Gernot Kronreif

Robotic assistance for ultrasound-guided prostate brachytherapy

We present a robotically assisted prostate brachytherapy system and test results in training phantoms and Phase-I clinical trials. The system consists of a transrectal ultrasound (TRUS) and a spatially co-registered robot, fully integrated with an FDA-approved commercial treatment planning system. The salient feature of the system is a small parallel robot affixed to the mounting posts of the template. The robot replaces the template interchangeably, using the same coordinate system. Established clinical hardware, workflow and calibration remain intact. In all phantom experiments, we recorded the first insertion attempt without adjustment. All clinically relevant locations in the prostate were reached. Non-parallel needle trajectories were achieved. The pre-insertion transverse and rotational errors (measured with a Polaris optical tracker relative to the templates coordinate frame) were 0.25 mm (STD=0.17 mm) and 0.75 degrees (STD=0.37 degrees). In phantoms, needle tip placement errors measured in TRUS were 1.04 mm (STD=0.50mm). A Phase-I clinical feasibility and safety trial has been successfully completed with the system. We encountered needle tip positioning errors of a magnitude greater than 4mm in only 2 of 179 robotically guided needles, in contrast to manual template guidance where errors of this magnitude are much more common. Further clinical trials are necessary to determine whether the apparent benefits of the robotic assistant will lead to improvements in clinical efficacy and outcomes.

Robotic needle guide for prostate brachytherapy: Clinical testing of feasibility and performance

PURPOSE Optimization of prostate brachytherapy is constrained by tissue deflection of needles and fixed spacing of template holes. We developed and clinically tested a robotic guide toward the goal of allowing greater freedom of needle placement. METHODS AND MATERIALS The robot consists of a small tubular needle guide attached to a robotically controlled arm. The apparatus is mounted and calibrated to operate in the same coordinate frame as a standard template. Translation in x and y directions over the perineum ±40 mm are possible. Needle insertion is performed manually. RESULTS Five patients were treated in an institutional review board-approved study. Confirmatory measurements of robotic movements for initial 3 patients using infrared tracking showed mean error of 0.489 mm (standard deviation, 0.328 mm). Fine adjustments in needle positioning were possible when tissue deflection was encountered; adjustments were performed in 54 (30.2%) of 179 needles placed, with 36 (20.1%) of 179 adjustments of >2mm. Twenty-seven insertions were intentionally altered to positions between the standard template grid to improve the dosimetric plan or avoid structures such as pubic bone and blood vessels. CONCLUSIONS Robotic needle positioning provided a means of compensating for needle deflections and the ability to intentionally place needles into areas between the standard template holes. To our knowledge, these results represent the first clinical testing of such a system. Future work will be incorporation of direct control of the robot by the physician, adding software algorithms to help avoid robot collisions with the ultrasound, and testing the angulation capability in the clinical setting.

Robotic assistance for ultrasound guided prostate brachytherapy

We present a robotically assisted prostate brachytherapy system and test results in training phantoms. The system consists of a transrectal ultrasound (TRUS) and a spatially co-registered robot integrated with an FDA-approved commercial treatment planning system. The salient feature of the system is a small parallel robot affixed to the mounting posts of the template. The robot replaces the template interchangeably and uses the same coordinate system. Established clinical hardware, workflow and calibration are left intact. In these experiments, we recorded the first insertion attempt without adjustment. All clinically relevant locations were reached. Non-parallel needle trajectories were achieved. The pre-insertion transverse and rotational errors (measured with Polaris optical tracker relative to the templates coordinate frame) were 0.25mm (STD = 0.17mm) and 0.75 degrees (STD = 0.37 degrees). The needle tip placement errors measured in TRUS were 1.04mm (STD = 0.50mm). The system is in Phase-I clinical feasibility and safety trials, under Institutional Review Board approval.

Transrectal ultrasound for image-guided adaptive brachytherapy in cervix cancer - An alternative to MRI for target definition?

