Positron emission tomography/computed tomography guided percutaneous biopsies of Ga-68 avid lesions using an automated robotic arm

Comparison of a Patient-Mounted Needle-Driving Robotic System versus Single-Rotation CT Fluoroscopy to Perform CT-Guided Percutaneous Lung Biopsies

PURPOSE

To compare the effectiveness of percutaneous lung biopsy using a patient-mounted needle-driving robotic system with that using a manual insertion of needles under computed tomography (CT) fluoroscopy guidance.

MATERIALS AND METHODS

In this institutional review board approved study, the cohort consisted of a series of patients who underwent lung biopsies following the intention-to-treat protocol from September 2022 to September 2023 using robot (n = 15) or manual insertion under single-rotation CT fluoroscopy (n = 66). Patient and procedure characteristics were recorded as well as outcomes.

RESULTS

Although age, body mass index, and skin-to-target distance were not statistically different, target size varied (median, 8 mm [interquartile range, 6.5-9.5 mm] for robot vs 12 mm [8-18 mm] for single-rotation CT fluoroscopy; P = .001). No statistical differences were observed in technical success (86.7% [13/15] vs 89.4% [59/66], P = .673), Grade 3 adverse event (AE) (6.7% [1/15] vs 12.1% [8/66], P = .298), procedural time (28 minutes [22-32 minutes] vs 19 minutes [14.3-30.5 minutes], P = .086), and patient radiation dose (3.9 mSv [3.2-5.6 mSv] vs 4.6 mSv [3.3-7.5 mSv], P = .398). In robot-assisted cases, the median angle out of gantry plane was 10° (6.5°-16°), although it was null (0°-5°) for single-rotation CT fluoroscopy (P = .001).

CONCLUSIONS

Robot-assisted and single-rotation CT fluoroscopy-guided percutaneous lung biopsies were similar in terms of technical success, diagnostic yield, procedural time, AEs, and radiation dose, although robot allowed for out-of-gantry plane navigation along the needle axis.

Innovations in dedicated PET instrumentation: from the operating room to specimen imaging

This review casts a spotlight on intraoperative positron emission tomography (PET) scanners and the distinctive challenges they confront. Specifically, these systems contend with the necessity of partial coverage geometry, essential for ensuring adequate access to the patient. This inherently leans them towards limited-angle PET imaging, bringing along its array of reconstruction and geometrical sensitivity challenges. Compounding this, the need for real-time imaging in navigation systems mandates rapid acquisition and reconstruction times. For these systems, the emphasis is on dependable PET image reconstruction (without significant artefacts) while rapid processing takes precedence over the spatial resolution of the system. In contrast, specimen PET imagers are unburdened by the geometrical sensitivity challenges, thanks to their ability to leverage full coverage PET imaging geometries. For these devices, the focus shifts: high spatial resolution imaging takes precedence over rapid image reconstruction. This review concurrently probes into the technical complexities of both intraoperative and specimen PET imaging, shedding light on their recent designs, inherent challenges, and technological advancements.

Convoluted Neural Network for Detection of Clinically Significant Prostate Cancer on 68 Ga PSMA PET/CT Delayed Imaging by Analyzing Radiomic Features

Purpose

To assess the utility of convoluted neural network (CNN) in differentiating clinically significant and insignificant prostate cancer in patients with 68 Ga PSMA PET/CT-targeted prostate biopsy-proven prostate cancer.

Methods

In this retrospective study, 142 patients with clinical suspicion of prostate cancer were evaluated who underwent 68 Ga-PSMA PET/CT imaging followed by 68 Ga-PSMA PET/CT-targeted prostate biopsy from the PSMA-avid prostate lesion. Twenty patients with no PSMA-avid lesions were excluded. Local Image Features Extraction (LifeX) software was used to extract radiomic features (RF) from delayed 68 Ga-PSMA PET/CT images of 122 patients. LifeX failed to extract radiomic features in 24 patients, and the remaining 98 were evaluated. RFs were fed to an in-built CNN of the software for computation and results were achieved. Patients with Gleason Score ≥ 7 on histopathology were labeled clinically significant prostate cancer (csPCa). The diagnostic values of radiomic features were evaluated.

