Patent Application
20100056900
The present invention generally relates to devices, apparatuses and methods for inserting a medical device such as a needle into a mammalian body while the body is within the imaging field of a medical imager, particularly devices, apparatuses and methods for inserting and guiding a needle to a target site within a body while the body is within the imaging field of a medical imager, and more particularly to devices, apparatuses and methods for inserting and guiding a needle to a target site within a body selected by the user while the body is within the imaging field of a medical imager.
Prostate diseases represent a significant health problem in the United States. After cardiac diseases and lung cancer, metastatic prostate cancer is the third leading cause of death among the American men over fifty years, resulting in approximately 31,000 deaths annually. The definitive diagnostic method of prostate cancer is core needle biopsy. Annually in the U.S., approximately 1 million prostate biopsies are performed. The average number of new prostate cancer patients detected by needle biopsy has stabilized around 200,000 per year. Due to the evolution in screening techniques, more cases are diagnosed at an earlier stage, when patients are candidates for some form of minimally invasive localized therapy typically delivered with needles. The majority of the cancer-free biopsied patients are likely to have benign prostate hyperplasia (BPH). Currently more than 10 million American men suffer from BPH. Significant attention has been focused on minimally invasive local therapies of this condition, because its definitive treatment, transurethral resection (TURP) is a highly invasive surgical procedure with potentially adverse side effects. Needle-based ablative therapies have shown promising results lately in the treatment of BPH.
Currently, transrectal ultrasound (TRUS) guided needle biopsy is primary technique being utilized for the diagnosis of prostate cancer [Presti J C Jr. Prostate cancer: assessment of risk using digital rectal examination, tumor grade, prostate-specific antigen, and systematic biopsy. Radiol Clin North Am. 2000 January; 38(1):49-58. Review] and contemporary intraprostatic delivery of therapeutics is also primarily performed under TRUS guidance. This technique has been overwhelmingly popular due to its excellent specificity, real-time nature, low cost, and apparent simplicity. At the same time, however, TRUS-guided biopsy fails to correctly detect the presence of prostate cancer in approximately 20% of cases [Norberg M, Egevad L, Holmberg L, Sparen P, Norlen B J, Busch C. The conventional sextant protocol for ultrasound-guided core biopsies of the prostate underestimates the presence of cancer. Urology. 1997 October; 50(4):562-6; Wefer A E, Hricak H, Vigneron D B, Coakley F V, Lu Y, Wefer J, Mueller-Lisse U, Carroll P R, Kurhanewicz J. Sextant localization of prostate cancer: comparison of sextant biopsy, magnetic resonance imaging and magnetic resonance spectroscopic imaging with step section histology. J Urol. 2000 August; 164(2):400-4].
For the same reason, targeted local therapy today also is not possible with the use of TRUS guidance. Instead, major anatomical regions (or most often the entire prostate gland) are treated uniformly while trying to maintain the fragile balance between minimizing toxic side effects in surrounding normal tissues and providing/giving a sufficient therapeutic dose to the actual cancer. Also importantly, the transrectal ultrasound probe applies variable normal force on the prostate through the rectal wall, causing dynamically changing deformation and dislocation of the prostate and surrounding tissue during imaging and needle insertion, an issue that has to be eliminated in order to achieve accurate and predictable needle placement. The key to successful prostate biopsy and local therapy is accurate, consistent and predictable needle placement into the prostate, and some form of image guidance.
MRI imaging has a high sensitivity for detecting prostate tumors. Unfortunately, MRI imaging alone, without concurrent biopsy, suffers from low diagnostic specificity. In addition, there are other fundamental obstacles that must be addressed when using MRI imaging techniques in prostate biopsy and related localized therapy of the prostate. Conventional high-field MRI scanners use whole-body magnets that surround the patient completely and do not allow access to the patients during imaging. Thus, the workspace inside the bore of the whole-body magnet is so extremely limited, that conventional medical robots and mechanical linkages do not fit inside the whole-body magnet. Also, the strength of the magnetic field being generated within the whole-body magnet is about 200,000 times stronger than the magnetic field of the earth. Due to these ultra-strong magnetic fields, ferromagnetic materials and electronic devices are not allowed to be in the magnet due to safety and/or imaging concerns, which excludes the use of traditional electro-mechanical robots and mechanical linkages.
Tempany, D'Amico, et al. [Cormack R A, D'Amico A V, Hata N, Silverman S, Weinstein M, Tempany C M. Feasibility of transperineal prostate biopsy under interventional magnetic resonance guidance. Urology. 2000 Oct. 1; 56(4):6634; D'Amico A V, Tempany C M, Cormack R, Hata N, Jinzaki M, Tuncali K, Weinstein M, Richie J P. Transperineal magnetic resonance image guided prostate biopsy. J Urol. 2000 August; 164(2):385-7] proposed to use an open MRI configuration in order to overcome spatial limitations of the scanner. The magnet configuration for this open MRI configuration allows the physician to step inside the magnet and deliver biopsy and therapeutic needles into the prostate. This approach showed that it was possible to use an MRI imaging process to detect cancer previously missed by ultrasound guided needle biopsy and to perform targeted brachytherapy of the prostate. This technique has limitations, however, because it involves the use of an open MRI scanner. Perhaps most importantly, the incurred cost and complexity of open MRI imaging are substantial, especially when compared to transrectal ultrasound imaging.
Open magnets also tend to have weaker magnetic fields than the magnetic fields that are generated using closed magnets, thus open magnets tend to have lower signal-to-noise ratio (SNR) than the SNR for a closed high-field MRI scanners. Consequently, intra-operative images for an open magnet tend to be of a lower quality than the diagnostic images from a closed MRI scanner. While this approach seems to be acceptable when used in a research type of environment, it adds to the complexity and cost of the open MRI. Tempany et al. apply transperineal needle placement for both biopsy and brachytherapy, which is conventionally accepted for therapy, but for biopsy, it is a significantly more invasive route than through the rectum.
Traditionally, needles are placed into the prostate manually while observing some intra-operative guiding images, typically real-time transrectal ultrasound. TRUS biopsy is executed with entirely free hand. Transperineal needle placement is significantly more controlled by stepping transrectal ultrasound and template jigs, however, it still depends on the physicians hand-eye coordination. Therefore, the outcomes of TRUS guided procedures show significant variability among practitioners.
Recently, a 6-DOF robot has been presented for transperineal needle placement into the prostate, but that kinematic concept is not applicable in transrectal procedures [G. Fichtinger, T. L DeWeese, A. Patriciu, A. Tanacs, D. Mazilu, J. H. Anderson, K. Masamune, R H. Taylor, D. Stoianovici: Robotically Assisted Prostate Biopsy And Therapy With Intra-Operative CT Guidance: Journal of Academic Radiology, Vol 9, No 1, pp. 60-74]. An industrial robot also has been applied to assist TRUS-guided prostate biopsy with the use of a conventional end-shooting probe [Rovetta A, Sala R: Execution of robot-assisted biopsies within the clinical context., Journal of Image Guided Surgery. 1995; 1(5):280-287]. In this application, the robot mimicked the manual handling of TRUS biopsy device in the patient's rectum, in a telesurgery scenario.
A robotic manipulator has been reported for use inside an open MRI configuration, which device is intended to augment the Tempany et al. developed system [Chinzei K, Hata N, Jolesz F A, Kikinis R, MR Compatible Surgical Robot: System Integration and Preliminary feasibility study, Medical Image Computing and Computer-assisted Intervention 2000, Pittsburgh, Pa. Lecture Notes in Computer Science, MICCAI 2000, Springer-Verlag, Vol. 1935, pp. 921-930). The motors of this robot are situated outside the first magnetic zone, while the motors actuate two long arms to manipulate the surgical instrument in the field of imaging. This solution is not suitable for a closed magnet configuration. In addition, the long arms of this robotic manipulator amplify the effects of flexure and sagging, which can render this system inaccurate for certain procedures. Moreover, because the device is intended to be mounted permanently with respect to the MRI scanner, the robotic manipulator is not flexibly adaptable to different sides of the body.
Recently, a robot has been developed for use inside a conventional MRI scanner that is custom-designed for breast biopsy, [Kaiser W A, Fischer H, Vagner J, Selig M. Robotic system for biopsy and therapy of breast lesions in a high-field whole-body magnetic resonance tomography unit. Invest Radiol. 2000 August; 35(8):513-9]. This robot is mounted on the table of the scanner and it realized six degrees of freedom (6 DOF). This robot is demonstrated in accessing the breast, but it is not readily adaptable for abdominal and intracavity use. There also has been published variations of an in-MRI robot for stereotactic brain surgery, but the actual embodiments of that system also are not applicable in transrectal biopsy [Masamune et. al., Development of an MRI-compatible needle insertion manipulator for stereotactic neurosurgery. Journal of image Guided Surgery, 1995, 1 (4), pp. 242-248].
The development of magnetic resonance imaging (MRI) guided robotic intervention instruments also necessarily involves and is complicated by the need to track in real-time the position and orientation of these instruments within the MRI scanner. Consequently a variety of methods have been developed for the spatial registration and tracking of robotic and manual instruments within MRI scanners. The reported approaches include joint encoding, passive fiducial features, optical position sensing, gradient field sensing and micro-tracking sensing coils.
As is known to those skilled in the art, in the joint encoding approach the position of the intervention device (e.g., needle or other surgical device) is determined by joint encoders. This approach has its limitations in that it requires or involves the addition of a rigid mechanical mounting system to the MRI scanner so the intervention device is mounted rigidly on the MRI scanner, in a highly repeatable manner and also requires a precise pre-calibration of the device with respect to the scanner coordinate system before using the interventional device.
A number of systems or methods have been developed around the use of passive MRI fiducials that are attached or registered to the intervention device in a pre-set geometric arrangement. As is known to those in the art, the fiducials include materials that are visible or detectable during the MRI process. In one reported system, template holes of a passive needle guiding template for transperineal MRI-guided HDR prostate brachytherapy were filled with a contrast material, which were pre-operatively localized in standard T1 or T2-weighted images and registered to the coordinate frame of the MRI scanner. In a reported MRI guided transrectal needle biopsy system a passive fiducial marker sleeve coaxial with the biopsy needle was employed. In this system, the needle position is manually adjusted while the passive marker is imaged with oblique T2-weighted turbo spin echo (TSE) image sequences. While this approach is based on the use of inexpensive and robust passive fiducials, the approach does require or involve repeated volume imaging of high resolution that takes considerable time to acquire.
The optical position sensing approach involves an optical tracking system that is deployed and calibrated with respect to the scanner coordinate system. Such a system also requires line-of-sight between the optical tracking cameras and the device, and requires tethered light-emitting diodes (LEDs) to be attached to the instrument. Although this approach provides real-time tracking performance suitable for visual servoing, the line-of-sight requirement of such a system renders this approach from unusable with conventional closed-bore MRI scanners.
In the gradient field sensing approach, the gradient field and conventional pulse sequences are used for localization. In regards to this approach, Hushek et al. investigated an FDA-approved commercial tracking mechanism called EndoScout (Robin Medical Systems, Baltimore, Md.) in the open MRI scanner (the device utilizes conventional image pulse sequences and gradient field for localization). In present implementations, however, the tracking sensors must be placed close to the MRI magnet's isocenter, and thus may occupy critical volume in the interventional device. This approach also requires a precise one time calibration procedure to be performed over the entire field of interest in each MRI system on which it is installed.
Another of the previously reported tracking methods employs a number of micro-tracking coils (e.g., three or more micro-tracking coils) that are rigidly attached to an MRI-compatible instrument. In this approach, a series of custom-programmed MRI pulse sequences provide one dimensional projections of the coil positions for each coil. Each individual projection pulse sequence takes several milliseconds, and the Cartesian position of all three micro-tacking coils can be completed within 50 ms. The individual micro-coil position data are employed to compute the six degree-of-freedom (6-DOF) position and orientation of the instrument with respect to the scanner coordinate system. Update rates of 20 Hz for fill 6-DOF tracking have been reported. While the micro-coil tracking approach advantageously yields high accuracy (e.g., mean positional errors of 0.2 mm and 0.3 degrees), high speed (full 6-DOF tracking update rates of 20 Hz have been reported) and direct real-time 6-DOF tracking of the tool end-point, there are some shortcomings.
