MRI of laser-induced interstitial thermal injury in an in vivo animal liver model with histologic correlation

Magnetic Resonance Thermometry and Laser Interstitial Thermal Therapy for Brain Tumors

Recent technological advancements in intraoperative imaging are shaping the way for a new era in brain tumor surgery. Magnetic resonance thermometry has provided intraoperative real-time imaging feedback for safe and effective application of laser interstitial thermal therapy (LITT) in neuro-oncology. Thermal ablation has also established itself as a surgical option in epilepsy surgery and is currently used in spine oncology with promising results. This article reviews the principles and rationale as well as the clinical application of LITT for brain tumors. It also discusses the technical nuances of the current commercially available systems.

Association of computerized texture features on MRI with early treatment response following laser ablation for neuropathic cancer pain: preliminary findings

Laser interstitial thermal therapy (LITT) has recently emerged as a new treatment modality for cancer pain management that targets the cingulum (pain center in the brain) and has shown promise over radio frequency (RF)-based ablation, due to magnetic resonance image (MRI) guidance that allows for precise ablation. Since laser ablation for pain management is currently exploratory and is only performed at a few centers worldwide, its short- and long-term effects on the cingulum are currently unknown. Traditionally, treatment effects for neurological conditions are evaluated by monitoring changes in intensities and/or volume of the ablation zone on post-treatment Gadolinium-contrast T1-w (Gd-T1) MRI. However, LITT introduces subtle localized changes corresponding to tissues response to treatment, which may not be appreciable on visual inspection of volumetric or intensity changes. Additionally, different MRI protocols [Gd-T1, T2w, gradient echo sequence (GRE), fluid-attenuated inversion recovery (FLAIR)] are known to capture complementary diagnostic information regarding the patient's response to treatment; the utility of these MRI protocols has so far not been investigated to evaluate early and localized response to LITT treatment in the context of neuropathic cancer pain. In this work, we present the first attempt at (a) examining early treatment-related changes on a per-voxel basis via quantitative comparison of computer-extracted texture descriptors across pre- and post-LITT multiparametric (MP-MRI) (Gd-T1, T2w, GRE, FLAIR), subtle microarchitectural texture changes that may not be appreciable on original MR intensities or volumetric differences, and (b) investigating the efficacy of different MRI protocols in accurately capturing immediate post-treatment changes reflected (1) within and (2) outside the ablation zone. A retrospective cohort of four patient studies comprising pre- and immediate (24 h) post-LITT 3 Tesla Gd-T1, T2w, GRE, and FLAIR acquisitions was considered. Our quantitative approach first involved intensity standardization to allow for grayscale MR intensities acquired pre- and post-LITT to have a fixed tissue-specific meaning within the same imaging protocol, the same body region, and within the same patient. An affine registration was then performed on individual post-LITT MRI protocols to a reference MRI protocol pre-LITT. A total of 78 computerized texture features (co-occurrence matrix homogeneity, neighboring gray-level dependence matrix, Gabor) are then extracted from pre- and post-LITT MP-MRI on a per-voxel basis. Quantitative, voxelwise comparison of the changes in MRI texture features between pre- and post-LITT MRI indicate that (a) Gabor texture features at specific orientations were highly sensitive as well as specific in predicting subtle microarchitectural changes within and around the ablation zone pre- and post-LITT, (b) FLAIR was identified as the most sensitive MRI protocol in identifying early treatment changes yielding a normalized percentage change of 360% within the ablation zone relative to its pre-LITT value, and (c) GRE was identified as the most sensitive MRI protocol in quantifying changes outside the ablation zone post-LITT. Our preliminary results thus indicate potential for noninvasive computerized MP-MRI features over volumetric features in determining localized microarchitectural early focal treatment changes post-LITT for neuropathic cancer pain treatment.

Identifying MRI markers associated with early response following laser ablation for neurological disorders: preliminary findings

There is a renewed interest in MR-guided laser interstitial thermal therapy (LITT) as a minimally invasive alternative to craniotomy for local treatment of various brain tumors and epilepsy. LITT allows for focused delivery of laser energy monitored in real time by MRI, for precise ablation of the lesion. Although highly promising, the long-term effects of laser ablation as a viable treatment option for neurological disorders have yet to be rigorously studied and quantified. In this work, we present a quantitative framework for monitoring per-voxel thermal-induced changes post-LITT over time on multi parametric MRI. We demonstrate that voxel-by-voxel quantification of MRI markers over time can enable a careful and accurate (a) characterization of early LITT-related changes (if and when they are exaggerated and when they subside), and (b) identification and monitoring of MRI markers that potentially allow for better quantification of response to LITT therapy. The framework was evaluated on two distinct cohorts of patients (GBM, epilepsy), who were monitored post-LITT at regular time-intervals via multi-parametric MRI. On a cohort of six GBM studies we found that (a) it may be important for the initial treatment-related changes to subside to more reliably capture MRI markers relating to tumor recurrence, and (b) T1w MRI and T2-GRE may better differentiate changes that may correspond to tumor recurrence from patients with no recurrence, as compared to T2w-MRI, and FLAIR. Similarly, our preliminary analysis of four epilepsy studies suggests that (a) early LITT changes (attributed to swelling, edema) appear to subside within 4-weeks post-LITT, and (b) ADC may be more reflective of early treatment changes (up to 1 month), while T1w may be more reflective of early delayed treatment changes (1 month, 3 months), while T2-w and T2-FLAIR appeared to be more sensitive to late treatment related changes (6-months post-LITT) compared to the other MRI protocols under evaluation.

