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Abstract
For both primary and metastatic liver cancer, thermal ablation represents an interesting alternative to surgery. However, except for a small fraction of patients, conventional ultrasound- and CT-guided single-probe approaches have not achieved oncologic outcomes comparable with surgery. In this overview, we describe our stereotactic ablation workflow and discuss the short- and long-term results of stereotactic radiofrequency ablation (SRFA) and stereotactic microwave ablation (SMWA) for the treatment of primary and secondary liver tumours. The advantages of this method are discussed together with a summary of the existing stereotactic techniques for thermal ablation and the clinical data that support them. Stereotactic ablation is based on an optical navigation system and a specialized aiming tool. The workflow includes advanced three-dimensional planning, precise needle/probe placements according to the plan and intraoperative image fusion to check the needle positions and the ablation margins. Stereotactic ablation offers all the advantages of a minimally invasive procedure while producing oncological results comparable with surgery. The number of locally treatable liver cancers may be significantly expanded with these cutting-edge instruments and methods. We firmly believe that it can become a cornerstone in the treatment of liver cancers.
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Affiliation(s)
- Reto Bale
- Interventional Oncology/Stereotaxy and Robotics, Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gregor Laimer
- Interventional Oncology/Stereotaxy and Robotics, Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter Schullian
- Interventional Oncology/Stereotaxy and Robotics, Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
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Audigier C, Mohaiu AT, Alzaga A, Bale R, Mansi T. A comparative study on computational models of multi-electrode radiofrequency ablation of large liver tumors. Int J Comput Assist Radiol Surg 2022; 17:1489-1496. [PMID: 35776400 DOI: 10.1007/s11548-022-02689-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/24/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Thermal ablation of liver tumors has emerged as a first-line curative treatment for single small tumors (diameter < 2.5 cm) due to similar overall survival rates as surgical resection. Moreover, it is far less invasive, has lower complication rates, a superior cost-effectiveness, and an extremely low treatment-associated mortality. However, in many cases, complete tumor coverage cannot be achieved only with a single electrode and several electrodes are used to create overlapping ablations. Multi-electrode planning is a challenging 3D task with many contradictive constraints to consider, a dimensionality difficult to assess even for experts. It requires extremely long planning time since it is mostly performed mentally by clinicians looking at 2D CT views. An accurate and reliable prediction of the ablation zone would help to turn thermal ablation into a first-line curative treatment also for large liver tumors treated with multiple electrodes. In order to determine the level of model simplification that can be acceptable, we compared three computational models, a simple spherical model, a biophysics-based model and an Eikonal model. METHODS RF ablation electrodes were virtually placed at a desired position in the patient pre-operative CT image and the models predicted the ablation zone generated by multiple electrodes. The last two models are patient-specific. In these cases, hepatic structures were automatically segmented from the pre-operative CT images to predict a patient-specific ablation zone. RESULTS The three models were used to simulate multiple electrode ablations on 12 large tumors from 11 patients for which the procedure information was available. Biophysics-based simulations approximate better the post-operative ablation zone in term of Hausdorff distance, Dice Similarity Coefficient, radius, and volume compared to two other methods. It also predicts better the coverage percentage and thus the tumor ablation margin. CONCLUSION The results obtained with the biophysics-based model indicate that it could improve ablation planning by accurately predicting the ablation zone, avoiding over or under-treatment. This is particularly beneficial for multi-electrode radiofrequency ablation of larger liver tumors where the planning phase is particularly challenging.
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Affiliation(s)
- Chloé Audigier
- Advanced Clinical Imaging Technology, Siemens Healthcare, Lausanne, Switzerland.
