Integrated Planning, Navigation and Targeting for Tumor Ablation
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1 Integrated Planning, Navigation and Targeting for Tumor Ablation
2 Ablation Assessment: Can we get beyond Contrast Enhancement? Contrast-enhanced radiologic imaging is the basis of current response evaluation criteria for HCC Novel imaging approaches do not seem to be able to overcome the main limitation of dynamic imaging, i.e., the inability to detect tiny foci of residual viable tumor Volumetric techniques provide objective documentation of the ablation margin and thus appear as the best method to confirm AO treatment Volumetric planning of the ablation strategy, including selection of device, approach and treatment protocol should become standard of care for clinical practice by Dr Riccardo Lencioni, MD, University of Pisa - Italy, at RSNA 2012 This compilation of diagnostic and therapeutic procedures were performed on Perfint s targeting systems. Information contained here is for private circulation only. The information is intended for the purpose it serves and not beyond. In case of any issue, error or complaint please write to: clinicalmarketing@perfinttech.com Perfint Healthcare ( is a world leader in planning and targeting solutions for image guided interventional procedures - with an emphasis on oncology and pain care. Perfint s products, PIGA CT and ROBIO, are used by radiologists around the world for biopsy, drug delivery, ablation, drainage and fine needle aspiration. PIGA CT and ROBIO are installed at some of the world s top hospitals and are CE marked. Perfint s newest product MAXIO, is set to change the world of Interventional Oncology. MAXIO will allow clinicians to visually plan, execute and validate ablation procedures on a single system and all in 3D. MAXIO has been designed to make complex, multi-probe ablations simpler, which will help to make these life-saving procedures available to more cancer sufferers than ever before. New Directions New hope
3 Integrated Planning, Navigation and Targeting for Tumor Ablation Clinical Cases as performed with MAXIO Classified by type of procedure Clinicians benefit from MAXIO s intelligent planning suite and targeting... Registering pre-operative images and offline procedure plan with current CT images Organ specific tumor visualisation and segmentation Multiple VOI, Multi-probe placement plan for multiple procedures Accurate placement without fluoroscopic radiation PROCEDURE PAGES ABLATION 6-42 PAIN MANAGEMENT IRE 54 BIOPSY 56 Ability to treat hard to access and larger tumors Post procedure verification Tumor Ablation is heading in a whole new direction... And MAXIO is leading the way. MAXIO IS NOT AVAILABLE FOR SALE OR DISTRIBUTION IN THE US, IT IS PENDING 510 K CLEARANCE. 4 5
4 Case 01 Radio Frequency Ablation of Multiple Liver Lesions Patient planned for RFA of mulitple lesions in the liver Lesions are situated close to diaphragm and bowel. Critical organs like lung, vasculature and bowel surround the targets. With free hand technique it is difficult to place the probe in target(s) without traumatizing critical organs. MAXIO assisted in the precise planning & targeting of the deep-seated lesions through safe trajectory with a combination of both Cranio-caudal and orbital angles. Parameters: Tumor 1 Tumor 2 Lesion Size : 15 mm 9 mm Location : Segment 7 Close to diaphragm Segment 4 close to bowel Angulation : Orbital : Cranio caudal: Orbital : Craniocaudal: 5.39 Entry slice : Target slice : Target depth : mm mm Tumor 1 Tumor 2 6 7
5 02 Case Radio Frequency Ablation of recurrent HCC after TACE A patient was planned for radiofrequency ablation of 3.8 x 3.7 cm lesion at segment 8 of liver Post TACE lesion was not visible on ultrasound. The residual lesion was situated below diaphragm. Patient was planned under GA, coolitip: 17G 150/30 Two probes were used. Orbital angle : 64/63 CC angle : 18/13 Depth : 90.9 / 91 mm Procedure time : 28 min Planning in 3D and 2D Ablated area 8 Doctor placing probe with MAXIO Post RFA shows ablated area covering tumour 9
6 Case 03 Radio Frequency Ablation of a HCC and a Lung Lesion Patient planned for RFA of 25 mm mass at 6th segment of the liver and 9 mm mass in right lung during the same procedure Planning safe trajectories with minimal patient discomfort and less procedure related complications is a challenge. Ablation procedure planned in two sittings. Lesions targeted precisely with the assistance of MAXIO in sequential mode. No post procedure complications. Liver plan: Orbital angle : CC angle : 0 Depth : 93 mm Lung Plan : Orbital angle : CC angle : 0 Depth : mm Needle used : 17G Cooltip : Planning time : 10 min Procedure time : 40 m Planning in 3D and 2D Ablated area 10 Check scan shows probe Post RFA shows ablated area covering tumour 11
