August 6, 2014
North American first in children: SickKids doctors destroy bone tumour using incisionless surgery
A patient at The Hospital for Sick Children (SickKids) is the first child in North America to have undergone a specialized procedure that uses ultrasound and magnetic resonance imaging (MRI) to destroy a tumour in his leg without piercing the skin. In collaboration with Sunnybrook Health Sciences Centre, doctors used an MRI to guide high-intensity ultrasound waves to destroy a benign bone tumour called osteoid osteoma. The lesion had caused 16-year-old Jack Campanile excruciating pain for a year prior to the July 17 procedure. By the time he went to bed that night, the athletic teen experienced complete pain relief.
In previous decades, osteoid osteoma was treated with orthopaedic surgery that involved scraping the tumour from the bone or removing the affected part of the bone. The procedure was very painful and the recovery could take many weeks. Since the mid-1990s, minimally-invasive treatments have been used to burn the tumour; in these treatments, radiofrequency or laser energy is delivered through a needle placed in the tumour using computerized tomography (CT) guidance. These therapies are effective and less risky than invasive surgery, and are currently widely used. However, these procedures still carry risks, including radiation exposure, infection, burning of the surrounding tissue, and bone fractures resulting from the hole that remains following treatment of the tumour.
High-intensity focused ultrasound therapy uses sound waves to heat an area the size of a grain of rice, under MRI guidance, to destroy the tumour. The treatment is completely non-invasive, so the skin and surrounding bone remain intact, greatly reducing the risk of complications like infections. The use of MRI rather than CT scan to guide the sound waves means the patient avoids exposure to radiation. The risk of bone fracture is also likely lower than in other treatments, and recovery is quick. An added benefit is rapid pain relief.
“With high-intensity focused ultrasound, we are moving from minimally-invasive to non-invasive therapy, significantly reducing risk to the patient and fast-tracking recovery,” says SickKids interventional radiologist Dr. Michael Temple, who led the team that performed the surgery. Sunnybrook’s MRI technologists, medical physicists and radiation oncology group led by Dr. Gregory Czarnota supported this research by providing the technology and sharing their experience working with MRI-guided focused ultrasound protocols. “The osteoid osteoma tumour was chosen as our pilot study because the lesion is easily accessible and while the procedure is sophisticated, it is relatively straightforward. The success of this first case is great news for Jack, and exciting for our team as we look at developing more complex incisionless treatments in the future.”
The July 17 procedure was performed by SickKids staff, using a specialized MRI table at Sunnybrook Health Sciences Centre. While the surgery itself took 30 minutes, it required about three hours of preparation, which involved general anaesthesia and precise placement of the patient on the table, which is equipped with a built-in, high-intensity focused ultrasound transducer. The team used the MRI to determine the exact location of the tumour and to help target the ultrasound waves to burn the whole tumour, one focal spot at a time at a high energy. The MRI also enabled them to monitor the temperature induced by the ultrasound to ensure that there was no unexpected increase in heat in surrounding tissues. Accurate positioning and monitoring are critical, as the ultrasound waves could damage surrounding tissues, nerves or skin.
A few hours after the procedure, Jack was discharged home, where his recovery has been smooth and quick, with no complications to date. After dealing with a few hours of severe pain following the procedure, he was suddenly pain free. That night, he had uninterrupted sleep for the first time in months. Two days following the procedure, Jack was able to resume most daily activities, including a day trip to Niagara Falls on Day 4.
Before the surgery, Jack’s pain was so debilitating that he needed to take pain medication up to four times daily. “If I didn’t treat the pain attack early enough, it would be so strong that it felt like someone was trying to bend my femur into the shape of a hockey stick,” says the 16-year-old hockey player, snowboarder and wakeboarder, who took his last painkiller following the procedure. The idea of being the first to undergo this new treatment was intriguing, Jack explains. “I wanted to see what it would be like. If it did work, it would be a whole new world for medical procedures and treating osteoid osteoma.”
This breakthrough is the latest from SickKids’ Centre for Image-Guided Innovation and Therapeutic Intervention (CIGITI), a research program that brings together surgeons, radiologists, software developers and engineers to develop innovative technologies in robotic and minimally-invasive surgery.
“This achievement is both a technical and organizational feat and required several years of collaborative work and fine tuning. We see huge potential in using this technology to develop new, non-invasive therapies in a number of other medical and surgical areas, including the treatment of soft-tissue tumours, paediatric stroke and epilepsy,” Dr. James Drake, Lead of CIGITI, Head of the Division of Neurosurgery and Senior Associate Scientist at SickKids.
High-intensity focused ultrasound therapy is available in paediatric and adult centres in Europe. The procedure was first performed on patients with osteoid osteoma in Italy in 2010 and is currently used in North America to treat uterine fibroids and bone metastases in adult patients.
Osteoid osteoma occurs most commonly in males 10 to 35 years of age. The condition has been reported in patients as young as seven months. Despite its small size – about 1 cm – the tumour is known to cause extreme pain. SickKids sees as many as 18 patients per year with this condition.
Temple is Associate Professor of Medical Imaging at the University of Toronto. Drake is Professor of Surgery, also at U of T.
The CIGITI bone tumour treatment project is funded by the Canada Foundation for Innovation, the Ontario Research Fund, FedDev Ontario, the Canadian Institutes of Health Research, the Natural Sciences and Engineering Research Council of Canada and the Garron Family Cancer Centre at SickKids. The clinical pilot study is funded by grants from the Focused Ultrasound Foundation’s Clinical Indication Track and the Mary Jo Haddad Innovation Fund from SickKids Foundation.
This breakthrough was made possible thanks to the efforts of a multidisciplinary team at SickKids: Drs. Adam Waspe, Joao Amaral, Thomas Looi, Maria Lamberti-Pasculli, Joost de Ruiter, Fiona Campbell, Sevan Hopyan and Jane Church. From Sunnybrook: Dr. Greg Czarnota, Dr. Kullervo Hynynen, Claire McCann, Dr. Yuexi Huang, Dr. Young Lee, and Ruby Endre.
About The Hospital for Sick Children
The Hospital for Sick Children (SickKids) is recognized as one of the world’s foremost paediatric health-care institutions and is Canada’s leading centre dedicated to advancing children’s health through the integration of patient care, research and education. Founded in 1875 and affiliated with the University of Toronto, SickKids is one of Canada’s most research-intensive hospitals and has generated discoveries that have helped children globally. Its mission is to provide the best in complex and specialized family-centred care; pioneer scientific and clinical advancements; share expertise; foster an academic environment that nurtures health-care professionals; and champion an accessible, comprehensive and sustainable child health system. SickKids is proud of its vision forHealthier Children. A Better World. For more information, please visit www.sickkids.ca.
For more information, please contact:
The Hospital for Sick Children
416-813-7654, ext. 202059
The Hospital for Sick Children
416-813-7654 ext 201436