Preclinical Three-Dimensional Vibrational Shear Wave Elastography for Mapping of Tumour Biomechanical Properties In Vivo.

Preclinical investigation of the biomechanical properties of tissues and their treatment-induced changes are essential to support drug-discovery, clinical translation of biomarkers of treatment response, and studies of mechanobiology. Here we describe the first use of preclinical 3D elastography to map the shear wave speed (cs), which is related to tissue stiffness, in vivo and demonstrate the ability of our novel 3D vibrational shear wave elastography (3D-VSWE) system to detect tumour response to a therapeutic challenge. We investigate the use of one or two vibrational sources at vibrational frequencies of 700, 1000 and 1200 Hz. The within-subject coefficients of variation of our system were found to be excellent for 700 and 1000 Hz and 5.4 and 6.2%, respectively. The relative change in cs measured with our 3D-VSWE upon treatment with an anti-vascular therapy ZD6126 in two tumour xenografts reflected changes in tumour necrosis. U-87 MG drug vs vehicle: Δcs = −24.7 ± 2.5 % vs 7.5 ± 7.1%, (p = 0.002) and MDA-MB-231 drug vs vehicle: Δcs = −12.3 ± 2.7 % vs 4.5 ± 4.7%, (p = 0.02). Our system enables rapid (<5 min were required for a scan length of 15 mm and three vibrational frequencies) 3D mapping of quantitative tumour viscoelastic properties in vivo, allowing exploration of regional heterogeneity within tumours and speedy recovery of animals from anaesthesia so that longitudinal studies (e.g., during tumour growth or following treatment) may be conducted frequently.

Characterization of Acoustic, Cavitation, and Thermal Properties of Poly(vinyl alcohol) Hydrogels for Use as Therapeutic Ultrasound Tissue Mimics.

The thermal and mechanical effects induced in tissue by ultrasound can be exploited for therapeutic applications. Tissue-mimicking materials (TMMs), reflecting different soft tissue properties, are required for experimental evaluation of therapeutic potential. In the study described here, poly(vinyl alcohol) (PVA) hydrogels were characterized. Hydrogels prepared using different concentrations (5%-20% w/w) and molecular weights of PVA ± cellulose scatterers (2.5%-10% w/w) were characterized acoustically (sound speed, attenuation) as a function of temperature (25°C-45°C), thermally (thermal conductivity, specific heat capacity) and in terms of their cavitation thresholds. Results were compared with measurements in fresh sheep tissue (kidney, liver, spleen). Sound speed depended most strongly on PVA concentration, and attenuation, on cellulose content. For the range of formulations investigated, the PVA gel acoustic properties (sound speed: 1532 ± 17 to 1590 ± 9 m/s, attenuation coefficient: 0.08 ± 0.01 to 0.37 ± 0.02 dB/cm) fell within those measured in fresh tissue. Cavitation thresholds for 10% PVA hydrogels (50% occurrence: 4.1-5.4 MPa, 75% occurrence: 5.4-8.2 MPa) decreased with increasing cellulose content. In summary, PVA cellulose composite hydrogels may be suitable mimics of acoustic, cavitation and thermal properties of soft tissue for a number of therapeutic ultrasound applications.

Amplitude based segmentation of ultrasound echoes for attenuation coefficient estimation.

In vivo ultrasound attenuation coefficient measurements are of interest as they can provide insight into tissue pathology. They are also needed so that measurements of the tissue's frequency dependent ultrasound backscattering coefficient may be corrected for attenuation. In vivo measurements of the attenuation coefficient are challenging because it has to be estimated from the depth dependent decay of backscatter signals that display a large degree of magnitude variation. In this study we describe and evaluate an improved backscatter method to estimate ultrasound attenuation which is tolerant to the presence of some backscatter inhomogeneity. This employs an automated algorithm to segment and remove atypically strong echoes to lessen the potential bias these may introduce on the attenuation coefficient estimates. The benefit of the algorithm was evaluated by measuring the frequency dependent attenuation coefficient of a gelatine phantom containing randomly distributed cellulose scatterers as a homogeneous backscattering component and planar pieces of cooked leek to provide backscattering inhomogeneities. In the phantom the segmentation algorithm was found to improve the accuracy and precision of attenuation coefficient estimates by up to 80% and 90%, respectively. The effect of the algorithm was then measured invivo using 32 radiofrequency B-mode datasets from the breasts of two healthy female volunteers, producing a 5 to 25% reduction in mean attenuation coefficient estimates and a 30 to 50% reduction in standard deviation of attenuation coefficient across different positions within each breast. The results suggest that the segmentation algorithm may improve the accuracy and precision of attenuation coefficient estimates invivo.