| | | | | | - Reto Bale
- Innsbruck University Hospital, Innsbruck, Austria
| | - Tommaso Mansi
- Siemens Healthineers, Digital Technology and Innovation, Princeton, NJ, USA
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Pelanis E, Teatini A, Eigl B, Regensburger A, Alzaga A, Kumar RP, Rudolph T, Aghayan DL, Riediger C, Kvarnström N, Elle OJ, Edwin B. Evaluation of a novel navigation platform for laparoscopic liver surgery with organ deformation compensation using injected fiducials. Med Image Anal 2020; 69:101946. [PMID: 33454603 DOI: 10.1016/j.media.2020.101946] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 11/28/2020] [Accepted: 12/15/2020] [Indexed: 12/11/2022]
Abstract
In laparoscopic liver resection, surgeons conventionally rely on anatomical landmarks detected through a laparoscope, preoperative volumetric images and laparoscopic ultrasound to compensate for the challenges of minimally invasive access. Image guidance using optical tracking and registration procedures is a promising tool, although often undermined by its inaccuracy. This study evaluates a novel surgical navigation solution that can compensate for liver deformations using an accurate and effective registration method. The proposed solution relies on a robotic C-arm to perform registration to preoperative CT/MRI image data and allows for intraoperative updates during resection using fluoroscopic images. Navigation is offered both as a 3D liver model with real-time instrument visualization, as well as an augmented reality overlay on the laparoscope camera view. Testing was conducted through a pre-clinical trial which included four porcine models. Accuracy of the navigation system was measured through two evaluation methods: liver surface fiducials reprojection and a comparison between planned and navigated resection margins. Target Registration Error with the fiducials evaluation shows that the accuracy in the vicinity of the lesion was 3.78±1.89 mm. Resection margin evaluations resulted in an overall median accuracy of 4.44 mm with a maximum error of 9.75 mm over the four subjects. The presented solution is accurate enough to be potentially clinically beneficial for surgical guidance in laparoscopic liver surgery.
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Affiliation(s)
- Egidijus Pelanis
- The Intervention Centre, Oslo University Hospital Rikshospitalet 0424, Oslo, Norway; Institute of Clinical Medicine, University of Oslo 1072, Oslo, Norway.
| | - Andrea Teatini
- The Intervention Centre, Oslo University Hospital Rikshospitalet 0424, Oslo, Norway; Department of Informatics, University of Oslo 1072, Oslo, Norway
| | | | | | | | - Rahul Prasanna Kumar
- The Intervention Centre, Oslo University Hospital Rikshospitalet 0424, Oslo, Norway
| | | | - Davit L Aghayan
- The Intervention Centre, Oslo University Hospital Rikshospitalet 0424, Oslo, Norway; Institute of Clinical Medicine, University of Oslo 1072, Oslo, Norway; Department of Surgery N1, Yerevan State Medical University, 0025 Yerevan, Armenia
| | - Carina Riediger
- University Hospital Carl Gustav Carus, Technische Universität Dresden, 01307 Dresden, Germany
| | | | - Ole Jakob Elle
- The Intervention Centre, Oslo University Hospital Rikshospitalet 0424, Oslo, Norway; Department of Informatics, University of Oslo 1072, Oslo, Norway
| | - Bjørn Edwin
- The Intervention Centre, Oslo University Hospital Rikshospitalet 0424, Oslo, Norway; Institute of Clinical Medicine, University of Oslo 1072, Oslo, Norway; Department of Hepato-Pancreatic-Biliary surgery 0424, Oslo University Hospital, Oslo, Norway
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Giménez M, Gallix B, Costamagna G, Vauthey JN, Moche M, Wakabayashi G, Bale R, Swanström L, Futterer J, Geller D, Verde JM, García Vazquez A, Boškoski I, Golse N, Müller-Stich B, Dallemagne B, Falkenberg M, Jonas S, Riediger C, Diana M, Kvarnström N, Odisio BC, Serra E, Overduin C, Palermo M, Mutter D, Perretta S, Pessaux P, Soler L, Hostettler A, Collins T, Cotin S, Kostrzewa M, Alzaga A, Smith M, Marescaux J. Definitions of Computer-Assisted Surgery and Intervention, Image-Guided Surgery and Intervention, Hybrid Operating Room, and Guidance Systems: Strasbourg International Consensus Study. Ann Surg Open 2020; 1:e021. [PMID: 33392607 PMCID: PMC7771637 DOI: 10.1097/as9.0000000000000021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/05/2020] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE To develop consensus definitions of image-guided surgery, computer-assisted surgery, hybrid operating room, and surgical navigation systems. SUMMARY BACKGROUND DATA The use of minimally invasive procedures has increased tremendously over the past 2 decades, but terminology related to image-guided minimally invasive procedures has not been standardized, which is a barrier to clear communication. METHODS Experts in image-guided techniques and specialized engineers were invited to engage in a systematic process to develop consensus definitions of the key terms listed above. The process was designed following review of common consensus-development methodologies and included participation in 4 online surveys and a post-surveys face-to-face panel meeting held in Strasbourg, France. RESULTS The experts settled on the terms computer-assisted surgery and intervention, image-guided surgery and intervention, hybrid operating room, and guidance systems and agreed-upon definitions of these terms, with rates of consensus of more than 80% for each term. The methodology used proved to be a compelling strategy to overcome the current difficulties related to data growth rates and technological convergence in this field. CONCLUSIONS Our multidisciplinary collaborative approach resulted in consensus definitions that may improve communication, knowledge transfer, collaboration, and research in the rapidly changing field of image-guided minimally invasive techniques.
