A new strategy to enhance cavitational tissue erosion using a high-intensity, Initiating sequence

Insights from in vivo preclinical cancer studies with histotripsy

Histotripsy is the first noninvasive, non-ionizing, and non-thermal ablation technique that mechanically fractionates target tissue into acellular homogenate via controlled acoustic cavitation. Histotripsy has been evaluated for various preclinical applications requiring noninvasive tissue removal including cancer, brain surgery, blood clot and hematoma liquefaction, and correction of neonatal congenital heart defects. Promising preclinical results including local tumor suppression, improved survival outcomes, local and systemic anti-tumor immune responses, and histotripsy-induced abscopal effects have been reported in various animal tumor models. Histotripsy is also being investigated in veterinary patients with spontaneously arising tumors. Research is underway to combine histotripsy with immunotherapy and chemotherapy to improve therapeutic outcomes. In addition to preclinical cancer research, human clinical trials are ongoing for the treatment of liver tumors and renal tumors. Histotripsy has been recently approved by the FDA for noninvasive treatment of liver tumors. This review highlights key learnings from in vivo shock-scattering histotripsy, intrinsic threshold histotripsy, and boiling histotripsy cancer studies treating cancers of different anatomic locations and discusses the major considerations in planning in vivo histotripsy studies regarding instrumentation, tumor model, study design, treatment dose, and post-treatment tumor monitoring.

DNA release from plant tissue using focused ultrasound extraction (FUSE)

Premise

Sample preparation in genomics is a critical step that is often overlooked in molecular workflows and impacts the success of downstream genetic applications. This study explores the use of a recently developed focused ultrasound extraction (FUSE) technique to enable the rapid release of DNA from plant tissues for genetic analysis.

Methods

FUSE generates a dense acoustic cavitation bubble cloud that pulverizes targeted tissue into acellular debris. This technique was applied to leaf samples of American chestnut (Castanea dentata), tulip poplar (Liriodendron tulipifera), red maple (Acer rubrum), and chestnut oak (Quercus montana).

Results

We observed that FUSE can extract high quantities of DNA in 9-15 min, compared to the 30 min required for control DNA extraction methods. FUSE extracted DNA quantities of 24.33 ± 6.51 ng/mg and 35.32 ± 9.21 ng/mg from American chestnut and red maple, respectively, while control methods yielded 6.22 ± 0.87 ng/mg and 11.51 ± 1.95 ng/mg, respectively. The quality of the DNA released by FUSE allowed for successful amplification and next-generation sequencing.

Discussion

These results indicate that FUSE can improve DNA extraction efficiency for leaf tissues. Continued development of this technology aims to adapt to field-deployable systems to increase the cataloging of genetic biodiversity, particularly in low-resource biodiversity hotspots.

Control of the dynamics of a boiling vapour bubble using pressure-modulated high intensity focused ultrasound without the shock scattering effect: A first proof-of-concept study

Boiling histotripsy is a promising High-Intensity Focused Ultrasound (HIFU) technique that can be used to induce mechanical tissue fractionation at the HIFU focus via cavitation. Two different types of cavitation produced during boiling histotripsy exposure can contribute towards mechanical tissue destruction: (1) a boiling vapour bubble at the HIFU focus and (2) cavitation clouds in between the boiling bubble and the HIFU source. Control of the extent and degree of mechanical damage produced by boiling histotripsy is necessary when treating a solid tumour adjacent to normal tissue or major blood vessels. This is, however, difficult to achieve with boiling histotripsy due to the stochastic formation of the shock scattering-induced inertial cavitation clouds. In the present study, a new histotripsy method termed pressure-modulated shockwave histotripsy is proposed as an alternative to or in addition to boiling histotripsy without inducing the shock scattering effect. The proposed concept is (a) to generate a boiling vapour bubble via localised shockwave heating and (b) subsequently control its extent and lifetime through manipulating peak pressure magnitudes and a HIFU pulse length. To demonstrate the feasibility of the proposed method, bubble dynamics induced at the HIFU focus in an optically transparent liver tissue phantom were investigated using a high speed camera and a passive cavitation detection systems under a single 10, 50 or 100 ms-long 2, 3.5 or 5 MHz pressure-modulated HIFU pulse with varying peak positive and negative pressure amplitudes from 5 to 89 MPa and -3.7 to -14.6 MPa at the focus. Furthermore, a numerical simulation of 2D nonlinear wave propagation with the presence of a boiling bubble at the focus of a HIFU field was conducted by numerically solving the generalised Westervelt equation. The high speed camera experimental results showed that, with the proposed pressure-modulated shockwave histotripsy, boiling bubbles generated by shockwave heating merged together, forming a larger bubble (of the order of a few hundred micron) at the HIFU focus. This coalesced boiling bubble then persisted and maintained within the HIFU focal zone until the end of the exposure (10, 50, or 100 ms). Furthermore, and most importantly, no violent cavitation clouds which typically appear in boiling histotripsy occurred during the proposed histotripsy excitation (i.e. no shock scattering effect). This was likely because that the peak negative pressure magnitude of the backscattered acoustic field by the boiling bubble was below the cavitation cloud intrinsic threshold. The size of the coalesced boiling bubble gradually increased with the peak pressure magnitudes. In addition, with the proposed method, an oval shaped lesion with a length of 0.6 mm and a width of 0.1 mm appeared at the HIFU focus in the tissue phantom, whereas a larger lesion in the form of a tadpole (length: 2.7 mm, width: 0.3 mm) was produced by boiling histotripsy. Taken together, these results suggest that the proposed pressure-modulated shockwave histotripsy could potentially be used to induce a more spatially localised tissue destruction with a desired degree of mechanical damage through controlling the size and lifetime of a boiling bubble without the shock scattering effect.

