Respiration-Induced Intraorgan Deformation of the Liver: Implications for Treatment Planning in Patients Treated With Fiducial Tracking.

Stereotactic body radiation therapy is a well-tolerated modality for the treatment of primary and metastatic liver lesions, and fiducials are often used as surrogates for tumor tracking during treatment. We evaluated respiratory-induced liver deformation by measuring the rigidity of the fiducial configuration during the breathing cycle. Seventeen patients, with 18 distinct treatment courses, were treated with stereotactic body radiosurgery using multiple fiducials. Liver deformation was empirically quantified by measuring the intrafiducial distances at different phases of respiration. Data points were collected at the 0%, 50%, and 100% inspiration points, and the distance between each pair of fiducials was measured at the 3 phases. The rigid body error was calculated as the maximum difference in the intrafiducial distances. Liver disease was calculated with Child-Pugh score using laboratory values within 3 months of initiation of treatment. A peripheral fiducial was defined as within 1.5 cm of the liver edge, and all other fiducials were classified as central. For 5 patients with only peripheral fiducials, the fiducial configuration had more deformation (average maximum rigid body error 7.11 mm, range: 1.89-11.35 mm) when compared to patients with both central and peripheral and central fiducials only (average maximum rigid body error 3.36 mm, range: 0.5-9.09 mm, P = .037). The largest rigid body errors (11.3 and 10.6 mm) were in 2 patients with Child-Pugh class A liver disease and multiple peripheral fiducials. The liver experiences internal deformation, and the fiducial configuration should not be assumed to act as a static structure. We observed greater deformation at the periphery than at the center of the liver. In our small data set, we were not able to identify cirrhosis, which is associated with greater rigidity of the liver, as predictive for deformation. Treatment planning based only on fiducial localization must take potential intraorgan deformation into account

2D-3D registration of CT vertebra volume to fluoroscopy projection: A calibration model assessment (doi:10.1155/2010/806094)

This study extends a previous research concerning intervertebral motion registration by means of 2D dynamic fluoroscopy to obtain a more comprehensive 3D description of vertebral kinematics. The problem of estimating the 3D rigid pose of a CT volume of a vertebra from its 2D X-ray fluoroscopy projection is addressed. 2D-3D registration is obtained maximising a measure of similarity between Digitally Reconstructed Radiographs (obtained from the CT volume) and real fluoroscopic projection. X-ray energy correction was performed. To assess the method a calibration model was realised a sheep dry vertebra was rigidly fixed to a frame of reference including metallic markers. Accurate measurement of 3D orientation was obtained via single-camera calibration of the markers and held as true 3D vertebra position; then, vertebra 3D pose was estimated and results compared. Error analysis revealed accuracy of the order of 0.1 degree for the rotation angles of about 1?mm for displacements parallel to the fluoroscopic plane, and of order of 10?mm for the orthogonal displacement.<br/

Advanced tracking and image registration techniques for intraoperative radiation therapy

