35
Integrated Planning, Navigation and Targeting for Tumor Ablation www.perfinthealthcare.com
Integrated Planning, Navigationand Targeting for Tumor Ablation
www.perfinthealthcare.com
Ablation Assessment: Can we get beyond Contrast Enhancement?
• Contrast-enhanced radiologic imaging is the basis of current response evaluation
criteriaforHCC
• Novelimagingapproachesdonotseemtobeabletoovercomethemainlimitation
ofdynamicimaging,i.e.,theinabilitytodetecttinyfociofresidualviabletumor
• Volumetrictechniquesprovideobjectivedocumentationoftheablationmarginand
thusappearasthebestmethodtoconfirm“AO”treatment
• Volumetricplanningoftheablationstrategy,includingselectionofdevice,approach
andtreatmentprotocolshouldbecomestandardofcareforclinicalpractice
by Dr Riccardo Lencioni, MD, University of Pisa - Italy, at RSNA 2012
NewDirections…Newhope
ThiscompilationofdiagnosticandtherapeuticprocedureswereperformedonPerfint’stargetingsystems.Informationcontainedhereisforprivatecirculationonly.
Theinformationisintendedforthepurposeitservesandnotbeyond.Incaseofanyissue,errororcomplaintpleasewriteto:[email protected]
PerfintHealthcare(www.perfinthealthcare.com)isaworldleaderinplanningandtargetingsolutionsforimageguidedinterventionalprocedures-withanemphasison
oncologyandpaincare.Perfint’sproducts,PIGACTandROBIO,areusedbyradiologistsaroundtheworldforbiopsy,drugdelivery,ablation,drainageandfineneedle
aspiration.PIGACTandROBIOareinstalledatsomeoftheworld’stophospitalsandareCEmarked.Perfint’snewestproductMAXIO,issettochangetheworldof
InterventionalOncology.MAXIOwillallowclinicianstovisuallyplan,executeandvalidateablationproceduresonasinglesystemandallin3D.MAXIOhasbeendesigned
tomakecomplex,multi-probeablationssimpler,whichwillhelptomaketheselife-savingproceduresavailabletomorecancersufferersthaneverbefore.
Clinicians benefit from MAXIO’s intelligent planning suite and targeting...
Registering pre-operative images and offline procedure plan with current CT images
Organ specific tumor visualisation andsegmentation
Multiple VOI, Multi-probe placement plan for multiple procedures
Accurate placement without fluoroscopicradiation
Ability to treat hard to access and larger tumors
Post procedure verification
www.perfinthealthcare.com
MAXIOISNOTAVAILABLEFORSALEORDISTRIBUTIONINTHEUS, ITISPENDING510KCLEARANCE.
Tumor Ablation is heading in a whole new direction... And MAXIO is leading the way.
Classifiedbytypeofprocedure
PROCEDURE PAGES
ABLATION 6-42
PAIN MANAGEMENT 44-52
IRE 54
BIOPSY 56
Clinical Cases as performed with MAXIO
54
Integrated Planning, Navigationand Targeting for Tumor Ablation
Challenge: Procedure:
Patient planned for RFA of mulitple lesions in the liver
Radio Frequency Ablation of Multiple Liver Lesions
MAXIOassistedinthepreciseplanning&targetingofthedeep-seatedlesionsthroughsafetrajectorywithacombinationofbothCranio-caudalandorbitalangles.
Lesionsaresituatedclosetodiaphragmandbowel.Critical organslikelung,vasculatureandbowelsurroundthetargets.Withfreehandtechniqueitisdifficulttoplacetheprobeintarget(s)withouttraumatizingcriticalorgans.
01CASE
Parameters: Tumor 1 Tumor 2LesionSize : 15mm 9mm Location : Segment7Closetodiaphragm Segment4closetobowel Angulation : Orbital:11.93Craniocaudal:37.03 Orbital:29.36Craniocaudal:5.39 Entryslice : 235 272 Targetslice : 306 282 Targetdepth : 117.89mm 106.43mm
Tumor 1 Tumor 2
Notes
76
Challenge: Procedure:
A patient was planned for radiofrequency ablation of 3.8 x 3.7 cm lesion at segment 8 of liver
Radio Frequency Ablation of recurrent HCC after TACE
Planningin3Dand2D
Orbitalangle :64/63° CCangle : 18/13° Depth :90.9/91mmProceduretime :28min
PatientwasplannedunderGA, coolitip:17G150/30Twoprobeswereused.
