Volume 4 Supplement 1
5th International Symposium on Focused Ultrasound
- Menashe Zaaroor1,
- Alon Sinai1,
- Dorit Goldsher1,
- Ayelet Eran1,
- Maria Nassar1,
- Ilana Schlesinger1,
- Jonathon Parker2,
- Vinod Ravikumar2,
- Pejman Ghanouni2,
- Sherman Stein3,
- Casey Halpern2,
- Vibhor Krishna4,
- Amelia Hargrove4,
- Punit Agrawal4,
- Barbara Changizi4,
- Eric Bourekas4,
- Michael Knopp4,
- Ali Rezai4,
- Brian Mead5,
- Namho Kim6,
- Panagiotis Mastorakos6,
- Jung Soo Suk6,
- Wilson Miller5,
- Alexander Klibanov5,
- Justin Hanes6,
- Richard Price5,
- Shutao Wang7,
- Oluyemi Olumolade7,
- Tara Kugelman7,
- Vernice Jackson-Lewis7,
- Maria Eleni (Marilena) Karakatsani7,
- Yang Han7,
- Serge Przedborski7,
- Elisa Konofagou7,
- Kullervo Hynynen8,
- Isabelle Aubert9,
- Gerhard Leinenga10,
- Rebecca Nisbet11,
- Robert Hatch10,
- Anneke Van der Jeugd12,
- Harrison Evans11,
- Jürgen Götz11,
- Jürgen Götz11,
- Rebecca Nisbet11,
- Ann Van der Jeugd11,
- Harrison Evans11,
- Gerhard Leinenga10,
- Paul Fishman13,
- Paul Yarowsky14,
- Victor Frenkel15,
- Shen Wei-Bin15,
- Ben Nguyen15,
- Carlos Sierra Sanchez7,
- Camilo Acosta7,
- Cherry Chen7,
- Shih-Ying Wu7,
- Maria Eleni (Marilena) Karakatsani7,
- Elisa Konofagou7,
- Muna Aryal16, 17,
- Iason T. Papademetriou18,
- Yong-Zhi Zhang17,
- Chanikarn Power16, 17,
- Nathan McDannold1, 17,
- Tyrone Porter18,
- Zsofia Kovacs19,
- Saejeong Kim19,
- Neekita Jikaria19,
- Farhan Qureshi20,
- Michele Bresler20,
- Joseph Frank20,
- Henrik Odéen21,
- George Chiou16, 17,
- John Snell22,
- Nick Todd16,
- Bruno Madore16, 17,
- Dennis Parker21,
- Kim Butts Pauly2,
- Mike Marx2,
- Pejman Ghanouni2,
- Sumeeth Jonathan23,
- William Grissom23,
- Costas Arvanitis24,
- Nathan McDannold16, 17,
- Gregory Clement25,
- Dennis Parker21,
- Joshua de Bever21,
- Henrik Odéen21,
- Allison Payne21,
- Douglas Christensen21,
- Guillaume Maimbourg26,
- Mathieu David Santin27,
- Alexandre Houdouin26,
- Stéphane Lehericy27,
- Mickael Tanter26,
- Jean Francois Aubry26,
- Kim Butts Pauly2,
- Christian Federau2,
- Beat Werner28,
- Casey Halpern2,
- Pejman Ghanouni2,
- Dong-Guk Paeng22, 29,
- Zhiyuan Xu5,
- John Snell22,
- Anders Quigg22,
- Matt Eames22,
- Changzhu Jin22,
- Ashli Everstine5,
- Jason Sheehan5,
- M. Beatriz Lopes5,
- Neal Kassell22,
- John Snell22,
- Anders Quigg22,
- James Drake30,
- Karl Price31,
- Lior Lustgarten30,
- Vivian Sin31,
- Charles Mougenot32,
- Elizabeth Donner30,
- Emily Tam30,
- Mojgan Hodaie33,
- Adam Waspe30,
- Thomas Looi31,
- Samuel Pichardo34,
- Wonhye Lee16,
- Yong An Chung35,
- Yujin Jung35,
- In-Uk Song35,
- Seung-Schik Yoo16,
- Wonhye Lee16,
- Hyun-Chul Kim36,
- Yujin Jung35,
- Yong An Chung35,
- In-Uk Song35,
- Jong-Hwan Lee36,
- Seung-Schik Yoo16,
- Charles Caskey23,
- Wolf Zinke23,
- Josh Cosman23,
- Jillian Shuman23,
- Jeffrey Schall23,
- Christian Aurup7,
- Shutao Wang7,
- Hong Chen37,
- Camilo Acosta37,
- Elisa Konofagou37,
- Hermes Kamimura38,
- Antonio Carneiro38,
- Nick Todd16,
- Tao Sun16, 17,
- Yong-Zhi Zhang17,
- Chanikarn Power16, 17,
- Navid Nazai18,
- Sam Patz16,
- Margaret Livingstone17,
- Nathan McDannold16, 17,
- Todd Mainprize8,
- Yuexi Huang39,
- Ryan Alkins40,
- Martin Chapman40,
- James Perry9,
- Nir Lipsman8,
- Allison Bethune8,
- Arjun Sahgal9,
- Maureen Trudeau9,
- Kullervo Hynynen8,
- Hao-Li Liu41,
- Po-Hung Hsu41,
- Kuo-Chen Wei42,
- Tao Sun16, 17,
- Chanikarn Power16, 17,
- Yong-Zhi Zhang17,
- Jonathan Sutton16, 17,
- Phillip Alexander16, 17,
- Muna Aryal16, 17,
- Eric Miller43,
- Nathan McDannold16, 17,
- Thiele Kobus44,
- Yong-Zhi Zhang17,
- Nathan McDannold16, 17,
- Alexandre Carpentier45,
- Michael Canney46,
- Alexandre Vignot47,
- Kevin Beccaria45,
- Delphine Leclercq45,
- Cyril Lafon5, 48,
- Jean Yves Chapelon48,
- Khe Hoang-Xuan49,
- Jean-Yves Delattre45,
- Ahmed Idbaih45,
- Zhiyuan Xu5,
- David Moore22,
- Alexis Xu5,
- Paul Schmitt50,
- John Snell22,
- Jessica Foley22,
- Matt Eames22,
- Jason Sheehan5,
- Neal Kassell22,
- Jonathan Sukovich51,
- Charles Cain51,
- Zhiyuan Xu5,
- Aditya Pandey51,
- John Snell22,
- Neeraj Chaudhary51,
- Sandra Camelo-Piragua51,
- Steven Allen51,
- Dong-Guk Paeng29,
- Jon Cannata52,
- Dejan Teofilovic52,
- Jim Bertolina52,
- Neal Kassell22,
- Timothy Hall51,
- Zhen Xu51,
- Shih-Ying Wu7,
- Maria Eleni (Marilena) Karakatsani7,
- Julien Grondin7,
- Carlos Sierra Sanchez7,
- Vincent Ferrera7,
- Elisa Konofagou7,
- Gail ter Haar53,
- Petros Mouratidis53,
- Elizabeth Repasky54,
- Kelsie Timbie5, 22,
- Lena Badr5,
- Benjamin Campbell5,
- John McMichael5,
- Andrew Buckner5,
- Jessica Prince5,
- Aaron Stevens5,
- Timothy Bullock5,
- Richard Price5,
- Karin Skalina55,
- Chandan Guha56,
- Franco Orsi,
- Guido Bonomo57,
- Paolo Della Vigna57,
- Giovanni Mauri57,
- Gianluca Varano57,
- George Schade58,
- Yak-Nam Wang58,
- Venu Pillarisetty58,
- Joo Ha Hwang58,
- Vera Khokhlova58,
- Michael Bailey58,
- Tatiana Khokhlova58,
- Vera Khokhlova58,
- Ilya Sinilshchikov59,
- Petr Yuldashev59,
- Yulia Andriyakhina59,
- Wayne Kreider58,
- Adam Maxwell58,
- Tatiana Khokhlova58,
- Oleg Sapozhnikov58,
- Ari Partanen60,
- Jonathan Lundt51,
- Steven Allen51,
- Jonathan Sukovich51,
- Timothy Hall51,
- Charles Cain51,
- Zhen Xu51,
- Tobias Preusser61, 62,
- Sabrina Haase61,
- Mario Bezzi63,
- Jürgen Jenne64,
- Thomas Langø65,
- Massimo Midiri66,
- Michael Mueller67,
- Giora Sat68,
- Christine Tanner69,
- Stephan Zangos70,
- Matthias Guenther61,
- Andreas Melzer71,
- Arianna Menciassi72,
- Selene Tognarelli72,
- Andrea Cafarelli72,
- Alessandro Diodato72,
- Gastone Ciuti72,
- Sven Rothluebbers61,
- Julia Schwaab64,
- Jan Strehlow61,
- Senay Mihcin73,
- Christine Tanner69,
- Steffen Tretbar74,
- Tobias Preusser61, 62,
- Matthias Guenther61,
- Jürgen Jenne61,
- Thomas Payen7,
- Carmine Palermo7,
- Steve Sastra7,
- Hong Chen37,
- Yang Han7,
- Kenneth Olive7,
- Elisa Konofagou7,
- Matthew Adams75,
- Vasant Salgaonkar76,
- Serena Scott76,
- Graham Sommer2,
- Chris Diederich77,
- Joan Vidal-Jove78,
- Eloi Perich79,
- Antonio Ruiz79,
- Manuela Velat79,
- David Melodelima80,
- Aurelien Dupre81,
- Jeremy Vincenot80,
- Chen Yao81,
- David Perol81,
- Michel Rivoire81,
- Samantha Tucci82,
- Lisa Mahakian82,
- Brett Fite82,
- Elizabeth Ingham82,
- Sarah Tam82,
- Chang-il Hwang83,
- David Tuveson83,
- Katherine Ferrara82,
- Stephen Scionti84,
- Lili Chen85,
- Dusica Cvetkovic85,
- Xiaoming Chen85,
- Roohi Gupta85,
- Bin Wang85,
- Charlie Ma85,
- Kenneth Bader86,
- Kevin Haworth86,
- Adam Maxwell58,
- Christy Holland86,
- Narendra Sanghvi87,
- Roy Carlson87,
- Wohsing Chen88,
- Christian Chaussy89,
- Stefan Thueroff90,
- Claudio Cesana91,
- Carlo Bellorofonte91,
- Qingguo Wang92,
- Han Wang93,
- Shengping Wang,
- Junhai Zhang94,
- Alberto Bazzocchi95,
- Alessandro Napoli96,
- Robert Staruch97,
- Chenchen Bing98,
- Sumbul Shaikh98,
- Joris Nofiele98,
- Debra Szczepanski98,
- Michelle Wodzak Staruch99,
- Noelle Williams98,
- Theodore Laetsch98,
- Rajiv Chopra98,
- Pejman Ghanouni2,
- Jarrett Rosenberg2,
- Rachelle Bitton2,
- Alessandro Napoli100,
- Suzanne LeBlang22,
- Joshua Meyer85,
- Mark Hurwitz101,
- Kim Butts Pauly2,
- Ari Partanen60,
- Pavel Yarmolenko102,
- Ari Partanen102,
- Haydar Celik102,
- Avinash Eranki103,
- Viktoriya Beskin103,
- Domiciano Santos103,
- Janish Patel103,
- Matthew Oetgen103,
- AeRang Kim103,
- Peter Kim103,
- Karun Sharma103,
- Alexander Chisholm104,
- James Drake105,
- Dionne Aleman104,
- Adam Waspe105,
- Thomas Looi106,
- Samuel Pichardo107,
- Alessandro Napoli108,
- Alberto Bazzocchi109,
- Roberto Scipione110,
- Michael Temple111,
- Adam Waspe111,
- Joao Guilherme Amaral111,
- Yuexi Huang112,
- Ruby Endre112,
- Maria Lamberti-Pasculli111,
- Joost de Ruiter111,
- Fiona Campbell111,
- Jennifer Stimec111,
- Samit Gupta111,
- Manoj Singh111,
- Charles Mougenot113,
- Sevan Hopyan111,
- Kullervo Hynynen112,
- Gregory Czarnota112,
- James Drake111,
- David Brenin114,
- Carrie Rochman114,
- Roussanka Kovatcheva115,
- Jordan Vlahov115,
- Katja Zaletel116,
- Julian Stoinov115,
- Yang Han117,
- Shutao Wang117,
- Elisa Konofagou117,
- Matthew Bucknor118,
- Viola Rieke118,
- Jenny Shim119, 120,
- Robert Staruch120,
- Korgun Koral121,
- Rajiv Chopra121,
- Theodore Laetsch121,
- Brian Lang122,
- Carlos Wong122,
- Heather Lam123,
- Roussanka Kovatcheva124,
- Jordan Vlahov125,
- Katja Zaletel124,
- Julian Stoinov125,
- Alexander Shinkov126,
- Jim Hu127,
- Karun Sharma128,
- Xi Zhang129,
- Jonathan Macoskey129,
- Kimberly Ives129,
- Gabe Owens129,
- Hitinder Gurm129,
- Jiaqi Shi129,
- Matthew Pizzuto129,
- Charles Cain129,
- Zhen Xu129,
- Allison Payne130,
- Christopher Dillon130,
- Ivy Christofferson130,
- Elaine Hilas130,
- Jill Shea130,
- Paul Greillier131,
- Bénédicte Ankou132,
- Francis Bessière132,
- Ali Zorgani131,
- Mathieu Pioche132,
- Wojciech Kwiecinski133,
- Julie Magat134,
- Sandrine Melot-Dusseau135,
- Romain Lacoste135,
- Bruno Quesson134,
- Mathieu Pernot133,
- Stefan Catheline131,
- Philippe Chevalier132,
- Cyril Lafon136,
- Fabrice Marquet137,
- Pierre Bour137,
- Fanny Vaillant137,
- Sana Amraoui137,
- Rémi Dubois137,
- Philippe Ritter137,
- Michel Haïssaguerre137,
- Mélèze Hocini137,
- Olivier Bernus137,
- Bruno Quesson137,
- Pamela Tebebi138,
- Scott Burks139,
- Saejeong Kim139,
- Blerta Milo139,
- Joseph Frank139,
- Michael Gertner140,
- Jimin Zhang140,
- Andrew Wong141,
- Brett Fite141,
- Yu Liu141,
- Azadeh Kheirolomoom141,
- Jai Seo141,
- Katherine Watson141,
- Lisa Mahakian141,
- Sarah Tam141,
- Hua Zhang141,
- Josquin Foiret141,
- Alexander Borowsky141,
- Katherine Ferrara141,
- Doudou Xu142,
- Andreas Melzer143,
- Maya Thanou144,
- Miguell Centelles144,
- Mike Wright144,
- Maral Amrahli144,
- Po-Wah So144,
- Wladyslaw Gedroyc145,
- Miguell Centelles146,
- Mike Wright146,
- Wladyslaw Gedroyc147,
- Maya Thanou146,
- Esther Kneepkens148,
- Edwin Heijman149,
- Jochen Keupp150,
- Steffen Weiss150,
- Klaas Nicolay148,
- Holger Grüll149,
- Brett Fite151,
- Andrew Wong151,
- Yu Liu151,
- Azadeh Kheirolomoom151,
- Lisa Mahakian151,
- Sarah Tam151,
- Josquin Foiret151,
- Katherine Ferrara151,
- Scott Burks152,
- Matthew Nagle152,
- Saejeong Kim152,
- Blerta Milo152,
- Joseph Frank152,
- Oleg Sapozhnikov153,
- Anastasia V. Nikolaeva154,
- Marina E. Terzi154,
- Sergey A. Tsysar154,
- Adam Maxwell153,
- Bryan Cunitz153,
- Michael Bailey153,
- Pierre Mourad155,
- Matthew Downs156,
- Georgiana Yang156,
- Qi Wang156,
- Elisa Konofagou156,
- Scott Burks157,
- Matthew Nagle157,
- Ben Nguyen157,
- Michele Bresler157,
- Saejeong Kim157,
- Blerta Milo157,
- Joseph Frank157,
- Scott Burks158,
- Matthew Nagle158,
- Saejeong Kim159,
- Blerta Milo158,
- Joseph Frank158,
- Johnny Chen160,
- Justin Farry160,
- Adam Dixon160,
- Zhongmin Du160,
- Ali Dhanaliwala160,
- John Hossack160,
- Alexander Klibanov160,
- Ashish Ranjan161,
- Danny Maples161,
- Rajiv Chopra162,
- Chenchen Bing162,
- Robert Staruch163,
- Rachel Wardlow161,
- Michelle Wodzak Staruch164,
- Jerry Malayer161,
- Akhilesh Ramachandran161,
- Joris Nofiele162,
- Hirofumi Namba165,
- Motohiro Kawasaki165,
- Masashi Izumi165,
- Katsuhito Kiyasu165,
- Ryuichi Takemasa165,
- Masahiko Ikeuchi165,
- Takahiro Ushida166,
- Calum Crake167, 168,
- Iason T. Papademetriou169,
- Yong-Zhi Zhang168,
- Tyrone Porter169,
- Nathan McDannold167, 168,
- Satya V. V. N. Kothapalli170,
- Wan Leighton170,
- Zhaorui Wang170,
- Ari Partanen171,
- H. Michael Gach170,
- William Straube170,
- Michael Altman170,
- Hong Chen170,
- Young-sun Kim172,
- Hyo Keun Lim172,
- Hyunchul Rhim172,
- Young-sun Kim173,
- Hyo Keun Lim173,
- Hyunchul Rhim173,
- Johanna van Breugel174,
- Manon Braat174,
- Chrit Moonen174,
- Maurice van den Bosch174,
- Mario Ries174,
- Cristina Marrocchio175,
- Susan Dababou175,
- Rachelle Bitton176,
- Kim Butts Pauly176,
- Pejman Ghanouni176,
- Jae Young Lee177,
- Jae Young Lee177,
- Hyun Hoon Chung177,
- Soo Yeon Kang177,
- Kook Jin Kang178,
- Keon Ho Son178,
- Dandan Zhang179,
- Matthew Adams180,
- Vasant Salgaonkar180,
- Juan Plata181,
- Peter Jones180,
- Aurea Pascal-Tenorio181,
- Donna Bouley181,
- Graham Sommer181,
- Kim Butts Pauly181,
- Chris Diederich180,
- Aaron Bond182,
- Robert Dallapiazza182,
- Diane Huss182,
- Amy Warren182,
- Scott Sperling182,
- Ryder Gwinn183,
- Binit Shah182,
- W. Jeff Elias182,
- Colleen Curley184,
- Ying Zhang184,
- Karina Negron185,
- Wilson Miller184,
- Alexander Klibanov184,
- Roger Abounader184,
- Jung Soo Suk186,
- Justin Hanes186,
- Richard Price184,
- Maria Eleni (Marilena) Karakatsani187,
- Gesthimani Samiotaki187,
- Shutao Wang187,
- Tara Kugelman187,
- Camilo Acosta187,
- Elisa Konofagou187,
- Zsofia Kovacs188,
- Tsang-Wei Tu188,
- Georgios Papadakis188,
- Dima Hammoud188,
- Joseph Frank188,
- Matthew Silvestrini189,
- Frank Wolfram190,
- Daniel Güllmar191,
- Juergen Reichenbach191,
- Denis Hofmann192,
- Joachim Böttcher192,
- Harald Schubert193,
- Thomas G. Lesser192,
- Scott Almquist194,
- Dennis Parker194,
- Douglas Christensen194,
- Francisco Camarena195,
- Sergio Jiménez-Gambín195,
- Noé Jiménez196,
- Elisa Konofagou197,
- Jin Woo Chang198,
- Vandiver Chaplin199,
- Rebekah Griesenauer200,
- Michael Miga200,
- Charles Caskey200,
- Nicholas Ellens201,
- Raag Airan202,
- Alfredo Quinones-Hinojosa201,
- Keyvan Farahani203,
- Ari Partanen204,
- Xue Feng205,
- Samuel Fielden205,
- Li Zhao205,
- Wilson Miller205,
- Max Wintermark205,
- Kim Butts Pauly206,
- Craig Meyer205,
- Sijia Guo207,
- Xin Lu207,
- Jiachen Zhuo207,
- Su Xu207,
- Rao Gullapalli207,
- Dheeraj Gandhi207,
- Changzhu Jin208,
- Omer Brokman209,
- Matt Eames208,
- John Snell208,
- Dong-Guk Paeng208,
- Hongchae Baek210,
- Hyungmin Kim210,
- Steven Leung211,
- Taylor Webb211,
- Kim Butts Pauly211,
- Nathan McDannold212,
- Yong-Zhi Zhang213,
- Natalia Vykhodtseva212,
- Thai-Son Nguyen214,
- Jonathan Sukovich214,
- Timothy Hall214,
- Zhen Xu214,
- Charles Cain214,
- Chang Kyu Park215,
- Sang Man Park215,
- Na Young Jung215,
- Min Soo Kim215,
- Won Seok Chang215,
- Hyun Ho Jung215,
- Jin Woo Chang216,
- Samuel Pichardo217,
- Kullervo Hynynen218,
- Michael Plaksin219,
- Yoni Weissler219,
- Shy Shoham219,
- Eitan Kimmel219,
- Anders Quigg220,
- John Snell220,
- Dong-Guk Paeng220, 221, 222,
- Matt Eames220,
- Oleg Sapozhnikov223,
- Pavel B. Rosnitskiy224,
- Vera Khokhlova223,
- Shy Shoham225,
- Steve Krupa226,
- Eilon Hazan226,
- Omer Naor226,
- Yoav Levy225,
- Noam Maimon225,
- Inbar Brosh226,
- Eitan Kimmel226,
- Itamar Kahn226,
- Jonathan Sukovich227,
- Zhen Xu227,
- Timothy Hall227,
- Steven Allen227,
- Charles Cain227,
- Jessica Cahill228,
- Tao Sun229,
- Yong-Zhi Zhang230,
- Chanikarn Power229,
- Margaret Livingstone230,
- Nathan McDannold229,
- Nick Todd231,
- Elodie Constanciel Colas232,
- Adrian Wydra233,
- Adam Waspe234,
- Thomas Looi232,
- Roman Maev233,
- Samuel Pichardo235,
- James Drake234,
- Amirah Aly236,
- Tao Sun237,
- Yong-Zhi Zhang238,
- Ozge Sesenoglu-Laird239,
- Linas Padegimas239,
- Mark Cooper239,
- Nathan McDannold237,
- Barbara Waszczak236,
- Seruz Tehrani240,
- Wilson Miller240,
- Craig Slingluff240,
- James Larner240,
- Kumari Andarawewa240,
- Matthew Bucknor241,
- Eugene Ozhinsky241,
- Rutwik Shah241,
- Roland Krug241,
- Viola Rieke241,
- Roel Deckers242,
- Sabine Linn242,
- Britt Suelmann242,
- Manon Braat242,
- Arjen Witkamp242,
- Paul Vaessen242,
- Paul van Diest242,
- Lambertus W. Bartels242,
- Clemens Bos242,
- Maurice van den Bosch242,
- Nicolas Borys243,
- Gert Storm244,
- Elsken Van der Wall242,
- Chrit Moonen242,
- Navid Farr245,
- Moez Alnazeer245,
- Pavel Yarmolenko246,
- Prateek Katti245,
- Ari Partanen247,
- Avinash Eranki248,
- Peter Kim248,
- Bradford Wood245,
- Alexis Farrer249,
- Scott Almquist249,
- Christopher Dillon249,
- Dennis Parker249,
- Douglas Christensen249,
- Allison Payne249,
- Cyril Ferrer250,
- Lambertus W. Bartels250,
- Baudouin Denis de Senneville250,
- Marijn van Stralen250,
- Chrit Moonen250,
- Clemens Bos250,
- Yu Liu251,
- Jingfei Liu251,
- Brett Fite251,
- Josquin Foiret251,
- J. Kent Leach251,
- Katherine Ferrara251,
- Roohi Gupta252,
- Dusica Cvetkovic252,
- Charlie Ma252,
- Lili Chen252,
- Sabrina Haase253,
- Stephan Zidowitz253,
- Andreas Melzer254,
- Tobias Preusser253, 255,
- Hsin-Lun Lee256,
- Fang-Chi Hsu256,
- Chia-Chun Kuo256,
- Shiu-Chen Jeng256,
- Tung-Ho Chen256,
- Nai-Yi Yang256,
- Jeng-Fong Chiou256,
- Shiu-Chen Jeng257,
- Yi-tzu Kao257,
- Chia-Hsin Pan257,
- Jing-Fu Wu257,
- Tung-Ho Chen257,
- Fang-Chi Hsu257,
- Hsin-Lun Lee257,
- Jeng-Fong Chiou257,
- Fang-Chi Hsu258,
- Yi-Chieh Tsai258,
- Hsin-Lun Lee258,
- Jeng-Fong Chiou258,
- Sara Johnson259,
- Dennis Parker259,
- Allison Payne259,
- Dawei Li260,
- Ye He260,
- Senay Mihcin261,
- Ioannis Karakitsios262,
- Jan Strehlow263,
- Michael Schwenke263,
- Sabrina Haase263,
- Daniel Demedts263,
- Yoav Levy264,
- Tobias Preusser263, 265,
- Andreas Melzer262,
- Senay Mihcin266,
- Sven Rothluebbers267,
- Ioannis Karakitsios268,
- Xu Xiao269,
- Jan Strehlow267,
- Daniel Demedts267,
- Ian Cavin270,
- Giora Sat271,
- Tobias Preusser267, 272,
- Andreas Melzer268,
- Emilee Minalga273,
- Allison Payne273,
- Robb Merrill273,
- Dennis Parker273,
- Rock Hadley273,
- Pascal Ramaekers274,
- Mario Ries274,
- Chrit Moonen274,
- Martijn de Greef274,
- Kian Shahriari275,
- Mohammad Hossein Parvizi275,
- Kiana Asadnia275,
- Marzieh Chamanara275,
- Seyed Kamran Kamrava276,
- Hamid Reza Chabok277,
- Michael Schwenke278,
- Jan Strehlow278,
- Daniel Demedts278,
- Christine Tanner279,
- Sven Rothluebbers278,
- Tobias Preusser278, 280,
- Jan Strehlow281,
- Ruben Stein281,
- Daniel Demedts281,
- Michael Schwenke281,
- Sven Rothluebbers281,
- Tobias Preusser281, 282,
- Daniel Demedts283,
- Sabrina Haase283,
- Sébastien Muller284,
- Jan Strehlow283,
- Thomas Langø284,
- Tobias Preusser283, 285,
- Jeremy Tan287,
- Cornel Zachiu287,
- Pascal Ramaekers287,
- Chrit Moonen287,
- Mario Ries287,
- Frank Wolfram288,
- Daniel Güllmar289,
- Harald Schubert290,
- Thomas G. Lesser288,
- Hans-Peter Erasmus291, 293,
- Elodie Constanciel Colas292,
- Adam Waspe293,
- Charles Mougenot294,
- Thomas Looi292,
- Glen Van Arsdell293,
- Lee Benson293,
- James Drake293,
- Kee W. Jang295,
- Tsang-Wei Tu295,
- Neekita Jikaria296,
- Matthew Nagle295,
- Mary Angstadt295,
- Bobbi Lewis295,
- Farhan Qureshi295,
- Scott Burks295,
- Joseph Frank295,
- Hailey McLean297,
- Allison Payne297,
- Martijn Hoogenboom298,
- Dylan Eikelenboom298,
- Martijn den Brok298,
- Pieter Wesseling298,
- Arend Heerschap298,
- Jurgen Fütterer298,
- Gosse Adema298,
- Kevin Wang299,
- Ying Zhang300,
- Pei Zhong300,
- Xu Xiao301,
- Joyce Joy302,
- Helen McLeod302,
- Andreas Melzer302,
- Chenchen Bing303,
- Robert Staruch304,
- Joris Nofiele303,
- Debra Szczepanski303,
- Michelle Wodzak Staruch305,
- Theodore Laetsch303,
- Rajiv Chopra303,
- Chenchen Bing306,
- Robert Staruch307,
- Pavel Yarmolenko307,
- Haydar Celik308,
- Joris Nofiele306,
- Debra Szczepanski306,
- Peter Kim309,
- Harry Kim310,
- Matthew Lewis306,
- Rajiv Chopra306,
- Rutwik Shah311,
- Eugene Ozhinsky311,
- Viola Rieke311,
- Matthew Bucknor311,
- Chris Diederich311,
- Vasant Salgaonkar312,
- Peter Jones311,
- Matthew Adams311,
- Arda Ozilgen311,
- Peter Zahos313,
- Dezba Coughlin311,
- Xinyan Tang311,
- Jeff Lotz311,
- Kathleen Jedruszczuk314,
- Amitabh Gulati,
- Stephen Solomon314,
- Elena Kaye314,
- Samuel Fielden315,
- John Mugler315,
- Wilson Miller315,
- Kim Butts Pauly316,
- Craig Meyer315,
- Gaetano Barbato317,
- Gian Luca Scoarughi317,
- Cristiano Corso317,
- Alessandro Gorgone317,
- Ilaria Giuseppina Migliore317,
- Zachary Larrabee5, 22,
- Arik Hananel318,
- Matt Eames5, 22,
- Jean-Francois Aubry26,
- Avinash Eranki319,
- Navid Farr320,
- Ari Partanen321,
- Karun Sharma319,
- Pavel Yarmolenko322,
- Bradford Wood320,
- Peter Kim319,
- Navid Farr323,
- Satya V. V. N. Kothapalli324,
- Avinash Eranki325,
- Ayele Negussie323,
- Emmanuel Wilson325,
- Reza Seifabadi323,
- Peter Kim325,
- Hong Chen324,
- Bradford Wood323,
- Ari Partanen326,
- Hyungwon Moon327,
- Jeeun Kang328,
- Changbeom Sim328,
- Jin Ho Chang328,
- Hyuncheol Kim328,
- Hak Jong Lee327,
- Noboru Sasaki329,
- Mitsuyoshi Takiguchi329,
- Lukas Sebeke330,
- Xi Luo331,
- Bram de Jager331,
- Maurice Heemels331,
- Edwin Heijman332,
- Holger Grüll331,
- Jan Strehlow333,
- Michael Schwenke332,
- Daniel Demedts332,
- Tobias Preusser332, 334,
- Helen McLeod335,
- Christopher Abraham336,
- Samuel Pichardo336,
- Laura Curiel336,
- Pascal Ramaekers337,
- Martijn de Greef337,
- Rémi Berriet338,
- Chrit Moonen337,
- Mario Ries337,
- Christopher Dillon339,
- Margit Janát-Amsbury339,
- Allison Payne339,
- Joseph Corea340,
- Patrick Peiyong Ye340,
- Ana Clauda Arias340,
- Kim Butts Pauly341,
- Micheal Lustig340,
- Bryant Svedin342,
- Allison Payne342 and
- Dennis Parker342
© The Author(s). 2016
Published: 21 November 2016
A1 Treatment of essential tremor and Parkinson’s disease tremor by MRI guided Focused Ultrasound: a report of 38 consecutive cases in a single center
Menashe Zaaroor, Alon Sinai, Dorit Goldsher, Ayelet Eran, Maria Nassar, Ilana Schlesinger
Rambam Health Care Campus, Haifa, Israel
Thalamotomy of the ventral intermediate nucleus (VIM) is effective in alleviating medication resistant tremor in patients with essential tremor (ET) and Parkinson’s disease (PD). MRI guided Focused Ultrasound (MRgFUS) is an innovative technology that enables non-invasive thalamotomy via thermal ablation.
