Attenuation of porcine tissues in vivo after high-intensity ultrasound treatment

Therapeutic ultrasound transducer technology and monitoring techniques: a review with clinical examples

The exponential growth of therapeutic ultrasound applications demonstrates the power of the technology to leverage the combinations of transducer technology and treatment monitoring techniques to effectively control the preferred bioeffect to elicit the desired clinical effect.Objective: This review provides an overview of the most commonly used bioeffects in therapeutic ultrasound and describes existing transducer technologies and monitoring techniques to ensure treatment safety and efficacy.Methods and materials: Literature reviews were conducted to identify key choices that essential in terms of transducer design, treatment parameters and procedure monitoring for therapeutic ultrasound applications. Effective combinations of these options are illustrated through descriptions of several clinical indications, including uterine fibroids, prostate disease, liver cancer, and brain cancer, that have been successful in leveraging therapeutic ultrasound to provide effective patient treatments.Results: Despite technological constraints, there are multiple ways to achieve a desired bioeffect with therapeutic ultrasound in a target tissue. Visualizations of the interplay of monitoring modality, bioeffect, and applied acoustic parameters are presented that demonstrate the interconnectedness of the field of therapeutic ultrasound. While the clinical indications explored in this review are at different points in the clinical evaluation path, based on the ever expanding research being conducted in preclinical realms, it is clear that additional clinical applications of therapeutic ultrasound that utilize a myriad of bioeffects will continue to grow and improve in the coming years.Conclusions: Therapeutic ultrasound will continue to improve in the next decades as the combination of transducer technology and treatment monitoring techniques will continue to evolve and be translated in clinical settings, leading to more personalized and efficient therapeutic ultrasound mediated therapies.

Sound speed and attenuation of human pancreas and pancreatic tumors and their influence on focused ultrasound thermal and mechanical therapies

BACKGROUND

There is increasing interest in using ultrasound for thermal ablation, histotripsy, and thermal or cavitational enhancement of drug delivery for the treatment of pancreatic cancer. Ultrasonic and thermal modelling conducted as part of the treatment planning process requires acoustic property values for all constituent tissues, but the literature contains no data for the human pancreas.

PURPOSE

This study presents the first acoustic property measurements of human pancreatic samples and provides examples of how these properties impact a broad range of ultrasound therapies.

METHODS

Data were collected on human pancreatic tissue samples at physiological temperature from 23 consented patients in cooperation with a hospital pathology laboratory. Propagation of ultrasound over the 2.1-4.5 MHz frequency range through samples of various thicknesses and pathologies was measured using a set of custom-built ultrasonic calipers, with the data processed to estimate sound speed and attenuation. The results were used in acoustic and thermal simulations to illustrate the impacts on extracorporeal ultrasound therapies for mild hyperthermia, thermal ablation, and histotripsy implemented with a CE-marked clinical system operating at 0.96 MHz.

RESULTS

The mean sound speed and attenuation coefficient values for human samples were well below the range of values in the literature for non-human pancreata, while the human attenuation power law exponents were substantially higher. The simulated impacts on ultrasound mediated therapies for the pancreas indicated that when using the human data instead of the literature average, there was a 30% reduction in median temperature elevation in the treatment volume for mild hyperthermia and 43% smaller volume within a 60°C contour for thermal ablation, all driven by attenuation. By comparison, impacts on boiling and intrinsic threshold histotripsy were minor, with peak pressures changing by less than 15% (positive) and 1% (negative) as a consequence of the counteracting effects of attenuation and sound speed.

CONCLUSION

This study provides the most complete set of speed of sound and attenuation data available for the human pancreas, and it reiterates the importance of acoustic material properties in the planning and conduct of ultrasound-mediated procedures, particularly thermal therapies.

Polyethylenimine (PEI)-modified poly (lactic-co-glycolic) acid (PLGA) nanoparticles conjugated with tumor-homing bacteria facilitate high intensity focused ultrasound-mediated tumor ablation

The acoustic propagation characteristic of ultrasound determines that the energy of ultrasound beam will decrease with the increase of its propagation depth in the body. Similarly, the energy of High Intensity Focused Ultrasound (HIFU) will be attenuated with the increase of HIFU propagation depth in the body. Ensuring sufficient ultrasound energy deposition in the HIFU ablation region for tumor ablation is usually achieved by increasing the ultrasound irradiation power or prolonging the ultrasound ablation time. However, these two methods may damage the normal tissue adjacent to the HIFU ablation region. Herein, we constructed the nanoparticles conjugated with tumor-homing bacteria as the biological tumor-homing synergist to facilitate HIFU-mediated tumor ablation avoiding the potential safety risk. In our strategy, Bifidobacterium bifidum (B.bifidum) was selectively colonized in the hypoxic region of solid tumors after been injected into 4T1 breast cancer bearing-BALB/c mice via the tail vein due to its anaerobic growth characteristic. The amount of B. bifidum with negative surface potential in the hypoxic region of solid tumors was increased by its anaerobic proliferation. Polyethylenimine (PEI) -modified Poly (lactic-co-glycolic) acid nanoparticles loaded sodium bicarbonate (PEI-PLGA-NaHCO₃-NPs) with positive surface potential injected into 4T1 breast cancer bearing-BALB/c mice via the tail vein displayed the tumor-homing ability by the electrostatic adsorption with B. bifidum colonized solid tumors. PEI-PLGA-NaHCO₃-NPs could release NaHCO₃ to produce carbon dioxide (CO₂) as cavitation nuclei inside the acidic microenvironment of solid tumors. When HIFU irradiated solid tumors contained with more cavitation nuclei, the ultrasound energy deposition at the tumor region was increased to destroy the tumors more effectively. Meanwhile, the improved efficiency of HIFU-mediated tumor ablation reduced the dependence of the tumor ablation on the ultrasound energy dose, which improved the safety of HIFU-mediated tumor ablation to the non-targeted ablation tissue. This tumor-homing synergist shows the potential application value on the HIFU-mediated tumor ablation in the clinical.