PostTACElesionwasnotvisibleonultrasound.Theresiduallesionwassituatedbelowdiaphragm.
Doctorplacing probewithMAXIO
PostRFAshowsablatedareacovering tumour
Ablated area
02CASE Notes
98
Challenge: Procedure:
Patient planned for RFA of 25 mm mass at 6th segment of the liver and 9 mm mass in right lung during the same procedure
Radio Frequency Ablation of a HCC and a Lung Lesion
Planningin3Dand2D
Ablationprocedureplannedintwosittings.LesionstargetedpreciselywiththeassistanceofMAXIOinsequentialmode.Nopostprocedurecomplications.
Planningsafetrajectorieswithminimalpatientdiscomfortandlessprocedurerelatedcomplicationsisachallenge.
CheckscanshowsprobePostRFAshowsablatedareacovering tumour
Ablated area
03CASE
Liver plan: Orbitalangle : -16.05 CCangle :0° Depth :93mm
Lung Plan : Orbitalangle : -61.84 CCangle :0°Depth : -74.42mm Needleused : 17GCooltip : 150-30 Planningtime : 10min Proceduretime :40m
Notes
1110
Challenge: Procedure:
Notes
Planningin3Dand2D
Checkscanneedleinsitu
Patient diagnosed with HCC underwent liver transplant now with solitary adrenal metastatic lesion
Radio Frequency Ablation of Adrenal Tumor04CASE
Size : 15mm Orbital : -5.49° Craniocaudal :48.55° Targetdepth :48.55mm
Infreehand,itisdifficulttoplacetheprobewithsteepangulationstoreachthetargetwithouttraumatisingthediaphragmandrenalvessels.
MAXIOhelpsinpreciseplanningandtargetingoftheadrenallesionwithsuchcomplexobliqueapproach,soastoavoidpassingthroughpleuralrecess.
1312
Challenge: Procedure:
A patient planned for Radio-frequency ablation with multi-probe placement
Orbitalangle :7.85° Depth :93.83mm Needleused : 17G Cooltip : 150-40 Planningtime : 15min Proceduretime :80min
MAXIOhelpsinmulti-probeplacementandprecisetargetingofthelesion.Ablationplannedin5sittingsthroughsimultaneousandsequentialmode.
Multipleprobeplacementrequiredtocoverthelesioncompletely.Overlappingtheablationzonesisachallengetoavoidtheresidualtumors.
05CASE Radio Frequency Ablation of Liver lesion with multiple probes
Planningin3Dand2D
CheckscanshowsprobePostRFAshowsablatedareacovering tumour
Ablated area
Notes
1514
Challenge: Procedure:
Patient planned for radiofrequency ablation at 7th segment of liver
Radio Frequency Ablation of 2 cm of HCC
Planningin3Dand2D
Orbitalangle : 19.46° Depth :76.28mm Needleused : 17GCooltip : 150-30 Numberofneedles :onePlanningtime : 10min Proceduretime :30min
2cmlesionwastargetedunderGAinproneposition.Thethermalsimulationareacoveredthelesion.
Lesionissituatedposteriorlysoplanningandtreatmentisdoneinproneposition.
CheckscanshowsprobePostRFAshowsablatedareacovering tumour
Ablated area
06CASE Notes
1716
Challenge: Procedure:
Notes
Planningin3Dand2D
Checkscanneedleinsitu
A patient is planned for Radio-frequency ablation of 3 sub-cm lung lesions of primary HCC
Radio Frequency Ablation of Multiple Lung Lesions 07CASE
Craniocaudal :9.37° Targetangle :65.56mm
MAXIOenablesbetterplanningforsmalllunglesions,minimisingnumberofpasses/adjustmentsrequiredforoptimalprobepositioning.Procedurecompletedwithoutanycomplication.
Precisetargetingofthe6mmperipherallungnoduleisdifficult.
