ROBOTIC IMAGE GUIDED BIOPSY FOR BREAST INTERVENTION SYSTEM

Muhammad Haikal Zakariya, Muhammad Nasih Saifullah, Nur Hidayah Darmizal, Syaza Hannah Mohd Yusof, School of Electrical and Electronic Engineering Universiti Teknologi PETRONAS, Bandar Seri Iskandar, 31750 Tronoh, Perak Darul Ridzuan, Malaysia.
E-mail: haikal.mags7@gmail.com, mnasihs@gmail.com, ieyda21.ran@gmail.com, syazathirdteen@gmail.com
AbstractRobot-assisted breast intervention system has a number of advantages. Low cost and low morbidity are two of the advantages that are worth mentioning. However, the success of these procedures is critically dependent on precise placement of the biopsy probe at the location of the tumor. Besides that, during manual image-guided breast interventions, freehand ultrasound (US) imaging is challenging and it require requires high level of skill to simultaneously coordinate image acquisition with probe insertion and breast stabilization. To address the problems mentioned, a novel robotic breast intervention device is presented in this paper. This system assists the clinician by: 1) ensuring accurate placement of the instrument at the tumor location and 2) autonomously acquiring real-time images of the tumor. Experimental results on breast phantoms demonstrate the efficacy of this device. This system is proven to have the potential to increase targeting accuracy while at the same time reducing the level of skill required to perform minimally invasive breast interventional procedures.

and precise placement of a biopsy needle at the target (in this paper, the word target is used to refer to a tumour, lesion, or just a suspected region of tissue) in the breast. During the procedures, a hollow core needle is percutaneously inserted into the soft, inhomogeneous breast tissue in order to sample a target. In such procedures, it is critical to position the needle tip precisely at the target. This is challenging due to several reasons, such as tissue heterogeneity, tissue deformation, target mobility, patient movement, and poor manoeuvrability of the needle. The current state-of-the-art minimally invasive procedure is highly dependent on the skill of the clinician and requires extraordinary level of handeye coordination. Quality discrepancy has been noted in many studies and appears to be related to surgeon volume and/or specific breast surgery or surgical oncology training. It is concluded in that breast-focused surgeons are more competent than the 50% of surgeons who do the occasional case. To overcome the aforementioned limitations, a new paradigm for image-guided minimally invasive procedures is presented. To demonstrate the efficacy of this paradigm, a novel robot-assisted breast intervention device is developed. Sonography is the most widely used imaging technique because of its real-time capability and cost-effectiveness. Therefore, the robot-assisted breast intervention system presented in this paper is designed for ultrasound (US)-guided percutaneous breast biopsy. The biopsy instrument used for experimental validation is a 10gauge vacuum-assisted hollow core biopsy needle. The specific subsystems of this device are as follows. 1) A robotic manipulation mechanism: a mechanism to compensate for needletarget misalignment for providing access to mobile targets. 2) A US imaging system: an image acquisition system for dynamic tracking of the location of a target in real time using a 2-D US probe. These two subsystems are then integrated for a semi-automated modality of breast interventions. II. LITERATURE REVIEW A biopsy is a medical test commonly performed by a surgeon or an interventional radiologist. It involves sampling of tissues or cells of living subjects for examination purposes. From those samples, the presence or extent of a disease can be determined. Generally, the samples are examined under a

Keywords-autonomous ultrasound (US) imaging; robotassisted intervention; tumor manipulation

I.

INTRODUCTION

Breast cancer is the most common cancer among American women and is the third leading cause of cancer death in women. On the next year, it is approximated that 182 000 new breast cancer cases will be diagnosed with an estimated death of more than 40 000 women. New minimally invasive procedures such as percutaneous core needle biopsy, radiofrequency ablation, interstitial laser ablation, and cryotherapy offer treatment options that are psychologically and cosmetically more acceptable to patients than traditional surgery. These procedures also have numerous benefits such as low morbidity, decreased cost, short operating time, quick recovery of patient, etc. Early detection of breast cancer has been proven to reduce mortality by about 20%35%. For definitive diagnosis of cancer, histopathological examination is considered to be the Gold Standard, but requires tissue samples that are collected through biopsy. There are two major approaches for breast biopsy. One is needle biopsy and another one is open excisional biopsy. Of these two, needle biopsy is more attractive because it is less traumatic, produces little or no scar, allows quicker recovery, and is less costly. However, of all these advantages of needle biopsy, there are significant technical challenges concerning accurate steering

