Background Assessment of lymphatic status via sentinel lymph node (SLN) biopsy is an integral and crucial part of melanoma surgical oncology. The most common technique for sentinel node mapping is preoperative planar scintigraphy of an injected gamma-emitting lymphatic tracer followed by intraoperative node localization using a non-imaging gamma probe with auditory feedback. In recent years, intraoperative visualization of SLNs in 3-D has become possible by coupling the probe to an external system capable of tracking its location and orientation as it is read out, thereby enabling computation of the 3D distribution of the tracer (freehand SPECT). In this project, the non-imaging probe of the fhSPECT system was replaced by a unique handheld gamma camera containing an array of sodium iodide crystals optically coupled to an array of silicon photomultipliers (SiPMs). A feasibility study was performed in which preoperative SLN mapping was performed using camera fhSPECT and the number of detected nodes was compared to that visualized by lymphoscintigraphy, probe fhSPECT, and to the number ultimately excised under non-imaging probe guidance.Results Among five subjects, SLNs were detected in nine lymphatic basins, with one to five SLNs detected per basin. A basin-by-basin comparison showed that the number of SLNs detected using camera fhSPECT exceeded that using lymphoscintigraphy and probe fhSPECT in seven of nine basins and five of five basins, respectively (probe fhSPECT scans were not performed for four basins). It exceeded the number excised under non-imaging probe guidance for seven of nine basins, and equaled the number excised for the other two basins. Conclusions Freehand SPECT using a prototype SiPM-based gamma camera demonstrates high sensitivity for detection of SLNs in a preoperative setting. Camera fhSPECT is a potential means for efficiently obtaining real-time 3D activity distribution maps in applications such as image-guided percutaneous biopsy, and surgical SLN biopsy or radioguided tumor excision.

BACKGROUND:Sentinel lymph node biopsy (SLNB) in melanoma using one-dimensional gamma probes is a standard of care worldwide. Reports on the performance are claimed by most groups to successfully detect the SLNs during the surgical procedure in almost 100% of the patients. In clinical practice, however, several issues remain which are usually not addressed: the difficulty of intraoperative detection of deeply located nodes, SLN detection in obese patients or in the groin and the impossibility to make a scan of the entire wound after SLN resection to avoid false negative testing for eventually remaining SLNs.MATERIALS AND METHODS:The concept behind freehand SPECT is to combine a gamma probe as used for conventional radio-guided surgery with a tracking system as used in neurosurgical navigation. From this combination and a proper algorithm framework the 3D reconstruction of radioactivity distributions and displaying these intraoperatively is possible.CONCLUSION:In summary, the feasibility of freehand SPECT could be shown and provides an image-guided SLNB and a truly minimally invasive and optimized surgical procedure.

Freehand SPECT is a 3-D tomographic imaging modality based on data acquisition with a hand-held detector that is moved freely, in contrast to conventional, fixed gamma camera systems. In this pilot study, the feasibility of freehand SPECT for 3-D lymphatic mapping in breast cancer was evaluated.

Mobile C-arm is an essential tool in everyday trauma and orthopedics surgery. Minimally invasive solutions, based on X-ray imaging and coregistered external navigation created a lot of interest within the surgical community and started to replace the traditional open surgery for many procedures. These solutions usually increase the accuracy and reduce the trauma. In general, they introduce new hardware into the OR and add the line of sight constraints imposed by optical tracking systems. They thus impose radical changes to the surgical setup and overall procedure. We augment a commonly used mobile C-arm with a standard video camera and a double mirror system allowing real-time fusion of optical and X-ray images. The video camera is mounted such that its optical center virtually coincides with the C-arm's X-ray source. After a one-time calibration routine, the acquired X-ray and optical images are coregistered. This paper describes the design of such a system, quantifies its technical accuracy, and provides a qualitative proof of its efficiency through cadaver studies conducted by trauma surgeons. In particular, it studies the relevance of this system for surgical navigation within pedicle screw placement, vertebroplasty, and intramedullary nail locking procedures. The image overlay provides an intuitive interface for surgical guidance with an accuracy of <;1 mm, ideally with the use of only one single X-ray image. The new system is smoothly integrated into the clinical application with no additional hardware especially for down-the-beam instrument guidance based on the anteroposterior oblique view, where the instrument axis is aligned with the X-ray source. Throughout all experiments, the camera augmented mobile C-arm system proved to be an intuitive and robust guidance solution for selected clinical routines.

We present a novel method to generate parallax-free panoramic X-ray images during surgery by enabling the mobile C-arm to rotate around its X-ray source center, relative to the patient's table. Rotating the mobile C-arm around its X-ray source center is impractical and sometimes impossible due to the mechanical design of mobile C-arm systems. In order to ensure that the C-arm motion is a relative pure rotation around its X-ray source center, we propose to move the table to compensate for the translational part of the motion based on C-arm pose estimation. For this we employ a visual marker pattern and a Camera Augmented Mobile C-arm system that is a standard mobile C-arm augmented by a video camera and mirror construction. We are able to produce a parallax-free panoramic X-ray image independent of the geometric configuration of imaged anatomical structures. Our method does not require a fronto-parallel setup or any overlap between the acquired X-ray images. This generated parallax-free panoramic X-ray image preserves the linear perspective projection property. It also presents a negligible difference (below 2 pixels) in the overlapping area between two consecutive individual X-ray images and has a high visual quality. This promises suitability for intra-operative clinical applications in orthopedic and trauma surgery. The experiments on phantoms and ex-vivo bone structure demonstrate both the functionality and accuracy of the method.