7 04 Case Radio Frequency Ablation of Adrenal Tumor Patient diagnosed with HCC underwent liver transplant now with solitary adrenal metastatic lesion In free hand, it is difficult to place the probe with steep angulations to reach the target without traumatising the diaphragm and renal vessels. MAXIO helps in precise planning and targeting of the adrenal lesion with such complex oblique approach, so as to avoid passing through pleural recess. Size : 15 mm Orbital : Cranio caudal : Target depth : mm Planning in 3D and 2D 12 Check scan needle in situ 13
8 Case 05 Radio Frequency Ablation of Liver lesion with multiple probes A patient planned for Radio-frequency ablation with multi-probe placement Multiple probe placement required to cover the lesion completely. Overlapping the ablation zones is a challenge to avoid the residual tumors. MAXIO helps in multi-probe placement and precise targeting of the lesion. Ablation planned in 5 sittings through simultaneous and sequential mode. Orbital angle : 7.85 Depth : mm Needle used : 17G Cooltip : Planning time : 15 min Procedure time : 80 min Planning in 3D and 2D Ablated area 14 Check scan shows probe Post RFA shows ablated area covering tumour 15
9 06 Case Radio Frequency Ablation of 2 cm of HCC Patient planned for radiofrequency ablation at 7th segment of liver Lesion is situated posteriorly so planning and treatment is done in prone position. 2 cm lesion was targeted under GA in prone position. The thermal simulation area covered the lesion. Orbital angle : Depth : mm Needle used : 17G Cooltip : Number of needles : one Planning time : 10 min Procedure time : 30 min Planning in 3D and 2D Ablated area 16 Check scan shows probe Post RFA shows ablated area covering tumour 17
10 Case 07 Radio Frequency Ablation of Multiple Lung Lesions A patient is planned for Radio-frequency ablation of 3 sub-cm lung lesions of primary HCC Precise targeting of the 6mm peripheral lung nodule is difficult. MAXIO enables better planning for small lung lesions, minimising number of passes / adjustments required for optimal probe positioning. Procedure completed without any complication. Cranio caudal : 9.37 Target angle : mm Planning in 3D and 2D 18 Check scan needle in situ 19
11 08 Case Radio Frequency Ablation of 12 mm Mass in Liver RFA of 12 mm mass at 5th segment of the liver followed by alcohol ablation Ablation area cannot be predicted easily due to its position in the liver segment. MAXIO helps to visualize the ablation zone, so it can be adjusted to treat the tumor precisely. The site of lesion is well within the ablation zone in post RFA CT. Orbital angle : 45.6 Depth : 64.5 mm Needle used : 17G Cooltip : Number of needles : one Planning time : 5 min Procedure time : 22 min Planning in 3D and 2D Ablated area 20 Check scan shows probe Post RFA shows ablated area in region of tumour 21
12 09 Case Radio Frequency Ablation 1.8 cm HCC A patient is planned for radiofrequency ablation of 5th segment of 1.8 cm lesion A deep seated lesion requiring the short and safe trajectory. 1.8 cm lesion is targeted with cooltip probe. Orbital angle : CC angle : 0.97 Depth : 118 mm Needle used : 17G Cooltip : Number of needles : 1 Planning time : 9 min Procedure time : 30 min Planning in 3D and 2D Ablated area 22 Check scan shows probe Post RFA shows ablated area covering tumour 23
13 Case 10 Radio Frequency Ablation of 3.4 cm HCC A patient is planned for radio frequency ablation of 3.4 cm lesion in 5 th segment of liver Completely covering the tumour with safety margin by thermal ablation zone in sequential probe placements. The lesion is ablated in two sitting of ablation. Two needles placed in simultaneous and first sitting of ablation done and third needle placed towards caudal border by manipulation and second sitting of ablation done. Orbital angle : CC angle : 0 Depth : 140 mm Needle used : 17G Cooltip : Number of needles : 2 Planning time : 9 min Procedure time : 45 min Planning in 3D and 2D Ablated area 24 Check scan shows probe Post RFA shows ablated area covering tumour 25