Mención Internacional en el título de doctorIntraoperative electron radiation therapy (IOERT) is a technique used to deliver radiation to the surgically opened tumor bed without irradiating healthy tissue. Treatment planning systems and mobile linear accelerators enable clinicians to optimize the procedure, minimize stress in the operating room (OR) and avoid transferring the patient to a dedicated radiation room. However, placement of the radiation collimator over the tumor bed requires a validation methodology to ensure correct delivery of the dose prescribed in the treatment planning system. In this dissertation, we address three well-known limitations of IOERT: applicator positioning over the tumor bed, docking of the mobile linear accelerator gantry with the applicator and validation of the dose delivery prescribed. This thesis demonstrates that these limitations can be overcome by positioning the applicator appropriately with respect to the patient’s anatomy. The main objective of the study was to assess technological and procedural alternatives for improvement of IOERT performance and resolution of problems of uncertainty. Image-to-world registration, multicamera optical trackers, multimodal imaging techniques and mobile linear accelerator docking are addressed in the context of IOERT. IOERT is carried out by a multidisciplinary team in a highly complex environment that has special tracking needs owing to the characteristics of its working volume (i.e., large and prone to occlusions), in addition to the requisites of accuracy. The first part of this dissertation presents the validation of a commercial multicamera optical tracker in terms of accuracy, sensitivity to miscalibration, camera occlusions and detection of tools using a feasible surgical setup. It also proposes an automatic miscalibration detection protocol that satisfies the IOERT requirements of automaticity and speed. We show that the multicamera tracker is suitable for IOERT navigation and demonstrate the feasibility of the miscalibration detection protocol in clinical setups. Image-to-world registration is one of the main issues during image-guided applications where the field of interest and/or the number of possible anatomical localizations is large, such as IOERT. In the second part of this dissertation, a registration algorithm for image-guided surgery based on lineshaped fiducials (line-based registration) is proposed and validated. Line-based registration decreases acquisition time during surgery and enables better registration accuracy than other published algorithms. In the third part of this dissertation, we integrate a commercial low-cost ultrasound transducer and a cone beam CT C-arm with an optical tracker for image-guided interventions to enable surgical navigation and explore image based registration techniques for both modalities. In the fourth part of the dissertation, a navigation system based on optical tracking for the docking of the mobile linear accelerator to the radiation applicator is assessed. This system improves safety and reduces procedure time. The system tracks the prescribed collimator location to solve the movements that the linear accelerator should perform to reach the docking position and warns the user about potentially unachievable arrangements before the actual procedure. A software application was implemented to use this system in the OR, where it was also evaluated to assess the improvement in docking speed. Finally, in the last part of the dissertation, we present and assess the installation setup for a navigation system in a dedicated IOERT OR, determine the steps necessary for the IOERT process, identify workflow limitations and evaluate the feasibility of the integration of the system in a real OR. The navigation system safeguards the sterile conditions of the OR, clears the space available for surgeons and is suitable for any similar dedicated IOERT OR.La Radioterapia Intraoperatoria por electrones (RIO) consiste en la aplicación de radiación de alta energía directamente sobre el lecho tumoral, accesible durante la cirugía, evitando radiar los tejidos sanos. Hoy en día, avances como los sistemas de planificación (TPS) y la aparición de aceleradores lineales móviles permiten optimizar el procedimiento, minimizar el estrés clínico en el entorno quirúrgico y evitar el desplazamiento del paciente durante la cirugía a otra sala para ser radiado. La aplicación de la radiación se realiza mediante un