The use of micro-coils for tracking involves the development of custom tracking pulse sequences which necessarily must be implemented, and tested for each scanner. These pulse sequences differ from the standard imaging pulse sequences normally available on MRI scanners. Also, few scanners presently support micro-coil tracking as a standard capability. In addition a custom interface between the scanner software and a tracking program must be established to access the tracking coil locations.
Also, the tracking coils require a minimum of three scanner receiver channels. Most present-day MRI scanners posses four or more receiver channels, thus this method can be used on most scanners, however this does limits the number of imaging coils that can be used simultaneously for an interventional procedure. Further, this approach requires a minimum of three micro-coils to be incorporated within the navigated instrument. This can complicate the design and manufacturing of the instrument. Moreover, the micro-coils normally require a custom-built tuning, detuning and impedance matching circuit to be developed for each scanner. Based on experience the frequent failures in the micro-coils and electrical circuit significantly degrades the reliability of the overall MRI guided instrument.
It thus would be desirable to provide a new device, apparatus, systems and methods for image-guided biopsy and/or a wide range of therapeutic techniques including needle therapy that employs high resolution MRI imaging inside a closed MRI scanner. It also would be particularly desirable to provide such devices, apparatuses, systems and methods for image guided biopsy and/or therapeutic techniques of the prostate, rectum, vagina or cervix, as well as an artificial opening created in the body such as for example those used in connection with laparoscopic procedures/techniques. It would be particularly desirable to provide such a device, apparatus, system and method that would replace the conventional manual technique with a controlled needle insertion and guiding technique to maximize needle placement accuracy and also to minimize dynamic tissue deformation during the procedure. It also would be particularly desirable to provide such devices, apparatuses, systems and methods that employ real-time MRI guidance, are compatible with conventional high-field MRI scanners with no artifact, that can fit inside a closed whole-body magnet, that can perform needle insertion (e.g., transrectal needle insertion), that minimizes organ motion and deformation in a non-invasive manner and which provides three degree-of-freedom motion to reach a target within the body and selected by the user/redical personnel. It also would be particularly desirable to provide devices, apparatuses, systems and methods that embody a tracking methodology having an accuracy comparable to the accuracy for active tracking coils, but which does not require the use of such active tracking coils.
The present invention features devices, systems, apparatuses and methods for entering a medical device such as a needle into a mammalian body (e.g. a human body), while the body is inside a medical imager such as a MRI scanner, CT, X-ray fluoroscopy, and ultrasound imaging, from within a body cavity (such as the rectum, vagina, or laparoscopically accessed cavity). A minimum three degree-of-freedom mechanical device translates and rotates devices according to the present invention inside the cavity and enters the medical device (e.g., a needle) into the body, and steers the needle to a target point selected by the user. The device is guided by real-time images from the medical imager. Networked computers process the medical images and enable the clinician to control the motion of the mechanical device that is operated directly within the imager, outside of the imager or remotely from outside the imager.
The devices, systems, apparatuses, and methods of the present invention are particularly adaptable for use in image-guided prostate biopsy that employs high resolution MRI imaging inside a closed MRI scanner, while maintaining safe transrectal access. In addition, such devices, apparatuses, systems and methods embody a controlled needle insertion technique, as compared to the conventional manual manipulation technique, thereby maximizing needle placement accuracy and also minimize dynamic tissue deformation during the procedure. The device, system, apparatus and methods of the present invention also can employ real-time MRI guidance while the system is compatible with high-field MRI scanners with no imaging artifacts. In addition, a device and/or apparatus of the present invention fits inside a closed magnet, minimizes organ motion and deformation in a non-invasive manner and uses at least three degree-of-freedom motion to reach a selected target.
According to one aspect of the present invention there is featured an interventional device for use while a mammalian body is within an imaging field of a medical imaging apparatus. Such an interventional device includes an end-effector member a portion of which is inserted into one of a natural cavity or an artificially formed cavity of a mammalian body while the body is within the imaging field of the medical imaging apparatus. The natural body cavity includes any natural occurring orifice of the mammalian body including the rectum and uterus. An artificial formed body cavity includes those cavities formed as a result of surgical procedures such as laparoscopic surgical procedures.
In one aspect of the invention, the end-effector member includes a sheath member having a longitudinally extending interior compartment and a carrier member being one of translatably or rotatably disposed within the sheath member interior compartment. According to another aspect of the invention, the end-effector member includes a sheath member having a longitudinally extending interior compartment and an inner member being rotatbly and/or translatably disposed within the sheath member interior compartment. The sheath member also is configured and arranged so it can be received with said one of natural or artificial body cavity. For example, the sheath member is shaped and sized so as to be received in the rectum without causing damage to the tissues thereof. Further, the end-effector is configured and arranged to selectively deploy a medical device therefrom between a stored position and a deployed position. In the deployed position a portion of the medical device is disposed in certain of tissues (i.e., target tissues) about said one of the natural or artificial body cavity. The target tissues include the tissue or cells being targeted for one of diagnosis (e.g., biopsy) or treatment.
More particularly, the sheath member and the carrier member and inner member are configured and arranged so rotation and/or translation of the carrier or inner member is not imparted to the sheath member. In this way, and in contrast to prior art devices, the movement of the carrier or inner member does not dynamically change deformation or dislocation of the prostate for example. In more specific embodiments, the carrier or inner member can be selectively translated (e.g., move longitudinally) within the sheath member and then rotated within the sheath member so the end-effector is put into the desired orientation for performing a biopsy, delivering of a therapeutic medium and/or other actions as herein described.
In particular embodiments, the sheath member is configured so as to include a through aperture that communicates with the sheath member interior compartment and which extends partially circumferentially and partially longitudinally so as to form a window in an exterior surface of the sheath member. It also is within the scope of the present invention for the medical device to penetrate through or pierce a surface (e.g., end or side surface) of the sheath member as it is being deployed from the carrier or inner member to the target tissues. In further embodiments, the sheath member also is arranged so it can rotate and the carrier or inner member also can rotate and/or translate within the sheath member interior compartment.
In more particular embodiments, the end-effector member further includes an imaging device that is configured and arranged so as to image a volume of tissues including the certain tissues. More particularly, the end-effector member further includes an MRI receive antenna that is configured and arranged to image a volume of tissues including the certain tissues. More specifically, the MRI receive antenna is arranged so as to image tissues opposite the sheath member through aperture or opposite an area of a surface the sheath member that the medical device is to penetrate through.
In more particular embodiments, the end-effector member further includes one or more tracking devices, each of said one or more tracking devices being configured and arranged so a position of each tracking device can be determined using an imaging system external to the interventional device. In one exemplary embodiment, the one or more tracking devices are passive fiducials appropriate for the particular imaging technique embodied in the external imaging system and the one or more tracking devices are arranged (e.g., within the carrier member) so as to allow a determination to be made of an amount the carrier member is being translated or rotated within the sheath member.
In further embodiments, the external imaging system is an MRI imaging system and the one or plurality or more tracking devices comprise one of a passive fiducial or a tracking coil. More particularly, one of the passive fiducials or the tracking coils are arranged so as to allow a determination to be made of an amount the carrier member is being translated or rotated within the sheath member. In exemplary embodiments, the end-effector member includes three tracking coils that are arranged so as to allow a determination to be made of an amount the carrier member is being translated or rotated within the sheath member. Such an end-effector member also can include passive fiducials appropriate for tracking the device in MRI images. Reference also shall be made to U.S. Pat. Nos. 5,271,400; 6,470,204 and 6,492,814, the teaching of which are incorporated herein by reference as to further details about tracking coils and the use thereof.
According to yet further aspects/embodiments of the present invention, the interventional device of the present invention provides improved access to a target from within a body cavity through multiple needle channels and/or with a steerable needle channel and/or embodies easy to implement scanner independent tracking methods, on-the-fly signal intensity correction, and/or reduction of organ deformation.
In more particular aspects/embodiments, the present invention include new device mechanics particularly multiple needle channels; steerable channel; rotating sheath; new device tracking and tracking methods which can include tracking by combining passive and position encoder (e.g., opto-electrical encoder) tracking; signal intensity correction which can be combined with tracking; and/or new methods and systems for reduction of organ motion with variable geometry prostate stabilization. These aspects may be applied singularly or more preferably two or more of these aspects can be applied in a device or method in combination.
Also featured are systems, apparatuses and method related thereto. Such systems and methods of the present invention can have a variety of applications including, but not limited to, prostate biopsy in a closed MRI scanner; prostate local therapy in a closed MRI scanner; and/or percutaneous medical procedures from within natural body cavity (e.g., rectum, vagina, uterus, etc) or laparoscopic cavity, under intra-operative image guidance (e.g., MRI, CT, PET, SPECT, PET-CT and cone beam CT).
Systems of the invention can be manually operated or automated, e.g., devices of the invention can be motorized to obtain fast image controlled tissue biopsies and delivery of needles for therapeutic procedures without the need of pulling the patient in and out of the imaging scanner. Vacuum assisted biopsy, and motorized exchange of biopsy needles can facilitate automated extraction of tissue samples.
Systems of the invention also can impact organ deformation, including via software which accounts for organ deformation based on tissue models and can adjust targeting parameters prior to inserting a needle in order to increase targeting accuracy.
Other aspects and embodiments of the invention are discussed below.
The instant invention is most clearly understood with reference to the following definitions:
As used in the specification and claims, the singular form “a”, “an” and “the” include plural references unless the context clearly dictates otherwise. For example, the term “a cell” includes a plurality of cells, including mixtures thereof. The term “a nucleic acid molecule” includes a plurality of nucleic acid molecules.
As used herein, the term “comprising” or “including” is intended to mean that the compositions, methods, devices, apparatuses and systems include the recited elements, but do not exclude other elements. “Consisting essentially of”, when used to define compositions, devices, apparatuses, systems, and methods, shall mean excluding other elements of any essential significance to the combination. Thus, a composition consisting essentially of the elements as defined herein would not exclude trace contaminants from the isolation and purification method and pharmaceutically acceptable carriers, such as phosphate buffered saline, preservatives, and the like. “Consisting of” shall mean excluding more than trace elements of other ingredients, elements and substantial method steps. Embodiments defined by each of these transition terms are within the scope of this invention.
As used herein, a “target cell” or “recipient cell” refers to an individual cell or cell which is desired to be, or has been, a recipient of exogenous nucleic acid molecules, polynucleotides and/or proteins and includes cells of tissues being targeted by the devices, apparatuses, systems and methods of the present invention. The term is also intended to include progeny of a single cell, and the progeny may not necessarily be completely identical (in morphology or in genomic or total DNA complement) to the original parent cell due to natural, accidental, or deliberate mutation. A target cell may be in contact with other cells (e.g., as in a tissue) or may be found circulating within the body of an organism. As used herein, a “target cell” is generally distinguished from a “host cell” in that a target cell is one which is found in a tissue, organ, and/or multicellular organism, while as host cell is one which generally grows in suspension or as a layer on a surface of a culture container.
As used herein, a “subject” is a vertebrate, preferably a mammal, more preferably a human. Mammals include, but are not limited to, murines, simians, humans, farm animals, sport animals, and pets.
The terms “cancer,” “neoplasm,” and “tumor,” are used interchangeably and in either the singular or plural form, refer to cells that have undergone a malignant transformation that makes them pathological to the host organism. Primary cancer cells (that is, cells obtained from near the site of malignant transformation) can be readily distinguished from non-cancerous cells by well-established techniques, particularly histological examination. The definition of a cancer cell, as used herein, includes not only a primary cancer cell, but any cell derived from a cancer cell ancestor. This includes metastasized cancer cells, and in vitro cultures and cell lines derived from cancer cells. When referring to a type of cancer that normally manifests as a solid tumor, a “clinically detectable” tumor is one that is detectable on the basis of tumor mass; e.g., by procedures such as CAT scan, MR imaging, X-ray, ultrasound or palpation, and/or which is detectable because of the expression of one or more cancer-specific antigens in a sample obtainable from a patient.