PURPOSE To compare the maximum high risk clinical target volume (CTVHR) dimensions and image quality between magnetic resonance imaging (MRI), transrectal ultrasound (TRUS) and computed tomography (CT) in image guided adaptive brachytherapy (IGABT) of locally advanced cervical cancer. MATERIAL AND METHODS All patients with locally advanced cervical cancer treated with radiochemotherapy and IGABT between 09/2012-05/2013 were included in this study. T2-weighted MRI (1.5 tesla), TRUS and CT were performed before (MRIpreBT, TRUSpreBT) and/or after (MRIBT, TRUSBT and CTBT) insertion of the applicator. 3D TRUS image acquisition was done with a customized US stepper device and software. The HR CTV was defined on 3D image sequences acquired with different imaging modalities by one blinded observer, in accordance to the GEC-ESTRO recommendations for MRI-based target volume delineation, as the complete cervical mass including the tumour, any suspicious areas of parametrial involvement and the normal cervical stroma. Maximum HR CTV width and thickness were measured on transversal planes. Image quality was classified using the following scoring system: Grade 0: not depicted, Grade 1: inability to discriminate, margin not recognizable, Grade 2: fair discrimination, margin indistinct, Grade 3: excellent discrimination, margin distinct. Descriptive statistics, mean differences between the groups, with MRIBT as reference, and a paired t-test were calculated. RESULTS Images from 19 patients (FIGO IB: 3, IIB: 9, IIIB: 5, IVB: 2) were available for analysis. The mean difference in maximum HR CTV width of TRUSBT, TRUSpreBT, MRIpreBT, CTBT to MRIBT was 0.0mm±4.7 (n.s.), -1.1mm±5.6 (n.s.), 0.7mm±6.4 (n.s.) and 13.8mm±6.7 (p<0.001). The mean difference in maximum HR CTV thickness of TRUSBT, TRUSpreBT, MRIpreBT, CTBT to MRIBT was -3.4mm±5.9 (p=0.037), -3.4mm±4.2 (p<0.001), 2.0mm±6.1 (n.s.) and 13.9mm±6.3 (p<0.001). Mean scores of image quality of the target volume was 2.9 for TRUSpreBT, 2.3 for TRUSBT, 2.9 for MRIpreBT, 2.7 for MRIBT and 2.1 for CTBT. CONCLUSION For the assessment of the HR CTV in IGABT of cervical cancer, TRUS is within the intraobserver variability of MRI. TRUS is superior to CT as it yields systematically smaller deviations from MRI, with good to excellent image quality. Small differences of TRUS HR CTV thickness are likely related to differences in image slice orientation and compression of the cervix by the TRUS probe before insertion of the brachytherapy applicator.

Combining transrectal ultrasound and CT for image-guided adaptive brachytherapy of cervical cancer: Proof of concept.

PURPOSE To investigate the feasibility of a treatment planning workflow for three-dimensional image-guided cervix cancer brachytherapy, combining volumetric transrectal ultrasound (TRUS) for target definition with CT for dose optimization to organs at risk (OARs), for settings with no access to MRI. METHODS AND MATERIALS A workflow for TRUS/CT-based volumetric treatment planning was developed, based on a customized system including ultrasound probe, stepper unit, and software for image volume acquisition. A full TRUS/CT-based workflow was simulated in a clinical case and compared with MR- or CT-only delineation. High-risk clinical target volume was delineated on TRUS, and OARs were delineated on CT. Manually defined tandem/ring applicator positions on TRUS and CT were used as a reference for rigid registration of the image volumes. Treatment plan optimization for TRUS target and CT organ volumes was performed and compared to MRI and CT target contours. RESULTS TRUS/CT-based contouring, applicator reconstruction, image fusion, and treatment planning were feasible, and the full workflow could be successfully demonstrated. The TRUS/CT plan fulfilled all clinical planning aims. Dose-volume histogram evaluation of the TRUS/CT-optimized plan (high-risk clinical target volume D90, OARs D2cm³ for) on different image modalities showed good agreement between dose values reported for TRUS/CT and MRI-only reference contours and large deviations for CT-only target parameters. CONCLUSIONS A TRUS/CT-based workflow for full three-dimensional image-guided cervix brachytherapy treatment planning seems feasible and may be clinically comparable to MRI-based treatment planning. Further development to solve challenges with applicator definition in the TRUS volume is required before systematic applicability of this workflow.

Recent trends in automating robotic surgery

Eversince computer technology entered the operating room (OR), surgery has gone through one of the greatest changes in the history of medicine, and now we are foreseeing the age of the digital OR. The range of the novel applications spans from intra-operative navigation to the development of autonomous suturing tools. More recently, after 20 years of experience with pre-programmed, image-guided and teleoperational surgical robots, a new trend is emerging: to create autonomous, or partially autonomous surgical robots. These advanced systems are intended to fit into the surgical workflow, and to help the surgeon in the least intrusive way possible. It is only the recent development of surgical-digital applications which can overcome a the barrier of the cognitive load on surgeons, to become able to completely control of the operating field. Three major trends have been identified in current products and advanced research prototypes: 1) aiming to improve camera handling 2) Sub-task automation 3) complete automation.

Experimental platform for intra-uterine needle placement procedures

A framework has been investigated to enable a variety of comparative studies in the context of needle–based gynaecological brachytherapy. Our aim was to create an anthropomorphic phantom–based platform. The three main elements of the platform are the organ model, needle guide, and needle drive. These have been studied and designed to replicate the close environment of brachytherapy treatment for cervical cancer. Key features were created with the help of collaborating interventional radio–oncologists and the observations made in the operating room. A phantom box, representing the uterus model, has been developed considering available surgical analogies and operational limitations, such as organs at risk. A modular phantom–based platform has been designed and prototyped with the capability of providing various boundary conditions for the target organ. By mimicking the female pelvic floor, this framework has been used to compare a variety of needle insertion techniques and configurations for cervical and uterine interventions. The results showed that the proposed methodology is useful for the investigation of quantifiable experiments in the intraabdominal and pelvic regions.

