Conceptual framework for the design, implementation and validation of psychomotor skills’ assessment systems in minimally invasive surgery

Las técnicas de cirugía de mínima invasión (CMI) se están consolidando hoy en día como alternativa a la cirugía tradicional, debido a sus numerosos beneficios para los pacientes. Este cambio de paradigma implica que los cirujanos deben aprender una serie de habilidades distintas de aquellas requeridas en cirugía abierta. El entrenamiento y evaluación de estas habilidades se ha convertido en una de las mayores preocupaciones en los programas de formación de cirujanos, debido en gran parte a la presión de una sociedad que exige cirujanos bien preparados y una reducción en el número de errores médicos. Por tanto, se está prestando especial atención a la definición de nuevos programas que permitan el entrenamiento y la evaluación de las habilidades psicomotoras en entornos seguros antes de que los nuevos cirujanos puedan operar sobre pacientes reales. Para tal fin, hospitales y centros de formación están gradualmente incorporando instalaciones de entrenamiento donde los residentes puedan practicar y aprender sin riesgos. Es cada vez más común que estos laboratorios dispongan de simuladores virtuales o simuladores físicos capaces de registrar los movimientos del instrumental de cada residente. Estos simuladores ofrecen una gran variedad de tareas de entrenamiento y evaluación, así como la posibilidad de obtener información objetiva de los ejercicios. Los diferentes estudios de validación llevados a cabo dan muestra de su utilidad; pese a todo, los niveles de evidencia presentados son en muchas ocasiones insuficientes. Lo que es más importante, no existe un consenso claro a la hora de definir qué métricas son más útiles para caracterizar la pericia quirúrgica. El objetivo de esta tesis doctoral es diseñar y validar un marco de trabajo conceptual para la definición y validación de entornos para la evaluación de habilidades en CMI, en base a un modelo en tres fases: pedagógica (tareas y métricas a emplear), tecnológica (tecnologías de adquisición de métricas) y analítica (interpretación de la competencia en base a las métricas). Para tal fin, se describe la implementación práctica de un entorno basado en (1) un sistema de seguimiento de instrumental fundamentado en el análisis del vídeo laparoscópico; y (2) la determinación de la pericia en base a métricas de movimiento del instrumental. Para la fase pedagógica se diseñó e implementó un conjunto de tareas para la evaluación de habilidades psicomotoras básicas, así como una serie de métricas de movimiento. La validación de construcción llevada a cabo sobre ellas mostró buenos resultados para tiempo, camino recorrido, profundidad, velocidad media, aceleración media, economía de área y economía de volumen. Adicionalmente, los resultados obtenidos en la validación de apariencia fueron en general positivos en todos los grupos considerados (noveles, residentes, expertos). Para la fase tecnológica, se introdujo el EVA Tracking System, una solución para el seguimiento del instrumental quirúrgico basado en el análisis del vídeo endoscópico. La precisión del sistema se evaluó a 16,33ppRMS para el seguimiento 2D de la herramienta en la imagen; y a 13mmRMS para el seguimiento espacial de la misma. La validación de construcción con una de las tareas de evaluación mostró buenos resultados para tiempo, camino recorrido, profundidad, velocidad media, aceleración media, economía de área y economía de volumen. La validación concurrente con el TrEndo® Tracking System por su parte presentó valores altos de correlación para 8 de las 9 métricas analizadas. Finalmente, para la fase analítica se comparó el comportamiento de tres clasificadores supervisados a la hora de determinar automáticamente la pericia quirúrgica en base a la información de movimiento del instrumental, basados en aproximaciones lineales (análisis lineal discriminante, LDA), no lineales (máquinas de soporte vectorial, SVM) y difusas (sistemas adaptativos de inferencia neurodifusa, ANFIS). Los resultados muestran que en media SVM presenta un comportamiento ligeramente superior: 78,2% frente a los 71% y 71,7% obtenidos por ANFIS y LDA respectivamente. Sin embargo las diferencias estadísticas medidas entre los tres no fueron demostradas significativas. En general, esta tesis doctoral corrobora las hipótesis de investigación postuladas relativas a la definición de sistemas de evaluación de habilidades para cirugía de mínima invasión, a la utilidad del análisis de vídeo como fuente de información y a la importancia de la información de movimiento de instrumental a la hora de caracterizar la pericia quirúrgica. Basándose en estos cimientos, se han de abrir nuevos campos de investigación que contribuyan a la definición de programas de formación estructurados y objetivos, que puedan garantizar la acreditación