As used herein, a “composition” refers to the combination of an active agent (e.g., such as a therapeutic agent, nucleic acid vector) with a contrast agent. The composition additionally can comprise a pharmaceutically acceptable carrier or excipient and/or one or more accessory molecules which may be suitable for diagnostic or therapeutic use in vitro or in vivo. The term “pharmaceutically acceptable carrier” as used herein encompasses any of the standard pharmaceutical carriers, such as a phosphate buffered saline solution, water, and emulsions, such as an oil/water or water/oil emulsion, and various types of wetting agents. The compositions also can include stabilizers and preservatives. For examples of carriers, stabilizers and adjuvants, see Martin Remington's Pharm. Sci., 15th Ed. (Mack Publ. Co., Easton (1975)).
For a fuller understanding of the nature and desired objects of the present invention, reference is made to the following detailed description taken in conjunction with the accompanying drawing figures wherein like reference character denote corresponding parts throughout the several views and wherein:
FIG. 36A,B are graphical views of histograms of angular errors for a active tracking method from A. Krieger, R. C. Susil, C. Menard, J. A. Coleman, G. Fichtinger, E. Atalar, and L. L. Whitcomb. Design of a novel MRO compatible manipulator for image guided prostate interventions. IEEE Transactions on Biomedical Engineering., 52(2):306-313, February 2005 (
Referring now to the various figures of the drawings wherein like reference characters refer to like parts, there is shown in
The illustrative positioning apparatus 400 includes a slide member 410, a sliding mount 402 and a support arm 404. The slide member 410 is affixed or secured to the table, bed or platform of the scanner or imaging apparatus. The support arm 404, which in an exemplary embodiment comprises a snake mount, is secured to the sliding mount 402 and to the interventional device positioning stage 200. The sliding mount 402 is slidably disposed or mounted upon the slide member and is configured with a locking mechanism that allows the slide mount to be selectively locked to and unlocked from the slide member.
Such an interventional device 100 includes an end-effector 150, a positioning stage 200, an insertion stage 250 and actuation shafts 300a,b that are operably coupled to the positioning device and the insertion device. Although described in more detail hereinafter, in general terms; the end-effector 150 is introduced into a natural cavity in a subject (e.g., mammalian body), such as for example a rectum or uterus, or an artificial cavity formed in the body such as for example using laparoscopic type of procedures. The positioning stage 200 or the motion stage is operably coupled to the end-effector 150 and provides translation and/or rotation for the end-effector. The insertion stage 250 is operably coupled to the end-effector 150 so as to control the insertion of a medical device such as a needle into the tissues of the target site (e.g., target tissues) such as for example the prostate and its retraction therefrom. The actuation shafts 300a,b are operably coupled to the insertion stage 250 and the positioning stage 200 respectively in such a manner so as to allow for remote operation of the interventional device 100, more particularly the remote operation of each of the insertion stage 250 and the positioning stage 200, from a location that is outside the confines of the scanner/imaging device as well as being outside the field of view of the scanner/imaging device.
It should be recognized that while the interventional device 100 is illustrated with an in seriatim ordering of the end-effector 150, positioning stage 200 and the insertion stage 250, this shall not be considered a limitation on the present invention as it is within the skill of any of those knowledgeable in the art to arrange and configure the interventional device so the insertion stage is disposed between the positioning stage and the end-effector as well as arranging the insertion stage so as to be functionally in parallel with the positioning stage.
Referring now to
The sheath 152 is configured and arranged so as to form a relatively rigid member that minimizes deformation and displacement of the organ during positioning (i.e., during rotation or translation) of the needle carrier 154 and to maintain a generally stationary position with respect to the organ of interest/target tissues when the interventional device is in use (e.g., imaging tissue, inserting needle into tissue, etc.). In the illustrated embodiment, the sheath 152 is in a non-moving relation with respect to the positioning stage 200. In other embodiments, as described hereinafter, the sheath is arranged so as to be moveable with respect to the positioning stage 200 (e.g., rotated with respect to the positioning stage and about a long axis of the sheath).
The sheath 152 also is configured so as to include a small window or through aperture 162, which through aperture extends partially about the circumference of the sheath and partially axially along the length of the sheath. In particular exemplary embodiments, the through aperture 162 is located in a portion of the sheath proximal a distal end of the sheath that is inserted into the natural or artificial body cavity. In another embodiment, the through aperture 162 or window is formed in an end surface of the sheath 152.
It also is within the scope of the present invention, and yet another embodiment, for the sheath to be configured and arranged without a through aperture or window. In this embodiment, an area or region of the sheath 152 is designated as an area (hereinafter penetration area) in which the needle 350 penetrates through or pierces a wall (e.g. a side or end wall) of the sheath 152 as the needle is deployed from the carrier member through the exit port 175 to the target site. In further embodiments, the sheath 152, more particularly the penetration area of the sheath, is configured and arranged to facilitate such penetration or piercing by the needle 350. For example, the wall thickness of the sheath 152 in the penetration area is reduced, thereby reducing the force required to be developed for penetration or piercing.
The window or through aperture 162 or the penetration area is configured and sized so as to accommodate a predetermined amount of rotation and translation movement by the needle carrier 154 to locally adjust the exit port 175 for the needle 350 exiting the end-effector 150 with respect to the target site in the target tissues. In the case where the interventional device includes a plurality of guide channels 174a,b, the window or through aperture 162 or the penetration area is configured and sized so as to accommodate a predetermined amount of rotation and translation movement by the needle carrier 154 to locally adjust the exit ports 175a,b for the needle 350 exiting the end-effector 150 with respect to the target site in the target tissues. This provides a mechanism for fine-tuning the location of the needle carrier exit port 175 with respect to the target site without requiring the re-positioning of the sheath 152 in the natural or artificial body cavity. As described herein, the needle 350 exits from the exit port 175 of the needle carrier 154 and passes through the through aperture 162 and thence through the tissues until the end of the needle is positioned at the target site. In the case where the sheath is rotatable with respect to the positioning stage 200 as described herein, the configuration and size of the window or through aperture 162 or the penetration area can be reduced in comparison to that described above when the sheath is in fixed relation to the positioning stage 200.
In a further embodiment, the sheath further includes a second window or through aperture 163 in which is received an extension member 172 for one of the tracking coils 170c. The second window or through aperture 163 is configured and sized so as to accommodate a predetermined amount of rotation and translation movement by the needle carrier 154 so that the rotational or translational motion of the extension member 172 does not cause the extension member to come into contact with the sides of the second through aperture 163.
Disposed in the sheath 152 and about the perimeter of the first through aperture 162 is an MRI imaging loop antenna 164 that produces real-time anatomic images stationary with respect to the subject anatomy. The MR imaging loop antenna 164 or coil antenna is so arranged such that the volume of tissue that can be imaged by this antenna includes the possible target sites of the needle when it is deployed from the needle carrier 154 into the target tissues. The MRI imaging antenna 164 is sized and otherwise configured as is known by those skilled in the MR arts so that the antenna can image the desired depth that includes the amount the needle can be deployed within the target tissues and with a desired SNR.
The needle guide or carrier 154 is configured and arranged so as to include therein a guide channel 174 that generally extends lengthwise or longitudinally from a proximal end of the needle carrier 154 to the needle exit port 175. In an exemplary embodiment, the guide channel is 174 is sized and configured so as to movable receive therein a flexible standard MRI-compatible 18 G biopsy needle. The guide channel 174 can be formed in the structure comprising the needle carrier 154, be a tubular member disposed, mounted/affixed or secured within the needle carrier (e.g., a plastic or Teflon tubular member) or be formed of a combination of such structure and tubular members.
In a preferred embodiment, the needle exit port 175 is positioned in a side surface of the needle carrier 154, although other positions and orientations of the needle exit port 175 are contemplated for use with the present invention, including a needle exit port that is positioned in an end surface of the needle carrier. In this way, the needle 350 generally passes axially through the end-effector 152 via the channel 174 but is re-directed by portions of the channel such that the needle exits through a surface of the needle carrier 154, including a side or end surface thereof, to enter the tissues or the body, for example through the rectum wall when the target tissues are those of the prostate. Consequently, the configuration of the end-effector of the present invention allows the needle exit port 175 to be relatively easily positioned at an ideal location with respect to the target tissues in particular when compared or contrasted with the procedures or techniques followed for conventional devices such as end-shot type of devices. Also, the configuration and methodology of the present invention provides a mechanism by which the needle can be successively steered or directed to a same tissue target location which as indicated herein cannot be readily accomplished with conventional devices or techniques particularly those that use manual manipulation.
In more particular embodiments, the guide channel 174 includes arcuate portions, in particular, the portion of the guide channel 174 that intersects with a wall (e.g., sidewall) of the needle carrier 154 and the needle exit port 175 forms a circular arc. The needle 350 exits the channel 174 via the exit port 175 and follows a straight trajectory tangential to the arc at the point of exit. As also indicated herein, the needle can be rotated as it is being translated through the channel and exiting through the exit port. As explained herein, the angle formed between the needle and the wall (e.g., side or end wall) of the needle carrier is determined using a calibration procedure/methodology according to the present invention.
Referring now particularly to
In more particular embodiments, the plurality of guide channels 174a,B are arranged in the needle carrier 154a, so that the exit ports for each of the guide channels are displaced from each other along with respect to one, two or three dimensions or directions so that the needle(s) exiting the needle carrier can reach different parts of the tissue (e.g., different parts of the prostrate). In an illustrative embodiment, the portions of the guide channels 174a,b proximal the respective exit port are located in a single plane and so that they are at different angles with respect to a long axis of the needle carrier 154a, for example to form a 20 degree guide channel portion and a 30 degree guide channel portion. This shall not be considered limiting as the needle carrier can be configured with three or more guide channel, for example, three guide channels having 20, 27.5 and 35 degree channel portions respectively.
As also illustrated in
In yet another alternative embodiment, and as discussed hereinafter, the portion of the guide channel 174 proximal the exit port 175 is configured and arranged so as to be flexible and moveable in at last one direction and more particularly in three directions such that the guide channel intersects different locations at least longitudinally and more particularly, angularly and/or longitudinally along the surface of the needle carrier 154. For example, this portion of the guide channel 174 can be in the form of a flexible tubular member. Also, any of a number of mechanisms known to those skilled in the art is operably coupled to the flexible portion to allow the exit port 175 to be selectively repositioned via manual action or via a remote located device.
In further embodiments, the flexible portion of the guide channel 174 and the mechanism that is operably coupled to the flexible portion are configured and arranged so as to control and adjust the exit angle of the needle 350 with respect to a wall or axis of the needle carrier 154. In this way, the needle 350 can be steered or directed to different target areas without repositioning the exit port 175 or without re-positioning of the needle carrier.
In an illustrative exemplary embodiment, the needle carrier 154 is comprised of two halves that are pinned or otherwise secured together. One half section of the exemplary needle carrier 154 is configured and arranged so as to carry the three registration coils 170a-c that comprise active fiducials, providing the spatial position of the probe in the MRI coordinate system. In this embodiment, two coils 170a,b are positioned along the main axes of the needle carrier 154 and the third coil 170c is positioned at a certain offset of the axes so as to allow registering the rotation of the probe. Reference also shall be made to U.S. Pat. Nos. 5,271,400; 6,470,204 and 6,492,814 the teachings of which are incorporated herein by reference for details as to such MRI active tracking coils. The other half section of the exemplary needle carrier 154 is configured so as to include the guide channel 174 for guiding the needle 350 to the exit port 175.
In more particular embodiments, one or more of the sections of the needle carrier 154 is configured and arranged so as to include one or more passive fiducial channels 171. A material that is appropriate for passively visualizing using a given imaging technique is disposed in the passive fiducial channels 171 or secured in an appropriate fashion to and/or within the carrier guide 154. For example, in the case of imaging techniques embodying MRI techniques, a material comprising an MRI contrast agent such as gadolinium is disposed in the fiducial channel 171. This shall not be limiting as any of a number different kinds and types of passive fiducials can be located in the fiducial channel that is appropriate for the external imaging technique being used to image the tissues and ate least the end-effector 150 of the interventional device 100 including that described further herein.