Laser ablation for small hepatocellular carcinoma: State of the art and future perspectives

During the last two decades, various local thermal ablative techniques for the treatment of unresectable hepatocellular carcinoma (HCC) have been developed. According to internationally endorsed guidelines, percutaneous thermal ablation is the mainstay of treatment in patients with small HCC who are not candidates for surgical resection or transplantation. Laser ablation (LA) represents one of currently available loco-ablative techniques. In this article, the general principles, technique, image guidance, and patient selection are reported. Primary effectiveness, long-term outcome, and complications are also discussed. A review of published data suggests that LA is equivalent to the more popular and widespread radiofrequency ablation in both local tumor control and long-term outcome in the percutaneous treatment of early HCC. In addition, the LA technique using multiple thin laser fibres allows improved ablative effectiveness in HCCs greater than 3 cm. Reference centres should be equipped with all the available techniques so as to be able to use the best and the most suitable procedure for each type of lesion for each patient.

Identifying MRI markers to evaluate early treatment related changes post laser ablation for cancer pain management

Laser interstitial thermal therapy (LITT) has recently emerged as a new treatment modality for cancer pain management that targets the cingulum (pain center in the brain), and has shown promise over radio-frequency (RF) based ablation which is reported to provide temporary relief. One of the major advantages enjoyed by LITT is its compatibility with magnetic resonance imaging (MRI), allowing for high resolution in vivo imaging to be used in LITT procedures. Since laser ablation for pain management is currently exploratory and is only performed at a few centers worldwide, its short-, and long-term effects on the cingulum are currently unknown. Traditionally treatment effects are evaluated by monitoring changes in volume of the ablation zone post-treatment. However, this is sub-optimal since it involves evaluating a single global parameter (volume) to detect changes pre-, and post-MRI. Additionally, the qualitative observations of LITT-related changes on multi-parametric MRI (MP-MRI) do not specifically address differentiation between the appearance of treatment related changes (edema, necrosis) from recurrence of the disease (pain recurrence). In this work, we explore the utility of computer extracted texture descriptors on MP-MRI to capture early treatment related changes on a per-voxel basis by extracting quantitative relationships that may allow for an in-depth understanding of tissue response to LITT on MRI, subtle changes that may not be appreciable on original MR intensities. The second objective of this work is to investigate the efficacy of different MRI protocols in accurately capturing treatment related changes within and outside the ablation zone post-LITT. A retrospective cohort of studies comprising pre- and 24-hour post-LITT 3 Tesla T1-weighted (T1w), T2w, T2-GRE, and T2-FLAIR acquisitions was considered. Our scheme involved (1) inter-protocol as well as inter-acquisition affine registration of pre- and post-LITT MRI, (2) quantitation of MRI parameters by correcting for intensity drift in order to examine tissue-specific response, and (3) quantification of MRI maps via texture and intensity features to evaluate changes in MR markers pre- and post-LITT. A total of 78 texture features comprising of non-steerable and steerable gradient and second order statistical features were extracted from pre- and post-LITT MP-MRI on a per-voxel basis. Quantitative, voxel-wise comparison of the changes in MRI texture features between pre-, and post-LITT MRI indicate that (a) steerable and non-steerable gradient texture features were highly sensitive as well as specific in predicting subtle micro-architectural changes within and around the ablation zone pre- and post-LITT, (b) FLAIR was identified as the most sensitive MRI protocol in identifying early treatment changes yielding a normalized percentage change of 360% within the ablation zone relative to its pre-LITT value, and (c) GRE was identified as the most sensitive MRI protocol in quantifying changes outside the ablation zone post-LITT. Our preliminary results thus indicate great potential for non-invasive computerized MRI features in determining localized micro-architectural focal treatment related changes post-LITT.

Fiducial markers for combined 3-dimensional mass spectrometric and optical tissue imaging

Mass spectrometric imaging (MSI) has become widely used in the analysis of a variety of biological surfaces. Biological samples are spatially, morphologically, and metabolically complex. Multimodal molecular imaging is an emerging approach that is capable of dealing with this complexity. In a multimodal approach, different imaging modalities can provide precise information about the local molecular composition of the surfaces. Images obtained by MSI can be coregistered with images obtained by other molecular imaging techniques such as microscopic images of fluorescent protein expression or histologically stained sections. In order to properly coregister images from different modalities, each tissue section must contain points of reference, which are visible in all data sets. Here, we report a newly developed coregistration technique using fiducial markers such as cresyl violet, Ponceau S, and bromophenol blue that possess a combination of optical and molecular properties that result in a clear mass spectrometric signature. We describe these fiducial markers and demonstrate an application that allows accurate coregistration and 3-dimensional reconstruction of serial histological and fluorescent microscopic images with MSI images of thin tissue sections from a breast tumor model.

Technical note: fiducial markers for correlation of whole-specimen histopathology with MR imaging at 7 tesla

PURPOSE

There is increasing interest in the registration of 3-D histopathology with 3-D in vivo imaging, for example, to validate tumor boundary delineation for targeted radiation cancer therapy. However, accurate correlation is compromised by tissue distortion induced by histopathological processing. Reference landmarks that are visible in both data sets are required. In this study, two iridescent acrylic paints, "Bronze" (containing iron oxide coated mica particles) and "Stainless Steel" (containing iron, chromium, and nickel), were evaluated for creating MRI-visible and histology-visible fiducial markers at 7 T, where resolution is more similar to histology, but artifacts are accentuated. Furthermore, a straight-line paint-track fiducial method was developed to assist in registration and 3-D histopathology reconstruction.

METHODS

First, the paints were injected into ex vivo porcine tissue samples, which were MR imaged prefixation and postfixation, and subsequently prepared for hematoxylin and eosin staining to verify stability through histopathological processing. Second, the severity of marker susceptibility artifacts produced was compared while using spin-echo and gradient-echo MRI pulse sequences. Finally, multiple paint tracks were injected prefixation through an ex vivo canine prostate sample to validate the potential for line-based registration between MR images of prefixation and postfixation tissue and whole mount histology slides.