Vein wall shrinkage induced by thermal coagulation with high-intensity-focused ultrasound: numerical modeling and in vivo experiments in sheep

BACKGROUND

Varicose veins are a common disease that may significantly affect quality of life. Different approaches are currently used in clinical practice to treat this pathology.

MATERIALS AND METHODS

In thermal therapy (radiofrequency or laser therapy), the vein is directly heated to a high temperature to induce vein wall coagulation, and the heat induces denaturation of the intramural collagen, which results macroscopically in vein shrinkage. Thermal vein shrinkage is a physical indicator of the efficiency of endovenous treatment. High-intensity focused ultrasound (HIFU) is a noninvasive technique that can thermally coagulate vein walls and induce vein shrinkage. In this study, we evaluated the vein shrinkage induced in vivo by extracorporeal HIFU ablation of sheep veins: six lateral saphenous veins (3.4mm mean diameter) were sonicated for 8 s with 3MHz continuous waves. Ultrasound imaging was performed before and immediately post-HIFU to quantify the HIFU-induced shrinkage.

RESULTS

Luminal constriction was observed in 100% (6/6) of the treated veins. The immediate findings showed a mean diameter constriction of 53%. The experimental HIFU-induced shrinkage data were used to validate a numerical model developed to predict the thermally induced vein contraction during HIFU treatment.

CONCLUSIONS

This model is based on the use of the k-wave library and published contraction rates of vessels immersed in hot water baths. The simulation results agreed well with those of in vivo experiments, showing a mean percent difference of 5%. The numerical model could thus be a valuable tool for optimizing ultrasound parameters as functions of the vein diameter, and future clinical trials are anticipated.

Identification of Denatured Biological Tissues Based on Compressed Sensing and Improved Multiscale Dispersion Entropy during HIFU Treatment

Identification of denatured biological tissue is crucial to high-intensity focused ultrasound (HIFU) treatment, which can monitor HIFU treatment and improve treatment efficiency. In this paper, a novel method based on compressed sensing (CS) and improved multiscale dispersion entropy (IMDE) is proposed to evaluate the complexity of ultrasonic scattered echo signals during HIFU treatment. In the analysis of CS, the method of orthogonal matching pursuit (OMP) is employed to reconstruct the denoised signal. CS-OMP can denoise the ultrasonic scattered echo signal effectively. Comparing with traditional multiscale dispersion entropy (MDE), IMDE improves the coarse-grained process in the multiscale analysis, which improves the stability of MDE. In the analysis of simulated signals, the entropy value of the IMDE method has less fluctuation compared with MDE, indicating that the IMDE method has better stability. In addition, MDE and IMDE are applied to the 300 cases of ultrasonic scattered echo signals after denoising (including 150 cases of normal tissues and 150 cases of denatured tissues). The experimental results show that the MDE and IMDE values of denatured tissues are higher than normal tissues. Both the MDE and IMDE method can be used to identify whether biological tissue is denatured. However, the multiscale entropy curve of IMDE is smoother and more stable than MDE. The interclass distance of IMDE is greater than MDE, and the intraclass distance of IMDE is less than MDE at different scale factors. This indicates that IMDE can better distinguish normal tissues and denatured tissues to obtain more accurate clinical diagnosis during HIFU treatment.

A lab-on-chip ultrasonic platform for real-time and nondestructive assessment of extracellular matrix stiffness

Extracellular matrix (ECM) mechanical stiffness and its dynamic change is one of the main cues that directly affects the differentiation and proliferation of normal cells as well as the progression of disease processes such as fibrosis and cancer. Recent advancements in biomaterials have enabled a wide range of polymer matrices that could mimic the ECM of different tissues for a wide range of in vitro basic research and drug discovery. However, most of the technologies utilized to quantify the stiffness of such ECM are either destructive or expensive, and therefore are unsuitable for the in situ, long-term monitoring of variations in ECM stiffness for on-chip cell culture applications. This work demonstrates a novel noninvasive on-chip platform for characterization of ECM stiffness in vitro, by monitoring ultrasonic wave attenuation through the targeted material. The device is composed of a pair of millimeter scale ultrasonic transmitter and receiver transducers with the test medium placed in between them. The transmitter generates an ultrasonic wave that propagates through the material, triggers the piezoelectric receiver and generates a corresponding electrical signal. The characterization reveals a linear (r² = 0.86) decrease in the output voltage of the piezoelectric receiver with an average sensitivity of -15.86 μV kPa^-1 by increasing the stiffnesses of hydrogels (from 4.3 kPa to 308 kPa made with various dry-weight concentrations of agarose and gelatin). The ultrasonic stiffness sensing is also demonstrated to successfully monitor dynamic changes in a simulated in vitro tissue by gradually changing the polymerization density of an agarose gel, as a proof-of-concept towards future use for 3D cell culture and drug screening. In situ long-term ultrasonic signal stability and thermal assessment of the device demonstrates its high robust performance even after two days of continuous operation, with negligible (<0.5 °C) heating of the hydrogel in contact with the piezoelectric transducers. In vitro biocompatibility assessment of the device with mammary fibroblasts further assures that the materials used in the platform did not produce a toxic response and cells remained viable under the applied ultrasound signals in the device.

