Standardized image-guided and robotic assisted biopsies in lung cancer

Annually, approximately 10,000 people die from lung cancer, making lung cancer by far the leading cause of cancer deaths. The prognosis is generally poor but increases greatly when lung cancer is detected at an early stage. This is why the introduction of lung cancer screening is investigated in another CMI-NEN project: the NELSON study.

In the NELSON study participants with a high risk of lung cancer are included and participants in the screen arm are screened with multi-detector CT. Lesions detected in the lung (lung nodules) are characterized based on volume, growth rate (volume doubling time) and other radiological features. Participants with suspicious lung nodules are referred to a pulmonary physician for further diagnostic work up.

Besides additional imaging such as bronchoscopy and PET-CT the pulmonary physician requires tissue of the nodule to diagnose lung cancer and to accurate determine the treatment. For peripheral nodules this can be done using CT guided transthoracic biopsy. This is an iterative procedure where a biopsy needle is inserted between the ribs and guided towards the nodule, using CT scans to check the position of the needle after every repositioning. When the nodule is reached the biopsy can be performed.

Because of respiratory movement the position of the nodule is not stationary, making it a difficult procedure to perform. Also, the repetitive manipulation of the biopsy needle leads to a pneumothorax in 40% of the cases and if large vessels are hit, bleeding can occur. This increases hospital stay and thereby costs.

When lung cancer screening is introduced, an increasing number of suspicious lung nodules will have to be analyzed. It will be of great value to be able to obtain tissue samples of these nodules more easily, without having to resort to surgery.

That is why in the RICIBION project (which stands for Robotic Interventions using CT-Images for Biopsies of lung Nodules) a robotic needle guiding device is developed and tested. This device will assist the physician in the lung biopsy. It will be placed over the patient and when the CT scan is made, the access path to the nodule is determined automatically. 3D reconstruction techniques are used to verify no critical structures such as vessels will be hit. Next, the device automatically aims the biopsy needle in the right direction. This allows the physician to insert the biopsy needle in a single movement.

This technique reduces the number of CT scans and needle manipulations which results in a reduction of radiation dose, time and cost. Because the biopsy needle placement will be more precise, smaller nodules and more centrally located lung nodules will be accessible too. Moreover, a reduction in needle manipulation is expected to result in a decrease of complications.

The robotic guiding device is developed with DEMCON and the first prototype was finished in 2015. Currently, initial phantom testing (testing the device on an artificial patient) is finished and the results are looking promising. Permission has been granted by the ethics committee to use the needle aiming device for needle placement in CT-guided liver ablation. We expect to start a pilot study, using the device for biopsy in patients with lung nodules in 2017.

More background information can be found on the website of CMI-NEN