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Non-invasive magnetic resonance-guided high intensity focused ultrasound ablation of a vascular malformation in the lower extremity: a case report.

van Breugel JM, Nijenhuis RJ, Ries MG, Toorop RJ, Vonken EJ, Wijlemans JW, van den Bosch MA - J Ther Ultrasound (2015)

Bottom Line: Three-month follow-up imaging indicated successful nidus destruction, which resulted in reduction of >30 % of the tumor volume.Furthermore, both techniques require probe insertion, which is associated with risks of wound infection and hospitalization.The patient reported qualitatively sustained pain reduction up to 13 months post treatment.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands.

ABSTRACT

Introduction: Therapy of choice for symptomatic vascular malformations consists of surgery, sclerotherapy, or embolization. However, these techniques are invasive with possible complications and require hospitalization. We present a novel non-invasive technique, i.e., magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) ablation, for the treatment of a vascular malformation in a patient. This technique applies high-intensity sound waves transcutaneously to the body and is fully non-invasive. MRI guidance is the novel aspect of HIFU treatments and is used for exquisite delineation and localization of the lesion and accurate real-time temperature monitoring during tissue ablation. MR-HIFU is a well-established treatment option for uterine fibroids and is currently being investigated for, e.g., bone tumors, breast cancer, prostate cancer, and liver cancer. MR-HIFU of vascular malformations has not been a topic of research yet.

Case description: Volumetric MR-HIFU ablation of a vascular malformation in the lower extremity of an 18-year-old male patient was performed. Temperatures of 62-80 °C were reached in the target lesion with sonications of 4 × 4 × 8 mm using powers of 200 W for <20 s. At 1-month follow-up, the patient reported qualitatively sustained reduction of pain and normal motor function. Three-month follow-up imaging indicated successful nidus destruction, which resulted in reduction of >30 % of the tumor volume. After 13 months, pain score was reduced to <2 after extreme exertion for several hours and to 0 for daily activities.

Discussion and evaluation: Radiofrequency ablation and cryoablation are minimally invasive techniques that have been tried on low-flow vascular malformations with inconsistent results. Furthermore, both techniques require probe insertion, which is associated with risks of wound infection and hospitalization. Since MR-HIFU is truly non-invasive, these risks are negligible.

Conclusions: In conclusion, we reported a successful non-invasive treatment of a vascular malformation with MR-HIFU in a clinical patient including long-term follow-up data for the first time. The patient reported qualitatively sustained pain reduction up to 13 months post treatment.

No MeSH data available.


Related in: MedlinePlus

Set-up of the HIFU including the device for active skin cooling, which is integrated in the MR scanner (a). Temperature measurement during HIFU treatment. b Coronal and (c) sagittal views
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Fig3: Set-up of the HIFU including the device for active skin cooling, which is integrated in the MR scanner (a). Temperature measurement during HIFU treatment. b Coronal and (c) sagittal views

Mentions: At the patient’s request, the procedure was performed under full anesthesia. It should be noted, however, that this is not the preferred method of approach under normal circumstances for this type of malformation as this procedure could also be performed under conscious sedation. The patient was positioned in supine position on a 1.5 T MR-HIFU Sonalleve system (Philips Healthcare, Vantaa, Finland). An actively cooled water cushion provided skin cooling and enhanced acoustic coupling (Fig. 3a). First, a T2-weighted planning scan was performed for treatment planning. Therapeutic ablation consisted of five point ablations (4 × 4 × 8 mm, 200 W, duration 8.3–19.5 s), which were planned to cover as much volume of the vascular malformation as possible while keeping a safety margin (2 mm) from the adjacent nerve and vessels. During ablation, MR thermometry provided near real-time temperature mapping of the target area and adjacent tissues. This allowed the physician to observe the heating in and outside the target area (Fig. 3). Temperatures of 62–81 °C were reached during the ablation procedure.Fig. 3


