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Image-Guided Surgery and Interventions
in the
dvanced ultimodality mage- uided
perating Suite
Tina Kapur, PhD
Executive Director, Image-Guided Therapy
Brigham and Women’s Hospital & Harvard Medical School
August 1, 2016, AAPM, Washington DC
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Advanced Multimodality Image Guided Operating (AMIGO) Suite
Precise Localization of Tumor Boundaries for Therapy
Clinical Testbed for P41 EB015898 (PI Tempany)
National Center for Image-Guided Therapy
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MRI
PET/CT
OR
ANGIO
Courtesy Balasz Lengyel 3
Precise Localization of Tumor Boundaries for
Therapy
+ultrasound
+ navigation
+mass spect 5700 Square Feet
Launched in 2011
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Advanced Multimodality Image
Guided Operating (AMIGO) Suite
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1134 Procedures in AMIGO
08/31/2011-05/13/2016
Brain 191
• MRI and Ultrasound Brain Tumor Resection 121
• MRI Deep Brain Stimulation 29
• MRI Transsphenoidal Pituitary Tumor 22
• MRI Laser Brain Tumor Ablation 10
• MRI Skull Base Surgery 5
Head and Neck 27
• MRI Cryotherapy Head & Neck Tumor 11
• Parathyroidectomy 5
Skeletal 17
• MRI Cryoablation Spine Tumor 8
• MRI Cryoablation Degenerative Spine 4
Heart, Lung, Breast 95
• Video Assisted Thoracoscopic surgery (iVats) 30
• MRI Breast Conserving Surgery 23
• MRI Cardiac EP Ablation 7
• PET/CT Microwave Ablation Lung Tumor 7
Abdominal 319
• MRI Cryoablation Liver/Kidney Tumor 185
• PET/CT Microwave Ablation Liver/Kidney Tumor 50
• PET/CT Cryoablation Liver/Kidney Tumor 42
• PET/CT Pheochromocytoma Resection 3
Pelvic 485
• MRI Prostate Biopsy 368
• MRI and US Gynecologic Brachytherapy 92
• MRI and US Prostate Brachytherapy 8
• MRI Cryoablation Prostate Tumor 8
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AMIGO Procedures are
• Standard of Care +
• Under IRB (17 IRB protocols in place)
• Typically one surgery at a time, now 2 IR
procedures in parallel
• Physician decides when AMIGO is beneficial
Gliomas for brain tumor surgery
Large cervical cancers for gynecologic brachytherapy
Repeat negative TRUS biopsy and rising PSA for MR-
guided prostate biopsy
Location of tumor for osteoid osteomas for MR-guided
cryoablation
Difficult to localize pheochromocytoma for FDG-PET/CT-
guided resection
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Some examples
• Brain tumor resection (121)
• Breast cancer surgery (23)
• Gynecologic Brachytherapy (92)
Optimal surgery for brain tumors
Goal • Complete resection
• No neurologic injury
Alexandra Golby, MD Neurosurgeon
Goals of image-guided neurosurgery
Lesion and define margins
Critical structures
Relationship between lesion and eloquent areas
Pre-operative planning
Surgical decision-making
Surgeon wants to see:
For the individual patient
To accomplish:
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iMRI impact on survival, BWH 0.5T MRI
series: 90 vs. 39 months, 164 patients
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non-iMRI iMRI
4-yearsurvival
no-survival
4 y
ea
r S
urv
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Olubiyi OZ, Rigolo L, Golby AJ. Intraoperative Magnetic Resonance
Imaging in Intracranial Glioma Resection: A Single-Center,
Retrospective Blinded Volumetric Study. World Neurosurg. 2015
Brain tumor resection in AMIGO.
Navigation on pre-operative MRI is used to perform a
minimal craniotomy with optimized exposure of the lesion
When the dura is exposed, navigated ultrasound imaging
is performed prior to making any incisions. Ultrasound
provides a fast initial orientation, including the location of
major blood vessels.
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In a very small subset of cases (now), after the dura is opened
and the cortex is exposed, intracranial electrical stimulation testing
(ECS) is performed to map important functional areas. This is
valuable in confirming and applying preoperative fMRI findings.
Increasingly BOLD fMRI maps are used (without ECS)
to delineate the proximity of ‘eloquent cortex’ to lesion.
Navigation provides the
surgeon with location
and trajectory of her
tools.
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White matter tractography provides visualization of the
tumor relative to the arcuate fasciculus white matter tract.
Image guidance makes effective tumor resection
possible.
Intraoperative MR: Prior to intraoperative MRI,
a temporary closure is performed.
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A ceiling mounted high field (3T) MR scanner is brought
into the OR for intra-operative imaging.
Tumor assessment from pre-op MRI image vs. residual tumor
Post-operative MR scan confirms no intraoperative complications
and sets a new baseline. Once conscious, the patient is
immediately asked to demonstrate motor control, such as foot
movement.
