Digital Radiography

Beyond the Eye Medical Applications of 3D Rapid Prototyping Objects

a report by

F a b i a n R e n g i e r , 1 , 2 H e n d r i k v o n T e n g g - K o b l i g k , 1 C h r i s t i a n Z e c h m a n n , 1 H a n s - U l r i c h K a u c z o r 3 and F r e d e r i k L G i e s e l 1 , 3
1. Department of Radiology, German Cancer Research Centre (DKFZ); 2. Research Training Group 1126: Intelligent Surgery, University Hospital Heidelberg; 3. Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg

In the last few years, medical imaging and image post-processing techniques have rapidly advanced. Todays multislice computed tomography (MSCT) and high-performance magnetic resonance imaging (MRI) can acquire thousands of images within a breath-hold, recording volumes at incredibly high spatial resolution.1 MRI has experienced improvements in a variety of aspects such as increasing image quality and reducing acquisition times, thus strengthening its usefulness in daily clinical routine.2 Both modalities have their advantages and disadvantages, but thanks to rapid evolution during the last decades both have grown beyond two dimensions, giving rise to new opportunities for the medical and bioengineering community.3 Rapid prototyping is one of the most recently evolving techniques in this field4 and is expected to lead great progress in different industrial fields, including healthcare. This article will illustrate the pathway from medical imaging via 3D virtual visualisation to 3D solid objects using the rapid prototyping technique and discuss the medical applications and implications. From Medical Imaging to 3D Solid Objects The process chain from medical imaging to 3D solid objects can be divided into three major parts: image acquisition, image postprocessing and rapid prototyping. Images are acquired using CT or MRI, stored at a picture archiving and communication system (PACS) and transferred to a dedicated image post-processing workstation (see

Figure 1). On the workstation, 3D segmentation and visualisation are performed and the segmented structures are exported as machinereadable data with the possibility of further geometric modelling using computer-aided design (CAD) software. Such data can then be used by rapid prototyping machines to generate a 3D solid object. Image Acquisition 3D data volumes of adequate image quality are of vital importance for the basis of the process chain. To begin with, high spatial resolution with a reconstructed slice thickness not exceeding 1mm and nearly isotropic voxel size is essential to minimise partial volume effects and step artefacts during image reformation,5 as well as to obtain highly detailed imaging information. In cases of vascular applications, optimal timing of contrast material injection is required to achieve sufficient and homogenous enhancement of the arterial vasculature and to avoid streak artefacts from adjacent veins.6,7 Today, 3D data can be easily acquired using both CT and MRI. However, CT is still the preferred imaging modality compared with MRI because isotropy is easier to achieve and less time-consuming and, fundamentally, because segmentation algorithms work better with CT data. Nevertheless, MRI offers the possibility of acquiring 3D data of any structure within the body without radiation exposure. 8 Furthermore, 3D data can also be acquired using positron emission tomography (PET), single photon emission computed tomography (SPECT) or ultrasound. Image Post-processing

Fabian Rengier is a Research Fellow in the Department of Radiology at the National German Cancer Research Centre in Heidelberg. He is a Junior Lecturer in the Institute of Anatomy and Cell Biology at the University of Heidelberg, Head of the Concise Anatomy academic project and a founding member of the Virtual Anatomy working group. His research focuses on new cardiovascular imaging and image post-processing techniques. He has received grants from the German Research Foundation (DFG), the German National Academic Foundation and the University of Heidelberg. Dr Rengier attended medical school in Heidelberg.

The 3D data are stored using the common digital imaging and communications in medicine (DICOM) format and transferred to a dedicated image post-processing workstation for image analysis and reconstruction. By processing and recording extremely large streams of data, high-performance computers can conduct state-of-the-art image post-processing that transforms radiological individual images into 3D and even 4D worlds (adding synchronised motion). It is a technology that radiologists and hospital employees have used for some time. In this context, volume rendering (VR), maximum intensity projection (MIP) and other techniques are highly appreciated by the clinicians. For example, minimally invasive vascular surgery is planned and performed almost exclusively using 3D image post-processing to pinpoint the extent of the disease and treat it accordingly.9 Furthermore, 3D reconstruction of complex multifragment fractures is helpful for the orthopaedic surgeon to plan the operation and choose the correct osteosynthesis material. This next step in visualisation is achieved by using intricate mathematical algorithms to derive individual structures from radiological 3D volumes, transforming those structures and altering them as appropriate and