Transcutaneous Ultrasound-Mediated Nonviral Gene Delivery to the Liver in a Porcine Model

Ultrasound (US)-mediated gene delivery (UMGD) of nonviral vectors was demonstrated in this study to be an effective method to transfer genes into the livers of large animals via a minimally invasive approach. We developed a transhepatic venous nonviral gene delivery protocol in combination with transcutaneous, therapeutic US (tUS) to facilitate significant gene transfer in pig livers. A balloon catheter was inserted into the pig hepatic veins of the target liver lobes via jugular vein access under fluoroscopic guidance. tUS exposure was continuously applied to the lobe with simultaneous infusion of pGL4 plasmid (encoding a luciferase reporter gene) and microbubbles. tUS was delivered via an unfocused, two-element disc transducer (H105) or a novel focused, single-element transducer (H114). We found applying transcutaneous US using H114 and H105 with longer pulses and reduced acoustic pressures resulted in an over 100-fold increase in luciferase activity relative to untreated lobes. We also showed effective UMGD by achieving focal regions of >10⁵ relative light units (RLUs)/mg protein with minimal tissue damage, demonstrating the feasibility for clinical translation of this technique to treat patients with genetic diseases.

Broadband Ultrasonic Attenuation Estimation and Compensation With Passive Acoustic Mapping

Several active and passive techniques have been developed to detect, localize, and quantify cavitation activity during therapeutic ultrasound procedures. Much of the prior cavitation monitoring research has been conducted using lossless in vitro systems or small animal models in which path attenuation effects were minimal. However, the performance of these techniques may be substantially degraded by attenuation between the internal therapeutic target and the external monitoring system. As a further step toward clinical application of passive acoustic mapping (PAM), this paper presents methods for attenuation estimation and compensation based on broadband cavitation data measured with a linear ultrasound array. Soft tissue phantom experiment results are used to illustrate: 1) the impact of realistic attenuation on PAM; 2) the possibility of estimating attenuation from cavitation data; 3) cavitation source energy estimation following attenuation compensation; and 4) the impact of sound speed uncertainty on PAM-related processing. Cavitation-based estimates of attenuation were within 1.5%-6.2% of the values found from conventional through-transmission measurements. Tissue phantom attenuation reduced the PAM energy estimate by an order of magnitude, but array data compensation using the cavitation-based attenuation spectrum enabled recovery of the PAM energy estimate to within 2.9%-5.9% of the values computed in the absence of the phantom. Sound speed uncertainties were found to modestly impact attenuation-compensated PAM energies, inducing errors no larger than 28% for a 40-m/s path-averaged speed error. Together, the results indicate the potential to significantly enhance the quantitative capabilities of PAM for ensuring therapeutic safety and efficacy.

Ex Vivo and In Vivo Monitoring and Characterization of Thermal Lesions by High-Intensity Focused Ultrasound and Microwave Ablation Using Ultrasonic Nakagami Imaging

The feasibility of ultrasonic Nakagami imaging to evaluate thermal lesions by high-intensity focused ultrasound and microwave ablation was explored in ex vivo and in vivo liver models. Dynamic changes of the ultrasonic Nakagami parameter in thermal lesions were calculated, and ultrasonic B-mode and Nakagami images were reconstructed simultaneously. The contrast-to-noise ratio (CNR) between thermal lesions and normal tissue was used to estimate the contrast resolution of the monitoring images. After thermal ablation, a bright hyper-echoic region appeared in the ultrasonic B-mode and Nakagami images, identifying the thermal lesion. During thermal ablation, mean values of Nakagami parameter showed an increasing trend from 0.72 to 1.01 for the ex vivo model and 0.54 to 0.72 for the in vivo model. After thermal ablation, mean CNR values of the ultrasonic Nakagami images were 1.29 dB (ex vivo) and 0.80 dB (in vivo), significantly higher ( ) than those for B-mode images. Thermal lesion size, assessed using ultrasonic Nakagami images, shows a good correlation to those obtained from the gross-pathology images (for the ex vivo model: length, = 0.96; width, = 0.90; for the in vivo model: length, = 0.95; width, = 0.85). This preliminary study suggests that ultrasonic Nakagami parameter may have a potential use in evaluating the formation of thermal lesions with better image contrast. Moreover, ultrasonic Nakagami imaging combined with B-mode imaging may be utilized as an alternative modality in developing monitoring systems for image-guided thermal ablation treatments.

Acoustic Properties of Small Animal Soft Tissue in the Frequency Range 12-32 MHz

Quality assurance phantoms are made of tissue-mimicking materials (TMMs) the acoustic properties of which mimic those of soft tissue. However, the acoustic properties of many soft tissue types have not been measured at ultrasonic frequencies >9 MHz. With the increasing use of high-frequency ultrasound for both clinical and pre-clinical applications, it is of increasing interest to ensure that TMMs accurately reflect the acoustic properties of soft tissue at these higher frequencies. In this study, the acoustic properties of ex vivo brain, liver and kidney samples from 50 mice were assessed in the frequency range 12-32 MHz. Measurements were performed within 6 min of euthanasia in a phosphate-buffered saline solution maintained at 37.2 ± 0.2 °C. The measured mean values for the speed of sound for all organs were found to be higher than the International Electrotechnical Commission guideline recommended value for TMMs. The attenuation coefficients measured for brain, liver and kidney samples were compared with the results of previous studies at lower frequencies. Only the measured kidney attenuation coefficient was found to be in good agreement with the International Electrotechnical Commission guideline. The information provided in this study can be used as a baseline on which to manufacture a TMM suitable for high-frequency applications.