14 Case 11 Radio Frequency Ablation of 1.5 cm HCC A patient planned for a radiofrequency ablation of 1.5 cm lesion in 3rd segment of liver Avoiding the No Go region like stomach in planning and targeting is a challenge. RFA done under GA. Cooltip : 150/30 Orbital angle : 9.56 CC angle : 6.88 Depth : mm Planning time : 5 min Procedure time : 15 min Planning in 3D and 2D 26 Overlaid image shows tip of the probe on the target and thermal simulation is not covering the stomach 27
15 Case 12 Radio Frequency Ablation of Segment 5 HCC Patient planned for RFA of (HCC) at Segment 5, with liver cirrhosis and fluid around liver It is a tough case because the lesion, to be targeted, is bouncing due to cirrhosis and fluid around liver. 2 cms HCC targeted for RFA with MAXIO at segment 5 of the liver and RFA performed. Trauma to the bowel was avoided by adjusting thermal simulation option. Post ablation scan shows, a wedge-shaped area without enhancement covering lesion. Lesion size : 1.6 x 2 x1.3 cms Orbital angle : 44 Depth : 69 mm Needle used : 17 G/100 mm, Cooltip : Number of needles : 1 Planning time : 10 min Procedure time : 25 min Planning in 3D and 2D 28 Check scan, probe in situ Check scan, post RFA 29
16 Case 13 Multiple Liver tumours planned for MWA Multiple probe planning in sequential mode Overlapping ablation zone can be estimated Collision detection and sequencing algorithm 30 31
17 Case 14 Pancreatic tumour - IRE Tumor in pancreatic region, precisely targeted with assistance of MAXIO. Multiple probes placed in parallel for IRE. No post procedure complications
18 Case 15 Radio Frequency Ablation of Liver Patient planned for RFA of 3 cm HCC mass Lateral approach requires precise trajectory to target the mass in liver. MAXIO assisted in precise targeting of the lesion on lateral position. No post procedure complications. Orbital angle : 86.5 Depth : mm Needle used : Starburst 100 mm Number of needles : 1 Planning to needle : 10 min placement 34 35
19 Case 16 Radio Frequency Ablation of Liver Tumor Heterogeneous large volume Liver lesion ablated using RFA probe in sequential manner. MAXIO s planning software displays segmented organs, tumors and vascular structure for effective planning 36 37
20 Case 17 Volumetric Planning & Assistance for an AO Ablation Strategy Solutions like MAXIO will help Interventional Oncologists to plan and achieve AO ablation which is as important as RO resection in surgery. 3D visualization of tumor and vasculature with MAXIO s intuitive planning 38 39
21 Case 18 Planning of Multiple Liver Lesions for Ablation MAXIO allows to segment and visualize multiple liver lesions in addition to checking the respective ablation volumes. MAXIO s intuitive planning helps in volumetric assessment of liver and ablated area Segmentation of multiple liver lesions 40 41
22 Case 19 Ablation Planning in 3D Anatomical View MAXIO helps to plan safest probe trajectory. This helps to minimize damage to surrounding structures. Probe planning in MPR or in 3D view 42 43
23 20 Case Multiple Facet Joint Injections at L4-L5 & L5-S1 Patient with degenerative lumbar spine planned for facet joint injections at L4-L5 and L5-S1 on right and left side simultaneously Multiple Facet joints at L4-L5 and L5-S1 on right side and left side to be targeted. Facet joint targeted at multiple levels with multiple needles simultaneously, with assistance of MAXIO. Each Facet joint injected with 1ml of Marcaine and 1ml of Celestone Chronodose. Procedure completed precisely. Orbital angle : 10 Depth : 68 to 75 mm Needle used : 19G/127.5 mm Number of needles : 4 Planning time : 15 min Procedure time : 35 min Planning in 3D and 2D 44 Check scan, needles in situ 45
24 Case 21 Multiple Facet Joint Injections at L4-L5-S1 Patient with degenerative lower back pain and Non-operative management, planned for facet joint injection at L4-L5-S1 level Multiple Facet joints at L4-L5-S1 to be targeted. Facet joint targeted at multiple levels with multiple needles simultaneously, with assistance of MAXIO. Each Facet joint injected with 1ml of Marcaine and 1ml of Celestone Chronodose. Procedure completed precisely. Orbital angle : 0 Depth : 44 to 52 mm Needle used : 22G/100 mm Number of needles : 4 Planning time : 6 min Procedure time : 31 min for four needles Planning in 3D and 2D 46 47
25 22 Case Ozone Injection Into Inter Vertebral Disc Disc bulge causing compression on L5 nerve root on left side The depth is more and need precise plan to reach the central nucleus of affected disc. Ozone nucleus Injection into the Disc to suck out the water content, after the injection the size of the disc will get reduced in diameter and relieves pressure on nerve roots. The L4-L5 central nucleus of the disc is targeted Orbital angle : 38 Depth : 102 mm Needle used : 18G / 150 mm Number of needles : one Planning time : 5 min Procedure time : 10 min Planning in 3D and 2D 48 49