Zielsetzung: Das Freehand-SPECT ist ein im Gegensatz zur herkömmlichen stationären Gammakamera frei bewegliches System zur intraoperativen 3D-Visualisierung von Radioaktivität in vivo. In der Pilotstudie wurde die Anwendbarkeit von Freehand-SPECT zur 3D-Darstellung der Sentinellymphknoten bei Mammakarzinom untersucht.

In trauma and orthopedic surgery, imaging through X-ray fluoroscopy with C-arms is ubiquitous. This leads to an increase in ionizing radiation applied to patient and clinical staff. Placing these devices in the desired position to visualize a region of interest is a challenging task, requiring both skill of the operator and numerous X-rays for guidance. We propose an extension to C-arms for which position data is available that provides the surgeon with so called artificial fluoroscopy. This is achieved by computing digitally reconstructed radiographs (DRRs) from pre- or intraoperative CT data. The approach is based on C-arm motion estimation, for which we employ a Camera Augmented Mobile C-arm (CAMC) system, and a rigid registration of the patient to the CT data. Using this information we are able to generate DRRs and simulate fluoroscopic images. For positioning tasks, this system appears almost exactly like conventional fluoroscopy, however simulating the images from the CT data in realtime as the C-arm is moved without the application of ionizing radiation. Furthermore, preoperative planning can be done on the CT data and then visualized during positioning, e.g. defining drilling axes for pedicle approach techniques. Since our method does not require external tracking it is suitable for deployment in clinical environments and day-to-day routine. An experiment with six drillings into a lumbar spine phantom showed reproducible accuracy in positioning the C-arm, ranging from 1.1 mm to 4.1 mm deviation of marker points on the phantom compared in real and virtual images.

514 Objectives Evaluate the feasibility of the recently introduced freehand SPECT imaging technology for 3D lympathic mapping of breast cancer patients. Methods The position and orientation of a gamma probe is acquired simultaneously with its read-out using an optical positioning system. After obtaining readings from a freehand scan containing the region of interest, the information is used to reconstruct 3D tomographic nuclear images using ad hoc models and iterative reconstruction algorithms. In addition, imaging with a SPECT/CT camera was performed. SPECT data were registered to the coordinate system of the freehand SPECT reconstruction to serve as reference. Results A group of 35 pts (age 29-87) with T1 or T2 invasive breast cancer and no clinical suspicion of nodal involvement underwent lymphatic mapping (Tc-99m nanocol, 50-70 MBq). In 33 pts with at least one visible SLN, SPECT/CT and a freehand SPECT scan were generated (8.7±2.5 min). 63 SLNs were mapped using SPECT/CT, whereas 48 were mapped with freehand SPECT. Assuming that the SPECT/CT result is correct, freehand SPECT presented 3 false positives (3 pts) and 15 false negatives (10 pts). False negative findings can be explained by 2 insufficient scans and low tracer uptake in 13 nodes (0.05-0.41%). Conclusions In this pilot study, we could demonstrate that novel freehand SPECT is capable of localizing hot spots at the same 3D position compared to that of conventional SPECT. In case of lymphatic mapping in breast cancer, this approach has a potential to allow guided biopsy and further standardization of SLN dissection, thus opening new paths of Nuclear Medicine in the OR.

In this paper, we present a novel method to create parallax-free panoramic X-ray images of long bones during surgery by making the C-arm rotate around its X-ray source, relative to the patient's table. In order to ensure that the C-arm motion is a relative pure rotation around its X-ray source, we move the table to compensate for the translational part of the motion based on C-arm pose estimation, for which we employed a Camera Augmented Mobile C-arm system [1] and a visual planar marker pattern. Thus, we are able to produce a parallax-free panoramic X-ray image that preserves the property of linear perspective projection. We additionally implement a method to reduce the error caused by varying intrinsic parameters of C-arm X-ray imaging. The results show that our proposed method can generate a parallax-free panoramic X-ray image, independent of the configuration of bone structures and without the requirement of a fronto-parallel setup or any overlap in the X-ray images. The resulting panoramic images have a negligible difference (below 2 pixels) in the overlap between two consecutive individual X-ray images and have a high visual quality, which promises suitability for intra-operative clinical applications in orthopedic and trauma surgery.

Fragestellung: Ist die neu entwickelte Technik des freehand SPECT für eine 3D-Darstellung des Sentinellymphknotens bei Mammakarzinompatientinnen geeignet?

Electromagnetic tracking is currently one of the most promising means of localizing flexible endoscopic instruments such as flexible laparoscopic ultrasound transducers. However, electromagnetic tracking is also susceptible to interference from ferromagnetic material, which distorts the magnetic field and leads to tracking errors. This paper presents new methods for real-time online detection and reduction of dynamic electromagnetic tracking errors when localizing a flexible laparoscopic ultrasound transducer. We use a hybrid tracking setup to combine optical tracking of the transducer shaft and electromagnetic tracking of the flexible transducer tip. A novel approach of modeling the poses of the transducer tip in relation to the transducer shaft allows us to reliably detect and significantly reduce electromagnetic tracking errors. For detecting errors of more than 5 mm, we achieved a sensitivity and specificity of 91% and 93%, respectively. Initial 3-D rms error of 6.91 mm were reduced to 3.15 mm.