Early health technology assessment of magnetic resonance-guided high intensity focused ultrasound ablation for the treatment of early-stage breast cancer

MR Imaging-Guided Focused Ultrasound for Breast Tumors

Breast tumors remain a complex and prevalent health burden impacting millions of individuals worldwide. Challenges in treatment arise from the invasive nature of traditional surgery and, in malignancies, the complexity of treating metastatic disease. The development of noninvasive treatment alternatives is critical for improving patient outcomes and quality of life. This review aims to explore the advancements and applications of focused ultrasound (FUS) technology over the past 2 decades. FUS offers a promising noninvasive, nonionizing intervention strategy in breast tumors including primary breast cancer, fibroadenomas, and metastatic breast cancer.

2D ultrasound thermometry during thermal ablation with high-intensity focused ultrasound

The clinical use of high intensity focused ultrasound (HIFU) therapy for noninvasive tissue ablation has recently gained momentum. Guidance is provided by either magnetic resonance imaging (MRI) or conventional B-mode ultrasound imaging, each with its own advantages and disadvantages. The main limitation of ultrasound imaging is its inability to provide temperature measurements over the ranges corresponding to the target temperatures during ablative thermal therapies (between 55 °C and 70 °C). Here, variations in ultrasound backscattered energy (ΔBSE) were used to monitor temperature increases in liver tissue up to an absolute value of 90 °C during and after HIFU treatment. In vitro experimental measurements were performed in 47 bovine liver samples using a toroidal HIFU transducer operating at 2.5 MHz to increase the temperature of tissues. An ultrasound imaging probe working at 7.5 MHz was placed in the center of the HIFU transducer to monitor the backscattered signals. The free-field acoustic power was set to 9 W, 12 W or 16 W in the different experiments. HIFU sonications were performed for 240 s using a duty cycle of 83 % to allow ultrasound imaging and raw radiofrequency data acquisition during exposures. Measurements showed a linear relationship between ΔBSE (in dB) and temperature (r = 0.94, p < 0.001) over a temperature range from 37 °C to 90 °C, with a high reliability of temperature measurements below 75 °C. Monitoring can be performed at the frame rate of ultrasound imaging scanners with an accuracy within an acceptable threshold of 5 °C, given the temperatures targeted during thermal ablations. If the maximum temperature reached is below 70 °C, ΔBSE is also a reliable approach for estimating the temperature during cooling. Histological analysis shown the impact of the treatment on the spatial arrangement of cells that can explain the observed variation of ΔBSE. These results demonstrate the ability of ΔBSE measurements to estimate temperature in ultrasound images within an effective therapeutic range. This method can be implemented clinically and potentially applied to other thermal-based therapies.

Thermal immuno-nanomedicine in cancer

Immunotherapy has revolutionized the treatment of patients with cancer. However, promoting antitumour immunity in patients with tumours that are resistant to these therapies remains a challenge. Thermal therapies provide a promising immune-adjuvant strategy for use with immunotherapy, mostly owing to the capacity to reprogramme the tumour microenvironment through induction of immunogenic cell death, which also promotes the recruitment of endogenous immune cells. Thus, thermal immunotherapeutic strategies for various cancers are an area of considerable research interest. In this Review, we describe the role of the various thermal therapies and provide an update on attempts to combine these with immunotherapies in clinical trials. We also provide an overview of the preclinical development of various thermal immuno-nanomedicines, which are capable of combining thermal therapies with various immunotherapy strategies in a single therapeutic platform. Finally, we discuss the challenges associated with the clinical translation of thermal immuno-nanomedicines and emphasize the importance of multidisciplinary and inter-professional collaboration to facilitate the optimal translation of this technology from bench to bedside.

Experimental evaluation of the near-field and far-field heating of focused ultrasound using the thermal dose concept

BACKGROUND

Conventional motion algorithms utilized during High Intensity Focused Ultrasound (HIFU) procedures usually sonicate successive tissue cells, thereby inducing excess deposition of thermal dose in the pre-focal region. Long delays (~60 s) are used to reduce the heating around the focal region. In the present study the experimental evaluation of six motion algorithms so as to examine the required delay and algorithm for which the pre-focal (near-field) and post-focal (far-field) heating can be reduced using thermal dose estimations is presented.

MATERIALS AND METHODS

A single element spherically focused transducer operating at 1.1 MHz and focusing beam at 9 cm, was utilized for sonication on a 400 mm2 area of an agar-based phantom. Movement of the transducer was performed with each algorithm, using 0-60 s (10 s step) delays between sonications. Temperatures were recorded at both near and far-field regions and thermal dose calculations were implemented.

RESULTS

With the algorithms used in the present study, a delay of 50-60 s was required to reduce heating in the near-field region. A 30 s delay induced a safe thermal dose in the far-field region using all algorithms except sequential which still required 60 s delay.

