Guided Therapeutics in Cancer Surgery Guided Therapeutics in Cancer - - PowerPoint PPT Presentation

Guided Therapeutics in Cancer Surgery Guided Therapeutics in Cancer Surgery Guided Therapeutics in Cancer Surgery Guided Therapeutics in Cancer Surgery Jeff Jeff Siewerdsen Siewerdsen J th I i h J th I i h Jonathan Irish Jonathan Irish

University of Toronto University of Toronto

Cone-Beam CT Cone Beam CT

M l i l 2D j i i Multiple 2D projection images acquired over ~180o Image acquisition N i l 60

• Nominal:

60 s Image reconstruction

• High-res (0.4 mm): 180 s

Patient dose

• Low: 1 – 5 mGy
• (down to 1/10th that of a CT

(down to 1/10 that of a CT scan)

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Intra-Operative Cone-Beam CT p

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Projection data 200 – 500 images over 180o

Intra-Operative Cone-Beam CT p

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Image Quality Image Quality

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Temporal Bone Surgery

T l B I i

Temporal Bone Surgery

• Temporal Bone Imaging
• Complex 3D anatomy
• Sub-mm spatial resolution

High resolution (and high

• High-resolution (and high

dose) diagnostic CT

S i l T k

• Surgical Tasks
• Middle ear surgery
• Cochlear implant

Facial nerve decompression

• Facial nerve decompression
• Trans-labyrinth approach to

the internal auditory canal

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Intra-Operative Imaging f h Middl E

• f the Middle Ear

Stapes Crura

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Axial

Stapes Crura

(essentially the finest bony features in the human body)

Sub-millimeter Resolution

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Half-Resolution

1/8-Resolution

Mi i l A A h Minimal Access Approaches

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Pre-operative Planning Pre-operative Planning

S h th id t S h id M l

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• Sphenoethmoidectomy. Sphenoid Mucocele

Intra-Operative Guidance Intra Operative Guidance

Intra operative clarification that pointer is at Anterior wall of

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Intra-operative clarification that pointer is at Anterior wall of Mucocele

Conclusion Conclusion

• Rapid Intra-Operative imaging
• Sub Millimeter Resolution of Bone and Soft Tissue
• Sub-Millimeter Resolution of Bone and Soft Tissue
• Exquisite 3-D Visualization within 90 seconds

q

• No registration process required

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Skull Base Surgery: Target Abation in the Clivus

Intra-Operative CBCT Critical TARGET l

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TARGET volume NORMAL volume

Intra-Operative Guidance Intra Operative Guidance

Clivus Excision (Open Approach)

Target Ablation

Guided: 56% Unguided: 27%

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Intra-Op CBCT Intra-Op CBCT Intra-Operative CBCT

Tomosynthesis-Guided Surgery

θtot ∼ 30°

y g y

• Tomosynthesis
• Limited-angle 3D imaging
• Significant reduction in:

Radiation dose Time required for acq / recon

θtot ∼ 180°

• Intra-Operative Updates
• Task-specific imaging:

High- speed / Low-dose

tot

When target and critical structures are in a well-defined ROI

Tomosynthesis-Guided Surgery y g y

PA Radiograph Tomosynthesis Cone-Beam CT

θtot = 120° θtot = 90° θtot = 60° θtot = 45° θtot = 30° θtot = 20° θtot = 10° θtot = 180°

tot

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5 5

15 20

tot

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5 5

15

tot

• 5

5 5

tot

• 5

5 5

10 12

tot

• 5

5 5

8

tot

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5 5

5 6

tot

• 5

5 5

3

• 5

5 5

0 25 0.3

• 5

5 5

20

m Gy m Gy m Gy

5 10 15 5 10 5 10 4 6 8 4 6 2 3 4 5 1 2 0.1 0.15 0.2 0.25 10 15

y ( cm ) y ( cm ) y ( cm )

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5

• 5

5

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2

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2

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1

• 5

1

• 5

0.05

• 5

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X ( cm ) X ( cm ) X ( cm )

Tomosynthesis-Guided Surgery y g y

Tomosynthesis θtot = 30o Do ~ 1.5 mGy LAT C B CT Cone-Beam CT θtot = 180o Do ~ 10 mGy Coronal

3.2mm CSF leak

Progress Toward

Patient Selection Before Surgery

Clinical Trials

Patient Consent Form Setup C-Arm in OR Intra-Operative Surgical Procedure 12 Patients

Phase 1 (6 Pt)

CBCT Scans

Milestone Scans Patient Prep Anesthesia Clean and drape field Surgical Resection Open surgical field Imaging only Phase 2 (6 Pt) Imaging + guidance Milestone Scans (4) (Phase 1 and 2) Guidance Scans (up to 2) (Phase 2) Open surgical field Approach lesion Resection Hemostasis Close surgical field

Transfer to PACU and/or Surgeon Questionnair After Surgery Step-Down Unit Questionnair e Data Analysis

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Post-Excision Cone-Beam CT

Patient Specific 3D Template for Patient-Specific 3D Template for Surgical Reconstruction of the Mandible Surgical Reconstruction of the Mandible

Jeffrey H. Siewerdsen, Ph.D. Ontario Cancer Institute, Toronto ON Jonathan Irish, MD

Coronal Sagittal Axial Front View Side View Top View Front View Side View Top View

Perspective View

Production on 3D Prototyping Printer

3D Polycarbonate Mandible Template 3D Polycarbonate Mandible Template

Bend Plate to Patient-Specific Template

Patient-Specific Mandible Plate – In Practice

A “perfect fit” achieved without time spent / uncertainty / iteration y during the procedure.

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“Docking” the Robot

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Robotic Endoscopic Surgery (RES) of the Skull Base Skull Base

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“The best way to predict the y p future is to invent it”

Alan Kay

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