Thirty eight ET and PD patients with severe medication resistant tremor underwent MRgFUS underwent unilateral VIM thalamotomy using MRgFUS. Effect was evaluated using clinical Rating Scale of Tremor (CRST) in ET patients and Unified PD Rating Scale motor part (UPDRS) in PD patients. Quality of life was assessed by Quality of life in ET Questionnaire (QUEST) and PD Questionaire (PDQ-39).
Tremor stopped in the treated hand in 37 patients immediately following the treatment. In one patients tremor was modified but not abolished. At one month post-treatment, the ET patients’ CRST score decreased from 38.6 ± 12.0 to 9.3 ± 7.7 (p < 0.001) and QUEST scores decreased from 44.8 ± 17.8 to 13.1 ± 15.9 (p < 0.001). In PD patients UPDRS-motor part decreased from 26.2 ± 8.7 to 16.3 ± 11.0 (p = 0.0087) and PDQ39 decreased from 40.8 ± 18.2 to 26.5 ± 15.1 (p = 0.027). During follow up of 1-24 months (mean 10.9 ± 8.1 months) tremor reappeared in seven of the patients, but in all but three, to a lesser degree than before the procedure.
Adverse events that transiently occurred during sonication included: Headache (n = 11), short lasting vertigo (n = 17) and dizziness (n = 4), nausea (n = 4), burning scalp sensation (n = 3), vomiting (n = 3) and lip paresthesia (n = 2). Adverse events that lasted after the procedure included gait ataxia (n = 5), unsteady feeling when walking (n = 4,) unilateral taste disturbances (n = 3) and hand ataxia (n = 3). All adverse events were transient and none lasted beyond 3 months.
MRgFUS VIM thalamotomy to relieve medication resistant tremor was safe and effective in ET, and PD. Current results emphasize its low adverse events profile and high efficacy in treating tremor. Large randomized studies are needed to assess prolonged efficacy and safety.
A2 Focused Ultrasound likely dominates deep brain stimulation and stereotactic radiosurgery for medically-refractory essential tremor: an initial decision and cost-effectiveness analysis
Jonathon Parker1, Vinod Ravikumar1, Pejman Ghanouni1, Sherman Stein2, Casey Halpern1
1Stanford University, Stanford, California, USA; 2University of Pennsylvania, Philadelphia, Pennsylvania, USA
Essential Tremor (ET) is one of the most common neurologic conditions, and conservative measures are frequently suboptimal. Recent data from a multi-institution, randomized controlled clinical trial demonstrated that Magnetic Resonance-guided Focused Ultrasound (MRgFUS) thalamotomy improves upper limb tremor in medically refractory ET. This study assesses the cost-effectiveness of this novel therapy in comparison to existing procedural options.
PubMed and Cochrane Library searches were performed for studies of MRgFUS, Deep Brain Stimulation (DBS), and Stereotactic Radiosurgery (SRS) for ET. Pre- and post-operative tremor-related disability scores were collected from 32 studies involving 83 MRgFUS, 615 DBS, and 260 SRS cases. Utility (defined as percent change in functional disability) was calculated, and Medicare reimbursements were collected as a proxy for societal cost – costs of MRgFUS for ET were derived from a combination of available costs of approved indications and SRS costs where appropriate. A decision and cost-effectiveness analysis was then constructed, implementing meta-analytic techniques.
MRgFUS thalamotomy resulted in significantly higher utility scores compared with DBS and SRS based on estimates of Medicare reimbursement (p < 0.001). MRgFUS was also the most inexpensive procedure out of the three (p < 0.001).
Preliminary experience with MRgFUS for ET suggests that this novel therapeutic may be more effective than available alternatives and potentially less costly for society. It thus will likely “dominate” DBS and SRS as a more cost-effective option for medically refractory ET. Our findings support further investigation of MRgFUS for ET and broad adoption.
A3 Tractography-based VIM identification for Focused Ultrasound thalamotomy: initial results
Vibhor Krishna, Amelia Hargrove, Punit Agrawal, Barbara Changizi, Eric Bourekas, Michael Knopp, Ali Rezai
The Ohio State University, Columbus, Ohio, USA
The ventral intermediate nucleus (VIM) is not visible on conventional Magnetic Resonance Imaging (MRI). A novel method for tractography-based VIM identification has recently been described. We report the short-term clinical results of prospective VIM targeting with tractography in a cohort of patients undergoing Focused Ultrasound thalamotomy.
All patients underwent structural and diffusion weighted imaging (60 diffusion directions, 2 mm isovoxel) with 3 Tesla MRI scanner (Philips Ingenia CX). The images were processed using streamline tractography (Stealth Viz, Medtronic Inc.). The lateral and posterior borders of VIM were defined by tracking the pyramidal tract and medial lemniscus respectively. A VIM region of interest (ROI) was placed 3 mm away from these borders (Figs. 1, 2 and 3). The structural connectivity of this VIM ROI was confirmed to the motor cortex (M1) and cerebellum. The coordinates of tractography-based VIM in relation to posterior commissure were noted for surgical targeting. The parameters analyzed include a clinical tremor scale (pre-, intraoperative, and post operative), operative time, and number of sonications.
Tractography-based VIM targeting was successful in 7 out of 8 patients. The coordinates of tractography-based VIM were significantly different from the standard coordinates (3-D distance 3.9 ± 2.4 mm). Therapeutic sonication (>55 °C temperature, 10 seconds) at the tractography target resulted in >50 % tremor improvement with intraoperative objective tremor assessment without any motor or sensory side-effects. The mean operative time was 78 ± 3.3 minutes with 12.8 ± 3.9 average sonications. Overall the tremor scores significantly improved one month after surgery (preop CRST total 62.1 ± 15.5 versus 30.3 ± 14.1, two tailed t-test p = 0.006). None of the patients experienced sensory deficits or motor weakness during follow-up.
A4 Targeted delivery of brain-penetrating non-viral GDNF gene vectors to the striatum with MRI-guided Focused Ultrasound reverses neurodegeneration in a Parkinson’s disease model
Brian Mead1, Namho Kim2, Panagiotis Mastorakos2, Jung Soo Suk2, Wilson Miller1, Alexander Klibanov1, Justin Hanes2, Richard Price1
1University of Virginia, Charlottesville, Virginia, USA; 2Center for Nanomedicine/Wilmer Eye Institute, Johns Hopkins University, Baltimore, Maryland, USA
Parkinson’s disease (PD) is characterized by the degeneration of dopaminergic neurons in the motor control pathways of the brain. Gene therapy using glial cell derived neurotrophic factor (GDNF) has shown some limited promise for treating PD; however, we hypothesize that outcomes could be further improved by enhancing gene vector distribution. We previously developed a gene therapy approach that entails delivering systemically administered non-viral gene-bearing nanoparticles (BPN) across the Blood-Brain Barrier with MRI-guided Focused Ultrasound (FUS). BPN rapidly penetrate brain tissue due to a dense coat of polyethylene glycol, and this approach mediates efficient and localized transgene expression in the brain of healthy rats. Here, we tested whether the FUS-mediated delivery of GDNF plasmid-bearing BPN (GDNF-BPN) reverses neurodegeneration in the rat 6-OHDA PD model.
6-OHDA rats were ultrasonically coupled to a 1.15 MHz MRI-compatible FUS transducer. T2 and T2* pre-treatment scans were obtained to allow FUS targeting of striatum. Microbubbles (2x105/g) and 100 μg of ~50 nm non-viral GDNF plasmid-bearing BPN (polyethylene glycol/polyethylenimine) were co-injected i.v. and FUS was applied at 0.6 MPa, with a 0.5 % duty cycle, for 2 min. Contrast T1 and T2* images allowed semi-real time confirmation of BBB disruption and safety, respectively. Efficacy was assessed using an ELISA for GDNF, tyrosine hydroxylase (TH) and VMAT2 immunolabeling for neural degeneration, HPLC for dopamine, and behavioral analysis (i.e. apomorphine-induced rotational asymmetry and forepaw use bias in 6-OHDA rats).
Striatum-targeted delivery of GDNF plasmid-bearing BPN with FUS led to an ~80 % reduction in apomorphine-induced rotational asymmetry, eliminated forepaw use bias (Fig. 4a,b), and fully restored TH+ dopaminergic neuron density in both the substantia nigra pars compacta (SNpc) and striatum compared to untreated 6-OHDA rats (Fig. 4c,d). T2* MRI confirmed safety of the BBB opening approach.
A5 Focused ultrasound facilitated gene delivery for neuro-restoration in Parkinson’s disease mice
Shutao Wang, Oluyemi Olumolade, Tara Kugelman, Vernice Jackson-Lewis, Maria Eleni (Marilena) Karakatsani, Yang Han, Serge Przedborski, Elisa Konofagou
Columbia University, New York, New York, USA
Not released for publication
Not released for publication
Not released for publication
Not released for publication
A6 MRI-g-FUS for the treatment of Alzheimer’s disease
Kullervo Hynynen1, Isabelle Aubert2
1Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; 2Sunnybrook Research Institute, Toronto, Ontario, Canada
Over the past ten years consistent effort has been put forward at the University of Toronto to develop Focused Ultrasound methods for the treatment of AD. This talk will review the progress made so far.
The first studies demonstrated safe antibody delivery in AD mouse model with significant reduction in the plaque load. A follow up studies with two-photon microscopy showed that blood vessels with plague deposits showed a different type of opening than vessels in normal brain but large molecule delivery into the brain was still possible in these animals. Another study demonstrated that plaque reduction can be achieved by just opening the BBB with microbubbles.
The histology revealed stimulation of neurogenesis. Multiple treatments of old mice resulted in memory rescue without any observable side-effects. A follow up study demonstrated that this neurogenesis was not induced with exposures that did not cause observable BBB opening even with the presence of the microbubbles. An ongoing study in large animals has shown that half-brain BBB opening can be safely and repeatable performed indicating the feasibility of clinical translation.
A7 Scanning Focused Ultrasound disruption of the blood-brain barrier as an Alzheimer’s disease therapy
Gerhard Leinenga1, Rebecca Nisbet2, Robert Hatch1, Anneke Van der Jeugd3, Harrison Evans2, Jürgen Götz2
1Clem Jones Centre for Ageing Dementia Research, Queensland Brain Institute, The University of Queensland, St Lucia, Queensland, Australia; 2The University of Queensland, Brisbane (St Lucia Campus), QLD, Australia; 3University of Leuven, Leuven, Belgium, Belgium
Alzheimer’s disease is the most common form of dementia. Pathological abnormalities in the Alzheimer’s disease brain includes the presence of amyloid-beta plaques, hyperphosphorylation and intracellular aggregation of tau and synaptic degeneration. Focused ultrasound combined with intravenous injection of microbubbles has been shown to reversibly open the blood-brain-barrier (BBB). By moving the focus in scanning mode we are able to open the BBB throughout the brain of a mouse. Here we tested the effects of repeated scanning ultrasound (SUS) in APP23 amyloid plaque-bearing mice, pR5 tau mice and wild-type mice to determine the effects of SUS on amyloid, tau and dendritic spines.
The device used was the Therapy Imaging Probe System (TIPS, Philips Research), which has an eight-element annular array transducer with a focal length of 80 mm a radius of curvature of 80 mm, a 33 mm central opening, and a motorized 3D positioning system. The focus 6 dB size was 1.5 mm x 1.5 mm x 12 mm at 1 MHz. Settings that were applied were 1 MHz centre frequency, 0.7 MPa peak rarefactional pressure applied outside the skull, 10 Hz pulse repetition frequency, 10 ms pulse length and 10 % duty cycle immediately after retroorbital injection of in-house made microbubbles. APP23 mice that accumulate amyloid beta, pR5 mice that overexpress FTD-mutant tau, and wild-type C57Bl/6 mice were treated weekly by scanning ultrasound (SUS) for periods of 4 to 7 weeks.
In APP23 mice we used repeated scanning ultrasound (SUS) treatments of the mouse brain to remove amyloid-beta. Spinning disk confocal microscopy revealed extensive internalization of Abeta into the lysosomes of activated microglia in mouse brains subjected to SUS. Plaque burden was reduced in SUS-treated AD mice compared to sham-treated animals. Treated AD mice also displayed improved performance on three memory tasks.
In PR5 mice we investigated the efficacy of a novel tau isoform-specific single chain antibody fragment, RNX, delivered by passive immunization in the P301L human tau transgenic pR5 mouse model. When administration of RNX was combined with scanning ultrasound (SUS), RNX delivery into the brain and uptake by neurons were markedly increased, as were reductions in tau phosphorylation and anxiety-like behavior.
In wild-type mice we investigated the effects of SUS on neuronal excitability and morphology. We performed patch-clamp recordings from hippocampal CA1 pyramidal neurons in wild-type mice 2 and 24 hours after a single SUS treatment, and one-week and three months after six weekly SUS treatments. No change in CA1 neuronal excitability was observed compared to sham-treated neurons at any time-point. Multiple SUS treatments had the effect of preventing the loss of CA1 synapses that occurred in sham-treated neurons.
We show that scanning Focused Ultrasound disruption of the BBB has multiple biological effects in the brain which make it an attractive candidate for an Alzheimer disease therapy. SUS reduced plaque burden and amyloid-beta levels in APP23 amyloid mice, through activation of microglia, and improved performance on tests of memory function. In pR5 tau mice SUS alone reduced hyperphosphorylation of tau, and enhanced the delivery of anti-tau antibodies resulting in improved reductions in pathology and behavioral abnormalities. In wild-type mice SUS was shown to have no effect on the firing of hippocampal neurons or their morphology, but prevented spine loss at 3 months after six weekly SUS treatments. If these effects on Abeta and tau pathology, and dendritic morphology are recapitulated in human patients SUS may emerge as a promising AD therapy.
A8 Scanning ultrasound as a treatment tool of proteinopathies including Alzheimer’s disease
Jürgen Götz1, Rebecca Nisbet1, Ann Van der Jeugd1, Harrison Evans1, Gerhard Leinenga2
1The University of Queensland, Brisbane (St Lucia Campus), QLD, Australia; 2Clem Jones Centre for Ageing Dementia Research, Queensland Brain Institute, The University of Queensland, St Lucia, Queensland, Australia
Neurological disorders constitute a substantial social and economic burden, as they cause considerable ill health but few direct deaths. Treatment strategies for neurodegenerative diseases are hampered by the fact that the Blood-Brain Barrier (BBB) establishes an efficient barrier for therapeutic agents (Leinenga et al., Nature Reviews Neurology 2016). We have recently shown that scanning ultrasound (SUS) allows microglial-mediated clearance of extracellularly deposited amyloid-beta in APP mutant APP23 mice and restores memory functions in three cognitive tests to wild-type levels, in the absence of overt damage to the brain (Leinenga and Götz, Science Translational Medicine 2015) However, it had not been determined whether SUS treatment reduces the intracellular tau pathology that together with amyloid deposition characterizes Alzheimer’s disease.
We investigated the efficacy of a novel tau-specific single chain antibody fragment, delivered by passive immunization in the human tau transgenic pR5 mouse model, a model of the tau pathology of Alzheimer’s disease (Götz et al., Science 2001). To further assess the efficacy and drug-delivering ability of SUS, we established four experimental groups, using the novel anti-tau antibody that was injected weekly over four weeks, either on its own, or together with SUS. A third group used SUS only, and a fourth was the anaesthesia control group. The mice were analysed on the elevated plus maze, histologically and biochemically. Furthermore, uptake of the antibody by the brain was determine using fluorescently labelled single-chain antibody fragments.
A histological and biochemical analysis of the pR5 tau transgenic mice revealed that SUS as well as the employed antibody ameliorated the tau pathology that characterizes the pR5 mice. In addition, the anxiety-like behaviour that characterizes pR5 mice was significantly reduced. We furthermore found enhanced delivery of the antibody using SUS yielding a synergistic therapeutic effect as determined by histology and using the elevated plus maze.
Our study suggests that SUS is a method that benefits diseases with protein aggregates more generally, whether they are intra- or extracellular. The therapeutic delivery combined with SUS could offer significant clinical benefits for the treatment of patients with Alzheimer’s disease and related tauopathies. Considering that the yearly costs of passive immunotherapy for AD is expected to exceed $25,000 per patient, combining SUS with antibody delivery could drastically reduce these costs.
A9 Enhancement of FUS mediated delivery of stem cells to the brain
Paul Fishman1, Paul Yarowsky2, Victor Frenkel3, Shen Wei-Bin3, Ben Nguyen3
1University of Maryland School of Medicine/Baltimore VAMC, Baltimore, Maryland, USA; 2Research & Development Service, VA Maryland Healthcare System and University of Maryland School of Medicine, Baltimore, Maryland, USA; 3University of Maryland School of Medicine, Baltimore, Maryland, USA
FUS mediated Blood-Brain Barrier disruption (BBBD) can enable even large therapeutics such as stem cells to enter brain from the bloodstream and could be a major advance in cell delivery over current invasive methods of brain injection. The efficiency of cellular entry after FUS mediated BBBD alone however is low. We hypothesized that this process could be enhanced by combining it with a complementary strategy termed magnetic targeting. Stem cells can be safely loaded with super-paramagnetic iron oxide nanoparticles (SPION) in culture, allowing cells to be attracted by an external magnet. Our previous study showed SPION loaded stem cells to have enhanced brain retention near a magnet on the skull in a rat model of traumatic brain injury, where BBBD also occurs. The goal of our current project was to determine if magnetic attraction of SPION loaded stem cells would also enhance their delivery to brain after FUS mediated BBBD.
With a small animal MRI guided FUS device (Image Guided Therapy, IGT and 7 T Bruker MRI), we sonicated young adult rats (~120 g) with both radiologic (enhancement of the target region with gadolinium on post-sonication TI MRI), and histologic (staining with Evans’ blue dye) evidence of BBBD, without tissue damage or hemorrhage. Confirmation of the cells within brain as those injected was performed by staining with Perl’s reagent for iron and by immuno-histochemistry with a human specific antigen. The procedure was then combined with the application of a powerful magnet to the head directly after IV injection of hNPCs.
With BBBD alone human neuro-progenitor cells (hNPCs) loaded with SPION were observed in rat brain after intravenous (IV) injection directly after sonication only within the treated regions. To demonstrate the effect of magnetic attraction, we injected equal numbers of SPION and non-SPION labeled cells, where each cell type was labeled with a different fluorophore. In animals that had FUS mediated BBBD followed by a magnet applied to the head, significantly greater numbers of SPION labeled cells were observed compared to the non-labeled cells. This result was most pronounced in regions of the brain close to the skull (cerebral cortex) and magnet surface. More powerful magnets including magnetic arrays resulted in more effective retention of SPION labeled cells in even deeper brain regions such as the striatum. There, 90 % of hNPCs observed contained SPIONs compared to 60-70 % with a less powerful magnet.
These results demonstrate that the use of magnetic attraction can substantially enhance delivery of stem cells after BBBD. In prior published work, stem cells were delivered to brain after FUS mediated BBBD using cells injected directly into the carotid artery. In an effort to accomplish this goal in a safer and less invasive manner, our study utilized IV cell injection (tail vein), supporting the view that the combination of FUS mediated BBBD and magnetic attraction can allow stem cells to enter brain with a minimally invasive strategy.
A10 Fluorescent lipid microbubbles for targeted brain drug delivery through the Focused Ultrasound-induced blood-brain barrier opening in vivo
Carlos Sierra Sanchez, Camilo Acosta, Cherry Chen, Shih-Ying Wu, Maria Eleni (Marilena) Karakatsani, Elisa Konofagou
Columbia University, New York, New York, USA
Focused ultrasound (FUS) in the presence of lipid microbubbles can induce non-invasive, transient and reversible Blood-Brain Barrier (BBB) opening. This study entailed assessment of the feasibility of fluorescently loaded microbubbles, labeled with the fluorophore 5-dodecanoylaminfluorescein (C-12), as a vector for targeted brain drug delivery. Compared to prior studies by our group, where fluorescently-labeled dextrans were co-administered with microbubbles, this new methodology improves the safety and allows a more targeted drug delivery with potentially lower toxicity, avoiding systemic exposure. The main objective was thus to determine feasibility and safety of using the loaded microbubbles as carriers towards targeted brain drug delivery with simultaneous cavitation monitoring.
A spherical, single-element, FUS transducer (center frequency 1.5 MHz) was used. A pulse-echo transducer (center frequency 10 MHz), confocally mounted at the center of the FUS transducer, was utilized for passive cavitation detection (PCD). FUS (pulse length 10,000 cycles; pulse repetition frequency 5 Hz; duration 5 minutes; acoustic pressure 450-750 kPa) targeted mouse brains in vivo, in combination with fluorescent microbubbles for C-12 delivery, which was evaluated by in vivo transcranial PCD, through the quantification of inertial (ICD) and stable harmonic (SCDh) and ultraharmonic (SCDu) cavitation doses at 30, 60 and 300 s; together with ex vivo fluorescence imaging. The BBB opening was verified using in vivo T1-w Magnetic Resonance Imaging (MRI). The safety of this technique was assessed through ex vivo hematoxylin & eosin staining for microhemorrhage detection and immunohistochemistry (Iba-1 for microglial activation) together with in vivo T2-w MRI for edema assessment.
Successful targeted C-12 delivery was achieved at 600 and 750 kPa in six out of 14 cases (Fig. 5). Comparison of ICD, SCDh and SCDu between successful and unsuccessful cases yielded a statistically significant linear relationship between the successful targeted drug delivery and CD and specific thresholds for efficient delivery were identified.
No edema was detected in mice sacrificed on Day 0 but edema appeared on Day 1 on mice sacrificed on Day 7. In all cases cases (except one) it was repaired within a week. Microhemorrhages were observed after sonication in some cases but were also cleared within the first week. However, a higher number of cell nuclei was observed in the sonicated region compared to the unsonicated side in some mice survived up to one week after opening. Iba-1 immunohistochemistry also showed microglial activation.
A11 Ultrasound-mediated delivery of gadolinium and fluorescent–labelled liposomes through the Blood-Brain Barrier
Muna Aryal1,2, Iason T Papademetriou3, Yong-Zhi Zhang2, Chanikarn Power1,2, Nathan McDannold1,2, Tyrone Porter3
1Brigham and Women’s Hospital, Boston, Massachusetts, USA; 2Harvard Medical School, Boston, Massachusetts, USA; 3Boston University, Boston, Massachusetts, USA
The main objectives of this study were: 1) to examine whether gadolinium and fluorescent labelled liposomes can extravasate into the brain parenchyma after ultrasound mediated Blood-Brain Barrier disruptions; and 2) to test whether extravasated liposomes were size dependent or not. The liposomes were labelled with gadolinium (Gd) and fluorophore, thus enabling detection of extravasated liposomes via MRI in vivo and fluorescence methods in tissue, respectively.
Liposomes labelled with gadolinium and fluorophore were prepared using lipid film hydration and extrusion to two different sizes; ~70-85 nm and ~ 130-150 nm. Animals were divided into two different groups based on the use of particle sizes; group A (~70-85 nm) and group B (~130-150 nm). Focused ultrasound mediated Blood-Brain Barrier disruption (BBBD) was produced in one hemisphere in 15 mice. Particles were injected before sonication. Sonications (0.69 MHz at 0.42 MPa) were performed in two locations combine with Definity (10 μl/kg). Acoustic emissions were recorded during FUS. T1-weighted contrast enhanced and T2*-weighted MRI were used to confirm Gd leakage and damage detection respectively. Mice were euthanized 5-24 hours after FUS and post-process for fluorescence measurement.
In T1-weighted contrast enhanced MRI, gadolinium-leakage was able to detect on sonicated area at 5-24 after FUS but not on non-sonicated area (control). Detection of fluorescence signal from brain tissue homogenates confirm the liposomal particles extravasation on sonicated locations. On group A, gadolinium and fluorescence signal intensities on sonicated locations were increased by 26 % and 62 % respectively as compared with control and signal enhancement were statistically significant compared with control ( p = 0.017 and p = 0.02 respectively, two-tailed, paired ttest). On group B, gadolinium and fluorescence signal intensities on sonicated locations were increased by 24 % and 40 % respectively as compared with control. Comparison of fluorescence signal intensities between two groups on sonicated location was statically significant whereas it was not significant on controls (p < 0.05 and p = 0.07 respectively, one-tailed unpaired ttest).
Overall, this work demonstrates that ultrasound can deliver upto ~ 150 nm liposomes that labelled with gadolinium and fluorophore through the Blood-Brain Barrier. The results indicate that the extravasation of liposomes were size dependent.
A12 Sterile inflammatory response (SIR) in the brain following exposure to low intensity pulsed Focused Ultrasound and microbubble infusion
Zsofia Kovacs1, Saejeong Kim1, Neekita Jikaria1, Farhan Qureshi2, Michele Bresler2, Joseph Frank2
1National Institutes of Health, Bethesda, Maryland, USA; 2National Institutes of Health Clinical Center, Bethesda, Maryland, USA
Magnetic Resonance Imaging (MRI)-guided pulsed Focused Ultrasound (pFUS) in combination with systemic injection of microbubbles (MB) is being advocated to increase drug or gene delivery by causing localized Blood-Brain Barrier (BBB) disruption (D). The objective of this study is to investigate the molecular and cellular responses following pFUS + MB associated with BBBD in the rat brain.
Female Sprague Dawley rats (<200 g) were sonicated at 0.3 MPa acoustic pressures with 10 ms burst length and 1 % duty cycle (9 focal points, 120 sec/9 focal points) using a single-element spherical FUS transducer (589.636 kHz; FUS Instruments). 100 μl Optison™ MB (GE Healthcare) was administered intravenously. Gadofosveset-enhanced T1w images were obtained with a 3.0 T MRI (Phillips). Proteomic and mRNA expression in the brain following pFUS + MB were analyzed with ELISA, Western blot, quantitative real-time PCR or immunofluorescent staining (Fig. 6a). Proteomics were normalized to sham and statistical analysis was performed by one-way ANOVA corrected for multiple comparisons. Rats were also injected with 8 mg/kg Rhodamine encapsulated magnetic polymers (MicroTRACK™; BioPal) 3 days prior to sonication to label splenic macrophages (CD68) to monitor tropism to the brain.
Post contrast T1w MRI and histology showed open BBB without evidence of microhemorrhage. Within 5 minutes following sonication, increased expression of pro-inflammatory and anti-inflammatory cytokines, chemokines and trophic factors (CCTF) was detected in the parenchyma lasting up to 24 hours (Fig. 6b). Increases in heat shock protein 70 (HSP70), tumor necrosis alpha (TNFa), and interleukin (IL) 1a, 1b and 18 consistent with damage associated molecular patterns (DMAP)1 and activation of nuclear factor kappa-light-chain-enhancer of activated B cells (NFkB) inflammatory pathways were observed with SIR to injury2 (Fig. 6b). NFkB pathway-related gene activation along with anti-apoptotic genes, immune cell chemoattractants, selectins, and cell adhesion molecules showed significant (>2fold) increases in mRNA expression (Fig. 6c). Histological analysis showed significant increases (p < 0.05) in the following: number of TUNEL positive cells within 6 hrs, GFAP and Iba1 staining for activated astrocytes and microglia (1-24 hrs) and increase of ICAM up to 24 hrs post sonication. We also detected a >4 fold greater (p < 0.05) CD68 positive cells on day 6 post sonication containing intracellular fluorescent beads within the pFUS + MB treated hemisphere compared to contralateral hemisphere.