Frederik L Giesel is a Physician and Senior Researcher in the Department of Radiology at the National German Cancer Research Centre in Heidelberg. He is also an Honorary Visiting Lecturer at the University of Sheffield. His research focuses on image analysis, 3D visualisation and image postprocessing in neuro-imaging. He holds several patents for contrast media, undertakes various clinical trials and has broad expertise in industrial co-operation. Recently, Dr Giesel gained an international MBA to extend his expertise from medicine to economics and is a lecturer at the Frankfurt School of Finance and Management. E: f.giesel@dkfz.de

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Beyond the Eye Medical Applications of 3D Rapid Prototyping Objects

necessary. Such segmentation ultimately renders radiological imaging data into a virtual 3D reconstruction of the segmented structures in the form of slice contours or 3D triangle mesh models.10 This virtual model is then exported as machine-readable data, the kind of data that is needed to create models a procedure the automotive industry calls rapid prototyping. Outputs are normally saved in initial graphics exchange specification (IGES), surface tessellation language (STL) or virtual reality modelling language (VRML) format. These output files can be either directly transferred to a rapid prototyping machine or further processed using CAD software. CAD offers powerful geometrical modelling tools that can be used, for example, to prepare surgical implants or medical phantoms depending on their purpose. Rapid Prototyping In general, rapid prototyping can be defined as an approach or methodology used to quickly manufacture physical models using 3D CAD data. Rapid prototyping has also been referred to as solid freeform, computer-automated or layered manufacturing. Rapid prototyping has its obvious use as a truly 3D method for visualisation and better haptic impression. Currently, rapid prototyping is mainly devoted to producing 3D prototypes and models. The word rapid should be interpreted rather figuratively producing complex, individual models can take any time between hours and days. However, complex models would take weeks or months to produce using traditional approaches. In this way, rapid prototyping has revolutionised product development in the non-medical world and opens tremendous opportunities in the medical arena. The principle of rapid prototyping is to use 3D computer models for the construction of 3D solid physical models by the addition of layers of material.11 By building the solid object layer by layer, even complexshaped structures can be produced that would be difficult or impossible using conventional methods of material removal.12 Rapid prototyping refers to a number of established manufacturing techniques and a multitude of experimental technologies either in development or used by small groups of individuals. Each technique is based on different materials and offers different possibilities for all kinds of purposes. Established rapid prototyping techniques include sterolithography (SLA) based on photopolymers, selective laser sintering (SLS) based on plastic, metal or ceramic powders, laminated object

Figure 1: The Process Chain from Medical Imaging to 3D Solid Objects Image acquisition Image post-processing Rapid prototyping

The process chain from medical imaging to 3D solid objects can be divided into three major parts. Images are acquired using computed tomography or magnetic resonance imaging, stored in a picture archiving and communication system (PACS) and transferred to a dedicated image post-processing workstation. On the workstation, 3D segmentation and visualisation are performed and a computer-aided design (CAD) model of the segmented structures can be generated. Such data can then be used by rapid prototyping machines to create the 3D solid object.

Figure 2: The 3D Visualisation of the Ventricular System of a Child with Dandy-Walker Malformation A B

A: Image was exported and transferred to a rapid prototyping printer. A 3D print of the 3D ventricular system was created (B). 3D prints offer the unique possibility of a truly 3D appreciation and palpation of the complex ventricular morphology. Both 3D visualisation and 3D prints are invaluable to help parents of children with structural brain abnormalities and their clinicians to understand the exact nature of a childs anatomical abnormalities.

Medical Applications and Implications Medical applications are some of the most compelling applications of rapid prototyping. In the last decade, rapid prototyping has been used for a broad variety of medical purposes, including individual patient care, research, education and training. It is useful and beneficial for patients as it produces even complex solid models of anatomical structures. Individual Patient Care Anatomical Information for Surgery and Radiation Therapy Rapid prototyping objects can improve and facilitate diagnosis, preoperative planning of surgical procedures and intra-operative orientation. This is especially helpful in craniofacial and maxillofacial surgery,1318 but is also beneficial in many other applications ranging

In general, rapid prototyping can be defined as an approach or methodology used to quickly manufacture physical models using 3D computer-aided design data.

manufacturing (LOM) based on paper or plastic films, fused deposition modelling (FDM) based on thermoplastics or eutectic metals, solid ground curing (SGC) based on photopolymers, electron beam melting (EBM) based on metal powders and inkjet printing techniques using different kinds of fine powders.

from pelvic surgery,19,20 neurosurgery (see Figure 2)21 including spine surgery,22 cardiovascular surgery23,24 and visceral surgery.25 Studies dealing with these applications have demonstrated significant improvements in diagnosis and pre-operative planning due to better 3D appreciation of the pathology and increased accuracy of

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Figure 3: Rapid Prototyping Can Be Used to Produce Models of Living Organs from High-resolution In Vivo Images Representing the Actual Structure in 3D A B C

Humans are considered to be the most evolved and complicated organisms, yet we are still uncertain about many human physiological processes because in vitro models are used to mimic in vivo processes. In this work, a rapid prototyping model of the human trachea and bronchial tree was constructed from in vivo human computed tomography images (A) and remodelled 1:1 (B). The resulting model was then used as a flow phantom for gas-flow experiments with hyperpolarised helium (3He) magnetic resonance imaging to study the flow pattern of gas through the bronchial tree (C).