RESULTS

The Stainless Steel paint produced excessive susceptibility artifacts and image distortion, while the Bronze paint created stable and appropriate markers in MRI and histology. The Bronze paint produced artifacts approximately three times larger in gradient-echo than in spin-echo MR images. Finally, the paint-track fiducials were visible in the prefixation and postfixation MRI and on whole mount histology.

CONCLUSIONS

The Bronze iridescent acrylic paint is appropriate for fiducial marker creation in MRI at 7 T. The straight-line paint-track fiducials may assist 3-D histopathology reconstruction and can provide important information on the deformation effects of fixation, and hence may improve registration accuracy.

MRI-guided Thermal Ablation Therapy: Model and Parameter Estimates to Predict Cell Death from MR Thermometry Images

Solid tumors and other pathologies can be treated using laser thermal ablation under interventional magnetic resonance imaging (iMRI) guidance. A model was developed to predict cell death from magnetic resonance (MR) thermometry measurements based on the temperature-time history, and validated using in vivo rabbit brain data. To align post-ablation T2-weighted spin-echo MR lesion images to gradient-echo MR images, from which temperature is derived, a registration method was used that aligned fiducials placed near the thermal lesion. The outer boundary of the hyperintense rim in the post-ablation MR lesion image was used as the boundary for cell death, as verified from histology. Model parameters were simultaneously estimated using an iterative optimization algorithm applied to every interesting voxel in 328 images from multiple experiments having various temperature histories. For a necrotic region of 766 voxels across all lesions, the model provided a voxel specificity and sensitivity of 98.1 and 78.5%, respectively. Mislabeled voxels were typically within one voxel from the segmented necrotic boundary with median distances of 0.77 and 0.22 mm for false positives (FP) and false negatives (FN), respectively. As compared to the critical temperature cell death model and the generalized Arrhenius model, our model typically predicted fewer FP and FN. This is good evidence that iMRI temperature maps can be used with our model to predict therapeutic regions in real-time during treatment.

Fiducial markers for MR histological correlation in ex vivo or short-term in vivo animal experiments: a screening study

PURPOSE

To test injectable fiducial markers for magnetic resonance (MR) histological correlation in ex vivo or in vivo animal experiments.

MATERIALS AND METHODS

A total of 35 potential markers were tested ex vivo in pork muscle. The end-points were: 1) visibility, size, and shape on MR images and at macroscopic examination; 2) 24-hour stability; and 3) microscopic appearance. Selected markers were injected in vivo (rabbit's muscle and breast tumor tissue) to test their three-hour in vivo stability and their potential toxicity. Finally, different dilutions of the two best markers were assessed again through the same screening tests to determine whether their size on MR images could be customized by dilution.

RESULTS

Two fluid acrylic paints containing inorganic pigments were found to be potentially interesting markers. On MR images, they created well-defined susceptibility artifacts. The markers made with iridescent bronze paint (iron oxide coated mica particles) were readily visible on microscopy and their size on MR images could be customized by dilution. The iridescent stainless steel paint (iron, chromium, nickel) created ex vivo the smallest markers in tissue but needed colloidal iron staining to be visible on microscopy and could not be easily diluted.

CONCLUSION

Fluid acrylic paints are potentially interesting markers for MR histological correlation. Further studies are needed to assess their long-term properties.

MR histological correlation: a method for cutting specimens along the imaging plane in animal or ex vivo experiments

PURPOSE

To assess a method aimed at cutting histological specimens along the magnetic resonance (MR) imaging plane.

MATERIAL AND METHODS

The method is performed in two steps: the imaging plane (defined by three acrylic paint markers) is made horizontal under MR guidance by using a mobile platform that can be rotated in three directions (PlaneFinder device [PFD]); then, the specimen is embedded in wax and cut horizontally. Three-dimensional images parallel to the markers' plane were obtained on 31 pork muscles containing a central hole with a pyramidal shape, with a technique of reference (RT images) and with PFD (PF images), before and after fixation. The last 17 fixed specimens were cut in the markers' plane (tissue section [TS] images). The central hole area (CHA) in the markers' plane was used to compare RT, PF, and TS images. Using a workstation, PF images were rotated and translated to estimate the shift along each direction that could explain the entire CHA difference between RT, PF, and TS images (maximum error, worst-case scenario).

RESULTS

Excellent correlation was found between RT and PF images (r = 0.989, slope = 1.0175), PF and TS images (r = 0.991, slope = 1.0058), and RT images on fresh specimens and TS images (r = 0.979, slope = 1.0732). For each step, the maximum angle error was < or = 3 degrees in 88-95% of the specimens.

CONCLUSION

Our methodology can be used to cut specimens along the imaging plane with high accuracy.

Intratumor injections of cisplatin and laser thermal therapy for palliative treatment of recurrent cancer

OBJECTIVE

The aim of this work was to report initial findings on the clinical application of intratumor injection of cisplatin in a gel (CDDP/gel) combined with laser-induced thermal therapy (LITT) for cancer treatment in a single patient with advanced stage disease.

BACKGROUND DATA

LITT with the neodymium:yttriumaluminum- garnet (Nd:YAG) laser via fiberoptics is a precise, minimally invasive alternative for thermoablation of unresectable or recurrent head and neck neoplasms, but recurrence is often seen at the treatment margins. Combining intratumor chemotherapy with interstitial laser should be most effective using drugs with thermally enhanced toxicity, such as cisplatin. The CDDP/gel therapeutic implant was expected to retain a higher concentration of cisplatin in the tumor margins for improved LITT treatment of the patient presented.