Scan Parameter Optimization for Histotripsy Treatment of S. Aureus Biofilms on Surgical Mesh

There is a critical need to develop new noninvasive therapies to treat bacteria biofilms. Previous studies have demonstrated the effectiveness of cavitation-based ultrasound histotripsy to destroy these biofilms. In this study, the dependence of biofilm destruction on multiple scan parameters was assessed by conducting exposures at different scan speeds (0.3-1.4 beamwidths/s), step sizes (0.25-0.5 beamwidths), and the number of passes of the focus across the mesh (2-6). For each of the exposure conditions, the number of colony-forming units (CFUs) remaining on the mesh was quantified. A regression analysis was then conducted, revealing that the scan speed was the most critical parameter for biofilm destruction. Reducing the number of passes and the scan speed should allow for more efficient biofilm destruction in the future, reducing the treatment time.

For Whom the Bubble Grows: Physical Principles of Bubble Nucleation and Dynamics in Histotripsy Ultrasound Therapy

Histotripsy is a focused ultrasound therapy for non-invasive tissue ablation. Unlike thermally ablative forms of therapeutic ultrasound, histotripsy relies on the mechanical action of bubble clouds for tissue destruction. Although acoustic bubble activity is often characterized as chaotic, the short-duration histotripsy pulses produce a unique and consistent type of cavitation for tissue destruction. In this review, the action of histotripsy-induced bubbles is discussed. Sources of bubble nuclei are reviewed, and bubble activity over the course of single and multiple pulses is outlined. Recent innovations in terms of novel acoustic excitations, exogenous nuclei for targeted ablation and histotripsy-enhanced drug delivery and image guidance metrics are discussed. Finally, gaps in knowledge of the histotripsy process are highlighted, along with suggested means to expedite widespread clinical utilization of histotripsy.

Coalescence of residual histotripsy cavitation nuclei using low-gain regions of the therapy beam during electronic focal steering

Following collapse of a histotripsy cloud, residual microbubbles may persist for seconds, distributed throughout the focus. Their presence can attenuate and scatter subsequent pulses, hindering treatment speed and homogeneity. Previous studies have demonstrated use of separate low-amplitude (~1 MPa) pulses interleaved with histotripsy pulses to drive bubble coalescence (BC), significantly improving treatment speed without sacrificing homogeneity. We propose that by using electronic focal steering (EFS) to direct the therapy focus throughout specially-designed EFS sequences, it is possible to use low-gain regions of the therapy beam to accomplish BC during EFS without any additional acoustic sequence. First, to establish proof of principle for an isolated focus, a 50-foci EFS sequence was constructed with the first position isolated near the geometric focus and remaining positions distributed post-focally. EFS sequences were evaluated in tissue-mimicking phantoms with gas concentrations of 20% and 100% with respect to saturation. Results using an isolated focus demonstrated that at 20% gas concentration, 49 EFS pulses were sufficient to achieve BC in all samples for pulse repetition frequency (PRF)  ⩽  800 Hz and 84.1%  ±  3.0% of samples at 5 kHz PRF. For phantoms prepared with 100% gas concentration, BC was achieved by 49 EFS pulses in 39.2%  ±  4.7% of samples at 50 Hz PRF and 63.4%  ±  15.3% of samples at 5 kHz. To show feasibility of using the EFS-BC method to ablate a large volume quickly, a 1000-foci EFS sequence covering a volume of approximately 27 ml was tested. Results indicate that the BC effect was similarly present. A treatment rate of 27  ±  6 ml min^-1 was achieved, which is signficantly faster than standard histotripsy and ultrasound thermal ablation. This study demonstrates that histotripsy with EFS can achieve BC without employing a separate acoustic sequence which has the potential to accelerate large-volume ablation while minimizing energy deposition.

Histotripsy Treatment of S. Aureus Biofilms on Surgical Mesh Samples Under Varying Pulse Durations