Maternal and fetal cardiometabolic recovery following ultrasound-guided high-intensity focused ultrasound placental vascular occlusion.

High-intensity focused ultrasound (HIFU) is a non-invasive method of selective placental vascular occlusion, providing a potential therapy for conditions such as twin-twin transfusion syndrome. In order to translate this technique into human studies, evidence of prolonged fetal recovery and maintenance of a healthy fetal physiology following exposure to HIFU is essential. At 116 ± 2 days gestation, 12 pregnant ewes were assigned to control ( n = 6) or HIFU vascular occlusion ( n = 6) groups and anaesthetized. Placental blood vessels were identified using colour Doppler ultrasound; HIFU-mediated vascular occlusion was performed through intact maternal skin (1.66 MHz, 5 s duration, in situ ISPTA 1.8-3.9 kW cm-2). Unidentifiable colour Doppler signals in targeted vessels following HIFU exposure denoted successful occlusion. Ewes and fetuses were then surgically instrumented with vascular catheters and transonic flow probes and recovered from anaesthesia. A custom-made wireless data acquisition system, which records continuous maternal and fetal cardiovascular data, and daily blood sampling were used to assess wellbeing for 20 days, followed by post-mortem examination. Based on a comparison of pre- and post-treatment colour Doppler imaging, 100% (36/36) of placental vessels were occluded following HIFU, and occlusion persisted for 20 days. All fetuses survived. No differences in maternal or fetal blood pressure, heart rate, heart rate variability, metabolic status or oxygenation were observed between treatment groups. There was evidence of normal fetal maturation and no evidence of chronic fetal stress. There were no maternal injuries and no placental vascular haemorrhage. There was both a uterine and fetal burn, which did not result in any obstetric or fetal complications. This study demonstrates normal long-term recovery of fetal sheep from exposure to HIFU-mediated placental vascular occlusion and underlines the potential of HIFU as a potential non-invasive therapy in human pregnancy.

'Relationship between thermal dose and cell death for "rapid" ablative and "slow" hyperthermic heating'.

AIM: Thermal isoeffective dose (TID) has not been convincingly validated for application to predict biological effects from rapid thermal ablation (e.g., using >55 °C). This study compares the classical method of quantifying TID (derived from hyperthermia data) with a temperature-adjusted method based on the Arrhenius model for predicting cell survival in vitro, after either 'rapid' ablative or 'slow' hyperthermic exposures. METHODS: MTT assay viability data was obtained from two human colon cancer cell lines, (HCT116, HT29), subjected to a range of TIDs (120-720 CEM43) using a thermal cycler for hyperthermic (>2 minutes, <50 °C) treatments, or a novel pre-heated water bath based technique for ablative exposures (<10 seconds, >55 °C). TID was initially estimated using a constant RCEM>43°C=0.5, and subsequently using RCEM(T), derived from temperature dependent cell survival (injury rate) Arrhenius analysis. RESULTS: 'Slow' and 'rapid' exposures resulted in cell survival and significant regrowth (both cell lines) 10 days post-treatment for 240 CEM43 (RCEM>43°C=0.5), while 340-550 CEM43 (RCEM>43°C =0.5) delivered using 'rapid' exposures showed 12 ± 6% viability and 'slow' exposures resulted in undetectable viability. Arrhenius analysis of experimental data (activation energy ΔE = 5.78 ± 0.04 × 105 J mole-1, frequency factor A = 3.27 ± 11 × 1091 sec-1) yielded RCEM=0.42 * e0.0041*T which better-predicted cell survival than using R CEM> 43°C=0.5. CONCLUSIONS: TID calculated using an RCEM(T) informed by Arrhenius kinetic parameters provided a more consistent, heating strategy independent, predictor of cell viability, improving dosimetry of ablative thermal exposures. Cell viability was only undetectable above 305 ± 10 CEM43 using this revised measure.

Trans-abdominal in vivo placental vessel occlusion using High Intensity Focused Ultrasound.