In further embodiments, the interventional device 100 further includes a mechanism that is operably coupled to the needle, or to each needle when the interventional device is configured with a plurality of guide channels 174a,b, so as to rotate the needle about the long axis thereof; more particularly rotating about the long axis as the needle is being deployed from the needle carrier 154 to the tissues. Trials have revealed that a needle 350 can be passed though significantly bigger curvatures (e.g., smaller radii of curvatures) by rotating the needle as it passes through a channel 174 with such curvatures while inserting it into the tissues. This rotating insertion distributes elastic deformation equally along a helical path in the needle, resulting in a straight trajectory for the needle. In other words, as the needle is advanced through a needle passage, such as the carrier member channel 174, with simultaneous rotation and translation, the needle will emerge from the passage straight (i.e., with negligible curvature). In the case where the needle 350 is only being translated (i.e., without rotation) through a passage having a small radius of curvature; as the needle passes through the needle passage inelastic bending deformation occurs resulting in the needle emerging from the passage with a repeatable curvature and thus following a non-linear trajectory. Alternatively, such significant curvatures can be used to direct the needle 350 as it exits the needle exit port 175 in a non-linear fashion to a target site.
The sheath 152 and needle carrier 154 are each constructed of any of a number of materials known to those skilled in the art that are bio-compatible, appropriate for the intended use and are appropriate for use with the particular imaging technique being utilized for imaging the target tissues. In more particular embodiments, the materials of the sheath 152 and needle carrier 154 are selected so as to minimize the creation of unwanted image artifacts by these components. In exemplary embodiments, the end-effector 150 including the sheath 152 and needle carrier 154 are manufactured from any of a number of biocompatible plastic materials having sufficient strength and rigidity characteristics for the intended use. The MRI loop 164 antenna and the tracking coils 170a-c are made from copper wire or other acceptable material and the needle 350 is made of a material that preferably is non-magnetic and resilient.
Referring now to
Two concentric shafts 300b are operably coupled to the positioning stage 200 so as to transform rotation of one or more of these shafts into translation and/or rotation of the main shaft 202. In one embodiment, the concentric shafts 300b are manually actuated from outside the gantry of the imaging scanner. In another embodiment, the concentric shafts 300b are coupled to any of a number of drive mechanisms or motors, electrical or hydraulic, as is known to those skilled in the art for remote, selective, and controlled rotation of the concentric shafts.
In exemplary embodiments, the concentric shafts 300b are coupled so as to act over a gear reduction 203a,b to turn two separate nuts 206, 210 that are engaged with the main shaft 202. The rotation nut 206 connects to the main shaft 202 through two splines 208 that run in a linear groove of the shaft, providing the rotation of the main shaft. The translation nut 210 is a threaded nut that engages threads of the main shaft 202. Thus, rotation of the translation nut 210 thereby provides the translation of the main shaft 202.
The positioning stage 200 also includes a housing 212 that in an illustrated embodiment includes a block and two lids. The housing 212 rotatably supports the main shaft 202 and also restricts the rotation and translation nuts 206, 210 from translating which as is known to those skilled in the art causes the main shaft to translate and/or rotate responsive to rotation of the respective nut(s). The housing block also includes an attachment member that is secured to a universal mount such as that illustrated above in
In one embodiment, the positioning stage 200 and the components thereof are constructed of any of a number of materials known to those skilled in the art that are appropriate for use with the particular imaging technique being utilized for imaging the tissues as well as being appropriate for the intended use. In more particular embodiments, the materials are selected so as to minimize the creation of unwanted image artifacts by these components. In exemplary embodiments, the materials include any of a number of plastics known to those in the art that are appropriate for the intended use (e.g., having sufficient strength and rigidity characteristics for the intended use).
In as much as the interventional device 100 is typically arranged so that the positioning stage 200 is not in the field of view of the medical imaging apparatus; or is at least outside the first zone of the MRI imaging device, it is within the scope of the present invention that in alternative embodiments other materials, for example non-magnetic materials such as aluminum, brass, titanium and the like to be used for one or more of the components comprising the positioning stage. For example, the meshing gears comprising the gear reduction or the rotational or translation nuts can be made of such non-magnetic materials thereby allowing part sizes to be reduced because of the strength characteristics of such materials as compared to typical medical grade plastics.
Referring now to
The knob turns a lead screw 252 that engages a thread in a block 254 of the insertion stage 250. The coupling transfers movement of the screw into the cartridge 260, which runs in a pocket of the block and carries the biopsy gun 262. Switching between a round cartridge 260a (
In other embodiments, the insertion stage is configured and arranged so as to allow access to the proximal end of the needle 350 that is located outside of the subject. In use, the user can insert any of a number of medical devices, therapeutic mediums or compositions, imaging devices and the like through the lumen of the needle 350 and into the target site of the target tissues. For example, a loopless MRI imaging antenna can be passed along the length of the needle so as to more directly image the tissues at or about the target site.
Markers or seeds can be passed though the needle lumen and deposited within the tissues at or about a target site to facilitate localization of the tissues within target site. Thus, and for example, medical personnel can use such markers or seeds to provide a more accurately identified location for therapeutic treatment for example by a beam therapy technique. Such seeds or markers themselves also can comprise a source of radiotherapy as well as devices that provide long-term and controlled release of therapeutic compounds of chemotherapeutic agents to the tissues. The foregoing is illustrative of a few medical techniques and procedures that can be used in combination with the interventional device 100 of the present invention so as to provide diagnostic and/or therapeutic treatment.
Because such materials, agents and medical devices are introduced outside the field of view of the imaging apparatus, the medical personnel need not have significant access to the bore of the main magnet. Also, because the medical devices and the like are not present within the field of view while imaging the tissues before treatment the medical devices and the like do not present a concern with the generation of a problematic image artifact. Finally, the medical device and the like can be configured and arranged so that it can be imaged using the desired imaging technique (e.g., MRI) after the medical device or the like have been inserted or localized to the target site of the target tissues.
In the case where therapeutic agents are to be administered to the tissues or cells at or about the target site, the insertion stage 200 can include a syringe, a syringe pump or other mechanism or device known to those skilled in that art that is fluidly coupled to the proximal end of the needle 350. In use, the therapeutic medium or other fluid is thereby injected through the needle lumen 350 by such syringe, syringe pump or other such mechanism or device.
In one embodiment of the present invention, the insertion stage 250, more particularly the components thereof except the push-pull plunger 263 are made from a material that is appropriate for the imaging process and for not creating image artifacts. In an exemplary embodiment, when MRI comprises the imaging technique, the insertion stage 250 including the constituents thereof except for the push-pull plunger, and the medical devices, delivery devices and the like coupled to the proximal end of the needle, are made from plastics. In an illustrative embodiment, the push-pull plunger is made from aluminum or other non-magnetic materials when MRI is the imaging technique. The push-pull plunger 263 is located sufficiently far from the field of view of the imaging apparatus so as to not cause a measurable signal distortion. In as much as the interventional device 100 is typically arranged so that the insertion stage 250 is not in the field of view of the medical imaging apparatus; it is within the scope of the present invention for other materials, for example non-magnetic materials such as aluminum, brass, titanium and the like to be used for one or more of the components comprising the insertion stage.
Referring now to
The interventional device 500 includes an end-effector 520, a positioning stage 550 and an insertion device 250, where reference shall be made to the above discussion regarding
The positioning stage 550 of this embodiment includes two flexible shafts 570a,b that have actuation elements (e.g., knobs, motors, and the like) that are located remote from the field of view of the imaging apparatus. The flexible shaft 570a for controlling translation motion of the needle carrier is coupled to a nut 572 via gear reduction 574 such that rotation of the flexible shaft in turn causes the nut to rotate over a gear reduction 574. The nut 572 is threaded and threadably engages the main shaft 552, which is threaded. Thus, as the nut 572 rotates, such rotation drives the main shaft in a translational motion.
The other flexible shaft 570b is connected to a small gear 575, which engages an internal gear 576. The internal gear 576 is held stationary by the housing of the positioning stage 550. Consequently, rotation of the small gear 575 causes the entire inner assembly including the actuation shafts 570a,b and the main shaft 552 to rotate.
In the foregoing discussion, the mechanisms and methods described for tracking the rotational and/or translational movement of the needle carrier uses an external imaging apparatus for locating the tracking devices. It is within the scope of the present invention for an interventional device according to the present invention to embody any of a number of positional tracking devices, apparatuses, systems and methods as is known to those skilled in the art. In an exemplary embodiment, and with reference to
In the illustrated embodiment, a positioning encoder 577 is positioned or mounted to the housing 555 of the positioning stage proximal the nut 572 that causes translation motion of the main shaft 552. The positioning encoder is configured and arranged so as to measure the rotation of the translation nut 572, and thus provide an output signal representative of the translation of main shaft 552. In an exemplary embodiment the positioning encoder is an optical encoder or a potentiometer. In this way, the amount of rotation of the translation nut 572 can be equated to amount of translation of the main shaft 552 and thus an amount of translation of the carrier member 154. The positioning encoder 577 or encoder device is operably coupled via a cable 579 to instrumentation and/or devices positioned external to the field of view of the imaging apparatus that provide a remote indication to the user of the amount of translation.
Similarly, a positioning encoder or other position determining device can be placed within the positioning stage housing 555 and appropriately positioned so as to measure the rotation of the main shaft 552. Further, the needle 350 can be configured so as to include a mechanism, for example a code strip affixed to the needle that could be used in conjunction with an encoding or position determining device to determine an amount of translation of the needle and thereby an amount of insertion of the needle into the tissues. Reference also should be made to the discussion hereinafter describing embodiments and/or aspects of other interventional device of the present invention configured with a rotating sheath. As also described hereinafter, in other aspects of the present invention the interventional device can embody a hybrid tracking methodology. As such, it is within the scope of the present invention for any of the interventional devices described herein to be adapted so as to embody any of the tracking methodologies and systems/devices described herein.
Reference also should be made to the foregoing discussion as to
In the interventional devices 100, 500 hereinabove described, after insertion of the end-effector into the subject, the target tissues are imaged using an MRI imaging loop antenna or coil 164. Referring now to
The end-effector 700 includes a sheath 702 and a medical device or needle carrier 704 that is disposed within an interior compartment 730 of the sheath. Also, the device/needle carrier 704 is disposed within the sheath interior compartment 730 so as to be rotatable and/or translatable along the long axis therein. In an exemplary embodiment, the device/needle carrier 704 is a substantially cylindrical member. In the following discussion the device/needle carrier 704 is referred to as the needle carrier for simplicity, however, this shall not be construed as narrowing the scope of the present invention to this specific example.
The sheath 702 is configured and arranged so as to form a relatively rigid member that minimizes the deformation and displacement of the organ during positioning (i.e., during rotation or translation) of the needle carrier 704 probe and to maintain a generally stationary position with respect to the organ of interest/target tissues. The sheath 702 also is configured so as to include a small window or through aperture 710, which through aperture extends partially about the circumference of the sheath and partially axially along the lengthwise of the sheath. In particular exemplary embodiments, the through aperture 710 is located in a portion of the sheath proximal a distal end of the sheath that is inserted into the natural or artificial body cavity. As also indicated herein, in further embodiments, the sheath 702 can be configured and arranged so as to include a penetration area or penetration region instead of the through aperture 710.
The window or through aperture 710 or the penetration area is configured and sized so as to accommodate a predetermined amount of rotation and translation movement by the needle carrier 704 to locally adjust the exit port 725 entrance site for the needle 350 exiting the end-effector 700 with respect to the target site in to the target tissues. This provides a mechanism for fine tuning the location of the needle carrier exit port 725 with respect to the target site without requiring the re-positioning of the sheath 702 in the natural or artificial body cavity. As described herein, the needle 350 exits from the exit port 725 of the needle carrier 704 and passes through the through aperture 710 and thence through the tissues until the end of the needle is positioned at the target site.
