Transforming treatment: the promise and practice of interventional MRI (iMRI)

Episode Transcript

Recorded live from Cook Medical and featuring leading experts in the field of interventional radiology discussing a wide range of IR-related topics, this is the Cook@ SIR podcast series.

Thanks so much for joining us today. My name is Joshua Krieger. I’m director of Product Management for Cook Medical’s new iMRI division, and I’m here with Dr. Kavi Krishnasamy, head of Interventional Oncology at UAB. And we’re here to talk about interventional MRI, now that we’ve released the product and launched that publicly— the collaboration with Siemens and the work that we’re doing in IMRI— wanted to get together and talk about some of the suite, some of the clinical aspects and usage of the suite and where we start to go from here. So thank you so much for joining today.

Thanks for having me. And I know this has been a lot of hard work for the entire team. It’s a big day today with the launch, so congratulations to the team.

Thank you so much. It’s been an amazing team effort from Cook, from Siemens, and from our physician collaborators. It really is a team effort and amazing to see out in the public now, so.

Absolutely.

I’d love to maybe start with just how you got interested in iMRI as a potential part of your practice.

Yeah, it’s a great question, and it really goes back to— I— early in my career, I pivoted from vascular disease therapies, or just vascular therapies, to oncologic therapies, and really found my passion in oncologic therapies. And I got my start at the NIH, as you know. I spent about 5 years there, and I like to describe it as a boutique cancer practice. I mean, it was a lot of thermal ablation, a lot of TACE, didn’t have Y-90 in that practice, just didn’t have access to it. And so it became very facile with multifocal ablation in different organs. But obviously as I grew and learned— realized that there are challenges to that approach and— visibility of lesions, imaging surrogates around thermal ablation margins, things like that. And so when I joined my second practice in 2019 at Emory, I actually had a colleague who’s practicing in interventional MRI, and I didn’t know much about it at the time.

And I continued to build my cancer practice at Emory. And one of my roles was to really develop the thermal ablation practice. There wasn’t really a large thermal ablation practice at the time at Emory. And so as I built that program— again, gaps in what I could offer, and— but it became very easy for me to then just turn around and say, “You know, Dr. Nour”—it was Sherif Nour—”I can’t get this lesion. Can you take a look and can you treat this patient?” And he was wonderful. And the unfortunate part is I just didn’t get to really dive into interventional MR, and— while I was at Emory. And since that time, I have been looking for a way to get to interventional MR, because it fills a significant gap in what we can offer in CT and ultrasound. And I think for those of us that have never seen interventional MR, it’s very easy to not realize what some of those gaps are.

But there are gaps there. And so when this collaboration I think was started between Cook and Siemens, it was like Christmas came early, because this is the kind of opportunity that there were several of us in the field that were waiting to see grow and develop, and then with the potential optimization and ramifications that come from it. And so that was just a tremendous opportunity and complete by-chance meeting that we had at the time and that has now led to this— fast-forward a few years. And so that’s super exciting.

Absolutely. It’s been really exciting. I remember we were introduced by a colleague, and a little bit later we got to bring you over to the research suite that we have that has really been a test ground for what we’ve announced today. And I wonder if we could maybe dig into that. So you were able to see this at Emory?

Yeah.

I think you had moved institutions a couple points at the time we met.

Yeah.

Walking into the suite, walking into that for the first time, and doing needle-guided procedures for the first time in phantom and then preclinical— a lot of folks have this idea of iMRI as slow, as quite difficult— limited visibility, even though you’ve got really good soft-tissue contrast. I wonder what your first reaction was. What was your first response to coming into the room and utilizing the devices for the first time?

Yeah, it’s a great question. I want to back up one second, though, because I think when we met, I think it was SIR Phoenix.

I think that’s right.

And I was at Columbia at the time. And again, another CT-based percutaneous practice. And I like to describe my oncologic journey as a practitioner as— ablation was my first love, so I’m a very heavy CT and ultrasound user, including with imaging surrogates and fusion softwares and things like that. So I’m definitely not an MRI expert. In fact, I describe myself as an MRI novice, as you know. I’m not like David Woodrum, who does this on a day-to-day basis.