Pre-clinically, High Intensity Focused Ultrasound (HIFU) has been shown to safely and effectively occlude placental blood vessels in the acute setting, when applied through the uterus. However, further development of the technique to overcome the technical challenges of targeting and occluding blood vessels through intact skin remains essential to translation into human studies. So too does the assessment of fetal wellbeing following this procedure, and demonstration of the persistence of vascular occlusion. At 115 ± 10 d gestational age (term~147 days) 12 pregnant sheep were exposed to HIFU (n = 6), or to a sham (n = 6) therapy through intact abdominal skin (1.66 MHz, 5 s duration, in situ ISPTA 1.3-4.4 kW.cm-2). Treatment success was defined as undetectable colour Doppler signal in the target placental vessel following HIFU exposures. Pregnancies were monitored for 21 days using diagnostic ultrasound from one day before HIFU exposure until term, when post-mortem examination was performed. Placental vessels were examined histologically for evidence of persistent vascular occlusion. HIFU occluded 31/34 (91%) of placental vessels targeted, with persistent vascular occlusion evident on histological examination 20 days after treatment. The mean diameter of occluded vessels was 1.4 mm (range 0.3-3.3 mm). All pregnancies survived until post mortem without evidence of significant maternal or fetal iatrogenic harm, preterm labour, maternal or fetal haemorrhage or infection. Three of six ewes exposed to HIFU experienced abdominal skin burns, which healed without intervention within 21 days. Mean fetal weight, fetal growth velocity and other measures of fetal biometry were not affected by exposure to HIFU. Fetal Doppler studies indicated a transient increase in the umbilical artery pulsatility index (PI) and a decrease in middle cerebral artery PI as a result of general anaesthesia, which was not different between sham and treatment groups. We report the first successful application of fully non-invasive HIFU for occlusion of placental blood flow in a pregnant sheep model, with a low risk of significant complications. This proof of concept study demonstrates the potential of this technique for clinical translation.

Value of diffusion-weighted imaging for monitoring tissue change during magnetic resonance-guided high-intensity focused ultrasound therapy in bone applications: an ex-vivo study.

BACKGROUND: Magnetic resonance (MR)-guided high-intensity focused ultrasound (HIFU) can palliate metastatic bone pain by periosteal neurolysis. We investigated the value of diffusion-weighted imaging (DWI) for monitoring soft tissue changes adjacent to bone during MR-guided HIFU. We evaluated the repeatability of the apparent diffusion coefficient (ADC) measurement, the temporal evolution of ADC change after sonication, and its relationship with thermal parameters. METHODS: Ex-vivo experiments in lamb legs (n = 8) were performed on a Sonalleve MR-guided HIFU system. Baseline proton resonance frequency shift (PRFS) thermometry evaluated the accuracy of temperature measurements and tissue cooling times after exposure. PRFS acquired during sonication (n = 27) was used to estimate thermal dose volume and temperature. After repeat baseline measurements, DWI was assessed longitudinally and relative ADC changes were derived for heated regions. RESULTS: Baseline PRFS was accurate to 1 °C and showed that tissues regained baseline temperatures within 5 min. Before sonication, coefficient of variation for repeat ADC measurements was 0.8%. After sonication, ADC increased in the muscle adjacent to the exposed periosteum, it was maximal 1-5 min after sonication, and it significantly differed between samples with persistent versus non-persistent ADC changes beyond 20 min. ADC increases at 20 min were stable for 2 h and correlated significantly with thermal parameters (ADC versus applied acoustic energy at 16-20 min: r = 0.77, p < 0.001). A 20% ADC increase resulted in clear macroscopic tissue damage. CONCLUSIONS: Our preliminary results suggest that DWI can detect intra-procedural changes in ex-vivo muscle overlying the periosteum. This could be useful for studying the safety and efficacy of clinical MR-guided HIFU bone treatments.

Focused ultrasound transducer spatial peak intensity estimation: a comparison of methods.

Characterisation of the spatial peak intensity at the focus of high intensity focused ultrasound transducers is difficult because of the risk of damage to hydrophone sensors at the high focal pressures generated. Hill et al (1994 Ultrasound Med. Biol. 20 259-69) provided a simple equation for estimating spatial-peak intensity for solid spherical bowl transducers using measured acoustic power and focal beamwidth. This paper demonstrates theoretically and experimentally that this expression is only strictly valid for spherical bowl transducers without a central (imaging) aperture. A hole in the centre of the transducer results in over-estimation of the peak intensity. Improved strategies for determining focal peak intensity from a measurement of total acoustic power are proposed. Four methods are compared: (i) a solid spherical bowl approximation (after Hill et al 1994 Ultrasound Med. Biol. 20 259-69), (ii) a numerical method derived from theory, (iii) a method using measured sidelobe to focal peak pressure ratio, and (iv) a method for measuring the focal power fraction (FPF) experimentally. Spatial-peak intensities were estimated for 8 transducers at three drive powers levels: low (approximately 1 W), moderate (~10 W) and high (20-70 W). The calculated intensities were compared with those derived from focal peak pressure measurements made using a calibrated hydrophone. The FPF measurement method was found to provide focal peak intensity estimates that agreed most closely (within 15%) with the hydrophone measurements, followed by the pressure ratio method (within 20%). The numerical method was found to consistently over-estimate focal peak intensity (+40% on average), however, for transducers with a central hole it was more accurate than using the solid bowl assumption (+70% over-estimation). In conclusion, the ability to make use of an automated beam plotting system, and a hydrophone with good spatial resolution, greatly facilitates characterisation of the FPF, and consequently gives improved confidence in estimating spatial peak intensity from measurement of acoustic power.

