Tutorial: Image Guided Therapy - Stanford...
Transcript of Tutorial: Image Guided Therapy - Stanford...
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LearningobjecIve
• Tounderstandthefundamentalsofmedicalimaging
• Tounderstandtheroleofmedicalimagingtoguidetherapyanddiagnosis–ImageGuidedTherapy
• TolearnroleofroboIcsinImageGuidedTherapyresearchandkeyenablingtechnologies
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Imaginginmedicine
• Weareinaperfectcitytodiscussmedicalimaging.
Copyright©NobelsINelsen2007Foto:HansMehlin
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TheNobelPrizeinPhysics1901
WilhelmConradRöntgenX-ray X-rayFluoroscope
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TheNobelPrizeinPhysiologyorMedicine1979
Cormack HounsfieldEMICTScannerLondonSciencemuseum
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SlicerDemonstraIonofCT
Toshiba
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TheNobelPrizeinPhysiologyorMedicine2003
Lauterber Mansfield MappingofNuclearmagneIcresonance(NMR):quantummechanicalmagneIcproperIesofthehydrogenatomsinwaterandfat
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SlicerDemonstraIonofMRI
Siemens
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JapanPrize1991
Wild
Philips
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ImageGuidedTherapy
Philips
[QUIZ]
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LiverCancer
Unresectablelivercancers(someT1toT4,N0,M0tumors)ThetumoristoolargetoberemovedsafelyThetumorisinapartoftheliverthatmakesithardtoremove(suchasveryclosetoalargebloodvessel)Thereareseveraltumorsorthecancerhasspreadthroughouttheliver
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Acad Radiol 2005;12:1100-109
ImageGuidedTherapyExample…AblaIvetherapy
• Suitableforunresectablelivercancers• HeatandcoolingenergytodestroycancerousIssue
• Lessinvasivethanopensurgery• Imageguidanceiscrucialfor[QUIZ]
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RoleofImagingforTherapy
• TargeIng• NavigaIonandGuidance
• Monitoring
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Song,Tuncali
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ImageGuidedTherapy
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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)
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Problemstatement• PreciseandcontrolledplacementofablaIveprobes
mandatory– Tomaximizethetreatmenteffect– MinimizedamagetosurroundingcriIcalstructures
• Freehandapproachlimitphysicians’precisionplacementofablaIontools.
SegmentedtumoronCTwithprobesposiIoned
SegmentedtumoronCTwithiceball
3DevaluaIonofablaIonprocedure
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NeedleposiIoningdeviceonasurfacecoilforMRgliverintervenIons
Wu,Torabi,Walsh(MIT/Harvard),Tuncali,Yamada,Hata(BWH),Fischer(WPI),NCIGTWSposter
WithConorWalsh(Harvard)andKemalTuncali(BWH)
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3DSlicer
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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
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TreatmentopIonsforlocalizedStageIprostatecancer
• WatchfulwaiIng.• AcIvesurveillance.Ifthecancer
beginstogrow,hormonetherapymaybegiven.
• Radicalprostatectomy,usuallywithpelviclymphadenectomy.External-beamradiaIontherapy.
• InternalradiaIontherapywithradioacIveseeds.
Biopsyiscrucialpartofstagingandmakingtreatmentdecisions
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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
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MRIandMRI-guidedbiopsies
• MRIofprostatecandetectclinicallysignificantcancers[Barentsz12]
• MRIlocalizesprostatecancersbeqerthandigitalexamandblindbiopsy[Mullerard05]
• WhynotuseMRIforguidingbiopsy?
