Real-time visualization of high-intensity focused ultrasound treatment using ultrasound imaging

Real-time monitoring of HIFU treatment using pulse inversion

Ultrasound (US) imaging is widely used for the real-time guidance of high-intensity focused ultrasound (HIFU) treatment at a relatively low cost. However, ultrasound image guided HIFU (USgHIFU) is limited in the real-time monitoring of HIFU treatment due to the large amplitude HIFU signals received by the US imaging transducer. The amplitude of the HIFU scattered signal is generally much higher than the amplitude of the pulse-echo signal received by the imaging transducer. This creates an interference pattern obscuring the image of the tissue. As such, it is difficult to monitor lesion location. This paper proposes a real-time monitoring method to be performed concurrently with the HIFU insonation, but without HIFU interference, which allows for the improvement of treatment accuracy and safety in USgHIFU. The proposed method utilizes the physical properties of pulse inversion which is capable of removing the fundamental and odd harmonic components of the HIFU interference. Therefore, it is possible to secure the desired spectral bandwidth used to construct US images for HIFU treatment monitoring. The performance of the proposed method was evaluated through experiments with both a bovine serum albumin phantom and a chicken breast. The results demonstrated that the proposed method is capable of providing interference-free US images, thus successfully allowing for US imaging during HIFU treatment.

Estimating dynamic changes of tissue attenuation coefficient during high-intensity focused ultrasound treatment

BACKGROUND

This study investigated the dynamic changes of tissue attenuation coefficients before, during, and after high-intensity focused ultrasound (HIFU) treatment at different total acoustic powers (TAP) in ex vivo porcine muscle tissue. It further assessed the reliability of employing changes in tissue attenuation coefficient parameters as potential indicators of tissue thermal damage.

METHODS

Two-dimensional pulse-echo radio frequency (RF) data were acquired before, during, and after HIFU exposure to estimate changes in least squares attenuation coefficient slope (Δβ) and attenuation coefficient intercept (Δα 0). Using the acquired RF data, Δβ and Δα 0 images, along with conventional B-mode ultrasound images, were constructed. The dynamic changes of Δβ and Δα 0, averaged in the region of interest, were correlated with B-mode images obtained during the HIFU treatment process.

RESULTS

At a HIFU exposure duration of 40 s and various HIFU intensities (737-1,068 W/cm(2)), Δβ and Δα 0 increased rapidly to values in the ranges 1.5-2.5 dB/(MHz.cm) and 4-5 dB/cm, respectively. This rapid increase was accompanied with the appearance of bubble clouds in the B-mode images. Bubble activities appeared as strong hyperechoic regions in the B-mode images and caused fluctuations in the estimated Δβ and Δα 0 values. After the treatment, Δβ and Δα 0 values gradually decreased, accompanied by fade-out of hyperechoic spots in the B-mode images. At 10 min after the treatment, they reached values in ranges 0.75-1 dB/(MHz.cm) and 1-1.5 dB/cm, respectively, and remained stable within those ranges. At a long HIFU exposure duration of around 10 min and low HIFU intensity (117 W/cm(2)), Δβ and Δα 0 gradually increased to values of 2.2 dB/(MHz.cm) and 2.2 dB/cm, respectively. This increase was not accompanied with the appearance of bubble clouds in the B-mode images. After HIFU treatment, Δβ and Δα 0 gradually decreased to values of 1.8 dB/(MHz.cm) and 1.5 dB/cm, respectively, and remained stable at those values.

CONCLUSIONS

Δβ and Δα 0 estimations were both potentially reliable indicators of tissue thermal damage. In addition, Δβ and Δα 0 images both had significantly higher contrast-to-speckle ratios compared to the conventional B-mode images and outperformed the B-mode images in detecting HIFU thermal lesions at all investigated TAPs and exposure durations.

Electroacoustic response of 1-3 piezocomposite transducers for high power applications

The electroacoustic performance of 1-3 piezoelectric composite transducers with low loss polymer filler was studied and compared to monolithic Pb(Zr,Ti)O(3) (PZT) piezoelectric transducers. The 1-3 composite transducers exhibited significantly high electromechanical coupling factor (k(t) ∼ 0.64) when compared to monolithic counterparts (k(t) ∼ 0.5), leading to the improved bandwidth and loop sensitivity, being on the order of 67% and -24.0 dB versus 44% and -24.8 dB, respectively. In addition, the acoustic output power and transmit efficiency (∼50%) were found to be comparable to the monolithic PZT transducers, demonstrating potential for broad bandwidth, high power ultrasonic transducer applications.

High-intensity focused ultrasound: principles, therapy guidance, simulations and applications

In the past two decades, high-intensity focused ultrasound (HIFU) in combination with diagnostic ultrasound (USgFUS) or magnetic resonance imaging (MRgFUS) opened new ways of therapeutic access to a multitude of pathologic conditions. The therapeutic potential of HIFU lies in the fact that it enables the localized deposition of high-energy doses deep within the human body without harming the surrounding tissue. The addition of diagnostic ultrasound or in particular MRI with HIFU allows for planning, control and direct monitoring of the treatment process. The clinical and preclinical applications of HIFU range from the thermal treatment of benign and malign lesions, targeted drug delivery, to the treatment of thrombi (sonothrombolysis). Especially the therapy of prostate cancer under US-guidance and the ablation of benign uterine fibroids under MRI monitoring are now therapy options available to a larger number of patients. The main challenges for an abdominal application of HIFU are posed by partial or full occlusion of the target site by bones or air filled structures (e.g. colon), as well as organ motion. In non-trivial cases, the implementation of computer based modeling, simulation and optimization is desirable. This article describes the principles of HIFU, ultrasound and MRI therapy guidance, therapy planning and simulation, and gives an overview of the current and potential future applications.

Pulse compression technique for simultaneous HIFU surgery and ultrasonic imaging: a preliminary study

In an ultrasound image-guided High Intensity Focused Ultrasound (HIFU) surgery, reflected HIFU waves received by an imaging transducer should be suppressed for real-time simultaneous imaging and therapy. In this paper, we investigate the feasibility of pulse compression scheme combined with notch filtering in order to minimize these HIFU interference signals. A chirp signal modulated by the Dolph-Chebyshev window with 3-9MHz frequency sweep range is used for B-mode imaging and 4MHz continuous wave is used for HIFU. The second order infinite impulse response notch filters are employed to suppress reflected HIFU waves whose center frequencies are 4MHz and 8MHz. The prototype integrated HIFU/imaging transducer that composed of three rectangular elements with a spherically con-focused aperture was fabricated. The center element has the ability to transmit and receive 6MHz imaging signals and two outer elements are only used for transmitting 4MHz continuous HIFU wave. When the chirp signal and 4MHz HIFU wave are simultaneously transmitted to the target, the reflected chirp signals mixed with 4MHz and 8MHz HIFU waves are detected by the imaging transducer. After the application of notch filtering with pulse compression process, HIFU interference waves in this mixed signal are significantly reduced while maintaining original imaging signal. In the single scanline test using a strong reflector, the amplitude of the reflected HIFU wave is reduced to -45dB. In vitro test, with a sliced porcine muscle shows that the speckle pattern of the restored B-mode image is close to that of the original image. These preliminary results demonstrate the potential for the pulse compression scheme with notch filtering to achieve real-time ultrasound image-guided HIFU surgery.