de cirujanos sobradamente preparados y promocionen la seguridad del paciente en el quirófano. Abstract Minimally invasive surgery (MIS) techniques have become a standard in many surgical sub-specialties, due to their many benefits for patients. However, this shift in paradigm implies that surgeons must acquire a complete different set of skills than those normally attributed to open surgery. Training and assessment of these skills has become a major concern in surgical learning programmes, especially considering the social demand for better-prepared professionals and for the decrease of medical errors. Therefore, much effort is being put in the definition of structured MIS learning programmes, where practice with real patients in the operating room (OR) can be delayed until the resident can attest for a minimum level of psychomotor competence. To this end, skills’ laboratory settings are being introduced in hospitals and training centres where residents may practice and be assessed on their psychomotor skills. Technological advances in the field of tracking technologies and virtual reality (VR) have enabled the creation of new learning systems such as VR simulators or enhanced box trainers. These systems offer a wide range of tasks, as well as the capability of registering objective data on the trainees’ performance. Validation studies give proof of their usefulness; however, levels of evidence reported are in many cases low. More importantly, there is still no clear consensus on topics such as the optimal metrics that must be used to assess competence, the validity of VR simulation, the portability of tracking technologies into real surgeries (for advanced assessment) or the degree to which the skills measured and obtained in laboratory environments transfer to the OR. The purpose of this PhD is to design and validate a conceptual framework for the definition and validation of MIS assessment environments based on a three-pillared model defining three main stages: pedagogical (tasks and metrics to employ), technological (metric acquisition technologies) and analytical (interpretation of competence based on metrics). To this end, a practical implementation of the framework is presented, focused on (1) a video-based tracking system and (2) the determination of surgical competence based on the laparoscopic instruments’ motionrelated data. The pedagogical stage’s results led to the design and implementation of a set of basic tasks for MIS psychomotor skills’ assessment, as well as the definition of motion analysis parameters (MAPs) to measure performance on said tasks. Validation yielded good construct results for parameters such as time, path length, depth, average speed, average acceleration, economy of area and economy of volume. Additionally, face validation results showed positive acceptance on behalf of the experts, residents and novices. For the technological stage the EVA Tracking System is introduced. EVA provides a solution for tracking laparoscopic instruments from the analysis of the monoscopic video image. Accuracy tests for the system are presented, which yielded an average RMSE of 16.33pp for 2D tracking of the instrument on the image and of 13mm for 3D spatial tracking. A validation experiment was conducted using one of the tasks and the most relevant MAPs. Construct validation showed significant differences for time, path length, depth, average speed, average acceleration, economy of area and economy of volume; especially between novices and residents/experts. More importantly, concurrent validation with the TrEndo® Tracking System presented high correlation values (>0.7) for 8 of the 9 MAPs proposed. Finally, the analytical stage allowed comparing the performance of three different supervised classification strategies in the determination of surgical competence based on motion-related information. The three classifiers were based on linear (linear discriminant analysis, LDA), non-linear (support vector machines, SVM) and fuzzy (adaptive neuro fuzzy inference systems, ANFIS) approaches. Results for SVM show slightly better performance than the other two classifiers: on average, accuracy for LDA, SVM and ANFIS was of 71.7%, 78.2% and 71% respectively. However, when confronted, no statistical significance was found between any of the three. Overall, this PhD corroborates the investigated research hypotheses regarding the definition of MIS assessment systems, the use of endoscopic video analysis as the main source of information and the relevance of motion analysis in the determination of surgical competence. New research fields in the training and assessment of MIS surgeons can be proposed based on these foundations, in order to contribute to the definition of structured and objective learning programmes that guarantee the accreditation of well-prepared professionals and the promotion of patient safety in the OR.

