MRI Guided Cryoablations of Liver and Kidney Tumors

Cryoablation, also called cryotherapy, is defined as therapeutic tissue destruction by freezing. It is a minimally invasive (percutaneous) thermal ablation technique that can treat kidney, bone, liver, lung, adrenal, and prostate lesions. It is particularly useful in treating tumors near critical structures. The visibility of the iceball intra-procedurally under MRI-guidance is a significant advantage of this technique.

Cryoablation in AMIGO is performed using an argon gas-based system (CryoHit, Galil Medical, Arden Hills, MN). Under MRI-guidance, 17-gauge cryoablation probes are placed by an attending interventional radiologist with the assistance of a clinical fellow-in-training. MRI scans are performed during each of four phases of the procedure: planning, targeting, monitoring, and survey.

MRI Guided Cryoablation Workflow in AMIGO

Planning. An initial planning MRI scan of the tumor is obtained. This scan allows the interventional radiologist to choose how many probes will be used and where to enter.
Planning. The number and positions of the probes are chosen based on the size of the tumor so that the resultant iceball will encompass the tumor plus a minimum 5-10 mm margin all around. Here, you can see different probes and their iceball sizes. No argon leaves the probe; it is confined in the probe and becomes extremely cold so as to generate the iceball.
Targeting. Targeting phase of placing four probes. Freezing begins only after probes are placed in ideal locations using MR guidance.
Targeting. Multiple MRI scans are taken during the targeting phase to assure proper location of the probes in the tumor and with the cryoprobes, ideally, approximately 1.5 cm apart.
Monitoring. In the monitoring phase, cryoablation probes are activated simultaneously. The iceball generated during cryoablation will appear as a signal void (black in color) under MRI-guidance. Monitoring is used to confirm that the iceball has encompassed the tumor plus a margin. If necessary, a lower power can be used to prevent damage to adjacent critical structures.
Monitoring: Iceball formation. The cryoablation protocol consists of a 15-minute freeze (argon gas), followed by a 10-minute thaw (helium gas), followed by a second 15-minute freeze.
Monitoring.
1) Intracellular ice → Cell membrane rupture
2) Extracellular ice → Cellular dehydration (thaw)
3) Vascular stasis → Local tissue ischemia.
Formation. Iceball is monitored by MRI scans. Scans are made every 3 minutes during each freeze to watch the iceball grow and assess nearby critical structures.
Formation. Upon completion of the cryoablation protocol, the probes are removed and a final MRI scan acquired to survey the ablation site for possible complications.