High-frequency rapid B-mode ultrasound imaging for real-time monitoring of lesion formation and gas body activity during high-intensity focused ultrasound ablation

The goal of this study was to examine the ability of high-frame-rate, high-resolution imaging to monitor tissue necrosis and gas-body activities formed during high-intensity focused ultrasound (HIFU) application. Ex vivo porcine cardiac tissue specimens (n = 24) were treated with HIFU exposure (4.33 MHz, 77 to 130 Hz pulse repetition frequency (PRF), 25 to 50% duty cycle, 0.2 to 1 s, 2600 W/cm(2)). RF data from B-mode ultrasound imaging were obtained before, during, and after HIFU exposure at a frame rate ranging from 77 to 130 Hz using an ultrasound imaging system with a center frequency of 55 MHz. The time history of changes in the integrated backscatter (IBS), calibrated spectral parameters, and echo-decorrelation parameters of the RF data were assessed for lesion identification by comparison against gross sections. Temporal maximum IBS with +12 dB threshold achieved the best identification with a receiver-operating characteristic (ROC) curve area of 0.96. Frame-to-frame echo decorrelation identified and tracked transient gas-body activities. Macroscopic (millimeter-sized) cavities formed when the estimated initial expansion rate of gas bodies (rate of expansion in lateral-to-beam direction) crossed 0.8 mm/s. Together, these assessments provide a method for monitoring spatiotemporal evolution of lesion and gas-body activity and for predicting macroscopic cavity formation.

High-intensity focused ultrasound treatment of liver tumours: post-treatment MRI correlates well with intra-operative estimates of treatment volume

OBJECTIVES

To assess the safety and feasibility of high-intensity focused ultrasound (HIFU) ablation of liver tumours and to determine whether post-operative MRI correlates with intra-operative imaging.

METHODS

31 patients were recruited into two ethically approved clinical trials (median age 64; mean BMI 26 kg m(-2)). Patients with liver tumours (primary or metastatic) underwent a single HIFU treatment monitored using intra-operative B-mode ultrasound. Follow-up consisted of radiology and histology (surgical trial) or radiology alone (radiology trial). Radiological follow-up was digital subtraction contrast-enhanced MRI.

RESULTS

Treatment according to protocol was possible in 30 of 31 patients. One treatment was abandoned because of equipment failure. Transient pain and superficial skin burns were seen in 81% (25/31) and 39% (12/31) of patients, respectively. One moderate skin burn occurred. One patient died prior to radiological follow-up. Radiological evidence of ablation was seen in 93% (27/29) of patients. Ablation accuracy was good in 89% (24/27) of patients. In three patients the zone of ablation lay ≤2 mm outside the tumour. The median cross-sectional area (CSA) of the zone of ablation was 5.0 and 5.1 cm(2) using intra-operative and post-operative imaging, respectively. The mean MRI:B-mode CSA ratio was 1.57 [95% confidence interval (CI)=0.57-2.71]. There was positive correlation between MRI and B-mode CSA (Spearman's r=0.48; 95% CI 0.11-0.73; p=0.011) and the slope of linear regression was significantly non-zero (1.23; 95% CI=0.68-1.77; p<0.0001).

CONCLUSIONS

HIFU ablation of liver tumours is safe and feasible. HIFU treatment is accurate, and intra-operative assessment of treatment provides an accurate measure of the zone of ablation and correlates well with MRI follow-up.

Mechanobiological modulation of cytoskeleton and calcium influx in osteoblastic cells by short-term focused acoustic radiation force

Mechanotransduction has demonstrated potential for regulating tissue adaptation in vivo and cellular activities in vitro. It is well documented that ultrasound can produce a wide variety of biological effects in biological systems. For example, pulsed ultrasound can be used to noninvasively accelerate the rate of bone fracture healing. Although a wide range of studies has been performed, mechanism for this therapeutic effect on bone healing is currently unknown. To elucidate the mechanism of cellular response to mechanical stimuli induced by pulsed ultrasound radiation, we developed a method to apply focused acoustic radiation force (ARF) (duration, one minute) on osteoblastic MC3T3-E1 cells and observed cellular responses to ARF using a spinning disk confocal microscope. This study demonstrates that the focused ARF induced F-actin cytoskeletal rearrangement in MC3T3-E1 cells. In addition, these cells showed an increase in intracellular calcium concentration following the application of focused ARF. Furthermore, passive bending movement was noted in primary cilium that were treated with focused ARF. Cell viability was not affected. Application of pulsed ultrasound radiation generated only a minimal temperature rise of 0.1°C, and induced a streaming resulting fluid shear stress of 0.186 dyne/cm(2), suggesting that hyperthermia and acoustic streaming might not be the main causes of the observed cell responses. In conclusion, these data provide more insight in the interactions between acoustic mechanical stress and osteoblastic cells. This experimental system could serve as basis for further exploration of the mechanosensing mechanism of osteoblasts triggered by ultrasound.

A fast tissue stiffness-dependent elastography for HIFU-induced lesions inspection

To monitor HIFU-induced lesion with elastography in quasi-real time, a fast correlation based elastographic algorithm using tissue stiffness-dependent displacement estimation (SdDE) is developed in this paper. The high time efficiency of the proposed method contributes to the reduction on both the number of the displacement points and the computational time of most of the points by utilizing local uniformity of the tissue under HIFU treatment. To obtain admirable comprehensive performance, the key algorithm parameter, a threshold to densify the displacement points, is optimized with simulation over a wedge-inclusion tissue model by compromising the axial resolution (AR) and the computational cost. With the optimum parameter, results from both simulations and phantom experiments show that the SdDE is faster in about one order of magnitude than the traditional correlation based algorithm. At the same time, other performance parameters, such as the signal-to-noise ratio (SNRe), the contrast-to-noise ratio (CNRe) and the axial resolution (AR), are superior to or comparable with that obtained from the traditional algorithm. In vitro experiments on bovine livers validate the improvement on the time efficiency under the circumstances of real tissue and real radio frequency (RF) signal. This preliminary work implies potential of the SdDE in dynamic or close real time guidance and monitoring of HIFU treatment.