A generic, context sensitive analysis framework for object oriented programs

Abstract interpreters rely on the existence of a nxpoint algorithm that calculates a least upper bound approximation of the semantics of the program. Usually, that algorithm is described in terms of the particular language in study and therefore it is not directly applicable to programs written in a different source language. In this paper we introduce a generic, block-based, and uniform representation of the program control flow graph and a language-independent nxpoint algorithm that can be applied to a variety of languages and, in particular, Java. Two major characteristics of our approach are accuracy (obtained through a topdown, context sensitive approach) and reasonable efficiency (achieved by means of memoization and dependency tracking techniques). We have also implemented the proposed framework and show some initial experimental results for standard benchmarks, which further support the feasibility of the solution adopted.

Environmental variables modeling based on remote sensing data using time series analysis: forestry and agricultural applications

En la actualidad, el seguimiento de la dinámica de los procesos medio ambientales está considerado como un punto de gran interés en el campo medioambiental. La cobertura espacio temporal de los datos de teledetección proporciona información continua con una alta frecuencia temporal, permitiendo el análisis de la evolución de los ecosistemas desde diferentes escalas espacio-temporales. Aunque el valor de la teledetección ha sido ampliamente probado, en la actualidad solo existe un número reducido de metodologías que permiten su análisis de una forma cuantitativa. En la presente tesis se propone un esquema de trabajo para explotar las series temporales de datos de teledetección, basado en la combinación del análisis estadístico de series de tiempo y la fenometría. El objetivo principal es demostrar el uso de las series temporales de datos de teledetección para analizar la dinámica de variables medio ambientales de una forma cuantitativa. Los objetivos específicos son: (1) evaluar dichas variables medio ambientales y (2) desarrollar modelos empíricos para predecir su comportamiento futuro. Estos objetivos se materializan en cuatro aplicaciones cuyos objetivos específicos son: (1) evaluar y cartografiar estados fenológicos del cultivo del algodón mediante análisis espectral y fenometría, (2) evaluar y modelizar la estacionalidad de incendios forestales en dos regiones bioclimáticas mediante modelos dinámicos, (3) predecir el riesgo de incendios forestales a nivel pixel utilizando modelos dinámicos y (4) evaluar el funcionamiento de la vegetación en base a la autocorrelación temporal y la fenometría. Los resultados de esta tesis muestran la utilidad del ajuste de funciones para modelizar los índices espectrales AS1 y AS2. Los parámetros fenológicos derivados del ajuste de funciones permiten la identificación de distintos estados fenológicos del cultivo del algodón. El análisis espectral ha demostrado, de una forma cuantitativa, la presencia de un ciclo en el índice AS2 y de dos ciclos en el AS1 así como el comportamiento unimodal y bimodal de la estacionalidad de incendios en las regiones mediterránea y templada respectivamente. Modelos autorregresivos han sido utilizados para caracterizar la dinámica de la estacionalidad de incendios y para predecir de una forma muy precisa el riesgo de incendios forestales a nivel pixel. Ha sido demostrada la utilidad de la autocorrelación temporal para definir y caracterizar el funcionamiento de la vegetación a nivel pixel. Finalmente el concepto “Optical Functional Type” ha sido definido, donde se propone que los pixeles deberían ser considerados como unidades temporales y analizados en función de su dinámica temporal. ix SUMMARY A good understanding of land surface processes is considered as a key subject in environmental sciences. The spatial-temporal coverage of remote sensing data provides continuous observations with a high temporal frequency allowing the assessment of ecosystem evolution at different temporal and spatial scales. Although the value of remote sensing time series has been firmly proved, only few time series methods have been developed for analyzing this data in a quantitative and continuous manner. In the present dissertation a working framework to exploit Remote Sensing time series is proposed based on the combination of Time Series Analysis and phenometric approach. The main goal is to demonstrate the use of remote sensing time series to analyze quantitatively environmental variable dynamics. The specific objectives are (1) to assess environmental variables based on remote sensing time series and (2) to develop empirical models to forecast environmental variables. These objectives have been achieved in four applications which specific objectives are (1) assessing and mapping cotton crop phenological stages using spectral and phenometric analyses, (2) assessing and modeling fire seasonality in two different ecoregions by dynamic models, (3) forecasting forest fire risk on a pixel basis by dynamic models, and (4) assessing vegetation functioning based on temporal autocorrelation and phenometric analysis. The results of this dissertation show the usefulness of function fitting procedures to model AS1 and AS2. Phenometrics derived from function fitting procedure makes it possible to identify cotton crop phenological stages. Spectral analysis has demonstrated quantitatively the presence of one cycle in AS2 and two in AS1 and the unimodal and bimodal behaviour of fire seasonality in the Mediterranean and temperate ecoregions respectively. Autoregressive models has been used to characterize the dynamics of fire seasonality in two ecoregions and to forecasts accurately fire risk on a pixel basis. The usefulness of temporal autocorrelation to define and characterized land surface functioning has been demonstrated. And finally the “Optical Functional Types” concept has been proposed, in this approach pixels could be as temporal unities based on its temporal dynamics or functioning.