The temporal molecular response to pFUS + MB is indicative of SIR2 originating from the parenchyma. The pattern of cytokines immediately after pFUS + MB is initiated by cellular release of DAMPs and TNFa observed with mild cerebral trauma or ischemia [1,2]. Increases in monocyte chemoattractant protein (MCP-1), vascular endothelial growth factors (VEGF), stromal derived factor 1 (SDF-1), erythropoietin (EPO) and brain derived neurotropic factor (BDNF) are associated with BBBD stimulating angiogenesis, neurogenesis and stem cell migration observed with ischemia and trauma. These results indicate that pFUS + MB rapidly affects the cerebral vasculature as evident by BBBD in addition to the shockwave from MB collapse that induces mild stress within various cellular elements in the parenchyma inducing a SIR.
1. Chen, G. Y., et al. 2010 Nat Rev Immunol 10(12):826-37.
A13 Volumetric MR thermometry in a clinical transcranial MR guided Focused Ultrasound system
Henrik Odéen1, George Chiou2,3, John Snell4, Nick Todd2, Bruno Madore2,3, Dennis Parker1
1University of Utah, Salt Lake City, Utah, USA; 2Brigham and Women’s Hospital, Boston, Massachusetts, USA; 3Harvard Medical School, Boston, Massachusetts, USA; 4Focused Ultrasound Foundation, Charlottesville, Virginia, USA
Transcranial MR-guided Focused Ultrasound (tcMRgFUS) applied within a small central brain volume has achieved excellent outcomes in treatment of movement disorders (Elias NEJM 2013). Although transducers used in tcMRgFUS have been designed with large apertures to spread the beam energy over as much skull as possible to reduce skull and cortex heating, currently used MR temperature imaging (MRTI) methods cannot monitor the temperature increase over the entire insonified brain volume. Instead, temperatures are typically measured in one 2D slice, leaving the majority of the insonified brain volume unmonitored. We have previously developed and published methods to achieve fully 3D MRTI covering the entire insonified brain with good spatial and temporal resolution (Todd MRM 2009/2010) but the techniques have not been evaluated on clinical tcMRgFUS systems. In this work-in-progress study we demonstrate the value of volumetric MRTI with two different pulse sequences applied during heating on a clinical tcMRgFUS system.
PRF MRTI was performed with a product 3D gradient recalled echo (GRE) pulse sequence and a custom-implemented 3D GRE segmented echo planar imaging (EPI) pulse sequence on a 3 T MRI (Discovery 750 T, GEMS). tcFUS heatings were performed in an ex vivo human skull filled with tissue-mimicking gel (ATS Laboratories) in a clinical tcMRgFUS system (ExAblate Neuro, Insightec).
Pulse sequences parameters are listed in Table 1. All data were zero filled interpolated (ZFI) to 1-mm isotropic spacing (GRE data additionally ZFI to 0.5-mm spacing). The skull was physically positioned in the FUS system, and the focus electronically steered, to target deep brain-structures located outside the normal treatment envelope. FUS sonications were applied at 940 W for 30/60 s while imaging with the GRE/EPI sequences, respectively. The EPI sequence used an echotrain length of 16 with bi-polar readout gradient, sampling 192 phase encodings in each direction, so that full “positive only” and “negative only” images could be reconstructed.
k-space data were retrospectively down sampled by a factor of R = 4 and 8 (split into multiple time-frames without throwing any data away) for the GRE and EPI experiments, respectively, giving acquisitions times of 3.6 and 7.8 s, and reconstructed with a temporally constrained reconstruction algorithm (Todd MRM 2009).
Figure 7 shows three orthogonal views of temperature maps overlaid on magnitude images in the GRE experiment. Attempting to focus this far outside the normal treatment envelope results in severe near- and far-field heating. Heating on both the cortex and in the far-field along the petrous bone is visible. In Fig. 8 the temperature evolution at the focal spot is compared to that near the petrous bone. The gel near the bone shows a delayed and greater maximum temperature compared to the focus.
Three orthogonal views of the larger FOV in the segmented EPI experiment are shown in Fig. 9. Heating along large parts of the cortex can be seen. In the underlying magnitude images it can be seen that the EPI sequence experiences more artifacts than the GRE sequence.
The focal spot position (evaluated as the temperature center-of-mass) was tracked as a function of time during the heating in the GRE data ZFI to 0.5 mm (data not shown). The focal spot did not experience any shift to within the finer ZFI spacing.
This study shows that volumetric thermometry over a FOV covering the focal spot and the skull base can be achieved with readily available pulse sequences. With custom implemented pulse sequences the fully insonified FOV (from skull cap to skull base) can be covered. Even though the reconstruction is done retrospectively, the described methods are valuable as research tools in e.g. treatment envelope evaluations. By utilizing 3D imaging ZFI can be performed in all directions to minimize partial volume effects, and very accurate dynamic focal spot localization can be performed.
MR scan parameters. TR – Repetition time, TE – Echo time, FA – Flip angle, BW – Bandwidth (readout), FOV – Field of view, Res – Resolution, Tacq – Acquisition time (before subsampling)
A14 Multi-echo MR thermometry compared to single echo MR thermometry in the treatment of essential tremor
Kim Butts Pauly, Mike Marx, Pejman Ghanouni
Stanford University, Stanford, California, USA
The choice of receive bandwidth in MR thermometry acquisitions needs to balance two competing choices. Low bandwidths improve SNR, while high bandwidths reduce spatial shift of the hotspot due to the temperature off-resonance. The low bandwidth MR thermometry sequence in use in essential tremor MRgFUS treatments required repeated swapping of phase and frequency directions since the location of the hotspot could only be trusted in the phase encode direction.
A solution is to use multiple high bandwidth acquisitions, which when averaged, regain much of the SNR of the lower bandwidth image. Such a multiecho sequence has recently become available for clinical use. The purpose of this work was to compare the performance of the multi-echo (ME) MR thermometry to the single echo (SE) MR thermometry in clinical treatments of essential tremor.
Fifteen patients were treated for essential tremor, 12 with only single echo thermometry (TE and BW/pix = 12.8 and 44), 2 with only multi-echo thermometry (TE and BW/pix = 3, 8, 13, 18, 22 and 278), and 1 with both sequences. All other image parameters remained the same, including TR = 100. All thermometry images were processed offline in Matlab with a single baseline subtraction (α = -0.00909), followed by referenceless processing for constant and linear terms. The multi-echo thermometry was further processed with a phase unwrapping algorithm in the TE dimension. The multiple echoes were then combined with a weighting by the square of the temperature SNR of each image.
The decrease in sampling time for the ME thermometry dictates a theoretical decrease in temperature SNR of only 11 % due to the decrease in sampling time alone. In the one patient that had both sequences in the same scan planes for two sonications, there was a 9 % decrease in SNR in the ME thermometry as measured in the frame used for the referenceless processing, comparing well with theory.
A review of all sonications with ME thermometry when phase encoding was S/I revealed much reduced artifacts over SE thermometry with phase encoding in the S/I direction. Example images are provided in Fig. 10. The region of interest measurement indicated a 30 % improvement in temperature SNR for the ME over the single echo, due to this artifact reduction.
The spatial shifts should theoretically be reduced by a factor of 6.3 in the ME thermometry, as compared to the SE thermometry, due to the increase in receive BW. For example, a 23 °C temperature rise would result in a 0.6 mm shift with the single echo, and only a 0.1 mm shift with the multi-echo.
A15 High-resolution whole-brain MR thermometry with a 3D EPI stack-of-stars pulse sequence
Sumeeth Jonathan, William Grissom
Vanderbilt University, Nashville, Tennessee, USA
Real-time whole-brain MR thermometry is needed for transcranial MR-guided Focused Ultrasound to accurately track rapid heating at the focus and to monitor for unsafe heating in the near- and far-field. Previous efforts to meet this need have been based on 3D segmented echo planar imaging (EPI) and spiral MR readouts (Fielden et al., 2014). Here, we propose a 3D EPI stack-of-stars temperature mapping pulse sequence that enables greater volume coverage than has been reported with previous approaches. The sequence allows flexible adjustment of the scan acceleration factor and does not require a high density of receive coils for high frame rate thermometry.
Readout Trajectory: Fig. 11 shows the proposed readout trajectory. Each TR comprises a 2D EPI plane that is frequency-encoded in the axial (x-y) and phase-encoded in the slice (z) dimensions. The plane is rotated between TRs by 111.25 degrees to sample a golden angle stack-of-stars k-space. The sequence was implemented on a Philips Achieva 3 Tesla scanner with parameters: field-of-view = 28.0 x 28.0 x 11.9 cm, 43 slices, in-plane resolution = 1.50 x 1.50 x 2.75 mm, 17 ms TE/45 ms TR, 14.5° flip angle, spectrally-selective fat suppression.
In vivo Experiment: To confirm the achievable brain volume coverage and image quality, with local IRB approval, brain images in a healthy volunteer were acquired without heating using the pulse sequence with one, two, and three interleaved shots and with an 8-channel receive coil array. Fully-sampled images were reconstructed using the density-compensated conjugate gradient method.
Phantom Heating Experiment: A tissue-mimicking gel phantom was sonicated using a clinical MR-HIFU system (Philips Sonalleve) operated at 1.2 MHz and 80 W for 12 s, while scanning with the proposed sequence with one shot and with 5 abdominal receive coils. Temperature maps were reconstructed in one second increments using the k-space hybrid method at three scan acceleration factors.
In vivo Results: Distortions and signal dropouts caused by off resonance are visible in the sagittal and lower axial single-shot brain images in Fig. 12 (white arrows). The distortions can be reduced by increasing the number of EPI shots per angle, which increases the pixel bandwidth in z. An axial slice positioned for monitoring Focused Ultrasound thalamotomy (red arrow) is also shown, which contains no visible distortions at any multishot factor.
Phantom Heating Results: Fig. 13a shows reconstructed sagittal and axial temperature maps through the middle of the phantom at peak heat. Significant temperature aliasing does not appear until the scan is accelerated by a factor of 14.1 or a 1 second window width. The hotspot temperature curve plots in Fig. 13b show that the reconstructed temperatures all coincide, though the 14.1x curve appears noisier. Importantly, at all acceleration factors, there is agreement with a hotspot measurement obtained by a 2D multislice Cartesian EPI temperature mapping pulse sequence (7 slices, same in-plane resolution) which was used as a reference standard.
A video of the entire sonication monitored using this pulse sequence can be viewed at https://www.youtube.com/watch?v=z3cVXjkgyLg.
A16 Ultrafast and sensitive volumetric passive acoustic mapping
Costas Arvanitis1, Nathan McDannold2,3, Gregory Clement4
1Georgia Institute of Technology, Atlanta, Georgia, USA; 2Brigham and Women’s Hospital, Boston, Massachusetts, USA; 3Harvard Medical School, Boston, Massachusetts, USA; 4Cleveland Clinic, Cleveland, Ohio, USA
Not released for publication
Not released for publication
Not released for publication
Not released for publication
A17 Tissue stiffness imaging with interleaved multiple-point MR-ARFI
Dennis Parker, Joshua de Bever, Henrik Odéen, Allison Payne, Douglas Christensen
University of Utah, Salt Lake City, Utah, USA
Although Focused Ultrasound (FUS) has the potential to treat a number of pathologies the methods used to guide treatment are still limited in the ability to identify effective treatment endpoints. Changes in MRI parameters such as proton density and T1 and T2 relaxation times may result from reversible edema instead of tissue death. While dynamic contrast enhanced and late Gd-enhanced MRI are more specific, Gd contrast cannot be administered multiple times during a procedure to monitor treatment progression. MRI acoustic radiation force impulse imaging (MR-ARFI) can monitor tissue stiffness, but the acquisition is relatively slow, and must be repeated to measure tissue displacement at more than a single point . The purpose of this work was to develop an efficient method to use MR-ARFI to measure tissue displacement volumetrically with an array of points as a first step towards monitoring tissue stiffness changes during MRgFUS procedures.
A 3D segmented gradient echo (GRE) echo-planar pulse sequence, designed to simultaneously measure tissue displacement with MR-ARFI and the corresponding tissue heating [2–5], was further modified to allow interleaved acquisition of multiple point MR-ARFI (mpMR-ARFI) volumes. Phase change due to displacement was separated from that due to temperature by complex subtraction of an interleaved volume acquired with no FUS applied. Temperature was obtained using the proton resonance frequency method with a referenceless background phase subtraction .
Experiments were performed in a gelatin phantom and excised pig brain on 3 T MRI scanners (Siemens Tim Trio and PrismaFit). Pulse sequence parameters were: TR/TE = 73/43 ms, FA = 30°, readout bandwidth = 752 Hz/pixel, echotrain length = 7, FOV = 160x114x55mm, matrix = 128x91x22 giving voxel dimensions of 1.25x1.25x2.5 mm before zero filled-interpolation. Bipolar motion-encoding gradients (MEG) of 15 ms duration (each bipolar lobe) were applied prior to signal readout. Ultrasound pulses of 50 acoustic watts were applied during the second 15 ms bipolar MEG lobe. Navigator echoes were used to measure and compensate for B0 field drift due to gradient heating caused by high MEG strength and duty cycle. The same navigators echoes can be used for respiratory correction in vivo .
Results from a13-point mpMR-ARFI acquisition in a gelatin phantom using the Siemens Tim Trio and MEG = 20mT/m are given in Fig. 14. An example cropped single slice from 10 of the 13 acquired displacement volumes is shown in Fig. 14a with a cropped slice of the mpMR-ARFI composite of all 13 displacement volumes shown in Fig. 14b. The corresponding temperature increase measured during the mpMR-ARFI acquisition is shown in Fig. 14c and was relatively low (<3 °C). (For all mpMR-ARFI images, point separation is 5 mm).
Figure 15 shows the improved image quality achieved by the phase-navigator correction in mpMR-ARFI measurements obtained using a PrismaFit 3 T MRI scanner with MEG = 40 mT/m. The ghosting artifact in Fig. 15a due to B0 field drift caused by high amplitude (40mT/m) and duty cycle (40 %) MEG gradients during mpMR-ARFI acquisition. After correction (Fig. 15b) mpMR-ARFI displacement images have negligible artifact.
Results of the displacement measured in excised pig brain using the Siemens PrismaFit 3 T MRI scanner and MEG = 40 are shown in Fig. 16 before (Fig. 16a) and after (Fig. 16c) FUS ablation. An estimate of the cumulative thermal dose is shown in Fig. 16b. Note the decreased displacement at central point.
Measuring tissue stiffness (displacement as a function of ultrasound intensity) and changes in displacement before, during, and after the procedure provides the unique potential to remotely palpate the ablated volume to monitor the formation of lesions created with MRgFUS. It will also provide a crucially needed assessment of tissue change in regions of fat where conventional MR thermometry fails.
1. Gerstenmayer M, Magnin R, Fellah B, Le Bihan D, Larrat B. MAGNETIC RESONANCE ACOUSTIC RADIATION FORCE IMAGING FOR IN VIVO ESTIMATION OF ULTRASONIC TRANSMISSION FACTOR THROUGH RAT SKULLS. ISTU; 2016; Tel Aviv, Isreal. P 95.
2. de Bever J, Farrer A, Odeen H, Parker DL. A 3D multi-contrast pulse sequence for acquisition of MR acoustic radiation force imaging concurrently with proton resonance shift thermometry. ISTU; 2014; Las Vegas, Nevada.
3. de Bever J, Farrer A, Odeen H, Parker DL. Simultaneous Acquisition of MR Acoustic Radiation Force Imaging and Proton Resonance Shift Thermometry with 3D Multi-Contrast Pulse Sequence. ISMRM; 2014; Milan, Italy.
4. de Bever J, Odeen H, Parker DL. Measurement of dynamic tissue response to focused ultrasound using 3D MR-ARFI. ISTU; 2014 April 17, 2015; Utrecht, The Netherlands. p Abstract: 2174218
5. de Bever J, Odeen H, Parker DL. Simultaneous Acquisition of Acoustic Radiation Force Imaging and Proton Resonance Frequency Shift Thermometry Using Interleaved Acquisition with Temporally Constrained Reconstruction for Increased Temporal Resolution. ISMRM; 2016; Singapore.
6. Rieke V, Vigen KK, Sommer G, Daniel BL, Pauly JM, Butts K. Referenceless PRF shift thermometry. Magn Reson Med 2004;51(6):1223-1231.
A18 Binary localization of cavitation activity based on harmonic content for transcranial brain therapy
Guillaume Maimbourg1, Mathieu David Santin2, Alexandre Houdouin1, Stéphane Lehericy2, Mickael Tanter1, Jean Francois Aubry1
1Institut Langevin Ondes et Images, ESPCI ParisTech, CNRS UMR 7587, INSERM U979, Paris, France; 2CENIR, ICM, CNRS U7225, INSERM U975, Paris, France
Cavitation activity may occur during BBB disruption (due to UCA injections) and also during HIFU treatment due to nucleation under high negative pressure. The corresponding microbubble activity has to be monitored to assess the safety and efficiency of brain treatments by ultrasound. The purpose of this study is to binary discriminate the position of microbubbles, inside or outside the skull, in order to know whether cavitation occurs in the brain of the patient or not.
Binary localization is achieved here by taking advantage of the attenuation properties of the skull. The skull acts indeed as a low pass filter for acoustic signals. Thus we hypothesize that the harmonic content of signals from cavitation events could be used as a binary indicator of their localization: inside or outside the brain case.
A wideband Passive Cavitation Detector (PCD) recorded the acoustic signals from microbubbles activity.
An in vitro setup (Fig. 17) mimics a BBB opening configuration (contrast agent flow with 0.6 MPa sonication during 10 ms at focus) or a thermal ablation (calf brain sample at focus with 3-4 MPa sonication during 0.3 s at focus). Experiments were performed either with no skull in place, or with human (6 samples) or monkey (1 sample) skull in front of the PCD.
In vivo BBB opening were conducted on macaque (900 kHz, 0.6 MPa at focus) with the same PCD mounted on the monkey head.
The spectra are computed from data recorded by the PCD and reveal harmonics, subharmonic and ultraharmonics of the excitation frequency (900 kHz in all cases).
The ratio of a high frequency harmonics over a lower frequency harmonic was then calculated. This ratio is expected to decrease when the acoustic signal from cavitation activity crosses through the skull. In order to achieve binary localization, two types of ratio have been computed: ultraharmonic ratios (e.g. 5/2 over 1/2) and harmonic ratios (e.g. 4 over 2).
The ultraharmonics ratio obtained during in vitro thermal-like ablation is plotted in Fig. 18. This ratio significantly decreases when acoustic signal crosses through the skull. Thus a threshold can be introduced to binary localize cavitation inside/outside the skull.
Table 2 summarises the results for harmonic ratio 4 over 2 and ultraharmonic ratio 5/2 over 1/2 obtained in vitro and in vivo during BBB opening and thermal necrosis. For BBB opening, neither the sub- nor the ultraharmonics appears in vivo, probably due to the confinment of the largest microbubbles by the vasculature. Thankfully in vitro experiments point out that the harmonic ratio remains relevant to binary localize microbubbles in the human case. Indeed the harmonic ratio 4 over 2 exhibits a -30 ± 3 dB decrease when crossing through human skull.
In order to ensure the repeatability of this method, each configuration was statistically investigated by plotting receiver operating characteristics (ROC) curves. These plots (Fig. 19) illustrate the performance of this approach. Except for in vivo BBB opening on monkey, ROC curves demonstrate that a sensitivity and a specificity which are simultaneously nearly 100 % can be obtained for the binary localization of cavitation activity.
ultraharmonic (5/2 over 1/2) and harmonic (4 over 2) ratio during thermal necrosis and BBB opening in dB scale
Harmonic 4 Harmonic 2
Ultraharmonic 5/2 Subharmonic 1/2
BBB opening (UCA + US)
Reference: no skull
Thermal necrosis (US only in calf brain)
Reference: no skull
A19 Inflection of temperature vs. power curve in tcMRgFUS: correlation with lesion location
Kim Butts Pauly1; Christian Federau1; Beat Werner2; Casey Halpern1; Pejman Ghanouni1
1Stanford University, Stanford, California, USA; 2University Children’s Hospital Zurich, Zurich, Switzerland
During tcMRgFUS, power levels are progressively increased to align, verify treatment location, and create a durable ablation. It is predicted that the measured temperature at the focus for a consistent timepoint will increase monotonically with power. However, the temperature rise is often observed to actually decrease with increasing power, creating an inflection in the peak temperature vs. power graph (Fig. 20). The purpose of this work was to show this behavior in the temperature rise is correlated with a lack of alignment between the thermal lesion and the monitored scan plane.
Fifteen ET datasets were included in this study. Post-treatment 3D T2-weighted FSE images (FOV 24 cm, matrix 320x320, slice thickness 1 mm) were thresholded at the signal intensity of zone 1 (Fig. 20). Measurements from the targeted ACPC plane to the top and bottom edges of zone 2 were made in the sagittal plane.
MR thermometry (TE/TR = 12.8/100 (n = 13); TE/TR = 3,8,13,18,22/100, (n = 2)) was processed with a single baseline subtraction (α = -0.00909), followed by referenceless processing for constant and linear terms. The maximum temperature of the third time point (k-space center 8.8 s after sonication initiation) in the axial scan plane was plotted vs. power. This time point was chosen because all sonications were at least 10s in duration. The number of sonications after any inflection was noted.
In 12 cases, temperature-power curves from early sonications in the axial scan plane were extrapolated to higher power levels. The amount that the measured temperature was below the estimated temperature was measured.
The results are shown in Fig. 21. While the distance from the treatment plane to the inferior aspect of the lesion remains essentially constant, the distance from the treatment plane to the superior aspect of the lesion increases with number of sonications after inflection. While it is expected that multiple sonications at the same location may increase lesion size, this data demonstrates that lesion size increases preferentially in the direction of the transducer as we increase sonications after inflection.
The movement of the lesion superiorly from the AC-PC plane is correlated with the difference between the actual and estimated temperature (✰). Although this was quantitated only in the axial scan plane, the inflection was seen in all three scan planes. Prior work demonstrated that the lesion is double oblique (the superior aspect of the lesion is posterior and medial); therefore, movement of the focal spot towards the effective transducer aperture moves it also out of the monitored sagittal and coronal scan planes.
One interpretation of this data is that an increase in the acoustic absorption effectively shields the focal spot, with subsequent hotspots located closer to the transducer. A second explanation is that the acoustic properties of the skull may be changing during treatment.
A20 MR-guided Focused Ultrasound pig brain tissue and its histology as a function of thermal dose
Dong-Guk Paeng1,3, Zhiyuan Xu2, John Snell3, Anders Quigg3, Matt Eames3, Changzhu Jin3, Ashli Everstine2, Jason Sheehan2, M. Beatriz Lopes2, Neal Kassell3
1Jeju National University, Jeju, Republic of Korea; 2University of Virginia, Charlottesville, Virginia, USA; 3Focused Ultrasound Foundation, Charlottesville, Virginia, USA
This study is to investigate the effects of Magnetic Resonance-guided Focused Ultrasound (MRgFUS) on in vivo pig brain tissue by comparison of the tissue damage in histology with the changes in MR images as a function of thermal dose (TD) up to 200 cumulative equivalent minutes (CEM) at 43 °C.
We have implemented a PI (proportional-Integral) control system in a laptop with an Arduino-based controller to modulate pulse duration of a FUS system (ExAblate 4000 Neuro 650 kHz system, InSightec) based on the temperature difference between target temperature and focal temperature as measured by an MRI system (Discovery MR75-3.0 T, GE Medical systems) with proton resonant frequency (PRF) thermometry. Accumulated thermal dose in CEM was calculated every 3.7 seconds and used to stop the sonication when a prescribed thermal dose of interest was reached and delivered to the target brain tissue. After tuning of a closed loop control system in a phantom, one acute and seven chronic pig experiments with three-day survival were conducted to investigate the correlation of lesions between the MR images of pig brain tissue with the corresponding histology. Craniectomy was performed to create an acoustic window, and sonication was applied on 4 spots in the thalamus of each pig. Absolute temperature in pig brain tissue was computed based on the MR thermometry using the rectal temperature as a baseline. TD varied from 7 to 195 CEM with target temperature between 46 and 52 °C at appropriate acoustic powers. This pig study was approved by the University of
From the acute pig experiment, we observed one large and 2 small lesions on MR images 1 hour after a sonication and subsequent histology showed 4 lesions of target. For the chronic pig experiments, 22 sonication spots in 6 pigs were analyzed through MR images and histology. One pig was excluded due to air bubbles introduced between the dura and scalp during the surgery procedure, and 2 sonication spots were failed to generate due to technical problems. Results show that large brain tissue damage was observed in MR images in all 7 spots with doses larger than 100 CEM and the corresponding histology results confirmed infarction with necrotic center for all except one with a dose of 101 CEM. The diameter of those lesions on T2-weighted axial MR images was measured to 2.9 ± 0. 4 mm (mean ± SD,) with a mean volume of 30.7 ± 12.9 mm3. All with TD lower than 17 CEM produced no visible lesions in either MR images or histology. There was a discrepancy in generating lesions with TD between 18 and 100 CEM, so that six smaller lesions (3 in volume) were shown except one large change in MR images at
In conclusion, large tissue damages were observed on MR images and histology for all TD above104 CEM, but no change was shown for all TD below 17 CEM. There is a variability in tissue changes between these TD levels. These results may contribute toward prescription of thermal dose rather than peak temperature or acoustic power for brain treatments, and expand the treatment envelope beyond the current limitations in selecting targets and patients.
A21 Visualization tools for transcranial Focused Ultrasound procedure planning, simulation and analysis
John Snell, Anders Quigg
Focused Ultrasound Foundation, Charlottesville, Virginia, USA
The interactions between particular transcranial transducer and skull geometries are challenging to understand without interactive visual computing tools. Such a tool has been created to allow the visual exploration of the estimated treatment envelope of a transcranial transducer given a patient specific imaging dataset. The impetus for developing such a system is to aid in understanding treatment envelope constraints and to serve as a tool for specifying the input to various acoustic simulation systems.
A visualization application was created which makes heavy use of a modern GPU to interactively display a transcranial Focused Ultrasound transducer, patient specific brain and skull anatomy, and the interaction of each transducer element beam path with the skull. The incident angle of each transducer element beam axis with the outer table of the skull is calculated and displayed in an interactive fashion as the natural focus of the transducer is moved within the intracranial volume. Skull geometry is derived from a treatment compatible CT dataset. An MR dataset is registered with the CT for targeting. Due to the interactive nature of the tool, presumptive targets can be rapidly and intuitively explored and understood in terms of geometric constraints and estimated treatment efficiency.
The visualization system functions will be demonstrated including targeting, transducer positioning and assessment of transducer efficiency in terms of effective transducer element count.
An interactive visualization system has proven valuable for facilitating understanding of the complex interaction of transducer and skull geometries. Future applications of this system may include patient screening, post-treatment analysis, indication feasibility screening and acoustic simulation initialization.
A22 HIFU for Pediatric Operations (HOPE) – a pediatric neurosurgical treatment system
James Drake1, Karl Price2, Lior Lustgarten1, Vivian Sin2, Charles Mougenot3, Elizabeth Donner1, Emily Tam1, Mojgan Hodaie4, Adam Waspe1, Thomas Looi2, Samuel Pichardo5
1Hospital for Sick Children, Toronto, Ontario, Canada; 2Centre for Image Guided Innovation and Therapeutic Intervention, Toronto, Ontario, Canada; 3Philips Healthcare Canada, Toronto, Ontario, Canada; 4Toronto Western Hospital, Toronto, Ontario, Canada; 5Thunder Bay Regional Research Institute, Thunder Bay, Ontario, Canada
Pediatric patients have distinctive neuroanatomic features and specific disorders that make them unique candidates for transcranial MR-guided Focused Ultrasound treatment. Children have thinner skulls, and neonates in particular, possess a natural acoustic window through their fontanelle. This results in lower phase aberration and decreases the need for the larger hemispherical dome transducers used for current adult transcranial procedures. These systems also require fixation of the head in a stereotactic frame, which is dangerous for their fragile skull. In addition, neonates often require MR-compatible incubators and dedicated neuro-interventional coils for imaging. Focal brain ablation/disconnection for medical refractory epilepsy and lysis of intra-ventricular hemorrhage are some of the proposed noninvasive treatment options for this population. To provide such treatment, we have developed HOPE – HIFU for Pediatric Operations – an integrated neonatal HIFU treatment system.
HOPE is composed of multiple elements: a 5 degree of freedom MR-compatible robot positioning device, a 256 element phased-array transducer, an 8 channel neuro-interventional coil, and a real-time Python-based treatment planning and delivery software system. The specifications for HOPE were determined by a team of clinicians and researchers as follows: compatible with clinical neonatal incubators and MRI techniques, imaging coil integrated into the incubator, positioning system to couple and deliver the HIFU treatment and real-time control/monitoring of the treatment (Fig. 22). The hardware elements are designed and tested with a Philips Achieva 3.0TX MRI with an Imasonic 256 element transducer. For coupling, a custom designed water bag system was created to interface with the patients’ head. The software platform includes robot kinematics, robot visualization, registration, transducer control and MRI communication. A calibration procedure was developed using a series of Vitamin E markers visible in a 3D gradient echo sequence without fat suppression; the markers were attached to an extension of the robot that recreates the acoustic cone of the HIFU beam. A user-interface module was developed to calculate the center of mass of each marker and to co-register the coordinate systems of the MRI and the robot.
