Thermal dosimetry of a focused ultrasound beam in vivo by magnetic resonance imaging

MR imaging-controlled focused ultrasound ablation: a noninvasive image-guided surgery

The history of MR-guided FUS demonstrates the need for merging advanced therapy technology with advanced imaging. Without the ability of MR imaging to localize the tumor margins and without the temperature-sensitive imaging that provides the closed-loop control of energy deposition, this method is inadequate for most clinical applications. Given these limitations,high-intensity focused ultrasound initially appeared to have a narrow application area and was not able to compete with other surgical or ablation methods. Today, MR imaging-guided FUS has become a safe and effective means of performing probe-delivered thermal ablations and minimally invasive surgery. Moreover, it has the potential to replace treatments that use ionizing radiation such as radiosurgery and brachytherapy. Although the cost of integrating"big ticket" MR imaging systems with complex and expensive phased arrays is high, this expenditure will largely be offset by eliminating hospitalization and anesthesia and by reducing complications. In effect, an investment in this emerging technology will ultimately redound to the benefit of the health care delivery system and, most important, to the patient. The FUS system provides a safe, repeatable treatment approach for benign tumors (eg, uterine fibroid and breast fibroadenoma) that do not require an aggressive approach. MR-guided FUS can also be used for debulking cancerous tissue. It has already been tested as a breast cancer treatment; its application for other malignancies in the brain, liver, and prostate is under development. MR-guided FUS offers an attractive alternative to conventional surgery because it incorporates intraoperative MR imaging, which provides far more precise target definition than is possible with the surgeon's direct visualization of the lesion. MR-guided FUS is undeniably the most promising interventional MR imaging method in the field of image-guided therapy today. It is applicable not only in the thermal coagulative treatment of tumors but also in several other medical situations for which invasive surgery or radiation may not be treatment options. The use of FUS for treating vascular malformation or functional disorders of the brain is also exciting. It is uniquely applicable for image-guided therapy using targeted drug delivery methods and gene therapy. Further advances in this technology will no doubt improve energy deposition and reduce treatment times. In the near future, FUS will offer a viable alternative to conventional surgery and radiation therapy; in the longer-term, it may also enable a host of targeted treatment methods aimed at eradicating or arresting heretofore intractable diseases such as certain brain malignancies and forms of epilepsy.

MRI-guided focused ultrasound surgery of uterine leiomyomas

Uterine fibroids are the most common pelvic tumors in women and are a significant cause of morbidity for women of reproductive age. Today, there are a variety of less invasive alternatives available to hysterectomy, such as myomectomy, hormonal therapy, uterine artery embolization, and more recently magnetic resonance-guided focused ultrasound surgery (MRgFUS). With this technique, ultrasound waves are focused through intact skin of the anterior abdominal wall resulting in localized thermal tissue ablation, monitored by online MR temperature control. By using an effective combination of image guidance and energy delivery, MRgFUS therefore allows for preservation of uterine function while obviating the need for a minimally invasive procedure or surgery.

Direct thermal dose control of constrained focused ultrasound treatments: phantom and in vivo evaluation

The first treatment control system that explicitly and automatically balances the efficacy and safety goals of noninvasive thermal therapies is described, and its performance is evaluated in phantoms and in vivo using ultrasound heating with a fixed, focused transducer. The treatment efficacy is quantified in terms of thermal dose delivered to the target. The developed feedback thermal dose controller has a cascade structure with the main nonlinear dose controller continuously generating the reference temperature trajectory for the secondary, constrained, model predictive temperature controller. The control system ensures thermal safety of the normal tissue by automatically complying with user-specified constraints on the maximum allowable normal tissue temperatures. To reflect hardware limitations and to prevent cavitation, constraints on the maximum transducer power can also be imposed. It is shown that the developed controller can be used to achieve the minimum-time delivery of the desired thermal dose to the target without violating safety constraints, which is a novel and clinically desirable feature. The developed controller is model based, and requires patient- and site-specific models for its operation. These models were obtained during pre-treatment identification experiments. In our implementation, predictive models, internally used by the automatic treatment controller, are dynamically updated each time new temperature measurements become available. The adaptability of internal models safeguards against adverse effects of modelling errors, and ensures robust performance of the control system in the presence of a priori unknown treatment disturbances. The successful validation with two experimental models of considerably different thermal and ultrasound properties suggests the applicability of the developed treatment control system to different anatomical sites.