METHODS

In this case report, the cisplatin dose was 0.25 mL gel/cm(3) tumor volume (20 mg of CDDP) followed by LITT (Nd:YAG laser, 50 W, PD = 2,200 J/cm(2)) after the chemotherapy session.

RESULTS

The patient responded with local tumor eradication, and no signs of systemic toxicity were observed related to this therapy. However, the patient developed progressive metastatic disease in the lungs and died 2.5 months later.

CONCLUSIONS

This is a report of a patient with an accessible solid tumor who was treated with intratumor injection of CDDP/gel followed by LITT, which proved to be feasible. Based on preclinical evidence obtained at UCLA and the results of this study, we are encouraged to continue our refinement of LITT combined with chemotherapy for cancer treatment.

Three-dimensional comparison of interventional MR radiofrequency ablation images with tissue response

OBJECTIVE

Solid tumors are being treated using radiofrequency (RF) ablation under interventional magnetic resonance imaging (MRI) guidance. We are investigating the ability of MRI to monitor ablation treatments by comparing MR images of thermal lesions to histologically assayed tissue damage.

MATERIAL AND METHODS

An open MRI system was used to guide an ablation electrode into five rabbit thigh muscles and acquire post-ablation MR image volumes. We developed a methodology using a 3D computer registration to make spatial correlations. After MR and histology images were registered with an accuracy of 1.32+/-0.39 mm (mean+/-SD), a boundary of necrosis identified in the histology was compared with the outer boundary of the hyperintense region in MR images.

RESULTS

For 14 T2-weighted MR images, the absolute distance between boundaries was 0.96+/-0.34 mm (mean+/-SD). Since the small discrepancy between boundaries is comparable to our registration accuracy, the boundaries may match exactly. Similar correlations to histology were obtained with a deformable model segmentation method.

CONCLUSIONS

This is good evidence that MR thermal lesion images can be used during RF ablation treatments to accurately localize the zone of necrosis at the lesion margin.

Correcting spatial distortion in histological images

We described an interactive method for correcting spatial distortion in histology samples, applied them to a large set of image data, and quantitatively evaluated the quality of the corrections. We demonstrated registration of histology samples to photographs of macroscopic tissue samples and to MR images. We first described methods for obtaining corresponding fiducial and anatomical points, including a new technique for determining boundary correspondence points. We then describe experimental methods for tissue preparation, including a technique for adding color-coded internal and boundary ink marks that are used to validate the method by measuring the registration error. We applied four different transformations with internal and boundary correspondence points, and measured the distance error between other internal ink fiducials. A large number of boundary points, typically 20-30, and at least two internal points were required for accurate warping registration. Interior errors with the transformation methods were ordered: thin plate spline (TPS) approximately non-warping<<triangle warping<polynomial warping. Although non-warping surprisingly gave the lowest interior distance error (0.5+/-0.3mm), TPS was more robust, gave an insignificantly greater error (0.6+/-0.3mm) and much better results near boundaries where distortion was more evident, and allowed us to correct torn histology samples, a common problem. Using the method to evaluate RF thermal ablation, we found good zonal correlation between MR images and corrected histology samples. The method can be practically applied to this and other emerging applications such as in vivo molecular imaging.

Three-Dimensional Registration of Magnetic Resonance Image Data to Histological Sections with Model-Based Evaluation

We developed a three-dimensional (3D) registration method to align medical scanner data with histological sections. After acquiring 3D medical scanner images, we sliced and photographed the tissue using, a custom apparatus, to obtain a volume of tissue section images. Histological samples from the sections were digitized using a video microscopy system. We aligned the histology and medical images to the reference tissue images using our 3D registration method. We applied the method to correlate in vivo magnetic resonance (MR) and histological measurements for radio-frequency thermal ablation lesions in rabbit thighs. For registration evaluation, we used an ellipsoid model to describe the lesion surfaces. The model surface closely fit the inner (M1) and outer (M2) boundaries of the hyperintense region in MR lesion images, and the boundary of necrosis (H1) in registered histology images. We used the distance between the model surfaces to indicate the 3D registration error. For four experiments, we measured a registration accuracy of 0.96+/- 0.13 mm (mean+/-SD) from the absolute distance between the M2 and H1 model surfaces, which compares favorably to the 0.70 mm in-plane MR voxel dimension. This suggests that our registration method provides sufficient spatial correspondence to correlate 3D medical scanner and histology data.

Radiofrequency ablation of thoracic lesions: part 1, experiments in the normal porcine thorax

OBJECTIVE

Radiofrequency ablation has been used extensively in the liver for the localized thermal coagulation of tumors. It has been applied more recently percutaneously in the lung under CT imaging guidance. In advance of our own clinical application, we performed experimental percutaneous radiofrequency ablation in normal lung tissues in a large animal model using a U.S. Food and Drug Administration-approved device to assess its use.

MATERIALS AND METHODS

Radiofrequency ablation of 22 thoracic sites was performed in vivo in three pigs with an array-style electrode. Tissue impedance and ablation duration were measured for each site. The intact lungs were excised for gross inspection and for imaging with CT and MRI. Representative lesions were evaluated histologically.

RESULTS

The mean intraprocedural tissue impedance was 93 Ohms (range, 52-184 Ohms). Six of 22 ablations exhibited a marked increase in impedance after 5 min of treatment. On gross inspection, parenchymal lesions were generally round and targetlike in appearance. CT showed sites of ablation to be composed of a heterogeneous inner zone surrounded by a high-density outer zone. On MRI, the inner zone was typically hyperintense on T1-weighted fast spin-echo imaging, and the outer zone was hyperintense on T2-weighted fast spin-echo imaging. At histology, the inner zone was characterized by coagulation necrosis, and the outer zone by hyperemia and edema. No acute lung-specific complications were seen. There was one extensive skin burn and one cardiac-related death.