The hardware system of HOPE has been designed and tested to show it can perform T1, T2 and DTI imaging that is comparable to clinical coils while delivering HIFU treatment in a phantom model. The neuro-interventional coils provide high resolution images for treatment planning (Fig. 23). The MR-conditional robotic system positions the transducer to an accuracy of 0.59 +/- 0.25 mm and delivers thermal ablation treatment to targets in a Philips HIFU quality assurance phantom. The custom water coupler bag provided a transmission path for the HIFU with minimal energy loss. The HOPE software platform controls each of the robotic positioning axes with hardware safety switches in a real-time Python interface (Fig. 24). The software registration of the patient, MRI and robot frame allows the user to select specific brain targets. During treatment, real-time thermometry is displayed.
A23 Simultaneous stimulation of the human primary and secondary somatosensory cortices using transcranial Focused Ultrasound
Wonhye Lee1, Yong An Chung2, Yujin Jung2, In-Uk Song2, Seung-Schik Yoo1
1Brigham and Women’s Hospital, Boston, Massachusetts, USA; 2Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon, Republic of Korea
Low-intensity transcranial Focused Ultrasound (FUS) is making progress as a new mode of non-invasive brain stimulation, having potential for superior spatial selectivity and depth penetration compared to transcranial direct current stimulation (tDCS) or transcranial magnetic stimulation (TMS). With accumulating evidences of the FUS-mediated neuromodulatory effects in small and large animal models, the sonication given to the primary somatosensory cortex (SI) has recently shown to be capable of eliciting tactile sensations in humans. Here, we further investigated the creation of tactile sensations induced by simultaneous FUS stimulation of the secondary somatosensory cortex (SII) and SI of the hand.
Ten healthy volunteers (two females, ages = 23–34, average of 27.8 ± 4.1 yrs) participated, and all procedures were conducted under the approval of the local Institutional Review Board of the Catholic University of Korea. For targeting of FUS focus to the individual functional neuroanatomy, each participant’s brain image was acquired using a 3-T MR scanner with anatomical (T1-weighted) and functional MRI (fMRI, T2*-weighted) protocols. The SI and SII areas were mapped while using four types of external tactile stimuli to the palm of the right hand—vibrotactile, pressure, warmth, and coolness. CT scan of the head was also acquired for the planning of transcranial sonication path. As guided by these individual-specific neuroimage data, FUS sonication (210 kHz, single-element FUS transducer with focal length of 38 mm) was administered to the SI and SII simultaneously (or separately), with an incident acoustic intensity of 35 W/cm2 Isppa, tone-burst-duration of 1 ms, pulse-repetition frequency of 500 Hz (yielding a 50 % duty cycle), and a sonication duration of 500 ms. The SII was targeted as divided into four sub-regions that are specifically activated by the external tactile stimuli.
Across the differential selective stimulations (i.e., SI only, SII only, or SI and SII simultaneously), participants felt various types of elicited tactile sensations (while ‘tingling’ was dominant) from the hand areas contralateral to the sonication, such as the palmar/dorsal side of the hand or as single/multiple adjacent fingers. These results were similar to our previous study on FUS stimulation of the SI, while the elicitations of ‘vibrotactile’ and ‘warmth’ sensations were newly reported in the present study. The types of tactile sensations did not match to the sensations that are associated with the specific sub-regions in the SII. However, two individuals reported matching types of sensations (‘vibrotactile’, ‘pressure’, and ‘warmth’) during stimulation of the SI/SII simultaneously or the SII only. The stimulatory effects of the FUS were transient and reversible, and the sonication procedures did not induce any discomforts or adverse changes in the subjects’ physical/mental status.
Simultaneous stimulation of the SI/SII in the same hemisphere was achieved by using multiple FUS transducers, which elicited various types of tactile sensations. Stimulation of the SII only also induced the creation of tactile sensations. The ability to stimulate multiple region-specific brain areas may shed light on examining the causal relationships between regional brain activities and subsequent behavioral/cognitive outcomes.
A24 Transcranial Focused Ultrasound stimulation of the primary visual cortex in humans
Wonhye Lee1, Hyun-Chul Kim2, Yujin Jung3, Yong An Chung3, In-Uk Song3, Jong-Hwan Lee2, Seung-Schik Yoo1
1Brigham and Women’s Hospital, Boston, Massachusetts, USA; 2Department of Brain and Cognitive Engineering, Korea University, Seoul, Republic of Korea; 3Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon, Republic of Korea
Transcranial Focused Ultrasound (FUS) has been suggested as a new non-invasive modality of regional brain stimulation, with potential to be more spatially-selective and to reach deep cortical/subcortical areas compared to the conventional methods of transcranial magnetic stimulations (TMS) or transcranial direct current stimulation (tDCS). In humans, low-intensity FUS sonication has been demonstrated to temporarily change the neural activities in the primary somatosensory cortex (SI), based on the observations of subjective sensory manifestations and electrophysiological responses. However, functional neuroimaging evidence of increased neural activity in the stimulated region, as well as the associated network-wide brain responses, has not yet been shown in humans. Here, we administered stimulatory FUS to the primary visual cortex (V1) as guided by the individual-specific neuroanatomy. Concurrent functional MRI was acquired to assess the brain regions that were activated due to the stimulation.
19 healthy volunteers (five females, ages 20–45, average 26.1 ± 5.4 yrs) participated, and all procedures were conducted under the approval of the Institutional Review Boards of both the Catholic University of Korea and Korea University. Functional MRI (fMRI; for mapping of the visual areas) and cranial CT were obtained from each participant to provide the individual-specific V1 location for sonication planning/targeting. Then, in a separate session, an MR-compatible sonication setup (270 kHz, single-element FUS transducer with radius-of-curvature of 30 mm) was used to deliver FUS to the V1 under a clinical 3-T MR scanner for the image-guidance and the simultaneous acquisition of fMRI data. Separate from the FUS-fMRI session, electroencephalographic (EEG) potentials elicited by the FUS stimulation were also measured. We used a pulsing scheme having a sonication duration of 300 ms with a tone-burst-duration of 1 ms repeated at a pulse repetition frequency of 500 Hz (yielding a 50 % duty cycle). The incident acoustic intensity at the FUS focus was 16.6 W/cm2 Isppa. Retrospective numerical simulation of the transcranial acoustic wave propagation was performed proximal to the sonicated area to estimate the in situ acoustic intensity and spatial accuracy of sonication.
Simultaneous acquisition of fMRI during FUS sonication to the V1 revealed the elicited activation not only from the sonicated brain area, but also from the network of regions involved in visual and higher-order cognitive processes. Accompanying phosphene perception was also reported. The EEG responses showed distinct peaks associated with the sonication, having similarities with the classical visual evoked potentials (VEP) generated by photic stimulation. The procedures did not induce any discomforts or adverse effects from the participants, based on the subjective reporting and neuroradiological/neurological examinations. Retrospective numerical simulation of the transcranial FUS suggested the variability in individual responsiveness to the stimulation.
Simultaneous fMRI acquisition during FUS application to the V1 revealed the functional neuroimaging-based evidence in humans that the FUS stimulation activates the sonicated brain area and concurrently elicits the associated phosphene perception. Successful stimulation of the V1 was also supported by the presence of the evoked EEG potentials associated with FUS. The individual variability in responsiveness to the stimulation suggested needs for an elaborate image-guidance.
A25 Focused Ultrasound modulation of visual search performance and associated EEG in monkeys
Charles Caskey, Wolf Zinke, Josh Cosman, Jillian Shuman, Jeffrey Schall
Vanderbilt University, Nashville, Tennessee, USA
Focused ultrasound (FUS) is a promising tool for neuromodulation because of its noninvasivness and better spatial precision compared to other noninvasive methods, such as transcranial magnetic stimulation (TMS) or transcranial direct current stimulation (tDCS). FUS neuromodulation has been demonstrated in multiple animal models, including a prior study where ultrasound was applied transcranially over macaque frontal eye field (FEF) to influence saccade response time in an anti-saccade task. In this work, we applied FUS through a craniotomy over the macaque FEF while measuring saccade response times and EEG signals associated with selective attention.
A single element focused transducer was positioned through a craniotomy over FEF, a cortical area that plays a key role in the eye movement and attention systems. FUS stimulation was applied during a complex visual search task where the monkey was required to shift its gaze to a target among distractors. We alternated blocks of trials with or without FUS stimulation (300 ms of pulsed FUS with a 50 % duty cycle starting 150 ms before search display onset, center frequency 500 kHz, repetition frequency 2 kHz, pulse duration 0.25 ms, peak negative pressures of 250 kPa or 425 kPa, warming of brain tissue < 1.5 °C). Saccade response time and intracranial EEG recordings were acquired in two monkeys performing 9 sessions each.
In both monkeys, event-related potentials (ERPs) associated with selective attention (N2pc) were significantly reduced during stimulation with both intensities. FUS stimulation attenuated the N2pc over the entire session block, rather than on a trial-by-trial basis. In one monkey with a craniotomy positioned directly over FEF, the mean saccade response times were reduced by 5 ms by FUS stimulation at 425 kPa (p < 0.001) when the target appeared in the upper hemifield contralateral to the FUS stimulation, while another animal with a craniotomy more ventrally did not show such a systematic behavioral modulation.
We are continuing to explore potential spatial relationships between stimulation location and behavioral modulations in ongoing work. Overall, our findings demonstrate prolonged FUS modulation of attention ERPs and suggest potential spatial selectivity based on the location of stimulation.
A26 Ultrasound-mediated modulation of motor and ocular responses in anesthetized mice in vivo
Christian Aurup1, Shutao Wang1, Hong Chen2, Camilo Acosta1, Elisa Konofagou1, Hermes Kamimura3, Antonio Carneiro3
1Columbia University, New York, New York, USA; 2Washington University in St. Louis, St. Louis, Missouri, USA; 3Universidade de Sao Paolo, Sao Paulo, Brazil
Focused ultrasound has been identified as a non-invasive technique for modulating brain activity. Most studies involving sedate rodents utilize frequencies in the kilohertz-range, which allow for optimal transmission of acoustic power through the skull. The tradeoff with using lower frequencies involves producing larger acoustic foci and resultant poor target-specificity. Megahertz-range frequencies can therefore be used to improve target-specificity. This study demonstrates that Focused Ultrasound in the megahertz range can be used to evoke motor and ocular responses in mice under deep anesthesia by targeting cortical and subcortical structures, respectively. Contralateral-paired hind limb movements were observed when stimulating cortical regions, demonstrating the ability of megahertz-range FUS to stimulate activity in highly-targeted regions. Additionally, pupil dilation was observed when deep-seated anxiety-related structures were targeted, demonstrating the ability of FUS to modulate activity in a small subcortical structures.
For this study, wild-type adult male mice were anesthetized with intraperitoneal injections of sodium pentobarbital (65 mg/kg) and fixed in a stereotaxic frame. A single-element FUS transducer with fundamental frequency of 1.94 MHz was fixed to a 3D positioning system for accurate navigation through the brain. A 6x6 mm grid centered +2 mm anterior of the lambda skull suture was sonicated in a random order using a center frequency of 1.9 MHz, pulse repetition frequency of 1 kHz, 50 % duty cycle, 1 second pulse duration, 1 second inter-pulse interval for a total of 10 pulse repetitions. The acoustic pressure applied was varied in order to evaluate thresholds for eliciting physiological responses like motor movement, eye movement, or pupil dilation. Motor movements were validated using video recordings and intramuscular electromyography recordings from the biceps femoris in both hind limbs. Pupil movement and dilation from subcortical modulation were evaluated using a high-resolution camera aimed at the right eye and frame-by-frame processing technique.
The minimum peak rarefactional pressure required to elicit hind limb movements was 1.45 MPa when targeting cortical regions, calibrated using an excised mouse skull. Higher pressures increased the success rate from 20 % (at the 1.45 MPa threshold) to 70 % (1.79 MPa) (Fig. 25). Targeting eye-motor and anxiety-related regions of the brain elicited eye movements and pupil dilations up to 20 %. Sonicating the superior colliculus resulted in both eye movement and pupil dilation at a lower threshold pressure (1.20 MPa) than the hippocampus and locus coeruleus, which required pressures greater than 1.80 MPa. A histological evaluation performed in five mice at 1.93 MPa and 3 MPa peak rarefactional pressure resulted in no red blood cell extravasation (Fig. 26).
A27 Non-invasive neuromodulation via targeted delivery of neurotransmitter chemicals
Nick Todd1, Tao Sun1,2, Yong-Zhi Zhang2, Chanikarn Power1,2, Navid Nazai3, Sam Patz1, Margaret Livingstone2, Nathan McDannold1,2
1Brigham and Women’s Hospital, Boston, Massachusetts, USA; 2Harvard Medical School, Boston, Massachusetts, USA; 3Boston University, Boston, Massachusetts, USA
Focused ultrasound (FUS)-microbubble treatment has been used to open the Blood-Brain Barrier (BBB) for targeted delivery of a wide variety of therapeutics. Here we propose to deliver neurotransmitter chemicals such as GABA or glutamate for the purpose of non-invasive neuromodulation. These chemicals function to transmit or suppress signals across the chemical synapses that connect neurons in the brain. This novel approach affects signaling between neurons, as opposed to existing neuromodulation techniques that affect the transmission of electrical signals along neurons. Such an approach could be an important new complimentary tool for basic neuroscience or lead to new therapies for neurological disorders.
Previously, we used electrophysiology measurements to demonstrate functional blockade via BBB disruption and GABA administration. Here we present initial results demonstrating the proof of concept in a rodent model using delivered GABA to modulate neuronal activity and functional MRI to measure the effects.
Sprague-Dawley rats underwent bilateral hindpaw electrical stimulation (1-5 mA, 0.3 ms duration, 2 Hz) to elicit a functional response of the somatosensory network. Varying levels of GABA were systemically injected under conditions No BBB opening and BBB opening. Functional activity in the thalamus and S1 was measured using fMRI to quantify any effects of neuromodulation.
BBB opening: Microbubbles injected (Optison, 200 μl/kg), 274 kHz dual aperture transcranial FUS with 32 ms bursts applied at 4 Hz for 60 seconds.
GABA delivery: Systemic tail vein bolus injection in doses from 10 mg/kg to 50 mg/kg.
fMRI: Images acquired on a Bruker 7 T scanner with a single shot EPI sequence (TR = 1.5 s, TE = 18 ms, 18 slices, 300 images). Stimulation performed in a 40 s OFF, 20 s ON block design over 7.5 total minutes. T-scores obtained using general linear model analysis in SPM 12.
BBB Closed: Fig. 27 shows activation results in S1 for the case of No BBB opening. Compared to the baseline case of No GABA injected, a GABA injection of 10 mg/kg showed significant decrease in activity (p < 0.05) but GABA injections of 25 mg/kg and 50 mg/kg did not.
BBB Open: Fig. 28 shows activation results in the thalamus for the case of BBB opening. BBB opening was targeted, and confirmed through gadolinium imaging, in the right hemisphere. Bilateral activation was seen in the thalamus for the baseline case of No GABA injected. For GABA injection of 25 mg/kg, a significant decrease in activation was seen in the right (opened) ROI (p < 0.001), but not the left (unopened) ROI. For GABA injection of 50 mg/kg, a significant decrease in activation was seen in both ROIs (p < 0.001).
A28 Initial experience in a pilot study of Blood-Brain Barrier opening for chemo-drug delivery to brain tumors by MR-guided Focused Ultrasound
Todd Mainprize1, Yuexi Huang2, Ryan Alkins3, Martin Chapman3, James Perry4, Nir Lipsman1, Allison Bethune1, Arjun Sahgal4, Maureen Trudeau4, Kullervo Hynynen1
1Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; 2Physical Sciences Platform, Sunnybrook Research Institute, Toronto, Ontario, Canada; 3University of Toronto, Toronto, Ontario, Canada; 4Sunnybrook Research Institute, Toronto, Ontario, Canada
Magnetic Resonance-guided Focused Ultrasound (MRgFUS) has been shown to reversibly open the Blood-Brain Barrier (BBB) for targeted drug delivery . Research on animal models, including non-human primates , has been conducted to investigate the effectiveness and characteristics of BBB openings. Here we describe our initial experience in a pilot clinical study to establish the feasibility, safety and preliminary efficacy of Focused Ultrasound to temporarily open the BBB to deliver chemotherapy to brain tumors.
The opening of the BBB was successful at both locaitons with clear Gd enhancement in the 3x3 grid pattern. (Figs. 30 and 31). Despite using the same power level, the actual acoustic pressure at the 2nd target was lower than the first due to steering of the FUS beam. Low-level extravasation of red blood cells were seen as small dark signals within individual sonicated sponts in the T2* image (Fig. 32). The quantification of drug concentration is pending further analysis.
The 3 mm spacing of the 9 spots was intentionally designed to form a grid pattern of Gd enhancement for easier confirmation in heterogeneous tumors for the initial cases. We do not expect an impact on other parameters if the spacing needs to be reduced for a more uniform drug distribution within the BBB opening volume. There was a small level of RBC extravasation but this was not a concern in the tumor enviromment. Our animal experiments have shown that the cavitation signal can be used during the sonications to control the power level for eliminating the RBC exravasations . The current system did not use this method during sonications.
The tumor in this patient was in the right temporal lobe adjacent to the skull. The two targets were ~4 cm lateral from the midline of the brain, and the 2nd target was also ~2.5 cm posterior. Thermal ablations by FUS at these off-centre locations are technically challenging due to excessive skull heating. However, successful BBB openings at these locations were demonstrated at low powers at 230 kHz. If these results can be repeated in other patients without complications, then the method may provide a new way to deliver therapeutic agents into brain for the treatment of tumors and other brain diseases.
1. Hynynen K et al. Radiology 2001;220:640-6.
2. McDannold N et al. Cancer Research 2012;72:3652-63.
3. Huang Y et al. ISMRM 2015, abstract 37.
A29 Enhanced bevacizumab delivery to the CNS by Focused Ultrasound induced blood-brain barrier opening for malignant glioma treatment
Hao-Li Liu1, Po-Hung Hsu1, Kuo-Chen Wei2
1Chang Gung University, Taoyuan, Taiwan; 2Chang Gung Memorial Hospital, Taoyuan, Taiwan
Malignant glioma is the most severe form of primary brain tumors with an extremely high recurrence rate and the poorest prognosis. Current anti-angiogenic monoclonal antibody (mAb) treatment failed to show therapeutic efficacy due to transient “vascular normalization” stage that restores BBB integrity in tumor regions and restricts anti-angiogenic mAb penetration, preventing angiogenic suppression of tumor cells in the CNS and diminishing the improvement in overall survival in clinical treatment observation. The purpose of this study is to demonstrate that transcranial Focused Ultrasound (FUS) enhances Blood-Brain Barrier (BBB) permeability of the antiangiogenic monoclonal antibody, bevacizumab, for glioblastoma multiforme (GBM) treatment.
Transcranial FUS in the presence of microbubbles was used to transiently open BBB, and enhance CNS penetration of bevacizumab in normal and glioma-bearing mice. Bevacizumab was quantitated by high-performance liquid chromatography (HPLC), and Western blotting confirmed bevacizumab in the CNS. Bevacizumab permeability was estimated in vivo via contrast-enhanced Magnetic Resonance Imaging (CE-MRI), and glioma progression was longitudinally followed via T2-MRI. Morphological changes and vascular inhibition were confirmed histologically with H&E and CD-31 immunohistochemistry (Fig. 33).
HPLC confirmed that FUS significantly enhanced CNS delivery of bevacizumab from 5.7- to 56.7-fold. The high correlations between CE-MRI imaging indices and bevacizumab concentration (r2 = 0.56-0.7378) suggested feasible non-invasive in vivo imaging of large-molecule BBB penetration. FUS-enhanced bevacizumab delivery significantly inhibited glioma progression, and improved median survival (ISTmedian = 135 %, compared to 48 % in bevacizumab-administration alone, Fig. 34).
A30 Closed-loop control of targeted drug delivery across the blood-brain barrier in rat glioma models
Tao Sun1,2, Chanikarn Power1,2, Yong-Zhi Zhang2, Jonathan Sutton1,2, Phillip Alexander1,2, Muna Aryal1,2, Eric Miller3, Nathan McDannold1,2
1Brigham and Women’s Hospital, Boston, Massachusetts, USA; 2Harvard Medical School, Boston, Massachusetts, USA; 3Tufts University, Medford, Massachusetts, USA
Microbubble-mediated Focused Ultrasound (FUS) can induce targeted drug delivery through Blood-Brain Barrier disruption (BBBD). Real-time feedback control of cavitation is critical to realize desired treatment outcome while avoiding tissue damage. Here, we propose an acoustic emissions-based controlling paradigm that can sustain stable cavitation (harmonic emission, HE) while suppressing inertial cavitation (broadband emission, BE). Our objective is to deliver desired drug dose by controlling HE strength during BBBD, while keeping the brain damage-free.
A dual-aperture FUS setup (f = 274.3 kHz) produced a sub-centimeter focal depth in rats’ brain (n = 50) in vivo, and a passive detector (fcentral = 650 kHz) monitored cavitation activity. HE and BE were analyzed during 32-ms bursts in real time and fed back for control of the next pulse. The impact of multiple FUS parameters and microbubble (Optison) injection protocol on the controller performance was studied. To avoid inertial cavitation, the pressure was reduced if BE was detected and terminated if it crossed a set threshold. Both wild type and F98 glioma (ATCC # CRL-2397) models have been used in this study. Delivery of a model drug (Trypan Blue; 960 Da) and chemotherapeutic drug (Doxorubicin) was assessed using fluorescent imaging of formalin-fixed tissue blocks 1-h post sonication.
Pilot study demonstrated the HE-pressure linearity (R2 = 0.93) and found that the BE threshold decreased as bubble dose (up to 400 μl/kg) was augmented. To optimize controller performance in sustaining HE while suppressing BE, a Phase-1 study demonstrated that: 1) 4-Hz PRF (compared to 1-Hz, P < 0.001) significantly suppressed the HE signal variance; 2) Infusing microbubbles after an initial bolus prevented the decline of HE and a corresponding increase in pressure, and further improved HE stability (P < 0.05 for all comparisons, Fig. 35a) while reducing the likelihood of BE (33.7 % vs. 16.7 %).
Using optimal settings, a Phase-2 study investigated HE control and Trypan Blue delivery (Fig. 35b). Integrated HE was exponentially correlated with epi-fluorescence intensity (R2 = 0.82; red symbols in Fig. 35c). Based on this calibration, a Phase-3 study tested if we could deliver a desired amount of drug by sonicating until the HE reached a preset goal. The resulting fluorescent intensity matched well with the reference curve for three different goals (n > 5 per group, green symbols in Fig. 35c).
A31 MR-guided Focused Ultrasound for antibody delivery in a brain metastasis model
Thiele Kobus1, Yong-Zhi Zhang2, Nathan McDannold2,3
1Radboud University Medical Center, Nijmegen, Netherlands; 2Harvard Medical School, Boston, Massachusetts, USA; 3Brigham and Women’s Hospital, Boston, Massachusetts, USA
Treatment options for breast cancer patients with metastases in the brain are limited. The blood-brain barrier (BBB) prevents most drugs from entering the brain and tumor. Although survival in patients with extracranial metastases of HER2-positive breast cancer can be prolonged by the use of antibody therapies like trastuzumab and pertuzumab, the response of brain metastases to these drugs is poor . We aim to improve antibody delivery by temporary disruption of the BBB using magnetic resonance (MR)-guided focused ultrasound (MRgFUS) in combination with microbubbles. The treatment benefit was evaluated using MR imaging.
The treatment effect of the antibodies trastuzumab and pertuzumab in combination with MRgFUS to disrupt the BBB was evaluated. MDA-MB-361 cells (HER2-positive human cancer cells) were injected in the brain. Six weekly treatments started 5 weeks later. Three groups of 10 nude rats were included: a control-group that received no treatment; a group that only received both antibodies; and a FUS + antibody-group that received the antibodies in combination with BBB disruption using MRgFUS. The ultrasound treatments took place in a 7 T MR-system using a spherically-focused 690 kHz-transducer. Before and after the sonications, T2-weighted (T2w) and T1w images were obtained for targeting and confirmation of BBB disruption. At the start of each sonication (duration 60s, 10-ms bursts, burst repetition frequency 1 Hz), the ultrasound contrast agent Optison (100 μl/kg) was injected. The complete tumor was treated in 4 to 14 sonications using peak negative pressures between 0.46 and 0.62 MPa.
After the sonications gadolinium (Magnevist) was injected and T1w was repeated to confirm BBB disruption. The difference in signal intensity change in pre- and post-contrast T1w images was determined between the tumor and contralateral brain region (=ΔSI%). In two animals tumor leakiness was studied before the tumors were sonicated and quantified similarly.
Every other week, high-resolution T2w imaging was performed to determine tumor volume. The volumes were fitted with: volume(t) = a*exp(r*t), in which r is the growth rate and t is the time in days. r was determined for the treatment period (week 5 to 11) and the follow-up period (week 11 till sacrifice). An animal was classified as ‘responder’ if the growth rate r was lower than the mean r of the control animals minus two standard deviations.
The animal was euthanized if its condition was poor or the tumor diameter exceeded 13 mm. Brains were stained for hematoxylin and eosin (H&E) and HER2.
BBB disruption was successful in all sessions with an average ΔSI% of 21.2 % (range 4.5–77.6 %). The mean ΔSI% of two tumors before BBB disruption during the six treatment weeks were 0.4 % and 0.6 %, indicating that the tumors were not leaky before disruption.
In the FUS + antibody-group, 4/10 animals were classified as responders during the treatment period with an average growth rate of 0.010 ± 0.007, compared to 0.043 ± 0.013 for the non-responders. There was no difference in the average ΔSI% of the responding rats (21.8 % ± 16.7) and the non-responding rats (20.7 % ± 9.7). None of the control or antibody-only animals were classified as responder. For the follow-up period, none of the animals was classified as responder.
High-resolution T2w imaging showed that the tumor was homogenous in most animals till week 13-15, when cystic and necrotic areas started to develop. The tumors showed also a heterogeneous appearance on H&E-stained sections and the complete tumor was HER2-expressing in the examined brains (Fig. 37).
In this study, we demonstrate that BBB disruption using MRgFUS in combination with antibody therapy can slow down the growth of breast cancer brain metastasis. As the tumors were not leaky before BBB disruption and there were no responders in the antibody-only group, the disruption of the BBB is necessary for drug delivery to these brain metastasis. Part of the rats responded to the treatment, while the other animals had the same growth rate as the control-group. This is in line with a previous study , where antibody therapy was combined with FUS in a different breast cancer brain metastasis model and only in part of the animals a response was observed. The difference in response could not be explained by the tumor volume at the start of the treatment, nor was there a difference in contrast-enhancement after BBB disruption or in HER2-expression. Better understanding of why certain animals respond is needed and will help in translating this technique to the clinic.
1. Pieńkowski and Zielinski. 2009. Ann Oncol: 917–24.
A32 Phase I/IIa clinical trial of blood-brain barrier disruption by pulsed ultrasound
Alexandre Carpentier1, Michael Canney2, Alexandre Vignot3, Kevin Beccaria1, Delphine Leclercq1, Cyril Lafon4,5, Jean Yves Chapelon5, Khe Hoang-Xuan6, Jean-Yves Delattre1, Ahmed Idbaih1
1Hopital de la Pitié-Salpêtrière, Assistance Publique Hopitaux de Paris, Paris, France; 2CarThera, Denver, Colorado, USA; 3CarThera, Lyon, France; 4University of Virginia, Charlottesville, Virginia, USA; 5INSERM Unit 1032, Lyon, France; 6Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
The Blood-Brain Barrier (BBB) limits the delivery and efficacy of systemically administered drugs to the brain. Pre-clinical studies have demonstrated that ultrasound-induced disruption of the BBB can significantly increase the intracerebral concentration of chemotherapy. To harness this approach, our group has developed an implantable ultrasound device, SonoCloud®, that allows for simple and repeated disruption of the BBB. The goal of this work was to determine the safety of repeated disruption of the BBB using the SonoCloud® device in patients with recurrent glioblastoma prior to receiving carboplatin chemotherapy.
A Phase 1/2a clinical trial was initiated at the Hospital Pitie Salpetriere in Paris, France in July 2014. Patients with recurrent glioblastoma were implanted with an 11.5-mm diameter biocompatible 1 MHz ultrasound transducer. The device was fixed to the skull bone in a standard burr hole, after which the skin was closed. Once a month, the device was connected to an external generator system using a transdermal needle connection and patients received a 150 second ultrasound sonication (25,000 cycles/burst, 1 Hz) in combination with systemic administration of an ultrasound contrast agent. BBB disruption was monitored immediately after sonication using gadolinium-enhanced Magnetic Resonance Imaging (MRI). Systemic intravenous injection of carboplatin chemotherapy (AUC 4-6) was administered immediately following acquisition of each patient’s post-sonication MRI (<1 hr after BBB disruption). Patients followed a progression of ultrasound dose in which the acoustic pressure was increased from 0.5 to 1.1 MPa throughout the course of the study.
Fifteen patients were included in this on-going study from July 2014-January 2016. A total of 41 BBB disruption sessions were performed. Contrast-enhanced MRI indicated that the BBB was disrupted at acoustic pressure levels up to 1.1 MPa without detectable adverse effects on MRI or clinical examination.
