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Brain surgery that’s not invasive

Experimental procedure pioneered in Boston uses ultrasound to zap tumors

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A medical team can conduct the experimental MRI-guided focused ultrasound procedure from a room adjacent to where the patient is lying in the MRI machine.

UNIVERSITY OF VIRGINIA

Before-and-after writing samples of patients undergoing MRI-guided focused ultrasound.

When Glenn German had brain surgery last year, he remained awake and chatted with his surgeons throughout the four-hour procedure. At the end, he got up from the table and walked out of the room. The operation left no scar, produced only minor side effects, and cured the right-hand tremors that had, for years, made buttoning a shirt, eating soup, or carrying a full cup of coffee nearly impossible.

“The lifestyle of having a malady like that takes away so much,’’ said German, 72, of Midlothian, Va., but treatment would normally mean an operation inside the brain. “I don’t think I would have had [conventional] surgery,’’ German said.

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German’s experimental surgery was performed without slicing open his skull or cutting into healthy brain tissue. The procedure, called MRI-guided focused ultrasound, uses 1,000 otherwise harmless ultrasound beams. Focused on a particular area of the brain, the beams heat up and kill the cells in that spot.

UNIVERSITY OF VIRGINIA

Drawing tests by patient with essential tremor before and after MRgFUS treatment.

The noninvasive treatment was pioneered at Brigham and Women’s Hospital by a team led by Dr. Ferenc A. Jolesz, a radiologist and former neurosurgeon who has worked on the project for more than two decades.

Focused ultrasound has the potential to transform neuroscience, Jolesz and others believe, by destroying cells with pinpoint precision and helping to deliver medications directly to the brain.

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“I think that focused ultrasound will be a noninvasive alternative to a lot of other either surgical approaches or radio-surgical approaches,’’ said Dr. Neal Kassell, chairman and founder of the Focused Ultrasound Surgery Foundation in Charlottesville, Va., formed to advance the field. “It will be something which has the potential to revolutionize the treatment of a variety of neurological disorders, but its potential remains to be proven.’’

At the Brigham, four advanced-stage brain cancer patients were treated with focused ultrasound in 2007, in a procedure meant to test the technique’s safety. The fourth patient developed a brain bleed five days after the surgery, so the program was put on hold. Jolesz said he expects to resume the surgeries within a few months and begin operating on people with metastatic cancer, chronic pain, and so-called essential tremors.

“There is no tumor, even if it’s next to the optic nerve, that we cannot treat with that method,’’ he said.

Jolesz’s original insight was to combine ultrasound with the advanced MRI technology available in almost every major hospital, allowing a measured dose of heat that can be easily controlled. More recently, he and his team have figured out how to account for the skull’s varied thickness; a beam shot through a thicker section of skull would not travel as far as one shot through thinner bone.

The surgery costs about the same as conventional methods, but the investment for hospitals is significant. A typical MRI machine costs roughly $3 million; the focused ultrasound equipment for the brain adds $2 million, Jolesz said, though he expects costs will fall if the technique’s popularity rises.

MRI-guided focused ultrasound has been used to treat 8,000 women worldwide with uterine fibroids, harmless but often painful growths in the uterus. Stroke, epilepsy, and Parkinson’s disease also may be treatable, said Kassell, a professor of neurosurgery at the University of Virginia, where German had his operation.

Research is also underway at Stanford University, where the technique is being used to treat cancer patients with bone pain. Treating nerve endings with ultrasound dramatically reduced patients’ pain, allowing them to limit their medications and resume everyday activities like sitting and driving, according to Stanford’s Dr. Pejman Ghanouni, an assistant professor of radiology who has been leading the multi-center trial.

At lower doses than are used to kill cells, focused ultrasound can also open the blood-brain barrier, according to work by Brigham researcher Nathan McDannold. This barrier normally protects the brain from harmful bugs and chemicals, but it also prevents chemotherapy drugs from reaching the brain. Breaking through that barrier can help to better target chemotherapy drugs and allow for the use of higher doses, Jolesz said.

Like German, Arthur Lively, a 75-year-old retiree from Waynesboro, Va., received MRI-guided ultrasound surgery at the University of Virginia, to correct essential tremors. His head was immobilized in a frame, and he was put into the MRI machine. With the help of mirrors, he could see the room around him.

Lively and German were asked to write during their procedures and to talk to the surgeon and technicians to make sure the beams were correctly aimed. Their surgeon, Dr. William Jeffrey Elias, sent a low dose of ultrasound to the targeted area in each man’s thalamus, inside the brain, to make sure he hit the right area. Then he sent higher doses of heat to the area to destroy a small area of brain cells.

Lively wishes he had paid closer attention when the surgeon asked him if prodding a particular spot caused him to lose sensation in his lips or fingers, he said. He lost a little sensation in both - enough to be noticeable.

German can eat soup and peas in public again, he said, and continues to design high-end homes. As for Lively, he said he is grateful to have been able to participate in the clinical trial and hopes the treatment can eventually be used to help his three sons and a grandson, who all suffer from tremors.

“I don’t think I’d have to recommend it’’ to them after seeing his results, Lively said. If they could get the surgery now, “they’d be signing up already.’’

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