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Naoyuki Shono, Brian Ninni, Franklin King, Takahisa Kato, Junichi Tokuda, Takahiro Fujimoto, Kemal Tuncali, and Nobuhiko Hata. 6/2020. “Simulated Accuracy Assessment of Small Footprint Body-mounted Probe Alignment Device for MRI-guided Cryotherapy of Abdominal Lesions.” Med Phys, 47, 6, Pp. 2337-49.Abstract
PURPOSE: Magnetic resonance imaging (MRI)-guided percutaneous cryotherapy of abdominal lesions, an established procedure, uses MRI to guide and monitor the cryoablation of lesions. Methods to precisely guide cryotherapy probes with a minimum amount of trial-and-error are yet to be established. To aid physicians in attaining precise probe alignment without trial-and-error, a body-mounted motorized cryotherapy-probe alignment device (BMCPAD) with motion compensation was clinically tested in this study. The study also compared the contribution of body motion and organ motion compensation to the guidance accuracy of a body-mounted probe alignment device. METHODS: The accuracy of guidance using the BMCPAD was prospectively measured during MRI-guided percutaneous cryotherapies before insertion of the probes. Clinical parameters including patient age, types of anesthesia, depths of the target, and organ sites of target were collected. By using MR images of the target organs and fiducial markers embedded in the BMCPAD, we retrospectively simulated the guidance accuracy with body motion compensation, organ motion compensation, and no compensation. The collected data were analyzed to test the impact of motion compensation on the guidance accuracy. RESULTS: Thirty-seven physical guidance of probes were prospectively recorded for sixteen completed cases. The accuracy of physical guidance using the BMCPAD was 13.4 ± 11.1 mm. The simulated accuracy of guidance with body motion compensation, organ motion compensation, and no compensation was 2.4 ± 2.9 mm, 2.2 ± 1.6 mm, and 3.5 ± 2.9 mm, respectively. Data analysis revealed that the body motion compensation and organ motion compensation individually impacted the improvement in the accuracy of simulated guidance. Moreover, the difference in the accuracy of guidance either by body motion compensation or organ motion compensation was not statistically significant. The major clinical parameters impacting the accuracy of guidance were the body and organ motions. Patient age, types of anesthesia, depths of the target, and organ sites of target did not influence the accuracy of guidance using BMCPAD. The magnitude of body surface movement and organ movement exhibited mutual statistical correlation. CONCLUSIONS: The BMCPAD demonstrated guidance accuracy comparable to that of previously reported devices for CT-guided procedures. The analysis using simulated motion compensation revealed that body motion compensation and organ motion compensation individually impact the improvement in the accuracy of device-guided cryotherapy probe alignment. Considering the correlation between body and organ movements, we also determined that body motion compensation using the ring fiducial markers in the BMCPAD can be solely used to address both body and organ motions in MRI-guided cryotherapy.
Junichi Tokuda, Qun Wang, Kemal Tuncali, Ravi T Seethamraju, Clare M Tempany, and Ehud J Schmidt. 5/2020. “Temperature-Sensitive Frozen-Tissue Imaging for Cryoablation Monitoring Using STIR-UTE MRI.” Invest Radiol, 55, 5, Pp. 310-7.Abstract
PURPOSE: The aim of this study was to develop a method to delineate the lethally frozen-tissue region (temperature less than -40°C) arising from interventional cryoablation procedures using a short tau inversion-recovery ultrashort echo-time (STIR-UTE) magnetic resonance (MR) imaging sequence. This method could serve as an intraprocedural validation of the completion of tumor ablation, reducing the number of local recurrences after cryoablation procedures. MATERIALS AND METHODS: The method relies on the short T1 and T2* relaxation times of frozen soft tissue. Pointwise Encoding Time with Radial Acquisition, a 3-dimensional UTE sequence with TE = 70 microseconds, was optimized with STIR to null tissues with a T1 of approximately 271 milliseconds, the threshold T1. Because the T1 relaxation time of frozen tissue in the temperature range of -40°C < temperature < -8°C is shorter than the threshold T1 at the 3-tesla magnetic field, tissues in this range should appear hyperintense. The sequence was evaluated in ex vivo frozen tissue, where image intensity and actual tissue temperatures, measured by thermocouples, were correlated. Thereafter, the sequence was evaluated clinically in 12 MR-guided prostate cancer cryoablations, where MR-compatible cryoprobes were used to destroy cancerous tissue and preserve surrounding normal tissue. RESULTS: The ex vivo experiment using a bovine muscle demonstrated that STIR-UTE images showed regions approximately between -40°C and -8°C as hyperintense, with tissues at lower and higher temperatures appearing dark, making it possible to identify the region likely to be above the lethal temperature inside the frozen tissue. In the clinical cases, the STIR-UTE images showed a dark volume centered on the cryoprobe shaft, Vinner, where the temperature is likely below -40°C, surrounded by a doughnut-shaped hyperintense volume, where the temperature is likely between -40°C and -8°C. The hyperintense region was itself surrounded by a dark volume, where the temperature is likely above -8°C, permitting calculation of Vouter. The STIR-UTE frozen-tissue volumes, Vinner and Vouter, appeared significantly smaller than signal voids on turbo spin echo images (P < 1.0 × 10), which are currently used to quantify the frozen-tissue volume ("the iceball"). The ratios of the Vinner and Vouter volumes to the iceball were 0.92 ± 0.08 and 0.29 ± 0.07, respectively. In a single postablation follow-up case, a strong correlation was seen between Vinner and the necrotic volume. CONCLUSIONS: Short tau inversion-recovery ultrashort echo-time MR imaging successfully delineated the area approximately between -40°C and -8°C isotherms in the frozen tissue, demonstrating its potential to monitor the lethal ablation volume during MR-guided cryoablation.
Junichi Tokuda, Laurent Chauvin, Brian Ninni, Takahisa Kato, Franklin King, Kemal Tuncali, and Nobuhiko Hata. 2018. “Motion Compensation for MRI-compatible Patient-mounted Needle Guide Device: Estimation of Targeting Accuracy in MRI-guided Kidney Cryoablations.” Phys Med Biol, 63, 8, Pp. 085010.Abstract
Patient-mounted needle guide devices for percutaneous ablation are vulnerable to patient motion. The objective of this study is to develop and evaluate a software system for an MRI-compatible patient-mounted needle guide device that can adaptively compensate for displacement of the device due to patient motion using a novel image-based automatic device-to-image registration technique. We have developed a software system for an MRI-compatible patient-mounted needle guide device for percutaneous ablation. It features fully-automated image-based device-to-image registration to track the device position, and a device controller to adjust the needle trajectory to compensate for the displacement of the device. We performed: (a) a phantom study using a clinical MR scanner to evaluate registration performance; (b) simulations using intraoperative time-series MR data acquired in 20 clinical cases of MRI-guided renal cryoablations to assess its impact on motion compensation; and (c) a pilot clinical study in three patients to test its feasibility during the clinical procedure. FRE, TRE, and success rate of device-to-image registration were [Formula: see text] mm, [Formula: see text] mm, and 98.3% for the phantom images. The simulation study showed that the motion compensation reduced the targeting error for needle placement from 8.2 mm to 5.4 mm (p  <  0.0005) in patients under general anesthesia (GA), and from 14.4 mm to 10.0 mm ([Formula: see text]) in patients under monitored anesthesia care (MAC). The pilot study showed that the software registered the device successfully in a clinical setting. Our simulation study demonstrated that the software system could significantly improve targeting accuracy in patients treated under both MAC and GA. Intraprocedural image-based device-to-image registration was feasible.
Daniel I Glazer, Servet Tatli, Paul B Shyn, Mark G Vangel, Kemal Tuncali, and Stuart G Silverman. 2017. “Percutaneous Image-Guided Cryoablation of Hepatic Tumors: Single-Center Experience with Intermediate to Long-Term Outcomes.” AJR Am J Roentgenol, 209, 6, Pp. 1381-9.Abstract
OBJECTIVE: The purpose of this article is to report our intermediate to long-term outcomes with image-guided percutaneous hepatic tumor cryoablation and to evaluate its technical success, technique efficacy, local tumor progression, and adverse event rate. MATERIALS AND METHODS: Between 1998 and 2014, 299 hepatic tumors (243 metastases and 56 primary tumors; mean diameter, 2.5 cm; median diameter, 2.2 cm; range, 0.3-7.8 cm) in 186 patients (95 women; mean age, 60.9 years; range, 29-88 years) underwent cryoablation during 236 procedures using CT (n = 126), MRI (n = 100), or PET/CT (n = 10) guidance. Technical success, technique efficacy at 3 months, local tumor progression (mean follow-up, 2.5 years; range, 2 months to 14.6 years), and adverse event rates were calculated. RESULTS: The technical success rate was 94.6% (279/295). The technique efficacy rate was 89.5% (231/258) and was greater for tumors smaller than 4 cm (93.4%; 213/228) than for larger tumors (60.0%; 18/30) (p < 0.0001). Local tumor progression occurred in 23.3% (60/258) of tumors and was significantly more common after the treatment of tumors 4 cm or larger (63.3%; 19/30) compared with smaller tumors (18.0%; 41/228) (p < 0.0001). Adverse events followed 33.8% (80/236) of procedures and were grade 3-5 in 10.6% (25/236) of cases. Grade 3 or greater adverse events more commonly followed the treatment of larger tumors (19.5%; 8/41) compared with smaller tumors (8.7%; 17/195) (p = 0.04). CONCLUSION: Image-guided percutaneous cryoablation of hepatic tumors is efficacious; however, tumors smaller than 4 cm are more likely to be treated successfully and without an adverse event.
Xinyang Liu, Kemal Tuncali, William M Wells III, and Gary P. Zientara. 2015. “Automatic Iceball Segmentation with Adapted Shape Priors for MRI-guided Cryoablation.” J Magn Reson Imaging, 41, 2, Pp. 517-24.Abstract