Our preliminary results from this Phase I/IIa study indicate that repeated disruption of the BBB using the SonoCloud® device is safe and well tolerated in patients with recurrent GBM and may improve chemotherapy delivery in the brain.
A33 Preliminary report on sonodynamic therapy for C6 glioma rat model
Zhiyuan Xu1, David Moore2, Alexis Xu1, Paul Schmitt3, John Snell2, Jessica Foley2, Matt Eames2, Jason Sheehan1, Neal Kassell2
1University of Virginia, Charlottesville, Virginia, USA; 2Focused Ultrasound Foundation, Charlottesville, Virginia, USA; 3University of Virginia Health System, Charlottesville, Virginia, USA
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A34 In vivo porcine histotripsy brain treatments
Jonathan Sukovich1, Charles Cain1, Zhiyuan Xu2, Aditya Pandey1, John Snell3, Neeraj Chaudhary1, Sandra Camelo-Piragua1, Steven Allen1, Dong-Guk Paeng4, Jon Cannata5, Dejan Teofilovic5, Jim Bertolina5, Neal Kassell3, Timothy Hall1, Zhen Xu1
1University of Michigan, Ann Arbor, Michigan, USA; 2University of Virginia, Charlottesville, Virginia, USA; 3Focused Ultrasound Foundation, Charlottesville, Virginia, USA; 4Jeju National University, Jeju, Jeju, Republic of Korea; 5HistoSonics, Inc., Ann Arbor, Michigan, USA
Focused ultrasound thermal therapies have been explored for brain applications including treatment of essential tremors, Parkinson’s disease, and stroke. Histotripsy, a cavitation based ultrasound therapy, is being investigated for treatment of brain tumor and intracerebral hemorrhage, but there are concerns that excessive hemorrhage may be induced in the brain during histotripsy treatment by disrupting blood vessels. This study investigates the in vivo feasibility and safety of generating targeted lesions in the porcine brain using histotripsy. The goal is to demonstrate that lesion generation may be accomplished safely and without excess hemorrhage, edema, or other major complications associated with treatment. We also seek to investigate the histotripsy dose required to fully ablate target brain regions.
Histotripsy treatments were delivered to brains of 11 pigs using a 1.5 MHz focused transducer following a craniotomy. Lesions generated were targeted in the cortex at depths of 5 to 20 mm from the exposed surface of the brain. Using ultrasound imaging guidance, treatment regions were targeted to be contained within individual gyri to avoid perforations into the sulci. During dosage studies, single lesions were generated using between 1 and 200 histotripsy pulses delivered at ≤10Hz PRF with an estimated peak negative pressure of 45 MPa. Large lesions were generated by incrementally repositioning the histotripsy target site during treatment to ablate entire target volumes. 7 acute pigs were sacrificed within 6 hours of treatment and brains were removed for MRI and histology. 4 sub-acute pigs were survived for 3 days after treatment. To assess lesion damage, hemorrhage and edema surrounding the lesions, MR images of the brains were acquired at 1 hour and at 3 days after treatment for sub-acute pigs. After euthanization brains were dissected for histology.
In 4 acute pigs, with ultrasound guidance, histotripsy was used to generate precise single lesions of 1.5x2.5 mm within the gyri. Dosage studies revealed that a single histotripsy pulse was sufficient to generate identifiable damage in the brain in MRI and complete cell fractionation in lesions was achieved by 50 pulses. In 3 acute pigs, 5 larger lesions measuring up to 7 mm diameter were generated in the brain. MRI and histology revealed that lesions confined to within the gyri show no hemorrhage or other major complication associated with treatment. In 4 sub-acute pigs, 6 single lesions were generated by 10 and 50 pulses, and two larger square lesions of 3.5 mm were created. MRI following treatment showed no hemorrhage or damage outside the target regions and at 3 days showed no additional hemorrhage and only minor edema near the lesion boundary. No midline shift or brain herniation was observed. Histology showed damage confined to within target volumes, with well demarcated boundaries between treated and untreated tissues and no evidence of hemorrhage, ischemic changes, encephalitis, or acute, sub-acute or chronic inflammatory infiltrate beyond the areas of the lesion.
The results of this study demonstrate that histotripsy may be used to generate targeted lesions in the brain without causing excess hemorrhage, edema, or other major complications associated with treatment. Lesions were observed to have well defined boundaries between treated and untreated tissues, with little damage beyond the confines of the lesion area. Tissues surrounding the lesions appear very viable with no acute, sub-acute or chronic inflammatory infiltrate, and tissues in adjacent gyri appear uninvolved and unremarkable. These results demonstrate that histotripsy may be applied in the brain without causing major complications and suggest the potential of histotripsy for use in brain therapy applications.
A35 Neuronavigation-guided Focused Ultrasound and real-time acoustic mapping: evaluation in non-human primates with blood-brain barrier opening
Shih-Ying Wu, Maria Eleni (Marilena) Karakatsani, Julien Grondin, Carlos Sierra Sanchez, Vincent Ferrera, Elisa Konofagou
Columbia University, New York, New York, USA
Focused ultrasound (FUS) has shown great promise for noninvasive brain treatment, including surgical ablation, Blood-Brain Barrier (BBB) opening and drug delivery, and neuromodulation. Accurate and precise targeting with personalized planning is the key for treatment success. Furthermore, repetitive procedure is often required for BBB opening and drug delivery as well as neuromodulation, which entails the demand for a portable system apart from the current MR-guided FUS system requiring a dedicated and custom-built suite. In this study, a neuronavigation-guided FUS system was developed (Fig. 38), combined with in silico preplanning based on CT and MRI as well as real-time acoustic mapping in visualizing the location and intensity of the cavitation events associated with BBB opening. The system was evaluated in non-human primates with BBB opening, with the treatment preplanning and targeting accuracy validated both in silico and in vivo.
Three rhesus macaques were sonicated (N = 15) and the subcortical structure of the basal ganglia was targeted, which is associated with neurodegenerative diseases including Parkinson’s and Huntington’s disease. Both CT and MRI were acquired for personalized pre-planning and neuronavigation guidance (Brainsight). The 3D numerical simulation of the acoustic pressure field was performed for pre-planning and post comparison with the BBB opening. A single-element, 0.5-MHz FUS transducer (diameter: 64 mm) with in-house microbubbles were used for sonication, and a programmable data acquisition system (Verasonics) with an array of acoustic detectors for real-time passive cavitation mapping. Both the FUS and cavitation mapping were guided with the neuronavigation system in real time during the FUS procedure. After sonication, the contrast enhanced T1-weighted MRI was used to confirm the location and size of BBB opening. The accuracy of both the FUS targeting and cavitation mapping were assessed.
The target shift was on average 2.0 mm laterally and 3.5 mm axially in the in vivo experiment, and the shift due to the skull was predicted to be 0-1 mm laterally and 1.0-5.5 mm axially in silico. Real-time cavitation mapping confirmed the sonicated area with and without BBB opening, and distance between the centroid of the cavitation map and that of the resulting BBB opening was under 2 mm. In order to achieve the desired BBB opening volume, the pressure and focal spot size in situ were estimated in silico and tailored for targeting in each subject. Simulation results showed a smaller focal spot size through the skull (2.6 mm laterally and 16.7 mm axially, compared with the original size of 4.0 mm laterally and 35.3 mm axially), which corresponded to the BBB opening volume under specific peak negative pressures (NHP 1 at 200 kPa, NHP 2 at 600 kPa). This pressure difference between individuals was due to the difference in skull attenuation, since the in silico pressure reduction was estimated to be 30.9 % ± 12.4 % and 53.9 % ± 14.3 % in NHP 1 and NHP 2, respectively.
A36 Definition of basic properties of physical immunotherapy in pancreatic cancer using HIFU and immune checkpoint inhibition
Gail ter Haar1, Petros Mouratidis1, Elizabeth Repasky2
1The Institute of Cancer Research, Sutton, Surrey, United Kingdom; 2Roswell Park Cancer Institute, Buffalo, New York, USA
The latest advances in cancer immunotherapy have improved our understanding of how to stimulate the patient’s immune system to fight their own disease. Notwithstanding the unparalleled success of treating melanoma tumours and non-small cell lung cancer with immune checkpoint inhibitors, patients are not all getting the same benefit. In this context, pancreatic cancer presents unique challenges. Its dense stroma characteristics result in limited immune cell infiltration in the tumour microenvironment. In addition the low number of mutations in pancreatic cancer cells result in few tumour antigens, thereby reducing their immunogenicity. HIFU may address some of these limitations by ablating segments of the tumour to induce a stronger inflammatory response and degrade the stroma to facilitate enhanced diffusion of tumour antigens out of the tumour, and increased penetration of lymphocytes to the tumour. We propose to co-treat pancreatic tumours with HIFU and immune checkpoint inhibitors to elicit an effective anti-tumour immune
In vitro characterization of the effects of heat on the presentation of cell surface receptors associated with the immune response has been undertaken in human colon cancer HCT116 cells and mouse pancreatic cancer Panc02 cells using FACS analysis. A KPC-derived pancreatic cancer cell line will be transplanted in C57BL/6 subjects to form syngeneic subcutaneous and orthotopic pancreatic tumours. These tumours will be treated with HIFU, and within vivo monoclonal anti-CLTA-4 and anti-PD-1 antibodies. The phenotype of markers of the adaptive immune response will be assessed to identify whether HIFU exposures can initiate intrinsic anti-tumoural cellular immunity at the site of treatment. Analysis by flow cytometry and immunohistochemistry of both effector cells (cytotoxic CD8+ T cells, dendritic cells), and immunosuppressive cells (Tregs, myeloid derived suppressor cells), as well as cytokines and chemokines at various time points post HIFU will be performed. Tumour growth will be determined using high resolution ultrasound imaging, and the results will be correlated with overall survival.
Thermal exposure of cancer cells results in a time-dependent regulation of the transmembrane receptor CD47. CD47 decreases immediately after, and 1 day after treatment, and increases 3 and 4 days after treatment relative to the sham-exposed cancer cells. Further data on the effects of thermal exposures on the regulation of immune-associated pancreatic cancer cell surface receptors will be presented.
Detailed pre-clinical studies in various mouse models of pancreatic cancer can provide a mechanistic understanding of the combinatorial effects of HIFU and immune checkpoint inhibitors. Strong evidence that HIFU stimulates endogenous immunity against pancreatic tumor cells, and augments the immunotherapy treatment of poorly immunogenic pancreatic tumours could be used as proof-of-concept for the initiation of Phase 1 clinical trials of HIFU-enhanced immunotherapy in patients with pancreatic cancer.
A37 Melanoma growth control via ultrasound depends on the adaptive immune system and surpasses αPD-1
Kelsie Timbie1,2, Lena Badr2, Benjamin Campbell2, John McMichael2, Andrew Buckner2, Jessica Prince2, Aaron Stevens2, Timothy Bullock2, Richard Price2
1Focused Ultrasound Foundation, Charlottesville, Virginia, USA; 2University of Virginia, Charlottesville, Virginia, USA
Melanoma incidence continues to rise, while Stage IV 5 year survival remains below 20 %. Targeted immunotherapy approaches, designed to enhance natural anti-tumor mechanisms or inhibit the immunosuppressive tumor microenvironment, have shown promise in early clinical use. The programmed death receptor and its ligand (PD-1 and PD-L1) have drawn considerable attention. PD-L1 is known to inhibit the activity of anti-tumorigenic cytotoxic T cells, promoting a pro-tumor immune profile, and ultrasound (US) can promote the infiltration of immune cells into the tumor. Here, we tested the hypothesis that a combination of pulsed US, microbubbles (MBs) and anti-PD-1 will improve tumor growth control in a mouse model of melanoma in a manner dependent on the adaptive immune system. Melanoma incidence continues to rise, while Stage IV 5 year survival remains below 20 %. Targeted immunotherapy approaches, designed to enhance natural anti-tumor mechanisms or inhibit the immunosuppressive tumor microenvironment, have shown promise in early clinical use.
Eight week old immunocompetent C57BL/6 male mice were inoculated unilaterally with B16-F10 melanoma cells and divided into four groups: Control (untreated), US + MBs, αPD-1, or US + MBs + αPD-1. Immunocompromised Rag1-/- mice were similarly inoculated and divided into two groups: Control (untreated) or US + MBs. On day 11 post-inoculation, animals receiving US were anesthetized and sonicated with a 0.75” unfocused 1 MHz transducer as previously described1 for 60 minutes. MBs (105/g b.w.) were injected i.v. throughout the sonication. The αPD-1 groups were given an IP injection of 250 μg of αPD-1 on Days 10, 13 and 16. Tumors were monitored until Day 18, when tumors were resected for flow cytometry. Helper T cells (CD4+), cytotoxic T cells (CD8+), T regulatory cells (Treg), macrophages and natural killer cells (NK) were counted in immunocompetent mice, and dendritic cells (DC), natural killer cells, M1 and non-M1 macrophages were counted in immunocompromised mice.
In immunocompetent mice, treatment with US + MBs provided improved tumor growth control compared to all other groups (Fig. 39a) as well as a significant survival benefit (not shown). Additionally, US + MBs generated a significant increase in macrophages (not shown) and Tregs (Fig. 39b) compared to control. Interestingly, the αPD-l and US + MBs groups performed similarly in CD4+ and CD8+ cell counts (Fig. 39b), but the combined US + MBs + αPD-1 treatment generated fewer T cells than either treatment alone. In immunocompromised animals, treatment with US + MBs did not provide tumor growth control (Fig. 39c) or a survival benefit (not shown), but did generate a significant decrease in M1 macrophages within the tumor (Fig. 39d), although total myeloid cell counts remained the same (not shown).
US indiscriminately increases the numbers of immune cells within subcutaneous melanoma; therefore, we expected that US-enhanced delivery of αPD-1 would provide an additional benefit; namely, a shift towards an anti-tumorigenic immune profile. However, αPD-1 did not synergize with US + MB treatment. While the mechanism is not yet understood, low power noninvasive US + MBs provided excellent tumor growth control and may serve as a stand-alone clinical treatment. Furthermore, this anti-tumor effect is clearly dependent on the adaptive immune system, since US + MBs treatment in immunocompromised mice produced no benefit. A better understanding of this mechanism may identify adjunct treatments that would synergize with US and further enhance the anti-tumor effect demonstrated here.
A38 Stress response of cancer cells after low intensity Focused Ultrasound
Karin Skalina1, Chandan Guha2
1Albert Einstein College of Medicine, Bronx, New York, USA; 2Montefiore Medical Center, Bronx, New York, USA
Low intensity Focused Ultrasound (LOFU) results in sublethal stress to tumor cells. We investigated the cell surface expression of immunomodulatory molecules in three murine cell lines (Lewis lung, breast and prostate adenocarcinoma). The immunomodulation was examined by flow cytometry of cell surface stress proteins: HSP70 & calreticulin, of immunomodulatory co-activating signals: CD40, CD80, CD86 and other receptors: MHC I, Fas). Surface expression of these molecules trigger activation of or phagocytosis by dendritic cells. Additionally, the activation of the unfolded protein response (indicated by phosphorylation of PERK or IRE1α or cleavage of ATF6α) can trigger apoptosis – a programmed cellular death pathway which can also activate the immune system. We hypothesize that by altering the total acoustic power of LOFU, we can modulate the stress signals both on the cell surface and within the cells.
LOFU treatment was performed on the Philips Therapy and Imaging Probe System (TIPS, Philips Research Briarcliff, USA) using 3 W or 5 W, 100 % duty cycle, 1.5 seconds, 1 mm spacing. LOFU treatment was performed on a cell pellet which were then replated and incubated at 37 °C, 5 % CO2 for the specified time. At the end of the incubation time, cells were lightly scraped for flow cytometry staining or lysis buffer was added to the adherent cells and then scraped for Western blot analysis.
The analysis of murine lung and breast cancer indicates that there is a significant surface localization of both HSP70 and calreticulin as early as 4 hours after LOFU treatment and this localization diminishes by 24 hours post treatment. For murine prostate cancer cells, however, the surface localization of HSP70 increases at 4 hours after treatment and increases further at 24 hours. Additionally, there is a significant increase in surface localization of both HSP70 and calreticulin with a higher output power of 5 W compared to 3 W. For immunomodulatory co-activating signals, there is increased surface expression in Lewis lung carcinoma and prostate adenocarcinoma, but not breast carcinoma. Results of the activation of the unfolded protein response are still pending at the time of submission, but preliminary results indicate the both phosphorylation of PERK and IRE1α are increased following LOFU treatment.
Tumor stress response to LOFU treatment can be altered by the total acoustic power of LOFU treatment. The increased surface localization of HSP70, calreticulin, CD40, CD80 and CD86 have the capacity to augment the immune response to the tumor. Therefore, LOFU can be used in combination with ablative therapies in order to induce anti-tumor immunity and destroy the primary tumor.
A39 The “abscopal” effect after USgHIFU treatment of advanced pancreatic cancer
Franco Orsi, Guido Bonomo, Paolo Della Vigna, Giovanni Mauri, Gianluca Varano
Istituto Europeo di Oncologia, Milan, Italy
Pancreatic cancer is considered one of the main big “killers” in Oncology, with still a very poor prognosis, both in patients amenable to resection and of course in more advanced stage disease. More than 50 % of patients are diagnosed with an advanced stage disease, where chemotherapy is usually the main therapy option. External radiotherapy is the most common palliative loco-regional treatment in pancreatic cancer, but in the last few years HIFU has been proposed as an alternative option for palliation in advanced stage.
From our specific experience of USgHIFU for pancreatic cancer, we report few cases of ABSCOPAL effect: where after a local treatment not only the target tumor but also the distant deposits will shrink
From 2008 until April 2016, 72 consecutive patients affected by pancreatic tumors were selected by a dedicated Tumor Board for receiving treatment with USgHIFU, for local tumor control and palliation. 64 % of patients were affected by pancreatic adenocarcinoma and 84 % of all the treated tumors were located at the level of pancreatic head. Majority of the patients had at least two lines of chemotherapy and 45 % of them received concurrent and/or consequent external RT. USgHIFU treatment was performed always during general anesthesia with GI catheter and abdominal compression with a dedicated water balloon in order to reduce the distance between the HIFU probe and the target and for push the bowel loop away from the acoustic treatment window. Patients were than evaluated by clinical and instrumental follow up.
All the procedures were technically successful, with only one main complication due to a complete portal thrombosis developed 24 hrs after treatment. Objective response (OR) at MDCT, MRI and PET was 64 % with a disease control (DC) up to 90 % of all the patients. Pain was palliated in 23/27 of symptomatic patients. In four patients (4/46 with adenocarcinoma) the imaging follow up after the treatment revealed the shrinkage of metastases located in other sites: 2 retroperitoneal lymphnode (Figs. 40 and 41), 1 liver and 1 lung.
A40 Characterizing the immune response to boiling histotripsy ablation of renal carcinoma in the Eker rat
George Schade, Yak-Nam Wang, Venu Pillarisetty, Joo Ha Hwang, Vera Khokhlova, Michael Bailey, Tatiana Khokhlova
University of Washington, Seattle, Washington, USA
Boiling histotripsy (BH) is an experimental non-invasive Focused Ultrasound (US) technology. BH uses milliseconds-long US pulses at low duty cycle to mechanically homogenize targeted tissue. We aim to evaluate the adaptive immune response to BH ablation of spontaneous renal tumors in the Eker rat hereditary renal carcinoma (RCC) model.
Genotyped Eker rats (Tsc2 heterozygotes) were monitored for de novo RCCs with serial US until tumors were ≥8 mm. Syngeneic Wild-type (WT) (planned total n = 36) and Eker rats (planned total n = 48) were then randomly assigned to BH (n = 10 total to date) or an US SHAM procedure (n = 22 to date). BH was performed extracorporeally using US-guided small animal FUS system (VIFU-2000, Alpinion). The 1.5 MHz transducer was operated at duty cycle of 1 %, 10 ms pulses, 525-550 W electric power. Treatments targeted a ~0.5 cc area of the lower pole in WT rats and the largest RCC with a margin of normal kidney in the Eker rats. Blood samples were collected immediately before treatment and serially post-treatment. Rats were euthanized at 48 hrs, 7 days, 14 days, or 56 days following treatment. At euthanasia, ipsilateral and contralateral kidneys, hilar lymph nodes, and the spleen were collected. Intrarenal and circulating plasma cytokines were assessed using a 10 cytokine multiplex assay. Renal/tumor infiltrating leukocyte populations were assessed using immunohistochemistry. Leukocyte populations in tumor draining hilar lymph nodes and spleens were assessed with flow cytometry.
BH treatment has been successful in all treated (n = 4 Eker, n = 6 WT to date) subjects, producing hypoechoic regions on US consistent with BH treatment effect. BH treatment was associated with significantly increased mean relative-plasma TNF-α vs. sham treatment at 0.25 (p = 0.02), 1 (p0.04), and 24 (p = 0.05) hours. At 48 hours, significant differences in intra-renal cytokines were observed in BH (n = 4) vs SHAM (n = 4) treated rats: IFN-gamma, IL-10, and IL-8 with trend towards differences in TNF-alpha and IL-6 (Fig. 42). On immunohistochemistry, BH treated Eker rats had increased CD8+ T-cells in both the treated and contralateral kidney compared to SHAM treated rats at 48 hours (Fig. 43). Additionally, increased infiltration of f4/80+ M1 macrophages into the treated kidney, was observed in 2/4 BH treated rats vs. SHAM at 48 hours. Longer-term data is pending at this time.
A41 Use of shock-wave exposures for accelerating thermal ablation of localized tissue volumes
Vera Khokhlova1, Ilya Sinilshchikov2, Petr Yuldashev2, Yulia Andriyakhina2, Wayne Kreider1, Adam Maxwell1, Tatiana Khokhlova1, Oleg Sapozhnikov1, Ari Partanen3
1University of Washington, Seattle, Washington, USA; 2M.V. Lomonosov Moscow State University, Moscow, Russian Federation; 3Philips, Bethesda, Maryland, USA
In High Intensity Focused Ultrasound (HIFU) applications, nonlinear acoustic effects can result in the formation of high-amplitude shock fronts in focal waveforms, with amplitudes exceeding 100 MPa. The presence of such shocks leads to increased tissue heating which can be beneficial for HIFU thermal therapy. The goal of this work was to evaluate the efficacy of different shock-wave exposures to accelerate thermal ablation of tissue volumes while enabling safer conditions for intervening tissues.
Simulation studies were performed for a multi-element 1.2 MHz HIFU phased array of a clinical system (Fig. 44a, Sonalleve V1, Philips, Vantaa, Finland) for three different peak intensity levels at the array elements of 1.2, 8, and 15 W/cm2. A pulsing scheme was combined with discrete electronic steering of the array focus over a series of foci separated about 1 mm and arranged in 4 concentric circles (Fig. 44b). The circles were positioned in a plane at 25 mm depth in liver tissue of 50 mm thickness (Fig. 44a). The period between consecutive pulses was 20 ms. Pulse duration was varied to keep a constant time-average intensity at the array elements: 20 ms at 1.2 W/cm2, 3 ms at 8 W/cm2, and 1.6 ms at 15 W/cm2. The Westervelt equation combined with the bioheat equation was used for modeling temperature and thermal dose in tissue. Initial temperature in tissue was 20 °C, sonication was performed starting from the center and spiraling outward until a thermal dose of 1.76 s at 56 °C (equivalent to 240 CEM at 43 °C) was reached at each circle of the trajectory.
The focal waveforms simulated in tissue for different peak intensities representing quasilinear sonication (1.2 W/cm2), sonication with a fully developed shock of 95 MPa at the focus (8 W/cm2), and sonication with higher focal shock amplitude of 118 MPa (15 W/cm2). Tissue ablation was achieved much faster at higher peak intensities with more clearly defined boundary between treated and untreated tissue. While temperature distributions and thermal dose contours in the focal plane were similar in shape for each trajectory and intensity level, corresponding distributions in the axial plane varied greatly. Slower heating at 1.2 W/cm2 resulted in strong heat diffusion in the axial direction and much larger ablation volumes. On the contrary, with rapid shock-wave heating, the ablated tissue volume followed the geometry of the targeted heat deposition. Although overall ablated volumes were smaller at higher peak intensities, the ablation rate was the highest at 15 W/cm2.
A42 Effects of dosing and focal spacing in rapid ablation of large tissue volume using histotripsy with electronic focal steering
Jonathan Lundt, Steven Allen, Jonathan Sukovich, Timothy Hall, Charles Cain, Zhen Xu
University of Michigan, Ann Arbor, Michigan, USA
Current tumor ablation techniques, typically thermal-based, are either limited to treating tumors <3 cm in diameter (RFA and microwave) or are very slow (HIFU). Because histotripsy uses microsecond-length pulses separated by up to seconds of off-time for a given focus, it is possible to electronically steer the therapy focus of a phased array transducer to excite cavitation events throughout a large volume consisting of many foci during the off-time. We hypothesize that histotripsy combined with electronic focal steering can achieve rapid ablation of a large volume. This hypothesis was investigated in this paper, and the effects of number of pulses per focal location and focal spacing on tissue damage generated using histotripsy with electrical focal steering were studied.
Histotripsy was applied using a 250 kHz, 256-element hemispherical phased array transducer with a 15 cm focal distance, generating 1.5-cycle, 6-microsecond pulses. Each element produced ~0.5 MPa P- individually, but focal pressure produced by all elements could not be measured due to cavitation. To establish treatment parameters including pulse repetition frequency (PRF) and number of pulses (dose) to deliver, a single-focus lesion was generated in tissue-mimicking phantoms containing a thin layer of red blood cells (RBCs) and monitored by optical imaging. Based on these results, 35 ex vivo bovine hepatic tissue samples were treated by electronically scanning the therapy focus at 200 Hz over 1000 sites (or .2 Hz per focal site) (Fig. 45). To evaluate the dose required for complete tissue fractionation, dose was varied between 20-120 pulses per focus. Focal spacing was varied from 2.5, 3.15, and 3.5 mm in the lateral direction and held constant at 4.1 mm in the axial direction to assess the extent of overlap between adjacent foci required to achieve complete homogenization. Lesion size was assessed by gross morphology and Magnetic Resonance Imaging (MRI). The degree of tissue fractionation was examined by histology (Fig. 46). Surrounding tissue temperature was measured by thermocouples 1 cm from the lesion.
RBC phantom results suggested that fractionation efficiency was optimal near 0.2 Hz and that 120 pulses were sufficient to achieve complete homogenization. Using lateral spacing ≥ 3.15 mm or < 100 pulses, unfractionated tissue structures were observed between foci. Using 2.5 mm lateral focal spacing and 120 pulses per focal location, complete, homogeneous tissue ablation of 43 +/- 6 mL region was achieved within 10 minutes, resulting in an ablation rate of 4.3 mL/min. A temperature increase of ~4 ° C was measured at the surrounding tissue. This work demonstrates that histotripsy combined with electronic focal steering can achieve rapid ablation of large volume at a rate more than double the rate of current available ablation techniques such as RFA.
A43 The TRANS-FUSIMO system — towards a prototype for HIFU treatment of the liver under breathing motion
Tobias Preusser1,2, Sabrina Haase1, Mario Bezzi3, Jürgen Jenne4, Thomas Langø5, Massimo Midiri6, Michael Mueller7, Giora Sat8, Christine Tanner9, Stephan Zangos10, Matthias Guenther1, Andreas Melzer11
1Fraunhofer MEVIS, Bremen, Germany; 2Jacobs University Bremen, Bremen, Germany; 3Universita Degli Studi Di Roma La Sapienza, Rome, Italy; 4mediri GmbH, Heidelberg, Germany; 5Stiftelsen SINTEF, Trondheim, Norway; 6University of Palermo, Palermo, Italy; 7IBSmm Engineering spol. s r.o., Brno, Czech Republic; 8GE Medical Systems Israel Ltd., Tirat Carmel, Israel; 9ETH Zurich, Computer Vision Laboratory, Zurich, Switzerland; 10Johann Wolfgang Goethe-Universität, Frankfurt, Germany; 11University of Dundee, Dundee, United Kingdom
The movement of the liver under breathing and its partial occlusion by the rib cage challenge the application of High Intensity Focused Ultrasound (HiFU/MRgFUS) for the thermal treatment of tumors. To explore the full potential of extracorporeal FUS to safely and precisely destroy tissue in the depth of the moving liver requires sophisticated technology. The European FUSIMO consortium (www.fusimo.eu) has shown in a proof of concept experiment that patient specific image processing, mathematical modeling of the organ’s motion, ultrasound propagation in the moving organ, and tissue heating is such enabling technology that empowers a physician to perform safe, effective and efficient ablation of tumors and to facilitate prediction of the outcome. In TRANS-FUSIMO (www.trans-fusimo.eu) the consortium is currently developing a prototype of a fully integrated system for the FUS treatment of the liver, which will be evaluated in an animal study and a patient study.
a planning software that incorporates image processing, motion modeling and prediction, as well as FUS simulations. This part of the system allows to plan and to assess the feasibility of the treatment;
a treatment system that performs the actual treatment control using previously evaluated treatment plans, as well as model based MR/US motion tracking and prediction and MR thermometry (Fig. 47);
a training system which acts as a treatment simulator that is based on real cases and the simulation of FUS propagation, tissue heating, and organ motion.