High-intensity focused ultrasound in the treatment of breast tumours

High-intensity focused ultrasound (HIFU) is a minimally invasive technique that has been used for the treatment of both benign and malignant tumours. With HIFU, an ultrasound (US) beam propagates through soft tissue as a high-frequency pressure wave. The US beam is focused at a small target volume, and due to the energy building up at this site, the temperature rises, causing coagulative necrosis and protein denaturation within a few seconds. HIFU is capable of providing a completely non-invasive treatment without causing damage to the directly adjacent tissues. HIFU can be either guided by US or magnetic resonance imaging (MRI). Guided imaging is used to plan the treatment, detect any movement during the treatment and monitor response in real-time. This review describes the history of HIFU, the HIFU technique, available devices and gives an overview of the published literature in the treatment of benign and malignant breast tumours with HIFU.

Fast lesion mapping during HIFU treatment using harmonic motion imaging guided focused ultrasound (HMIgFUS) in vitro and in vivo

The successful clinical application of high intensity focused ultrasound (HIFU) ablation depends on reliable monitoring of the lesion formation. Harmonic motion imaging guided focused ultrasound (HMIgFUS) is an ultrasound-based elasticity imaging technique, which monitors HIFU ablation based on the stiffness change of the tissue instead of the echo intensity change in conventional B-mode monitoring, rendering it potentially more sensitive to lesion development. Our group has shown that predicting the lesion location based on the radiation force-excited region is feasible during HMIgFUS. In this study, the feasibility of a fast lesion mapping method is explored to directly monitor the lesion map during HIFU. The harmonic motion imaging (HMI) lesion map was generated by subtracting the reference HMI image from the present HMI peak-to-peak displacement map, as streamed on the computer display. The dimensions of the HMIgFUS lesions were compared against gross pathology. Excellent agreement was found between the lesion depth (r ²  =  0.81, slope  =  0.90), width (r ²  =  0.85, slope  =  1.12) and area (r ²  =  0.58, slope  =  0.75). In vivo feasibility was assessed in a mouse with a pancreatic tumor. These findings demonstrate that HMIgFUS can successfully map thermal lesions and monitor lesion development in real time in vitro and in vivo. The HMIgFUS technique may therefore constitute a novel clinical tool for HIFU treatment monitoring.

In vivo ultrasonic attenuation in cetacean soft tissues

In vivo ultrasonic attenuation was estimated for extracranial soft tissues of two Tursiops truncatus and one Delphinapterus leucas. Backscatter data was non-invasively collected as part of routine health-based ultrasound examinations using a transducer operating in the 1.6-3.7 MHz frequency range. Data collected over the proximal mandible and temporal regions was processed to yield attenuation estimates using a reference tissue phantom whose properties had been independently determined. The estimated attenuations were at the low end of the range of literature-reported values for mammalian fatty and connective tissues. A companion model-based analysis quantified errors arising from tissue composition and sound speed uncertainties.

The effect of temperature dependent tissue parameters on acoustic radiation force induced displacements

Multiple ultrasound elastography techniques rely on acoustic radiation force (ARF) in monitoring high-intensity focused ultrasound (HIFU) therapy. However, ARF is dependent on tissue attenuation and sound speed, both of which are also known to change with temperature making the therapy monitoring more challenging. Furthermore, the viscoelastic properties of tissue are also temperature dependent, which affects the displacements induced by ARF. The aim of this study is to quantify the temperature dependent changes in the acoustic and viscoelastic properties of liver and investigate their effect on ARF induced displacements by using both experimental methods and simulations. Furthermore, the temperature dependent viscoelastic properties of liver are experimentally measured over a frequency range of 0.1-200 Hz at temperatures reaching 80 °C, and both conventional and fractional Zener models are used to fit the data. The fractional Zener model was found to fit better with the experimental viscoelasticity data with respect to the conventional model with up to two orders of magnitude lower sum of squared errors (SSE). The characteristics of experimental displacement data were also seen in the simulations due to the changes in attenuation coefficient and lesion development. At low temperatures before thermal ablation, attenuation was found to affect the displacement amplitude. At higher temperature, the decrease in displacement amplitude occurs approximately at 60-70 °C due to the combined effect of viscoelasticity changes and lesion growth overpowering the effect of attenuation. The results suggest that it is necessary to monitor displacement continuously during HIFU therapy in order to ascertain when ablation occurs.

Tissue Attenuation Estimation by Mean Frequency Downshift and Bandwidth Limitation

Attenuation of ultrasound in tissue can be estimated from the propagating pulse center frequency downshift. This method assumes that the envelope of the emitted pulse can be approximated by a Gaussian function and that the attenuation linearly depends on frequency. The resulting downshift of the mean frequency depends not only on attenuation but also on pulse bandwidth and propagation distance. This kind of approach is valid for narrowband pulses and shallow penetration depth. However, for short pulses and deep penetration, the frequency downshift is rather large and the received spectra are modified by the limited bandwidth of the receiving system. In this paper, the modified formula modeling the mean frequency of backscattered echoes is presented. The equation takes into account the limitation of the bandwidth due to bandpass filtration of the received echoes. This approach was applied to simulate the variation of the mean frequency of the pulse propagating for both weakly and strongly attenuating media and for narrowband and wideband pulses. The behavior of both the standard and modified estimates of attenuation has been validated using RF data from a tissue-mimicking phantom. The ultrasound attenuation of the phantom, determined with a corrected equation, was close to its true value, while the result obtained using the original formula was lower by as much as 50% at a depth of 8 cm.

Method for Estimating the Acoustic Pressure in Tissues Using Low-Amplitude Measurements in Water

The aim of this study was to evaluate a simple, reliable and reproducible method for accuracy in estimating the acoustic pressure delivered in tissue exposed to ultrasound. Such a method would be useful for therapeutic applications of ultrasound with microbubbles, for example, sonoporation. The method is based on (i) low-amplitude water measurements that are easily made and do not suffer from non-linear propagation effects, and (ii) the attenuation coefficient of the tissue of interest. The range of validity of the extrapolation method for different attenuation and pressure values was evaluated with a non-linear propagation theoretical model. Depending on the specific tissue attenuation, the method produces good estimates of pressures in excess of 10 MPa. Ex vivo machine-perfused pig liver tissue was used to validate the method for source pressures up to 3.5 MPa. The method can be used to estimate the delivered pressure in vivo in diagnostic and therapeutic applications of ultrasound.