colimador del haz de radiación (aplicador) que se coloca sobre el lecho tumoral de forma manual por el oncólogo radioterápico. Sin embargo, para asegurar una correcta deposición de la dosis prescrita y planificada en el TPS, es necesaria una adecuada validación de la colocación del colimador. En esta Tesis se abordan tres limitaciones conocidas del procedimiento RIO: el correcto posicionamiento del aplicador sobre el lecho tumoral, acoplamiento del acelerador lineal con el aplicador y validación de la dosis de radiación prescrita. Esta Tesis demuestra que estas limitaciones pueden ser abordadas mediante el posicionamiento del aplicador de radiación en relación con la anatomía del paciente. El objetivo principal de este trabajo es la evaluación de alternativas tecnológicas y procedimentales para la mejora de la práctica de la RIO y resolver los problemas de incertidumbre descritos anteriormente. Concretamente se revisan en el contexto de la radioterapia intraoperatoria los siguientes temas: el registro de la imagen y el paciente, sistemas de posicionamiento multicámara, técnicas de imagen multimodal y el acoplamiento del acelerador lineal móvil. El entorno complejo y multidisciplinar de la RIO precisa de necesidades especiales para el empleo de sistemas de posicionamiento como una alta precisión y un volumen de trabajo grande y propenso a las oclusiones de los sensores de posición. La primera parte de esta Tesis presenta una exhaustiva evaluación de un sistema de posicionamiento óptico multicámara comercial. Estudiamos la precisión del sistema, su sensibilidad a errores cometidos en la calibración, robustez frente a posibles oclusiones de las cámaras y precisión en el seguimiento de herramientas en un entorno quirúrgico real. Además, proponemos un protocolo para la detección automática de errores por calibración que satisface los requisitos de automaticidad y velocidad para la RIO demostrando la viabilidad del empleo de este sistema para la navegación en RIO. Uno de los problemas principales de la cirugía guiada por imagen es el correcto registro de la imagen médica y la anatomía del paciente en el quirófano. En el caso de la RIO, donde el número de posibles localizaciones anatómicas es bastante amplio, así como el campo de trabajo es grande se hace necesario abordar este problema para una correcta navegación. Por ello, en la segunda parte de esta Tesis, proponemos y validamos un nuevo algoritmo de registro (LBR) para la cirugía guiada por imagen basado en marcadores lineales. El método propuesto reduce el tiempo de la adquisición de la posición de los marcadores durante la cirugía y supera en precisión a otros algoritmos de registro establecidos y estudiados en la literatura. En la tercera parte de esta tesis, integramos un transductor de ultrasonido comercial de bajo coste, un arco en C de rayos X con haz cónico y un sistema de posicionamiento óptico para intervenciones guiadas por imagen que permite la navegación quirúrgica y exploramos técnicas de registro de imagen para ambas modalidades. En la cuarta parte de esta tesis se evalúa un navegador basado en el sistema de posicionamiento óptico para el acoplamiento del acelerador lineal móvil con aplicador de radiación, mejorando la seguridad y reduciendo el tiempo del propio acoplamiento. El sistema es capaz de localizar el colimador en el espacio y proporcionar los movimientos que el acelerador lineal debe realizar para alcanzar la posición de acoplamiento. El sistema propuesto es capaz de advertir al usuario de aquellos casos donde la posición de acoplamiento sea inalcanzable. El sistema propuesto de ayuda para el acoplamiento se integró en una aplicación software que fue evaluada para su uso final en quirófano demostrando su viabilidad y la reducción de tiempo de acoplamiento mediante su uso. Por último, presentamos y evaluamos la instalación de un sistema de navegación en un quirófano RIO dedicado, determinamos las necesidades desde el punto de vista procedimental, identificamos las limitaciones en el flujo de trabajo y evaluamos la viabilidad de la integración del sistema en un entorno quirúrgico real. El sistema propuesto demuestra ser apto para el entorno RIO manteniendo las condiciones de esterilidad y dejando despejado el campo quirúrgico además de ser adaptable a cualquier quirófano similar.Programa Oficial de Doctorado en Multimedia y ComunicacionesPresidente: Raúl San José Estépar.- Secretario: María Arrate Muñoz Barrutia.- Vocal: Carlos Ferrer Albiac

