hifu application
TRANSCRIPT
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HIFU Clinical
applications
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Clinical applications (1)
Prostate tumors: – several devices under ultrasonic guidance
commercially available (Ablatherm®, Sonablate
®)
ibroids
– !"g#$% procedures
– &'ablate ® ($nsightec &)* +A --.
– Philips C& approuved +ec --/ 0reast cancer
– clinical research
0one tumors
– clinical research
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Clinical application ()
0rain – small clinical studies – imitation: s2ull (bone) acoustic inter3ace – 4o motion
iver: – #ai3u® under ultrasonic guidance – !"g#$% procedures: Small clinical studies – imitation:
aeric and bone inter3aces!otions
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!"$ guidance o3 3ocused ultrasound
therapy o3 %terine 3ibroids
%terine 3ibroids: ma5or
cause o3 morbidity
Symptomatic in 167 o3
patients
– 0leeding
– !ass
e33ect
– Pain
– 88
Age years Lumbiganon Parazzini
< 30 1,4% 4,7%
30-39 25,1% 22,5%
40-49 61% 61,8%
50 12,5% 10,9%
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ibroids: therapy!ormona" #rug transient e33ect
– Progestin
– onadotrophin*releasing*hormone*agonist
$onsera&ie a''roa() *+mini-inasie – yome(&omy – .&erine ar&ery embo"iza&ion – !/. outpatient procedure
and very short recovery period)ys&re(&omy
irs& surgery in .A mos& or ibrois
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%terine ibroidsComparing treatment options
Treatment Factors Hysterectomy Myomectomy UF Embolization MR-HIFU
Procedure count(%SA, --9)
-;--- ;--- ;--- < .;---(total ==)
#ospital stay – days 1 – 7 days days -
Complication rate – -> – 7.> Peri op: 1->Post op: >
? 7>
"eturn tonormal activity
@ – days .. days 1- days 1* day
uture 3ertility 4o yes-> increasedris2 duringpregnancy
(yes)Possible ovarianemboliBation
(yes)&'clusioncriteria, butencouraging
data
+ra=bac2s6complications
4o 3uturepregnancy,emotional stress
7-> recurrence=ithin y
e33ective in /-> o3patients at 1 yearand @-> at years
e33ectivenessdepends on the4Plong*termmonitoringD
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!"g#$% advantages 3or 3ibroids
Ambu"a&ory
o gnra" anaes&)esia
o (u&aneous 'ene&ra&ione&urn &o or ay 1-2
*)ys&ere(&omy 1-2 mon&)
ae&y *e aerse ee(&s
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/ bes& imaging &e()ni:ue or ibrois
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AdEnomyosis
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X
Y
0
M
Phase image
during heating
/ a &)ermome&er;;
Thermal Map
(∆T C + 37
C)
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Temperaturre map based on PR
d! " dT # $ # 0%0& ppm"'C *T # * ," ($ - . - /o-
T)
1radient e2ho ith spoiler Phase 4 5 Phase &
"inear an ine'enen& o &issue &y'e
Phase &
6oom 8
Phase 4
6oom 8
Relati9e temp map
6oom 8 40 mm
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!"g#$%
1/ goo &ra(ing o &)e ibroi2/ goo &arge&ing o &)e !/. in &)eibrois3 / &em'era&ures ()anges uring
!/.4 aus&men& o !/. in rea" &ime
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!"*#$% Plat3orm: Sonalleve !"*#$%
Phased array transducer
F channels
F ocal point siBe: 1 ' 1 ' @ mm7
F reGuency 1; !#B
ast electronic 3ocal point steering
!echanical plat3orm arge range o3 displacements
H $ntegrated into a 1;I Philips Scanner
Anatomical images =ith +edicatedS&4S& Pelvis coil
Ihermal maps
