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Model-Guided Therapy and the role of DICOM in Surgery

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Title: Model-Guided Therapy and the role of DICOM in Surgery


1
Model-Guided Therapy and the role of DICOM in
Surgery
Heinz U. Lemke, PhD
Chair of Working Group 24 DICOM in Surgery
2
Content
  • Introduction (problems and solutions)
  • Model guided therapy with TIMMS
  • Classification and model classes
  • Virtual human model examples
  • Conclusion

3
Computer Assisted Digital OR Suite for Endoscopic
MISSProblems Multiple Data Sources
Courtesy of Dr. John Chiu
4
Model Guided Therapy and the Patient Specific
Model
  • Model Guided Therapy (MGT) is a methodology
    complementing Image Guided Therapy (IGT) with
    additional vital patient-specific data.
  • It brings patient treatment closer to achieving a
    more precise diagnosis, a more accurate
    assessment of prognosis, as well as a more
    individualized planning, execution and validation
    of a specific therapy.
  • By definition, Model Guided Therapy is based on a
    Patient Specific Model (PSM) and allows for a
    patient specific intervention via an adapted
    therapeutic workflow.

5
Model Guided Therapy and data structures
  • Model Guided Therapy based on patient specific
    modelling requires appropriate IT architectures
    and data structures for its realisation.
  • For PSMs, archetypes and templates allow
    different levels of generalisation and
    specialisation, respectively.

6
Model Based Patient Care
Modalities (X-ray,CT, US, MR,SPECT, PET,OI)
Model Creation and Diagnosis (Data fusion, CAD,
)
Model Maintenanceand Intervention (Simulation, de
cision support, validation, )
Biosensors (physiology, metabolism, serum,
tissue, )
IT Communication Infrastructure
7
Content
  • Introduction (problems and solutions)
  • Model guided therapy with TIMMS
  • Classification and model classes
  • Virtual human model examples
  • PM data structures (SDTM and OpenEHR)
  • Conclusion

8
Interventional Cockpit/SAS modules
IT Model-Centric World View
Repo- sitory
Engine
Data Exch.
Control
Therapy Imaging and Model Management System
(TIMMS)
Modelling
Simulation
Kernel for WF and KD Management
Visualisation Rep. Manager
Intervention
Validation
IO Imaging and Biosensors
Therapy Imaging and Model Management System
(TIMMS) ICT infrastructure (based on DICOM-X) for
data, image, model and tool communication for
patient model-guided therapy
Models and intervention records
Data and information
9
Model Guided Therapy with TIMMS
  • For a therapeutic intervention it is assumed that
    human, mechatronic, radiation or pharmaceutical
    agents interact with the model.
  • MGT provides the scientific basis for an
    accurate, transparent and reproducible
    intervention with the potential for validation
    and other services.
  • TIMMS is an IT meta architecture allowing for
    interoperability of the agents to facilitate a
    MGT intervention.

10
Model Guided Therapy 
  • The basic TIMMS patient model must have the
    following features
  • The TIMMS patient model must have components
    which represent the patient as an n-dimensional
    and multiscale (in space and time) data set.
  • The TIMMS patient model must facilitate
    interfacing to the surgeon and other operative
    personnel, the TIMMS engines, TIMMS repositories,
    and the IT infrastructure.
  • The TIMMS patient model must be capable of
    linking these components, which may be static or
    dynamic, in a meaningful and accurate way.
  • For dynamic components, the TIMMS patient model
    must be able to process morphological and
    physiological data and perform the necessary
    mathematical functions to maintain the model in
    an up-to-date state.

11
Model Guided Therapy 
  • The TIMMS patient model must be capable of being
    incorporated by the TIMMS executing workflow and
    responding to its changes.
  • The TIMMS patient model must be amenable to be
    developed using readily available, standardized
    informatics methodology. Tools may include UML,
    XML, Visio, block diagrams, workflow diagrams,
    MATLAB, Simulink, DICOM (including surgical
    DICOM), Physiome, CDISC SDTM, openEHR and similar
    products and tools.
  • The TIMMS patient model must comply to software
    engineering criteria, for example, to open
    standards and service-oriented architectures to
    allow for multi-disciplinary information
    exchange.
  • The TIMMS patient model must allow for further
    extensions to incorporate advances in molecular
    medical imaging, genomics, proteomics and
    epigenetics.
  • The TIMMS patient model must be amenable to be
    used for clinical trials, predictive modeling,
    personal health records and in the long term
    contribute to a Model Based Medical Evidence
    (EBME) methodology.

12
Interventional Cockpit/SAS modules
IT Model-Centric World View
Repo- sitory
Engine
Data Exch.
Control
Therapy Imaging and Model Management System
(TIMMS)
Modelling
Simulation
Kernel for WF and KD Management
Visualisation Rep. Manager
Intervention
Validation
IO Imaging and Biosensors
Therapy Imaging and Model Management System
(TIMMS) ICT infrastructure (based on DICOM-X) for
data, image, model and tool communication for
patient model-guided therapy
Models and intervention records
Data and information
13
Generic and patient specific n-D modelling tools
Modelling tools
  • Geometric modelling
  • Prosthesis modelling
  • Properties of cells and tissue
  • Segmentation and reconstruction
  • Biomechanics and damage
  • Tissue growth
  • Tissue shift
  • Properties of biomaterials
  • ...

