HIFU Application

8/18/2019 HIFU Application

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HIFU Clinical

applications


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Clinical applications (1)

Prostate tumors: – several devices under ultrasonic guidance

commercially available (Ablatherm®, Sonablate

®)

ibroids

– !"g#$% procedures

– &'ablate ® ($nsightec &)* +A --.

– Philips C& approuved +ec --/ 0reast cancer

– clinical research

0one tumors

– clinical research


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Clinical application ()

0rain – small clinical studies – imitation: s2ull (bone) acoustic inter3ace – 4o motion

iver: – #ai3u® under ultrasonic guidance – !"g#$% procedures: Small clinical studies – imitation:

aeric and bone inter3aces!otions


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!"$ guidance o3 3ocused ultrasound

therapy o3 %terine 3ibroids

%terine 3ibroids: ma5or

cause o3 morbidity

Symptomatic in 167 o3

patients

– 0leeding

– !ass

e33ect

– Pain

– 88

Age years Lumbiganon Parazzini

< 30 1,4% 4,7%

30-39 25,1% 22,5%

40-49 61% 61,8%

50 12,5% 10,9%


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ibroids: therapy!ormona" #rug transient e33ect

– Progestin

– onadotrophin*releasing*hormone*agonist

$onsera&ie a''roa() *+mini-inasie – yome(&omy – .&erine ar&ery embo"iza&ion – !/. outpatient procedure

and very short recovery period)ys&re(&omy

irs& surgery in .A mos& or ibrois


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%terine ibroidsComparing treatment options

Treatment Factors Hysterectomy Myomectomy UF Embolization MR-HIFU

Procedure count(%SA, --9)

-;--- ;--- ;--- < .;---(total ==)

#ospital stay – days 1 – 7 days days -

Complication rate – -> – 7.> Peri op: 1->Post op: >

? 7>

"eturn tonormal activity

@ – days .. days 1- days 1* day

uture 3ertility 4o yes-> increasedris2 duringpregnancy

(yes)Possible ovarianemboliBation

(yes)&'clusioncriteria, butencouraging

data

+ra=bac2s6complications

4o 3uturepregnancy,emotional stress

7-> recurrence=ithin y

e33ective in /-> o3patients at 1 yearand @-> at years

e33ectivenessdepends on the4Plong*termmonitoringD


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!"g#$% advantages 3or 3ibroids

Ambu"a&ory

o gnra" anaes&)esia

o (u&aneous 'ene&ra&ione&urn &o or ay 1-2

*)ys&ere(&omy 1-2 mon&)

ae&y *e aerse ee(&s


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/ bes& imaging &e()ni:ue or ibrois


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AdEnomyosis


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X

Y

0

M

Phase image

during heating

/ a &)ermome&er;;

Thermal Map

(∆T C + 37

C)


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Temperaturre map based on PR

d! " dT # $ # 0%0& ppm"'C *T # * ," ($ - . - /o-

T)

1radient e2ho ith spoiler Phase 4 5 Phase &

"inear an ine'enen& o &issue &y'e

Phase &

6oom 8

Phase 4

6oom 8

Relati9e temp map

6oom 8 40 mm


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!"g#$%

1/ goo &ra(ing o &)e ibroi2/ goo &arge&ing o &)e !/. in &)eibrois3 / &em'era&ures ()anges uring

!/.4 aus&men& o !/. in rea" &ime


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!"*#$% Plat3orm: Sonalleve !"*#$%

Phased array transducer

F channels

F ocal point siBe: 1 ' 1 ' @ mm7

F reGuency 1; !#B

ast electronic 3ocal point steering

!echanical plat3orm arge range o3 displacements

H $ntegrated into a 1;I Philips Scanner

Anatomical images =ith +edicatedS&4S& Pelvis coil

Ihermal maps

4on*per3used volume


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3D anatomy and

temperature mapping

thermotherapy

position,timing,

& power

control

US

power

Motorcontrol

MRI-controlled HIFU

MR is essential for 3D planning and to monitor temperature in real-

MR with integrated HIFU Therapy Planning Console

Phased Array Transducer

In Mechanical Positioner

Focused Ultrasound

Electronics


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Point*by*point ablation

Challenge L1 – treatment time

– Ablation speed limit M1 ml6

min

– &'cessive cooling times – ong procedure times 7h

Challenge L – tissue properties

– ocal variations in tissue properties

– $nhomogeneous absorption,

attenuation, per3usion, di33usion $rregular heating patterns

"is2 o3 incomplete coverage

4e= ablation concept

olumetric heating addressing L1 *

!"*#$%Iraditional ablation concept


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olumetric ablation

Cell

$ncreased e33iciency

eera" o"ume&ri( ab"a&ion ere'erorme in orer &o (oer &)e "argeibroi o"ume

="e(&roni( beam s&eering>u&ars-moing(on(en&ri( (ir("es

4 ? 16 mm @


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Au&oma&i( ab"a&ion (on&ro"