Changes in ultrasonic properties of liver tissue in vitro during heating-cooling cycle concomitant with thermal coagulation

The present work considers the ultrasonic properties of porcine liver tissue in vitro measured during heating concomitant with thermal coagulation followed by natural cooling, so as to provide information about changes in the ultrasonic properties of the tissue after thermal coagulation. The excised liver samples were heated in a degassed water bath up to 75°C and naturally cooled down to 30°C. The tissue was observed to begin thermally coagulating at temperatures lower than 75°C. The ultrasonic parameters considered include the speed of sound, the attenuation coefficient, the backscatter coefficient and the nonlinear parameter of B/A. They were more sensitive to temperature when heating than during natural cooling. All of the parameters were shown to rise significantly on completion of the heating-cooling cycle. At 35°C after thermal coagulation, the B/A value was increased by 96%, the attenuation and backscatter coefficients were increased by 50%∼68% and 33%∼37%, respectively, in the typical frequency ranges of 3 MHz∼5 MHz used for ultrasonic imaging and the speed of sound was increased by 1.4%. The results of this study added to the evidence that tissue characterization, in particular, based on the B/A could be valuable for ultrasonically imaging the thermal lesions following high-intensity focused ultrasound (HIFU) surgery.

Combined ultrasonic thermal ablation with interleaved ARFI image monitoring using a single diagnostic curvilinear array: a feasibility study

The goal of this work is to demonstrate the feasibility of using a diagnostic ultrasound system (Siemens Antares and CH6-2 curvilinear array) to ablate ex vivo liver with a custom M-mode sequence and monitor the resulting tissue stiffening with 2-D Acoustic Radiation Force Impulse (ARFI) imaging. Images were taken before and after ablation, as well as in 5- s intervals during the ablation sequence in order to monitor the ablation lesion formation temporally. Ablation lesions were generated at depths up to 1.5 cm from the surface of the liver and were not visible in B-mode. ARFI images showed liver stiffening with heating that corresponded to discolored regions in gross pathology. As expected, the contrast of ablation lesions in ARFI images is observed to increase with ablation lesion size. This study demonstrated the ability of a diagnostic system using custom beam sequences to localize an ablation site, heat the site to the point of irreversible damage and monitor the formation of the ablation lesion with ARFI imaging.

Microbubble-enhanced functional changes in arteries induced by pulsed high-intensity focused ultrasound exposure

The purpose of this study is to investigate the dose-dependent effects of ultrasound contrast agent (UCA) on the changes of peak systolic velocity (PSV) and pulsatility index (PI) in the arteries of 24 male Sprague-Dawley rats. The rats were sonicated with 1.0-MHz pulsed high-intensity focused ultrasound (HIFU) at two acoustic powers, 15 W and 30 W, with UCA present at four concentrations (0, 150, 300, and 450 μL/kg). Ultrasound imaging was used to localize and to monitor the pulsed-HIFU exposure. The mean PSV of blood flow, as measured by Doppler ultrasound imaging, increased immediately in the arteries where UCA has been administrated at all four doses after pulsed-HIFU at 15 W. However, the normalized PSV change decreased with each injected dose of UCA at 30 W. Furthermore, the normalized pulsatility index changes increased as the injected dose of UCA increased at two acoustic powers. No obvious changes were found in terms of histological structures and temperature rise at the vessel wall. Our results demonstrated that the response of the artery to pulsed-HIFU was dependent on UCA dose at the same acoustic power. The value of normalized PSV change was minimal and the normalized PI change reached a maximum when the UCA dose was at the highest dose of UCA (450 μL/kg) with the two acoustic powers.

Treatment of small hepatocellular carcinomas with US-guided high-intensity focused ultrasound

High-intensity focused ultrasound (HIFU) is a noninvasive method that can cause complete coagulation necrosis without requiring the insertion of any instruments. The purpose of this study was to evaluate the safety and efficacy of HIFU treatment for small liver cancers without performing transcatheter arterial chemoembolization (TACE) or rib resection. HIFU ablation was performed without rib resection or the aid of TACE or percutaneous ethanol injection (PEI) in 12 patients with hepatocelullar carcinoma. The HIFU system (Chongqing Haifu Tech, Chongqing, China) was used under ultrasound guidance. All 12 patients completed the treatment without experiencing any adverse events. Complete coagulation was achieved by applying the sonications from the intercostal space when the tumor was located in the right lobe. After treatment, serum alanine aminotransferase (ALT) and serum aspartate aminotransferase (AST) levels were significantly higher than the baseline values; these levels recovered within 1 week. C-reactive protein (CRP) levels increased 1 week after treatment but decreased within 1 month. An epidural anesthetic provided sufficient pain suppression during the procedure. Edema of the subcutaneous tissue was detected in five cases, but the edema disappeared within 1 month. None of the patients developed acute hepatic failure, liver abscess or renal dysfunction. In conclusion, HIFU is effective for the treatment of patients with small liver cancer.

Development and characterization of a tissue-mimicking material for high-intensity focused ultrasound

A tissue-mimicking material (TMM) for the acoustic and thermal characterization of high-intensity focused ultrasound (HIFU) devices has been developed. The material is a high-temperature hydrogel matrix (gellan gum) combined with different sizes of aluminum oxide particles and other chemicals. The ultrasonic properties (attenuation coefficient, speed of sound, acoustical impedance, and the thermal conductivity and diffusivity) were characterized as a function of temperature from 20 to 70°C. The backscatter coefficient and nonlinearity parameter B/A were measured at room temperature. Importantly, the attenuation coefficient has essentially linear frequency dependence, as is the case for most mammalian tissues at 37°C. The mean value is 0.64f(0.95) dB·cm(-1) at 20°C, based on measurements from 2 to 8 MHz. Most of the other relevant physical parameters are also close to the reported values, although backscatter signals are low compared with typical human soft tissues. Repeatable and consistent temperature elevations of 40°C were produced under 20-s HIFU exposures in the TMM. This TMM is appropriate for developing standardized dosimetry techniques, validating numerical models, and determining the safety and efficacy of HIFU devices.

High-intensity focused ultrasound for hepatocellular carcinoma: a single-center experience

OBJECTIVE

This study aims to evaluate the outcome of patients with hepatocellular carcinoma (HCC) treated by high-intensity focused ultrasound (HIFU) in a single tertiary referral center.

BACKGROUND

HIFU is the latest developed local ablation technique for unresectable HCC. The initial experience on its efficacy is promising, but the survival benefit of patients undergoing HIFU for HCC is poorly defined.

METHODS

From October 2006 to December 2008, 49 patients received HIFU for unresectable HCC. Each patient underwent a single session of HIFU with a curative intent. Treatment efficacy and survival outcome were evaluated. Clinicopathologic factors affecting the primary technique effectiveness and overall survival rates were investigated by univariate analysis.

RESULTS

The median size of the treated tumors was 2.2 cm, ranging from 0.9 to 8 cm. The majority of patients had single tumors (n = 41, 83.6%). Thirty-one patients (63.2%) had artificial right pleural effusion during HIFU treatment to reduce damage to the lung and diaphragm. The hospital mortality rate was 2% (n = 1) and the complication rate was 8.1% (n = 4). The primary technique effectiveness rate was 79.5% (39 of 49 patients). It increased from 66.6% in the initial series to 89.2% in the last 28 patients. Tumor size (≥3.0 cm) was the significant risk factor affecting the complete ablation rate. The 1- and 3-year overall survival rates were 87.7% and 62.4%, respectively. Child-Pugh liver function grading was the significant prognostic factor influencing the overall survival rate.

