Ultrasound-Guided Cancer Imaging: The Future of Targeted Cancer Treatment

Tumor margins and malignant grade are best defined by vascular imaging modalities such as Doppler flow or contrast enhancement combined with videomicroscopy. The following are image-guided treatment options that can be performed on breast, prostate, liver, and skin cancers.

NEW DOPPLER APPLICATIONS

Blood vessel mapping using the various Doppler modalities is routinely used in both cancer treatment and reconstructive planning. In cancer surgery, it is critical to locate aberrant veins or arterial feeders in the operative site so postoperative blood loss is minimized. Advanced 3D Doppler systems allow for histogram vessel density measurement of neoplastic angiogenesis.

VESSEL DENSITY INDEX

(Fig 1) Baseline neovascularity is a treatment surrogate endpoint and therapy is maintained, increased, or suspended based on quantitative angiogenesis data.

SOLID ORGAN CANCER IMAGING UPDATES

Breast cancer, invading the lower dermis and nipple, discovered with high-resolution probes signifies the tumor has outflanked clinical observation essential for detecting the newly discovered entity of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). This capability is also vital for diagnosing the recent epidemic of male breast cancers arising near the mammographically difficult nipple areolar complex, occurring in our 911 First Responders.

For prostate cancer, 4D ultrasound can identify low-grade cancer delimited by the capsule and with low vessel density, and should be followed serially at 6-month intervals.

CONTRAST-ENHANCED ULTRASOUND (CEUS)

In 1990, Dr. Rodolfo Campani developed ultrasound contrast for liver imaging and Drs. Cosgrove (London) and Lassau (Paris) extended the use to breast, skin, and prostate tumors. CEUS is currently used worldwide but is not Food and Drug Administration (FDA)-approved in the United States.

One use for CEUS is microbubble neovascularity, which demonstrates therapeutic response since the Response Evaluation Criteria in Solid Tumors (RECIST) studies noted tumor enlargement during treatment might be related to cell death with cystic degeneration or immune cell infiltration destroying malignant tissue. Doppler ultrasound or CEUS reliably verifies decreased angiogenesis in place of contrast CT or dynamic contrast-enhanced (DCE) MRI. If vascular perfusion ceases, thermal treatments, such as cryotherapy, high-intensity focused ultrasound (HIFU), or laser ablation, should be completed.

Four-dimensional (4D) ultrasound imaging is real-time evaluation of a 3D volume so we can show the patient immediately the depth and the probability of recurrence. Specific echoes in skin cancer generated by nests of keratin are strong indicators of aggression and analyzed volumetrically. Highly suspect areas are checked for locoregional spread and a search is performed for lymphadenopathy so we can determine if the disease is confined and whether further surgical intervention is unlikely at this time. Patients are reassured because they simultaneously see the exam proceed in systematic stages. In serious cases, the patient is forewarned that the operation involves skin grafts and tissue construction.  4D ultrasound permits image-guided biopsy of the most virulent area of the dermal tumor and allows the pathologist to focus on the most suspicious region of the lymph node mass excised from the armpit, neck, or groin. Some laboratories are using postop radiography and sonography for better specimen analysis.

VIDEO DIGITAL MICROSCOPY VS BIOPSY

Fear of complications can deter patients from seeking medical opinion and surgical intervention, so many opt for noninvasive options. Imaging can help to reduce unnecessary biopsies because it can help identify the 1 out of every 33,000 moles that is malignant, while weeding out those that are not.

Once skin cancer is diagnosed, the treatment depends on depth penetration, possibly involving facial nerves, muscles around the eye and nasal bone or ear cartilage. Verified superficial tumors are treated topically or by low dose non-scarring radiation. Many cancers provoke a benign local immune response or coexistent inflammatory reaction that simulates a much larger area of malignancy, and cicatrix accompanies the healing response. 4D imaging combined with optical microscopy (RCM (reflectance confocal microscopy) or OCT (optical coherence tomography)) defines the true border during surgery, sparing healthy tissue, resulting in smaller excisional margins and less scar formation.