Thereby, the treatment system fully integrates with the GE MR scanner and the InSightec ExAblate Conformal Bone System (CBS). The control system and the model components have been validated in phantom and ex vivo experiments. Currently, the safety, efficacy and efficiency of the system are being evaluated in an in vivo animal study. Following, a two-arm study (neoadjuvant TRANS-FUSIMO MRgFUS + resection, TRANS-FUSIMO MRgFUS only) for human patients with metastases or HCC will show the feasibility of the TRANS-FUSIMO prototype for the clinical setting.
The core of the TRANS-FUSIMO system comprises patient specific models for the motion of the liver under breathing, ultrasound propagation, and thermal damage. On the one hand the models are used for the planning of the treatment and in the training system. On the other hand the models are used to augment US/MR data during the treatment in order to achieve motion compensation and thermal monitoring.
A44 Multifunctional robotic platform for USgFUS
Arianna Menciassi, Selene Tognarelli, Andrea Cafarelli, Alessandro Diodato, Gastone Ciuti
Scuola Superiore Sant’Anna - The BioRobotics Institute, Pontedera, Italy
Despite its promising results, FUS suffers from limited flexibility in therapy delivery, which narrows the applicability to non-moving and non-essential organs, mainly under Magnetic Resonance Imaging (MRI). We strongly believe that a robotic-assisted approach may offer the chance to overcome the current limitations of FUS by guaranteeing high robustness, flexibility/adaptability and precision of therapy. In this framework, the FUTURA (Focused Ultrasound Therapy Using Robotic Approaches) project (www.futuraproject.eu) is developing an autonomous, multi-functional and multi-robotic assisted platform able to perform non-invasive FUS on abdominal organs under US monitoring (USgFUS).
The FUTURA platform (Fig. 48) consist of: i) two six degrees of freedoms anthropomorphic manipulators, ii) a dedicated broadband 16 channels wave generator and a 16 channels annular array HIFU transducer; iii) two different US probes both connected to an acquisition system (SonixTablet, Analogic Ultrasound). The control architecture is implemented by using Robot Operating System software (ROS) with a purposely developed HMI.
The FUTURA architecture allows to maximize the flexibility of the procedure both for organs targeting and during the sonication procedure and lesion assessment. In addition, the FUTURA robotic integrated approach allows for safe interaction and cooperation between robots, patient and medical staff by using environmental reconstruction sensors.
In order to demonstrate the unique features of the FUTURA platform, several tests have been performed in in vitro and ex vivo static conditions by using a home-made tissue-mimicking phantom made up by a bulk of agar gel with internal cylinders (representing the targets of the therapy), based on polyacrylamide gel (PAA) mixed with egg white and ex vivo material (i.e. porcine liver or breast chicken instead of PAA cylinders into an Agar structure).
The complete workflow of the FUTURA procedure is reported in Fig. 49; more specifically, the effective use of two US imaging probes during different phases of the lesion treatment has been carried out. The sonication is composed by 10 repetitions of 1 second with 90 % duty cycle. The value of frequency and acoustic power of the sonication are 1200 kHz and 120 Watts, respectively.
During the target identification phase, both the US imaging probes are used. Although the US confocal probe is rigidly attached to the HIFU transducer, the FUTURA platform maintains US imaging flexibility thanks to the 3D US probe mounted on the second manipulator. The 3D US phantom reconstruction and the related 2D US confocal images acquired before sonication show the target without any lesion. In addition, the estimated HIFU transducer focus, located in the center of the target, assesses the correctness in positioning of the therapeutic manipulator (intersection of blue lines in pictures B.I-II-III). During the sonication process an on-line monitoring of the lesion is performed by exploiting a PWM signal for the HIFU transducer generator. Finally, the 3D US phantom reconstruction and the related 2D US confocal images acquired after sonication allow the lesion assessment (i.e., accuracy better than 1 mm). An optical assessment on the sectioned targets in proximity of the performed lesion was also carried out (Fig. 50). Finally, a specific analysis of the HIFU properties has been performed by observing the typical dimensions of the lesions induced by the transducer into the breast chicken tissue at different output power and duration of exposure (Fig. 51).
The most important features of FUTURA platform have been demonstrated. This work assesses the possibility to use a robotic platform for USgFUS treatment, using two US imaging probe for the different phases of the procedure. Synchronizing the HIFU transducer shot with the US imaging acquisition enables to monitor the lesion progress during the sonication phase, which is very important for patient safety. In addition, the use of both US probes during the sonication phase enables the tracking of moving 3D organs.
A45 Real time MR and US motion tracking for abdominal US/MRgFUS
Sven Rothluebbers1, Julia Schwaab2, Jan Strehlow1, Senay Mihcin3, Christine Tanner4, Steffen Tretbar5, Tobias Preusser1,6, Matthias Guenther1, Jürgen Jenne1
1Fraunhofer MEVIS, Bremen, Germany; 2mediri GmbH, Heidelberg, Baden-Württemberg, Germany; 3University of Dundee - TRANS-FUSIMO, Dundee, Scotland, United Kingdom; 4ETH Zurich, Computer Vision Laboratory, Zurich, Switzerland; 5Fraunhofer IBMT, St. Ingbert, Germany; 6Jacobs University Bremen, Bremen, Germany
The ablation with HIFU/FUS would be a fantastic tool for liver tumor treatment and would lead to an invaluable benefit for patients suffering from malignant liver metastasis or hepatocellular carcinoma. However, FUS of liver has still not yet reached a significant clinical spread, particularly in the western world. There are two major challenges for FUS ablation of the liver: the rib cage and the permanent motion of the liver, e.g. due to respiration. Both, MRI as well as diagnostic US imaging are suitable to provide real-time information about the liver positon. For several years, we have been developing and improving US and MR based motion tracking for HIFU/FUS, e.g. currently in the European TRANS-FUSIMO project (www.trans-fusimo.eu). A further goal of the presented work is the automated detection of suited tracking features and the assessment of feature quality on MR and US image data.
US or MR image streams are analyzed in real-time to track liver motion. In a first step, pronounced structures, like the diaphragm, or landmarks/features like liver vessels are automatically detected or manually defined on 2D US or MR-EPI images. For motion tracking, a particle filter-based algorithm evaluates state hypotheses of local affine transformations to follow these features through the image stream. Data fidelity is assured by not only tracking each landmark separately, but also incorporating information about global motion. For each landmark, an estimate of the current position and the current uncertainty of that estimate is provided. Features with high uncertainty may then be ignored in following processing steps or replaced by more stable landmarks by the algorithm. For use in an application, the output of the algorithm is sent to the HIFU/FUS treatment unit, which can incorporate the data into further motion compensating components. This may either be established through direct beam steering of the FUS focus or by gating the therapy.
US as well as MR based liver tracking was evaluated in different phantom experiments and on data from volunteers. Figures 52 and 53 show US and MR liver images with sample data provided by the algorithm. The arrows show the displacement of the feature related to a reference image due to liver motion. The discs indicate a relative measure of positional uncertainty. Automated feature detection, e.g. of blood vessels in EPI liver images, enabled fast and reliable definition of tracking features. Automated tracking quality assessment allowed a reliable detection of poor quality features which were replaced to allow a stable and reliable tracking over longer time periods. The mean tracking error on US liver images was 1.5 mm in 2D and 2.79 mm in 3D with a processing time of about 2 ms/frame. 1.7 mm was the mean error of MR based liver tracking with a computing time of 2 ms/frame and feature.
A46 Pancreatic tumor monitoring and treatment using Harmonic Motion Imaging for Focused Ultrasound (HMIFU) in a transgenic mouse model
Thomas Payen1, Carmine Palermo1, Steve Sastra1, Hong Chen2, Yang Han1, Kenneth Olive1, Elisa Konofagou1
1Columbia University, New York, New York, USA; 2Washington University in St. Louis, St. Louis, Missouri, USA
Pancreatic ductal adenocarcinoma (PDA) is one of the deadliest cancers with the lowest prognosis due to late diagnosis. PDA is characterized by an unusually dense stroma limiting chemotherapy perfusion. Harmonic Motion Imaging (HMI) assesses tissue mechanical properties by inducing localized oscillation resulting from a periodic acoustic radiation force. The amplitude of the induced displacement is directly related to the underlying tissue stiffness. The sonication is kept short for imaging (HMI) without tissue damage or the duration is prolonged for simultaneous HMI and HIFU treatment (Harmonic Motion Imaging for Focused Ultrasound or HMIFU).
This study first aimed at using HMI for characterizing the development of pancreatic tumors as a function of size and fibrosis extent in the KPC genetically-engineered mouse model. Secondly, the tumors were treated using HMIFU. HMI measurements were then resumed to monitor the mechanical changes resulting from the treatment.
A 4.5-MHz Focused Ultrasound transducer (FUS) generated an amplitude-modulated beam resulting in harmonic tissue oscillations at its focus. Axial tissue displacement was estimated using 1D cross-correlation of RF signals acquired with a confocally aligned, 7.8-MHz diagnostic transducer (P12-5, ATL) using a plane-wave beam sequence at a framerate of 1 kHz. Imaging was performed with 0.2 s sonication for each scan position, when treatment required 60-s long sonications which were shown to generate lesion in this model according to previous work by our group. KPC mice were genetically-engineered to develop pancreatic tumors with pathophysiological and molecular features similar to those of human PDA. Pancreatic tumor growth was monitored for 15 days with HMI scans performed every two days. For the second part of the study, HMIFU was performed on 5-mm tumors. The success of the treatment was assessed by measuring both the tumor area and its elasticity up to 14 days.
HMI demonstrated its capability to provide reproducible elasticity measurements in murine pancreatic tumors. Figure 54 shows that stiffening occurs progressively during pancreatic tumor growth from the very early stages. When plotting the HMI displacement against the tumor size, an exponential trend was fitted to the data with R2 > 0.87 in accordance to general models. When ablated with HMIFU for 60s, the tumor stiffened displaying a decrease in HMI displacement (Fig. 55). The lesion was confirmed by histology. The follow-up of the HMIFU treatment is performed with HMI to assess long-term tissue mechanical changes after treatment.
A47 Preliminary investigation of integrating deployable reflectors and fluid lenses with endoluminal ultrasound to enhance and dynamically adjust focal gain and depth
Matthew Adams1, Vasant Salgaonkar2, Serena Scott2, Graham Sommer3, Chris Diederich4
1UCSF Thermal Therapy Research Group, San Francisco, California, USA; 2University of California, San Francisco, Sunnyvale, California, USA; 3Stanford University, Stanford, California, USA; 4University of California San Francisco, San Francisco, California, USA
Endoluminal and endovascular catheter-based high-intensity ultrasound offer spatially-controlled thermal ablation in tissue targets adjacent to body lumens, such as the pancreas, liver, prostate, heart, etc. Due to the size constraints necessary for applicators to traverse through luminal passages, the integrated therapeutic transducers have minimal aperture size, limiting the depth of energy and thermal penetration typically to within a few centimeters beyond lumen borders. This study introduces concepts for a deployable applicator that features inflatable balloon reflectors and adjustable fluid-lenses to permit compact delivery and expansion at target sites (e.g. stomach, bladder, colon) to augment the effective therapeutic aperture for deeper and more selective heating generation. A preliminary theoretical analysis of potential designs, incorporating acoustic and thermal parametric studies, was performed along with benchtop proof-of-concept experiments as an initial investigation of the feasibility and capabilities of this design strategy.
Two applicator designs, representing end-firing and side-firing configurations, were conceptualized and modeled, as shown in Fig. 56. The end-firing configuration consists of an array of tubular transducers surrounded by an expandable conical balloon that reflects acoustic energy into a fluid lens at the applicator’s distal tip. The side-firing configuration consists of an array of planar and tubular transducer segments surrounded by a parabolic reflector balloon that diverts energy through a fluid lens adjacent to the assembly. Acoustic simulations of the two assemblies were performed using a MATLAB implementation of the rectangular radiator method and incorporation of reflection/refraction of wave-fronts at material interfaces through the method of secondary sources. Thermal modeling, implemented in COMSOL, was used to generate resulting temperature distributions in homogenous and heterogenous tissue models. Parametric studies were performed to investigate performance of different potential lens fluids, and to evaluate acoustic focal gain and heating as functions of applicator/reflector/lens dimensions and geometries. Hydrophone beam plot measurements were made for a proof-of-concept end-firing applicator, consisting of a mounted tubular transducer centered in a conical brass reflector and covered by a perfluorocarbon fluid lens with adjustable radius-of-curvature (ROC).
Of the three potential lens fluids investigated (perfluorocarbon, silicone oil, and chloroform), perfluorocarbon offers the best acoustic transmission at lens focal lengths ranging from 0-100 mm, due to its greater speed-of-sound mismatch as compared to water or tissue. As demonstrated in Fig. 57, simulated achievable focal gain for either device configuration increases as a function of lens focal length to a maximum between ~20-50 mm, depending on the overall deployable reflector/lens size and tissue attenuation. Thermal simulations in homogenous muscle tissue with the end-firing configuration indicate capabilities of creating localized (~1 cm long X 5 mm wide) or volumetric (~3 cm long X 2 cm wide) ellipsoid thermal lesions at variable depths up to and beyond 5-6 cm in the tissue, as demonstrated in Fig. 58. Hydrophone beam plots of the preliminary proof-of-concept assembly illustrated capability of dynamically adjusting the focal plane depth between ~1-5 cm by adjusting the lens ROC, as shown in Fig. 59.
A48 Concurrent low dose Focused Ultrasound with chemotherapy in abdominal tumors
Joan Vidal-Jove1, Eloi Perich2, Antonio Ruiz2, Manuela Velat2
1Hospital University Mutua Terrassa, Barcelona, Spain; 2Institut Khuab Barcelona, Barcelona, Spain
Systemic therapies for advanced stage IV abdominal tumors as standard chemotherapy regimens usually lack efficacy, and often this is substantially reduced by means of toxicity. Hyperthermic therapies have demonstrated efficacy alone by themselves and as well as concurrent treatments along with chemotherapy and/or radiotherapy. Focused ultrasound has been increasingly used as a method to enhance drug delivery. Several previous experiences have used this approach to improve tumor control in different types of tumors and with different chemotherapy drugs.
This is a feasibility study to increase delivery of the chemotherapy drug to the tumor. We have employed Ultrasound guided High Intensity Focused Ultrasound (USgFUS) along with concurrent standard chemotherapy treatments in a clinical setting with abdominal tumors. We have included advanced stage IV liver metastases from colo-rectal tumors, advanced stage IV pancreatic tumors and advanced stage IV retroperitoneal sarcomas. All patients were previously treated with and failed at least to 2 chemotherapy lines. Patients should not be candidates for tumor ablation. Patients will receive 3 FUS treatments concurrent with their chemotherapy infusions. FUS therapies are delivered the day of the chemotherapy infusion, the day before and the day after the chemotherapy. FUS treatments are on the range of 100 Watts for 45 minutes average. The objective is to cover maximum volumetric treatment.
We measure performance status, complications rate, quality of life, symptoms control, pain control, and time to progression. Blood samples for functional studies and tumor markers as well as immunological studies: lymphocyte profile, immunoglobulines, complement, CRP were taken at daily basis during FUS treatments. MRI images were obtained previously and immediate after FUS treatments.
Study is in progress. We will report updated results at the meeting.
A49 Clinical experience of intra-operative High Intensity Focused Ultrasound in patients with colorectal liver metastases. Results of a Phase II study
David Melodelima1, Aurelien Dupre2, Jeremy Vincenot1, Chen Yao2, David Perol2, Michel Rivoire2
1LabTAU - INSERM U1032, Lyon, France; 2Centre Leon Berard, Lyon, France
Surgical resection is the only curative option for colorectal liver metastases (CLM), however, only 10 to 20 % of patients are suitable for surgery. High intensity focused ultrasound (HIFU) has been proven effective in a wide range of clinical applications. The liver is a particularly challenging organ for HIFU treatment due to the combined effect of respiratory-induced liver motion and partial blocking by the rib cage. A HIFU device based on toroidal transducers has been developed to enable the destruction of large liver volumes. Preliminary in vitro and in vivo studies demonstrated the feasibility, efficacy and safety of such HIFU ablations. This preclinical work is now translated into clinical practice. The aim of this study was to assess the feasibility, safety and accuracy of HIFU ablation in patients undergoing hepatectomy for CLM.
This study was a prospective, single-centre phase I/II study. The HIFU transducer has a toroidal shape and was divided into 32 concentric rings of equal surface (0.13 cm2). The diameter of the transducer and its radius of curvature were 70 mm. The operating frequency was 3 MHz. A 7.5 MHz ultrasound imaging probe was placed in the center of the device. The imaging plane was aligned with the HIFU acoustic axis. Nineteen patients were included in Phase I-IIa. In each patient two HIFU ablations were created. In step 1, ablations were centered in a target previously identified in ultrasound images. In step 2, ablations were created at distance from a target. Eight patients were included in Phase IIb and ten metastases (20 mm maximal diameter) were treated until now. HIFU ablations were created to ablate metastases with safety margins in all directions. The exposure time was adjusted from 40 seconds to 370 seconds according to the diameter of the metastases. For this first evaluation of the device, ablations were performed within the areas scheduled for resection. This study is registered with Clinical-Trials.gov (NCT01489787).
The dimensions of ablations measured on ultrasound imaging were correlated (r = 0.88, p < 0.001) with dimensions measured on gross pathology. The average dimensions of HIFU ablations obtained in 40 seconds (Phase I) were a diameter of 21.0 ± 3.9 mm and a long axis of 27.5 ± 6.0 mm. The phase IIa study showed both that the area of ablation could be precisely created in the liver with a precision of 1-2 mm. It was possible to target about 90 % of the liver and all major anatomical structures. In Phase IIb, one metastasis of 10 mm in diameter was ablated in 40 seconds with safety margins. Using electronic focusing nine metastases of 2 cm in diameter were ablated with safety margins (>3 mm in all directions) in 370 seconds. The dimensions of these HIFU ablations were a diameter of 48.0 ± 4.9 mm and a long axis of 51.0 ± 3.4 mm. No lesions occurred in surrounding tissues. Two patients had a post-operative complication (pneumonia with pleural effusion and a urinary tract infection) not related to the HIFU treatment. There were no significant changes in hemodynamic and respiratory parameters.
This HIFU device safely achieved large and fast volume of liver ablation, with a precision of one to two millimeters. HIFU ablations of metastases with a diameter of less than 2 cm were successfully created with safety margins of at least 3 mm in all directions. This study is the first clinical use of intra-operative HIFU in patients with CLM. Reducing the risk of potential important complications associated with an extracorporeal approach was among the reasons we developed an intra-operative device. An open procedure seems also more appropriate since 15-20 % of additional metastases are discovered intraoperatively. From these preliminary results, intra-operative use of a HIFU toroidal transducer appears feasible, safe and effective in ablating liver metastases.
A50 [18 F]-FDG PET and contrast MRI for enhanced guidance of Focused Ultrasound ablation in a syngeneic orthotopic model of murine pancreatic adenocarcinoma
Samantha Tucci1, Lisa Mahakian1, Brett Fite1, Elizabeth Ingham1, Sarah Tam1, Chang-il Hwang2, David Tuveson2, Katherine Ferrara1
1University of California Davis, Davis, California, USA; 2Cold Spring Harbor Laboratory, Cold Spring Harbor, New York, USA
Pancreatic ductal adenocarcinoma (PDA) is the most lethal cancer and there is a desperate need for new therapeutic strategies. Due to its characteristic hypovascularity, dense stromal architecture, rapid progression, and local invasiveness, conventional therapies fail to cure PAC. Magnetic Resonance guided Focused Ultrasound ablation (MRgFUS) offers a platform to build combination therapies due to its ability to debulk tumors, enhance delivery of chemotherapeutics, and stimulate an immune response. Here, the feasibility of MRgFUS is evaluated in a syngeneic orthotopic mouse model of PAC developed from the KrasLSL-G12D/+; Trp53LSL-R172H/+; Pdx-Cre (KPC) model 1. Further, [18 F]-FDG positron emission tomography (PET) is used to enhance guidance.
Murine mT4-2D cells (gift from the Tuveson laboratory, Cold Spring Harbor, NY) were injected orthotopically by a sterile laparotomy (n = 5, C57BL/6 female mice). Mice were treated with MRgFUS on day 16 post-implantation with an MR-compatible annular array (Imasonic SAS, 3 MHz center frequency, 4.7 Watt acoustic power, 5.6 MPa peak negative pressure, 0.5 x 0.5 x 1.5 mm3 focal volume) and positioning system (Image Guided Therapy) in a Bruker BioSpec 7 T. Tumors were ablated with a diameter of 2 mm and scanning speed of 1 revolution per second for ~40s. In a separate group (n = 6), on days 10 (n = 3 + 1 wild-type) and 14 (n = 3 + 2 wild-type), mice were injected with 200 uCi of [18 F]-FDG, rested for 30 minutes, and scanned with a Siemens Inveon DPET for 30 minutes. Following PET acquisition, T1w images were acquired post gadolinium contrast (TE/TR/FA = 11.7 ms/750 ms/180°, 4.3 x 4.3 cm2 FOV, 256 x 256 matrix, 17 slices). Mice were euthanized, organs of interest were harvested, and radioactivity was measured by Wizard 1470 Automatic Gamma Counter (PerkinElmer). Maximum intensity projections were registered with MR images and regions of interest (ROIs) were drawn on the tumors and normal pancreases using Siemens Inveon Research Workplace.
[18 F]-FDG-PET images enhanced the visualization of the tumor rim and demonstrated the heterogeneity of uptake within the tumor (Fig. 60a). In spite of the heterogeneity, ROI analysis indicated that primary pancreatic lesions (60.6 %ID/cc) exhibit a higher maximum uptake of [18 F]-FDG than the normal pancreas (17.8 %ID/cc) at day 14 of tumor progression (p < 0.05). Biodistribution confirmed these measurements, with 15.5 %ID/g and 16.9 %ID/g in the tumor-bearing pancreas at day 10 and day 14, respectively, as compared with 5.2 %ID/g in the normal pancreas (p < 0.5). Contrast enhanced T1w MRI facilitated visualization of lesions within both the pancreas and spleen (Fig. 60b-c). MRgFUS ablation was successfully completed under MR guidance (Fig. 60b), mice recovered well from treatment and the effect was confirmed on histopathology at 24 hours (Fig. 60d).
A51 Early experience with HIFU in the United States at Vituro Health, Sarasota
Scionti Prostate Center, Sarasota, Florida, USA
Not released for publication
Not released for publication
Not released for publication
Not released for publication
A52 Investigation of the Therapeutic Effects of Pulsed Focused Ultrasound Combined with Encapsulated Chemotherapeutic Agents for Treatment of Prostate Cancer in vivo
Lili Chen, Dusica Cvetkovic, Xiaoming Chen, Roohi Gupta, Bin Wang, Charlie Ma
Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA
To investigate the improvement of prostate cancer inhibition by combining pulsed Focused Ultrasound (pFUS) exposures and chemotherapeutic agents encapsulated nanodroplets under MR guidance for prostate cancer therapy.
Prostate cancer (LNCaP) cells were implanted orthotopically. First we developed nanodroplets encapsulated with chemotherapeutic agents for both paclitaxel (PTX) and docetaxel (DTX). Secondly, tumor–bearing mice were randomly divided into 5 groups (n = 5). Group 1 animals were treated with an i.v injection of DTX-encapsulated nanodroplets (DTX-ND) + pFUS. Group 2 were treated with pFUS alone. Group 3 were injected (i.v) with DTX-ND alone, Group 4 received free DTX and Group 5 was used as control. Ultrasound treatment parameters were 1 MHz, 25 W acoustic power, 10 % duty cycle and 60 seconds for each sonication. After treatment, animals were allowed to survive for 4 weeks. Tumor volumes were measured on MRI. Third, we repeated the experiment with PTX-ND. Finally we performed study on biodistribution of PTX-ND for prostate cancer and the treatment effects on tumor growth delay are being evaluated.
With DTX-ND, significant tumor growth delay was observed in Group 1 with p = 0.039. There was no significant tumor growth delay observed for Group 2 (p = 0.477), Group 3 (p = 0.209) and Group 4 (p = 0.476). The results are consistent with earlier PTX-ND studies in which significant tumor growth delay was observed in Group 1 with p = 0.004. There was no significant tumor growth delay observed for Group 2 (p = 0.285), Group 3 (p = 0.452) and Group 4 (p = 0.158). The peak of drug update in tumor appeared at 4 h after injection in the biodistribution study.
Our results showed a great potential of targeted nanodroplets for prostate cancer therapy, which could be activated by pFUS. Our study also suggested that the optimal timing for applying pFUS is 4 h after i.v injection of PTX-ND and the treatment effect is being evaluated.
A53 Monitoring histotripsy ablation with passive cavitation imaging
Kenneth Bader1, Kevin Haworth1, Adam Maxwell2, Christy Holland1
1University of Cincinnati, Cincinnati, Ohio, USA; 2University of Washington, Seattle, Washington, USA
Histotripsy is a form of therapeutic Focused Ultrasound that mechanically ablates tissue. Pre-clinical studies have explored the potential for histotripsy to treat fetal septal defects, deep vein thrombosis, liver cancer, and benign prostatic hyperplasia (BPH). Histotripsy technology is also being tested in a clinical trial for the treatment of BPH. The bubble clouds generated by histotripsy are hyperechoic, enabling standard B-mode ultrasound imaging to be used for image guidance of tissue ablation. The mechanical oscillations of the bubbles within the cloud generate acoustic emissions. Information about the amplitude and location of these acoustic emissions would provide an additional means to monitor the treatment progress from histotripsy. Passive cavitation imaging (PCI) is an ultrasound imaging modality currently under development that spatially maps the power of acoustic emissions generated by cavitation. In this study, the ability of PCI and plane wave B-mode imaging to predict the location and spatial extent of histotripsy
Histotripsy pulses were generated in a prostate tissue phantom with a 1-MHz, 8 annular element array with a 10-cm aperture and 9-cm focal length. All elements of the transducer were simultaneously driven in parallel by a custom class D amplifier and matching network. Histotripsy pulses over a range of pulse durations (5-20 microseconds) and peak negative pressures (12-23 MPa) were explored in this study. During histotripsy insonation of the phantom, a 128 element linear array controlled with an ultrasound research scanner was used to monitor cavitation activity with both PCI and plane wave B-mode imaging (Figs. 61 and 62). After application of the histotripsy pulses, the phantom was sectioned and stained with a periodic acid-Schiff stain to delineate the ablation zone. The passive cavitation images and plane wave B-mode images were co-registered with the histological images. A receiver operating characteristic curve was used to quantify the comparison between each imaging modality and the spatial extent of the ablation zone.
The area under the receiver operating characteristic (AUROC) was significantly greater than 0.5 for both plane wave B-mode and PCI, indicating both approaches can be used to predict the spatial extent of the ablation zone. The AUROC and accuracy were significantly greater for PCI compared to plane wave B-mode imaging. Furthermore, the sensitivity for predicting lesion formation was a factor of 3 larger for PCI compared to plane wave B-mode imaging.
A54 Real time Tissue Changes Monitoring during the treatment of prostate cancer with HIFU
Narendra Sanghvi1, Roy Carlson1, Wohsing Chen2
1SonaCare Medical, LLC, Indianapolis, Indiana, USA; 2Ulthera, Inc., Mesa, Arizona, USA
Backscattered RF ultrasound signals have been used clinically in differentiating normal and infarcted heart condition. Similarly, backscattered signals from pre and post hifu site are significantly different in magnitudes that provide correlation on degree of tissue changes. This is a validation study of Tissue Change Monitoring (TCM) algorithm performed with real-time thermometry. TCM performs spectral analysis of the RF backscattered (pulse-echo) ultrasound signals acquired before and immediately following the HIFU exposure. The RF signal analysis generates energy spectra of these signals and the difference of the energy magnitude is used as an estimator for tissue changes caused by the HIFU tissue ablation. TCM results are color coded and displayed on the each HIFU ablative site in Orange, Yellow and Green indicating tissue temperatures in the range from 75-100, 60-75 and 37-60 degrees C respectively.
Five (5) patients with histologically confirmed, organ confined prostate cancer were enrolled with approved protocol for this study. Four patients with focal cancer at stereotactic saturation biopsy had hemiablation only and one had a whole gland ablation. The Sonablate 500 HIFU device with Tissue Change Monitoring (TCM) software was used for the ablative treatment. Specifically designed 18 gauge needles containing three thermocouples per needle separated by a 1 cm distance were placed transperineally under TRUS guidance in the prostate. 4 or 5 needles were placed to cover the ablative sites. Temperatures from all thermocouples were recorded simultaneously at 0.5 seconds interval by a multi-channel thermometry system. Temperature data were acquired from a total of 56 sites,(26 focal zone sites, 22 posterior sites to the focal zone and 8 sites in the lateral gland of the prostate where there was no HIFU applied). Sixteen RF signals lines, pre and immediately post HIFU, for each ablative site were acquired at 50 MHz sampling rate. All RF data lines were processed by the SB-500 computer in the frequency domain to derive average energy spectra and change in magnitude for pre and post HIFU. The magnitude change and temperature from the site were used to derive cross correlation function and color code to overlay on the ablative site.
The measured temperatures (Average, Max, and Min) in the HIFU treatment zones were 84, 114 and 70 degree C respectively. TCM energy readings were 1.05, 2.6 and 0.4 resulting in 83 % orange (75-100 degree C) and 17 % yellow (60-75 degree C) indicating an estimated average temperature of 91 degree C. Outside the focal zone, average recorded temperature was 50 degree C. The temperature recorded in the lateral lobe where no HIFU was applied was 40.7 degrees C.