MRI Guidance of Focused Ultrasound Therapy of Uterine Fibroids:Early Results

OBJECTIVE

The purpose of this study was to explore our hypothesis that MRI-guided focused ultrasound therapy for the treatment of uterine fibroids will lead to a significant reduction in symptoms and improvement in quality of life. We describe focused ultrasound therapy applications and the method for monitoring the thermal energy deposited in the fibroids, including the MRI parameters required, in a prospective review of 108 treatments.

MATERIALS AND METHODS

Patients presenting with symptomatic uterine fibroids who attained a minimal symptom severity score and who would otherwise have been offered a hysterectomy were recruited. Thermal lesions were created within target fibroids using an MRI-guided focused ultrasound therapy system. The developing lesion was monitored using real-time MR thermometry, which was used to assess treatment outcome in real time to change treatment parameters and achieve the desired outcome. Fibroid volume, fibroid symptoms, and quality-of-life scores were measured before treatment and 6 months after treatment. Adverse events were actively monitored and recorded.

RESULTS

In this study, 79.3% of women who had been treated reported a significant improvement in their uterine fibroid symptoms on follow-up health-related quality-of-life questionnaires, which supports our hypothesis. The mean reduction in fibroid volume at 6 months was 13.5%, but nonenhancing volume (mean, 51 cm(3)) remained within the treated fibroid at 6 months.

CONCLUSION

This early description of MRI-guided focused ultrasound therapy treatment of fibroids includes follow-up data and shows that, although the volume reduction is moderate, it correlates with treatment volume and the symptomatic response to this treatment is encouraging.

Small (<2.0-cm) Breast Cancers: Mammographic and US Findings at US-guided Cryoablation—Initial Experience

PURPOSE

To determine the mammographic and ultrasonographic (US) findings at cryoablation of small solitary invasive breast cancers and compare them with presence of residual malignancy after treatment.

MATERIALS AND METHODS

Institutional review board approval and informed patient consent were obtained. Nine patients with small solitary invasive breast cancers diagnosed at core biopsy were treated with US-guided cryoablation and a 2.7-mm cryoprobe. Mean cancer size was 12 mm (range, 8-18 mm); four were palpable. Tabletop argon gas-based cryoablation system with a double-freeze-thaw protocol was used to treat cancers in outpatient setting. Tumor sites were excised at lumpectomy 2-3 weeks after cryoablation. Findings at mammography and US before, during, and after cryoablation were assessed to categorize densities and masses on mammograms and masses on US images with Breast Imaging Reporting and Data System (BI-RADS); maximum cancer size was measured. Imaging findings and clinical breast examination data were compared with histologic findings from lumpectomy specimens to determine presence of intraductal or invasive cancer.

RESULTS

With US guidance, ice balls (maximal mean size, 4.4 cm) were formed around cancers. Before excision, eight patients underwent mammography; all had new focal densities (maximum size, 2.5-5.0 cm) at cancer sites. Six patients underwent preexcisional US; 100% of them had new hyperechogenicity in tissue surrounding cancer site. Seven (78%) of nine patients had no residual cancer; specimens contained fat necrosis. One patient had a small focus of invasive cancer; one had extensive multifocal ductal carcinoma in situ. Patients with BI-RADS category 1 or 2 densities on mammograms or nonpalpable tumors had no residual malignancy. No residual invasive cancer occurred in tumors 17 mm or smaller or in cancers without spiculated margins at US.

CONCLUSION

After cryoablation, there was increased echogenicity at US and increased density at mammography; these findings were observed in areas that approximated location and size of the ice ball. Tumor size, mammographic density, and US characteristics may be indicators of likelihood of complete cryoablation.

Noninvasive thermal ablation of hepatocellular carcinoma by using magnetic resonance imaging-guided focused ultrasound

A number of minimally invasive methods have been tested for the thermal ablation of liver tumors as an alternative to surgical resection. The use of focused ultrasound transducers to ablate deep tumors offers the first completely noninvasive alternative to these techniques. By increasing the flexibility of this technology with modern phased-array transducer design and by combining it with magnetic resonance imaging for targeting and online guidance, a powerful tool results with the potential to offer treatment to a larger population of patients, to reduce trauma to the patient, and to reduce the cost of treatment. In this article, we review previous work with focused ultrasound in the liver and recent experimental results with magnetic resonance imaging guidance.

Cryoablation of early-stage breast cancer: work-in-progress report of a multi-institutional trial

BACKGROUND

With recent improvements in breast imaging, our ability to identify small breast tumors has markedly improved, prompting significant interest in the use of ablation without surgical excision to treat early-stage breast cancer. We conducted a multi-institutional pilot safety study of cryoablation in the treatment of primary breast carcinomas.