microscope by a pathologist but the samples may be analysed chemically as well. There are a few kinds of biopsies; excisional biopsy, incisional/core biopsy, and needle aspiration biopsy. The need of biopsy arises due to diseases that require tissues or cells examination. A common example would be cancer. Statistics have shown that in North America, the most common type of cancer among men is prostate cancer [1]. On the other hand, breast cancer tops the list among women in the United States [2]. As of now, there is no cure for cancer. The only way cancer can be fought is by early detection of symptoms through biopsies. The common type of biopsy being applied is the core biopsy in which needle is inserted into certain parts of the body to obtain sample of tissues or cells. The insertion of needle requires accuracy and precision. However, precise placement of the needle at the target is challenging because of several reasons, such as tissue heterogeneity, tissue deformation, target mobility, patient movement, and poor maneuverability of the needle itself [3]. These limitations can cause serious problems especially for cancer patients. For instance, lung cancer patients will have to hold their breaths for a certain time in order to allow biopsies being performed into their lung nodes. This will make them feel uncomfortable which may result in an inaccuracy of needle positioning, an increase in the number off needle passes and occurrence of complications such aspneumotharax and bleeding [4]. Due to these limitations, physicians are often forced to take large safety margins and as a result these ultra-minimally invasive techniques cannot be used near sensitive anatomy [5]. Once inserted, repositioning the distal tip of a straight percutaneous instrument in tissue is challenging, if not impossible, because of forces along its length from the tissue that resist its pivoting motion. Thus, if an instrument is incorrectly placed, a radiologist is forced to retract it and attempt to re-insert it along the correct trajectory. Thus, instead of a manual biopsy, a new system is introduced using magnetic resonance imaging. MRI-guided biopsy has its pros and cons. Although it is cost-effective, timeefficient and less invasive, it may produce an inconclusive scan, not to forget, the technical failures that may happen from time to time. There are improvements being made to this system, such as the use of a masterslave haptic device using a novel haptic control scheme based upon a neural network speed model [6]. However, reflecting on the current available technology, the control system used can be further improved in terms of its efficiency and effectiveness. For prostate cancer patients, trans rectal ultra sound or TRUS-guided prostate biopsy is widely employed due to its real-time nature, relatively low cost, and ease of use. Its limitations, however, are substantial. Although shortcomings have been known over a decade and often reconfirmed, there are no major improvements in sight. Using standard techniques, biopsy of men with PSA blood test values in the range of 410 ng/mL, generally result in a cancer detection rate of 20%30%. Numerous studies have shown that TRUSguided prostate biopsy fails to detect cancer in at least 20% of

patients with cancer [7]. Studies have shown that more than one-third of men, whose first biopsies were negative, were rebiopsied within the next five years, resulting in a large number of repeat biopsy cases. Despite advances in ultrasound imaging methods, TRUS imaging is generally unable to differentiate between healthy tissue and cancerous lesions in the prostate. In consequence, contemporary TRUS-guided biopsy cannot identify or target lesions, and cancerous nodes of clinically significant size are routinely missed. Clearly, significantly improved alternatives to TRUS image guidance are needed [8]. In this case, the physician manually places a TRUS probe in the rectum of the patient and, under ultrasound guidance, inserts a biopsy needle through the wall of the rectum into the prostate gland. The needle removes a half-cylinder of tissue, which is examined pathologically to determine if cancer is present [9]. The limitations of this method are the same when compared to a core biopsy. Manual implementation of needle insertion will lead to errors and ineffectiveness. Researches have been made and there was a suggestion of a new concept; cooperative tele-surgical systems whereby robotic technology is introduced to counter the problem of having logistic problems to transfer patients from remote areas to central areas due to the lack of skillful healthcare personnel [10]. In this paper, the main focus is to implement robotic image-guided biopsy on breast intervention. This will help in ensuring accurate placement of the instrument at the tumor location and autonomously acquiring real-time images of the tumor. This system has the potential to increase targeting accuracy while at the same time reducing the level of skill required to perform minimally invasive breast interventional procedures. III. MATERIALS AND METHODS A. Control Block Diagram

Figure 1: Control structure for the manipulation mechanism.

