495 research outputs found

    Radiofrequency ablation of small liver malignancies under magnetic resonance guidance: progress in targeting and preliminary observations with temperature monitoring

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    Objectives: To evaluate the feasibility and effectiveness of magnetic resonance (MR)-guided radiofrequency (RF) ablation for small liver tumours with poor conspicuity on both contrast-enhanced ultrasonography (US) and computed tomography (CT), using fast navigation and temperature monitoring. Methods: Sixteen malignant liver nodules (long-axis diameter, 0.6-2.4cm) were treated with multipolar RF ablation on a 1.5-T wide-bore MR system in ten patients. Targeting was performed interactively, using a fast steady-state free precession sequence. Real-time MR-based temperature mapping was performed, using gradient echo-echo planar imaging (GRE-EPI) and hardware filtering. MR-specific treatment data were recorded. The mean follow-up time was 19 ± 7months. Results: Correct placement of RF electrodes was obtained in all procedures (image update, <500ms; mean targeting time, 21 ± 11min). MR thermometry was available for 14 of 16 nodules (88%) with an accuracy of 1.6°C in a non-heated region. No correlation was found between the size of the lethal thermal dose and the ablation zone at follow-up imaging. The primary and secondary effectiveness rates were 100% and 91%, respectively. Conclusions: RF ablation of small liver tumours can be planned, targeted, monitored and controlled with MR imaging within acceptable procedure times. Temperature mapping is technically feasible, but the clinical benefit remains to be prove

    High-Frequency Rapid B-Mode Ultrasound Imaging for Real-Time Monitoring of Lesion Formation and Gas Body Activity During High-Intensity Focused Ultrasound Ablation

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    Abstract: The goal of this study was to examine the ability of high-frame-rate, high-resolution imaging to monitor tissue necrosis and gas-body activities formed during high-intensity focused ultrasound (HIFU) application. Ex vivo porcine cardiac tissue specimens (n = 24) were treated with HIFU exposure (4.33 MHz, 77 to 130 Hz pulse repetition frequency (PRF), 25 to 50% duty cycle, 0.2 to 1 s, 2600 W/cm2). RF data from Bmode ultrasound imaging were obtained before, during, and after HIFU exposure at a frame rate ranging from 77 to 130 Hz using an ultrasound imaging system with a center frequency of 55 MHz. The time history of changes in the integrated backscatter (IBS), calibrated spectral parameters, and echo-decorrelation parameters of the RF data were assessed for lesion identification by comparison against gross sections. Temporal maximum IBS with +12 dB threshold achieved the best identification with a receiver-operating characteristic (ROC) curve area of 0.96. Frame-to-frame echo decorrelation identified and tracked transient gas-body activities. Macroscopic (millimetersized) cavities formed when the estimated initial expansion rate of gas bodies (rate of expansion in lateral-to-beam direction) crossed 0.8 mm/s. Together, these assessments provide a method for monitoring spatiotemporal evolution of lesion and gas-body activity and for predicting macroscopic cavity formation

    Minimally invasive image-guided therapy for inoperable hepatocellular carcinoma: What is the evidence today?

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    Hepatocellular carcinoma (HCC) is a primary malignant tumor of the liver that accounts for an important health problem worldwide. Only 10–15% of HCC patients are suitable candidates for hepatic resection and liver transplantation due to the advanced stage of the disease at time of diagnosis and shortage of donors. Therefore, several minimally invasive image-guided therapies for locoregional treatment have been developed. Tumor ablative techniques are either based on thermal tumor destruction, as in radiofrequency ablation, cryoablation, microwave ablation, laser ablation and high-intensity focused ultrasound, or chemical tumor destruction, as in percutaneous ethanol injection. Image-guided catheter-based techniques rely on intra-arterial delivery of embolic, chemoembolic or radioembolic agents. These minimally invasive image-guided therapies have revolutionized the management of inoperable HCC. This review provides a description of all minimally invasive image-guided therapies currently available, an up-to-date overview of the scientific evidence for their clinical use, and thoughts for future directions