Non-invasive magnetic resonance-guided high intensity focused ultrasound ablation of a vascular malformation in the lower extremity: a case report.

van Breugel JM, Nijenhuis RJ, Ries MG, Toorop RJ, Vonken EJ, Wijlemans JW, van den Bosch MA - J Ther Ultrasound (2015)

Set-up of the HIFU including the device for active skin cooling, which is integrated in the MR scanner (a). Temperature measurement during HIFU treatment. b Coronal and (c) sagittal views
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4696245&req=5

Fig3: Set-up of the HIFU including the device for active skin cooling, which is integrated in the MR scanner (a). Temperature measurement during HIFU treatment. b Coronal and (c) sagittal views
Mentions: At the patient’s request, the procedure was performed under full anesthesia. It should be noted, however, that this is not the preferred method of approach under normal circumstances for this type of malformation as this procedure could also be performed under conscious sedation. The patient was positioned in supine position on a 1.5 T MR-HIFU Sonalleve system (Philips Healthcare, Vantaa, Finland). An actively cooled water cushion provided skin cooling and enhanced acoustic coupling (Fig. 3a). First, a T2-weighted planning scan was performed for treatment planning. Therapeutic ablation consisted of five point ablations (4 × 4 × 8 mm, 200 W, duration 8.3–19.5 s), which were planned to cover as much volume of the vascular malformation as possible while keeping a safety margin (2 mm) from the adjacent nerve and vessels. During ablation, MR thermometry provided near real-time temperature mapping of the target area and adjacent tissues. This allowed the physician to observe the heating in and outside the target area (Fig. 3). Temperatures of 62–81 °C were reached during the ablation procedure.Fig. 3

Bottom Line: Three-month follow-up imaging indicated successful nidus destruction, which resulted in reduction of >30 % of the tumor volume.Furthermore, both techniques require probe insertion, which is associated with risks of wound infection and hospitalization.The patient reported qualitatively sustained pain reduction up to 13 months post treatment.

View Article: PubMed Central - PubMed

Affiliation: Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands.

ABSTRACT

Introduction: Therapy of choice for symptomatic vascular malformations consists of surgery, sclerotherapy, or embolization. However, these techniques are invasive with possible complications and require hospitalization. We present a novel non-invasive technique, i.e., magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) ablation, for the treatment of a vascular malformation in a patient. This technique applies high-intensity sound waves transcutaneously to the body and is fully non-invasive. MRI guidance is the novel aspect of HIFU treatments and is used for exquisite delineation and localization of the lesion and accurate real-time temperature monitoring during tissue ablation. MR-HIFU is a well-established treatment option for uterine fibroids and is currently being investigated for, e.g., bone tumors, breast cancer, prostate cancer, and liver cancer. MR-HIFU of vascular malformations has not been a topic of research yet.

Case description: Volumetric MR-HIFU ablation of a vascular malformation in the lower extremity of an 18-year-old male patient was performed. Temperatures of 62-80 °C were reached in the target lesion with sonications of 4 × 4 × 8 mm using powers of 200 W for <20 s. At 1-month follow-up, the patient reported qualitatively sustained reduction of pain and normal motor function. Three-month follow-up imaging indicated successful nidus destruction, which resulted in reduction of >30 % of the tumor volume. After 13 months, pain score was reduced to <2 after extreme exertion for several hours and to 0 for daily activities.

Discussion and evaluation: Radiofrequency ablation and cryoablation are minimally invasive techniques that have been tried on low-flow vascular malformations with inconsistent results. Furthermore, both techniques require probe insertion, which is associated with risks of wound infection and hospitalization. Since MR-HIFU is truly non-invasive, these risks are negligible.

Conclusions: In conclusion, we reported a successful non-invasive treatment of a vascular malformation with MR-HIFU in a clinical patient including long-term follow-up data for the first time. The patient reported qualitatively sustained pain reduction up to 13 months post treatment.

No MeSH data available.


Related in: MedlinePlus