Full thickness abdominal burn following magnetic resonance guided focused ultrasound

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Case reportFull thickness abdominal burn following magnetic resonanceguided focused ultrasound therapyJorge Leon-Villapalos *,Magdalini Kaniorou-Larai,Peter DziewulskiDepartment of Plastic and Reconstructive Surgery,St.Andrew’s Centre for Plastic Surgery and Burns,Court Road,Broomfield,Chelmsford,Essex CM17ET,UKReceived 17January 20051.Case reportA 39-year-old woman under the joint care of the Gynaecology and Radiology Departments at another hospital was admitted to our unit for assessment and treatment of a lower abdomen full thickness burn.She had recently undergone treatment for uterine fibroids,as part of a clinical trial,with magnetic resonance guided focused ultrasound therapy,a non-invasive technique that causes thermal ablation of tissue through localised high-energy ultrasound waves that produce coagulative necrosis at a targeted point.The location and extent of the treatment is monitored by magnetic resonance [1].The burn was initially treated at the referring centre with Flammazine dressings.Radiology input was sought.Magnetic resonance imaging of the pelvis (reported by the referring center Consultant Radiologist)2weeks after treatment ‘‘did not show any significant haematoma or fluid collection’’but identified ‘‘a small area of hyperintensity close to the skin burns site within the left rectus muscle’’;this was reported as ‘‘probably representing muscle oedema areas presumably related to the injury that caused the skin burn’’.No MRI abnormalities were reported in the subcutaneous fat or muscle fascia.Bowel damage was not expected,as ultrasound cannot propagate through air-filled viscera.Due to concerns about the depth of the burn,the patient was referred to our unit 2weeks following the original injury.On examination,she presented with a 10cm Â5cm full thickness burn in the lower abdomen and other areas of partial thickness surrounding this area (Fig.1).The burns were non-sensate,leathery white in appearance and overlying palpable uterine fibroids.The injuries were treated by excision of the burned area as an ellipse and direct closure.It was found that the burn involved the full thickness of the skin and had caused localised areas of subcutaneous fat necrosis.The burn had gone down to the abdominal fascia where the effects of the injury were clearly visible (Fig.2).The rectus muscles did not appear to be affected on visual examination.The remaining burned areas were treated conservatively.The patient was discharged home 1day post-surgery.She was followed up in the outpatients department and no post-operative complications were reported.2.DiscussionMagnetic resonance guided focused ultrasound treatment is a safe and reliable technique for the treatment of soft tissue tumours in multiple body locations [1–3]./locate/burnsBurns 31(2005)1054–1055Fig.1.Abdominal burns on arrival at our unit.*Corresponding author at:Flat 3,22Sussex Street,London SW1V 4RW,UK.Tel.:+447813085731.E-mail address:villapalos@ (J.Leon-Villapalos).0305-4179/$30.00#2005Elsevier Ltd and ISBI.All rights reserved.doi:10.1016/j.burns.2005.04.019It works by causing coagulative tissue necrosis through the use of high-energy ultrasound waves that destroy cells by raising temperatures to above608C,causing protein denaturation and cell death.The focused beam of high intensity ultrasound waves makes possible the destruction of the targeted tissue at a distance.It is of paramount importance to focus accurately the beam on the target tissue in order to protect the surrounding structures from the rising temperature.In order to monitor accurately the location and extent of treatment and minimise complications,focused ultrasound therapy is coupled with real-time magnetic resonance imaging and thermal mapping.Maybe because of its obvious benefits and the enthusiasm for this technique[4,5]there are few clinical papers reporting complications and most papers report potential adverse effects based on experimental models[6–8].Superficial burns with the use of this technique as a result of delivery of energy outside of the target focus are rare and have been reported before[1].We report thefirst case,to our knowledge,of full thickness burns in a woman following magnetic resonance guided focused ultrasound therapy for uterinefibroids despite continuous real-time magnetic resonance imaging monitoring and thermal mapping.Strict clinical observation and patient guidance may be necessary,in addition to, technical surveillance to avoid this infrequent but unpleasant complication of treatment.Despite its rarity,we feel that the potential risk of full thickness burn arising from this treatment must be counted as an important part in the informed consent of patients undergoing this treatment.References[1]Stewart EA,Gedroyc WMW,Tempany CMC,et al.Focused ultrasoundtreatment of uterinefibroid tumors:safety and feasibility of a non-invasive thermoablative technique.Am J Obstet Gynaecol2003;189(1): 48–54.[2]Gianfelice D,Khiat A,Amara M,Belblidia A,Boulanger Y.MRimaging-guided focused ultrasound therapy of breast cancer:correla-tion of dynamic contrast-enhanced MRI with histopathologicalfind-ings.Breast Cancer Res Treat2003;82:93–101.[3]Randal J.High intensity focused ultrasound makes its debut.J NatlCancer Inst2002;94(13):962–4.[4]Kennedy JE,Ter Haar GR,Cranston D.High Intensity focused ultra-sound:surgery of the future.Br J Radiol2003;76:590–9.[5]Yagel S.High-intensity focused ultrasound:a revolution in non-invasive ultrasound treatment.Ultrasound Obstet Gynaecol2004;23: 216–7.[6]Linke CA,Carstensen EL,Frizzwell LA,Elbadawi A,Fridd C.Localised tissue destruction by high-intensity focused ultrasound.Arch Surg1973;107:887–91.[7]Hynynen K,Chung AH,Collucci V,Jolesz FA.Potential adverse effectsof high-intensity focused ultrasound exposure on blood vessels in vivo.Ultrasound Med Biol1996;22(2):193–201.[8]Clarke RL,Ter Haar GR.Temperature rise recorded during lesionformation by high-intensity focused ultrasound.Ultrasound Med Biol 1997;23(2):299–306.J.Leon-Villapalos et al./Burns31(2005)1054–10551055Fig.2.Perioperative view following full thickness defect excision.Note the marks on the abdominal fascia caused by the burn(arrow).。