New 3-D printed, air-powered, biopsy robot that can collect sample inside MRI unveiled

The University of Twente revealed its latest version of world’s most accurate 3D-printed biopsy robot during the Surgical Robot Challenge at the international Hamlyn Symposium in London. The robot is named Sunram 5 and is faster and accurate than its previous self.

Today, most breast biopsies are performed by handheld needles under sonographic guidance, based on previous radiological films. But, many a time the needle placement is not perfect because what was seen on MRI or mammography may look quite different on sonography. Coupled with human error, this may create serious problems such as a malignant lesion may be reported as benign.

MRI scanners are unparalleled in terms of locating lesions, and it would be perfect if a biopsy is taken under their guidance. This would though require a robot small enough to fit beside the patient under MRI robot that could fit. The robot should also be made of a material not influenced by strong magnetic field created by MRI.

Researchers at the Twente University, Netherlands, have tailor-made a robot to above specification. The robot is very small and easily fit under the breast compression device. It is powered by air pressure maintained through external pumps, which also enables it to be under operator control. It is made up of hard plastic except for the MR-conditional needle itself.

The dual speed motors in the updated model have improved the speed so as the robot can reach its target location in about 10 seconds. In case of any technical mishap, a safety mechanism in the device retracts the needle from the breast.

Here is the video showing how the new robot works.

University of Twente press release

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$10 Microchip by Duke and Stanford turns 2-D Ultrasound Machines to 3-D Imaging Devices

Researchers from Duke University and Stanford University have designed a $10 microchip to make a simple 3D ultrasound imaging device that produces 3D scans similar in quality to CT or MRI scans using your regular 2D ultrasound machine.

The researchers and physicians from Duke demonstrated their device on Oct. 31 at the American College of Emergency Physicians (ACEP) Research Forum in Washington, D.C. 

The budget microchip is roughly the size of a fingernail, and like a Nintendo Wii video game controller, the chip registers the probe’s orientation, then uses software to seamlessly stitch hundreds of individual slices of the anatomy together in three dimensions to give an instant 3-D model similar in quality to a CT scan or MRI. And the better the ultrasound machine being used, the higher the quality of the generated 3D image.

The chip can be added to your regular 2D ultrasound armament by using a 3D printed clip on attachment. 3D ultrasound machines can cost around $250,000, around five times more than their 2D counterparts.

 Joshua Broder, M.D., an emergency physician and associate professor of surgery at Duke Health and one of the creators of the technology got the idea behind the chip while playing Nintendo games with his son.

 After working on the chip for a year, he took sketches to Duke’s Pratt School of Engineering, connecting with then-undergraduate Matt Morgan, and biomedical engineering instructors and professors Carl Herickhoff and Jeremy Dahl, who have since taken positions at Stanford where they continue to develop the device.

The team has used Duke’s own 3-D printing labs to create a prototype, in the form of a streamlined plastic holster that slips onto the ultrasound probe. A physician can use the probe as a regular 2D probe or add the 3-D capability by simply snapping on a plastic attachment containing the location-sensing microchip. To get the best 3-D images, the team also devised a plastic stand to help steady the probe as the user hones in on one part of the anatomy.

The microchip and the ultrasound probe connect via computer cables to a laptop programmed for the device. As the user scans, the computer program whips up a 3-D model in seconds.

Both Duke and Stanford are testing the technology in clinical trials to determine how it fits in the flow of patient care. The creators believe some of the most promising uses could be when CT scans or MRIs are not available, in rural or developing areas, or when they are too risky.

“Instead of looking through a keyhole to understand what’s in the room, we can open a door and see everything in front of us.”

This upgrade is especially important for babies and trauma patients who cannot be moved. The team has already received a grant from Emergency Medicine Foundation and General Electric to conduct clinical trials for application of the device to located bleeding vessels in trauma patients.

The quality of resulting 3D model is comparable to images produced by a 3D sonography machine, CT scan or MRI scan.”

Clinical trials are already on the way to test the technology in real life applications and emergency scenarios.

Here is a video in which Dr.Broder demonstrate the device.

ACOG updates recommendations for diagnostic imaging during pregnancy and lactation

http://www.infantrisk.com/content/radiological-procedures-pregnancy

ACOG has issued recommendations addressing the concerns surrounding the use of X-ray, sonography, nuclear medicine, CT and MRI in pregnancy and lactation. The committee opinion was published in October issue of Journal Obstetrics and Gynecology.