TH‐B‐224C‐03: Robotically Assisted Needle Placement for Prostate Brachytherapy

Purpose: To present preliminary results for a robotically‐assisted prostate brachytherapy treatment system. Method and Materials: A 4 degree‐of‐freedom (DOF) robotic device was developed to replace the ultrasound template in a commercially available prostate brachytherapy treatment system (Interplant, Computerized Medical Systems, St. Louis, MO). The robot mounts to the existing template mounting points on the ultrasound stepper, and is capable of positioning the needles at arbitrary positions and orientations. The robot is spatially co‐registered to the Interplant treatment planningsoftware through a calibration procedure. We performed a seed‐implantation experiment on a prostate training phantom in which the needles were positioned by the robot. The needles were preloaded with one seed, then inserted manually by the operator under transrectal ultrasound(TRUS) guidance. In this experiment, ten seeds were implanted, and their implanted positions were reconstructed using data from a post‐implant CT of the phantom and the Interplant post‐implant analysissoftware (iPAS). Results: Using the results from the iPAS software, we measured both the relative error of each seed (with respect to the other seeds), and the absolute error of each seed with respect to the treatment plan. The relative root‐mean‐ square (RMS) transverse error was 0.8 mm (worst case 2.1 mm, 70% under 0.7mm), and the relative RMS sagittal error was 2.5 mm (worst case 4mm, 60% under 2.5 mm). The absolute transverse RMS error was 2.4 mm (worst case 4.3 mm, 50% under 2.4 mm), and the absolute sagittal RMS error was 2.5 mm (worst case 4.5 mm, 80% under 2.5 mm). However, the absolute transverse errors were characterized by an offset in each direction, most likely resulting from errors in the measurement of the robot position relative to the phantom. Conclusion: Our system for robotically‐assisted prostate brachytherapy shows potential for improved needle placement, repeatability, and accuracy.

Ultrasound imaging of the posterior skull for neurosurgical registration.

PURPOSE: Neurosurgical registration using optical tracking in prone position is problematic due to a lack of anatomical landmarks on the posterior skull. The current method of registration involves insertion of screws into the skull. Surface registration using ultrasound has been proposed as a less invasive method of registration. Obtaining full access to the posterior skull would require patient hair removal, which is not favored by patients as it can cause an increased risk of surgical site infection and a less aesthetic outcome. We performed ultrasound scans on participants with no hair removal to evaluate the visibility of the mastoid processes and occipital base of the posterior skull in ultrasound imaging. METHODS: Participants were scanned using a linear and a curvilinear ultrasound probe. Scans were taken at the maximum and minimum frequency of each probe. Ultrasound scans captured the region around each mastoid process, the external occipital protuberance, and the occipital base of the skull. Scans were recorded using the Sequences extension in 3D Slicer and replayed for visual analysis. RESULTS: At its minimum frequency, the linear probe was found to have identifiable bone surfaces with some level of uncertainty. At its maximum frequency, clear identification of the mastoid processes and occipital base was possible. The curvilinear probe did not allow identification of bone surfaces in the ultrasound image. CONCLUSION: A linear probe at a high frequency provides clearly identifiable bone surfaces, allowing for the selection of points used in an iterative closest point algorithm for surface registration.

Skull registration for prone patient position using tracked ultrasound

PURPOSE: Tracked navigation has become prevalent in neurosurgery. Problems with registration of a patient and a preoperative image arise when the patient is in a prone position. Surfaces accessible to optical tracking on the back of the head are unreliable for registration. We investigated the accuracy of surface-based registration using points accessible through tracked ultrasound. Using ultrasound allows access to bone surfaces that are not available through optical tracking. Tracked ultrasound could eliminate the need to work (i) under the table for registration and (ii) adjust the tracker between surgery and registration. In addition, tracked ultrasound could provide a non-invasive method in comparison to an alternative method of registration involving screw implantation. METHODS: A phantom study was performed to test the feasibility of tracked ultrasound for registration. An initial registration was performed to partially align the pre-operative computer tomography data and skull phantom. The initial registration was performed by an anatomical landmark registration. Surface points accessible by tracked ultrasound were collected and used to perform an Iterative Closest Point Algorithm. RESULTS: When the surface registration was compared to a ground truth landmark registration, the average TRE was found to be 1.6±0.1mm and the average distance of points off the skull surface was 0.6±0.1mm. CONCLUSION: The use of tracked ultrasound is feasible for registration of patients in prone position and eliminates the need to perform registration under the table. The translational component of error found was minimal. Therefore, the amount of TRE in registration is due to a rotational component of error.