EVA: Laparoscopic instrument tracking based on endoscopic video analysis for psychomotor skills assessment

INTRODUCTION: The EVA (Endoscopic Video Analysis) tracking system a new tracking system for extracting motions of laparoscopic instruments based on non-obtrusive video tracking was developed. The feasibility of using EVA in laparoscopic settings has been tested in a box trainer setup. METHODS: EVA makes use of an algorithm that employs information of the laparoscopic instrument's shaft edges in the image, the instrument's insertion point, and the camera's optical centre to track the 3D position of the instrument tip. A validation study of EVA comprised a comparison of the measurements achieved with EVA and the TrEndo tracking system. To this end, 42 participants (16 novices, 22 residents, and 4 experts) were asked to perform a peg transfer task in a box trainer. Ten motion-based metrics were used to assess their performance. RESULTS: Construct validation of the EVA has been obtained for seven motion-based metrics. Concurrent validation revealed that there is a strong correlation between the results obtained by EVA and the TrEndo for metrics such as path length (p=0,97), average speed (p=0,94) or economy of volume (p=0,85), proving the viability of EVA. CONCLUSIONS: EVA has been successfully used in the training setup showing potential of endoscopic video analysis to assess laparoscopic psychomotor skills. The results encourage further implementation of video tracking in training setups and in image guided surgery.

Three dimensional (3D) microstructure-based modeling of interfacial decohesion in particle reinforced metal matrix composites

Modeling and prediction of the overall elastic–plastic response and local damage mechanisms in heterogeneous materials, in particular particle reinforced composites, is a very complex problem. Microstructural complexities such as the inhomogeneous spatial distribution of particles, irregular morphology of the particles, and anisotropy in particle orientation after secondary processing, such as extrusion, significantly affect deformation behavior. We have studied the effect of particle/matrix interface debonding in SiC particle reinforced Al alloy matrix composites with (a) actual microstructure consisting of angular SiC particles and (b) idealized ellipsoidal SiC particles. Tensile deformation in SiC particle reinforced Al matrix composites was modeled using actual microstructures reconstructed from serial sectioning approach. Interfacial debonding was modeled using user-defined cohesive zone elements. Modeling with the actual microstructure (versus idealized ellipsoids) has a significant influence on: (a) localized stresses and strains in particle and matrix, and (b) far-field strain at which localized debonding takes place. The angular particles exhibited higher degree of load transfer and are more sensitive to interfacial debonding. Larger decreases in stress are observed in the angular particles, because of the flat surfaces, normal to the loading axis, which bear load. Furthermore, simplification of particle morphology may lead to erroneous results.

Design and modeling of the multi-agent robotic system: SMART

This article presents the design, kinematic model and communication architecture for the multi-agent robotic system called SMART. The philosophy behind this kind of system requires the communication architecture to contemplate the concurrence of the whole system. The proposed architecture combines different communication technologies (TCP/IP and Bluetooth) under one protocol designed for the cooperation among agents and other elements of the system such as IP-Cameras, image processing library, path planner, user Interface, control block and data block. The high level control is modeled by Work-Flow Petri nets and implemented in C++ and C♯♯. Experimental results show the performance of the designed architecture.

