Disclosure. Industry-sponsored grants. Consultant. Research Collaboration. Educational and research grants from Olympus Corporation

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1 Image Guided Surgery Kazuhiro Yasufuku MD, PhD Director of Endoscopy, University Health Network Director, Interventional Thoracic Surgery Program Associate Professor of Surgery, University of Toronto Division of Thoracic Surgery, Toronto General Hospital 2016 Duke Masters of Minimally Invasive Thoracic Surgery Sep th,

2 Disclosure Industry-sponsored grants Educational and research grants from Olympus Corporation Consultant Olympus America Inc. Intuitive Surgical Inc. Covidien Johnson and Johnson Research Collaboration Siemens Novadaq Corp. Veran Medical Systems 2

3 63F 40pk yr smoker CT screening R lower lobe GGO

4 63F, 40pk yr smoker

5 63F, 40pk yr smoker

6 CT guided FNA non-diagnostic What next? a. Follow up b. VATS c. Thoracotomy d. None of the above

7 Image Guided Surgery (IGS) Definition? 7

8 Image Guided Surgery (IGS) Definition? General term used for any surgical procedure where surgeons employs tracked surgical instruments in conjunction with preoperative or intraoperative images in order to indirectly guide the procedure IGS was originally developed for treatment of brain tumors Various applications of navigations for neurosurgery have been widely used for almost two decades 8

9 Image Guided Surgery (IGS) in Thoracic Surgery Fluorescence Image Guided Surgery Virtual/Electromagnetic Navigation Guided Surgery Preoperative CT Guided Surgery Intraoperative Cone Beam CT Guided Surgery 9

10 10 Fluorescence Image Guided Surgery

11 Molar extinction coefficient (cm- 1/M) ICG and Near Infrared (NIR) Imaging Indocyanine green NIR thoracoscope M.W: nm Surv Opthalmol, 2000 PinPoint, Novadaq Technologies TM 11

12 ICG Fluorescence-Guided Surgery Sentinel LN Mapping A-dose escalation phase 1 clinical trial real-time NIR imaging after peritumoral injection of 3.8 to 2500 μg 26 NIR(+) SLNs identified in 15 pts with 7 NIR(+) SLNs (6 pts) harboring metastatic disease on histologic analysis Metastatic nodal disease never identified in pts with a histologically negative NIR(+) SLN J Thorac Cardiovasc Surg. 2013; 146:

13 ICG Fluorescence-Guided Surgery NIR Thoracoscopic Segmental Resection ICG injection into the bronchus of target pulmonary segments under GA NIR Thoracoscopic identification of the target segments (Hamamatsu Photonics, Hamamatsu, Japan) Intersegmental lines and planes identified to allow segmental resection J Thorac Cardiovasc Surg. 2012; 143:

14 ICG Fluorescence-Guided Surgery NIR Robotic Segmental Resection iv ijection of ICG after division of segment bronchus, vein and artery (2.5mg/10mL, 6-8mL bolus) Da Vinci Firefly fluorescence imaging for identification of the target segments J Thorac Cardiovasc Surg. 2014; 148:

15 Virtual/Electromagnetic Navigation Guided Surgery 15

16 Virtual assisted Lung Mapping VAL-MAP Bronchoscopic multispot dye-marking technique using virtual images, for precise navigation of thoracoscopic sublobar lung resection J Thorac Cardiovasc Surg. 2014; 147:

17 Preoperative bronchoscopic marking CT Fluoroscopy-guided bronchoscopic dye marking for resection of small peripheral pulmonary nodules CHEST 2004; 125:

18 Preoperative ENB marking (fiducial, dye) ENB-guided VATS wedge resection of peripheral lung nodules Seminars in Thoracic and Cardiovascular Surgery, 22, 2011 J Community Hosp Intern Med Perspect. 2014; 4(1): 10 18

19 19 GTx (Guided Therapeutics) Program

20 GTx OR at Toronto General Hospital 20

21 GTx OR Capabilities Cone-Beam CT Dual Source- Dual Energy CT MIS, Endoscopic Technology 21 Guided Therapeutics (GTx) Core

22 GTx OR Capabilities Cone-Beam CT 22 Guided Therapeutics (GTx) Core

23 Multi-Modality Surgical Guidance Pre-Operative Imaging Intraoperative CBCT Surgical Tool Tracking Surgical Planning Surgical Dashboard Optical Imaging 23 X-Eyes 3D Visualization Software (University Health Network) Courtesy of Michael Daly

