Making a Splash

More than a century ago, scientists figured out how to deploy sound waves to locate the position and distance of enemy submarines. This discovery would also lay the groundwork for using high-frequency sound waves to peer inside the human body and usher in the age of ultrasound.

Today, ultrasound (or sonography) is the most widely used imaging tool in medicine. It was first used to detect gallstones and breast masses in the years following World War II. But it didn’t become a household word until a Scottish obstetrician, familiar with wave-detecting radar as a pilot, teamed up with an engineer to create the first compact sonar machine to show Glasgow pregnant women grainy images of their unborn children.

The 21st century is taking ultrasound to a new level—emerging as a tool to not only detect but to treat disease.

Radiation and surgery long have been used to remove unwanted tissue deep inside the body. A more recent tool, high-intensity focused ultrasound (HIFU), can do the same thing but in a safer way. It works how a magnifying glass concentrates light to create heat at a focal point, but instead, HIFU concentrates sound waves to ablate (or destroy) tissue. HIFU is becoming more common throughout the U.S., approved to treat everything from uterine fibroids to essential tremor, pain from bone metastases, and the prostate gland.

Focused ultrasound is being researched for over 90 diseases worldwide, according to the Focused Ultrasound Foundation based in Charlottesville, Va. The foundation was created to accelerate the development of new applications for focused ultrasound and the widespread adoption of the technology as a standard of care.

The Pittsburgh medical research community has been slow to adopt focused ultrasound, but elsewhere it is being studied for depression (Korea) and even Alzheimer’s disease (in Toronto, an early-stage clinical trial showed that FUS can safely open the blood-brain barrier in Alzheimer’s patients, an important step to allow medications to reach where they could be more effective).

HIFU has been particularly popular for treating prostate cancer—which strikes one in nine men. In 2015, the U.S. Food and Drug Administration cleared the first focused ultrasound device for the ablation of prostate tissue but didn’t specifically clear it as a treatment for cancer. No Pittsburgh-area doctors could be found to be using HIFU to treat prostate cancer.

“I’m not a big fan of HIFU,” says Allegheny Health Network urologist Dr. Jeffrey Cohen, who built one of Western Pennsylvania’s largest urology practices and now serves as president of Allegheny General Hospital. “The research isn’t there. It’s not going to replace radiation and surgical removal for treating prostate cancer.” He predicts HIFU falling out of favor the way cryotherapy (or freezing prostate tissue) did a decade ago.

Men who would be candidates for HIFU, Dr. Cohen adds, are better served, research now shows, with a “watchful waiting” approach. (See sidebar about a Pittsburgh area man who favors HIFU and more about its use in cancer treatment.)

While focused ultrasound’s role in medicine is still being defined, other forms of ultrasound are driving medicine forward in unexpected ways. Pittsburgh doctors share how they’re using ultrasound to better treat conditions ranging from knee pain to common and life-threatening gastrointestinal conditions.

“Ultrasound is one-fourth of the cost and offers three times the spatial resolution to detect subtleties that an MRI might not catch.”
—Dr. Kentaro Onishi

Beyond babies

Ultrasound long has been used to look at the structure of a beating heart or to assess the growth of a fetus. But now it can help doctors better find and more precisely treat the source of a painful knee, shoulder or other parts of the body. Ultrasound is a key component of Dr. Kentaro Onishi’s quest since leaving Tokyo at age 20 “to become the best sports medicine doctor I can be.” He is among a relatively small number of sports medicine doctors who specialize in musculoskeletal ultrasound. He joined the UPMC Department of Physical Medicine and Rehabilitation after training among this field’s leaders at Mayo Clinic.

“For diagnosing many conditions, ultrasound is far superior to MRI (magnetic resonance imaging),” Dr. Onishi says. “Ultrasound is one-fourth of the cost and offers three times the spatial resolution to detect subtleties that an MRI might not catch.”

For a Pittsburgh university basketball player, Dr. Onishi’s use of an ultrasound-guided procedure was nothing short of wizardry. Right before a recent basketball tournament, the player’s longtime knee pain was cured with an office procedure. Dr. Onishi used ultrasound to uncover the source of her pain—a chronically irritated tendon caused, not by a tear, but by a nearby fat pad sending blood flow to the tendon in a misguided attempt to heal it but instead “resulting in sensitization of the tendon,” Dr. Onishi explains. “I used local anesthetic and an ultrasound-guided needle to separate this growth between the fat pad and tendon, as this ‘relationship’ had become destructive.” If he had been just one millimeter off, Dr. Onishi adds, he could have damaged the tendon. The procedure brought immediate pain relief and no increase in risk of a ruptured tendon. Shortly afterwards, “She texted me and said, ‘You’re like Harry Potter.’ ”

Ultrasound can also be used to guide the precise injection of platelet-rich plasma (PRP), increasingly popular among injured elite athletes including Penguins players. (With PRP, a person’s own blood is withdrawn, specially treated, then injected back into an injured area to hasten the healing process.) Unlike cortisone steroid injections, PRP injections don’t diffuse widely throughout an area so they need a precise placement that ultrasound guidance can offer, Dr. Onishi says.

‘Amazing ramifications’

In digestive health, endoscopic ultrasound has had “amazing ramifications” as a way to detect and less invasively cure deadly GI diseases, says Dr. Shyam Thakkar, an advanced therapeutic endoscopist and AHN’s chief of endoscopy.

“Endoscopic ultrasound (EUS) was first introduced in the mid-1990s and was used primarily just for looking,” he says. “Now we’ve been able to take it from a diagnostic tool to a therapeutic tool where we can do all sorts of interventions.”