The needle guide or carrier 154 is configured and arranged so as to include therein a guide channel 724 that generally extends lengthwise or longitudinally from a proximal end of the needle carrier 704 to the needle exit port 725. In an exemplary embodiment, the guide channel is 724 is sized and configured so as to movable receive therein a flexible standard needle. The guide channel 724 can be formed in the structure comprising the needle carrier 704, be a tubular member disposed, mounted/affixed or secured within the needle carrier (e.g., a plastic or Teflon tubular member) or be formed of a combination of such structure and tubular members.
In a preferred embodiment, the needle exit port 725 is positioned in a side surface of the needle carrier 704, although other positions and orientations of the needle exit port 725 are contemplated for use with the present invention, including a needle exit port positioned in an end surface of the needle carrier 704. The needle 350 generally passes axially through the end-effector 700 via the channel 724 but is re-directed by portions of the channel such that the needle exits through a surface, a side or end surface, of the needle carrier 704 to and finally enters the tissues or the body, for example through the rectum wall when the target tissues are those of the prostate. Consequently, the configuration of the end-effector 700 of the present invention allows the needle exit port 725 to be relatively easily positioned at an ideal location with respect to the target tissues in particular when compared or contrasted with the procedures or techniques followed for conventional devices such as end-shot type of devices. Also, the configuration and methodology of the present invention provides a mechanism by which the needle can be successively steered or directed to a same tissue target location which as indicated herein cannot be readily accomplished with conventional devices or techniques particularly those that use manual manipulation.
In more particular embodiments, the guide channel 724 includes arcuate portions, in particular, the portion of the guide channel 724 that intersects with the sidewall of the needle carrier 704 and the needle exit port 725 forms a circular arc. The needle 350 exits the channel 724 via the exit port 725 and follows a straight trajectory tangential to the arc at the point of exit. As also indicated herein, the needle 350 can be rotated concurrent with translation through the channel. As explained herein, after assembly of the needle carrier, the angle formed between the needle and sidewall of the needle carrier is determined using a calibration procedure/methodology according to the present invention. As indicated herein, it also is contemplated and thus within the scope of this embodiment, for the end-effector 700 to be arranged so as include a plurality of guide channels.
In an alternative embodiment, the portion of the guide channel 724 proximal the exit port 725 is configured and arranged so as to be flexible and moveable in at last one direction and more particularly in three directions such that the guide channel intersects different locations at least longitudinally and more particularly, angularly and/or longitudinally along the side surface of the needle carrier 704. For example, this portion of the guide channel 724 can be in the form of a flexible tubular member. Also, any of a number of mechanisms known to those skilled in the art is operably coupled to the flexible portion to allow the exit port 725 to be selectively re-positioned via manual action or via a remote located device.
In further embodiments, the flexible portion of the guide channel 174 and the mechanism that is operably coupled to the flexible portion are configured and arranged so as to control and adjust the exit angle of the needle 350 with respect to a wall or axis of the needle carrier 154. In this way, the needle 350 can be steered or directed to different target areas without repositioning the exit port 175 or without re-positioning of the needle carrier.
The needle carrier 704 also is configured and arranged so as to include an ultrasound crystal 720 that is arranged so as to image a volume of tissues that includes the tissues of the target site and the tissues in which the needle would be disposed if deployed from the needle carrier in a given position. The ultrasound crystal is any of a number of ultrasound crystals known in the art and appropriate for the intended use, including those crystals and devices embodying crystals such as those used in connection with transrectal ultrasound guided needle biopsy and low permanent seed brachytherapy procedures.
The sheath 702 and needle carrier 704 are each constructed of any of a number of materials known to those skilled in the art that are bio-compatible, appropriate for the intended use and are appropriate for use with the particular imaging technique being utilized for imaging the target tissues. In more particular embodiments, the materials of the sheath 702 and needle carrier 704 are selected so as to minimize the creation of unwanted image artifacts by these components. In exemplary embodiments, the end-effector 700 including the sheath 702 and needle carrier 704 are manufactured from any of a number of a biocompatible plastic materials having sufficient strength and rigidity characteristics for the intended use.
Although the mechanism for imaging the tissues of the target site after an interventional device including an end-effector 700 according to this aspect of the present invention is ultrasound, it is within the scope of the present invention for other imaging techniques, including CT and MRI techniques to be used, to determine the initial position of the interventional device as well as any imaging occurring concurrent with and following post treatment or diagnostic procedures. As such, it is within the scope of the present invention for the needle carrier 704 according to this aspect of the present invention to include passive and/or active fiducials to assist such other imaging systems in imaging and determining the location of the end-effector within the subject or body.
Referring now to
The positioning stage 820 or the motion stage is operably coupled to the end-effector 850 and provides translation and/or rotation for the end-effector. As described hereinabove, the insertion stage is operably coupled to an inner member 854 so as to control the insertion of a medical device such as a needle into the tissues of the target site (e.g., target tissues) such as for example the prostate and its retraction therefrom. Reference shall be made to the foregoing discussion for
The end-effector 850 includes a sheath 852 and an inner member 854 that is disposed within an interior compartment of the sheath. Also, the inner member 854 is disposed within the sheath interior compartment so as to be rotatable and/or translatable along the long axis therein. In an exemplary embodiment, the inner member 154 is a substantially cylindrical member (e.g., rod like).
The sheath 852 is configured so as to be generally cylindrical in shape. The sheath also is moveably connected to the positioning stage 820 so the sheath is rotatable with respect to or about a long axis of the sheath. In interventional devices described above for
As indicated above, the sheath 852 is moveable coupled or connected to the positioning stage 820, more particularly, the sheath is operably coupled to a drive mechanism 822 so that movement of the drive mechanism causes the sheath 852 to rotate as described herein. In particular embodiments, the drive mechanism 822 is a drive wheel or knob, where rotation of the drive wheel causes the sheath to rotate. In further embodiments, the positioning stage 820 includes a positioning encoder 824 that is operably coupled to the drive mechanism 822 or the sheath 852 so that a signal is outputted from the positioning encoder that is representative of the rotational movement of the sheath. Such an positioning encoder 824 is an of a number of such devices known to those skilled in the art and includes electrical, optical, electro-optical or mechanical position encoders.
The inner member 854 is moveable coupled or connected to the insertion stage 840, more particularly, the inner member is operably coupled to a drive mechanism 844 so that movement of the drive mechanism causes the inner member to rotate within the sheath as described herein. In particular embodiments, the drive mechanism 842 is a drive wheel or knob, where rotation of the drive wheel causes the inner member 854 to rotate. In further embodiments, the insertion stage 840 includes a positioning encoder 844 that is operably coupled to the drive mechanism 842 or the inner member 854 so that a signal is outputted from the positioning encoder that is representative of the rotational movement of the sheath. Such an positioning encoder 844 is an of a number of such devices known to those skilled in the art and includes electrical, optical, electro-optical or mechanical position encoders.
In further embodiments/aspects the interventional device 800 is configured so as to include a needle channel 864 that can be steered or moved in one or more directions. Stated another way, the interventional device 800 includes a mechanism that moves the needle channel 864 so as to thereby cause the needle 350 to exit the inner member 854 at one of a number angles with respect to the long axis of the inner member (i.e., mechanism changes angle of portion of the needle channel proximal the exit port in either one plane or three dimensionally). In this way, instead of having a number of needle channels such as shown in
There also is shown in
It should be recognized that it is within the scope of the present invention for the above-described interventional device to be configured so as to include a plurality of needle channels as described above in connection with
The interventional device according to this aspect also is configured so as to include a plurality of fiducials 871a-d. In the illustrated embodiment, there are two passive fiducial marker tubes 871a,b incorporated into the main axis of the interventional device and two fiducial marker tubes 871c,d placed parallel to the needle channel. These fiducials 871a-d and the position encoders 824,844 are utilized in combination with a hybrid tracling methodology of the present invention as described hereinafter to determine the location of the imaging mechanism embodied in the end-effector as well as the location of the end-effector. It should be recognized, that is within the scope of the present invention to adapt the tracking method and functionalities (e.g., tracking coils) described above in connection with
Referring now to
The positioning stage 920 or the motion stage is operably coupled to the end-effector 950 and provides translation and/or rotation for the end-effector. As described herein, the insertion stage 940 is operably coupled to an inner member 954 so as to control the insertion of a medical device such as a needle into the tissues of the target site (e.g., target tissues) such as for example the prostate and its retraction therefrom. Reference shall be made to the foregoing discussion for
The end-effector 950 includes a sheath 952 and an inner member 954 that is disposed within an interior compartment of the sheath and is coupled to the sheath, for example coupled by a key 953. The inner member 954 is coupled or connected to the sheath 952 using any of a number of techniques known to those skilled in the art so that the inner member is rotated by the rotation of the sheath. In an illustrative embodiment, the inner member 854 is coupled to the sheath using a key structure 953 as is known to those skilled in the art. The inner member 954 also is disposed in the sheath interior compartment so as to be translatable along the long axis therein. In an exemplary embodiment, the inner member 954 is a substantially cylindrical member (e.g. rod like).
As with the sheath 854 described above, the sheath 952 according to this aspect is configured so as to be generally cylindrical in shape. The sheath also is moveably connected to the positioning stage 920 so the sheath is rotatable with respect to or about a long axis of the sheath. In more specific embodiments, the window or through aperture (e.g., cutout) for the sheath 952 is configured and arranged as a slot.
As indicated above, the sheath 852 is moveable coupled or connected to the positioning stage 920, more particularly, the sheath is operably coupled to a drive mechanism 922 so that movement of the drive mechanism causes the sheath 952 and thus also the inner member 954 to rotate as described herein. In particular embodiments, the drive mechanism 922 is a drive wheel or knob. In further embodiments, the positioning stage 920 includes a positioning encoder 924 that is operably coupled to the drive mechanism 922 or the sheath 952 so that a signal is outputted from the positioning encoder that is representative of the rotational movement of the sheath.
The inner member 954 is moveable coupled or connected to the insertion stage 940, more particularly, the inner member is operably coupled to a drive mechanism 944 so that movement of the drive mechanism causes the inner member to translate within the sheath as described herein. In particular embodiments, the drive mechanism 942 is a drive wheel or knob. In further embodiments, the insertion stage 940 includes a positioning encoder 944 that is operably coupled to the drive mechanism 942 or the inner member 954 so that a signal is outputted from the positioning encoder that is representative of the rotational movement of the sheath.
In further embodiments/aspects the interventional device 900 is configured so as to include a needle channel 964 that can be steered or moved in one direction. Stated another way, the interventional device 900 includes a mechanism that moves the needle channel 964 so as to thereby cause the needle 350 to exit the inner member 954 at one of a number angles with respect to the long axis of the inner member (i.e., mechanism changes angle of portion of the needle channel proximal the exit port in a plane. In this way, instead of having a number of needle channels such as shown in
There also is shown in
It should be recognized that it is within the scope of the present invention for the above-described interventional device to be configured so as to include a plurality of needle channels as described above in connection with
The interventional device according to this aspect includes a plurality of fiducials 871a-d as described above in connection with
Referring now to
In an embodiment, after the sheath 992 is inserted into the body opening (e.g. in the rectum of the patient), the geometry of the sheath in effect is changed by the stabilizing mechanism 996 so as to thereafter stabilize the prostate during insertion of needles. In particular embodiments, the stabilizing mechanism 996 includes an inflatable balloon disposed about at least a significant portion of the sheath 992 and which acts like a cradle for the prostate. In this embodiment, the inflatable balloon includes an opening therein so that needles can be inserted into the prostate through the inner, open part of the balloon.
In further embodiments, the MR imaging coil 164 is incorporated into the inflatable balloon. As the signal to noise ratio depends on the diameter of the imaging coil, an imaging coil in the inflated balloon provides an improved signal level over a rigid imaging coil design. In yet further embodiments, such an MRI imaging coil is arranged so as to expand outwardly responsive to inflation of the balloon so that the imaging coil is capable of imaging a larger volume than when it is affixed directly to the sheath.
The balloon is selectively interconnected to one of a fluid source and a fluid discharge via interconnecting tubing and valves (not shown). In use, the balloon is fluidly coupled to the fluid source when the balloon is to be inflated and fluidly coupled to the fluid discharge when the balloon is top be deflated. It also is contemplated that the stabilizing mechanism can embody an actuatable mechanism (e.g., spring loaded mechanism) that is configured and arranged so that when the actuatable mechanism is actuated it causes the stabilizing mechanism to be deployed to contact the tissue.
