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Advanced patient positioning techniques enable MR-HIFU therapy

Case Study
Prof. Kim, Young-sun, M.D. Samsung Medical Center • Korea, Republic of
Keserci, Bilgin Philips Healthcare • Korea, Republic of

Advanced patient positioning techniques enable successful large volume uterine therapy

Patient history

37 year-old married female. 168 cm tall and a weight of 62 kg. Diagnosed with uterine fibroids with chief complaints of urinary frequency and a growing, palpable mass in her abdomen.

MR examination

Sonalleve MR-HIFU V1 system with R2.1L1 version software.

 

 <center>T2-weighted planning image</center>
T2-weighted planning image

Patient presented with a single large fibroid of 11.6 cm in diameter. On examination, there was no scar or small bowel interposed in the potential ultrasound beam path.

The large fibroid may be of concern in reaching the full depth of the fibroid during therapy. The geometrical focus of the ultrasound beam on the V1 Sonalleve system is 12 cm from the transducer surface. Since there is a gel pad and some abdominal fat present, the realistic maximum measurement from the skin to the posterior edge of the dose is approximately 10 cm. 

Planning images

 <center>T2-weighted</center></b> A small bowel loop is positioned directly in front of the top half of fibroid, as observed in the sagittal scan shown above. <center>T1-weighted bowel sequence</center></b> Better visualization of the bowel loop in the near-field is achieved with this sequence.
T2-weighted
A small bowel loop is positioned directly in front of the top half of fibroid, as observed in the sagittal scan shown above.
T1-weighted bowel sequence
Better visualization of the bowel loop in the near-field is achieved with this sequence.



While there was no bowel in the beam path at the time of screening, on treatment day a small bowel loop has moved directly in front of the top half of fibroid. Advanced patient positioning techniques utilized to push the bowel out of the beam path.

Patient positioning to displace the small bowel

 <center>T1-weighted bowel sequence</center></b> Urinary bladder filling to push the fibroid up along with rectal filling to push the fibroid forward. <center>T1-weighted bowel sequence</center></b> Urinary bladder emptying while retaining the rectal fill to lower the fibroid pushing forward.
T1-weighted bowel sequence
Urinary bladder filling to push the fibroid up along with rectal filling to push the fibroid forward.
T1-weighted bowel sequence
Urinary bladder emptying while retaining the rectal fill to lower the fibroid pushing forward.



Displacement of the small bowel is performed by a combination of urinary bladder filling with saline, followed by rectal filling with ultrasound gel using a syringe. This pushes the fibroid forward and up. While maintaining the rectal fill to keep the fibroid pushed forward, the urinary bladder is emptied and the fibroid is lowered. The small bowel loop is no longer in the beam path.

This approach is successful in most of the cases with an anteflexed or anteverted uterus.

Treatment strategy

 <center>Planned treatment cells with single layer strategy</center> <center>Temperature map in sagittal plane</center>
Planned treatment cells with single layer strategy
Temperature map in sagittal plane

Case considerations

Cells were positioned in single plane using the technique published in Radiology by Kim et al. in May 2012.*

Procedure times:
Total MR room time: 3 hours, 53 minutes
Procedure time: 2 hours, 51 minutes

*J.-H. K. Young-sun Kim, MD PhD, H. K. L. Hyunchul Rhim, MD MD, D.-S. B. Bilgin Keserci, PhD MD, J.-W. L. Byoung-Gie Kim, MD MD, and C. H. C. Tae-Joong Kim, MD MD.
“Volumetric MR-guided High-Intensity Focused Ultrasound Ablation with a One-Layer Strategy to Treat Large Uterine Fibroids: Initial Clinical Outcomes”
Radiology, vol. 263, no. 2, p. 2012 May.

Post-treatment MR images

 <center>T1-weighted, contrast-enhanced post-treatment sagittal image</center> <center>T1-weighted, contrast-enhanced post-treatment coronal image</center>
T1-weighted, contrast-enhanced post-treatment sagittal image
T1-weighted, contrast-enhanced post-treatment coronal image

Results

Non-perfused volume (NPV) was 88% of total fibroid volume. NPV was calculated slice-by-slice from the T1w-contrast enhanced image acquired immediately following treatment.

Outcomes and 3-month follow-up

 <center>T2-weighted post-treatment sagittal image</center> <center>T1-weighted, contrast-enhanced post-treatment sagittal image</center>
T2-weighted post-treatment sagittal image
T1-weighted, contrast-enhanced post-treatment sagittal image

At 3 months follow-up the patient reported a reduction in symptom severity score (SSS) from 24 to 11. SSS is used to assess the quality of life and is commonly utilized in uterine fibroid patients.

In addition to an improved symptom profile, the patient had a reduction in fibroid volume of 42.5% from the baseline volume taken at screening. 

Note: Results from case studies are not predictive of results in other cases. Case results may vary.

*NetForum case studies provide information about procedures performed by Philips users, yet Philips takes no responsibility for non-device content (medicine used, positioning preparation, etc)


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Case Study
Sonalleve MR-HIFU
Body, fibroid, HIFU, Interventional, MR-HIFU, Uterine fibroid, Uterus, Women's health
 

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