14
Model Guided Therapy
  • MGT in its simpliest instantiation is an
    intervention with a subset, a single or a set of
    voxels representing locations within the patient
    body. With this view, it is an extension from
    Image (pixel) Guided Therapy (IGT) to model
    (voxel) guided therapy. Examples of model guided
    therapy are
  • a) interventions within a subset of a voxel,
    e.g. cells, organelles, molecules,
    etc.
  • b) interventions with a voxel, e.g. small
    tissue parts of an organ or lesion,
    etc.
  • c) interventions with a set of voxels, e.g.
    part of functional structures of organs,
    organ components, soft tissue, lesions,
    etc.

15
Model Guided Therapy 
In a simple PSM, voxels may be associated with
several dimensions of data
  1. 1-D signals (e.g. EEG)
  2. 2-D projection and tomographic images
  3. 3-D reconstructions
  4. Temporal change
  5. Tissue/cell type
  6. Ownership to organ, lesion, system, prothesis,
    chronic condition, etc.
  7. Spatial occupancy/extension
  8. Permeability (blood brain barrier)
  9. Flow (e.g. electric, heat, liquid, perfusion,
    diffusion, etc.)

16
Model Guided Therapy 
In a simple PSM, voxels may be associated with
several dimensions of data
  • Level of oxygenation (e.g. level of hypoxia)
  • Pharmacokinetics (e.g. effect of tissue on
    pharmaceutical agent, flow parameters, time to
    peak, etc.)
  • Pharmacodynamics (effect of pharmaceutical agent
    on tissue, ablation parameters)
  • Biological marker types (in vitro and/or in vivo
    molecular spectrum)
  • Reference coordinate system (e.g.
    Schaltenbrand/Warren, Talaraich/Tourneaux)
  • Value (life critical to life threatening)
  • Neighbourhood (e.g. 3³, 5³, 7³, etc.)
  • ...

17
Example ENT model elements
Source G. Strauss
18
Example ENT model elements
Source G. Strauss
19
Content
  • Introduction (problems and solutions)
  • Model guided therapy with TIMMS
  • Classification and model classes
  • Virtual human model examples
  • Conclusion

20
Strategies for multiscale modelling
  • Modelling is essential for understanding the
    knowledge of human characteristics such as,
    anatomy, physiology, metabolism, genomics,
    proteomics, pharmacokinetics, etc.
  • Because of the complexity of integrating the
    knowledge about the different characteristics the
    model of a human has to be realised on different
    levels (multiscale in space and time) and with
    different ontologies, depending on the questions
    posed and answered delivered.
  • The problems associated with using reduced-form
    components within large systems models stem
    primarily from their limited range of validity.

21
Source J. Bassingthwaighte
22
Patient specific and associated modelling
functions
In the Model-Centric World View a wide variety of
information, relating to the patient, can be
integrated with the images and their derivatives,
providing a more comprehensive and robust view of
the patient. By default, the broader the
spectrum of different types of interventional/surg
ical workflows which have to be considered, the
more effort has to be given for designing
appropriate multiscale PSMs and associated
services.
23
Patient specific and associated modelling
functions
Management of n-D and multi resolutional
knowledge (model of the biologic continuum in
space and time) is still a research and
development challenge. If solved successfully,
it will transform surgery into a more
scientifically based activity.
24
Content
  • Introduction (problems and solutions)
  • Model guided therapy with TIMMS
  • Classification and model classes
  • Virtual human model examples
  • Conclusion

25
Patient Specific CMB
Human Laser Scan (CAESAR DB)
Multimodal Imaging(MRI, CT, Angio,..DT-MRI)
Visible Human Anatomical Templateorgan surface
meshes
Roberts JHU
Spitzer 2006 Virtual Anatomy
PKPD
FEM Mesh (Roberts JHU)
26
Content
  • Introduction (problems and solutions)
  • Model guided therapy with TIMMS
  • Classification and model classes
  • Virtual human model examples
  • Conclusion

27
Solutions and Research Focus(medical)
  • Transition from image guided to model guided
    therapy (e.g. through workflow and use case
    selection/creation/repositories)
  • Concepts and specification of patient specific
    models in a multiscale domain of discourse
  • Concepts and design of a canonical set of low
    level surgical functions
  • Prototyping