So I think when I came to you guys and to the research suite that first time— I think we had a phantom on the table— put my hands in the bore and placed a needle into a target under live MR fluoroscopy— and we’re not talking about CT fluoroscopy step-and-shoot, we’re talking about live, real time, I’m watching my needle move in real time. And it took me—what?—less than 10 seconds to get from the skin to the target. And I’d always had the idea that that this could be a game changer. That was what solidified in my head, that I don’t know how I can survive in the next 15 years of my career without this kind of technology, right? And it really solidified that and clicked in my head at that point.

I love that. Yeah. I remember that we had a phantom on the table. We were going after about a 5, 6 millimeter target. I think we set you up right away with a double oblique approach.

Yeah.

And running live biplane, orthogonal biplane, from the skin down to the target at about 3, 4 frames a second. It did not take you long to catch on. It was a really quick learning curve, and it was off to the races.

Yeah. I remember fondly when I was a fellow my attendings all telling me that skills will translate. Don’t worry so much about not having done a specific type of procedure. And 100%, I’m used to placing needles like that in CT, just not with the live aspect of it, the fluoroscopy aspect of it. But I just— it felt the same, just a slightly different workflow. I think there tends to be a little bit of a negative connotation around interventional MRI because of the history around interventional MRI, but this iteration is not what it was 10 years ago, right? And that’s, I think, the important thing for people in the community to understand.

Absolutely. There are many things that have gone into that. I think the low field offers some really—

Yep.

—great opportunity to design devices that are more like what you would expect. We have the ability to use a little bit more metal and more to refine those needle artifacts because of the lower field strength. But I think it is— it has been the collaboration, that 3-legged stool of imaging devices and physicians coming together to really integrate that—the devices, the imaging, and ultimately the workflows and procedures— has really been what’s transformed this. Huge amount of respect to the folks that have been doing this for the last 20+ years.

Without that collaboration.

Without that collaboration, they have done incredible things. And some of them are still doing those incredible things today. And the hope is that what we’ve done here with their help is going to really open that up to a whole new generation of physicians.

I want to say that again. I think that part is so impactful, that Siemens, as an imaging company, came together with Cook, as a device company, and, instead of running in different directions and hoping that it fits somehow, really developed a program together. And that has changed the way— and will change how we do this. So that’s— that was just an amazing endeavor.

And I think you’ve gotten to see some of that firsthand. I mean, I remember the next time you came to visit us, it was a preclinical day.

Yeah.

And we went around the room to do introductions, and then we pulled up the Teams group and introduced the folks over in Erlangen, Germany, and across the US and— all present there to support, to learn, and to refine and advance.

Yep.

I remember quite early in the day, we gave you, I think, a 20 gage Chiba needle.

Yep.

And we placed a small 5 millimeter fiducial marker up in the dome of the liver.

Yep.

And it was really amazing to see how quickly you could get to target with that live, real-time imaging, with the soft-tissue definition that we get out of MRI, but also then the ability to do that real-time with free breathing.

Yes.

I think we went back and we clocked it, and it was about 45 seconds from the skin down to that 5 millimeter target—

Yeah.

—in the liver. I wonder if you could maybe speak to that from the standpoint of somebody who does a lot of work in CT, how that’s different from your normal workflow.

Yeah, absolutely. And it’s really funny, because there are 2 concepts around that that I really talk to my fellows about. And sometimes they really look at me like I’m crazy. And one is chasing a lesion, like in the base of the lung. We all have different ways of doing things. I think in my practice, I have found that asking a patient to hold their breath is never exactly the same as the next time you ask the patient to hold a breath. It’s always a little bit different. So I’ve just gotten used to chasing lesions around in the lung when I can see them, obviously. Liver, I think is a little bit different in CT, because you don’t have the soft-tissue contrast or the negative contrast from your filled lung, right? But I’m very comfortable just chasing a lesion in the lung, but it’s a little bit time-consuming, right?