1918
Challenge: Procedure:
08CASE
RFA of 12 mm mass at 5th segment of the liver followed by alcohol ablation
Radio Frequency Ablation of 12 mm Mass in Liver
Planningin3Dand2D
Orbitalangle :45.6° Depth :64.5mm Needleused : 17GCooltip : 100-30 Numberofneedles :onePlanningtime :5min Proceduretime :22min
MAXIOhelpstovisualizetheablationzone,soitcanbeadjustedtotreatthetumorprecisely.ThesiteoflesioniswellwithintheablationzoneinpostRFACT.
Ablationareacannotbepredictedeasilyduetoitspositionintheliversegment.
CheckscanshowsprobePostRFAshowsablatedarea in region of tumour
Ablated area
Notes
2120
Challenge: Procedure:
A patient is planned for radiofrequency ablation of 5th segment of 1.8 cm lesion
Radio Frequency Ablation 1.8 cm HCC
Planningin3Dand2D
Orbitalangle :23.17CCangle :0.97° Depth : 118mm Needleused : 17G Cooltip : 150-30 Numberofneedles : 1 Planningtime :9min Proceduretime :30min
1.8cmlesionistargetedwithcooltipprobe.Adeepseatedlesionrequiringtheshortandsafetrajectory.
CheckscanshowsprobePostRFAshowsablatedareacovering tumour
09CASE
Ablated area
Notes
2322
Challenge: Procedure:
A patient is planned for radio frequency ablation of 3.4 cm lesion in 5 th segment of liver
Radio Frequency Ablation of 3.4 cm HCC
Planningin3Dand2D
Orbitalangle :47.08 CCangle :0° Depth : 140mm Needleused : 17G Cooltip :200-30 Numberofneedles :2 Planningtime :9min Proceduretime :45min
Thelesionisablatedintwosittingofablation.Twoneedlesplacedinsimultaneousandfirstsittingofablationdoneandthirdneedleplacedtowardscaudalborderbymanipulationandsecondsittingofablationdone.
Completelycoveringthetumourwithsafetymarginbythermalablationzoneinsequentialprobeplacements.
CheckscanshowsprobePostRFAshowsablatedareacovering tumour
10CASE Notes
2524
Ablated area
Challenge: Procedure:
A patient planned for a radiofrequency ablation of 1.5 cm lesion in 3rd segment of liver
Radio Frequency Ablation of 1.5 cm HCC
Planningin3Dand2D
Cooltip : 150/30Orbitalangle :9.56°CCangle :6.88° Depth : 100.23mm Planningtime :5minProceduretime : 15min
RFAdoneunderGA.AvoidingtheNoGoregionlikestomachinplanningandtargetingisachallenge.
Overlaidimageshowstip oftheprobeonthetargetandthermalsimulationisnotcoveringthestomach
11CASE Notes
2726
Challenge: Procedure:
Notes
Planningin3Dand2D
Checkscan,probeinsitu Checkscan,postRFA
Patient planned for RFA of (HCC) at Segment 5, with liver cirrhosis and fluid around liver
Radio Frequency Ablation of Segment 5 HCC12CASE
Lesionsize : 1.6x2x1.3cms Orbitalangle :44° Depth :69mm Needleused : 17G/100mm, Cooltip : 100-30 Numberofneedles : 1 Planningtime : 10min Proceduretime :25min
2cmsHCCtargetedforRFAwithMAXIOatsegment5oftheliverandRFAperformed.Traumatothebowelwasavoidedbyadjustingthermalsimulationoption.Postablationscanshows,awedge-shapedareawithoutenhancementcoveringlesion.
Itisatoughcasebecausethelesion,tobetargeted,isbouncingduetocirrhosisandfluidaroundliver.
2928
Notes
• Multipleprobeplanninginsequentialmode• Overlappingablationzonecanbeestimated• Collisiondetectionandsequencingalgorithm
Multiple Liver tumours planned for MWA13CASE
313030
Tumor in pancreatic region, precisely targeted with assistance of MAXIO. Multiple probes placed in parallel for IRE. No post procedure complications.