METHODS

Twenty-nine patients with ultrasound-visible primary invasive breast cancer </=2.0 cm were enrolled. Twenty-seven (93%) successfully underwent ultrasound-guided cryoablation with a tabletop argon gas-based cryoablation system with a double freeze/thaw cycle. Standard surgical resection was performed 1 to 4 weeks after cryoablation. Patients were monitored for complications, and pathology data were used to assess efficacy.

RESULTS

Cryoablation was successfully performed in an office-based setting with only local anesthesia. There were no complications to the procedure or postprocedural pain requiring narcotic pain medications. Cryoablation successfully destroyed 100% of cancers <1.0 cm. For tumors between 1.0 and 1.5 cm, this success rate was achieved only in patients with invasive ductal carcinoma without a significant ductal carcinoma-in-situ (DCIS) component. For unselected tumors >1.5 cm, cryoablation was not reliable with this technique. Patients with noncalcified DCIS were the cause of most cryoablation failures.

CONCLUSIONS

Cryoablation is a safe and well-tolerated office-based procedure for the ablation of early-stage breast cancer. At this time, cryoablation should be limited to patients with invasive ductal carcinoma </=1.5 cm and with <25% DCIS in the core biopsy. A multicenter phase II clinical trial is planned.

Prediction of subtle thermal histopathological change using a novel analysis of Gd-DTPA kinetics

PURPOSE

To investigate Gd-DTPA kinetics as predictors of histopathological changes following focused ultrasound (FUS) thermal ablation for improved planning and assessment.

MATERIALS AND METHODS

Twenty-nine FUS lesions were created in the thigh muscle of eight rabbits under MR-guidance at 1.5 Tesla. Three rabbits were killed at four hours; and 11 lesions were analyzed with histopathology. Temperature-sensitive MRI using proton-resonant frequency-shift was used for time-dependent temperature measurements. Analysis of the uptake kinetics of Gd-DTPA was performed after Gd-DTPA injection, within 20 minutes after heating and again at two hours after heating. The resulting kinetic maps, permeability (K(trans)) and leakage space (v(e)), were correlated to peak temperatures, T(2)-weighted MR, and histopathology.

RESULTS

Images of K(trans) and v(e) reveal regions of histopathological change not visible on conventional post-therapy MR. At early times after heating, v(e) predicts the area of injury more accurately than T(2) (7 +/- 2% vs. 25 +/- 6% underestimation). A circular region of extensive structural/vascular disruption is indicated only on K(trans) maps. The sharp decrease in K(trans) at the boundary of this region occurs at 47.5 +/- 0.5 degrees C, and may be a better estimate of cell death than the conventional method of temperature threshold (55 degrees C for coagulation) used in therapy planning.

CONCLUSION

Our results suggest Gd-DTPA kinetics can predict different histopathological changes following FUS ablation and may be valuable for early prediction.

Thermal contribution of compact bone to intervening tissue-like media exposed to planar ultrasound

The presence of bone in the ultrasound beam path raises concerns, both in diagnostic and therapeutic applications, because significant temperature elevations may be induced at nearby soft tissue-bone interfaces due the facts that ultrasound is (i) highly absorbed in bone and (ii) reflected at soft tissue-bone interfaces in various degrees depending on angle of incidence. Consequently, in ultrasonic thermal therapy, the presence of bone in the ultrasound beam path is considered a major disadvantage and it is usually avoided. However, based on clinical experience and previous theoretical studies, we hypothesized that the presence of bone in superficial unfocused ultrasound hyperthermia can actually be exploited to induce more uniform and enhanced (with respect to the no-bone situation) temperature distributions in superficial target volumes. In particular, we hypothesize that the presence of underlying bone in superficial target volume enhances temperature elevation not only by additional direct power deposition from acoustic reflection, but also from thermal diffusion from the underlying bone. Here we report laboratory results that corroborate previous computational studies and strengthen the above-stated hypothesis. Three different temperature measurement techniques, namely, thermometric (using fibre-optic temperature probes), thermographic (using an infrared camera) and magnetic resonance imaging (using proton resonance frequency shifts), were used in high-power short-exposure, and in low-power extended-exposure, experiments using a 19 mm diameter planar transducer operating at 1.0 and 3.3 MHz (frequencies of clinical relevance). The measurements were performed on three technique-specific phantoms (with and without bone inclusions) and experimental set-ups that resembled possible superficial ultrasound hyperthermia clinical situations. Results from all three techniques were in general agreement and clearly showed that significantly higher heating rates (greater than fourfold) were induced in soft tissue-like phantom materials adjacent (within approximately 5 mm) to a bovine bone as compared to similar experiments without bone inclusions. For low-power long-exposure experiments, where thermal conduction effects are significant, the thermal impact of bone reached at distances > 10 mm from the bone surface (upstream of the bone). Therefore, we hypothesize that underlying bone exposed to planar ultrasound hyperthermia creates a high-temperature thermal boundary at depth that compensates for beam attenuation, thus producing more uniform temperature distribution in the intervening tissue layers. With appropriate technology, this finding may lead to improved thermal doses in superficial treatment sites such as the chest wall and the head/neck.

