7/8/2015
Disclosures
Clinical Applications
of
Contrast Enhanced Sonography
Arthur C. Fleischer, M.D.
Vanderbilt U Med Ctr
Radiology and Ob/Gyn
• These applications are real, not just “academic”
• Microbubble contrast is currently not approved by FDA for non‐cardiac general applications, but is approved for cardiac applications
• There is an imminent chance of approval within 1‐
2 years
USA is only country in world with this constraint (should be lifted within 1‐2 yrs)
Microbubbles can be used “off label”
Clinical Applications
Research Support
•
•
•
•
•
•
NIH/NCI grant R21 CA 125227‐01
AIUM discovery grants
Multiple NIH/NCI grants imminent
Philips Healthcare‐software support
Bracco‐contrast and software
Lantheus‐Definity contrast
Other Applications
Assessment of completeness of TACE, ablation
Prostate cancer‐localization prior to Bx
Reflux‐urethral, ureteric
Splenic, renal, liver laceration 2/2 trauma
Adnexal torsion‐both depiction of vascular pedicle and “viability” of parenchyma
• Tubal patency
• Vascular complications‐endovascular shunt leaks
• Breast cancer detection (Liu JUM 34:117,’15) •
•
•
•
•
• Hepatic Masses‐DDx of metastasis, focal nodular hyperplasia, hepatocellular carcinoma, hemangioma
• Renal Masses‐evaluation of “indeterminate” renal mass, particularly in patients with poor renal function‐DDx of renal cell carcinoma, oncocytoma
• Ovarian masses‐DDx of carcinoma, fibroma, dermoid, endometrioma
• Assessment of tumor response
• Potential targeted therapy ‐“theranostics”
Tumor angiogenesis
(according to Judah Folkman,
MD, PhD)
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Tumor angiogenesis
Microbubble vs Gd‐MRI
Kuszyk, B., AJR 177:747, 2001
MB stay intravascular, whereas Gd-MRI leaks into interstitium
Kuszyk, B. S. et al. Am. J. Roentgenol. 2001;177:747-753
Scientific American, 2005
Tumor Neovascularity
McDonald, Choyke Nat Med 9:713, 2003
Increased vascularity, clustered vessels, irregular branching pattern, irregular caliber
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Microbubbles used for
Contrast Enhanced Sonography (CE‐US)
Definity microbubbles
____
5 um
Microbubbles for US Contrast
5u
_____
Capillary Perfusion
Perfusion ~ blood flow (ml/s)
volume (mg)
Blood flow ~ vascular area (α) x mean blood velocity (β)
Mean blood = slice x replenishment
velocity thickness rate
(β) (α)
Interaction of Ultrasound
and Microbubbles Contrast Agents
Linear
resonance
• Shell
– albumin, lipid/phospholipid or polymer 5 microns
Nonlinear
resonance
Transient
scattering
50 microns
• Gas
– air, low diffusivity gas
• Diameter
– 2-15 microns
POWERPOWER POWER
• Resonant frequencies - 2-10 MHz
• Nonlinearity allows bubbles to be differentiated from surrounding
tissue
• Persistence – circulate for minutes
c/o C. Caskey
Fundamental
enhancement
Harmonic
enhancement
Bubble disruption
Burns. In: Rumack et al, eds. Diagnostic Ultrasound. Vol 1. 2nd ed. St. Louis:
Mosby; 1998:57.
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Microbubble Destruction
• At diagnostic output levels, bubble can expand a few times original radius
• Most stabilizing coatings give way, leaving a free bubble to dissolve
• After insonification at normal imaging levels, most agents are destroyed
• This can be avoided with new sensitive imaging modes, or can be used to advantage
Principles of Harmonic Imaging
3.0 MHz
• Tissue and blood
reflect at the
fundamental
frequency
3.0 MHz + 6 MHz
3.0 MHz
Caskey, C J Ac S A, 2009
Method
Bmode
Pulse
Inversion
Contrast
pulse
sequencing
(CPS)
Summed
Tissue Echo
Continuous Imaging
With Low MI
Interval Time Delay Imaging
With High MI
CE‐US steps
Summed
Bubble Echo
N/A
a
Echo1 +
Echo2
b
Echo1 + Echo2 +
Echo3
c
Power
Modulation
Continuous vs Interval Time Delay Imaging
Continuous Imaging
With High MI
Burns. In: Rumack et al, eds. Diagnostic
Ultrasound. Vol 1. 2nd ed. St. Louis: Mosby; 1998:57.