Pancreatic tumour - IRE 14CASE Notes
3332
Challenge: Procedure:
Patient planned for RFA of 3 cm HCC mass
Radio Frequency Ablation of Liver
Orbitalangle :86.5° Depth :68.68mm Needleused :Starburst
100 mm Numberofneedles : 1 Planningtoneedle: 10min placement
MAXIOassistedinprecisetargetingofthelesiononlateralposition.Nopostprocedurecomplications.
Lateralapproachrequiresprecisetrajectorytotargetthemassinliver.
15CASE Notes
3534
Heterogeneous large volume Liver lesion ablated using RFA probe in sequential manner. MAXIO’s planning software displays segmented organs, tumors and vascular structure for effective planning
Radio Frequency Ablation of Liver Tumor16CASE Notes
3736
“Solutions like MAXIO will help Interventional Oncologists to plan and achieve AO ablation which is as important as RO resection in surgery.”
Volumetric Planning & Assistance for an “AO” Ablation Strategy
3DvisualizationoftumorandvasculaturewithMAXIO’sintuitiveplanning
17CASE Notes
3938
MAXIOallowstosegmentandvisualizemultipleliverlesionsinadditiontochecking the respective ablation volumes. MAXIO’s intuitive planning helps in volumetric assessment of liver and ablated area
Planning of Multiple Liver Lesions for Ablation
Segmentation of multiple liver lesions
18CASE Notes
4140
MAXIO helps to plan safest probe trajectory. This helps tominimizedamagetosurroundingstructures.
19CASE
Probe planning in MPR or in 3D view
Ablation Planning in 3D Anatomical View Notes
4342
Challenge: Procedure:
Patient with degenerative lumbar spine planned for facet joint injections at L4-L5 and L5-S1 on right and left side simultaneously
Multiple Facet Joint Injections at L4-L5 & L5-S1
Planningin3Dand2D
Checkscan,needlesinsitu
Orbitalangle :10° Depth :68to75mm Needleused : 19G/127.5mm Numberofneedles :4 Planningtime : 15min Proceduretime :35min
Facetjointtargetedatmultiplelevelswithmultipleneedlessimultaneously,withassistanceofMAXIO.EachFacetjointinjectedwith1mlofMarcaineand1mlofCelestoneChronodose.Procedurecompletedprecisely.
MultipleFacetjointsatL4-L5and L5-S1onrightsideandleftsidetobe targeted.
20CASE Notes
4544
Challenge: Procedure:
Patient with degenerative lower back pain and Non-operative management, planned for facet joint injection at L4-L5-S1 level
Multiple Facet Joint Injections at L4-L5-S121CASE
Planningin3Dand2D
Orbitalangle :0° Depth :44to52mm Needleused :22G/100mm Numberofneedles :4Planningtime :6min Proceduretime :31minfor
fourneedles
Facetjointtargetedatmultiplelevelswithmultipleneedlessimultaneously,withassistanceofMAXIO.EachFacetjointinjectedwith1mlofMarcaineand1mlofCelestoneChronodose.Procedurecompletedprecisely.
MultipleFacetjointsatL4-L5-S1tobe targeted.
Notes
4746
Challenge: Procedure:
Disc bulge causing compression on L5 nerve root on left side
Ozone Injection Into Inter Vertebral Disc 22CASE
Planningin3Dand2D
TheL4-L5centralnucleusofthediscistargeted Orbitalangle :38° Depth : 102mm Needleused : 18G/150mm Numberofneedles :one Planningtime :5min Proceduretime : 10min
OzonenucleusInjectionintotheDisctosuckoutthewatercontent,aftertheinjectionthesizeofthediscwillgetreducedindiameterandrelievespressureonnerveroots.
Thedepthismoreandneedpreciseplantoreachthecentralnucleusofaffecteddisc.
Notes
4948
Challenge: Procedure:
Patient with post lumbar decompression and left Para spinal pain planned for multilevel facet joint injections on left side
Facet Joint Injections23CASE
Planningin3Dand2DandMPR
Orbitalangle :0to1° Depth :58to59mm Needleused :22G/100mm Numberofneedles :3 Planningtime :7min Proceduretime :25minfor
threeneedles
FacetjointsontheleftsideatL3-L4,L4-L5,L5,S1preciselytargetedsimultaneouslywithMAXIO.EachFacetjointinjectedwith1mlofMarcaineand1mlofCelestoneChronodose.