24 Multi-Modality Surgical Guidance Pre-Operative Imaging Intraoperative CBCT Surgical Tool Tracking Surgical Planning Optical Imaging Intraoperative localization Image assistance during MIS/Robotic Surgery Real time monitoring of minimally invasive thoracic intervention 24

25 Optical Surgical Navigation 1. Preoperative CT imaging 2. Cone-beam CT nodule localization 3. Image registration with surgical navigation Pre-Operative Imaging Intraoperative CBCT Surgical Tool Tracking

26 GTx OR VATS localization 26

27 GTx OR Image guided Transbronchial Interventions 27

28 A Novel Minimally Invasive Near-infrared Thoracoscopic Localization Technique of Small Pulmonary Nodules A Phase I Feasibility Trial Hideki Ujiie 1, Tatsuya Kato 1, Hsin-pei Hu 1, Priya Patel 1, Hironobu Wada 1, Daiyoon Lee 1, Kosuke Fujino 1, Robert Weersink 2,3, Elsie Nguyen 4, Marcelo Cypel 1, Andrew Pierre 1, Marc de Perrot 1, Gail Darling 1, Thomas K. Waddell 1, Shaf Keshavjee 1, Kazuhiro Yasufuku 1,2 1 Division of Thoracic Surgery, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada 2 TECHNA Institute, University Health Network, University of Toronto 3 Department of Radiation Oncology, University Health Network, University of Toronto 4 Division of Cardiothoracic Imaging, Joint Department of Medical Imaging and University Health Network, University of Toronto

29 CT-guided Microcoil Placement and ICG Injection small lung nodule CT guided microcoil insertion CT guided injection of ICG Ujiie et al, AATS 2016 abstract 29

30 CT-guided Microcoil Placement and ICG Injection Ujiie et al, AATS 2016 abstract

31 Intraoperative NIR Localization Ujiie et al, AATS 2016 abstract

32 Patient characteristics (n=20) CT nodule size 12 mm (5-24) CT nodule depth 13.5 mm (2-48) CT findings Pure GGN 11 Part-solid GGN 6 Solid nodule 3 Pathological tumor size 10mm (5-24) Pathological diagnosis Adenocarcinoma (AIS, MIA, LPD, ACI) 16 (6, 2, 4, 4) Squamous cell carcinoma 1 SCLC 1 Metastatic lung tumor 1 Focal perivascular lymphoid infiltrate 1

33 Results CT-guided intervention time 35 min (19-59) VATS procedural time 54 min (28-84) Localization success rate 19/20 (95%) Negative surgical margin rate 20/20 (100%) Adverse effect 0 /20 (0%)

34 GTx OR CBCT localization 34

35 Intraoperative pulmonary nodule tracking with CBCT and deformable image registration Pilot clinical study to acquire cone-beam CT images during VATS Lung deflation for VATS decreased CT image contrast, so nodules cannot be distinguished directly Image registration methods help determine the correspondence of regions between CT images Registering the cone-beam CT images of the inflated lung to the deflated lung helps project the known nodule location to the deflated lung Hsin-pei Hu, Master of Health Science in Clinical Engineering, 2016 Institute of Biomaterials and Biomedical Engineering, University of Toronto 35

36 Inflated Lung Deflated Lung Registered Lung Axial Axial Axial Coronal Coronal Coronal Sagittal Sagittal Sagittal

37 3D reconstruction of registration results helps localize regions of interest Example Region of Interest (ROI) (inflated lung) Registered (projected) location and size of ROI in deflated lung Actual location and size of ROI in deflated lung Legend: Inflated Lung Deflated Lung Registered Lung

38 Summary Hybrid OR with capabilities of preoperative and intraoperative real-time radiologic imaging as well as advanced endoscopic procedures will assist surgeons during Image Guided Surgery Advances in imaging technology will enable intraoperative localization of small peripheral nodule during minimally invasive surgery 38

39 Acknowledgement Latner Thoracic Surgery Laboratory Yasufuku Laboratory Tatsuya Kato Hideki Ujiie Kosuke Fujino Hitoshi Igai Spencer Hu Salma Hindy Judy McConnell Alexandria Grindlay TECHNA Institute David Jaffray Robert Weersink Jonathan Irish Harley Chan Michael Dunne Jimmy Qiu 39

40 Division of Thoracic Surgery Toronto General Hospital University Health Network Kazuhiro Yasufuku, MD, PhD, FCCP Thank you 40