High-intensity focused ultrasound for the treatment of liver tumours

Weighted ultrasound entropy imaging for HIFU ablation monitoring with improved sensitivity and contrast

BACKGROUND

Although B-mode imaging has been widely used in ultrasound-guided high-intensity focused ultrasound (HIFU) treatment, challenges remain in improving its quality and sensitivity for monitoring the thermal dose. Recently, quantitative ultrasound (QUS) imaging has been recognized with the potential to better sense the changes in the microstructure of ablated tissues.

PURPOSE

This study proposed to use a QUS method called weighted ultrasound entropy (WUE) imaging to monitor the HIFU ablation.

METHODS

Based on ex-vivo and in-vivo experiments, WUE images reflecting tissue changes during HIFU treatment under different acoustic power levels (174-308 W) were reconstructed with a newly established imaging framework. The performance of the proposed WUE imaging in the monitoring of HIFU treatment was compared with the corresponding B-mode images in terms of their contrast-to-noise ratios (CNRs) between the focal region and the background.

RESULTS

It was found that HIFU irradiation with higher power generated larger WUE values in the focal region, and the bright spots grew in size as the acoustic sonication proceeded. Compared with the in-situ B-mode images, the WUE images had higher image quality in indicating lesion formation, with a 39.2%-53.4% improvement in the CNR at different stages. Meanwhile, a correlation (R = 0.84) between the damage area estimated in WUE images and that measured from the dissected ex-vivo tissue samples was found.

CONCLUSIONS

WUE imaging is more sensitive and accurate than B-mode imaging in monitoring HIFU therapy. These findings suggest that WUE imaging could be a promising technique for assisting ultrasound-guided HIFU ablation.

Resolved magnetohydrodynamic wave lensing in the solar corona

Electromagnetic wave lensing, a common physical phenomenon recognized in visible light for centuries, finds extensive applications in manipulating light in optical systems such as telescopes and cameras. Magnetohydrodynamic wave is a common perturbation phenomenon in the corona. By using high spatio-temporal resolution observations from the Solar Dynamics Observatory, here, we report the observation of a magnetohydrodynamic wave lensing in the highly ionized and magnetized coronal plasma, where quasi-periodic wavefronts emanated from a flare converged at a specific point after traversing a coronal hole. The entire process resembles an electromagnetic wave lensing from the source to the focus. Meanwhile, the magnetohydrodynamic wave lensing is well reproduced through a magnetohydrodynamic numerical simulation with full spatio-temporal resolution. We further investigate potential applications for coronal seismology, as the lensing process encodes information on the Alfvén speed, in conjunction with favorable geometric and density variations.

Nanosized Prussian blue and its analogs for bioimaging and cancer theranostics

Prussian blue (PB) nanoparticles (NPs) and Prussian blue analogs (PBAs) can form metal-organic frameworks through the programmable coordination of ferrous ions with cyanide. PB and PBAs represent a burgeoning class of hybrid functional nano-systems with a wide-ranging application spectrum encompassing biomedicine, cancer diagnosis, and therapy. A comprehensive overview of recent advancements is crucial for gaining insights for future research. In this context, we reviewed the synthesis techniques and surface modification strategies employed to tailor the dimensions, morphology, and attributes of PB NPs. Subsequently, we explored advanced biomedical utilities of PB NPs, encompassing photoacoustic imaging, magnetic resonance imaging, ultrasound (US) imaging, and multimodal imaging. In particular, the application of PB NPs-mediated photothermal therapy, photodynamic therapy, and chemodynamic therapy to cancer treatment was reviewed. Based on the literature, we envision an evolving trajectory wherein the future of Prussian blue-driven biological applications converge into an integrated theranostic platform, seamlessly amalgamating bioimaging and cancer therapy. STATEMENT OF SIGNIFICANCE: Prussian blue, an FDA-approved coordinative pigment with a centuries-long legacy, has paved the way for Prussian blue nanoparticles (PB NPs), renowned for their remarkable biocompatibility and biosafety. These PB NPs have found their niche in biomedicine, playing crucial roles in both diagnostics and therapeutic applications. The comprehensive review goes beyond PB NP-based cancer therapy. Alongside in-depth coverage of PB NP synthesis and surface modifications, the review delves into their cutting-edge applications in the realm of biomedical imaging, encompassing techniques such as photoacoustic imaging, magnetic resonance imaging, ultrasound imaging, and multimodal imaging.

Ablative and non-surgical therapies for early and very early hepatocellular carcinoma: a systematic review and network meta-analysis

Background

A wide range of ablative and non-surgical therapies are available for treating small hepatocellular carcinoma in patients with very early or early-stage disease and preserved liver function.

Objective

To review and compare the effectiveness of all current ablative and non-surgical therapies for patients with small hepatocellular carcinoma (≤ 3 cm).

Design

Systematic review and network meta-analysis.

Data sources

Nine databases (March 2021), two trial registries (April 2021) and reference lists of relevant systematic reviews.

Review methods

Eligible studies were randomised controlled trials of ablative and non-surgical therapies, versus any comparator, for small hepatocellular carcinoma. Randomised controlled trials were quality assessed using the Cochrane Risk of Bias 2 tool and mapped. The comparative effectiveness of therapies was assessed using network meta-analysis. A threshold analysis was used to identify which comparisons were sensitive to potential changes in the evidence. Where comparisons based on randomised controlled trial evidence were not robust or no randomised controlled trials were identified, a targeted systematic review of non-randomised, prospective comparative studies provided additional data for repeat network meta-analysis and threshold analysis. The feasibility of undertaking economic modelling was explored. A workshop with patients and clinicians was held to discuss the findings and identify key priorities for future research.

Results

Thirty-seven randomised controlled trials (with over 3700 relevant patients) were included in the review. The majority were conducted in China or Japan and most had a high risk of bias or some risk of bias concerns. The results of the network meta-analysis were uncertain for most comparisons. There was evidence that percutaneous ethanol injection is inferior to radiofrequency ablation for overall survival (hazard ratio 1.45, 95% credible interval 1.16 to 1.82), progression-free survival (hazard ratio 1.36, 95% credible interval 1.11 to 1.67), overall recurrence (relative risk 1.19, 95% credible interval 1.02 to 1.39) and local recurrence (relative risk 1.80, 95% credible interval 1.19 to 2.71). Percutaneous acid injection was also inferior to radiofrequency ablation for progression-free survival (hazard ratio 1.63, 95% credible interval 1.05 to 2.51). Threshold analysis showed that further evidence could plausibly change the result for some comparisons. Fourteen eligible non-randomised studies were identified (n ≥ 2316); twelve had a high risk of bias so were not included in updated network meta-analyses. Additional non-randomised data, made available by a clinical advisor, were also included (n = 303). There remained a high level of uncertainty in treatment rankings after the network meta-analyses were updated. However, the updated analyses suggested that microwave ablation and resection are superior to percutaneous ethanol injection and percutaneous acid injection for some outcomes. Further research on stereotactic ablative radiotherapy was recommended at the workshop, although it is only appropriate for certain patient subgroups, limiting opportunities for adequately powered trials.

Limitations

Many studies were small and of poor quality. No comparative studies were found for some therapies.

Conclusions

The existing evidence base has limitations; the uptake of specific ablative therapies in the United Kingdom appears to be based more on technological advancements and ease of use than strong evidence of clinical effectiveness. However, there is evidence that percutaneous ethanol injection and percutaneous acid injection are inferior to radiofrequency ablation, microwave ablation and resection.

Study registration

PROSPERO CRD42020221357.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment (HTA) programme (NIHR award ref: NIHR131224) and is published in full in Health Technology Assessment; Vol. 27, No. 29. See the NIHR Funding and Awards website for further award information.