CONCLUSIONS

HIFU is an effective treatment modality for unresectable HCC with a high technique effectiveness rate and favorable survival outcome.

Single-element ultrasound transducer for combined vessel localization and ablation

This report describes a system that utilizes a single high-intensity focused ultrasound (HIFU) transducer for both the localization and ablation of arteries with internal diameters of 0.5 and 1.3 mm. In vitro and in vivo tests were performed to demonstrate both the imaging and ablation functionalities of this system. For imaging mode, pulsed acoustic waves (3 cycles for in vitro and 10 cycles for in vivo tests, 2 MPa peak pressure) were emitted from the 2-MHz HIFU transducer, and the backscattered ultrasonic signal was collected by the same transducer to calculate Doppler shifts in the target region. The maximum signal amplitude of the Doppler shift was used to determine the location of the target vessel. The operation mode was then switched to the therapeutic mode and vessel occlusion was successfully produced by high-intensity continuous HIFU waves (12 MPa) for 60 s. The system was then switched back to imaging mode for residual flow to determine the need for a second ablation treatment. The new system might be used to target and occlude unwanted vessels such as vasculature around tumors, and to help with tumor destruction.

Findings of multidetector row computed tomography of HCCs treated by HIFU ablation

PURPOSE

We evaluated the efficacy of high-intensity focused ultrasound (HIFU) ablation for hepatocellular carcinoma (HCC), and a long-term study by follow-up multidetector-row computed tomography (CT) was conducted to evaluate the changes occurring in the treatment area following the HIFU ablation.

MATERIALS AND METHODS

HIFU ablation was carried out in 14 patients with small HCCs (≤3 lesions, ≤3cm in diameter). The HIFU system (Chongqing Haifu Tech) was used under ultrasound guidance. The evaluations were performed by follow-up CT at 1 week, 1, 3, 6 and 12 months after the HIFU ablation.

RESULTS

HIFU ablation was carried out successfully in 11 of the 14 patients. At 1 week after the HIFU, a peripheral rim enhancement was found in all cases (100%). This finding was persistent in 6 of the 11 cases (54.5%) at 1 month, and in 1 of the 11 (9%) cases at 3 months after HIFU ablation. In all cases, the rim enhancement disappeared by 6 or 12 months after the HIFU ablation. At the 12 months follow-up, a decrease in the diameter of the ablated lesions was found. The enhancement around the treated area was found to be persistent at the 12 months follow-up in the one case of recurrence of the treated site in which the safety margin was not sufficiently wide. During the follow-up period, there were 2 cases with residual of HCC tumors. We performed radiofrequency ablation (RFA) for these residual tumors after the HIFU ablation.

CONCLUSION

To ascertain the cause of the peripheral enhancement on follow-up CT images after the HIFU ablation, in particular, to determine whether it might be caused by residual tumor or recurrence at the treated site, careful follow-up is important, especially in cases where the safety margin of the ablated area was not sufficiently wide.

Real-time monitoring of high-intensity focused ultrasound lesion formation using acousto-optic sensing

High-intensity focused ultrasound (HIFU) is a promising modality that is used to noninvasively ablate soft tissue tumors. Nevertheless, real-time treatment monitoring with diagnostic ultrasound still poses a significant challenge since tissue necrosis, in the absence of cavitation or boiling, provides little acoustic contrast with normal tissue. In comparison, the optical properties of tissue are significantly altered accompanying lesion formation. A photorefractive crystal-based acousto-optic (AO) sensing system that uses a single HIFU transducer to simultaneously generate tissue necrosis and pump the AO interaction is used to monitor the real-time optical changes associated with thermal lesions induced in chicken breast ex vivo. It is found that the normalized change in AO response increases proportionally with the volume of necrosis. This study demonstrates AO sensing can identify the onset and growth of lesion formation in real time and, when used as feedback to guide exposures, results in more predictable lesion formation.

Extracorporeal, low-energy focused ultrasound for noninvasive and nondestructive targeted hyperthermia

The benefits of hyperthermia are well known as both a primary treatment modality and adjuvant therapy for treating cancer. Among the different techniques available, high-intensity focused ultrasound is the only noninvasive modality that can provide local hyperthermia precisely at a targeted location at any depth inside the body using image guidance. Traditionally, focused ultrasound exposures have been provided at high rates of energy deposition for thermal ablation of benign and malignant tumors. At present, exposures are being evaluated in pulsed mode, which lower the rates of energy deposition and generate primarily mechanical effects for enhancing tissue permeability to improve local drug delivery. These pulsed exposures can be modified for low-level hyperthermia as an adjuvant therapy for drug and gene delivery applications, as well as for more traditional applications such as radiosensitization. In this review, we discuss the manner by which focused ultrasound exposures at low rates of energy deposition are being developed for a variety of clinically translatable applications for the treatment of cancer. Specific preclinical studies will be highlighted. Additional information will also be provided for optimizing these exposures, including computer modeling and simulations. Various techniques for monitoring temperature elevations generated by focused ultrasound will also be reviewed.

Influence of temperature variations on the average grayscale of B-mode images of HIFU-induced lesions

The aim of this work is to understand how the variations in grayscale values of B-mode ultrasound (US) images can be used as an approach for non-invasive temperature estimation. In order to obtain real-time monitoring of HIFU treatment, an US imaging system and HIFU were synchronized. Images were acquired using an electronic convex imaging probe. An 8% BSA tissue-mimicking polyacrylamide gel was used for the experiments. First, the HIFU power was set to 10 W. The application of HIFU resulted in the appearance of hyperechoic regions that were used to place a thermocouple tip at the focal spot by means of US imaging. Afterwards, the power was gradually increased up to 40 W for 4 min. The temperature sampling rate was set to 5 Hz. For each temperature sample the synchronization system captured one frame. The region of interest (ROI) was manually selected and a set of morphological operations were implemented in order to obtain the shape and size of the thermal lesion. From here, the average grayscale (AGS) and area of the thermal lesion were calculated to assess temperature quantification. The AGS parameter showed a maximum correlation coefficient of 0.6626 as a function of temperature whereas the thermal lesion appeared. In contrast, area values showed a greater correlation coefficient of 0.9122. In conclusion, temperature shows a non-linear behavior with respect to the parameters estimated due to the nature of the thermal lesion formation by HIFU exposure.

In vivo imaging and treatment of solid tumor using integrated photoacoustic imaging and high intensity focused ultrasound system

PURPOSE

The purpose of this study is to show the feasibility of combined contrast imaging and treatment of solid tumor in vivo by an integrated photoacoustic imaging and high intensity focused ultrasound (HIFU) system.

