Tutorial:ImageGuidedTherapy

NobuhikoHata,PhDBrighamandWomen’sHospital

HarvardMedicalSchoolhata@bwh.harvard.edu

LearningobjecIve

•  Tounderstandthefundamentalsofmedicalimaging

•  Tounderstandtheroleofmedicalimagingtoguidetherapyanddiagnosis–ImageGuidedTherapy

•  TolearnroleofroboIcsinImageGuidedTherapyresearchandkeyenablingtechnologies

Imaginginmedicine

•  Weareinaperfectcitytodiscussmedicalimaging.

Copyright©NobelsINelsen2007Foto:HansMehlin

TheNobelPrizeinPhysics1901

WilhelmConradRöntgenX-ray X-rayFluoroscope

TheNobelPrizeinPhysiologyorMedicine1979

Cormack HounsfieldEMICTScannerLondonSciencemuseum

SlicerDemonstraIonofCT

Toshiba

TheNobelPrizeinPhysiologyorMedicine2003

Lauterber Mansfield MappingofNuclearmagneIcresonance(NMR):quantummechanicalmagneIcproperIesofthehydrogenatomsinwaterandfat

SlicerDemonstraIonofMRI

Siemens

JapanPrize1991

Wild

Philips

ImageGuidedTherapy

Philips

[QUIZ]

LiverCancer

Unresectablelivercancers(someT1toT4,N0,M0tumors)ThetumoristoolargetoberemovedsafelyThetumorisinapartoftheliverthatmakesithardtoremove(suchasveryclosetoalargebloodvessel)Thereareseveraltumorsorthecancerhasspreadthroughouttheliver

Acad Radiol 2005;12:1100-109

ImageGuidedTherapyExample…AblaIvetherapy

•  Suitableforunresectablelivercancers•  HeatandcoolingenergytodestroycancerousIssue

•  Lessinvasivethanopensurgery•  Imageguidanceiscrucialfor[QUIZ]

RoleofImagingforTherapy

•  TargeIng•  NavigaIonandGuidance

•  Monitoring

14

Song,Tuncali

ImageGuidedTherapy

Roentgen•  Nov. 8, 1895: found

X-ray •  Dec. 28:paper

submitted •  Jan. 5:paper

published •  Jan 13:First

diagnostic imaging •  Jan 14: First image-

guided therapy (needle removal)

Problemstatement•  PreciseandcontrolledplacementofablaIveprobes

mandatory–  Tomaximizethetreatmenteffect–  MinimizedamagetosurroundingcriIcalstructures

•  Freehandapproachlimitphysicians’precisionplacementofablaIontools.

SegmentedtumoronCTwithprobesposiIoned

SegmentedtumoronCTwithiceball

3DevaluaIonofablaIonprocedure

NeedleposiIoningdeviceonasurfacecoilforMRgliverintervenIons

Wu,Torabi,Walsh(MIT/Harvard),Tuncali,Yamada,Hata(BWH),Fischer(WPI),NCIGTWSposter

WithConorWalsh(Harvard)andKemalTuncali(BWH)

3DSlicer

CanonRobotsforabdominalintervenIons

•  Patient-attached, RCM at skin entry •  Can accommodate an imaging coil •  Fiducial marker based registration

23

Prostate Cancer

•  IntheUS,220,000menarediagnosedwithProstatecancer.

•  80%ofprostatecancerpaIentshavelocalizedcancer,StageI,cancer.

•  Prostatecancerisslowglowingdisease.

•  5yearsurvivalrateoflocalizedprostatecanceris100%.

ConfidenIal 24

SEER182006-2012,AllRaces,MalesbySEERSummaryStage2000

TreatmentopIonsforlocalizedStageIprostatecancer

•  WatchfulwaiIng.•  AcIvesurveillance.Ifthecancer

beginstogrow,hormonetherapymaybegiven.

•  Radicalprostatectomy,usuallywithpelviclymphadenectomy.External-beamradiaIontherapy.

•  InternalradiaIontherapywithradioacIveseeds.

Biopsyiscrucialpartofstagingandmakingtreatmentdecisions

Today’s Standard Transrectal Ultrasound Prostate Biopsy Misses 25% of Significant Cancers

• Standard Transrectal Ultrasound biopsy procedure is inadequate because:

–  6-12 locations are “blindly” sampled

–  High incidence of false negative results drives 31% repeat rate

–  Can cause serious complications

–  Low detection of tumors in prostate apex

AUA

MRIandMRI-guidedbiopsies

•  MRIofprostatecandetectclinicallysignificantcancers[Barentsz12]

•  MRIlocalizesprostatecancersbeqerthandigitalexamandblindbiopsy[Mullerard05]

•  WhynotuseMRIforguidingbiopsy?