Because yes, I’m using CT step-and-shoot, but I’m not continuously fluoring, especially in my hands. I’m going to adjust my needle, get a quick image, move the patient en route a little bit, and then continue to track the lesion in my needle in unison as best I can. And it takes a little bit of time, but with some experience, it does work. But the experience part is important there as well. And I think you take the experience part out of it. We all probably played a little bit of some video games when we were younger, and it’s like playing a video game. You’re just hitting a moving target in real time and it can be live. And so that is one aspect to not having to worry about breath holes or jet ventilation or any of those things with technology like this.

The other aspect, I think, is working out of plane. I think in CT we get stuck with this notion that we have to be in plane. Reality: I work out of plane quite a bit. You can also angle the gantry obviously, but sometimes that can be a little cumbersome. But that’s, again, something that comes with time and, I think, experience, and I’m definitely not saying that I have the most experience. There are people that are more senior to me that do many more complex things in CT. But you’re taking those things out of the equation and the— that learning curve, out of the equation with a technology like this.

And then you’re effectively democratizing percutaneous interventions. And that’s super, super cool, right? So then it’s not about— “Well, I’ve never really done that to this level before, so hopefully it goes well. I don’t really have the experience.” But now it’s like, all right, this is, again, like playing a video game. I can do this regardless of how many times I’ve done it before. And so those are very important things as we try to standardize from academics to community, from the US to the rest of the world. That is one of the goals— is how can we give the same level of care to people everywhere? And these are things that help us do that.

Yeah. I love that. For people who haven’t seen some of the imaging that comes out of this, as we think about— the diagnostic imaging is very, very good coming out of these machines. It is what you’d expect of a very good MRI. I wonder if you could give your impression of the imaging, the real-time imaging, and the quality compared to the other imaging modes that you use.

In MR?

In MR.

Compared to like CT?

Yeah. Just those first impressions as you came in, as we did that. Again, this is a research suite— prototype devices in that preclinical environment. What were those first impressions of image quality, and how you were able to use those to do the work that you do?

Yeah, great question. I think first and foremost, it’s important to realize that this is a diagnostic scanner.

Yeah.

This is used as a diagnostic scanner. So I have a Free.max locally at UAB; it’s being used as a diagnostic scanner. My abdomen— I do a lot of local regional therapy in the liver, obviously. And my abdomen radiologists love the Free.max. It is a great scanner. Images are great. So I think we’re starting with that aspect. We know that it is a functional diagnostic scanner. And then when we get in from an interventional standpoint— and my background is not in MR physics, so I will try to say this as articulately as I can— but there’s always a little bit of a trade-off, right? So when we want temporal resolution, we’re losing some spatial resolution or contrast resolution or both, right?

And there’s that little bit of a trade-off. But I think when you have a team built around MR-guided interventions, or iMRI, and you have somebody you trust at the console outside the room, which— that’s also a little bit— we haven’t really talked about that, but that’s a different aspect of this. In CT, I’m used to controlling everything, or most things, table-side, right? In MR it’s being controlled outside the room by somebody you are working closely with and communicating with via some sort of mic-and-ear set.

And so understanding that part of it, being on the same page with that individual, whoever that is outside the room, to really switch the images from a live fluoro low-spatial resolution, high-temporal resolution, to then go quickly to a high-spatial resolution sequence that’ll take a little bit longer, but that really give you great definition where your needle tip is compared to where your target is, is important. But this is MR, right? We’re not guessing at where the lesion is, and if the needle is shadowing out the lesion like we do in CT. Yes, if we’re in, we have an ultrasound-visible lesion, it becomes significantly easier.

Yeah, absolutely.

But if it’s not ultrasound-visible and it’s small, it’s a real pain in CT, right? And those things also go away. You see that lesion, and then you see your needle tip, and that’s super cool.

Yeah. There’s not a lot of navigating by landmarks.

Yeah. Yep. Which— you know me, and you know that’s a pet peeve of mine, so.