28
Interventional Cockpit/SAS modules
IT Model-Centric World View
Repo- sitory
Engine
Data Exch.
Control
Therapy Imaging and Model Management System
(TIMMS)
Prototyping
Modelling
Simulation
Kernel for WF and KD Management
Visualisation Rep. Manager
Intervention
Validation
IO Imaging and Biosensors
Therapy Imaging and Model Management System
(TIMMS) ICT infrastructure (based on DICOM-X) for
data, image, model and tool communication for
patient model-guided therapy
Models and intervention records
Data and information
29
Solutions and Research Focus(technical)
  • Concepts and data structure design of patient
    specific models (e.g. with archetypes and
    templates)
  • Model management with open architectures (e.g.
    SOA)
  • SOA modulariation with repositories, engines,
    LLMs and HLMs
  • LLMs as adaptive (cognitive/intelligent) agents
  • HLMs as application modules (competitive
    differentiation)
  • LLMs possibly as open source
  • Kernel (engine and repository) for adaptive
    workflow and KD management
  • Cooperative and competitive RD framework for
    engine and repository building
  • Therapy based open standard ( e.g. S-DICOM)
  • Transition from CAD to CAT modelling

30
Interventional Cockpit/SAS modules
IT Model-Centric World View
Repo- sitory
Engine
Data Exch.
Control
Therapy Imaging and Model Management System
(TIMMS)
Archetypes and Templates
Modelling
Simulation
Kernel for WF and KD Management
Visualisation Rep. Manager
Intervention
Validation
IO Imaging and Biosensors
Therapy Imaging and Model Management System
(TIMMS) ICT infrastructure (based on DICOM-X) for
data, image, model and tool communication for
patient model-guided therapy
Models and intervention records
Data and information
31
Solutions and Research Focus(medical and
technical)
  • Transition from image guided to model guided
    therapy (e.g. through workflow and use case
    selection/creation/repositories)
  • Use cases for adaptive workflow, exception
    handling and KD management for selected
    interventions
  • Cooperative and competitive RD framework for low
    (open source) and high level (competitive
    differentiation) surgical function
    computerisation
  • Information/model flow from diagnosis (e.g. CAD)
    to CAT (i.e. interdisciplinary cooperation)
  • Development of standards for patient modelling in
    WG24 DICOM in Surgery

32
Interventional Cockpit/SAS modules
IT Model-Centric World View
Repo- sitory
Engine
Data Exch.
Control
Candidate components for open source
Open Source
Modelling
Simulation
Kernel for WF and KD Management
Visualisation Rep. Manager
Intervention
Validation
IO Imaging and Biosensors
Therapy Imaging and Model Management System
(TIMMS) ICT infrastructure (based on DICOM-X) for
data, image, model and tool communication for
patient model-guided therapy
Models and intervention records
Data and information
33
WG 24 DICOM in Surgery Project Groups
  • PG1 WF/MI Neurosurgery
  • PG2 WF/MI ENT and CMF Surgery
  • PG3 WF/MI Orthopaedic Surgery
  • PG4 WF/MI Cardiovascular Surgery
  • PG5 WF/MI Thoraco-abdominal Surgery
  • PG6 WF/MI Interventional Radiology
  • PG7 WF/MI Anaesthesia
  • PG8 S-PACS Functions
  • PG9 WFMS Tools
  • PG10 Image Processing and Display
  • PG11 Ultrasound in Surgery

34
Definition of Surgical Workflows (S-WFs)
  • Micro Laryngeal Surgery (MLS) (PG2 ENT/CMF)
  • Foreign Body Excision (PG2 ENT/CMF)
  • Total Hip Replacement Surgery (PG3 Orthopaedic)
  • Total Endoscopic Coronary Artery Bypass (TECAB)
    (PG4 Cardiovascular)
  • Mitral Valve Reconstruction (MVR) (PG4
    Cardiovascular)
  • Laparoscopic Splenectomy (PG5
    Thoraco-abdominal)
  • Laparoscopic Cholecystectomy (PG5
    Thoraco-abdominal)
  • Laparoscopic Nephrectomy left (PG5
    Thoraco-abdominal)
  • Angiography with PTA and Stent (PG6
    Interventional Radiology)
  • Hepatic Tumor Radio Frequency Ablation (PG6
    Interventional Radiology)
  • Trajugular Intrahepatic Portosystemic Shunt (PG6
    Interventional Radiology)

35
CARS 2008 Computer Assisted Radiology and Surgery
CARS / SPIE / EuroPACS 9th Joint Workshop
onSurgical PACS and the Digital Operating
RoomBarcelona, 28 June, 2008

12th Meeting of the DICOM Working Group WG 24
DICOM in Surgery Barcelona, 28 June 2008
http//www.cars-int.org
36
(No Transcript)
37
WG24 DICOM in Surgery
  • Secretariat Howard Clark, NEMA
  • Secretary Franziska Schweikert,
    CARS/CURAC Office
    fschweikert_at_cars-int.org
  • General Chair Heinz U. Lemke, ISCAS/CURAC,
    Germany
  • Co-Chair Ferenc Jolesz, Harvard Medical
    School, Boston(Surgery/Radiology)
  • Co-Chair tbd
  • (Industry)
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