Results

The csPCa was revealed in 69/98 (70.4%) patients, and insignificant PCa was noticed in 29/98 (29.6%) patients. The software extracted 124 RF from the delayed 68 Ga-PSMA PET/CT images. The accuracy of the CNN was 80.7% to differentiate clinically significant and clinically insignificant prostate cancer, with an error percentage (E %) of 19.3%. The sensitivity, specificity, positive predictive, and negative predictive values were 90.3%, 57.7%, 83.6%, and 71.4%, respectively, to detect csPCa.

Conclusion

CNN is a feasible pre-biopsy screening tool for identifying clinically significant prostate cancer and can be used as an adjunct in the initial diagnosis and early treatment planning.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13139-023-00832-3.

Petre E, Marinelli B, Sarkar D, Barral M, H Cornelis F. Percutaneous liver interventions with robotic systems: a systematic review of available clinical solutions

OBJECTIVE

Robotic-guided interventions are emerging techniques that are gradually becoming a common tool for performing biopsies and tumor ablations in liver. This systematic review aims to evaluate their advancements, challenges, and outcomes.

METHODS

A systematic review was conducted using the PubMed database to identify relevant articles published between January 2000 and February 2023. Inclusion criteria focused on studies that assessed robotic systems for percutaneous liver biopsies and tumor ablations. Data extraction was performed to collect information on study characteristics; robotic systems; components and software; imaging modality; degree of freedom; and needle insertion methods. The outcome measures analyzed were procedure time, radiation dose, and accuracy.

RESULTS

10 studies met the inclusion criteria. The robotic devices used included MAXIO, EPIONE, ROBIO-EX, AcuBot, and ACE robotic systems. The data set consisted of 429 percutaneous thermal ablations and 57 biopsies, both robot-guided. On average, the mean deviation of probes was reduced by 30% (from 1.6 vs 3.3 mm to 2.4 vs 3.9 mm (p < 0.001)), and 40% (p < 0.05) fewer readjustments were required during the robotic-assisted interventions. Moreover, robotic systems contributed to a reduction in operating time, ranging from 15% (18.3 vs 21.7 min, p < 0.001) to 25% (63.5 vs 87.4 min, p < 0.001). Finally, the radiation dose delivered to both the patient and the operator was decreased by an average of 50% (p < 0.05) compared to manual procedures.

ADVANCES IN KNOWLEDGE

Robotic systems could provide precise navigation and guidance during liver biopsies and percutaneous ablations.

A systematic review of image-guided, surgical robot-assisted percutaneous puncture: Challenges and benefits

Percutaneous puncture is a common medical procedure that involves accessing an internal organ or tissue through the skin. Image guidance and surgical robots have been increasingly used to assist with percutaneous procedures, but the challenges and benefits of these technologies have not been thoroughly explored. The aims of this systematic review are to furnish an overview of the challenges and benefits of image-guided, surgical robot-assisted percutaneous puncture and to provide evidence on this approach. We searched several electronic databases for studies on image-guided, surgical robot-assisted percutaneous punctures published between January 2018 and December 2022. The final analysis refers to 53 studies in total. The results of this review suggest that image guidance and surgical robots can improve the accuracy and precision of percutaneous procedures, decrease radiation exposure to patients and medical personnel and lower the risk of complications. However, there are many challenges related to the use of these technologies, such as the integration of the robot and operating room, immature robotic perception, and deviation of needle insertion. In conclusion, image-guided, surgical robot-assisted percutaneous puncture offers many potential benefits, but further research is needed to fully understand the challenges and optimize the utilization of these technologies in clinical practice.

Starting CT-guided robotic interventional oncology at a UK centre

OBJECTIVE

A commercially available CT-guided robot offers enhanced abilities in planning, targeting, and confirming accurate needle placement. In this short communication, we describe our first UK experience of robotic interventional oncology procedures.

METHODS

We describe the device, discuss installation, operation, and report upon needle insertion success, accuracy (path deviation; PD and tip deviation; TD), number of adjustments, complications, and procedural success.

RESULTS

Nine patients (seven males), median age 66 years (range 43-79) were consented for biopsy or ablation between March and April 2021. Needle placement in biopsy was more accurate than ablation (median 1 vs 11 mm PD and 1 vs 20 mm TD) and required fewer adjustments (median 0 vs 5). No complications arose, and all procedures were successful (diagnostic material obtained or complete ablation at follow-up).

