Aberration correction in abdominal histotripsy

In transabdominal histotripsy, ultrasound pulses are focused on the body to noninvasively destroy soft tissues via cavitation. However, the ability to focus is limited by phase aberration, or decorrelation of the ultrasound pulses due to spatial variation in the speed of sound throughout heterogeneous tissue. Phase aberration shifts, broadens, and weakens the focus, thereby reducing the safety and efficacy of histotripsy therapy. This paper reviews and discusses aberration effects in histotripsy and in related therapeutic ultrasound techniques (e.g., high intensity focused ultrasound), with an emphasis on aberration by soft tissues. Methods for aberration correction are reviewed and can be classified into two groups: model-based methods, which use segmented images of the tissue as input to an acoustic propagation model to predict and compensate phase differences, and signal-based methods, which use a receive-capable therapy array to detect phase differences by sensing acoustic signals backpropagating from the focus. The relative advantages and disadvantages of both groups of methods are discussed. Importantly, model-based methods can correct focal shift, while signal-based methods can restore substantial focal pressure, suggesting that both methods should be combined in a 2-step approach. Aberration correction will be critical to improving histotripsy treatments and expanding the histotripsy treatment envelope to enable non-invasive, non-thermal histotripsy therapy for more patients.

A Novel Concept of a Phased-Array HIFU Transducer Optimized for MR-Guided Hepatic Ablation: Embodiment and First In-Vivo Studies

Purpose

High-intensity focused ultrasound (HIFU) is challenging in the liver due to the respiratory motion and risks of near-/far-field burns, particularly on the ribs. We implemented a novel design of a HIFU phased-array transducer, dedicated to transcostal hepatic thermo-ablation. Due to its large acoustic window and strong focusing, the transducer should perform safely for this application.

Material and Methods

The new HIFU transducer is composed of 256 elements distributed on 5 concentric segments of a specific radius (either 100, 111, or 125 mm). It has been optimally shaped to fit the abdominal wall. The shape and size of the acoustic elements were optimized for the largest emitting surface and the lowest symmetry. Calibration tests have been conducted on tissue-mimicking gels under 3-T magnetic resonance (MR) guidance. In-vivo MR-guided HIFU treatment was conducted in two pigs, aiming to create thermal ablation deep in the liver without significant side effects. Imaging follow-up was performed at D0 and D7. Sacrifice and post-mortem macroscopic examination occurred at D7, with the ablated tissue being fixed for pathology.

Results

The device showed −3-dB focusing capacities in a volume of 27 × 46 × 50 mm³ as compared with the numerical simulation volume of 18 × 48 × 60 mm³. The shape of the focal area was in millimeter-range agreement with the numerical simulations. No interference was detected between the HIFU sonication and the MR acquisition. In vivo, the temperature elevation in perivascular liver parenchyma reached 28°C above physiological temperature, within one breath-hold. The lesion was visible on Gd contrast-enhanced MRI sequences and post-mortem examination. The non-perfused volume was found in pig #1 and pig #2 of 8/11, 6/8, and 7/7 mm along the LR, AP, and HF directions, respectively. No rib burns or other near-field side effects were visually observed on post-mortem gross examination. High-resolution contrast-enhanced 3D MRI indicated a minor lesion on the sternum.

Conclusion

The performance of this new HIFU transducer has been demonstrated in vitro and in vivo. The transducer meets the requirement to perform thermal lesions in deep tissues, without the need for rib-sparing means.

Calculating the Effect of Ribs on the Focus Quality of a Therapeutic Spherical Random Phased Array

The overlaying rib cage is a major hindrance in treating liver tumors with high intensity focused ultrasound (HIFU). The problems caused are overheating of the ribs due to its high ultrasonic absorption capability and degradation of the ultrasound intensity distribution in the target plane. In this work, a correction method based on binarized apodization and geometric ray tracing approach was employed to avoid heating the ribs. A detailed calculation of the intensity distribution in the focus plane was undertaken to quantify and avoid the effect on HIFU beam generated by a 1-MHz 256-element random phased array after the ultrasonic beam passes through the rib cage. Focusing through the ribs was simulated for 18 different idealized ribs-array configurations and 10 anatomically correct ribs-array configurations, to show the effect of width of the ribs, intercostal spacing and the relative position of ribs and array on the quality of focus, and to identify the positions that are more effective for HIFU applications in the presence of ribs. Acoustic simulations showed that for a single focus without beam steering and for the same total acoustic power, the peak intensity at the target varies from a minimum of 211 W/cm² to a maximum of 293 W/cm² for a nominal acoustic input power of 15 W, whereas the side lobe level varies from 0.07 I_peak to 0.28 I_peak and the separation between the main lobe and side lobes varies from 2.5 mm to 6.3 mm, depending on the relative positioning of the array and ribs and the beam alignment. An increase in the side lobe level was observed by increasing the distance between the array and the ribs. The parameters of focus splitting and the deterioration of focus quality caused by the ultrasonic propagation through the ribs were quantified in various possible different clinical scenarios. In addition to idealized rib topology, anatomical realistic ribs were used to determine the focus quality of the HIFU beam when the beam is steered both in axial and transverse directions and when the transducer is positioned at different depths from the rib cage.