Usefulness of contrast kinetics for predicting and monitoring tissue changes in muscle following thermal therapy in long survival studies

PURPOSE

To investigate Gd-DTPA kinetics as indicators of subacute and subchronic histopathological changes following focused ultrasound (FUS) thermal therapy for improved evaluation.

MATERIALS AND METHODS

A total of 18 FUS lesions were created in the thigh muscle of five rabbits under magnetic resonance (MR) guidance at 1.5 Tesla. The rabbits were killed at different times: 40 hours, three days, and seven days. All lesions were analyzed histologically. An analysis of the uptake kinetics of Gd-DTPA, injected within two hours postheating and before sacrifice, was performed. The resulting kinetic maps, permeability (K(trans)) and leakage space (v(e)), were correlated to T(2)-weighted MR and histology.

RESULTS

Images of K(trans) and v(e) better differentiate subacute and subchronic changes not visible on conventional MR in the days following therapy and are consistent with the histopathology observed. In particular, the border between nonviable and viable tissue is well demarcated. The extent of damage is best indicated on v(e), whereas the borders of inflammation are shown on K(trans). The total lesion extent is relatively stable over the 7 days posttherapy and can be predicted by v(e) or T(2)-weighted MR at early times after heating.

CONCLUSION

Our results suggest that Gd-DTPA kinetics can complement conventional MR for improved evaluation of FUS thermal therapy by providing finer differentiation of necrotic states, inflammation, and repair processes.

MRI investigation of the threshold for thermally induced blood-brain barrier disruption and brain tissue damage in the rabbit brain

The ability of MRI-derived thermometry to predict thermally induced tissue changes in the brain was tested, and the thermal thresholds for blood-brain barrier (BBB) disruption and brain tissue damage were estimated. In addition, the ability of standard MRI to detect threshold-level effects was confirmed. These safety thresholds are being investigated to provide guidelines for clinical thermal ablation studies in the brain. MRI-monitored focused ultrasound heating was delivered to 63 locations in 26 rabbits. Tissue changes were detected in T(2)-weighted imaging and T(1)-weighted imaging (with and without contrast) and with light microscopy. The probability for tissue damage as a function of the accumulated thermal dose, the peak temperature achieved, the applied acoustic energy, and the peak acoustic power was estimated with probit regression. The discriminative abilities of these parameters were compared using the areas under the receiver operator characteristic (ROC) curves. In MRI, BBB disruption was observed in contrast-enhanced T(1)-weighted imaging shortly after the ultrasound exposures, sometimes accompanied by changes in T(2)-weighted imaging. Two days later, changes in T(2)-weighted imaging were observed, sometimes accompanied by changes in T(1)-weighted imaging. In histology, tissue damage was seen at every location where MRI changes were observed, ranging from small (diameter <1.0 mm) areas of tissue necrosis to severe vascular damage and associated hemorrhagic infarct. In one location, small (diameter: 0.8 mm) damage was not detected in MRI. The thermal dose and peak temperature thresholds were between 12.3-40.1 equivalent min at 43 degrees C and 48.0-50.8 degrees C, respectively, and values of 17.5 equivalent min at 43 degrees C and 48.4 degrees C were estimated to result in tissue damage with 50% probability. Thermal dose and peak temperature were significantly better predictors than the applied acoustic energy and peak acoustic power (P < 0.01). BBB disruption was always accompanied by tissue damage. The temperature information was better than the applied acoustic power or energy for predicting the damage than the ultrasound parameters. MRI was sensitive in detecting threshold-level damage.

