Alessandro Napoli MD, PhD - Congressi Medici a Genova

Alessandro Napoli MD, PhD
Department of Radiological and Oncological Sciences
Sapienza University of Rome
High Intensity Focused Ultrasound!
!
!
!
How does it work?!
- Principles!
- Accurate Location!
- Real Time Thermal Feedback!
- Improved Safety and Efficacy!
HIFU is an Image Guided Intervention!
- Ultrasound!
- Magnetic Resonance!
- Transcutaneous Coagulative Necrosis!
- Totally NON-INVASIVE!
- Radioactive Decontamination!
- Low complication rates!
MR-Guided High-Intensity Focused Ultrasound: Current Status!
of an Emerging Technology. A. Napoli et al, CVIR 2013!
MR guided focused ultrasound
combines
• High intensity focused ultrasound that heats and destroys
targeted tissue, non-invasively.
MR guided focused ultrasound
combines
• High intensity focused ultrasound that heats and destroys
targeted tissue, non-invasively.
Archimedes of Syracuse (Sicily 287-212 BC)
High intensity focused ultrasound that heats and
destroys targeted tissue, non-invasively.
MR Guidance and Control
IDENTIFICATION
THERMOMETRY and
EFFICACY ANALYSIS
PLANNING
Treatment
Uterinemyomas,asbenigntumours,can
generallybemanagedexpectantlyunlessthey
causesymptoms.
•  Surgicaltherapy
•  Hysterectomy
•  Myomectomy
(Abdominal,Laparo,Hystero)
•  Uterine-arteryembolisa>on
•  Medicaltherapy
Futuredirec.ons
•  nofuturechild-bearingplans
•  <50%treatmentfibroidvolume
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
Relevancetosymptoms
Fibroidtype
Fibroidsize
Distancefromtheskin
Fibroidnumber
Distancefromsacralbonesurface
Obstaclestotheultrasoundbeampath
Fibroidvascularity
Adenomyosis
Malignancy
•  EligiblePaJents
•  PersonalExperience
CONTRAINDICATIONS:
ü  Weight>115Kg
ü  ConcomitantDisease
ü  Contraindica.onstoMR
ü  Pregnancy
ü  AbdominalScar(es.laparotomy)
ü  PeduncolatedFibroids
SYMPTOMSEVALUATION:
ü Menorrhagia
ü Dismenorrhagia
ü Dispareunia
ü Bulksymtomsofpressure
ü Urinaryfrequency
ü Pelvicpain
ü Infer.lity
ü Difficultytostart
andtomaintainpregnancy
ELEGIBILITYCRITERIA
PelvicMRIscanw/c
Pre-TreatmentScreening
localiza.on,size,number,accessibility,
structureandvascularity
STRUCTURE
HYPERINTENSE UF ARE LESS FAVORABLE TO TREATMENT AS THEY
TEND TO ABSORB LESS FOCUSED US ENERGY
HuangJetal.JAcoustSocAm2004
ACCESSIBILITY
Non devono essere presenti anse
intestinali davanti al fascio di
ultrasuoni in quanto contengono aria
o particelle che assorbono energia.