26 23 Case Facet Joint Injections Patient with post lumbar decompression and left Para spinal pain planned for multilevel facet joint injections on left side Multiple Facet joints to be precisely targeted. Facet joints on the left side at L3-L4, L4-L5, L5, S1 precisely targeted simultaneously with MAXIO. Each Facet joint injected with 1ml of Marcaine and 1ml of Celestone Chronodose. Orbital angle : 0 to 1 Depth : 58 to 59 mm Needle used : 22G/100 mm Number of needles : 3 Planning time : 7 min Procedure time : 25 min for three needles Planning in 3D and 2D and MPR 50 Three needle at Multiple level on left side 51
27 24 Case Facet Joint Injections Patient with lower back pain, planned for facet Joint injection at L4-L5 and L5-S1 level Multiple Facet joints at L4-L5 and L5-S1 to be targeted. MAXIO assisted in precise and simutaneous targeting of facet joint at Multiple level. Each Facet joint injected with 1ml of Marcaine and 1ml of Celestone Chronodose Patient tolerated the procedure well. Orbital angle : 0 to 1 Depth : 52 to 60 mm Needle used : 22G/90 mm Number of needles : 4 Planning time : 6 min Procedure time : 60 min Planning in 3D and 2D 52 53
28 Case 25 IRE on Iliac Bone IRE with Nano Knife performed on solitary metastasis right iliac wing from Ca. Prostate Placing two parallel probes with in a narrow space of 8 mm is very difficult and time consuming, requiring repeated check scans and needle manipulations. 8 mm lesion at iliac bone precisely and quickly targeted with MAXIO for two IRE parallel probe. IRE performed by Nano knife with maximum 3k voltage and Amps current. Patient discharged on same day (Advantage of CT guided intervention). Orbital angle : 39 Depth : 69 mm Needle used : 11G/100 mm Nanoknife : 150/40 Number of needles : 2 Planning time : 10 min Procedure time : 60 min Planning in 3D and 2D 54 First needle with MAXIO Two parallel needle with Nano Knife 55
29 26 Case Exophytic renal mass Biopsy 1.2 cm left renal mass was targeted with 5 orbital angle at depth of 108 mm. Precise targeting helped to avoid any complications. Planning in 3D and 2D 56 Check scan needle in situ 57
30 Winning with Customers Globally Some of Our Key Users* St. Petersburg Oncology Centre Alfred Hospital, Melbourne, Australia NKI-AVL Dutch Cancer Insitute, Amsterdam Zurich University Hospital, Zurich St. Petersburg Oncology Centre, Russia All India Institute of Medical Sciences, India AC Camargo, Sao Paulo, Brazil Tata Memorial Centre, India Makati Medical Center, Manila, Philipines University of Malaya Mediccal Center, Malaysia Hassanuddin University Makassar, Indonesia EGE University, IZMIR, Turkey National Cancer Hospital, Bogota, Colombia Hospital Barros Luco Santiago, Chile Jaslok Hospital, India PGI, India JIPMER, India Hospital Barros Luco, Santiago * This is a partial list of customers world wide, using Perfint s assistance solutions. * 58 *applied for regulatory clearance 59
31 World Class IO Systems Integrated Planning, Navigation and Targeting for Tumor Ablation Visualization, planning and navigation for interventional oncology 60 61
32 TUMOR ABLATION Current practice Today, clinicians plan their interventional oncology procedures by viewing 2 dimensional CT slices, and combining what they see with their understanding of human anatomy, to determine the optimal approach to target the tumor. They must determine the probe trajectory path and the amount of energy needed to destroy the MAXIO A new approach Clinicians can now visualize and plan an entire ablation procedure in 3D - pre-operative registration, segmentation and visualization of multiple VOI, multi probe placement planning, estimated ablation volume* visualization, probe placement sequence, all before advancing a single probe into the patient. Tumor Ablation is heading in a whole new direction... And MAXIO is leading the way. Clinicians benefit from MAXIO s intelligent planning suite and targeting... Registering pre-operative images and off-line plan with current CT images tumor, while sparing healthy tissue. Multiple energy probes must be manually advanced into the tumor one at a time, without coming in contact with one another, and without damaging vital organs. Once the plan is confi rmed, MAXIO s targeting system combined with adaptive intra-operative registration provides spatial positioning and orientation for a probe guide, through which the clinician then carefully advances each probe and