Clinical situations for which 3D printing is considered an appropriate representation or extension of data contained in a medical imaging examination: pediatric congenital heart disease conditions.

BACKGROUND: The use of medical 3D printing (focusing on anatomical modeling) has continued to grow since the Radiological Society of North America's (RSNA) 3D Printing Special Interest Group (3DPSIG) released its initial guideline and appropriateness rating document in 2018. The 3DPSIG formed a focused writing group to provide updated appropriateness ratings for 3D printing anatomical models across a variety of congenital heart disease. Evidence-based- (where available) and expert-consensus-driven appropriateness ratings are provided for twenty-eight congenital heart lesion categories. METHODS: A structured literature search was conducted to identify all relevant articles using 3D printing technology associated with pediatric congenital heart disease indications. Each study was vetted by the authors and strength of evidence was assessed according to published appropriateness ratings. RESULTS: Evidence-based recommendations for when 3D printing is appropriate are provided for pediatric congenital heart lesions. Recommendations are provided in accordance with strength of evidence of publications corresponding to each cardiac clinical scenario combined with expert opinion from members of the 3DPSIG. CONCLUSIONS: This consensus appropriateness ratings document, created by the members of the RSNA 3DPSIG, provides a reference for clinical standards of 3D printing for pediatric congenital heart disease clinical scenarios.

Clinical situations for which 3D Printing is considered an appropriate representation or extension of data contained in a medical imaging examination: vascular conditions.

BACKGROUND: Medical three-dimensional (3D) printing has demonstrated utility and value in anatomic models for vascular conditions. A writing group composed of the Radiological Society of North America (RSNA) Special Interest Group on 3D Printing (3DPSIG) provides appropriateness recommendations for vascular 3D printing indications. METHODS: A structured literature search was conducted to identify all relevant articles using 3D printing technology associated with vascular indications. Each study was vetted by the authors and strength of evidence was assessed according to published appropriateness ratings. RESULTS: Evidence-based recommendations for when 3D printing is appropriate are provided for the following areas: aneurysm, dissection, extremity vascular disease, other arterial diseases, acute venous thromboembolic disease, venous disorders, lymphedema, congenital vascular malformations, vascular trauma, vascular tumors, visceral vasculature for surgical planning, dialysis access, vascular research/development and modeling, and other vasculopathy. Recommendations are provided in accordance with strength of evidence of publications corresponding to each vascular condition combined with expert opinion from members of the 3DPSIG. CONCLUSION: This consensus appropriateness ratings document, created by the members of the 3DPSIG, provides an updated reference for clinical standards of 3D printing for the care of patients with vascular conditions.

Clinical situations for which 3D printing is considered an appropriate representation or extension of data contained in a medical imaging examination: neurosurgical and otolaryngologic conditions.

BACKGROUND: Medical three dimensional (3D) printing is performed for neurosurgical and otolaryngologic conditions, but without evidence-based guidance on clinical appropriateness. A writing group composed of the Radiological Society of North America (RSNA) Special Interest Group on 3D Printing (SIG) provides appropriateness recommendations for neurologic 3D printing conditions. METHODS: A structured literature search was conducted to identify all relevant articles using 3D printing technology associated with neurologic and otolaryngologic conditions. Each study was vetted by the authors and strength of evidence was assessed according to published guidelines. RESULTS: Evidence-based recommendations for when 3D printing is appropriate are provided for diseases of the calvaria and skull base, brain tumors and cerebrovascular disease. Recommendations are provided in accordance with strength of evidence of publications corresponding to each neurologic condition combined with expert opinion from members of the 3D printing SIG. CONCLUSIONS: This consensus guidance document, created by the members of the 3D printing SIG, provides a reference for clinical standards of 3D printing for neurologic conditions.

Assessment of Staphylococcus Aureus growth on biocompatible 3D printed materials.