The backscattered RF data analysis is capable of estimating tissue changes reliably during the HIFU procedures in real-time and can be used as an aid in the operating procedure. TCM was found highly sensitive to tissue motion. When the tissue reached boiling temperature, TCM output resulted in higher energy and was beyond the linear range of temperature monitoring from the RF backscattered signals.
A55 Focal therapy with High Intensity Focused Ultrasound in low risk prostate cancer
Christian Chaussy1, Stefan Thueroff2, Claudio Cesana3, Carlo Bellorofonte3
1Caritas Hospital St. Josef, University of Regensburg, Strasslach-Dingharting, Germany; 2Klinikum Muenchen Harlaching, Munich, Germany; 3Clinica Columbus, Milano, Italy
Prostate cancer (PCa) therapy undeniably exposes patients to a risk of impotence and incontinence. Therefore, low-risk localized prostate cancer is increasingly managed with watchful waiting or active surveillance, although this management bears some psychological burden and the risk of under staging and under grading. Alternatively, High Intensity Focused Ultrasound (HIFU) therapy allows non-invasive partial ablation of detected PCa in a single session (focal therapy). Aim of this study was to evaluate clinical efficacy and side effects of a single focal HIFU session in low risk PCa patients.
66 patients with localized prostate cancer who refused both definitive radical therapy and conservative management and had a strong desire to preserve potency were treated with focal HIFU. Men with strong obstructive symptoms, severe calcifications in the target area or severe prostatitis/abscess history were excluded. Treatments were performed with Ablatherm® intergrated imaging.
53 % of the patients had positive staging biopsies on the right, 47 % on the left lobe. Initial PSA (PSAi = at diagnosis) was median 5.58 (1.02- 10.43) and increased to a PSA at treatment (PSAtr) of median 6.01 (0.2-11.4) within 4 months (period of first diagnosis until HIFU treatment), corresponding to a median pretherapeutic PSA velocity of 1,29 ng spinal anesthesia in median 50 (27-75) min with 16 french urethral catheter in place. Applied HIFU lesions were median 138 (86-338). There were no significant therapy related intra-/postoperative side effects within the follow-up period of median 4.4 (0.25-9.85) years, according to CLAVIEN Score . Based on patient interviews 3 months after HIFU treatment potency was: worse (4.5 %), equal (93.5 %); better (0 %). PDE-5 inhibitors were used by 74 % of patients. Urinary continence was preserved in all cases, 3 patients used a safety pad before and after treatment. There were no rectal disorder, fistulae or rectal incontinence. Post-HIFU catheter time was 22.7 % 5 days occurred. No late HIFU induced side effects were observed. PSA was reduced from median PSAtr (6.45) to a median Nadir of 1.45 ng/ml within median 12.5 weeks and showed a trend to relapse with a post-HIFU PSA velocity
Focal HIFU - a non invasive single session therapy performed under spinal anesthesia - demonstrated high potency- and continence preservation while treating diagnosed prostate cancer lesions. There were no significant therapy related intra-/postoperative side effects within the follow-up period. Focal HIFU results in a significant deceleration of PSA velocity from pre-HIFU 1.29 to post-HIFU 0.12 ng/ml/year by treating only 25 % of the prostatic volume. PCa diagnosis and consecutive watchful waiting and active surveillance bears an imminent psychological burden for the patient. The option of therapeutic efficacy, the wish to avoid therapeutic side effects and to preserve potency as well influences patients` decision for focal therapy with HIFU.
A56 Factors affecting the efficacy of the Magnetic Resonance guided Focused Ultrasound ablation for painful bone metastases: results from a multicenter study in China
Qingguo Wang1, Han Wang1, Shengping Wang2, Junhai Zhang3
1Shanghai First People’s Hospital, Shanghai, China; 2Shanghai Cancer Center, Shanghai, China; 3Shanghai Huashan Hospital, Shanghai, China
Bone is the third most common target organ that carcinomas metastasize to after lung and liver. Bone pain induced by cancer metastases contributes substantially to morbidity and mortality in patients with malignant carcinomas. Magnetic Resonance guided Focused Ultrasound (MRgFUS) is considered as one of the most promising therapeutic modality for tumor ablation. But, not all patients could obtain satisfied therapeutic efficacy. Some factors such as the number of bone metastasis, KPS and NPVR score can affects the results. The purpose of this non-randomized study was to evaluate the factors affecting the efficacy of the Magnetic Resonance guided Focused Ultrasound (MRgFUS) ablation for painful bone metastases treatment, and the safety and efficacy of this new non-invasive treatment modality.
One hundred and thirty one patients with painful bone metastases were screened for this study from June 2014 to September 2015. Seventy-one patients were finally enrolled in our study. All 71 patients underwent MRgFUS and none of them received radiotherapy or chemotherapy for pain palliation in the past two weeks. The Numerical Rating Scale for pain (NRS), the Brief Pain Inventory (BPI-QoL) score, the karnofsky performance scale (KPS), morphine equivalent daily intake dose (MEDID), and the adverse events (AEs) were respectively recorded before and 1-week, 1-month, 2-month, 3-month after the treatment.
1) Seventy-one metastatic bone lesions in 71 patients were treated by MRgFUS and the treatment data was as follows: the mean treatment time was (83.94 ± 27.87) minutes, the mean sonication number was (12.74 ± 7.30) minutes. 2) Adverse events included: pain in therapy area in 3 patients and sciatica in 1 patient, which were obviously reduced after physiotherapy. 3) The NRS before treatment and at 1-week, 1-month, and 3-month after treatment was 6.70 ± 1.82, 4.37 ± 2.55, 3.96 ± 2.83, 3.70 ± 2.81 respectively. The NRS significantly decreased after treatment at all time points (P < 0.01). 4) The BPI-QoL score before treatment and at 1-week, 1-month, and 3-month after treatment respectively was 5.70 ± 2.09, 4.62 ± 2.36, 4.42 ± 2.60, and 4.42 ± 2.70. The BPI-QoL score significantly decreased after the treatment at all time points (P < 0.01). 5) After treatment, at 3-month, the mean ΔBPI-QoL score improvement in patients with solitary bone metastasis was statistically superior to that in patients with multiple bone metastases (P < 0.05). 6) At 1-week and 1-month, the mean ΔBPI-QoL score improvement in patients with osteogenic bone metastasis was statistically superior to other two groups (P < 0.05).
MRgFUS can be used as a non-invasive, safe, and effective method for treating painful bone metastases. The patients with solitary bone metastasis or osteogenic bone metastasis can achieve better therapeutic efficacy than those with multiple bone metastasis or osteolytic bone metastasis.
A57 Can MRgFUS achieve local control of bone metastases?
Alberto Bazzocchi1, Alessandro Napoli2
1The “Rizzoli” Orthopaedic Institute, Bologna, Italy; 2Policlinico Umberto I, University of Rome – La Sapienza, Rome, Italy
Magnetic Resonance Imaging guided Focused Ultrasound (MRgHIFU or MRgFUS) treatment of bone metastases is effective and safe for pain palliation. In a few circumstances, MRgFUS showed a partial or complete local control of the tumoral mass affecting bone. The aim of the work was to understand the efficacy of MRgFUS in terms of local tumor control of bone metastases and to explore this opportunity and the reasons for success or failure.
Patients with painful bone metastases were enrolled and submitted to MRgFUS (ExAblate 2100, InSightec Ltd, Israel), with imaging (CT/MRI) before and 3, 6 and 12 months after treatment. The primary endopoint was the number of lesions with partial or complete response at 3 months according to MD Anderson criteria.
Out of 65 patients, 18 were lost and missed the 3-month imaging check. Forty-seven patients with 49 lesions were evaluated. The procedure was successful in terms of local control at 3 months in 24 lesions (49 %) – complete in 11, partial in 13. A stable disease was observed in 20 lesions and a progression in 5. Lesions with osteolytic (or mixed) pattern, with complete accessibility of the margins to the ultrasound beam are perfect candidate for ablation with the intent to control the lesion. Results were statistically independent of histology (primary cancer), previous radiation therapy (59 %), and size (up to 14 cm), though smaller lesions were generally more associated with complete or wide accessibility. Body mass index, age and sex of patients did not influence the outcome.
At present, MRgFUS for painful bone metastases may produce a local control of the lesion. In the future, patients with bone metastases should be selected for MRgFUS with three different intents, and the target should be clearly established before the treatment according to patient conditon, prognosis, symptoms and to the features of the lesion: 1) palliation of pain; 2) palliation and local tumor control; or 3) ablation / local control.
A58 Effect of heating duration on therapeutic ratio in MR-HIFU hyperthermia mediated drug delivery using thermosensitive liposomes in rabbit Vx2 tumors
Robert Staruch1, Chenchen Bing2, Sumbul Shaikh2, Joris Nofiele2, Debra Szczepanski2, Michelle Wodzak Staruch3, Noelle Williams2, Theodore Laetsch2, Rajiv Chopra2
1Philips Research, Dallas, Texas, USA; 2University of Texas Southwestern Medical Center, Dallas, Texas, USA; 3University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
Localized drug delivery using MR-HIFU hyperthermia to trigger the release of chemotherapeutic agents from thermosensitive liposomes (TSLs) has the potential to increase the therapeutic ratio between antitumor effect and systemic toxicity. For doxorubicin (DOX), which is active in many pediatric solid tumors, the late effects of cumulative dose to the heart are treatment-limiting. In this study, we investigate the effect of mild hyperthermia duration (10 vs. 40 minutes) on the ratio of DOX deposited in heated tumors compared to cardiac muscle, using a clinical formulation of TSL-DOX in a rabbit Vx2 tumor model.
Rabbits had Vx2 tumor cells injected into each thigh 12 days before therapy. For each rabbit, mild hyperthermia (10 or 40 minutes, 42 °C) was delivered to a 10 mm diameter region in one tumor using a clinical MR-HIFU system (Sonalleve V2, Philips Healthcare) incorporated into a 3 T MRI (Ingenia, Philips Healthcare). Feedback control of hyperthermia sonications was performed by modified software designed for mild hyperthermia, using MR thermometry data acquired in 6 slices every 3.2 seconds. During heating, TSL-DOX (Thermodox, Celsion Corporation) was administered intravenously at 2.5 mg/kg over 5-6 minutes. Rabbits were sacrificed and perfused with saline for tissue harvest 3 hours after the start of TSL-DOX infusion (Fig. 63). Tissue DOX concentrations were quantified using liquid chromatography-mass spectrometry against a daunorubicin standard following homogenization in cell lysis buffer and extraction in silver nitrate.
Vx2 tumors treated with 10 vs. 40 minutes of mild hyperthermia (n = 10 per group) had largest dimensions of 24.3 and 29.9 mm, and body temperatures of 36.6 °C and 36.6 °C before sonication. Heating quality in the two groups was similar: target region temperatures averaged 41.9 and 41.8 °C, respectively, with T90 of 41.1 and 41.0 °C, and T10 of 42.7 and 42.7 °C. The average duration that target region voxels exceeded 40 °C in the 10 and 40 min heating groups was 11.3 vs. 40.7 min.
In non-targeted organs (heart, lung, spleen, muscle) DOX concentrations demonstrated no significant differences between the two heating groups (ANOVA with selected Bonferroni post-tests). This indicates that systemic toxicity does not increase with heating duration (Fig. 64).
In both heated and unheated tumors, tumor DOX concentrations were higher for 40 vs. 10 min (25.4 vs. 14.0 μg/g and 6.7 vs. 5.4 μg/g, Fig. 65). Similarly, therapeutic ratio (DOX in tumor / DOX in heart) increased with heating duration (3.9 vs 2.2 times). Heated tumors had higher DOX concentrations and therapeutic ratios than unheated tumors (p = 0.03, 2-way ANOVA with Bonferroni). Therapeutic ratio and DOX concentration for heated tumors had a significant correlation with duration above 40 °C.
A59 Technical and imaging parameters predicting successful Magnetic Resonance guided Focused Ultrasound treatment of painful osseous metastases
Pejman Ghanouni1, Jarrett Rosenberg1 Rachelle Bitton1, Alessandro Napoli2, Suzanne LeBlang3, Joshua Meyer4, Mark Hurwitz5, Kim Butts Pauly1
1Stanford University, Stanford, California, USA; 2University of Rome, Rome, Italy; 3Focused Ultrasound Foundation, Charlottesville, Virginia, USA; 4Fox Chase Cancer Center, Philadelphia, Pennsylvania, USA; 5Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
Magnetic Resonance guided Focused Ultrasound (MRgFUS) has proven to be effective in the treatment of painful osseous metastases. The results of the phase III randomized clinical trial comparing MRgFUS to sham treatment of bone metastases demonstrated a 64 % response rate in the treatment group, compared to a 20 % response rate in the sham arm (Fig. 66). We hypothesized that this intention to treat analysis included patients who were suboptimally treated. We reviewed images from the patient procedures to identify imaging features that indicated technically successful treatment, and assessed technical parameters for predictors of pain relief.
All images were anonymized such that the reviewer was blinded to the treatment outcome. Imaging features (size of tumor, osteolytic vs blastic tumor, location of tumor, T2 signal intensity, presence of edema around the tumor after treatment, devascularization of the periosteum around the tumor, tumor devascularization, etc.) and technical parameters of the treatments (number of sonications, total energy, average energy, sonication time, type of anesthesia etc.) were documented for each patient. After de-anonymization, imaging features and technical parameters were then correlated with successful pain relief (defined as at least a 2 point decline in pain score without significant increase in analgesic medication).
We identified an imaging feature that we call the black band (BB), which represents devascularization of the periosteum around the tumor, as best seen on subtracted contrast enhanced T1 weighted fat saturated images obtained immediately after treatment (Fig. 67). The presence of the black band correlated with response to treatment (Odds Ratio of Complete or Partial Response with BB = 5.97; 95 % CI: 1.08 – 33.0; p = 0.041; sensitivity: 96 %, 95 % CI: 88-99 %; specificity: 22 %, 95 % CI: 9 – 40 %). The presence of the BB after treatment predicted a successful treatment (positive predictive value = 72 %, 95 % CI: 61 – 81 %).
We also identified a simple technical parameter, the Energy Density on Bone Surface (EDBS), which is the total energy delivered normalized by the bone surface area. EDBS was the only parameter that independently correlated with the likelihood of achieving complete or partial pain relief (OR of CR/PR with EDBS > 5 J/mm2 = 5.51; 95 % CI: 1.70 – 17.8; sensitivity = 57 %, 95 % CI: 44- 69 %; specificity = 81 %, 95 % CI: 61- 92 %). The black band was significantly correlated with high EDBS (EDBSmean with BB was 5.7 ± 2.8 J/mm2; without BB was 2.7 ± 0.9 J/mm2, p < 0.001).
Percentage of patients with complete or partial response
No prior experience
A60 Technical aspects, feasibility, safety, and initial efficacy of osteoid osteoma ablation with MR-guided High Intensity Focused Ultrasound
Ari Partanen1, Pavel Yarmolenko2, Ari Partanen2, Haydar Celik2, Avinash Eranki3, Viktoriya Beskin3, Domiciano Santos3, Janish Patel3, Matthew Oetgen3, AeRang Kim3, Peter Kim3, Karun Sharma3
1Philips, Bethesda, Maryland, USA; 2Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Health System, Washington, DC, USA; 3Children’s National Health System, Washington, DC, USA
Osteoid osteoma (OO) is a benign bone tumor that causes dull, but often debilitating pain, affecting mainly children and young adults. It is most commonly treated with computed tomography (CT)-guided radiofrequency ablation (RFA). However, RFA is invasive and CT guidance requires exposure to ionizing radiation. These shortcomings may be addressed through the use of Magnetic Resonance Imaging-guided High Intensity Focused Ultrasound (MR-HIFU), which allows non-invasive thermal ablation under real-time MRI guidance, with high spatial precision and without ionizing radiation. MR-HIFU may be used to reduce or eliminate pain through destruction of periosteal nerves and the OO nidus, without need for incisions or drilling. In an ongoing Phase I clinical trial, eight of the planned total of 12 children with symptomatic OOs have been treated at the Children’s National Medical Center (Washington D.C.). Herein we report on the technical aspects, feasibility, safety, and preliminary efficacy of OO MR-HIFU therapy.
Treatments were performed using the Sonalleve V2 clinical MR-HIFU system (Philips, Vantaa, Finland). The system includes a 256-element phased-array transducer, a positioning system with 5 degrees of freedom, and integrated MRI receive coils. Prior to therapy, patients were anesthetized or sedated, and positioned on the HIFU tabletop using gel pads, ultrasound gel, and degassed water for acoustic coupling. T2w and T1w MR images were acquired as a 3D stack, and subsequently used for treatment planning. Sonications of 16-48 s duration were performed at a frequency of 1.2 MHz, targeting regions 4-12 mm in diameter with acoustic powers of 20-160 W. During sonications, real-time MRI temperature maps were acquired using a fast-field-echo pulse sequence and the proton resonance frequency shift method (3 orthogonal slices centered on the target region and an additional slice in the near field). Post-therapy, T1w contrast-enhanced MR images were acquired to report on ablated regions. While complete follow-up is still pending, we assess technical aspects of OO MR-HIFU therapy. Specifically, the following were evaluated: patient positioning, sonication parameters, tissue temperature and thermal dose, tissue perfusion changes, treatment times, and other technical data.
Patient positioning on the HIFU table was feasible in all eight cases, with some modification to the shape of standard ultrasound standoff pads to provide acoustic coupling to extremities. Lesion locations included the tibia (n = 3), femur (n = 3), talus (n = 1), and the great toe (n = 1). Distance between OO nidus center and skin ranged 1.1-7.7 cm, with estimated 43 ± 16 % power remaining at the bone surface due to soft tissue attenuation. Average acoustic power was 50 ± 30 W per sonication and total energy deposition per therapy session was on average 10 ± 7 kJ, resulting in complete lack of MR contrast enhancement of the OO nidus on T1w-imaging in six of eight patients, and partial enhancement in two patients. Immediately after the treatment, nonperfused volume extended 7 ± 4 mm into the bone and 4 ± 6 mm into adjacent soft tissue. For seven of the eight patients, complete or nearly complete resolution of OO-related pain followed within days and all patients were able to cease using medication 28 days following treatment. Sonications, including cool-down times, took 30-77 min, with 101-195 min of MRI suite time required. The treatments required less than 4 hours of total anesthesia and/or sedation and they were well-tolerated without any serious adverse events.
With complete symptom resolution in all patients evaluated thus far, MR-HIFU has the potential to offer a fast, safe, completely noninvasive, and radiation-free treatment option for children with painful OO. Sonication parameters were chosen conservatively in this initial clinical trial, and overall treatment quality may be improved and its duration reduced through optimization of sonication power, duration, and frequency, as well as improved, or more specialized MRI equipment.
A61 Bone thermal modelling for MRgFUS of osteoid osteoma — validation with human clinical data
Alexander Chisholm1, James Drake2, Dionne Aleman1, Adam Waspe2, Thomas Looi3, Samuel Pichardo4
1University of Toronto, Toronto, Ontario, Canada; 2Hospital for Sick Children, Toronto, Ontario, Canada; 3Centre for Image Guided Innovation and Therapeutic Intervention, Toronto, Ontario, Canada; 4Thunder Bay Regional Research Institute, Thunder Bay, Ontario, Canada
MR-guided High Intensity Focused Ultrasound (MRgFUS) has recently been applied to patients with bone lesions such as osteoid osteomas (OO), which are painful benign tumours. While initial results are positive, there is much uncertainty about the ideal target location, effective thermal dose, overall bone heating and possible inadvertent injury. Simulation of MRgFUS heat transfer within and around bone can be used as a pre-treatment planning tool that could optimize and improve the safety and efficacy of this therapy.
To address the uncertainties of MRgFUS treatment, a computer simulator was developed. The simulator has three main components: 1) an automatic bone segmentation tool; 2) an acoustic propagation simulation to calculate the acoustic velocity distribution at the target; and 3) a heat distribution model, calculated by the Pennes Bioheat Equation, which simulates the temperature distribution at the target location. Concurrently, a clinical pilot study is being conducted, to treat OO patients with MRgFUS. The MR imaging and MRgFUS sonication data from the first four patients from this study was reprocessed with the simulator and the results were compared with the measured clinical thermal results.
Automatically segmented femurs were compared to the manually segmented ones. The average volume overlap (VO) and sensitivity (S) between the automatic and manual segmentations were 92.2 % and 96.3 %, respectively. The calculations for VO and S are as follows: VO = 1-(FP + FN)/Vm and S = TP/Vm, were FP is the number of false positives, FN is the number of false negatives, TP is the number of true positives and Vm is the manually segmented volume. The average maximum temperature difference between the simulation and clinical data at a region near the sonication focus, after 20 seconds of sonication, was 1.4oC; after 40 seconds of cool down time, the difference was 7.3oC. The max temperature is defined to be the average of the hottest 9 voxels. The average distance between ablation centroids was 2.9 mm. Figure 68 represents the clinical MR thermometry distribution (left) and the simulated temperature distribution (right) from a representative sonication in one patient. Figure 69 represents the max temperature comparison over 60 seconds for this sonication.
A62 Non-invasive therapy for osteoid osteoma: double site, long term, prospective development study with MR guided Focalized Ultrasound
Alessandro Napoli1, Alberto Bazzocchi2, Roberto Scipione3
1Policlinico Umberto I, University of Rome – La Sapienza, Rome, Italy; 2The “Rizzoli” Orthopaedic Institute, Bologna, Italy; 3University of Rome – La Sapienza, Rome, Italy
Percutaneous or surgical therapy can lead to non-negligible side-effects and limited efficacy for paediatric population or young adults with a benign, self-limiting pathology such as osteoid osteoma. Over a period of 6- years we followed treated patients for at least 3-year for clinical, imaging and rehabilitation process. The aim of the study was to demonstrate that a completely non-invasive radiation-free focal ablation of osteoid lesions with MRgFUS can be a safe, effective and durable treatment option.
Patients were eligible for this dual-centre prospective development study if they had both clinical and radiological diagnosis of non-vertebral osteoid osteoma (typical nocturnal-worsening pain relieved with NSAIDs, pain score [VAS] >4, CT and MRI specific findings), and if they could safely undergo MRI, focalized US procedure and anesthetic. Patients received non-invasive therapy using MRI guided high-intensity Focused Ultrasound, delivered to all known osteoid lesions, identified on MRI, CT, or both. Feasibility, patient safety (adverse events), and clinical relevance profiles of MRgFUS were considered as primary outcomes; tumour control at imaging was considered as secondary outcome. Analyses were done on a per-protocol basis. This study is registered with ClinicalTrials.gov, number NCT02302651.
Among 50 subjects recruited with both clinical and radiological diagnosis of OO, 45 underwent MRgFUS treatment and were included in the analysis. After intervention, no complications related to treatment or anaesthesia occurred and every patient leaved our hospital within 12-24 hours. Even during follow-up, no long-term complication related to treatment was reported. Clinical benefit was effective in all patients and overall VAS median value shifted from 8 (IQR 7-9) points before treatment to 0 at 1-week, 1-month, 6-month, 12-month, 24-month and 36-month follow-up. Similarly, VAS Scores median values for sleep disturbances, overall physical limitation, sport limitation and daily activities limitation dropped to 0 within the first month after treatment, and didn’t increase in subsequent controls. Quality of Life, assessed with FACT-BP Score, rose from a median value of 28 (22-34) before treatment to 55 at 1-week, 59 at 1-month, 60 at 6-month, 12-month, 24-month and 36-month follow-up. There was a complete response (a zero pain score one month after treatment, without recurrent symptoms, stable at follow up) in 80.00 % of cases. 4 patients required a second line of intervention. Overall, patients who reached and maintained a stable 0 VAS score during our 3-year observation with MRgFUS treatment alone were 86.67 %. At final
MRgFUS has shown complete absence of adverse events, persistent clinical efficacy and great tolerance profile. These strong features may induce a change in the current paradigm of OO management, making MRgFUS the treatment of choice, whilst CTgRFA role may shift to a second-line intervention.
A63 MRI-guided High Intensity Focused Ultrasound treatment of osteoid osteoma in pediatric patients: preliminary results
Michael Temple1, Adam Waspe1, Joao Guilherme Amaral1, Yuexi Huang2, Ruby Endre2, Maria Lamberti-Pasculli1, Joost de Ruiter1, Fiona Campbell1, Jennifer Stimec1, Samit Gupta1, Manoj Singh1, Charles Mougenot3, Sevan Hopyan1, Kullervo Hynynen2, Gregory Czarnota2, James Drake1
1Hospital for Sick Children, Toronto, Ontario, Canada; 2Sunnybrook Health Sciences Center, Toronto, Ontario, Canada; 3Philips Healthcare Canada, Toronto, Ontario, Canada
Osteoid osteoma (OO) is the most common benign bone tumor in children. The vascularized, central nidus (Fig. 70) contains cells that produce pain-inducing prostaglandin hormones. While pain can be managed with non-steroidal anti-inflammatory drugs, many patients choose to undergo CT-guided thermal ablation using radiofrequency or laser, the standard-of-care for definitive treatment. Minimally invasive thermal ablation techniques include risks from ionizing radiation, fracture, infection and transmitted thermal damage along the needle. Non-target tissue injury is a concern as temperature cannot be measured with CT, and the treatment induces temperatures around 90 °C that are maintained for several minutes. Magnetic Resonance guided High Intensity Focused Ultrasound (MRgHIFU) is an alternative modality to successfully treat OO. There is no mechanical penetration of the bone, reducing the chance of pathologic fractures and reducing the potential for infection. We present our initial experience with OO MRgHIFU treatment in six pediatric pilot study patients.
The study was performed to determine the impact of focused ultrasound treatment on bone pain, medication usage and health-related quality of life (HRQL). Standardized metrics, such as physical, emotional, social, and school functioning were collected through the use of age-appropriate and validated surveys (Pediatric Ouch, and PedsQLTM). An initial planning MRI was performed to ensure lesion accessibility/patient eligibility. MR thermometry (Fig. 71) was used during treatment to measure temperature in the target and surrounding tissue to ensure patient safety. Procedures were performed under general anesthesia or deep sedation. Post procedure, contrast enhanced MRI, to assess the non-perfused tissues that correspond to the ablated tissue volume (Fig. 70). Pain, HRQL and drug usage surveys were recorded on days 1, 7, 14, 30, 90 and 180 post treatment. Clinical visits on days 30, 90 and 180 included physical examination and diagnostic MRI of the target lesion.
Between July 2014 and May 2016, 6 patients underwent 7 MR-HIFU procedures. Subject 2 underwent MR-HIFU twice due to an inadequate pain response after the first procedure. The average age of patients enrolled was 13 ± 4.1 years (range: 8 – 17) and weight was 52.2 ± 19.4 kg (range: 24 – 74). During this period, a total of 12 patients were referred for OO treatment. Reasons for exclusion from the study included acoustically inaccessible locations (proximity to nerve or growth plate) in 6 patients and patient refusal in 1. The overall technical success rate was 83 % (5/6 subjects). Subject 4 could not be treated due to poor acoustic access to the lesion. Complete response (treatment success) was seen in of 80 % (4/5) and partial response in 20 % (1/5) of the treated subjects. Pain scores dropped from an average of 7.8 prior to treatment to 1.2 by day 7, as shown in Table 4. Prior to treatment, the time to fall asleep was reported as 30-60 minutes. Following MR-HIFU, this decreased to 7-38 minutes. There were no significant adverse events.
Pain scores pre and post HIFU treatment (at days 1, 2, 7, 14, 30 and 90) for all treated patients. Patient 4 could not be treated, and exited the study. Only the data from the first treatment of Patient 2 was used
A64 Treatment of breast fibroadenoma with High Intensity Focused Ultrasound: update of feasibility study IDE #G130252
David Brenin, Carrie Rochman
University of Virginia, Charlottesville, Virginia, USA
Fibroadenomas are common in the United States and many patients find their fibroadenoma bothersome, and thus opt for surgical excision.
Study objectives are to evaluate the safety and feasibility of Ultrasound guided High Intensity Focused Ultrasound (USgHIFU) delivered by the Echopulse device (Theraclion, Paris) for treatment of breast fibroadenomas. General patient safety, cosmetic outcome, tumor response, patient experience, physician/operator experience, and device performance are being assessed.
Twenty female patients diagnosed with palpable breast fibroadenomas 1 cm or larger were enrolled in a single arm study and underwent treatment of their tumor utilizing a computer-driven, continuously cooled, extra-corporal HIFU probe mounted on an arm moved by motors, and guided in real-time with an integrated ultrasound imaging scanner. The integrated probe is positioned by the operator and the lesion is imaged. Treatment planning is automated and presented for review and approval on an integrated computer screen. Patients had tumors meeting the following criteria: Distance from the skin of ≤ 23 mm to the posterior border of the fibroadenoma, ≥ 5 mm from the anterior border of the fibroadenoma, and ≥ 11 mm from the focal point of the HIFU treatment. The chest wall must be more than 1 cm from the posterior margin of the tumor, and tumor volume must be between 0.3 cc and 10 cc.
Subjects are assessed immediately after treatment and at 3, 6, and 12 months.
