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