3D synthetic aperture imaging with a therapeutic spherical random phased array for transcostal applications

Experimental validation of a synthetic aperture imaging technique using a therapeutic random phased array is described, demonstrating the dual nature of imaging and therapy of such an array. The transducer is capable of generating both continuous wave high intensity beams for ablating the tumor and low intensity ultrasound pulses to image the target area. Pulse-echo data is collected from the elements of the phased array to obtain B-mode images of the targets. Since therapeutic arrays are optimized for therapy only with concave apertures having low f-number and large directive elements often coarsely sampled, imaging can not be performed using conventional beamforming. We show that synthetic aperture imaging is capable of processing the acquired RF data to obtain images of the field of interest. Simulations were performed to compare different synthetic aperture imaging techniques to identify the best algorithm in terms of spatial resolution. Experimental validation was performed using a 1 MHz, 256-elements, spherical random phased array with 130 mm radius of curvature. The array was integrated with a research ultrasound scanner via custom connectors to acquire raw RF data for variety of targets. Imaging was implemented using synthetic aperture beamforming to produce images of a rib phantom and ex vivo ribs. The array was shown to resolve spherical targets within ±15 mm of either side of the axis in the focal plane and obtain 3D images of the rib phantom up to ±40 mm of either side of the central axis and at a depth of 3-9 cm from the array surface. The lateral and axial full width half maximum was 1.15 mm and 2.75 mm, respectively. This study was undertaken to emphasize that both therapy and image guidance with a therapeutic random phased array is possible and such a system has the potential to address some major limitations in the existing high intensity focused ultrasound (HIFU) systems. The 3D images obtained with a therapeutic array can be used to identify and locate strong scattering objects aiding to image guidance and treatment planning of the HIFU procedure.

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.

The Optimization of Transcostal Phased Array Refocusing Using the Semidefinite Relaxation Method

Tumors in organs partially obscured by the rib cage represent a challenge for high-intensity focused ultrasound (HIFU) therapy. The ribs distort the HIFU beams in a manner that reduces the focusing gain at the target, which could result in treatment-limiting collateral damage. In fact, skin burns are a common complication during the ablation of hepatic tumors. This problem can be addressed by employing optimal refocusing algorithms that are designed to achieve a specified focusing gain at the target while controlling the exposure to the ribs in the path of the HIFU beam. However, previously proposed optimal refocusing algorithms did not allow for the controlled transmission through the ribs. In this article, we introduce a new approach for refocusing that can more efficiently steer power toward the target while limiting the power deposition on the ribs. The approach utilizes the semidefinite relaxation (SDR) technique to approximate the original (nonconvex) optimization problem. An important advantage of the SDR-based method over previously proposed optimization methods is the control of the side lobes in the focal plane. The method also allows for specifying an acceptable level of exposure to the ribs. Simulation results using a 1-MHz spherical concave phased array focused on an inhomogeneous medium are presented to demonstrate the performance of the SDR refocusing approach. A finite-difference time-domain propagation model was used to model the propagation in the inhomogeneous tissues, including the ribs. Temperature simulations based on the inhomogeneous transient bioheat transfer equation (tBHTE) demonstrate the significance of the improvements in the focusing gain when using the limited power deposition (LPD) method. The results also demonstrate that the LPD method yields well-behaved array excitation vectors, realizable by currently existing drivers.