Prior studies demonstrated that histotripsy generated by high-intensity tone bursts to excite a bubble cloud adjacent to a medical implant can destroy the bacteria biofilm responsible for the infection. The goal of this paper was to treat Staphylococcus aureus (S. aureus) biofilms on surgical mesh samples while varying the number of cycles in the tone burst to minimize collateral tissue damage while maximizing therapy effectiveness. S. aureus biofilms were grown on 1-cm square surgical mesh samples. The biofilms were then treated in vitro using a spherically focused transducer (1.1 MHz, 12.9-cm focal length, 12.7-cm diameter) using either a sham exposure or histotripsy pulses with tone burst durations of 3, 5, or 10 cycles (pulse repetition frequency of 333 Hz, peak compressional pressure of 150 MPa, peak rarefactional pressure of 17 MPa). After treatment, the number of colony forming units (CFUs) on the mesh and the surrounding gel was independently determined. The number of CFUs remaining on the mesh for the sham exposure (4.8 ± 0.9-log₁₀) (sample mean ± sample standard deviation-log10 from 15 observations) was statistically significantly different from the 3-cycle (1.9 ± 1.5-log₁₀), 5-cycle (2.2 ± 1.1-log₁₀), and 10-cycle exposures (1 ± 1.5-log₁₀) with an average reduction in the number of CFUs of 3.1-log₁₀. The numbers of CFUs released into the gel for both the sham and exposure groups were the same within a bound of 0.86-log₁₀, but this interval was too large to deduce the fate of the bacteria in the biofilm following the treatment.

Efficacy of histotripsy combined with rt-PA in vitro

Histotripsy, a form of therapeutic ultrasound that uses the mechanical action of microbubble clouds for tissue ablation, is under development to treat chronic deep vein thrombosis (DVT). We hypothesize that combining thrombolytic agents with histotripsy will enhance clot lysis. Recombinant tissue plasminogen activator (rt-PA) and rt-PA-loaded echogenic liposomes that entrain octafluoropropane microbubbles (OFP t-ELIP) were used in combination with highly shocked histotripsy pulses. Fully retracted porcine venous clots, with similar features of DVT occlusions, were exposed either to histotripsy pulses alone (peak negative pressures of 7-20 MPa), histotripsy and OFP t-ELIP, or histotripsy and rt-PA. Microbubble cloud activity was monitored with passive cavitation imaging during histotripsy exposure. The power levels of cavitation emissions from within the clot were not statistically different between treatment types, likely due to the near instantaneous rupture and destruction of OFP t-ELIP. The thrombolytic efficacy was significantly improved in the presence of rt-PA. These results suggest the combination of histotripsy and rt-PA could serve as a potent therapeutic strategy for the treatment of DVT.

Removal of residual cavitation nuclei to enhance histotripsy fractionation of soft tissue

Remanent bubble nuclei generated by primary cavitation collapse can limit the efficiency of histotripsy softtissue fractionation. When these residual bubbles persist from one histotripsy pulse to the next, they can seed the repetitive nucleation of cavitation bubbles at a discrete set of sites within the focal volume. This effect-referred to as cavitation memory- manifests in inefficient lesion formation, because certain sites within the focal volume are overtreated whereas others remain undertreated. Although the cavitation memory effect can be passively mitigated by using a low pulse repetition frequency (PRF) that affords remanent nuclei sufficient time for dissolution between successive pulses, this low PRF also results in slow lesion production. As such, it would be highly desirable to maintain the high per-pulse efficiency associated with low pulse rates when much higher PRFs are utilized. In this vein, we have developed a strategy for the active removal of the remanent bubble nuclei following primary cavitation collapse, using low-amplitude ultrasound sequences (termed bubble-removal sequences) to stimulate the aggregation and subsequent coalescence of these bubbles. In this study, bubbleremoval sequences were incorporated in high-PRF histotripsy treatment (100 Hz) of a red blood cell tissue-mimicking phantom that allows for the visualization of lesion development in real time. A series of reference treatments were also conducted at the low PRF of 1 Hz to provide a point of comparison for which cavitation memory effects are minimal. It was found that bubble-removal sequences as short as 1 ms are capable of maintaining the efficacious lesion development characteristics associated with the low PRF of 1 Hz when the much higher pulse rate of 100 Hz is used. These results were then extended to the treatment of a large volume within the tissue phantom, and optimal bubble-removal sequences identified for the singlefocal- spot case were utilized to homogenize a 10 × 10 mm region at high rate.

Real-time feedback of histotripsy thrombolysis using bubble-induced color Doppler

Histotripsy thrombolysis is a non-invasive, drug-free, image-guided therapy that fractionates blood clots using well-controlled acoustic cavitation alone. Real-time quantitative feedback is highly desired during histotripsy thrombolysis treatment to monitor the progress of clot fractionation. Bubble-induced color Doppler (BCD) monitors the motion after cavitation generated by each histotripsy pulse, which has been found in gel and ex vivo liver tissue to be correlated with histotripsy fractionation. We investigated the potential of BCD to quantitatively monitor histotripsy thrombolysis in real time. To visualize clot fractionation, transparent three-layered fibrin clots were developed. Results indicated that a coherent motion follows the cavitation generated by each histotripsy pulse with a push and rebound pattern. The temporal profile of this motion expands and saturates as treatment progresses. A strong correlation exists between the degree of histotripsy clot fractionation and two metrics extracted from BCD: time of peak rebound velocity (tPRV) and focal mean velocity at a fixed delay (Vf,delay). The saturation of clot fractionation (i.e., treatment completion) matches well the saturations detected using tPRV and Vf,delay. The mean Pearson correlation coefficients between the progression of clot fractionation and the two BCD metrics were 93.1% and 92.6%, respectively. To validate BCD feedback in in vitro clots, debris volumes from histotripsy thrombolysis were obtained at different therapy doses and compared with Vf,delay. There is also good agreement between the increasing and saturation trends of debris volume and Vf,delay. Finally, a real-time BCD feedback algorithm to predict complete clot fractionation during histotripsy thrombolysis was developed and tested. This work illustrates the potential of BCD to monitor histotripsy thrombolysis treatment in real time.