Figure 4: 3D Visualisation (A) and Rapid Prototyping Model (B) of the Aorta in a Patient with Thoracic Aortic Aneurysm

Prostheses and Implants In addition to being useful for surgical planning and navigation, the rapid prototyping technique can serve for producing medical prostheses and implants, in particular for bone reconstructions. The great potential of the rapid prototyping technique lies within the possibility of customised prostheses and implants. Commercially available standard-sized bone replacement parts may be sufficient for most surgical procedures and cases, but not for all cases of any given procedure. There are three reasons emphasising the need for individually produced prostheses. First, there are patients outside the standard range with respect to size or other special requirements caused by disease or genetics. Second, surgical outcome may be improved using customised devices because standard prostheses or implants do not always adequately match the individual anatomy. Third, customised prostheses and implants allow for minimisation of the amount of resected patient tissue. Hence, the time and costs for the production of customised rapid prototyping prostheses and implants seem to be reasonable in selected patients. The rapid prototyping technique has been applied to the reconstruction of a variety of anatomical structures, showing the potential of this

B A

Rapid prototyping is helpful in illustrating complex pathological structures. The rapid prototyping object of the aorta and its branches clearly depict the thoracic aortic aneurysm and the severe aortic kinking. It may be useful for vascular surgeons to discuss the best treatment strategy. Furthermore, the model can help the patient to understand the pathology and facilitate the informed consent for surgical procedures.

technique in a time where individual patient care is becoming more and more important. Customised prostheses and implants using rapid prototyping have been successfully used for skull reconstructions,13,30 hip replacements,31 femoral reconstructions,32 hemi-knee joints33,34 and dental restorations.35

measurements and the possibility of planning, preparing and simulating the surgical procedure in advance.15 Furthermore, 3D replicas of the surgically treated structures can be intra-operatively viewed side by side to the patient and thus facilitate orientation and navigation particularly in complex cases. These advantages are associated with reduced operating times, allowing for cost-effective use of operating rooms.26 In this way, the advantages exceed the limitations of the technique, namely the time and costs for creating rapid prototyping objects. Moreover, rapid prototyping is a helpful tool for radiation treatment planning and simulation27,28 and can be used to create individual radiation shields.29 Visualisation and Perception Medical images most often clearly depict the pathology and its patient-specific characteristics. However, medical images may be The rapid prototyping technique is beneficial not only for bone reconstructions but also for replacing soft tissues, as rapid prototyping can be applied to a variety of materials. Individual auricular prostheses36,37 probably provide the most vivid impression on the possible usefulness of the technique. In patients with a missing ear, a mirrored scan of the remaining ear is used for manufacturing a flesh-like rapid prototyping ear model.

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Beyond the Eye Medical Applications of 3D Rapid Prototyping Objects

difficult to grasp for the patients themselves because they most often do not have any previous knowledge for interpreting medical images, and radiologists or surgeons may have difficulties in explaining the patient his or her disease. The expression grasp has a double meaning: rapid prototyping may help the patient to understand the pathology by providing a real, touchable model.19 Consequently, patients will feel more comfortable giving informed consent for surgical procedures,26 especially parents having to decide for their children (see Figure 2). Research Rapid prototyping offers new opportunities for scientific research. On the one hand, research with phantoms produced by rapid prototyping can help to elucidate physiological processes that are not yet fully understood (see Figure 3).3841 On the other hand, rapid prototyping objects may contribute to a better understanding of complex pathologies.24,38,42 Complex pathologies are characterised by either complex morphology or functional consequences. Complex morphologies may be better to depict 3D solid objects than 2D medical images or 3D visualisations.24 Functional consequences can be assessed with patient-based phantoms simulating in vivo conditions38 and can provide new insights into haemodynamic or aerodynamic aspects of cardiovascular or airway diseases. By using the established CAD techniques from the automotive industry, medical data can be post-processed in terms of deformation or pressure processes as well. Moreover, rapid prototyping offers the possibility to evaluate medical imaging and post-processing techniques43 and to develop artificial organs.44 Current research also focuses on tissue11 and neural engineering.42 Education Both surgical and minimally invasive procedures require a thorough knowledge of anatomical structures and their topographical relations. This comprehensive knowledge is traditionally learned through the preparation of human cadavers during pre-clinical studies at medical school, and then put into practice and consolidated during actual surgeries. However, gaining greater experience in the special area of