Self-adaptive ultrasonic beam amplifiers: application to transcostal shock wave therapy

Ultrasound shock wave therapy is increasingly used for non-invasive surgery. It requires the focusing of very high pressure amplitude in precisely controlled focal spots. In transcostal therapy of the heart or the liver, the high impedance mismatch between the bones and surrounding tissues gives rise to strong aberrations and attenuation of the therapeutic wavefront, with potential risks of injury at the tissue-bone interface. An adaptive propagation of the ultrasonic beam through the intercostal spaces would be required. Several solutions have been developed so far, but they require a prior knowledge of the patient's anatomy or an invasive calibration process, not applicable in clinic. Here, we develop a non-invasive adaptive focusing method for ultrasound therapy through the ribcage using a time reversal cavity (TRC) acting as an ultrasonic beam amplifier. This method is based on ribcage imaging through the TRC and a projection orthogonally to the strongest identified reflectors. The focal pressure of our device was improved by up to 30% using such self-adaptive processing, without degrading the focal spots size and shape. This improvement allowed lesion formation in an Ultracal^® phantom through a ribcage without invasive calibration of the device. This adaptive method could be particularly interesting to improve the efficiency and the safety of pulsed cavitational therapy of the heart or the liver.

Imaging beyond ultrasonically-impenetrable objects

Ultrasound images are severely degraded by the presence of obstacles such as bones and air gaps along the beam path. This paper describes a method for imaging structures that are distal to obstacles that are otherwise impenetrable to ultrasound. The method uses an optically-inspired holographic algorithm to beam-shape the emitted ultrasound field in order to bypass the obstacle and place the beam focus beyond the obstruction. The resulting performance depends on the transducer aperture, the size and position of the obstacle, and the position of the target. Improvement compared to standard ultrasound imaging is significant for obstacles for which the width is larger than one fourth of the transducer aperture and the depth is within a few centimeters of the transducer. For such cases, the improvement in focal intensity at the location of the target reaches 30-fold, and the improvement in peak-to-side-lobe ratio reaches 3-fold. The method can be implemented in conventional ultrasound systems, and the entire process can be performed in real time. This method has applications in the fields of cancer detection, abdominal imaging, imaging of vertebral structure and ultrasound tomography. Here, its effectiveness is demonstrated using wire targets, tissue mimicking phantoms and an ex vivo biological sample.

Blocked Elements in 1-D and 2-D Arrays-Part II: Compensation Methods as Applied to Large Coherent Apertures

In Part I of this paper, we detected elements blocked by ribs during simulated and in vivo transcostal liver scans, and we turned those elements OFF to compensate for the loss in visibility of liver vasculature. Here, we apply blocked-element detection and adaptive compensation to large synthetic-aperture (SA) data collected through rib samples ex vivo, in order to reduce near-field clutter and to recover lateral resolution. To construct large synthetic transmit and receive apertures, we collected the individual-channel signals from a fully sampled matrix array at multiple and known array locations across the tissue samples. The blocked elements in SAs were detected using the method presented in Part I and retroactively turned OFF, while the subapertures covering intercostal spaces were either compounded, or coherently summed using uniform and adaptive element-weighting schemes. Turning OFF the blocked elements reduced the reverberation clutter by 5 dB on average. Adaptive weighing of the nonblocked elements to rescale the attenuated spatial frequencies reduced sidelobe levels by up to 5 dB for the transcostal acquisitions, and demonstrated a potential to restore lateral resolution to the nonblocked levels. In addition, the arrival-time surfaces were reconstructed to estimate the aberration from intercostal spaces and to offer further means to compensate for the loss of focus quality in transthoracic imaging.

Procedural sedation and analgesia for respiratory-gated MR-HIFU in the liver: a feasibility study

BACKGROUND

Previous studies demonstrated both pre-clinically and clinically the feasibility of magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) ablations in the liver. To overcome the associated problem of respiratory motion of the ablation area, general anesthesia (GA) and mechanical ventilation was used in conjunction with either respiratory-gated energy delivery or energy delivery during induced apnea. However, clinical procedures requiring GA are generally associated with increased mortality, morbidity, and complication rate compared to procedural sedation and analgesia (PSA). Furthermore, PSA is associated with faster recovery and an increased eligibility for non- and mini-invasive interventions.