performs the ablative procedure. Organ specific ctumor visualization and segmentation Multiple VOI, multi-probe placement plan for multiple procedures Accurate placement without fluoroscopic radiation Once ablation has been completed, MAXIO s visualization tool allows the clinician to verify if the procedure was executed as planned and determine whether additional treatments may be required. MAXIO s reporting tool then Ability to treat hard to access and large tumors Post procedure verifi cation generates the required reports. All this while factoring in the potential for organ movement Tumor ablation made easier and more predictable. during patient respiration. It s not surprising the procedure is performed by only the most skilled and practiced clinicians. * as provided by the device manufacturer or as determined by the clinician
33 Integrated planning, execution and verifi cation of interventional oncology procedures. SETUP PLAN 1. Roll MAXIO into position and register to the CT table using InstaReg TM [A] 2. Prepare the patient, obtain CT images on MAXIO [B] 3. Register current images with pre-operative images or plan, if available 4. Segment one or more Volumes of Interest, identify no-go regions, define tumor margins 5. Target tumor, with upto 6 probes, on 2D / 3D image 6. Visualize and edit estimated ablation volumes* EXECUTE VERIFY 7. Enable MAXIO s stereotactic arm to position the probe guide for the procedure [C] 8. Manually advance each probe through the probe guide to reach the tumor 9. Perform intra-operative registration to verify probe placement and adapt subsequent plan(s), if needed 10. Ablate tumor as planned 11. Register post-operative and pre-operative organ images 12. Verify if volume within tumor margin is ablated fully, extend treatment if needed 13. Generate patient reports to document procedure *Step 6 is optional. Ablation volumes as provided by the device manufacturer or as determined by the clinician 14. Image registration may be used to monitor tumor progression during follow-up visits Pre-operative Intra-operative Post operative MAXIO s powerful planning software provides 2D and 3D visualization of the affected region and a wide range of tools to aid the development and execution of the plan. MAXIO allows clinicians to move seamlessly from planning to execution. to advance the probes. Intra-operative registration allows verifi cation of With the click of a button, the arm moves into position for the clinician probe(s) placement prior to ablation Post-procedure images can be viewed, and compared to the plan or pre-operative images 64 65
34 1 Multi phasic contrast image of liver co registered prior to procedure planning on MAXIO suite Works with all DICOM3 CT images Supports RF, MW, IRE, Cryo ablation Patient and Respiratory motion management. Sterile disposable kit* to enhance clinical efficiency * Please contact your Perfint representative for details With MAXIO everyone benefits... Clinicians are better able to plan interventional oncology procedures with the help of MAXIO s visualization and planning software, then successfully perform the procedure with the help of MAXIO s targeting system. 2 Intuitive one touch segmentation helps segment organs & tumor Hospitals are looking for effi ciency and it s the goal of MAXIO to make interventional procedures faster and more predictable, a key challenge to scheduling of the CT suite. 3 Multiple probe / multiple VOI planning Patients deserve access to life-saving treatments that are safe and effective. MAXIO strives to reduce the potential for unintended organ damage due to repeat punctures and is likely to reduce the need for repeat scans which would mean less radiation exposure for the patient
35 Acknowledgement Alfred Hospital, Australia UMMC, Malaysia Tata Memorial Hospital, India Medanta, India Research Analysis Library, Pisa Copyright 2012 perfint healthcare corporation. All rights reserved. ( V2) Together with clinicians, improve quality of life of those fighting cancer Perfint Healthcare Corporation Contact your local sales representative to learn more about MAXIO. All claims of product performance and indications for use contained within this document relate only to data submitted to and reviewed by regulatory authorities in those jurisdictions in which clearance(s) and/or approval(s) have been obtained. No product performance claims or indications for use are made for jurisdictions in which such clearance(s) and/or approval(s) have not been obtained.
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