The study remains open to accrual, the following are PRELIMINARY RESULTS, thus the denominators vary by data point: Enrolment at the time of the writing of the abstract is16 patients. Six patients remain in follow-up. To date, there have been no grade 3 adverse events, nor any skin burns, persistent changes in skin appearance, nor other significant toxicities/morbidities observed in the patients treated. Mean patient-rated pain score during treatment on a scale from 0 to 100 was 17.8. One patient has reported persistent mild pain at 6 months follow-up (2 on a scale from 0 to 100). The most common toxicity observed was pain (reported by 9 of 16 patients). Preliminary patient satisfaction was 4.65 on a scale of 1-5 (5 = most satisfied), 10 of 11 patients reported they would undergo the procedure again, and 11/11 reported they would recommend the procedure to a friend or family member. Reduction in the size of the palpable mass was reported by both the patient and evaluating physician in almost all cases. Similar findings were found on ultrasound in the majority of cases. Cosmesis can be excellent, and unchanged from baseline in all cases to date.
To-date, USgHIFU, delivered by the Echopulse device for treatment of breast fibroadenomas in the IDE G130252 study has been well tolerated by patients, resulted in minimal toxicity, and appears to have been effective.
A65 Long-term efficacy and tolerability of one or two US-guided HIFU treatment of breast fibroadenoma
Roussanka Kovatcheva1, Jordan Vlahov1, Katja Zaletel2, Julian Stoinov1
1University Hospital of Endocrinology, Sofia, Bulgaria; 2University Medical Centre Ljubljana, Ljubljana, Slovenia
Breast fibroadenoma (FA) is the most prevalent benign tumor, accounting for up to 70 % of benign breast lesions [1,2]. They affect females in the reproductive period with two peaks of incidence in the third and in the fifth decade of life. During the follow-up, a minority of FA decrease in size or disappear, more than half of them remain unchanged, and some of them significantly increase .
Ultrasound (US)-guided high-intensity focused ultrasound (HIFU) is the only non-surgical and non-invasive procedure, where thermal destruction is achieved by precisely delivered energy to the target, without interrupting skin integrity. Recently, a multicentre study established that US-guided HIFU treatment of 51 FA resulted in 72.5 % volume reduction at 1 year .
The purpose of our study was to compare the long-term efficacy and tolerability of one or two HIFU treatments in patients with breast FA.
Twenty patients with 26 FA were selected for US-guided HIFU. The therapy was performed with the system EchoPulse (Theraclion, France) on an outpatient basis, in one or two sessions, under conscious sedation. FA volume was assessed before and followed up to 24 months after the last HIFU treatment. After each procedure, adverse events were evaluated. Written informed consent was acquired from all patients.
In 19/26 FA (73.1 %) one HIFU was performed (group 1), whereas 7/26 FA (26.9 %) received second HIFU (group 2) 6-9 months (median, 7 months) after the first session. In group 1 and 2, FA volume decreased significantly at 1-month (p < 0.001) and 3-month follow-up (p = 0.005), respectively, and continued to reduce until 24-month follow-up (p < 0.001 and p = 0.003, respectively). At 24 months, mean volume reduction was 77.32 % in group 1 and 90.47 % in group 2 (p = 0.025). Mild subcutaneous oedema was observed in 4 patients and skin irritation in 3 patients.
US-guided HIFU represents a promising non-invasive method with sustainable FA volume reduction and patient’s tolerability. Although one treatment is highly efficient, the volume reduction can be increased with second treatment.
1. Olu-Eddo AN, Ugiagbe EE (2011) Benign breast lesions in an African population: A 25-year histopathological review of 1864 cases. Niger Med J 52:211-216
2. Aslam HM, Saleem S, Shaikh HA, Shahid N, Mughal A, Umah R (2013) Clinico- pathological profile of patients with breast diseases. Diagn Pathol 8:77
3. Dixon JM, Dobie V, Lamb J, Walsh JS, Chetty U (1996) Assessment of the acceptability of conservative management of fibroadenoma of the breast. Br J Surg 83:264-265
4. Kovatcheva R, Guglielmina JN, Abehsera M, Boulanger L, Laurent N, Poncelet E (2015) Ultrasound-guided high-intensity focused ultrasound treatment of breast fibroadenoma-a multicenter experience. J Ther Ultrasound 3:1
A66 Harmonic motion imaging for characterization and Focused Ultrasound ablation monitoring of post-surgical human breast tumors
Yang Han, Shutao Wang, Elisa Konofagou
Columbia University, New York, New York, USA
Each year in the United States, over 60,000 women are diagnosed with breast cancer. High-Intensity Focused Ultrasound (HIFU) holds promise as a non-invasive and targeted therapeutic technique for breast cancer patients. To facilitate its widespread translation to the clinic, however, there is still a need for a real-time and cost-effective device that can reliably monitor HIFU ablation. Harmonic Motion Imaging for Focused Ultrasound (HMIFU) is an all-ultrasound radiation-force-based technique, which can be used for real-time HIFU ablation monitoring by tracking relative stiffness change at the treated area without interrupting HIFU.
Specimen collection and handling of post-surgical breast tissues were approved by the Institutional Review Board (IRB) board of Columbia University and informed consent was obtained from all enrolled patients. HMIFU was performed in 10 normal, 10 malignant tumor (invasive ductal carcinoma, namely IDC) and one benign tumor (fibroadenoma, namely FA) specimens. The HMIFU setup consists of a 93-element, 4.5-MHz HIFU transducer and a confocally-aligned 64-element, 2.5-MHz phased array imaging probe, which is connected to an ultrasound imaging research system. All HIFU elements were synchronously excited by a 25 Hz amplitude-modulated signal to vibrate the tissue at 50 Hz. A GPU-based fast image reconstruction method was used to monitor lesion development in real-time.
For real-time monitoring, the displacement map and lesion map were streamed on the computer screen at a display frame rate of 2.4 Hz during treatment without interruption. Following a 2D raster scan, 3D HMI displacement maps were reconstructed representing the relative stiffness of the tissue (Fig. 72). The mean HMI displacement within the ROI decreased by 60 % from 24.73 ± 10.97 μm to 9.83 ± 6.46 μm in normal breast tissue (n = 10, p = 0.0048), decreased by 58 % from 12.77 ± 3.50 μm to 5.35 ± 2.74 μm (n = 10, p = 0.045) in IDC and decreased by 20 % from 2.56 μm to 2.06 μm (n = 1) in FA. There were statistically significant differences between before and after HMIFU ablation in both the normal and tumor specimens.
A67 MRgFUS for desmoid tumors within the thigh: Early clinical experiences
Matthew Bucknor, Viola Rieke
University of California San Francisco, San Francisco, California, USA
Desmoid tumors are benign but locally aggressive tumors derived from fibroblasts. Surgery, chemotherapy, and radiation therapy have historically been the mainstay of treatment but recurrence is common and side effects can result in significant morbidity. Desmoid tumors of the thigh are particularly difficult to treat with conventional approaches and have a higher recurrence rate. MRgFUS has increasingly been used for management of desmoid tumors because of the favorable side effect profile. In this case series we highlight our experiences performing treatments in the thigh, including strategies for optimizing ablation size and safety.
Since December 2014, 14 MRgFUS treatments for desmoid tumors were performed at our institution in seven patients. 9 of these treatments were completed in three patients with large tumors within the posterior thigh. The first was a 7 year-old boy who had previously been treated with surgical resection, intraoperative radiation, along with courses of vinblastine/methotrexate and sorafenib. The second was a 21 year-old woman who had previously taken sulindac and celecoxib but had no other therapy. The third patient was a 14 year-old girl with no prior treatment. Treatment efficacy was evaluated by calculation of post-contrast ablation volume immediately following treatment and in diagnostic studies between treatments. Side effects and complications were also documented for each treatment.
Case 1: Pre-treatment tumor volume 770 cc with 75 % non-enhancing volume following the initial treatment. However, first treatment was complicated by a third degree burn along the far-field skin. Despite the complication, the family and referring clinicians wished to proceed with additional treatments. Enhanced safety measures were implemented to protect the far-field skin including water bags and fiber-optic temperature probes, as well as interval skin checks. The patient had four subsequent treatments over 14 months, without complication, with non-perfused volume of 90 % most recently.
Case 2: Pretreatment tumor volume 740 cc. Notably, the sciatic nerve courses along the tumor’s anterior margin. Left lateral decubitus position was used to minimize the amount of energy through the sciatic nerve. Enhanced safety measures as above. First treatment resulted in a relatively low non-perfused volume of 30 %, likely related to a prominent fascial band. Second treatment resulted in 75-80 % ablation of the target.
Case 3: Pretreatment tumor volume was approximately 440 cc. The sciatic nerve was encased by the anteromedial portion of the mass. Left lateral decubitus position and enhanced safety measures again used. First treatment resulted in a relatively low non-perfused volume of 30 %, likely related to low energies. Second treatment resulted in 70-80 % ablation.
MRgFUS is an effective treatment for desmoid tumors with a favorable side effect profile, allowing for repeated treatments if necessary. Ablation size and safety can be improved by use of far-field coupling devices, careful patient positioning, and optimized sonication planning.
Consent to publish had been obtained from the patients and guardians.
A68 Anatomical distribution of pediatric sarcoma and neuroblastoma: Targetability with MR-HIFU
Jenny Shim1,2, Robert Staruch2, Korgun Koral3, Rajiv Chopra3, Theodore Laetsch3
1Children’s Health, Decatur, Georgia, USA; 2Philips Research, Dallas, Texas, USA; 3University of Texas Southwestern Medical Center, Dallas, Texas, USA
Not released for publication
Not released for publication
Not released for publication
Not released for publication
A69 A prospective study on the efficacy of single High Intensity Focused Ultrasound treatment of patients with benign symptomatic thyroid nodule
Brian Lang1, Carlos Wong1, Heather Lam2
1University of Hong Kong, Hong Kong, Hong Kong SAR; 2Theraclion Asia Pacific Limited, Hong Kong, Hong Kong SAR
Benign thyroid nodules are prevalent among the general population and some nodules may exhibit growth over time leading to compression symptoms or cosmetic concerns. Although surgery remains the treatment of choice for symptomatic thyroid nodule, it is associated with a 2 %–10 % risk of complications and requires a general anesthesia. The aims of the present study were to assess the efficacy of a single treatment of High Intensity Focused Ultrasound (HIFU) in reducing benign thyroid nodule volume and to evaluate the changes in health-related quality of life (HRQL) following a single HIFU treatment.
After obtaining IRB approval, consecutive patients with symptomatic thyroid nodule were assessed for eligibility. Inclusions were nodule(s): 1) without signs of malignancy (i.e. no suspicious clinical and ultrasonic features and benign cytology on fine needle aspiration); 2) measuring ≥10 mm on ultrasound (USG) in three orthogonal dimensions; and 3) menable to HIFU. Exclusions were nodule(s): 1) measuring < 40 mm (by largest dimension); and 2) located <2 mm from trachea, esophagus or recurrent laryngeal nerve (where ablation might pose thermal injury). Eligible patients were offered a choice of HIFU treatment, active observation or surgical resection. HIFU treatment was conducted with the USG-guided Echopulse (Theraclion SA, France). Primary outcome was a change in index thyroid nodule volume 6 months after HIFU. To have 80 % power and 95 % confidence interval (two-sided) to detect minimal important difference of 20 %, 20 patients were needed. Assuming a 10 % incomplete and withdrawal rate, 22 patients were required. Thyroid volume (mL) was assessed at baseline (i.e. before ablation), 1-week, 3-month and 6-month while HRQL was assessed by the Chinese version of the SF-12v2 at baseline and 6-month. The HRQL measured by eight domain scores and two summary scores (physical and mental component summary) was then compared between those who received HIFU and those who chose active observation (controls) at 6-month.
Over this period, 22 (52.4 %) chose to receive a single course of HIFU (HIFU group) while the other 20 patients chose to have active observation (controls). Among the HIFU group, the majority were females (90.9 %) and the majority (77.3 %) had their index nodule as the dominant nodule in a multinodular goiter. The mean base index nodule volume was 6.48 ± 4.34 mL (range: 0.92 - 16.76 mL). At 6-month following HIFU, the treated nodule volume decreased to 1.38 ± 1.31 mL (n = 22, p < 0.001). The average extent of nodule reduction was 71.58 ± 11.81 % (range: 54.45 – 90.09 %). However, there was no significant correlation between extent of 6-month volume reduction and basal volume (r = 0.096, p = 0.806), total treatment time (r = 0.503, p = 0.168), total energy delivered (r = 0.122, p = 0755) or mean delivered energy per treated volume tissue (r = 0.150, p = 0.700). Compared with controls, the HIFU group achieved a significantly greater improvement in four quality-of-life domains (17.57 ± 6.46, p = 0.009 for role physical; 18.01 ± 6.78, p = 0.011 for bodily pain; 24.77 ± 8.15, p = 0.004 for general health; 32.61 ± 8.93 for social functioning), and physical component summary of the SF-12v2 ((7.89 ± 2.83, p = 0.001).
USG-guided HIFU ablation is not only an effective and safe treatment option for patients with benign symptomatic thyroid nodules but has the potential of improving the HRQL of patients who do not wish to undergo surgical resection.
A70 The effect of different treatment regimens with US-guided HIFU on thyroid nodule volume
Roussanka Kovatcheva1, Jordan Vlahov2, Katja Zaletel1, Julian Stoinov2, Alexander Shinkov3
1University Medical Centre Ljubljana, Ljubljana, Slovenia; 2University Hospital of Endocrinology, Sofia, Bulgaria; 3Medical University Sofia, Clinical Center of Endocrinology, Sofia, Bulgaria
Thyroid nodules prevalence can reach 67 % on ultrasound (US) examination. Although 95 % of them are benign, 1/3 show continuous growth and should be treated because of clinical symptoms or cosmetic concerns (1). Surgery is still the main therapeutic strategy, in spite of the fact that it carries 2–10 % risk of complications (2).
US-guided high-intensity focused ultrasound (HIFU) is a non-invasive ablative technique, designed to decrease thyroid nodule size (3, 4). The purpose of our work was to compare the long-term efficacy and safety of one and two consecutive HIFU sessions for the ablation of benign solid thyroid nodules.
Twenty patients (mean age, 44.5 years) with euthyroid benign nodular goitre were treated with US-guided HIFU device (EchoPulse, Theraclion, France) under procedural sedation and analgesia. US volume measurement was performed at baseline, 3 and 12 months after the final treatment. Three months after the first treatment, 12 patients (group 1) continued the follow-up and 8 patients (group 2) received second HIFU treatment. Adverse events were evaluated after each HIFU procedure. Written informed consent was acquired from all patients.
Concerning the baseline nodule volume and the energy applied per nodule volume, there was not significant difference between group 1 and group 2 (5.04 ± 2.70 ml and 4.83 ± 2.74 ml, respectively; 3.5 ± 1.4 kJ/mL and 4.1 ± 1.6 kJ/mL, respectively). At 12-month follow-up the mean nodule volume decreased significantly in both groups (2.35 ± 2.44 ml, p = 0.003, and 2.63 ± 1.85 ml, p = 0.017, respectively) with a maximal volume reduction of 95.4 % and 66 %, respectively. The mean percent of volume reduction at M3 after the first HIFU and at M12 after the final HIFU differed significantly between group 1 and 2 (47.4 % ± 20.8 vs 24.2 % ± 15.8, p = 0.02 at M3, and 55.5 % ± 28.4 vs 46 % ± 22, p = 0.011 at M12). In two patients, transient subcutaneous oedema and mild skin redness were registered after the first HIFU procedure and after the second procedure one patient developed transient Horner syndrom, which resolved in 6 months.
The long-term effect of one and two HIFU sessions in solid benign thyroid nodules is comparable. Larger studies are needed to explain the different thyroid nodule susceptibility to HIFU ablation.
1. Erdogan MF, Gursoy A, Erdogan G. Natural course of benign thyroid nodules in a moderately iodine-deficient area. Clin Endocrinol (Oxf) 2006;65(6):767-771.
2. Bergenfelz A, Jansson S, Kristoffersson A et al. Complications to thyroid surgery: results as reported in a database from a multicenter audit comprising 3,660 patients. Langenbecks Arch Surg 2008;393(5):667-673.
3. Esnault O, Franc B, Ménégaux F et al. High-intensity focused ultrasound ablation of thyroid nodules: first human feasibility study. Thyroid 2011;21(9):965-973.
4. Kovatcheva RD, Vlahov JD, Stoinov JI, Zaletel K. Benign Solid Thyroid Nodules: US-guided High-Intensity Focused Ultrasound Ablation-Initial Clinical Outcomes. Radiology, 2015, 276(2):597-605.
A71 Prostate cancer HIFU — novelty or innovation?
Weill Cornell Medicine, New York, New York, USA
Not released for publication
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A72 MR-HIFU ablation of osteoid osteoma: Experience in a pediatric tertiary care center
Children’s National Health System, Washington, DC, USA
To describe our experience with Magnetic Resonance-guided High Intensity Focused Ultrasound (MR-HIFU) ablation of painful Osteoid Osteoma (OO) in children.
Nine children with OO (7 M, 2 F; 16 ± 6 years) underwent MR-HIFU ablation through an FDA and IRB-approved safety and feasibility clinical trial using the Sonalleve V2 MR-HIFU system. Treatment feasibility, patient safety, and clinical response were evaluated in all patients over 28 days. Additional follow-up was performed to evaluate longer-term safety and durability of clinical response.
MR-HIFU therapy was feasible in all nine patients without any serious treatment-related adverse events. Eight out of 9 patients reported complete response in terms of pain resolution and cessation of medication usage and one out of 9 patients reported partial response. All treatments were performed on an outpatient basis without overnight admission.
These findings show that MR-HIFU ablation of OO is feasible and safe in pediatric patients and offers clinical response rates similar to those seen with radiofrequency ablation, the standard of care therapy at most US hospitals. However, the completely noninvasive and radiation-free nature of MR-HIFU is advantageous over RFA, particularly in children and adolescents for whom collateral damage and radiation exposure may cause long-term morbidity.
A73 Noninvasive thrombolysis using microtripsy in a porcine deep vein thrombosis model
Xi Zhang, Jonathan Macoskey, Kimberly Ives, Gabe Owens, Hitinder Gurm, Jiaqi Shi, Matthew Pizzuto, Charles Cain, Zhen Xu
University of Michigan, Ann Arbor, Michigan, USA
Histrotripsy is a novel therapeutic technique that uses ultrasound generated from outside the body to create controlled cavitation in a target tissue, and fractionates it into acellular debris. We have developed a new histotripsy approach, termed microtripsy, to improve targeting accuracy and to avoid collateral tissue damage. This in vivo study evaluates the efficacy and safety of microtripsy thrombolysis in a deep vein thrombosis (DVT) model.
Acute thrombi were formed in the left femoral veins of pigs (~35 kg) by occluding the vessel using two balloon catheters and infusing with thrombin. Guided by ultrasound imaging, microtripsy thrombolysis treatment was conducted in 14 pigs. 10 pigs were euthanized on the same day (acute) and 4 at 2 weeks (subacute). To evaluate the vessel damage, 30-min free-flow treatment (no thrombus) in the right femoral vein was also conducted in 8 acute pigs.
Blood flow was restored or significantly increased after treatment in 13 out of the 14 pigs (Fig. 73). One treatment was not effective due to a technical issue with clot formation. The flow channels reopened by microtripsy had a diameter up to 64 % of the vessel diameter (~6 mm). The average treatment time was 16 minute per cm-long thrombus. Minor hemolysis was observed in both thrombolysis and free-flow treatments. Histology showed no vessel damage and only microscopic hemorrhage outside the veins for the free-flow treatments with nothing abnormal observed for the subacute treatments (Fig. 74).
A74 Acute blood pressure response during MRgFUS renal denervation in a normotensive rat model
Allison Payne, Christopher Dillon, Ivy Christofferson, Elaine Hilas, Jill Shea
University of Utah, Salt Lake City, Utah, USA
Hypertension represents a critical health challenge for millions of people and despite the availability of numerous pharmaceutical agents, approximately 10 % of the patient population who are currently taking three or more medications continue to have high blood pressure and are identified with resistant hypertension. Renal sympathetic nerves are key in initiating and maintaining systemic hypertension. Many studies have demonstrated that performing renal denervation (RD) using both catheter-based and Focused Ultrasound have achieved significant decreases in blood pressure. Mixed clinical trial results and the lack of an acute metric that demonstrates successful RD highlight the need to find alternative technologies and monitoring techniques that can consistently result in RD.
This work evaluates using MRgFUS as a RD technique in a normotensive rat model. Real-time MR monitoring, acute invasive blood pressure probe measurements and histological results all demonstrate the potential of using MRgFUS to control resistant hypertension.
In this pilot study, both male and female (n = 6 treated/5 sham) normotensive Sprague-Dawley rats underwent bilateral RD with MRgFUS. All procedures were performed in a 3 T MRI scanner (Siemens 3 T Trio) using a small animal MRgFUS system (f = 3 MHz, Image Guided Therapy). Sonications were applied along the length of both renal arteries (8 points/animal, 2 W, 20s) and monitored in real-time with 3D MR thermometry. Pre- and post-RD procedure T1 maps were obtained evaluating the entire insonified area. In 5 animals (36 total sonications), mean arterial pressure (MAP) was monitored continuously using an invasive fiberoptic blood pressure probe (SA instruments) inserted in the tail artery. One month post-RD procedure, animals were euthanized and kidney medulla norepinephrine concentration, a proven, robust metric of successful denervation, was obtained using an ELISA (Rocky Mountain Diagnostics). Histological analysis was performed on both renal arteries and surrounding tissues and kidney function, as measured by blood urea nitrogen and urinary albumin secretion, was evaluated.
Acute blood pressure response: A transient decrease in MAP (>5 %) was observed during 11 of the 36 monitored sonications (~30 %). The normalized MAP measurements obtained during these 11 sonications are seen in Fig. 75. In all animals the effect was dependent on sonication location. In addition, the change in MAP occurred several seconds after the sonication start time indicating it was an accumulated effect. Treatment efficacy: Kidney medulla norepinephrine concentration was reduced by 36 % (p = 0.05) one-month post ablation when compared to the sham animals, indicating RD was successfully performed. Efficacy was further confirmed by the presence of inflammatory cells, pyknotic nuclei as well as degraded nerve architecture in the histological results (Fig. 76). Treatment safety: Comparison of the treated and sham RD animal’s blood urea nitrogen and urinary albumin/creatinine ratio resulted in no significant changes indicating kidney function was not affected by MRgFUS renal denervation. In addition, mean T1 values in both kidneys did not significantly change during the MRgFUS RD procedure. The peak mean temperature rise measured by real-time MR thermometry in the back muscle (Fig. 77) located in the near field of all animals ranged from 15.5 to 25.0 °C, confirming energy delivery and targeting accuracy.
A75 Trans esophageal HIFU for cardiac ablation: first experiment in non-human primate
Paul Greillier1, Bénédicte Ankou2, Francis Bessière2, Ali Zorgani1, Mathieu Pioche2, Wojciech Kwiecinski3, Julie Magat4, Sandrine Melot-Dusseau5, Romain Lacoste5, Bruno Quesson4, Mathieu Pernot3, Stefan Catheline1, Philippe Chevalier2, Cyril Lafon6
1INSERM / Université de Lyon, Lyon, France; 2Hospices Civils de Lyon, Lyon, France; 3Institut Langevin Ondes et Images, ESPCI ParisTech, CNRS UMR 7587, INSERM U979, Paris, France; 4IHU Liryc, Electrophysiology and Heart Modeling Institute, Pessac-Bordeaux, France; 5Station de Primatologie-UPS846-CNRS, Rousset sur Arc, France; 6University of Virginia, Charlottesville, Virginia, United States and INSERM Unit 1032, Lyon, France
Atrial fibrillation and ventricular tachycardia are currently treated with catheter ablation using radiofrequency or cryoenergy. These endocardiac approaches are invasive and not fully satisfactory as the treatments are often incomplete and can be associated with serious side effects. The esophagus offers an excellent acoustic window to the heart and transesophageal HIFU were proposed as an alternative strategy. The present work describes the first attempt to perform thermal ablation with trans esophageal HIFU in the heart of a non-human primate.
For that purpose, an endoscope integrating a 5 MHz 64-element commercial transesophageal echocardiography (TEE) probe and a HIFU transducer was built. Anatomical configuration and numerical simulations (Constanciel 2013) allowed setting the features of the HIFU transducer: 8 elements truncated at 14 mm, 3 MHz operating frequency and 40 mm focal length. The focus could be steered electronically over a 15 to 55 mm range from the transducer. Circulation of water at 5 °C inside the endoscope ensured cooling of the front face of the HIFU transducer and acoustic coupling through the inflation of a latex balloon. The probe was tested in vivo in a 30 kg-baboon after preliminary TEE and CT-scanner demonstrated the acoustic access from the esophagus to the heart in this animal model. HIFU were delivered to the interatrial septum, the inferior wall of the left atrium and the upper posterior wall of the left ventricle (LV). A multi channel amplifier allowed delivering a focal intensity (Ispta) of 3000 W/cm2 applied 4 times for 16 s at each selected locations. B-mode, shear-wave (SWE) and passive elastography were performed before and after HIFU with an ultrafast scanner. MR imaging (T1 mapping and contrast) was performed one-day post HIFU. Animal experimentation approved under agreement 04938.04.
The endoscope was successfully inserted in the esophagus of the baboon. The inflation of the latex balloon allowed acoustic transmission from the esophagus to the heart and visualizing satisfactorily the cardiac structures by TEE. HIFU could be delivered at the locations identified on the CT scans even though the heart was slightly shifted in the chest due to different positions of the animal during CT and HIFU procedures. The ECG was not impacted by the treatments. No change in echogenicity of treated zones could be evidenced after HIFU. SWE showed a stiffening of the LV myocardial wall after ablation (two-fold increase of the myocardial stiffness). Increase of stiffness could be observed similarly in the beating heart on passive elastogram. MRI of the atrial wall for detecting thermal ablation could not be achieved. A hypo signal zone could be evidenced on T1 maps in the lateral wall of the LV where one treatment was performed. Contrast MRI did not show local fibrosis in the heart. Endoscopic examination did not reveal esophageal damage. The baboon recovered properly from the protocol and no significant side effect could be evidenced for one month after treatment.
This experiment was a first attempt to perform thermal ablation in the heart with a trans esophageal probe in vivo in a non-human primate. While the procedure was safe and lesions seemed to be induced in the heart, developments will be necessary in order to 1- Deliver more power locally by HIFU, to compensate for motion and heat sink by blood circulation and to generate more pronounced lesions, 2- Improve the performance of monitoring techniques for the atrium (sensitivity and resolution) and for the ventricle (difficult to generate shearwave farther than 50 mm from the esophagus).
A76 Ex vivo and in vivo non-invasive ultrasound-based cardiac pacing
Fabrice Marquet, Pierre Bour, Fanny Vaillant, Sana Amraoui, Rémi Dubois, Philippe Ritter, Michel Haïssaguerre, Mélèze Hocini, Olivier Bernus, Bruno Quesson
IHU Liryc, Electrophysiology and Heart Modeling Institute, Pessac-Bordeaux, France
Currently, no non-invasive cardiac pacing device acceptable for prolonged use in conscious patients exists. The main approach is invasive, employing intravascular catheters, which has associated risks. Focused ultrasound can be used to perform remote pacing using reversibility of electromechanical coupling of cardiomyocytes. This technique might be useful in the short term in the clinical settings in various conditions: temporary pacing for bradycardia or any clinical condition with risks of asystole; terminating or examining the inducibility of tachyarrhythmia; screening and optimization of cardiac resynchronization therapy. Here we described an extracorporeal cardiac stimulation device and study its efficiency and safety.
Ex vivo acoustic stimulation threshold was determined performing 756 sonications in 10 pig beating hearts. In vivo non-invasive stimulation was performed using 314 sonications in 4 anesthetized pigs. The animals were injected with ultrasound contrast agents. Experiments were performed using a Focused Ultrasound device (256 elements, 13/13 cm aperture/focal, operating at 1 MHz) under MR-guidance. At the end of each in vivo experiment, a navigated delayed inversion-recovery 3D Flash sequence was performed. Masson’s staining was performed to assess acute damages screening from acoustic stimulation of both ex vivo and in vivo experiments.
Using HIFU it was possible to perform ventricular continuous pacing (Fig. 78a) or to induce ventricular tachycardia (Fig. 78b). Consecutive stimulations of different heart chambers with a single ultrasonic probe was shown, allowing to modify the resulting atrio-ventricular delay (Fig. 78c-d). The results of the 756 stimulation sites performed in the right atrium, and the left and right ventricles in 10 ex vivo beating hearts from pigs were processed to determine stimulation threshold for pulse duration ranging from 30 μs to 10 ms. Two different pressure thresholds were highlighted: one around 4 MPa peak negative for HIFU pulse durations above 1 ms and one around 6 MPa peak negative for HIFU pulses ranging from 50 μs to 1 ms (Fig. 78e). The same setup was used in vivo in 4 pigs to show clinical potential (Fig. 78f). Electrophysiological changes were also confirmed by arterial pressure modifications (Fig. 78g). The maximal peak negative pressure was estimated to be around 2 MPa at focus during in vivo experiments, due to the limited acoustic window. At this pressure level, stimulation of the LV was observed but with an insufficient success rate. Using ultrasound contrast agents, consistent cardiac stimulation was achievable for up to 1 hour sessions in 4 different animals. No damage was observed in the 4 animals.