Nanodroplet-mediated histotripsy for image-guided targeted ultrasound cell ablation

This paper is an initial work towards developing an image-guided, targeted ultrasound ablation technique by combining histotripsy with nanodroplets that can be selectively delivered to tumor cells. Using extremely short, high-pressure pulses, histotripsy generates a dense cloud of cavitating microbubbles that fractionates tissue. We hypothesize that synthetic nanodroplets that encapsulate a perfluoropentane (PFP) core will transition upon exposure to ultrasound pulses into gas microbubbles, which will rapidly expand and collapse resulting in disruption of cells similar to the histotripsy process but at a significantly lower acoustic pressure. The significantly reduced cavitation threshold will allow histotripsy to be selectively delivered to the tumor tissue and greatly enhance the treatment efficiency while sparing neighboring healthy tissue. To test our hypothesis, we prepared nanodroplets with an average diameter of 204±4.7 nm at 37°C by self-assembly of an amphiphilic triblock copolymer around a PFP core followed by cross-linkage of the polymer shell forming stable nanodroplets. The nanodroplets were embedded in agarose tissue phantoms containing a sheet of red blood cells (RBCs), which were exposed to 2-cycle pulses applied by a 500 kHz focused transducer. Using a high speed camera to monitor microbubble generation, the peak negative pressure threshold needed to generate bubbles >50 μm in agarose phantoms containing nanodroplets was measured to be 10.8 MPa, which is significantly lower than the 28.8 MPa observed using ultrasound pulses alone. High speed images also showed cavitation microbubbles produced from the nanodroplets displayed expansion and collapse similar to histotripsy alone at higher pressures. Nanodroplet-mediated histotripsy created consistent, well-defined fractionation of the RBCs in agarose tissue phantoms at 10 Hz pulse repetition frequency similar to the lesions generated by histotripsy alone but at a significantly lower pressure. These results support our hypothesis and demonstrate the potential of using nanodroplet-mediated histotripsy for targeted cell ablation.

Potential and problems in ultrasound-responsive drug delivery systems

Ultrasound is an important local stimulus for triggering drug release at the target tissue. Ultrasound-responsive drug delivery systems (URDDS) have become an important research focus in targeted therapy. URDDS include many different formulations, such as microbubbles, nanobubbles, nanodroplets, liposomes, emulsions, and micelles. Drugs that can be loaded into URDDS include small molecules, biomacromolecules, and inorganic substances. Fields of clinical application include anticancer therapy, treatment of ischemic myocardium, induction of an immune response, cartilage tissue engineering, transdermal drug delivery, treatment of Huntington’s disease, thrombolysis, and disruption of the blood–brain barrier. This review focuses on recent advances in URDDS, and discusses their formulations, clinical application, and problems, as well as a perspective on their potential use in the future.

Assessment of ultrasound histotripsy-induced damage to ex vivo porcine muscle

OBJECTIVES

Cavitation-based histotripsy uses high-intensity focused ultrasound pulses at a low duty cycle to generate energetic bubble clouds inside tissue to fractionate cells and is a potential noninvasive tumor treatment modality. Aiming at determining therapy efficiency, we experimentally investigated the effects of pulse repetition frequency and lateral scan step size on the degree of damage of histotripsy-induced lesions in porcine muscle tissue.

METHODS

A single-element spherically focused source (1.1 MHz, 6.34-cm focal length, f/1) was excited to reach the peak compressional and rarefactional pressures of approximately 102 and 17 MPa, respectively. A targeted square of 9 mm wide (lateral to focal plane) was scanned in a raster pattern with the step sizes of 375, 750, 1500, 2250, and 4500 μm. Pulses at each treatment location consisted of 5000 20-cycle sine wave tone bursts with a pulse repetition frequency of 167, 333, or 1000 Hz. Histopathologic examination and image processing were performed to evaluate the tissue damage for each experimental condition.

RESULTS

Skeletal myofiber damage was successfully created with our 7 exposure conditions. Three scales for muscle damage were identified through performing quad-tree decomposition to photomicrograph images and then relating decomposition with lesion homogeneity.

CONCLUSIONS

Using a finer scan step size promoted the lesion homogeneity. Selection of the optimal condition does not depend solely on the comparison of tissue damage. Given the uncertainty on which of the 3 scales for tissue damage allows muscle repair, 2 conditions were identified as optimal: the 1500 μm-333 Hz condition for scale 3 (related to mild damage) and the 750 μm-333 Hz condition for scale 1 (related to severe damage).