/n&eru'&ion&)res)o"

em'era&ure

)erma" ose

&o' )ea&ing

e"iab"e ne(rosis size

-

em'era&ure B )erma"#ose oer"ays

ea" &ime isua"iza&ionC

Au&oma&i( (on&ro"

em'D borer E 54-57F$ or #ose E 240

=


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$ > 7

> 6 A L

3 A G /

A

L

ariable cell siBe

8mm @4mm @ 12mm @ 16mm @

em'era&ure a& &)e en o soni(a&ion

Temp.[°C]

75

47

43

39

56

2cm 2cm2cm2cm

2cm 2cm2cm2cm


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$ > 7

> 6 A L

3 A G /

A

L

ariable cell siBe

)erma" ose a& &)e en o (oo"-on

Dose[EM]

240

180

120

60

30

480

2cm 2cm2cm2cm

2cm 2cm2cm2cm

8mm @4mm @ 12mm @ 16mm @


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=Ham'"e o a 12mm @ soni(a&ion

47

43

39

Dose[EM]

24

Temp.

[°C]75

56


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25

Above lef! P"anning= 2 3#, >I250,1D42H2D10H2D5mm,

Above "#$%! P"a(ing&rea&men& (e""s on '"anning

imagesD ."&rasoun beam (onean sae&y margins ini(a&e

&elo' lef! &em'era&ure ma'rea"-&ime, sagi&&a" ieJ12H30 mm ab"a&ion o"ume=P/ Proe&, 2D5H2D5H7D0 mm

&elo' "#$%! 'os& &rea&men&on Peruse Io"ume *PI1 = !/I= 3# PA/$C >I200,1D0H1D10H4D00mm

rea&men& &ime 130 min


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Patient =ell*beingo (om'"i(a&ions or

serious aerse een&s an

no unin&ene "esions ere

obsereD

!os'i&a" s&ay

e&urn &o norma" a(&ii&y

2D4 1D8 ays

ym'&oms * a&er 1

mon&)

- 13D6 'oin&s *-26D9%

*rom C10D0% &o-92D3%


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olumetric #eating =ith eedbac2

-

.

@

1

1,1-

1.

1

1@

- . @

Cell diameter

NmmO

1 1

A b l a t i o n s p e e d N m l 6 m

i n O

4

4

4

9

4

7

-

-,

1

,

- . @

Cell diameter

NmmO

1

1

A b l a t i o n e 3 3 i c e n c y N m l 6 2

Q O

4

7

4

9

4

4

/m'roe ei(ien(y an s'ee in ("ini(a" 'ra(&i(e

Ab"a&ion s'ee Ab"a&ion ei(ien(y

10H as&er ab"a&ion &)an 'oin& by'oin&

Larger (e""s nee 2-3H "onger(oo"ing

16 mm 35H more ei(ien& &)an 4mmLess near ie" )ea&ing, s)or&er(oo"ing


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C),*DE,TA


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&'ample o3 an #$% treatment outcome

DA( )* T+EATME,T 1 M),T- *))/+ET+EATME,T

C),*DE,TA


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&'ample o3 an #$% treatment outcome

Keore !/.1 mon&) a&er !/.

us& a&er !/.


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1 year a3ter #$%


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$n practice


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> o3 treatment volume and e33iciency

Larger &rea&men& o"umes are 'reerre &o reu(eibroi o"ume as mu() as 'ossib"e

ennessy e& a" 2007aio"ogy

Treatment olume

of Fibroid

! 33 " ! ##"

> o3 patients =ith 1- pointsimprovment (SSS) at 7 months

9/>

> o3 patients =ith 1- pointsimprovment (SSS) at months

9/> @@>

> o3 patients =ith 1- pointsimprovment (SSS) at 1months

9@> /1>

4P 1> R 1,1 ,9 R 1,@


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Kone absorbs . more rea"i"y &)an so& &issue an "o energiesare sui(ien& &o )ea& a bone sura(e &o )ig) &em'era&ureD/n &)is area neres are aa(en& o &)e bone sura(e an may beeH'ose