    The clinical effectiveness and cost-effectiveness of ablative therapies in the management of liver metastases: systematic review and economic evaluation

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    Background: Many deaths from cancer are caused by metastatic burden. Prognosis and survival rates vary, but survival beyond 5 years of patients with untreated metastatic disease in the liver is rare. Treatment for liver metastases has largely been surgical resection, but this is feasible in only approximately 20–30% of people. Non-surgical alternatives to treat some liver metastases can include various forms of ablative therapies and other targeted treatments.Objectives: To evaluate the clinical effectiveness and cost-effectiveness of the different ablative and minimally invasive therapies for treating liver metastases.Data sources: Electronic databases including MEDLINE, EMBASE and The Cochrane Library were searched from 1990 to September 2011. Experts were consulted and bibliographies checked.Review methods: Systematic reviews of the literature were undertaken to appraise the clinical effectiveness and cost-effectiveness of ablative therapies and minimally invasive therapies used for people with liver metastases. Studies were any prospective study with sample size greater than 100 participants. A probabilistic model was developed for the economic evaluation of the technologies where data permitted.Results: The evidence assessing the clinical effectiveness and cost-effectiveness of ablative and other minimally invasive therapies was limited. Nine studies of ablative therapies were included in the review; each had methodological shortcomings and few had a comparator group. One randomised controlled trial (RCT) of microwave ablation versus surgical resection was identified and showed no improvement in outcomes compared with resection. In two prospective case series studies that investigated the use of laser ablation, mean survival ranged from 41 to 58 months. One cohort study compared radiofrequency ablation with surgical resection and five case series studies also investigated the use of radiofrequency ablation. Across these studies the median survival ranged from 44 to 52 months. Seven studies of minimally invasive therapies were included in the review. Two RCTs compared chemoembolisation with chemotherapy only. Overall survival was not compared between groups and methodological shortcomings mean that conclusions are difficult to make. Two case series studies of laser ablation following chemoembolisation were also included; however, these provide little evidence of the use of these technologies in combination. Three RCTs of radioembolisation were included. Significant improvements in tumour response and time to disease progression were demonstrated; however, benefits in terms of survival were equivocal. An exploratory survival model was developed using data from the review of clinical effectiveness. The model includes separate analyses of microwave ablation compared with surgery and radiofrequency ablation compared with surgery and one of radioembolisation in conjunction with hepatic artery chemotherapy compared with hepatic artery chemotherapy alone. Microwave ablation was associated with an incremental cost-effectiveness ratio (ICER) of £3664 per quality-adjusted life-year (QALY) gained, with microwave ablation being associated with reduced cost but also with poorer outcome than surgery. Radiofrequency ablation compared with surgical resection for solitary metastases &lt; 3 cm was associated with an ICER of –£266,767 per QALY gained, indicating that radiofrequency ablation dominates surgical resection. Radiofrequency ablation compared with surgical resection for solitary metastases ? 3 cm resulted in poorer outcomes at lower costs and a resultant ICER of £2538 per QALY gained. Radioembolisation plus hepatic artery chemotherapy compared with hepatic artery chemotherapy was associated with an ICER of £37,303 per QALY gained.Conclusions: There is currently limited high-quality research evidence upon which to base any firm decisions regarding ablative therapies for liver metastases. Further trials should compare ablative therapies with surgery, in particular. A RCT would provide the most appropriate design for undertaking any further evaluation and should include a full economic evaluation, but the group to be randomised needs careful selection.Source of funding: Funding for this study was provided by the Health Technology Assessment programme of the National Institute for Health Research

