title: 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.
  
  
  METHODS
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave. Crile Building, A-41, Cleveland, OH, 44195, USA. meskon@ccf.org.
authors.forename: Nathan W
authors.initials: NW
authors.lastname: Mesko
authors.affiliation: Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave. Crile Building, A-41, Cleveland, OH, 44195, USA.
authors.forename: David M
authors.initials: DM
authors.lastname: Joyce
authors.affiliation: Department of Diagnostic Radiology, Cleveland Clinic, Cleveland, OH, USA.
authors.forename: Hakan
authors.initials: H
authors.lastname: Ilaslan
authors.affiliation: Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Ave. Crile Building, A-41, Cleveland, OH, 44195, USA.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Joyce
mesh_terms: D004867:Equipment Design; D005260:Female; D005629:Frozen Sections; D006801:Humans; D007430:Intraoperative Care; D018208:Liposarcoma, Myxoid / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D008279:Magnetic Resonance Imaging / Q000295:instrumentation; D000072662:Margins of Excision; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local; D018365:Neoplasm, Residual; D009873:Operating Rooms / Q000458:organization & administration*; D058638:Operating Tables; D011237:Predictive Value of Tests; D012086:Reoperation; D012983:Soft Tissue Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D025321:Surgery, Computer-Assisted / Q000295:instrumentation / Q000379:methods*; D016896:Treatment Outcome; D057188:Workflow