High-intensity focused ultrasound therapy: an overview for radiologists

Analytical and numerical calculations of optimum design frequency for focused ultrasound therapy and acoustic radiation force

Focused ultrasound therapy relies on acoustic power absorption by tissue. The stronger the absorption the higher the temperature increase is. However, strong acoustic absorption also means faster attenuation and limited penetration depth. Hence, there is a trade-off between heat generation efficacy and penetration depth. In this paper, we formulated the acoustic power absorption as a function of frequency and attenuation coefficient, and defined two figures of merit to measure the power absorption: spatial peak of the acoustic power absorption density, and the acoustic power absorbed within the focal area. Then, we derived "rule of thumb" expressions for the optimum frequencies that maximized these figures of merit given the target depth and homogeneous tissue type. We also formulated a method to calculate the optimum frequency for inhomogeneous tissue given the tissue composition for situations where the tissue structure can be assumed to be made of parallel layers of homogeneous tissue. We checked the validity of the rules using linear acoustic field simulations. For a one-dimensional array of 4cm acoustic aperture, and for a two-dimensional array of 4×4cm(2) acoustic aperture, we found that the power absorbed within the focal area is maximized at 0.86MHz, and 0.79MHz, respectively, when the target depth is 4cm in muscle tissue. The rules on the other hand predicted the optimum frequencies for acoustic power absorption as 0.9MHz and 0.86MHz, respectively for the 1D and 2D array case, which are within 6% and 9% of the field simulation results. Because radiation force generated by an acoustic wave in a lossy propagation medium is approximately proportional to the acoustic power absorption, these rules can be used to maximize acoustic radiation force generated in tissue as well.

Volumetric MR-HIFU ablation of uterine fibroids: role of treatment cell size in the improvement of energy efficiency

PURPOSE

To evaluate the energy efficiency of differently sized volumetric ablations in MR-guided high-intensity focused ultrasound (MR-HIFU) treatment of uterine fibroids.

MATERIALS AND METHODS

This study was approved by the institutional review board and informed consent was obtained from all participants. Ten symptomatic uterine fibroids (mean diameter 8.9 cm) in 10 women (mean age 42.2) were treated by volumetric MR-HIFU ablation under binary feedback control. The energy efficiency (mm3/J) of each sonication was calculated as the volume of lethal thermal dose (240 equivalent minutes at 43 °C) per unit acoustic energy applied. Operator-controllable parameters and signal intensity ratio of uterine fibroid to skeletal muscle on T2-weighted MR images were tested with univariate and multivariate analyses to discern which parameters significantly correlated with the ablation energy efficiency.

RESULTS

We analyzed a total of 236 sonications. The energy efficiency of the ablations was 0.42±0.25 mm3/J (range 0.004-1.18) with energy efficiency improving with the treatment cell size (4 mm, 0.06±0.06 mm3/J; 8 mm, 0.29±0.12 mm3/J; 12 mm, 0.58±0.18 mm3/J; 16 mm, 0.91±0.17 mm3/J). Treatment cell size (r=0.814, p<0.001), distance of ultrasound propagation (r=-0.151, p=0.020), sonication frequency (1.2 or 1.45 MHz; p<0.001), and signal intensity ratio (r=-0.205, p=0.002) proved to be significant by univariate analysis, while multivariate analysis revealed treatment cell size (B=0.075, p<0.001), US propagation distance (B=-6.928, p<0.001), and signal intensity ratio (B=-0.024, p=0.001) to be independently significant.

CONCLUSION

Energy efficiency in volumetric MR-HIFU ablation of uterine fibroids improves with increased treatment cell size, independent of other significant contributors such as distance of ultrasound propagation or signal intensity of the tumor on T2-weighted MR imaging.

Whole-Body Bone Scan Findings after High-Intensity Focused Ultrasound (HIFU) Treatment

PURPOSE

This study aims to examine the findings of (99m)Tc-diphosphonate bone scans in cancer patients with a history of HIFU treatment.

METHODS

Bone scan images of patients with a history of HIFU treatment for primary or metastatic cancer from January 2006 to July 2010 were retrospectively reviewed. Cases of primary bone tumor or HIFU treatment reaching only the superficial soft tissue layer were excluded.

RESULTS

Bone scan images of 62 patients (26 female, 36 male; mean age 57 ± 9 years) were studied. HIFU treatment was performed in the liver (n = 40), pancreas (n = 16), and breast (n = 6). Mean interval time between HIFU treatment and bone scan was 106 ± 105 days (range: 1-572 days). Of 62 scans, 43 showed diffusely decreased uptake of bone within the path of HIFU treatment: antero-axillary and/or posterior arcs of right 5th to 11th ribs in 34 cases after treatment of hepatic lesions; anterior arcs of 2nd to 5th ribs in 5 cases after treatment for breast tumors; and posterior arcs of left 9th to 11th ribs or thoraco-lumbar vertebrae in 4 cases after treatment for pancreas tumor. Of 20 patients who had bone scans more than twice, five showed recovered uptake of the radiotracer in the involved ribs in the follow-up bone scan.

CONCLUSION

Of 62 bone scans in patients with a history of HIFU treatment for primary or metastatic cancer, 69% presented diffusely decreased uptake in the bone in the path of HIFU treatment.

