From left: Wallis Urmenyhazi and Scott Swanson

Wallis Urmenyhazi, PhD, was speaking with her primary care physician by phone after a recent chest X-ray when he said four words that would change her life: “You have a lesion.” 

“I didn’t know what he meant by lesion, but he told me to see a thoracic surgeon,” says Urmenyhazi, a retired professor of French literature, who had seen her physician for a persistent cough.

After meeting with a thoracic surgeon in her home state of Pennsylvania, Urmenyhazi learned that her lesion was a thymoma, a rare disease in which a tumor grows within the thymus gland, a butterfly-shaped organ that sits in front of the heart and makes immune cells. There are only 1.5 cases of thymoma for every million people each year in the United States.   

The most common treatment is to remove the tumor with surgery. Accessing a thymoma can be challenging, however. The thymus sits behind the sternum, between the lungs, and is surrounded by sensitive blood vessels. A traditional surgery opens the chest by making a large incision in the breastplate.   

Urmenyhazi had misgivings. It was a major operation with a long recovery process. Her tumor had been caught early; her only symptom was a cough. Through online research, she learned that some surgical procedures approached thymomas through small incisions and used less-invasive techniques aided by video or robotic technology.  

“I asked my surgeon at the time if he would perform a minimally invasive procedure, but he didn’t have that expertise. He recommended the more complex traditional operation, which had no guarantee of success,” she said.    

Despite her reservations, Urmenyhazi scheduled the operation – but canceled a day later. She searched online for a surgeon with experience in minimally invasive techniques for thymoma, ultimately finding Scott Swanson, MD, director of Minimally Invasive Thoracic Surgery in BWH’s Lung Center. 

A member of the surgical team for Dana-Farber/Brigham and Women’s Cancer Center, Swanson is an expert in video-assisted thoracic surgery (VATS) and teaches the technique around the world.

“After meeting Wallis, I recommended VATS, a minimally invasive procedure where we insert a tiny camera and instruments into small incisions in the chest. This allows us to access the thymus without opening the chest. Compared with traditional approaches, patients can expect less pain and a quicker recovery,” Swanson said.  

The procedure was performed without complications. After the surgery, Urmenyhazi had no pain. It was almost as if the surgery hadn’t happened, she said.   

VATS has been available for 25 years, but not enough surgeons are trained to do it, Swanson explained. That’s why he and members of the Division of Thoracic Surgery travel to hospitals across the globe to train surgeons in minimally invasive techniques and expand access to this lifesaving procedure.

Swanson applauded Urmenyhazi for being an advocate for her own care. “Sometimes, the patient needs to seek out the physicians who are trained to perform the most cutting-edge surgical techniques,” he said.   

Urmenyhazi meets yearly with Swanson for follow-up scans. “I will be forever grateful for Dr. Swanson,” she said.

From left: Michael Belkin, Felicity Billings and Edwin Gravereaux, beside the ARTIS Pheno imaging system in BWH’s hybrid OR.

BWH surgeons and interventionalists working in the Michael J. Davidson, MD, Hybrid Operating Room are among the first clinicians in the Northeast to use the new ARTIS Pheno angiography imaging system.

The powerful, robotically controlled device delivers high-end imaging for patients undergoing certain cardiac, endovascular or thoracic surgeries or procedures.

The Brigham has a rich history of pioneering technologies and imaging tools in the hybrid operating room (OR) to deliver the most advanced care to patients. Some interventions that once took place over several days – historically in multiple operating rooms and diagnostic labs – can now be done over the course of one visit in the hybrid OR. BWH was the first hospital in the U.S. to use the ARTIS Zeego system, the Pheno’s predecessor, in the OR.

Known as “C-arms” for their C-shaped design, the Zeego and Pheno perform real-time X-ray imaging during angiograms and therapeutic procedures. Both are designed to rotate completely around a patient’s body, making it easier to diagnose a condition in the OR and, if necessary, immediately operate.