CONCLUSION

These results support current seminal clinical evidence that percutaneous radiofrequency ablation in the lung is feasible and can be applied safely. Radiofrequency-induced lesions in the normal porcine lung can be visualized with both CT and MRI; image appearance is concordant with histologic tissue changes.

Nuclear magnetic resonance parameters for monitoring coagulation of liver tissue

A new NMR parameter is suggested as a sensitive tool for monitoring thermal coagulation of liver tissue. That parameter is the proton magnetization exchange time (tau(MEX)) between water and the proteins. tau(MEX) was very sensitive to coagulation and insensitive to temperature, therefore representing only damage to the tissue, independent of effects caused by temperature fluctuations. The measurement of tau(MEX) by two different methods revealed the existence of two or more groups of proteins, characterized by their different transverse relaxation time, and tau(MEX).

Experimental application of thermosensitive paramagnetic liposomes for monitoring magnetic resonance imaging guided thermal ablation

The use of a liposomal paramagnetic agent with a T(1)-relaxivity that increases markedly at temperatures above the phase transition temperature (T(m)) of the liposomal membrane was evaluated during magnetic resonance imaging (MRI) guided hyperthermia ablation. A neodymium-yttrium aluminum garnet (Nd-YAG) laser unit and a radiofrequency ablation system were used for tissue ablation in eight rabbit livers in vivo. One ablation was made in each animal prior to administration of the liposomal agent. Liposomes with a T(m) of 57 degrees C containing gadodiamide (GdDTPA-BMA) were injected iv, and two additional ablations were performed. T(1)-weighted scans were performed in heated tissue, after tissue temperature had normalized, and 15-20 min after normalization of tissue temperature. Increase in signal intensity (DeltaSI) for ablations prior to injection of the agent was 13.0% (SD = 5.7) for the laser group and 9.1% (SD = 7.9) for the radiofrequency group. Signal intensity after administration of the agent unrelated to heating was not statistically significant (DeltaSI = 1.4%, P = 0.35). For ablations made after injection of the agent, a significant increase was found in the laser (DeltaSI = 34.5%, SD = 11.9) and radiofrequency group (DeltaSI = 21.6%, SD = 22.7). The persistent signal enhancement found in areas exposed to a temperature above the threshold temperature above T(m) allows thermal monitoring of MRI guided thermal ablation.

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.

Radiofrequency thermal ablation: Correlation of hyperacute MR lesion images with tissue response

PURPOSE

To investigate the hypothesis that the outer boundary of the hyperintense region observed in hyperacute (several minutes post-ablation) T2 and gadolinium contrast-enhanced (CE) T1-weighted magnetic resonance (MR) lesion images is an accurate predictor of eventual cell death from radiofrequency (RF) thermal ablation.

MATERIALS AND METHODS

A low-field, open MR imaging system was used to guide an ablation electrode into a thigh muscle of five rabbits and acquire in vivo T2 and CE T1-weighted MR volumes. Ablation occurred by applying RF current for two minutes with the electrode's temperature maintained at 90 degrees +/- 2 degrees C. After fixation, we sliced and photographed the tissue at 3 mm intervals, using a specially designed apparatus, to obtain a volume of tissue images. Digital images of hematoxylin and eosin (H&E) and Masson trichrome-stained histologic samples were obtained, and distinct regions of tissue damage were labeled using a video microscopy system. After the MR and histology images were aligned using a three-dimensional registration method, we compared tissue damage boundaries identified in histology with boundaries marked in MR images.

RESULTS

The lesions have distinct zones of tissue damage histologically: a central zone of necrotic cells surrounded by an outer zone with cells that appeared non-viable and associated with marked interstitial edema. In 14 histology images from five lesions, the inner and outer boundaries of the outer zone were compared with the boundaries of a hyperintense rim that surrounds a central hypointense region in the T2 and CE T1-weighted MR images. For T2 and CE T1-weighted MR images, respectively, the mean absolute distance was 1.04 +/- 0.30 mm (mean +/- SD) and 1.00 +/- 0.34 mm for the inner boundaries, and 0.96 +/- 0.34 mm and 0.94 +/- 0.44 mm for the outer boundaries. The mean absolute distances for T2 and CE T1-weighted MR images were not sufficiently different to achieve statistical significance (P = 0.745, 0.818, for the inner and outer boundary, respectively).

CONCLUSION

In hyperacute T2 and CE T1-weighted MR lesion images, observations strongly suggest that the outer boundary of the hyperintense rim corresponds to the region of eventual cell necrosis within a distance comparable to our ability to measure. This is good evidence that during RF ablation procedures, MR lesion images can be used to accurately localize the zone of irreversible tissue damage at the lesion margin.

Interstitial laser thermotherapy for liver tumours

BACKGROUND

Primary hepatocellular carcinoma (HCC) and metastases from colorectal cancer are the most common malignant liver tumours. Surgical resection is the optimum treatment in suitable patients. Interstitial laser thermotherapy (ILT) is gaining acceptance for the treatment of irresectable liver tumours and as a potential alternative to surgery. An understanding of the principles of therapy and review of clinical outcomes may allow better use of this technology.

METHOD

An electronic search using the Medline database was performed for studies on the treatment of hepatic malignancy published between January 1983 and February 2003.

RESULTS

Current information on the efficacy of ILT is based on prospective studies. ILT appears to be a safe and minimally invasive technique that consistently achieves tumour destruction. The extent of destruction depends on the fibre design, delivery system, tumour size and tumour biology. Real-time magnetic resonance imaging provides the most accurate assessment of laser-induced tumour necrosis. In selected patients with HCC and colorectal cancer liver metastases, ILT achieves complete tumour necrosis, provides long-term local control, and improves survival, compared with the natural history of the disease. In addition, ILT has survival benefits for patients with other tumour types, especially those with isolated liver metastases from a breast cancer primary.

