Ultrasound-guided therapeutic focused ultrasound: current status and future directions

Suppressing the HIFU interference in ultrasound guiding images with a diffusion-based deep learning model

BACKGROUND AND OBJECTIVES

In ultrasound guided high-intensity focused ultrasound (HIFU) surgery, it is necessary to transmit sound waves at different frequencies simultaneously using two transducers: one for the HIFU therapy and another for the ultrasound imaging guidance. In this specific setting, real-time monitoring of non-invasive surgery is challenging due to severe contamination of the ultrasound guiding images by strong acoustic interference from the HIFU sonication.

METHODS

This paper proposed the use of a deep learning (DL) solution, specifically a diffusion implicit model, to suppress the HIFU interference. We considered the images contaminated with HIFU interference as low-resolution images, and those free from interference as high-resolution. While suppressing HIFU interference using the diffusion implicit (HIFU-Diff) model, the task was transformed into generating a high-resolution image through a series of forward diffusion steps and reverse sampling. A series of ex-vivo and in-vivo experiments, conducted under various parameters, were designed to validate the performance of the proposed network.

RESULTS

Quantitative evaluation and statistical analysis demonstrated that the HIFU-Diff network achieved superior performance in reconstructing interference-free images under a variety of ex-vivo and in-vivo conditions, compared to the most commonly used notch filtering and the recent 1D FUS-Net deep learning network. The HIFU-Diff maintains high performance with 'unseen' datasets from separate experiments, and its superiority is more pronounced under strong HIFU interferences and in complex in-vivo situations. Furthermore, the reconstructed interference-free images can also be used for quantitative attenuation imaging, indicating that the network preserves acoustic characteristics of the ultrasound images.

CONCLUSIONS

With the proposed technique, HIFU therapy and the ultrasound imaging can be conducted simultaneously, allowing for real-time monitoring of the treatment process. This capability could significantly enhance the safety and efficacy of the non-invasive treatment across various clinical applications. To the best of our knowledge, this is the first diffusion-based model developed for HIFU interference suppression.

Numerical studies on shortening the duration of HIFU ablation therapy and their experimental validation

High Intensity Focused Ultrasound (HIFU) is used in clinical practice for thermal ablation of malignant and benign solid tumors located in various organs. One of the reason limiting the wider use of this technology is the long treatment time resulting from i.a. the large difference between the size of the focal volume of the heating beam and the size of the tumor. Therefore, the treatment of large tumors requires scanning their volume with a sequence of single heating beams, the focus of which is moved in the focal plane along a specific trajectory with specific time and distance interval between sonications. To avoid an undesirable increase in the temperature of healthy tissues surrounding the tumor during scanning, the acoustic power and exposure time of each HIFU beam as well as the time intervals between sonications should be selected in such a way as to cover the entire volume of the tumor with necrosis as quickly as possible. This would reduce the costs of treatment. The aim of this study was to quantitatively evaluate the hypothesis that selecting the average acoustic power and exposure time for each individual heating beam, as well as the temporal intervals between sonications, can significantly shorten treatment time. Using 3D numerical simulations, the dependence of the duration of treatment of a tumor with a diameter of 5 mm or 9 mm (requiring multiple exposure to the HIFU beam) on the sonication parameters (acoustic power, exposure time) of each single beam capable of delivering the threshold thermal dose (CEM43 = 240 min) to the treated tissue volume was examined. The treatment duration was determined as the sum of exposure times to individual beams and time intervals between sonications. The tumor was located inside the ex vivo tissue sample at a depth of 12.6 mm. The thickness of the water layer between the HIFU transducer and the tissue was 50 mm. The sonication and scanning parameters selected using the developed algorithm shortened the duration of the ablation procedure by almost 14 times for a 5-mm tumor and 20 times for a 9-mm tumor compared to the duration of the same ablation plan when a HIFU beam was used of a constant acoustic power, constant exposure time (3 s) and constant long time intervals (120 s) between sonications. Results of calculations of the location and size of the necrotic lesion formed were experimentally verified on ex vivo pork loin samples, showing good agreement between them. In this way, it was proven that the proper selection of sonication and scanning parameters for each HIFU beam allows to significantly shorten the time of HIFU therapy.

Adeno-associated virus vector delivery to the brain: Technology advancements and clinical applications

Adeno-associated virus (AAV) vectors have emerged as a promising tool in the development of gene therapies for various neurological diseases, including Alzheimer's disease and Parkinson's disease. However, the blood-brain barrier (BBB) poses a significant challenge to successfully delivering AAV vectors to the brain. Strategies that can overcome the BBB to improve the AAV delivery efficiency to the brain are essential to successful brain-targeted gene therapy. This review provides an overview of existing strategies employed for AAV delivery to the brain, including direct intraparenchymal injection, intra-cerebral spinal fluid injection, intranasal delivery, and intravenous injection of BBB-permeable AAVs. Focused ultrasound has emerged as a promising technology for the noninvasive and spatially targeted delivery of AAV administered by intravenous injection. This review also summarizes each strategy's current preclinical and clinical applications in treating neurological diseases. Moreover, this review includes a detailed discussion of the recent advances in the emerging focused ultrasound-mediated AAV delivery. Understanding the state-of-the-art of these gene delivery approaches is critical for future technology development to fulfill the great promise of AAV in neurological disease treatment.

Frequency-Domain Robust PCA for Real-Time Monitoring of HIFU Treatment

High intensity focused ultrasound (HIFU) is a thriving non-invasive technique for thermal ablation of tumors, but significant challenges remain in its real-time monitoring with medical imaging. Ultrasound imaging is one of the main imaging modalities for monitoring HIFU surgery in organs other than the brain, mainly due to its good temporal resolution. However, strong acoustic interference from HIFU irradiation severely obscures the B-mode images and compromises the monitoring. To address this problem, we proposed a frequency-domain robust principal component analysis (FRPCA) method to separate the HIFU interference from the contaminated B-mode images. Ex-vivo and in-vivo experiments were conducted to validate the proposed method based on a clinical HIFU therapy system combined with an ultrasound imaging platform. The performance of the FRPCA method was compared with the conventional notch filtering method. Results demonstrated that the FRPCA method can effectively remove HIFU interference from the B-mode images, which allowed HIFU-induced grayscale changes at the focal region to be recovered. Compared to notch-filtered images, the FRPCA-processed images showed an 8.9% improvement in terms of the structural similarity (SSIM) index to the uncontaminated B-mode images. These findings demonstrate that the FRPCA method presents an effective signal processing framework to remove the strong HIFU acoustic interference, obtains better dynamic visualization in monitoring the HIFU irradiation process, and offers great potential to improve the efficacy and safety of HIFU treatment and other focused ultrasound related applications.

Deep learning for real-time multi-class segmentation of artefacts in lung ultrasound

Lung ultrasound (LUS) has emerged as a safe and cost-effective modality for assessing lung health, particularly during the COVID-19 pandemic. However, interpreting LUS images remains challenging due to its reliance on artefacts, leading to operator variability and limiting its practical uptake. To address this, we propose a deep learning pipeline for multi-class segmentation of objects (ribs, pleural line) and artefacts (A-lines, B-lines, B-line confluence) in ultrasound images of a lung training phantom. Lightweight models achieved a mean Dice Similarity Coefficient (DSC) of 0.74, requiring fewer than 500 training images. Applying this method in real-time, at up to 33.4 frames per second in inference, allows enhanced visualisation of these features in LUS images. This could be useful in providing LUS training and helping to address the skill gap. Moreover, the segmentation masks obtained from this model enable the development of explainable measures of disease severity, which have the potential to assist in the triage and management of patients. We suggest one such semi-quantitative measure called the B-line Artefact Score, which is related to the percentage of an intercostal space occupied by B-lines and in turn may be associated with the severity of a number of lung conditions. Moreover, we show how transfer learning could be used to train models for small datasets of clinical LUS images, identifying pathologies such as simple pleural effusions and lung consolidation with DSC values of 0.48 and 0.32 respectively. Finally, we demonstrate how such DL models could be translated into clinical practice, implementing the phantom model alongside a portable point-of-care ultrasound system, facilitating bedside assessment and improving the accessibility of LUS.