BWH clinicians are using these imaging systems to guide increasingly complex procedures, such as aortic valve replacements and transcatheter aortic valve replacements (TAVRs). These require high-quality, granular imaging – an area in which the Pheno offers several improvements, according to Michael Belkin, MD, chief of the Division of Vascular and Endovascular Surgery.

“The Pheno algorithms will allow us to better perform these procedures,” he said. By better, Belkin means faster imaging, less radiation exposure for patients and interventional surgeons, and higher-quality images. Resolution for two-dimensional imaging in Pheno is four times higher than in the older device.

Last month, BWH clinicians began enrolling patients in a clinical trial for transcatheter mitral valve replacement, a study the Pheno will support, said cardiac surgeon Tsuyoshi Kaneko, MD, of the Division of Cardiac Surgery.

“This trial requires a thoracotomy – a surgery to open the chest wall – which we will perform in the hybrid OR. It’s a perfect example of where the Pheno will be really useful,” Kaneko explained, as the newer system will provide better visibility and resolution with less contrast load.

Improving Quality and Safety

In addition to the new system’s advanced capabilities, parts of its design are expected to improve care quality and safety for patients in the hybrid OR, providers said. Pheno’s wider-space robotic C-arm moves more easily in and out of the patient field without interrupting the sterile surgical field. And as a more closed system compared to the Zeego, the Pheno is easier to keep sterile.

“The Zeego moves like an old-generation robot, whereas Pheno will be silky smooth when the arm moves and will make our procedures much, much easier,” Kaneko said.

The new device also enables clinicians to obtain images faster. “We want to see the image in a matter of seconds, especially when working on an urgent or complex case,” said Kaneko. This isn’t only a matter of convenience; it also concerns patient safety. Because the Pheno scans up to 15 percent faster than earlier systems, images are produced with less IV contrast – an added benefit, as contrast can tax the kidneys.

While the Pheno likely won’t be used for conventional open cardiac, thoracic or endovascular procedures, Belkin is enthused about the device’s potential benefits for patients for whom its use is appropriate.

“We are already doing hundreds of cases every year in the hybrid OR now,” Belkin said. “With this newest machine, we can deliver even better care to our patients.”

CAR T-cell therapy uses T cells (illustrated above) from a patient’s own immune system to attack cancer.

What if the key to a cure for cancer is already inside our own bodies?

Scientists at BWH and Dana-Farber Cancer Institute have asked that question over the past several years as they studied an immunotherapy – that is, a treatment that uses a person’s own immune system – for adult cancer patients.

Now, following a successful clinical trial and recent approval from the U.S. Food and Drug Administration (FDA), Dana-Farber/Brigham and Women’s Cancer Center (DF/BWCC) is one of a few locations nationwide certified to offer the first chimeric antigen receptor (CAR) T-cell therapy for a form of non-Hodgkin lymphoma.

CAR T-cell therapy, like all forms of cancer immunotherapy, seeks to sharpen and strengthen the immune system’s inherent cancer-fighting powers. It involves giving patients modified versions of their own immune system’s T cells – white blood cells that help protect the body from disease.

“Treating patients with CAR T cells has been one of my most exciting professional experiences, and the FDA approval of this therapy offers hope and optimism to a subset of patients whose other treatments have failed them,” said Caron Jacobson, MD, medical director of the Immune Effector Cell Therapy program at DF/BWCC. “It is extremely rewarding to be able to offer a new therapy to patients who had virtually no other options just 12 to 24 months ago.”

Clinical Trial Demonstrates Safety, Effectiveness

The drug, known as Yescarta (axicabtagene ciloleucel), was developed by Kite Pharma and can be used to treat adults with refractory aggressive B-cell non-Hodgkin lymphoma.

Over the past couple of years, Jacobson and her team have been testing Yescarta in a clinical trial at DF/BWCC, the only facility in the northeast that was part of the trial.

The FDA ruling is based on the results of this nationwide trial, which showed the therapy to be safe and effective. Of the 101 patients who received Yescarta, 82 percent responded to the treatment, with 54 percent having a complete response to therapy. Thirty-six percent of patients remain in complete remission six months after treatment.