Thermal ablation

Image-guided tumor ablation refers to a group of treatment modalities that have emerged during the past 2 decades as important tools in the treatment of a wide range of tumors throughout the body. Although most widely recognized in the treatment of hepatic and renal malignancies, the role of thermal ablation has expanded to include lesions of the lung, breast, prostate, bone, as well as other organs and its clinical applications continue to increase. In the following article, we discuss the major thermal ablation modalities, their respective strengths and weaknesses, potential complications and how to avoid them, as well as possible future applications.

Concurrent chemotherapy and pulsed high-intensity focused ultrasound therapy for the treatment of unresectable pancreatic cancer: initial experiences

Objective

This study was performed to evaluate the potential clinical value of concurrent chemotherapy and pulsed high intensity focused ultrasound (HIFU) therapy (CCHT), as well as the safety of pulsed HIFU, for the treatment of unresectable pancreatic cancer.

Materials and Methods

Twelve patients were treated with HIFU from October 2008 to May 2010, and three of them underwent CCHT as the main treatment (the CCHT group). The overall survival (OS), the time to tumor progression (TTP), the complications and the current performance status in the CCHT and non-CCHT groups were analyzed. Nine patients in the non-CCHT group were evaluated to determine why CCHT could not be performed more than twice.

Results

The OS of the three patients in the CCHT group was 26.0, 21.6 and 10.8 months, respectively, from the time of diagnosis. Two of them were alive at the time of preparing this manuscript with an excellent performance status, and one of them underwent a surgical resection one year after the initiation of CCHT. The TTP of the three patients in the CCHT group was 13.4, 11.5 and 9.9 months, respectively. The median OS and TTP of the non-CCHT group were 10.3 months and 4.4 months, respectively. The main reasons why the nine patients of the non-CCHT group failed to undergo CCHT more than twice were as follows: pancreatitis (n = 1), intolerance of the pain during treatment (n = 4), palliative use of HIFU for pain relief (n = 1) and a poor physical condition due to disease progression (n = 3). No major complications were encountered except one case of pancreatitis.

Conclusion

This study shows that CCHT is a potentially effective and safe modality for the treatment of unresectable pancreatic cancer.

Tumor ablation and nanotechnology

Next to surgical resection, tumor ablation is a commonly used intervention in the treatment of solid tumors. Tumor ablation methods include thermal therapies, photodynamic therapy, and reactive oxygen species (ROS) producing agents. Thermal therapies induce tumor cell death via thermal energy and include radiofrequency, microwave, high intensity focused ultrasound, and cryoablation. Photodynamic therapy and ROS producing agents cause increased oxidative stress in tumor cells leading to apoptosis. While these therapies are safe and viable alternatives when resection of malignancies is not feasible, they do have associated limitations that prevent their widespread use in clinical applications. To improve the efficacy of these treatments, nanoparticles are being studied in combination with nonsurgical ablation regimens. In addition to better thermal effect on tumor ablation, nanoparticles can deliver anticancer therapeutics that show a synergistic antitumor effect in the presence of heat and can also be imaged to achieve precision in therapy. Understanding the molecular mechanism of nanoparticle-mediated tumor ablation could further help engineer nanoparticles of appropriate composition and properties to synergize the ablation effect. This review aims to explore the various types of nonsurgical tumor ablation methods currently used in cancer treatment and potential improvements by nanotechnology applications.

Ultrasound-mediated gene delivery

IMPORTANCE OF THE FIELD

The use of ultrasound with microbubbles raises the possibility of an efficient and safe gene delivery.

AREAS COVERED IN THIS REVIEW

This review summarizes the current state of the art of gene delivery by sonoporation under the following topics. First, the basic ultrasound parameters and the characteristics of microbubble in biological systems are discussed. Second, the extensions of sonoporation to other fields of gene delivery such as viral and non-viral vector are briefly reviewed. Finally, recent applications in an animal model for various diseases are introduced.

WHAT THE READER WILL GAIN

Information and comments on gene delivery by sonoporation or enhanced cell membrane permeability by means of ultrasound.

TAKE HOME MESSAGE

Ultrasound-mediated gene delivery combined with microbubble agents provides significant safety advantages over other methods of local gene delivery.

Thermal effects generated by high-intensity focused ultrasound beams at normal incidence to a bone surface

Experiments and computations were performed to study factors affecting thermal safety when high-intensity focused ultrasound (HIFU) beams are normally incident (i.e., beam axis normal to the interface) upon a bone/soft-tissue interface. In particular, the temperature rise and thermal dose were determined as a function of separation between the beam focus and the interface. Under conditions representative of clinical HIFU procedures, it was found that the thermal dose at the bone surface can exceed the threshold for necrosis even when the beam focus is more than 4 cm from the bone. Experiments showed that reflection of the HIFU beam from the bone back into the transducer introduced temperature fluctuations of as much as +/-15% and may be an important consideration for safety analyses at sufficiently high acoustic power. The applicability of linear propagation models in predicting thermal dose near the interface was also addressed. Linear models, while underpredicting thermal dose at the focus, provided a conservative (slight overprediction) estimate of thermal dose at the bone surface. Finally, temperature rise due to absorption of shear waves generated by the HIFU beam in the bone was computed. Modeling shear-wave propagation in the thermal analysis showed that the predicted temperature rise off axis was as much as 30% higher when absorption of shear waves is included, indicating that enhanced heating due to shear-wave absorption is potentially important, even for normally incident HIFU beams.