MultipleFacetjointstobepreciselytargeted.
ThreeneedleatMultiplelevelonleftside
Notes
5150
Challenge: Procedure:
Patient with lower back pain, planned for facet Joint injection at L4-L5 and L5-S1 level
Facet Joint Injections24CASE
Planningin3Dand2D
Orbitalangle :0to1° Depth :52to60mm Needleused :22G/90mm Numberofneedles :4 Planningtime :6min Proceduretime :60min
MAXIOassistedinpreciseandsimutaneoustargetingoffacetjointatMultiplelevel.EachFacetjointinjectedwith1mlofMarcaineand1mlofCelestoneChronodosePatienttoleratedtheprocedurewell.
MultipleFacetjointsatL4-L5andL5-S1tobetargeted.
Notes
5352
Challenge: Procedure:
Notes
25CASE
IRE with Nano Knife performed on solitary metastasis right iliac wing from Ca. Prostate
IRE on Iliac Bone
Planningin3Dand2D
FirstneedlewithMAXIOTwoparallelneedlewith Nano Knife
Orbitalangle :39° Depth :69mm Needleused : 11G/100mmNanoknife : 150/40 Numberofneedles :2Planningtime : 10min Proceduretime :60min
8mmlesionatiliacbonepreciselyandquicklytargetedwithMAXIOfortwoIREparallelprobe.IREperformedbyNanoknifewithmaximum3kvoltageand12-15Ampscurrent.Patientdischargedonsameday(AdvantageofCTguidedintervention).
Placingtwoparallelprobeswithinanarrowspaceof8mmisvery difficultandtimeconsuming,requiringrepeatedcheckscans andneedlemanipulations.
5554
Exophytic renal mass Biopsy 26CASE
Planningin3Dand2D
1.2cmleftrenalmasswastargetedwith5°orbitalangleatdepthof108mm.Precisetargetinghelpedtoavoidanycomplications.
Checkscanneedleinsitu
Procedure:
Notes
5756
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University of Malaya Mediccal Center, Malaysia
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All India Institute of Medical Sciences, India
National Cancer Hospital, Bogota, Colombia
Makati Medical Center,Manila, Philipines
Hospital Barros Luco, Santiago
Hospital Barros Luco Santiago, Chile
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St. Petersburg Oncology Centre
Zurich University Hospital, Zurich
EGE University, IZMIR, Turkey
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Some of Our Key Users*
5958
*
*applied for regulatory clearance
Visualization,planningand navigation for
interventional oncology
World Class IO Systems
6160
Integrated Planning, Navigation and Targeting for Tumor Ablation
TUMOR ABLATION Current practiceToday,cliniciansplantheirinterventionaloncology
proceduresbyviewing2dimensionalCTslices,and
combiningwhattheyseewiththeirunderstandingof
humananatomy,todeterminetheoptimalapproachto
targetthetumor.Theymustdeterminetheprobetrajectory
pathandtheamountofenergyneededtodestroythe
tumor,whilesparinghealthytissue.
Multipleenergyprobesmustbemanuallyadvancedinto
thetumoroneatatime,withoutcomingincontactwith
oneanother,andwithoutdamagingvitalorgans.
Allthiswhilefactoringinthepotentialfororganmovement
duringpatientrespiration.It’snotsurprisingtheprocedure
isperformedbyonlythemostskilledandpracticed
clinicians.
MAXIO A new approachClinicianscannowvisualize and plan an entire ablation
procedurein3D-pre-operativeregistration,segmentation
andvisualizationofmultipleVOI,multiprobeplacement
planning,estimatedablationvolume*visualization,probe
placementsequence,allbeforeadvancingasingleprobe
intothepatient.
Oncetheplanisconfirmed,MAXIO’stargeting system
combinedwithadaptiveintra-operativeregistration
providesspatialpositioningandorientationforaprobe
guide,throughwhichtheclinicianthencarefullyadvances
eachprobeandperformstheablativeprocedure.
