Theranostics in Interventional Oncology: Versatile Carriers for Diagnosis and Targeted Image-Guided Minimally Invasive Procedures

A critical review on metal-organic frameworks (MOFs) based nanomaterials for biomedical applications: Designing, recent trends, challenges, and prospects

Nanomaterials (NMs) have garnered significant attention in recent decades due to their versatile applications in a wide range of fields. Thanks to their tiny size, enhanced surface modifications, impressive volume-to-surface area ratio, magnetic properties, and customized optical dispersion. NMs experienced an incredible upsurge in biomedical applications including diagnostics, therapeutics, and drug delivery. This minireview will focus on notable examples of NMs that tackle important issues, demonstrating various aspects such as their design, synthesis, morphology, classification, and use in cutting-edge applications. Furthermore, we have classified and outlined the distinctive characteristics of the advanced NMs as nanoscale particles and hybrid NMs. Meanwhile, we emphasize the incredible potential of metal-organic frameworks (MOFs), a highly versatile group of NMs. These MOFs have gained recognition as promising candidates for a wide range of bio-applications, including bioimaging, biosensing, antiviral therapy, anticancer therapy, nanomedicines, theranostics, immunotherapy, photodynamic therapy, photothermal therapy, gene therapy, and drug delivery. Although advanced NMs have shown great potential in the biomedical field, their use in clinical applications is still limited by issues such as stability, cytotoxicity, biocompatibility, and health concerns. This review article provides a thorough analysis offering valuable insights for researchers investigating to explore new design, development, and expansion opportunities. Remarkably, we ponder the prospects of NMs and nanocomposites in conjunction with current technology.

The LMIT: Light-mediated minimally-invasive theranostics in oncology

Minimally-invasive diagnosis and therapy have gradually become the trend and research hotspot of current medical applications. The integration of intraoperative diagnosis and treatment is a development important direction for real-time detection, minimally-invasive diagnosis and therapy to reduce mortality and improve the quality of life of patients, so called minimally-invasive theranostics (MIT). Light is an important theranostic tool for the treatment of cancerous tissues. Light-mediated minimally-invasive theranostics (LMIT) is a novel evolutionary technology that integrates diagnosis and therapeutics for the less invasive treatment of diseased tissues. Intelligent theranostics would promote precision surgery based on the optical characterization of cancerous tissues. Furthermore, MIT also requires the assistance of smart medical devices or robots. And, optical multimodality lay a solid foundation for intelligent MIT. In this review, we summarize the important state-of-the-arts of optical MIT or LMIT in oncology. Multimodal optical image-guided intelligent treatment is another focus. Intraoperative imaging and real-time analysis-guided optical treatment are also systemically discussed. Finally, the potential challenges and future perspectives of intelligent optical MIT are discussed.

Quantitative dual-energy computed tomography with cesium as a novel contrast agent for localization of thermochemical ablation in phantoms and ex vivo models

BACKGROUND

Thermochemical ablation (TCA) is a minimally invasive therapy under development for hepatocellular carcinoma. TCA simultaneously delivers an acid (acetic acid, AcOH) and base (sodium hydroxide, NaOH) directly into the tumor, where the acid/base chemical reaction produces an exotherm that induces local ablation. However, AcOH and NaOH are not radiopaque, making monitoring TCA delivery difficult.

PURPOSE

We address the issue of image guidance for TCA by utilizing cesium hydroxide (CsOH) as a novel theranostic component of TCA that is detectable and quantifiable with dual-energy CT (DECT).

MATERIALS AND METHODS

To quantify the minimum concentration of CsOH that can be positively identified by DECT, the limit of detection (LOD) was established in an elliptical phantom (Multi-Energy CT Quality Assurance Phantom, Kyoto Kagaku, Kyoto, Japan) with two DECT technologies: a dual-source system (SOMATOM Force, Siemens Healthineers, Forchheim, Germany) and a split-filter, single-source system (SOMATOM Edge, Siemens Healthineers). The dual-energy ratio (DER) and LOD of CsOH were determined for each system. Cesium concentration quantification accuracy was evaluated in a gelatin phantom before quantitative mapping was performed in ex vivo models.