Suppressing HIFU interference in ultrasound images using 1D U-Net-based neural networks

Objective.One big challenge with high-intensity focused ultrasound (HIFU) is that the intense acoustic interference generated by HIFU irradiation overwhelms the B-mode monitoring images, compromising monitoring effectiveness. This study aims to overcome this problem using a one-dimensional (1D) deep convolutional neural network.Approach. U-Net-based networks have been proven to be effective in image reconstruction and denoising, and the two-dimensional (2D) U-Net has already been investigated for suppressing HIFU interference in ultrasound monitoring images. In this study, we propose that the one-dimensional (1D) convolution in U-Net-based networks is more suitable for removing HIFU artifacts and can better recover the contaminated B-mode images compared to 2D convolution.Ex vivoandinvivoHIFU experiments were performed on a clinically equivalent ultrasound-guided HIFU platform to collect image data, and the 1D convolution in U-Net, Attention U-Net, U-Net++, and FUS-Net was applied to verify our proposal.Main results.All 1D U-Net-based networks were more effective in suppressing HIFU interference than their 2D counterparts, with over 30% improvement in terms of structural similarity (SSIM) to the uncontaminated B-mode images. Additionally, 1D U-Nets trained usingex vivodatasets demonstrated better generalization performance ininvivoexperiments.Significance.These findings indicate that the utilization of 1D convolution in U-Net-based networks offers great potential in addressing the challenges of monitoring in ultrasound-guided HIFU systems.

High-resolution acoustic mapping of tunable gelatin-based phantoms for ultrasound tissue characterization

Background: The choice of gelatin as the phantom material is underpinned by several key advantages it offers over other materials in the context of ultrasonic applications. Gelatin exhibits spatial and temporal uniformity, which is essential in creating reliable tissue-mimicking phantoms. Its stability ensures that the phantom's properties remain consistent over time, while its flexibility allows for customization to match the acoustic characteristics of specific tissues, in addition to its low levels of ultrasound scattering. These attributes collectively make gelatin a preferred choice for fabricating phantoms in ultrasound-related research. Methods: We developed gelatin-based phantoms with adjustable parameters and conducted high-resolution measurements of ultrasound wave attenuation when interacting with the gelatin phantoms. We utilized a motorized acoustic system designed for 3D acoustic mapping. Mechanical evaluation of phantom elasticity was performed using unconfined compression tests. We particularly examined how varying gelatin concentration influenced ultrasound maximal intensity and subsequent acoustic attenuation across the acoustic profile. To validate our findings, we conducted computational simulations to compare our data with predicted acoustic outcomes. Results: Our results demonstrated high-resolution mapping of ultrasound waves in both gelatin-based phantoms and plain fluid environments. Following an increase in the gelatin concentration, the maximum intensity dropped by 30% and 48% with the 5 MHz and 1 MHz frequencies respectively, while the attenuation coefficient increased, with 67% more attenuation at the 1 MHz frequency recorded at the highest concentration. The size of the focal areas increased systematically as a function of increasing applied voltage and duty cycle yet decreased as a function of increased ultrasonic frequency. Simulation results verified the experimental results with less than 10% deviation. Conclusion: We developed gelatin-based ultrasound phantoms as a reliable and reproducible tool for examining the acoustic and mechanical attenuations taking place as a function of increased tissue elasticity and stiffness. Our experimental measurements and simulations gave insight into the potential use of such phantoms for mimicking soft tissue properties.

Magnetic Resonance Acoustic Radiation Force Imaging (MR-ARFI) for the monitoring of High Intensity Focused Ultrasound (HIFU) ablation in anisotropic tissue

OBJECTIVE

We introduce a non-invasive MR-Acoustic Radiation Force Imaging (ARFI)-based elastography method that provides both the local shear modulus and temperature maps for the monitoring of High Intensity Focused Ultrasound (HIFU) therapy.

MATERIALS AND METHODS

To take tissue anisotropy into account, the local shear modulus μ is determined in selected radial directions around the focal spot by fitting the phase profiles to a linear viscoelastic model, including tissue-specific mechanical relaxation time τ. MR-ARFI was evaluated on a calibrated phantom, then applied to the monitoring of HIFU in a gel phantom, ex vivo and in vivo porcine muscle tissue, in parallel with MR-thermometry.

RESULTS

As expected, the shear modulus polar maps reflected the isotropy of phantoms and the anisotropy of muscle. In the HIFU monitoring experiments, both the shear modulus polar map and the thermometry map were updated with every pair of MR-ARFI phase images acquired with opposite MR-ARFI-encoding. The shear modulus was found to decrease (phantom and ex vivo) or increase (in vivo) during heating, before remaining steady during the cooling phase. The mechanical relaxation time, estimated pre- and post-HIFU, was found to vary in muscle tissue.

DISCUSSION

MR-ARFI allowed for monitoring of viscoelasticity changes around the HIFU focal spot even in anisotropic muscle tissue.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Surgical Management of Brain Tumors with Focused Ultrasound

Focused ultrasound is a novel technique for the treatment of aggressive brain tumors that uses both mechanical and thermal mechanisms. This non-invasive technique can allow for both the thermal ablation of inoperable tumors and the delivery of chemotherapy and immunotherapy while minimizing the risk of infection and shortening the time to recovery. With recent advances, focused ultrasound has been increasingly effective for larger tumors without the need for a craniotomy and can be used with minimal surrounding soft tissue damage. Treatment efficacy is dependent on multiple variables, including blood-brain barrier permeability, patient anatomical features, and tumor-specific features. Currently, many clinical trials are currently underway for the treatment of non-neoplastic cranial pathologies and other non-cranial malignancies. In this article, we review the current state of surgical management of brain tumors using focused ultrasound.

Multivariable-incorporating super-resolution residual network for transcranial focused ultrasound simulation

BACKGROUND AND OBJECTIVE

Transcranial focused ultrasound (tFUS) has emerged as a new non-invasive brain stimulation (NIBS) modality, with its exquisite ability to reach deep brain areas at a high spatial resolution. Accurate placement of an acoustic focus to a target region of the brain is crucial during tFUS treatment; however, the distortion of acoustic wave propagation through the intact skull casts challenges. High-resolution numerical simulation allows for monitoring of the acoustic pressure field in the cranium but also demands extensive computational loads. In this study, we adopt a super-resolution residual network technique based on a deep convolution to enhance the prediction quality of the FUS acoustic pressure field in the targeted brain regions.

METHODS

The training dataset was acquired by numerical simulations performed at low-(1.0 mm) and high-resolutions (0.5mm) on three ex vivo human calvariae. Five different super-resolution (SR) network models were trained by using a multivariable dataset in 3D, which incorporated information on the acoustic pressure field, wave velocity, and localized skull computed tomography (CT) images.

RESULTS

The accuracy of 80.87±4.50% in predicting the focal volume with a substantial improvement of 86.91% in computational cost compared to the conventional high-resolution numerical simulation was achieved. The results suggest that the method can greatly reduce the simulation time without sacrificing accuracy and improve the accuracy further with the use of additional inputs.

CONCLUSIONS

In this research, we developed multivariable-incorporating SR neural networks for transcranial focused ultrasound simulation. Our super-resolution technique may contribute to promoting the safety and efficacy of tFUS-mediated NIBS by providing on-site feedback information on the intracranial pressure field to the operator.

Phase aberration correction for ultrasound imaging guided extracorporeal shock wave therapy (ESWT): Feasibility study

Image guidance of extracorporeal shock wave therapy (ESWT) is important to enhance its efficacy while lowering pain in patients. Real-time ultrasound imaging is an appropriate modality for image guidance, but its image quality substantially reduces due to severe phase aberration from the different speed of sound between soft tissues and a gel pad, which is utilized to control a therapeutic focal point in ESWT. This paper presents a phase aberration correction method for improving image quality in the ultrasound imaging guided ESWT. To correct an error from phase aberration, a time delay based on a two-layer model with different speeds of sound is calculated for dynamic receive beamforming. For the phantom and in vivo studies, a rubber type gel pad (i.e., 1400 m/s) with a specific thickness (3 or 5-cm) was placed on the top of soft tissue and full scanline RF data were acquired. In the phantom study, with phase aberration correction, image quality was highly increased compared to image reconstructions with a fixed speed of sound (i.e., 1540 or 1400 m/s), i.e., 1.1 vs. 2.2 and 1.3 mm in -6dB lateral resolution and 0.64 vs. 0.61 and 0.56 in contrast-to-noise ratio (CNR), respectively. From an in vivo musculoskeletal (MSK) imaging, the phase aberration correction method provided a clearly improved depiction of muscle fibers in a rectus femoris region. These results indicate that the proposed method enables effective imaging guidance of ESWT by improving image quality of ultrasound imaging in real-time.