A fitting algorithm for random modeling the PLC channel

The characteristics of the power-line communication (PLC) channel are difficult to model due to the heterogeneity of the networks and the lack of common wiring practices. To obtain the full variability of the PLC channel, random channel generators are of great importance for the design and testing of communication algorithms. In this respect, we propose a random channel generator that is based on the top-down approach. Basically, we describe the multipath propagation and the coupling effects with an analytical model. We introduce the variability into a restricted set of parameters and, finally, we fit the model to a set of measured channels. The proposed model enables a closed-form description of both the mean path-loss profile and the statistical correlation function of the channel frequency response. As an example of application, we apply the procedure to a set of in-home measured channels in the band 2-100 MHz whose statistics are available in the literature. The measured channels are divided into nine classes according to their channel capacity. We provide the parameters for the random generation of channels for all nine classes, and we show that the results are consistent with the experimental ones. Finally, we merge the classes to capture the entire heterogeneity of in-home PLC channels. In detail, we introduce the class occurrence probability, and we present a random channel generator that targets the ensemble of all nine classes. The statistics of the composite set of channels are also studied, and they are compared to the results of experimental measurement campaigns in the literature.

Novel lateral moving tracking optics with the SMS design method

Lateral moving optics along straight path has already been studied in the past. However, their relative small angular range can be a limitation to potential applications. In this work, a new design concept of SMS moving optics is developed, in which the movement is no longer lateral but follows a curved trajectory, which is calculated in the design process. We have chosen an afocal system, which aim to direct the parallel rays of large incident angles to parallel output rays, and we have obtained that the RMS of the divergence angle of the output rays remains below 1 degree within a input angular range of ±45 output. Potential applications of this beam-steering device are: skylights to provide steerable natural illumination, building integrated CPV systems, and steerable LED illumination.

Adaptive neuro-fuzzy inference systems (ANFIS) for supervised classification of competence in MIS based on psychomotor skills

INTRODUCTION: Objective assessment of motor skills has become an important challenge in minimally invasive surgery (MIS) training.Currently, there is no gold standard defining and determining the residents' surgical competence.To aid in the decision process, we analyze the validity of a supervised classifier to determine the degree of MIS competence based on assessment of psychomotor skills METHODOLOGY: The ANFIS is trained to classify performance in a box trainer peg transfer task performed by two groups (expert/non expert). There were 42 participants included in the study: the non-expert group consisted of 16 medical students and 8 residents (< 10 MIS procedures performed), whereas the expert group consisted of 14 residents (> 10 MIS procedures performed) and 4 experienced surgeons. Instrument movements were captured by means of the Endoscopic Video Analysis (EVA) tracking system. Nine motion analysis parameters (MAPs) were analyzed, including time, path length, depth, average speed, average acceleration, economy of area, economy of volume, idle time and motion smoothness. Data reduction was performed by means of principal component analysis, and then used to train the ANFIS net. Performance was measured by leave one out cross validation. RESULTS: The ANFIS presented an accuracy of 80.95%, where 13 experts and 21 non-experts were correctly classified. Total root mean square error was 0.88, while the area under the classifiers' ROC curve (AUC) was measured at 0.81. DISCUSSION: We have shown the usefulness of ANFIS for classification of MIS competence in a simple box trainer exercise. The main advantage of using ANFIS resides in its continuous output, which allows fine discrimination of surgical competence. There are, however, challenges that must be taken into account when considering use of ANFIS (e.g. training time, architecture modeling). Despite this, we have shown discriminative power of ANFIS for a low-difficulty box trainer task, regardless of the individual significances between MAPs. Future studies are required to confirm the findings, inclusion of new tasks, conditions and sample population.

A hierarchical strategy for real-time tracking on-board UAVs

In this paper, we present a real-time tracking strategy based on direct methods for tracking tasks on-board UAVs, that is able to overcome problems posed by the challenging conditions of the task: e.g. constant vibrations, fast 3D changes, and limited capacity on-board. The vast majority of approaches make use of feature-based methods to track objects. Nonetheless, in this paper we show that although some of these feature-based solutions are faster, direct methods can be more robust under fast 3D motions (fast changes in position), some changes in appearance, constant vibrations (without requiring any specific hardware or software for video stabilization), and situations where part of the object to track is out the field of view of the camera. The performance of the proposed strategy is evaluated with images from real-flight tests using different evaluation mechanisms (e.g. accurate position estimation using a Vicon sytem). Results show that our tracking strategy performs better than well known feature-based algorithms and well known configurations of direct methods, and that the recovered data is robust enough for vision-in-the-loop tasks.