The customizability of 3D printing allows for the manufacturing of personalized medical devices such as laryngectomy tubes, but it is vital to establish the biocompatibility of printing materials to ensure that they are safe and durable. The goal of this study was to assess the presence of S. aureus biofilms on a variety of 3D printed materials (two surgical guide resins, a photopolymer, an elastomer, and a thermoplastic elastomer filament) as compared to standard, commercially available laryngectomy tubes.C-shaped discs (15 mm in height, 20 mm in diameter, and 3 mm in thickness) were printed with five different biocompatible 3D printing materials and S. aureus growth was compared to Shiley™ laryngectomy tubes made from polyvinyl chloride. Discs of each material were inoculated with S. aureus cultures and incubated overnight. All materials were then removed from solution, washed in phosphate-buffered saline to remove planktonic bacteria, and sonicated to detach biofilms. Some solution from each disc was plated and colony-forming units were manually counted the following day. The resulting data was analyzed using a Kruskal-Wallis and Wilcoxon Rank Sum test to determine pairwise significance between the laryngectomy tube material and the 3D printed materials.The Shiley™ tube grew a median of 320 colonies (IQR 140-520), one surgical guide resin grew a median of 640 colonies (IQR 356-920), the photopolymer grew a median of 340 colonies (IQR 95.5-739), the other surgical guide resin grew a median of 431 colonies (IQR 266.5-735), the thermoplastic elastomer filament grew a median of 188 colonies (IQR 113.5-335), and the elastomer grew a median of 478 colonies (IQR 271-630). Using the Wilcoxon Rank Sum test, manual quantification showed a significant difference between biofilm formation only between the Shiley™ tube and a surgical guide resin (p = 0.018).This preliminary study demonstrates that bacterial colonization was comparable among most 3D printed materials as compared to the conventionally manufactured device. Continuation of this work with increased replicates will be necessary to determine which 3D printing materials optimally resist biofilm formation.

Advanced 3D Visualization and 3D Printing in Radiology.

Since the discovery of X-rays in 1895, medical imaging systems have played a crucial role in medicine by permitting the visualization of internal structures and understanding the function of organ systems. Traditional imaging modalities including Computed Tomography (CT), Magnetic Resonance Imaging (MRI) and Ultrasound (US) present fixed two-dimensional (2D) images which are difficult to conceptualize complex anatomy. Advanced volumetric medical imaging allows for three-dimensional (3D) image post-processing and image segmentation to be performed, enabling the creation of 3D volume renderings and enhanced visualization of pertinent anatomic structures in 3D. Furthermore, 3D imaging is used to generate 3D printed models and extended reality (augmented reality and virtual reality) models. A 3D image translates medical imaging information into a visual story rendering complex data and abstract ideas into an easily understood and tangible concept. Clinicians use 3D models to comprehend complex anatomical structures and to plan and guide surgical interventions more precisely. This chapter will review the volumetric radiological techniques that are commonly utilized for advanced 3D visualization. It will also provide examples of 3D printing and extended reality technology applications in radiology and describe the positive impact of advanced radiological image visualization on patient care.

Impact of 3D printed models on quantitative surgical outcomes for patients undergoing robotic-assisted radical prostatectomy: a cohort study.

BACKGROUND: Three-dimensional (3D) printed anatomic models can facilitate presurgical planning by providing surgeons with detailed knowledge of the exact location of pertinent anatomical structures. Although 3D printed anatomic models have been shown to be useful for pre-operative planning, few studies have demonstrated how these models can influence quantitative surgical metrics. OBJECTIVE: To prospectively assess whether patient-specific 3D printed prostate cancer models can improve quantitative surgical metrics in patients undergoing robotic-assisted radical prostatectomy (RARP). METHODS: Patients with MRI-visible prostate cancer (PI-RADS V2 ≥ 3) scheduled to undergo RARP were prospectively enrolled in our IRB approved study (n = 82). Quantitative surgical metrics included the rate of positive surgical margins (PSMs), operative times, and blood loss. A qualitative Likert scale survey to assess understanding of anatomy and confidence regarding surgical approach was also implemented. RESULTS: The rate of PSMs was lower for the 3D printed model group (8.11%) compared to that with imaging only (28.6%), p = 0.128. The 3D printed model group had a 9-min reduction in operating time (213 ± 42 min vs. 222 ± 47 min) and a 5 mL reduction in average blood loss (227 ± 148 mL vs. 232 ± 114 mL). Surgeon anatomical understanding and confidence improved after reviewing the 3D printed models (3.60 ± 0.74 to 4.20 ± 0.56, p = 0.62 and 3.86 ± 0.53 to 4.20 ± 0.56, p = 0.22). CONCLUSIONS: 3D printed prostate cancer models can positively impact quantitative patient outcomes such as PSMs, operative times, and blood loss in patients undergoing RARP.