METHODS

During this study, photoacoustic imaging was performed to identify the location of a CT26 tumor, which was subcutaneously inoculated on the hip of a BALB/c mouse. Then the CT26 tumor was ablated by HIFU with the guidance of photoacoustic images. To enhance the contrast and specificity of photoacoustic imaging, gold nanorods were used as the contrast agents during the experiment. After being injected into the blood stream, gold nanorods passively accumulated around the tumor region, and therefore outlined the location and shape of the tumor in the photoacoustic images, which were used to guide the subsequent HIFU therapy.

RESULTS

The experiment results showed that the tumor was clearly visible on photoacoustic images after the injection of gold nanorods and HIFU was able to ablate the tumor under the guidance of photoacoustic imaging.

CONCLUSIONS

The authors demonstrated that their integrated photoacoustic imaging and HIFU system has the potential for contrast imaging with gold nanorods with possible diagnosis and treatment of solid tumors.

A study of bubble activity generated in ex vivo tissue by high intensity focused ultrasound

Cancer treatment by extracorporeal high-intensity focused ultrasound (HIFU) is constrained by the time required to ablate clinically relevant tumour volumes. Although cavitation may be used to optimize HIFU treatments, its role during lesion formation is ambiguous. Clear differentiation is required between acoustic cavitation (noninertial and inertial) effects and bubble formation arising from two thermally-driven effects (the vapourization of liquid into vapour, and the exsolution of formerly dissolved permanent gas out of the liquid and into gas spaces). This study uses clinically relevant HIFU exposures in degassed water and ex vivo bovine liver to test a suite of cavitation detection techniques that exploit passive and active acoustics, audible emissions and the electrical drive power fluctuations. Exposure regimes for different cavitation activities (none, acoustic cavitation and, for ex vivo tissue only, acoustic cavitation plus thermally-driven gas space formation) were identified both in degassed water and in ex vivo liver using the detectable characteristic acoustic emissions. The detection system proved effective in both degassed water and tissue, but requires optimization for future clinical application.

Therapeutic effects and prognostic factors in high-intensity focused ultrasound combined with chemoembolisation for larger hepatocellular carcinoma

The purpose of this study is to evaluate high-intensity focused ultrasound (HIFU) ablation combined with transcatheter arterial chemoembolisation (TACE) in the treatment of larger hepatocellular carcinoma (HCC). Eighty-nine (89) patients with unrespectable larger HCC were randomised into a TACE group (n=45) and a TACE plus HIFU group (n=44). Therapeutic effects were assessed at follow-up with physical examination, level of serum alpha-fetoprotein and computed tomography or magnetic resonance imaging. All patients were followed up to observe long-term therapeutic effects and evaluated prognostic factors for survival. No severe complication was observed. Follow-up images showed that total effective rate in tumour response accounted for 72.8% in the TACE-HIFU group, which were significantly higher than that of TACE group (44.5%, P<0.05). The 1-, 2-, 3- and 5-year overall survival rates for the TACE-HIFU group were 72.7%, 50.0%, 31.8% and 11.4%, respectively; correspondingly, for the TACE group were 47.2%, 16.7%, 2.8% and 0%, respectively (P<0.01). The 1-, 2-, 3- and 5-year disease-free survival rates for the TACE-HIFU group were 34.1%, 18.2%, 9.1% and 0%, respectively; correspondingly, for the TACE group were 13.9%, 5.6%, 0% and 0%, respectively (P<0.01). TNM stage, portal vein tumour thrombosis and Child-Pugh classification each had a significant effect on the survival. HIFU ablation combined with TACE is safe, effective and a promising approach for the treatment of larger HCC.

Real-time ultrasound image-monitored focal changes of the vascular function in rats by pulsed HIFU

It has been shown that B-mode ultrasound can be useful for the real-time visualization of high-intensity focused ultrasound (HIFU) treatment. The aim of this study is to demonstrate the real-time ultrasound observation of functional changes when a vessel is exposed to pulsed-HIFU in the presence of preformed microbubbles. Using in vivo experiments, 12 male Sprague-Dawley rats were sonicated by 1-MHz pulsed-HIFU in the presence of ultrasound contrast agent (UCA) at four doses (0, 150, 300, and 450 microL/kg). The microbubbles passing through the aorta can be discerned with B-mode imaging. The mean peak systolic velocity (PSV) of the blood flow, as measured by Doppler ultrasound imaging, increased in arteries when the low-dose UCA groups (0 and 150 microL/kg) were examined after pulsed-HIFU at 45 W, but decreased when the high-dose UCA groups (300 and 450 microL/ kg) were examined. Additionally, the normalized pulsatility index (PI) changes increased with the injected dose of UCA. The interactions between ultrasound and the microbubbles can be seen to change the tissue permeability of the drug. Thus, monitoring of PSV or PI might be useful as an online method to ensure the correct sonicated position and to indicate when drug delivery has occurred.

Interstitial thermal ablation with a fast rotating dual-mode transducer

Interstitial ultrasound applicators can be a minimally invasive alternative for treating targets that are unresectable or are inaccessible by extracorporeal methods. Dual-mode transducers for ultrasound imaging and therapy were developed to address the constraints of a miniaturized applicator and real-time treatment monitoring. We propose an original treatment strategy that combines ultrasound imaging and therapy using a dual-mode transducer rotating at 8 revolutions per second. Real-time B-mode imaging was interrupted to emit high-intensity ultrasound over a selected therapy aperture. A full 360 degrees image was taken every 8th rotation to image the therapy aperture. Numerical simulations were performed to study the effect of rotation on tissue heating, and to study the effect of the treatment sequence on transducer temperature. With the time-averaged transducer surface intensity held at 12 W/cm(2) to maintain transducer temperature below 66 degrees C, higher field intensities and deeper lesions were produced by narrower therapy apertures. A prototype system was built and tested using in vitro samples of porcine liver. Lesions up to 8 mm were produced using a time-averaged transducer surface intensity of 12 W/cm(2) applied for a period of 240 s over a therapy aperture of 40 degrees. Apparent strain imaging of the therapy aperture improved the contrast between treated and spared tissues, which could not be differentiated on B-mode images. With appropriate limits on the transducer output, real-time imaging and deep thermal ablation are feasible and sustainable using a rotating dual-mode transducer.