METHODS

In this study, we investigate both in an animal model and on a small patient group the kinetics of the diaphragm during free-breathing, when a tailored remifentanil/propofol-based PSA protocol inducing partial respiratory depression is used. Subsequently, we demonstrate in an animal study the compatibility of the resulting respiratory pattern of the PSA protocol with a gated HIFU ablation in the liver by direct comparison with gated ablations conducted under GA. Wilcoxon signed-rank tests were performed for statistical analysis of non-perfused and necrosed tissue volumes. Duty cycles (ratio or percentage of the breathing cycle with the diaphragm in its resting position, such that acoustic energy delivery with MR-HIFU was allowed) were statistically compared for both GA and PSA using student's t tests.

RESULTS

In both animal and human experiments, the breathing frequency was decreased below 9/min, while maintaining stable vital functions. Furthermore an end-exhalation resting phase was induced by this PSA protocol during which the diaphragm is virtually immobile. Median non-perfused volumes, non-viable volumes based on NADH staining, and duty cycles were larger under PSA than under GA or equal.

CONCLUSIONS

We conclude that MR-HIFU ablations of the liver under PSA are feasible and potentially increase the non-invasive nature of this type of intervention.

A clinically feasible treatment protocol for magnetic resonance-guided high-intensity focused ultrasound ablation in the liver

OBJECTIVES

Magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) allows for noninvasive thermal ablation under real-time temperature imaging guidance. The purpose of this study was to assess the feasibility and safety of MR-HIFU ablation of liver tissue in a clinically acceptable setting. The experimental protocol was designed with a clinical ablation procedure of a small malignant tumor in mind; the procedures were performed within a clinically feasible time frame and care was taken to avoid adverse events. The main outcome was the size and quality of the ablated liver tissue volume on imaging and histology. Secondary outcomes were safety and treatment time.

MATERIALS AND METHODS

Healthy pigs (n = 10) under general anesthesia were positioned on a clinical MR-HIFU system, which consisted of an HIFU tabletop with a skin cooling system integrated into a 1.5-T MR scanner. A liver tissue volume was ablated with multiple sonication cells (4 × 4 × 10 mm, 450 W). Both MR thermometry and sonication were respiratory-gated using a pencil beam navigator on the diaphragm. Contrast-enhanced T1-weighted (CE-T1w) imaging was performed for treatment evaluation. Targeted total treatment time was 3 hours. The abdominal wall, liver, and adjacent organs were inspected postmortem for thermal damage. Ablated tissue volumes were processed for cell viability staining. The ablated volumes were analyzed using MR imaging, MR thermometry, and cell viability histology.

RESULTS

Eleven volume ablations were performed in 10 animals, resulting in a median nonperfused volume (NPV) on CE-T1w imaging of 1.6 mL (interquartile range [IQR], 0.8-2.3; range, 0.7-3.0). Cell viability histology showed a damaged volume of 1.5 mL (IQR, 1.1-1.8; range, 0.7-2.3). The NPV was confluent in 10 of the 11 cases. The ablated tissue volume on cell viability histology was confluent in all 9 available cases. In all cases, there was a good correspondence between the aspects of the NPV on CE-T1w and the ablated volume on cell viability histology. Two treatment-related adverse events occurred: 1 animal had a 7-mm skin burn and 1 animal showed evidence of thermal damage on the surface of the spleen. Median ablation time was 108 minutes (IQR, 101-120; range, 96-181 minutes) and median total treatment time was 180 minutes (IQR, 165-224; 130-250 minutes).

CONCLUSIONS

Our results demonstrate the feasibility and safety of MR-HIFU ablation of liver tissue volumes. The imaging data and cell viability histology show, for the first time, that confluent ablation volumes can be achieved with motion-gated ablation and MR guidance. These results were obtained using a readily available MR-HIFU system with only minor modifications, within a clinically acceptable time frame, and with only minor adverse events. This shows that this technique is sufficiently reliable and safe to initiate a clinical trial.

Cavitation-enhanced back projection for acoustic rib detection and attenuation mapping

High-intensity focused ultrasound allows for minimally invasive, highly localized cancer therapies that can complement surgical procedures or chemotherapy. For high-intensity focused ultrasound interventions in the upper abdomen, the thoracic cage obstructs and aberrates the ultrasonic beam, causing undesired heating of healthy tissue. When a phased array therapeutic transducer is used, such complications can be minimized by applying an apodization law based on analysis of beam path obstructions. In this work, a rib detection method based on cavitation-enhanced ultrasonic reflections is introduced and validated on a porcine tissue sample containing ribs. Apodization laws obtained for different transducer positions were approximately 90% similar to those obtained using image analysis. Additionally, the proposed method provides information on attenuation between transducer elements and the focus. This principle was confirmed experimentally on a polymer phantom. The proposed methods could, in principle, be implemented in real time for determination of the optimal shot position in intercostal high-intensity focused ultrasound therapy.