$atient to include


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$atient to include

A 3ar 3ield margin o3 .-mm should be

available

T2 sagittal

Chec2 that the 3ar 3ield doesnt include sacrum or bo=el

Alternatively treat only the anterior part o3 the 3ibroid

!a': .-mm

$atient to e%clude


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$atient to e%clude

0o=els are located in the beam path

bet=een the 3ibroid and the gel pad

4o sonication possible across air structure or scarves

Air bloc2 ultrasound and produce local heating (bo=els damage)

$atient to include


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$atient to include

0o=els are not located in the beam path

bet=een the 3ibroid and the gel pad

T2 sagittal

#o=ever be care3ul to avoid bo=el =hen sonicating

$ts better to avoid bladder but its possible to sonicate across the


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$atient to e%clude&


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$atient to e%clude&

T1 sagittal before gado T1 sagittal after gado

Patient =ith too many 3ibroidsD

$atient to e%clude


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T1 sagittal before gado T1 sagittal after gado

Ihe transducer displacement and ma'imum 3ocal point is

limited

$atient to e%clude

1@mm

$atient to include


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$atient to include

T2 sagittal T1 sagittal after gado

ibroid =ith a mass center at less than /- mm 3rom the s2in could be

treated

;

!a': 1mm

$atient to include


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Consider the 3act that the bladder =ill be empty during treatment

!ight help to obtain a better 3ar margin relatively to the

sacrum

During pre treatment M!

$atient to include

During treatment M"#!$U

$atient to e%clude


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Patient =ith calci3ication in or close to the beam path should be

e'clude Calci3ication could be identi3ied by ultrasound echo

image

Calci3ication stops the ultrasound =ave (local heating)

and produces local image distortion (=rong treatment planning)

$atient to e%clude

'alcification

$atient to e%clude


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Patient =ith clips in or close to the beam path should be

e'clude

T2 trans%ersal T1 trans%ersal

after gado'

Clips stops the ultrasound =ave (local heating), produces local

image distortion (=rong treatment planning)and induces thermal map instability

$atient to e%clude

'lip 'lip

$atient to include


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Patient =ith scar in the beam path should be

e'clude

T2 trans%ersal

Scar stops the ultrasound =ave (local heating)

+ra= t=o lines =ith same length to chec2 beam

((

$atient to include

)car

$atient to include


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Consider possibility to 3ill the bladder to avoid scar

Caution, in this case the bladder =ill continue to 3ill progressively

Chec2 3reGuently the 3ibroid location =ith mar2ers

((

$atient to include

)car )car


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Signal o3 the 3ibroid

‐!/. 'rou(e a grea&er o"ume reu(&ionin 2 )y'oin&ense ibrois &)an in)y'erin&ense ibrois


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Jthers applications

iver


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#CC: traitement

Surgery: – liver transplantation,

– iver resection but di33icult due to cirrhosis:

Percutaneous therapy – PhysiGue: "

– Chimioembolisation


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!etastasis 3rom colon carcinoma

Jne o3 the K the most 3rEGuent

!Etastasis

– synchronous: 1*>,

– +uring the 3ollo= up: -> ive years survival i3 !

– +rug only: >

– Surgery o3 the metastasis: 7-*.-> only1-> o3 the patient =ith metastasis can be treatedby

surgery


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TransverseAbl ti RF 1 Abl ti RF 2


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Tumour before

RF

Ablation RF 1 Ablation RF 2

Slice1

Slice2 Slice2

Slice1


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Ablation RF N°1

Ablation RF N°2

T2w


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After RF ablation

T1w

Tumour before RF

CE-T1w

T2w


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#$% and iver:

– #ai3u® under ultrasonic guidance

– !"g#$% procedures: Smallclinical studies

– imitation: aeric and bone inter3aces!otions


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!otions


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ree brea&)ing1- C

- C

C

Anatomicalimage

standards Déviationsof T (nocorrection)

standards Déviationsof T (withcorrection)

MR thermometry with motion :correction

eect

#$% and pig liver =ith motion


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#$% and pig liver =ith motion

correction


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Combined !" contrast agents 3or


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Iarget speci3ic part

– !A0 (3ragments)

– Peptides

– Aptamers (short

+4A6"4A strings)

#eat sensitive in2age

Contrast agent (multiple)

– d

– $ron particle

– +rugs

Combined !" contrast agents 3or

imaging6therapy

D


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MRI guided FUS for spatio-temporal control of gene expression


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g p p g punder control of a heat sensitive promoter

Heated region

Ana"ysis o Green"uores(en& Pro&ein gene

=H'ression using $ono(a"i(ros(o'e

Fuorescence Image Transmission Image


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HIFU Application

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