Impact of preconditioning pulse on lesion formation during high-intensity focused ultrasound histotripsy

Therapeutic applications with high-intensity focused ultrasound (HIFU) fall into two classifications-one using thermal effect for coagulation or ablation while generally avoiding cavitation and the other using cavitation-mediated mechanical effects while suppressing heating. Representative of the latter, histotripsy uses HIFU at low duty factor to create energetic bubble clouds inside tissue to liquefy a region and has the advantages in real-time monitoring and lesion fidelity to treatment planning. We explored the impact of a preconditioning/heating pulse on histotripsy lesion formation in porcine muscle samples. During sonication, a targeted square region 9 mm wide (lateral to the focal plane) was scanned in a raster pattern with a step size of 0.75 mm. The 20-s exposure at each treatment location consisted of a 5-s duration preconditioning burst at spatial-peak intensities from 0-1386 W/cm² followed by 5000 tone bursts at high intensity (with spatial-peak pulse-average intensity of 47.34 kW/cm², spatial-peak temporal-average intensity of 284 W/cm², peak compressional pressure of 102 MPa and peak rarefactional pressure of 17 MPa). The temperature increase for all exposures was measured using a thermal imager immediately after each exposure. Lesion volume increased with increasing amplitude of the preconditioning pulse until coagulation was observed, but lesion width/area did not change significantly with the amplitude. In addition, the lesion dimensions became smaller when the global tissue temperature was raised before applying the histotripsy pulsing sequence. Therefore, the benefit of the preconditioning pulse was not caused by global heating.

An efficient treatment strategy for histotripsy by removing cavitation memory

Cavitation memory effects occur when remnants of cavitation bubbles (nuclei) persist in the host medium and act as seeds for subsequent events. In pulsed cavitational ultrasound therapy, or histotripsy, this effect may cause cavitation to repeatedly occur at these seeded locations within a target volume, producing inhomogeneous tissue fractionation or requiring an excess number of pulses to completely homogenize the target volume. We hypothesized that by removing the cavitation memory, i.e., the persistent nuclei, the cavitation bubbles could be induced at random locations in response to each pulse; therefore, complete disruption of a tissue volume may be achieved with fewer pulses. To test the hypothesis, the cavitation memory was passively removed by increasing the intervals between successive pulses, ∆t, from 2, 10, 20, 50 and 100, to 200 ms. Histotripsy treatments were performed in red blood cell tissue phantoms and ex vivo livers using 1-MHz ultrasound pulses of 10 cycles at P-/P+ pressure of 21/59 MPa. The phantom study allowed for direct visualization of the cavitation patterns and the lesion development process in real time using high-speed photography; the ex vivo tissue study provided validation of the memory effect in real tissues. Results of the phantom study showed an exponential decrease in the correlation coefficient between cavitation patterns in successive pulses from 0.5 ± 0.1 to 0.1 ± 0.1 as ∆t increased from 2-200 ms; correspondingly, the lesion was completely fractionated with significantly fewer pulses for longer ∆ts. In the tissue study, given the same number of therapy pulses, complete and homogeneous tissue fractionation with well-defined lesion boundaries was achieved only for ∆t ≥ 100 ms. These results indicated that the removal of the cavitation memory resulted in more efficient treatments and homogeneous lesions.

Intermediate-term effects of intracardiac communications created noninvasively by therapeutic ultrasound (histotripsy) in a porcine model

The authors have demonstrated that histotripsy (pulsed cavitational ultrasound) can create atrial septal defects and ventricular septal defects (VSDs) in an open-chest canine model transcutaneously through the intact chest of neonatal pigs. To assess the potential untoward effects of these applications, the clinical, systemic, and pathologic effects of histotripsy-induced intracardiac communications were analyzed. Six neonatal pigs received noninvasive ultrasound therapy to their ventricular septa, then were allowed to survive 1 month for evaluation of intermediate-term effects. The results were compared with those of six previous animals killed immediately and three others killed 2-3 days after the procedure. Brain magnetic resonance imaging (MRI) and an assessment of cardiac function were performed with long-term survivors, and pathologic specimens were obtained when the animals were killed. In all 15 animals, VSDs 2-6.5 mm wide were successfully created. No fatalities occurred, and all the animals thrived, achieving normal weight gain by the time they were killed. Brain MRI and lung pathology exhibited no evidence of thromboembolic events. No damage to intervening tissue was observed. Pathologic analysis showed demarcated damage to the ventricular septa. Flanking injury and hemorrhage observed acutely were resolved by 1 month, with tissue remodeling present. Transcutaneous histotripsy is a safe and effective technique for creating intracardiac communications noninvasively without intermediate-term untoward effects. With further refinement and development, histotripsy has the potential to become an effective tool for palliation of congenital heart disease.

Experimental investigation of the effect of stiffness, exposure time and scan direction on the dimension of ultrasound histotripsy lesions

Histotripsy uses high-intensity focused ultrasound to create energetic bubble clouds inside tissue to liquefy a region and has the advantages of higher contrast B-mode monitoring and sharp borders. This study experimentally investigated the effects of stiffness, exposure time and scan direction on the size of histotripsy-induced lesions in agar samples. A targeted region 0.45 cm wide (lateral) and 0.6 cm deep (axial) was scanned with the step sizes of 0.075 cm and 0.3 cm, respectively. The single-element spherically focused source (1.1 MHz, 6.34 cm focal length, f/1) had the peak compressional and rarefactional pressures of approximately 102 and 17 MPa. Pulses consisted of 20-cycle sine wave tone bursts with a burst period of 3 ms and exposure time of 15, 30 or 60 s. Also, both inward and outward scan direction were tested along the beam axis. The liquefied lesions generally had a larger size than the initially targeted region with larger sizes corresponding to softer agar and longer exposure. There was not a statistically significant difference in the lesion size with scan direction.