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Affiliation(s)
- Mariano Giménez
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
- DAICIM Foundation, Buenos Aires, Argentina
| | - Benôit Gallix
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
- Department of Radiology, McGill University & Health Centre, Quebec, Canada
| | - Guido Costamagna
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, and Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jean-Nicolas Vauthey
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Michael Moche
- Department of Interventional Radiology, Helios Park-Klinikum, Leipzig, Germany
| | - Go Wakabayashi
- Department of Surgery, Ageo Central General Hospital, Saitama, Japan
| | - Reto Bale
- Interventional Oncology—Microinvasive Therapy (SIP), University Clinic for Radiology, Medical University, Innsbruck, Austria
| | - Lee Swanström
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
| | - Jürgen Futterer
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - David Geller
- Division of Hepatobiliary and Pancreatic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Juan M. Verde
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
- DAICIM Foundation, Buenos Aires, Argentina
| | - Alain García Vazquez
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
- DAICIM Foundation, Buenos Aires, Argentina
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, and Centre for Endoscopic Research Therapeutics and Training (CERTT), Università Cattolica del Sacro Cuore, Rome, Italy
| | - Nicolas Golse
- Centre Hépato-Biliaire, Hôpital Paul Brousse, Villejuif, France
| | - Beat Müller-Stich
- Minimally Invasive Surgery, Surgical Clinic University Hospital, Heidelberg, Germany
| | - Bernard Dallemagne
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
- Service de Chirurgie Digestive & Endocrinienne, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Mårten Falkenberg
- Department of Radiology at the Department of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sven Jonas
- Department of Visceral Surgery, 310Klinik, Nuremberg, Germany
| | - Carina Riediger
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Michele Diana
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
| | - Niklas Kvarnström
- Department of Surgery at Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Bruno C. Odisio
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | | | | | - Didier Mutter
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
- Service de Chirurgie Digestive & Endocrinienne, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Silvana Perretta
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
- Service de Chirurgie Digestive & Endocrinienne, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Patrick Pessaux
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
- Service de Chirurgie Digestive & Endocrinienne, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | - Alexandre Hostettler
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
| | - Toby Collins
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
| | | | - Michael Kostrzewa
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
| | | | - Martin Smith
- ‡‡‡Department of Surgery, University of the Witwatersrand, Johannesburg, South Africa
| | - Jacques Marescaux
- From the Research Institute against Cancer of the Digestive System (IRCAD), Strasbourg, France
- Institut Hospitalo-Universitaire IHU, University of Strasbourg, Strasbourg, France
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Laimer G, Schullian P, Jaschke N, Putzer D, Eberle G, Alzaga A, Odisio B, Bale R. Minimal ablative margin (MAM) assessment with image fusion: an independent predictor for local tumor progression in hepatocellular carcinoma after stereotactic radiofrequency ablation. Eur Radiol 2020; 30:2463-2472. [PMID: 32002642 PMCID: PMC7160081 DOI: 10.1007/s00330-019-06609-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/22/2019] [Accepted: 12/05/2019] [Indexed: 12/15/2022]
Abstract
Objectives To assess the minimal ablative margin (MAM) by image fusion of intraprocedural pre- and post-ablation contrast-enhanced CT images and to evaluate if it can predict local tumor progression (LTP) independently. Furthermore, to determine a MAM with which a stereotactic radiofrequency ablation (SRFA) can be determined successful and therefore used as an intraprocedural tool to evaluate treatment success. Methods A total of 110 patients (20 women, 90 men; mean age 63.7 ± 10.2) with 176 hepatocellular carcinomas were assessed by retrospective analysis of prospectively collected data. The MAM was determined through image fusion of intraprocedural pre- and post-ablation images using commercially available rigid imaging registration software. LTP