Artificial intelligence-assisted ultrasound-guided focused ultrasound therapy: a feasibility study

OBJECTIVES

Focused ultrasound (FUS) therapy has emerged as a promising noninvasive solution for tumor ablation. Accurate monitoring and guidance of ultrasound energy is crucial for effective FUS treatment. Although ultrasound (US) imaging is a well-suited modality for FUS monitoring, US-guided FUS (USgFUS) faces challenges in achieving precise monitoring, leading to unpredictable ablation shapes and a lack of quantitative monitoring. The demand for precise FUS monitoring heightens when complete tumor ablation involves controlling multiple sonication procedures.

METHODS

To address these challenges, we propose an artificial intelligence (AI)-assisted USgFUS framework, incorporating an AI segmentation model with B-mode ultrasound imaging. This method labels the ablated regions distinguished by the hyperechogenicity effect, potentially bolstering FUS guidance. We evaluated our proposed method using the Swin-Unet AI architecture, conducting experiments with a USgFUS setup on chicken breast tissue.

RESULTS

Our results showed a 93% accuracy in identifying ablated areas marked by the hyperechogenicity effect in B-mode imaging.

CONCLUSION

Our findings suggest that AI-assisted ultrasound monitoring can significantly improve the precision and control of FUS treatments, suggesting a crucial advancement toward the development of more effective FUS treatment strategies.

The Role of Ultrasound in Cancer and Cancer-Related Pain-A Bibliometric Analysis and Future Perspectives

Ultrasound has a deep penetrating ability with minimal or no tissue injury, while cancer-mediated complications during diagnosis, therapy, and surgery have become a serious challenge for clinicians and lead to the severity of the primary condition (cancer). The current study highlights the importance of ultrasound imaging and focused ultrasound therapy during cancer diagnosis, pain reduction, guidance for surgical resection of cancer, and the effectiveness of chemotherapy. We performed the bibliometric analysis on research domains involving ultrasound, cancer management, pain, and other challenges (chemotherapy, surgical guidance, and postoperative care), to observe the trend by which the research field has grown over the years and propose a possible future trend. The data was obtained from the Web of Science, processed, and exported as plain text files for analysis in the Bibliometrix R web interface using the Biblioshiny package. A total of 3248 documents were identified from 1100 journal sources. A total of 390 articles were published in 2022, with almost a 100% growth rate from previous years. Based on the various network analysis, we conclude that the outcome of the constant research in this domain will result in better patient care during the management of various diseases, including cancer and other co-morbidities.

Niche preclinical and clinical applications of photoacoustic imaging with endogenous contrast

In the past decade, photoacoustic (PA) imaging has attracted a great deal of popularity as an emergent diagnostic technology owing to its successful demonstration in both preclinical and clinical arenas by various academic and industrial research groups. Such steady growth of PA imaging can mainly be attributed to its salient features, including being non-ionizing, cost-effective, easily deployable, and having sufficient axial, lateral, and temporal resolutions for resolving various tissue characteristics and assessing the therapeutic efficacy. In addition, PA imaging can easily be integrated with the ultrasound imaging systems, the combination of which confers the ability to co-register and cross-reference various features in the structural, functional, and molecular imaging regimes. PA imaging relies on either an endogenous source of contrast (e.g., hemoglobin) or those of an exogenous nature such as nano-sized tunable optical absorbers or dyes that may boost imaging contrast beyond that provided by the endogenous sources. In this review, we discuss the applications of PA imaging with endogenous contrast as they pertain to clinically relevant niches, including tissue characterization, cancer diagnostics/therapies (termed as theranostics), cardiovascular applications, and surgical applications. We believe that PA imaging's role as a facile indicator of several disease-relevant states will continue to expand and evolve as it is adopted by an increasing number of research laboratories and clinics worldwide.

Controlled Hyperthermia With High-Intensity Focused Ultrasound and Ultrasound Contrast Agent Microbubbles in Porcine Liver

OBJECTIVE

The objective of this work was to study microbubble-enhanced temperature elevation with high-intensity focused ultrasound (HIFU) at different acoustic pressures and under image guidance. The microbubbles were administered with either local or vascular injections (that mimic systemic injections) in perfused and non-perfused ex vivo porcine liver under ultrasound image guidance.

METHODS

Porcine liver was insonified for 30 s with a single-element HIFU transducer (0.9 MHz, 0.413 ms, 82% duty cycle, focal pressures of 0.6-3.5 MPa). Contrast microbubbles were injected either locally or through the vasculature. A needle thermocouple at the focus measured temperature elevation. Diagnostic ultrasound (Philips iU22, C5-1 probe) guided placement of the thermocouple and delivery of microbubbles and monitored the procedure in real time.

RESULTS

At lower acoustic pressures (0.6 and 1.2 MPa) in non-perfused liver, inertial cavitation of the injected microbubbles led to greater temperatures at the focus compared with HIFU-only treatments. At higher pressures (2.4 and 3.5 MPa) native inertial cavitation in the tissue (without injecting microbubbles) resulted in temperature elevations similar to those after injecting microbubbles. The heated area was larger when using microbubbles at all pressures. In the presence of perfusion, only local injections provided a sufficiently high concentration of microbubbles necessary for significant temperature enhancement.

CONCLUSION

Local injections of microbubbles provide a higher concentration of microbubbles in a smaller area, avoiding acoustic shadowing, and can lead to higher temperature elevation at lower pressures and increase the size of the heated area at all pressures.

Non-invasive High-Intensity Focused Ultrasound Treatment of Liver Tissues in an In Vivo Porcine Model: Fast, Large and Safe Ablations Using a Toroidal Transducer

A toroidal high-intensity focused ultrasound (HIFU) transducer was used to non-invasively treat liver tissues in vivo in a pig model. The transducer was divided into 32 concentric rings with equal surface areas operating at 2.5 MHz. First, attenuation of skin, fat, muscle and liver tissues was measured in fresh animal samples to adjust the energy delivered to the focal zone. Then, 8 animals were included in the present protocol and placed in a dorsal decubitus proclive position at an angle of 15°. The device was held by hand, and sonications were performed during apnea. Two thermal HIFU lesions were created in 40 s in each animal. The average abdominal wall thickness was 14.8 ± 1.3 mm (12.5-17.6 mm). The longest and shortest axes of the HIFU ablations were 20.9 ± 6.3 mm (14.0-33.7 mm) and 14.2 ± 5.5 mm (7.0-22.0 mm), respectively. All HIFU lesions were visible on sonograms. The correlation between the dimensions of the HIFU lesions observed on sonograms and those obtained during gross examination was r = 0.84. Creating large and fast ablations with reliable ultrasound imaging guidance in the liver using this handheld device may represent a new therapeutic option for patients with liver tumors.

Tissue specific considerations in implementing high intensity focussed ultrasound under magnetic resonance imaging guidance

High-intensity focused ultrasound can ablate a target permanently, leaving tissues through which it passes thermally unaffected. When delivered under magnetic resonance (MR) imaging guidance, the change in tissue relaxivity on heating is used to monitor the temperatures achieved. Different tissue types in the pre-focal beam path result in energy loss defined by their individual attenuation coefficients. Furthermore, at interfaces with different acoustic impedances the beam will be both reflected and refracted, changing the position of the focus. For complex interfaces this effect is exacerbated. Moreover, blood vessels proximal to the focal region can dissipate heat, altering the expected region of damage. In the target volume, the temperature distribution depends on the thermal conductivity (or diffusivity) of the tissue and its heat capacity. These are different for vascular tissues, water and fat containing tissues and bone. Therefore, documenting the characteristics of the pre-focal and target tissues is critical for effective delivery of HIFU. MR imaging provides excellent anatomic detail and characterization of soft tissue components. It is an ideal modality for real-time planning and monitoring of HIFU ablation, and provides non-invasive temperature maps. Clinical applications involve soft-tissue (abdomino-pelvic applications) or bone (brain applications) pre-focally and at the target (soft-tissue tumors and bone metastases respectively). This article addresses the technical difficulties of delivering HIFU effectively when vascular tissues, densely cellular tissues, fat or bone are traversed pre-focally, and the clinical applications that target these tissues. The strengths and limitations of MR techniques used for monitoring ablation in these tissues are also discussed.