MRI monitoring of heating produced by ultrasound absorption in the skull: In vivo study in pigs

The purpose of this study was to test the utility of MR thermometry for monitoring the temperature rise on the brain surface and in the scalp induced by skull heating during ultrasound exposures. Eleven locations in three pigs were targeted with unfocused ultrasound exposures (frequency = 690 kHz; acoustic power = 8.2-16.5 W; duration = 20 s). MR thermometry (a chemical shift technique) showed an average temperature rise in vivo of 2.8 degrees C +/- 0.6 degrees C and 4.4 degrees C +/- 1.4 degrees C on the brain surface and scalp, respectively, at an acoustic power level of 10 W. The temperature rise on the scalp agreed with that measured with a thermocouple probe inserted adjacent to the skull (average temperature rise = 4.6 degrees C +/- 1.0 degrees C). Characterization of the transducer showed that the average acoustic intensity was 1.3 W/cm(2) at an acoustic power of 10 W. The ability to monitor the temperature rise next to the skull with MRI-based thermometry, as shown here, will allow for safety monitoring during clinical trials of transcranial focused ultrasound.

Focused ultrasound treatment of uterine fibroid tumors: safety and feasibility of a noninvasive thermoablative technique

OBJECTIVE

The purpose of this study was to determine the safety and efficacy of focused ultrasound surgery with magnetic resonance imaging guidance for the noninvasive treatment of uterine leiomyomas.

STUDY DESIGN

Fifty-five women with clinically significant uterine leiomyomas were treated. Pain and complications were assessed prospectively, and posttreatment magnetic resonance imaging was used to measure the treatment effects. Patients in three of the five centers underwent planned hysterectomy after treatment, which provided pathologic correlation of treatment.

RESULTS

Seventy-six percent of the enrolled patients completed the full treatment session. All treatments were conducted in an outpatient setting with minimal discomfort for subjects and no major complications. Pathologic examination of the uterus confirmed that magnetic resonance imaging guidance provides the safe and accurate delivery of effective levels of thermal energy with a 3-fold increase in volume of histologically documented necrosis, compared with treatment volume (6.6 +/- 0.8 vs 18.4 +/- 3.9 mL, P <.005).

CONCLUSION

Magnetic resonance imaging-guided focused ultrasound surgery appears to be a well-tolerated treatment for uterine leiomyomas.

Histologic evolution of high-intensity focused ultrasound in rabbit muscle

RATIONALE AND OBJECTIVES

The purpose of this study was to examine the histologic evolution over time of rabbit skeletal muscle thermally ablated with high-intensity focused ultrasound. The objectives included determining the extent and focality of damage created by this noninvasive, transcutaneous ablative technology.

METHODS

Transcutaneous, thermal ablation with an external focused ultrasound transducer was applied to the paraspinous muscles of 19 rabbits. At varying times, up to 100 days after therapy, single sonications were examined histologically.

RESULTS

Initially, only subtle staining changes were identified within lesions. In the chronic phase (day 51-100), the muscle was replaced or infiltrated by variable amounts of scar and fat similar to degenerative muscle disorders. Histologic changes were limited to the tissue within the intensity focus of the transducer and were not seen in intervening tissues.

DISCUSSION

The current study took a systematic approach to study the long term, in vivo histologic effects of single HIFU lesions in a nonregenerative tissue. This experience in muscle tissue will provide a basis for understanding ultrasound effects for clinical applications such as treatment of uterine fibroids, cardiac tissue, and sarcomas.

MR imaging-guided focused ultrasound surgery of uterine leiomyomas: a feasibility study

The feasibility and safety of magnetic resonance (MR) imaging-guided focused ultrasound surgery for uterine leiomyomas is reported. Sequential sonications were delivered to nine targets. Temperature-sensitive phase-difference MR imaging monitored the location of the focus and measured tissue temperature elevations, ensuring therapeutic dose. MR images and hysterectomy specimens were evaluated. Six leiomyomas received full therapeutic doses, and 98.5% of the sonications were visualized. MR thermometry was successful in all sonications and cases. Focal necrotic lesions were seen in all cases at MR, and five were pathologically confirmed. MR imaging-guided focused ultrasound causes thermocoagulation and necrosis in uterine leiomyomas and is feasible and safe, without serious consequences.

