Ultrasound surgery healing without cuts Yoav Medan

for the last 13 years

1 3 13 years I’ve been part of an

exceptional team at insightiq in Israel

and partners around the world for taking

this idea this concept non-invasive

surgery from the research lab to routine

clinical use and this is what I’ll tell

you about 13 years for some of you they

can empathize with that number for me

today on this stage it’s like a second

Bar Mitzvah experience so so this this

dream is really enabled by the

convergence of two non technologies one

is the force of ultrasound and the other

one is the vision enabled by magnetic

resonance imaging so let’s first talk

about focused ultrasound and I hold in

my hand the tissue mimicking phantom it

is made out of silicone it is

transparent made just for you so you see

it’s all intact completely transparent

okay I’ll take you now to the acoustic

lab you see the phantom within the

aquarium this is a setup I put in a

physics lab on the right hand side you

see an ultrasonic transducer so the

ultrasonic transducer emits basically an

ultrasonic beam that focuses inside the

phantom okay when you hear the click

this is when the energy starts to emit

and you see a lesion form inside the

phantom okay so everything around it is

whole and intact it’s just a lesion

formed inside so think about this is in

your brain we need to reach a target

inside the brain we can do it without

harming any tissue so this is I think

the first kosher Hippocratic

okay so so let’s talk a little bit about

ultrasound the force of ultrasound you

know all about imaging right ultrasound

imaging and you know also about little

tricks right breaking breaking kidney

stones but ultrasound can be shaved to

be anything in between because it’s it’s

a mechanical force basically it’s a

force acting on a tissue that we

transverses so you can change the

intensity the frequency the duration the

pulse shape of the ultrasound to create

anything from an airbrush you know to a

hammer okay and I’m going to show you

multiple application in the medical

field that can be enabled just by

focusing physically focusing okay so

this idea of harnessing focused

ultrasound to treat lesions in the brain

is not new at all it’s when I was born

this idea was already conceived by

pioneers such as the Frey brother in

large black cell who is known actually

as the inventor of the gamma knife but

you may not know that he tried to

perform lobotomies in the brain

non-invasively with focused ultrasound

in the 50s he failed

so we then invented the gamma knife and

it makes you ponder you know why why

those pioneers fail and there was

something fundamental that they were

missing they were missing the vision it

wasn’t until the invention of the EMR

and really the integration of M R with

focused ultrasound that we could get the

feedback both the anatomical and

physiological in order to have a

completely non-invasive closed-loop

surgical procedure okay so this is how

it looks you know the operating room of

the future today okay this is an ml

suite with the focused ultrasound system

and I’ll give several examples so the

first one is in the brain one of the

neurological conditions that can be

treated with focus ultrasound

our movement disorders like Parkinson’s

or essential tremor what is typical to

those conditions for essential tremor

for example is inability to drink or eat

cereal or soup without spilling

everything all over you or write legibly

so people can understand it and be

really independent in your life without

the the help of others so I’d like you

to meet John John is a retired professor

of history from Virginia so he suffered

from essential tremor for many years and

medication did not help him anymore and

many of those patients refused to

undergo surgery to have people cut into

the brain and about four or five months

ago he underwent an experimental

procedure it is approved on the FDA IDE

at the University of Virginia in

Charlottesville using focused ultrasound

to ablate a point in his talent mousse

okay and this is his handwriting on June

20th if you can read it

2011 okay this is his handwriting in the

morning of the treatment before going

into the EMA so now I’ll take you

through how a typical procedure like

that looks like how non-invasive surgery

looks looks like so we put the patient

on an mr table we attach a transducer in

this case to the brain but if it will be

a different organ it will be a different

transducer attached to the patient and

the physician will then take a regular

mr scan okay and the objective of that I

don’t have a pointer here but you see

the green sort of rectangle or trapeze

this is sort of a general area of the

treatment it’s a safety boundary around

the target it’s a target in the thalamus

okay so once those pictures are acquired

and the physician has drawn you know all

the necessary

safety limits and so on he selects

basically a point to see the round point

in the middle where the cursor is and he

presses this blue button called Sonic

eight we called this instance of

injecting the energy we call it

sonication the only handwork the

physician does here is moving a mouse

this is the only device in aids in this

treatment so he presses sonic eight and

this is what happens you see the

transducer the light blue there’s water

in between the scar and the transducer

and it does this bursts of energy

it elevates the temperature we first

need to verify that we are on target

right so the first sonication is at

lower energy it doesn’t do any damage

but it elevates the temperature by a few

degrees and one of the unique

capabilities that we leverage with the

EMR is the ability to measure

temperature non-invasively okay this is

really a unique capability of the EMR

it’s not you it is not being used in

regular diagnostic imaging but here we

can get both the anatomical imaging and

the temperature maps in real time and

you can see the points there on the

