2,350 research outputs found

    Investigating the impact of lung cancer cell-of-origin on tumour metabolic phenotype and heterogeneity

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    Non-small-cell lung cancer has been described as highly heterogenous which results in different metabolic phenotypes. There are multiple factors which contribute to this heterogeneity, one of which is the tumour cell-of-origin. In the lung, there are five cell types reported to be cells-of-origin: alveolar epithelial type 2, club, basal, neuroendocrine and bronchioalveolar stem cells. This project focuses on the interaction between the cell-of-origin and the metabolic phenotype of lung cancer, and we aim to assess the contribution of the cell-of-origin to lung cancer metabolic resultant phenotype and heterogeneity. To accomplish this, we have established two complementary model systems, one in vitro and one in vivo. In our in vitro model, we isolated specific lung cell types, including AT2 cells, basal cells, and club cells, utilising their unique cell surface markers. By introducing oncogenic KRAS mutations and deleting the P53 gene, we are creating lineage-restricted organoids. These organoids will serve as valuable tools for characterizing the metabolic aspects of tumours arising from different cell-of-origin backgrounds within an in vitro setting. In our in vivo model, we induced NSCLC tumours in mice with genetic modifications using viral vectors, namely Ad5-mSPC-Cre, Ad5-CC10-Cre, and Ad5- bk5-Cre. These vectors are selectively expressed in AT2, club, and basal cells, respectively. To ensure the validity of our comparisons, we have carefully monitored tumour growth dynamics and burden in these mouse models. Our comprehensive analysis has revealed three distinct transcriptomic subtypes (S1, S2, and Acetate) within these NSCLC tumours. Notably, S1 and Acetate subtypes are enriched in tumours originating from specific cell types. Positron emission tomography (PET) imaging has unveiled metabolic variations, with S1 tumours displaying heightened [18F]FDG uptake and the Acetate subtype exhibiting increased [11C]acetate uptake. Furthermore, our multi-omics approach, encompassing transcriptomics, proteomics, and metabolomics, has exposed disparities in critical metabolic pathways, such as glycolysis, hypoxia response, and apoptosis. In summary, our research provides a comprehensive examination of the metabolic heterogeneity of NSCLC based on the cell-of-origin independently of genomic alterations

    Converging organoids and extracellular matrix::New insights into liver cancer biology

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    PANCREATODUODENECTOMY FOR MALIGNANCY: FACTORS INFLUENCING SURGICAL AND ONCOLOGICAL OUTCOMES

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    Introduction: Fit patients with a resectable pancreatic head adenocarcinoma (PDAC), ampullary adenocarcinoma (AA) or distal cholangiocarcinoma (CC) may be offered pancreatoduodenectomy (PD) with curative-intent. However, perioperative morbidity and cancer recurrence rates are high. This thesis aimed to explore the factors influencing PD outcomes. A focus was placed on nutrition, postoperative complications, and recurrence in AA patients. It is hoped the findings will guide patient selection/consenting and have implications for patient management. Methods: A retrospective cohort study of patients who underwent PD for histologically-confirmed malignancy was carried out (2012-2015). Twenty-nine centres from eight countries were involved. Data on the following were collected: preoperative comorbidities and investigations, neoadjuvant treatment, operative details, postoperative complications, histology, adjuvant treatment, cancer recurrence, palliative treatment, and overall survival (OS). Results: In total, 1484 patients were included; 885 (59.6%), 394 (26.5%) and 205 (13.8%) had PDAC, AA and CC, respectively. Overall morbidity, major morbidity (Clavien-Dindo grade 11 ≥III) and 90-day mortality rates were 53.4%, 16.9% and 3.8%, respectively. A high body mass index (BMI), an American Society of Anesthesiologists (ASA) grade >II and a classic Whipple approach all correlated with morbidity. Additionally, ASA grade >II patients were at increased risk of major morbidity and a raised BMI correlated with a greater risk of pancreatic leak. Almost half of the cohort received nutritional support (NS). Of these, 55.6% received parenteral nutrition (PN). In total, 19.6% of the patients who had an uneventful postoperative recovery received PN. Among the PDAC cohort, commencing adjuvant chemotherapy (AC) correlated with improved OS, and those who experienced major morbidity commenced AC less frequently. Among the AA cohort, 176 patients (44.7%) developed recurrence and the median time-to-recurrence was 14 months. Local only, local and distant, and distant only recurrence affected 34, 41 and 94 patients, respectively (site unknown: 7). A higher number of resected nodes, histological T stage >II, lymphatic invasion, perineural invasion (PNI), peripancreatic fat invasion (PPFI) and ≥1 positive resection margin all correlated with AA recurrence. Further, ≥1 positive margin, PPFI and PNI were associated with reduced time-to-recurrence. Conclusions: A considerable number of the patients that had an uneventful recovery received PN. Patients with a high BMI or ASA grade had worse perioperative outcomes. Those who experienced major morbidity commenced AC less frequently. Numerous histopathological predictors of AA recurrence and reduced time-to-recurrence were identified