Review of Robot-Assisted HIFU Therapy

This paper provides an overview of current robot-assisted high-intensity focused ultrasound (HIFU) systems for image-guided therapies. HIFU is a minimally invasive technique that relies on the thermo-mechanical effects of focused ultrasound waves to perform clinical treatments, such as tumor ablation, mild hyperthermia adjuvant to radiation or chemotherapy, vein occlusion, and many others. HIFU is typically performed under ultrasound (USgHIFU) or magnetic resonance imaging guidance (MRgHIFU), which provide intra-operative monitoring of treatment outcomes. Robot-assisted HIFU probe manipulation provides precise HIFU focal control to avoid damage to surrounding sensitive anatomy, such as blood vessels, nerve bundles, or adjacent organs. These clinical and technical benefits have promoted the rapid adoption of robot-assisted HIFU in the past several decades. This paper aims to present the recent developments of robot-assisted HIFU by summarizing the key features and clinical applications of each system. The paper concludes with a comparison and discussion of future perspectives on robot-assisted HIFU.

Array-based high-intensity focused ultrasound therapy system integrated with real-time ultrasound and photoacoustic imaging

High-intensity focused ultrasound (HIFU) is a promising non-invasive therapeutic technique in clinical applications. Challenges in stimulation or ablation HIFU therapy are to accurately target the treatment spot, flexibly deliver or fast-move focus points in the treatment region, and monitor therapy progress in real-time. In this paper, we develop an array-based HIFU system integrated with real-time ultrasound (US) and photoacoustic (PA) imaging. The array-based HIFU transducer can be dynamically focused in a lateral range of ∼16 mm and an axial range of ∼40 mm via electronically adjusting the excitation phase map. To monitor the HIFU therapy progress in real-time, sequential HIFU transmission, PA imaging, PA thermometry, and US imaging are implemented to display the dual-modal images and record the local temperature changes. Co-registered dual-modal images show structural and functional information and thus can guide the HIFU therapy for precise positioning and dosage control. Besides therapy, the multi-element HIFU transducer can also be used to acquire US images to precisely align the imaging coordinates with the HIFU coordinates. Phantom experiments validate the precise and dynamic steering capability of HIFU ablation. We also show that dual-modal imaging can guide HIFU in the designated region and monitor the temperature in biological tissue in real-time.

Image-Guided Measurement of Radiation Force Induced by Focused Ultrasound Beams

The radiation force balance (RFB) is a widely used method for measuring acoustic power output of ultrasonic transducers. The reflecting cone target is attractive due to its simplicity and long-term stability, at a reasonable cost. However, accurate measurements using this method depend on the alignment between the ultrasound beam and cone axes, especially for highly focused beams utilized in therapeutic applications. With the advent of dual-mode ultrasound arrays (DMUAs) for imaging and therapy, image-guided measurements of acoustic output using the RFB method can be used to improve measurement accuracy. In this article, we describe an image-guided RFB measurement of focused DMUA beams using a widely used commercial instrument. DMUA imaging is used to optimize the alignment between the acoustic beam and reflecting cone axes. In addition to image-guided alignment, DMUA echo data is used to track the displacement of the cone, which provides an auxiliary measurement of acoustic power. Experimental results using a DMUA prototype with [Formula: see text] shows that 1-2 mm of misalignment can result in 5%-14% error in the measured acoustic power. In addition to the use of B-mode image guidance for improving measurement accuracy, we present preliminary results demonstrating the benefit of displacement tracking using real-time DMUA imaging during the application of (sub)therapeutic focused beams. Displacement tracking provides a direct measurement of the radiation force with high sensitivity and follows the expected dependence on changes in amplitude and duty cycle (DC) of the focused ultrasound (FUS) beam. This could lead to simpler, more reliable methods for measuring acoustic power based on the radiation force principle. Combined with appropriate computational modeling, the direct measurement of acoustic radiation force could lead to reliable dosimetry in situ in emerging applications such as transcranial FUS (tFUS) therapies.

Ultrasound-Enhanced Antibacterial Activity of Polymeric Nanoparticles for Eradicating Bacterial Biofilms

Bacterial biofilms are a major healthcare concern resulting in refractory conditions such as chronic wounds, implant infections and failure, and multidrug-resistant infections. Aggressive and invasive strategies are employed to cure biofilm infections but are prone to long and expensive treatments, adverse side-effects, and low patient compliance. Recent strategies such as ultrasound-based therapies and antimicrobial nanomaterials have shown some promise in the effective eradication of biofilms. However, maximizing therapeutic effect while minimizing healthy tissue damage is a key challenge that needs to be addressed. Here a combination treatment involving ultrasound and antimicrobial polymeric nanoparticles (PNPs) that synergistically eradicate bacterial biofilms is reported. Ultrasound treatment rapidly disrupts biofilms and increases penetration of antimicrobial PNPs thereby enhancing their antimicrobial activity. This results in superior biofilm toxicity, while allowing for a two- to sixfold reduction in both the concentration of PNPs as well as the duration of ultrasound. Furthermore, that this reduction minimizes cytotoxicity toward fibroblast cells, while resulting in a 100- to 1000-fold reduction in bacterial concentration, is demonstrated.

An ultrasonically actuated needle promotes the transport of nanoparticles and fluids

Non-invasive therapeutic ultrasound (US) methods, such as high-intensity focused ultrasound (HIFU), have limited access to tissue targets shadowed by bones or presence of gas. This study demonstrates that an ultrasonically actuated medical needle can be used to translate nanoparticles and fluids under the action of nonlinear phenomena, potentially overcoming some limitations of HIFU. A simulation study was first conducted to study the delivery of a tracer with an ultrasonically actuated needle (33 kHz) inside a porous medium acting as a model for soft tissue. The model was then validated experimentally in different concentrations of agarose gel showing a close match with the experimental results, when diluted soot nanoparticles (diameter < 150 nm) were employed as delivered entity. An additional simulation study demonstrated a threefold increase in the volume covered by the delivered agent in liver under a constant injection rate, when compared to without US. This method, if developed to its full potential, could serve as a cost effective way to improve safety and efficacy of drug therapies by maximizing the concentration of delivered entities within, e.g., a small lesion, while minimizing exposure outside the lesion.

Feasibility of ultrasound tomography-guided localized mild hyperthermia using a ring transducer: Ex vivo and in silico studies

BACKGROUND

As of 2022, breast cancer continues to be the most diagnosed cancer worldwide. This problem persists within the United States as well, as the American Cancer Society has reported that ∼12.5% of women will be diagnosed with invasive breast cancer over the course of their lifetime. Therefore, a clinical need continues to exist to address this disease from a treatment and therapeutic perspective. Current treatments for breast cancer and cancers more broadly include surgery, radiation, and chemotherapy. Adjuncts to these methods have been developed to improve the clinical outcomes for patients. One such adjunctive treatment is mild hyperthermia therapy (MHTh), which has been shown to be successful in the treatment of cancers by increasing effectiveness and reduced dosage requirements for radiation and chemotherapies. MHTh-assisted treatments can be performed with invasive thermal devices, noninvasive microwave induction, heating and recirculation of extracted patient blood, or whole-body hyperthermia with hot blankets.

PURPOSE

One common method for inducing MHTh is by using microwave for heat induction and magnetic resonance imaging for temperature monitoring. However, this leads to a complex, expensive, and inaccessible therapy platform. Therefore, in this work we aim to show the feasibility of a novel all-acoustic MHTh system that uses focused ultrasound (US) to induce heating while also using US tomography (UST) to provide temperature estimates. Changes in sound speed (SS) have been shown to be strongly correlated with temperature changes and can therefore be used to indirectly monitor heating throughout the therapy. Additionally, these SS estimates allow for heterogeneous SS-corrected phase delays when heating complex and heterogeneous tissue structures.