Intraoperative Navigation in Plastic Surgery with Augmented Reality: A Preclinical Validation Study.

BACKGROUND: Augmented reality allows users to visualize and interact with digital images including three-dimensional holograms in the real world. This technology may have value intraoperatively by improving surgical decision-making and precision but relies on the ability to accurately align a hologram to a patient. This study aims to quantify the accuracy with which a hologram of soft tissue can be aligned to a patient and used to guide intervention. METHODS: A mannequin's face was marked in a standardized fashion with 14 incision patterns in red and nine reference points in blue. A three-dimensional photograph was then taken, converted into a hologram, and uploaded to HoloLens (Verto Studio LLC, San Diego, Calif.), a wearable augmented reality device. The red markings were then erased, leaving only the blue points. The hologram was then viewed through the HoloLens in augmented reality and aligned onto the mannequin. The user then traced the overlaid red markings present on the hologram. Three-dimensional photographs of the newly marked mannequin were then taken and compared with the baseline three-dimensional photographs of the mannequin for accuracy of the red markings. This process was repeated for 15 trials (n = 15). RESULTS: The accuracy of the augmented reality-guided intervention, when considering all trials, was 1.35 ± 0.24 mm. Markings that were positioned laterally on the face were significantly more difficult to reproduce than those centered around the facial midline. CONCLUSIONS: Holographic markings can be accurately translated onto a mannequin with an average error of less than 1.4 mm. These data support the notion that augmented reality navigation may be practical and reliable for clinical integration in plastic surgery.

Three-Dimensional Printed Anatomic Models Derived From Magnetic Resonance Imaging Data: Current State and Image Acquisition Recommendations for Appropriate Clinical Scenarios.

Three-dimensional (3D) printing technologies have been increasingly utilized in medicine over the past several years and can greatly facilitate surgical planning thereby improving patient outcomes. Although still much less utilized compared to computed tomography (CT), magnetic resonance imaging (MRI) is gaining traction in medical 3D printing. The purpose of this study was two-fold: 1) to determine the prevalence in the existing literature of using MRI to create 3D printed anatomic models for surgical planning and 2) to provide image acquisition recommendations for appropriate clinical scenarios where MRI is the most suitable imaging modality. The workflow for creating 3D printed anatomic models from medical imaging data is complex and involves image segmentation of the regions of interest and conversion of that data into 3D surface meshes, which are compatible with printing technologies. CT is most commonly used to create 3D printed anatomic models due to the high image quality and relative ease of performing image segmentation from CT data. As compared to CT datasets, 3D printing using MRI data offers advantages since it provides exquisite soft tissue contrast needed for accurate organ segmentation and it does not expose patients to unnecessary ionizing radiation. MRI, however, often requires complicated imaging techniques and time-consuming postprocessing procedures to generate high-resolution 3D anatomic models needed for 3D printing. Despite these challenges, 3D modeling and printing from MRI data holds great clinical promises thanks to emerging innovations in both advanced MRI imaging and postprocessing techniques. EVIDENCE LEVEL: 2 TECHNICAL EFFICATCY: 5.

A workflow to generate patient-specific three-dimensional augmented reality models from medical imaging data and example applications in urologic oncology.

