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University of Groningen
CT-guided percutaneous interventionsHeerink, Wouter
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Citation for published version (APA):Heerink, W. (2019).
CT-guided percutaneous interventions: Improving needle placement
accuracy for lungand liver procedures. Rijksuniversiteit
Groningen.
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CHAPTER 1
General Introduction
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CHAPTER 1
Lung cancer Lung cancer is the most common cause of
cancer-related deaths worldwide [1]. In the USA, lung cancer
screening by low-dose computed tomography (CT) is recommended for
people at high risk, and the European Society of Radiology and the
European Respiratory Society are recommending lung cancer screening
within clinical trial or in routine clinical practice at certified
medical centers [2, 3]. With the expected introduction of lung
cancer screening, an increase of CT detected lung nodules is
anticipated. Nodules larger than 10 mm in diameter and most likely
even smaller nodules with significant growth will be eligible for
medical work-up [3].
Bronchoscopy is often used to diagnose these lung nodules and to
get a tissue diagnosis, but it is limited to centrally located
lesions [4]. CT-guided transthoracic lung biopsy is a minimally
invasive diagnostic procedure for tissue diagnosis of peripheral
lung nodules. These can alternatively be reached with surgery, but
the percutaneous approach is less invasive and associated with
lower costs. Other imaging modalities used for percutaneous needle
guidance include fluoroscopy, CT-fluoroscopy, ultrasound and
magnetic resonance imaging (MRI). Fluoroscopy lacks
three-dimensional imaging possibilities, so the operator has to be
capable of translating the two-dimensional projections to a
volumetric environment. Additionally, it requires the operator to
be in the room during image acquisition, causing exposure to
harmful radiation. Whilst CT-fluoroscopy does provide volumetric
images, it too exposes the operator to radiation. Ultrasound does
not induce radiation to the patient or the operator and with this
technique, the nodule and biopsy needle can be followed in
real-time. The downside is that only pleural lesions can be
visualized as the air-filled lungs are poorly suited for
ultrasound. Lastly, MRI is sometimes used but it is more cumbersome
as the metallic biopsy needles are generally not MRI compatible.
Additionally, patient access is limited within the bore and lung
lesions are relatively poorly visualized, compared to CT. So, even
though CT-guidance exposes the patient to radiation and lacks
real-time feedback for the operator, it is still the method of
choice for many percutaneous interventions [5].
Liver cancer Primary liver cancer combined with liver metastases
is the second most common cause of cancer death [1]. Over the last
20 years, thermal ablation has emerged as a successful treatment
method for hepatic malignancies [6–8]. Radiofrequency ablation
(RFA) and microwave ablation (MWA) are currently recommended for
treatment of hepatocellular carcinoma (HCC) and colorectal liver
metastasis (CRLM) in patients unfit for surgery or in combination
with surgery [9, 10]. Currently, antenna placement is frequently
performed with CT as imaging modality for planning and positional
feedback of the ablation antenna.
Other imaging modalities offer similar drawbacks as those
mentioned for transthoracic lung biopsy, with the exception of
ultrasound. In theory, ultrasound is more suitable for percutaneous
needle placement procedures in the liver compared to the lung.
However, liver tumors are often not easily delineable from the
underlying liver parenchyma on ultrasound. With contrast-enhanced
CT, delineation of liver tumors is achieved more accurately.
Because CT is a three-dimensional imaging technique, planning of
multiple overlapping ablation zones to cover the entire tumor is
less prone to errors.
2
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1 INTRODUCTION
The main drawback of percutaneous liver tumor ablation is local
recurrence of disease, with reported ablation site recurrence rates
ranging from 5.0% to 32.1% [7, 11–13]. Risk factors for ablation
site recurrences include larger tumor size, peritumoral
vascularity, and insufficient ablation safety margin surrounding
the tumor [14–16]. The latter can be caused by inaccurate placement
of the ablation antenna, so for CT-guided liver tumor ablation
accurate needle placement is critical. Another cause of incomplete
ablation is the creation of unreliable ablation zones: when the
actual ablation zone is inconsistent with the claimed protocol,
there is a chance of incomplete ablation treatment, despite correct
positionings of the ablation antenna. Heat-sink caused by blood
vessels adjacent to the tumor is a well-known cause of ablation
zone volume reduction [17]. Differences in tumor type and pathology
of the underlying parenchyma have been demonstrated to affect the
microwave ablation zone, too, in a two-compartment computer model
[18]. Because ablation device manufacturers currently supply
ablation protocols that are mainly based on ex-vivo non-perfused
animal livers, these do not correlate very well with clinical
practice.
Freehand approach While CT is an excellent imaging modality for
feedback of target and needle position, the actual guidance of the
needle is still performed by hand (freehand method). Thus, based on
the images provided by the CT, the operator has to determine how to
angle and insert the needle towards the target. This is often an
iterative process, where every needle repositioning increases the
chance of complications.
With percutaneous needle placement, a differentiation can be
made between in-plane and out-of-plane procedures. With in-plane
approaches, the target is in the same axial position as the entry
point on the skin, so the entire needle path can be imaged on a
single axial CT slice. Here, the operator has to angle the needle
towards the target on one axis. With out-of-plane approaches, the
target is either cranial or caudal to the entry point. In order to
image the needle path on a single slice, an oblique view must be
used. Moreover, the operator has to angle the needle towards the
target on two axes. Where the in-plane procedures are not too
difficult to perform freehand, the out-of-plane procedures often
require multiple needle repositionings in order to achieve adequate
placement accuracy.