Comparing Measured and Theoretical Target Registration Error of an Optical Tracking System

The goal of this thesis is to experimentally measure the accuracy of an optical tracking system used in commercial surgical navigation systems. We measure accuracy by constructing a mechanism that allows a tracked target to move with spherical motion (i.e., there exists a single point on the mechanism—the center of the sphere—that does not change position when the tracked target is moved). We imagine that the center of the sphere is the tip of a surgical tool rigidly attached to the tracked target. The location of the tool tip cannot be measured directly by the tracking system (because it is impossible to attach a tracking marker to the tool tip) and must be calculated using the measured location and orientation of the tracking target. Any measurement error in the tracking system will cause the calculated position of the tool tip to change as the target is moved; the spread of the calculated tool tip positions is a measurement of tracking error called the target registration error (TRE). The observed TRE will be compared to an analytic model of TRE to assess the predictions of the analytic model

On uncertainty propagation in image-guided renal navigation: Exploring uncertainty reduction techniques through simulation and in vitro phantom evaluation

Image-guided interventions (IGIs) entail the use of imaging to augment or replace direct vision during therapeutic interventions, with the overall goal is to provide effective treatment in a less invasive manner, as an alternative to traditional open surgery, while reducing patient trauma and shortening the recovery time post-procedure. IGIs rely on pre-operative images, surgical tracking and localization systems, and intra-operative images to provide correct views of the surgical scene. Pre-operative images are used to generate patient-specific anatomical models that are then registered to the patient using the surgical tracking system, and often complemented with real-time, intra-operative images. IGI systems are subject to uncertainty from several sources, including surgical instrument tracking / localization uncertainty, model-to-patient registration uncertainty, user-induced navigation uncertainty, as well as the uncertainty associated with the calibration of various surgical instruments and intra-operative imaging devices (i.e., laparoscopic camera) instrumented with surgical tracking sensors. All these uncertainties impact the overall targeting accuracy, which represents the error associated with the navigation of a surgical instrument to a specific target to be treated under image guidance provided by the IGI system. Therefore, understanding the overall uncertainty of an IGI system is paramount to the overall outcome of the intervention, as procedure success entails achieving certain accuracy tolerances specific to individual procedures. This work has focused on studying the navigation uncertainty, along with techniques to reduce uncertainty, for an IGI platform dedicated to image-guided renal interventions. We constructed life-size replica patient-specific kidney models from pre-operative images using 3D printing and tissue emulating materials and conducted experiments to characterize the uncertainty of both optical and electromagnetic surgical tracking systems, the uncertainty associated with the virtual model-to-physical phantom registration, as well as the uncertainty associated with live augmented reality (AR) views of the surgical scene achieved by enhancing the pre-procedural model and tracked surgical instrument views with live video views acquires using a camera tracked in real time. To better understand the effects of the tracked instrument calibration, registration fiducial configuration, and tracked camera calibration on the overall navigation uncertainty, we conducted Monte Carlo simulations that enabled us to identify optimal configurations that were subsequently validated experimentally using patient-specific phantoms in the laboratory. To mitigate the inherent accuracy limitations associated with the pre-procedural model-to-patient registration and their effect on the overall navigation, we also demonstrated the use of tracked video imaging to update the registration, enabling us to restore targeting accuracy to within its acceptable range. Lastly, we conducted several validation experiments using patient-specific kidney emulating phantoms using post-procedure CT imaging as reference ground truth to assess the accuracy of AR-guided navigation in the context of in vitro renal interventions. This work helped find answers to key questions about uncertainty propagation in image-guided renal interventions and led to the development of key techniques and tools to help reduce optimize the overall navigation / targeting uncertainty

An Image-Based Tool to Examine Joint Congruency at the Elbow

Post-traumatic osteoarthritis commonly occurs as a result of a traumatic event to the articulation. Although the majority of this type of arthritis is preventable, the sequence and mechanism of the interaction between joint injury and the development of osteoarthritis (OA) is not well understood. It is hypothesized that alterations to the joint alignment can cause excessive and damaging wear to the cartilage surfaces resulting in OA. The lack of understanding of both the cause and progression of OA has contributed to the slow development of interventions which can modify the course of the disease. Currently, there have been no reported techniques that have been developed to examine the relationship between joint injury and joint alignment. Therefore, the objective of this thesis was to develop a non-invasive image-based technique that can be used to assess joint congruency and alignment of joints undergoing physiologic motion. An inter-bone distance algorithm was developed and validated to measure joint congruency at the ulnohumeral joint of the elbow. Subsequently, a registration algorithm was created and its accuracy was assessed. This registration algorithm registered 3D reconstructed bone models obtained using x-ray CT to motion capture data of cadaveric upper extremities undergoing simulated elbow flexion. In this way, the relative position and orientation of the 3D bone models could be visualized for any frame of motion. The effect of radial head arthroplasty was used to illustrate the utility of this technique. Once this registration was refined, the inter-bone distance algorithm was integrated to be able to visualize the joint congruency of the ulnohumeral joint undergoing simulated elbow flexion. The effect of collateral ligament repair was examined. This technique proved to be sensitive enough to detect large changes in joint congruency in spite of only small changes in the motion pathways of the ulnohumeral joint following simulated ligament repair. Efforts were also made in this thesis to translate this research into a clinical environment by examining CT scanning protocols that could reduce the amount of radiation exposure required to image patient’s joints. For this study, the glenohumeral joint of the shoulder was examined as this joint is particularly sensitive to potential harmful effects of radiation due to its proximity to highly radiosensitive organs. Using the CT scanning techniques examined in this thesis, the effective dose applied to the shoulder was reduced by almost 90% compared to standard clinical CT imaging. In summary, these studies introduced a technique that can be used to non-invasively and three-dimensionally examine joint congruency. The accuracy of this technique was assessed and its ability to predict regions of joint surface interactions was validated against a gold standard casting approach. Using the techniques developed in this thesis the complex relationship between injury, loading and mal-alignment as contributors to the development and progression of osteoarthritis in the upper extremity can be examined