Augmented reality (AR) and virtual reality (VR) are burgeoning technologies that have the potential to greatly enhance patient care. Visualizing patient-specific three-dimensional (3D) imaging data in these enhanced virtual environments may improve surgeons' understanding of anatomy and surgical pathology, thereby allowing for improved surgical planning, superior intra-operative guidance, and ultimately improved patient care. It is important that radiologists are familiar with these technologies, especially since the number of institutions utilizing VR and AR is increasing. This article gives an overview of AR and VR and describes the workflow required to create anatomical 3D models for use in AR using the Microsoft HoloLens device. Case examples in urologic oncology (prostate cancer and renal cancer) are provided which depict how AR has been used to guide surgery at our institution.

A guideline for 3D printing terminology in biomedical research utilizing ISO/ASTM standards.

First patented in 1986, three-dimensional (3D) printing, also known as additive manufacturing or rapid prototyping, now encompasses a variety of distinct technology types where material is deposited, joined, or solidified layer by layer to create a physical object from a digital file. As 3D printing technologies continue to evolve, and as more manuscripts describing these technologies are published in the medical literature, it is imperative that standardized terminology for 3D printing is utilized. The purpose of this manuscript is to provide recommendations for standardized lexicons for 3D printing technologies described in the medical literature. For all 3D printing methods, standard general ISO/ASTM terms for 3D printing should be utilized. Additional, non-standard terms should be included to facilitate communication and reproducibility when the ISO/ASTM terms are insufficient in describing expository details. By aligning to these guidelines, the use of uniform terms for 3D printing and the associated technologies will lead to improved clarity and reproducibility of published work which will ultimately increase the impact of publications, facilitate quality improvement, and promote the dissemination and adoption of 3D printing in the medical community.

A Case Report Describing Pre-operative Contouring of an Orthopedic Implant using a 3D-Printed Patient-specific Model.

Introduction: Paget's disease is a metabolic bone disorder characterized by abnormal patterns in bone remodeling, resulting in variable degrees of chronic bone pain, deformation of the long bones and rarely, and pathologic fracture. These issues can pose difficult surgical challenges, particularly in the elderly frail population, where the benefits of orthopedic intervention must be balanced with minimizing inherent surgical risks. Such considerations often include reducing operative time and blood loss, allowing for early mobilization, stabilizing an impending fracture, and providing symptom relief. Case Report: A 77-year-old female with a 10-year history of Paget's disease presented to an outside orthopedic clinic with progressive right leg pain and worsening anterior bowing following minor trauma to the extremity. Ultimately, the patient was offered in situ prophylactic intramedullary (IM) nail fixation, intended to augment her bone's native strength and prevent further microfractures and subsequent deformation. A three-dimensional (3D) printed patient specific model was developed to permit for pre-contouring of an off-the-shelf implant and subsequent sterilization and use at a future point in time. She underwent uneventful IM nailing of her tibia with the pre-contoured implant and proceeded to progress clinically postoperatively. Conclusion: In this report, we present an innovative use of a 3D printed patient-specific tibia model to pre-contour an IM nail. This surgical approach was undertaken to treat an elderly patient with a symptomatic and progressive deformity of the tibia secondary to Paget's disease of bone.

Three-Dimensional Facial Scanning at the Fingertips of Patients and Surgeons: Accuracy and Precision Testing of iPhone X Three-Dimensional Scanner.