PURPOSE: To develop and evaluate an automatic segmentation method that extracts the 3D configuration of the ablation zone, the iceball, from images acquired during the freezing phase of MRI-guided cryoablation. MATERIALS AND METHODS: Intraprocedural images at 63 timepoints from 13 kidney tumor cryoablation procedures were examined retrospectively. The images were obtained using a 3 Tesla wide-bore MRI scanner and axial HASTE sequence. Initialized with semiautomatically localized cryoprobes, the iceball was segmented automatically at each timepoint using the graph cut (GC) technique with adapted shape priors. RESULTS: The average Dice Similarity Coefficients (DSC), compared with manual segmentations, were 0.88, 0.92, 0.92, 0.93, and 0.93 at 3, 6, 9, 12, and 15 min timepoints, respectively, and the average DSC of the total 63 segmentations was 0.92 ± 0.03. The proposed method improved the accuracy significantly compared with the approach without shape prior adaptation (P = 0.026). The number of probes involved in the procedure had no apparent influence on the segmentation results using our technique. The average computation time was 20 s, which was compatible with an intraprocedural setting. CONCLUSION: Our automatic iceball segmentation method demonstrated high accuracy and robustness for practical use in monitoring the progress of MRI-guided cryoablation.

Kemal Tuncali, X Liu, William M Wells III, Stu G Silverman, and Gary P. Zientara. 2014. “Real‐time Quantitative Monitoring of Percutaneous MRI‐guided Cryoablation of Renal Cancer.” In International Society for Magnetic Resonance in Medicine. Vol. 22.Abstract
The safety and effectiveness of percutaneous image‐guided ablations can be improved if the procedure could be assessed quantitatively and in real time. Using MRI’s ability to depict both the tumor and the iceball during cryoablations, we developed a novel computerized tool that utilizes fast automatic segmentation methods to compute ablation metrics and tested its accuracy in MRI guided cryoablations of renal cancer.
Alexandra H Fairchild, Servet Tatli, Ruth M Dunne, Paul B Shyn, Kemal Tuncali, and Stuart G Silverman. 2014. “Percutaneous Cryoablation of Hepatic Tumors Adjacent to the Gallbladder: Assessment of Safety and Effectiveness.” J Vasc Interv Radiol, 25, 9, Pp. 1449-55.Abstract
PURPOSE: To assess safety and effectiveness of percutaneous image-guided cryoablation of hepatic tumors adjacent to the gallbladder. MATERIALS AND METHODS: Twenty-one cryoablation procedures were performed to treat 19 hepatic tumors (mean size, 2.7 cm; range, 1.0-5.0 cm) adjacent to the gallbladder in 17 patients (11 male; mean age, 59.2 y; range, 40-82 y) under computed tomography (n = 15) or magnetic resonance imaging (n = 6) guidance in a retrospective study. All tumors (mean size, 2.67 cm; range, 1.0-5.0 cm) were within 1 cm (mean, 0.4 cm) of the gallbladder; seven (33%) were contiguous with the gallbladder. Primary outcomes included complication rate and severity and postprocedure gallbladder imaging findings. Secondary outcomes included technical success and technique effectiveness at 6 months. RESULTS: Complications occurred in six of 21 procedures (29%); one (5%) was severe. Ice balls extended into the gallbladder lumen in 20 of 21 procedures (95%); no gallbladder-related complications occurred. The most common gallbladder imaging finding was mild, asymptomatic focal wall thickening after nine of 21 procedures (42%), which resolved on follow-up. Technical success was achieved in 19 of 21 sessions (90%). Six-month follow-up was available for 16 tumors; of these, all but two (87%) had no imaging evidence of local tumor progression. CONCLUSIONS: Percutaneous cryoablation of hepatic tumors adjacent to the gallbladder can be performed safely and successfully. Although postprocedural gallbladder changes are common, they are self-limited and clinically inconsequential, even when the ice ball extends into the gallbladder lumen.
Ruth M Dunne, Paul B Shyn, Jeffrey C Sung, Servet Tatli, Paul R Morrison, Paul J Catalano, and Stuart G Silverman. 2014. “Percutaneous Treatment of Hepatocellular Carcinoma in Patients with Cirrhosis: A Comparison of the Safety of Cryoablation and Radiofrequency Ablation.” Eur J Radiol, 83, 4, Pp. 632-8.Abstract