METHODS

Feasibility to induce localized heat in tissue was investigated in silico with a simulated breast model, including an embedded tumor using continuous wave US. Here, both heterogenous acoustic and thermal properties were modeled in addition to blood perfusion. We further demonstrate, with ex vivo tissue phantoms, the feasibility of using ring-based UST to monitor temperature by tracking changes in SS. Two phantoms (lamb tissue and human abdominal fat) with latex tubes containing varied temperature flowing water were imaged. The measured SS of the water at each temperature were compared against values that are reported in literature.

RESULTS

Results from ex vivo tissue studies indicate successful tracking of temperature under various phantom configurations and ranges of water temperature. The results of in silico studies show that the proposed system can heat an acoustically and thermally heterogenous breast model to the clinically relevant temperature of 42°C while accounting for a reasonable time needed to image the current cross section (200 ms). Further, we have performed an initial in silico study demonstrating the feasibility of adjusting the transmit waveform frequency to modify the effective heating height at the focused region. Lastly, we have shown in a simpler 2D breast model that MHTh level temperatures can be maintained by adjusting the transmit pressure intensity of the US ring.

CONCLUSIONS

This work has demonstrated the feasibility of using a 256-element ring array transducer for temperature monitoring; however, future work will investigate minimizing the difference between measured SS and the values shown in literature. A hypothesis attributes this bias to potential volumetric average artifacts from the ray-based SS inversion algorithm that was used, and that moving to a waveform-based SS inversion algorithm will greatly improve the SS estimates. Additionally, we have shown that an all-acoustic MHTh system is feasible via in silico studies. These studies have indicated that the proposed system can heat a tumor within a heterogenous breast model to 42°C within a narrow time frame. This holds great promise for increasing the accessibility and reducing the complexity of a future all-acoustic MHTh system.

Combined Therapy Planning, Real-Time Monitoring, and Low Intensity Focused Ultrasound Treatment Using a Diagnostic Imaging Array

Low intensity focused ultrasound (FUS) therapies use low intensity focused ultrasound waves, typically in combination with microbubbles, to non-invasively induce a variety of therapeutic effects. FUS therapies require pre-therapy planning and real-time monitoring during treatment to ensure the FUS beam is correctly targeted to the desired tissue region. To facilitate more streamlined FUS treatments, we present a system for pre-therapy planning, real-time FUS beam visualization, and low intensity FUS treatment using a single diagnostic imaging array. Therapy planning was accomplished by manually segmenting a B-mode image captured by the imaging array and calculating a sonication pattern for the treatment based on the user-input region of interest. For real-time monitoring, the imaging array transmitted a visualization pulse which was focused to the same location as the FUS therapy beam and ultrasonic backscatter from this pulse was used to reconstruct the intensity field of the FUS beam. The therapy planning and beam monitoring techniques were demonstrated in a tissue-mimicking phantom and in a rat tumor in vivo while a mock FUS treatment was carried out. The FUS pulse from the imaging array was excited with an MI of 0.78, which suggests that the array could be used to administer select low intensity FUS treatments involving microbubble activation.

Safety and feasibility study of non-invasive robot-assisted high-intensity focused ultrasound therapy for the treatment of atherosclerotic plaques in the femoral artery: protocol for a pilot study

INTRODUCTION

Peripheral arterial disease (PAD) is an atherosclerotic disease leading to stenosis and/or occlusion of the arterial circulation of the lower extremities. The currently available revascularisation methods have an acceptable initial success rate, but the long-term patency is limited, while surgical revascularisation is associated with a relatively high perioperative risk. This urges the need for development of less invasive and more effective treatment modalities. This protocol article describes a study investigating a new non-invasive technique that uses robot assisted high-intensity focused ultrasound (HIFU) to treat atherosclerosis in the femoral artery.

METHODS AND ANALYSIS

A pilot study is currently performed in 15 symptomatic patients with PAD with a significant stenosis in the common femoral and/or proximal superficial femoral artery. All patients will be treated with the dual-mode ultrasound array system to deliver imaging-guided HIFU to the atherosclerotic plaque. Safety and feasibility are the primary objectives assessed by the technical feasibility of this therapy and the 30-day major complication rate as primary endpoints. Secondary endpoints are angiographic and clinical success and quality of life.

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained in 2019 from the Medical Ethics Committee of the University Medical Center Utrecht, the Netherlands. Data will be presented at national and international conferences and published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NL7564.

Development and characterization of polyurethane-based tissue and blood mimicking materials for high intensity therapeutic ultrasound

A polyurethane-based tissue mimicking material (TMM) and blood mimicking material (BMM) for the acoustic and thermal characterization of high intensity therapeutic ultrasound (HITU) devices has been developed. Urethane powder and other chemicals were dispersed into either a high temperature hydrogel matrix (gellan gum) or degassed water to form the TMM and BMM, respectively. The ultrasonic properties of both TMM and BMM, including attenuation coefficient, speed of sound, acoustical impedance, and backscatter coefficient, were characterized at room temperature. The thermal conductivity and diffusivity, BMM viscosity, and TMM Young's modulus were also measured. Importantly, the attenuation coefficient has a nearly linear frequency dependence, as is the case for most soft tissues and blood at 37 °C. Their mean values are 0.61f^1.2dB cm^-1 (TMM) and 0.2f^1.1dB cm^-1 (BMM) based on measurements from 1 to 8 MHz using a time delay spectrometry (TDS) system. Most of the other relevant physical parameters are also close to the reported values of soft tissues and blood. These polyurethane-based TMM and BMM are appropriate for developing standardized dosimetry techniques, validating numerical models, and determining the safety and efficacy of HITU devices.

Focal position control of ultrasonic transducer made of plano-concave form piezoelectric vibrator

The use of therapeutic focused ultrasound requires control of the focal position for different treatment regions. In this study, a piezoelectric ultrasonic transducer of plano-concave form was designed, and the change of the focal position depending on the frequency of the driving signal of the fabricated transducer was experimentally investigated. PVA gel and thermochromic liquid crystal film were used to observe the thermal distribution in the focal region caused by focused ultrasound produced by the transducer. The ability to control the position of the focal region between (62 and 154) % of the geometric focal length of the transducer, depending on the input signal frequency change, was confirmed. The change of acoustic field distribution, which was calculated using the transfer function of the vibration element distributed on the surface of the transducer as the source strength, showed good agreement with the change of temperature distribution experimentally observed.

High-spatial-resolution, instantaneous passive cavitation imaging with temporal resolution in histotripsy: a simulation study

Purpose

In histotripsy, a shock wave is transmitted, and the resulting inertial bubble cavitation that disrupts tissue is used for treatment. Therefore, it is necessary to detect when cavitation occurs and track the position of cavitation occurrence using a new passive cavitation (PC) imaging method.

Methods

An integrated PC image, which is constructed by collecting the focused signals at all times, does not provide information on when cavitation occurs and has poor spatial resolution. To solve this problem, we constructed instantaneous PC images by applying delay and sum beamforming at instantaneous time instants. By calculating instantaneous PC images at all data acquisition times, the proposed method can detect cavitation when it occurs by using the property that when signals from the cavitation are focused, their amplitude becomes large, and it can obtain a high-resolution PC image by masking out side lobes in the vicinity of cavitation.

Results

Ultrasound image simulation confirmed that the proposed method has higher resolution than conventional integrated PC imaging and showed that it can determine the position and time of cavitation occurrence as well as the signal strength.

Conclusion

Since the proposed novel PC imaging method can detect each cavitation separately when the incidence of cavitations is low, it can be used to monitor the treatment process of shock wave therapy and histotripsy, in which cavitation is an important mechanism of treatment.