without the risk of damage to the patient.47,48 Trainees do not hesitate to perform difficult procedures on rapid prototyping objects as they may do in patients. After being trained, they will feel more self-confident when going to the operating room. Furthermore, the pre-operative simulation of a specific, complex and sensitive surgery provides the unique opportunity to employ surgical instruments identical to those used in the actual procedure, in order to determine the best operating strategy.15 Hence, it increases the surgeons confidence in the operation.

Rapid prototyping could serve as the medium to bring anatomical variations from clinics to pre-clinical studies in order to improve the understanding of anatomy.

Discussion Rapid prototyping has grown beyond its initial use in industrial sectors, such as the automobile industry, and today can be regarded as one of the most promising techniques to be associated with medical imaging. A variety of rapid prototyping applications have recently emerged and will probably find their way into the clinical arena, in medical education, training and medical research. Although the medical applications are relatively young, their enormous potential has already been demonstrated in several studies.16,19,26 The application of rapid prototyping techniques in surgery is beneficial for diagnosis, treatment planning and intra-operative navigation, especially in complex cases where 2D source images or 3D virtual visualisations are insufficient to give a complete understanding of the pathology.1325 Furthermore, rapid prototyping objects are useful for training surgeons because they allow surgical procedures to be simulated in a realistic manner.15 Additionally, customised prostheses and implants can be manufactured using the presented process chain.3037 Finally, 3D solid objects are highly beneficial for communication between doctors, patients and family members. These applications will probably gain further importance when more attention is paid to individual patient care. Medical research has already profited by rapid prototyping giving new insights into physiological and pathological processes.38,39 Efforts have been made on the development of artificial organs and tissues using rapid prototyping.11,42,44 Much of the medical research using

A variety of rapid prototyping applications have recently emerged and will probably find their way into the clinical arena, in medical education, training and medical research.

interest before operating on a patient is desirable. 2D medical images or 3D visualisations on a 2D screen are insufficient for obtaining an intuitive understanding of complex anatomical details.24,45 Rapid prototyping objects enhance 3D learning especially in challenging anatomical and pathological conditions (see Figure 4).

rapid prototyping directly focuses on patients due to the individuality of the technique itself; therefore, we predict that the knowledge gained will eventually be transferred to the clinics and subsequently the benefit to the patients themselves. The traditional approach of teaching anatomy mainly focuses on normal

Training Furthermore, the possibility of surgical training procedures in general and patient-specific procedures in complex cases improves the abilities and results of surgeons.46 Rapid prototyping objects allow for intensive training of young surgeons mimicking in vivo situations and real tissues

anatomy without considering its variation and pathological changes. Medical students will only experience a greater variety when dealing with patients. Rapid prototyping could serve as the medium to bring anatomical variations from clinics to pre-clinical studies in order to improve the understanding of anatomy. By adapting the transparency or

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rigidity of the used material, certain aspects can be emphasised for the trainee or medical student as well. The process chain from medical imaging to 3D solid objects involves knowledge from a variety of fields, ranging from the acquisition of raw data to image post-processing and the manufacturing of the final models. Radiologists are the most important players in this process chain as they combine expert know-how in both image acquisition and post-processing. Nevertheless, the process chain only runs smoothly if radiologists, computer scientists and material scientists work closely together. The greatest limitation to rapid prototyping is that it can only be applied to objects not exceeding a certain dimension because the printers are not yet able to handle extremely large objects. Future developments may overcome this limitation. The costs and time needed for rapid prototyping should not be regarded as limitations because they are due to the individuality of each rapid prototyping object. Acknowledgements We greatly appreciate the support by VitalRecon Ltd, Frankfurt, Germany, in providing image analysis, segmentation and manufacturing of rapid prototyping models. Fabian Rengier received a grant from the German Research Foundation (DFG) under the auspices of the Research training group 1126: Intelligent Surgery Development of new computer-based methods for the future workplace in surgery. We further acknowledge the support by the Klaus Tschira Foundation and by 4D concepts, Gross Gerau, Germany, in particular Rainer Neumann. Conclusions Rapid prototyping has established a variety of medical applications such as surgical and interventional planning and training, bone reconstructions or medical education. A tremendous growth in utilisation as well as application development can be anticipated in the field of individual patient care, medical education and training, as well as medical research.

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VALENCIA / ES ESGAR 2009

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