BACKGROUND: The iPhone X (Apple, Inc., Cupertino, Calif.) is the first smartphone to be released with a high-fidelity three-dimensional scanner. At present, half of all U.S. smartphone users use an iPhone. Recent data suggest that the majority of these 230 million individuals will upgrade to the iPhone X within 2 years. This represents a profound expansion in access to three-dimensional scanning technology, not only for plastic surgeons but for their patients as well. The purpose of this study was to compare the iPhone X scanner against a popular, portable three-dimensional camera used in plastic surgery (Canfield Vectra H1; Canfield Scientific, Inc., Parsippany, N.J.). METHODS: Sixteen human subjects underwent three-dimensional facial capture with the iPhone X and Canfield Vectra H1. Results were compared using color map analysis and surface distances between key anatomical landmarks. To assess repeatability and precision of the iPhone X three-dimensional scanner, six facial scans of a single participant were obtained and compared using color map analysis. In addition, three-dimensionally-printed facial masks (n = 3) were captured with each device and compared. RESULTS: For the experiments, average root mean square was 0.44 mm following color map analysis and 0.46 mm for surface distance between anatomical landmarks. For repeatability and precision testing, average root mean square difference following color map analysis was 0.35 mm. For the three-dimensionally-printed facial mask comparison, average root mean square difference was 0.28 mm. CONCLUSIONS: The iPhone X offers three-dimensional scanning that is accurate and precise to within 0.5 mm when compared to a commonly used, validated, and expensive three-dimensional camera. This represents a significant reduction in the barrier to access to three-dimensional scanning technology for both patients and surgeons.

MRI guided procedure planning and 3D simulation for partial gland cryoablation of the prostate: a pilot study.

PURPOSE: This study reports on the development of a novel 3D procedure planning technique to provide pre-ablation treatment planning for partial gland prostate cryoablation (cPGA). METHODS: Twenty men scheduled for partial gland cryoablation (cPGA) underwent pre-operative image segmentation and 3D modeling of the prostatic capsule, index lesion, urethra, rectum, and neurovascular bundles based upon multi-parametric MRI data. Pre-treatment 3D planning models were designed including virtual 3D cryotherapy probes to predict and plan cryotherapy probe configuration needed to achieve confluent treatment volume. Treatment efficacy was measured with 6 month post-operative MRI, serum prostate specific antigen (PSA) at 3 and 6 months, and treatment zone biopsy results at 6 months. Outcomes from 3D planning were compared to outcomes from a series of 20 patients undergoing cPGA using traditional 2D planning techniques. RESULTS: Forty men underwent cPGA. The median age of the cohort undergoing 3D treatment planning was 64.8 years with a median pretreatment PSA of 6.97 ng/mL. The Gleason grade group (GGG) of treated index lesions in this cohort included 1 (5%) GGG1, 11 (55%) GGG2, 7 (35%) GGG3, and 1 (5%) GGG4. Two (10%) of these treatments were post-radiation salvage therapies. The 2D treatment cohort included 20 men with a median age of 68.5 yrs., median pretreatment PSA of 6.76 ng/mL. The Gleason grade group (GGG) of treated index lesions in this cohort included 3 (15%) GGG1, 8 (40%) GGG2, 8 (40%) GGG3, 1 (5%) GGG4. Two (10%) of these treatments were post-radiation salvage therapies. 3D planning predicted the same number of cryoprobes for each group, however a greater number of cryoprobes was used in the procedure for the prospective 3D group as compared to that with 2D planning (4.10 ± 1.37 and 3.25 ± 0.44 respectively, p = 0.01). At 6 months post cPGA, the median PSA was 1.68 ng/mL and 2.38 ng/mL in the 3D and 2D cohorts respectively, with a larger decrease noted in the 3D cohort (75.9% reduction noted in 3D cohort and 64.8% reduction 2D cohort, p 0.48). In-field disease detection was 1/14 (7.1%) on surveillance biopsy in the 3D cohort and 3/14 (21.4%) in the 2D cohort, p = 0.056) In the 3D cohort, 6 month biopsy was not performed in 4 patients (20%) due to undetectable PSA, negative MRI, and negative MRI Axumin PET. For the group with traditional 2D planning, treatment zone biopsy was positive in 3/14 (21.4%) of the patients, p = 0.056. CONCLUSIONS: 3D prostate cancer models derived from mpMRI data provide novel guidance for planning confluent treatment volumes for cPGA and predicted a greater number of treatment probes than traditional 2D planning methods. This study prompts further investigation into the use of 3D treatment planning techniques as the increase of partial gland ablation treatment protocols develop.