•  EligiblePaJents
•  PersonalExperience
♀30yo,pelvicpain
T2wT2w
T1wpost-mdc
T1wpost-mdc
Treatment:
ValutazionePre-Tra]amento:
RectalgeltomoveanteriorlytheuterusbodyandliUsuperiorlytheintesJne
Uteroretroverso
AnsedelpiccolointesJnointerpostetrapareteaddominaleedutero
Post-treatmentMRcontroldemonstrateshighNPV
FibromaipointensonellesequenzeT2evascolarizzato
FOLLOWUP:
6 cm
Pre-treatment
5 cm
6-mosfu
3.9 cm
12-mosfu
UAEvsMRgFUS
NecrosisRaJoArea:
•  UAE78-98%
•  MRgFUS40-50%
Re-intervenJonRate:
•  UAE(2/30,6.7%),nopregnancies
•  MRgFUS(15/50,30%)10pregnancies;7vaginaldeliver
RESULTS
JULY2010–JAN2015
245TreatedPa.ents
• 
• 
• 
• 
Necrosis>70%
SymptomsImprovement
Pregnancy
VolumeReduc>on
♀28yo,pelvicpainandabdominaltension
T2w
T1wpost-mdc
59 mm
Post-Tx
FOLLOWUP…
49 mm
…6mos
40 mm
…12mos
245TreatedPa.ents
OUTCOME
ü QuickSymptomsRelief(96%)
ü VariableVolumeReduc.on
ü 29Pregnancies
♀44annicondolorepelvicoemenorragia
FOLLOWUPat6months:
♀48yo,symptoma.cpa.ent
Jan2013
78 mm
Post-Tx
FOLLOWUP
60 mm
June2013
50 mm
Jan2014
•  HIGHLYSELECTIVETX
•  REALTIME3DTREATMENTMONITOR
•  TOTALLYNON-INVASIVE
•  SPAREDADJACENTSTRUCTURES–LowcomplicaJonsrate
•  NOANESTHESIA–NOHOSPITALNIGHT–DH
♀46yo,Menorragiaandanemia
T2
UF2V2
T1FSconmdc
NPVdel90%
6mosFOLLOWUPnot
performedduetosurgery
♀34yo
Menorragiaandpain
T1postmdc
T2w
52mm
FOLLOWUP
6mos
v Symptoms
Improvement
v Painfree
v VolumeReduc.on:
10%
T1postmdc
T2w
47mm
1yearFOLLOWUPnot
performedduetopregnancy
RMpre-treatment
Followupat12months:13.09.2013
NOWPREGNANT!!!!
♀29anni,sensodipesoemenorragia
T2
T1post-tra]amento
T2
T1post-mdc
NPVdel70%
3mosfollow-up
245TreatedPa.ents
ADVERSEVENTS
ü 2SKINBURN
(1moderate,1selfresolving)
ü 1rectalinflamma.on
ü 1Scia.cnervestupor(3mos)
ü 8myomectomy
At12months,fibroidsizedecreased
28.4%indiameter
45.9%involume
Alltreatedpa.ents
significantreducJonoffibroid-relatedsymptoms
bemerqualityoflife
NapoliAetal;CardiovascInterventRadiol2013
SignificantImprovementofQoLinmostcases
akerMRgFUS
TherisnotonebesttreatmentopJonbecauseoffibroidsheterogeneity
Thechoiceoffibroidtreatmentisdependentonsymptoms,locaJon,burden,cost,
paJentpreference,andqualityoflifeimplicaJons.
Expressedintermsofdollarsperquality-adjustedlife-years,cost-uJlityanalysis
definesthebesttreatmentopJonasthatwhichgainsthemostquality-adjusted
life-yearswiththeleastcost.
Quality-adjustedlife-yearsaresubjecJveandarebasedonapaJent’spreference
forstatesofhealth.
FennessyFMetal.;Radiology2011
Adenomyosis
MR-Guided High-Intensity Focused Ultrasound: Current Status of an Emerging Technology
-
Napoli A. et al. - CVIR, 2013
Fer.lityData
• Numerototaledigravidanzeosservate=54
(51paJents)
• Etàcompresatra28-49anni(media=37)
• Gravidanzeportateatermine=22(41%)
–  Pesomedioneonatoallanascita:3.4kg
• 11womensJllpregnant
• Remainder(21)elecJve(13%)or
portateatermineconpartonaturale(26%)
RabinoviciJetal;Fer>lityandSterility,2008Nov13.
LIMITATIONS
• TreatmentTimeasafuncJonofFibroidSize
• PerformedinahighlyselectedpaJentpopulaJon
• ConsciousSedaJon,urinarycatheterandrectalgel
TakeHomePoints
•  HighlyPrecise
•  Totallynon-invasive
•  Symptomsandvolumereduc.on
•  Fer.lityFriendly
•  NosignificantAEs
•  DHprocedure,nohosp.taliza.onnoranesthesia
•  Costy procedure but with costs and complica.ons far
lowerthanothertechniques
•  Repea.ble
www.fibromi-uterini.it
www.alessandronapoli.it
IDEALPATHWAY
SYMPTOMATICIM-SMUF
PelvicMRIscan
MulJdisciplinary
DesireforconservaJvetreatment+
EvaluaJon
MRcriteria
MRgFUS(20/30%)
UAE(20/30%)
SURGERY(40/60%)
www.fibromi-uterini.it
www.alessandronapoli.it
Grazie!