Phase-shift Perfluoropentane Nanoemulsions Enhance Pulsed High-intensity Focused Ultrasound Ablation in an Isolated Perfused Liver System and Their Potential Value for Cancer Therapy

PURPOSE

To investigate whether phase-shift perfluoropetane (PFP) nanoemulsions can enhance pulsed high-intensity focused ultrasound (HIFU) ablation.

METHODS

PFP was encapsulated by poly(lactic-co-glycolic acid) (PLGA) to form a nanometer-sized droplet (PLGA-PFP), which was added to an isolated perfused liver system. Meanwhile, phosphate-buffered saline (PBS) was used as a control. The perfused liver was exposed to HIFU (150 W, t = 3/5/10 s) at various duty cycles (DCs). The ultrasound images, cavitation emissions, and temperature were recorded. Rabbits with subcutaneous VX2 tumors were exposed to HIFU (150 W) at various DCs with or without PLGA-PFP. After ablation, necrosis volume and energy efficiency factor were calculated. Pathologic characteristics were observed.

RESULTS

Compared to the PBS control, PLGA-PFP nanoemulsions markedly enhanced HIFU-induced necrosis volume in both perfused livers and subcutaneous VX2 tumor-bearing rabbits (P <.05). Inertial cavitation was much stronger in the pulsed-HIFU exposure at 10% than that in the continuous-wave HIFU exposure (P <.01). Peak temperature at 100% DC was significantly higher than that at 10% (P <.05). Compared to 100% DC HIFU exposure, the mean necrosis volume induced by 10 s exposure at 50% DC was significantly larger (P <.005) but lower at 10% DC in the isolated perfused livers (P <.05). In addition, the mean necrosis volume in subcutaneous VX2 tumor-bearing rabbits was significantly increased after HIFU exposure at 10% DC when compared to those at 100% DC (P <.05). Histopathologic analysis showed liquefaction necrosis in pulsed HIFU.

CONCLUSION

PLGA-PFP nanoemulsions can enhance HIFU ablation in the isolated perfused livers and promote tumor ablation in the subcutaneous xenograft rabbit model. Appropriate pulsed HIFU exposure may increase the necrosis volume and reduce total ultrasound energy required for HIFU ablation.

Oxford's clinical experience in the development of high intensity focused ultrasound therapy

High Intensity Focused Ultrasound (HIFU) capably bridges the disciplines of surgery, oncology and biomedical engineering science. It provides the precision associated with a surgical tool whilst remaining a truly non-invasive technique. Oxford has been a centre for both clinical and preclinical research in HIFU over the last twenty years. Research into this technology in the UK has a longer history, with much of the early research being carried out by Professor Gail ter Haar and her team at the Institute of Cancer Research at Sutton in Surrey. A broad range of potential applications have been explored extending from tissue ablation to novel drug delivery. This review presents Oxford's clinical studies and applications for the development of this non-invasive therapy. This includes treatment of solid abdominal tumours comprising those of the liver, kidney, uterus, pancreas, pelvis and prostate. It also briefly introduces preclinical and translational works that are currently being undertaken at the Institute of Biomedical Engineering, University of Oxford. The safety, wide tolerability and effectiveness of this technology is comprehensively demonstrated across these studies. These results can facilitate the incorporation of HIFU as a key clinical management strategy.

Message Passing Interface Parallelization for Two-Way Coupled Euler-Lagrange Simulation of Microbubble Enhanced HIFU

Microbubble enhanced high intensity focused ultrasound (HIFU) is of great interest to tissue ablation for tumor treatment such as in liver and brain cancers. To accurately characterize the acoustic and thermal fields during this process, a coupled Euler-Lagrange model is used. The ultrasound field is modeled using compressible Navier-Stokes equations on an Eulerian grid, while the microbubbles are tracked in a Lagrangian fashion. The coupling is realized through the void fraction computed from the instantaneous bubble volumes. To speed up the computations, an message passing interface parallelization scheme based on domain decomposition is herein proposed. During each time-step, message passing interface processors, each handling one subdomain, are first used to execute the fluid computation, and then the bubble computations. This is followed by the coupling procedure. The coupling is challenging as the effect of the bubbles through the void fraction at an Eulerian point near a subdomain border will require information from bubbles located in different subdomains, and vice versa. This is addressed by a special utilization of ghost cells surrounding each fluid subdomain, which allows bubbles to spread their void fraction effects across subdomain edges without the need of exchanging directly bubble information between subdomains and significantly increasing overhead. After a careful verification of gas effects conservation, this parallelization scheme is validated and illustrated on a typical microbubble enhanced HIFU problem, followed by parallelization scaling tests and efficiency analysis.

AAPM Task Group 241: A medical physicist's guide to MRI-guided focused ultrasound body systems

Magnetic resonance-guided focused ultrasound (MRgFUS) is a completely non-invasive technology that has been approved by FDA to treat several diseases. This report, prepared by the American Association of Physicist in Medicine (AAPM) Task Group 241, provides background on MRgFUS technology with a focus on clinical body MRgFUS systems. The report addresses the issues of interest to the medical physics community, specific to the body MRgFUS system configuration, and provides recommendations on how to successfully implement and maintain a clinical MRgFUS program. The following sections describe the key features of typical MRgFUS systems and clinical workflow and provide key points and best practices for the medical physicist. Commonly used terms, metrics and physics are defined and sources of uncertainty that affect MRgFUS procedures are described. Finally, safety and quality assurance procedures are explained, the recommended role of the medical physicist in MRgFUS procedures is described, and regulatory requirements for planning clinical trials are detailed. Although this report is limited in scope to clinical body MRgFUS systems that are approved or currently undergoing clinical trials in the United States, much of the material presented is also applicable to systems designed for other applications.

Heating technology for malignant tumors: a review

The therapeutic application of heat is very effective in cancer treatment. Both hyperthermia, i.e., heating to 39-45 °C to induce sensitization to radiotherapy and chemotherapy, and thermal ablation, where temperatures beyond 50 °C destroy tumor cells directly are frequently applied in the clinic. Achievement of an effective treatment requires high quality heating equipment, precise thermal dosimetry, and adequate quality assurance. Several types of devices, antennas and heating or power delivery systems have been proposed and developed in recent decades. These vary considerably in technique, heating depth, ability to focus, and in the size of the heating focus. Clinically used heating techniques involve electromagnetic and ultrasonic heating, hyperthermic perfusion and conductive heating. Depending on clinical objectives and available technology, thermal therapies can be subdivided into three broad categories: local, locoregional, or whole body heating. Clinically used local heating techniques include interstitial hyperthermia and ablation, high intensity focused ultrasound (HIFU), scanned focused ultrasound (SFUS), electroporation, nanoparticle heating, intraluminal heating and superficial heating. Locoregional heating techniques include phased array systems, capacitive systems and isolated perfusion. Whole body techniques focus on prevention of heat loss supplemented with energy deposition in the body, e.g., by infrared radiation. This review presents an overview of clinical hyperthermia and ablation devices used for local, locoregional, and whole body therapy. Proven and experimental clinical applications of thermal ablation and hyperthermia are listed. Methods for temperature measurement and the role of treatment planning to control treatments are discussed briefly, as well as future perspectives for heating technology for the treatment of tumors.

