NonRigid MultiModality Image Registration for Thermal Ablation PreProcedural

Non-Rigid, Multi-Modality Image Registration for Thermal Ablation: Pre-Procedural MRI to Intra. Procedural CT for Tumor Targeting N. Archip, P. R. Morrison Brigham & Women’s Hospital © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop

WORKSHOP OBJECTIVE To illustrate the need for image registration to address limitations in targeting a tumor during a tumor ablation procedure. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop

ABLATION GUIDANCE MODALITY ABLATIVE AGENT MRI CRYOTHERAPY TREATMENT SITE LIVER KIDNEY/ADRENAL CT RFA BONE/SOFT TISSUE US ETOH © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop LUNG Acad Radiol 2005; 12: 1100 -109

THERMAL ABLATION • • • RFA: RADIOFREQUENCY ABLATION CRYO: CRYOTHERAPY LITT, ILT: LASER ABLATION MWA: MICROWAVE ABLATION HIFU, FUS: FOCUSED ULTRASOUND © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop Images courtesy Cross-sectional Interventional Radiology, Brigham & Women’s Hospital, Boston, MA

CLINICAL SYSTEMS PERCUTANEOUS ABLATION • • RF generator & electrode CRYO unit & probe LASER & optical fiber MW generator & antenna © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop Images courtesy Cross-sectional Interventional Radiology, Brigham & Women’s Hospital, Boston, MA

CLINICAL ENIRONMENT © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop Images courtesy Cross-sectional Interventional Radiology, Brigham & Women’s Hospital, Boston, MA

IMAGE-GUIDANCE Ø DEFINE Ø PLAN Ø TARGET Ø MONITOR Ø CONTROL Ø ASSESS © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop Radiology 2005; 236: 716 -724

DYNAMIC PROCESSES • MRI-guided cryotherapy of a 3. 4 cm liver metastasis • Sagittal T 2 -weighted fse imaging used to place cryoprobes (arrowheads) into the tumor (arrow) • Iceballs form around each probe; these coalesce • Tumor is eclipsed © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop Acad Radiol 2005; 12: 1100 -109

3 -D PROCESS Pre Intra Post in 3 -D Post © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop Modified from AJR 2004; 183: 707– 712

TARGET CT-GUIDED RFA IN LUNG RFA Post-RFA MRI Coronal © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop Images courtesy Cross-sectional Interventional Radiology, Brigham & Women’s Hospital, Boston, MA

PLAN – TX - ASSESS CT-GUIDED RFA IN SOFT TISSUE CE CT PRE CT INTRA © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop Images courtesy Cross-sectional Interventional Radiology, Brigham & Women’s Hospital, Boston, MA CE MRI POST

Non-Rigid, Multi-Modality Image Registration for Thermal Ablation: Pre-Procedural MRI to Intra. Procedural CT for Tumor Targeting © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop

CLINICAL NEED – Example 1 Pre-Procedure CE MRI at 1. 5 T Intra-Procedure Non-Enhanced CT Recent BWH ablation case: Pre-Proc MRI vs Intra-CT 47 yo M, 3 cm liver metastasis of sq cell ca in Seg 8; lung & vessels nearby © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop Images courtesy Cross-sectional Interventional Radiology, Brigham & Women’s Hospital, Boston, MA Procedure 071107

CLINICAL NEED – Example 2 Pre-Procedure CE MRI at 1. 5 T Intra-Procedure Non-Enhanced CT Recent BWH Ablation Case: Pre. Proc MRI vs Intra-CT 69 yo M, 7 cm liver metastasis of colon cancer; look for coverage; GB & colon nearby © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop Images courtesy Cross-sectional Interventional Radiology, Brigham & Women’s Hospital, Boston, MA Procedure 080304

CLINICAL NEED Dx comes from one imaging modality … Tx takes place under another. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop

SOLUTION: REGISTRATION Bring Pre-procedural diagnostic MRI into the Intra-procedural interventional space © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop

PRE-PROCEDURAL CE MRI Example: Registered Data --MRI Pre BWH Ablation Case 50 yo M, 2 cm primary liver tumor (HCC) in segment 2 © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop 051021 CEMRI Images courtesy Cross-sectional Interventional Radiology, Brigham & Women’s Hospital, Boston, MA Pre. Tx Ser 08 i 270

INTRA-PROCEDURAL CT Example: Registered Data --CT Intra © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop 051220 CT Images courtesy Cross-sectional Interventional Radiology, Brigham & Women’s Hospital, Boston, MA Pre. Tx Ser 04 i 21