“This therapy requires just a one-time infusion for patients, and the results are evident within one month,” Jacobson said. “It is our goal as clinicians to help patients and improve their quality of life. Seeing these patients return to work, their families and their livelihoods so quickly is an important reminder of how far we have come. It is also inspiration for the work we still need to do.”

The initial clinical trials of CAR T-cell therapy have involved pediatric and adult patients with blood-based cancers such as leukemia, lymphoma and multiple myeloma. Based on the therapy’s success so far, CAR T-cell therapy trials are now opening for certain types of solid tumors as well.

“The successful development of CAR T-cells as a therapy for cancer is a testament to the progress we have made in understanding how our immune system is regulated and how cancer evades the immune system,” Jacobson said. “It is a perfect example of how basic science research can fuel clinical progress. Now we need to take what we can from the clinic back to the laboratory to make this therapy even better.”

From left: Frannie Carr Toth and her son, Michael, reunite with obstetrician Daniela Carusi, who delivered Michael at BWH.

Following an ultrasound appointment 24 weeks into her second pregnancy, Frannie Carr Toth tried to process the information she just received: a diagnosis of placenta accreta, a rare but serious condition that occurs when the placenta embeds too deeply in the uterine wall. The complication carries a high risk of severe bleeding during delivery.

Carr Toth was closely monitored throughout the rest of her pregnancy by her obstetrician, Daniela Carusi, MD, MSc, of the Department of Obstetrics and Gynecology, and a multidisciplinary care team at the Brigham. However, the severity of the accreta – that is, how deeply embedded the placenta was – would not be known until the baby was born.

“It was really scary. I was worried about my life and my baby’s life,” Carr Toth said.

After experiencing several episodes of bleeding shortly before her scheduled caesarean section, she lost half of her body’s blood volume during delivery. But thanks to a lifesaving surgery, expert care and the well-stocked blood bank at BWH, Carr Toth and baby Michael are now healthy and at home with their loved ones.

Hoping to encourage more people to donate blood and platelets, Carr Toth shared their story during the Brigham’s third annual Accreta Awareness Blood Drive, hosted by the Kraft Family Blood Donor Center at Stoneman Centennial Park on April 7.

“I put so much of the credit on Dr. Carusi and the team’s shoulders, but also among the big heroes in this story are the nameless donors who took it upon themselves to give blood, and I wish I could personally thank them,” Carr Toth said.

Placenta accreta affects about one in 500 pregnancies in the U.S., and it is more likely to occur in women who have had a prior C-section or uterine surgery, said Carusi, who specializes in treating mothers with the condition. During childbirth, the placenta typically separates from the uterus. In patients with placenta accreta, there is a high risk of severe bleeding when the placenta cannot detach. A C-section is required to deliver the baby safely; even so, mothers can still experience life-threatening blood loss.

“Pregnancy and delivery, which is usually such a normal and exciting time, can be very dangerous for some women,” Carusi said. “Having providers who are trained to take care of this – and having blood banks that are ready to respond – are really essential to keeping mothers safe.”

Blood banks nationwide have faced a blood shortage since last May, said Malissa Lichtenwalter, supervisor for donor recruitment at the Kraft Center. Drives like the one held for accreta awareness and individual donations are vital to keeping BWH’s blood bank stocked, she said.

Carr Toth noted another reason she feels grateful to receive care at BWH. Although placenta accreta results in a hysterectomy for most women, Carr Toth’s C-section was performed using a novel technique called “hybrid surgery” that enables some patients, including her, to avoid a hysterectomy. In this collaborative procedure, interventional radiologists embolize – that is, temporarily block – blood flow to the uterus as soon as the baby is delivered.

“I knew that it might not work out, but I wanted to try,” Carr Toth said. “I put my trust in the team, and we emerged from this worst-case scenario with best-case outcomes.”