27

AUA

Prostate Intervention Tools

(A) Base board (B) Leg support (C) Stationary frame (D) Template (plexiglas) (E) �Z-frame�

(A)

(B)(C),(D)

(E)

(B)

(D)

Tempany et al

3DSlicer

31

Tempany,Song,Tokuda,Kacher,Iordachita,Fairhurst,Kanan,Tuncali

Tempany et al

Tempany et al

Tempany, Fennessy, Tuncali

SmartTemplate

Song,Tokuda,Tuncali,Tempany

SmartTemplateDesign

Ultrasonic Motors

Timing Belts

Biopsy Gun

Limiter Sensors

Crossbar Needle Hole

Z-frame attached Inside view

39

TeleoperaIontoControlRoboIcInserIonGregFischer,WPI

ROBITOM,UniversityofJena

•  KaiserFischeretal2000•  Pfleidereretal2008•  Breastbiopsy•  1.5Tscanner•  14casestested

Pfleidereretal2008

UtrechtProstateRobot

•  1.5T•  vandenBosch2010•  DeliverfiducialgoldmarkersinsideprostatesofpaIentseligibleforexternalbeamradiotherapytreatment(EBRT)

UtrechtProstateRobot•  “TherobottappedtheneedlestepwisetowardsthisposiIonwhile

controllingthestepsize(typically5mm)andtheneedledepth.”•  “Duringthetappingfast2DMRscanswereacquiredtotracktheneedle

trajectoryon-lineandtoindependentlymonitortheneedledepth”

QuesIons?

FundamentalsofRoboIcsinIGT

DesignconsideraIon

•  Diseaseandanatomy•  Procedure(approach,medicaltools,anesthesia)

•  Metricforclinicalsuccess

•  ParIcipantsintheprocedure

•  Workflow•  Devicesinvolved

Targeting

Monitoring

Navigation and Control

TechnicalComponents

Roles of robotics can be best described using space technology as analogy.

Guidance,NavigaIonandControl

Charles Stark Draper and MIT Draper Labs (1969)

Targeting

Monitoring

Navigation and Control

TechnicalComponents

EnablingengineeringmethodsinImageGuidedTherapy

•  Imaging•  Graphics•  Control

•  Tracking/Guidance/NavigaIoninacIon(demonstraIon)

•  Imageprocessing(demonstraIon)•  Vision->moIoncompensaIonanddetecIon•  RegistraIon

–  Registeringadevicetoimages

SlicerIGTDemonstraIon

ImageProcessingDeformableRegistraIonofPre-andIntra-proceduralImages

BrainsFitModulein3DSlicerRigid,Affine,B-splinedeformableregistraIonFederovetal,ISMRM2011

Vision- Image-based Motion Adaptive Instrument

Hong J, Hata N, et.al.,Phys Med Biol, 49(3), 441-455, 2004

Tool to image registration •  Mandatory to use devices and robots in IGT •  To register the template guide’s coordinate system

to images •  Often disruptive to clinical workflows

Z-frame

Template

DesignconsideraIon

•  Diseaseandanatomy•  Procedure(approach,medicaltools,anesthesia)

•  Metricforclinicalsuccess

•  ParIcipantsintheprocedure

•  Workflow•  Devicesinvolved

DiMaioetal

MRIscan

RegistraIonMRIvs.designmodel

TemlpateandMRIregistered

RegistraIonforabdominalrobot

ImageGuidedSurgery:$1.4

Billion

RoboIcsAssistedSurgery:$2.6

Billion

RoboIcRadioSurgery:$560

Million

ImageGuidedTherapyMarketSegments:NotIndependentSilos,theBoundariesareBlurring…

59

NavigaIonSystems:$1.6Billion

Frost&Sullivan2014EsImatesforU.S.,WesternEurope,andAsia

$-

$5

$10

$15

$20

$25

ImageGuidedTherapy MedicalImaging

Revenues($Billion)

2014E

2019E

ImageGuidedTherapiesareGrowing>TwiceasFastasMedicalImagingMarket

60Market:U.S.,WesternEurope,andAsia(excludingChinaandIndia)Source:Frost&Sullivan

7%peryear

2.7%peryear

Monteris

VisualaseMRI-guidedlaserablaIonofbraintumorandepilepsy

CopyrightHarmonus

•  1999-2007–  SBIRgrantfromtheNIH–  Over$7.2MinNIHandstategrantfunding–  $9.4Minprivateinvestments

•  2006–  Firstinmanstudy

•  2007–  ThedevicereceivedFDA510(k)clearanceforneurosurgery–  thengeneralsurgeryandurology

•  2014–  thecompanywasacquiredbyMedtronicforupto$105M

•  ProvidessignificantbenefitsforhealthcaresystemsandpaIents–  reducedpaIenttrauma– shorterrecoveryImesandhospitalstays–  lowercostsfromfewermedicalerrorsandcomplicaIons.

•  Improvesaccuracyandefficiencyofcomplexsurgicalprocedures

Conclusion-ImageGuidedTherapy

64CopyrightHarmonus

Real-ImeintraoperaIveimaging

•  CaptureschangesinpaIentanatomy•  notapparentthroughpre-operaIveimaging

•  WithRoboIcs,enablesphysicianstocreateexactdetailedsurgicalplan•  thebestincisionsite,theopImalpathtothetargetedarea,andwhatcriIcalstructuresmustbeavoided

•  Convertsopensurgerytominimallyinvasiveprocedures•  offeringnewalternaIvesforpaIentswhowouldhavebeenconsideredinoperableinthepast