Image-Guided Robotics for Standardized and Automated Biopsy and Ablation

Image-guided robotics for biopsy and ablation aims to minimize procedure times, reduce needle manipulations, radiation, and complications, and enable treatment of larger and more complex tumors, while facilitating standardization for more uniform and improved outcomes. Robotic navigation of needles enables standardized and uniform procedures which enhance reproducibility via real-time precision feedback, while avoiding radiation exposure to the operator. Robots can be integrated with computed tomography (CT), cone beam CT, magnetic resonance imaging, and ultrasound and through various techniques, including stereotaxy, table-mounted, floor-mounted, and patient-mounted robots. The history, challenges, solutions, and questions facing the field of interventional radiology (IR) and interventional oncology are reviewed, to enable responsible clinical adoption and value definition via ergonomics, workflows, business models, and outcome data. IR-integrated robotics is ready for broader adoption. The robots are coming!

Generalized chest CT and lab curves throughout the course of COVID-19

A better understanding of temporal relationships between chest CT and labs may provide a reference for disease severity over the disease course. Generalized curves of lung opacity volume and density over time can be used as standardized references from well before symptoms develop to over a month after recovery, when residual lung opacities remain. 739 patients with COVID-19 underwent CT and RT-PCR in an outbreak setting between January 21st and April 12th, 2020. 29 of 739 patients had serial exams (121 CTs and 279 laboratory measurements) over 50 ± 16 days, with an average of 4.2 sequential CTs each. Sequential volumes of total lung, overall opacity and opacity subtypes (ground glass opacity [GGO] and consolidation) were extracted using deep learning and manual segmentation. Generalized temporal curves of CT and laboratory measurements were correlated. Lung opacities appeared 3.4 ± 2.2 days prior to symptom onset. Opacity peaked 1 day after symptom onset. GGO onset was earlier and resolved later than consolidation. Lactate dehydrogenase, and C-reactive protein peaked earlier than procalcitonin and leukopenia. The temporal relationships of quantitative CT features and clinical labs have distinctive patterns and peaks in relation to symptom onset, which may inform early clinical course in patients with mild COVID-19 pneumonia, or may shed light upon chronic lung effects or mechanisms of medical countermeasures in clinical trials.

CT and clinical assessment in asymptomatic and pre-symptomatic patients with early SARS-CoV-2 in outbreak settings

Objectives

The early infection dynamics of patients with SARS-CoV-2 are not well understood. We aimed to investigate and characterize associations between clinical, laboratory, and imaging features of asymptomatic and pre-symptomatic patients with SARS-CoV-2.

Methods

Seventy-four patients with RT-PCR-proven SARS-CoV-2 infection were asymptomatic at presentation. All were retrospectively identified from 825 patients with chest CT scans and positive RT-PCR following exposure or travel risks in outbreak settings in Japan and China. CTs were obtained for every patient within a day of admission and were reviewed for infiltrate subtypes and percent with assistance from a deep learning tool. Correlations of clinical, laboratory, and imaging features were analyzed and comparisons were performed using univariate and multivariate logistic regression.

Results

Forty-eight of 74 (65%) initially asymptomatic patients had CT infiltrates that pre-dated symptom onset by 3.8 days. The most common CT infiltrates were ground glass opacities (45/48; 94%) and consolidation (22/48; 46%). Patient body temperature (p < 0.01), CRP (p < 0.01), and KL-6 (p = 0.02) were associated with the presence of CT infiltrates. Infiltrate volume (p = 0.01), percent lung involvement (p = 0.01), and consolidation (p = 0.043) were associated with subsequent development of symptoms.

Conclusions

COVID-19 CT infiltrates pre-dated symptoms in two-thirds of patients. Body temperature elevation and laboratory evaluations may identify asymptomatic patients with SARS-CoV-2 CT infiltrates at presentation, and the characteristics of CT infiltrates could help identify asymptomatic SARS-CoV-2 patients who subsequently develop symptoms. The role of chest CT in COVID-19 may be illuminated by a better understanding of CT infiltrates in patients with early disease or SARS-CoV-2 exposure.

Key Points

• Forty-eight of 74 (65%) pre-selected asymptomatic patients with SARS-CoV-2 had abnormal chest CT findings.

• CT infiltrates pre-dated symptom onset by 3.8 days (range 1–5).

• KL-6, CRP, and elevated body temperature identified patients with CT infiltrates. Higher infiltrate volume, percent lung involvement, and pulmonary consolidation identified patients who developed symptoms.