integration of enhanced optical tracking techniques and imaging in igrt

Patient setup/Optical tracking/IGRT/Treatment surveillance. In external beam radiotherapy, modern technologies for dynamic dose delivery and beam conformation provide high selectivity in radiation dose administration to the pathological volume. A comparable accuracy level is needed in the 3-D localization of tumor and organs at risk (OARs), in order to accomplish the planned dose distribution in the reality of each irradiation session. In-room imaging techniques for patient setup verification and tumor targeting may benefit of the combined daily use of optical tracking technologies, supported by techniques for the detection and compensation of organ motion events. Multiple solutions to enhance the use of optical tracking for the on-line correction of target localization uncertainties are described, with specific emphasis on the compensation of setup errors, breathing movements and non-rigid deformations. The final goal is the implementation of customized protocols where appropriate external landmarks, to be tracked in real-time by means of noninvasive optical devices, are selected as a function of inner target localization. The presented methodology features high accuracy in patient setup optimization, also providing a valuable tool for on-line patient surveillance, taking into account both breathing and deformation effects. The methodic application of optical tracking is put forward to represent a reliable and low cost procedure for the reduction of safety margins, once the patient-specific correlation between external landmarks and inner structures has been established. Therefore, the integration of optical tracking with in-room imaging devices is proposed as a way to gain higher confidence in the framework of Image Guided Radiation Therapy (IGRT) treatments

Review on Image Guided Surgery Systems

Nowadays modern imaging techniques can grant an excellent quality 3D images that clearly show the anatomy, vascularity, pathology and active functions of the tissues. The ability to register these preoperative images to each other, to offer a comprehensive information, and later the ability to register the image space to the patient space intraoperatively is the core for the image guided surgery systems (IGS). Other main elements of the system include the process of tracking the surgical tools intraoperatively by reflecting their positions within the 3D image model. In some occasions an intraoperative image may be acquired and registered to the preoperative images to make sure the 3D model used to guide the operation describes the actual situation at surgery time. This survey overviews the history of IGS and discusses the modern system components for a reliable application and gives information about the different applications in medical specialties that benefited from the use of IGS

Development and characterization of methodology and technology for the alignment of fMRI time series

This dissertation has developed, implemented and tested a novel computer based system (AUTOALIGN) that incorporates an algorithm for the alignment of functional Magnetic Resonance Image (fMRI) time series. The algorithm assumes the human brain to be a rigid body and computes a head coordinate system on the basis of three reference points that lie on the directions correspondent to two of the eigenvectors of inertia of the volume, at the intersections with the head boundary. The eigenvectors are found weighting the inertia components with the voxel\u27s intensity values assumed as mass. The three reference points are found in the same position, relative to the origin of the head coordinate system, in both test and reference brain images. Intensity correction is performed at sub-voxel accuracy by tri-linear interpolation. A test fMR brain volume in which controlled simulations of rigid-body transformations have been introduced has preliminarily assessed system performance. Further experimentation has been conducted with real fMRI time series. Rigid-body transformations have been retrieved automatically and the values of the motion parameters compared to those obtained by the Statistical Parametric Mapping (SPM99), and the Automatic Image Registration (AIR 3.08). Results indicated that AUTOALIGN offers subvoxel accuracy in correcting both misalignment and intensity among time points in fMR images time series, and also that its performance is comparable to that of SPM99 and AIR3.08