AUTOFLY-Aid: Flight Deck Automation Support with Dynamic 4D Trajectory Management for Responsive and Adaptive Airborne Collision Avoidance

AUTOFLY-Aid Project aims to develop and demonstrate novel automation support algorithms and tools to the flight crew for flight critical collision avoidance using “dynamic 4D trajectory management”. The automation support system is envisioned to improve the primary shortcomings of TCAS, and to aid the pilot through add-on avionics/head-up displays and reality augmentation devices in dynamically evolving collision avoidance scenarios. The main theoretical innovative and novel concepts to be developed by AUTOFLY-Aid project are a) design and development of the mathematical models of the full composite airspace picture from the flight deck’s perspective, as seen/measured/informed by the aircraft flying in SESAR 2020, b) design and development of a dynamic trajectory planning algorithm that can generate at real-time (on the order of seconds) flyable (i.e. dynamically and performance-wise feasible) alternative trajectories across the evolving stochastic composite airspace picture (which includes new conflicts, blunder risks, terrain and weather limitations) and c) development and testing of the Collision Avoidance Automation Support System on a Boeing 737 NG FNPT II Flight Simulator with synthetic vision and reality augmentation while providing the flight crew with quantified and visual understanding of collision risks in terms of time and directions and countermeasures.

Novel parameters for evaluating the Spatial and Thematic accuracy of land cover maps.

Se proponen novedosas fórmulas para evaluar la certeza de la cartografía

Dynamic Studies of Shell and Spatial Structures

For the past 20 years, dynamic analysis of shells has been one of the most fascinating fields for research. Using the new light materials the building engineer soon discovered that the subsequent reduction of gravity forces produced not only the desired shape freedom but the appearance of ecologic loads as the first factor of design; loads which present strong random properties and marked dynamic influence. On the other hand, the technological advance in the aeronautical and astronautical field placed the engineers in front of shell structures of nonconventional shape and able to sustain substantialy dynamic loads. The response to the increasingly challenger problems of the last two decades has been very bright; new forms, new materials and new methods of analysis have arosen in the design of off-shore platforms, nuclear vessels, space crafts, etc. Thanks to the intensity of the lived years we have at our disposition a coherent and homogeneous amount of knowledge which enable us to face problems of inconceivable complexity when IASS was founded. The open minded approach to classical problems and the impact of the computer are, probably, important factors in the Renaissance we have enjoyed these years, and a good proof of this are the papers presented to the previous IASS meetings as well as that we are going to consider in this one. Particularly striking is the great number of papers based on a mathematical modeling in front of the meagerness of those treating laboratory experiments on physical models. The universal entering of the computer into almost every phase of our lifes, and the cost of physical models, are –may be- reasons for this lack of experimental methods. Nevertheless they continue offering useful results as are those obtained with the shaking-table in which the computer plays an essential role in the application of loads as well as in the instantaneous treatment of control data. Plates 1 and 2 record the papers presented under dynamic heading, 40% of them are from Japan in good correlation with the relevance that Japanese research has traditionally showed in this area. Also interesting is to find old friends as profesors Tanaka, Nishimura and Kostem who presented valuable papers in previous IASS conferences. As we see there are papers representative of all tendencies, even purely analytical! Better than discuss them in detail, which can be done after the authors presentation, I think we can comment in the general pattern of the dynamical approach are summarized in plate 3.

Emission inventories and modeling requirements for the development of air quality plans. Application to Madrid (Spain)

Modeling is an essential tool for the development of atmospheric emission abatement measures and air quality plans. Most often these plans are related to urban environments with high emission density and population exposure. However, air quality modeling in urban areas is a rather challenging task. As environmental standards become more stringent (e.g. European Directive 2008/50/EC), more reliable and sophisticated modeling tools are needed to simulate measures and plans that may effectively tackle air quality exceedances, common in large urban areas across Europe, particularly for NO2. This also implies that emission inventories must satisfy a number of conditions such as consistency across the spatial scales involved in the analysis, consistency with the emission inventories used for regulatory purposes and versatility to match the requirements of different air quality and emission projection models. This study reports the modeling activities carried out in Madrid (Spain) highlighting the atmospheric emission inventory development and preparation as an illustrative example of the combination of models and data needed to develop a consistent air quality plan at urban level. These included a series of source apportionment studies to define contributions from the international, national, regional and local sources in order to understand to what extent local authorities can enforce meaningful abatement measures. Moreover, source apportionment studies were conducted in order to define contributions from different sectors and to understand the maximum feasible air quality improvement that can be achieved by reducing emissions from those sectors, thus targeting emission reduction policies to the most relevant activities. Finally, an emission scenario reflecting the effect of such policies was developed and the associated air quality was modeled.