    Converging organoids and extracellular matrix::New insights into liver cancer biology

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    Primary liver cancer, consisting primarily of hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), is a heterogeneous malignancy with a dismal prognosis, resulting in the third leading cause of cancer mortality worldwide [1, 2]. It is characterized by unique histological features, late-stage diagnosis, a highly variable mutational landscape, and high levels of heterogeneity in biology and etiology [3-5]. Treatment options are limited, with surgical intervention the main curative option, although not available for the majority of patients which are diagnosed in an advanced stage. Major contributing factors to the complexity and limited treatment options are the interactions between primary tumor cells, non-neoplastic stromal and immune cells, and the extracellular matrix (ECM). ECM dysregulation plays a prominent role in multiple facets of liver cancer, including initiation and progression [6, 7]. HCC often develops in already damaged environments containing large areas of inflammation and fibrosis, while CCA is commonly characterized by significant desmoplasia, extensive formation of connective tissue surrounding the tumor [8, 9]. Thus, to gain a better understanding of liver cancer biology, sophisticated in vitro tumor models need to incorporate comprehensively the various aspects that together dictate liver cancer progression. Therefore, the aim of this thesis is to create in vitro liver cancer models through organoid technology approaches, allowing for novel insights into liver cancer biology and, in turn, providing potential avenues for therapeutic testing. To model primary epithelial liver cancer cells, organoid technology is employed in part I. To study and characterize the role of ECM in liver cancer, decellularization of tumor tissue, adjacent liver tissue, and distant metastatic organs (i.e. lung and lymph node) is described, characterized, and combined with organoid technology to create improved tissue engineered models for liver cancer in part II of this thesis. Chapter 1 provides a brief introduction into the concepts of liver cancer, cellular heterogeneity, decellularization and organoid technology. It also explains the rationale behind the work presented in this thesis. In-depth analysis of organoid technology and contrasting it to different in vitro cell culture systems employed for liver cancer modeling is done in chapter 2. Reliable establishment of liver cancer organoids is crucial for advancing translational applications of organoids, such as personalized medicine. Therefore, as described in chapter 3, a multi-center analysis was performed on establishment of liver cancer organoids. This revealed a global establishment efficiency rate of 28.2% (19.3% for hepatocellular carcinoma organoids (HCCO) and 36% for cholangiocarcinoma organoids (CCAO)). Additionally, potential solutions and future perspectives for increasing establishment are provided. Liver cancer organoids consist of solely primary epithelial tumor cells. To engineer an in vitro tumor model with the possibility of immunotherapy testing, CCAO were combined with immune cells in chapter 4. Co-culture of CCAO with peripheral blood mononuclear cells and/or allogenic T cells revealed an effective anti-tumor immune response, with distinct interpatient heterogeneity. These cytotoxic effects were mediated by cell-cell contact and release of soluble factors, albeit indirect killing through soluble factors was only observed in one organoid line. Thus, this model provided a first step towards developing immunotherapy for CCA on an individual patient level. Personalized medicine success is dependent on an organoids ability to recapitulate patient tissue faithfully. Therefore, in chapter 5 a novel organoid system was created in which branching morphogenesis was induced in cholangiocyte and CCA organoids. Branching cholangiocyte organoids self-organized into tubular structures, with high similarity to primary cholangiocytes, based on single-cell sequencing and functionality. Similarly, branching CCAO obtain a different morphology in vitro more similar to primary tumors. Moreover, these branching CCAO have a higher correlation to the transcriptomic profile of patient-paired tumor tissue and an increased drug resistance to gemcitabine and cisplatin, the standard chemotherapy