graph the temperature was raised to 43

degrees temporarily this doesn’t cause

any damage but the point is we are right

on target

so once the physician verifies that the

focal spot is on the target that he has

chosen then we can move to perform you

know a full energy ablation like you see

here and you see the temperature rises

to like 55 to 60 degrees if you do it

for more than second it’s enough to

basically destroy the proteins the cells

this is the outcome from a patient

perspective same day after this

treatment okay

this is an immediate relief

John is one of like dozen very heroic

courageous people who volunteer for the

study and you have to understand you

know what is in people’s mind when when

they are willing to take the risk and

this is quote from John after he wrote

it we said miraculous and his wife said

this is the happiest moment of my life

and you wonder why I mean one of the

messages I’d like to carry over is what

about defending quality of life I mean

those people lose their independence

they are dependent on others and John

today is fully independent

he returned to normal life routine and

is also playing golf like you’re doing

in Virginia right when you’re retired

okay so you can see here the spot it’s

like three millimeters in the middle of

the brain there’s dog damage outside he

suffers from low neural deficit there’s

no recovery needed no nothing he’s back

to his normal life let’s move now to a

more painful subject pain is something

that can make your life miserable and

people are suffering from all kinds of

pain like neuropathic pain lower back

pain and cancer pain from bone

metastasis well did you know the

metastases get to your brain sometimes

they are very painful

all those indication have already been

shown to be successfully treated by

focused ultrasound relieving the pain

again very fast and I would like to tell

you about PJ he’s a 78 years farmer who

suffered from how should I say it’s

called pain in the butt he had

metastasis in his right buttock but and

he couldn’t see even with medication he

had to forego you know about all the

farmer farm activities

he was treated with radiation therapy

state-of-the-art radiation therapy but

it didn’t help many patients like that

fake radiation therapy and again he

volunteered to a pivotal study that we

run worldwide also in the US and his

wife actually took him they drove like

three hours from their farm to the

hospital he had to sit on on a cushion

stand still

I mean not to move because it was very

painful he took the treatment and on the

way back he drove the car the truck by

himself so again this is an immediate

relief and and you have to understand

what’s you know those people feel and

what their family experience when it

happens he returned again to you know

his daily routine in the farm and rides

his tractor he rides his horse to their

mountain cabin regularly and he has been

very happy but now you ask me you know

but what about war you know the war on

cancer show us some primary concern what

can be done there so I have good news

and bad news the good news there’s a lot

that can be done and it has been shown

actually outside of the US and doing

that in the u.s. is very painful I mean

III don’t see without you know this

nation taking it as something collective

will or something that is a national

goal to make that happen

it will not happen and it’s not just

because of regulation it’s because of

the amount of money needed under the

current you know evidence-based medicine

and the size of trials and so on to make

to make it happen so the first two

applications are breast cancer and

prostate cancer they were the first to

be treated by focused ultrasound

we have better than surgery results in

breasts but I have a message for the man

here we heard yesterday yen talking

about the adverse event rate in prostate

cancer there is a unique opportunity now

with focused ultrasound guided by mr

because we can actually think about

prostate lumpectomy treating just the

focal lesion and not removing the whole

gland and by that avoiding all the

issues with potency in incontinence

well there are other you know cancer

tumors in the abdomen quite little very

little actually pancreas liver kidney

the challenge there with a breathing and

awake patient and in all our treatment

the patient is awake and conscious and

he speaks with the physician is you have

to learn teach TMR some tricks how to do

it in real time and this will take time

this will take two years but I have now

a message to the ladies and this is in

2004 the FDA has approved a marketed

focus ultrasound for the treatment of

symptomatic uterine fibroids women

suffers from that disease or those

tumors have heavy bleeding during period

abdominal pressure back pain frequent

urination and sometimes that kind of

they cannot even conceive and become

pregnant because of the fibroid this is

Francis she was diagnosed with a

grapefruit-sized fibroid this is a big

fibroid she was offered hysterectomy but

this is an inconceivable proposition for

someone who wants to keep her pregnancy

option so is she elected to undergo a

focused ultrasound procedure in 2008 and

in 2010 she became the first-time mother

to hurt the baby

so new life was born

so in conclusion I’d like to leave you

with with actually four messages one is

think about the amount of suffering that

is saved from patient undergoing

non-invasive surgery and also the

economical an emotional burden removed

from their families and communities and

the society at large and I think also

from their physicians by the way and the

other thing I would like you to think

about is the new type of relationship

between physician and patients when you

have a patient on the table which is

awake and can monitor even you know the

treatment in all our treatment the

patient holds a stop sonication button

he can stop the surgery you know at any

moment and with that note I would like

to thank you for listening