Clinical situations for which 3D printing is considered an appropriate representation or extension of data contained in a medical imaging examination: adult cardiac conditions.

BACKGROUND: Medical 3D printing as a component of care for adults with cardiovascular diseases has expanded dramatically. A writing group composed of the Radiological Society of North America (RSNA) Special Interest Group on 3D Printing (SIG) provides appropriateness criteria for adult cardiac 3D printing indications. METHODS: A structured literature search was conducted to identify all relevant articles using 3D printing technology associated with a number of adult cardiac indications, physiologic, and pathologic processes. Each study was vetted by the authors and graded according to published guidelines. RESULTS: Evidence-based appropriateness guidelines are provided for the following areas in adult cardiac care; cardiac fundamentals, perioperative and intraoperative care, coronary disease and ischemic heart disease, complications of myocardial infarction, valve disease, cardiac arrhythmias, cardiac neoplasm, cardiac transplant and mechanical circulatory support, heart failure, preventative cardiology, cardiac and pericardial disease and cardiac trauma. CONCLUSIONS: Adoption of common clinical standards regarding appropriate use, information and material management, and quality control are needed to ensure the greatest possible clinical benefit from 3D printing. This consensus guideline document, created by the members of the RSNA 3D printing Special Interest Group, will provide a reference for clinical standards of 3D printing for adult cardiac indications.

RadioGraphics Update: Medical 3D Printing for the Radiologist.

Editor's Note.-Articles in the RadioGraphics Update section provide current knowledge to supplement or update information found in full-length articles previously published in RadioGraphics. Authors of the previously published article provide a brief synopsis that emphasizes important new information such as technological advances, revised imaging protocols, new clinical guidelines involving imaging, or updated classification schemes. Articles in this section are published solely online and are linked to the original article.

Radiological Society of North America (RSNA) 3D Printing Special Interest Group (SIG) clinical situations for which 3D printing is considered an appropriate representation or extension of data contained in a medical imaging examination: abdominal, hepatobiliary, and gastrointestinal conditions.

BACKGROUND: Medical 3D printing has demonstrated value in anatomic models for abdominal, hepatobiliary, and gastrointestinal conditions. A writing group composed of the Radiological Society of North America (RSNA) Special Interest Group on 3D Printing (SIG) provides appropriateness criteria for abdominal, hepatobiliary, and gastrointestinal 3D printing indications. METHODS: A literature search was conducted to identify all relevant articles using 3D printing technology associated with a number of abdominal pathologic processes. Each included study was graded according to published guidelines. RESULTS: Evidence-based appropriateness guidelines are provided for the following areas: intra-hepatic masses, hilar cholangiocarcinoma, biliary stenosis, biliary stones, gallbladder pathology, pancreatic cancer, pancreatitis, splenic disease, gastric pathology, small bowel pathology, colorectal cancer, perianal fistula, visceral trauma, hernia, abdominal sarcoma, abdominal wall masses, and intra-abdominal fluid collections. CONCLUSION: This document provides initial appropriate use criteria for medical 3D printing in abdominal, hepatobiliary, and gastrointestinal conditions.

3D Printing, Augmented Reality, and Virtual Reality for the Assessment and Management of Kidney and Prostate Cancer: A Systematic Review.

Three-dimensional (3D) printing, augmented reality, and virtual reality technologies have an increasing presence in the management of prostate and kidney cancer. To assess the utility of 3D printing, augmented reality, and virtual reality for (1) quantitative outcomes, (2) surgical planning, (3) intraoperative guidance, (4) training and simulation, and (5) patient education for patients with kidney and prostate cancer a systematic literature review was performed. Existing evidence demonstrates improvement in clinical outcomes, surgical planning and intra-operative guidance, as well as training. Future studies are needed to assess the impact of 3D technologies on long-term patient-related outcomes.