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 Jonathan Irish J Jonathan Irish J th th I i h I i h University of Toronto University of Toronto

Cone-Beam CT Cone Beam CT M l i l 2D Multiple 2D projection images j i i acquired over ~180 o Image acquisition - Nominal: N i l 60 60 s Image reconstruction - High-res (0.4 mm): 180 s Patient dose - Low: 1 – 5 mGy - (down to 1/10 th that of a CT (down to 1/10 that of a CT scan) 3

Intra-Operative Cone-Beam CT p Projection data 4 200 – 500 images over 180 o

5 Intra-Operative Cone-Beam CT p

6 Image Quality Image Quality

Temporal Bone Surgery Temporal Bone Surgery • Temporal Bone Imaging T l B I i - Complex 3D anatomy - Sub-mm spatial resolution - High-resolution (and high High resolution (and high dose) diagnostic CT • Surgical Tasks S i l T k - Middle ear surgery - Cochlear implant - Facial nerve decompression Facial nerve decompression - Trans-labyrinth approach to the internal auditory canal 7

Intra-Operative Imaging of the Middle Ear f h Middl E Stapes Crura Stapes Crura (essentially the finest bony Axial 8 features in the human body)

Sub-millimeter Resolution 1 / 8 -Resolution Half-Resolution 9

Minimal Access Approaches 10 h A l A Mi i

Pre-operative Planning Pre-operative Planning S h Sphenoethmoidectomy. Sphenoid Mucocele th id t S h id M l 11

Intra-Operative Guidance Intra Operative Guidance Intra operative clarification that pointer is at Anterior wall of Intra-operative clarification that pointer is at Anterior wall of Mucocele 12

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 13

Skull Base Surgery: Target Abation in the Clivus Intra-Operative CBCT Critical TARGET TARGET volume l NORMAL volume 14

Intra-Operative Guidance Intra Operative Guidance Clivus Excision (Open Approach) Target Ablation Guided: 56% Unguided: 27% 15 Intra-Op CBCT Intra-Operative CBCT Intra-Op CBCT

Tomosynthesis-Guided Surgery y g y θ tot ∼ 30° • Tomosynthesis - Limited-angle 3D imaging - Significant reduction in: Radiation dose Time required for acq / recon θ tot ∼ 180° tot • Intra-Operative Updates - Task-specific imaging: High- speed / Low-dose When target and critical structures are in a well-defined ROI

Tomosynthesis-Guided Surgery y g y PA Radiograph Tomosynthesis Cone-Beam CT θ tot = 180° θ tot = 90° θ tot = 45° θ tot = 10° θ tot = 120° θ tot = 30° θ tot = 20° θ tot = 60° tot tot tot tot tot tot tot m Gy m Gy m Gy -5 0 5 -5 -5 -5 -5 -5 -5 -5 0 0 0 0 0 0 0 5 5 5 5 5 5 5 -5 0 5 20 12 6 0.3 20 8 15 10 5 5 5 5 5 5 5 5 5 3 5 5 0 25 0.25 15 15 10 15 8 6 4 y ( cm ) y ( cm ) y ( cm ) 0.2 10 2 0 0 0 0 0 0 0 0 0 6 10 3 0.15 10 4 5 4 0.1 2 5 5 1 1 5 5 5 2 -5 -5 -5 -5 -5 -5 -5 -5 -5 2 1 0.05 0 0 0 0 0 0 0 0 X ( cm ) X ( cm ) X ( cm )

Tomosynthesis-Guided Surgery y g y Tomosynthesis θ tot = 30 o LAT D o ~ 1.5 mGy C Cone-Beam CT B CT θ tot = 180 o D o ~ 10 mGy Coronal

3.2mm CSF leak

Progress Toward Before Surgery Patient Selection Clinical Trials Patient Consent Form Setup C-Arm in OR Intra-Operative Surgical 12 Patients Procedure Phase 1 (6 Pt) Patient Prep Imaging only Anesthesia Phase 2 (6 Pt) Clean and drape field Imaging + guidance CBCT Scans Surgical Resection Milestone Scans Milestone Scans Open surgical field Open surgical field (4) (Phase 1 and 2) Approach lesion Guidance Scans Resection (up to 2) (Phase 2) Hemostasis Close surgical field After Surgery Transfer to PACU Surgeon and/or Questionnair Questionnair Step-Down Unit 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 Front View Side View Side View Top 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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35 “Docking” the Robot

Robotic Endoscopic Surgery (RES) of the Skull Base Skull Base 36

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

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