A comparison of methods for focusing the field of a HIFU array transducer through human ribs

A forward model, which predicts the scattering by human ribs of a multi-element high-intensity focused ultrasound transducer, was used to investigate the efficacy of a range of focusing approaches described in the literature. This forward model is based on the boundary element method and was described by Gélat et al (2011 Phys. Med. Biol. 56 5553-81; 2012 Phys. Med. Biol. 57 8471-97). The model has since been improved and features a complex surface impedance condition at the surface of the ribs. The inverse problem of focusing through the ribs was implemented on six transducer array-rib topologies and five methods of focusing were investigated, including spherical focusing, binarized apodization based on geometric ray tracing, phase conjugation and the decomposition of the time-reversal operator method. The excitation frequency was 1 MHz and the array was of spherical-section type. Both human and idealized rib topologies were considered. The merit of each method of focusing was examined. It was concluded that the constrained optimization approach offers greater potential than the other focusing methods in terms of maximizing the ratio of acoustic pressure magnitudes at the focus to those on the surface of the ribs whilst taking full advantage of the dynamic range of the phased array.

Focused ultrasound development and clinical adoption: 2013 update on the growth of the field

The field of therapeutic focused ultrasound, which first emerged in the 1940s, has seen significant growth, particularly over the past decade. The eventual widespread clinical adoption of this non-invasive therapeutic modality require continued progress, in a multitude of activities including technical, pre-clinical, and clinical research, regulatory approval and reimbursement, manufacturer growth, and other commercial and public sector investments into the field, all within a multi-stakeholder environment. We present here a snapshot of the field of focused ultrasound and describe how it has progressed over the past several decades. It is assessed using metrics which include quantity and breadth of academic work (presentations, publications), funding trends, manufacturer presence in the field, number of treated patients, number of indications reaching first-in-human status, and quantity and breadth of clinical indications.

Real-time implementation of a dual-mode ultrasound array system: in vivo results

A real-time dual-mode ultrasound array (DMUA) system for imaging and therapy is described. The system utilizes a concave (40-mm radius of curvature) 3.5 MHz, 32 element array, and modular multichannel transmitter/receiver. The system is capable of operating in a variety of imaging and therapy modes (on transmit) and continuous receive on all array elements even during high-power operation. A signal chain consisting of field-programmable gate arrays and graphical processing units is used to enable real time, software-defined beamforming and image formation. Imaging data, from quality assurance phantoms as well as in vivo small- and large-animal models, are presented and discussed. Corresponding images obtained using a temporally-synchronized and spatially-aligned diagnostic probe confirm the DMUA's ability to form anatomically-correct images with sufficient contrast in an extended field of view around its geometric center. In addition, high-frame rate DMUA data also demonstrate the feasibility of detection and localization of echo changes indicative of cavitation and/or tissue boiling during high-intensity focused ultrasound exposures with 45-50 dB dynamic range. The results also show that the axial and lateral resolution of the DMUA are consistent with its f(number) and bandwidth with well-behaved speckle cell characteristics. These results point the way to a theranostic DMUA system capable of quantitative imaging of tissue property changes with high specificity to lesion formation using focused ultrasound.

Computational study on the propagation of strongly focused nonlinear ultrasound in tissue with rib-like structures

The presence of a rib cage is a significant hindrance to the potential applications of focused ultrasound as a noninvasive extracorporeal surgery modality for various internal organs. Here the influence of ribs on the propagation of strongly focused high-intensity nonlinear ultrasound beam inside the body is studied. Based on the spheroidal beam equation, a three-dimensional numerical algorithm is developed to solve the nonlinear acoustic field generated by a focused ultrasonic transducer with a large aperture angle. Idealized ribs, of rectangular cross sectional, with high absorption and impedance, and various dimensions, are used to simulate human anatomical configurations. The changes in the spatial distribution of acoustic intensity and the reduction of the acoustic pressure amplitude and heat deposition rate due to the presence of "ribs" are investigated. It is somewhat surprising that in some cases, the axial peak positions shift less than 2 mm and more than 80% of the sound energy can propagate through the space of the rib cage in the strongly focused sound field. This study also includes quantitative analyses of the effects of different rib configurations and transducers of various f-numbers. The results can be used as reference information for further study and clinical applications.