Noninvasive high-intensity focused ultrasound treatment of twin-twin transfusion syndrome: A preliminary in vivo study.

We investigated the efficacy, maternofetal responses, and safety of using high-intensity focused ultrasound (HIFU) for noninvasive occlusion of placental vasculature compared to sham treatment in anesthetized pregnant sheep. This technique for noninvasive occlusion of placental vasculature may be translatable to the treatment of conditions arising from abnormal placental vasculature, such as twin-twin transfusion syndrome (TTTS). Eleven pregnant sheep were instrumented with maternal and fetal arterial catheters and time-transit flow probes to monitor cardiovascular, acid-base, and metabolic status, and then exposed to HIFU (n = 5) or sham (n = 6) ablation of placental vasculature through the exposed uterine surface. Placental vascular flow was occluded in 28 of 30 targets, and histological examination confirmed occlusion in 24 of 30 targets. In both HIFU and sham exposures, uterine contact reduced maternal uterine artery flow, but delivery of oxygen and glucose to the fetal brain remained normal. HIFU can consistently occlude in vivo placental vessels and ablate blood flow in a pregnant sheep model. Cardiovascular and metabolic fetal responses suggest that the technique is safe in the short term and potentially translatable to human pregnancy.

The Feasibility of Thermal Imaging as a Future Portal Imaging Device for Therapeutic Ultrasound.

This technical note describes a prototype thermally based portal imaging device that allows mapping of energy deposition on the surface of a tissue mimicking material in a focused ultrasound surgery (FUS) beam by using an infrared camera to measure the temperature change on that surface. The aim of the work is to explore the feasibility of designing and building a system suitable for rapid quality assurance (QA) for use with both ultrasound- and magnetic resonance (MR) imaging-guided clinical therapy ultrasound systems. The prototype was tested using an MR-guided Sonalleve FUS system (with the treatment couch outside the magnet bore). The system's effective thermal noise was 0.02°C, and temperature changes as low as 0.1°C were easily quantifiable. The advantages and drawbacks of thermal imaging for QA are presented through analysis of the results of an experimental session.

Quality assurance for clinical high intensity focused ultrasound fields.

As the use of HIFU in the clinic becomes more widespread there is an ever increasing need to standardise quality assurance protocols, an important step in facilitating the wider acceptance of HIFU as a therapeutic modality. This article reviews pertinent aspects of HIFU treatment delivery, encompassing the closely related aspects of quality assurance and calibration. Particular attention is given to the description and characterisation of relevant acoustic field parameters and the measurement of acoustic power. Where appropriate, recommendations are made.

Development of a hybrid magnetic resonance and ultrasound imaging system.

A system which allows magnetic resonance (MR) and ultrasound (US) image data to be acquired simultaneously has been developed. B-mode and Doppler US were performed inside the bore of a clinical 1.5 T MRI scanner using a clinical 1-4 MHz US transducer with an 8-metre cable. Susceptibility artefacts and RF noise were introduced into MR images by the US imaging system. RF noise was minimised by using aluminium foil to shield the transducer. A study of MR and B-mode US image signal-to-noise ratio (SNR) as a function of transducer-phantom separation was performed using a gel phantom. This revealed that a 4 cm separation between the phantom surface and the transducer was sufficient to minimise the effect of the susceptibility artefact in MR images. MR-US imaging was demonstrated in vivo with the aid of a 2 mm VeroWhite 3D-printed spherical target placed over the thigh muscle of a rat. The target allowed single-point registration of MR and US images in the axial plane to be performed. The system was subsequently demonstrated as a tool for the targeting and visualisation of high intensity focused ultrasound exposure in the rat thigh muscle.

A comparison of acoustic cavitation detection thresholds measured with piezo-electric and fiber-optic hydrophone sensors.