Cavitation clouds created by shock scattering from bubbles during histotripsy

Histotripsy is a therapy that focuses short-duration, high-amplitude pulses of ultrasound to incite a localized cavitation cloud that mechanically breaks down tissue. To investigate the mechanism of cloud formation, high-speed photography was used to observe clouds generated during single histotripsy pulses. Pulses of 5-20 cycles duration were applied to a transparent tissue phantom by a 1-MHz spherically focused transducer. Clouds initiated from single cavitation bubbles that formed during the initial cycles of the pulse, and grew along the acoustic axis opposite the propagation direction. Based on these observations, we hypothesized that clouds form as a result of large negative pressure generated by the backscattering of shockwaves from a single bubble. The positive-pressure phase of the wave inverts upon scattering and superimposes on the incident negative-pressure phase to create this negative pressure and cavitation. The process repeats with each cycle of the incident wave, and the bubble cloud elongates toward the transducer. Finite-amplitude propagation distorts the incident wave such that the peak-positive pressure is much greater than the peak-negative pressure, which exaggerates the effect. The hypothesis was tested with two modified incident waves that maintained negative pressure but reduced the positive pressure amplitude. These waves suppressed cloud formation which supported the hypothesis.

Combined passive detection and ultrafast active imaging of cavitation events induced by short pulses of high-intensity ultrasound

The activation of natural gas nuclei to induce larger bubbles is possible using short ultrasonic excitations of high amplitude, and is required for ultrasound cavitation therapies. However, little is known about the distribution of nuclei in tissues. Therefore, the acoustic pressure level necessary to generate bubbles in a targeted zone and their exact location are currently difficult to predict. To monitor the initiation of cavitation activity, a novel all-ultrasound technique sensitive to single nucleation events is presented here. It is based on combined passive detection and ultrafast active imaging over a large volume using the same multi-element probe. Bubble nucleation was induced using a focused transducer (660 kHz, f-number = 1) driven by a high-power electric burst (up to 300 W) of one to two cycles. Detection was performed with a linear array (4 to 7 MHz) aligned with the single-element focal point. In vitro experiments in gelatin gel and muscular tissue are presented. The synchronized passive detection enabled radio-frequency data to be recorded, comprising high-frequency coherent wave fronts as signatures of the acoustic emissions linked to the activation of the nuclei. Active change detection images were obtained by subtracting echoes collected in the unnucleated medium. These indicated the appearance of stable cavitating regions. Because of the ultrafast frame rate, active detection occurred as quickly as 330 μs after the high-amplitude excitation and the dynamics of the induced regions were studied individually.

High intensity focused ultrasound in clinical tumor ablation

Recent advances in high intensity focused ultrasound (HIFU), which was developed in the 1940s as a viable thermal tissue ablation approach, have increased its popularity. In clinics, HIFU has been applied to treat a variety of solid malignant tumors in a well-defined volume, including the pancreas, liver, prostate, breast, uterine fibroids, and soft-tissue sarcomas. In comparison to conventional tumor/cancer treatment modalities, such as open surgery, radio- and chemo-therapy, HIFU has the advantages of non-invasion, non-ionization, and fewer complications after treatment. Over 100 000 cases have been treated throughout the world with great success. The fundamental principles of HIFU ablation are coagulative thermal necrosis due to the absorption of ultrasound energy during transmission in tissue and the induced cavitation damage. This paper reviews the clinical outcomes of HIFU ablation for applicable cancers, and then summarizes the recommendations for a satisfactory HIFU treatment according to clinical experience. In addition, the current challenges in HIFU for engineers and physicians are also included. More recent horizons have broadened the application of HIFU in tumor treatment, such as HIFU-mediated drug delivery, vessel occlusion, and soft tissue erosion ("histotripsy"). In summary, HIFU is likely to play a significant role in the future oncology practice.

Therapeutic ultrasound to noninvasively create intracardiac communications in an intact animal model

OBJECTIVE

To determine if pulsed cavitational ultrasound therapy (histotripsy) can accurately and safely generate ventricular septal defects (VSDs) through the intact chest of a neonatal animal, with the eventual goal of developing a noninvasive technique of creating intra-cardiac communications in patients with congenital heart disease.

BACKGROUND

Histotripsy is an innovative ultrasonic technique that generates demarcated, mechanical tissue fractionation utilizing high intensity ultrasound pulses. Previous work has shown that histotripsy can create atrial septal defects in a beating heart in an open-chest canine model.

METHODS

Nine neonatal pigs were treated with transcutaneous histotripsy targeting the ventricular septum. Ultrasound pulses of 5-μsec duration at a peak negative pressure of 13 MPa and a pulse repetition frequency of 1 kHz were generated by a 1 MHz focused transducer. The procedure was guided by real-time ultrasound imaging.

RESULTS

VSDs were created in all pigs with diameters ranging from 2 to 6.5 mm. Six pigs were euthanized within 2 hrs of treatment, while three were recovered and maintained for 2-3 days to evaluate lesion maturation and clinical side effects. There were only transient clinical effects and pathology revealed mild collateral damage around the VSD with no significant damage to other cardiac or extra-cardiac structures.

