Early Experience of a Commercial Available Robot (Maxio) for CT-guided Radiofrequency Ablation of livertumours

1 BJJ Abdullah, 1 CH Yeong, 2 KL Goh, 3 BK Yoong, 4 GF Ho, 5 Anjali Kulkarni 1 Department of Biomedical Imaging and University of Malaya Research Imaging Centre, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.Departments of 2Internal Medicine, 3Surgery and 4Oncology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.5Perfint Healthcare Corporation, Florence, OR 97439, United State.

Tumor visualization difficult in many cases

Impossible to visualize related structures

Skill dependent

Visualization

Limited ToolsCurrent fusion techniques -

Cumbersome

Ablation zone

Planning

Complex spatial orientation of organsNeedle visualization

Multiple needle Big Learning Curve

Positioning

No tool to validate

Patient follow up

Validation

Challenges in Ablation

Local tumor progression occurs due to failures in establishing ablative margin(Minami & Kudo, 2011)

Ablation tool lacks the critical level of control, accuracy, stability, and guaranteed performance (Emad M. Boctor et. Al, 2004)

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Challenges of current CT-guided RFA

Repeated PuncturesRepeated Punctures

High CT fluoro doseHigh CT fluoro dose

Real timeReal time

Time ConsumingTime Consuming

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Target

Entry point

Angle

Depth

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MAXIOTM (Perfint Healthcare Pvt Ltd, Oregon, USA)

Foot Switch

CT Gantry Coordinate system

CT Console

Z

Y

X

Y

X

ROBIO EX Coordinate system

Integrated monitor(ROBIO EX-Console)

Ethernet connection either thro hospital Network or thro a Ethernet Hub to CT

RS485 thro USB/ Serial to 485 converter to ROBIO console

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MAXIO

MAXIO console

Robotic-Assisted RFA

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Purpose of Study

•To assess the accuracy of needle placement, radiation dose and performance level during robotic-assisted radiofrequency ablation (RA-RFA) of liver tumours using a CT-guidance robotic system (MAXIO, Perfint Healthcare, USA).

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Methodology

• 19 patients (39 lesions, <5.0 cm diameter) were treated with RA-RFA.

• All the procedures were performed under GA. • Following baseline CT scans the lesions were identified.• The CT images (1 mm reconstructed SL) were registered to

the MAXIO workstation for treatment planning.• Target point (X, Y, Z) and needle entry point were determined

during the treatment plan.• The needle trajectory path, angulation and depth of lesion

were calculated and shown on the treatment plan.

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Methodology

• The plan was carefully checked to avoid any critical organs or bone across the trajectory.

• Once the plan was confirmed, MAXIO was executed.• The robotic arm then moved automatically to the planned

location and the radiologist inserted the RFA needle through the bush holder at the end-effector of the robotic arm.

• Post-needle insertion, a CT-fluoro was done to confirm accurate placement of the needle within the target volume.

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Methodology

• The accuracy of needle placement, number of readjustments and total radiation dose to each patient were recorded.

• The performance level was evaluated for each procedure on a five-point scale (5-1: Excellent-Poor) by the operated radiologist.

• The radiation doses and readjustments were then compared against 30 RFA patients treated without robotic assistance.

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Image Registration Segmentation Simulation

Adaptive Intra-op. registration

Post procedure confirmation

Robotic Targeting

EXECUTE

SCAN

VALIDATE

PLAN VISUALISE

MaxioTM

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Results

• All 39 lesions were targeted successfully.• No immediate complications were noted in all the patients.

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RA-RFA Conventional RFA P-valueAverage number of needle readjustment

0.8 ± 0.8

Performance level 4.7 ± 0.5 CT Fluoro Dose per Lesion (DLP, mGy.cm)

422.27 ± 370.611(-16%)

501.20 ± 366.54 P>0.05

Total CTDIvol per patient (mGy)

534.71 ± 397.74(-6%)

567.33 ± 398.62 P>0.05

Total DLP per patient (mGy.cm)

1390.37 ± 549.02(-14%)

1611.27 ± 708.38

P>0.05

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Conclusion

•Robotic-assisted planning and needle placement appears to be ▫ technically easier▫ requires fewer number of needle passes▫ fewer check scans▫ lower radiation dose (patient & staff)

•Study with large sample size is needed to confirm these preliminary findings.

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Other Potential Advantages of RA-RFA

• Time

• Pain

• Allows access to difficult lesions

• Accuracy & consistency

• Level of confidence & safety

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References

•BJJ Abdullah, CH Yeong, KL Goh, BK Yoong, GF Ho, Carolyn Yim, Anjali Kulkarni. Robotic-assisted radiofrequency ablation of primary and secondary tumours. European Radiology, Vol 23(9), 2013.

•Perfint Healthcare Corporation official website. www.perfinthealthcare.com

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