I want to pull something out there, and you mentioned this, and it’s the ability to choose. I also think of spatial-temporal contrast resolution, and those as sliders, they have to add up to the same number, but you get to choose what combination there. And I think one of the things I love and have seen in the workflows is you get to choose what combination you want at every step—

Yeah.

—and can move fluidly between them, depending on what you need as a physician to take that next step, to make that next clinical decision, as a part of a procedure.

Yeah. Yep. Yep. Great point.

I think that’s maybe a really good— talking about workflows. I wonder as you step back, as you’ve— we’ve obviously not done this clinically in our research suite, but as you think about the workflow work that we’ve done that you’ve gotten to experience in the suite, I wonder what you would tell other IRs who are in this space, who are maybe curious, but not quite sure what this iMRI thing is— what would be valuable for them to understand about the workflows today, even knowing that we’re going to optimize them further?

I think the specialty is built on innovation.

Mm-hmm.

Right? We’ve known that for years and years and years. And that’s— in part defines what interventional radiology is, right? Going all the way back to Dotter and everything that’s happened in the last 50, 60 years. But it’s not infrequent that I run into somebody that— I mean, “CT and ultrasound is good enough. If I can’t get it, I can’t get it. But it’s good enough,” right? I don’t think that’s a totally uncommon sentiment. I think for people that have seen something like this, then it kind of clicks in their head and makes sense. But I think to those people that this is a departure from what they’re used to on a daily basis, it’s different. It’s not the same workflow, right? And so there is a learning curve that comes with that as well. There is a team environment that also comes with that as well.

Those are not– those are good things; those are not bad things. But it’s a different workflow, as we’ve kind of alluded to a little bit as well—wearing an earpiece so you can communicate with people both in and out of the room. And I fully expect as this continues to grow and develop, there will probably be some sort of headset and microphone for the patient as well to be able to communicate directly with the nurse for awake patients. Even though a lot of our ablations are under anesthesia, I do envision going to more sedation or local anesthesia for some of these biopsies in iMRI. And then— so some of those things need to be incorporated into the workflow. We’ll figure that out over time as well. But just getting used to, again, somebody else running the machine in the table for me that— again, it’s a departure from what I’m used to— again, not bad, but it’s a change.

And so trusting somebody to be able to do that, understanding that there is a relationship and a team that has to be built around this, and it can’t be plugging in every interventional radiologist or plugging in every MR physicist or technologist into this team. I analogize it to— I do PHP, right? And so in PHP, we have a PHP team, we have our anesthesiologist, we have our perfusionist, we have our IR, and we function as a— almost like an independent group to perform the intervention locally with the experience and the training that we have to do that intervention. And so I think this is a little bit similar to that. I think as we go forward with gen. 2 of the scanner, ergonomics are going to change. That was one thing I did notice. And I analogize it— I make fun of my colleagues that like to do dialysis, because I describe it as hugging the flat panel or hugging the II, like the— literally wrapping your arms around it in weird angles to get the catheters to where they need to be.

And I think ergonomically reaching into the bore consistently in a— in— I know it’s a short bore, but it’s still longer than CT, right? We’re still reaching into a bore. I think with the next iteration of the scanner, the flared opening, as well as the ability to be off isocenter, will change some of those ergonomic potential challenges, depending on— you have long arms. I have short arms, right? So maybe that makes it a little harder for me. So— and so those are positive incremental steps as we continue to build this program. But that’s the nature of every new technology.

Absolutely.

It’s not abnormal, right? You have a first iteration, you eventually get to a second iteration, and you continue to build beyond that. And that’s exciting in itself, to be along for that ride.

Absolutely. And I— have you gotten to try out? So the new— the second- generation machine launched, the Free.XL, today—

Yeah.

—here at CIRSE. Have you gotten to go up and reach in bore and try it out? How did you like that?

I did— and the detachable table, and all of those things— and play with the flexible interventional coil. And it’s a great time to be getting into interventional MRI. That’s exciting. I think for those of us interested in this space, we can’t wait for the new scanner to come out. I know we’ve got to wait a little bit under a year, but can’t come fast enough.