regimen for CCA patients in the clinic. As discussed, CCAO represent the epithelial compartment of CCA. Proliferation, invasion, and metastasis of epithelial tumor cells is highly influenced by the interaction with their cellular and extracellular environment. The remodeling of various properties of the extracellular matrix (ECM), including stiffness, composition, alignment, and integrity, influences tumor progression. In chapter 6 the alterations of the ECM in solid tumors and the translational impact of our increased understanding of these alterations is discussed. The success of ECM-related cancer therapy development requires an intimate understanding of the malignancy-induced changes to the ECM. This principle was applied to liver cancer in chapter 7, whereby through a integrative molecular and mechanical approach the dysregulation of liver cancer ECM was characterized. An optimized agitation-based decellularization protocol was established for primary liver cancer (HCC and CCA) and paired adjacent tissue (HCC-ADJ and CCA-ADJ). Novel malignancy-related ECM protein signatures were found, which were previously overlooked in liver cancer transcriptomic data. Additionally, the mechanical characteristics were probed, which revealed divergent macro- and micro-scale mechanical properties and a higher alignment of collagen in CCA. This study provided a better understanding of ECM alterations during liver cancer as well as a potential scaffold for culture of organoids. This was applied to CCA in chapter 8 by combining decellularized CCA tumor ECM and tumor-free liver ECM with CCAO to study cell-matrix interactions. Culture of CCAO in tumor ECM resulted in a transcriptome closely resembling in vivo patient tumor tissue, and was accompanied by an increase in chemo resistance. In tumor-free liver ECM, devoid of desmoplasia, CCAO initiated a desmoplastic reaction through increased collagen production. If desmoplasia was already present, distinct ECM proteins were produced by the organoids. These were tumor-related proteins associated with poor patient survival. To extend this method of studying cell-matrix interactions to a metastatic setting, lung and lymph node tissue was decellularized and recellularized with CCAO in chapter 9, as these are common locations of metastasis in CCA. Decellularization resulted in removal of cells while preserving ECM structure and protein composition, linked to tissue-specific functioning hallmarks. Recellularization revealed that lung and lymph node ECM induced different gene expression profiles in the organoids, related to cancer stem cell phenotype, cell-ECM integrin binding, and epithelial-to-mesenchymal transition. Furthermore, the metabolic activity of CCAO in lung and lymph node was significantly influenced by the metastatic location, the original characteristics of the patient tumor, and the donor of the target organ. The previously described in vitro tumor models utilized decellularized scaffolds with native structure. Decellularized ECM can also be used for creation of tissue-specific hydrogels through digestion and gelation procedures. These hydrogels were created from both porcine and human livers in chapter 10. The liver ECM-based hydrogels were used to initiate and culture healthy cholangiocyte organoids, which maintained cholangiocyte marker expression, thus providing an alternative for initiation of organoids in BME. Building upon this, in chapter 11 human liver ECM-based extracts were used in combination with a one-step microfluidic encapsulation method to produce size standardized CCAO. The established system can facilitate the reduction of size variability conventionally seen in organoid culture by providing uniform scaffolding. Encapsulated CCAO retained their stem cell phenotype and were amendable to drug screening, showing the feasibility of scalable production of CCAO for throughput drug screening approaches. Lastly, Chapter 12 provides a global discussion and future outlook on tumor tissue engineering strategies for liver cancer, using organoid technology and decellularization. Combining multiple aspects of liver cancer, both cellular and extracellular, with tissue engineering strategies provides advanced tumor models that can delineate fundamental mechanistic insights as well as provide a platform for drug screening approaches.<br/

    Effects of municipal smoke-free ordinances on secondhand smoke exposure in the Republic of Korea