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Agar, NYR., Golby, AJ, Ligon, KL, Norton, I, Mohan, V, Wiseman, JM, Tannenbaum, A, and Jolesz, FA (2011)
Neurosurgery. Development of Stereotactic Mass Spectrometry for Brain Tumor Surgery. 68(2):280-89
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T: ITMS - p NSI Full ms [100.00-1500.00]
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Stereotactic Mass Spectrometry for Tumor Margin and Composition
Why Mass Spectrometry in Neurosurgery?
Many Intra-operative decisions are based on Frozen sections a
technology that has been around for the last 150 years. This
takes on average 30 minutes.
We want rapid and actionable intra-operative methods for
molecular characterization of tissue samples in AMIGO.
Desorption electrospray ionization (DESI) MS can detect 2-
hydroxyglutarate (2-HG), an onco-metabolite from tissue
sections.
2-HG is present in very small amounts in normal cells.
It has been found in large quantities in cells with IDH-1/2
mutations. These include gliomas.
http://www.sigmaaldrich.com/technical-documents/articles/analytical/applications/lcms_hydroxyglutarates.html
80% of grade II and grade III gliomas and majority of
secondary glioblastomas contain IDH1 or IDH2 mutations
Monitoring 2-HG with intra-operative MS could become
routinely used for surgeries of primary brain tumors, first to
classify the tumor and then, if 2-HG is present, to guide
optimal resection.
Intra-operative mass spectrometry mapping of
an Onco-metabolite to guide brain tumor
surgery Santagata S, Eberlin LS, Norton I, Calligaris D, Feldman DR, Ide JL, Liu X, Wiley
JS, Vestal ML, Ramkissoon Sh, Orringer DA, Gill KK, Dunn IF, Dias-Santagata
D, Ligon KL, Jolesz FA, Golby AJ, Cooks RG, Agar NY
http://www.sigmaaldrich.com/technical-documents/articles/analytical/applications/lcms_hydroxyglutarates.htmlhttp://www.sigmaaldrich.com/technical-documents/articles/analytical/applications/lcms_hydroxyglutarates.htmlhttp://www.sigmaaldrich.com/technical-documents/articles/analytical/applications/lcms_hydroxyglutarates.htmlhttp://www.sigmaaldrich.com/technical-documents/articles/analytical/applications/lcms_hydroxyglutarates.html
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Breast Conservation Surgery
•Need for re-excision is 20-40% in US
•AMIGO
intra-procedural supine breast MRI
for assessment of tumor margins and
localization of residual disease
Gombos EC, Jayender J, Richman DM, Caragacianu DL, Mallory
MA, Jolesz FA, Golshan M.
Intraoperative Supine Breast MR Imaging to Quantify Tumor
Deformation and Detection of Residual Breast Cancer: Preliminary
Results. Radiology. 2016 Jun
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Breast Conservation Surgery
Pre-procedural imaging Surgery
Post-procedural imaging Re-excision
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Gynecologic Cancers
• 500,000 cases per year
worldwide: Cervical, Uterine,
Vaginal, Vulvar, Ovarian
• 4th leading cause of death in
women in the US
• Treated with chemo-
radiation, brachytherapy
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30% outcome improvement
over chemo-radiation
MR is the preferred imaging
modality for gyn cancer
Needle artifacts in MR are
ambiguous vs. x-ray or CT
CTV
Needles
Rectum
Bladder
Sigmoid
MRI-guided Gynecologic Cancer
Brachytherapy
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The Segmentation Algorithm
1. For each needle, use a manually defined tip to iteratively
search for a short, dark, thin tube
add this to segmentation if it conforms with the ”physical model” for the needle; large deflections allowed near the tip and only very small near the base.
2. After all needs are individually segmented, identify needle pairs that are physically
improbable
remove the artifact that is causing the errors
repeat the individual segmentation algorithm for the erroneous needle(s).
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Search for a short, dark, thin
tubes
Goal: Find points on the needle path to fit a Bézier
curve accurately approximating the catheter shape
Pernelle et al. MICCAI 2013
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Constrain by Angular Spring Model: large
deflections near the tip and only very
small near the base
Andre Mastmeyer 2014
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Remove Physical Improbably Pairs
Re-Segment
Ruibin Ma 2015
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54 Patients
760 Catheters
93% accuracy
3sec/Catheter
• Mastmeyer et al. [In preparation] 2016
• Pernelle, G. et al., MICCAI. 2013.
• Kapur, T. et al. Magnetic Resonance Imaging 2012.
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Augment the eye with imaging
Augment the hand with robotics
Update images intraoperatively
Navigate to delivery site
Reduce invasiveness of surgery
Apply to multiple procedures
Image-Guided Therapy is the new Surgery Integration of advanced imaging technology in the OR
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Workshops and Events
9th National IGT Workshop
March 14-15, 2017, Washington DC
24th NA-MIC Project Week Open Source Hackathon January 9-13, 2017, MIT
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Advanced Multimodality Image Guided Operating (AMIGO) Suite
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