1、Model-Guided Therapy and the role of DICOM in Surgery,Heinz U. Lemke, PhD,Chair of Working Group 24 “DICOM in Surgery“,Content,Introduction (problems and solutions) Model guided therapy with TIMMS Classification and model classes Virtual human model examples Conclusion,Computer Assisted Digital OR S
2、uite for Endoscopic MISS Problems: Multiple Data Sources,Courtesy of Dr. John Chiu,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
3、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
4、 an adapted therapeutic workflow.,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 specialis
5、ation, respectively.,Biosensors (physiology, metabolism, serum, tissue, ),Modalities (X-ray,CT, US, MR,SPECT, PET,OI),Model Based Patient Care,Model Creation and Diagnosis (Data fusion, CAD, ),Model Maintenance and Intervention (Simulation, decision support, validation, ),IT Communication Infrastruc
6、ture,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,IT Model-Centric World View,Interventional Cockpit/SAS modules,Modelling,Therapy Imaging and Model Managem
7、ent System (TIMMS) ICT infrastructure (based on DICOM-X) for data, image, model and tool communication for patient model-guided therapy,Simulation,Kernel for WF and K+D Management,Visualisation Rep. Manager,Intervention,Validation,Repo- sitory,Engine,Data Exch.,Control,IO Imaging and Biosensors,Data
8、 and information,Models and intervention records,Therapy Imaging and Model Management System (TIMMS),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
9、 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.,Model Guided Therapy,The basic TIMMS patient model must have the following feat
10、ures: 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 infrastr
11、ucture. 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
12、 to maintain the model in an up-to-date state.,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
13、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 an
14、d 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 clinica
15、l trials, predictive modeling, personal health records and in the long term contribute to a Model Based Medical Evidence (EBME) methodology.,IT Model-Centric World View,Interventional Cockpit/SAS modules,Modelling,Therapy Imaging and Model Management System (TIMMS) ICT infrastructure (based on DICOM
16、-X) for data, image, model and tool communication for patient model-guided therapy,Simulation,Kernel for WF and K+D Management,Visualisation Rep. Manager,Intervention,Validation,Repo- sitory,Engine,Data Exch.,Control,IO Imaging and Biosensors,Data and information,Models and intervention records,Ther
17、apy Imaging and Model Management System (TIMMS),Generic and patient specific n-D modelling tools,Geometric modelling Prosthesis modelling Properties of cells and tissue Segmentation and reconstruction Biomechanics and damage Tissue growth Tissue shift Properties of biomaterials .,Modelling tools,Mod
18、el 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 ther
19、apy 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, e
20、tc.,Model Guided Therapy,1-D signals (e.g. EEG) 2-D projection and tomographic images 3-D reconstructions Temporal change Tissue/cell type Ownership to organ, lesion, system, prothesis, chronic condition, etc. Spatial occupancy/extension Permeability (blood brain barrier) Flow (e.g. electric, heat,
21、liquid, perfusion, diffusion, etc.),In a simple PSM, voxels may be associated with several dimensions of data,Model Guided Therapy,Level of oxygenation (e.g. level of hypoxia) Pharmacokinetics (e.g. effect of tissue on pharmaceutical agent, flow parameters, time to peak, etc.) Pharmacodynamics (effe
22、ct 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. 3, 5, 7, etc.) .,In a simple PSM,
23、 voxels may be associated with several dimensions of data,Example: ENT model elements,Source: G. Strauss,Example: ENT model elements,Source: G. Strauss,Content,Introduction (problems and solutions) Model guided therapy with TIMMS Classification and model classes Virtual human model examples Conclusi
24、on,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
25、 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 ran
26、ge of validity.,Source: J. Bassingthwaighte,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 patie
27、nt.By default, the broader the spectrum of different types of interventional/surgical workflows which have to be considered, the more effort has to be given for designing appropriate multiscale PSMs and associated services.,Patient specific and associated modelling functions,Management of n-D and mu
28、lti 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.,Content,Introduction (problems and solutions) Model guided therapy with TIMMS Cla
29、ssification and model classes Virtual human model examples Conclusion,Patient Specific CMB,Visible Human Anatomical Template organ surface meshes,Multimodal Imaging (MRI, CT, Angio,DT-MRI),PKPD,Spitzer 2006 Virtual Anatomy,FEM Mesh (Roberts JHU),Human Laser Scan (CAESAR DB),Roberts JHU,Content,Intro
30、duction (problems and solutions) Model guided therapy with TIMMS Classification and model classes Virtual human model examples Conclusion,Solutions and Research Focus (medical),Transition from image guided to model guided therapy (e.g. through workflow and use case selection/creation/repositories) C
31、oncepts 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,IT Model-Centric World View,Interventional Cockpit/SAS modules,Modelling,Therapy Imaging and Model Management System (TIMMS) ICT
32、 infrastructure (based on DICOM-X) for data, image, model and tool communication for patient model-guided therapy,Simulation,Kernel for WF and K+D Management,Visualisation Rep. Manager,Intervention,Validation,Repo- sitory,Engine,Data Exch.,Control,IO Imaging and Biosensors,Data and information,Model
33、s and intervention records,Therapy Imaging and Model Management System (TIMMS),Prototyping,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
34、 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 K+D management Cooperative and competitive R+D framework for engi
35、ne and repository building Therapy based open standard ( e.g. S-DICOM) Transition from CAD to CAT modelling,IT Model-Centric World View,Interventional Cockpit/SAS modules,Modelling,Therapy Imaging and Model Management System (TIMMS) ICT infrastructure (based on DICOM-X) for data, image, model and to
36、ol communication for patient model-guided therapy,Simulation,Kernel for WF and K+D Management,Visualisation Rep. Manager,Intervention,Validation,Repo- sitory,Engine,Data Exch.,Control,IO Imaging and Biosensors,Data and information,Models and intervention records,Therapy Imaging and Model Management
37、System (TIMMS),Archetypes and Templates,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 K+D management for selected i
38、nterventions Cooperative and competitive R+D 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 W
39、G24 “DICOM in Surgery”,IT Model-Centric World View,Interventional Cockpit/SAS modules,Modelling,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,Simulation,Kernel for WF and K+D Ma
40、nagement,Visualisation Rep. Manager,Intervention,Validation,Repo- sitory,Engine,Data Exch.,Control,IO Imaging and Biosensors,Data and information,Models and intervention records,Candidate components for open source,Open Source,WG 24 “DICOM in Surgery“ Project Groups,PG1 WF/MI Neurosurgery PG2 WF/MI
41、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,Definition of Surgical Work
42、flows (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 Thor
43、aco-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 (P
44、G6 Interventional Radiology),CARS / SPIE / EuroPACS 9th Joint Workshop on Surgical PACS and the Digital Operating Room Barcelona, 28 June, 2008,12th Meeting of the DICOM Working Group WG 24 “DICOM in Surgery“ Barcelona, 28 June 2008,CARS 2008 Computer Assisted Radiology and Surgery,http:/www.cars-int.org,WG24 “DICOM in Surgery”,Secretariat: Howard Clark, NEMA Secretary: Franziska Schweikert, CARS/CURAC Office fschweikertcars-int.org General Chair: Heinz U. Lemke, ISCAS/CURAC, Germany Co-Chair: Ferenc Jolesz, Harvard Medical School, Boston (Surgery/Radiology) Co-Chair: tbd(Industry),