RESULTS

On the dual-source system, the DER and LOD were 2.94 and 1.36-mM CsOH, respectively. For the split-filter system, the DER and LOD were 1.41- and 6.11-mM CsOH, respectively. The signal on cesium maps in phantoms tracked linearly with concentration (R2  = 0.99) on both systems with an RMSE of 2.56 and 6.72 on the dual-source and split-filter system, respectively. In ex vivo models, CsOH was detected following delivery of TCA at all concentrations.

CONCLUSIONS

DECT can be used to detect and quantify the concentration of cesium in phantom and ex vivo tissue models. When incorporated in TCA, CsOH performs as a theranostic agent for quantitative DECT image-guidance.

AI and machine learning ethics, law, diversity, and global impact

Artificial intelligence (AI) and its machine learning (ML) algorithms are offering new promise for personalized biomedicine and more cost-effective healthcare with impressive technical capability to mimic human cognitive capabilities. However, widespread application of this promising technology has been limited in the medical domain and expectations have been tampered by ethical challenges and concerns regarding patient privacy, legal responsibility, trustworthiness, and fairness. To balance technical innovation with ethical applications of AI/ML, developers must demonstrate the AI functions as intended and adopt strategies to minimize the risks for failure or bias. This review describes the new ethical challenges created by AI/ML for clinical care and identifies specific considerations for its practice in medicine. We provide an overview of regulatory and legal issues applicable in Europe and the United States, a description of technical aspects to consider, and present recommendations for trustworthy AI/ML that promote transparency, minimize risks of bias or error, and protect the patient well-being.

Effective therapy with Bismuth-212 labeled macroaggregated albumin in orthotopic mouse breast tumor models

Intravascularly administered radiation therapy using beta (β-)-emitting radioisotopes has relied on either intravenously injected radiolabeled peptides that target cancer or radiolabeled microspheres that are trapped in the tumor following intra-arterial delivery. More recently, targeted intravenous radiopeptide therapies have explored the use of alpha (α)-particle emitting radioisotopes, but microspheres radiolabeled with α-particle emitters have not yet been studied. Here, FDA-approved macroaggregated albumin (MAA) particles were radiolabeled with Bismuth-212 (Bi-212-MAA) and evaluated using clonogenic and survival assays in vitro and using immune-competent mouse models of breast cancer. The in vivo biodistribution of Bi-212-MAA was investigated in Balb/c and C57BL/6 mice with 4T1 and EO771 orthotopic breast tumors, respectively. The same orthotopic breast cancer models were used to evaluate the treatment efficacy of Bi-212-MAA. Our results showed that macroaggregated albumin can be stably radiolabeled with Bi-212 and that Bi-212-MAA can deliver significant radiation therapy to reduce the growth and clonogenic potential of 4T1 and EO771 cells in vitro. Additionally, Bi-212-MAA treatment upregulated γH2AX and cleaved Caspase-3 expression in 4T1 cells. Biodistribution analyses showed 87-93% of the Bi-212-MAA remained in 4T1 and EO771 tumors 2 and 4 h after injection. Following single-tumor treatments with Bi-212-MAA there was a significant reduction in the growth of both 4T1 and EO771 breast tumors over the 18-day monitoring period. Overall, these findings showed that Bi-212-MAA was stably radiolabeled and inhibited breast cancer growth. Bi-212-MAA is an exciting platform to study α-particle therapy and will be easily translatable to larger animal models and human clinical trials.

Intra-Arterial Delivery of Radiopharmaceuticals in Oncology: Current Trends and the Future of Alpha-Particle Therapeutics

A paradigm shift is underway in cancer diagnosis and therapy using radioactivity-based agents called radiopharmaceuticals. In the new strategy, diagnostic imaging measures the tumor uptake of radioactive agent “X” in a patient’s specific cancer, and if uptake metrics are realized, the patient can be selected for therapy with radioactive agent “Y”. The X and Y represent different radioisotopes that are optimized for each application. X–Y pairs are known as radiotheranostics, with the currently approved route of therapy being intravenous administration. The field is now evaluating the potential of intra-arterial dosing of radiotheranostics. In this manner, a higher initial concentration can be achieved at the cancer site, which could potentially enhance tumor-to-background targeting and lead to improved imaging and therapy. Numerous clinical trials are underway to evaluate these new therapeutic approaches that can be performed via interventional radiology. Of further interest is changing the therapeutic radioisotope that provides radiation therapy by β- emission to radioisotopes that also decay by α-particle emissions. Alpha (α)-particle emissions provide high energy transfer to the tumors and have distinct advantages. This review discusses the current landscape of intra-arterially delivered radiopharmaceuticals and the future of α-particle therapy with short-lived radioisotopes.