Artificial intelligence for the detection of COVID-19 pneumonia on chest CT using multinational datasets

Chest CT is emerging as a valuable diagnostic tool for clinical management of COVID-19 associated lung disease. Artificial intelligence (AI) has the potential to aid in rapid evaluation of CT scans for differentiation of COVID-19 findings from other clinical entities. Here we show that a series of deep learning algorithms, trained in a diverse multinational cohort of 1280 patients to localize parietal pleura/lung parenchyma followed by classification of COVID-19 pneumonia, can achieve up to 90.8% accuracy, with 84% sensitivity and 93% specificity, as evaluated in an independent test set (not included in training and validation) of 1337 patients. Normal controls included chest CTs from oncology, emergency, and pneumonia-related indications. The false positive rate in 140 patients with laboratory confirmed other (non COVID-19) pneumonias was 10%. AI-based algorithms can readily identify CT scans with COVID-19 associated pneumonia, as well as distinguish non-COVID related pneumonias with high specificity in diverse patient populations.

Disposable Isolation Device to Reduce COVID-19 Contamination During CT Scanning

Rationale and Objectives

The use of chest computed tomography (CT) in the era of the COVID-19 pandemic raises concern regarding the transmission risks to patients and staff caused by CT room contamination. Meanwhile the Center for Disease Control guidance for air exchange in between patients may heavily impact workflows. To design a portable custom isolation device to reduce imaging equipment contamination during a pandemic.

Materials and Methods

Center for Disease Control air exchange guidelines and requirements were reviewed. Device functional requirements were outlined and designed. Engineering requirements were reviewed. Methods of practice and risk mitigation plans were outlined including donning and doffing procedures and failure modes. Cost impact was assessed in terms of CT patient throughput.

Results

CT air exchange solutions and alternatives were reviewed. Multiple isolation bag device designs were considered. Several designs were custom fabricated, prototyped and reduced to practice. A final design was tested on volunteers for comfort, test-fit, air seal, and breathability. Less than 14 times enhanced patient throughput was estimated, in an ideal setting, which could more than counterbalance the cost of the device itself.

Conclusion

A novel isolation bag device is feasible for use in CT and might facilitate containment and reduce contamination in radiology departments during the COVID Pandemic.

Preparation of a radiology department in an Italian hospital dedicated to COVID-19 patients

Preparedness for the ongoing coronavirus disease 2019 (COVID-19) and its spread in Italy called for setting up of adequately equipped and dedicated health facilities to manage sick patients while protecting healthcare workers, uninfected patients, and the community. In our country, in a short time span, the demand for critical care beds exceeded supply. A new sequestered hospital completely dedicated to intensive care (IC) for isolated COVID-19 patients needed to be designed, constructed, and deployed. Along with this new initiative, the new concept of "Pandemic Radiology Unit" was implemented as a practical solution to the emerging crisis, born out of a critical and urgent acute need. The present article describes logistics, planning, and practical design issues for such a pandemic radiology and critical care unit (e.g., space, infection control, safety of healthcare workers, etc.) adopted in the IC Hospital Unit for the care and management of COVID-19 patients.

Improving detection of prostate cancer foci via information fusion of MRI and temporal enhanced ultrasound

PURPOSE

The detection of clinically significant prostate cancer (PCa) is shown to greatly benefit from MRI-ultrasound fusion biopsy, which involves overlaying pre-biopsy MRI volumes (or targets) with real-time ultrasound images. In previous literature, machine learning models trained on either MRI or ultrasound data have been proposed to improve biopsy guidance and PCa detection. However, quantitative fusion of information from MRI and ultrasound has not been explored in depth in a large study. This paper investigates information fusion approaches between MRI and ultrasound to improve targeting of PCa foci in biopsies.

METHODS

We build models of fully convolutional networks (FCN) using data from a newly proposed ultrasound modality, temporal enhanced ultrasound (TeUS), and apparent diffusion coefficient (ADC) from 107 patients with 145 biopsy cores. The architecture of our models is based on U-Net and U-Net with attention gates. Models are built using joint training through intermediate and late fusion of the data. We also build models with data from each modality, separately, to use as baseline. The performance is evaluated based on the area under the curve (AUC) for predicting clinically significant PCa.

RESULTS

Using our proposed deep learning framework and intermediate fusion, integration of TeUS and ADC outperforms the individual modalities for cancer detection. We achieve an AUC of 0.76 for detection of all PCa foci, and 0.89 for PCa with larger foci. Results indicate a shared representation between multiple modalities outperforms the average unimodal predictions.

CONCLUSION

We demonstrate the significant potential of multimodality integration of information from MRI and TeUS to improve PCa detection, which is essential for accurate targeting of cancer foci during biopsy. By using FCNs as the architecture of choice, we are able to predict the presence of clinically significant PCa in entire imaging planes immediately, without the need for region-based analysis. This reduces the overall computational time and enables future intra-operative deployment of this technology.