Carbon nanotube-mediated high intensity focused ultrasound

High intensity focused ultrasound (HIFU) is emerging as a novel therapeutic technique for cancer treatment through a hyperthermal mechanism using ultrasound. However, collateral thermal damages to healthy tissue and skin burns due to the use of high levels of ultrasonic energy during HIFU treatment remain major challenges to clinical application. The main objective of the current study is to evaluate the potential of carbon nanotubes (CNTs) as effective absorption-enhancing agents for HIFU to mediate the heating process at low ultrasonic power levels, and consequently upgrade hyperthermal therapeutic effects of HIFU. An experimental study using in vitro tissue phantoms was conducted to assess the effects of CNTs on HIFU’s heating mechanism. Detailed information was extracted from the experiments for thermal analysis, including rate of absorbed energy density and temperature rise profile at the focal region. Parametric studies were carried out, revealing the effects of ultrasound parameters (ultrasonic power and driving frequency) on the performance of CNTs in various concentrations. The results indicated that CNTs significantly enhanced the thermal effect of HIFU by elevating energy absorption rate and consequential temperature rise. Moreover, it was demonstrated that an increase in ultrasonic power and driving frequency could lead to a better performance of CNTs during HIFU ablation procedures; the effects of CNTs could be further enhanced by increasing their volume concentration inside the medium.

The Distribution of Skull Score and Skull Density Ratio in Tremor Patients for MR-Guided Focused Ultrasound Thalamotomy

Objective

Magnetic resonance-guided focused ultrasound (MRgFUS) is a minimum-invasive surgical approach to non-incisionally cause the thermos-coagulation inside the human brain. The skull score (SS) has already been approved as one of the most dominant factors related to a successful MRgFUS treatment. In this study, we first reveal the SS distribution of the tremor patients, and correlate the SS with the image feature from customized skull density ratio (cSDR). This correlation might give a direction to future clinical studies for improving the SS.

Methods

Two hundred and forty-six patients received a computed tomography (CT) scan of the brain, and a bone-enhanced filter was applied and reconstructed to a high spatial resolution CT images. The SS of all patients would be estimated by the MRgFUS system after importing the reconstructed CT images into the MRgFUS system. The histogram and the cumulative distribution of the SS from all the patients were calculated to show the percentage of the patients whose SS lower than 0.3 and 0.4. The same CT images of all patients were utilized to calculated the cSDR by first segmented the trabecular bone and the cortical bone from the CT images and divided the average trabecular bone intensity (aTBI) by the average cortical bone intensity (aCBI). The Pearson’s correlations between the SS and the cSDR, aTBI, and the aCBI were calculated, respectively.

Results

There were 19.19 and 50% of the patient who had the SS lower than the empirical threshold 0.3 and 0.4, respectively. The Pearson’s correlation between the SS and the cSDR, aCBI, and the aTBI were R = 0.8145, 0.5723, and 0.8842.

Conclusion

Half of the patients were eligible for the MRgFUS thalamotomy based on the SS, and nearly 20% of patients were empirically difficult to achieve a therapeutic temperature during MRgFUS. The SS and our cSDR are highly correlated, and the SS had a higher correlation with aTBI than with aCBI. This is the first report to explicitly reveal the SS population and indicate a potential way to increase the chance to achieve a therapeutic temperature for those who originally have low SS.

Metallic nanoparticles as drug delivery system for the treatment of cancer

INTRODUCTION

The targeted delivery of anticancer agents to tumor is a major challenge because most of the drugs show off-target effect resulting in nonspecific cell death. Multifunctionalized metallic nanoparticles (NPs) are explored as new carrier system in the era of cancer therapeutics. Researchers investigated the potential of metallic NPs to target tumor cells by active and passive mechanisms, thereby reducing off-target effects of anticancer agents. Moreover, photocatalytic activity of upconversion nanoparticles (UCNPs) and the enhanced permeation and retention (EPR) effect have also gained wide potential in cancer treatment. Recent advancement in the field of nanotechnology highlights their potency for cancer therapy.

AREAS COVERED

This review summarizes the types of gold and silver metallic NPs with targeting mechanisms and their potentiality in cancer therapy.

EXPERT OPINION

Recent advances in the field of nanotechnology for cancer therapy offer high specificity and targeting efficiency. Targeting tumor cells through mechanistic pathways using metallic NPs for the disruption/alteration of molecular profile and survival rate of the tumor cells has led to an effective approach for cancer therapeutics. This alteration in the survival rate of the tumor cells might decrease the proliferation thereby resulting in more efficient management in the treatment of cancer.

Modifications of Plasma Membrane Organization in Cancer Cells for Targeted Therapy

Modifications of the composition or organization of the cancer cell membrane seem to be a promising targeted therapy. This approach can significantly enhance drug uptake or intensify the response of cancer cells to chemotherapeutics. There are several methods enabling lipid bilayer modifications, e.g., pharmacological, physical, and mechanical. It is crucial to keep in mind the significance of drug resistance phenomenon, ion channel and specific receptor impact, and lipid bilayer organization in planning the cell membrane-targeted treatment. In this review, strategies based on cell membrane modulation or reorganization are presented as an alternative tool for future therapeutic protocols.

Applications of High-Intensity Focused Ultrasound in the Treatment of Different Pathologies

Objective:

The purpose of this literature search was to review the benefits of high-intensity focused ultrasound (HIFU) and its application for different pathologies.

Methods:

This review summarizes the implementation of HIFU for different pathologic conditions. An National Center for Biotechnology Information, PubMed, MEDLINE, Medscape, and Google Scholar database search (1992–2016) was done with the following keywords: high-intensity focused ultrasound; uses of HIFU; and applications of HIFU in the liver, bones, uterine fibroids, prostate, breast, thyroid, pancreas, kidneys, brain, urinary bladder, and so on. Tables and graphs were created for all the variables included in the study, and descriptive statistics were applied.

Results:

In total, 110 records were identified, through database search. In addition, 20 articles were identified through other sources. Screening of the articles was performed, and 20 were removed due to duplication; further screening was performed for 110 articles, and 30 records were further excluded. Full-text articles were assessed for eligibility and 30 were retained. Full-text articles were excluded (N = 36) on the basis that research was performed on animals, and this review article was performed solely for human application. There were 42 qualitative syntheses that researches added to the review. In addition, 42 quantitative synthesis (meta-analysis) were added to the review.

Conclusion:

The conclusion of this narrative review indicates that HIFU is noninvasive, nonharmful, and effective in treating diseases and tumors of the brain, breast, bone, hepatic, renal, pancreas, and prostate; uterine fibroids; and many other solid tumors. Recent technological development suggests that HIFU is likely to play a significant role in future surgical practices. Further research works should be conducted on a large sample size to obtain more accurate results in the application of HIFU.

Design and evaluation of an open-source, conformable skin-cooling system for body magnetic resonance guided focused ultrasound treatments

PURPOSE

Magnetic resonance guided focused ultrasound (MRgFUS) treatment of tumors uses inter-sonication delays to allow heat to dissipate from the skin and other near-field tissues. Despite inter-sonication delays, treatment of tumors close to the skin risks skin burns. This work has designed and evaluated an open-source, conformable, skin-cooling system for body MRgFUS treatments to reduce skin burns and enable ablation closer to the skin.

METHODS

A MR-compatible skin cooling system is described that features a conformable skin-cooling pad assembly with feedback control allowing continuous flow and pressure maintenance during the procedure. System performance was evaluated with hydrophone, phantom and in vivo porcine studies. Sonications were performed 10 and 5 mm from the skin surface under both control and forced convective skin-cooling conditions. 3D MR temperature imaging was acquired in real time and the accumulated thermal dose volume was measured. Gross analysis of the skin post-sonication was further performed. Device conformability was demonstrated at several body locations.

RESULTS

Hydrophone studies demonstrated no beam aberration, but a 5-12% reduction of the peak pressure due to the presence of the skin-cooling pad assembly in the acoustic near field. Phantom evaluation demonstrated there is no MR temperature imaging precision reduction or any other artifacts present due to the coolant flow during MRgFUS sonication. The porcine studies demonstrated skin burns were reduced in size or eliminated when compared to the control condition.

CONCLUSION

An open-source design of an MRgFUS active skin cooling system demonstrates device conformability with a reduction of skin burns while ablating superficial tissues.