PURPOSE: To compare the safety of image-guided percutaneous cryoablation and radiofrequency ablation in the treatment of hepatocellular carcinoma in patients with cirrhosis. MATERIALS AND METHODS: This retrospective HIPAA-compliant study received institutional review board approval. Forty-two adult patients with cirrhosis underwent image-guided percutaneous ablation of hepatocellular carcinoma from 2003 to 2011. Twenty-five patients underwent 33 cryoablation procedures to treat 39 tumors, and 22 underwent 30 radiofrequency ablation procedures to treat 39 tumors. Five patients underwent both cryoablation and radiofrequency ablation procedures. Complication rates and severity per procedure were compared between the ablation groups. Potential confounding patient, procedure, and tumor-related variables were also compared. Statistical analyses included Kruskal-Wallis, Wilcoxon rank sum, and Fisher's exact tests. Two-sided P-values <0.05 were considered significant. RESULTS: The overall complication rates, 13 (39.4%) of 33 cryoablation procedures versus eight (26.7%) of 30 radiofrequency ablation procedures and severe/fatal complication rates, two (6.1%) of 33 cryoablation procedures versus one (3.3%) of 30 radiofrequency ablation procedures, were not significantly different between the ablation groups (both P=0.26). Severe complications included pneumothoraces requiring chest tube insertion during two cryoablation procedures. One death occurred within 90 days of a radiofrequency ablation procedure; all other complications were managed successfully. CONCLUSION: No significant difference was seen in the overall safety of image-guided percutaneous cryoablation and radiofrequency ablation in the treatment of hepatocellular carcinoma in patients with cirrhosis.
Ayaz Aghayev and Servet Tatli. 2014. “The use of Cryoablation in Treating Liver Tumors.” Expert Rev Med Devices, 11, 1, Pp. 41-52.Abstract
Percutaneous image-guided tumor ablation techniques have been used as an alternative method for patients with unresectable liver tumors. Although all techniques avoid morbidity and mortality of major surgery and have advantage of preserving non-tumoral liver parenchyma, cryoablation currently is the only percutaneous ablation technique allowing intraprocedural monitoring because of visibility of its ablation effect with computed tomography and MRI. Cryoablation uses extremely low temperatures to induce local tissue necrosis to treat both primary and metastatic liver tumors. This article discusses the principles of liver tumor percutaneous cryoablation, including mechanisms of tissue injury, technique, equipment, image-guidance used, patient selection criteria, clinical outcome and complications as well as current trends and future goals.
Xinyang Liu, Kemal Tuncali, William M Wells III, Paul R Morrison, and Gary P. Zientara. 2012. “Fully automatic 3D segmentation of iceball for image-guided cryoablation.” Conf Proc IEEE Eng Med Biol Soc, 2012, Pp. 2327-30.Abstract

The efficient extraction of the cryoablation iceball from a time series of 3D images is crucial during cryoablation to assist the interventionalist in determining the coverage of the tumor by the ablated volume. Conventional semi-automatic segmentation tools such as ITK-SNAP and 3D Slicer's Fast Marching Segmentation can attain accurate iceball segmentation in retrospective studies, however, they are not ideal for intraprocedure real time segmentation, as they require time-consuming manual operations, such as the input of fiducials and the extent of the segmented region growth. In this paper, we present an innovative approach for the segmentation of the iceball during cryoablation, that executes a fully automatic computation. Our approach is based on the graph cuts segmentation framework, and incorporates prior information of iceball shape evolving in time, modeled using experimentally-derived iceball growth parameters. Modeling yields a shape prior mask image at each timepoint of the imaging time series for use in the segmentation. Segmentation results of our method and the ITK-SNAP method are compared for 8 timepoints in 2 cases. The results indicate that our fully automatic approach is accurate, robust and highly efficient compared to manual and semi-automatic approaches.

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