The road to clinical use of high-intensity focused ultrasound for liver cancer: technical and clinical consensus

Clinical use of high-intensity focused ultrasound (HIFU) under ultrasound or MR guidance as a non-invasive method for treating tumors is rapidly increasing. Tens of thousands of patients have been treated for uterine fibroid, benign prostate hyperplasia, bone metastases, or prostate cancer. Despite the methods' clinical potential, the liver is a particularly challenging organ for HIFU treatment due to the combined effect of respiratory-induced liver motion, partial blocking by the rib cage, and high perfusion/flow. Several technical and clinical solutions have been developed by various groups during the past 15 years to compensate for these problems. A review of current unmet clinical needs is given here, as well as a consensus from a panel of experts about technical and clinical requirements for upcoming pilot and pivotal studies in order to accelerate the development and adoption of focused ultrasound for the treatment of primary and secondary liver cancer.

Image-guided non-invasive ultrasound liver ablation using histotripsy: feasibility study in an in vivo porcine model

Hepatocellular carcinoma (HCC), or liver cancer, is one of the fastest growing cancers in the United States. Current liver ablation methods are thermal based and share limitations resulting from the heat sink effect of blood flow through the highly vascular liver. In this study, we explore the feasibility of using histotripsy for non-invasive liver ablation in the treatment of liver cancer. Histotripsy is a non-thermal ablation method that fractionates soft tissue through the control of acoustic cavitation. Twelve histotripsy lesions ∼1 cm(3) were created in the livers of six pigs through an intact abdomen and chest in vivo. Histotripsy pulses of 10 cycles, 500-Hz pulse repetition frequency (PRF), and 14- to 17-MPa estimated in situ peak negative pressure were applied to the liver using a 1-MHz therapy transducer. Treatments were performed through 4-6 cm of overlying tissue, with 30%-50% of the ultrasound pathway covered by the rib cage. Complete fractionation of liver parenchyma was observed, with sharp boundaries after 16.7-min treatments. In addition, two larger volumes of 18 and 60 cm(3) were generated within 60 min in two additional pigs. As major vessels and gallbladder have higher mechanical strength and are more resistant to histotripsy, these remained intact while the liver surrounding these structures was completely fractionated. This work shows that histotripsy is capable of non-invasively fractionating liver tissue while preserving critical anatomic structures within the liver. Results suggest histotripsy has potential for the non-invasive ablation of liver tumors.

Transcostal high-intensity focused ultrasound treatment using phased array with geometric correction

In the high-intensity focused ultrasound treatment of liver tumors, ultrasound propagation is affected by the rib cage. Because of the diffraction and absorption of the bone, the sound distribution at the focal plane is altered, and more importantly, overheating on the rib surface might occur. To overcome these problems, a geometric correction method is applied to turn off the elements blocked by the ribs. The potential of steering the focus of the phased-array along the propagation direction to improve the transcostal treatment was investigated by simulations and experiments using different rib models and transducers. The ultrasound propagation through the ribs was computed by a hybrid method including the Rayleigh-Sommerfeld integral, k-space method, and angular spectrum method. A modified correction method was proposed to adjust the output of elements based on their relative area in the projected "shadow" of the ribs. The simulation results showed that an increase in the specific absorption rate gain up to 300% was obtained by varying the focal length although the optimal value varied in each situation. Therefore, acoustic simulation is required for each clinical case to determine a satisfactory treatment plan.

The role of acoustic nonlinearity in tissue heating behind a rib cage using a high-intensity focused ultrasound phased array

The goal of this study was to investigate theoretically the effects of nonlinear propagation in a high-intensity focused ultrasound (HIFU) field produced by a therapeutic phased array and the resultant heating of tissue behind a rib cage. Three configurations of focusing were simulated: in water, in water with ribs in the beam path and in water with ribs backed by a layer of soft tissue. The Westervelt equation was used to model the nonlinear HIFU field, and a 1 MHz phased array consisting of 254 circular elements was used as a boundary condition to the model. The temperature rise in tissue was modelled using the bioheat equation, and thermally necrosed volumes were calculated using the thermal dose formulation. The shapes of lesions predicted by the modelling were compared with those previously obtained in in vitro experiments at low-power sonications. Intensity levels at the face of the array elements that corresponded to the formation of high-amplitude shock fronts in the focal region were determined as 10 W cm(-2) in the free field in water and 40 W cm(-2) in the presence of ribs. It was shown that exposures with shocks provided a substantial increase in tissue heating, and its better spatial localization in the main focal region only. The relative effects of overheating ribs and splitting of the focus due to the periodic structure of the ribs were therefore reduced. These results suggest that utilizing nonlinear propagation and shock formation effects can be beneficial for inducing confined HIFU lesions when irradiating through obstructions such as ribs. Design of compact therapeutic arrays to provide maximum power outputs with lower intensity levels at the elements is necessary to achieve shock wave regimes for clinically relevant sonication depths in tissue.