Onceablationhasbeencompleted,MAXIO’svisualization
toolallowsthecliniciantoverifyiftheprocedurewas
executedasplannedanddeterminewhetheradditional
treatmentsmayberequired.MAXIO’sreporting tool then
generatestherequiredreports.
Tumor ablation made easier and more predictable.
*asprovidedbythedevicemanufacturerorasdeterminedby
theclinician.
Tumor Ablation is heading in a whole new direction... And MAXIO is leading the way.
Clinicians benefit from MAXIO’s intelligent planning suite and targeting...
• Registeringpre-operativeimages
and off-line plan with current CT
images
• Organspecificctumorvisualization
and segmentation
• MultipleVOI,multi-probeplacement
plan for multiple procedures
• Accurateplacementwithout
fluoroscopic radiation
• Abilitytotreathardtoaccessand
large tumors
• Postprocedureverification
6362
Integrated planning, execution and verifi cation of
interventional oncology procedures.
1. RollMAXIOintopositionandregistertotheCTtableusingInstaRegTM[A]
2. Preparethepatient,obtainCTimagesonMAXIO[B]
3. Registercurrentimageswithpre-operativeimagesorplan,ifavailable
4. SegmentoneormoreVolumesofInterest,identifyno-goregions,definetumormargins
5. Targettumor,withupto6probes,on2D/3Dimage
6. Visualizeandeditestimatedablationvolumes*
Pre-operativeMAXIO’s powerful planning software provides 2D and 3D visualizationoftheaffectedregionandawiderangeoftools to aid the development and execution of the plan.
Post operativePost-procedure images can be viewed, and compared to the plan or pre-operative images
Intra-operativeMAXIO allows clinicians to move seamlessly from planning to execution. With the click of a button, the arm moves into position for the clinician to advance the probes. Intra-operative registration allows verifi cation of probe(s) placement prior to ablation
SETU
P
EXEC
UTE
VERI
FY
PLAN
7. EnableMAXIO’sstereotacticarmtopositiontheprobe guidefortheprocedure[C]
8. Manuallyadvanceeachprobethroughtheprobeguidetoreachthetumor
9. Performintra-operativeregistrationtoverifyprobeplacementandadaptsubsequentplan(s),ifneeded
10. Ablatetumorasplanned
11. Registerpost-operativeandpre-operativeorganimages
12. Verifyifvolumewithintumormarginisablatedfully,extendtreatmentifneeded
13. Generatepatientreportstodocumentprocedure
14. Imageregistrationmaybeusedtomonitortumorprogressionduringfollow-upvisits
*Step6isoptional.Ablationvolumesasprovidedbythedevicemanufacturerorasdeterminedbytheclinician
6564
• WorkswithallDICOM3CTimages
• SupportsRF,MW,IRE,Cryoablation
•
•
PatientandRespiratorymotionmanagement.
Steriledisposablekit*toenhanceclinical
efficiency
*PleasecontactyourPerfintrepresentativefordetails
1
2
3
Multi phasic contrast image of liver co registered prior to procedure planning on MAXIO suite
Intuitive one touch segmentation helps segment organs & tumor
Multiple probe / multiple VOI planning
With MAXIO everyone benefits...Cliniciansarebetterabletoplaninterventional
oncologyprocedureswiththehelpofMAXIO’s
visualizationandplanningsoftware,then
successfullyperformtheprocedurewiththehelp
ofMAXIO’stargetingsystem.
Hospitalsarelookingforefficiencyandit’sthe
goalofMAXIOtomakeinterventionalprocedures
fasterandmorepredictable,akeychallengeto
schedulingoftheCTsuite.
Patientsdeserveaccesstolife-savingtreatments
thataresafeandeffective.MAXIOstrivesto
reducethepotentialforunintendedorgan
damageduetorepeatpuncturesandislikelyto
reducetheneedforrepeatscanswhichwould
meanlessradiationexposureforthepatient.
6766
Acknowledgement
AlfredHospital,Australia
UMMC,Malaysia
TataMemorialHospital,India
Medanta,India
Research Analysis Library, Pisa
©Cop
yright2012perfinthealth
carecorpo
ratio
n.Allrightsreserved.(6936-200
613-V2
)
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