University of Groningen CT-guided percutaneous interventions Heerink, Wouter

University of Groningen

CT-guided percutaneous interventions

Heerink, Wouter

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2019

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Citation for published version (APA):

Heerink, W. (2019). CT-guided percutaneous interventions: Improving needle placement accuracy for lung

and liver procedures. Rijksuniversiteit Groningen.

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O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 O2 O2 O2 O2 O2 O2O2 O2 O₂ O2 O2 O2 O2 O2O2 O2 Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb 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HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb HbHb Hb Hb Hb Hb HbHb Hb Hb Hb Hb Hb Hb 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CHAPTER 1

General Introduction

CHAPTER 1

Lung cancer

Lung cancer is the most common cause of cancer-related deaths worldwide [1]. In the

USA, lung cancer screening by low-dose computed tomography (CT) is recommended

for people at high risk, and the European Society of Radiology and the European

Respiratory Society are recommending lung cancer screening within clinical trial or in

routine clinical practice at certified medical centers [2, 3]. With the expected

introduction of lung cancer screening, an increase of CT detected lung nodules is

anticipated. Nodules larger than 10 mm in diameter and most likely even smaller

nodules with significant growth will be eligible for medical work-up [3].

Bronchoscopy is often used to diagnose these lung nodules and to get a tissue diagnosis,

but it is limited to centrally located lesions [4]. CT-guided transthoracic lung biopsy is

a minimally invasive diagnostic procedure for tissue diagnosis of peripheral lung

nodules. These can alternatively be reached with surgery, but the percutaneous

approach is less invasive and associated with lower costs. Other imaging modalities used

for percutaneous needle guidance include fluoroscopy, CT-fluoroscopy, ultrasound and

magnetic resonance imaging (MRI). Fluoroscopy lacks three-dimensional imaging

possibilities, so the operator has to be capable of translating the two-dimensional

projections to a volumetric environment. Additionally, it requires the operator to be in

the room during image acquisition, causing exposure to harmful radiation. Whilst

CT-fluoroscopy does provide volumetric images, it too exposes the operator to radiation.

Ultrasound does not induce radiation to the patient or the operator and with this

technique, the nodule and biopsy needle can be followed in real-time. The downside is

that only pleural lesions can be visualized as the air-filled lungs are poorly suited for

ultrasound. Lastly, MRI is sometimes used but it is more cumbersome as the metallic

biopsy needles are generally not MRI compatible. Additionally, patient access is limited

within the bore and lung lesions are relatively poorly visualized, compared to CT. So,

even though CT-guidance exposes the patient to radiation and lacks real-time feedback

for the operator, it is still the method of choice for many percutaneous interventions [5].

Liver cancer

Primary liver cancer combined with liver metastases is the second most common cause

of cancer death [1]. Over the last 20 years, thermal ablation has emerged as a successful

treatment method for hepatic malignancies [6–8]. Radiofrequency ablation (RFA) and

microwave ablation (MWA) are currently recommended for treatment of hepatocellular

carcinoma (HCC) and colorectal liver metastasis (CRLM) in patients unfit for surgery or

in combination with surgery [9, 10]. Currently, antenna placement is frequently

performed with CT as imaging modality for planning and positional feedback of the

ablation antenna.

Other imaging modalities offer similar drawbacks as those mentioned for transthoracic

lung biopsy, with the exception of ultrasound. In theory, ultrasound is more suitable for

percutaneous needle placement procedures in the liver compared to the lung. However,

liver tumors are often not easily delineable from the underlying liver parenchyma on

ultrasound. With contrast-enhanced CT, delineation of liver tumors is achieved more

accurately. Because CT is a three-dimensional imaging technique, planning of multiple

overlapping ablation zones to cover the entire tumor is less prone to errors.

1

INTRODUCTION

The main drawback of percutaneous liver tumor ablation is local recurrence of disease,

with reported ablation site recurrence rates ranging from 5.0% to 32.1% [7, 11–13]. Risk

factors for ablation site recurrences include larger tumor size, peritumoral vascularity,

and insufficient ablation safety margin surrounding the tumor [14–16]. The latter can

be caused by inaccurate placement of the ablation antenna, so for CT-guided liver tumor

ablation accurate needle placement is critical. Another cause of incomplete ablation is

the creation of unreliable ablation zones: when the actual ablation zone is inconsistent

with the claimed protocol, there is a chance of incomplete ablation treatment, despite

correct positionings of the ablation antenna. Heat-sink caused by blood vessels adjacent

to the tumor is a well-known cause of ablation zone volume reduction [17]. Differences

in tumor type and pathology of the underlying parenchyma have been demonstrated to

affect the microwave ablation zone, too, in a two-compartment computer model [18].

Because ablation device manufacturers currently supply ablation protocols that are

mainly based on ex-vivo non-perfused animal livers, these do not correlate very well

with clinical practice.

Freehand approach

While CT is an excellent imaging modality for feedback of target and needle position,

the actual guidance of the needle is still performed by hand (freehand method). Thus,

based on the images provided by the CT, the operator has to determine how to angle

and insert the needle towards the target. This is often an iterative process, where every

needle repositioning increases the chance of complications.

With percutaneous needle placement, a differentiation can be made between in-plane

and out-of-plane procedures. With in-plane approaches, the target is in the same axial

position as the entry point on the skin, so the entire needle path can be imaged on a

single axial CT slice. Here, the operator has to angle the needle towards the target on

one axis. With out-of-plane approaches, the target is either cranial or caudal to the entry

point. In order to image the needle path on a single slice, an oblique view must be used.