The optimization of acoustic fields for ablative therapies of tumours in the upper abdomen

High intensity focused ultrasound (HIFU) enables highly localized, non-invasive tissue ablation and its efficacy has been demonstrated in the treatment of a range of cancers, including those of the kidney, prostate and breast. HIFU offers the ability to treat deep-seated tumours locally, and potentially bears fewer side effects than more invasive treatment modalities such as resection, chemotherapy and ionizing radiation. There remains however a number of significant challenges which currently hinder its widespread clinical application. One of these challenges is the need to transmit sufficient energy through the ribcage to ablate tissue at the required foci whilst minimizing the formation of side lobes and sparing healthy tissue. Ribs both absorb and reflect ultrasound strongly. This sometimes results in overheating of bone and overlying tissue during treatment, leading to skin burns. Successful treatment of a patient with tumours in the upper abdomen therefore requires a thorough understanding of the way acoustic and thermal energy is deposited. Previously, a boundary element approach based on a Generalized Minimal Residual (GMRES) implementation of the Burton-Miller formulation was developed to predict the field of a multi-element HIFU array scattered by human ribs, the topology of which was obtained from CT scan data (Gélat et al 2011 Phys. Med. Biol. 56 5553-81). The present paper describes the reformulation of the boundary element equations as a least-squares minimization problem with nonlinear constraints. The methodology has subsequently been tested at an excitation frequency of 1 MHz on a spherical multi-element array in the presence of ribs. A single array-rib geometry was investigated on which a 50% reduction in the maximum acoustic pressure magnitude on the surface of the ribs was achieved with only a 4% reduction in the peak focal pressure compared to the spherical focusing case. This method was then compared with a binarized apodization approach based on ray tracing and against the decomposition of the time-reversal operator (DORT). In both cases, the constrained optimization provided a superior ratio of focal peak pressure to maximum pressure magnitude on the surface of the ribs.

Lesion generation through ribs using histotripsy therapy without aberration correction

This study investigates the feasibility of using high-intensity pulsed therapeutic ultrasound, or histotripsy, to non-invasively generate lesions through the ribs. Histotripsy therapy mechanically ablates tissue through the generation of a cavitation bubble cloud, which occurs when the focal pressure exceeds a certain threshold. We hypothesize that histotripsy can generate precise lesions through the ribs without aberration correction if the main lobe retains its shape and exceeds the cavitation initiation threshold and the secondary lobes remain below the threshold. To test this hypothesis, a 750-kHz focused transducer was used to generate lesions in tissue-mimicking phantoms with and without the presence of rib aberrators. In all cases, 8000 pulses with 16 to 18 MPa peak rarefactional pressure at a repetition frequency of 100 Hz were applied without aberration correction. Despite the high secondary lobes introduced by the aberrators, high-speed imaging showed that bubble clouds were generated exclusively at the focus, resulting in well-confined lesions with comparable dimensions. Collateral damage from secondary lobes was negligible, caused by single bubbles that failed to form a cloud. These results support our hypothesis, suggesting that histotripsy has a high tolerance for aberrated fields and can generate confined focal lesions through rib obstacles without aberration correction.

Adaptive projection method applied to three-dimensional ultrasonic focusing and steering through the ribs

An adaptive projection method for ultrasonic focusing through the rib cage, with minimal energy deposition on the ribs, was evaluated experimentally in 3D geometry. Adaptive projection is based on decomposition of the time-reversal operator (DORT method) and projection on the "noise" subspace. It is shown that 3D implementation of this method is straightforward, and not more time-consuming than 2D. Comparisons are made between adaptive projection, spherical focusing, and a previously proposed time-reversal focusing method, by measuring pressure fields in the focal plane and rib region using the three methods. The ratio of the specific absorption rate at the focus over the one at the ribs was found to be increased by a factor of up to eight, versus spherical emission. Beam steering out of geometric focus was also investigated. For all configurations projecting steered emissions were found to deposit less energy on the ribs than steering time-reversed emissions: thus the non-invasive method presented here is more efficient than state-of-the-art invasive techniques. In fact, this method could be used for real-time treatment, because a single acquisition of back-scattered echoes from the ribs is enough to treat a large volume around the focus, thanks to real time projection of the steered beams.