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AUA
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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)
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Tempany et al
3DSlicer
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Tempany,Song,Tokuda,Kacher,Iordachita,Fairhurst,Kanan,Tuncali
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Tempany et al
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Tempany et al
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Tempany, Fennessy, Tuncali
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SmartTemplate
Song,Tokuda,Tuncali,Tempany
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SmartTemplateDesign
Ultrasonic Motors
Timing Belts
Biopsy Gun
Limiter Sensors
Crossbar Needle Hole
Z-frame attached Inside view
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TeleoperaIontoControlRoboIcInserIonGregFischer,WPI
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ROBITOM,UniversityofJena
• KaiserFischeretal2000• Pfleidereretal2008• Breastbiopsy• 1.5Tscanner• 14casestested
Pfleidereretal2008
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UtrechtProstateRobot
• 1.5T• vandenBosch2010• DeliverfiducialgoldmarkersinsideprostatesofpaIentseligibleforexternalbeamradiotherapytreatment(EBRT)
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UtrechtProstateRobot• “TherobottappedtheneedlestepwisetowardsthisposiIonwhile
controllingthestepsize(typically5mm)andtheneedledepth.”• “Duringthetappingfast2DMRscanswereacquiredtotracktheneedle
trajectoryon-lineandtoindependentlymonitortheneedledepth”
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QuesIons?
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FundamentalsofRoboIcsinIGT
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DesignconsideraIon
• Diseaseandanatomy• Procedure(approach,medicaltools,anesthesia)
• Metricforclinicalsuccess
• ParIcipantsintheprocedure
• Workflow• Devicesinvolved
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Targeting
Monitoring
Navigation and Control
TechnicalComponents
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Roles of robotics can be best described using space technology as analogy.
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Guidance,NavigaIonandControl
Charles Stark Draper and MIT Draper Labs (1969)
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Targeting
Monitoring
Navigation and Control
TechnicalComponents
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EnablingengineeringmethodsinImageGuidedTherapy
• Imaging• Graphics• Control
• Tracking/Guidance/NavigaIoninacIon(demonstraIon)
• Imageprocessing(demonstraIon)• Vision->moIoncompensaIonanddetecIon• RegistraIon
– Registeringadevicetoimages
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SlicerIGTDemonstraIon
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ImageProcessingDeformableRegistraIonofPre-andIntra-proceduralImages
BrainsFitModulein3DSlicerRigid,Affine,B-splinedeformableregistraIonFederovetal,ISMRM2011
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Vision- Image-based Motion Adaptive Instrument
Hong J, Hata N, et.al.,Phys Med Biol, 49(3), 441-455, 2004
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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
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DesignconsideraIon
• Diseaseandanatomy• Procedure(approach,medicaltools,anesthesia)
• Metricforclinicalsuccess
• ParIcipantsintheprocedure
• Workflow• Devicesinvolved
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DiMaioetal
MRIscan
RegistraIonMRIvs.designmodel
TemlpateandMRIregistered
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RegistraIonforabdominalrobot
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ImageGuidedSurgery:$1.4
Billion
RoboIcsAssistedSurgery:$2.6
Billion
RoboIcRadioSurgery:$560
Million
ImageGuidedTherapyMarketSegments:NotIndependentSilos,theBoundariesareBlurring…
59
NavigaIonSystems:$1.6Billion
Frost&Sullivan2014EsImatesforU.S.,WesternEurope,andAsia
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$-
$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
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Monteris
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VisualaseMRI-guidedlaserablaIonofbraintumorandepilepsy
CopyrightHarmonus
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• 1999-2007– SBIRgrantfromtheNIH– Over$7.2MinNIHandstategrantfunding– $9.4Minprivateinvestments
• 2006– Firstinmanstudy
• 2007– ThedevicereceivedFDA510(k)clearanceforneurosurgery– thengeneralsurgeryandurology
• 2014– thecompanywasacquiredbyMedtronicforupto$105M
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• ProvidessignificantbenefitsforhealthcaresystemsandpaIents– reducedpaIenttrauma– shorterrecoveryImesandhospitalstays– lowercostsfromfewermedicalerrorsandcomplicaIons.
• Improvesaccuracyandefficiencyofcomplexsurgicalprocedures
Conclusion-ImageGuidedTherapy
64CopyrightHarmonus
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Real-ImeintraoperaIveimaging
• CaptureschangesinpaIentanatomy• notapparentthroughpre-operaIveimaging
• WithRoboIcs,enablesphysicianstocreateexactdetailedsurgicalplan• thebestincisionsite,theopImalpathtothetargetedarea,andwhatcriIcalstructuresmustbeavoided
• Convertsopensurgerytominimallyinvasiveprocedures• offeringnewalternaIvesforpaIentswhowouldhavebeenconsideredinoperableinthepast