I wonder— maybe a different— another way to think about that workflow piece— as you think about— I know you do a lot with training younger physicians. As you think about training someone in CT, training someone in ultrasound— I know that you’ve done vascular work training someone under fluoro and training someone in iMRI. How do you think about that? There is the addition of the magnetic field and some of the safety that comes along with that, obviously. But as far as understanding the imaging modality, being able to work with the team and then being able to skillfully manipulate devices, how do you think about iMRI, just for others, in comparison to those modes that everyone is using?

Simultaneously, I think it’s challenging but also not challenging in different ways. And so I think for younger IRs that are adapting to a new technology, I feel like if I could— if I had done this 10 years ago, I would be better faster, right? I think the uptake, the older I get as an IR, is probably a little bit longer, unfortunately, right? So I think that’s a very positive thing. I think when you’re trying to analogize from CT and ultrasound— it’s funny, I like to talk about this with some of my colleagues. I feel like it’s a little— becoming a little bit of a lost art. We’re so heavy transvascular these days that my fellows are doing hundreds of angios, but not that many percutaneous ablations.

Interesting.

Yeah. And so— but it’s also a fact of— we have so many angio rooms running, but only one CT scanner, so there are just less fellows available to learn in that space. And then ultrasound-guided access—not just vascular access, but tumoral access by itself—is its own skillset. And I talk about it as something that really delineates us as an IR from other specialties and what other people can do: being able to access a lesion potentially in a moving target—small, large, whatever, off plane, on plane, intercostal, non-intercostal—I mean, those are important skills to have. And I don’t know that we’re giving that to all our fellows like we used to. I’ll be honest, I learned that as a junior faculty anyway. I didn’t really learn that in training. So I— hopefully, some of our trainees are going out and learning it on their own as well. But then again, I think that gets back to— interventional MRI takes a lot of that out of the equation, right? And the transition to me is also going to be getting used to just having your hand in the gantry.

Mm-hmm.

A lot of my fellows are very averse to leaving their hand in the radiation field and manipulating a needle or anything. And I fully understand why; I don’t disagree with that at all.

Yeah.

I also have gotten to a point in my career where if I can manipulate the needle and get it to where it needs to go in a less amount of time, I’ll do it with my hand in the radiation field, unfortunately. So I think that’ll be a little bit of a departure, and getting people used to having a hand in more— in gantry all the time and manipulating the needle. But I don’t see that as insurmountable.

It’s very interesting. We’ve seen a couple people when the machine starts at— out— actually jump back, because they realize they don’t have lead on—

Yeah. There you go.

—and then realize that they don’t need lead—

Yeah.

—in about a second timeframe. And it’s happened a couple times, and it’s really— it’s funny to see.

Yeah.

But it’s ingrained—

Yes.

—and the ability to reach in without radiation—

Yeah.

—not have to worry about that, to not don lead.

Yep. And it’s an important concept. I fully, fully recognize that, and shielding, and all the little things we drum into our trainees: lower the II and put the ceiling shield in, put the table side skirt on, and make sure you’re protecting yourself. And all of that goes away.

Right.

But, again, it’s an adaptation.

Absolutely. I think one other thing I wanted to get your thought on— you mentioned ultrasound; we’ve mentioned it a couple times. And one of the things that we’ve done as far as workflow goes is we do now have ultrasound in zone 4— the ability to have ultrasound in the room and to integrate that into the displays that we have in the room. I wonder if you could just speak to that. I know you use ultrasound in the CT room as we think about— we’ve got all the power of the MRI, that addition of the ultrasound. I think that’s probably— that’s something you’ve voiced as valuable. And I wonder if you could say more as to why.

Unlike CT, the needle is dark in MRI, right?

Mm-hmm.

The markers have a negative artifact—

Yep.