Experimental Demonstration of Trans-Skull Volumetric Passive Acoustic Mapping With the Heterogeneous Angular Spectrum Approach

Real-time, 3-D, passive acoustic mapping (PAM) of microbubble dynamics during transcranial focused ultrasound (FUS) is essential for optimal treatment outcomes. The angular spectrum approach (ASA) potentially offers a very efficient method to perform PAM, as it can reconstruct specific frequency bands pertinent to microbubble dynamics and may be extended to correct aberrations caused by the skull. Here, we experimentally assess the abilities of heterogeneous ASA (HASA) to perform trans-skull PAM. Our experimental investigations demonstrate that the 3-D PAMs of a known 1-MHz source, constructed with HASA through an ex vivo human skull segment, reduced both the localization error (from 4.7 ± 2.3 to 2.3 ± 1.6 mm) and the number, size, and energy of spurious lobes caused by aberration, with the modest additional computational expense. While further improvements in the localization errors are expected with arrays with denser elements and larger aperture, our analysis revealed that experimental constraints associated with the array pitch and aperture (here, 1.8 mm and 2.5 cm, respectively) can be ameliorated by interpolation and peak finding techniques. Beyond the array characteristics, our analysis also indicated that errors in the registration (translation and rotation of ±5 mm and ±5°, respectively) of the skull segment to the array can lead to peak localization errors of the order of a few wavelengths. Interestingly, errors in the spatially dependent speed of sound in the skull (±20%) caused only subwavelength errors in the reconstructions, suggesting that registration is the most important determinant of point source localization accuracy. Collectively, our findings show that HASA can address source localization problems through the skull efficiently and accurately under realistic conditions, thereby creating unique opportunities for imaging and controlling the microbubble dynamics in the brain.

Ultrasonic Thermal Monitoring of the Brain Using Golay-Coded Excitations-Feasibility Study

Thermal monitoring during focused ultrasound (FUS) transcranial procedures is mandatory and commonly performed by MRI. Transcranial ultrasonic thermal monitoring is an attractive alternative. Furthermore, using the therapeutic FUS transducer itself for this task is highly desirable. Nonetheless, such application is challenged by massive skull-induced signal attenuation and aberrations. This study examined the feasibility of implementing the Golay-coded excitations (CoE) for temperature monitoring in bovine brain samples in the range of 35 °C-43 °C (hyperthermia). Feasibility was assessed using computer simulations, water-based phantoms, and ex vivo bovine brain white-matter samples. The samples were gradually heated to about 45 °C and sonicated during cool down with a 1-MHz therapeutic FUS implementing Golay CoE. Initially, a calibration curve correlating the normalized time-of-flight (TOF) changes and the temperature was generated. Next, a bovine bone was positioned between the FUS and the brain samples, and the scanning process was repeated for different fresh samples. The calibration curve was then used as a mean for estimating the temperature, which was compared to thermocouple measurements. The simulations demonstrated a substantial improvement in signal-to-noise ratio (SNR) and suggested that the implementation of 4-bit sequences is advantageous. The experimental measurements with bone demonstrated good temperature estimation with an average absolute error for the water phantoms and brains of 1.46 °C ± 1.22 °C and 1.23 °C ± 0.99 °C, respectively. In conclusion, a novel noninvasive method utilizing the Golay CoE for ultrasonic thermal monitoring using a therapeutic FUS transducer is introduced. This method can lead to the development of an acoustic tool for brain thermal monitoring.

New Perspectives for Eye-Sparing Treatment Strategies in Primary Uveal Melanoma

Simple Summary

Uveal melanoma is the most common intraocular cancer. The current eye-sparing treatment options include mostly plaque brachytherapy. However, the effectiveness of these methods is still unsatisfactory. In this article, we review several possible new treatment options. These methods may be based on the physical destruction of the cancerous cells by applying ultrasounds. Another approach may be based on improving the penetration of the anti-cancer agents. It seems that the most promising technologies from this group are based on enhancing drug delivery by applying electric current. Finally, new advanced nanoparticles are developed to combine diagnostic imaging and therapy (i.e., theranostics). However, these methods are mostly at an early stage of development. More advanced studies on experimental animals and clinical trials would be needed to introduce some of these techniques to routine clinical practice.

Abstract

Uveal melanoma is the most common intraocular malignancy and arises from melanocytes in the choroid, ciliary body, or iris. The current eye-sparing treatment options include surgical treatment, plaque brachytherapy, proton beam radiotherapy, stereotactic photon radiotherapy, or photodynamic therapy. However, the efficacy of these methods is still unsatisfactory. This article reviews several possible new treatment options and their potential advantages in treating localized uveal melanoma. These methods may be based on the physical destruction of the cancerous cells by applying ultrasounds. Two examples of such an approach are High-Intensity Focused Ultrasound (HIFU)—a promising technology of thermal destruction of solid tumors located deep under the skin and sonodynamic therapy (SDT) that induces reactive oxygen species. Another approach may be based on improving the penetration of anti-cancer agents into UM cells. The most promising technologies from this group are based on enhancing drug delivery by applying electric current. One such approach is called transcorneal iontophoresis and has already been shown to increase the local concentration of several different therapeutics. Another technique, electrically enhanced chemotherapy, may promote drug delivery from the intercellular space to cells. Finally, new advanced nanoparticles are developed to combine diagnostic imaging and therapy (i.e., theranostics). However, these methods are mostly at an early stage of development. More advanced and targeted preclinical studies and clinical trials would be needed to introduce some of these techniques to routine clinical practice.

Ultrasound-targeted nucleic acid delivery for solid tumor therapy

Depending upon multiple factors, malignant solid tumors are conventionally treated by some combination of surgical resection, radiation, chemotherapy, and immunotherapy. Despite decades of research, therapeutic responses remain poor for many cancer indications. Further, many current therapies in our armamentarium are either invasive or accompanied by toxic side effects. In lieu of traditional pharmaceutics and invasive therapeutic interventions, gene therapies offer more flexible and potentially more durable approaches for new anti-cancer therapies. Nonetheless, many current gene delivery approaches suffer from low transfection efficiency due to physiological barriers limiting extravasation and uptake of genetic material. Additionally, systemically administered gene therapies may lack target-specificity, which can lead to off-target effects. To overcome these challenges, many preclinical studies have shown the utility of focused ultrasound (FUS) to increase macromolecule uptake in cells and tissue under image guidance, demonstrating promise for improved delivery of therapeutics to solid tumors. As FUS-based drug delivery is now being tested in several clinical trials around the world, FUS-targeted gene therapy for solid tumor therapy may not be far behind. In this review, we comprehensively cover the literature pertaining to preclinical attempts to more efficiently deliver therapeutic genetic material with FUS and offer perspectives for future studies and clinical translation.

Acoustic beam mapping for guiding HIFU therapy in vivo using sub-therapeutic sound pulse and passive beamforming

OBJECTIVE

Although HIFU has been successfully applied in various clinical applications in the past two decades for the ablation of many types of tumors, one bottleneck in its wider applications is the lack of a reliable and affordable strategy to guide the therapy. This study aims at estimating the therapeutic beam path at the pre-treatment stage to guide the therapeutic procedure.

METHODS

An incident beam mapping technique using passive beamforming was proposed based on a clinical HIFU system and an ultrasound imaging research system. An optimization model was created to map the cross-like beam pattern by maximizing the total energy within the mapped area. This beam mapping technique was validated by comparing the estimated focal region with the HIFU-induced actual focal region (damaged region) through simulation, in-vitro, ex-vivo and in-vivo experiments.

RESULTS

The results of this study showed that the proposed technique was, to a large extent, tolerant of sound speed inhomogeneities, being able to estimate the focal location with errors of 0.15 mm and 0.93 mm under in-vitro and ex-vivo situations respectively, and slightly over 1 mm under the in-vivo situation. It should be noted that the corresponding errors were 6.8 mm, 3.2 mm, and 9.9 mm respectively when the conventional geometrical method was used.

CONCLUSION

This beam mapping technique can be very helpful in guiding the HIFU therapy and can be easily applied in clinical environments with an ultrasound-guided HIFU system.

SIGNIFICANCE

The technique is non-invasive and can potentially be adapted to other ultrasound-related beam manipulating applications.

