Disclosure. Industry-sponsored grants. Consultant. Research Collaboration. Educational and research grants from Olympus Medical Systems Corp.

Transcription

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

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

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

4 63F, 40pk yr smoker

5 63F, 40pk yr smoker

6 63F, 40pk yr smoker What is the next step? a. Follow up b. Transbronchial biopsy c. CT guided FNA d. VATS e. None of the above

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

8 Diagnostic Approach to Pulmonary Nodules Minimally Invasive Biopsy Bronchoscopic biopsy CT guided FNA Surgical biopsy VATS Thoracotomy 8

9 VATS (Video-assisted thoracoscopic surgery) Procedure of choice for surgical biopsy of peripheral pulmonary nodule Limitation Identification of the nodule Lack of digital palpation in small, non-solid deep nodules May require conversion to thoracotomy 9

10 Localizing Techniques - VATS Intraoperative imaging CT Thoracic ultrasound Preoperative CT guided marking Liquid material (contrast media, colored adhesive agents, dyes) Radionuclides Wires (hookwires, microcoils) Preoperative bronchoscopic marking Dye Fiducials Radiology 2002; 225:

11 Wire Localization - Microcoil Localization 73/75 (97%) 4-24-mm nodules successfully removed low rate of intervention (3%) for procedural complications Radiology 2009; 250:

12 Microcoil Localization 1. CT guided micro coil placement 2. VATS microcoil detection 3. Fluoroscopy guided VATS wedge resection 4. Confirmation of microcoil 12

13 Microcoil Localization Toronto Experience First case October cases Complete resection with VATS in 62/64 cases (97%) 100% diagnostic yield 13

14 14 GTx (Guided Therapeutics) Program

15 GTx Surgery Overview TRIGOR = Translation Research Image Guided OR 15 Guided Therapeutics (GTx) Core

16 TRIGOR A Design Translation Research Image Guided OR TRIGORA General OR Space 16 Guided Therapeutics (GTx) Core

17 TRIGOR A Capabilities Cone-Beam CT Dual Source- Dual Energy CT MIS, Endoscopic Technology 17 Guided Therapeutics (GTx) Core

18 TRIGOR A Capabilities Cone-Beam CT 18 Guided Therapeutics (GTx) Core

19 TRIGOR A GTx OR 19

20 Multi-Modality Surgical Guidance Pre-Operative Imaging Intraoperative CBCT Surgical Tool Tracking Surgical Planning Surgical Dashboard Optical Imaging 20 X-Eyes 3D Visualization Software (University Health Network) Courtesy of Michael Daly

21 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 21

22 GTx OR VATS localization 22

23 GTx OR Image guided Transbronchial Interventions 23

24 Ultra-minimally Invasive Treatment of Lung Cancer Potential Technology 24

25 Nanoparticles enabled lung cancer detection and ablation Porphysomes : Liposomes like bilayer porphyrin-phospholipid Working as both fluorophore and photo-enhancer A schematic representation (left) and a transmission electron micrograph (right) of a pyropheophorbide-lipid porphysome. Scale bar, 100 nm

26 EPR effect: Enhanced permeability and retention effect Only small molecules highly permeable neo-vascularture: Normal capillary : polymer molecules can not be permeable

27 Porphysome distribution in A549 Orthotopic lung cancer Xenograft model LUL RUL Macroscopic Maestro hyperspectral fluorescence imager Excitation : yellow Emission: >670 nm LLL RLL DAPI: HV775V, Offset 30% Gain 1x Porphysomes: HV700V, offset 30%, Gain 1x Excitation 633nm, Emission 647nm

28 Porphysome distribution in Rabbit VX2 orthotopic lung tumor model CT Macro FL (in-vivo fluorescence imager) Peripheral nodule Mediastinal tumor

29 Development of prototype bronchoscope for visualization of porphysome fluorescence Fiberscope Optical filter box Emission (bronchoscope side) : A long pass filter : nm Exitation (light source side): Red diode of 10 mw output A band-pass filter : nm

30 In-vivo model Prototype fluorescence bronchoscope WL 0 time 24hr 48hr

31 Porphysome thermal effect on resected VX2 tumor tissue ( ex-vivo)

32 Ultra-minimally invasive multi-modal image guided phothermal ablation of lung cancer 32

33 Division of Thoracic Surgery Toronto General Hospital University Health Network Kazuhiro Yasufuku, MD, PhD, FCCP Thank you 33