Creating an Intraoperative MRI Suite for the Musculoskeletal Tumor Center

Abstract

Background Altered anatomy in a previously irradiated surgical bed can make accurate localization of anatomic landmarks and local recurrence nearly impossible. The use of intraoperative MRI (iMRI) has been described in neurosurgical settings, but to our knowledge, no such description has been made regarding its utility for local recurrence localization in sarcoma surgery. Case Description A 58-year-old female presented after previously undergoing two previous resection and reresection procedures of a myxoid liposarcoma located adjacent to her proximal femoral vasculature. After postoperative radiation therapy, she was referred to our institution where she underwent two additional reexcisions of local recurrences during a 3-year span, eventually undergoing a regional rotational muscle flap for coverage. Two years after her third reexcision procedure, she presented with two additional, nonpalpable surgical-bed local recurrences. After converting an MRI bed and scanner to allow for proximal thigh imaging in an iMRI surgical suite, the patient underwent a successful resection that achieved negative margins. To date, she remains without evidence of disease at 37 months. Literature Review Real-time iMRI in neurosurgical studies has shown a high rate of residual disease leading to immediate subsequent reexcision, thus lending to improved rates of negative margin resection. To our knowledge, this is the first example using iMRI technology to remove a recurrent soft tissue sarcoma that otherwise was clinically nonlocalizable. Clinical Relevance The use of an iMRI surgical suite can aid with identification of soft tissue nodules in conditions such as an altered tumor bed from prior resection and radiotherapy, which otherwise make recurrences difficult to localize. A team approach between administration, surgeons, and engineers is required to design and pragmatically implement the use of an MRI-compatible table extension to enhance existing iMRI surgical suite technology for extremity sarcoma resection procedures.

Editorial Comment

“…The authors attribute these differences to the inherent limitations of our current mp-MRI sequences, which are optimized for lesion detection and not staging, and significant interobserver variability in Gleason histological grading. 5,6 These findings highlight few critical points concerning the adoption of MRI/US fusion prostate biopsy in our clinics. First, the accuracy of the fusion biopsy is not sufficient to forego the conventional systematic biopsy at the present time.…”

A three-dimensional visualization of the full-field surgical region based on thin-slice MRI: A helpful approach for simultaneously guiding tumor resection and perforator flap elevation

“…Kwon et al ( 11 ) demonstrated that there was a relatively high concordance in tumor thickness between MRI and histopathology in patients with oral tongue squamous cell carcinoma. With the progressive development of intraoperative MRI, surgeons have tried to use intraoperative MRI to guide the resection of soft tissue sarcoma to reduce the re-resection rates ( 12 , 13 ). On the other hand, MRI with or without enhanced contrast has made noteworthy progress in perforator mapping in the past decades.…”

Utility of intraoperative magnetic resonance imaging for giant cell tumor of bone after denosumab treatment: a pilot study

“…The only cost to the patient is the cost of the surgery plus the cost of the MRI scan (approximately $286). However, to the best of our knowledge, there are only two reports to date describing the use of iMRI for musculoskeletal tumors (17,18) and none focusing on GCTB resection after denosumab therapy. We hypothesized that iMRI could be used to identify residual tumor tissue, thus enabling successful curettage.…”