CONCLUSION

ILT improves overall survival in specific patients with liver tumours. Advances in laser technology and refinements in technique, and a better understanding of the processes involved in laser-induced tissue injury, may allow ILT to replace surgery as the procedure of choice in selected patients with liver malignancies.

Three-dimensional method for comparing in vivo interventional MR images of thermally ablated tissue with tissue response

PURPOSE

To investigate the ability of magnetic resonance (MR) to monitor radio-frequency (RF) ablation treatments by comparing MR images of thermal lesions to histologically assayed cellular damage. We developed a new methodology using three-dimensional registration for making spatial correlations.

MATERIALS AND METHODS

A low-field, open MRI system was used to guide an ablation probe into rabbit thigh muscle and acquire MR volumes after ablation. After fixation, we sliced and photographed the tissue at 3-mm intervals, using a specially designed apparatus, to obtain a volume of tissue images. Histologic samples were digitized using a video microscopy system. For our three-dimensional registration method, we used the tissue images as the reference, and registered histology and MR images to them using two different computer alignment steps. First, the MR volume was aligned to the volume of tissue images by registering needle fiducials placed near the tissue of interest. Second, we registered the histology images with the tissue images using a two-dimensional warping technique that aligned internal features and the outside boundary of histology and tissue images.

RESULTS

The MR and histology images were very well aligned, and registration accuracy, determined from displacement of needle fiducials, was 1.32 +/- 0.39 mm (mean +/- SD), which compared favorably to the MR voxel dimensions (0.70 mm in-plane and 3.0 mm thick). A preliminary comparison of MR and tissue response showed that the region inside the elliptical hyperintense rim in MR closely corresponds to the region of necrosis as established by histology, with a mean absolute distance between MR and histology boundaries of 1.17 mm, slightly smaller than the mean registration error. The MR region slightly overestimated the region of necrosis, with a mean signed distance between boundaries of 0.85 mm.

CONCLUSION

Our results suggest that our methodology can be used to achieve three-dimensional registration of histology and in vivo MR images. In MR lesion images, the inner border of the hyperintense region corresponds to the border of irreversible cell damage. This is good evidence that during RF ablation treatments, iMRI lesion images can be used for real-time feedback.

Other thermal ablation techniques: microwave and interstitial laser ablation of liver tumors

BACKGROUND

Thermal ablation of hepatic malignancies is becoming a widespread treatment approach. In addition to radiofrequency ablation, microwave coagulation (MCT) and laser-induced interstitial thermotherapy (LITT) are being used clinically to treat patients with liver cancers.

METHODS

The principles and clinical indications for MCT and LITT are described. Treatment approaches and results from published clinical studies are reviewed. The evolution of these thermal treatment modalities and limitations of currently available equipment is provided.

RESULTS

The interstitial probes and equipment used for MCT and LITT for liver tumors are undergoing changes to improve treatment efficacy. Both MCT and LITT have been limited by the relatively small zone of coagulation produced with a single probe placement. Both techniques can be performed safely, and local recurrence and long-term survival rates are being established.

CONCLUSIONS

MCT and LITT are two alternative thermal ablation techniques being used to treat patients with primary and metastatic hepatic malignancies. The utility of these two treatments has been limited by the relatively small area of thermal necrosis produced around the interstitial probes, but design modifications and new equipment may improve these limitations.

Volume registration using needle paths and point landmarks for evaluation of interventional MRI treatments

We created a method for three-dimensional (3-D) registration of medical images (e.g., magnetic resonance imaging (MRI) or computed tomography) to images of physical tissue sections or to other medical images and evaluated its accuracy. Our method proved valuable for evaluation of animal model experiments on interventional-MRI guided thermal ablation and on a new localized drug delivery system. The method computes an optimum set of rigid body registration parameters by minimization of the Euclidean distances between automatically chosen correspondence points, along manually selected fiducial needle paths, and optional point landmarks, using the iterative closest point algorithm. For numerically simulated experiments, using two needle paths over a range of needle orientations, mean voxel displacement errors depended mostly on needle localization error when the angle between needles was at least 20 degrees. For parameters typical of our in vivo experiments, the mean voxel displacement error was < 0.35 mm. In addition, we determined that the distance objective function was a useful diagnostic for predicting registration quality. To evaluate the registration quality of physical specimens, we computed the misregistration for a needle not considered during the optimization procedure. We registered an ex vivo sheep brain MR volume with another MR volume and tissue section photographs, using various combinations of needle and point landmarks. Mean registration error was always < or = 0.54 mm for MR-to-MR registrations and < or = 0.52 mm for MR to tissue section registrations. We also applied the method to correlate MR volumes of radio-frequency induced thermal ablation lesions with actual tissue destruction. In this case, in vivo rabbit thigh volumes were registered to photographs of ex vivo tissue sections using two needle paths. Mean registration errors were between 0.7 and 1.36 mm over all rabbits, the largest error less than two MR voxel widths. We conclude that our method provides sufficient spatial correspondence to facilitate comparison of 3-D image data with data from gross pathology tissue sections and histology.

Radiofrequency ablation of hepatic tumors

Radiofrequency thermal ablation is receiving increasing attention as an alternative to standard surgical therapies for the treatment of liver neoplasms. Benefits over surgical resection include the anticipated reduction in morbidity and mortality, low cost, suitability for real time image guidance, the ability to perform ablative procedures on outpatients, and the potential application in a wider spectrum of patients, including nonsurgical candidates. This review examines reported clinical results of this new therapeutic technique, potential complications, current limitations, thermal ablation mechanisms, as well as technical features and diagnostic modalities used in the procedure.