Enhanced lesion-to-bubble ratio on ultrasonic Nakagami imaging for monitoring of high-intensity focused ultrasound

OBJECTIVES

This work explored the feasibility of using ultrasonic Nakagami imaging to enhance the contrast between thermal lesions and bubbles induced by high-intensity focused ultrasound (US) in a transparent tissue-mimicking phantom at different acoustic power levels.

METHODS

The term "lesion-to-bubble ratio" was proposed and defined as the ratio of the scattered power from the thermal lesion to the scattered power from the bubbles calculated in the various monitoring of images for high-intensity focused US. Two-dimensional radiofrequency data backscattered from the exposed region were captured by a modified diagnostic US scanner to estimate the Nakagami statistical parameter, m, and reconstruct the ultrasonic B-mode images and Nakagami parameter images. The dynamic changes in the lesion-to-bubble ratio over the US exposure procedure were calculated simultaneously and compared among video photos, B-mode images, and Nakagami images for monitoring of high-intensity focused US.

RESULTS

After a small thermal lesion was induced by high-intensity focused US in the phantom, the lesion-to-bubble ratio values corresponding to the video photo, B-mode image, and Nakagami image were 5.3, 1, and 9.8 dB, respectively. When a large thermal lesion appeared in the phantom, the ratio values increased to 7.2, 3, and 14 dB. During US exposure, the ratio values calculated for the video photo, B-mode image, and Nakagami image began to increase gradually and rose to peak values of 8.3, 2.9, and 14.8 dB at the end of the US exposure.

CONCLUSIONS

This preliminary study on a tissue-mimicking phantom suggests that Nakagami imaging may have a potential use in enhancing the lesion-to-bubble ratio for monitoring high-intensity focused US. Further studies in vivo and in vitro will be needed to evaluate the potential applications for high-intensity focused US.

MR-guided focused ultrasound surgery, present and future

MR-guided focused ultrasound surgery (MRgFUS) is a quickly developing technology with potential applications across a spectrum of indications traditionally within the domain of radiation oncology. Especially for applications where focal treatment is the preferred technique (for example, radiosurgery), MRgFUS has the potential to be a disruptive technology that could shift traditional patterns of care. While currently cleared in the United States for the noninvasive treatment of uterine fibroids and bone metastases, a wide range of clinical trials are currently underway, and the number of publications describing advances in MRgFUS is increasing. However, for MRgFUS to make the transition from a research curiosity to a clinical standard of care, a variety of challenges, technical, financial, clinical, and practical, must be overcome. This installment of the Vision 20∕20 series examines the current status of MRgFUS, focusing on the hurdles the technology faces before it can cross over from a research technique to a standard fixture in the clinic. It then reviews current and near-term technical developments which may overcome these hurdles and allow MRgFUS to break through into clinical practice.

Tomographic reconstruction of tissue properties and temperature increase for high-intensity focused ultrasound applications

The acoustic and thermal properties as well as the temperature change within a tissue volume during high-intensity focused ultrasound ablation are critically important for treatment planning and monitoring. Described in this article is a tomographic reconstruction method used to determine the tissue properties and increase in temperature in a 3-D volume. On the basis of the iterative finite-element solution to the bioheat equation coupled with Tikhonov regularization techniques, our reconstruction algorithm solves the inverse problem of bioheat transfer and uses the time-dependent temperature measured on a tissue surface to obtain the acoustic absorption coefficient, thermal diffusivity and temperature increase within the subsurface volume. Numerical simulations were performed to validate the reconstruction algorithm. The method was initially conducted in ex vivo experiments in which time-dependent temperature on a tissue surface was measured using high-resolution, non-invasive infrared thermography.

Characterization of Lesion Formation and Bubble Activities during High Intensity Focused Ultrasound Ablation using Temperature-Derived Parameters

Successful high-intensity focused ultrasound (HIFU) thermal tissue ablation relies on accurate information of the tissue temperature and tissue status. Often temperature measurements are used to predict and monitor the ablation process. In this study, we conducted HIFU ablation experiments with ex vivo porcine myocardium tissue specimens to identify changes in temperature associated with tissue coagulation and bubble/cavity formation. Using infrared (IR) thermography and synchronized bright-field imaging with HIFU applied near the tissue surface, parameters derived from the spatiotemporal evolution of temperature were correlated with HIFU-induced lesion formation and overheating, of which the latter typically results in cavity generation and/or tissue dehydration. Emissivity of porcine myocardium was first measured to be 0.857 ± 0.006 (n = 3). HIFU outcomes were classified into non-ablative, normal lesion, and overheated lesion. A marked increase in the rate of temperature change during HIFU application was observed with lesion formation. A criterion using the maximum normalized second time derivative of temperature change provided 99.1% accuracy for lesion identification with a 0.05 s^-1 threshold. Asymmetric temperature distribution on the tissue surface was observed to correlate with overheating and/or bubble generation. A criterion using the maximum displacement of the spatial location of the peak temperature provided 90.9% accuracy to identify overheated lesion with a 0.16 mm threshold. Spatiotemporal evolution of temperature obtained using IR imaging allowed determination of the cumulative equivalent minutes at 43 °C (CEM₄₃) for lesion formation to be 170 min. Similar temperature characteristics indicative of lesion formation and overheating were identified for subsurface HIFU ablation. These results suggest that parameters derived from temperature changes during HIFU application are associated with irreversible changes in tissue and may provide useful information for monitoring HIFU treatment.