Mejoras en el procesamiento de imágenes de TC para el tratamiento con radioterapia adaptativa del cáncer de próstata

El cáncer de próstata es el tipo de cáncer con mayor prevalencia entre los hombres del mundo occidental y, pese a tener una alta tasa de supervivencia relativa, es la segunda mayor causa de muerte por cáncer en este sector de la población. El tratamiento de elección frente al cáncer de próstata es, en la mayoría de los casos, la radioterapia externa. Las técnicas más modernas de radioterapia externa, como la radioterapia modulada en intensidad, permiten incrementar la dosis en el tumor mientras se reduce la dosis en el tejido sano. Sin embargo, la localización del volumen objetivo varía con el día de tratamiento, y se requieren movimientos muy pequeños de los órganos para sacar partes del volumen objetivo fuera de la región terapéutica, o para introducir tejidos sanos críticos dentro. Para evitar esto se han desarrollado técnicas más avanzadas, como la radioterapia guiada por imagen, que se define por un manejo más preciso de los movimientos internos mediante una adaptación de la planificación del tratamiento basada en la información anatómica obtenida de imágenes de tomografía computarizada (TC) previas a la sesión terapéutica. Además, la radioterapia adaptativa añade la información dosimétrica de las fracciones previas a la información anatómica. Uno de los fundamentos de la radioterapia adaptativa es el registro deformable de imágenes, de gran utilidad a la hora de modelar los desplazamientos y deformaciones de los órganos internos. Sin embargo, su utilización conlleva nuevos retos científico-tecnológicos en el procesamiento de imágenes, principalmente asociados a la variabilidad de los órganos, tanto en localización como en apariencia. El objetivo de esta tesis doctoral es mejorar los procesos clínicos de delineación automática de contornos y de cálculo de dosis acumulada para la planificación y monitorización de tratamientos con radioterapia adaptativa, a partir de nuevos métodos de procesamiento de imágenes de TC (1) en presencia de contrastes variables, y (2) cambios de apariencia del recto. Además, se pretende (3) proveer de herramientas para la evaluación de la calidad de los contornos obtenidos en el caso del gross tumor volumen (GTV). Las principales contribuciones de esta tesis doctoral son las siguientes: _ 1. La adaptación, implementación y evaluación de un algoritmo de registro basado en el flujo óptico de la fase de la imagen como herramienta para el cálculo de transformaciones no-rígidas en presencia de cambios de intensidad, y su aplicabilidad a tratamientos de radioterapia adaptativa en cáncer de próstata con uso de agentes de contraste radiológico. Los resultados demuestran que el algoritmo seleccionado presenta mejores resultados cualitativos en presencia de contraste radiológico en la vejiga, y no distorsiona la imagen forzando deformaciones poco realistas. 2. La definición, desarrollo y validación de un nuevo método de enmascaramiento de los contenidos del recto (MER), y la evaluación de su influencia en el procedimiento de radioterapia adaptativa en cáncer de próstata. Las segmentaciones obtenidas mediante el MER para la creación de máscaras homogéneas en las imágenes de sesión permiten mejorar sensiblemente los resultados de los algoritmos de registro en la región rectal. Así, el uso de la metodología propuesta incrementa el índice de volumen solapado entre los contornos manuales y automáticos del recto hasta un valor del 89%, cercano a los resultados obtenidos usando máscaras manuales para el registro de las dos imágenes. De esta manera se pueden corregir tanto el cálculo de los nuevos contornos como el cálculo de la dosis acumulada. 3. La definición de una metodología de evaluación de la calidad de los contornos del GTV, que permite la representación de la distribución espacial del error, adaptándola a volúmenes no-convexos como el formado por la próstata y las vesículas seminales. Dicha metodología de evaluación, basada en un nuevo algoritmo de reconstrucción tridimensional y una nueva métrica de cuantificación, presenta resultados precisos con una gran resolución espacial en un tiempo despreciable frente al tiempo de registro. Esta nueva metodología puede ser una herramienta útil para la comparación de distintos algoritmos de registro deformable orientados a la radioterapia adaptativa en cáncer de próstata. En conclusión, el trabajo realizado en esta tesis doctoral corrobora las hipótesis de investigación postuladas, y pretende servir como cimiento de futuros avances en el procesamiento de imagen médica en los tratamientos de radioterapia