A decade ago, only a few specialists in Pittsburgh used EUS. Dr. Thakkar is now among about 10 specialists in the area who specialize in EUS, which involves inserting a scope, topped with a tiny camera, ultrasound transducer and other tools, through the throat or rectal area.

With EUS, Dr. Thakkar says, he can safely clean out dead and infected parts of a pancreas—the No. 1 GI-related reason for ER visits and hospitalization. “For necrotizing pancreatitis,” Dr. Thakkar says, “surgery or death has gone down significantly and treatment has really been revolutionized with endoscopic ultrasound.”

EUS is also a significant advance for the growing number of people having gastric bypass surgery to treat obesity. With EUS, Dr. Thakkar says, physicians are better able to navigate through these patients’ altered GI tracts to treat obstructing gallstones —a common condition especially in gastric bypass patients. The intervention is known as an EUS Directed Gastrostomy ERCP (EDGE procedure).

Dolores Ries, 68, of Whitehall, knows firsthand the power of endoscopic ultrasound. Dr. Thakkar was able to find the beginnings of pancreatic cancer—a disease that killed her mother and four years later struck her younger brother.

At an annual physical about five years ago, Ries mentioned that she was experiencing occasional abdominal pain. Knowing Ries’ family history, her physician sent her to AHN’s Pancreas Center. Dr. Thakkar performed a highly sensitive endoscopic ultrasound and found a very early neuroendocrine cancer of the pancreas. It was curable with surgery to remove 30 percent of her pancreas. She didn’t need chemotherapy or radiation and has been cancer-free for almost five years. “Dr. Thakkar is amazing,” she says. “I don’t know what I would have done without him. He found it (my cancer) instantly and made sure to get it out.” She still sees Dr. Thakkar for regular checkups. “It’s always reassuring to see his face and to know somebody’s keeping up with me.”

Ultrasound pays off?

Substituting ultrasound for MRI to diagnose many musculoskeletal injuries would save Medicare more than $6.9 billion from 2006 to 2020, according to a cost analysis done at Thomas Jefferson University Hospital in Philadelphia and reported in the Journal of the American College of Radiology. “That’s a savings at just one hospital,” notes Dr. Kentaro Onishi, a UPMC sports medicine doctor who specializes in musculoskeletal ultrasound imaging.

Differing views of HIFU

When Gary Crissman of McCandless learned he had prostate cancer, he did his homework and decided that high intensity focused ultrasound (HIFU) was the best treatment for him. It was 2008 and HIFU had not yet been approved in the U.S. for prostate disease so he traveled to Puerto Vallarta, Mexico, to have a HIFU procedure done there by an American doctor. He paid $25,000 out of pocket for a procedure that involves placing a scope through the rectum and concentrating sound waves to heat the prostate to temperatures near boiling. He wasn’t alone: Between 2003 and 2013, an estimated 40,000 prostate cancer patients were treated by HIFU systems in over 30 countries, according to an article in the Journal of the Acoustical Society of America.

Crissman, now 64, enthusiastically reports that he has experienced none of the common side effects of prostate cancer treatment—incontinence or impotence. More important, he remains cancer-free 10 years later, according to annual PSA (prostate specific antigen) screening tests. “HIFU is great. I wish it would become available in the Pittsburgh area,” he says. He has recommended to other men facing prostate cancer to go see Dr. Stephen Scionti, who did Crissman’s procedure. Based in Sarasota, Fla., Dr. Scionti touts himself as the “nation’s most experienced HIFU surgeon with over 2,000 prostate cancer ablative procedures, and inventor of the Scionti MMM (triple M) HIFU technique.”

One Sewickley urologist, Dr. Robert Doebler, once offered HIFU but an assistant at his Valley Urological Associates practice confirmed that he no longer does the procedure. Others in Pittsburgh remain skeptical so HIFU for prostate cancer isn’t likely to come back anytime soon. “For cancer treatment, this may eventually have a place to add to our armamentarium but it’s still pretty early in development,” says Dr. David Parda, chair of AHN’s Cancer Institute.

In 2015, the U.S. Food and Drug Administration gave two HIFU devices approval for general ablation of prostate tissues but did not give them approval for treating cancer. “The FDA says these focused ultrasound devices can deliver heat to a localized area and it ablates prostate tissue but it’s unclear whether it’s useful for a cancer patient,” Dr. Parda says. “With vague approval, the FDA is basically saying, ‘Can you guys figure it out?’ We have to do the clinical studies.”

One thing that has been well studied for effectively, and non-invasively, eradicating cancer is highly focused radiation, Dr. Parda adds. “With radiation, you have differential sensitivity between normal and cancer cells. This means normal cells are less sensitive to damage from radiation. That doesn’t exist with heating and freezing techniques,” Dr. Parda says. “When you heat tissues (as with HIFU), you get rid of cancer and normal cells equally.”

New approach to carpal tunnel release taps ultrasound

Carpal tunnel syndrome affects more than 12 million Americans. It can cause pain, numbness, tingling and sometimes weakness in the hand or arm when a major nerve gets compressed. Surgery to release this compression is one of the most common procedures done in America today. Dr. Kentaro Onishi, a UPMC sports medicine doctor, is excited to bring an ultrasound-guided carpal tunnel release procedure to Pittsburgh this year. Developed by his former colleagues at Mayo Clinic, the procedure can be done with a 4- to 5-millimeter wrist incision—approximately half the size of the incisions used for endoscopic carpal tunnel release and much smaller than traditional open surgery. The exciting thing about this procedure, Dr. Onishi says, is that patients can now have much shorter downtime from work or activities.