Low Intensity Focused Ultrasound (LOFU)-mediated Acoustic Immune Priming and Ablative Radiation Therapy for in situ Tumor Vaccines

Optimization of the Tracking Beam Sequence in Harmonic Motion Imaging

Harmonic motion imaging (HMI) is an ultrasound elastography technique that estimates the viscoelastic properties of tissues by inducing localized oscillatory motion using focused ultrasound (FUS). The resulting displacement, assumed to be inversely proportional to the tissue local stiffness, is estimated using an imaging array based on RF speckle tracking. In conventional HMI, this is accomplished with plane-wave (PW) imaging, which inherently suffers from low lateral resolution. Coherent PW compounding (PWC) leverages spatial and temporal resolution using synthetic focusing in transmit. In this study, we introduced focused imaging with parallel tracking in HMI and compared parallel tracking of various transmit F-numbers (F/2.6, 3, 4, and 5) qualitatively and quantitatively with PW and PWC imaging at various compounded angle ranges (6°, 12°, and 18°). An in silico model of a 56-kPa spherical inclusion (diameter: 3.6 mm) embedded in a 5.3-kPa background and a 5.3-kPa elastic phantom with cylindrical inclusions (Young's moduli: 22-56 kPa, diameters: 2.0-8.6 mm) were imaged to assess different tracking beam sequences. Speckle biasing in displacement estimation associated with parallel tracking was also investigated and concluded to be negligible in HMI. Parallel tracking in receive (Rx) resulted in 2%-7% and 8%-12% increase compared to PW imaging ( ) in HMI contrast and contrast-to-noise ratio in silico and phantoms. Focused imaging with parallel tracking in Rx was concluded to be most robust among PW and PWC imaging for displacement estimation, and its preclinical feasibility was demonstrated in postsurgical human cancerous breast tissue specimens and in vivo murine models of breast cancer.

Enhancing Immunogenicity in Metastatic Melanoma: Adjuvant Therapies to Promote the Anti-Tumor Immune Response

Advanced melanoma is an aggressive form of skin cancer characterized by low survival rates. Less than 50% of advanced melanoma patients respond to current therapies, and of those patients that do respond, many present with tumor recurrence due to resistance. The immunosuppressive tumor-immune microenvironment (TIME) remains a major obstacle in melanoma therapy. Adjuvant treatment modalities that enhance anti-tumor immune cell function are associated with improved patient response. One potential mechanism to stimulate the anti-tumor immune response is by inducing immunogenic cell death (ICD) in tumors. ICD leads to the release of damage-associated molecular patterns within the TIME, subsequently promoting antigen presentation and anti-tumor immunity. This review summarizes relevant concepts and mechanisms underlying ICD and introduces the potential of non-ablative low-intensity focused ultrasound (LOFU) as an immune-priming therapy that can be combined with ICD-inducing focal ablative therapies to promote an anti-melanoma immune response.

Low-Intensity Focused Ultrasound Produces Immune Response in Pancreatic Cancer

Pancreatic adenocarcinoma is an aggressive malignancy with limited therapeutic treatments available and a 5-y survival less than 10%. Pancreatic cancers have been found to be immunogenically "cold" with a largely immunosuppressive tumor microenvironment. There is emerging evidence that focused ultrasound can induce changes in the tumor microenvironment and have a constructive impact on the effect of immunotherapy. However, the immune cells and timing involved in these effects remain unclear, which is essential to determining how to combine immunotherapy with ultrasound for treatment of pancreatic adenocarcinoma. We used low-intensity focused ultrasound and microbubbles (LoFU + MBs), which can mechanically disrupt cellular membranes and vascular endothelia, to treat subcutaneous pancreatic tumors in C57BL/6 mice. To evaluate the immune cell landscape and expression and/or localization of damage-associated molecular patterns (DAMPs) as a response to ultrasound, we performed flow cytometry and histology on tumors and draining lymph nodes 2 and 15 d post-treatment. We repeated this study on larger tumors and with multiple treatments to determine whether similar or greater effects could be achieved. Two days after treatment, draining lymph nodes exhibited a significant increase in activated antigen presenting cells, such as macrophages, as well as expansion of CD8+ T cells and CD4+ T cells. LoFU + MB treatment caused localized damage and facilitated the translocation of DAMP signals, as reflected by an increase in the cytoplasmic index for high-mobility-group box 1 (HMGB1) at 2 d. Tumors treated with LoFU + MBs exhibited a significant decrease in growth 15 d after treatment, indicating a tumor response that has the potential for additive effects. Our studies indicate that focused ultrasound treatments can cause tumoral damage and changes in macrophages and T cells 2 d post-treatment. The majority of these effects subsided after 15 d with only a single treatment, illustrating the need for additional treatment types and/or combination with immunotherapy. However, when larger tumors were treated, the effects seen at 2 d were diminished, even with an additional treatment. These results provide a working platform for further rational design of focused ultrasound and immunotherapy combinations in poorly immunogenic cancers.

Imaging of Single Transducer-Harmonic Motion Imaging-Derived Displacements at Several Oscillation Frequencies Simultaneously

Mapping of mechanical properties, dependent on the frequency of motion, is relevant in diagnosis, monitoring treatment response, or intra-operative surgical resection planning. While shear wave speeds at different frequencies have been described elsewhere, the effect of frequency on the "on-axis" acoustic radiation force (ARF)-induced displacement has not been previously investigated. Instead of generating single transducer-harmonic motion imaging (ST-HMI)-derived peak-to-peak displacement (P2PD) image at a particular frequency, a novel multi-frequency excitation pulse is proposed to generate P2PD images at 100-1000 Hz simultaneously. The performance of the proposed excitation pulse is compared with the ARFI by imaging 16 different inclusions (Young's moduli of 6, 9, 36, 70 kPa and diameters of 1.6, 2.5, 6.5, and 10.4 mm) embedded in an 18 kPa background. Depending on inclusion size and stiffness, the maximum CNR and contrast were achieved at different frequencies and were always higher than ARFI. The frequency, at which maximum CNR and contrast were achieved, increased with stiffness for fixed inclusion's size and decreased with size for fixed stiffness. In vivo feasibility is tested by imaging a 4T1 breast cancer mouse tumor on Day 6, 12, and 19 post-injection of tumor cells. Similar to phantoms, the CNR of ST-HMI images was higher than ARFI and increased with frequency for the tumor on Day 6. Besides, P2PD at 100-1000 Hz indicated that the tumor became stiffer with respect to the neighboring non-cancerous tissue over time. These results indicate the importance of using a multi-frequency excitation pulse to simultaneously generate displacement at multiple frequencies to better delineate inclusions or tumors.

The impact of low intensity ultrasound on cells: Underlying mechanisms and current status

Low intensity ultrasound (LIUS) has been adopted for a variety of therapeutic purposes because of its bioeffects such as thermal, mechanical, and cavitation effects. The mechanism of impact and cellular responses of LIUS in cellular regulations have been revealed, which helps to understand the role of LIUS in tumor treatment, stem cell therapy, and nervous system regulation. The review summarizes the bioeffects of LIUS at the cellular level and its related mechanisms, detailing the corresponding theoretical basis and latest research in the study of LIUS in the regulation of cells. In the future, the design of specific LIUS-mediated treatment strategies may benefit from promising investigations which is hoped to provide encouraging therapeutic data.

Recent Progress on Therapeutic Vaccines for Breast Cancer

Breast cancer remains the most frequently diagnosed malignancy worldwide. Advanced breast cancer is still an incurable disease mainly because of its heterogeneity and limited immunogenicity. The great success of cancer immunotherapy is paving the way for a new era in cancer treatment, and therapeutic cancer vaccination is an area of interest. Vaccine targets include tumor-associated antigens and tumor-specific antigens. Immune responses differ in different vaccine delivery platforms. Next-generation sequencing technologies and computational analysis have recently made personalized vaccination possible. However, only a few cases benefiting from neoantigen-based treatment have been reported in breast cancer, and more attention has been given to overexpressed antigen-based treatment, especially human epidermal growth factor 2-derived peptide vaccines. Here, we discuss recent advancements in therapeutic vaccines for breast cancer and highlight near-term opportunities for moving forward.

Hypoxia-Adapted Sono-chemodynamic Treatment of Orthotopic Pancreatic Carcinoma Using Copper Metal-Organic Frameworks Loaded with an Ultrasound-Induced Free Radical Initiator

The efficacy of sonodynamic therapy (SDT) is largely dependent upon oxygen availability to generate deleterious reactive oxygen species, and as such, hypoxic microenvironments greatly constrain the efficacy of SDT. Development of free radical generators that are not dependent on oxygen and related combination treatment strategies thus have the potential to enhance the antitumor potential of SDT. Combined treatment strategies are expected to improve the efficacy of sonodynamic antitumor therapy. As metal-organic framework (MOF) platforms are highly amenable to integration with other therapeutic approaches, we herein report the development of tumor microenvironment (TME)-responsive nanoparticles constructed by embedding the azo initiator 2,2'-azobis[2-(2-imidazolin-2-yl)propane]dihydrochloride (AIPH) into hypoxia-triggered copper metal-organic framework (Cu-MOF) nanovectors to achieve synergistic sono-chemodynamic therapy in an orthotopic murine pancreatic carcinoma model system. When exposed to hypoxic conditions within the TME, this Cu-MOF structure underwent degradation, leading to the release of Cu2+ and AIPH. Cu2+ was then able to deplete local glutathione stores, resulting in the reduction of Cu2+ to Cu+, which then reacts with endogenous H2O2 in a Fenton-like reaction to yield cytotoxic hydroxyl radicals (•OH) for chemodynamic therapy. When exposed to ultrasound irradiation, AIPH further degraded in an oxygen-independent manner to yield nitrogen bubbles and alkyl radicals, the former of which enhanced the ability of these nanoparticles to penetrate deeply into the tumor. The resultant radicals induced substantial DNA damage and apoptotic cell death within target tumors under different levels of oxygen availability. As such, this hypoxic TME-responsive synergistic sono-chemodynamic approach offers an ideal means of achieving oxygen-independent free radical generation and enhanced treatment efficacy.

Using nanoparticles for in situ vaccination against cancer: mechanisms and immunotherapy benefits

Immunotherapy to treat cancer is now an established clinical approach. Immunotherapy can be applied systemically, as done with checkpoint blockade antibodies, but it can also be injected directly into identified tumors, in a strategy of in situ vaccination (ISV). ISV is designed to stimulate a strong local antitumor immune response involving both innate and adaptive immune cells, and through this generate a systemic antitumor immune response against metastatic tumors. A variety of ISVs have been utilized to generate an immunostimulatory tumor microenvironment (TME). These include attenuated microorganisms, recombinant proteins, small molecules, physical disruptors of TME (alternating magnetic and focused ultrasound heating, photothermal therapy, and radiotherapy), and more recently nanoparticles (NPs). NPs are attractive and unique since they can load multiple drugs or other reagents to influence immune and cancer cell functions in the TME, affording a unique opportunity to stimulate antitumor immunity. Here, we describe the NP-ISV therapeutic mechanisms, review chemically synthesized NPs (i.e., liposomes, polymeric, chitosan-based, inorganic NPs, etc.), biologically derived NPs (virus and bacteria-based NPs), and energy-activated NP-ISVs in the context of their use as local ISV. Data suggests that NP-ISVs can enhance outcomes of immunotherapeutic regimens including those utilizing tumor hyperthermia and checkpoint blockade therapies.

Feasibility of Harmonic Motion Imaging Using a Single Transducer: In Vivo Imaging of Breast Cancer in a Mouse Model and Human Subjects

Harmonic motion imaging (HMI) interrogates the mechanical properties of tissues by simultaneously generating and tracking harmonic oscillation using focused ultrasound and imaging transducers, respectively. Instead of using two transducers, the objective of this work is to develop a single transducer HMI (ST-HMI) to both generate and track harmonic motion at "on-axis" to the force for facilitating data acquisition. In ST-HMI, the amplitude-modulated force was generated by modulating excitation pulse duration and tracking of motion was performed by transmitting tracking pulses interleaved between excitation pulses. The feasibility of ST-HMI was performed by imaging two elastic phantoms with three inclusions (N = 6) and comparing it with acoustic radiation force impulse (ARFI) imaging, in vivo longitudinal monitoring of 4T1, orthotropic breast cancer mice (N = 4), and patients (N = 3) with breast masses in vivo. Six inclusions with Young's moduli of 8, 10, 15, 20, 40, and 60 kPa were embedded in a 5 kPa background. The ST-HMI-derived peak-to-peak displacement (P2PD) successfully detected all inclusions with [Formula: see text] of the linear regression between the P2PD ratio of background to inclusion versus Young's moduli ratio of inclusion to background. The contrasts of 10 and 15 kPa inclusions were higher in ST-HMI than ARFI-derived images. In the mouse study, the median P2PD ratio of tumor to non-cancerous tissues was 3.0, 5.1, 6.1, and 7.7 at 1, 2, 3, and 4 weeks post-injection of the tumor cells, respectively. In the clinical study, ST-HMI detected breast masses including fibroadenoma, pseudo angiomatous stromal hyperplasia, and invasive ductal carcinoma with a P2PD ratio of 1.37, 1.61, and 1.78, respectively. These results indicate that ST-HMI can assess the mechanical properties of tissues via generation and tracking of harmonic motion "on-axis" to the ARF. This study is the first step towards translating ST-HMI in clinics.

Focused Ultrasound for Immunomodulation of the Tumor Microenvironment

Focused ultrasound (FUS) has recently emerged as a modulator of the tumor microenvironment, paving the way for FUS to become a safe yet formidable cancer treatment option. Several mechanisms have been proposed for the role of FUS in facilitating immune responses and overcoming drug delivery barriers. However, with the wide variety of FUS parameters used in diverse tumor types, it is challenging to pinpoint FUS specifications that may elicit the desired antitumor response. To clarify FUS bioeffects, we summarize four mechanisms of action, including thermal ablation, hyperthermia/thermal stress, mechanical perturbation, and histotripsy, each inducing unique vascular and immunological effects. Notable tumor responses to FUS include enhanced vascular permeability, increased T cell infiltration, and tumor growth suppression. In this review, we have categorized and reviewed recent methods of using therapeutic ultrasound to elicit an antitumor immune response with examples that reveal specific solutions and challenges in this new research area.

Modulation of the triggered apoptosis by nano emodin transfersome-mediated sonodynamic therapy on head and neck squamous cell carcinoma cell lines

BACKGROUND

Non-invasive sonodynamic therapy (SDT) is a new treatment modality that uses low-intensity ultrasound to activate a non-toxic sensitizing chemical agent for cancer therapy in a site-directed manner. This study aimed to investigate the anti-cancer effects of ultrasound combined with nano emodin transfersome (NET) on head and neck squamous cell carcinoma (HNSCC) cell lines.

MATERIALS AND METHODS

A transfersome form of nano emodin as a novel sono-responsive nanomaterial was synthesized to enhance the accumulation and penetration of nanoparticles. iIn vitro experiments including hemolytic activity, cell proliferation, intracellular reactive oxygen species (ROS) generation, apoptosis induction, DNA fragmentation, and mRNA expressions of caspase 3 and 9 were conducted to explore the anti-cancer effects of NET-SDT on FaDu and CAL-27 cell lines.

RESULTS

Characterization tests showed the round and uniform morphology of NET with transfersome structure, resulting in a high drug-loading content and encapsulation efficiency. No significant hemolytic activity was observed (P > 0.05). Cytotoxicity gradually increased with increasing concentrations of NET, so that 10 × 10^-4 g/L of NET plus 5 min ultrasound irradiation at a frequency of 1 MHz and ultrasonic intensity of 2 W/cm² effectively killed 98.2 % and 97.3 % of FaDu and CAL-27 cell lines, respectively (P < 0.05). We found that ROS generation in NET-SDT was dose-dependent and the triggered apoptosis and caspase-3/9 gene expression levels were significantly enhanced as the concentration of NET increased (P < 0.05). No significant difference was found in the rate of apoptosis induction and gene expression between two cell lines.

CONCLUSIONS

Our data demonstrated that SDT with NET as a sonosensitizer can induce apoptosis and significantly decrease cell viability of HNSCC cell lines, which represents the role of NET-SDT as a potent anti-cancer modality.

Externally-Controlled Systems for Immunotherapy: From Bench to Bedside

Immunotherapy is a very promising therapeutic approach against cancer that is particularly effective when combined with gene therapy. Immuno-gene therapy approaches have led to the approval of four advanced therapy medicinal products (ATMPs) for the treatment of p53-deficient tumors (Gendicine and Imlygic), refractory acute lymphoblastic leukemia (Kymriah) and large B-cell lymphomas (Yescarta). In spite of these remarkable successes, immunotherapy is still associated with severe side effects for CD19+ malignancies and is inefficient for solid tumors. Controlling transgene expression through an externally administered inductor is envisioned as a potent strategy to improve safety and efficacy of immunotherapy. The aim is to develop smart immunogene therapy-based-ATMPs, which can be controlled by the addition of innocuous drugs or agents, allowing the clinicians to manage the intensity and durability of the therapy. In the present manuscript, we will review the different inducible, versatile and externally controlled gene delivery systems that have been developed and their applications to the field of immunotherapy. We will highlight the advantages and disadvantages of each system and their potential applications in clinics.