CONCLUSIONS

Histotripsy can accurately and safely generate VSDs through the intact chest in a neonatal animal model. These results suggest that with further advances, histotripsy can be a useful, noninvasive technique to create intracardiac communications, which currently require invasive catheter-based or surgical procedures, to clinically stabilize newborn infants with complex congenital heart disease.

Noninvasive thrombolysis using pulsed ultrasound cavitation therapy - histotripsy

Clinically available thrombolysis techniques are limited by either slow reperfusion (drugs) or invasiveness (catheters) and carry significant risks of bleeding. In this study, the feasibility of using histotripsy as an efficient and noninvasive thrombolysis technique was investigated. Histotripsy fractionates soft tissue through controlled cavitation using focused, short, high-intensity ultrasound pulses. In vitro blood clots formed from fresh canine blood were treated by histotripsy. The treatment was applied using a focused 1-MHz transducer, with five-cycle pulses at a pulse repetition rate of 1kHz. Acoustic pressures varying from 2 to 12MPa peak negative pressure were tested. Our results show that histotripsy can perform effective thrombolysis with ultrasound energy alone. Histotripsy thrombolysis only occurred at peak negative pressure >or=6MPa when initiation of a cavitating bubble cloud was detected using acoustic backscatter monitoring. Blood clots weighing 330mg were completely broken down by histotripsy in 1.5 to 5min. The clot was fractionated to debris with >96% weight smaller than 5mum diameter. Histotripsy thrombolysis treatment remained effective under a fast, pulsating flow (a circulatory model) as well as in static saline. Additionally, we observed that fluid flow generated by a cavitation cloud can attract, trap and further break down clot fragments. This phenomenon may provide a noninvasive method to filter and eliminate hazardous emboli during thrombolysis.

Shock-induced bubble jetting into a viscous fluid with application to tissue injury in shock-wave lithotripsy

Shock waves in liquids are known to cause spherical gas bubbles to rapidly collapse and form strong re-entrant jets in the direction of the propagating shock. The interaction of these jets with an adjacent viscous liquid is investigated using finite-volume simulation methods. This configuration serves as a model for tissue injury during shock-wave lithotripsy, a medical procedure to remove kidney stones. In this case, the viscous fluid provides a crude model for the tissue. It is found that for viscosities comparable to what might be expected in tissue, the jet that forms upon collapse of a small bubble fails to penetrate deeply into the viscous fluid "tissue." A simple model reproduces the penetration distance versus viscosity observed in the simulations and leads to a phenomenological model for the spreading of injury with multiple shocks. For a reasonable selection of a single efficiency parameter, this model is able to reproduce in vivo observations of an apparent 1000-shock threshold before wide-spread tissue injury occurs in targeted kidneys and the approximate extent of this injury after a typical clinical dose of 2000 shock waves.

The destruction of Escherichia coli biofilms using high-intensity focused ultrasound

High-intensity focused ultrasound (HIFU) has shown great potential for replacing surgery in many applications. In this work, HIFU was used to destroy Escherichia coli (E. coli) biofilms that had been grown on chambered microscope slides. Biofilms are central to the pathogenesis and persistence of nosocomial (hospital-acquired) infections associated with indwelling medical devices. The slides were exposed to 9.1 mus pulses at a pulse repetition frequency of 1000 Hz. The pulses were generated by a 1.1 MHz spherically focused source with a focal length of 6.3 cm and an active diameter of 7 cm. The peak rarefactional pressure for the pulses was varied as 3.1, 4.1, 5.2, 6.2 and 7.6 MPa in addition to a sham where the biofilms were not exposed. The effectiveness of the treatment was assessed by determining the number of colony forming units (CFU) remaining following exposure of the bacteria to HIFU. Most of the biofilms treated at the higher exposures of 6.2 and 7.6 MPa had no detectable CFU, indicating that bacteria in the biofilm were killed by the treatment or that treatment disrupted the biofilm and released bacteria from the slide. However, the ability of some bacteria to survive at the higher exposure settings needs to be resolved prior to implementing the treatment clinically.

Quantitative ultrasound backscatter for pulsed cavitational ultrasound therapy- histotripsy

Histotripsy is a well-controlled ultrasonic tissue ablation technology that mechanically and progressively fractionates tissue structures using cavitation. The fractionated tissue volume can be monitored with ultrasound imaging because a significant ultrasound backscatter reduction occurs.This paper correlates the ultrasound backscatter reduction with the degree of tissue fractionation characterized by the percentage of remaining normal-appearing cell nuclei on histology.Different degrees of tissue fractionation were generated in vitro in freshly excised porcine kidneys by varying the number of therapeutic ultrasound pulses from 100 to 2000 pulses per treatment location. All ultrasound pulses were 15 cycles at 1 MHz delivered at 100 Hz pulse repetition frequency and 19 MPa peak negative pressure. The results showed that the normalized backscatter intensity decreased exponentially with increasing number of pulses. Correspondingly, the percentage of normal appearing nuclei in the treated area decreased exponentially as well. A linear correlation existed between the normalized backscatter intensity and the percentage of normal appearing cell nuclei in the treated region. This suggests that the normalized backscatter intensity may be a potential quantitative real-time feedback parameter for histotripsy-induced tissue fractionation. This quantitative feedback may allow the prediction of local clinical outcomes, i.e., when a tissue volume has been sufficiently treated.

Ultrasound histotripsy and the destruction of Escherichia coli biofilms

Ultrasound histotripsy has shown great potential for replacing surgery in many applications. In this work, a modification of ultrasound histotripsy was used to destroy Escherichia coli (E. coli) biofilms that had been grown on chambered microscope slides. Biofilms are central to the pathogenesis and persistence of nosocomial (hospital-acquired) infections associated with indwelling medical devices. The slides were exposed to 9.1 micros pulses at a pulse repetition frequency of 1000 Hz. The pulses were generated by a 1.1 MHz spherically focused source with a focal length of 6.3 cm and an active diameter of 7 cm. The peak rarefactional pressure for the pulses was varied as 3.1, 4.1, 5.2, 6.2, and 7.6 MPa in addition to a sham where the biofilms were not exposed. The effectiveness of the treatment was assessed by determining the viable number of colony forming units (CFU) remaining in the biofilm. Most of the biofilms treated at the higher exposures of 6.2 and 7.6 MPa had no remaining CFU indicating that the biofilm was completely destroyed. However, the persistence of some CFU for some of the biofioms at the higher exposure settings needs to be resolved prior to implementing the treatment clinically.

Evolution of bubble clouds induced by pulsed cavitational ultrasound therapy - histotripsy

Mechanical tissue fractionation can be achieved using successive, high-intensity ultrasound pulses in a process termed histotripsy. Histotripsy has many potential clinical applications where noninvasive tissue removal is desired. The primary mechanism for histotripsy is believed to be cavitation. Using fast-gated imaging, this paper studies the evolution of a cavitating bubble cloud induced by a histotripsy pulse (10 and 14 cycles) at peak negative pressures exceeding 21MPa. Bubble clouds are generated inside a gelatin phantom and at a tissue-water interface, representing two situations encountered clinically. In both environments, the imaging results show that the bubble clouds share the same evolutionary trend. The bubble cloud and individual bubbles in the cloud were generated by the first cycle of the pulse, grew with each cycle during the pulse, and continued to grow and collapsed several hundred microseconds after the pulse. For example, the bubbles started under 10 microm, grew to 50 microm during the pulse, and continued to grow 100 microm after the pulse. The results also suggest that the bubble clouds generated in the two environments differ in growth and collapse duration, void fraction, shape, and size. This study furthers our understanding of the dynamics of bubble clouds induced by histotripsy.

Role of acoustic cavitation in the delivery and monitoring of cancer treatment by high-intensity focused ultrasound (HIFU)

Acoustic cavitation has been shown to play a key role in a wide array of novel therapeutic ultrasound applications. This paper presents a brief discussion of the physics of thermally relevant acoustic cavitation in the context of high-intensity focussed ultrasound (HIFU). Models for how different types of cavitation activity can serve to accelerate tissue heating are presented, and results suggest that the bulk of the enhanced heating effect can be attributed to the absorption of broadband acoustic emissions generated by inertial cavitation. Such emissions can be readily monitored using a passive cavitation detection (PCD) scheme and could provide a means for real-time treatment monitoring. It is also shown that the appearance of hyperechoic regions (or bright-ups) on B-mode ultrasound images constitutes neither a necessary nor a sufficient condition for inertial cavitation activity to have occurred during HIFU exposure. Once instigated at relatively large HIFU excitation amplitudes, bubble activity tends to grow unstable and to migrate toward the source transducer, causing potentially undesirable pre-focal damage. Potential means of controlling inertial cavitation activity using pulsed excitation so as to confine it to the focal region are presented, with the intention of harnessing cavitation-enhanced heating for optimal HIFU treatment delivery. The role of temperature elevation in mitigating bubble-enhanced heating effects is also discussed, along with other bubble-field effects such as multiple scattering and shielding.

Optical and acoustic monitoring of bubble cloud dynamics at a tissue-fluid interface in ultrasound tissue erosion

Short, high-intensity ultrasound pulses have the ability to achieve localized, clearly demarcated erosion in soft tissue at a tissue-fluid interface. The primary mechanism for ultrasound tissue erosion is believed to be acoustic cavitation. To monitor the cavitating bubble cloud generated at a tissue-fluid interface, an optical attenuation method was used to record the intensity loss of transmitted light through bubbles. Optical attenuation was only detected when a bubble cloud was seen using high speed imaging. The light attenuation signals correlated well with a temporally changing acoustic backscatter which is an excellent indicator for tissue erosion. This correlation provides additional evidence that the cavitating bubble cloud is essential for ultrasound tissue erosion. The bubble cloud collapse cycle and bubble dissolution time were studied using the optical attenuation signals. The collapse cycle of the bubble cloud generated by a high intensity ultrasound pulse of 4-14 micros was approximately 40-300 micros depending on the acoustic parameters. The dissolution time of the residual bubbles was tens of ms long. This study of bubble dynamics may provide further insight into previous ultrasound tissue erosion results.