CONCLUSION

Short procedure times and very high levels of accuracy were readily achieved with biopsy procedures, although tumour ablation was less accurate which likely reflects higher procedural complexity.

ADVANCES IN KNOWLEDGE

Achieving highly accurate robotic biopsy with is feasible within a very short time span. Further work is required to maximise the potential of robotic guidance in tumour ablation procedures, which is likely due to higher complexity giving a longer learning curve.

Safety and Diagnostic Yield of 68Ga Prostate-specific Membrane Antigen PET/CT Guided Robotic-assisted Transgluteal Prostatic Biopsy

Background Transrectal US-guided biopsy with or without MRI fusion is performed for diagnosing prostate cancer (PCa) but has limitations. Gallium 68 (⁶⁸Ga) prostate-specific membrane antigen (PSMA) PET/CT-guided targeted biopsy has the potential to improve diagnostic yield of PCa. Purpose To evaluate the safety and diagnostic yield of ⁶⁸Ga PSMA PET/CT-guided, robotic-arm assisted transgluteal prostatic biopsy. Materials and Methods In this single-center nonrandomized prospective trial, participants with a clinical suspicion of PCa (serum prostate-specific antigen level > 4 ng/mL) were recruited from January 2019 to September 2020. After whole-body ⁶⁸Ga PSMA PET/CT, participants with PSMA-avid intraprostatic lesions underwent PET-guided transgluteal biopsy by using an automated robotic arm. To assess safety and diagnostic yield, procedure-related complications and histopathologic results were documented. Pain during the procedure was scored by a visual analog scale. Descriptive statistics were applied; qualitative variables were reported in percentages. Results Seventy-eight participants (mean age, 66 years ± 7 [standard deviation]; 36 participants [46%] with prior negative results at transrectal US-guided biopsy) were enrolled. Fifty-six (72%) participants had PSMA-avid lesions (prior negative results at transrectal US-guided biopsy in 22 of 56 [39%]) and underwent targeted biopsy. PCa was confirmed in 54 of 56 (96%) participants, and clinically significant PCa (Gleason score ≥ 7) was confirmed in 24 of 54 (44%). Two participants had nonrepresentative samples that required rebiopsy. All participants experienced pain during the procedure, mild (median visual analog scale score, 1; interquartile range, 1-2) in 36 of 56 (64%) and moderate (median visual analog scale score, 5; interquartile range, 5-6) in 20 of 56 (36%). Postprocedure complications were noted in five of 56 (9%) participants and were minor (hematuria, four participants; hematospermia, one participant; and gluteal pain, two participants). No participant developed a postprocedural infection. Conclusion Transgluteal prostate-specific membrane antigen (PSMA) PET/CT-guided, robotic-targeted prostatic biopsy is safe with a high diagnostic yield of prostate cancer for PSMA-avid lesions. Clinical trial registration no. NCT05022576 © RSNA, 2022.

ASSESSMENT OF PATIENT'S RADIATION EXPOSURES RESULTED FROM PET/CT 18F-FCH AND 68GA-PSMA PROCEDURES

This study has sought to evaluate patient exposures during the course of particular diagnostic positron emission tomography and computed tomography (PET/CT) techniques. A total of 73 patients were examined using two types of radiopharmaceutical: 18F-fluorocholine (FCH, 48 patients) and 68Ga-prostate-specific membrane antigen (PSMA, 25 patients). The mean and range of administered activity (AA) in MBq, and effective dose (mSv) for FCH were 314.4 ± 61.6 (462.5-216.8) and 5.9 ± 1.2 (8.8-4.11), respectively. Quoted in the same set of units, the mean and range of AA and effective dose for 68Ga-PSMA were 179.3 ± 92.3 (603.1-115.1) and 17.9 ± 9.2 (60.3-11.5). Patient effective doses from 18F-FCH being a factor of two greater than the dose resulting from 68Ga-PSMA PET/CT procedures. CT accounts for some 84 and 23% for 18F-FCH and 68Ga-PSMA procedures, accordingly CT acquisition parameter optimization is recommended. Patient doses have been found to be slightly greater than previous studies.

