Yoav Medan: Ultrasound surgery -- healing without cuts

Over the last 13 years --

one, three, 13 years --

I've been part of an exceptional team at InSightec in Israel

and partners around the world

for taking this idea, this concept,

noninvasive surgery,

from the research lab to routine clinical use.

And this is what I'll tell you about.

13 years --

for some of you, you can empathize with that number.

For me, today, on this date,

it's like a second bar mitzvah experience.

(Laughter)

So this dream

is really enabled

by the convergence

of two known technologies.

One is the focused ultrasound,

and the other one is the

vision-enabled magnetic resonance imaging.

So let's first talk about focused ultrasound.

And I hold in my hand

a tissue-mimicking phantom.

It is made out of silicon.

It is transparent, made just for you.

So you see, it's all intact,

completely transparent.

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 little 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 surgical system.

(Laughter)

Okay, 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 lithotripsy --

breaking kidney stones.

But ultrasound can be shaped

to be anything in between,

because it's a mechanical force.

Basically, it's a force acting on a tissue

that it transverses.

So you can change the intensity, the frequency,

the duration, the pulse shape of the ultrasound

to create anything

from an airbrush to a hammer.

And I am going to show you

multiple applications in the medical field

that can be enabled

just by focusing,

physically focusing.

So this idea

of harnessing focused ultrasound to treat lesions in the brain

is not new at all.

When I was born, this idea was already conceived

by pioneers such as the Fry brothers

and Lars Leksell,

who is know actually

as the inventor of the gammaknife.

But you may not know

that he tried to perform lobotomies in the brain,

noninvasively,

with focused ultrasound in the '50s.

He failed,

so he then invented the gammaknife.

And it makes you ponder

why those pioneers failed.

And there was something fundamental

that they were missing.

They were missing the vision.

It wasn't until the invention of the MR

and really the integration of MR

with focused ultrasound

that we could get the feedback --

both the anatomical and the physiological

in order to have a completely noninvasive, closed-loop

surgical procedure.

So this is how it looks, you know,

the operating room of the future today.

This is an MR suite with a focused ultrasound system.

And I will give you several examples.

So the first one is in the brain.

One of the neurological conditions

that can be treated with focused ultrasound

are movement disorders,

like Parkinson's or essential tremor.

What is typical to those conditions,

to 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 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 didn't help him anymore.

And many of those patients refused to undergo surgery

to have people cut into their brain.

And about four or five months ago,

he underwent an experimental procedure.

It is approved under an FDAIDE

at the University of Virginia

in Charlottesville

using focused ultrasound

to ablate a point in his thalamus.

And this is his handwriting.

"On June 20th," if you can read it,

"2011."

This is his handwriting

on the morning of the treatment

before going into the MR

So now I'll take you through

[what] a typical procedure like that looks like,

[what] noninvasive surgery looks like.

So we put the patient on the 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.

And the objective of that?

I don't have a pointer here,

but you see the green, sort of rectangle or trapezoid?

This is the sort of general area of the treatment.

It's a safety boundary

around the target.

It's a target in the thalamus.

So once those pictures are acquired

and the physician has drawn

all the necessary safety limits and so on,

he selects basically a point --

you see the round point in the middle where the cursor is --

and he presses this blue button called "sonicate."

We call 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 he needs in this treatment.

So he presses "sonicate," and this is what happens.

You see the transducer, the light blue.

There's water in between the skull and the transducer.

And it does this burst of energy.

It elevates the temperature.

We first need to verify

that we are on target.

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 MR

is the ability to measure temperature noninvasively.

This is really a unique capability of the MR.

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 C temporarily.

This doesn't cause any damage.

But the point is we are right on target.

So once the physician verifies

that the focus spot is on the target he has chosen,

then we move to perform

a full-energy ablation

like you see here.

And you see the temperature rises

to like 55 to 60 degrees C.

If you do it for more than a second,

it's enough to basically destroy

the proteins of the cells.

This is the outcome from a patient perspective --

same day after the treatment.

This is an immediate relief.

(Applause)

Thank you.

John is one of [about] a dozen

very heroic, courageous people

who volunteered for the study.

And you have to understand

what is in people's mind

when they are willing to take the risk.

And this is a quote from John after he wrote it.

He 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 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 a normal life routine.

And he also plays golf,

like you do in Virginia

when you are retired.

Okay, so you can see here the spot.

It's like three millimeters in the middle of the brain.

There's no damage outside.

He suffers from no neurodeficit.

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 metastases,

when the metastases get to your bones,

sometimes they are very painful.

All those I've indicated

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 year-old farmer

who suffered from -- how should I say it? --

it's called pain in the butt.

He had metastases in his right buttock,

and he couldn't sit

even with medication.

He had to forgo all the farm activities.

He was treated with radiation therapy,

state-of-the-art radiation therapy,

but it didn't help.

Many patients like that favor radiation therapy.

And again, he volunteered

to a pivotal study

that we ran worldwide,

also in the U.S.

And his wife actually took him.

They drove like three hours

from their farm to the hospital.

He had to sit on a cushion,

stand still, not move,

because it was very painful.

He took the treatment,

and on the way back,

he drove the truck by himself.

So again, this is an immediate relief.

And you have to understand

what those people feel

and what their family experiences

when it happens.

He returned again

to his daily routine on the farm.

He rides his tractor.

He rides his horse to their mountain cabin regularly.

And he has been very happy.

But now, you ask me,

but what about war, the war on cancer?

Show us some primary cancer.

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 U.S.

And doing that in the U.S.

is very painful.

I don't see, without this nation

taking it as some 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 evidence-based medicine

and the size of trials and so on

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.

And we have better-than-surgery results in breasts.

But I have a message for the men here.

We heard here yesterday Quyen

talking about the adverse event trait

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 and incontinence.

Well, there are other cancer tumors in the abdomen --

quite lethal, very lethal actually --

pancreas, liver, kidney.

The challenge there

with a breathing and awake patient --

and in all our treatments,

the patient is awake and conscious

and speaks with the physician --

is you have to teach the MR 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 MR-guided focused ultrasounds

for the treatment of symptomatic uterine fibroids.

Women suffer from that disease.

All those tumors

have heavy bleeding during periods,

abdominal pressure, back pain,

frequent urination.

And sometimes, they cannot even conceive and become pregnant

because of the fibroid.

This is Frances.

She was diagnosed with a grapefruit-sized fibroid.

This is a big fibroid.

She was offered a hysterectomy,

but this is an inconceivable proposition

for someone who wants to keep her pregnancy option.

So she elected to undergo a focused ultrasound procedure

in 2008.

And in 2010, she became a first-time mother to a healthy baby.

So new life was born.

(Applause)

So in conclusion,

I'd like to leave you with actually four messages.

One is, think about the amount

of suffering that is saved

from patients undergoing noninvasive surgery,

and also the economical and 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

[who] is awake and can even monitor the treatment.

In all our treatments,

the patient holds a stop sonication button.

He can stop the surgery at any moment.

And with that note,

I would like to thank you for listening.

(Applause)