MRI-guided gas bubble enhanced ultrasound heating in in vivo rabbit thigh

In this study, we propose a focused ultrasound surgery protocol that induces and then uses gas bubbles at the focus to enhance the ultrasound absorption and ultimately create larger lesions in vivo. MRI and ultrasound visualization and monitoring methods for this heating method are also investigated. Larger lesions created with a carefully monitored single ultrasound exposure could greatly improve the speed of tumour coagulation with focused ultrasound. All experiments were performed under MRI (clinical, 1.5 T) guidance with one of two eight-sector, spherically curved piezoelectric transducers. The transducer, either a 1.1 or 1.7 MHz array, was driven by a multi-channel RF driving system. The transducer was mounted in an MRI-compatible manual positioning system and the rabbit was situated on top of the system. An ultrasound detector ring was fixed with the therapy transducer to monitor gas bubble activity during treatment. Focused ultrasound surgery exposures were delivered to the thighs of seven New Zealand while rabbits. The experimental, gas-bubble-enhanced heating exposures consisted of a high amplitude 300 acoustic watt, half second pulse followed by a 7 W, 14 W or 21 W continuous wave exposure for 19.5 s. The respective control sonications were 20 s exposures of 14 W, 21 W and 28 W. During the exposures, MR thermometry was obtained from the temperature dependency of the proton resonance frequency shift. MRT2-enhanced imaging was used to evaluate the resulting lesions. Specific metrics were used to evaluate the differences between the gas-bubble-enhanced exposures and their respective control sonications: temperatures with respect to time and space, lesion size and shape, and their agreement with thermal dose predictions. The bubble-enhanced exposures showed a faster temperature rise within the first 4 s and higher overall temperatures than the sonications without bubble formation. The spatial temperature maps and the thermal dose maps derived from the MRI thermometry closely correlated with the resulting lesion as examined by T2-weighted imaging. The lesions created with the gas-bubble-enhanced heating exposures were 2-3 times larger by volume, consistently more spherical in shape and closer to the transducer than the control exposures. The study demonstrates that gas bubbles can reliably be used to create significantly larger lesions in vivo. MRI thermometry techniques were successfully used to monitor the thermal effects mediated by the bubble-enhanced exposures.

Intraoperative magnetic resonance imaging and magnetic resonance imaging-guided therapy for brain tumors

Since their introduction into surgical practice in the mid 1990s, intraoperative MRI systems have evolved into essential, routinely used tools for the surgical treatment of brain tumors in many centers. Clear delineation of the lesion, "under-the-surface" vision, and the possibility of obtaining real-time feedback on the extent of resection and the position of residual tumor tissue (which may change during surgery due to "brain-shift") are the main strengths of this method. High-performance computing has further extended the capabilities of intraoperative MRI systems, opening the way for using multimodal information and 3D anatomical reconstructions, which can be updated in "near real time." MRI sensitivity to thermal changes has also opened the way for innovative, minimally invasive (LASER ablations) as well as noninvasive therapeutic approaches for brain tumors (focused ultrasound). Although we have not used intraoperative MRI in clinical applications sufficiently long to assess long-term outcomes, this method clearly enhances the ability of the neurosurgeon to navigate the surgical field with greater accuracy, to avoid critical anatomic structures with greater efficacy, and to reduce the overall invasiveness of the surgery itself.

The temperature dependence of ultrasound-stimulated acoustic emission

Given the high variability of tissue properties during sonication, temperature monitoring is one of the most crucial components for accurate thermal treatment of tissues with focused ultrasound and other thermotherapy devices. Recently, the method of ultrasound-stimulated acoustic emission (USAE) has been introduced as a potential method for measurements of mechanical properties of tissues. In this paper, the dependence of USAE on tissue temperature is determined. Because USAE depends on the acoustic and mechanical properties, both of which vary with temperature, it is hypothesized that the USAE signal is also temperature-dependent and in such a way that it can be used to guide thermal therapy. In a series of experiments, ex vivo porcine muscle and fat samples were exposed to ultrasound at power levels that induce temperature elevation. In both tissue types, below the coagulation threshold, the USAE amplitude was found to vary linearly with temperature. However, at higher powers, the correlation with temperature was lost due mainly to the irreversible nature of the changes in the tissue properties. Theoretical simulations were used to interpret the USAE response change with temperature involving both reversible and irreversible changes and during both heating and cooling. These results indicate that USAE may have important promise as a potential method for localizing temperature elevation and, thus, thermal surgery monitoring, as well as detection of irreversible changes in tissues.

Magnetic resonance imaging-guided focused ultrasound thermal therapy in experimental animal models: correlation of ablation volumes with pathology in rabbit muscle and VX2 tumors

PURPOSE

To further investigate the use of magnetic resonance-guided focused ultrasound therapy (MRgFUS) as a noninvasive alternative to surgery in the local control of soft-tissue tumors by ablating prescribed volumes of VX2 rabbit tumors and comparing with ablation of normal tissue volumes.

