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Offering imaging-guided therapy to cancer patients is a natural evolutionary step in imaging-based management of cancer patients. Moreover, as imaging-based detection of cancer becomes common, the number of patients presenting with small and localized cancer lesions increases. This serves as an incentive to treat the disease with a more targeted approach or, in today’s jargon, “Focal (or Focused) Treatment”.

This means pushing the role of imaging during treatment beyond the classical support it provides to the practitioner in controlling what he does towards:

1. Limiting treatment only to the life-threatening cancerous tissue.
2. Controlling and minimizing undesired damage to surrounding tissues.
3. Providing evidence that treatment has reached its goal. This is a clear technological challenge in non-chirurgical interventions, although one might argue that predicting clear surgical margins is not any less challenging.

Since this is a post J and not an essay, for each of the above requirements I will only discuss one technology component that I perceive as the most difficult to develop.

In order to treat only the cancerous lesion, or, even more ambitiously  in the case of some cancers (e.g. prostate, breast), to treat just the life-threatening (aggressive) part of the lesion, we need a device that will reliably characterize the lesion, map the aggressive parts inside the lesion and, based on 3D imaging, enable accurate volume segmentation of the tissue we want to treat. For example, I can think of solutions in the form of a device that incorporates imaging-based tissue characterisation, or a device that relies on accurate registration between an image and bio-markers’ detector. Efforts to develop such solutions are ongoing [1-5].

Minimizing damage to surrounding tissues requires real-time feedback to the practitioner during the treatment, regarding the location he is treating. This becomes even more crucial when the intervention is not chirurgical but some sort of non-invasive or minimally invasive treatment such as external beam radiation, HIFU, photothermal ablation etc. These devices still suffer from limited control over treatment location (e.g. due to limitation of accuracy between imaging modalities and treating modalities, patient’s movements etc..) and the spatial deposition of energy [6-10]. It would be my preference to combine the source of energy and the imaging-guidance under one device, e.g. when using HIFU as an ablation method, conduct the treatment, the treatment navigation and the treatment efficacy control using ultrasound-based tissue characterisation and avoid the complexity such as the one offered in [7]:

Being able to receive feedback on treatment efficacy in a timely and noninvasive manner will enable not only the acceptance of focal treatments but will also be a game-changer in the way cancer is being treated by drugs [8, 9]. The potential technological route in this case will require development of reproducible imaging work-flow that will enable reliable identification and comparable measures of the same lesion over and over again. It will definitely rely on imaging-based real-time tissue characterisation which will enable measuring temporal changes in a certain tissue characteristic, e.g. tracking changes in tissue temperature through using ultrasound for tracking changes in its density or using MRI for tracking change in response to magnetic fields [7].

References

1. SIMMONS (L.A.M.), AUTIER (P.), ZATURA (F.), BRAECKMAN (J.G.), PELTIER (A.), ROMICS (I.), STENZL (A.), TREURNICHT (K.), WALKER (T.), NIR (D.), MOORE (C.M.), EMBERTON (M.). Detection, localisation and characterisation of prostate cancer by Prostate HistoScanning.. British Journal of Urology International (BJUI). Issue 1 (July). Vol. 110, Page(s): 28-35
2. WILKINSON (L.S.), COLEMAN (C.), SKIPPAGE (P.), GIVEN-WILSON (R.), THOMAS (V.). Breast HistoScanning: The development of a novel technique to improve tissue characterization during breast ultrasound. European Congress of Radiology (ECR), A.4030, C-0596, 03-07/03/2011.
3. Hebert Alberto Vargas, MD, Tobias Franiel, MD,Yousef Mazaheri, PhD, Junting Zheng, MS, Chaya Moskowitz, PhD, Kazuma Udo, MD, James Eastham, MD and Hedvig Hricak, MD, PhD, Dr(hc), Diffusion-weighted Endorectal MR Imaging at 3 T for Prostate Cancer: Tumor Detection and Assessment of Aggressiveness. June 2011 Radiology, 259,775-784.
4. Wendie A. Berg, Kathleen S. Madsen, Kathy Schilling, Marie Tartar, Etta D. Pisano, Linda Hovanessian Larsen, Deepa Narayanan, Al Ozonoff, Joel P. Miller, and Judith E. Kalinyak Breast Cancer: Comparative Effectiveness of Positron Emission Mammography and MR Imaging in Presurgical Planning for the Ipsilateral Breast Radiology January 2011 258:1 59-72.
5. Anwar R. Padhani, Dow-Mu Koh, and David J. Collins Reviews and Commentary – State of the Art: Whole-Body Diffusion-weighted MR Imaging in Cancer: Current Status and Research Directions Radiology December 2011 261:3 700-718
6. Eggener S, Salomon G, Scardino PT, De la Rosette J, Polascik TJ, Brewster S. Focal therapy for prostate cancer: possibilities and limitations. Eur Urol 2010;58(1):57–64).
7. Rajiv Chopra, PhD, Alexandra Colquhoun, MD, Mathieu Burtnyk, PhD, William A. N’djin, PhD, Ilya Kobelevskiy, MSc, Aaron Boyes, BSc, Kashif Siddiqui, MD, Harry Foster, MD, Linda Sugar, MD, Masoom A. Haider, MD, Michael Bronskill, PhD and Laurence Klotz, MD. MR Imaging–controlled Transurethral Ultrasound Therapy for Conformal Treatment of Prostate Tissue: Initial Feasibility in Humans. October 2012 Radiology, 265,303-313.
8. Black, Peter McL. M.D., Ph.D.; Alexander, Eben III M.D.; Martin, Claudia M.D.; Moriarty, Thomas M.D., Ph.D.; Nabavi, Arya M.D.; Wong, Terence Z. M.D., Ph.D.; Schwartz, Richard B. M.D., Ph.D.; Jolesz, Ferenc M.D.  Craniotomy for Tumor Treatment in an Intraoperative Magnetic Resonance Imaging Unit. Neurosurgery: September 1999 – Volume 45 – Issue 3 – p 423
9. Medel, Ricky MD,  Monteith, Stephen J. MD, Elias, W. Jeffrey MD, Eames, Matthew PhD, Snell, John PhD, Sheehan, Jason P. MD, PhD, Wintermark, Max MD, MAS, Jolesz, Ferenc A. MD, Kassell, Neal F. MD. Neurosurgery: Magnetic Resonance–Guided Focused Ultrasound Surgery: Part 2: A Review of Current and Future Applications. October 2012 – Volume 71 – Issue 4 – p 755–763
10. Bruno Quesson PhD, Jacco A. de Zwart PhD, Chrit T.W. Moonen PhD. Magnetic resonance temperature imaging for guidance of thermotherapy. Journal of Magnetic Resonance Imaging, Special Issue: Interventional MRI, Part 1, Volume 12, Issue 4, pages 525–533, October 2000
11. Kishino et al. Usefulness of 3’-Deoxy-3’F-18-Fluorothymidine PET for Predicting Early Response to Chemoradiotherapy in Head and Neck Cancer. The Journal of Nuclear Medicine, 2012
12. Olivier Rouvière, MD, PhD, Ludivine Glas, MD, Nicolas Girouin, MD, Florence Mège-Lechevallier, MD, Albert Gelet, MD, Emmanuelle Dantony, MEng, Muriel Rabilloud, MD, PhD, Jean-Yves Chapelon, PhD and Denis Lyonnet, MD, PhD.Prostate Cancer Ablation with Transrectal High-Intensity FocusedUltrasound: Assessment of Tissue Destruction with Contrast-enhanced US. May 2011 Radiology, 259, 583-591.