In yet further embodiments, the stabilizing mechanism 996 comprises a foam layer that is affixed to the sheath. This foam layer applies additional pressure to the rectal wall to reduce motion of the prostate.
Referring now to
The positioning system 1200 of the present invention provides a flexible initial positioning of the interventional device 900 and a safe and rigid attachment for this to the support-board 1202. The positioning securing procedure has two steps. The first step comprises a manually coarse positioning of the whole system concurrently with the insertion of the end effector 950 into the patient rectum. At the end of this phase the linear slide 1210 is locked with a locking mechanism as is known to those skilled in the art. The second step comprises a manually fine adjustment of the probe position inside of the patient rectum. After that the arm 1220 is locked with a locking mechanism as described further herein. This procedure is MRI-compatible and provides six degree of freedom (DOF) in a limited range of motion, to have a locking mechanism for all DOF, safe, easy, and fast, to be rigid enough to avoid the breaks and/or the extra large elastic deflections.
The arm 1220 includes three links or segments, a base segment, 1230, an intermediate segment 1232, and a top segment 1234. The base and intermediate segments are connected through a spherical joint 1240 and the top and intermediate segments are connected through another spherical joint 1242. Also, the base segment 1230 is operably coupled (e.g., attached) to the slide 1210 and the top segment is operably coupled (e.g., attached) to the interventional device 900. In an illustrative embodiment, the spherical joints are ball-socket type of spherical joints. Because the spherical joints 1240, 1242, individually provide 3DOF (i.e., 3 rotations), the top segment 1234 has 6 DOF (3 translations and 3 rotations) relatively to the base segment 1230. The motion range for each DOF depends on segments constructive shape and dimensions.
The locking mechanism 1260 includes pressure plates 1262a,b, a screw 1264, prism blocks 1266, pins 1268, and a handle 1270 including a handle nut 1272. In more particular embodiments, the locking mechanism 1260 is arranged so as to simultaneously eliminate the play in the spherical joints 1240, 1242 and to generate a pressure between each ball and its socket of a spherical joint that will generate a friction force (torque) greater than the active force (torque) applied on the segments.
By tightening the helical joint comprising the screw 1264 and handle-nut 1272 an axial force is created that in effect presses the pressure plates 1262a,b against each other. As the pins 1268 and the prism blocks 1266 are located between the pressure plates 1262a-b, the force is transmitted in a perpendicular direction, through the rods 1280 of the intermediate section 1232, to the sockets and thus developing the necessary pressure in the contact with the balls. The reactive forces work through the case and fixed sockets.
Such an arm 1220 of the positioning system 1200 makes it possible to mount the interventional device 900 in any of a prone, supine or decubitus positions. Also, the mounting allows the interventional device 900 to be oriented in arbitrary angle along the scanner's long axis, according to the clinician's preference. As is known to those skilled in the art, the prone, supine and decubitus position have their own clinical merits in the different clinical applications.
The following describes another tracking methodology according to the present invention that uses a combination of passive tacking and encoder tracking, and thus forms a hybrid tracking methodology. In this hybrid methodology, an initial position of the interventional device in scanner coordinates is obtained by segmenting fiducial markers 871a-d (
In illustrative embodiments and with reference to
In order to achieve easy segmentation of the markers, the sagittal images are reformatted using the scanner software as axial images along the main axis of the device and along the needle axis of the device. As shown in
When the fiducial markers are tubular, the tubular markers appear as circles on the reformatted axial images as illustrated in
Motion of the interventional device along its degrees of freedom is encoded with use of the position encoders 842, 844, which as indicated herein can be any of a number of devices or encoders known to those skilled in the art including electrical, optical, opto-electrical or mechanical encoders. The three degrees of freedom to reach a target are rotation of the device, change of the needle angle and insertion of the needle. Each of these degrees of freedom is encoded separately by the respective positioning encoder 822,844. In the illustrated embodiment, two rotational positioning encoders 822,824 are used to encode rotation and change in needle angle while the needle insertion depth is read manually using the scale on the needle. It is within the scope of the present invention for the interventional device to further include a translational positioning encoder to provide a signal of the translational movement of the needle as it is being inserted. It also is within the scope of the present invention to include manual or mechanical encoders for the rotation and needle angle so as to thereby provide a redundant encoding system.
Signal Intensity Correction with Tracking
As is known to those skilled in the art, the intensity of the signal detectable by an MRI antenna or coil varies as a function of the distance from the coil or antenna because of signal losses. Thus, the contrast between light and dark regions can be misleading because of the variation in the intensity of the signal being detected. As is known to those skilled in the art, the spatial distribution of the signal strength detected by the coil can be calculated or experimentally determined in advance of its use and thus algorithms can be developed for a given coil or antenna to correct for this variation in signal. These algorithms, however, are based on the assumption that the coil or antenna and/or the subject being imaged will not move or be moved during the acquisition of image data. If such movement occurs then there is no way to correct for signal intensity variations in the new spatial arrangement or location.
As the present invention continuously monitors and knows the location of the imaging coil, the present invention also features a methodology for correcting signal intensity using tracking. In the present invention, the location of the interventional device is tracked during the interventional procedure and so the position of the imaging coil 164, placed on the sheath 852 also is easily determined. In other words, if the imaging coil 164 is moved with respect to the tissue, the tracking methodology of the present invention provides a mechanism by which the new spatial location of the imaging coil in the Cartesian coordinates of the scanner can be determined. Thus, using the known field distribution of the imaging coil and the determined spatial location of the imaging coil, an image intensity correction scheme is run for all acquired images, resulting in a homogenous signal intensity distribution (e.g. a correction is made to the as-is signal intensity to produce a uniform image). Thus, by using the tracking information, the signal intensity correcting methodology of the present invention can correct signal intensity on the fly even when the imaging coil is moved to a new location.
The use of the interventional devices 100, 500, 800, 900 of the present invention as well as related systems, apparatuses and methods can be best understood from the following discussion along with
A system 1000 according to the present invention is shown in
In order to achieve an initial position, the adjustable mounting mechanism is unlocked. The subject or patient is positioned comfortably on the platform, bed, table or couch of the scanner or imaging apparatus in a prone, supine or decubitus body position (supine body position with the pelvis slightly elevated is illustrated). The interventional device 100, 500, 800, 900 is adjusted so its end piece, the end-effector 150, 525, 850, 950 is aligned with the rectum. The end-effector 150, 525, 850, 950 of the device is inserted into the rectum, in same way as transrectal ultrasound probes are used for brachytherapy implants. The end-effector sheath 152, 525, 850, 950 makes contact with the rectum, thus leaving the needle carrier 154 or inner member movable inside the sheath. The sheath prevents movement of the needle carrier 154 or the inner member 854 from causing mechanical distortion to the rectum wall and prostate. After a satisfactory initial position is achieved, the adjustable mount is secured to hold this position. Using the sliding table of the scanner, the patient and interventional device are moved into the bore of the scanner's magnet.
The MRI scanner produces signals with the subject or patient and device in the field, at the same time. Using signal processing tools, the spatial relationship between the interventional 100, 500, 800, 900 device and the coordinate system of the MRI scanner is determined as described herein. The MRI images are transferred onto a computer 1010 that produces three-dimensional graphical representation of the interventional device superimposed on anatomic images. The physician or medical personnel interacts with the display and selects the target point for the needle 350 (e.g., target point for the tip of the needle). The computer 1010 calculates the coordinate transformation to guide the end effector and the needle 350 from its current position to the selected target position. In other words, the computer 1010 determine how much to rotate and/or translate the end effector from its present position to a final position where the needle exit port 175 is at a location for deployment of the needle 350 and how much to insert the needle so the needle (e.g., the tip of the needle) will arrive at the three-dimensional coordinates corresponding to the target location.
It should be recognized that the interventional device of the present invention allows a surgeon or medical personnel to image the end effector using any one or a combination of active tracking mechanisms, passive fiducials and/or the positioning encoders as described herein during such rotation and translation to dynamically adjust for any changing conditions as well as to verify that the needle carrier has rotated and/or translated the desired amount before the needle is deployed or inserted into the tissues of the subject. In addition, the surgeon or medical personnel can image the tissue volume including the target tissue site to verify that the needle has been deployed to the intended target location. Consequently, the devices, systems and methods of the present invention, allow a surgeon or medical personnel to determine the parameters to control movement of the end-effector 150, 525, 850, 950 and needle 350 so as to reach a target site within a subject and to verify placement or deployment of the needle to the desired target site before a biopsy is taken or treatment is undertaken.
It should be recognized that the foregoing could not be readily accomplished using conventional procedures, techniques and devices. Such conventional techniques, devices and systems typically involve manual manipulation of an end-shooting type of device so that the end of the device is pointed at the volume of tissue including the target site. Because the needle and imaging device (e.g., ultrasound crystal) are at the end of the device, the surgeon or medical personnel have to push against the subject's rectum and/or anus in such a way so the body of the device is positioned within the rectum so the end is pointed in the desired direction. In other words, for conventional devices, systems and techniques, the body of the device being inserted into the rectum cannot be aligned with the rectum for insertion. In addition to creating the potential pain to the subject at least following the procedure, the process increases the risk of damage, trauma or insult to rectal tissues. In addition, because there is no practical way using conventional devices, methods and systems, to pre-determine and maintain direction or the position of the device end with respect to the target site, the user cannot determine precisely how much to move the device from a given location to a final position before a needle is inserted.
It is contemplated that the interventional device 100, 500, 800, 900, methods and systems of the present invention are to work with or embody computational image guidance techniques as described herein. For example, fiducial markers with known geometric distribution are incorporated with the end-effector 150, 525, 850, 950 preferably in a pre-established arrangement. Images are acquired with the interventional device and patient/subject together in the field of view of the scanner or imaging apparatus. The digital images are transferred from the scanner to the planning computer 1010 via local area network or other suitable connection. As described herein, using any one or a combination of active tracking coils, passive fiducials and/or position encoders, the planning computer 1010 calculates the location and orientation of the end-effector 150, 525, 850, 950 with respect to the imager. The operator/user selects the target within the prostate for example on the computer screen and the computer 1010 calculates the location of the target with respect to the imager. Using a priori geometric information of the end-effector 150, 525, 850, 950 the computer 1010 determines the spatial relationship between the current and the intended positions of the device.
The computer 1010 calculates three parameters for controlled motion: translation length for the end-effector 150, 525, 850,950 rotation angle for the end-effector, and insertion length for the needle 350. The program displays this information to the user, who can actuate the interventional device 100, 500, 800, 900 accordingly. The three stages of motion are kinematically decoupled in the interventional device and thus can be executed sequentially. This enables the user to acquire new image upon completing a phase of the motion and determine whether the sequence of motions was calculated and executed correctly. The above described image guidance mechanism is equally applicable with MRI, CT, X-ray, and ultrasound imaging.
There are described above two different techniques or methodologies for positional tracking of the end effector and/or needle; one technique involves a hybrid tracking technique involving the use of passive fiducials and position encoders and the other technique involves the use of a number of tracking coils. In the first technique, the interventional device embodies a number of passive fiducials in a preset geometric arrangement and includes position encoders to provide position information regarding rotational and translational movement of the end effector after initially establishing a position of the interventional device within the natural or artificial body opening.
As described herein, the initial position of the end effector and thus the components thereof, is first determined using MRI imaging data and the passive fiducials. Thereafter, the position encoders provide position data of the rotational and/or translational movement of the end effector within the body opening after establishing the initial position. As also described herein, using the scale on the medical device or another position encoder, the position of the inserted needle or medical device can be determined. Thus, the computer 1010 can compute the kinematic sequence for the individual motion stages: the length of translation of the end-effector inside the rectum, the degree of rotation of the end-effector inside the rectum, and the depth of insertion for the needle 350. The order of translation and rotation are interchangeable, but both are completed before the needle 350 is inserted into the tissues. Alternatively, these can be computed manually.