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    ObjectiveTo reduce premature deaths due to secondhand smoke (SHS) exposure among non-smokers, the Republic of Korea (ROK) adopted changes to the National Health Promotion Act, which allowed local governments to enact municipal ordinances to strengthen their authority to designate smoke-free areas and levy penalty fines. In this study, we examined national trends in SHS exposure after the introduction of these municipal ordinances at the city level in 2010.MethodsWe used interrupted time series analysis to assess whether the trends of SHS exposure in the workplace and at home, and the primary cigarette smoking rate changed following the policy adjustment in the national legislation in ROK. Population-standardized data for selected variables were retrieved from a nationally representative survey dataset and used to study the policy action’s effectiveness.ResultsFollowing the change in the legislation, SHS exposure in the workplace reversed course from an increasing (18% per year) trend prior to the introduction of these smoke-free ordinances to a decreasing (−10% per year) trend after adoption and enforcement of these laws (β2 = 0.18, p-value = 0.07; β3 = −0.10, p-value = 0.02). SHS exposure at home (β2 = 0.10, p-value = 0.09; β3 = −0.03, p-value = 0.14) and the primary cigarette smoking rate (β2 = 0.03, p-value = 0.10; β3 = 0.008, p-value = 0.15) showed no significant changes in the sampled period. Although analyses stratified by sex showed that the allowance of municipal ordinances resulted in reduced SHS exposure in the workplace for both males and females, they did not affect the primary cigarette smoking rate as much, especially among females.ConclusionStrengthening the role of local governments by giving them the authority to enact and enforce penalties on SHS exposure violation helped ROK to reduce SHS exposure in the workplace. However, smoking behaviors and related activities seemed to shift to less restrictive areas such as on the streets and in apartment hallways, negating some of the effects due to these ordinances. Future studies should investigate how smoke-free policies beyond public places can further reduce the SHS exposure in ROK

    Optimization of neural networks for deep learning and applications to CT image segmentation

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    [eng] During the last few years, AI development in deep learning has been going so fast that even important researchers, politicians, and entrepreneurs are signing petitions to try to slow it down. The newest methods for natural language processing and image generation are achieving results so unbelievable that people are seriously starting to think they can be dangerous for society. In reality, they are not dangerous (at the moment) even if we have to admit we reached a point where we have no more control over the flux of data inside the deep networks. It is impossible to open a modern deep neural network and interpret how it processes the information and, in many cases, explain how or why it gives back that particular result. One of the goals of this doctoral work has been to study the behavior of weights in convolutional neural networks and in transformers. We hereby present a work that demonstrates how to invert 3x3 convolutions after training a neural network able to learn how to classify images, with the future aim of having precisely invertible convolutional neural networks. We demonstrate that a simple network can learn to classify images on an open-source dataset without loss in accuracy, with respect to a non-invertible one. All that with the ability to reconstruct the original image without detectable error (on 8-bit images) in up to 20 convolutions stacked in a row. We present a thorough comparison between our method and the standard. We tested the performances of the five most used transformers for image classification on an open- source dataset. Studying the embedded matrices, we have been able to provide two criteria that can help transformers learn with a training time reduction of up to 30% and with no impact on classification accuracy. The evolution of deep learning techniques is also touching the field of digital health. With tens of thousands of new start-ups and more than 1B $ of investments only in the last year, this field is growing rapidly and promising to revolutionize healthcare. In this thesis, we present several neural networks for the segmentation of lungs, lung