Maximilian Rauch

Clinical Use of High-Intensity Focused Ultrasound (HIFU) for Tumor and Pain Reduction in Advanced Pancreatic Cancer.

PURPOSE Evaluation of ultrasound-guided high-intensity focused ultrasound (HIFU) used for the first time in Germany in patients with inoperable pancreatic cancer for reduction of tumor volume and relief of tumor-associated pain. MATERIALS AND METHODS 15 patients with locally advanced inoperable pancreatic cancer and tumor-related pain symptoms were treated by HIFU (n = 6 UICC stage III, n = 9 UICC stage IV). 13 patients underwent simultaneous standard chemotherapy. Ablation was performed using the JC HIFU system (Chongqing, China HAIFU Company) with an ultrasonic device for real-time imaging. Imaging follow-up (US, CT, MRI) and clinical assessment using validated questionnaires (NRS, BPI) was performed before and up to 15 months after HIFU. RESULTS Despite biliary or duodenal stents (4/15) and encasement of visceral vessels (15/15), HIFU treatment was performed successfully in all patients. Treatment time and sonication time were 111 min and 1103 s, respectively. The applied total energy was 386 768 J. After HIFU ablation, contrast-enhanced imaging showed devascularization of treated tumor regions with a significant average volume reduction of 63.8 % after 3 months. Considerable pain relief was achieved in 12 patients after HIFU (complete or partial pain reduction in 6 patients). CONCLUSION US-guided HIFU with a suitable acoustic pathway can be used for local tumor control and relief of tumor-associated pain in patients with locally advanced pancreatic cancer. KEY POINTS • US-guided HIFU allows an additive treatment of unresectable pancreatic cancer.• HIFU can be used for tumor volume reduction.• Using HIFU, a significant reduction of cancer-related pain was achieved.• HIFU provides clinical benefit in patients with pancreatic cancer. Citation Format: • Strunk HM, Henseler J, Rauch M et al. Clinical Use of High-Intensity Focused Ultrasound (HIFU) for Tumor and Pain Reduction in Advanced Pancreatic Cancer. Fortschr Röntgenstr 2016; 188: 662 - 670.

Treatment of Benign Prostatic Hyperplasia by Occlusion of the Impaired Urogenital Venous System – First Experience

PURPOSE To effect regression of benign prostatic hyperplasia (BPH), Gat et al. (Andrologia 2008) proposed to occlude incompetent spermatic veins to reduce increased hydrostatic pressure on the prostatic venous plexus and prevent reflux with androgen rich blood from the testicles. Our aim was to implement this treatment strategy in clinical practice and to report about first results. METHODS Embolization of the spermatic veins was performed in 30 patients with BPH. In 16 patients, we obtained follow-up data from at least 6 months. The sonographic transabdominal prostatic volume, prostate-specific antigen (PSA) and peripheral total testosterone levels were determined before and 6 months after the intervention. Subjective symptomatology was assessed using standardized questionnaires (International Prostate Symptom Score [IPSS] and Quality of Life score [QoL]) before and 6 months after the procedure. RESULTS The age of all treated patients was 46 - 77 years. The age of the 16 patients who received follow-up was 51 - 77 years. IPSS (median 18 [IQR 20.75 - 14.50] vs. 9 [IQR 11.00 - 7.25], p < 0.0001) and QoL score (4 [IQR 5 - 3] vs. 2 [IQR 3 - 1], p < 0.001) were significantly decreased 6 months after the intervention. The subjective improvement of symptoms did not correspond with prostatic volumes, which did not change significantly (54.31 ± 30.90 vs. 50.50 ± 29.26 ml, p = n. s.). 4/16 patients had a measurable post-void urine volume, which decreased in two patients 6 months after the procedure, remained unchanged in one patient, and was no longer detectable in one patient. 4 of the 11 had a sonographically detectable varicocele before the intervention, and one patient had a trabeculated bladder. Both the peripheral total testosterone levels (4.55 ± 1.27 vs. 3.93 ± 1.00 ng/ml; p = n. s.) and PSA levels (3.74 ± 2.83 vs. 4.06 ± 3.34 ng/ml; p = n. s.) showed no significant differences. CONCLUSION Interventional occlusion of the spermatic veins in patients with BPH is a feasible outpatient procedure with a low complication rate. Intermediate results are satisfactory. Mid- and long-term results and pathophysiologic mechanisms need to be further elucidated.

Clinical Effectiveness and Potential Survival Benefit of US-Guided High-Intensity Focused Ultrasound Therapy in Patients with Advanced-Stage Pancreatic Cancer

PURPOSE  Pancreatic cancer (PaC) is a life-limiting tumor with a wide range of incapacitating symptoms such as cancer pain in more than 80 % of patients. This prospective interventional study addresses the clinical effectiveness of ultrasound-guided high-intensity focused ultrasound (HIFU) treatment for patients with advanced-stage PaC, including pain perception, tumor size and survival benefit. MATERIALS AND METHODS  50 patients with late-stage PaC underwent HIFU. Clinical assessment included evaluation of tumor volume by imaging and pain burden (pain severity, pain sensation, interference with daily activities) using the Brief Pain Inventory at baseline and follow-up. Median overall survival, progression-free survival and time to local progression were estimated using Kaplan-Meier analysis. RESULTS  In 84 % of patients, significant early relief of cancer-induced abdominal pain was achieved by HIFU independent of metastatic status; it persisted during follow-up. Tumor volume reduction was 37.8 ± 18.1 % after 6 weeks and 57.9 ± 25.9 % after 6 months. 21 % of HIFU-treated patients had local tumor progression with a median time of 14.4 months from intervention. The median overall survival and progression-free survival were 16.2 and 16.9 months from diagnosis and 8.3 and 6.8 months from intervention. CONCLUSION  In patients with advanced pancreatic cancer and otherwise limited treatment options, HIFU resulted in significant early and long-lasting pain relief and tumor size reduction over time independent of metastatic status. Clinical data suggest an additional potential survival benefit.

Ultrasound-based therapies not mentioned.

The article discusses various chemotherapy regimens in the section on palliative treatment of pancreatic carcinoma (1), but regretfully fails to mention the treatment with ultrasound-guided high-intensity focused ultrasound (HIFU). HIFU is an innovative method, enabling targeted, non-invasive thermal ablation. In recent years, many reports about the use of high-intensity focused ultrasound with various diseases have been published, with a focus on the treatment of benign and malignant solid tumors. Current experience indicates that the proximity of a tumor to blood vessels does not play an important role, probably because the heat is rapidly removed by the blood stream. Thus, in principle, HIFU can be used to treat any solid space-occupying lesion accessible to ultrasound guidance, including, for example, uterine fibroids, skeletal and liver tumors, as well as pancreatic tumors encasing blood vessels. This is confirmed by the experiences we have gained in our hospital (the only ultrasound-guided HIFU system available in the German-speaking countries is located in Bonn, Germany) and by studies most of which have been performed in the East Asian region. These studies provide insight in the use of HIFU for pain relief and local tumor control: Gao et al. report (2) about the HIFU treatment of 39 patients with locally advanced pancreatic cancer. Pain relief was achieved in 79.5% of these patients. Another study of 251 patients (3) with advanced pancreatic cancer showed that HIFU treatment did not only reduce tumor size without serious complications, but also improved overall survival. A phase II study (4) evaluated HIFU treatment in combination with gemcitabin in patients with locally advanced pancreatic cancer. Two patients had a complete response and 15 patients a partial response.