Carr Toth said her overall experience as a Brigham patient has reinforced that she and her family came to the safest, most compassionate place to receive care.

“I felt like I was given all the information I needed and empathetic, wonderful care,” she said. “When I needed to be admitted, everybody from triage to labor and delivery to the antepartum floor just made me feel so well taken care of.”

While on a second tour of duty in Afghanistan in 2010, now-retired Marine Sgt. John Peck’s life changed in an instant when he stepped on an improvised explosive device (IED), triggering an explosion. He lost both of his legs and a large part of each arm. Later, he developed an infection, which required a further amputation of his left arm to save his life.

For two months after the blast, Peck remained at Walter Reed Army Medical Center in Washington, D.C. He has since undergone more than two dozen surgeries to address his injuries.

Ready to move forward, Peck, of Fredericksburg, Virginia, completed an evaluation at BWH in August 2014 to receive a double-arm transplant. Two years later, life was about to transform again—this time, for the better. He received a call this summer from Simon G. Talbot, MD, BWH director Upper Extremity Transplantation, with news that the bilateral arm transplant would take place at the Brigham.

“My life had been on a timeout for a while,” said Peck, now 31, a recipient of two Purple Hearts. “When I got the call, I broke down and cried. I quickly had to pull it together because I had to get to Boston. I was ready to face the challenges with patience and perseverance.”

At an Oct. 5 press conference in BWH’s Zinner Breakout Room, Peck joined Talbot and David Crandell, MD, medical director of the Amputee Program at Spaulding Rehabilitation Network, where Peck has been undergoing outpatient rehabilitation, to share his story with the world.

Peck recounted the moment he saw his new hands for the first time.

“It was pure love at first sight,” Peck said. “When I look down at my hands, they seem so natural. It was just a perfect match.”

In August, a multidisciplinary team—including 12 surgeons—worked nearly 14 hours to transplant the arms, one below the elbow and one above. Peck’s case was the fourth bilateral arm transplant performed at the Brigham.

Peck’s surgery went seamlessly, Talbot said. Although Peck experienced a brief episode of rejection about two weeks after surgery, which is common among transplant recipients, he’s now doing well and meeting all of his milestones, he added. Peck is expected to regain function and sensation in his new limbs over the next several months.

“While every patient is special to us, having the opportunity to care for a patient who has given so much in service to this country was especially meaningful to our team, particularly to those who have served,” Talbot said.

During the press conference, Alexandra Glazier, president and chief executive officer of the New England Organ Bank, thanked the donor family and talked about the life-changing benefits of organ donation.

“We are continually humbled and inspired by the willingness of donor families to give to others while they deal with the profound and sudden loss of a loved one,” Glazier said.

Peck is relearning how to perform basic tasks with his hands—picking things up, eating, brushing his teeth, getting in and out of a wheelchair and, perhaps most important to him, holding the hand of his fiancée, Jessica Paker.

His new arms serve another special purpose—he’s able to wear a memorial bracelet on his wrist that honors the memory of a friend killed in action.

“It means a lot to me that I can actually wear it now,” said Peck. “Military members wear these bracelets to celebrate the lives and successes of our fallen brothers. I’m just happy that I could finally put it on.”

Looking ahead, he would like to one day attend culinary school and audition to be a star on the Food Network channel—a dream of his since he was a child.

Peck commended his medical team for giving him a new chance at life.

“Their expertise is world class,” he said. “I am grateful to the entire team—including the surgeons, nurses, anesthesiologists, residents and specialists—who worked together to perform the surgery and provide my follow-up care.”

In addition, Peck gave special thanks to his anonymous donor and the donor’s family for making the transplant possible. Because of them, he’s been given a new chance at life.

“Every day when I look down at my new arms, I will drive on through the pain and I will never give up,” Peck said. “I will remember my donor’s selflessness and his gift until the day I die. I want the family to know that I appreciate their bravery and courage in making the decision to donate their loved one’s organs. I assure them that I will not let this gift go to waste.”