    Quantitative Analysis of Radiation-Associated Parenchymal Lung Change

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    Radiation-induced lung damage (RILD) is a common consequence of thoracic radiotherapy (RT). We present here a novel classification of the parenchymal features of RILD. We developed a deep learning algorithm (DLA) to automate the delineation of 5 classes of parenchymal texture of increasing density. 200 scans were used to train and validate the network and the remaining 30 scans were used as a hold-out test set. The DLA automatically labelled the data with Dice Scores of 0.98, 0.43, 0.26, 0.47 and 0.92 for the 5 respective classes. Qualitative evaluation showed that the automated labels were acceptable in over 80% of cases for all tissue classes, and achieved similar ratings to the manual labels. Lung registration was performed and the effect of radiation dose on each tissue class and correlation with respiratory outcomes was assessed. The change in volume of each tissue class over time generated by manual and automated segmentation was calculated. The 5 parenchymal classes showed distinct temporal patterns We quantified the volumetric change in textures after radiotherapy and correlate these with radiotherapy dose and respiratory outcomes. The effect of local dose on tissue class revealed a strong dose-dependent relationship We have developed a novel classification of parenchymal changes associated with RILD that show a convincing dose relationship. The tissue classes are related to both global and local dose metrics, and have a distinct evolution over time. Although less strong, there is a relationship between the radiological texture changes we can measure and respiratory outcomes, particularly the MRC score which directly represents a patient’s functional status. We have demonstrated the potential of using our approach to analyse and understand the morphological and functional evolution of RILD in greater detail than previously possible

    Quality assurance guidelines for interstitial hyperthermia

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    Quality assurance (QA) guidelines are essential to provide uniform execution of clinical hyperthermia treatments and trials. This document outlines the clinical and technical consequences of the specific properties of interstitial heat delivery and specifies recommendations for hyperthermia administration with interstitial techniques. Interstitial hyperthermia aims at tumor temperatures in the 40–44 \ub0C range as an adjunct to radiation or chemotherapy. The clinical part of this document imparts specific clinical experience of interstitial heat delivery to various tumor sites as well as recommended interstitial hyperthermia workflow and procedures. The second part describes technical requirements for quality assurance of current interstitial heating equipment including electromagnetic (radiative and capacitive) and ultrasound heating techniques. Detailed instructions are provided on characterization and documentation of the performance of interstitial hyperthermia applicators to achieve reproducible hyperthermia treatments of uniform high quality. Output power and consequent temperature rise are the key parameters for characterization of applicator performance in these QA guidelines. These characteristics determine the specific maximum tumor size and depth that can be heated adequately. The guidelines were developed by the ESHO Technical Committee with participation of senior STM members and members of the Atzelsberg Circle

    Utility of Monophasic Action Potentials in the Diagnosis and Treatment of Cardiac Arrhythmias

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    University of Minnesota Ph.D. dissertation. 2018. Major: Biomedical Engineering. Advisor: Paul Iaizzo. 1 computer file (PDF); 165 pages.The object of this thesis was to investigate applications for monophasic action potential (MAP) recordings in the diagnosis and treatment of cardiac arrhythmias. To meet this objective, MAPs were measured in situ and in vitro, during sinus rhythm and cardiac arrhythmias. MAPs were analyzed for potential clinical applications and in novel cardiac mapping and ablation catheter concepts. MAPs are focal action potential recordings which are directly proportional to the electrical activities of cells adjacent to a contacting electrode. When sufficient force is applied between a contacting electrode and the myocardium, the cells directly beneath become mechanically depolarized; i.e. electrically inactive. As a transmembrane action potential passes through this region, a change in boundary currents between the active and inactive cells, via gap junctions, results in a waveform that is proportional to the original action potential. The Visible Heart® Apparatus provides us with the ability to study large mammalian hearts, including human, in an in vitro setting; allowing the testing of prototype catheter concepts prior to in situ or in vivo work. To validate MAPs from an in vitro working heart model a comparison study was conducted. Over the course of 2 hours in situ and 2 hours in vitro MAPs were recorded from the right atrium, left atrium, and right ventricle (endocardially and epicardially). Overall, there were no significant differences between recorded signals when compared to in situ baseline recordings. Based on these findings, systems like the Visible Heart® Apparatus can be used as a platform on which cardiac action potentials can be studied. The clinical application of MAP recordings, as they pertain to radiofrequency (RF) ablations, was also evaluated. To ensure proper lesion formation, RF ablation requires a catheter contact force (CF) of between 10-20 grams to be maintained throughout energy delivery. It was determined that MAP waveforms could only be recorded when at least 10-15 grams of CF was applied to the myocardium. In other words, the presence of MAP waveforms would indicate that sufficient CF has been applied prior to the delivery of RF energy. Additionally, MAP waveforms were found to correlate with RF lesion size. MAP amplitudes at baseline (pre-ablation) were significantly larger than amplitudes from lesions which matured to greater than 1 mm deep. MAPs were also able to distinguish between lesions between 1-2mm deep, and those deeper than 2mm. Moving forward, MAPs may be used in evaluating cardiac viability, both through recording from induced lesions, as well as in regions of scarred or ischemic myocardium

