Year-Old with Flank Pain / MR-Guided Focused Ultrasound Ablation
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1 May 2005 A 52-Year Year-Old with Flank Pain / MR-Guided Focused Ultrasound Ablation Jai Eswara,, Harvard Medical School, Year III
2 Agenda Patient Presentation Differential Diagnosis Anatomy Discussion MR-Guided Focused Ultrasound Ablative Therapy 2
3 Patient Presentation J.F. is a 52-year year-old man with acute onset of right flank pain after moving heavy furniture No CVAT Rectal exam benign Normal urinalysis Guaiac negative 3
4 Differential Diagnosis Renal/vascular Abscess/pyelonephritis Infarction Thrombosis Nephrolithiasis Tumor Aorta AAA Radicular/musculoskeletal A CT Urogram was ordered 4
5 Low-dose CT Urogram w/o IV contrast PACS, BIDMC 5
6 CT Urogram w/ IV contrast Subcapsular hematoma PACS, BIDMC 6
7 Differential Diagnosis after CT Angiomyolipoma Renal Cell Carcinoma 7
8 Renal Angiomyolipoma Hamartoma muscle, vasc, fat 8
9 CT w/ IV contrast No fat visible in mass PACS, BIDMC 9
10 T1-Weighted Axial MR No fat visible in mass PACS, BIDMC 10
11 Coronal SSFSE/HASTE MR Hematoma beginning to organize PACS, BIDMC 11
12 Sagittal LAVA MR Midpolar mass - Indication for radical nephrectomy Identified on pathology as a papillary RCC PACS, BIDMC 12
13 Renal Anatomy 13
14 Types of Renal Cell Carcinoma Clear cell (80%) Papillary (15%) Chromophobic (5%) 14
15 Staging Renal Cell Carcinoma TNM classification T1 - mass < 7cm T2 - mass > 7cm T3 - mass extends into major veins, fat, or adrenal gland T4 - mass extends beyond Gerota s fascia 15
16 Spontaneous Rupture of Papillary RCC Extensive necrosis in tumor leads to rupture Necrosis can appear cystic on CT or U/S prcc s are FRAGILE! Approximately 10% may rupture Hora M, Hes O, Klecka J, Boudova L, Chudacek Z, Kreuzberg B, Michal M. Rupture of papillary renal cell carcinoma. Scand J Urol Nephrol. 2004;38(6):
17 MR-Guided Focused Ultrasound 17
18 Focusing Ultrasound Waves Ultrasound beams may be focused by curving the piezoelectric plate or by interposing a lens or reflector between a flat plate and the target. A phased array of transducers is focused electronically. 18
19 How does focused U/S destroy tissue? As waves interact with tissue, they transfer energy U/S causes gas bubbles to form within tissue Collapse of the gas bubbles transfers heat to nearby tissue ( cavitation cavitation ) 19
20 Thermal Ablation of Tissue Protein coagulation and consequent tissue damage result from a combination of temperature elevation and exposure duration. The graph shows the relationship between these factors. 20
21 MRI Planning/Monitoring of Thermal Ablation 21
22 Advantages of MRGFUS Noninvasive No ionizing radiation Fast energy delivery MR is temperature-sensitive: T1, diffusion coefficient, proton resonant frequency Thermal quantification Target can be as small as 2 mm in diameter 22
23 Disadvantages of MRGFUS U/S is blocked by & 23
24 Disadvantages of MRGFUS U/S is blocked by air & bone slow 24
25 MR Detection of Thermal Changes A temperaturesensitive magnetic resonance image along the transducer axis shows focal temperature elevation (arrow) induced by an ultrasound pulse in rabbit thigh muscle in vivo. The scale is in centimeters. 25
26 MR Detection of Thermal Changes in Tissue 26
27 Post-Mortem Rabbit Kidney After FUS 27
28 The Future of MRGFUS Improvement in speed Optimizing MRI parameters Developing MRI-compatible devices 28
29 References 1. Curti BD. Renal cell carcinoma. JAMA 2004; 292: Focused ultrasound Laboratory.Brigham & Women s Hospital / Harvard Medical School Online. Internet Hora M, Hes O, Klecka J, Boudova L, Chudacek Z, Kreuzberg B, Michal M. Rupture of papillary renal cell carcinoma. Scand J Urol Nephrol. 2004;38(6): Hynynen K. Focused ultrasound surgery guided by MRI. Science & Medicine Online. Internet < 5. Kennedy JE, High-intensity focused ultrasound in the treatment of solid tumours. Nat Rev Canc 2005; 5: Shvarts O, Lam JS, Kim HL, Belldegrun AS. Staging of renal cell carcinoma: current concepts. BJU Int Mar;95 Suppl 2: Wu F, Wang Z, Chen W-Z, Bai J, Zhu H, Qiao T-Y. Preliminary experience using high intensity focused ultrasound for the treatment of patients with advanced renal malignancy. J Urol 2003; 170: Yoshimitsu K, et al. MR imaging of renal cell carcinoma: It s role in determining cell type. Radiation Medicine 2004; 22:
30 Acknowledgements Jason Handwerker, MD Larry Barbaras Pamela Lepkowski 30
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