Moreover, the operator has to angle the needle towards the target on two axes. Where

the in-plane procedures are not too difficult to perform freehand, the out-of-plane

procedures often require multiple needle repositionings in order to achieve adequate

placement accuracy.

Robotic approach

Needle placement can be aided by the use of robotic systems. These generally provide

some sort of needle guide, for the operator to push the needle through in order to

increase needle placement accuracy. Over the years, numerous systems have been

developed [19]. Despite the relatively large number of (experimental) robotic systems,

there are few randomized patient studies that assess their functionality in real clinical

environments. Only two RCTs could be identified that compared robotic needle

placement with freehand needle placement. The study of Patriciu et al. from 2005 was

the only one performed in patients with liver tumors, testing a robotic device (AcuBot)

in a randomized study with only 14 patients [20]. The AcuBot reduced the number of

needle repositionings and targeting time, but needle placement accuracy was not

reported. To this date, the Acubot is still not on the market. In another, non-randomized

clinical study Engstrand et al. analyzed the accuracy and procedural safety of the

CAS-One for CT-guided percutaneous MWA of liver tumors [21]. They reported a lateral

CHAPTER 1

accuracy of 4.0 mm in 28 tumors, although no comparison with freehand positioning

was made. No differentiation between in- and out-of-plane procedures was mentioned

in either study.

Recently, the Needle Placement System (NPS) has been developed as a system to

facilitate accurate percutaneous needle placement for CT-guided interventions [22]. The

NPS mounts on a rail parallel to the CT table and can be manually maneuvered towards

the entry point on the skin. After locking the system, it automatically orients a needle

guide towards the target. Subsequently, the needle can be inserted by the operator to

the specified depth. It has the potential to offer simplicity in terms of device

maneuverability, while still providing a stable platform from which automatic needle

orientation is performed.

Respiratory motion

An often-overlooked issue with percutaneous needle placement is the effect of

respiration. For CT-guided liver ablation, where procedures are mostly performed under

general anesthesia, the respiration can be paused during acquisition of the CT scans and

manipulation the ablation antenna. The chest (and thus the organs) can be expected to

have returned to an approximately similar position when the CO

2

output is monitored

to have reduced to zero after stopping respiration; especially when patients are

positioned on a vacuum mattress. So, for procedures performed under general

anesthesia, respiratory motion is less of an issue. However, less invasive procedures

such as lung biopsies are performed under local sedation, because of the risk, time and

cost associated with general anesthesia. The downside to local sedation is that patients

are required to repeatedly hold their breath at a consistent level during the procedure.

Since lung nodules move on average 25 mm up and down with inspiratory capacity, the

level of breath-hold during acquisition of the planning CT scan and during needle

manipulation is not the same and accurate targeting is impossible [23].

Currently available respiratory tracking systems suitable for image-guided intervention

consist of respiratory belts that are cumbersome to install, only have a weak correlation

with nodule position, and do not adjust for a change in breathing pattern [24]. Several

groups have investigated the use of a depth camera (Kinect) to monitor patient

respiratory motion for four-dimensional radiotherapy planning and the Kinect has

potential to be used in image-guided interventions, too [25–27].

Outline of this thesis

The aims of the research described in this thesis are to investigate methods to improve

the accuracy of CT-guided needle placement and to find factors affecting the ablation

zone with liver tumor ablation.

Increased needle manipulations result in more tissue damage and can be expected to

increase the chance of complications. In Chapter 2, the complication rate and factors

affecting the complication rate of CT-guided lung biopsies are determined in

meta-analysis, as a baseline.

In the first part of this thesis, the NPS was put to the test. Chapter 3 shows the results

of a phantom study performed to validate this system. An anthropomorphic phantom

1

INTRODUCTION

was designed to simulate CT-guided liver ablation, mimicking clinical practice. With

this phantom, MWA antenna placement with the NPS was compared to freehand

antenna placement by experts and novices. Subsequently, the NPS was analyzed in

clinical practice. In Chapter 4, a randomized controlled trial is performed to compare the

NPS with freehand MWA antenna placement, in patients undergoing CT-guided liver

ablation. The primary outcome of this study was the number of antenna repositionings

required to achieve adequate placement.

In order to use the NPS in interventions performed under local sedation, a solution for

the respiratory motion was sought for. A system was developed in which the Kinect

camera was used to provide respiratory biofeedback to patients to help them return to

a consistent level of breath-hold. In Chapter 5, this system is tested with eight

volunteers, using spirometry. Alternatively, increased needle positioning accuracy can

be achieved by using a flexible, steerable needle. The advantage of such a needle

compared to a rigid needle is that it can avoid critical structures by steering around and

it can potentially compensate for respiratory movement. In Chapter 6, a CT-compatible

needle steering robot that utilizes an electromagnetic tracking system is presented and

tested in a phantom study.

In the last part of this thesis, the challenge of creating a predictable ablation zone is

addressed. Chapter 7 presents a systematic review of all FDA approved MWA systems,

in particular with regards to the variability of the ablation zone volume that is created

in animal and in- and ex-vivo studies. In Chapter 8, differences in the relation between

applied energy and ablation zone volume in hepatocellular carcinoma and colorectal

liver metastasis are investigated. The goal of this retrospective study was to find if

ablation protocols should be optimized for different tumor types for RFA and two MWA

devices.

In Chapter 9, the main results of the chapters in this thesis are discussed together with

future perspectives. Chapter 10 provides a Dutch summary.

CHAPTER 1

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