—if you will, right? So they’re black. And so in— outside the body where there’s no contrast and it’s just air, you can’t see the needle. And so, whereas in CT, if I’m feeling a little bit like I want to speed up that day, I’ll just forgo putting a grid on, and I’ll get to the slice that I need to get, and I’ll put the needle right there, and I’ll know exactly where I am, because the needle is bright on CT. It’s not that way in MR. So I still think there’s relevance to having ultrasound and maybe starting your pass with ultrasound and then directing with MR, potentially. Actually, of course, when we’re talking about potential transvascular application in MR, then you need ultrasound for access and all of those things, right?

So— and then it’s just always a nice little backup, right? And so I like to talk about this around thermal ablation and imaging surrogates around thermal ablation. Yes, if you have MR and you have MR thermometry and you know exactly where your ablation zone is, that’s awesome. But in CT, my backup is the microbubble cloud around the lesion with ultrasound. And I’m very used to just monitoring that in real time. So it’s just nice to have that backup as well. So I think having ultrasound capability is still important and will never not be needed.

Yeah. We’ve found it really valuable— those initial placements, or if you need to set another sheath—

Yeah.

—for transvascular—

Sure. Absolutely.

—that’s something— I don’t think it’ll come as a surprise to anybody that in the research setting, Cook, with a large vascular portfolio, is prototyping and interested in that side of things as well, and the power that MRI can offer as the primary visualization mode in vascular procedures, but then also some other procedures like MR lymphangiograms, the ability to set those needles right on the table in zone 4, move the patient in without having to go down the hall and down an elevator and move from an angio suite to a diagnostic MRI room just to do that in one room, so you know that those needles aren’t moving, and to be able to get your imaging— particularly as we’ve talked with folks in the pediatric world— to get a patient to be still for an MR lymphangiogram, you’re under general.

Sure.

And sometimes it’s saving 45, 60 minutes of general anesthesia for those patients.

Yeah. Great point. Great point. Also brings a question to my head. There are angio MR suites—

Mm-hmm.

—that are available, right? Is that relevant with a Free.max XL? Do we need an angio MR suite? Is there anything that— would it give us any extra capability?

I think the answer is yes right now. I don’t know if, looking 5, 10, 15 years in the future—

Yeah.

—what that holds. I know that all of these imaging modes will develop, but I really— I see incredible development around iMRI. What I would say is, as we look at some of the vascular procedures— MRI— we talked about the spatial contrast in temporal resolution. Fluoro excels at high temporal resolution, high spatial resolution. And that is the one combination where we see some good development still may be needed in the MRI. As we move to soft-tissue contrast, I— not even a comparison.

Yeah. Yep.

I remember prototyping things in the research lab, it’s amazing to put a stent in and be able to see where the external and internal iliac—

Sure.

—come apart without contrast, just visualizing it right there. But I think if you’re getting into navigating small vessels, high temporal resolution, if you’re getting into areas like the liver that have breathing motion, I think fluoro still has some real advantages there. And it’s something that is incredibly well known and practiced.

Yeah.

I think that’s something you do on a very regular basis.

Yeah.

So I think there’s— the vascular side of things, I think it has a little bit more work to be done compared to where the transcutaneous work is. I think that’s a little bit more ready today for prime time, but, I think, very, very promising. So I think— there’s a long answer to your question, but I think those places that do have angio MR— there is utility in having both. But our focus right now is on how do we utilize MR truly as that primary imaging mode as we’re developing things, and how do we utilize that to bring incredible value to you and the patients you serve?

Great point. And I totally, totally agree with you. I would be remiss if I didn’t mention, though, that you have participated in a preclinical TIPS all in MRI with no angio.

We have definitely done that. That is a— that’s a really neat procedure in the research environment. And we’ve had a couple folks in to do that. One of the things that— it’s really— it’s a needle-based procedure.

Yep.

It’s a catheter-based procedure.

Yes.

And it’s a procedure that it turns out really benefits an incredible amount from the ability to have multiple planes of visualization and soft-tissue contrast. So again, preclinical model, healthy model, the ability to see the hepatic vein, the entire portal system, and then to be able to have an off-angle sagittal that lets you directly visualize moving a needle from the exit point of the hepatic vein to your chosen entry point in the portal. To be able to see that off-angle sagittal, to understand if you’re slipping off one portion—

Sure.

