with implanted devices. Many of the current Radiology spaces throughout the BWH campus that cater to the needs of patients receiving other kinds of treatments will remain where they are.

“Rather than consolidating Radiology spaces, we’ve adapted to the needs of patients,” said Menard. “We’ve selected the right technology for patients who will be seen in this building, and we’ve tried to make access as convenient as possible so that patients can receive imaging without ever having to leave the building where they are being treated.”

Mukundan explains that Radiology will be embedded in the team rooms on the Neuroscience floor, as part of the patient-centered approach to care. With Neuroradiology in the new imaging facility in the basement of the building and in team rooms, the teams will be employing both a classic model and new model of clinical care.

“We will not only have the best of imaging resources available on the floor, but radiologists will be right there, able to help on the interpretive side,” said Mukundan.

Menard and his team have also worked with the BBF’s architects to design the building in a way that installing or upgrading imaging equipment will be feasible in the future.

“Our vision is to stay cutting-edge forever,” he said.

Radiology Chair Seltzer says that the advanced imaging that will be part of the BBF’s imaging facility and elsewhere in the building will be “second-to-none anywhere in the country.”

“BBF will be very synergistic in that the research community will have access to tools and technologies right where patients are, which is unusual,” said Seltzer. “It positions the Brigham research community beautifully to take advantage of these unique assets. Additionally, all of the MRIs, except for the 7.0T, are already FDA-approved for clinical care. For patients with Alzheimer’s, for example, imaging is indispensible in looking at the progression of disease and response to treatment. Having these devices adjacent to the clinic truly demonstrates the Brigham’s commitment to improving the standard of care.”