 

Do you have any tips on incorporating ultrasound in cancer imaging? Comment below, or, AIUM members, continue the conversation on Connect, the AIUM’s online community.

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Robert Bard, MD, DABR, FASLMS, currently runs a private consulting practice in New York City. He authored Image Guided Dermatologic Treatments, Image Guided Prostate Cancer Treatment, and DCE-MRI of Prostate Cancer and is a member of multiple leading international imaging societies. Since 1972, Dr. Bard has pioneered digital imaging technologies as alternatives to surgical biopsies for dermatologic and solid organ neoplastic disease.

Medicine, Music, and Moonlighting

I love my day job as a gynecologic oncologist at Princess Margaret Cancer Centre in Toronto as well as my role as the clinical lead for Royal Victoria Regional Health Centre regional gynecologic cancer program in Barrie, Ontario. My work keeps me very busy as do my three beautiful daughters. With great friends and family, and some of the best support staff any doctor could ask for, I’ve achieved my goal of becoming a successful doctor and surgeon for women with cancer. But I’ve always had another dream tucked away.

Dodge 2I’ve always been musical – in fact at age 3 I started playing the accordion, which I’m pretty sure was bigger than I was! But I put my musical dreams on hold while I pursued a medical career. I learned to play piano, percussion, and brass, and dabbled with songwriting over the years but most of my time was devoted to my medical training at Western University and University of Toronto.

A few years ago a patient in the palliative care ward asked me to play for her. I brought in my piano and surprised her with an original song I’d prepared for her titled, “It’s So Hard to Say Goodbye.” It was an emotional afternoon and afterward she made me promise that I would pursue my love of music professionally. Well, two albums later, here I am working on my third with two very accomplished and talented songwriters, Steve Dorff (whose songs have been sung by legends Barbra Streisand, Celine Dion, and Whitney Houston, to name a few) and Paul Overstreet (who wrote the number-one hit “Forever and Ever, Amen” for Randy Travis).

Many people ask me how I find the time to be a doctor at two hospitals and a professional musician.

Sometimes after a challenging day at the hospital, it can be hard to do anything at all, let alone write and play music. But music never feels like a chore. It calms my spirit and brings me a sense of peace. I find that music has a unique healing power both for me and for people going through tough times, whether struggling with illness or other personal issues. I always say that my goal is to share my music with as many people as possible with the hope that it will bring to them the same sense of passion, peace, and fulfillment it has brought to my own life. Here are a few ways in which music helps to heal both patients and myself.

How Music Helps Patients

  1. Pain relief
    Overall, music does have positive effects on pain management. It can help reduce both the sensation and distress of chronic pain, postoperative pain, and a range of conditions, according to a paper in the Journal of Advanced Nursing.
  2. Immunity boost
    Music can boost the immune function. A comprehensive study on the neurochemistry of music explains that a particular type of music can create a positive and profound emotional experience, which leads to secretion of immune-boosting hormones as well as endorphins. Listening to music, dancing, or singing can also decrease levels of the stress-related hormone cortisol.
  3. Increase energy and fight fatigue
    Many of my patients sometimes suffer from fatigue due to treatment or the postoperative healing process. Losing themselves in music helps reduce physical and emotional stress and can chase negative emotions away. Musical distraction can also help with sleepless nights.

How Music Helps Me

  1. Staying positive
    Music improves my moods and creates a more positive state of mind that helps me through busy days and emotional times.
  2. Mental and physical workout
    Music helps with concentration and staying focused. In addition, playing the piano improves motor coordination and dexterity – very beneficial when I’m at the operating table.
  3. Calm and cool
    The medical field can be very high-stress and emotionally taxing. Going home and playing the piano or writing lyrics really helps me channel this energy in a positive way. And music has been shown to help lower heart rate and blood pressure, which is great for my long-term health.

How does music affect you? What activities help you escape? How do you balance the demands of the job with your personal interests? Comment below or let us know on Twitter: @AIUM_Ultrasound.

Jason Dodge, MD, Med, is a surgical oncologist at Princess Margaret Cancer Centre in Toronto. He participated in the AIUM International Consensus Conference on Adnexal Masses in 2014. You can check out his music on his website or on iTunes.