—is just a really remarkable testament to the visualization capabilities of it as an imaging mode. There’s more to be done around— is that ready for prime time? A healthy preclinical model is not the patients that you’re doing TIPS in. And there are a lot of things like embolizing varices and how do you deal with some of the challenges that may come up in these very challenging procedures. But I think it’s a really great example of the power of MRI in this complex procedure.

And hence the buzz, hence the excitement, right? And the forward look at— what is the potential and possibilities?

So we’ve talked about some of the precision that iMRI can offer with the ability to operate in real time, with the soft-tissue contrast that you can see due to the MRI and its properties as a primary imaging mode. We’ve talked about radiation-free. I think that adds up to providing care where there was not the ability to before: something like a very small lesion up high in the liver dome that wouldn’t be visible under CT, or 100 other things. I wonder if you could think about in your own practice, what kinds of patients would benefit most from this and the kind of care that you see that has opened up in your practice with this as a primary imaging modality.

It’s not an insignificant number of patients that I see that have multifocal small-volume disease. I— let’s— even moving beyond the solitary or oligometastatic 3, 4 lesions in difficult spots, let’s say you have 8 to 10 lesions in difficult spots, right? Or just small. It’s not a— somebody I’m going to Y-90. That is, we’re very focused in this day and age on radiation dose to the normal liver as well as tumoral dose. And the small-volume patients usually end up getting a lot of dose to the background liver. So that’s not a therapy that I would like to employ personally. But in this scenario, even in CT and ultrasound, going and picking off those lesions can be very challenging, unless I can find a sonographic window randomly to get to, again, like an anterior segment 8 or an anterior 4a or a— traditionally, sometimes those posterior segment 3s can also be very hard because they sit right on top of the stomach and it’s very hard to separate, right?

And so they become challenging endeavors. How do you dose on the Y-90 side? How do you pick off lesions on the CT and ultrasound side? But again, it’s something that can change in an environment like this where I have the detail, not just of the lesion and the needle getting to the lesion, but then the therapy that I’m offering as well, knowing exactly the confines of my ablation zone in relation to the adjacent critical structure. And so that is an evolution that I think many of us are very excited about, because we’ve just not had that capability before. And then going back to what we talked about earlier and image fusion with small lesions, there’s always the potential for misregistration, right? And so, again, I take that out of the equation also. And so again, incremental steps with positive outcomes as we continue to move forward and optimize our therapies.

I’ve been doing it this way for years, but there’s still just gaps in what I can offer. And so that’s a massive potential add for some of these patients. And again, it’s not an infrequent referral that I get from some of my medical oncologists. “What can you offer?” And I do the best now with some sort of a multimodal approach. I may ablate a couple lesions in ultra— in CT with ultrasound. I may pick off a couple of lesions transarterially with a radiation segmentectomy or a superselective TACE or something like that. But maybe I can offer a curative therapy for all the lesions in a couple of settings with that precision that you’re talking about, right? And so that— again, huge value add and huge potential possibility.

The possibility there is just amazing. And I think, as somebody who’s unfortunately had family members who have experienced cancer, the change in care that we provide in the future as we continue to work on devices and software and the integration— I’d love to to move towards that point where that is a tool in your arsenal as you see those patients in your practice.

Absolutely. And we all know this is not going to be the only therapy that we offer, right?

No, of course not.

This is part of the armamentarium that we have in interventional radiology, interventional oncology, for these patients. And patient selection is also very, very important. But long ago were the days where we had a 60 or 70 centimeter bore, right? Where you’re basically touching the top of the gantry and the patient at the same time, where the needle was getting contaminated in real time in some fashion. And we’ve moved way, way past that. That’s very exciting.

Yeah, absolutely. I just want to pick up on something you said. As exciting as we see iMRI is, as powerful a tool as we’ve seen it in the research environment, there’s no impression that it’s the only tool needed. I think it’s a wonderful addition to the armamentarium. I think about something like a thyroid biopsy. That’s something really straightforward, high diagnostic yield under ultrasound in the MRI because of the depth there. That’s a real challenge.