Enhanced HIFU Theranostics with Dual-Frequency-Ring Focused Ultrasound and Activatable Perfluoropentane-Loaded Polymer Nanoparticles

High-intensity focused ultrasound (HIFU) has been widely used in tumor ablation in clinical settings. Meanwhile, there is great potential to increase the therapeutic efficiency of temporary cavitation due to enhanced thermal effects and combined mechanical effects from nonlinear vibration and collapse of the microbubbles. In this study, dual-frequency (1.1 and 5 MHz) HIFU was used to produce acoustic droplet vaporization (ADV) microbubbles from activatable perfluoropentane-loaded polymer nanoparticles (PFP@Polymer NPs), which increased the therapeutic outcome of the HIFU and helped realize tumor theranostics with ultrasound contrast imaging. Combined with PFP@Polymer NPs, dual-frequency HIFU changed the shape of the damage lesion and reduced the acoustic intensity threshold of thermal damage significantly, from 216.86 to 62.38 W/cm². It produced a nearly 20 °C temperature increase in half the irradiation time and exhibited a higher tumor inhibition rate (84.5% ± 3.4%) at a low acoustic intensity (1.1 MHz: 23.77 W/cm²; 5 MHz: 0.35 W/cm²) in vitro than the single-frequency HIFU (60.2% ± 11.9%). Moreover, compared with the traditional PFP@BSA NDs, PFP@Polymer NPs showed higher anti-tumor efficacy (81.13% vs. 69.34%; * p < 0.05) and better contrast-enhanced ultrasound (CEUS) imaging ability (gray value of 57.53 vs. 30.67; **** p < 0.0001), probably benefitting from its uniform and stable structure. It showed potential as a highly efficient tumor theranostics approach based on dual-frequency HIFU and activatable PFP@Polymer NPs.

A Comparison of Focused and Unfocused Ultrasound for Microbubble-Mediated Gene Delivery

We compared focused and unfocused ultrasound-targeted microbubble destruction (UTMD) for delivery of reporter plasmids to the liver and heart in mice. Optimal hepatic expression was seen with double-depth targeting at 5 and 13 mm in vivo, incorporating a low pulse repetition frequency and short pulse duration. Reporter expression was similar, but the transfection patterns were distinct, with intense foci of transfection using focused UTMD (F-UTMD). We then compared both approaches for cardiac delivery and found 10-fold stronger levels of reporter expression for F-UTMD and observed small areas of intense luciferase expression in the left ventricle. Non-linear contrast imaging of the liver before and after insonation also showed a substantially greater change in signal intensity for F-UTMD, suggesting distinct cavitation mechanisms for both approaches. Overall, similar levels of hepatic transgene expression were observed, but cardiac-directed F-UTMD was substantially more effective. Focused ultrasound presents a new frontier in UTMD-directed gene therapy.

Safety and feasibility of arterial wall targeting with robot-assisted high intensity focused ultrasound: a preclinical study

PURPOSE

High-intensity focused ultrasound (HIFU) is a potential noninvasive thermal ablation method for the treatment of peripheral artery disease. Dual-mode ultrasound arrays (DMUA) offer the possibility of simultaneous imaging and treatment. In this study, safety and feasibility of femoral artery robot-assisted HIFU/DMUA therapy was assessed.

METHODS

In 18 pigs (∼50kg), angiography and diagnostic ultrasound were used to visualize diameter and blood flow of the external femoral arteries (EFA). HIFU/DMUA-therapy was unilaterally applied to the EFA dorsal wall using a 3.5 MHz, 64-element transducer, closed-loop-control was used to automatically adjust energy delivery to control thermal lesion formation. A continuous lesion of at least 25 mm was created by delivering 6-8 HIFU shots per imaging plane perpendicular to the artery spaced 1 mm apart. Directly after HIFU/DMUA-therapy and after 0, 3 or 14 days follow up, diameter and blood flow were measured and the skin was macroscopically examined for thermal damage. The tissue was removed for histological analysis.

RESULTS

No complications were observed. The most frequently observed treatment effect was formation of scar tissue, predominantly in the adventitia and the surrounding tissue. No damage to the endothelium or excessive damage of the surrounding tissue was observed. There was no significant decrease in the mean arterial diameter after HIFU/DMUA-therapy.

CONCLUSION

HIFU/DMUA therapy successfully targeted the vessel walls of healthy porcine arteries, without causing endothelial damage or other vascular complications. Therefore, this therapy can be safely applied to healthy arterial walls in animals. Future studies should focus on safety and dose-finding in atherosclerotic diseased arteries.

Heating technology for malignant tumors: a review

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

Dual-Array Passive Acoustic Mapping for Cavitation Imaging With Enhanced 2-D Resolution

Passive acoustic mapping (PAM) techniques have been developed for the purposes of detecting, localizing, and quantifying cavitation activity during therapeutic ultrasound procedures. Implementation with conventional diagnostic ultrasound arrays has allowed planar mapping of bubble acoustic emissions to be overlaid with B-mode anatomical images, with a variety of beamforming approaches providing enhanced resolution at the cost of extended computation times. However, no passive signal processing techniques implemented to date have overcome the fundamental physical limitation of the conventional diagnostic array aperture that results in point spread functions with axial/lateral beamwidth ratios of nearly an order of magnitude. To mitigate this problem, the use of a pair of orthogonally oriented diagnostic arrays was recently proposed, with potential benefits arising from the substantially expanded range of observation angles. This article presents experiments and simulations intended to demonstrate the performance and limitations of the dual-array system concept. The key finding of this study is that source pair resolution of better than 1 mm is now possible in both dimensions of the imaging plane using a pair of 7.5-MHz center frequency conventional arrays at a distance of 7.6cm. With an eye toward accelerating computations for real-time applications, channel count reductions of up to a factor of eight induce negligible performance losses. Modest sensitivities to sound speed and relative array position uncertainties were identified, but if these can be kept on the order of 1% and 1 mm, respectively, then the proposed methods offer the potential for a step improvement in cavitation monitoring capability.

Quantifying cell death induced by doxorubicin, hyperthermia or HIFU ablation with flow cytometry

Triggered release and targeted drug delivery of potent anti-cancer agents using hyperthermia-mediated focused-ultrasound (FUS) is gaining momentum in the clinical setting. In early phase studies, tissue biopsy samples may be harvested to assess drug delivery efficacy and demonstrate lack of instantaneous cell death due to FUS exposure. We present an optimised tissue cell recovery method and a cell viability assay, compatible with intra-cellular doxorubicin. Flow cytometry was used to determine levels of cell death with suspensions comprised of: (i) HT29 cell line exposed to hyperthermia (30 min at 47 °C) and/or doxorubicin, or ex-vivo bovine liver tissue exposed to (ii) hyperthermia (up to 2 h at 45 °C), or (iii) ablative high intensity FUS (HIFU). Flow cytometric analysis revealed maximal cell death in HT29 receiving both heat and doxorubicin insults and increases in both cell granularity (p < 0.01) and cell death (p < 0.01) in cells recovered from ex-vivo liver tissue exposed to hyperthermia and high pressures of HIFU (8.2 MPa peak-to-peak free-field at 1 MHz) relative to controls. Ex-vivo results were validated with microscopy using pan-cytokeratin stain. This rapid, sensitive and highly quantitative cell-viability method is applicable to the small masses of liver tissue typically recovered from a standard core biopsy (5-20 mg) and may be applied to tissues of other histological origins including immunostaining.

Acoustic Coupling Quantification in Ultrasound-Guided Focused Ultrasound Surgery: Simulation-Based Evaluation and Experimental Feasibility Study

Adequate acoustic coupling between the therapeutic transducer and the patient's body is essential for safe and efficient focused ultrasound surgery (FUS). There is currently no quantitative method for acoustic coupling verification in ultrasound-guided FUS. In this work, a quantitative method was developed and a related metric was introduced: the acoustic coupling coefficient. This metric associates the adequacy of the acoustic coupling with the reflected signals recorded through an imaging probe during a low-energy sonication. The acoustic coupling issue was simulated in silico and validated through in vitro tests. Our results indicated a sigmoidal behavior of the introduced metric as the contact surface between the coupling system and the patient's skin increases. The proposed method could be a safety-check criterion for verifying the adequacy of the acoustic coupling before starting the FUS treatment, thus ensuring efficient energy transmission to the target and preventing damage to both the patient and the instrumentation.