Interstitial laser thermotherapy in the treatment of colorectal liver metastases

Metastatic liver disease is the commonest cause of death in patients with colorectal cancer. A small proportion of these patients (10%) may be treated by surgical resection with five year survival approaching 35-40%. Alternative treatment modalities for localised hepatic disease include in situ ablative techniques that have the advantages of percutaneous application and minimal morbidity. These include Interstitial Laser Thermotherapy (ILT), Radio Frequency Ablation, Percutaneous Microwave therapy, and Focussed Ultrasound Therapy. This article focuses specifically on the development and utilisation of ILT in the treatment of colorectal liver metastases. It provides a review of the pathophysiological factors involved, present status of clinical studies, and future directions. ILT is a safe technique for the treatment of colorectal liver metastases. It may be delivered by minimally invasive techniques to lesions considered unresectable by present criteria. Limitations include the extent and completeness of tumour necrosis achieved as well as imaging techniques. Clinical problems include a lack of controlled studies. Assessment of long-term survival in prospective randomised trials is needed to assess the efficacy of this procedure.

How does alteration of hepatic blood flow affect liver perfusion and radiofrequency-induced thermal lesion size in rabbit liver?

The purpose of this study was to test the hypothesis that decreasing liver perfusion in rabbits results in an increase in thermal lesion size and that these effects can be accurately monitored using magnetic resonance imaging (MRI). We additionally tested the hypothesis that the increase in thermal lesion size would depend on the particular vessel or vessels occluded (hepatic artery, portal vein, or both). Using an Institutional Animal Care and Use Committee approved protocol, 20 New Zealand white rabbits were randomly assigned to four treatment groups (five in each group): control and ligation of portal vein (PV), hepatic artery (HA), or both PV and HA (HAPV). Surgical ligation of the appropriate vessel was performed under general anesthesia. Immediately after ligation, the rabbits were placed in a 0.2-T open MR system, and an 18-G copper radiofrequency (RF) electrode with a 2-cm exposed tip was inserted into the liver. RF was applied for 10 minutes with the tip temperature maintained at 90 degrees +/- 2 degrees C. Before and after ablation, perfusion data were obtained for 90 seconds using 30 3-second sequential single oblique-slice fast imaging with steady-state progression (FISP) acquisitions after injection of gadolinium-diethylene triamine pentaacetic acid (Gd-DTPA) via the inferior vena cava. Postablation scanning included axial and oblique turbo spin-echo (TSE) T2-weighted (T2w), STIR, and Gd-enhanced T1w sequences. Lesion size was determined perpendicular to the RF electrode using software calipers on the imager. The rabbits were sacrificed after completion of the post-therapy scans, and their livers were harvested for histologic analysis. The liver showed a mean increase in signal amplitude (SA) of 76% 24 seconds after Gd contrast injection in the control group. After contrast injection, the SA increased to a mean of only 66% in the group with ligated hepatic arteries, with no difference in the time to peak compared with the control group. No significant SA increase over baseline could be found in the groups with ligated PV or ligated PV and HA. T2-weighted images demonstrated the highest lesion-to-liver contrast-to-noise ratios (CNRs; mean -5.5) on postprocedure images, followed by STIR images (mean -2.2) in the control group. The lesions were poorly delineated on the Gd-enhanced images. Average maximum lesion sizes (mean +/- 95% confidence interval) were 22 +/- 4.3 mm after ligation of PV, 22 +/- 2.6 mm after ligation of both PV and HA, 14 +/- 2.0 mm after ligation of HA, and 13 +/- 1.9 mm in the control group. We accept the hypothesis that the diameter of the region of coagulation necrosis achieved by standardized RF ablation in the liver increases with reduced organ perfusion and that this effect can be accurately monitored using MRI. The major factor influencing the size of the coagulation area is the portal venous flow. Occlusion of the hepatic artery alone does not significantly increase lesion size. T2w sequences are best suited for postprocedure imaging due to the high lesion-to-liver CNR in rabbits with normal hepatic perfusion. J. Magn. Reson. Imaging 2001;13:57-63.

MR-based temperature monitoring for hot saline injection therapy

We applied magnetic resonance (MR) phase mapping methods to monitor the thermal frequency shift of water in order to study temperature changes from percutaneous hot saline injection therapy (PSIT) using in vitro swine livers and in vivo rabbit livers. The thermal coefficients calculated from the shifts of the water frequency with thermocouple based temperature measurements were -0.0085 +/- 0.0019 ppm/ degrees C for the in vitro studies and -0.0089 ppm/ degrees C for the in vivo studies. The error range was estimated to be +/- 3 degrees C and +/- 4.5 degrees C, respectively. Color-coded temperature maps were compared with macroscopic lesion sizes of the specimen. Regions defined using a 20 degrees C elevation in the initial images following hot saline injection (around 55 degrees C in absolute temperature) closely correlated with visible coagulation in size. We conclude that MR temperature monitoring of PSIT is quite feasible and may be helpful in expanding the clinical use of this thermal therapeutic tool for liver tumors.