Calibration of ultrasound backscatter temperature imaging for high-intensity focused ultrasound treatment planning

High-intensity focused ultrasound (HIFU) is rapidly gaining acceptance as a non-invasive method for soft tissue tumor ablation, but improvements in the methods of treatment delivery, planning and monitoring are still required. Backscatter temperature imaging (BTI) uses ultrasound to visualize heating-induced echo strain and may be used to indicate the position of the HIFU focal region using low-power "sub-lesioning" exposure. The technique may also provide a quantitative tool for assessing the efficacy of treatment delivery if apparent strain measurements can be related to the underlying temperature rise. To obtain temperature estimates from strain measurements, the relationship between these variables has to be either measured or otherwise assumed from previous calibrations in similar tissues. This article describes experimental measurements aimed at deriving the relationship between temperature rise and apparent strain in the laboratory environment using both ex vivo bovine liver tissue samples and normothermically perfused porcine livers. A BTI algorithm was applied to radiofrequency ultrasound echo data acquired from a clinical ultrasound scanner (Z.One, Zonare Medical Systems, Mountain View, CA, USA) where the imaging probe was aligned with the focal region of a HIFU transducer. Temperature measurements were obtained using needle thermocouples implanted in the liver tissue. A series of "non-ablative" HIFU exposures giving peak temperatures below 10°C were made in three separate ex vivo bovine livers, yielding an average strain/temperature coefficient of 0.126 ± 0.088 percentage strain per degree Celsius. In the perfused porcine livers at a starting temperature of 38°C (normal body temperature) the strain/temperature coefficients were found to be 0.040 ± 0.029 percentage strain per degree Celsius. The uncertainty in these results is directly linked to the precision of the strain measurement, as well as the naturally occurring variance between different tissue samples, indicating that BTI may lack the accuracy required to be implemented successfully in practice as a quantitative treatment planning technique at a sub-lesioning exposure level. This is because, to be of use in treatment planning, temperature-rise estimates may require an accuracy greater (<10%) than that offered by BTI measurement. BTI may, however, still play a role in ensuring the correct positioning of the focal region and as a treatment monitoring modality capable of detecting an increased rate of heating in tissue after HIFU ablation.

An analytical solution for improved HIFU SAR estimation

Accurate determination of the specific absorption rates (SARs) present during high intensity focused ultrasound (HIFU) experiments and treatments provides a solid physical basis for scientific comparison of results among HIFU studies and is necessary to validate and improve SAR predictive software, which will improve patient treatment planning, control and evaluation. This study develops and tests an analytical solution that significantly improves the accuracy of SAR values obtained from HIFU temperature data. SAR estimates are obtained by fitting the analytical temperature solution for a one-dimensional radial Gaussian heating pattern to the temperature versus time data following a step in applied power and evaluating the initial slope of the analytical solution. The analytical method is evaluated in multiple parametric simulations for which it consistently (except at high perfusions) yields maximum errors of less than 10% at the center of the focal zone compared with errors up to 90% and 55% for the commonly used linear method and an exponential method, respectively. For high perfusion, an extension of the analytical method estimates SAR with less than 10% error. The analytical method is validated experimentally by showing that the temperature elevations predicted using the analytical method's SAR values determined for the entire 3D focal region agree well with the experimental temperature elevations in a HIFU-heated tissue-mimicking phantom.

Feasibility of using Nakagami distribution in evaluating the formation of ultrasound-induced thermal lesions

The acoustic posterior shadowing effects of bubbles influence the accuracy for defining the location and range of ablated thermal lesions during focused ultrasound surgery when using ultrasonic monitoring imaging. This paper explored the feasibility of using Nakagami distribution to evaluate the ablated region induced by focused ultrasound exposures at different acoustic power levels in transparent tissue-mimicking phantoms. The mean value of the Nakagami parameter m was about 0.5 in the cavitation region and increased to around 1 in the ablated region. Nakagami images were not subject to significant shadowing effects of bubbles. Ultrasound-induced thermal lesions observed in the photos and Nakagami images were overshadowed by bubbles in the B-mode images. The lesion size predicted in the Nakagami images was smaller than that predicted in the photos due to the sub resolvable effect of Nakagami imaging at the interface. This preliminary study on tissue-mimicking phantom suggested that the Nakagami parameter m may have the potential use in evaluating the formation of ultrasound-induced thermal lesion when the shadowing effect of bubbles is strong while the thermal lesion was small. Further studies in vivo and in vitro will be needed to evaluate the potential application.

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

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

Reconstruction of fully three-dimensional high spatial and temporal resolution MR temperature maps for retrospective applications

Many areas of MR-guided thermal therapy research would benefit from temperature maps with high spatial and temporal resolution that cover a large three-dimensional volume. This article describes an approach to achieve these goals, which is suitable for research applications where retrospective reconstruction of the temperature maps is acceptable. The method acquires undersampled data from a modified three-dimensional segmented echo-planar imaging sequence and creates images using a temporally constrained reconstruction algorithm. The three-dimensional images can be zero-filled to arbitrarily small voxel spacing in all directions and then converted into temperature maps using the standard proton resonance frequency shift technique. During high intensity focused ultrasound heating experiments, the proposed method was used to obtain temperature maps with 1.5 mm × 1.5 mm × 3.0 mm resolution, 288 mm × 162 mm × 78 mm field of view, and 1.7 s temporal resolution. The approach is validated to demonstrate that it can accurately capture the spatial characteristics and time dynamics of rapidly changing high intensity focused ultrasound-induced temperature distributions. Example applications from MR-guided high intensity focused ultrasound research are shown to demonstrate the benefits of the large coverage fully three-dimensional temperature maps, including characterization of volumetric heating trajectories and near- and far-field heating.