These investigative modalities have become an integral part of our diagnostic armamentarium for evaluating acute and chronic conditions. However, there is confusion and fear surrounding these tests among physician and patients alike that many times they are delayed or totally avoided. Many a times breast feeding is stopped while patient undergo these investigations.

The ACOG’s committee on obstetric practice make the following recommendations:

Ultrasonography and MRI are safe and are the imaging modalities of choice in pregnancy and lactation, although they should be availed only when they are expected to answer a relevant clinical dilemma or are provide health benefit to the patient.

Routine radiography, computed tomography (CT) scan, or nuclear medicine imaging techniques exposes the pregnant women to a dose that is much lower than what is associated with fetal harm and so these techniques should be used if deemed necessary in addition to USG or MRI or alone if they answer the relevant clinical question.

The use of gadolinium contrast with MRI is not advised in routine practice and should only be used as contrast if it significantly improve the diagnosis and maternal and fetal outcome during pregnancy.

Breastfeeding need not be interrupted after gadolinium administration.

Nuclear Medicine imaging should be limited to the use of technetium 99m at 5 mGy when indicated during pregnancy. 

Radioactive iodine (iodine 131) readily crosses placenta and is absolutely contraindicated in pregnancy.

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Are you dense? What every woman and her healthcare provider needs to know.

courtesy: Are you dense

Nearly 20 plus years of research have provided sufficient evidence to link dense breast tissue and increased risk of missing cancer diagnosis by screening mammography. As the breast density increases, the reliability of mammogram as a screening tool for picking up breast malignancy decreases.

What is meant by “being dense”? Breast density does not correlate with physically palpated firmness of breast, it is a radiologic finding and cannot be predicted without obtaining a mammogram. 

Mammographic breast density is defined as the relative amount of radio-opaque (white) elements to radiolucent (black) fat on the image. Increase in the proportion of radio-opaque elements leads to greater mammographic breast density.

Radiologists find it difficult to distinguish between tumor and normal dense tissue, both of which appear white on a mammogram.

In fact, mammography will only detect 30% cancer in dense breasts and 80% in non-dense breasts.

Nearly 40% of women have dense breast, which means that only using mammography as a screening tool puts this population at high risk of missing the diagnosis, delayed diagnosis or diagnosis at very late stage of disease. A recent search of PubMed revealed nearly 3,027 studies on masking risk of dense breast tissue.

Increased density of breast is a casual as well as masking risk factor for breast cancer. According to the American Cancer Society, having heterogeneously or extremely dense breast tissue puts you at risk of breast cancer that is equivalent having one first-degree relative with breast cancer. (2.1 to 4 times the normal risk)

Also, women with dense breast are put at increased risk of developing contralateral breast cancer and interval cancer (cancer detected within 12 months of a normal mammogram)

A recent Breast Cancer Surveillance Consortium study noted that breast density exceeds all other risk factors like obesity, family history and delayed childbirth.

About 28 states in USA have passed law regarding the mandatory reporting of breast density and the necessary follow up thereafter, after women have a screening mammogram.

So, is there a standard protocol for supplemental screening if a woman is diagnosed of having dense breast on screening mammogram? No, unfortunately not, the medical community has not agreed on a protocol regarding supplemental screening for women with dense breasts.

In a position statement, the ACOG, identifies dense breast as a moderate risk factor but does not support routine use of adjunct screening modalities in an average risk woman with dense breast. The American Cancer Society urges the patients with dense breast to talk to healthcare providers about additional screening modalities and advises an MRI along with her yearly mammogram in a high-risk group.

The American College of Radiology identifies breast density as a controversial risk factor for breast cancer with no consensus that it confers sufficient risk to warrant supplemental screening.

At this time, it is highly suggested that patient should initiate a dialogue with her physician, regarding the protocol to be followed after the diagnosis of dense breast. Each patient should be individually evaluated about her risk of breast cancer based on her genetics, family history and other risk factors.