nodules, and areas affected by pneumonia induced by COVID-19, in chest CT scans. The architecturesm we used are all residual convolutional neural networks inspired by UNet and Inception. We customized them with novel loss functions and layers studied to achieve high performances on these particular applications. The errors on the surface of nodule segmentation masks are not over 1mm in more than 99% of the cases. Our algorithm for COVID-19 lesion detection has a specificity of 100% and overall accuracy of 97.1%. In general, it surpasses the state-of-the-art in all the considered statistics, using UNet as a benchmark. Combining these with other algorithms able to detect and predict lung cancer, the whole work was presented in a European innovation program and judged of high interest by worldwide experts. With this work, we set the basis for the future development of better AI tools in healthcare and scientific investigation into the fundamentals of deep learning.[spa] Durante los últimos años, el desarrollo de la IA en el aprendizaje profundo ha ido tan rápido que Incluso importantes investigadores, políticos y empresarios están firmando peticiones para intentar para ralentizarlo. Los métodos más nuevos para el procesamiento y la generación de imágenes y lenguaje natural, están logrando resultados tan increíbles que la gente está empezando a preocuparse seriamente. Pienso que pueden ser peligrosos para la sociedad. En realidad, no son peligrosos (al menos de momento) incluso si tenemos que admitir que llegamos a un punto en el que ya no tenemos control sobre el flujo de datos dentro de las redes profundas. Es imposible abrir una moderna red neuronal profunda e interpretar cómo procesa la información y, en muchos casos, explique cómo o por qué devuelve ese resultado en particular, uno de los objetivos de este doctorado. El trabajo ha consistido en estudiar el comportamiento de los pesos en redes neuronales convolucionales y en transformadores. Por la presente presentamos un trabajo que demuestra cómo invertir 3x3 convoluciones después de entrenar una red neuronal capaz de aprender a clasificar imágenes, con el objetivo futuro de tener redes neuronales convolucionales precisamente invertibles. Nosotros queremos demostrar que una red simple puede aprender a clasificar imágenes en un código abierto conjunto de datos sin pérdida de precisión, con respecto a uno no invertible. Todo eso con la capacidad de reconstruir la imagen original sin errores detectables (en imágenes de 8 bits) en hasta 20 convoluciones apiladas en fila. Presentamos una exhaustiva comparación entre nuestro método y el estándar. Probamos las prestaciones de los cinco transformadores más utilizados para la clasificación de imágenes en abierto. conjunto de datos de origen. Al estudiar las matrices incrustadas, hemos sido capaz de proporcionar dos criterios que pueden ayudar a los transformadores a aprender con un tiempo de capacitación reducción de hasta el 30% y sin impacto en la precisión de la clasificación. La evolución de las técnicas de aprendizaje profundo también está afectando al campo de la salud digital. Con decenas de miles de nuevas empresas y más de mil millones de dólares en inversiones sólo en el año pasado, este campo está creciendo rápidamente y promete revolucionar la atención médica. En esta tesis, presentamos varias redes neuronales para la segmentación de pulmones, nódulos pulmonares, y zonas afectadas por neumonía inducida por COVID-19, en tomografías computarizadas de tórax. La arquitectura que utilizamos son todas redes neuronales convolucionales residuales inspiradas en UNet. Las personalizamos con nuevas funciones y capas de pérdida, estudiado para lograr altos rendimientos en estas aplicaciones particulares. Los errores en la superficie de las máscaras de segmentación de los nódulos no supera 1 mm en más del 99% de los casos. Nuestro algoritmo para la detección de lesiones de COVID-19 tiene una especificidad del 100% y en general precisión del 97,1%. En general supera el estado del arte en todos los aspectos considerados, estadísticas, utilizando UNet como punto de referencia. Combinando estos con otros algoritmos capaces de detectar y predecir el cáncer de pulmón, todo el trabajo se presentó en una innovación europea programa y considerado de gran interés por expertos de todo el mundo. Con este trabajo, sentamos las bases para el futuro desarrollo de mejores herramientas de IA en Investigación sanitaria y científica sobre los fundamentos del aprendizaje profundo

