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Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1 Rebecca Bascom, 2 and William E. Higgins 1 SPIE Medical Imaging 2013: Image-Guided Procedures, Robotic Interventions and Modeling Orlando, FL, 12 Feb. 2013. 1 Penn State University Dept. of Electrical Engineering 1 and Dept. of Medicine 2 University Park and Hershey, PA USA

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Page 1: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Technician-free system

for image-guided bronchoscopyRahul S. Khare,1 Rebecca Bascom,2 and William E. Higgins1

SPIE Medical Imaging 2013:

Image-Guided Procedures, Robotic Interventions and Modeling

Orlando, FL, 12 Feb. 2013.

1Penn State University

Dept. of Electrical Engineering1 and Dept. of Medicine2

University Park and Hershey, PA USA

Page 2: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Lung Cancer Assessment

1. 3D MDCT image-based

planning

Page 3: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Lung Cancer Assessment

Drawing by Terese Winslow, “Bronchoscopy,” NCI Visuals Online, National Cancer Institute

1. 3D MDCT image-based

planning

2. Follow-on diagnostic

bronchoscopy

Page 4: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Bronchoscopy Guidance Systems

“Manual” lung cancer assessment is HARD!!

EM-, image-, and sensor-based bronchoscopy

guidance systems mitigate difficulty, but ….

• Need an attending technician

• Need extra hardware

• Unable to detect faulty maneuvers

• Lengthy re-synchronization after adverse events

References: Helferty2007, Higgins2008, Solomon2000, Gildea2006, Schwartz2006, Wegner2007, Cornish2012, Luo2011

Page 5: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Our Approach to Image-Guided Bronchoscopy

1. Pre-procedure planning – Khare SPIE MI 2011

• Compute natural bronchoscope navigation maneuvers

2. Bronchoscopy navigation – Khare SPIE MI 2010 & 2012

• Technician-free guidance

• Enable bronchoscope position verification

via global registration

Page 6: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Precompute Guidance Pathsusing standard bronchoscope maneuvers

1. Rotate bronchoscope to left or right

2. Flex bronchoscope tip

3. Advance / withdraw bronchoscope

Source: J. Respiratory diseases, 29(11), “The technique of adult

flexible bronchoscopy: Part 1,” K. Y. YONEDA, B. M. MORRISSEY

Source: http://cfcenter.stanford.edu/education/Bronchoscopy.html

Advance

Withdraw

Rotation

Page 7: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Pre-Procedure PlanningPrevious

angle = 0

Previous

angle = +90

Previous

angle = -90

Positive angle: CW rotation

Negative angle: CCW rotation

CW ~ 30

Go “UP”

CCW ~ -150

Go “DOWN”

CW ~ 30

Go “UP”

Page 8: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Guidance Computer Set-up

Thumbnail Plan Tool CT-Video Guidance Tool

3D Surface Tool

Foot pedal Commands

Live Video Virtual Bronchoscope

Frozen View of Previous Site

Page 9: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Guidance Strategy

1. Real and virtual bronchoscopes positioned at main carina.2. Physician presses foot pedal to advance system display.

Virtual bronchoscope rotates.

3. Physician mimics maneuver by moving bronchoscope.

Real and virtual bronchoscopes become synchronized.

4. Physician presses foot pedal to advance system display.

System display depicts next bifurcation and freezes the previous view.

5. Physician copies maneuver by moving bronchoscope.

Real and virtual bronchoscopes become synchronized.

6. Physician presses foot pedal to activate targeting circles.

Physician properly positions bronchoscope and invokes global registration.

7. Global registration verifies current real bronchoscope’s position.8. If the physician makes a WRONG “off path” maneuver … 9. Physician presses foot pedal targeting circles appear.

Physician properly positions bronchoscope and invokes global registration.

10. Global registration Catches navigation error, suggests corrective action.

Page 10: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

1) Phantom Study Results

Phantom 1: 5 ROIs Phantom 2: 6 ROIs

Page 11: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Phantom Study Results

* Indicates bronchoscope unable to reach last airway generation

Successful guidance to ALL ROIs

• “success” = reach final airway

Bronchoscope navigation as deep as airway generation 12

ROIs 4, 5 for 21405.3a: penultimate airway generation reached

Page 12: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Phantom Study video (earlier system version)

Page 13: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

2) Human Pilot Study: Results

9 consented patients; 39 total ROIs

Bronchoscopes used: Olympus BF 1T180 (6 mm) or BF P180 (4.9 mm)

Physician underwent multiple training sessions during study

Physician previewed preplanned routes before each procedure

Page 14: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Usage during a Human Study

guidance

monitor

foot pedal

Page 15: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Human Study Results

97% Success rate (38/39 ROIs)

Navigated as deep as airway generation 10

Failure occurred during first pilot case

• System suggested a wrong maneuver (a bug!)

• We upgraded the system after this case!

Tumor prevented complete approach

to 2 ROIs, but guidance succeeded

Page 16: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Sample Frozen Views for a Human Study

ROI 2 for case 20349.3.65

Page 17: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Human Studies: video for 20349.3.65

Page 18: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Conclusion

Technician-free bronchoscopy guidance system

Relies on natural bronchoscope movements

Nearly perfect navigation success: phantoms, humans

Page 19: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

AcknowledgmentsNational Cancer Institute of the NIH

• Grants #R01-CA074325 and #R01-CA151433

The Multidimensional Image Processing Lab

at Penn State

Drs. Higgins and Bascom have an identified conflict of interest related to grant

R01-CA151433, which is under management by Penn State and has been reported

to the NIH.

Conflict of Interest Statement

Page 20: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Planning/Navigation Strategy

Left or right Rotate - Flex - Advance

Rotate

clockwise

Rotate

counter-

clockwise

Rotate

counter-

clockwise

Move UP Move

DOWN

Move

DOWN

Maneuvers

Device

Directions

“2D” Roads 3D airway tree

Page 21: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Guidance Strategy: System-Level Algorithm

Page 22: Technician-free system for image-guided bronchoscopy · Technician-free system for image-guided bronchoscopy Rahul S. Khare, 1Rebecca Bascom,2 and William E. Higgins SPIE Medical

Human Studies

Tumor ROIs

Failure ROI