Yeah.

I think ultrasound, CT will continue to be primary imaging modes in the transcutaneous space, fluoro in the transvascular space. But I think now there’s another tool that can augment and that can have incredible patient benefit to a subset of patients. And I think as we grow the capabilities, the workflow advancements, the optimization there, that group of patients gets to grow. I wonder, as you think about the couple times that you’ve joined us, is there anything else— one of your colleagues is interested— “Hey, you’ve gotten to see what this iMRI thing is. What else do I need to understand about this if I’m evaluating it? Is this something actually useful to me in my practice, in my IR practice?”

Great question. You mean as a practitioner?

Yeah.

Yeah. I think, great question. I think, yes, 100%, there is absolutely value. Again, there’s a learning curve, but there is absolutely value. I think when you then go beyond just needle placement and biopsy and then you start— on the percutaneous side, I’m speaking— and then you start talking about ablation thermometry in real time and understanding in real time what— whether we’re covering the lesion or not, whether we have an adequate margin or not, what temperature we’re getting to both on the microwave and then potentially on the cryo side as well, it really takes the conversation around image fusion out of the question and— not that image fusion is bad. The COVER-ALL trial came out recently; that was landmark work. We have moved towards non-manual confirmation of ablation zone margin, right?

A very, very important step I think for the field. There’s still a process to that, that iMRI can then obviate and then optimize beyond, right? And I think that’s really integral to those of us that do a lot of thermal ablation. And then when you look at cryo specifically, sometimes it’s not always easy to understand exactly where the edge of that ablation zone is and where it is in relation to critical other structures. And that also becomes significantly easier because it is so visible in the MR scan.

Oh, it is as crisp as can be.

Exactly.

Yeah.

Exactly. And then, so— and yes, that’s still the 0° isotherm—

Yeah.

—I understand that. We can still do potentially thermometry over the top of that, which is really exciting and understand where that –20 isotherm is—which, to my knowledge, there’s no other technology that can give us that kind of information at this juncture. So that is another huge step forward for the field. And that’s just percutaneous, right? And then going beyond that, it’s the— again, we talked about earlier, the invisible lesions, the small lesions and difficult-to-read locations that you can biopsy and treat. It is— there is not a week that goes by that one of my {inaudible} oncologists asks me to go after a difficult-to-reach lesion or a small lesion. And I will always try, but the tools haven’t caught up to what we’re being asked to do at times.

And so now maybe they are. And that’s, again, exciting. So, so many reasons, I think, for the average IR to start to wrap their head around what interventional MRI can bring to the table, so many reasons why we’re all so excited about what iMRI can bring to the table. And again, none of this would be possible without Siemens bringing the hardware, software, the scanner, and the sequences, right?— part of the software— and then Cook bringing the devices, right? And so that kind of marriage has really changed the space extremely positively. So, again, kudos to all the teams involved, but that’s, probably what I would say. Very long answer, but that’s what I would say.

Thank you so much. And I would just say we’ve announced the partnership today between Cook and Siemens— obviously between all of our collaborators. Siemens has announced the new Free.XL, which has that funneled opening, which has the detachable table, which has improved gradient performance to be able to really improve the imaging and provide exquisite imaging in that low-field environment. And I’m really excited in the coming months to be able to say even more about what that partnership is going to do, the support that we want to be able to provide any site interested in a full turnkey suite, the portfolio of products that Cook will be coming out with, first in the transcutaneous space, but already planning out what’s after that. And I loved, today, the launch of the scanner and the partnership was accompanied by the executive vice president of Siemens MRI and the president of Cook Medical. And I think just reinforcing the commitment: We created a whole new division within Cook.

Yeah.

Because this is a space where we see incredible value to physicians working in the space and the patients we all collectively serve. A lot more to come. We’ve been working under the radar for many years now, and internally we’ve joked we’ve finally reached the starting line. We’ve done our training and now we get to start the race. The really exciting part is all ahead. Thank you so much. Thanks for being a part of the journey.