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| Dr Shrinivas B Desai |
MR-guided Focused Ultrasound Surgery (MRgUS) is a non-invasive, outpatient procedure which uses high doses of focused ultrasound waves (HIFU) to treat lesions inside the body without surgery or operation. MRgFUS machine consists of a combination of a MRI scanner and HIFU transducer.
MRI is able to accurately localise the lesion and guide the HIFU beam that destroys the target tissue safely and accurately. The MRI scanner allows 3D visualisation of the lesion and this allows the doctor to pinpoint, guide, and continuously monitor the treatment.
The HIFU transducer focuses sound energy on the area to be treated and destroys the abnormal cells. Imagine using a magnifying glass to focus the sun’s energy on a single point to create a flame to burn a leaf. The focused ultrasound energy is directed at a small volume of the lesion (abnormal area) raising its temperature high enough to cause thermal ablation (killing of the cells) without impacting other tissues. Pulses of energy are repeated until the entire volume is treated.
Post treatment post contrast MRI images allow the doctor to confirm that the treatment is completed. Following the treatment the body gradually removes the treated tissue over a period of months.
MRgFUS was installed in Jaslok Hospital in May 2010. Since its inception we have treated more than 200 patients with conditions like uterine fibroid, adenomyosis, early prostate cancer, facet arthropathy and painful bony metastasis. But these are just numbers and real successes are measured by improvement of patient’s lives. Here are some of their and our success stories.
Ashwini Sule (name changed), 35- year-old works in Jaslok Hospital as a Personal Relations Manager. She started noticing a vague lower abdominal pain during her menses which slowly increased in intensity over a year. The bleeding during her menstrual cycle had become very heavy for almost days with passage of clots. She had come to dread those five days of heavy bleeding where every aspect of her life became difficult. Routine tasks like travelling in a train, counselling patients or even just having a regular conversation with a colleague became a strain due to the discomfort, leaving her frustrated at the end of the day. When her menstrual cycles became irregular she realised something was wrong and went to see the gynaecologist. An ultrasound and MRI pelvis showed that she had a small submucosal (below the endometrial lining) fibroid or myoma. The thought of surgery for the fibroid deepened her anxiety to such an extent that she avoided it for almost six months and bore the discomfort. Luckily for her MRgFUS was subsequently installed just next door in the Radiology Department at Jaslok Hospital and MRI pelvis with contrast showed that her fibroid was treatable in a single session itself. The treatment took just two hours and in fact much to her colleagues’ surprise and hers she was able to resume work on the same afternoon. By her next cycle she had considerable reduction in pain and by six months she was back to her normal painless cycle. Seeing her every day as I enter the hospital smiling and serving patients gives me a deep sense of satisfaction.
Ashish Ahuja (name changed), 53-year-old corporate magnate from South Africa had been feeling weak and lethargic. This was quite out of character for this dynamic personality. His routine blood tests showed an elevated PSA (blood marker for prostate cancer) leading to an ultrasound, MRI and biopsies revealing that he had an early prostate cancer without metastasis or spread. On meeting a local cancer specialist he was told that considering his age and medical condition it would be better for him to avoid surgery and the risks of general anaesthesia. He was advised to just wait and follow up the cancer with yearly scans. Ahuja left the doctors consulting room feeling dejected and anxious wondering when the cancer will decide to spread to his entire body. After a day of depression he decided this wait and watch policy was not for him. After extensive research he found out about MRgFUS and having visited Jaslok Hospital before he decided to consult us. His prostate cancer was amenable to treatment by MRgFUS. He underwent treatment during which care was taken to preserve his neurovascular bundles (which controls sexual potency) and urinary sphincter (gives control over urination). Post treatment he retained his potency as well as continence. He is now back at work without the sword of cancer hanging over his head. His six month scan shows complete ablation (treatment) of the prostate cancer with normal PSA levels.