Algebra
to
combine
Animation adapted from Dr. K Ferrara, UC Davis.
© Becher H and Burns PN, Handbook of Contrast
Echocardiography, Springer 2000,
www.Sunnybrook.utoronto.ca/EchoHandbook/
• Microbubbles reflect at
both the fundamental
and the harmonic
frequencies
3.0 MHz
Transmitted
Sequence (red have
inverted phase)
5
Echo1- 2*Echo2
Caskey, C . “Leveraging the Power of Ultrasound for Therapeutic Design and
Optimization” Journal of Controlled Release, 2011
• CDS to identify region of interest
• Prepare contrast
• IV injection‐contrast + 10 cc saline
– Bolus
– Infusion for Destruction/reperfusion
• Record in cine‐loop for approx. 3 min
• Analyze enhancement parameters‐time to peak, peak enhancement, washout, AUC,
microvessel perfusion
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Contrast Injection
Contrast Agent Preparation
A 3‐µL/kg dose of Definity (~0.3 mL) injected intravenously as a bolus, followed by bolus of 10 mL of 0.9% sodium chloride solution
Destruction/Reperfusion
I=(1‐et)
Hepatic Enhancement‐phases
• Arterial‐begins 10‐20s, ends 30‐45s
• Portal venous phase‐begins 10‐45s, ends 120s
• Late‐gr than 120 s, ends 5‐6 mins (300‐360s)
• Sustained=likely BENIGN
• Slow washout=likely MALIGNANT
• Patterns‐diffuse, nodular, peripheral
Focal Nodular
Hyperplasia
Liver Masses – Contrasted US
Vascularity
Arterial Phase
Portal Venous Phase
Hemangiomia
Marginal pools
Peripheral nodular
enhancement
Central progression
Focal Nodular
Hyperplasia
Profuse stellate
pattern feeding
artery
Hepatocellular
carcinoma
Profuse, often
dysmorphic
Metastases
Variable – Usually
low
Baseline
Arterial Phase
Hypervascular
with scar
Sustained enhancement
Hypervascular
Rapid washout
Portal Phase
Hypovascular
Hypovascular
Late Phase
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Focal Nodular
Hyperplasia
Focal Nodular
Hyperplasia
Baseline
Arterial phase
Portal phase
Focal Nodular
Hyperplasia
Hemangioma
Baseline
Arterial Phase
Portal Phase
Late phase
Late Phase Hemangioma
Hemangioma
Early phase
Late phase
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Metastasis
HCC
HCC
Baseline
Arterial phase
Early phase
Portal - late phase
HCC
Late phase
HCC
Late phase
HCC
Early phase
Metastasis
Baseline
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Metastasis
Metastasis
Late phase
Early phase
Easy to remember…
•
•
•
•
WATCH OUT for WASH OUT!
Rapid wash out is a sign of malignancy
Whereas……
Most benign lesions retain contrast in the late arterial, venous and portal venous phase CEUS of renal masses
CE‐US of Liver Masses
• PVP enhancement + in 92% benign, ‐ in 93% malignant; sustained PVP with arterial phase nodularity and centripetal progression in 92% of hemangioma; diffuse arterial phase enhancement gr liver in 95% of FNH (Wilson, S AJR, 186:1401, 2006)
• 92‐95% concordance with CT, MRI (Wilson, S Radiology 257: 24, 2010)
• Advantages‐Non‐toxic renal, non‐ionizing
• Approximately 50% of people over 50 have a renal mass
• Vast majority are cysts
• Most of the solid renal masses are malignant
• Classified by Bosniak criteria‐
– B1=cyst, 0% chance of malignancy
– B2=complex cyst, 0‐5% chance of malignancy
– B2F=increased # of septations, thick wall, 5% chance of malignancy (F=followup)
– B3=thick septations, solid parts, 31‐100% chance of malignancy
– B4=solid, vascular mass, 100% chance of malignancy
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CE‐US for DDx of indeterminate renal masses
(Barr, R Radiology, 2014)
•
•
•
•
Sensitivity=100%; specificity=95%
PPV=95%; NPV= 100%
5 false +’s= 3 oncocytomas, 2 B3 cysts
Based on 721 pts, 1018 indeterminate lesions
CE‐US for ovarian Ca
CE‐US in patients with compromised renal function
• Major advantage of CEUS over CT (potential nephrotoxicity of iodinated contrast)
