Tutorial: Image Guided Therapy - Stanford...
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Tutorial: Image Guided Therapy Nobuhiko Hata, PhD Brigham and Women’s Hospital Harvard Medical School [email protected]
Transcript of Tutorial: Image Guided Therapy - Stanford...
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
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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
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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?
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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
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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
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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…
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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