PET- and SPECT-based navigation strategies to advance procedural accuracy in interventional radiology and image-guided surgery

INTRODUCTION

Nuclear medicine has a crucial role in interventional strategies where a combination between the increasing use of targeted radiotracers and intraprocedural detection modalities enable novel, but often complex, targeted procedures in both the fields of interventional radiology and surgery. 3D navigation approaches could assist the interventional radiologist or surgeon in such complex procedures.

EVIDENCE ACQUISITION

This review aimed to provide a comprehensive overview of the current application of computer-assisted navigation strategies based on nuclear imaging to assist in interventional radiology and image-guided surgery. This work starts with a brief overview of the typical navigation workflow from a technical perspective, which is followed by the different clinical applications organized based on their anatomical organ of interest.

EVIDENCE SYNTHESIS

Although many studies have proven the feasibility of PET- and SPECT-based navigation strategies for various clinical applications in both interventional radiology and surgery, the strategies are spread widely in both navigation workflows and clinical indications, evaluated in small patient groups. Hence, no golden standard has yet been established.

CONCLUSIONS

Despite that the clinical outcome is yet to be determined in large patient cohorts, navigation seems to be a promising technology to translate nuclear medicine findings, provided by PET- and SPECT-based molecular imaging, to the intervention and operating room. Interventional Nuclear Medicine (iNM) has an exciting future to come using both PET- and SPECT-based navigation.

Practice and prospects for PET/CT guided interventions

During the past 10 years, performing real-time molecular imaging with positron emission tomography (PET) in combination with computed tomography (CT) during interventional procedures has undergone rapid development. Keeping in mind the interest of the nuclear medicine readers, an update is provided of the current workflows using real-time PET/CT in percutaneous biopsies and tumor ablations. The clinical utility of PET/CT guided biopsies in cancer patients with lung, liver, lymphoma, and bone tumors are reviewed. Several technological developments, including the introduction of new PET tracers and robotic arms as well as opportunities provided through acquiring radioactive biopsy specimens are briefly reviewed.

Percutaneous CT-guided lung biopsy for the diagnosis of persistent pulmonary consolidation

PURPOSE

The primary objective of this study was to determine the diagnostic accuracy of percutaneous computed tomography (CT)-guided biopsy of persistent pulmonary consolidations. The secondary objective was to determine the complication rate and identify factors affecting diagnostic yield.

MATERIALS AND METHODS

Two radiologists retrospectively reviewed 98 percutaneous CT-guided biopsies performed in 93 patients (60 men, 33 women; mean age, 62±14.0 (SD) years; range: 18-88 years) with persistent pulmonary consolidations. Final diagnoses were based on surgical outcomes or 12 months clinical follow-up findings. Biopsy results were compared to the final diagnosis to estimate diagnostic yield.

RESULTS

A final diagnosis was obtained for all patients: 51/93 (54.8%) had malignant lesions, 12/93 (12.9%) specific definite benign lesions (including 9 infections, two pneumoconiosis and one lipoid pneumonia) and 30/93 (32.3%) non-specific benign lesions. CT-guided biopsy had an overall diagnostic yield of 60% (59/98) with a correct diagnosis for 50/51 malignant lesions (diagnostic yield of 98% for malignancy) and for 9/47 benign lesions (diagnostic yield of 19% for benign conditions). Major complications occurred in 4/98 (4%) of lung biopsies (four pneumothoraxes requiring chest tube placement).

CONCLUSION

Percutaneous CT-guided biopsy is an alternative to endoscopic or surgical biopsy for the diagnosis of persistent consolidation with a low risk of severe complication.

Perineum and penile invasion of recurrent prostate carcinoma shown by Ga-68 PSMA PET/CT

Imaging of prostate cancer has recently had new modalities. Ga-68 Prostate Specific Membrane Antigen (PSMA) Positron Emission Tomography/Computed Tomography (PET/CT) has gained important diagnostic role in the management of the patients with prostate cancer. Patients with progressively elevated serum prostate specific antigen (PSA) level may be evaluated by Ga-68 PSMA PET/CT imaging. This case report presents a seventy five year old man with diagnosis of prostate cancer and progressive serum PSA increase. Local recurrence of the tumor as well as spread to the penis, perineum and skeleton was determined by Ga-68 PSMA imaging. This case illustrates that Ga-68 PSMA imaging may show unexpected sites of disease spread.