• And MR (potential risk for nephrosclerosis
syndrome)
• CEUS‐Low cost compared to CT, MR
• Readily repeatable
• The use of CEUS could decrease the needs for both CT and MRI (diminish radiation exposure)
CEUS Image Analysis
• IOTA study (US O/G, 2009)‐72 adnexal masses – AUC (0.84) better than grey scale (0.75), but less than pattern recognition (0.93)‐problem DDx of borderline vs Ca‐used parametric analysis, not time/intensity curves‐they found CEUS could not DDx b/w borderline tumor and malignancy
Fleischer, A et al (JUM,2008;AJR 2009)‐57 adnexal masses
sens.=93%; spec.=96%
max. enhancement=90% accuracy
washout/AUC=100% accuracy
The time to peak (TTP) = time from injection to the peak intensity CEUS Image Analysis
CEUS Image Analysis
The area under the enhancement curve (AUC) calculated from the arrival of the contrast agent to the end of the wash‐out period
Wash‐out (WO) = time between the peak intensity and the return to the baseline. 9
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CEUS Image Analysis
Paraovarian cyst
The area under the enhancement curve (AUC) calculated from the arrival of the contrast agent to the end of the wash‐out period
Paraovarian cyst
Cystadenoma
Paraovarian cyst-3D TV-CDS
Cystadenoma
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Cystadenoma
Adenocarcinoma (stage II)-r ov
Parametric Imaging
Peak Enhancement
Time to peak
Stage II AdenoCa
Adenocarcinoma (stage II)-r ov
Parametric map of a serous adenocarcinoma during peak enhancement (a),
time to peak (b), wiAUC (c), woAUC (d), wiwoAUC (e), and woR (f). Areas
of tumor neovascularity in red contrast sharply with the cystic portion of the
tumor shown in blue.
Serous adenocarcinoma, Stage II
Adenocarcinoma (stage II)-l ov
Parametric Imaging
Peak Enhancement
Time to peak
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Adenocarcinoma (stage II)- l ov
Bilateral Ov Ca (stage II)
Borderline mucinous
cystadenocarcinoma
Borderline mucinous
cystadenocarcinoma
Borderline mucinous
cystadenocarcinoma
Borderline mucinous
cystadenocarcinoma
T1
T2 fat-suppressed
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Borderline mucinous
cystadenocarcinoma
Borderline mucinous
cystadenocarcinoma
Borderline mucinous
cystadenocarcinoma
Fibroma
Parametric Imaging
Emax = 0.41 dB
T½ = 7.5 sec
AUC = 15.3 sec-1
Time to peak
Peak Enhancement
Fibroma
Histology of Ovarian Masses
Parametric Imaging
Peak Enhancement
Area under curve
Benign (n = 38)
endometrioma
serous cystadenofibroma
hemorrhagic corpus luteum
mucinous cystadenoma
teratoma
serous cystadenoma
paratubal/paraovarian cyst
fibroma
Borderline/Malignant (n = 12)
serous adenocarcinoma
endometroid carcinoma
breast carcinoma metastatsis
borderline mucinous cystadenocarcinoma
n =
12
7
5
5
3
3
2
1
6
2
2
2
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Diagnostic accuracy
Enhancement parameters (n=57)
Peak Enhancement, dB
Time to Peak, sec
35
30
25
20
25
100%
20
15
90%
10
15
Benign
Benign
Malignant
Area Under the Curve
1/2 Wash-Out Time, sec
80%
200
100
50
Sensitivity
Specificity
P<0.01
P=0.7
150
Malignant
2500
2000
1500
70%
2D VFI 3D VI 3D VFI Emax
1000
AUC
T 1/2
500
0
Benign
Malignant
P<0.01
Benign
Malignant
P<0.01
Procedural Applications
Labelled MB in Animal Models
of Ovarian Cancer
• Barua, A (Int J Gyn Ca; 24, 2014)‐labelled
– Alpha v beta 3 detected angiogenetic ov ca in hens
• s/p TACE‐assess completeness of ablation
• s/p RF ablation of renal masses‐assess for recurrence
• Detect abnormal sentinal nodes in breast ca
– Lutz, A (Cl Ca Res, 2014) CD276 targeted MB in mice
CE‐US:Tumor Response
• Lassau, N Radiology 2011‐Accurate assessment of HCC to antiangenic Rx‐
predictive of tumor response, progression‐free interval, and overall survival
• Williams, R Radiology 2011‐can depict changes in vascular volume earlier than RECIST