Sushant Singh (name changed), 26 year old carpenter was accustomed to strenuous work days with normal occasional post work mild back pain. He started experiencing back pain on waking up in the morning which would gradually diminish on regular activity to a constant dull ache by the end of the day. There was a gradual increase in pain intensity and duration essentially leaving him in pain throughout the day. He visited a doctor who gave him some pain medication which lead to temporary relief. He then consulted an orthopaedic surgeon (bone specialist) who advised him to undergo MRI of the spine. His scan in our department at Jaslok Hospital showed no intervertebral disc (cushioning between the spine bones) prolapse which is a common cause of pain. Rather he had facet joint (joints between spine bones) arthropathy which can also cause pain due to the irritation of pain-carrying nerves adjacent to these joints. This is actually the commonest cause of low backache in India. MRgFUS has the ability to ablate (treat) these nerves so as to eliminate the pain. This was explained to him and he was asked to consider this treatment option. He had a NRS (pain scoring system) of nine out of 10 before the treatment which is high. The fact that this treatment was non-invasive and could be performed as an out-patient procedure led to him choosing MRgFUS. After the treatment he was able to return to work in three short days. He is currently pain free (NRS is one) and is able to work normal hours without any medication.
Capt Bejoy Roy (name changed), 63-year-old merchant navy captain was diagnosed with inoperable cancer of the prostate. He was undergoing chemotherapy and radiotherapy when he started experiencing excruciating pain in his buttocks more on the right side. He was unable to sit even after taking multiple pain medications. His CT scan showed a destructive lesion in the right ischial tuberosity (bone which bears the body weight when we sit). He was offered radiation therapy which involves 21 sittings consisting of consecutive daily sessions. This meant he would have to lose 21 work days with gradual reduction in pain. He was referred to us for radio-frequency ablation in which a needle is put into the lesion and ablated (treated). Since treatment was for only pain palliation (not for cure of the disease) we offered him the option of MRgFUS. After hearing about this technology, where without inserting a single needle or any incision we were going to ablate the lesion and relieve his pain, he was sceptical but faith of our good intentions won through. His treatment under mild sedation lasted a short one hour and post treatment scan showed good ablation. He made a remarkable recovery and within a short 24 hours he was completely pain free. Post pain relief he became his regular jovial magnanimous self, making me realise there’s an even bigger evil than cancer and that’s pain. He is currently retired and as he puts it “sitting at home” pain free.
Dr Sumathi Rajan, 37-year-old gynaecologist from Hyderabad noticed a distinct change in her menstrual cycle. Her menstrual cycle had shortened with heavy bleeding for about four days with spotting lasting for almost 14 days. The heavy bleeding was accompanied by lower abdominal cramps that wouldn’t subside without considerable medication. She was going through the monthly nightmare that she had treated so many women for and knew what she had to do. An ultrasound revealed that she had diffuse adenomyosis, which is invasion of the normal uterine muscle with endometrial glands that bleed every cycle into the muscle leading to immense pain. Unfortunately the treatment options for diffuse adenomyosis are limited and these women usually end up with hysterectomy (complete removal of the uterus). Being an up to date gynaecologist she had heard of MRgFUS and its wonders. She visited us for a consult and I had to impart the bad news that so far we only had US FDA approval to treat focal adenomyosis not diffuse adenomyosis. I was quite surprised the following week when she told me that she had decided that MRgFUS was the only treatment for her. Despite my extensive counselling for probable treatment failure I could tell that her mind was made-up. Her treatment consisted of two sessions each of three hours duration. To my absolute delight she responded wonderfully to the treatment and within six months was pain free with near normal menstrual cycle. This last story is the closest to my heart as it truly illustrates “Fortune favours the brave”. This patient led me into unchartered territory and I cannot describe my joy that it reaped rich dividends for her.
The advantages of this treatment are it is non-invasive (without the need for any incisions). The treatment is completely safe as MRI guidance allows visualisation of lesion and surrounding area. This key technological amalgamation of MRI and HIFU allows accurate lesion targeting and provides real time feedback about temperature changes in the treatment area and outside to make sure that only the abnormal tissue is treated and the surrounding normal tissues are unharmed.
This procedure is conducted under mild sedation which means that the risks of anaesthesia are avoided and that the patient is conscious during the treatment and can provide feedback during the procedure to the physician. This live feedback gives the patient absolute control over the treatment and helps the doctor make this treatment more patient-friendly. However, there are some treatments like those of early prostate cancers and brain tumours where spinal anaesthesia is required.
The future of MRgFUS is bright with emerging applications for almost every part of the body. We at Jaslok Hospital have always been on the forefront of technology and will soon have a brain module which will allow us to treat lesions in the brain without surgery. There are as many neurons in our brains as there are stars in our galaxy, I wonder what they will come up with next.