As to the other technique involving use of tracking coils, three imaging coils 170a-c are situated in the end-effector 150 of the interventional device 100. Each imaging coil winds around a small capsule containing gadolinium solvent, in order to provide a strong signal in the vicinity of the coil. Two coils 170a-b are located in the central axis of the end-effector 150, to encode translational motion of the interventional device, more particularly translational motion of the needle carrier 154. The third imaging coil 170c is located off central axis, in order to encode rotation around the central axis. As also indicated herein, the interventional device of the present invention can be configured so as to include one or more devices or sensors as is known to those skilled in the art that can determine translational and/or rotational motion of the carrier member without the use of an external imaging apparatus. Such a position determining sub-system can be used alone or in combination with the external imaging apparatus to ascertain an amount of rotational and/or translational motion of the carrier member.
Thus and in regard to this particular aspect of the invention, the computer 1010 computes the kinematic sequence for the individual motion stages, the length of translation of the end-effector inside the rectum, the degree of rotation of the end-effector inside the rectum, and the depth of insertion for the needle 350. The order of translation and rotation are interchangeable, but both are completed before the needle 350 is inserted into the tissues.
Referring now also to
There also is illustrated in
In further embodiments, the first technique also includes a calibration methodology to determine the signal center of each MRI registration coil with respect to the needle in the end-effector. This information is constant for the entire lifetime of the device, provided the same image acquisition and processing parameters are used during operation. As illustrated in
According to another embodiment, the methodology of the present invention includes using visual guidance to navigate an interventional device 100, 500, 800, 900 of the present invention. In this embodiment, the user or medical personnel observes real-time or near real-time image data from the scanner or imaging apparatus, visually identifies the needle in the image and its location with respect to a target site. The user, physician, medical personnel using hand-eye coordination, continually actuates and repositions the interventional device till the end-effector and needle reaches the intended position or target site. In this way, the user, physician, or medical personnel manually navigates the interventional device so the needle 350 is deployed to the target site. Consequently, a plurality or more of placements or deployments of the needle 350 may be required before satisfactory needle placement is achieved.
As described above, there are two different techniques or methodologies for positional tracking of the end effector and/or needle; one technique involves a hybrid tracking technique involving the use of passive fiducials and position encoders and the other technique involves the use of a number of tracking coils. In the case where the interventional device embodies the hybrid tracking methodology, the initial position data and the movement position data are sent to the treatment monitoring computer 1010. The computer 1010 processes the transmitted position data and the three parameters of motion (translation, rotation, insertion depth) are calculated/recalculated, enabling real-time dynamic control of the interventional device such as for example, by adjusting the actuation of motors or other manual or automatic actuation devices of the interventional device. It also is contemplated, and thus within the scope of the present invention, that when a surgeon points and clicks on a target in a computer screen, a robot controls the operation of the insertion stage so as to move the needle 350 and insert it into the target.
In the case where the interventional device embodies tracking coils, while the actuation of the interventional device is in progress, the MRI scanner 1020 collects position data and sends the position data immediately to the treatment monitoring computer 1010. The computer 1010 processes the image data and visualizes the current image, with the model of the interventional device superimposed in the scene, allowing the physician to monitor the motion of the interventional device and/or needle 350 thereof toward its target. The three parameters of motion (translation, rotation, insertion depth) are recalculated in each imaging cycle, enabling real-time dynamic control of the interventional device such as for example, by adjusting the actuation of motors or other actuation devices of the interventional device. It also is contemplated, and thus within the scope of the present invention, that when a surgeon points and clicks on a target in a computer screen, a robot controls the operation of the insertion stage 250 so as to move the needle 350 and inserts it into the target, under real-time imaging surveillance but without manual intervention.
In addition, to use of the interventional device 100, 500, 800, 900 of the present invention to take tissue biopsies, it also is contemplated that the scope of the methodologies and systems of the present invention includes delivery of therapeutic mediums, medical devices via the inserted needle and that such insertion can be performed one or more times and at different locations or target sites within a predetermined volume of tissues of the subject. In particular embodiments, it is contemplated that the placement of the needle 350 within the prostate or other tissues of the body (e.g., cervix or vagina) provides a mechanism by which a therapeutic medium (including but not limited to drugs, genes, viruses and photodynamic substances) or diagnostic agents (including but not limited to molecular imaging agents) can be delivered to a desired target site(s) using the inserted needle of the interventional device. It also is contemplated that the cannula or lumen formed by the inserted needle can be utilized to insert medical devices through the needle and so as to be localized to the target site(s) so as to perform one of brachytherapy, or tissue ablation (including thermal, cyro, ultrasonic, chemical ablation). Further, it also is contemplated that the interventional device and related systems and methods can be adapted for use with any of a number of medical imaging or scanning techniques including conventional X-ray, fluoroscopy, bi-planar fluoroscopy, CT X-ray, MRI, and ultrasonic imaging as well as any other techniques referred to herein.
As indicated above, the interventional devices and related systems, and apparatuses of the present invention are configured and arranged so as to administer/deliver a therapeutic medium to the target tissues of a target site. The therapeutic medium can comprise a therapeutic agent or a therapeutic agent in combination with a contrast agent to facilitate the imaging (e.g., M imaging) of the therapeutic agent. In the present invention, therapeutic agent shall be understood to encompass or include, but are not limited to drugs, genes, nucleic acid molecules including encoding different types of nucleic acid molecules, an angiogenic factor, a growth factor, a chemotherapeutic agent, a radionuclide, a protein, a polypetide, a peptide, a viral protein, a lipid, an amphiphile, a nuclease inhibitor, a polymer, a toxin, a cell, and modified forms and combinations thereof that are used in therapeutic procedures in connection with the injury, insult, trauma or ischemia to the tissues or cells of the target site that is accessed via a lumen or body cavity of the mammalian body, more particularly a human body, more specifically, the vascular system of a human body. In addition, the therapeutic agent can be in an encapsulated form for long term sustained delivery to the target tissues.
The nucleic acid molecule is preferably provided in a nucleic acid delivery vehicle which is lipid-based, viral-based, or cell-based. More preferably, the vector comprises a gene operably linked to an expression control sequence. In one aspect, the nucleic acid molecule comprises a sequence encoding a polypeptide for preventing, correcting and/or normalizing an abnormal physiological response, such as a disease. Exemplary polypeptides include, but are not limited to, hirudin, tissue plasminogen activator, an anchored urokinase activator, a tissue inhibitor of metalloproteinase, proliferating cell nuclear antigen, an angiogenic factor, a tumor suppressor, a suicide gene and a neurotransmitter. The vector may comprise sequences to facilitate its delivery to, or expression in, a target cell. For example, the vector may comprise a marker gene (e.g., encoding a fluorescent protein) and/or an origin of replication for a host cell and/or target cell.
In the case where the therapeutic medium is being delivered and the particular imaging technique is being performed to track and observe the efficacy of such delivery, the therapeutic medium is a therapeutic composition that includes a therapeutic agent as hereinabove described and a contrast agent appropriate for the particular imaging technique being utilized. In a particular embodiment, the imaging technique is any of a number of MR/NMR imaging techniques and thus the contrast agent is a magnetic resonance imaging contrast agent.
MRI contrast agents primarily act by affecting T1 or T2 relaxation of water protons. Most MRI contrast agents generally shorten T1 and/or T2. When contrast agents shorten T1, this increases signal intensity on T1 weighted images. When contrast agents shorten T2, this decreases signal intensity particularly on T2 weighted pulse sequences. Thus, preferably, contrast agents used in the invention have adequate nuclear or relaxation properties for imaging that are different from the corresponding properties of the cells/tissue being imaged. Suitable contrast agents include an imageable nucleus (such as 19F), radionuclides, diamagnetic, paramagnetic, ferromagnetic, superparamagnetic substances, and the like. In a preferred aspect, iron-based or gadolinium-based contrast agents are used, where Iron-based agents include iron oxides, ferric iron, ferric ammonium citrate and the like. Gadolinium based contrast agents include diethylenetriaminepentaacetic (gadolinium-DTPA). Manganese paramagnetic substances also can be used. Typical commercial MRI contrast agents include Omniscan, Magnevist (Nycomed Salutar, Inc.), and ProHance.
In one preferred embodiment, gadolinium is used as the MRI contrast agent. Less than about 28.14 mg/mL gadolinium (such as less than 6% Magnevist) is an adequate concentration for imaging and is minimally destructive of nucleic acid delivery vehicles. However, it is well within the skill of those in the art to vary and optimize the amount of contrast agent to add to the compositions depending on the nature of the contrast agent (e.g., their osmotic effects) and the length of time during which a target cell is exposed.
In other embodiments, the composition comprises a pharmaceutically acceptable carrier. Preferably, the carrier is non-toxic, isotonic, hypotonic or weakly hypertonic and has a relatively low ionic strength (e.g., such as a sucrose solution). Furthermore, it may contain any relevant solvents, aqueous or partly aqueous liquid carriers comprising sterile, pyrogen-free water, dispersion media, coatings, and equivalents, or diluents (e.g. Tris-HCI, acetate, phosphate), emulsifiers, solubilizers and/or adjuvants. The pH of the pharmaceutical preparation is suitably adjusted and buffered in order to be appropriate for use in humans or animals. Representative examples of carriers or diluents for an injectable—composition include water or isotonic saline solutions which are preferably buffered at a physiological pH (e.g., such as phosphate buffered saline, Tris buffered saline, mannitol, dextrose, glycerol containing or not polypeptides or proteins such as human serum albumin). The compositions also can comprise one or more accessory molecules for facilitating the introduction of a nucleic acid delivery vector into a cell and/or for enhancing a particular therapeutic effect.
The foregoing is illustrative and shall not be considered limiting as to the drugs or therapeutic compounds or agents, carriers, and accessory molecules that can be used to comprise the therapeutic medium of the present invention. Applicants also herein incorporate by reference the teachings and disclosures in their entirety of pending U.S. application U.S. Ser. No. 10/116,708 entitled Enaging Nucleic Acid Delivery and in particular those teachings and disclosures of the various therapeutic agents described therein, which invention is assigned to the assignee of the present invention.
A mechanically actuated, transrectal needle guide is used to perform MR guided needle placements in the prostate. With a microcoil tracking method, the position and orientation of the biopsy needle guide in the MR imaging volume (60 msec) could be quickly and accurately located. Knowing the position of the biopsy needle allows for acquisition of realtime images of a plane including the needle and registration of the needle position with previously acquired, high-resolution images of the prostate. In four canine studies, the functionality and applications of a system was demonstrated.
A thin-walled, cylindrical plastic sheath (Delrin plastic, DuPont Inc., Wilmington, Del.) with a radius of 1.5 cm is inserted into the subject's rectum, forming a stable and stationary entry point through which the prostate can be accessed. Integral to the sheath is a single turn imaging loop (with a diameter of 2.5 cm) for local imaging of the prostate. The sheath has a window, located within the imaging loop, such that a needle can be advanced from inside the sheath, through the rectal wall, and into the body of the prostate.
Next, a cylindrical needle guide, also made of Delrin plastic, is placed within the rectal sheath. As the needle guide is coaxial with the rectal sheath, the needle guide is free to rotate and translate within the cavity formed by the sheath without causing deformation of the surrounding soft tissue. Integral to the needle guide are (1) three microcoil fiducials and (2) a curved channel for the needle. Note that because the needle channel is curved, the needle can be inserted along the axis of the needle guide and emerge out of its lateral wall, allowing for access to the prostate through the window in the stationary rectal sheath.
Next, both the rectal sheath and the needle guide are affixed to a positioning stage made of Nylon plastic (QTC, New Hyde Park, N.Y.) and Delrin. First, the positioning stage serves to hold the rectal sheath stationary within the subject's rectum. A linear track (aluminum rail, 80/20 Inc., Columbia City, Ind.) and a polyamide plastic articulated-arm with six joints that are operably connected to the positioning stage allow for full mobility of the positioning stage, such that it can be easily docked with the rectal sheath, at which point the linear track and articulated arm are locked down to prevent any subsequent motion.