Microwave coagulation therapy: ex vivo comparison of MR imaging and histopathology

We compared the findings of magnetic resonance (MR) images and pathological examination to determine whether or not MR images reflect pathological changes following microwave coagulation therapy (MCT) on liver tissue. We used microwave (generating frequency 2450 Mhz, wave length 12 cm, output 50 W, 60 second duration) to irradiate six canine livers under general anesthesia. After the animals were sacrificed, the livers were resected. The irradiated regions were cut with margins and divided into two pieces, one for MR study, and the other for pathological examination. The findings were compared. From the center to the marginal layer, the irradiated region presented 4/3 laminal patterns on T1/T2-weighted images: low/high, high/low, very high/high, and iso-low/high intensity. On gradient-echo imaging, the irradiated regions presented no decreasing signals using several echo time lengths. With hematoxylin and eosin stain, MR laminar patterns reflected the histopathological changes, as follows: a tissue loss area surrounding the inserted needle, low/high; decreased sinusoidal width with/without necrotic tissue, high/low; sinusoidal width dilation at the periphery, very high/high; and fatty degenerated tissue surrounding the irradiated area at the boundary of the normal hepatocytes, iso-low/high. The MR signal intensity, which reflected the histopathological changes, presented tissue characterization after MCT, and the macromolecular hydration effect influenced the high intensity on T1-weighted images.

MR imaging-guided radio-frequency thermal ablation in the pancreas in a porcine model with a modified clinical C-arm system

PURPOSE

To test the hypotheses that (a) magnetic resonance (MR) imaging-guided radio-frequency (RF) thermal ablation in the pancreas is safe and feasible in a porcine model and (b) induced thermal lesion size can be predicted with MR imaging monitoring.

MATERIALS AND METHODS

MR imaging-guided RF ablation was performed in the pancreas of six pigs. A 17-gauge monopolar RF probe was inserted into the pancreas with MR imaging guidance, and RF was applied for 10 minutes. After postprocedural imaging (T2-weighted, short inversion time inversion-recovery [STIR], and T1-weighted imaging before and after intravenous administration of gadodiamide), the pigs were observed for 7 days and follow-up MR images were acquired. The pigs were sacrificed, and pathologic examination was performed.

RESULTS

Successful RF probe placement was accomplished in all pigs; the interventional procedure took 46-80 minutes. Thermal lesions were 12-15 mm perpendicular to the probe track and were best seen on STIR and contrast material-enhanced T1-weighted images with a radiologic and/or pathologic mean difference in RF lesion diameter of 1.7 mm +/- 1.0 (SD) and 0.8 mm +/- 1.2, respectively. Diarrhea was the only side effect during the 1-week follow-up; no clinical signs of pancreatitis occurred.

CONCLUSION

MR imaging-guided RF thermal ablation in the pancreas is feasible and safe. Induced thermal lesion size can best be monitored with STIR and contrast-enhanced T1-weighted images. In the future, RF ablation may offer an alternative treatment option for pancreatic cancer.

MRI-guided radiofrequency thermal ablation of implanted VX2 liver tumors in a rabbit model: demonstration of feasibility at 0.2 T

Successful radiofrequency (RF) thermal ablation was performed on VX2 tumors implanted in 23 rabbit livers under magnetic resonance (MR) guidance using a C-arm-shaped low-field 0.2 T system. RF application and immediate postprocedure MRI of all animals was performed [T2-weighted, turbo short tau inversion recovery (STIR), T1-weighted before and after gadopentetate dimeglumine administration). Follow-up MRI with a superparamagnetic iron oxide (SPIO) contrast medium was performed in nine rabbits at 2 weeks and in four rabbits at 1 month post RF ablation. All livers were harvested for pathologic examination. T2-weighted and turbo-STIR images demonstrated the highest tumor-to-RF-thermal lesion contrast-to-noise ratios (CNRs; means 4.5 and 3.8, respectively) on postprocedure images; this was redemonstrated at 2- and 4-week follow-up imaging. T2-weighted imaging never overestimated pathologic lesion size by more than 2 mm, and the radiologic-pathologic correlation coefficient was not less than 0.90. In conclusion, MRI-guided RF thermal ablation in implanted liver tumor is feasible using a C-arm-shaped low-field 0.2 T system. The thermal lesion size can be most accurately monitored with T2-weighted and turbo-STIR images.

Interstitial laser coagulation for hepatic tumours

BACKGROUND

The potential role of interstitial laser coagulation (ILC) for patients with irresectable hepatic tumours is currently being investigated. Since its introduction in 1983 it has evolved into an innovative minimally invasive technique.

METHODS

On the basis of a Medline literature search and the authors' experience, the principles, current state and prospects of ILC for hepatic tumours are reviewed.

RESULTS

Animal studies and early clinical studies have shown the safety and feasibility of ILC. The site of interest can be approached at laparoscopy or percutaneously and treatment is easily repeatable. Recent advances include the use of fibres with a cylindrical diffusing light-emitting tip, the length of which is adaptable to tumour diameter, water-cooled fibre systems, simultaneous multiple fibre application, and hepatic inflow occlusion during laser treatment. ILC allows complete destruction of tumours up to 5 cm in diameter. Currently a limitation is the lack of reliable real-time monitoring of laser-induced effects but progress in magnetic resonance imaging techniques should allow accurate temperature measurements to be obtained rapidly during treatment. However, the actual benefit of ILC in terms of patient survival remains to be investigated.

CONCLUSION

In terms of tools and experience, ILC has now been developed sufficiently to study its effect on survival of patients with irresectable hepatic tumours.

MRI monitoring of laser ablation using optical flow

The optical flow method is used for visualizing and quantifying the dynamics of tissue changes observed by MRI during thermal ablations. An approach was implemented for parallel two-dimensional optical flow calculations including the replacement of spurious velocities. Velocity magnitude results were found to be accurate in low-noise cases in tests using series of synthetic images. Optical flow results are presented from thermal ablation experiments utilizing a homogeneous polyacrylamide gel phantom and heterogeneous rabbit liver tissue in vivo, exhibiting heating and cooling with the accompanying quantitative characterization of the dilation and contraction of the thermally affected region. Results demonstrate that optical flow is capable of noninvasive real-time monitoring and control of interstitial laser therapy (ILT).