• Pei, X unpublished, 2014‐Changes in cervical Ca with Rx
Good responder
pre-treatment
Volume = 19.1 cm3
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Good responder
Day 15 post treatment
Good responder @ d0, d15
Volume = 19.6 cm3
Pre-treatment
30
25
Day 15
25
20
15
10
5
0
Pre-treatment
Day 15
30
Pre-treatment
25
Day 15
30
Enhancement
intensity, dE
30
Enhancement
intensity, dE
Enhancement
intensity, dE
Good responder
Enhancement
intensity, dE
Patient #1 Good Responder
20
15
10
5
0
20
Pre-treatment
Day 15
25
20
15
10
5
0
0
20
40
60
80
100
120
140
160
180
0
1
2
3
4
5
6
7
Time, sec
Time, sec
15
10
Bolus sequence
5
Destruction-reperfusion sequence
0
0
20
40
60
80
100
120
140
160
180
0
1
2
3
4
5
6
7
Time, sec
Time, sec
Volume, cm3
Bolus sequence
Destruction-reperfusion
sequence
Contrast Enhancement, dB
Volume = 9.3 cm3
Day 15
19.1
19.6
25
17
Microvascular density, dB
22.7
13.7
Blood flow velocity, 1/sec
1.1
0.7
9/2009
Good responder
pre-treatment
Baseline
Pfizer Confidential – For Internal Use Only
88
Good responder
Day 15 post treatment
Volume = 9.5 cm3
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Good responder @ d0, d15
Good responder
30
Enhancement intensity,
dB
Pre-treatment
Day 15
15
10
5
0
0
20
40
60
80
100
120
140
160
180
Enhancement intensity, dB
20
Pre treatment
Day 15
25
20
15
10
5
0
0
2
4
Time, sec
Bolus sequence
6
Time, sec
8
10
12
Destruction-reperfusion
sequence
Patient # 2 Good Responder
Poor responder @ d0, d15
Destruction-reperfusion sequence
Baseline
Day 15
Volume, cm3
9.3
9.5
Contrast Enhancement, dB
15
10
Microvascular density, dB
21.5
9.4
Blood flow velocity, 1/sec
0.52
0.34
9/2009
93
Pfizer Confidential – For Internal Use Only
Good responder
30
10
5
0
0
20
40
60
80
100
120
140
Time, sec
Bolus sequence
160
180
Pre treatment
Day 15
25
20
30
Pre-treatment
Day 15
Enhancement intensity,
dB
Enhancement intensity,
dB
Pre-treatment
Day 15
15
Enhancement intensity, dB
20
Good responder
15
20
15
10
10
5
5
0
0
0
2
4
6
Time, sec
8
10
Destruction-reperfusion
sequence
12
0
20
40
60
80
100
120
140
Time, sec
Bolus sequence
160
180
Enhancement intensity, dB
Bolus sequence
Pre treatment
Day 15
25
20
15
10
5
0
0
2
4
6
Time, sec
8
10
12
Destruction-reperfusion
sequence
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Good responder
5
0
0
20
40
60
80
100
120
140
160
180
30
Pre-treatment
Day 15
15
20
15
10
10
5
5
0
0
0
Time, sec
Bolus sequence
20
Enhancement intensity,
dB
Enhancement intensity,
dB
10
Pre treatment
Day 15
25
Enhancement intensity, dB
30
Pre-treatment
Day 15
15
Enhancement intensity, dB
20
Good responder
2
4
6
Time, sec
8
10
0
12
20
40
60
80
100
120
140
160
180
Pre treatment
Day 15
25
20
15
10
5
0
0
2
4
Time, sec
Destruction-reperfusion
sequence
Bolus sequence
6
Time, sec
8
10
12
Destruction-reperfusion
sequence
Patient # 3 Poor Responder
5
Enhancement intensity,
dB
Poor responder @ d0, d15
Bolus sequence
Pre treatment
Day 15
4
3
2
1
0
0
Pfizer Confidential – For Internal Use Only
99
9/2009
4
6
Time, sec
8
10
12
Destruction-reperfusion sequence
Baseline
9/2009
2
Day 15
Volume, cm3
4.2
4.0
Contrast Enhancement, dB
8.9
11.3
Microvascular density, dB
1.9
3.2
Blood flow velocity, 1/sec
0.04
0.2
Pfizer Confidential – For Internal Use Only
100
Barriers Affecting Rx
Changes with Rx (c/o A. Lyshchik)
Kuszyk, B., AJR 177:747, 2001
9/2009
Pfizer Confidential – For Internal Use Only
102
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Poor responder (bolus)
Normalization of CEUS
Averkiou, M. et al. UMB. 2010
Poor responder (perfusion)
Fair Responder (bolus)
Fair Responder (bolus)
Good Responder (perfusion)
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Excellent Responder (perfusion)
Lots of unanswered ?’s
• What defines good, fair, poor responders?