Contrast agent shell properties effects on heat deposition in bubble enhanced high intensity focused ultrasound

The effects of the viscoelastic shell properties of ultrasound contrast agents on heat deposition in bubble enhanced high intensity focused ultrasound (HIFU) are studied numerically using a model that solves the ultrasound acoustic field and the multi-bubble dynamics. The propagation of the nonlinear acoustic waves in the test medium is modeled using the compressible Navier-Stokes equations in a fixed Eulerian grid, while the microbubbles are modeled as discrete flow singularities, which are tracked in a Lagrangian fashion. These two models are intimately coupled such that both the acoustic field and the bubbles influence each other at each time step. The resulting temperature rise in the field is then calculated by solving a heat transfer equation applied over a much longer time scale than the computed high frequency dynamics. Three shell models for the contrast agent are considered, and the effect of each of these models on the heat deposition at the focus is studied. The differences obtained in the bubble dynamics results between the shell models are discussed. The importance of modeling the elasticity of the shell is addressed by comparing the results between Newtonian and non-Newtonian shell models. Next, a parametric study varying the shell properties is carried out, and the relative roles of the shell viscosity and elasticity in affecting the heat deposition are discussed. These observations are then used to give recommendations for the design of innovative contrast agents, specifically for the purpose of obtaining higher heat deposition in bubble enhanced HIFU.

Stereotactic Transcranial Focused Ultrasound Targeting System for Murine Brain Models

An inexpensive, accurate focused ultrasound stereotactic targeting method guided by pretreatment magnetic resonance imaging (MRI) images for murine brain models is presented. An uncertainty of each sub-component of the stereotactic system was analyzed. The entire system was calibrated using clot phantoms. The targeting accuracy of the system was demonstrated with an in vivo mouse glioblastoma (GBM) model. The accuracy was quantified by the absolute distance difference between the prescribed and ablated points visible on the pre treatment and posttreatment MR images, respectively. A precalibration phantom study ( N = 6 ) resulted in an error of 0.32 ± 0.31, 0.72 ± 0.16, and 1.06 ± 0.38 mm in axial, lateral, and elevational axes, respectively. A postcalibration phantom study ( N = 8 ) demonstrated a residual error of 0.09 ± 0.01, 0.15 ± 0.09, and 0.47 ± 0.18 mm in axial, lateral, and elevational axes, respectively. The calibrated system showed significantly reduced ( ) error of 0.20 ± 0.21, 0.34 ± 0.24, and 0.28 ± 0.21 mm in axial, lateral, and elevational axes, respectively, in the in vivo GBM tumor-bearing mice ( N = 10 ).

Recent Advances in Nanomaterial-Assisted Combinational Sonodynamic Cancer Therapy

Ultrasound (US)-triggered sonodynamic therapy (SDT), as a promising noninvasive therapeutic modality, has received ever-increasing attention in recent years. Its specialized chemical agents, named sonosensitizers, are activated by low-intensity US to produce lethal reactive oxygen species (ROS) for oncotherapy. Compared with phototherapeutic strategies, SDT provides many noteworthy opportunities and benefits, such as deeper penetration depth, absence of phototoxicity, and fewer side effects. Nevertheless, previous studies have also demonstrated its intrinsic limitations. Thanks to the facile engineering nature of nanotechnology, numerous novel nanoplatforms are being applied in this emerging field to tackle these intrinsic barriers and achieve continuous innovations. In particular, the combination of SDT with other treatment strategies has demonstrated a superior efficacy in improving anticancer activity relative to that of monotherapies alone. Therefore, it is necessary to summarize the nanomaterial-assisted combinational sonodynamic cancer therapy applications. Herein, the design principles in achieving synergistic therapeutic effects based on nanomaterial engineering methods are highlighted. The ultimate goals are to stimulate the design of better-quality combined sonodynamic treatment schemes and provide innovative ideas for the perspectives of SDT in promoting its future transformation to clinical application.

Photoacoustic-guided Transcranial HIFU with Combined Time-reversal and Genetic Algorithm

High intensity focused ultrasound (HIFU) is a noninvasive therapy used to induce tissue ablation for treating malignant tissues. Photoacoustic (PA) has recently been proposed as an alternative method to guide HIFU. In this paper, we present a method of HIFU guided by time-reversing the transcranial PA signals of an optically selective target in a nonselective background. To improve the focus performance on target area, we further propose to utilize the time-reversed PA signals as the initial population of Genetic Algorithm (GA) to optimize the focusing iteratively. In particular, we mimic both optical and acoustic parameters of the human brain and intracranial media in the simulation study. Experimental results show that the focusing accuracy of the proposed method has been significantly improved compared to just one-step PA time-reversal. At the same time, the combination of TR and GA makes the iteration time consumption of the optimization process less than other traditional algorithms without TR, showing its potential HIFU in clinical scenarios.

Deployable tessellated transducer array for ultrasound focusing and bio-heat generation in a multilayer environment

High intensity focused ultrasound (HIFU) has great potential to thermally ablate diseased tissues with minimal invasion. Yet, HIFU practice has limited cancer treatment potential since the absorption, diffusion, and reflection of ultrasound prevent HIFU from penetrating the body to deep and concealed diseased tissue. To explore a vision of deployable HIFU transducers, this research introduces an origami-inspired concept wherein a deployable tessellated acoustic array is employed to reduce the distance between the HIFU transducer and diseased tissues. A flat-foldable HIFU transducer array is considered, such that the compact shape is used to pass through the human body and then deployed into the operational form for treatment. Here a theoretical framework is developed to study the focusing and thermal heating capabilities of the tessellated array in a multilayer environment. It is observed that the wavefield and thermal elevation realized by the foldable array are functionally similar to those of an ideal arc-shaped transducer. Folding patterns that permit adequate curvature and high quality factor, and that balance slenderness and conformability are found to be beneficial for an ultrasound focusing practice. The efficacy of the analytical predictions are verified through direct numerical simulations. All together, the results encourage attention to foldable array concepts as potential means to advance in-vivo HIFU-based procedures.

Patient-Specific 3-Dimensional Model for High-Intensity Focused Ultrasound Treatment Through the Rib Cage: A Preliminary Study

OBJECTIVES

The purpose of this study was to develop a patient-specific 3-dimensional model for high-intensity focused ultrasound (HIFU) treatment through the rib cage using patient data.

METHODS

Experimental testing to derive parameters used in defining the amount of energy and alteration needed in treatment protocols for upper abdominal disorders under the rib cage was performed. Reconstructed rib cage models based on patient data, tissue-mimicking material phantoms, and magnetic resonance imaging-guided HIFU using a multielement phased array transducer were used in the experiments. Changes in the focal temperature, acoustic power, and acoustic pressure distribution were investigated with and without the presence of the rib cage model. An ExAblate system (InSightec Ltd, Tirat Carmel, Israel) was used to sonicate phantoms by varying the target phantom or rib cage model location.

RESULTS

The effect of the rib cage on the acoustic pressure distribution and acoustic power was closely related to the anatomic structures of the ribs. Thermometry revealed that heating at the focus could be controlled by changing either the power or duration of HIFU application to improve the focal temperature change. The focal temperature change was found to be related to the distance between the rib cage model and focus and the shadow area on the transducer elements covered by the rib cage model in the beam path.

CONCLUSIONS

Experimental results suggest that the rib cage model is a valuable and useful tool that can provide realistic human anatomic structures and properties for evaluating the effects of the rib cage on ultrasound propagation.