    MedKLIP: Medical Knowledge Enhanced Language-Image Pre-Training in Radiology

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    In this paper, we consider enhancing medical visual-language pre-training (VLP) with domain-specific knowledge, by exploiting the paired image-text reports from the radiological daily practice. In particular, we make the following contributions: First, unlike existing works that directly process the raw reports, we adopt a novel triplet extraction module to extract the medical-related information, avoiding unnecessary complexity from language grammar and enhancing the supervision signals; Second, we propose a novel triplet encoding module with entity translation by querying a knowledge base, to exploit the rich domain knowledge in medical field, and implicitly build relationships between medical entities in the language embedding space; Third, we propose to use a Transformer-based fusion model for spatially aligning the entity description with visual signals at the image patch level, enabling the ability for medical diagnosis; Fourth, we conduct thorough experiments to validate the effectiveness of our architecture, and benchmark on numerous public benchmarks, e.g., ChestX-ray14, RSNA Pneumonia, SIIM-ACR Pneumothorax, COVIDx CXR-2, COVID Rural, and EdemaSeverity. In both zero-shot and fine-tuning settings, our model has demonstrated strong performance compared with the former methods on disease classification and grounding

    Current Challenges in the Application of Algorithms in Multi-institutional Clinical Settings

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    The Coronavirus disease pandemic has highlighted the importance of artificial intelligence in multi-institutional clinical settings. Particularly in situations where the healthcare system is overloaded, and a lot of data is generated, artificial intelligence has great potential to provide automated solutions and to unlock the untapped potential of acquired data. This includes the areas of care, logistics, and diagnosis. For example, automated decision support applications could tremendously help physicians in their daily clinical routine. Especially in radiology and oncology, the exponential growth of imaging data, triggered by a rising number of patients, leads to a permanent overload of the healthcare system, making the use of artificial intelligence inevitable. However, the efficient and advantageous application of artificial intelligence in multi-institutional clinical settings faces several challenges, such as accountability and regulation hurdles, implementation challenges, and fairness considerations. This work focuses on the implementation challenges, which include the following questions: How to ensure well-curated and standardized data, how do algorithms from other domains perform on multi-institutional medical datasets, and how to train more robust and generalizable models? Also, questions of how to interpret results and whether there exist correlations between the performance of the models and the characteristics of the underlying data are part of the work. Therefore, besides presenting a technical solution for manual data annotation and tagging for medical images, a real-world federated learning implementation for image segmentation is introduced. Experiments on a multi-institutional prostate magnetic resonance imaging dataset showcase that models trained by federated learning can achieve similar performance to training on pooled data. Furthermore, Natural Language Processing algorithms with the tasks of semantic textual similarity, text classification, and text summarization are applied to multi-institutional, structured and free-text, oncology reports. The results show that performance gains are achieved by customizing state-of-the-art algorithms to the peculiarities of the medical datasets, such as the occurrence of medications, numbers, or dates. In addition, performance influences are observed depending on the characteristics of the data, such as lexical complexity. The generated results, human baselines, and retrospective human evaluations demonstrate that artificial intelligence algorithms have great potential for use in clinical settings. However, due to the difficulty of processing domain-specific data, there still exists a performance gap between the algorithms and the medical experts. In the future, it is therefore essential to improve the interoperability and standardization of data, as well as to continue working on algorithms to perform well on medical, possibly, domain-shifted data from multiple clinical centers

    Towards Robot Autonomy in Medical Procedures Via Visual Localization and Motion Planning

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    Robots performing medical procedures with autonomous capabilities have the potential to positively effect patient care and healthcare system efficiency. These benefits can be realized by autonomous robots facilitating novel procedures, increasing operative efficiency, standardizing intra- and inter-physician performance, democratizing specialized care, and focusing the physician’s time on subtasks that best leverage their expertise. However, enabling medical robots to act autonomously in a procedural environment is extremely challenging. The deforming and unstructured nature of the environment, the lack of features in the anatomy, and sensor size constraints coupled with the millimeter level accuracy required for safe medical procedures introduce a host of challenges not faced by robots operating in structured environments such as factories or warehouses. Robot motion planning and localization are two fundamental abilities for enabling robot autonomy. Motion planning methods compute a sequence of safe and feasible motions for a robot to accomplish a specified task, where safe and feasible are defined by constraints with respect to the robot and its environment. Localization methods estimate the position and orientation of a robot in its environment. Developing such methods for medical robots that overcome the unique challenges in procedural environments is critical for enabling medical robot autonomy. In this dissertation, I developed and evaluated motion planning and localization algorithms towards robot autonomy in medical procedures. A majority of my work was done in the context of an autonomous medical robot built for enhanced lung nodule biopsy. First, I developed a dataset of medical environments spanning various organs and procedures to foster future research into medical robots and automation. I used this data in my own work described throughout this dissertation. Next, I used motion planning to characterize the capabilities of the lung nodule biopsy robot compared to existing clinical tools and I highlighted trade-offs in robot design considerations. Then, I conducted a study to experimentally demonstrate the benefits of the autonomous lung robot in accessing otherwise hard-to-reach lung nodules. I showed that the robot enables access to lung regions beyond the reach of existing clinical tools with millimeter-level accuracy sufficient for accessing the smallest clinically operable nodules. Next, I developed a localization method to estimate the bronchoscope’s position and orientation in the airways with respect to a preoperatively planned needle insertion pose. The method can be used by robotic bronchoscopy systems and by traditional manually navigated bronchoscopes. The method is designed to overcome challenges with tissue motion and visual homogeneity in the airways. I demonstrated the success of this method in simulated lungs undergoing respiratory motion and showed the method’s ability to generalize across patients.Doctor of Philosoph
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