Adaptive HIFU noise cancellation for simultaneous therapy and imaging using an integrated HIFU/imaging transducer

It was previously demonstrated that it is feasible to simultaneously perform ultrasound therapy and imaging of a coagulated lesion during treatment with an integrated transducer that is capable of high intensity focused ultrasound (HIFU) and B-mode ultrasound imaging. It was found that coded excitation and fixed notch filtering upon reception could significantly reduce interference caused by the therapeutic transducer. During HIFU sonication, the imaging signal generated with coded excitation and fixed notch filtering had a range side-lobe level of less than -40 dB, while traditional short-pulse excitation and fixed notch filtering produced a range side-lobe level of -20 dB. The shortcoming is, however, that relatively complicated electronics may be needed to utilize coded excitation in an array imaging system. It is for this reason that in this paper an adaptive noise canceling technique is proposed to improve image quality by minimizing not only the therapeutic interference, but also the remnant side-lobe 'ripples' when using the traditional short-pulse excitation. The performance of this technique was verified through simulation and experiments using a prototype integrated HIFU/imaging transducer. Although it is known that the remnant ripples are related to the notch attenuation value of the fixed notch filter, in reality, it is difficult to find the optimal notch attenuation value due to the change in targets or the media resulted from motion or different acoustic properties even during one sonication pulse. In contrast, the proposed adaptive noise canceling technique is capable of optimally minimizing both the therapeutic interference and residual ripples without such constraints. The prototype integrated HIFU/imaging transducer is composed of three rectangular elements. The 6 MHz center element is used for imaging and the outer two identical 4 MHz elements work together to transmit the HIFU beam. Two HIFU elements of 14.4 mm x 20.0 mm dimensions could increase the temperature of the soft biological tissue from 55 degrees C to 71 degrees C within 60 s. Two types of experiments for simultaneous therapy and imaging were conducted to acquire a single scan-line and B-mode image with an aluminum plate and a slice of porcine muscle, respectively. The B-mode image was obtained using the single element imaging system during HIFU beam transmission. The experimental results proved that the combination of the traditional short-pulse excitation and the adaptive noise canceling method could significantly reduce therapeutic interference and remnant ripples and thus may be a better way to implement real-time simultaneous therapy and imaging.

An acoustic backscatter-based method for localization of lesions induced by high-intensity focused ultrasound

Ultrasound B-mode visualization of lesions produced in soft tissues using high-intensity focused ultrasound (HIFU) has been shown to be challenging when there is no cavitation activity and, therefore, no hyperechogenecity in the focal region. We investigated a method for the visualization and localization of HIFU-induced lesions after HIFU delivery was complete based on the change in backscattered radio-frequency (RF) signals. A HIFU transducer was used with focal dimension of 8 mm by 2 mm working at 5 MHz. HIFU was applied at different intensities to produce lesions in ex vivo chicken breast, with or without the generation of hyperecho in B-mode images. We compared lesion locations obtained from our RF-processing method, from measurement of physical lesions after exposure and from the B-mode images, if exposures had resulted in hyperecho. The results showed that the RF amplitude decreased as a function of time immediately after stopping the HIFU exposure. The lesions were clearly visualized in two-dimensional (2-D) images of the decay rate of RF amplitude, no matter with or without hyperecho. In experiments with hyperecho, when comparing to physical lesion locations, there was no statistically significant difference in the localization accuracy between the RF-based and the hyperecho-based method (p = 0.76). In cases without hyperecho, the distance between RF-based locations and measured lesion locations was 3.37 +/- 1.59 mm (mean +/- standard deviation). The axial and lateral difference were 2.00 +/- 2.31 mm and 0.85 +/- 2.15 mm, respectively, and no statistically significant difference was found between lesion coordinates (axial: p = 0.37 and lateral: p = 0.15). We demonstrated the feasibility of our proposed RF-based method for the localization of HIFU-induced lesions immediately after HIFU treatment. Using the decay rate in RF amplitude as the signature of lesion formation, our method can detect lesion locations even without the appearance of hyperecho.

Extracorporeal high intensity focused ultrasound for renal tumours: a 3-year follow-up

OBJECTIVE

To determine whether primary extracorporeal high-intensity focused ultrasound (HIFU) is safe, feasible and effective for managing small renal tumours.

PATIENTS AND METHODS

Although surgery currently remains the standard treatment for localized renal cell carcinoma (RCC), the increasing incidence of small renal cancers has led to a shift towards nephron-sparing surgery, with associated morbidity in 20-25% of cases, and minimally invasive ablative therapies present an alternative management. HIFU results in 'trackless' homogenous tissue ablation and when administered via an extracorporeal device, is entirely noninvasive. The study comprised 17 patients (mean tumour size 2.5 cm) with radiologically suspicious renal tumours who underwent extracorporeal HIFU using the Model-JC System (Chongqing HAIFU™, China), under general anaesthesia with one overnight hospital stay. Real-time diagnostic ultrasonography was used for targeting and monitoring. Patients were followed with a clinical review and gadolinium-enhanced magnetic resonance imaging at 12 days and every 6 months for a mean of 36 months. The outcomes measures were patient morbidity and oncological efficacy of HIFU treatment.

RESULTS

Of the 17 patients, 15 were treated according to protocol; two procedures were abandoned due to intervening bowel. There were no major complications related to HIFU. Radiological evidence of ablation was apparent at 12 days in seven of the 15 patients. Before the 6-month follow-up one patient had surgery due to persisting central enhancement. Fourteen patients were evaluated at the 6-month follow-up; eight tumours had involuted (mean 12% decrease in tumour area). Four patients had irregular enhancement on imaging and had alternative therapies. Ten patients remain on follow-up at a mean (range) of 36 (14-55) months after HIFU (mean 30% decrease in tumour area). There was central loss of enhancement in all.

CONCLUSIONS

Renal HIFU achieves stable lesions in two-thirds of patients, with minimal morbidity, and might be appropriate in selected cases. Further trials with accurate histological follow-up are essential to fully evaluate this novel technique.

Model-based ultrasound temperature visualization during and following HIFU exposure

This paper describes the application of signal processing techniques to improve the robustness of ultrasound feedback for displaying changes in temperature distribution in treatment using high-intensity focused ultrasound (HIFU), especially at the low signal-to-noise ratios that might be expected in in vivo abdominal treatment. Temperature estimation is based on the local displacements in ultrasound images taken during HIFU treatment, and a method to improve robustness to outliers is introduced. The main contribution of the paper is in the application of a Kalman filter, a statistical signal processing technique, which uses a simple analytical temperature model of heat dispersion to improve the temperature estimation from the ultrasound measurements during and after HIFU exposure. To reduce the sensitivity of the method to previous assumptions on the material homogeneity and signal-to-noise ratio, an adaptive form is introduced. The method is illustrated using data from HIFU exposure of ex vivo bovine liver. A particular advantage of the stability it introduces is that the temperature can be visualized not only in the intervals between HIFU exposure but also, for some configurations, during the exposure itself.

