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MR Imaging–guided Focused Ultrasound Surgery of Uterine Leiomyomas: A Feasibility Study¹

¹ From the Departments of Radiology (C.M.C.T., N.M., F.A.J., K.H.), Obstetrics and Gynecology (E.A.S.), and Pathology (B.J.Q.), Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115. From the 2001 RSNA scientific assembly. Received April 3, 2002; revision requested June 11; final revision received October 7; accepted October 14. Supported in part by National Institutes of Health Image-guided Therapy grant P01 CA 67165-06, National Institutes of Health grant CA 46627, and InSightec-TxSonics, Haifa, Israel. Address correspondence to C.M.C.T. (e-mail: ctempany@bwh.harvard.edu).

View larger version (76K): [in a new window]   Figure 1. Patient 2. Left: Side-view diagram of the focused ultrasound system and patient positioning. Right: Sagittal T2-weighted fast SE MR image (repetition time msec/echo time msec = 2,500/98) obtained with the patient in position for treatment.

View larger version (74K): [in a new window]   Figure 2. Patients 3 and 4. Transverse (left, patient 3) and sagittal (right, patient 4) T2-weighted fast SE MR images (2,500/98) with the patient in position for ultrasound surgery of uterine fibroids. In these cases, the transducer was angled during the treatment. The arrow on the right indicates the bowel loop that was avoided by angling the transducer.

View larger version (31K): [in a new window]   Figure 3. Patient 8. T2-weighted fast SE (5,000/200) MR images acquired in a plane perpendicular to the ultrasound beam are displayed in three dimensions. After volume segmentation with the three-dimensional software, the images were used to help segmentation of the fibroid (purple line). Contrast-enhanced SE (left; 550/14) and gradient-recalled-echo (right; 245/1.8) MR images were used to help segmentation of the nonenhancing volume (pink line). On the right, note the markedly irregular shape of the nonenhancing region (green).

View larger version (77K): [in a new window]   Figure 4. Patient 8.Treatment planning, monitoring, progression, and posttreatment follow-up. A, Coronal T2-weighted fast SE MR image (4,000/90) was used for treatment planning. Sonication locations and sizes (green lines) were determined with the system planning software from this prescription (and the tissue depth) and were displayed on top of the treatment plan. During treatment, the accumulated thermal dose (yellow area) was displayed on top of treatment planning images. Dose threshold of 240 equivalent minutes at 43°C is displayed. B, Sagittal T2-weighted MR image (2,500/98) shows treatment plan and area that achieved threshold thermal dose. C, D, Temperature-sensitive phase-difference fast spoiled gradient-recalled-echo MR images (39.9/19.7) were acquired at peak temperature increase during two sonications. C (coronal view) was acquired perpendicular to the direction of the ultrasound beam, while D (sagittal view) was acquired parallel to the direction of the beam. C and D were used to estimate the thermal dose (blue line) for each sonication. E, F, Images depict result of treatment. E, Sagittal contrast-enhanced gradient-recalled-echo MR image (245/1.8) was acquired 2 days after ultrasound surgery. Nonenhancing area (arrow) is seen clearly in F, which is a gross pathologic cut specimen that shows the central area of hemorrhagic necrosis.

View larger version (95K): [in a new window]   Figure 5. Patient 9. A, Planning coronal T2-weighted fast SE (4,000/90) MR image shows the treatment plan. Inset shows sagittal view. B, Gross specimen shows central necrosis after focused ultrasound treatment. Inset photomicrograph shows microscopic view of treated area, with microscopic hemorrhagic necrosis in the right corner. (Hematoxylin-eosin stain.) C, D, Contrast-enhanced MR images show central area (arrow) of nonenhancement. C, Sagittal gradient-recalled-echo MR image (195/1.8) was acquired 2 days after treatment. D, Transverse SE MR image (600/14) was acquired 2 days after treatment.

View larger version (19K): [in a new window]   Figure 6. Patient 8. Line graph depicts temperature measured at the focus for 23 sonications in one treatment. The focal temperature increase was sufficient to cause thermal damage in each case. The variation from location to location was significant. Error bars = SD, dotted line = baseline body temperature (37°C).