RFA ELECTRODE PLACED Example: Registered Data --CT Intra © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop Images courtesy Cross-sectional Interventional Radiology, Brigham & Women’s Hospital, Boston, MA

REGISTERED IMAGES Example: Registered Data --Merged MRI & CT © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop Images courtesy Cross-sectional Interventional Radiology, Brigham & Women’s Hospital, Boston, MA

WORK FLOW Intra-Proc CT Pre-Proc MRI Registered CT & MRI © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop Images courtesy Cross-sectional Interventional Radiology, Brigham & Women’s Hospital, Boston, MA

SLICER 3. 0 © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop

WHAT IS 3 D SLICER? • A platform for exploring novel image analysis and visualization techniques • A freely-downloadable program – Source code and executables available for Windows, Linux, and Mac OS X • Slicer is a research platform: – NOT an FDA approved medical device – NOT finished – some parts will work better than others © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop

SLICER FEATURES • • Visualization Filtering Registration Segmentation DTI Quantification Real-time Integration © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop

“SLICER 3” • Next Generation of the 3 D Slicer software • Beta Release in Jan 2007 • Slicer 3. 0 schedule for June 2007 • www. slicer. org © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop Image: S Pieper

WHAT IS SLICER 3? • Total Rework of 3 D Slicer – At least 80% of code rewritten – New versions of VTK (5. 0), ITK (3. 2) – Improved Look and Feel (KWWidgets) – Improved Modularity • Analysis routines can be used as plugins or command line executables for batch processing – Draws on Multi-Institution Community • Kitware, Inc. , GE Research, Isomics, Inc. , BWH, UCLA, UCSD, UIowa, MIT, Ga. Tech, UNC, U Utah, MGH, UCI, Harvard, Wash. U… • NAC, NCIGT, NA-MIC, m. BIRN, f. BIRN © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop

SLICER 3 • Open Source, multiplatform • Over 500 k lines of code • www. slicer. org • Google: slicer 101 © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop Images: A Golby, F Talos, P Black

Image/Scene Management • XML-Based MRML File Stores Scene Description – Volumes (Images, Label Maps) – Models – Hierarchical Affine Transforms – Scene Data (Cameras, Colors, Fiducials, etc). • Manipulated in World Coordinates based on Patient RAS © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop Image: S Pieper

OPENING SCREEN The default display provides for primary 2 D planes and a 3 D Viewer space. Other display options can be selected. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop screen_01

LOAD VOLUME FILE Having selected the Volumes Module … Images can be selected as DICOM or. nrrd files. Here, a preprocedural MRI scan of the liver is opened. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop screen_03

VISUALIZE MRI DATA MRI opens in three orthogonal 2 D planes. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop screen_04

TUMOR LOCATION 3 D image planes can be viewed in the 3 D space. Can zoom, translate, rotate. Here we locate tumor in all 3 planes (arrows) © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop screen_05

3 -D ONLY View MRI planes in 3 D Viewer from above … and from below. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop screen_06 & 07

Add Volume CT Add a volume to the space … Here, an intraprocedural CT dataset is opened. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop screen_08

VISUALIZE CT DATA CT opens in three orthogonal 2 D planes. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop screen_09

PREP FOR LINEAR TRANSFORM Initial alignment of MRI to CT is the Linear Transform 1 under Transform Module. This manual transform is one of two options. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop screen_10

LINEAR TRANSFORM Initial linear alignment solves initial displacement of MRI and CT. Seen here in the 3 D Viewer. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop screen_20

PREP FOR AUTO TRANSFORM Initial alignment of MRI to CT can be done by selecting Linear under Registration Module menu. This automatic transform is the second of two options. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop screen_22

RESULT OF RIGID REGISTRATION Slider can be used to review the result of the linear alignment between the pre-procedural MRI and intraprocedural CT. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop screen_21 c

PREP FOR B-SPLINE REGISTRATION Alignment can be done on the data using the Deformable BSpline B-Spline Registration option. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop screen_25

RESULT OF B-SPLINE REGISTRATION Slider can be used to review the result of the linear alignment between the pre-procedural MRI and intraprocedural CT. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop screen_26

CLINICAL SIGNIFICANCE Image Registration has relevance for all aspects of an ablation procedure: Plan, Target, Monitor, Control, Assess This is true for any image guidance modality. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop