Endothelial cell injury in venule and capillary induced by contrast ultrasonography

Synchronous Intravital Imaging and Cavitation Monitoring of Antivascular Focused Ultrasound in Tumor Microvasculature Using Monodisperse Low Boiling Point Nanodroplets

Focused ultrasound-stimulated microbubbles can induce blood flow shutdown and ischemic necrosis at higher pressures in an approach termed antivascular ultrasound. Combined with conventional therapies of chemotherapy, immunotherapy, and radiation therapy, this approach has demonstrated tumor growth inhibition and profound synergistic antitumor effects. However, the lower cavitation threshold of microbubbles can potentially yield off-target damage that the polydispersity of clinical agent may further exacerbate. Here we investigate the use of a monodisperse nanodroplet formulation for achieving antivascular effects in tumors. We first develop stable low boiling point monodisperse lipid nanodroplets and examine them as an alternative agent to mediate antivascular ultrasound. With synchronous intravital imaging and ultrasound monitoring of focused ultrasound-stimulated nanodroplets in tumor microvasculature, we show that nanodroplets can trigger blood flow shutdown and do so with a sharper pressure threshold and with fewer additional events than conventionally used microbubbles. We further leverage the smaller size and prolonged pharmacokinetic profile of nanodroplets to allow for potential passive accumulation in tumor tissue prior to antivascular ultrasound, which may be a means by which to promote selective tumor targeting. We find that vascular shutdown is accompanied by inertial cavitation and complex-order sub- and ultraharmonic acoustic signatures, presenting an opportunity for effective feedback control of antivascular ultrasound.

The role of acoustofluidics and microbubble dynamics for therapeutic applications and drug delivery

Targeted drug delivery is proposed to reduce the toxic effects of conventional therapeutic methods. For that purpose, nanoparticles are loaded with drugs called nanocarriers and directed toward a specific site. However, biological barriers challenge the nanocarriers to convey the drug to the target site effectively. Different targeting strategies and nanoparticle designs are used to overcome these barriers. Ultrasound is a new, safe, and non-invasive drug targeting method, especially when combined with microbubbles. Microbubbles oscillate under the effect of the ultrasound, which increases the permeability of endothelium, hence, the drug uptake to the target site. Consequently, this new technique reduces the dose of the drug and avoids its side effects. This review aims to describe the biological barriers and the targeting types with the critical features of acoustically driven microbubbles focusing on biomedical applications. The theoretical part covers the historical developments in microbubble models for different conditions: microbubbles in an incompressible and compressible medium and bubbles encapsulated by a shell. The current state and the possible future directions are discussed.

Sonoporation based on repeated vaporization of gold nanodroplets

Background

Gold nanodroplets (AuNDs) have been proposed as agents for photothermal therapy and photoacoustic imaging. Previously, we demonstrated that the sonoporation can be more effectively achieved with synchronized optical and acoustic droplet vaporization. By applying a laser pulse at the rarefactional phase of the ultrasound (US) pulse, the vaporization threshold can be reached at a considerably lower laser average power. However, a large loading quantity of the AuNDs may increase the risk of air embolism. The destruction of phase‐shifted AuNDs at the inertial cavitation stage leads to a reduced drug delivery performance. And it also causes instability of echogenicity during therapeutic monitoring.

Purpose

In this study, we propose to further improve the sonoporation effectiveness with repeated vaporization. In other words, the AuNDs repeatedly undergo vaporization and recondensation so that sonoporation effects are accumulated over time at lower energy requirements. Previously, repeated vaporization has been demonstrated as an imaging contrast agent. In this study, we aim to adopt this repeated vaporization scheme for sonoporation.

Methods

Perfluoropentane NDs with a shell made of human serum albumin were used as the US contrast agents. Laser pulses at 808 nm and US pulses of 1 MHz were delivered for triggering vaporization and inertial cavitation of NDs. We detected the vaporization and cavitation effects under different activation firings, US peak negative pressures (PNPs), and laser fluences using 5‐ and 10‐MHz focused US receivers. Numbers of calcein‐AM and propidium iodide signals uptake by BNL hepatocarcinoma cancer cells were used to evaluate the sonoporation and cell death rate of the cells.

Results

We demonstrate that sonoporation can be realized based on repeatable vaporization instead of the commonly adopted inertial cavitation effects. In addition, it is found that the laser fluence and the acoustic pressure can be reduced. As an example, we demonstrate that the acoustic and optical energy for achieving a similar level of sonoporation rate can be as low as 0.44 MPa for the US PNP and 4.01 mJ/cm² for the laser fluence, which are lower than those with our previous approach (0.53 MPa and 4.95 mJ/cm², respectively).

Conclusion

We demonstrated the feasibility of vaporization‐based sonoporation at a lower optical and acoustic energy. It is an advantageous method that can enhance drug delivery efficiency, therapeutic safety and potentially deliver an upgraded gene therapy strategy for improved theragnosis.

Number concentration dependence of ultrasonic disruption ratio of diameter-sorted microcapsules

The use of ultrasound to destroy microcapsules in microbubble-assisted drug delivery systems (DDS) is of great interest. In the present study, the disruption ratios of capsule clusters were measured by observing and experimentally analyzing microcapsules with polymer shells undergoing disruption by ultrasound. The microcapsules were dispersed in a planar microchamber filled with a gelatin gel and sonicated using 1 MHz focused ultrasound. Different capsule populations were obtained using a filtration technique to modify and control the capsule sizes. The disruption ratio as a function of the concentration of capsules was obtained through image processing of the recorded photomicrographs. We found that the disruption ratio for each population exponentially decreases as the particle number concentration (PNC) increases. The maximum disruption ratio of the diameter-sorted capsules was larger than that of polydispersed capsules. Particularly, for resonant capsule populations, the ratio was more than twice that of polydispersed capsules. Furthermore, the maximum disruption ratio occurred at higher concentrations as the mean particle diameter of the capsule cluster decreased.

Localized Delivery of Caveolin-1 Peptide Assisted by Ultrasound-Mediated Microbubble Destruction Potentiates the Inhibition of Nitric Oxide-Dependent Vasodilation Response

In the endothelium, nitric oxide synthase (eNOS) is the enzyme that generates nitric oxide, a key molecule involved in a variety of biological functions and cancer-related events. Therefore, selective inhibition of eNOS represents an attractive therapeutic approach for NO-related diseases and anticancer therapy. Ultrasound-mediated microbubble destruction (UMMD) conjugated with cell-permeable peptides has been investigated as a drug delivery system for effective delivery of anticancer molecules. We investigated the feasibility of loading antennapedia-caveolin-1 peptide (AP-Cav), a specific eNOS inhibitor, onto microbubbles to be delivered by UMMD in rat aortic endothelium. AP-Cav-loaded microbubbles (AP-Cav-MBs) and US parameters were characterized. Aortas were treated with UMMD for 30 s with 1.3 × 10⁸ MBs/mL AP-Cav (8 μM)-MBs at 100-Hz pulse repetition frequency, 0.5-MPa acoustic pressure, 0.5 mechanical index and 10% duty cycle. NO-dependent vascular responses were assessed using an isolated organ system, 21 h post-treatment. Maximal relaxation response was inhibited 61.8% ± 1.6% in aortas treated with UMMD-AP-Cav-MBs, while in aortas treated with previously disrupted AP-Cav-MBs and then US, the inhibition was 31.6% ± 1.6%. The vascular contractile response was not affected. The impact of UMMD was evaluated in aortas treated with free AP-Cav; 30 μM of free AP-Cav was necessary to reach an inhibition response similar to that obtained with UMMD-AP-Cav-MBs. In conclusion, UMMD enhances the delivery and potentiates the effect of AP-Cav in the endothelial layer of rat aorta segments.

Effect of Treatment Sequencing on the Tumor Response to Combined Treatment With Ultrasound-Stimulated Microbubbles and Radiotherapy

OBJECTIVES

To investigate whether timing and sequencing of ultrasound-stimulated microbubbles (USMBs) and external beam radiotherapy (XRT) affect the treatment response in a preclinical prostate cancer model.

METHODS

Prostate cancer xenografts were treated with ultrasound-stimulated lipid microspheres before and after 8-Gy XRT. Treatments were separated by 0, 3, 6, 12, and 24 hours, with 5 tumors per group. Tumor effects were evaluated by microvessel density (measured by CD31 staining), cell death (terminal deoxynucleotidyl transferase deoxyuridine triphosphate nick end-labeling and hematoxylin-eosin staining), and hypoxia (carbonic anhydrase 9 staining).

RESULTS

Administering USMBs 6 hours before XRT showed the maximum treatment effect using all 3 assays. At this time, the mean cell death index ± SD was 36% ± 10%, compared with 19% ± 4% for no separation between USMB treatment and XRT; the microvessel density was 9 ± 3 counts per field (19 ± 5 without separation); and the percentage of hypoxic cells was 10% ± 5% (21% ± 4%). The observed treatment effect was greater with USMBs before XRT than when administering XRT first, but these differences were not statistically significant.

CONCLUSIONS

The maximum tumor effect was observed with USMBs delivered 6 hours before XRT. The sequencing of treatment did not have a significant effect on the tumor response.

Therapeutic Ultrasound in Cardiovascular Medicine

An advantage of therapeutic ultrasound (US) is the ability to cause controlled biological effects noninvasively. Depending on the magnitude and frequency of exposure parameters, US can interact in different ways with a variety of biological tissues. The development and clinical utility of therapeutic US techniques are now rapidly growing, especially with regard to the application of US pulses for cardiac pacing and the potential treatment of cardiovascular diseases. This review outlines the basic principles of US-based therapy in cardiology, including the acoustic properties of the cardiovascular tissue, and the use of US in therapeutic cardiovascular medicine.

Contrast-enhanced ultrasound for the assessment of placental development and function

The use of contrast agents as signal enhancers during ultrasound improves visualization and the diagnostic utility of this technology in medical imaging. Although widely used in many disciplines, contrast ultrasound is not routinely implemented in obstetrics, largely due to safety concerns of administered agents for pregnant women and the limited number of studies that address this issue. Here the microbubble characteristics that make them beneficial for enhancement of the blood pool and the quantification of real-time imaging are reviewed. Literature from pregnant animal model studies and safety assessments are detailed, and the potential for contrast-enhanced ultrasound to provide clinically relevant data and benefit our understanding of early placental development and detection of placental dysfunction is discussed.

Functional Activity and Endothelial-Lining Integrity of Ex Vivo Arteries Exposed to Ultrasound-Mediated Microbubble Destruction

Ultrasound-mediated microbubble destruction (UMMD) is a promising strategy to improve local drug delivery in specific tissues. However, acoustic cavitation can lead to harmful bioeffects in endothelial cells. We investigated the side effects of UMMD treatment on vascular function (contraction and relaxation) and endothelium integrity of ex vivo Wistar rat arteries. We used an isolated organ system to evaluate vascular responses and confocal microscopy to quantify the integrity and viability of endothelial cells. The arteries were exposed for 1-3 min to ultrasound at a 100 Hz pulse-repetition frequency, 0.5 MPa acoustic pressure, 50% duty cycle and 1%-5% v/v microbubbles. The vascular contractile response was not affected. The acetylcholine-dependent maximal relaxation response was reduced from 78% (control) to 60% after 3 min of ultrasound exposure. In arteries treated simultaneously with 1 min of ultrasound exposure and 1%, 2%, 3% or 5% microbubble concentration, vascular relaxation was reduced by 19%, 58%, 80% or 93%, respectively, compared with the control arteries. Fluorescent labeling revealed that apoptotic death, detachment of endothelial cells and reduced nitric oxide synthase phosphorylation are involved in relaxation impairment. We demonstrated that UMMD can be a safe technology if the correct ultrasound and microbubble parameters are applied. Furthermore, we found that tissue-function evaluation combined with cellular analysis can be useful to study ultrasound-microbubble-tissue interactions in the optimization of targeted endothelial drug delivery.

Optimization of microbubble enhancement of hyperthermia for cancer therapy in an in vivo breast tumour model

We have demonstrated that exposing human breast tumour xenografts to ultrasound-stimulated microbubbles enhances tumour cell death and vascular disruption resulting from hyperthermia treatment. The aim of this study was to investigate the effect of varying the hyperthermia and ultrasound-stimulated microbubbles treatment parameters in order to optimize treatment bioeffects. Human breast cancer (MDA-MB-231) tumour xenografts in severe combined immunodeficiency (SCID) mice were exposed to varying microbubble concentrations (0%, 0.1%, 1% or 3% v/v) and ultrasound sonication durations (0, 1, 3 or 5 min) at 570 kPa peak negative pressure and central frequency of 500 kHz. Five hours later, tumours were immersed in a 43°C water bath for varying hyperthermia treatment durations (0, 10, 20, 30, 40, 50 or 60 minutes). Results indicated a significant increase in tumour cell death reaching 64 ± 5% with combined treatment compared to 11 ± 3% and 26 ± 5% for untreated and USMB-only treated tumours, respectively. A similar but opposite trend was observed in the vascular density of the tumours receiving the combined treatment. Optimal treatment parameters were found to consist of 40 minutes of heat with low power ultrasound treatment microbubble parameters of 1 minute of sonification and a 1% microbubble concentration.

Delayed contrast enhancement of hepatic parenchyma after intravenous sonographic contrast agent: unusual phenomenon. Case report and review of literature

Aim

A case of heterogeneous late-phase hepatic enhancement (HLHE) using contrast‐enhanced ultrasound (CEUS) with SonoVue is presented, where HLHE lasted after 50 min of injection.

Methods

This study aims to review prior literature on this topic, to characterize the features of HLHE in the liver, and to find possible and reliable explanations for this phenomenon.

Results

From literature, thus far five publications discuss this phenomenon with a total of 21 patients.

Conclusion

We suggest that phagocytosis of contrast agent microbubbles by macrophages, and lymphocytosis of peripheral blood due to stress conditions of the patients might be in the background of HLHE.

Microbubble Formulations: Synthesis, Stability, Modeling and Biomedical Applications

Microbubbles are increasingly being used in biomedical applications such as ultrasonic imaging and targeted drug delivery. Microbubbles typically range from 0.1 to 10 µm in size and consist of a protective shell made of lipids or proteins. The shell encapsulates a gaseous core containing gases such as oxygen, sulfur hexafluoride or perfluorocarbons. This review is a consolidated account of information available in the literature on research related to microbubbles. Efforts have been made to present an overview of microbubble synthesis techniques; microbubble stability; microbubbles as contrast agents in ultrasonic imaging and drug delivery vehicles; and side effects related to microbubble administration in humans. Developments related to the modeling of microbubble dissolution and stability are also discussed.

Cerebral microembolism in the critically ill with acute kidney injury (COMET-AKI trial): study protocol for a randomized controlled clinical trial

Background

Microembolism is a frequent pathological event during extracorporeal renal replacement therapy (RRT). Some previous data indicate that microemboli are generated in patients who are undergoing RRT and that these may contribute to increased cerebrovascular and neurocognitive morbidity in patients with end-stage renal disease. The current trial aims to quantify the microembolic load and respective qualitative composition that effectively reaches the intracerebral circulation in critically ill patients treated with different RRT modalities for acute kidney injury (AKI).

Methods/design

The COMET-AKI trial is a prospective, randomized controlled clinical trial with a 2-day clinical assessment period and follow-up visits at 6 and 12 months. Consecutive critically ill patients with AKI on continuous renal replacement therapy (CRRT) scheduled for a switch to intermittent renal replacement therapy (IRRT) will be randomized to either switch to IRRT within the next 24 h or continued CRRT for an additional 24 h. Cerebral microembolic load will be determined at baseline, i.e., before switch (on CRRT for both groups) and on IRRT versus CRRT, whichever group they were randomized to. The primary endpoint is defined as the difference in mean total cerebral microemboli count during the measurement period on CRRT versus IRRT following randomization. Microemboli will be assessed within the RRT circuit by a 1.5-MHz ultrasound detector attached to the venous RRT tubing and cerebral microemboli will be measured in the middle cerebral artery using a 1.6-MHz robotic transcranial Doppler system with automatic classification of Doppler signals as solid or gaseous. In addition to Doppler measurements, patients will be examined by magnetic resonance imaging and neurocognitive tests to gain better understanding into the potential morphological and clinical consequences of embolization.

Discussion

The results of COMET-AKI may help to gain a better insight into RRT modality-associated differences regarding microbubble generation and the cerebral microembolic burden endured by RRT recipients. Furthermore, identification of covariates of microbubble formation and distribution may help to encourage the evolution of next-generation RRT circuits including machinery and/or filters.

Trial registration

ClinicalTrials.gov, ID: NCT02621749. Registered on 3 December 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2561-3) contains supplementary material, which is available to authorized users.

Mechanistic understanding the bioeffects of ultrasound-driven microbubbles to enhance macromolecule delivery

Ultrasound-driven microbubbles can trigger reversible membrane perforation (sonoporation), open interendothelial junctions and stimulate endocytosis, thereby providing a temporary and reversible time-window for the delivery of macromolecules across biological membranes and endothelial barriers. This time-window is related not only to cavitation events, but also to biological regulatory mechanisms. Mechanistic understanding of the interaction between cavitation events and cells and tissues, as well as the subsequent cellular and molecular responses will lead to new design strategies with improved efficacy and minimized side effects. Recent important progress on the spatiotemporal characteristics of sonoporation, cavitation-induced interendothelial gap and endocytosis, and the spatiotemporal bioeffects and the preliminary biological mechanisms in cavitation-enhanced permeability, has been made. On the basis of the summary of this research progress, this Review outlines the underlying bioeffects and the related biological regulatory mechanisms involved in cavitation-enhanced permeability; provides a critical commentary on the future tasks and directions in this field, including developing a standardized methodology to reveal mechanism-based bioeffects in depth, and designing biology-based treatment strategies to improve efficacy and safety. Such mechanistic understanding the bioeffects that contribute to cavitation-enhanced delivery will accelerate the translation of this approach to the clinic.

Mechanical and Biological Effects of Ultrasound: A Review of Present Knowledge

Ultrasound is widely used for medical diagnosis and increasingly for therapeutic purposes. An understanding of the bio-effects of sonography is important for clinicians and scientists working in the field because permanent damage to biological tissues can occur at high levels of exposure. Here the underlying principles of thermal mechanisms and the physical interactions of ultrasound with biological tissues are reviewed. Adverse health effects derived from cellular studies, animal studies and clinical reports are reviewed to provide insight into the in vitro and in vivo bio-effects of ultrasound.

Harmonic responses and cavitation activity of encapsulated microbubbles coupled with magnetic nanoparticles

Encapsulated microbubbles coupled with magnetic nanoparticles, one kind of hybrid agents that can integrate both ultrasound and magnetic resonance imaging/therapy functions, have attracted increasing interests in both research and clinic communities. However, there is a lack of comprehensive understanding of their dynamic behaviors generated in diagnostic and therapeutic applications. In the present work, a hybrid agent was synthesized by integrating superparamagnetic iron oxide nanoparticles (SPIOs) into albumin-shelled microbubbles (named as SPIO-albumin microbubbles). Then, both the stable and inertial cavitation thresholds of this hybrid agent were measured at varied SPIO concentrations and ultrasound parameters (e.g., frequency, pressure amplitude, and pulse length). The results show that, at a fixed acoustic driving frequency, both the stable and inertial cavitation thresholds of SPIO-albumin microbubble should decrease with the increasing SPIO concentration and acoustic driving pulse length. The inertial cavitation threshold of SPIO-albumin microbubbles also decreases with the raised driving frequency, while the minimum sub- and ultra-harmonic thresholds appear at twice and two thirds resonance frequency, respectively. It is also noticed that both the stable and inertial cavitation thresholds of SonoVue microbubbles are similar to those measured for hybrid microbubbles with a SPIO concentration of 114.7 μg/ml. The current work could provide better understanding on the impact of the integrated SPIOs on the dynamic responses (especially the cavitation activities) of hybrid microbubbles, and suggest the shell composition of hybrid agents should be appropriately designed to improve their clinical diagnostic and therapeutic performances of hybrid microbubble agents.

Acoustic power measurement of high-intensity focused ultrasound transducer using a pressure sensor

The acoustic power of high-intensity focused ultrasound (HIFU) is an important parameter that should be measured prior to each treatment to guarantee effective and safe outcomes. A new calibration technique was developed that involves estimating the pressure distribution, calculating the acoustic power using an underwater pressure blast sensor, and compensating the contribution of harmonics to the acoustic power. The output of a clinical extracorporeal HIFU system (center frequency of ~1 MHz, p+ = 2.5-57.2 MPa, p(-) = -1.8 to -13.9 MPa, I(SPPA) = 513-22,940 W/cm(2), -6 dB size of 1.6 × 10 mm: lateral × axial) was measured using this approach and then compared with that obtained using a radiation force balance. Similarities were found between each method at acoustic power ranging from 18.2 W to 912 W with an electrical-to-acoustic conversion efficiency of ~42%. The proposed method has advantages of low weight, smaller size, high sensitivity, quick response, high signal-to-noise ratio (especially at low power output), robust performance, and easy operation of HIFU exposimetry measurement.

Non-invasive monitoring of ultrasound-stimulated microbubble radiation enhancement using photoacoustic imaging

Modulation of the tumour microvasculature has been demonstrated to affect the effectiveness of radiation, stimulating the search for anti-angiogenic and vascular-disrupting treatment modalities. Microbubbles stimulated by ultrasound have recently been demonstrated as a radiation enhancer when used with different cancer models including PC3. Here, photoacoustics imaging technique was used to assess this treatment’s effects on haemoglobin levels and oxygen saturation. Correlations between this modality and power doppler assessments of blood flow, and histology measurements of vascular integrity and cell death were also investigated. Xenograft prostate tumours in SCID mice were treated with 0, 2, or 8 Gy radiation combined with microbubbles exposed to 500 kHz ultrasound at a peak negative pressure of 0, 570, and 750 kPa. Tumours were assessed and levels of total haemoglobin, oxygen saturation were measured using photoacoustics before and 24 hours after treatment along with power doppler measured blood flow. Mice were then sacrificed and tumours were assessed for cell death and vascular composition using immunohistochemistry. Treatments using 8 Gy and microbubbles resulted in oxygen saturation decreasing by 28 ± 10% at 570 kPa and 25 ± 29% at 750 kPa, which corresponded to 44 ± 9% and 40 ± 14% respective decreases in blood flow as measured with power doppler. Corresponding histology indicated 31 ± 5% at 570 kPa and 37 ± 5% at 750 kPa in terms of cell death. There were drops in intact vasculature of 15 ± 2% and 20 ± 2%, for treatments at 570 kPa and 750 kPa. In summary, photoacoustic measures of total haemoglobin and oxygen saturation paralleled changes in power doppler indicators of blood flow. Destruction of tumour microvasculature with microbubble-enhanced radiation also led to decreases in blood flow and was associated with increases in cell death and decreases in intact vasculature as detected with CD31 labeling.

Investigation on the inertial cavitation threshold and shell properties of commercialized ultrasound contrast agent microbubbles

The inertial cavitation (IC) activity of ultrasound contrast agents (UCAs) plays an important role in the development and improvement of ultrasound diagnostic and therapeutic applications. However, various diagnostic and therapeutic applications have different requirements for IC characteristics. Here through IC dose quantifications based on passive cavitation detection, IC thresholds were measured for two commercialized UCAs, albumin-shelled KangRun(®) and lipid-shelled SonoVue(®) microbubbles, at varied UCA volume concentrations (viz., 0.125 and 0.25 vol. %) and acoustic pulse lengths (viz., 5, 10, 20, 50, and 100 cycles). Shell elastic and viscous coefficients of UCAs were estimated by fitting measured acoustic attenuation spectra with Sarkar's model. The influences of sonication condition (viz., acoustic pulse length) and UCA shell properties on IC threshold were discussed based on numerical simulations. Both experimental measurements and numerical simulations indicate that IC thresholds of UCAs decrease with increasing UCA volume concentration and acoustic pulse length. The shell interfacial tension and dilatational viscosity estimated for SonoVue (0.7 ± 0.11 N/m, 6.5 ± 1.01 × 10(-8) kg/s) are smaller than those of KangRun (1.05 ± 0.18 N/m, 1.66 ± 0.38 × 10(-7) kg/s); this might result in lower IC threshold for SonoVue. The current results will be helpful for selecting and utilizing commercialized UCAs for specific clinical applications, while minimizing undesired IC-induced bioeffects.

Preliminary observations on the spatial correlation between short-burst microbubble oscillations and vascular bioeffects

The objective of this preliminary study was to examine the spatial correlation between microbubble (MB)-induced vessel wall displacements and resultant microvascular bioeffects. MBs were injected into venules in ex vivo rat mesenteries and insonated by a single short ultrasound pulse with a center frequency of 1 MHz and peak negative pressures spanning the range of 1.5-5.6 MPa. MB and vessel dynamics were observed under ultra-high speed photomicrography. The tissue was examined by histology or transmission electron microscopy for vascular bioeffects. Image registration allowed for spatial correlation of MB-induced vessel wall motion to corresponding vascular bioeffects, if any. In cases in which damage was observed, the vessel wall had been pulled inward by more than 50% of the its initial radius. The observed damage was characterized by the separation of the endothelium from the vessel wall. Although the study is limited to a small number of observations, analytic statistical results suggest that vessel invagination comprises a principal mechanism for bioeffects in venules by microbubbles.

Characteristic microvessel relaxation timescales associated with ultrasound-activated microbubbles

Ultrasound-activated microbubbles were used as actuators to deform microvessels for quantifying microvessel relaxation timescales at megahertz frequencies. Venules containing ultrasound contrast microbubbles were insonified by short 1 MHz ultrasound pulses. Vessel wall forced-deformations were on the same microsecond timescale as microbubble oscillations. The subsequent relaxation of the vessel was recorded by high-speed photomicrography. The tissue was modeled as a simple Voigt solid. Relaxation time constants were measured to be on the order of ∼10 μs. The correlation coefficients between the model and 38 data sets were never lower than 0.85, suggesting this model is sufficient for modeling tissue relaxation at these frequencies. The results place a bound on potential numerical values for viscosity and elasticity of venules.

Microbubble and ultrasound radioenhancement of bladder cancer

BACKGROUND

Tumour vasculature is an important component of tumour growth and survival. Recent evidence indicates tumour vasculature also has an important role in tumour radiation response. In this study, we investigated ultrasound and microbubbles to enhance the effects of radiation.

METHODS

Human bladder cancer HT-1376 xenografts in severe combined immuno-deficient mice were used. Treatments consisted of no, low and high concentrations of microbubbles and radiation doses of 0, 2 and 8 Gy in short-term and longitudinal studies. Acute response was assessed 24 h after treatment and longitudinal studies monitored tumour response weekly up to 28 days using power Doppler ultrasound imaging for a total of 9 conditions (n=90 animals).

RESULTS

Quantitative analysis of ultrasound data revealed reduced blood flow with ultrasound-microbubble treatments alone and further when combined with radiation. Tumours treated with microbubbles and radiation revealed enhanced cell death, vascular normalisation and areas of fibrosis. Longitudinal data demonstrated a reduced normalised vascular index and increased tumour cell death in both low and high microbubble concentrations with radiation.

CONCLUSION

Our study demonstrated that ultrasound-mediated microbubble exposure can enhance radiation effects in tumours, and can lead to enhanced tumour cell death.

Contrast ultrasound imaging of the aorta alters vascular morphology and circulating von Willebrand factor in hypercholesterolemic rabbits

OBJECTIVES

Ultrasound contrast agents (UCAs) are intravenously infused microbubbles that add definition to ultrasonic images. Ultrasound contrast agents continue to show clinical promise in cardiovascular imaging, but their biological effects are not known with confidence. We used a cholesterol-fed rabbit model to evaluate these effects when used in conjunction with ultrasound (US) to image the descending aorta.

METHODS

Male New Zealand White rabbits (n = 41) were weaned onto an atherogenic diet containing 1% cholesterol, 10% fat, and 0.11% magnesium. At 21 days, rabbits were exposed to contrast US at 1 of 4 pressure levels using either the UCA Definity (Lantheus Medical Imaging, Inc, North Billerica, MA) or a saline control (n = 5 per group). Blood samples were collected and analyzed for lipids and von Willebrand factor (vWF), a marker of endothelial function. Animals were euthanized at 42 days, and tissues were collected for histologic analysis.

RESULTS

After adjustment for pre-exposure vWF, high-level US (in situ [at the aorta] peak rarefactional pressure of 1.4 or 2.1 MPa) resulted in significantly lower vWF 1 hour post exposure (P = .0127; P(adj) < .0762). This difference disappeared within 24 hours. Atheroma thickness in the descending aorta was lower in animals receiving the UCA compared to animals receiving saline.

CONCLUSIONS

Contrast US affected the descending aorta, as evidenced by two separate outcome measures. These results may be a first step in elucidating a previously unknown biological effect of UCAs. Further research is warranted to characterize the effects of this procedure.

Adjustment of ultrasound exposure duration to microbubble sonodestruction kinetics for optimal cell sonoporation in vitro

Cell sonoporation enables the delivery of various exogenous molecules into the cells. To maximize the percentage of reversibly sonoporated cells and to increase cell viability we propose a model for implicit dosimetry for adjustment of ultrasound (US) exposure duration. The Chinese hamster ovary cell suspension was supplemented with microbubbles (MB) and exposed to US, operating at the frequency of 880kHz, with a 100% duty cycle and with an output peak negative pressure (PNP) of 500kPa for durations ranging from 0.5 to 30s. Using diagnostic B-scan imaging we showed that the majority of the MB at 500kPa US peak negative pressure undergo sonodestruction in less than a second. During this time maximal number of reversibly sonoporated cells was achieved. Increase of US exposure duration did not increase sonoporated cell number, however it induced additional cell viability decrease. Therefore aiming to achieve the highest level of reversibly sonoporated cells and also to preserve the highest level of cell viability, the duration of US exposure should not exceed the duration needed for complete MB sonodestruction.

Inhibition effects of high mechanical index ultrasound contrast on hepatic metastasis of cancer in a rat model

RATIONAL AND OBJECTIVES

The liver is the most common organ for tumor metastasis. The development of new methods to depress hepatic metastasis is of great importance in improving survival. The aim of this study was to observe the effects of high-mechanical index ultrasound contrast on hepatic metastasis of colorectal cancer.

MATERIALS AND METHODS

Hepatic metastasis models were established by injecting human colon carcinoma LoVo cells into the spleens of Sprague-Dawley rats. The rats were divided into a control group, a microbubble plus ultrasound group, a simple ultrasound group, and a simple microbubble group. The ultrasound contrast agent SonoVue (1 mL/kg) was injected via the tail vein, and high-mechanical index ultrasound contrast (frequency, 1.5 MHz; mechanical index, 1.7) was performed on the spleen intermittently for 2 minutes. The animals were sacrificed after 10 days, and the sizes and number of hepatic metastases were measured and compared. Histologic pathology and splenic ultrastructure were observed.

RESULTS

The number and sizes of hepatic metastases patently decreased in rats in the microbubble plus ultrasound group (P < .01). There were no obvious differences among the control group, simple ultrasound group, and simple microbubble group in hepatic metastases (P > .05). Histologic pathology showed that the number of tumor cells in the spleens decreased considerably, and massive necroses, hemorrhages, and thrombi were observed in the tumor and spleen tissues of rats in the microbubble plus ultrasound group. Transmission electron microscopy showed that the mitochondria of tumor cells and endothelial cells were clearly swelled, and there were gaps among endothelial cells and platelets aggregated in capillary vessels.

CONCLUSION

This research shows that intermittent high-mechanical index ultrasound contrast may inhibit the hepatic metastasis of cancer in a rat model.

Ultrasound bioeffects and safety

The main mechanisms by which ultrasound can induce biological effects as it passes through the body are thermal and mechanical in nature. The mechanical effects are primarily related to the presence of gas, whether drawn out of solution by the negative going ultrasound pressure wave (acoustic cavitation), a naturally occurring gas body (such as lung alveoli), or deliberately introduced into the blood stream to increase imaging contrast (microbubble contrast agents). Observed biological effects are discussed in the context of these mechanisms and their relevance to ultrasound safety is discussed.

Ultrasound imaging and contrast agents: A safe alternative to MRI?

Microbubble contrast media are used to enhance ultrasound images. Because ultrasound is a real-time investigation, contrast-enhanced ultrasound offers possibilities for perfusion imaging. This review is conducted to evaluate the safety of contrast-enhanced ultrasound and its possible role in medical imaging. The safety of diagnostic ultrasound is still an important field of research. The wanted and unwanted effects of ultrasound and microbubble contrast media as well as the effects of ultrasound on these microbubbles are described. Furthermore, some of the possible applications and indications of contrast-enhanced ultrasound will be discussed. The shared advantages of MRI and ultrasound are the use of non-ionizing radiation and non-nephrotoxic contrast media. From this review it can be concluded that, for certain indications, contrast enhanced ultrasound could be a safe alternative to MRI and a valuable addition to medical imaging.

Ultrasound contrast microbubbles in imaging and therapy: physical principles and engineering

Microbubble contrast agents and the associated imaging systems have developed over the past 25 years, originating with manually-agitated fluids introduced for intra-coronary injection. Over this period, stabilizing shells and low diffusivity gas materials have been incorporated in microbubbles, extending stability in vitro and in vivo. Simultaneously, the interaction of these small gas bubbles with ultrasonic waves has been extensively studied, resulting in models for oscillation and increasingly sophisticated imaging strategies. Early studies recognized that echoes from microbubbles contained frequencies that are multiples of the microbubble resonance frequency. Although individual microbubble contrast agents cannot be resolved-given that their diameter is on the order of microns-nonlinear echoes from these agents are used to map regions of perfused tissue and to estimate the local microvascular flow rate. Such strategies overcome a fundamental limitation of previous ultrasound blood flow strategies; the previous Doppler-based strategies are insensitive to capillary flow. Further, the insonation of resonant bubbles results in interesting physical phenomena that have been widely studied for use in drug and gene delivery. Ultrasound pressure can enhance gas diffusion, rapidly fragment the agent into a set of smaller bubbles or displace the microbubble to a blood vessel wall. Insonation of a microbubble can also produce liquid jets and local shear stress that alter biological membranes and facilitate transport. In this review, we focus on the physical aspects of these agents, exploring microbubble imaging modes, models for microbubble oscillation and the interaction of the microbubble with the endothelium.

Ultrasound targeted microbubble destruction for drug and gene delivery

BACKGROUND

Gas-filled microbubbles have been used as ultrasound contrast agents for some decades. More recently, such microbubbles have evolved as experimental tools for organ- and tissue-specific drug and gene delivery. When sonified with ultrasound near their resonance frequency, microbubbles oscillate. With higher ultrasound energies, oscillation amplitudes increase, leading to microbubble destruction. This phenomenon can be used to deliver a substance into a target organ, if microbubbles are co-administered loaded with drugs or gene therapy vectors before i.v. injection.

OBJECTIVE

This review focuses on different experimental applications of microbubbles as tools for drug and gene delivery. Different organ systems and different classes of bioactive substances that have been used in previous studies will be discussed.

METHODS

All the available literature was reviewed to highlight the potential of this non-invasive, organ-specific delivery system.

CONCLUSION

Ultrasound targeted microbubble destruction has been used in various organ systems and in tumours to successfully deliver drugs, proteins, gene therapy vectors and gene silencing constructs. Many proof of principle studies have demonstrated its potential as a non-invasive delivery tool. However, too few large animal studies and studies with therapeutic aims have been performed to see a clinical application of this technique in the near future. Nevertheless, there is great hope that preclinical large animal studies will confirm the successful results already obtained in small animals.

Ultrasonic gene and drug delivery to the cardiovascular system

Ultrasound targeted microbubble destruction has evolved as a promising tool for organ specific gene and drug delivery. This technique has initially been developed as a method in myocardial contrast echocardiography, destroying intramyocardial microbubbles to characterize refill kinetics. When loading similar microbubbles with a bioactive substance, ultrasonic destruction of microbubbles may release the transported substance in the targeted organ. Furthermore, high amplitude oscillations of microbubbles lead to increased capillary and cell membrane permeability, thus facilitating tissue and cell penetration of the released substance. While this technique has been successfully used in many organs, its application in the cardiovascular system has dominated so far. Drug delivery using microbubbles has played a minor role in the cardiovascular system. In contrast, gene transfer has been successfully achieved in many studies. Both viral and non-viral vectors were used for loading on microbubbles. This review article will give an overview on studies that have applied ultrasound targeted microbubble destruction to deliver substances in the heart and blood vessels. It will show potential therapeutic targets, especially for gene therapy, describe feasible substances that can be loaded on microbubbles, and critically discuss prospects and limitations of this technique.

Bioeffects considerations for diagnostic ultrasound contrast agents

Diagnostic ultrasound contrast agents have been developed for enhancing the echogenicity of blood and for delineating other structures of the body. Approved agents are suspensions of gas bodies (stabilized microbubbles), which have been designed for persistence in the circulation and strong echo return for imaging. The interaction of ultrasound pulses with these gas bodies is a form of acoustic cavitation, and they also may act as inertial cavitation nuclei. This interaction produces mechanical perturbation and a potential for bioeffects on nearby cells or tissues. In vitro, sonoporation and cell death occur at mechanical index (MI) values less than the inertial cavitation threshold. In vivo, bioeffects reported for MI values greater than 0.4 include microvascular leakage, petechiae, cardiomyocyte death, inflammatory cell infiltration, and premature ventricular contractions and are accompanied by gas body destruction within the capillary bed. Bioeffects for MIs of 1.9 or less have been reported in skeletal muscle, fat, myocardium, kidney, liver, and intestine. Therapeutic applications that rely on these bioeffects include targeted drug delivery to the interstitium and DNA transfer into cells for gene therapy. Bioeffects of contrast-aided diagnostic ultrasound happen on a microscopic scale, and their importance in the clinical setting remains uncertain.

Fetal ultrasound: mechanical effects

In this discussion, any biological effect of ultrasound that is accompanied by temperature increments less than 1 degrees C above normal physiologic levels is called a mechanical effect. However, one should keep in mind that the term mechanical effect also includes processes that are not of a mechanical nature but arise secondary to mechanical interaction between ultrasound and tissues, such as chemical reactions initiated by free oxygen species generated during cavitation and sonoluminescence. Investigations with laboratory animals have documented that pulsed ultrasound can produce damage to biological tissues in vivo through nonthermal mechanisms. The acoustic output used to induce these adverse bio-effects is considerably greater than the output of diagnostic devices when gas bodies are not present. However, low-intensity pulsed ultrasound is used clinically to accelerate the bone fracture repair process and induce healing of nonunions in humans. Low-intensity pulsed ultrasound also has been shown to enhance repair of soft tissue damage and accelerate nerve regeneration in animal models. Although such exposures to low intensity do not appear to cause damage to exposed tissues, they do raise questions about the acoustic threshold that might induce potentially adverse developmental effects in the fetus. To date, bioeffects studies in humans do not substantiate a causal relationship between diagnostic ultrasound exposure during pregnancy and adverse biological effects to the fetus. However, the epidemiologic studies were conducted with commercially available devices predating 1992, having outputs not exceeding a derated spatial-peak temporal-average intensity (ISPTA.3) of 94 mW/cm2. Current limits in the United States allow an ISPTA.3 of 720 mW/cm2 for obstetric modes. At the time of this report, available evidence, experimental or epidemiologic, is insufficient to conclude that there is a causal relationship between obstetric diagnostic ultrasound exposure and adverse nonthermal effects to the fetus. However, low-intensity pulsed ultrasound effects reported in humans and animal models indicate a need for further investigation of potentially adverse developmental effects.

[Ultrasound contrast agents. Pharmaceutical drug safety and bioeffects]

In this overview safety aspects of ultrasound contrast agents (USCA) are described and discussed. In general USCA are very safe drugs. However, allergic adverse reactions can rarely occur, particularly due to the colloidal structure of USCA. In addition, the use of USCA could reduce the threshold for acoustically induced bioeffects and has the potential to increase these effects. In in vitro studies and animal trials USCA caused petechial hemorrhages, vascular damage, and the formation of free radicals. Even DNA damage with single strand breaks could be demonstrated. In human studies and clinical practice none of these bioeffects could be observed. In contrast-enhanced echocardiography a higher rate of premature ventricular contractions has been reported when imaging was triggered at the end systole. Compared with other contrast agents contrast-enhanced ultrasound showed no nephrotoxic effects and could prove to be an alternative diagnostic method for patients with renal failure.

Nephron injury induced by diagnostic ultrasound imaging at high mechanical index with gas body contrast agent

The right kidney of anesthetized rats was imaged with intermittent diagnostic ultrasound (1.5 MHz; 1-s trigger interval) under exposure conditions simulating those encountered in human perfusion imaging. The rats were infused intravenously with 10 microL/kg/min Definity (Bristol-Myers Squibb Medical Imaging, Inc., N. Billerica, MA, USA) while being exposed to mechanical index (MI) values of up to 1.5 for 1 min. Suprathreshold MI values ruptured glomerular capillaries, resulting in blood filling Bowman's space and proximal convoluted tubules of many nephrons. The re-establishment of a pressure gradient after hemostasis caused the uninjured portions of the glomerular capillaries to resume the production of urinary filtrate, which washed some or all of the erythrocytes out of Bowman's space and cleared blood cells from some nephrons into urine within six hours. However, many of the injured nephrons remained plugged with tightly packed red cell casts 24 h after imaging and also showed degeneration of tubular epithelium, indicative of acute tubular necrosis. The additional damage caused by the extravasated blood amplified that caused by the original cavitating gas body. Human nephrons are virtually identical to those of the rat and so it is probable that similar glomerular capillary rupture followed by transient blockage and/or epithelial degeneration will occur after clinical exposures using similar high MI intermittent imaging with gas body contrast agents. The detection of blood in postimaging urine samples using standard hematuria tests would confirm whether or not clinical protocols need to be developed to avoid this potential for iatrogenic injury.

Insonation of the eye in the presence of microbubbles: preliminary study of the duration and degree of vascular bioeffects--work in progress

OBJECTIVE

The purpose of this study was to investigate the presence and duration of vascular permeability changes induced by the combination of ultrasound and an intravascular microbubble contrast agent in the rabbit eye.

METHODS

Five eyes were studied in 8 anaesthetized rabbits. Insonation was performed with a diagnostic B-mode system (center frequency = 2 MHz; mechanical index [MI] = 0.2 and 1.7) for 5 minutes after administration of perflutren microbubbles (0.07 mL/kg). Fluorescein fundus angiography was performed before and 3 minutes after insonation; at 6 minutes, color fundus photography was used to assess the dye leakage, bleeding, and alteration of the diameter of fundus vessels.

RESULTS

Alteration of fundus vessel diameters was observed in 1 of 5 cases at a low MI and in 4 of 5 cases at a higher MI. In 1 case, leakage of fluorescein indicated increased permeability at the higher MI. No bleeding was detected in any case.

CONCLUSIONS

The permeability change induced by insonation and this dose of an ultrasound contrast agent appears to be transient under the conditions studied, although the time delay between insonation and optical assessment limits the completeness of the findings. This preliminary study may be relevant to drug delivery strategies using ultrasound and microbubbles.

Ultrasound-biophysics mechanisms

Ultrasonic biophysics is the study of mechanisms responsible for how ultrasound and biological materials interact. Ultrasound-induced bioeffect or risk studies focus on issues related to the effects of ultrasound on biological materials. On the other hand, when biological materials affect the ultrasonic wave, this can be viewed as the basis for diagnostic ultrasound. Thus, an understanding of the interaction of ultrasound with tissue provides the scientific basis for image production and risk assessment. Relative to the bioeffect or risk studies, that is, the biophysical mechanisms by which ultrasound affects biological materials, ultrasound-induced bioeffects are generally separated into thermal and non-thermal mechanisms. Ultrasonic dosimetry is concerned with the quantitative determination of ultrasonic energy interaction with biological materials. Whenever ultrasonic energy is propagated into an attenuating material such as tissue, the amplitude of the wave decreases with distance. This attenuation is due to either absorption or scattering. Absorption is a mechanism that represents that portion of ultrasonic wave that is converted into heat, and scattering can be thought of as that portion of the wave, which changes direction. Because the medium can absorb energy to produce heat, a temperature rise may occur as long as the rate of heat production is greater than the rate of heat removal. Current interest with thermally mediated ultrasound-induced bioeffects has focused on the thermal isoeffect concept. The non-thermal mechanism that has received the most attention is acoustically generated cavitation wherein ultrasonic energy by cavitation bubbles is concentrated. Acoustic cavitation, in a broad sense, refers to ultrasonically induced bubble activity occurring in a biological material that contains pre-existing gaseous inclusions. Cavitation-related mechanisms include radiation force, microstreaming, shock waves, free radicals, microjets and strain. It is more challenging to deduce the causes of mechanical effects in tissues that do not contain gas bodies. These ultrasonic biophysics mechanisms will be discussed in the context of diagnostic ultrasound exposure risk concerns.

Interactions between consecutive sonications for characterizing the thermal mechanism in focused ultrasound therapy

The use of focused ultrasound for thermal ablation or therapy has become a promising modality due to its high selectivity and noninvasiveness. The temperature increase that induces thermal necrosis in the focal beam area has been reported to be attributed to the absorption of ultrasound energy and heating enhancement by acoustic cavitation. The purpose of this study is to propose a novel experimental arrangement to observe the thermal lesion formation and to demonstrate that the presence of the ultrasound-induced, macroscopically-visible bubbles may exert a key effect in thermal lesion formation. In our experiments, consecutive sonications with orthogonal intersections were applied to observe the thermal lesion interaction induced by 577- or 1155-kHz ultrasound. Results showed that the 1155-kHz heating was dominated by ultrasound energy absorption, with blocking of consecutive sonications being evident only rarely. However, in 577-kHz sonications, the thermal process was dominated by inertial cavitation and the corresponding ultrasound-induced, macroscopically-visible bubbles, which was verified from the later lesion being blocked by the former one and direct observation from light microscopy. This study demonstrates that the operating frequency for ultrasound thermal ablation should be selected based on the intended specific thermal mechanisms to be induced.

Overview of experimental studies of biological effects of medical ultrasound caused by gas body activation and inertial cavitation

Ultrasound exposure can induce bioeffects in mammalian tissue by the nonthermal mechanism of gas body activation. Pre-existing bodies of gas may be activated even at low-pressure amplitudes. At higher-pressure amplitudes, violent cavitation activity with inertial collapse of microbubbles can be generated from latent nucleation sites or from the destabilization of gas bodies. Mechanical perturbation at the activation sites leads to biological effects on nearby cells and structures. Shockwave lithotripsy was the first medical ultrasound application for which significant cavitational bioeffects were demonstrated in mammalian tissues, including hemorrhage and injury in the kidney. Lithotripter shockwaves can also cause hemorrhage in lung and intestine by activation of pre-existing gas bodies in these tissues. Modern diagnostic ultrasound equipment develops pressure amplitudes sufficient for inertial cavitation, but the living body normally lacks suitable cavitation nuclei. Ultrasound contrast agents (UCAs) are suspensions of microscopic gas bodies created to enhance the echogenicity of blood. Ultrasound contrast agent gas bodies also provide nuclei for inertial cavitation. Bioeffects from contrast-aided diagnostic ultrasound depend on pressure amplitude, UCA dose, dosage delivery method and image timing parameters. Microvascular leakage, capillary rupture, cardiomyocyte killing, inflammatory cell infiltration, and premature ventricular contractions have been reported for myocardial contrast echocardiography with clinical ultrasound machines and clinically relevant agent doses in laboratory animals. Similar bioeffects have been reported in intestine, skeletal muscle, fat, lymph nodes and kidney. These microscale bioeffects could be induced unknowingly in diagnostic examinations; however, the medical significance of bioeffects of diagnostic ultrasound with contrast agents is not yet fully understood in relation to the clinical setting.

The relationship of acoustic emission and pulse-repetition frequency in the detection of gas body stability and cell death

The effect of pulse-repetition frequency (PRF) and number of exposures on membrane damage and subsequent death of contrast agent-attached phagocytic cells was examined. Phagocytic cells of a mouse macrophage cell line were grown as monolayers on thin Mylar sheets. Optison microbubbles were attached to these cells by incubation. Focused ultrasound exposures (Pr = 2 MPa) were implemented at a frequency of 2.25 MHz with 46 cycle pulses and clinically relevant PRFs of 1 kHz, 100 Hz, 10 Hz, 1 Hz and 0.1 Hz in a degassed water bath. A 1-MHz receive transducer measured the scattered signal. The frequency spectrum was normalized to a control spectrum from linear scatterers. Photomicrographs of the cell monolayer were made before and after exposure, and a dye exclusion test (Trypan blue) was used to find the percentage of blue-stained cells indicating cell death, which was then related to acoustic emission. For 10 acoustic pulses and a high prerinse gas body concentration, there was less cell death and correspondingly lower change in the acoustic emissions at a PRF of 1 kHz than with PRFs of 100 Hz, 10 Hz, 1 Hz and 0.1 Hz (p < 0.001). The reduced effect at high PRF may be indicative of some evolution of the shelled microbubble that requires significant total exposure duration (> 10 ms, but < 100 ms).

Incidence of cardiac arrhythmias with therapeutic versus diagnostic ultrasound and intravenous microbubbles

OBJECTIVE

The purpose of this study was to determine the type of arrhythmias induced with therapeutic versus diagnostic transthoracic low-frequency ultrasound (TLFUS) transducers in the presence of intravenous microbubbles.

METHODS

Intravenous perfluorocarbon-exposed sonicated dextrose albumin (PESDA) microbubbles were infused or given as a bolus injection while TLFUS was applied in the standard parasternal and apical views with either a 1-MHz therapeutic ultrasound transducer or high-mechanical-index diagnostic ultrasound (1.7 MHz).

RESULTS

Significantly more ectopy was produced by the therapeutic transducer, especially at higher-intensity settings in the continuous wave mode after bolus injections of PESDA (P < .001 compared with lower intensities and lower continuous infusion rates). Six patients (15%) had either clinical supraventricular tachycardia or nonsustained ventricular tachycardia after intravenous PESDA with therapeutic TLFUS. In comparison, diagnostic high-mechanical-index ultrasound produced only isolated ventricular ectopy and no sustained ventricular arrhythmias.

CONCLUSIONS

Intravenously injected microbubbles and low-frequency therapeutic transducers operating at longer duty cycles and wide beam widths have the capability of eliciting clinically important arrhythmias in patients at high risk for such events.

Vascular effects induced by combined 1-MHz ultrasound and microbubble contrast agent treatments in vivo

Previous in vivo studies have demonstrated that microvessel hemorrhages and alterations of endothelial permeability can be produced in tissues containing microbubble-based ultrasound contrast agents when those tissues are exposed to MHz-frequency pulsed ultrasound of sufficient pressure amplitudes. The general hypothesis guiding this research was that acoustic (viz., inertial) cavitation, rather than thermal insult, is the dominant mechanism by which such effects arise. We report the results of testing five specific hypotheses in an in vivo rabbit auricular blood vessel model: (1) acoustic cavitation nucleated by microbubble contrast agent can damage the endothelia of veins at relatively low spatial-peak temporal-average intensities, (2) such damage will be proportional to the peak negative pressure amplitude of the insonifying pulses, (3) damage will be confined largely to the intimal surface, with sparing of perivascular tissues, (4) greater damage will occur to the endothelial cells on the side of the vessel distal to the source transducer than on the proximal side and (5) ultrasound/contrast agent-induced endothelial damage can be inherently thrombogenic, or can aid sclerotherapeutic thrombogenesis through the application of otherwise subtherapeutic doses of thrombogenic drugs. Auricular vessels were exposed to 1-MHz focused ultrasound of variable peak pressure amplitude using low duty factor, fixed pulse parameters, with or without infusion of a shelled microbubble contrast agent. Extravasation of Evans blue dye and erythrocytes was assessed at the macroscopic level. Endothelial damage was assessed via scanning electron microscopy (SEM) image analysis. The hypotheses were supported by the data. We discuss potential therapeutic applications of vessel occlusion, e.g., occlusion of at-risk gastric varices.

Delivery of systemic chemotherapeutic agent to tumors by using focused ultrasound: study in a murine model

PURPOSE

To quantitatively determine the delivery of systemic liposomal doxorubicin to tumors treated with pulsed high-intensity focused ultrasound and to study the mechanism underlying this delivery in a murine model.

MATERIALS AND METHODS

All animal work was performed in compliance with guidelines and approval of institutional animal care committee. C3H mice received subcutaneous injections in the flank of a cell suspension of SCC7, a murine squamous cell carcinoma cell line; mice (n = 32) in drug delivery study received unilateral injections, whereas mice (n = 10) in mechanistic study received bilateral injections. Tumors were treated when they reached 1 cm(3) in volume. In the drug delivery study, doxorubicin hydrochloride liposomes were injected into the tail vein: Mice received therapy with doxorubicin injections and high-intensity focused ultrasound, doxorubicin injections alone, or neither form of therapy (controls). Tumors were removed, and the doxorubicin content was assayed with fluorescent spectrophotometry. In the mechanistic study, all mice received an injection of 500-kDa dextran-fluorescein isothyocyanate into the tail vein, and half of them were exposed to high-intensity focused ultrasound prior to injection. Contralateral tumors served as controls for each group. Extravasation of dextran-fluorescein isothyocyanate was observed by using in vivo confocal microscopy.

RESULTS

Mean doxorubicin concentration in tumors treated with pulsed high-intensity focused ultrasound was 9.4 microg . g(-1) +/- 2.1 (standard deviation), and it was significantly higher (124% [9.4 microg . g(-1)/4.2 microg . g(-1)]) than in those that were not treated with high-intensity focused ultrasound (4.2 microg . g(-1) +/- 0.95) (P < .001, unpaired two-tailed Student t test). Extravasation of dextran-fluorescein isothyocyanate was observed in the vasculature of tumors treated with high-intensity focused ultrasound but not in that of untreated tumors.

CONCLUSION

Pulsed high-intensity focused ultrasound is an effective method of targeting systemic drug delivery to tumor tissue. Potential mechanisms for producing the observed enhancement are discussed.