MATERIALS AND METHODS

Small, ellipsoidal ablations at shallow depth were created using 5- to 15-second sonication pulses at radio frequency (RF) powers of 50-125 W using a spherical, air-backed transducer operating at 1.463 MHz under MR guidance in a 1.5-T clinical scanner.

RESULTS

Excellent correlation was observed between prescribed treatment volumes, MR thermal dosimetry, post-treatment verification MRI, and histopathology. Multifocal ablations of VX2 tumors in rabbits at depths of up to 2.5 cm resulted in complete ablation of the prescribed treatment volume.

CONCLUSION

MRgFUS is an effective technique for treating tumors in vivo. Techniques developed for treatments in homogeneous tissue volumes are applicable in the more complicated tumor environment if MR temperature feedback is available to modify treatment delivery parameters.

Temperature dosimetry using MR relaxation characteristics of poly(vinyl alcohol) cryogel (PVA-C)

Hyperthermic therapy is being used for a variety of medical treatments, such as tumor ablation and the enhancement of radiation therapy. Research in this area requires a tool to record the temperature distribution created by a heat source, similar to the dosimetry gels used in radiation therapy to record dose distribution. Poly(vinyl alcohol) cryogel (PVA-C) is presented as a material capable of recording temperature distributions between 45 and 70 degrees C, with less than a 1 degrees C error. An approximately linear, positive relationship between MR relaxation times and applied temperature is demonstrated, with a maximum of 16.3 ms/ degrees C change in T(1) and 10.2 ms/ degrees C in T(2) for a typical PVA-C gel. Applied heat reduces the amount of cross-linking in PVA-C, which is responsible for a predictable change in T(1) and T(2) times. Temperature distributions in PVA-C volumes may be determined by matching MR relaxation times across the volumes to calibration values produced in samples subjected to known temperatures. Factors such as thermotolerance, perfusion effects, and thermal conductivity of PVA-C are addressed for potentially extending this method to modeling thermal doses in tissue.

TmDOTA-: a sensitive probe for MR thermometry in vivo

The lanthanide complex, thulium 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (TmDOTA-), has been investigated as an agent for MR thermometry in vivo. The chemical shifts of the TmDOTA- protons were highly sensitive to temperature at a clinically relevant field strength, yet insensitive to pH and the presence of Ca2+. Given the excellent stability of lanthanide-DOTA complexes and high thermal sensitivity, TmDOTA- is expected to be a good candidate for MR thermometry in vivo.

MR imaging-guided focused ultrasound surgery of fibroadenomas in the breast: a feasibility study

PURPOSE

To test the feasibility of noninvasive magnetic resonance (MR) imaging-guided focused ultrasound surgery (FUS) of benign fibroadenomas in the breast.

MATERIALS AND METHODS

Eleven fibroadenomas in nine patients under local anesthesia were treated with MR imaging-guided FUS. Based on a T2-weighted definition of target volumes, sequential sonications were delivered to treat the entire target. Temperature-sensitive phase-difference-based MR imaging was performed during each sonication to monitor focus localization and tissue temperature changes. After the procedure, T2-weighted and contrast material-enhanced T1-weighted MR imaging were performed to evaluate immediate and long-term effects.

RESULTS

Thermal imaging sequences were improved over the treatment period, with 82% (279 of 342) of the hot spots visible in the last seven treatments. The MR imager was used to measure temperature elevation (12.8 degrees -49.9 degrees C) from these treatments. Eight of the 11 lesions treated demonstrated complete or partial lack of contrast material uptake on posttherapy T1-weighted images. Three lesions showed no marked decrease of contrast material uptake. This lack of effective treatment was most likely due to a lower acoustic power and/or patient movement that caused misregistration. No adverse effects were detected, except for one case of transient edema in the pectoralis muscle 2 days after therapy.

CONCLUSION

MR imaging-guided FUS can be performed to noninvasively coagulate benign breast fibroadenomas.