4on*per3used volume
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3D anatomy and
temperature mapping
thermotherapy
position,timing,
& power
control
US
power
Motorcontrol
MRI-controlled HIFU
MR is essential for 3D planning and to monitor temperature in real-
MR with integrated HIFU Therapy Planning Console
Phased Array Transducer
In Mechanical Positioner
Focused Ultrasound
Electronics
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Point*by*point ablation
Challenge L1 – treatment time
– Ablation speed limit M1 ml6
min
– &'cessive cooling times – ong procedure times 7h
Challenge L – tissue properties
– ocal variations in tissue properties
– $nhomogeneous absorption,
attenuation, per3usion, di33usion $rregular heating patterns
"is2 o3 incomplete coverage
4e= ablation concept
olumetric heating addressing L1 *
!"*#$%Iraditional ablation concept
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olumetric ablation
Cell
$ncreased e33iciency
eera" o"ume&ri( ab"a&ion ere'erorme in orer &o (oer &)e "argeibroi o"ume
="e(&roni( beam s&eering>u&ars-moing(on(en&ri( (ir("es
4 ? 16 mm @
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Au&oma&i( ab"a&ion (on&ro"
/n&eru'&ion&)res)o"
em'era&ure
)erma" ose
&o' )ea&ing
e"iab"e ne(rosis size
-
em'era&ure B )erma"#ose oer"ays
ea" &ime isua"iza&ionC
Au&oma&i( (on&ro"
em'D borer E 54-57F$ or #ose E 240
=
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$ > 7
> 6 A L
3 A G /
A
L
ariable cell siBe
8mm @4mm @ 12mm @ 16mm @
em'era&ure a& &)e en o soni(a&ion
Temp.[°C]
75
47
43
39
56
2cm 2cm2cm2cm
2cm 2cm2cm2cm
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$ > 7
> 6 A L
3 A G /
A
L
ariable cell siBe
)erma" ose a& &)e en o (oo"-on
Dose[EM]
240
180
120
60
30
480
2cm 2cm2cm2cm
2cm 2cm2cm2cm
8mm @4mm @ 12mm @ 16mm @
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=Ham'"e o a 12mm @ soni(a&ion
47
43
39
Dose[EM]
24
Temp.
[°C]75
56
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25
Above lef! P"anning= 2 3#, >I250,1D42H2D10H2D5mm,
Above "#$%! P"a(ing&rea&men& (e""s on '"anning
imagesD ."&rasoun beam (onean sae&y margins ini(a&e
&elo' lef! &em'era&ure ma'rea"-&ime, sagi&&a" ieJ12H30 mm ab"a&ion o"ume=P/ Proe&, 2D5H2D5H7D0 mm
&elo' "#$%! 'os& &rea&men&on Peruse Io"ume *PI1 = !/I= 3# PA/$C >I200,1D0H1D10H4D00mm
rea&men& &ime 130 min
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Patient =ell*beingo (om'"i(a&ions or
serious aerse een&s an
no unin&ene "esions ere
obsereD
!os'i&a" s&ay
e&urn &o norma" a(&ii&y
2D4 1D8 ays
ym'&oms * a&er 1
mon&)
- 13D6 'oin&s *-26D9%
*rom C10D0% &o-92D3%
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olumetric #eating =ith eedbac2
-
.
@
1
1,1-
1.
1
1@
- . @
Cell diameter
NmmO
1 1
A b l a t i o n s p e e d N m l 6 m
i n O
4
4
4
9
4
7
-
-,
1
,
- . @
Cell diameter
NmmO
1
1
A b l a t i o n e 3 3 i c e n c y N m l 6 2
Q O
4
7
4
9
4
4
/m'roe ei(ien(y an s'ee in ("ini(a" 'ra(&i(e
Ab"a&ion s'ee Ab"a&ion ei(ien(y
10H as&er ab"a&ion &)an 'oin& by'oin&
Larger (e""s nee 2-3H "onger(oo"ing
16 mm 35H more ei(ien& &)an 4mmLess near ie" )ea&ing, s)or&er(oo"ing
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C),*DE,TA
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&'ample o3 an #$% treatment outcome
DA( )* T+EATME,T 1 M),T- *))/+ET+EATME,T
C),*DE,TA
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&'ample o3 an #$% treatment outcome
Keore !/.1 mon&) a&er !/.
us& a&er !/.