Functional changes in arteries induced by pulsed high-intensity focused ultrasound

Continuous high-intensity focused ultrasound (HIFU) at various intensities has been shown to induce functional changes in arteries. The objective of the current study was to investigate the functional changes in arteries when pulsed HIFU is used at various acoustic power levels. Sonication was applied at an ultrasound frequency of 1 MHz with a burst length of 50 ms and a repetition frequency of 1 Hz. The duration of the whole sonication was 6 s. The femoral arteries and abdominal aortas of Sprague-Dawley rats were surgically exposed and sonicated with pulsed HIFU; the pulsed-HIFU beam was aimed using color images of the blood flow. The peak systolic velocity (PSV) of the blood flow, as measured by Doppler velocimetry, increased in the arteries to which pulsed HIFU had been applied at acoustic powers of 15, 30, and 45 W. The increase in PSV was correlated with the acoustic power of the pulsed HIFU. The temperatures recorded by the thermocouples placed above and below the aorta surfaces did not change significantly during the sonication. Furthermore, no histological changes were found and the vessel wall showed no obvious temperature rise. Therefore, our results indicate that the functional changes induced by pulsed-HIFU exposure are mainly due to mechanical effects.

Dynamic changes of integrated backscatter, attenuation coefficient and bubble activities during high-intensity focused ultrasound (HIFU) treatment

This paper simultaneously investigated the transient characteristics of integrated backscatter (IBS), attenuation coefficient and bubble activities as time traces before, during and after HIFU treatment, with different HIFU parameters (acoustic power and duty cycle) in both transparent tissue-mimicking phantoms and freshly excised bovine livers. These dynamic changes of acoustic parameters and bubble activities were correlated with the visualization of lesion development selected from photos, conventional B-mode ultrasound images and differential IBS images over the whole procedure of HIFU treatment. Two-dimensional radiofrequency (RF) data were acquired by a modified diagnostic ultrasound scanner to estimate the changes of mean IBS and attenuation coefficient averaged in the lesion region, and to construct the differential IBS images and B-mode ultrasound images simultaneously. Bubble activities over the whole procedure of HIFU treatment were investigated by the passive cavitation detection (PCD) method and the changes in subharmonic and broadband noise were correlated with the transient characteristics of IBS and attenuation coefficient. When HIFU was switched on, IBS and attenuation coefficient increased with the appearance of bubble clouds in the B-mode and differential IBS image. At the same time, the level of subharmonic and broadband noise rose abruptly. Then, there was an initial decrease in the attenuation coefficient, followed by an increase when at lower HIFU power. As the lesion appeared, IBS and attenuation coefficient both increased rapidly to a value twice that of normal. Then the changes in IBS and attenuation coefficient showed more complex patterns, but still showed a slower trend of increases with lesion development. Violent bubble activities were visible in the gel and were evident as strongly echogenic regions in the differential IBS images and B-mode images simultaneously. This was detected by a dramatic high level of subharmonic and broadband noise at the same time. These bubble activities caused fluctuations in IBS and attenuation coefficient during HIFU treatment. After HIFU, IBS and attenuation coefficient decreased gradually accompanied by the fadeout of bright hyperechoic spot in the B-mode and differential IBS image, but were still higher than normal when they were stable. The increases of IBS and attenuation coefficient were greater when using higher acoustic power or a higher duty cycle of the therapeutic emission. These experiments indicated that the bubble activities had the dominant effects on the transient characteristics of IBS and attenuation. This should be taken into consideration when using the dynamic acoustic-property changes for the potentially real-time monitoring imaging of HIFU treatment.

Design and characterization of a high-power ultrasound driver with ultralow-output impedance

We describe a pocket-sized ultrasound driver with an ultralow-output impedance amplifier circuit (less than 0.05 ohms) that can transfer more than 99% of the voltage from a power supply to the ultrasound transducer with minimal reflections. The device produces high-power acoustical energy waves while operating at lower voltages than conventional ultrasound driving systems because energy losses owing to mismatched impedance are minimized. The peak performance of the driver is measured experimentally with a PZT-4, 1.54 MHz, piezoelectric ceramic, and modeled using an adjusted Mason model over a range of transducer resonant frequencies. The ultrasound driver can deliver a 100 V(pp) (peak to peak) square-wave signal across 0-8 MHz ultrasound transducers in 5 ms bursts through continuous wave operation, producing acoustic powers exceeding 130 W. Effects of frequency, output impedance of the driver, and input impedance of the transducer on the maximum acoustic output power of piezoelectric transducers are examined. The small size, high power, and efficiency of the ultrasound driver make this technology useful for research, medical, and industrial ultrasonic applications.

Ultrasound transducer and system for real-time simultaneous therapy and diagnosis for noninvasive surgery of prostate tissue

For noninvasive treatment of prostate tissue using high-intensity focused ultrasound this paper proposes a design of an integrated multifunctional confocal phased array (IMCPA) and a strategy to perform both imaging and therapy simultaneously with this array. IMCPA is composed of triple-row phased arrays: a 6-MHz array in the center row for imaging and two 4-MHz arrays in the outer rows for therapy. Different types of piezoelectric materials and stack configurations may be employed to maximize their respective functionalities, i.e., therapy and imaging. Fabrication complexity of IMCPA may be reduced by assembling already constructed arrays. In IMCPA, reflected therapeutic signals may corrupt the quality of imaging signals received by the center-row array. This problem can be overcome by implementing a coded excitation approach and/or a notch filter when B-mode images are formed during therapy. The 13-bit Barker code, which is a binary code with unique autocorrelation properties, is preferred for implementing coded excitation, although other codes may also be used. From both Field II simulation and experimental results, we verified whether these remedial approaches would make it feasible to simultaneously carry out imaging and therapy by IMCPA. The results showed that the 13-bit Barker code with 3 cycles per bit provided acceptable performances. The measured -6 dB and -20 dB range mainlobe widths were 0.52 mm and 0.91 mm, respectively, and a range sidelobe level was measured to be -48 dB regardless of whether a notch filter was used. The 13-bit Barker code with 2 cycles per bit yielded -6 dB and -20 dB range mainlobe widths of 0.39 mm and 0.67 mm. Its range sidelobe level was found to be -40 dB after notch filtering. These results indicate the feasibility of the proposed transducer design and system for real-time imaging during therapy.

Passive spatial mapping of inertial cavitation during HIFU exposure

A novel method for mapping inertial cavitation activity during high-intensity focused ultrasound (HIFU) exposure is presented. Inertial cavitation has been previously shown to result in increased heat deposition and to be associated with broadband noise emissions that can be readily monitored using a passive receiver without interference from the main HIFU signal. In the present study, the signals received passively by each of 64 elements on a standard diagnostic array placed coaxially with the HIFU transducer are combined using time exposure acoustics to generate maps of inertially cavitating regions during HIFU exposure of an agar-based tissue-mimicking material. The technique is shown to be effective in localizing single-bubble activity, as well as contiguous and disjoint cavitating regions instigated by creating regions of lower cavitation threshold within the tissue phantom. The cavitation maps obtained experimentally are also found to be in good agreement with computational simulations and theoretical predictions. Unlike B-mode imaging, which requires interleaving with the HIFU pulse, passive array-based mapping of cavitation activity is possible during HIFU exposure. If cavitating regions can be directly correlated to increased tissue damage, this novel cavitation mapping technique could enable real-time HIFU treatment monitoring.