was assessed in contrast-enhanced CTs or MR scans at 3–6-month intervals. Results The MAM was the only significant independent predictor of LTP (p = 0.036). For each millimeter increase of the MAM, a 30% reduction of the relative risk for LTP was found (OR = 0.7, 95% CI 0.5–0.98, p = 0.036). No LTP was detected in lesions with a MAM > 5 mm. The overall LTP rate was 9 of 110 (8.2%) on a patient level and 10 of 173 (5.7%) on a lesion level. The median MAM was 3.4 (1.7–6.9) mm. The mean overall follow-up period was 26.0 ± 10.3 months. Conclusions An immediate assessment of the minimal ablative margin (MAM) can be used as an intraprocedural tool to evaluate the treatment success in patients treated with stereotactic RFA. A MAM > 5 mm has to be achieved to consider an ablation as successful. Key Points • An intraoperatively measured minimal ablative margin (MAM) > 5 mm correlates with complete remission. • MAM is the only significant independent predictor of LTP (OR = 0.7, 95% CI 0.5–0.98, p = 0.036) after stereotactic RFA of hepatocellular carcinoma. • Image fusion using commercially available rigid imaging registration software is possible, even though considerably complex. Therefore, improved (semi-)automatic fusion software is highly desirable.
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Affiliation(s)
- Gregor Laimer
- Department of Radiology, Interventional Oncology-Microinvasive Therapy (SIP), Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Peter Schullian
- Department of Radiology, Interventional Oncology-Microinvasive Therapy (SIP), Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Nikolai Jaschke
- Department of Internal Medicine I, Gastroenterology, Hepatology, Endocrinology and Metabolism, Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Daniel Putzer
- Department of Radiology, Interventional Oncology-Microinvasive Therapy (SIP), Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Gernot Eberle
- Department of Radiology, Interventional Oncology-Microinvasive Therapy (SIP), Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Amilcar Alzaga
- Siemens Healthineers, Siemensstraße 3, 91301, Forchheim, Germany
| | - Bruno Odisio
- Division of Diagnostic Imaging, Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Reto Bale
- Department of Radiology, Interventional Oncology-Microinvasive Therapy (SIP), Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria.
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Liu YY, Diana M, Halvax P, Cho S, Légner A, Alzaga A, Swanström L, Dallemagne B, Marescaux J. Flexible endoscopic single-incision extraperitoneal implant and fixation of peritoneal dialysis catheter: proof of concept in the porcine model. Surg Endosc 2014; 29:2402-6. [PMID: 25414067 DOI: 10.1007/s00464-014-3951-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 10/11/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Peritoneal dialysis (PD) catheters placed in the pelvic space without anchoring present a high rate of migration. We aimed to assess the feasibility of a single-incision approach, using a flexible endoscopic preperitoneal tunneling for catheter implantation and fixation. MATERIALS AND METHODS Eight pigs were involved in this experimental study. A 2/0 Vicryl loop was sutured at the tip of a PD catheter. In 4 pigs, a 1.5 cm incision was made on the left paramedian line and the parietal peritoneal layer was identified by splitting rectal muscles. A gastroscope was inserted in the incision and advanced in the extraperitoneal space. An exit hole was made in the peritoneum over the low pelvic cavity. A guidewire was left in the abdominal cavity, and the PD catheter was inserted over the guidewire. The endoscope was inserted in the tunnel again, and endoscopic clips were deployed over the Vicryl loop to fix the catheter. In 4 pigs, the PD catheter was inserted laparoscopically using a two-port approach. The catheter's tip was fixed with laparoscopic clips on the Vicryl loop. A strain test to assess the force required to detach clips was performed using a digital dynamometer. RESULTS Operative time for flexible endoscopic tunneling was longer when compared to the laparoscopic implant (29.5 ± 4.43 vs. 22.7 ± 2.51 min). Mean force to displace the catheter was similar after flexible endoscopic fixation when compared to laparoscopic clip fixation (5.57 N ± 2.76 vs. 4.15 N ± 1.76). CONCLUSIONS Flexible endoscopic extraperitoneal tunneling allows for minimally invasive single-incision PD catheter placement and fixation.
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Affiliation(s)
- Yu-Yin Liu
- IRCAD, Digestive and Endocrine Surgery, University of Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg Cedex, France
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