MRI monitoring of the thermal ablation of tissue: effects of long exposure times

MRI-derived thermometry based on the temperature-dependence of the proton resonant frequency (PRF) is extremely sensitive to changes in tissue unrelated to temperature changes, including tissue swelling. This study investigated the maximum amount of time that this phase-subtraction-based method can be used to accurately monitor temperature changes in vivo. Long-duration focused ultrasound sonications were delivered in rabbit thigh muscle with a phased-array transducer, and the time that tissue swelling began was monitored. Tissue swelling began to occur at about one minute. The temperature correlated well with an implanted thermocouple up to this time. After this time, severe artifacts in the phase-difference maps were observed. The thermal dose model predicted the extent of tissue damage well for subsequent one minute sonications. These results will have implications for MRI guidance of thermal therapies with long exposure times.

Apoptosis in ultrasound-produced threshold lesions in the rabbit brain

Focused ultrasound (US) surgery has been used to induce high temperature elevations in tissue to coagulate the proteins and kill the tissue. The introduction of noninvasive online temperature monitoring has made it possible to induce well-controlled thermal exposures. In this study, we used magnetic resonance imaging (MRI) thermometry to monitor thermal exposures near the threshold of tissue damage, and then investigated if apoptosis was induced. Rabbit brains were sonicated with an eight-sector phased array to create a large region of uniform temperature elevation at the end of a 30-s sonication. Histological examination demonstrated that apoptosis was induced in some cells. At 4 h after the sonications, the apoptotic cells constituted 9 +/- 7% of identifiable cells. By 48 h after the sonications, the number of apoptotic cells had increased up to 17 +/- 9%. The impact of this finding for therapy needs to be explored further.

Usefulness of MR imaging-derived thermometry and dosimetry in determining the threshold for tissue damage induced by thermal surgery in rabbits

PURPOSE

To investigate in vivo the feasibility of using magnetic resonance (MR) imaging-derived temperature and thermal dose measurements to find the threshold of thermal tissue damage.

MATERIALS AND METHODS

Sonications were delivered in rabbit thigh muscles at varying powers. Temperature-sensitive MR images obtained during the sonications were used to estimate the temperature and thermal dose. The temperature, thermal dose, and applied power were then correlated to the occurrence of tissue damage observed on postsonication images. An eight-element phased-array transducer was used to produce spatially flat temperature profiles that allowed for averaging to reduce the effects of noise and the voxel size.

RESULTS

The occurrence of tissue damage correlated well with the MR imaging-derived temperature and thermal dose measurements but not with the applied power. Tissue damage occurred at all locations with temperatures greater than 50.4 degrees C and thermal doses greater than 31.2 equivalent minutes at 43.0 degrees C. No tissue damage occurred when these values were less than 47.2 degrees C and 4.3 equivalent minutes.

CONCLUSION

MR imaging thermometry and dosimetry provide an index to predict the threshold for tissue damage in vivo. This index offers improved online control over minimally invasive thermal treatments and should allow for more accurate target volume coagulation.

Magnetic resonance image-guided thermal ablations

Magnetic resonance imaging (MRI)-based monitoring has been shown in recent years to enhance the effectiveness of minimally or noninvasive thermal therapy techniques, such as laser, radiofrequency, microwave, ultrasound, and cryosurgery. MRI's unique soft-tissue contrast and ability to image in three dimensions and in any orientation make it extremely useful for treatment planning and probe localization. The temperature sensitivity of several intrinsic parameters enables MRI to visualize and quantify the progress of ongoing thermal treatment. MRI is sensitive to thermally induced tissue changes resulting from the therapies, giving the physician a method to determine the success or failure of the treatment. These methods of using MRI for planning, guiding, and monitoring thermal therapies are reviewed.

MRI detection of the thermal effects of focused ultrasound on the brain

This study tested the hypothesis that MRI thermometry can be correlated with the different degrees of tissue damage observed after focused ultrasound (US) exposure of brain. The brains of 6 rabbits were sonicated to calibrate the MRI proton resonant shift with temperature. In addition, 13 rabbits were sonicated at acoustic powers ranging from 3.5 to 17.5 W. The experiments were performed in a 1.5-T MRI scanner with the temperature-sensitive phase imaging used during the sonications of 4-5 different locations in each rabbit. MR images were obtained 2 h and 2 days after the sonications, depending on when the animals were sacrificed. Whole brain histologic evaluation was performed by sectioning the brain and performing a microscopic investigation. The MRI-derived temperature elevation was found to correlate well with the degree of tissue damage. In addition to the common histology findings, apoptotic cells were observed in the lesions. The T1-weighted contrast enhanced and T2-weighted scans both detected the brain damage. The applied acoustic power did not correlate well with the degree of damage. As a conclusion, the results showed that the measurement of temperature elevations by MRI during sonications can improve the accuracy and safety of clinical US brain surgery.