NetForum uses cookies to ensure that we give you the best experience on our website. If you continue to use the site, we'll assume that you are happy to receive these cookies on the NetForum website. Read about our cookies.
NetForum Community
Learn. Share. Optimize.
Log in | Sign up now | Submit content | Contact
Go to similar content

MR-HIFU: Advanced patient positioning aided by shared clinical experience

Case Study
Prof. Thurnher, Siegfried, M.D. Hospital St.John of God • Austria
Keserci, Bilgin Philips Healthcare • Korea, Republic of
Beldoch, Michael, M.D. UKSH Lübeck • Germany

Patient history

45-year-old female. Diagnosed with uterine fibroids with chief complaints of pressure. Patient desires to retain uterus and possibility for pregnancy.

MR examination

 T2-weighted planning image T1-weighted contrast-enhanced planning image
T2-weighted planning image
T1-weighted contrast-enhanced planning image

Patient presented with an intramural fibroid 7.0 x 6.4 cm, positioned in the anterior uterine wall and reaching quite deep, with the deepest portion of the fibroid >10 cm from the skin surface.

Access to the fibroid was expected to be a considerable challenge, as a large amount of bowel was observed in the nearfield. With an empty bladder, the fibroid would be positioned very near the symphysis. As the imaging was performed supine, there was hope that on treatment day the acoustic window would be more favorable.

Additionally, the fibroid appeared to be Funaki classification Type II and heterogeneous based on the T1-weighted contrast-enhanced planning image.

MR-HIFU treatment

Sonalleve MR-HIFU V2 system with R3.2L3 version software was used along with an Ingenia 1.5T.

Treatment was performed in collaboration with Michael Beldoch, M.D. from the University of Lubeck and with the support of MR Therapy Clinical Scientist, Bilgin Keserci, Ph.D.

T2-weighted planning images

 T2-weighted planning image with bowels and symphysis in nearfield T2-weighted planning image with significant bladder fill and some rectal fill T2-weighted planning image
with significant bladder fill and
additional rectal fill
T2-weighted planning image with bowels and symphysis in nearfield
T2-weighted planning image with significant bladder fill and some rectal fill
T2-weighted planning image with significant bladder fill and additional rectal fill

On treatment day, the T2-weighted planning images were captured and unfortunately the bowel and symphysis in the nearfield pose a significant challenge for the ultrasound beam path to the fibroid.

Objectives of the manipulation techniques were to push the bowel up out of the acoustic path, move the fibroid away from the symphysis bone and push the fibroid anteriorly.

This technique was coined by Dr. Young-sun Kim of Samsung Medical Center in Seoul Korea for patient manipulation, whereby the bladder is filled to push the fibroid up, followed by rectal filling to push the fibroid anterior and typically the bladder is emptied.

In this particular case, the bladder was not emptied, as the full bladder enabled a better acoustic window and the patient was able to tolerate this during therapy.

Treatment planning with one- and two-layer strategy

 T2-weighted planning image with cell placement in single layer 2/3 deep into the fibroid
T2-weighted planning image with cell placement in single layer 2/3 deep into the fibroid

Upon obtaining a sufficient acoustic window for therapy, the clinicians assessed the application of the one-layer strategy developed by Dr. Young-sun Kim from Samsung Medical Center in Seoul, Korea.

Kim et. al.* showed that volumetric ablation could be used to more efficiently treat larger fibroids. They pursued this approach with the intention to cover as much of the fibroid volume as possible with this strategy.

A total of 31 sonications with cell sizes of 8 mm and 12 mm were used for therapy.

Procedure times
Total MR room time: 403 min
Preparation time: 30 min
Manipulation time: 120 min**
Procedure time: 223 min

*Y. S. Kim, J. H. Kim, H. Rhim, H. K. Lim, B. Keserci, D. S. Bae, B. G. Kim, J. W. Lee, T. J. Kim, and C. H. Choi, “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, pp. 600–609, May 2012.

**Note - as a teaching case, the therapy time was quite long. In addition the manipulation required for this case was extensive.
 T1-weighted, contrast-enhanced post-treatment sagittal image T1-weighted, contrast-enhanced post-treatment coronal image
T1-weighted, contrast-enhanced post-treatment sagittal image
T1-weighted, contrast-enhanced post-treatment coronal image

Results

Non-perfused volume (NPV) was 50% of total fibroid volume. NPV was calculated slice-by-slice from the T1-weighted contrast enhanced image acquired immediately following therapy.

Considerations and lessons learned

Bowel can be manipulated by bladder and rectal filling and/or emptying. In this particular case, patient manipulation took a very long time, mostly due to the teaching component of the case.

The one-layer strategy is not as effective for hypervascular fibroids, and in these cases a second layer should be considered. The second layer should be placed anterior and it's position based on possible cell size.

Peer-to-peer dialogue and training is a critical component of surmounting the learning curve of a new technique and may come in the form of on-site training, but also through case studies of other treating hospitals.



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.)

This content is intended for countries other than the USA.


This content has been made possible by NetForum Community.
Share this on: Share your link in twitter Share your link in facebook Share your link on LinkedIn Print Rate this article: Log in to vote

 
Rating:
Votes:
0
Views:
2445
Added:
Oct 7, 2013

Rate this:
Log in to vote
 

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

Clinical News
Best Practices
Case Studies
Publications and Abstracts
White Papers
Web seminars and Presentations
ExamCards
Protocols
Application Tips and FAQ
Training
Try an Application
Business News
Case Studies
White Papers
Web Seminars and Presentations
Utilization Services
Contributing Professionals
Contributing Institutions
Become a Contributor