A Fabry-Perot interferometer fiber-optic hydrophone (FOH) was investigated for use as an acoustic cavitation detector and compared with a piezo-ceramic passive cavitation detector (PCD). Both detectors were used to measure negative pressure thresholds for broadband emissions in 3% agar and ex vivo bovine liver simultaneously. FOH-detected half- and fourth-harmonic emissions were also studied. Three thresholds were defined and investigated: (i) onset of cavitation; (ii) 100% probability of cavitation; and (iii) a time-integrated threshold where broadband signals integrated over a 3-s exposure duration, averaged over 5-10 repeat exposures, become statistically significantly greater than noise. The statistical sensitiviy of FOH broadband detection was low compared with that of the PCD (0.43/0.31 in agar/liver). FOH-detected fourth-harmonic data agreed best with PCD broadband (sensitivity: 0.95/0.94, specificity: 0.89/0.76 in agar/liver). The FOH has potential as a cavitation detector, particularly in applications where space is limited or during magnetic resonance-guided studies.

Calibration of ultrasound backscatter temperature imaging for high-intensity focused ultrasound treatment planning.

High-intensity focused ultrasound (HIFU) is rapidly gaining acceptance as a non-invasive method for soft tissue tumor ablation, but improvements in the methods of treatment delivery, planning and monitoring are still required. Backscatter temperature imaging (BTI) uses ultrasound to visualize heating-induced echo strain and may be used to indicate the position of the HIFU focal region using low-power "sub-lesioning" exposure. The technique may also provide a quantitative tool for assessing the efficacy of treatment delivery if apparent strain measurements can be related to the underlying temperature rise. To obtain temperature estimates from strain measurements, the relationship between these variables has to be either measured or otherwise assumed from previous calibrations in similar tissues. This article describes experimental measurements aimed at deriving the relationship between temperature rise and apparent strain in the laboratory environment using both ex vivo bovine liver tissue samples and normothermically perfused porcine livers. A BTI algorithm was applied to radiofrequency ultrasound echo data acquired from a clinical ultrasound scanner (Z.One, Zonare Medical Systems, Mountain View, CA, USA) where the imaging probe was aligned with the focal region of a HIFU transducer. Temperature measurements were obtained using needle thermocouples implanted in the liver tissue. A series of "non-ablative" HIFU exposures giving peak temperatures below 10°C were made in three separate ex vivo bovine livers, yielding an average strain/temperature coefficient of 0.126 ± 0.088 percentage strain per degree Celsius. In the perfused porcine livers at a starting temperature of 38°C (normal body temperature) the strain/temperature coefficients were found to be 0.040 ± 0.029 percentage strain per degree Celsius. The uncertainty in these results is directly linked to the precision of the strain measurement, as well as the naturally occurring variance between different tissue samples, indicating that BTI may lack the accuracy required to be implemented successfully in practice as a quantitative treatment planning technique at a sub-lesioning exposure level. This is because, to be of use in treatment planning, temperature-rise estimates may require an accuracy greater (<10%) than that offered by BTI measurement. BTI may, however, still play a role in ensuring the correct positioning of the focal region and as a treatment monitoring modality capable of detecting an increased rate of heating in tissue after HIFU ablation.

The use of a segmented transducer for rib sparing in HIFU treatments.

The use of focused ultrasound as a minimally invasive treatment for tumours is rapidly expanding. Target organs include the liver and kidneys. Both single element and phased array transducers may be used in the clinic. The presence of the rib cage presents a problem in high intensity focused ultrasound (HIFU) treatment planning, due to its high attenuation of the HIFU beam resulting in a loss of power at the focus as well as an increase in the risk of damage at the rib and to overlying tissues, including the skin. In this paper, a linearly segmented transducer, in which all active elements are driven in phase, has been investigated. The aim of the study was to investigate how a beam with a clinically useful profile could be achieved by removing the contribution of edge segments from one side of the transducer to the field. We have considered the case in which the HIFU beam approaches the rib cage during a treatment and investigated configurations of the transducer for which up to three segments on the edge are switched off. This problem has been studied initially using a linear acoustic field program to model the segmented transducer's acoustic beam profile. Experimental measurements of the transducer's acoustic field were performed using an automated beam plotting system. Temperature measurements were made on a rib surface for two transducer configurations using a fine wire thermocouple. A thermochromic liquid crystal material was used to assess qualitatively the heating pattern generated by the ultrasound beam. We show the rib sparing potential of the segmented transducer during HIFU treatment by demonstrating a reduction in the prefocal width of the ultrasound beam when edge segments are switched off. This has been predicted with the acoustic field model and demonstrated experimentally by acoustic field measurements and observations of the heating pattern generated by the ultrasound beam. A significant decrease in the temperature rise on a rib was observed in the case for which three edge segments were switched off compared with when all segments were active. We conclude that a segmented transducer extends the potential for treating liver tumours. In the case where the tumour lies behind, but close to the edge of, the ribs, energy loss at the focus and excessive heating in the rib and overlying tissue can be avoided by switching off edge segments.