Robotic approach Needle placement can be aided by the use of
robotic systems. These generally provide some sort of needle guide,
for the operator to push the needle through in order to increase
needle placement accuracy. Over the years, numerous systems have
been developed [19]. Despite the relatively large number of
(experimental) robotic systems, there are few randomized patient
studies that assess their functionality in real clinical
environments. Only two RCTs could be identified that compared
robotic needle placement with freehand needle placement. The study
of Patriciu et al. from 2005 was the only one performed in patients
with liver tumors, testing a robotic device (AcuBot) in a
randomized study with only 14 patients [20]. The AcuBot reduced the
number of needle repositionings and targeting time, but needle
placement accuracy was not reported. To this date, the Acubot is
still not on the market. In another, non-randomized clinical study
Engstrand et al. analyzed the accuracy and procedural safety of the
CAS-One for CT-guided percutaneous MWA of liver tumors [21]. They
reported a lateral
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CHAPTER 1
accuracy of 4.0 mm in 28 tumors, although no comparison with
freehand positioning was made. No differentiation between in- and
out-of-plane procedures was mentioned in either study.
Recently, the Needle Placement System (NPS) has been developed
as a system to facilitate accurate percutaneous needle placement
for CT-guided interventions [22]. The NPS mounts on a rail parallel
to the CT table and can be manually maneuvered towards the entry
point on the skin. After locking the system, it automatically
orients a needle guide towards the target. Subsequently, the needle
can be inserted by the operator to the specified depth. It has the
potential to offer simplicity in terms of device maneuverability,
while still providing a stable platform from which automatic needle
orientation is performed.
Respiratory motion An often-overlooked issue with percutaneous
needle placement is the effect of respiration. For CT-guided liver
ablation, where procedures are mostly performed under general
anesthesia, the respiration can be paused during acquisition of the
CT scans and manipulation the ablation antenna. The chest (and thus
the organs) can be expected to have returned to an approximately
similar position when the CO2 output is monitored to have reduced
to zero after stopping respiration; especially when patients are
positioned on a vacuum mattress. So, for procedures performed under
general anesthesia, respiratory motion is less of an issue.
However, less invasive procedures such as lung biopsies are
performed under local sedation, because of the risk, time and cost
associated with general anesthesia. The downside to local sedation
is that patients are required to repeatedly hold their breath at a
consistent level during the procedure. Since lung nodules move on
average 25 mm up and down with inspiratory capacity, the level of
breath-hold during acquisition of the planning CT scan and during
needle manipulation is not the same and accurate targeting is
impossible [23].
Currently available respiratory tracking systems suitable for
image-guided intervention consist of respiratory belts that are
cumbersome to install, only have a weak correlation with nodule
position, and do not adjust for a change in breathing pattern [24].
Several groups have investigated the use of a depth camera (Kinect)
to monitor patient respiratory motion for four-dimensional
radiotherapy planning and the Kinect has potential to be used in
image-guided interventions, too [25–27].
Outline of this thesis The aims of the research described in
this thesis are to investigate methods to improve the accuracy of
CT-guided needle placement and to find factors affecting the
ablation zone with liver tumor ablation.
Increased needle manipulations result in more tissue damage and
can be expected to increase the chance of complications. In Chapter
2, the complication rate and factors affecting the complication
rate of CT-guided lung biopsies are determined in meta-analysis, as
a baseline.
In the first part of this thesis, the NPS was put to the test.
Chapter 3 shows the results of a phantom study performed to
validate this system. An anthropomorphic phantom
4
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1 INTRODUCTION
was designed to simulate CT-guided liver ablation, mimicking
clinical practice. With this phantom, MWA antenna placement with
the NPS was compared to freehand antenna placement by experts and
novices. Subsequently, the NPS was analyzed in clinical practice.
In Chapter 4, a randomized controlled trial is performed to compare
the NPS with freehand MWA antenna placement, in patients undergoing
CT-guided liver ablation. The primary outcome of this study was the
number of antenna repositionings required to achieve adequate
placement.
In order to use the NPS in interventions performed under local
sedation, a solution for the respiratory motion was sought for. A
system was developed in which the Kinect camera was used to provide
respiratory biofeedback to patients to help them return to a
consistent level of breath-hold. In Chapter 5, this system is
tested with eight volunteers, using spirometry. Alternatively,
increased needle positioning accuracy can be achieved by using a
flexible, steerable needle. The advantage of such a needle compared
to a rigid needle is that it can avoid critical structures by
steering around and it can potentially compensate for respiratory
movement. In Chapter 6, a CT-compatible needle steering robot that
utilizes an electromagnetic tracking system is presented and tested
in a phantom study.
In the last part of this thesis, the challenge of creating a
predictable ablation zone is addressed. Chapter 7 presents a
systematic review of all FDA approved MWA systems, in particular
with regards to the variability of the ablation zone volume that is
created in animal and in- and ex-vivo studies. In Chapter 8,
differences in the relation between applied energy and ablation
zone volume in hepatocellular carcinoma and colorectal liver
metastasis are investigated. The goal of this retrospective study
was to find if ablation protocols should be optimized for different
tumor types for RFA and two MWA devices.
In Chapter 9, the main results of the chapters in this thesis
are discussed together with future perspectives. Chapter 10
provides a Dutch summary.
5
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CHAPTER 1
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Chapter 1