adaptativa en cáncer de próstata. Asimismo, se siguen abriendo nuevas líneas de aplicación futura de métodos de procesamiento de imágenes médicas con el fin de mejorar los procesos de radioterapia adaptativa en presencia de cambios de apariencia de los órganos, e incrementar la seguridad del paciente. I.2 Inglés Prostate cancer is the most prevalent cancer amongst men in the Western world and, despite having a relatively high survival rate, is the second leading cause of cancer death in this sector of the population. The treatment of choice against prostate cancer is, in most cases, external beam radiation therapy. The most modern techniques of external radiotherapy, as intensity modulated radiotherapy, allow increasing the dose to the tumor whilst reducing the dose to healthy tissue. However, the location of the target volume varies with the day of treatment, and very small movements of the organs are required to pull out parts of the target volume outside the therapeutic region, or to introduce critical healthy tissues inside. Advanced techniques, such as the image-guided radiotherapy (IGRT), have been developed to avoid this. IGRT is defined by more precise handling of internal movements by adapting treatment planning based on the anatomical information obtained from computed tomography (CT) images prior to the therapy session. Moreover, the adaptive radiotherapy adds dosimetric information of previous fractions to the anatomical information. One of the fundamentals of adaptive radiotherapy is deformable image registration, very useful when modeling the displacements and deformations of the internal organs. However, its use brings new scientific and technological challenges in image processing, mainly associated to the variability of the organs, both in location and appearance. The aim of this thesis is to improve clinical processes of automatic contour delineation and cumulative dose calculation for planning and monitoring of adaptive radiotherapy treatments, based on new methods of CT image processing (1) in the presence of varying contrasts, and (2) rectum appearance changes. It also aims (3) to provide tools for assessing the quality of contours obtained in the case of gross tumor volume (GTV). The main contributions of this PhD thesis are as follows: 1. The adaptation, implementation and evaluation of a registration algorithm based on the optical flow of the image phase as a tool for the calculation of non-rigid transformations in the presence of intensity changes, and its applicability to adaptive radiotherapy treatment in prostate cancer with use of radiological contrast agents. The results demonstrate that the selected algorithm shows better qualitative results in the presence of radiological contrast agents in the urinary bladder, and does not distort the image forcing unrealistic deformations. 2. The definition, development and validation of a new method for masking the contents of the rectum (MER, Spanish acronym), and assessing their impact on the process of adaptive radiotherapy in prostate cancer. The segmentations obtained by the MER for the creation of homogenous masks in the session CT images can improve significantly the results of registration algorithms in the rectal region. Thus, the use of the proposed methodology increases the volume overlap index between manual and automatic contours of the rectum to a value of 89%, close to the results obtained using manual masks for both images. In this way, both the calculation of new contours and the calculation of the accumulated dose can be corrected. 3. The definition of a methodology for assessing the quality of the contours of the GTV, which allows the representation of the spatial distribution of the error, adapting it to non-convex volumes such as that formed by the prostate and seminal vesicles. Said evaluation methodology, based on a new three-dimensional reconstruction algorithm and a new quantification metric, presents accurate results with high spatial resolution in a time negligible compared to the registration time. This new approach may be a useful tool to compare different deformable registration algorithms oriented to adaptive radiotherapy in prostate cancer In conclusion, this PhD thesis corroborates the postulated research hypotheses, and is intended to serve as a foundation for future advances in medical image processing in adaptive radiotherapy treatment in prostate cancer. In addition, it opens new future applications for medical image processing methods aimed at improving the adaptive radiotherapy processes in the presence of organ’s appearance changes, and increase the patient safety.