Stanford otolaryngologist champions ultrasound imaging

Photo, of Lisa Orloff performing an ultrasound exame, by Stuart Kraybill
Photo, of Lisa Orloff performing an ultrasound exam, by Stuart Kraybill

Patients with thyroid nodules — extremely common lumps on the thyroid that are usually benign, but can be malignant — are typically sent for ultrasound imaging to evaluate the size and structure of their thyroid and nodules. A radiologist’s report is then sent to the treating physician, who discusses the report with the patient and recommends next steps.

Lisa Orloff, MD, director of the endocrine head and neck surgery program at Stanford, doesn’t follow this traditional procedure: she performs her own ultrasound exams in the office and is training other head and neck surgeons to do the same. I recently spoke with Orloff about the role of ultrasound imaging in her practice.

Why do you primarily use ultrasound imaging to diagnose head and neck disease?

“My clinical practice focuses on the surgical management of thyroid and parathyroid disease, especially thyroid cancer. In the head and neck region, ultrasound imaging has long been recognized as the ‘go to’ study if you want to evaluate the structure, size and content of the thyroid gland. What’s been recognized more recently is how great ultrasound is for most of the head and neck structures. So we’re moving into an era of ‘ultrasound first:’ See what you can see with ultrasound, and then decide if you need additional cross-sectional imaging to corroborate or complement the ultrasound findings. For patients with thyroid cancer, ultrasound is extremely useful for evaluating not only the thyroid, but the rest of the neck for aggressive features including possible metastases.

Ultrasound is a low risk, low cost and very high yield imaging study that better characterizes the details within thyroid nodules or lymph nodes; whereas, CT and MRI often rely more on size to say whether or not a thyroid nodule or lymph node is suspicious. It’s really phenomenal what you can see with modern, high-resolution ultrasound equipment.

However, ultrasound has been blamed for the recent increase in incidence of thyroid cancer, which is largely due to increased detection. Even malignant thyroid nodules can sometimes be very indolent cancers that may not require intervention, but can be monitored. A major challenge in thyroid cancer care is distinguishing potentially aggressive tumors from those that are very low risk.”

Why is it helpful to have a clinical doctor, instead of a technician, perform ultrasound?

“When used at the point of care — performed by the clinician who is taking care of the patient — ultrasound enables the treating clinician to immediately investigate and answer questions with ultrasound information, and then implement treatments. It’s sort of one-stop shopping.

There’s an invaluable connection made with the patient when the treating physician performs the ultrasound exam, while explaining findings to the patient and discussing whether and how to treat them. I think it translates into improved patient care. If I’m the one doing the ultrasound exam, I can plan and execute surgery better with first-hand knowledge of what lies beneath the surface — rather than relying on images that someone else captured. I can perform ultrasound-guided biopsies and treatments in the office. I can also judge firsthand when an intervention or even biopsy isn’t necessary.

At present, I’m the surgeon in the head and neck division who routinely uses office-based ultrasound to evaluate patients, many of whom are referred to me specifically for that reason. But my colleagues in comprehensive ENT also perform ultrasonography [ultrasound imaging], as do our fellows and residents. We’re very motivated to train the next generation of otolaryngologists so it becomes more widely practiced in the office setting. We want to reduce the need for multiple appointments and more costly or invasive studies.”

I heard you recently traveled to Zimbabwe. What did you do there?

“My department has developed a relationship with the only medical school in the country, the University of Zimbabwe. I spent two weeks this summer, mainly teaching ultrasonography to residents in both otolaryngology and surgery — introducing the concept of point-of-care ultrasound to a low-resource practice environment where this has the potential for even greater impact. Most patients there don’t have ready access to get an expensive CT or MRI scan. I think ultrasound has a particular application in that setting, because it’s inexpensive, portable, fast and so user friendly. It’s also painless and non-threatening — you can do it on kids without having to anesthetize them to stay still.

Going over there to teach was a really rewarding experience. I hope to go back soon. We were very fortunate to have ultrasound equipment loaned for teaching purposes by GE based in South Africa. My next goal is to raise funds for an ultrasound machine to equip the Zimbabwe program with this wonderful tool for their continuing use.”

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

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New Prostate Cancer Treatment Reduces Side Effects

Photograph of the University Hospital London
University College Hospital in London. Courtesy of Steve Parkinson via Creative Commons.

Standard prostate cancer treatments, such as prostatectomy surgery or radiotherapy, often lead to substantial side effects. These include erectile dysfunction (affecting 30-70%) and urinary incontinence (affecting 5-20%). However, these unwanted side effects could be reduced, if prostate cancer treatments could target just the cancer tumors while harming less of their surrounding healthy tissue.

A promising “proof of concept” research study has just demonstrated that a new technique to treat localized prostate cancer may significantly reduce side effects compared to standard treatments. This study was carried out by researchers from University College London and the results were just published in the peer-reviewed medical journal The Lancet Oncology.

This new treatment uses high-intensity focused ultrasound (HIFU) to target and destroy prostate tumors, while causing minimal damage to their surrounding nerves and muscles. A small ultrasound probe is placed close to the prostate through the patient’s rectum. This probe emits a narrow beam of intense sound waves that heat the targeted cells to 80 C for one second, killing a targeted area about the size of a grain of rice. The probe is then moved to focus and destroy additional cancerous areas.  The procedure is performed in the hospital under general anesthesia and most patients are back home within 24 hours.

Surgeon Hashim Ahmed from University College Hospital in London demonstrates in a BBC News short video how this probe heats only a small target area.

The “proof of concept” HIFU study was primarily focused on assessing the frequency and extent of side effects, rather than the success of the prostate cancer treatment. Forty-one men participated in the study, ranging in age from 45 to 80 years old. All participants had localized prostate cancer ranging from low to high risk, where 30 men (73%) had intermediate to high-risk disease. They also had a prostate volume of 40 mL or less in order to avoid an excessively long procedure. They had received no previous prostate treatment.

The prostate cancer tumor locations were identified using multiparametric MRI (magnetic resonance imaging) and a template-prostate-mapping biopsy. The identified tumors were then targeted by the HIFU treatment. The men were followed up at one, three, six, nine and twelve months after the HIFU procedure. Each follow-up included: (1) a PSA blood test to measure the levels of prostate specific antigen protein being produced by the prostate, since PSA is generally elevated for men with prostate cancer; and (2) questionnaires that evaluated side effects. In addition, the MRI and biopsy tests were repeated as part of the 6 months follow-up and an additional MRI was performed after a year.

Researchers found that a year after the HIFU treatment, 89% of the men still had erectile function and all were still continent. In addition, there was a significant decrease in PSA levels compared to baseline and 95% of the men showed no evidence of disease on the final MRI scan.

Clearly this HIFU pilot study has demonstrated a promising reduction in treatment side effects. However, it was a small observational study of 41 men and followed them for only a year. The results need to be confirmed by much larger clinical trials that assess both the effectiveness and safety of HIFU compared with standard therapies. As a result, the researchers at University College London have started recruiting patients for a larger phase 2 trial that will follow patients for 3 years.