Focus shift and phase correction in soft tissues during focused ultrasound surgery

During the treatment of soft tissue tumors using focused ultrasound surgery (FUS), the focus can shift away from the desired point due to tissue inhomogeneity. In this paper, a numerical method to calculate the focus shift in multiple-layered tissues and a faster phase-correction method to restore the focus were developed. Data from the simulations showed that the focus shifted about 2 mm along the transducer axis in multiple-layered soft tissues. After phase correction, the focus was restored at the desired point. The ex vivo experiments were conducted to verify the simulations, and the results agreed well with those of the simulations. An empirical formula was obtained to estimate the focus shift in a two-layered water-tissue model and was verified by numerical calculations. Moreover, the focus shift in multiple-layered tissues can be summed by the shifts in the component of each layer of tissues. The factors affecting the focus shift were studied. The focus shift varied linearly with the tissue acoustic speed and tissue thickness, whereas it slightly changed with transducer F number (radius of curvature/diameter). Overall, the findings of this study can help in the development of a better treatment plan for FUS in soft tissues.

A method for MRI guidance of intercostal high intensity focused ultrasound ablation in the liver

PURPOSE

High intensity focused ultrasound (HIFU) is a promising method for the noninvasive treatment of liver tumors. However, the presence of ribs in the HIFU beam path remains problematic since it may lead to adverse effects (skin burns) by absorption and reflection of the incident beam at or near the bone surface. This article presents a method based on magnetic resonance (MR) imaging for identification of the ribs in the HIFU beam, and for selection of the transducer elements to deactivate.

METHODS

The ribs are visualized on anatomical images acquired prior to heating and manually segmented. The resulting regions of interest surrounding the ribs are projected onto the transducer surface by ray tracing from the focal point. The transducer elements in the "shadow" of the ribs are then deactivated. The method was validated ex vivo and in vivo in pig liver during breathing under multislice real-time MR thermometry, using the proton resonance frequency shift method.

RESULTS

Ex vivo and in vivo temperature data showed that the temperature increase near the ribs was substantial when HIFU sonications were performed with all elements active, whereas the temperature was reduced with deactivation of the transducer elements located in front of the ribs. The temperature at the focal point was similar with and without deactivation of the transducer elements, indicative of no loss of heat efficiency with the proposed technique.

CONCLUSIONS

This method is simple, rapid, and reliable, and enables intercostal HIFU ablation while sparing ribs and their surrounding tissues.

Focusing of high-intensity ultrasound through the rib cage using a therapeutic random phased array

A method for focusing high-intensity ultrasound (HIFU) through a rib cage that aims to minimize heating of the ribs while maintaining high intensities at the focus (or foci) was proposed and tested theoretically and experimentally. Two approaches, one based on geometric acoustics and the other accounting for diffraction effects associated with propagation through the rib cage, were investigated theoretically for idealized source conditions. It is shown that for an idealized radiator, the diffraction approach provides a 23% gain in peak intensity and results in significantly less power losses on the ribs (1% vs. 7.5% of the irradiated power) compared with the geometric one. A 2-D 1-MHz phased array with 254 randomly distributed elements, tissue-mimicking phantoms and samples of porcine rib cages are used in experiments; the geometric approach is used to configure how the array is driven. Intensity distributions are measured in the plane of the ribs and in the focal plane using an infrared camera. Theoretical and experimental results show that it is possible to provide adequate focusing through the ribs without overheating them for a single focus and several foci, including steering at +/- 10-15 mm off and +/- 20 mm along the array axis. Focus splitting caused by the periodic spatial structure of ribs is demonstrated both in simulations and experiments; the parameters of splitting are quantified. The ability to produce thermal lesions with a split focal pattern in ex vivo porcine tissue placed beyond the rib phantom is also demonstrated. The results suggest that the method is potentially useful for clinical applications of HIFU, for which the rib cage lies between the transducer(s) and the targeted tissue.