Magnetic nanoparticles-enhanced focused ultrasound heating: size effect, mechanism, and performance analysis

High intensity focused ultrasound (HIFU) has attracted great interest as a new energy-based technique to treat disordered tissues, such as tumors, through a hyperthermal mechanism using ultrasonic waves. However, long treatment times and collateral damage to healthy tissues due to high acoustic powers are still challenges for the clinical application of HIFU. One possible strategy to enhance the deposition efficiency of HIFU at the tumor site is to employ magnetic nanoparticles (MNPs) as ultrasound absorption agents for the thermal therapy. The objectives of the current study are threefold: (i) to examine the effects of MNP features, including the size and volume concentration, on the thermal mechanism of HIFU (ii) to investigate the performance of MNPs as they were exposed to ultrasound fields at different ranges of power and frequency (iii) and to study the interaction mechanism between MNPs and ultrasonic waves during the MNPs-enhanced HIFU process. To this end, we developed an ultrasound-guided HIFU system to conduct an in vitro experimental study on tissue phantoms containing MNPs of different sizes and volume concentrations. A set of HIFU parameters such as temperature rise and the rate of absorbed energy was monitored to examine the role of MNPs during the NPs-enhanced HIFU thermal procedure. Results showed that the MNPs significantly improved the thermal effect of HIFU by enhancing the rate of energy converted to heat and the temperature rise at the focal region. Moreover, it was demonstrated that the increase of MNP size and volume concentration greatly enhanced the HIFU parameters; the effects of MNPs were further improved by increasing the power and frequency of acoustic field.

Analytical and Numerical Model of High Intensity Focused Ultrasound Enhanced With Nanoparticles

OBJECTIVE

High intensity focused ultrasound (HIFU) is a new noninvasive therapeutics that allows local treatment of solid tumors through a hyperthermal mechanism using ultrasonic energy. One promising strategy to increase the thermal efficiency of HIFU is to employ nanoparticles (NPs) as ultrasound agents for the hyperthermia procedure. However, the interaction mechanism between NPs and ultrasonic waves has not been well understood.

METHODS

In an effort to investigate the heating process of NPs-enhanced HIFU, we derived a set of HIFU equations governing the temperature variation during the thermal ablation based on the principle of conservation of energy for heat transfer mechanism. A numerical model was developed to solve the HIFU equations to simulate the absorption mechanism of HIFU in the presence of NPs, the consequent heat transfer process, and the temperature rise profile during the sonication period. The accuracy of numerical model was verified by performing a series of experiments on tissue-mimicking phantoms embedded with magnetic NPs (MNPs).

RESULTS

The transport processes taking place at the boundaries between NPs and surrounding medium played the major role in the temperature rise during HIFU sonication. Besides, the effects of MNPs on rising temperature were improved by amplifying the ultrasonic power and frequency as well as by increasing the MNP concentration.

CONCLUSION

A quantitative comparison with experimental results demonstrated the potential of the numerical model to accurately predict the heating mechanism of HIFU mediated by NPs.

SIGNIFICANCE

The proposed method can help with simulation of HIFU when NPs are employed as ultrasound agents.

A review of effects and applications of ultrasound in mineral flotation

Ultrasound technology is widely applied in the flotation process. From the perspective of the theory of ultrasound, this article explains the effects and applications of ultrasound in the flotation process. To obtain a clear understanding of ultrasonic effects, we observe the phenomena of ultrasound using a high-speed camera and a CCD camera, and investigate potential applications in flotation. From these different phenomena, the ultrasonic effects are classified into three types of effect: the transient cavitation effect, stable cavitation effect, and acoustic radiation force effect. Based on these effects, the applications of ultrasound to mineral flotation are reviewed, including slime coating removal, oxidation film removal, desulfuration, tiny bubble generation, flotation reagent dispersion, and aggregation. In addition, the ultrasonic equipment and treatment methods applied in flotation are classified and compared based on their characteristics. Finally, we propose some potential directions in the study of the stable cavitation effect and acoustic radiation force effect, which are important, but are seldom mentioned in previous reports.

Use of Micro-focused Ultrasound for Skin Tightening of Mid and Lower Face

The changes in the mid face and lower face are among the most prominent features of the aging process. Intense focused ultrasound, known as the Ulthera System (Ulthera Inc., Mesa, AZ, USA), was designed to correct this process. It employs micro-focused ultrasound to cause discrete focal heating of the dermis and stimulates neocollagenesis and elastin remodeling.

Enhancing Thermal Effect of Focused Ultrasound Therapy Using Gold Nanoparticles

High intensity focused ultrasound (HIFU) has gained increasing attention as a noninvasive therapeutic method for wide range of biomedical applications from drug delivery to cancer treatment. However, high level of ultrasonic power required for efficient HIFU treatment can cause adverse effects such as damage to surrounding healthy tissues and skin burns. One of the strategies to improve the therapeutic mechanism of HIFU is to use ultrasound absorption agents during the treatment. The objectives of current study are to investigate the feasibility of adopting gold nanoparticles (AuNPs) as ultrasound absorption agents to enhance the HIFU thermal ablation when the NPs were injected locally to the focal region; and to examine the dose effects of AuNPs on both heating and cooling mechanisms of HIFU. To this end, we conducted an experimental study on tissue-mimicking phantoms where AuNPs were injected to the focal region under the guidance of ultrasound imaging. A set of thermal parameters including temperature, specific absorption rate of acoustic energy, and cooling rate were measured to monitor the mechanism of AuNPs-mediated HIFU. The results suggest that both heating and cooling rates of HIFU procedure could be greatly improved by injecting AuNPs, which demonstrates the feasibility of using AuNPs to reduce the level of ultrasonic power from extracorporeal source for HIFU treatment.

Modeling of Microbubble-Enhanced High-Intensity Focused Ultrasound

Heat enhancement at the target in a high intensity focused ultrasound (HIFU) field is investigated by considering the effects of the injection of microbubbles in the vicinity of the tumor to be ablated. The interaction between the bubble cloud and the HIFU field is investigated using a 3-D numerical model. The propagation of non-linear ultrasonic waves in the tissue or in a phantom medium is modeled using the compressible Navier-Stokes equations on a fixed Eulerian grid, while the microbubbles dynamics and motion are modeled as discrete singularities, which are tracked in a Lagrangian framework. These two models are coupled to each other such that both the acoustic field and the bubbles influence each other. The resulting temperature rise in the field is calculated by solving a heat transfer equation applied over a much longer time scale. The compressible continuum part of the model is validated by conducting axisymmetric HIFU simulations without microbubbles and comparing the pressure and temperature fields against available experiments. The coupled Eulerian-Lagrangian approach is then validated against existing experiments conducted with a phantom tissue. The bubbles are distributed randomly in a 3-D fashion inside a cylindrical volume, while the background acoustic field is assumed axisymmetric. The presence of microbubbles modifies the ultrasound field in the focal region and significantly enhances heat deposition. The various mechanisms through which heat deposition is increased are then examined. Among these effects, viscous damping of the bubble oscillations is found to be the main contributor to the enhanced heat deposition. The effects of the initial void fraction in the cloud are then sought by considering the changes in the attenuation of the primary ultrasonic wave and the modifications of the enhanced heat deposition in the focal region. It is observed that although high bubble void fractions lead to increased heat deposition, they also cause significant pre-focal heating because of acoustic shielding. The effects of the microbubble cloud size and its location in the focal region are studied, and the effects of these parameters in altering the temperature rise and the location of the temperature peak are discussed. It is found that concentrating the bubbles adjacent to the focus and farther away from the acoustic source leads to effective heat deposition. Finally, the presence of a shell at the bubble surface, as in contrast agents, is seen to reduce heat deposition by restraining bubble oscillations.

Superparamagnetic iron oxide nanoparticles (SPIONs) as a multifunctional tool in various cancer therapies

Over the past two decades nanotechnology has become an important part of novel medical research. Researchers have made great progress in developing nanotechnology applications used for detecting and treating oncological diseases. Recently, many research groups have focused on the use of superparamagnetic iron oxide nanoparticles (SPIONs) in cancer treatment. Due to the range of therapeutic properties and possibilities of various modifications, SPIONs are a promising and multifunctional tool in various cancer therapies and may help to overcome the limitations of conventional therapies. Moreover, it is still necessary to develop new methods of treatment with expected properties, such as lower toxicity, long-lasting effectiveness and higher selectivity. Analyzing the literature data, we found that currently SPIONs are used in the transport of drugs, immunotherapy and hyperthermia. The main aim of this review is to present various cancer treatment therapies utilizing SPIONs, the importance of the experiments carried out by research groups and further perspectives in the nanotechnological use of SPIONs.