Chlorpyrifos removal: Nb/boron-doped diamond anode coupled with solid polymer electrolyte and ultrasound irradiation

Chlorpyrifos is an organophosphorus insecticide, acaricide and miticide used worldwide for the control of soil-borne insect pests. It must be considered as a substance of growing concern, given its use, toxicity, environmental occurrence, and potential for regional to long-range atmospheric transport. Considering the incomplete removal attained by conventional water treatment processes, we investigated the efficiency of electrolytic radicals production and sonoelectrolysis on the degradation of the pesticide. The treatment has been conducted in a novel electrochemical reactor, equipped with a boron-doped diamond anode and a solid polymer electrolyte (SPE). Different current intensity and times have been tested and coupled with sonication at 40 kHz. Up to 69% of chlorpyrifos was completely removed in 10 min by electrolysis operated at 0.1 mA, while 12.5% and 5.4% was converted into the treatment intermediates 3,5,6-trichloro-2-pyridinol (TCP) and diethyl (3,5,6-trichloropyridin-2-yl) phosphate, respectively. Ultrasound irradiation did not enhance the removal efficiency, likely due to mass transport limitations, while the energy consumption increased from 8.68∙10- 6 to 9.34∙10- 4 kWh µg- 1 removed. Further research is encouraged, given the promising processing by the SPE technology of low conductivity solutions, as pharmaceuticals streams, as well as the potential for water and in-situ groundwater remediation from different emerging pollutants as phytosanitary and personal care products.

Synergistic Effects of Pulsed Focused Ultrasound and a Doxorubicin-Loaded Microparticle-Microbubble Complex in a Pancreatic Cancer Xenograft Mouse Model

The synergistic effects of a doxorubicin (Dox)-loaded microparticle-microbubble complex (DMMC) and focused ultrasound (FUS) with a short duty cycle (5%) were evaluated in a pancreatic cancer xenograft model established by inoculating immunodeficient mice with CFPAC-1 cells. The efficacy of the DMMC with FUS (study 1), the effect of conjugating the particles as opposed to mixing them (study 2) and the levels of tumor apoptosis and intracellular Dox (study 3) were evaluated. The DMMC with FUS exhibited the lowest tumor growth rate (30.8 mm³/wk) and the highest intracellular Dox uptake (8.8%) and tumor cell apoptosis rate (58.7%) among all treatments. DMMC had a significantly lower growth rate than the mixture of Dox-loaded microparticles and microbubbles (44.2 mm³/wk, p < 0.01) when they were combined with FUS. In conclusion, DMMC with short-duty-cycle FUS holds promise for tumor growth suppression, which may be attributed to high intracellular Dox uptake.

Development and characterization of a tissue mimicking psyllium husk gelatin phantom for ultrasound and magnetic resonance imaging

Purpose: To develop and characterize a tissue-mimicking phantom that enables the direct comparison of magnetic resonance (MR) and ultrasound (US) imaging techniques useful for monitoring high-intensity focused ultrasound (HIFU) treatments. With no additions, gelatin phantoms produce little if any scattering required for US imaging. This study characterizes the MR and US image characteristics as a function of psyllium husk concentration, which was added to increase US scattering.Methods: Gelatin phantoms were constructed with varying concentrations of psyllium husk. The effects of psyllium husk concentration on US B-mode and MR imaging were evaluated at nine different concentrations. T1, T2, and T2* MR maps were acquired. Acoustic properties (attenuation and speed of sound) were measured at frequencies of 0.6, 1.0, 1.8, and 3.0 MHz using a through-transmission technique. Phantom elastic properties were evaluated for both time and temperature dependence.Results: Ultrasound image echogenicity increased with increasing psyllium husk concentration while quality of gradient-recalled echo MR images decreased with increasing concentration. For all phantoms, the measured speed of sound ranged between 1567-1569 m/s and the attenuation ranged between 0.42-0.44 dB/(cm·MHz). Measured T1 ranged from 974-1051 ms. The T2 and T2* values ranged from 97-108 ms and 48-88 ms, respectively, with both showing a decreasing trend with increased psyllium husk concentration. Phantom stiffness, measured using US shear-wave speed measurements, increased with age and decreased with increasing temperature.Conclusions: The presented dual-use tissue-mimicking phantom is easy to manufacture and can be used to compare and evaluate US-guided and MR-guided HIFU imaging protocols.

Spatially-directed cell migration in acoustically-responsive scaffolds through the controlled delivery of basic fibroblast growth factor

Hydrogels are commonly used in regenerative medicine for the delivery of growth factors (GFs). The spatial and temporal presentations of GFs are critical for directing regenerative processes, yet conventional hydrogels do not enable such control. We have developed a composite hydrogel, termed an acoustically-responsive scaffold (ARS), where release of a GF is non-invasively and spatiotemporally-controlled using focused ultrasound. The ARS consists of a fibrin matrix doped with a GF-loaded, phase-shift emulsion. The GF is released when the ARS is exposed to suprathreshold ultrasound via a mechanism termed acoustic droplet vaporization. In this study, we investigate how different spatial patterns of suprathreshold ultrasound can impact the biological response upon in vivo implantation of an ARS containing basic fibroblast growth factor (bFGF). ARSs were fabricated with either perfluorohexane (bFGF-C6-ARS) or perflurooctane (bFGF-C8-ARS) within the phase-shift emulsion. Ultrasound generated stable bubbles in bFGF-C6-ARS, which inhibited matrix compaction, whereas transiently stable bubbles were generated in bFGF-C8-ARS, which decreased in height by 44% within one day of implantation. The rate of bFGF release and distance of host cell migration were up to 6.8-fold and 8.1-fold greater, respectively, in bFGF-C8-ARS versus bFGF-C6-ARS. Ultrasound increased the formation of macropores within the fibrin matrix of bFGF-C8-ARS by 2.7-fold. These results demonstrate that spatially patterning suprathreshold ultrasound within bFGF-C8-ARS can be used to elicit a spatially-directed response from the host. Overall, these findings can be used in developing strategies to spatially pattern regenerative processes. STATEMENT OF SIGNIFICANCE: Hydrogels are commonly used in regenerative medicine for the delivery of growth factors (GFs). The spatial and temporal presentations of GFs are critical for directing regenerative processes, yet conventional hydrogels do not enable such control. We have developed a composite hydrogel, termed an acoustically-responsive scaffold (ARS), where GF release is non-invasively and spatiotemporally-controlled using focused ultrasound. The ARS consists of a fibrin matrix doped with a phase-shift emulsion loaded with GF, which is released when the ARS is exposed to ultrasound. In this in vivo study, we demonstrate that spatially patterning ultrasound within an ARS containing basic fibroblast growth factor (bFGF) can elicit a spatially-directed response from the host. Overall, these findings can be used in developing strategies to spatially pattern regenerative processes.

Robot-assisted ultrasound navigation platform for 3D HIFU treatment planning: Initial evaluation for conformal interstitial ablation

Interstitial Ultrasound-guided High Intensity Focused Ultrasound (USgHIFU) therapy has the potential to deliver ablative treatments which conform to the target tumor. In this study, a robot-assisted US-navigation platform has been developed for 3D US guidance and planning of conformal HIFU ablations. The platform was used to evaluate a conformal therapeutic strategy associated with an interstitial dual-mode USgHIFU catheter prototype (64 elements linear-array, measured central frequency f = 6.5 MHz), developed for the treatment of HepatoCellular Carcinoma (HCC). The platform included a 3D navigation environment communicating in real-time with an open research dual-mode US scanner/HIFU generator and a robotic arm, on which the USgHIFU catheter was mounted. 3D US-navigation was evaluated in vitro for guiding and planning conformal HIFU ablations using a tumor-mimic model in porcine liver. Tumor-mimic volumes were then used as targets for evaluating conformal HIFU treatment planning in simulation. Height tumor-mimics (ovoid- or disc-shaped, sizes: 3-29 cm³) were created and visualized in liver using interstitial 2D US imaging. Robot-assisted spatial manipulation of these images and real-time 3D navigation allowed reconstructions of 3D B-mode US images for accurate tumor-mimic volume estimation (relative error: 4 ± 5%). Sectorial and full-revolution HIFU scanning (angular sectors: 88-360°) could both result in conformal ablations of the tumor volumes, as soon as their radii remained ≤ 24 mm. The presented US navigation-guided HIFU procedure demonstrated advantages for developing conformal interstitial therapies in standard operative rooms. Moreover, the modularity of the developed platform makes it potentially useful for developing other HIFU approaches.