Lassau‐40% reduction in AUC
• How does this correlate with clinical response, survival?
• Multiple lesions?
• Areas of necrosis?
• Rx to decrease interstitial pressures, improve
hypoxic areas
Markers for endothelial cell surface
• Inflammation (p‐selectin)
• Thrombosis (aIIb3 integrin)
• Angiogenesis (VEGF2)
Future Opportunities and
Studies
• Perfusion quantification
• Angiogenesis/anti‐
angiogenesis monitoring
• Targeted drug delivery
• Gene Therapy
Targeting Ligand
Encapsulated
Drug
Gas
Courtesy: Evan Unger – ImaRx
Future Opportunities and
Studies
• Perfusion quantification
• Angiogenesis/anti‐
angiogenesis monitoring
• Targeted drug delivery
• Gene Therapy
Targeting Ligand
Encapsulated
Drug
Gas
Courtesy: Evan Unger – ImaRx
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Targeted US with labelled MB
(c/o C. Caskey, PhD)
minutes
post-injection:
only
bound
remain
microbubbles
with
targeting
ligand
17Inject
Minute
post-injection:
some
free,
some
bound
Neovessels with retained targeted
microbubbles
Leong-Poi, H. et al. Circulation 2003;107:455-460
Anti‐angiogenesis therapy
Angiogenesis
VEGF receptors targeting
Capillar
y
VEGF release
Endothelial cell
anti-VEGF Ab
VEGF
VEGF binding
VEGF receptor
Genentech Inc
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Control UCA imaging
Imaging strategy
VisualSonics Inc
VEGFR-2 targeted UCA imaging
B-mode ultrasound
UCA signal
Targeted ultrasound contrast agents
B-mode ultrasound
UCA signal
Molecular sonograms
High VEGFR2 expression
Low VEGFR2 expression
Targeted UCA as a drug delivery
vehicle
M. Tartis et al. Ultrasound in Medicine & Biology 2006
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Jets
ROI 2=11467
ROI 1=1.463e+05
Total BLI Counts
Treating brain metastasis with BBB
MB Disruption + DOX
4.0E+05
2.0E+05
0.0E+00
1
2
3
4
Weeks after Injection
Week 3
Week 4
c/o Caskey, C
C. F. Caskey, S. P. Qin, P. A. Dayton, and K. W. Ferrara, "Microbubble tunneling in gel
phantoms," Journal of the Acoustical Society of America 125, EL183-EL189 (2009).
Microbubble Rx for Alzheimers
(C. Jones Ctr, U Queensland‐
Science Translational Med)
Conclusions
• CE‐US excellent for DDx of hepatic, renal, and ovarian masses
• Potential means to assess tumor response
• Potential means to enhance specifically targeted therapies=“theranostics”
• Potential use to enhance sonothrombolysis,
antibodies to β‐amyloid in Alzheimer's disease
Rx cleared plaque-restored memory in 75% of mice w/i several wks
Thanks to
• Charles Caskey, PhD VIIS
• Chelsea Samson, VUMC; Katrina Kohornen, HUP; Ryan Moore, U Oregon
• Andrej Lyschik, MD, PhD Jefferson U Med Ctr
• Lars Thorielus, MD, Linkoping U, Sweden
• Lanteus (Definity)
• Bracco (Optison/Lumason)
• Pfizer Oncology
• John Bobbitt, VUMC
22