For Whom the Bubble Grows: Physical Principles of Bubble Nucleation and Dynamics in Histotripsy Ultrasound Therapy

Histotripsy is a focused ultrasound therapy for non-invasive tissue ablation. Unlike thermally ablative forms of therapeutic ultrasound, histotripsy relies on the mechanical action of bubble clouds for tissue destruction. Although acoustic bubble activity is often characterized as chaotic, the short-duration histotripsy pulses produce a unique and consistent type of cavitation for tissue destruction. In this review, the action of histotripsy-induced bubbles is discussed. Sources of bubble nuclei are reviewed, and bubble activity over the course of single and multiple pulses is outlined. Recent innovations in terms of novel acoustic excitations, exogenous nuclei for targeted ablation and histotripsy-enhanced drug delivery and image guidance metrics are discussed. Finally, gaps in knowledge of the histotripsy process are highlighted, along with suggested means to expedite widespread clinical utilization of histotripsy.

Real-Time Photoacoustic Thermometry Combined With Clinical Ultrasound Imaging and High-Intensity Focused Ultrasound

High-intensity focused ultrasound (HIFU) treatment is a promising non-invasive method for killing or destroying the diseased tissues by locally delivering thermal and mechanical energy without damaging surrounding normal tissues. In HIFU, measuring the temperature at the site of delivery is important for improving therapeutic efficacy, controlling safety, and appropriately planning a treatment. Several researchers have proposed photoacoustic thermometry for monitoring HIFU treatment, but they had many limitations, including the inability to image while the HIFU is on, inability to provide two-dimensional monitoring, and the inability to be used clinically. In this paper, we propose a novel integrated real-time photoacoustic thermometry system for HIFU treatment monitoring. The system provides ultrasound B-mode imaging, photoacoustic structural imaging, and photoacoustic thermometry during HIFU treatment in real-time for both in vitro and in vivo environments, without any interference from the strong therapeutic HIFU waves. We have successfully tested the real-time photoacoustic thermometry by investigating the relationship between the photoacoustic amplitude and the measured temperature with in vitro phantoms and in vivo tumor-bearing mice. The results show the feasibility of a real-time photoacoustic thermometry system for safe and effective monitoring of HIFU treatment.

Micron-sized PFOB liquid core droplets stabilized with tailored-made perfluorinated surfactants as a new class of endovascular sono-sensitizers for focused ultrasound thermotherapy

The effect of micro-droplet concentration on HIFU beam absorption.

HIFU induced particles redistribution in polymer matrix via synchrotron radiation X-ray microtomography

High-intensity Focused Ultrasound (HIFU) was used to stimulate the embedded copper sulfate (CuSO₄) particles to release from the crosslinked poly (methyl methacrylate-co-butyl acrylate) copolymer solid matrix. In order to better understand the ultrasound release mechanism for drug/polymer delivery systems, the synchrotron radiation X-ray computed microtomography (SR-CT) was used to non-destructively investigate the structure of drug/polymer delivery systems after different HIFU treatment time. For the first time, we clearly demonstrate that ultrasonic waves can overcome the constraints of the polymer chain and drive the filler to move from the strong region to the weak region in the solid polymer matrix, thus resulting in a change in distribution of the filler in solid polymers. This result also demonstrates that SR-CT is a powerful technique which can be used to quantitatively study the 3D structure of fillers/polymers composite as it can take a broader and overall view than the conventional localized two-dimensional analysis method such as SEM, TEM.

Comparison of Combination Stereotactic Body Radiotherapy Plus High-Intensity Focused Ultrasound Ablation Versus Stereotactic Body Radiotherapy Alone for Massive Hepatocellular Carcinoma

Background

Thermal high-intensity focused ultrasound ablation is a non-invasive treatment of massive hepatocellular carcinomas. In stereotactic body radiotherapy, ablative radiotherapy is administered to tumors in targeted, limited doses to minimize damage to nearby tissues. We evaluated the outcomes and survival of patients receiving stereotactic body radiotherapy (singular therapy) versus those receiving combination thermal high-intensity focused ultrasound ablation plus stereotactic body radiotherapy (combination therapy).

Material/Methods

We compared data of 160 patients with massive hepatocellular carcinomas (12.5–18 cm) who were treated with combination therapy to those treated with singular therapy between January 2009 and February 2016.

Results

Eighty-four patients were treated with single therapy while 76 were treated with combination therapy. Comparison of short-term outcomes and long-term survival between the groups revealed no significant differences in adverse events. In the combination group, the proportions of patients with complete response, partial response, stable disease, and progressive disease were 52.6%, 21.1%, 21.1%, and 5.3%, respectively; in the single therapy group, the corresponding rates were 0%, 23.8%, 50%, and 26.2%, respectively (P<0.0001). The 1-year, 3-year, and 5-year survival rates in the combination group were 33%, 20%, and 13%, respectively, while those in the single therapy group were 21%, 14%, and 1%, respectively. These data indicated no differences in complications between the groups except for a significantly higher level of skin edema in the combination group (P=0.015).

Conclusions

Combination therapy is more effective than single therapy for the treatment of massive hepatocellular carcinomas, although rates of most complications appear to be similar.

Design of Binary-Sequence Zone Plates in High Wavelength Domains

The design of zone plates is an important topic in many areas of physics, such as optics, X-rays, microwaves or ultrasonics. In this paper, a zone plate design method, which provides high flexibility in the shaping of the focusing profile, is analyzed. This flexibility is achieved through the use of binary sequences that produce zone plates with different properties and applications. It is shown that this binary-sequence method works properly at low wavelengths, but requires a modification term to work accurately in high wavelength domains. This additional term extends this powerful design method to any wavelength. Simulation results show acoustic focusing profiles for Fresnel, Fibonacci and Cantor zone plates operating at a wavelength of 1.5 mm without any distortion.

Numerical Study of Bubble Area Evolution During Acoustic Droplet Vaporization-Enhanced HIFU Treatment

Acoustic droplet vaporization has the potential to shorten treatment time of high-intensity focused ultrasound (HIFU) while minimizing the possible effects of microbubbles along the propagation path. Distribution of the bubbles formed from the droplets during the treatment is the major factor shaping the therapeutic region. A numerical model was proposed to simulate the bubble area evolution during this treatment. Using a linear acoustic equation to describe the ultrasound field, a threshold range was defined that determines the amount of bubbles vaporized in the treated area. Acoustic parameters, such as sound speed, acoustic attenuation coefficient, and density, were treated as a function of the bubble size distribution and the gas void fraction, which were related to the vaporized bubbles in the medium. An effective pressure factor was proposed to account for the influence of the existing bubbles on the vaporization of the nearby droplets. The factor was obtained by fitting one experimental result and was then used to calculate bubble clouds in other experimental cases. Comparing the simulation results to these other experiments validated the model. The dynamic change of the pressure and the bubble distribution after exposure to over 20 pulses of HIFU are obtained. It is found that the bubble area grows from a grainlike shape to a "tadpole," with comparable dimensions and shape to those observed in experiments. The process was highly dynamic with the shape of the bubble area changing with successive HIFU pulses and the focal pressure. The model was further used to predict the shape of the bubble region triggered by HIFU when a bubble wall pre-exists. The results showed that the bubble wall helps prevent droplet vaporization on the distal side of the wall and forms a particularly shaped region with bubbles. This simulation model has predictive potential that could be beneficial in applications, such as cancer treatment, by parametrically studying conditions associated with these treatments and designing treatment protocols.

