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Intrapleural Fluid Infusion for MR-Guided High-Intensity Focused Ultrasound Ablation in the Liver Dome

Posted Nov 30, 2014 Updated Apr 10, 2023
By Joost W. Wijlemans MD , Martijn de Greef PhD , Gerald Schubert PhD , Chrit T.W. Moonen PhD , Maurice A.A.J. van den Bosch MD PhD , Mario Ries PhD
8 min read

Rationale and Objectives

Magnetic resonance–guided high-intensity focused ultrasound (MR-HIFU) ablation of tumors in the liver dome is challenging because of the presence of air in the costophrenic angle. In this study, we used a porcine liver model and a clinical MR-HIFU system to assess the feasibility and safety of using intrapleural fluid infusion (IPI) to create an acoustic window for MR-HIFU ablation in the liver dome.

Materials and Methods

Healthy adult Dalland land pigs ( n = 6) under general anesthesia were used with animal committee approval. Degassed saline (200–800 mL) was infused into the intrapleural space under ultrasound guidance. A clinical 1.5-T MR-HIFU system was used to perform sonications (4-mm treatment cells, 300–450 W, 20–30 seconds) in the liver dome under real-time MR thermometry. An intercostal firing technique was used to prevent rib heating in one experiment. Technical success was defined as a temperature increase (>10°C) in the target area. After termination, the animal was examined for thermal damage to liver, diaphragm, pleura, lung, or intercostal muscle.

Results

An acoustic window was established in all animals. A temperature increase in the target area was achieved in all animals (max. 47°C–67°C). MR thermometry showed no heating outside the target area. Intercostal firing effectively reduced rib heating (55°C vs. 42°C). Postmortem examination revealed no unwanted thermal damage. One complication occurred, in the first experiment, because of an ill-suited needle (displacement of the needle).

Conclusions

The results indicate that IPI may be used safely to assist MR-HIFU ablation of tumors in the liver dome. For reliable tissue coagulation, IPI must be combined with an intercostal sonication technique. Considering the proportion of patients with tumors in the liver dome, IPI widens the applicability of MR-HIFU ablation for liver tumors considerably.

Magnetic resonance–guided high-intensity focused ultrasound (MR-HIFU) is an image-guided, noninvasive, thermal ablation technique which allows for precisely targeted tumor ablation while sparing the surrounding healthy tissue. The MR guidance provides near real-time image guidance and temperature feedback during ablation . MR-HIFU is used clinically for the treatment of uterine fibroids and bone metastases and is currently under investigation for several other oncologic applications such as ablation of prostate, pancreas, breast, and liver tumors and for targeted drug delivery .

For clinical implementation of MR-HIFU ablation of liver tumors, several organ-specific challenges have to be overcome . One of these challenges is the fact that the lung overlaps the liver dome, which is the cranial subdiaphragmatic part of the liver in the costophrenic angle (or costodiaphragmatic recess). This air–tissue interface forms an impassable barrier for the ultrasound beam, preventing ablation of tumors in the liver dome. To overcome this challenge, the use of intrapleural fluid infusion (IPI) has been proposed. This creates an acoustic window by infusing fluid into the costophrenic angle. This strategy has been reported for low-intensity diagnostic ultrasound guidance of percutaneous ablation procedures in the liver dome (eg, during radiofrequency [RF] ablation) . The use of IPI in combination with ultrasound-guided HIFU has been reported; however, to the best of our knowledge, no studies have been reported which were dedicated to the IPI technique, in particular not with real-time MR thermometry .

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Materials and methods

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Results

Intrapleural Fluid Infusion

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Table 1

Overview of the Experiments

Animal Infused Fluid Volume Needle Complications Acoustic Window Respiratory Compensation Intercostal Firing Technique Number of Sonications Distance Focal Point—Diaphragm, mm Peak Temperature Animal 1 ∼200 mL Venous catheter Fluid in intercostal muscle Sufficient Breath hold No 6 8 67°C Animal 2 ∼750 mL Veress No Good Breath hold No 4 5 65°C Animal 3 ∼800 mL Veress No Good Breath hold No 6 7 47°C ∗ Animal 4 ∼800 mL Veress No Good Respiratory gated No 7 4 55°C Animal 5 ∼800 mL Veress No Good Respiratory gated No 4 6 62°C Animal 6 ∼700 mL Veress No Good Respiratory gated Yes 4 11 59°C

The quality of the acoustic window depended mostly on displacement of the right lower lung lobe.

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Figure 1, Coronal T 2 -weighted magnetic resonance imaging of the liver. The saline in the intrapleural space can be easily identified. The lower edge of the right lung ( black arrow ) is displaced from its anatomic position in the costophrenic angle ( white arrow ). This creates an acoustic window to the liver dome.

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MR-HIFU Procedures

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Figure 2, The temperature evolution in the target area during ablation of a representative treatment cell.

Figure 3, A coronal T 2 -weighted image with magnetic resonance thermometry color overlay. The yellow lines represent the high-intensity focused ultrasound beam path. Image from animal 5 at peak temperature. For this experiment, no intercostal firing technique was used; therefore, significant heating of the ribs in the beam path can be seen. Also, note the displaced right lung tip ( black arrow ). (Color version of figure is available online.)

Figure 4, The near-field monitoring slices positioned in the thoracic wall for monitoring rib and intercostal muscle heating. The yellow circle represents the location where the ultrasound beam traverses the abdominal wall. (a) Peak near-field heating during normal sonication (ie, all transducer elements active). (b) Peak near-field heating after selective transducer element shutoff of the elements that are blocked by the ribs. (Color version of figure is available online.)

Figure 5, Coronal macroscopic histology slice of the liver dome, showing coagulation necrosis surrounded by hemorrhaging ( arrow ). Note that the hepatic capsule has not been damaged, despite the superficial location of the ablation volume.

Figure 6, Hematoxylin and eosin–stained histology slide of the coagulation necrosis in animal 2. Note that the lesions extend toward the hepatic capsule, which shows no damage.

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Discussion

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Academic Radiology, Volume 21, Issue 12
Journals General Radiology
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