B. System Modelling Design of a Robotic Manipulation Mechanism Currently available commercial biopsy instruments do not compensate for target movement. Freehand US-guided biopsy and stereotactic biopsy are the common techniques for sampling breast tissue supine position. During the procedure, clinicians simultaneously

1. 2. 3.

Manipulate the target position (by applying force on the breast using fingers) and stabilize the breast; Steer and insert the needle; and Manipulate US probe for imaging needle and target while monitoring the US image screen continuously.

Design of a US Imaging System One of the limitations of US-based imaging is that the US probe has to be continuously in contact with the surface of the breast to ensure acoustic coupling. Force sensors are typically used to ensure contact between the tissue surface and the US probe during image-guided robotic medical procedures. A speckle de-correlation technique for estimating out-of-plane motion of a target is presented. This approach assumes rigid motion of internal tissue to preserve correlation between successive image planes. Due to needle insertion and robotic manipulation, large tissue deformation occurs inside the breast, which limits application of this technique. We design a system for autonomous positioning of the US probe that can dynamically track the location of a target inside the breast. The design requirements for this system are as follows: 1. 2.
3.

Breast tissue is inhomogeneous and its biomechanical properties are nonlinear. Hence, tissue deformation displaces the target from its original location during needle insertion. Robotic fingers positioned around the breast apply force on the surface of the breast based on the image of the target to guide the target toward the line of insertion of the needle. The system can autonomously position a target at a desired location (typically in the path of the needle) with a high degree of accuracy. The overall design requirements for the manipulation mechanism are as follows. 1. As earlier discussed, planar manipulation of deformable objects requires three robotic fingers with a geometric arrangement such that the end points of their force direction vectors draw a nonzero triangle that includes their common origin point. Design should facilitate easy access to needle guidance system and US imaging system. Force applied by the fingers should be limited to avoid injury to the patient. Mechanism should be adjustable to accommodate different breast sizes. Mechanism should be compact. Mechanism should be inexpensive.

2. 3. 4. 5. 6.

The system should be developed for a 2-D US probe that is currently used for US-guided breast interventions. It should maintain contact between the US probe and the surface of the breast for acoustic coupling. It should have the ability to move the US probe in a 2-D plane that is perpendicular to the imaging plane of the probe to recapture the target image if the target deflects away from the original imaging plane.

Figure 3: Autonomous US image acquisition device with three DoF and two DoA Figure 2: Manipulation mechanism with three DoF and three DoA. ( Note that DoF is degrees of freedom and DoA is degrees of actuation)

4.

It should be compact.

Based on these requirements, a manipulation mechanism is designed, as shown in Fig. 2.

Based on these requirements, a design for the autonomous image acquisition system is developed, as shown in Fig. 3.

3. Design of a Needle Guidance System 4. 5.

Robotic fingers have built in switches to avoid over compression Range of motion of the fingers is also limited through software control A panic button is integrated into the system for manual shut down in case of emergency.

C. Theory / Techniques To determine the number of robotic fingers and their geometric arrangement necessary for planar position control of a target embedded inside the deformable object, we use the force closure theorem in mechanics: 1) at least three robotic fingers are required; and 2) the arrangement of the fingers should be such that the end points of their force direction vectors draw a nonzero triangle that includes their common origin point. With such an arrangement, the target position can be controlled in a plane. The robotic image-guided breast intervention system presented here is designed for prone position breast interventions. Prone position offers maximum workspace with good surface contact area on the breast for the robotic fingers. Needle incision site and orientation of the needle are chosen by the clinician considering factors, such as location of target, location of critical anatomical structures, and ease of access to target. The desired target position is the point where the line of insertion (of the needle) intersects the plane containing the target. While one can choose any plane that contains the target and has an intersection with the line of needle insertion, this plane is chosen to be the horizontal plane for simplicity. IV. DISCUSSION System using eye-approximation and joints of needle guidance are used in these experiments. However, the actual needle path could be a little bit different from the computed one. This is due to sensor accuracy and also mechanical limitations. In the future, needle path may be dynamically determined by using a 6-DOFs electromagnetic (EM) sensor (for instance miniBIRD from Ascension Tech has translational and angular accuracy of 1.8mmand 0.5, respectively), which also facilitates freehand needle insertion. Breast tissue properties vary greatly based on factors, such as age, presence of tissue abnormality, etc. In order to demonstrate the feasibility of this technique under significant parameter variation, phantoms are prepared with varying elastic properties to demonstrate that the controller can work in realistic scenarios. The phantom is suspended vertically (to mimic prone patient position) and the needle is inserted into the phantom using the needle guidance system. A 10-gauge (approximate diameter 2.5 mm) hollow core needle is used for this experiment. In this experimental setup, the US probe is coplanar (horizontal plane) with the robotic fingers. A needle is inserted at an angle (altitude ) to the horizontal plane. Therefore, needle insertion is not parallel to the image plane of the US probe. The US probe is placed