Ultrasonic attenuation estimation of the pregnant cervix: a preliminary report

OBJECTIVE

Estimates of ultrasonic attenuation (the loss of energy as an ultrasonic wave propagates through tissue) have been used to evaluate the structure and function of tissues in health and disease. The purpose of this research was to develop a method to estimate ultrasonic cervical attenuation during human pregnancy using a clinical ultrasound system.

METHODS

Forty women underwent a cervical scan once during pregnancy with the Zonare z.one clinical ultrasound system using a 4-9-MHz endovaginal transducer. This ultrasound system provides access to radiofrequency (RF) image data for processing and analysis. In addition, a scan of a tissue-mimicking phantom with a known attenuation coefficient was acquired and used as a reference. The same settings and transducer used in the clinical scan were used in the reference scan. Digital data of the beam-formed image were saved in Digital Imaging and Communications in Medicine (DICOM) format on a flash drive and converted to RF data on a personal computer using a Matlab program supplied by Zonare. Attenuation estimates were obtained using an algorithm that was independently validated using tissue-mimicking ultrasonic phantoms.

RESULTS

RF data were acquired and analyzed to estimate attenuation of the human pregnant cervix. Regression analysis revealed that attenuation was: a predictor of the interval from ultrasound examination to delivery (beta = 0.43, P = 0.01); not a predictor of gestational age at time of examination (beta = - 0.23, P = 0.15); and not a predictor of cervical length (beta = 0.077, P = 0.65).

CONCLUSIONS

Ultrasonic attenuation estimates have the potential to be an early and objective non-invasive method to detect interval between examination and delivery. We hypothesize that a larger sample size and a longitudinal study design will be needed to detect gestational age-associated changes in cervical attenuation.

Egg white as a blood coagulation surrogate

Egg white, a protein-containing solution, is characterized as a blood coagulation surrogate for the acoustical and thermal evaluation of therapeutic ultrasound, especially high intensity focused ultrasound (HIFU) devices. Physical properties, including coagulation temperature, frequency dependent attenuation, sound speed, viscosity, and thermal properties, were measured as a function of temperature (20-95 degrees C). Thermal coagulation and attenuation (5-12 and 1 MHz) of cow blood, pig blood, and human blood also were assessed and compared with egg white. For a 30 s thermal exposure, both egg white and blood samples (3 mm thickness) started to denature at 65 degrees C and coagulate into an elastic gel at 85 degrees C. The attenuation of egg white was found to be similar to that of the blood samples, having values of 0.23f(1.09), 1.58f(0.61), and 2.7f(0.5) dB/cm at 20, 75, and 95 degrees C, respectively. This significant attenuation increase with temperature was determined to be caused mainly by bubble cavity formation. The other temperature-dependent parameters are also similar to the reported values for blood. These properties make egg white a potentially useful bench testing tool for the safety and efficacy evaluation of therapeutic ultrasound devices.

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

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

Role of acoustic cavitation in the delivery and monitoring of cancer treatment by high-intensity focused ultrasound (HIFU)

Acoustic cavitation has been shown to play a key role in a wide array of novel therapeutic ultrasound applications. This paper presents a brief discussion of the physics of thermally relevant acoustic cavitation in the context of high-intensity focussed ultrasound (HIFU). Models for how different types of cavitation activity can serve to accelerate tissue heating are presented, and results suggest that the bulk of the enhanced heating effect can be attributed to the absorption of broadband acoustic emissions generated by inertial cavitation. Such emissions can be readily monitored using a passive cavitation detection (PCD) scheme and could provide a means for real-time treatment monitoring. It is also shown that the appearance of hyperechoic regions (or bright-ups) on B-mode ultrasound images constitutes neither a necessary nor a sufficient condition for inertial cavitation activity to have occurred during HIFU exposure. Once instigated at relatively large HIFU excitation amplitudes, bubble activity tends to grow unstable and to migrate toward the source transducer, causing potentially undesirable pre-focal damage. Potential means of controlling inertial cavitation activity using pulsed excitation so as to confine it to the focal region are presented, with the intention of harnessing cavitation-enhanced heating for optimal HIFU treatment delivery. The role of temperature elevation in mitigating bubble-enhanced heating effects is also discussed, along with other bubble-field effects such as multiple scattering and shielding.

Treatment monitoring and thermometry for therapeutic focused ultrasound

Therapeutic ultrasound is currently enjoying increasingly widespread clinical use especially for the treatment of cancer of the prostate, liver, kidney, breast, pancreas and bone, as well as for the treatment of uterine fibroids. The optimum method of treatment delivery varies between anatomical sites, but in all cases monitoring of the treatment is crucial if extensive clinical acceptance is to be achieved. Monitoring not only provides the operating clinician with information relating to the effectiveness of treatment, but can also provide an early alert to the onset of adverse effects in normal tissue. This paper reviews invasive and non-invasive monitoring methods that have been applied to assess the extent of treatment during the delivery of therapeutic ultrasound in the laboratory and clinic (follow-up after treatment is not reviewed in detail). The monitoring of temperature and, importantly, the way in which this measurement can be used to estimate the delivered thermal dose, is dealt with as a separate special case. Already therapeutic ultrasound has reached a stage of development where it is possible to attempt real-time feedback during exposure in order to optimize each and every delivery of ultrasound energy. To date, data from MR imaging have shown better agreement with the size of regions of damage than those from diagnostic ultrasound, but novel ultrasonic techniques may redress this balance. Whilst MR currently offers the best method for non-invasive temperature measurement, the ultrasound techniques under development, which could potentially offer more rapid visualisation of results, are discussed.