Principles of focused ultrasound

Focused ultrasound (FUS/HIFU) relies on ablation of pathological tissues by delivering a sufficiently high level of acoustic energy in situ of the human body. Magnetic Resonance guided FUS (MRgFUS/HIFU) and Ultrasound guided (USgFUS/HIFU) are image guided techniques combined with therapeutic FUS for monitoring purposes. The principles and technologies of FUS/HiFU are described in this paper including the basics of MR guidance techniques and MR temperature mapping. Clinical applications of FUS/HIFU gained CE and FDA approvals for the treatment of various benign and few malignant lesions in the last two decades. Current technical limitations of ultrasound guided and MRI guided Focused Ultrasound, as well as adverse effects for the application of this technique are outlined including challenges of ablating moving organs (liver and kidney). An outlook to possible applications is provided; exampling clinical trials discussing future options.

Real-Time Spatiotemporal Control of High-Intensity Focused Ultrasound Thermal Ablation Using Echo Decorrelation Imaging in ex Vivo Bovine Liver

The ability to control high-intensity focused ultrasound (HIFU) thermal ablation using echo decorrelation imaging feedback was evaluated in ex vivo bovine liver. Sonications were automatically ceased when the minimum cumulative echo decorrelation within the region of interest exceeded an ablation control threshold, determined from preliminary experiments as -2.7 (log-scaled decorrelation per millisecond), corresponding to 90% specificity for local ablation prediction. Controlled HIFU thermal ablation experiments were compared with uncontrolled experiments employing two, five or nine sonication cycles. Means and standard errors of the lesion width, area and depth, as well as receiver operating characteristic curves testing ablation prediction performance, were computed for each group. Controlled trials exhibited significantly smaller average lesion area, width and treatment time than five-cycle or nine-cycle uncontrolled trials and also had significantly greater prediction capability than two-cycle uncontrolled trials. These results suggest echo decorrelation imaging is an effective approach to real-time HIFU ablation control.

Gold nanoparticle nucleated cavitation for enhanced high intensity focused ultrasound therapy

High intensity focused ultrasound (HIFU) or focused ultrasound surgery is a non-invasive technique for the treatment of cancerous tissue, which is limited by difficulties in getting real-time feedback on treatment progress and long treatment durations. The formation and activity of acoustic cavitation, specifically inertial cavitation, during HIFU exposures has been demonstrated to enhance heating rates. However, without the introduction of external nuclei its formation an activity can be unpredictable, and potentially counter-productive. In this study, a combination of pulse laser illumination (839 nm), HIFU exposures (3.3 MHz) and plasmonic gold nanorods (AuNR) was demonstrated as a new approach for the guidance and enhancement of HIFU treatments. For imaging, short duration HIFU pulses (10 μs) demonstrated broadband acoustic emissions from AuNR nucleated cavitation with a signal-to-noise ranging from 5-35 dB for peak negative pressures between 1.19-3.19  ±  0.01 MPa. In the absence of either AuNR or laser illumination these emissions were either not present or lower in magnitude (e.g. 5 dB for 3.19 MPa). Continuous wave (CW) HIFU exposures for 15 s, were then used to generate thermal lesions for peak negative pressures from 0.2-2.71  ±  0.01 MPa at a fluence of 3.4 mJ [Formula: see text]. Inertial cavitation dose (ICD) was monitored during all CW exposures, where exposures combined with both laser illumination and AuNRs resulted in the highest level of detectable emissions. This parameter was integrated over the entire exposure to give a metric to compare with measured thermal lesion area, where it was found that a minimum total ICD of [Formula: see text] a.u. was correlated with the formation of thermal lesions in gel phantoms. Furthermore, lesion area (mm²) was increased for equivalent exposures without either AuNRs or laser illumination. Once combined with cancer targeting AuNRs this approach could allow for the future theranostic use of HIFU, such as providing the ability to identify and treat small multi-focal cancerous regions with minimal damage to surrounding healthy tissue.

Analysis of Fresnel Zone Plates Focusing Dependence on Operating Frequency

The focusing properties of Fresnel Zone Plates (FZPs) against frequency are analyzed in this work. It is shown that the FZP focal length depends almost linearly on the operating frequency. Focal depth and focal distortion are also considered, establishing a limit on the frequency span at which the operating frequency can be shifted. An underwater FZP ultrasound focusing system is demonstrated, and experimental results agree with the theoretical analysis and simulations.

Emerging Applications of Therapeutic Ultrasound in Neuro-oncology: Moving Beyond Tumor Ablation

: Transcranial focused ultrasound (FUS) can noninvasively transmit acoustic energy with a high degree of accuracy and safety to targets and regions within the brain. Technological advances, including phased-array transducers and real-time temperature monitoring with magnetic resonance thermometry, have created new opportunities for FUS research and clinical translation. Neuro-oncology, in particular, has become a major area of interest because FUS offers a multifaceted approach to the treatment of brain tumors. FUS has the potential to generate cytotoxicity within tumor tissue, both directly via thermal ablation and indirectly through radiosensitization and sonodynamic therapy; to enhance the delivery of therapeutic agents to brain tumors by transiently opening the blood-brain barrier or improving distribution through the brain extracellular space; and to modulate the tumor microenvironment to generate an immune response. In this review, we describe each of these applications for FUS, the proposed mechanisms of action, and the preclinical and clinical studies that have set the foundation for using FUS in neuro-oncology.

ABBREVIATIONS

BBB, blood-brain barrierCED, convection-enhanced delivery5-Ala, 5-aminolevulinic acidFUS, focused ultrasoundGBM, glioblastoma multiformeHSP, heat shock proteinMRgFUS, magnetic resonance-guided focused ultrasoundpFUS, pulsed focused ultrasound.

A framework for continuous target tracking during MR-guided high intensity focused ultrasound thermal ablations in the abdomen

Background

During lengthy magnetic resonance-guided high intensity focused ultrasound (MRg-HIFU) thermal ablations in abdominal organs, the therapeutic work-flow is frequently hampered by various types of physiological motion occurring at different time-scales. If left un-addressed this can lead to an incomplete therapy and/or to tissue damage of organs-at-risk. While previous studies focus on correction schemes for displacements occurring at a particular time-scale within the work-flow of an MRg-HIFU therapy, in the current work we propose a motion correction strategy encompassing the entire work-flow.

Methods

The proposed motion compensation framework consists of several linked components, each being adapted to motion occurring at a particular time-scale. While respiration was addressed through a fast correction scheme, long term organ drifts were compensated using a strategy operating on time-scales of several minutes. The framework relies on a periodic examination of the treated area via MR scans which are then registered to a reference scan acquired at the beginning of the therapy. The resulting displacements were used for both on-the-fly re-optimization of the interventional plan and to ensure the spatial fidelity between the different steps of the therapeutic work-flow. The approach was validated in three complementary studies: an experiment conducted on a phantom undergoing a known motion pattern, a study performed on the abdomen of 10 healthy volunteers and during 3 in-vivo MRg-HIFU ablations on porcine liver.

Results

Results have shown that, during lengthy MRg-HIFU thermal therapies, the human liver and kidney can manifest displacements that exceed acceptable therapeutic margins. Also, it was demonstrated that the proposed framework is capable of providing motion estimates with sub-voxel precision and accuracy. Finally, the 3 successful animal studies demonstrate the compatibility of the proposed approach with the work-flow of an MRg-HIFU intervention under clinical conditions.

Conclusions

In the current study we proposed an image-based motion compensation framework dedicated to MRg-HIFU thermal ablations in the abdomen, providing the possibility to re-optimize the therapy plan on-the-fly with the patient on the interventional table. Moreover, we have demonstrated that even under clinical conditions, the proposed approach is fully capable of continuously ensuring the spatial fidelity between the different phases of the therapeutic work-flow.