CONCLUSIONS

The study verified the conservative need for 60 s delay for the sequential plan treatment. Nevertheless, present findings suggest that prolonged treatment times can be significantly reduced in homogeneous tissues by selection of the optimized nonlinear algorithm and delay.

Development of a noninvasive HIFU treatment for breast adenocarcinomas using a toroidal transducer based on preliminary attenuation measurements

Breast cancer is the most commonly diagnosed type of cancer among women. For the last fifteen years, treatments that are less invasive than lumpectomy, such as high-intensity focused ultrasound (HIFU) therapy, have been developed, with encouraging results. In this study, a toroidal HIFU transducer was used to create lesions of at least 2 cm in diameter within less than one minute of treatment. The toroidal HIFU transducer created two focal zones that led to large, fast and homogeneous ablations (10.5 cc/min). The experiments were conducted in 30 human samples of normal breast tissues recovered from mastectomies to measure acoustic attenuation (N = 30), and then, HIFU lesions were created (N = 15). Eight HIFU ablations were performed to evaluate the reproducibility of the lesions. HIFU lesions were created in 45 s with a toroidal HIFU transducer working at 2.5 MHz. The longest and shortest axes of the HIFU lesions were 21.7 ± 3.1 mm and 23.5 ± 3.3 mm respectively, corresponding to an average volume of 7.3 ± 1.4 cm³. These HIFU lesions were performed at an average depth of 19.0 ± 1.5 mm, while the integrity of the skin was preserved. The HIFU-treated breast tissues had a higher level of attenuation (0.57 ± 0.11 Np.cm^-1.MHz^-1) when compared to the untreated tissues (0.21 ± 0.04 Np.cm^-1.MHz^-1). This study shows the feasibility of a fast and fully noninvasive treatment using a toroidal transducer for breast tumors measuring up to 15 mm in diameter.

The Use of High-Intensity Focused Ultrasound for the Rewarming of Cryopreserved Biological Material

High-intensity focused ultrasound (HIFU) has been used in different medical applications in the last years. In this work, we present for the first time the use of HIFU in the field of cryopreservation, the preservation of biological material at low temperatures. An HIFU system has been designed with the objective of achieving a fast and uniform rewarming in organs, key to overcome the critical problem of devitrification. The finite-element simulations have been carried out using COMSOL Multiphysics software. An array of 26 ultrasonic transducers was simulated, achieving an HIFU focal area in the order of magnitude of a model organ (ovary). A parametric study of the warming rate and temperature gradients, as a function of the frequency and power of ultrasonic waves, was performed. An optimal value for these parameters was found. The results validate the appropriateness of the technique, which is of utmost importance for the future creation of cryopreserved organ banks.

Fast and Selective Ablation of Liver Tumors by High-Intensity Focused Ultrasound Using a Toroidal Transducer Guided by Ultrasound Imaging: The Results of Animal Experiments

This study demonstrated that high-intensity focused ultrasound (HIFU) produced with an intra-operative toroidal-shaped transducer causes fast, selective liver tumor ablations in an animal model. The HIFU device is composed of 256 emitters working at 3 MHz. A 7.5 MHz ultrasound imaging probe centered on the HIFU transducer guided treatment. VX2 tumor segments (25 mg) were implanted into the right lateral liver lobes of 45 New Zealand rabbits. The animals were evenly divided into groups 1 (toroidal HIFU ablation), 2 (surgical resection) and 3 (untreated control). Therapeutic responses were evaluated with gross pathology and histology 11 d post-treatment. Toroidal transducer-produced HIFU ablation (average ablation rate 10.5 cc/min) allowed fast and homogeneous tumor treatment. Sonograms showed all ablations. VX2 tumors were completely coagulated and surrounded by safety margins without surrounding-organ secondary HIFU lesions. HIFU group tumor volumes at autopsy (39 mm³) were significantly lower than control group volumes (2610 mm³, p < 0.0001). HIFU group tumor metastasis (27%) was lower than resected (33%) and control (67%) group metastasis. Ultrasound imaging, gross pathology and histology results supported these outcomes. HIFU procedures had no complications. Rabbit liver tumor ablation using a toroidal HIFU transducer under ultrasound imaging guidance might therefore be an effective intra-operative treatment for localized liver metastases.