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1 year a3ter #$%
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$n practice
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> o3 treatment volume and e33iciency
Larger &rea&men& o"umes are 'reerre &o reu(eibroi o"ume as mu() as 'ossib"e
ennessy e& a" 2007aio"ogy
Treatment olume
of Fibroid
! 33 " ! ##"
> o3 patients =ith 1- pointsimprovment (SSS) at 7 months
9/>
> o3 patients =ith 1- pointsimprovment (SSS) at months
9/> @@>
> o3 patients =ith 1- pointsimprovment (SSS) at 1months
9@> /1>
4P 1> R 1,1 ,9 R 1,@
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Kone absorbs . more rea"i"y &)an so& &issue an "o energiesare sui(ien& &o )ea& a bone sura(e &o )ig) &em'era&ureD/n &)is area neres are aa(en& o &)e bone sura(e an may beeH'ose
$atient to include
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$atient to include
A 3ar 3ield margin o3 .-mm should be
available
T2 sagittal
Chec2 that the 3ar 3ield doesnt include sacrum or bo=el
Alternatively treat only the anterior part o3 the 3ibroid
!a': .-mm
$atient to e%clude
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$atient to e%clude
0o=els are located in the beam path
bet=een the 3ibroid and the gel pad
4o sonication possible across air structure or scarves
Air bloc2 ultrasound and produce local heating (bo=els damage)
$atient to include
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$atient to include
0o=els are not located in the beam path
bet=een the 3ibroid and the gel pad
T2 sagittal
#o=ever be care3ul to avoid bo=el =hen sonicating
$ts better to avoid bladder but its possible to sonicate across the
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$atient to e%clude&
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$atient to e%clude&
T1 sagittal before gado T1 sagittal after gado
Patient =ith too many 3ibroidsD
$atient to e%clude
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T1 sagittal before gado T1 sagittal after gado
Ihe transducer displacement and ma'imum 3ocal point is
limited
$atient to e%clude
1@mm
$atient to include
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$atient to include
T2 sagittal T1 sagittal after gado
ibroid =ith a mass center at less than /- mm 3rom the s2in could be
treated
;
!a': 1mm
$atient to include
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Consider the 3act that the bladder =ill be empty during treatment
!ight help to obtain a better 3ar margin relatively to the
sacrum
During pre treatment M!
$atient to include
During treatment M"#!$U
$atient to e%clude
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Patient =ith calci3ication in or close to the beam path should be
e'clude Calci3ication could be identi3ied by ultrasound echo
image
Calci3ication stops the ultrasound =ave (local heating)
and produces local image distortion (=rong treatment planning)
$atient to e%clude
'alcification
$atient to e%clude
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Patient =ith clips in or close to the beam path should be
e'clude
T2 trans%ersal T1 trans%ersal
after gado'
Clips stops the ultrasound =ave (local heating), produces local
image distortion (=rong treatment planning)and induces thermal map instability
$atient to e%clude
'lip 'lip
$atient to include
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Patient =ith scar in the beam path should be
e'clude
T2 trans%ersal
Scar stops the ultrasound =ave (local heating)
+ra= t=o lines =ith same length to chec2 beam
((
$atient to include
)car
$atient to include
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Consider possibility to 3ill the bladder to avoid scar
Caution, in this case the bladder =ill continue to 3ill progressively
Chec2 3reGuently the 3ibroid location =ith mar2ers
((
$atient to include
)car )car
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Signal o3 the 3ibroid
‐!/. 'rou(e a grea&er o"ume reu(&ionin 2 )y'oin&ense ibrois &)an in)y'erin&ense ibrois
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Jthers applications
iver
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#CC: traitement
Surgery: – liver transplantation,
– iver resection but di33icult due to cirrhosis:
Percutaneous therapy – PhysiGue: "
– Chimioembolisation
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!etastasis 3rom colon carcinoma
Jne o3 the K the most 3rEGuent
!Etastasis
– synchronous: 1*>,
– +uring the 3ollo= up: -> ive years survival i3 !
– +rug only: >
– Surgery o3 the metastasis: 7-*.-> only1-> o3 the patient =ith metastasis can be treatedby
surgery
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TransverseAbl ti RF 1 Abl ti RF 2
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Tumour before
RF
Ablation RF 1 Ablation RF 2
Slice1
Slice2 Slice2
Slice1
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Ablation RF N°1
Ablation RF N°2
T2w
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After RF ablation
T1w
Tumour before RF
CE-T1w
T2w
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#$% and iver:
– #ai3u® under ultrasonic guidance
– !"g#$% procedures: Smallclinical studies
– imitation: aeric and bone inter3aces!otions
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!otions
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ree brea&)ing1- C
- C
C
Anatomicalimage
standards Déviationsof T (nocorrection)
standards Déviationsof T (withcorrection)
MR thermometry with motion :correction
eect
#$% and pig liver =ith motion
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#$% and pig liver =ith motion
correction
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Combined !" contrast agents 3or
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Iarget speci3ic part
– !A0 (3ragments)
– Peptides
– Aptamers (short
+4A6"4A strings)
#eat sensitive in2age
Contrast agent (multiple)
– d
– $ron particle
– +rugs
Combined !" contrast agents 3or
imaging6therapy
D
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MRI guided FUS for spatio-temporal control of gene expression
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g p p g punder control of a heat sensitive promoter
Heated region
Ana"ysis o Green"uores(en& Pro&ein gene
=H'ression using $ono(a"i(ros(o'e
Fuorescence Image Transmission Image
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