    Spectral Ultrasound Characterization of Tissues and Tissue Engineered Constructs.

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    Even though ultrasound imaging is widely used in clinical diagnosis and image-guided interventions, the field is far behind other areas of clinical quantitative image analysis, such as MRI, CT and X-ray mammography. In this thesis, non-destructive and non-invasive ultrasound characterization techniques were developed to study the tissue micro-structural details using high frequency spectral ultrasound imaging (SUSI). The techniques were explored in in-vitro conditions of acellular and cellular tissue engineered constructs and then on ex-vivo tissues for their characterization. SUSI was used to assess the amount of hydroxyl-apatite (HA) mineral, differentiate HA mineral types and study their distribution in acellular tissue engineered constructs. The process of mineral deposition from surrounding mineralizing media onto simple collagen constructs was also studied and characterized with SUSI. 3D morphological changes of the constructs with MC3t3 cells was monitored and characterized for the developmental changes such as net cell proliferation/apoptosis and cell differentiation process through mineral production by the early osteoblastic MC3t3-cell constructs in-situ. A novel method was introduced using SUSI to estimate the amount of mineral secreted by the differentiated osteoblast cells in a non-destructive method. Then, SUSI was investigated in ex-vivo cardiac tissues to monitor and characterize the cellular changes during high-intensity focused ultrasound ablation with high-frame-rate and high-resolution ultrasound imaging. The mechanistic hypotheses behind the improvement in lesion detection were investigated and best identification methods to assess lesion formation and transient gas body activities were proposed to provide a method for visualizing spatiotemporal evolution of lesion and gas–body activity and for predicting macroscopic cavity formation upon its implementation as a real-time monitoring technique with feedback control system for HIFU treatment of atrial fibrillation to improve the ablation process. Even though the results from the developed techniques show great promise in in-vitro and ex-vivo settings, additional work needs to be carried out to demonstrate the applicability of the techniques in in-vivo.PHDBiomedical EngineeringUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/99788/1/msreddy_1.pd

    New insights in atrial fibrillation mechanisms, electrogram analysis and alternative therapeutic approaches

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    En la presente tesis se intentan evaluar aspectos importantes referentes al manejo integral de los pacientes con fibrilación auricular, desde aspectos mecanísticos (en concreto el papel del la apnea del sueño en el desarrollo y mantenimiento de la FA) hasta técnicos, relativos a la hora de mapeo de la FA durante el procedimiento de ablación (rentabilidad de los algoritmos automáticos de detección de actividad rotacional y focal además del análisis detallado de los mapas de voltaje en función del ritmo subyacente). Finalmente se presenta el primer atlas del sistema venoso auricular imprescindible con "estrategias de rescate" tales como la ablación alcohólica de la fibrilación auricular
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