In addition to holding the rectal sheath stationary, the positioning stage contains a screw drive mechanism that allows for both rotation and translation of the needle guide. This device converts rotation of two concentric control rods (Epoxy tubing, TAP Plastics, Dublin, Calif.), both of which extend outside of the scanner bore, into rotation and translation of the needle guide. This allowed the operator to position the needle guide while the subject is within the closed bore scanner.
As the entire device is constructed with a coaxial design, the central axis offers an unobstructed path for insertion of the needle. The depth of needle insertion is controlled using a variable offset stop that is inserted at the back of the device before introducing the needle. An 18G coaxial biopsy needle (MRI Devices Daum GmbH, Schwerin, Germany) is inserted such that the needle tip emerges from the side of the needle guide.
MR pulse sequences and hardware were designed to facilitate targeted needle placement in the prostate within a GE 1.5 T CV/i MRI scanner with 4 independent receiver channels. Three microcoil fiducials were integrated within a transrectal needle guide, each connected to a separate receiver channel. To determine the position and orientation of these coils, twelve 1-D dodecahedrally spaced readouts were collected (TE 2.3 msec, TR 5.0 msec, BW +/−64 KHz, FA 10, FOV 40 cm, 256 readout points), allowing for coil localization [Dumoulin C L, Souza S P, Darrow R D. Real-time position monitoring of invasive devices using magnetic resonance. Magn Reson Med 1993; 29:411-415; Derbyshire J A, Wright G A, Henkelman R M, Hinks R S. Dynamic scan-plane tracking using MR position monitoring. J Magn Reson Imaging 1998; 8:924-932]. The coil localization scan occupied 60 msec. Microcoil location errors due to gradient nonlinearity were removed using gradient dewarping algorithms (GE Medical Systems, Waukesha, Wis.).
Given the position of the three microcoil fiducials in the MR coordinate system and the location of a given intraprostatic target (also in the MR coordinate system), the remaining problem is to determine (1) the rotation and translation necessary to position the needle guide such that the needle trajectory is aligned with the target and (2) the amount of needle insertion necessary to reach the target. This can be calculated using a set of coordinate transformations—assuming that the relationship between the microcoil positions, the device axis, and the needle trajectory are all known. These relationships are established using a device calibration scan in which Gd-DTPA (Magnevist, Berlex Laboratories, Wayne, N.J.) fiducial tubes define the device axis and the needle trajectory (the same, single calibration scan was used for all studies described here). In addition to determining the rotation and translation necessary to reach the target site, the calibration of the microcoil positions with the needle trajectory allowed for definition of a scan plane that includes both the needle path and the device axis. ‘Realtime’ images were acquired based on the current position of the microcoil fiducials, such that the needle could be visualized as it was inserted into the prostate.
All experiments were performed on a GE 1.5 T CV/I MRI scanner (GE Medical Systems, Waukesha, Wis.). A fast gradient-echo pulse sequence (FGRE) was modified to allow for alternating acquisition of the microcoil-tracking readouts (i.e. the twelve, dodecahedrally spaced readouts) and realtime FGRE images. After the location of each coil was determined, the position and orientation of the imaging plane is defined such that the realtime FGRE image slice tracked with the position of the needle.
Realtime data processing and display were performed using a Sun Ultra II Workstation (Sun Microsystems, Mountain View, Calif.) connected to the scanner with a high-bandwidth data bus (Bit3 Corporation, St Paul, Minn.). In the current implementation, the tracking sequence takes 60 msec; image processing, communication, and scan plane localization occupies 150 msec; and imaging takes 300 to 1300 msec—yielding frame rates of 0.7 to 2 fps (depending predominantly on image acquisition time). Images were acquired using a rectal imaging coil while the other three receiver channels were used for the microcoil fiducials.
All animal protocols were reviewed and approved by the Animal Care and Use Committee at the Johns Hopkins University School of Medicine. Four mongrel dogs weighing approximately 25 kg were anesthetized with a bolus injection of thiopental and maintained on 1% isoflurane throughout the experiment. An intravenous catheter was placed in the right jugular vein for fluid administration and a Foley catheter was inserted to aid in stabilizing the prostate and to define the position of the prostatic urethra. The animals were placed prone on the scanner table with the pelvis slightly elevated (˜10 cm) with a 5-inch surface coil on the anterior surface of the abdomen at the level of the prostate. The rectal sheath was inserted into the rectum and docked with the positioning apparatus, which was then locked in place.
In the first animal study, the accuracy of needle placement was tested in-vivo. After the animal was positioned in the scanner, T1 weighted FSE images of the prostate and surrounding anatomy were acquired (TE 9.2 msec, TR 700 msec, BW +/−31.25 KHz, ETL 4, FOV 16 cm, slice thickness 3 mm, 256×256, NEX=4, scan time 3:00). Two receiver channels were used for these images: one for the 5-inch surface coil and one for the rectal coil. In these images, a target was selected within the body of the prostate and entered into the realtime control program. Scanning was then switched to the realtime FGRE imaging and tracking sequence.
While running the realtime FGRE imaging and tracking sequence, the operator is able to rotate and translate the needle guide from the mouth of the scanner bore using the control rods. On a scan room flat panel display, the operator watches both the realtime image slice, showing the trajectory of the needle, as well numerical values indicating the current amount of rotation and translation necessary to set the correct needle trajectory. As the needle guide is moved closer to the target position, these numbers move to zero—indicating that no more rotation or translation is necessary.
Once the needle guide on the proper trajectory, the insertion stop is set to the proper depth (also indicated on the flat panel display) and the needle is pushed until it is flush with the stop. The insertion of the needle can be visualized on the scan room display and once in place, the needle tip will be at the desired target location.
To confirm the location of the needle tip, a second set of T1 weighted FSE images were acquired. This protocol was repeated for four separate needle insertions.
To demonstrate MR monitored injection therapies, intraprostatic injections were preformed in two canine subjects. Similar to the needle placement protocol, targets in the prostate were selected on axial T1 weighted FSE images and the needle tip was placed at these locations using the realtime FGRE imaging and tracking sequence. After the coaxial needle was placed, the trocar (i.e. an inner stylus) was withdrawn, leaving only the 18G cannula (i.e., a hollow metal tube) in place. This provided a conduit through which injections into the body of the prostate could be performed.
In this demonstration, a mixture of 0.4% Trypan Blue (Sigma-Aldrich, St. Louis, Mo.) and 30 mM Gd-DTPA (Magnevist, Berlex Laboratories, Wayne, N.J.) was injected, in particular 0.3 mL of this solution was injected into the prostate. During the injection, the flow of the mixture was monitored using a high flip-angle, RF-spoiled, gradient echo imaging sequence (FSPGR, TE 1.5 msec, TR 6 msec, FA 900, BW +/−62.5 KHz, FOV 16 cm, slice thickness 10 mm, 256×160, 0.96 sec/image). The location of the injected solution was determined by comparing gradient echo axial images acquired both before and after the injection (FSPGR, TE 2.0 msec, TR 80 msec, FA 600, BW +/−31.25 KHz, FOV 16 cm, slice thickness 3 mm, 256×256, NEX 4, scan time 1:20).
In a fourth canine, the use of the device for MR guided brachytherapy seed placement was demonstrated. Targets were selected and the trocar and canula were placed, as described previously. Then, to insert the titanium brachytherapy seeds (OncoSeed blanks, Medi-Physics Inc., Arlington Heights, Ill.), the trocar was withdrawn, leaving the hollow cannula in place within the prostate. A brachytherapy seed was inserted into the cannula and then advanced to the end, but not out, of the cannula by pushing it with another trocar. With the seed at the end of the cannula, the cannula was withdrawn slightly while holding the trocar stationary, causing the brachytherapy seed to be ejected into the prostate tissue. Subsequently, the trocar and cannula were both withdrawn together.
Three seeds were placed using this technique. The location of the needle and of the seeds was confirmed using T1 weighted FSE images (TE 9.2 msec, TR 700 msec, BW +/−31.25 KHz, ETL 4, FOV 16 cm, slice thickness 3 mm, 256×256, NEX=4, scan time 3:00).
In the first canine subject, accurate needle placement within the body of the prostate is demonstrated. The results of this study are summarized in
For interpretation of these results, it is useful to examine the artifact created by the 18G MR compatible needle.
In two canine subjects, the use of the system for MR monitored intraprostatic injections was demonstrated. First, a target within the body of the prostate gland was selected and the needle was positioned as described in the previous section. Then, the trocar was withdrawn, leaving the cannula as a conduit into the prostate. A mixture of 30 mM Gd-DTPA and 0.4% Trypan Blue [Yang X, Atalar E, Li D, et al. Magnetic resonance imaging permits in vivo monitoring of catheter-based vascular gene delivery. Circulation 2001; 104:1588-1590] was then injected into the prostate. A high flip-angle, RF-spoiled, gradient echo acquisition was run during the injection of 0.3 mL of this solution. The box on the sagittal scout (
In
In the next canine, the injection protocol was repeated as before. In this case, however, the injected contrast/dye solution is seen to leak out of the prostate and into the surrounding connective tissue (
In the last canine subject, the application of the system for placing brachytherapy seeds within the prostate is demonstrated. The results of this study—in which three seeds were placed in the prostate—are summarized in
In
The accuracy of the passive tracking method for determining the initial device position according to the tracking method of the present invention was tested in a phantom experiment. As shown in
Referring now also to
There is provided in
Referring now to
The accuracy performance of the hybrid tracking method according to the present invention was compared to the active tracking method, by obtaining error histograms of 36 active tracking orientations and of 16 passive tracking orientations. Since the hybrid tracking method is comprised of initial passive tracking and subsequent encoder tracking, an error model for the encoders was added to the passive tracking results. The optical encoders, contemplated for use for the tracking in the present invention, have a resolution of 0.25 degrees. Therefore a random, zero mean error with uniform distribution and an amplitude of 0.25 degrees was added to the passive tracking results to simulate the combined error of the hybrid tracking method. For the passive tracking error, the marker combination 1 and 3 with one circle per marker for segmentation was selected for comparison to the active tracking. Markers 1 and 3 are located at a distance of 45 mm from each other. This distance between markers can be implemented in our device design, making this combination a logical choice.
Referring now to FIG. 36A,B, there are shown histograms of angular errors for the active tracking (
The experimental results demonstrated that the hybrid tracking method of the present invention can be used for accurate tracking of interventional robotic devices. Since only one location per marker is enough to accurately compute an axis, segmentation and consequent axis definition for initial position tracking can be achieved relatively quickly.
In sum, the hybrid tracking method of the present invention has a number of advantages effects. Tracking errors using the hybrid tracking method compare favorably to existing tracking methods. The passive tracking portion of method of the present invention uses only standard MRI pulse sequences in contrast to the custom sequences that need to be developed and implemented when using active tracking. Also, the passive tracking portion of method of the present invention does not occupy any scanner receiver channels. In addition, no custom programming on the MRI scanner is necessary, allowing the method to be employed easily in various scanners. Further, the method does not require any electronic or metal parts on the interventional device ensuring complete MRI-compatibility and MR-safety.
While active tracking methods such as micro-coils and gradient sensing remain the penultimate in their ability to provide extremely fast real-time absolute 6-DOF position measurement, the hybrid tracking method of the present invention offers an alternative, providing equivalent accuracy, real-time relative tracking, but with far greater ease of deployment on different scanners as compared to existing active tracking methods.
Although a preferred embodiment of the invention has been described using specific terms, such description is for illustrative purposes only, and it is to be understood that changes and variations may be made without departing from the spirit or scope of the following claims.
This application claims the benefit of U.S. Provisional Application Ser. No. 60/782,705 filed Mar. 14, 2006, the teachings of which are incorporated herein by reference.
The U.S. Government has provided finding under contract No./ grant No. EEC9731478 awarded by the National Science Foundation and under contract No./ grant 1R01EB02963 by the National Institute of Health, thus the government may have certain rights to and/or in the invention.
| Filing Document | Filing Date | Country | Kind | 371c Date |
|---|---|---|---|---|
| PCT/US2007/006531 | 3/14/2007 | WO | 00 | 11/16/2009 |
| Number | Date | Country | |
|---|---|---|---|
| 60782705 | Mar 2006 | US |