Proton Resonance Frequency Shift Thermometry: A Review of Modern Clinical Practices

Magnetic resonance imaging (MRI) has become a popular modality in guiding minimally invasive thermal therapies, due to its advanced, nonionizing, imaging capabilities and its ability to record changes in temperature. A variety of MR thermometry techniques have been developed over the years, and proton resonance frequency (PRF) shift thermometry is the current clinical gold standard to treat a variety of cancers. It is used extensively to guide hyperthermic thermal ablation techniques such as high-intensity focused ultrasound (HIFU) and laser-induced thermal therapy (LITT). Essential attributes of PRF shift thermometry include excellent linearity with temperature, good sensitivity, and independence from tissue type. This noninvasive temperature mapping method gives accurate quantitative measures of the temperature evolution inside biological tissues. In this review, the current status and new developments in the fields of MR-guided HIFU and LITT are presented with an emphasis on breast, prostate, bone, uterine, and brain treatments. LEVEL OF EVIDENCE: 5 TECHNICAL EFFICACY STAGE: 3.

Numerical modeling of ultrasound heating for the correction of viscous heating artifacts in soft tissue temperature measurements

Measuring temperature during focused ultrasound (FUS) procedures is critical for characterization, calibration, and monitoring to ultimately ensure safety and efficacy. Despite the low cost and the high spatial and temporal resolutions of temperature measurements using thermocouples, the viscous heating (VH) artifact at the thermocouple-tissue interface requires reading corrections for correct thermometric analysis. In this study, a simulation pipeline is proposed to correct the VH artifact arising from temperature measurements using thermocouples in FUS fields. The numerical model consists of simulating a primary source of heating due to ultrasound absorption and a secondary source of heating from viscous forces generated by the thermocouple in the FUS field. Our numerical validation found that up to 90% of the measured temperature rise was due to VH effects. Experimental temperature measurements were performed using thermocouples embedded in fresh chicken breast samples. Temperature corrections were demonstrated for single high-intensity FUS pulses at 3.1 MHz and for multiple pulses (3.1 MHz, 100 Hz, and 500 Hz pulse repetition frequency). The VH accumulated during sonications and produced a temperature increase of 3.1 °C and 15.3 °C for the single and multiple pulse sequences, respectively. The methodology presented here enables the decoupling of the temperature increase generated by absorption and VH. Thus, more reliable temperature measurements can be extracted from thermocouple measurements by correcting for VH.

Effects of breast structure on high-intensity focused ultrasound focal error

Background

The development of imaging technologies and breast cancer screening allowed early detection of breast cancers. High-intensity focused ultrasound (HIFU) is a non-invasive cancer treatment, but the success of HIFU ablation was depending on the system type, imaging technique, ablation protocol, and patient selection. Therefore, we aimed to determine the relationship between breast tissue structure and focal error during breast cancer HIFU treatment.

Methods

Numerical simulations of the breast cancer HIFU ablation were performed using digital breast phantoms constructed using the magnetic resonance imaging data obtained from 12 patients.

Results

The focal shapes were distorted despite breast tissue representing soft tissue. Focal errors are caused by the complex distribution of fibroglandular tissue, and they depend on the target position and the arrangement of the transducer. We demonstrated that the focusing ratio increases with the decrease in the local acoustic inhomogeneity, implying that it may be used as an indicator to reduce the HIFU focal error depending on the breast structure.

Conclusions

The obtained results demonstrated that the focal error observed during the breast cancer HIFU treatment is highly dependent on the structure of fibroglandular tissue. The optimal arrangement of the transducer to the target can be obtained by minimizing the local acoustic inhomogeneity before the breast cancer HIFU treatment.

Small PLGA nanocapsules Co-encapsulating copper sulfide nanodots and fluorocarbon compound for photoacoustic imaging-guided HIFU synergistic therapy

High intensity focused ultrasound (HIFU), as a promising and minimally invasive therapeutic modality against various solid tumors, has received considerable attention in the biomedical field. However, both the accuracy and efficacy of this technique are currently unsatisfactory. Herein, a nanometer-sized organic/inorganic hybrid enhancement agent for photoacoustic imaging (PAI)-guided HIFU therapy was designed and fabricated by concurrently encapsulating both Cu_2−xS nanodots (NDs) and perfluorooctyl bromide (PFOB) into a poly(lactic-co-glycolic acid) PLGA nanocapsule (denoted CPPNs). These nanocapsules assumed a unique core/satellite/shell sandwich structure, and combined the merits of small and uniform particle size (about 120 nm), favorable biosafety, and multifunctional theranostic ability into one system. The high performance of Cu_2−xS NDs in the absorption and conversion of near infrared laser confers high PAI contrast capability to the CPPNs, by which the location of the CPPNs within a tumor can be monitored successfully under PAI. Furthermore, our in vitro and in vivo results confirmed that the encapsulated PFOB in CPPNs increased the cavitation effect and thus enhanced the ablation efficacy under HIFU exposure. CPPNs show great potential as an efficient and powerful theranostic agent for future PAI-guided HIFU synergistic therapy.

A nanometer-sized inor-ganic/organic hybrid enhancement agent is constructed for photoacoustic imaging-guided high intensity focused ultrasound therapy.