One suggested approach based on a paper presented by Lee C. at Society of Breast Imaging/American College of Radiology Breast Imaging Symposium; April 26, 2015; Orlando, FL is to use tomosynthesis for all levels of risk, supplemental whole-breast ultrasonography for women with average risk, and supplemental magnetic resonance imaging for women with intermediate and high risk

For women who are at high risk and also have a contraindication to magnetic resonance imaging, whole breast ultrasonography or molecular breast imaging, if available, may be an appropriate alternative.

courtesy: https://www.moffitt.org/media/6369/125.pdf

The current options available in addition to screening mammography are Tomosynthesis or 3D mammography, Ultrasound, Magnetic Resonance Imaging (MRI), Molecular Breast Imaging (MBI) or Breast Specific Gamma Imaging (BSGI) and Contrast Enhanced Spectral Mammography (CESM)

Nancy M. Cappello, Ph.D. has founded Are You Dense, Inc., and Are You Dense Advocacy, Inc., to educate women and general public about the challenges women with dense breast face regarding the screening tools for detecting early breast cancer.

Classification of Breast Density: American College of  Radiology. 

click to enlarge

Virtual reality 3D technology allows parents to meet their unborn child: News from Radiological Society of North America 2016 Annual Conference.

3D virtual model MRI view of fetus at 26 weeks.Photo credit: Image courtesy of Radiological Society of North America

1. New technology combines MRI and Ultrasound data into a 3-D virtual reality model of a fetus.
2. The models are very similar to what the baby will look like after birth and can create any internal fetal organ replica to perfection.
3. Wearing a virtual reality headset, the parents can hear the baby’s heartbeat and see the anatomy. 

Parents may now be able to see their unborn babies developing in realistic 3-D immersive visualizations. This is made possible because of efforts of team of Brazilian researchers said Heron Werner Jr, MD, PhD, from the Clínica de Diagnóstico por Imagem in Rio de Janeiro.

The study was presented at the Radiological Society of North America 2016 Annual Meeting in Chicago on November 30,2016.[i]

“The 3-D fetal models combined with virtual reality immersive technologies may improve our understanding of fetal anatomical characteristics and can be used for educational purposes and as a method for parents to visualize their unborn baby,” said study co-author Heron Werner Jr., M.D., Ph.D., from the Clínica de Diagnóstico por Imagem, in Rio de Janeiro, Brazil.

The new technology transforms MRI and ultrasound data into a 3-D virtual reality model of a fetus. The construction of 3D accurate virtual model starts with the MRI scanning slices that are than sequentially stitched together to form a 3-D image. The physician decides the organ or body part he wants to visualize and   that part is reconstructed including the uterus, placenta, umbilical cord and fetus.  

At the beginning of the study the researchers scanned 6 mm "slices" and put them together, now they scan 1mm slices improving the resolution and producing more clear pictures.

The Virtual reality 3-D model is very similar to what a baby would look like after delivery. The doctors can create a very detailed structure of every organ of the fetal body.

 Werner and colleagues turned to the latest-generation Oculus Rift 2 (Oculus) headset to be used as the virtual reality viewing device. The parents don the device to interact with the baby in this very real immersive sensory environment. Adding the heartbeat by the use of headphone brings them further close to  the baby. Users can simply move their heads to study 3D fetal anatomy close-up.

Oculus device headset 

"The experience with the Oculus Rift has been wonderful," Werner said. "It provides fetal images that are sharper and clearer than ultrasound and MR images viewed on a traditional display." 

The virtual reality model has an array of potential applications, including detection of important structural malformations like cardiac and respiratory. It can also be of great help in cases requiring intrauterine surgeries. Using the models the team can simulate the surgeries in virtual reality.

https://3dprint.com

"We think this is especially interesting for training novice endoscopic surgeons." Dr Werner said.

"We believe that these images will help facilitate a multidisciplinary discussion about some pathologies, in addition to bringing a new experience for parents when following the development of their unborn child." said Dr. Werner.

Currently Dr Werner is working on many projects including creating models to study trisomy 11 and trisomy 18 syndromes, ZIKA syndrome.

The researchers have already used the technique in many cases in Rio that required postnatal surgeries. They are hoping for a broader use of the technology in near future.

Not everyone is ready to jump on the virtual reality 3-D visualizations. Some doctors still prefer the 3D-printed models with a hands-on experience.

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[i] https://press.rsna.org/timssnet/media/pressreleases/PDF/pressreleasePDF.cfm?ID=1912