Figure 4: Needle guidance system with four DoF and one DoA

Fig. 4 shows a needle guidance platform that facilitates orientation of the needle based on location of the target and other critical anatomical structures. The system has four DoF (P9, P10, P11, and P12) and one DoA (A6). All joints of the system are equipped with potentiometers for determining the needle orientation. Essentially, this platform is capable of orienting the needle to reach any target in the breast. Note that the needle guidance system facilitates manual needle insertion, which is under the direct control of the clinician. Also note that the needle guidance system is not used to steer the needle. Needletarget alignment is ensured only through target manipulation. The needle guidance system facilitates positioning of the needle based on the incision site and direction of insertion chosen by the clinician. In this regard, needle trajectory can be chosen anywhere by the clinician. Integrated System

Figure 5: Robotic image-guided breast intervention system.

Fig. 5 shows the integrated robotic breast intervention system. The robotic system is designed with the following safety features to avoid catastrophic failure or accidental injury during operation: 1. 2. All mechanical components of the system are designed to ensure structural safety Robotic fingers have built in overload protection so that if the force exceeds 45 N, actuator shuts off to prevent injury

coplanar with the robotic fingers because the thickness of the image slice obtained with the US probe is about 5 mm. Therefore, the maximum resolution (in controlled coordinates X and Y) of target position is obtained when the image plane is coplanar with the target manipulation plane (horizontal plane).

Figure 8 : Targeting Accuracy

V. CONCLUSION Usage of robotic fingers is used as the concept in manipulating the position of a targeted embedded in soft tissue. This is important in ensuring the minimization of needle- target misalignment. Advantages of this particular approach show in the increasing number of success rate. Apart from that, patient feels more comfortable and it also gives an enhanced outcome in quite large numbers of people.
Figure 6: Experimental Data

Results produced are very important to see if target is achieved or not. Thus, experiments after experiments need to be done in getting the goal. These results are necessary to indicate the accuracy in target positioning. This kind of approach is crucial because it helps to gain an accurate sample for the experiments in a short time. It only requires a single insertion during breast interventions. From the results, it is shown that this system is capable of tracking targets in 3-D space by using a 2-D probe. Through discussions with several breast surgeons and radiologists said that this kind of system will have utility in hospitals without dedicated breast centres, in which highly skilled breast surgeons are not available. However, this system has certain limitations: 1. Target position information is derived through segmentation of US images. Real-time segmentation of breast US image is more challenging. To maximize the resolution oftarget position coordinates, the US probe is arranged coplanar with the target manipulation plane. Hence, the needle and theUS image plane are not parallel. This may present difficulty to aclinician in identifying the needle tip before sampling the target.

2.

Figure 7 : Experimental Data

ACKNOWLEDGMENT First and foremost, we would like to express our utmost gratitude towards Dr Irraivan Elamvazuthi, the lecturer of Control Systems course for being helpful throughout the process of completing this project paper. Apart from that, we would like to thank all the group members for giving full commitment towards this project. Despite of the tight schedules, all the group members are willingly to spend time and complete the research paper in time. Last but not least, we would like to thank all the parties who had helped us directly or indirectly in the success accomplishment of completing this research paper. REFERENCES
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