1. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop Non-Rigid, Multi-Modality Image Registration for Thermal Ablation: 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

2. © 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.

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

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

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

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

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

8. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop MRI-guided cryotherapy of a 3.4cm liver metastasis Sagittal T2-weighted fse imaging used to place cryoprobes (arrowheads) into the tumor (arrow) Iceballs form around each probe; these coalesce Tumor is eclipsed DYNAMIC PROCESSES Acad Radiol 2005;12:1100-109

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

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

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

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

13. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop CLINICAL NEED – Example 1 Recent BWH ablation case: Pre-Proc MRI vs Intra-CT 47yo M, 3cm liver metastasis of sq cell ca in Seg 8; lung & vessels nearby Pre-Procedure CE MRI at 1.5T Intra-Procedure Non-Enhanced CT Procedure 071107 Images courtesy Cross-sectional Interventional Radiology, Brigham & Women’s Hospital, Boston, MA

14. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop CLINICAL NEED – Example 2 Recent BWH Ablation Case: PreProc MRI vs Intra-CT 69yo M, 7cm liver metastasis of colon cancer; look for coverage; GB & colon nearby Pre-Procedure CE MRI at 1.5T Intra-Procedure Non-Enhanced CT Procedure 080304 Images courtesy Cross-sectional Interventional Radiology, Brigham & Women’s Hospital, Boston, MA

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

16. © 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

17. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop PRE-PROCEDURAL CE MRI 051021 CEMRI PreTx Ser08 i270 Example: Registered Data --MRI Pre BWH Ablation Case 50yo M, 2cm primary liver tumor (HCC) in segment 2 Images courtesy Cross-sectional Interventional Radiology, Brigham & Women’s Hospital, Boston, MA

18. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop 051220 CT PreTx Ser04 i21 INTRA-PROCEDURAL CT Example: Registered Data --CT Intra Images courtesy Cross-sectional Interventional Radiology, Brigham & Women’s Hospital, Boston, MA

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

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

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

22. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop SLICER 3.0

23. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop WHAT IS 3D 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

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

25. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop “SLICER 3” Next Generation of the 3D Slicer software Beta Release in Jan 2007 Slicer 3.0 schedule for June 2007 www.slicer.org Image: S Pieper

26. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop WHAT IS SLICER 3? Total Rework of 3D 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, GaTech, UNC, U Utah, MGH, UCI, Harvard, WashU… NAC, NCIGT, NA-MIC, mBIRN, fBIRN

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

28. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop 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 Image: S Pieper

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

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

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

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

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

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

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

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

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

38. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop screen_22 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.

39. © NIH National Center for Image-Guided Therapy, March 2008 IGT Clinical Workshop screen_21c RESULT OF RIGID REGISTRATION Slider can be used to review the result of the linear alignment between the pre-procedural MRI and intra- procedural CT.

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

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

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

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