High intensity focused ultrasound: physical principles and devices

High intensity focused ultrasound (HIFU) is gaining rapid clinical acceptance as a treatment modality enabling non-invasive tissue heating and ablation for numerous applications. HIFU treatments are usually carried out in a single session, often as a day case procedure, with the patient either fully conscious, lightly sedated or under light general anaesthesia. A major advantage of HIFU over other thermal ablation techniques is that there is no necessity for the transcutaneous insertion of probes into the target tissue. The high powered focused beams employed are generated from sources placed either outside the body (for treatment of tumours of the liver, kidney, breast, uterus, pancreas and bone) or in the rectum (for treatment of the prostate), and are designed to enable rapid heating of a target tissue volume, while leaving tissue in the ultrasound propagation path relatively unaffected. Given the wide-ranging applicability of HIFU, numerous extra-corporeal, transrectal and interstitial devices have been designed to optimise application-specific treatment delivery. Their principle of operation is described here, alongside an overview of the physical mechanisms governing HIFU propagation and HIFU-induced heating. Present methods of characterising HIFU fields and of quantifying HIFU exposure and its associated effects are also addressed.

A novel strategy to increase heating efficiency in a split-focus ultrasound phased array

Focus splitting using sector-based phased arrays increases the necrosed volume in a single sonication and reduces the total treatment time in the treatment of large tumors. However, split-focus sonication results in a lower energy density and worse focal-beam distortion, which limits its usefulness in practical treatments. Here, we propose a new heating strategy involving consecutive strongly focused and split-focus sonications to improve the heating efficiency. Theoretical predictions including linear and thermal-dose-dependent attenuation change were employed to investigate potential factors of this strategy, and ex vivo tissue experiments were conducted to confirm its effectiveness. Results showed that the thermal lesions produced by the proposed strategy could be increased when comparing with the previous reported strategies. The proposed heating strategy also induces a thermal lesion more rapidly, and exhibits higher robustness to various blood perfusion conditions, higher robustness to various power/heating time combinations, and superiority to generate deep-seated lesions through tissues with complex interfaces. Possible mechanisms include the optimization of the thermal conduction created by the strongly focused sonication and the temperature buildup gained from thermally induced tissue attenuation change based on the theoretical analysis. This may represent a useful technique for increasing the applicability of split-focus and multiple-focus sonication techniques, and solve the obstacles encountered when attempting to use these methods to shorten the total clinical treatment time.

Monitoring imaging of lesions induced by high intensity focused ultrasound based on differential ultrasonic attenuation and integrated backscatter estimation

We investigated the feasibility of two monitoring imaging methods to visualize and evaluate the high intensity focused ultrasound (HIFU) induced lesions in vitro during and after their formation, which were based on differential ultrasonic parameter estimation. Firstly, ultrasonic attenuation slope of tissue sample was estimated based on the spectral analysis of ultrasound RF backscattered signals. The differential attenuation slope maps were acquired, which were interpreted as the differences between the pretreatment image and those obtained in different stages during HIFU therapy. Secondly, ultrasonic integrated backscatter (IBS), defined as the frequency average of the backscatter transfer function over the useful bandwidth, was proposed quantitatively to evaluate the extent of lesions with the same RF signals as the first method. Differential IBS maps were also acquired to visualize temporal evolution of lesion formation. It was found in pig liver in vitro that more precise definition of the treated area was obtained from the differential IBS images than from differential attenuation slope images. Dramatic increase in both attenuation and IBS value was observed during the therapy, which may be related to dramatic enhancement of cavitation due to boiling and accompanying tissue damage. Two methods to obtain one differential image were compared and the cumulative differential image was found to be able to eliminate noises and artifacts to some extent, which was the cumulation of a series of differential images acquired from the differences between the temporally adjacent RF data frames. Moreover, we presented a bidirectional color code for identification of the artifacts due to tissue movements caused by HIFU radiation force. We conclude that cumulative differential IBS images have the potential to monitor the formation of HIFU-induced lesions.

Combination of HIFU therapy with contrast-enhanced sonography for quantitative assessment of therapeutic efficiency on tumor grafted mice

The objective was to evaluate treatment efficiency of a new high-intensity focused ultrasound (HIFU) prototype combining a therapeutic transducer with a sonographic probe. The optimal HIFU sequence was defined on ex vivo samples before in vivo evaluation of tumor ablation was performed by perfusion quantification after contrast agent injection. The original feature of this prototype is a 9-MHz sonographic probe in a HIFU device and connected to an Aplio (Toshiba) sonograph. Acoustical power and treatment time were determined on ex vivo livers to generate 1-cm-long lesions. Lesion reproducibility was assessed for the power and treatment time selected. The gap between lesions and HIFU displacement shot procedures were optimized to ablate a 1-cm3 volume. The optimized protocol was applied to five murine tumors in vivo. Tumor ablation was quantified according to (1) contrast uptake (CU) after HIFU using perfusion software (Toshiba) in "vascular recognition imaging" mode and Sonovue (Bracco) contrast agent, and (2) the percentage of necrosis quantified on histologic slides. Ex vivo results: optimized settings, at 442 W/cm2 applied during three cycles (3 s on/5 s off) generated 10 identical elementary lesions measuring 9.78 (+/-0.66) * 2.11 (+/-0.33) mm2. A 4-mm gap between adjacent lesions and a 2-min pause between shot lines were found optimal. In vivo results: 60 % (+/-22) mean reduction in CU after HIFU and tumor necrosis histologically estimated at 58 % (+/-5.7) were quantified for the five animals. The therapeutic potential of this HIFU prototype was demonstrated in vivo through objective quantification of tumor ablation based on CU.