In vivo evaluation of a mechanically oscillating dual-mode applicator for ultrasound imaging and thermal ablation

Unresectable liver tumors are often treated with interstitial probes that modify tissue temperature, and efficacious treatment relies on image guidance for tissue targeting and assessment. Here, we report the in vivo evaluation of an interstitial applicator with a mechanically oscillating five-element dual-mode transducer. After thoroughly characterizing the transducer, tissue response to high-intensity ultrasound was numerically calculated to select parameters for experimentation in vivo. Using perfused porcine liver, B-mode sector images were formed before and after a 120-s therapy period, and M-mode imaging monitored the therapy axis during therapy. The time-averaged transducer surface intensity was 21 or 27 W/cm (2). Electroacoustic conversion efficiency was maximally 72 +/- 3% and impulse response length was 295 +/- 1.0 ns at -6 dB. The depth of thermal damage measured by gross histology ranged from 10 to 25 mm for 13 insertion sites. For six sites, M-mode data exhibited a reduction in gray-scale intensity that was interpreted as the temporal variation of coagulation necrosis. Contrast ratio analysis indicated that the gray-scale intensity dropped by 7.8 +/- 3.3 dB, and estimated the final lesion depth to an accuracy of 2.3 +/- 2.4 mm. This paper verified that the applicator could induce coagulation necrosis in perfused liver and demonstrated the feasibility of real-time monitoring.

Anniversary paper: evolution of ultrasound physics and the role of medical physicists and the AAPM and its journal in that evolution

Ultrasound has been the greatest imaging modality worldwide for many years by equipment purchase value and by number of machines and examinations. It is becoming increasingly the front end imaging modality; serving often as an extension of the physician's fingers. We believe that at the other extreme, high-end systems will continue to compete with all other imaging modalities in imaging departments to be the method of choice for various applications, particularly where safety and cost are paramount. Therapeutic ultrasound, in addition to the physiotherapy practiced for many decades, is just coming into its own as a major tool in the long progression to less invasive interventional treatment. The physics of medical ultrasound has evolved over many fronts throughout its history. For this reason, a topical review, rather than a primarily chronological one is presented. A brief review of medical ultrasound imaging and therapy is presented, with an emphasis on the contributions of medical physicists, the American Association of Physicists in Medicine (AAPM) and its publications, particularly its journal Medical Physics. The AAPM and Medical Physics have contributed substantially to training of physicists and engineers, medical practitioners, technologists, and the public.

Magnetic resonance imaging of boiling induced by high intensity focused ultrasound

Both mechanically induced acoustic cavitation and thermally induced boiling can occur during high intensity focused ultrasound (HIFU) medical therapy. The goal was to monitor the temperature as boiling was approached using magnetic resonance imaging (MRI). Tissue phantoms were heated for 20 s in a 4.7-T magnet using a 2-MHz HIFU source with an aperture and radius of curvature of 44 mm. The peak focal pressure was 27.5 MPa with corresponding beam width of 0.5 mm. The temperature measured in a single MRI voxel by water proton resonance frequency shift attained a maximum value of only 73 degrees C after 7 s of continuous HIFU exposure when boiling started. Boiling was detected by visual observation, by appearance on the MR images, and by a marked change in the HIFU source power. Nonlinear modeling of the acoustic field combined with a heat transfer equation predicted 100 degrees C after 7 s of exposure. Averaging of the calculated temperature field over the volume of the MRI voxel (0.3 x 0.5 x 2 mm(3)) yielded a maximum of 73 degrees C that agreed with the MR thermometry measurement. These results have implications for the use of MRI-determined temperature values to guide treatments with clinical HIFU systems.

Temporal and spatial detection of HIFU-induced inertial and hot-vapor cavitation with a diagnostic ultrasound system

The onset and presence of inertial cavitation and near-boiling temperatures in high-intensity focused ultrasound (HIFU) therapy have been identified as important indicators of energy deposition for therapy guidance. Passive cavitation detection is commonly used to detect bubble emissions, where a fixed-focus single-element acoustic transducer is typically used as a passive cavitation detector (PCD). This technique is suboptimal for clinical applications, because most PCD transducers are tightly focused and afford limited spatial coverage of the HIFU focal region. A Terason 2000 Ultrasound System was used as a PCD array to expand the spatial detection region for cavitation by operating in passive mode, obtaining the radiofrequency signals corresponding to each scan line and filtering the contribution from scattering of the HIFU signal harmonics. This approach allows for spatially resolved detection of both inertial and stable cavitation throughout the focal region. Measurements with the PCD array during sonication with a 1.1-MHz HIFU source in tissue phantoms were compared with single-element PCD and thermocouple sensing. Stable cavitation signals at the harmonics and superharmonics increased in a threshold fashion for temperatures >90 degrees C, an effect attributed to high vapor pressure in the cavities. Incorporation of these detection techniques in a diagnostic ultrasound platform could result in a powerful tool for improving HIFU guidance and treatment.

Prevention of post-focal thermal damage by formation of bubbles at the focus during high intensity focused ultrasound therapy

Safety concerns exist for potential thermal damage at tissue-air or tissue-bone interfaces located in the post-focal region during high intensity focused ultrasound (HIFU) treatments. We tested the feasibility of reducing thermal energy deposited at the post-focal tissue-air interfaces by producing bubbles (due to acoustic cavitation and/or boiling) at the HIFU focus. HIFU (in-situ intensities of 460-3500 W/cm2, frequencies of 3.2-5.5 MHz) was applied for 30 s to produce lesions (in turkey breast in-vitro (n = 37), and rabbit liver (n = 4) and thigh muscle in-vivo (n = 11)). Tissue temperature was measured at the tissue-air interface using a thermal (infrared) camera. Ultrasound imaging was used to detect bubbles at the HIFU focus, appearing as a hyperechoic region. In-vitro results showed that when no bubbles were present at the focus (at lower intensities of 460-850 W/cm2), the temperature at the interface increased continuously, up to 7.3 +/- 4.0 degrees C above the baseline by the end of treatment. When bubbles formed immediately after the start of HIFU treatment (at the high intensity of 3360 W/cm2), the temperature increased briefly for 3.5 s to 7.4 +/- 3.6 degrees C above the baseline temperature and then decreased to 4.0 +/- 1.4 degrees C above the baseline by the end of treatment. Similar results were obtained in in-vivo experiments with the temperature increases (above the baseline temperature) at the muscle-air and liver-air interfaces at the end of the high intensity treatment lower by 7.1 degrees C and 6.0 degrees C, respectively, as compared to the low intensity treatment. Thermal effects of HIFU at post-focal tissue-air interfaces, such as in bowels, could result in clinically significant increases in temperature. Bubble formation at the HIFU focus may provide a method for shielding the post-focal region from potential thermal damage.