Uterine Myomas: Focused Ultrasound Surgery

Uterine fibroids are the most common neoplasm in women. These lesions may be associated with impaired fertility and adverse obstetric outcomes. Medical treatment, myomectomy, hysterectomy and uterine artery embolization have been employed for the management of uterine fibroids. Focused ultrasound surgery (FUS) is a relatively recent technique that relies on mechanical and thermal energy of ultrasound for the ablation of a target tissue under an imaging guidance, that can be either ultrasound (US-guided FUS, USgFUS) or magnetic resonance (MR-guided FUS, MRgFUS). Pre- and peri-menopausal women are potential candidates for treatment; however, individual criteria need to be evaluated in order to establish the eligibility for the procedure. FUS procedure can be performed in an outpatient setting; it is a safe and effective treatment that has demonstrated to reduce symptoms associated with uterine fibroids. The adverse event rate is 8.7% and only 0.2% of patients experiences major complications. Pregnancy is possible after the treatment, and no damage to the endometrium has been observed following FUS procedure.

Imaging of Thermal Effects during High-Intensity Ultrasound Treatment in Liver by Passive Elastography: A Preliminary Feasibility in Vitro Study

High-intensity focused ultrasound is a non-invasive modality for thermal ablation of tissues through locally increased temperature. Thermal lesions can be monitored by elastography, following the changes in the elastic properties of the tissue as reflected by the shear-wave velocity. Most studies on ultrasound elastography use shear waves created by acoustic radiation force. However, in the human body, the natural noise resulting from cardiac activity or arterial pulsatility can be used to characterize elasticity through noise-correlation techniques, in the method known as passive elastography. The objective of this study was to investigate the feasibility of monitoring high-intensity ultrasound treatments of liver tissue using passive elastography. Bovine livers were heated to 80°C using a high-intensity planar transducer and imaged with a high-frame-rate ultrasound imaging device. The dynamics of lesion formation are captured through tissue stiffening and lesion expansion.

Feasibility study of MR-guided pancreas ablation using high-intensity focused ultrasound in a healthy swine model

Purpose: Pancreatic cancer is typically diagnosed in a late stage with limited therapeutic options. For those patients, ultrasound-guided high-intensity focused ultrasound (US-HIFU) can improve local control and alleviate pain. However, MRI-guided HIFU (MR-HIFU) has not yet been studied extensively in this context. To facilitate related research and accelerate clinical translation, we report a workflow for the in vivo HIFU ablation of the porcine pancreas under MRI guidance.Materials and methods: The pancreases of five healthy German landrace pigs (35-58 kg) were sonicated using a clinical MR-HIFU system. Acoustic access to the pancreas was supported by a specialized diet and a hydrogel compression device for bowel displacement. Organ motion was suspended using periods of apnea. The size of the resulting thermal lesions was assessed using the thermal threshold- and dose profiles, non-perfused volume, and gross examination. The effect of the compression device on beam path length was assessed using MRI imaging.Results: Eight of ten treatments resulted in clearly visible damage in the target tissue upon gross examination. Five treatments resulted in coagulative necrosis. Good agreement between the four metrics for lesion size and a clear correlation between the delivered energy dose and the resulting lesion size were found. The compression device notably shortened the intra-abdominal beam path.Conclusions: We demonstrated a workflow for HIFU treatment of the porcine pancreas in-vivo under MRI-guidance. This development bears significance for the development of MR-guided HIFU interventions on the pancreas as the pig is the preferred animal model for the translation of pre-clinical research into clinical application.

Precision Targeted Ablation of Fine Neurovascular Structures In Vivo Using Dual-mode Ultrasound Arrays

Carotid bodies (CBs) are chemoreceptors that monitor and register changes in the blood, including the levels of oxygen, carbon dioxide, and pH, and regulate breathing. Enhanced activity of CBs was shown to correlate with a significant elevation in the blood pressure of patients with hypertension. CB removal or denervation were previously shown to reduce hypertension. Here we demonstrate the feasibility of a dual-mode ultrasound array (DMUA) system to safely ablate the CB in vivo in a spontaneously hypertensive rat (SHR) model of hypertension. DMUA imaging was used for guiding and monitoring focused ultrasound (FUS) energy delivered to the target region. In particular, 3D imaging was used to identify the carotid bifurcation for targeting the CBs. Intermittent, high frame rate imaging during image-guided FUS (IgFUS) delivery was used for monitoring the lesion formation. DMUA imaging provided feedback for closed-loop control (CLC) of the lesion formation process to avoid overexposure. The procedure was tolerated well in over 100 SHR and normotensive rats that received unilateral and bilateral treatments. The measured mean arterial pressure (MAP) exhibited measurable deviation from baseline 2–4 weeks post IgFUS treatment. The results suggest that the direct unilateral FUS treatment of the CB might be sufficient to reduce the blood pressure in hypertensive rats and justify further investigation in large animals and eventually in human patients.

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.

A Pilot Study for a Quantitative Evaluation of Acoustic Coupling in US-guided Focused Ultrasound Surgery

In Ultrasound-guided High Intensity Focused Ultrasound (USgHIFU) surgery, the verification of the acoustic coupling correctness between the HIFU transducer and the patient's body is a fundamental step for an efficient and safe therapy. Nowadays, clinicians perform this check by qualitative inspecting Ultrasound images. The aim of this study is the introduction of an objective index to quantitively evaluate the coupling on the base of the radiofrequency echo signals acquired during a low-energy HIFU shot. The experimental session involved a tissue mimicking phantom and a robotic system composed by a HIFU therapeutic transducer and a 2D confocal Ultrasound probe. 15 different coupling conditions between the phantom and the transducer were tested: in each of them, the maximum absolute value of the Fourier Transform of the echo signals was computed and employed to determine an Acoustic Coupling (AC) coefficient.This metrics showed a sigmoidal trend between AC coefficient and coupling increase. This curve can be employed as a calibration tool to quantitatively assess the correctness of the therapeutic set-up before starting the HIFU treatment.

Four-dimensional optoacoustic monitoring of tissue heating with medium intensity focused ultrasound

Medium-intensity focused ultrasound (MIFU) concerns therapeutic ultrasound interventions aimed at stimulating physiological mechanisms to reinforce healing responses without reaching temperatures that can cause permanent tissue damage. The therapeutic outcome is strongly affected by the temperature distribution in the treated region and its accurate monitoring represents an unmet clinical need. In this work, we investigate on the capacities of four-dimensional optoacoustic tomography to monitor tissue heating with MIFU. Calibration experiments in a tissue-mimicking phantom have confirmed that the optoacoustically-estimated temperature variations accurately match the simultaneously acquired thermocouple readings. The performance of the suggested approach in real tissues was further shown with bovine muscle samples. Volumetric temperature maps were rendered in real time, allowing for dynamic monitoring of the ultrasound focal region, estimation of the peak temperature and the size of the heat-affected volume.

Focused Ultrasound Hyperthermia for Targeted Drug Release from Thermosensitive Liposomes: Results from a Phase I Trial

Purpose To demonstrate the feasibility and safety of using focused ultrasound planning models to determine the treatment parameters needed to deliver volumetric mild hyperthermia for targeted drug delivery without real-time thermometry. Materials and Methods This study was part of the Targeted Doxorubicin, or TARDOX, phase I prospective trial of focused ultrasound-mediated, hyperthermia-triggered drug delivery to solid liver tumors ( ClinicalTrials.gov identifier NCT02181075). Ten participants (age range, 49-68 years; average age, 60 years; four women) were treated from March 2015 to March 2017 by using a clinically approved focused ultrasound system to release doxorubicin from lyso-thermosensitive liposomes. Ultrasonic heating of target tumors (treated volume: 11-73 cm³ [mean ± standard deviation, 50 cm³ ± 26]) was monitored in six participants by using a minimally invasive temperature sensor; four participants were treated without real-time thermometry. For all participants, CT images were used with a patient-specific hyperthermia model to define focused ultrasound treatment plans. Feasibility was assessed by comparing model-prescribed focused ultrasound powers to those implemented for treatment. Safety was assessed by evaluating MR images and biopsy specimens for evidence of thermal ablation and monitoring adverse events. Results The mean difference between predicted and implemented treatment powers was -0.1 W ± 17.7 (n = 10). No evidence of focused ultrasound-related adverse effects, including thermal ablation, was found. Conclusion In this 10-participant study, the authors confirmed the feasibility of using focused ultrasound-mediated hyperthermia planning models to define treatment parameters that safely enabled targeted, noninvasive drug delivery to liver tumors while monitored with B-mode guidance and without real-time thermometry. Published under a CC BY 4.0 license. Online supplemental material is available for this article. See also the editorial by Dickey and Levi-Polyachenko in this issue.