title: A clinically feasible treatment protocol for magnetic resonance-guided high-intensity focused ultrasound ablation in the liver.
abstract: OBJECTIVE
  Magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) allows for noninvasive thermal ablation under real-time temperature imaging guidance. The purpose of this study was to assess the feasibility and safety of MR-HIFU ablation of liver tissue in a clinically acceptable setting. The experimental protocol was designed with a clinical ablation procedure of a small malignant tumor in mind; the procedures were performed within a clinically feasible time frame and care was taken to avoid adverse events. The main outcome was the size and quality of the ablated liver tissue volume on imaging and histology. Secondary outcomes were safety and treatment time.
  
  
  METHODS
  Healthy pigs (n = 10) under general anesthesia were positioned on a clinical MR-HIFU system, which consisted of an HIFU tabletop with a skin cooling system integrated into a 1.5-T MR scanner. A liver tissue volume was ablated with multiple sonication cells (4 × 4 × 10 mm, 450 W). Both MR thermometry and sonication were respiratory-gated using a pencil beam navigator on the diaphragm. Contrast-enhanced T1-weighted (CE-T1w) imaging was performed for treatment evaluation. Targeted total treatment time was 3 hours. The abdominal wall, liver, and adjacent organs were inspected postmortem for thermal damage. Ablated tissue volumes were processed for cell viability staining. The ablated volumes were analyzed using MR imaging, MR thermometry, and cell viability histology.
  
  
  RESULTS
  Eleven volume ablations were performed in 10 animals, resulting in a median nonperfused volume (NPV) on CE-T1w imaging of 1.6 mL (interquartile range [IQR], 0.8-2.3; range, 0.7-3.0). Cell viability histology showed a damaged volume of 1.5 mL (IQR, 1.1-1.8; range, 0.7-2.3). The NPV was confluent in 10 of the 11 cases. The ablated tissue volume on cell viability histology was confluent in all 9 available cases. In all cases, there was a good correspondence between the aspects of the NPV on CE-T1w and the ablated volume on cell viability histology. Two treatment-related adverse events occurred: 1 animal had a 7-mm skin burn and 1 animal showed evidence of thermal damage on the surface of the spleen. Median ablation time was 108 minutes (IQR, 101-120; range, 96-181 minutes) and median total treatment time was 180 minutes (IQR, 165-224; 130-250 minutes).
  
  
  CONCLUSIONS
  Our results demonstrate the feasibility and safety of MR-HIFU ablation of liver tissue volumes. The imaging data and cell viability histology show, for the first time, that confluent ablation volumes can be achieved with motion-gated ablation and MR guidance. These results were obtained using a readily available MR-HIFU system with only minor modifications, within a clinically acceptable time frame, and with only minor adverse events. This shows that this technique is sufficiently reliable and safe to initiate a clinical trial.
authors.affiliation: From the *Department of Radiology, and †Imaging Division, University Medical Center Utrecht, Utrecht, The Netherlands; ‡Philips Medical Systems MR, Vantaa, Finland; and §Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Joost W
authors.initials: JW
authors.lastname: Wijlemans
authors.forename: Martijn
authors.initials: M
authors.lastname: de Greef
authors.forename: Gerald
authors.initials: G
authors.lastname: Schubert
authors.forename: Lambertus W
authors.initials: LW
authors.lastname: Bartels
authors.forename: Chrit T W
authors.initials: CT
authors.lastname: Moonen
authors.forename: Maurice A A J
authors.initials: MA
authors.lastname: van den Bosch
authors.forename: Mario
authors.initials: M
authors.lastname: Ries
mesh_terms: D000818:Animals; D005240:Feasibility Studies; D005260:Female; D057086:High-Intensity Focused Ultrasound Ablation / Q000379:methods*; D008099:Liver / Q000601:surgery*; D053783:Magnetic Resonance Imaging, Interventional / Q000379:methods*; D023421:Models, Animal; D013552:Swine