From left: Sean Jackson, Clare Tempany, Angela Kanan and Alexandra Golby celebrate the AMIGO suite’s fifth anniversary.

In the five years since the Advanced Multimodality Image Guided Operating (AMIGO) suite opened at BWH, more than 1,200 procedures have been performed there—a figure Clare Tempany, MD, medical director of AMIGO, says wouldn’t have been possible without BWH’s commitment to expanding the boundaries of medicine.

“We’ve seen amazing results in many fields of medicine and surgery within AMIGO,” she said. “We’re honored so many people have supported the suite, and we hope they continue to do so for years to come.”

A joint endeavor between BWH and the National Institutes of Health, the AMIGO suite spans 5,700 square feet of operating and imaging technologies. Multidisciplinary teams of specialists—including radiologists, surgeons, anesthesiologists, nurses, technologists, engineers and researchers—use its equipment and novel design to efficiently and precisely guide treatment before, during and after a procedure, without the patient or clinical team having to leave the operating room.

It is the first operating suite in the world to house a complete array of advanced imaging equipment and interventional surgical systems, along with advanced navigational technologies for use during procedures, enabling less-invasive, more-effective therapies.

Clinicians have used the AMIGO suite to perform surgeries and procedures in several areas, including Neurosurgery, Interventional Radiology, Endocrine Surgery, Radiation Oncology and Surgical Oncology. Case volume in AMIGO has continued to rise, with about 296 cases performed in 2015 and 385 projected for 2016.

Neurosurgeon Alexandra Golby, MD, AMIGO co-director and director of Image-Guided Neurosurgery, recalls performing the first procedure in the suite in 2011. Looking back, she’s proud of how AMIGO’s scope has expanded.

“Even before AMIGO launched, we had a vision to make it a multispecialty and multi-organ suite,” Golby said. “In AMIGO, patients have access to state-of-the-art, first-in-human approaches, and everything we do is built on that as the guiding principle: Perform the best possible interventions for patients, which are really personalized to their needs.”

Golby said this includes patients who come to AMIGO with particularly complex cases that other treatments were unable to resolve.

During a recent event celebrating AMIGO’s five-year anniversary, Tina Kapur, PhD, co-director of AMIGO and executive director of Image-Guided Therapy in the Department of Radiology, who also provides research oversight in AMIGO, said she was happy that AMIGO continues to be a vibrant place for research. Over the last two years, several papers about research performed in the suite have been published in peer-reviewed journals.

“To know that we have performed more than 1,200 procedures has been amazing,” Kapur said. “We have been able to survive and thrive, and now our mission is to plan for the next 1,200 cases.”

AMIGO has played a pivotal role in pioneering discoveries, agreed Mehra Golshan, MD, distinguished chair in Surgical Oncology at BWH, who has tapped the center’s resources for a clinical trial studying women diagnosed with early-stage breast cancer.

“Groundbreaking research in AMIGO has translated to treatment-changing approaches for breast MRIs, which potentially affects tens of thousands of women who undergo breast-conserving therapy,” Golshan said. “In addition, AMIGO has been instrumental in BWH receiving its first grant from the Breast Cancer Research Foundation.”

Since AMIGO opened, about 900 interventional radiology cases have been performed there, including tumor ablations—minimally invasive destruction of cancer tissue—and MR-guided biopsies, which are performed when cancer is visible in MRI images but cannot be confirmed by traditional biopsies. More than 200 Neurosurgery procedures have been performed, including brain tumor resections and deep brain stimulations, which treat various disabling neurological symptoms.

Looking forward, Kapur hopes teams in AMIGO will be able to partner even more closely with technology companies to help develop and test new devices, software and imaging. “We’re a unique test bed to do that because we have an unusual mix, where researchers and clinicians work closely every day,” she said.

During the event, speakers acknowledged the late Ferenc A. Jolesz, MD, who was the driving force behind AMIGO.

“Ferenc was like a second father to me,” said Golby. “He was a true visionary. I hope we can do him proud as we take our work into the next five years of image-guided therapy.”