Dual-mode vehicles with simultaneous thermometry and drug release properties based on hollow Y2O3:Er,Yb and Y2O2SO4:Er,Yb spheres

Employing luminescence thermometry in the biomedical field is undeniably appealing as many health conditions are accompanied by temperature changes. In this work, we show our ongoing efforts and results at designing novel vehicles for dual-mode thermometry and pH-dependent drug release based on hollow spheres. Hereby for that purpose, we exploit the hollow Y₂O₃ and Y₂O₂SO₄ host materials. These two inorganic hollow phosphors were investigated and showed to have excellent upconversion Er³⁺-Yb³⁺ luminescence properties and could be effectively used as optical temperature sensors in the physiological temperature range when induced by near-infrared CW light (975 nm). Further, doxorubicin was exploited as a model anti-cancer drug to monitor the pH-dependent drug release of these materials showing that they can be used for simultaneous thermometry and drug delivery applications.

Association of Indocyanine Green with Chitosan Oleate Coated PLGA Nanoparticles for Photodynamic Therapy

Indocyanine green (ICG) is a safe dye widely used in the biomedical field. Its photodynamic effect (PDT), originating from laser irradiation at 803 nm, opens interesting perspectives in theranostic applications. To overcome its low water stability, ICG can be shielded with nanoparticles (NPs). In this work, previously developed NPs based on poly lactic-co-glycolic acid (PLGA) coated with chitosan oleate (CS-OA) and loaded with resveratrol as a hydrophobic model drug have been proposed as an ICG carrier. These systems have been selected for their observed immunostimulatory properties. The possible loading of the dye by adsorption onto NP surface by electrostatic interaction was studied here in comparison with the encapsulation into the PLGA core. The ICG-chitosan (CS) interaction has been characterized by spectrophotometry, spectroscopy and in-cell in vitro assays. Fluorescence quenching was observed due to the ionic interaction between ICG and CS and was studied considering the dye:polymer stoichiometry and the effect of the NP dilution in cell culture medium (DMEM). The NP systems have been compared in vitro, assessing their behaviour in Caco-2 cell lines. A reduction in cell viability was observed after irradiation of ICG associated with NPs, evident also for the samples loaded by adsorption. These findings open the opportunity to exploit the association of PDT’s effect on ICG with the properties of CS-OA coated NPs, whose immunostimulatory effect can be associated with PDT mechanism in cancer therapy.

Intraarterial Therapies for the Management of Hepatocellular Carcinoma

Image-guided locoregional therapies play a crucial role in the management of patients with hepatocellular carcinoma (HCC). Transarterial therapies consist of a group of catheter-based treatments where embolic agents are delivered directly into the tumor via their supplying arteries. Some of the transarterial therapies available include bland embolization (TAE), transarterial chemoembolization (TACE), drug-eluting beads-transarterial chemoembolization (DEB-TACE), selective internal radioembolization therapy (SIRT), and hepatic artery infusion (HAI). This article provides a review of pre-procedural, intra-procedural, and post-procedural aspects of each therapy, along with a review of the literature. Newer embolotherapy options and future directions are also briefly discussed.

Theragnostics in primary and secondary liver tumors: the need for a personalized approach

Primary and secondary hepatic tumors have a dramatic impact in oncology. Despite many advances in diagnosis and therapy, the management of hepatic malignancies is still challenging, ranging from various loco-regional approaches to system therapies. In this scenario, theragnostic approaches, based on the administration of a radiopharmaceuticals' pair, the first labeled with a radionuclide suitable for the diagnostic phase and the second one bound to radionuclide emitting particles for therapy, is gaining more and more importance. Selective internal radiation therapy (SIRT) with microspheres labeled with ⁹⁰Y or ¹⁶⁶Ho is widely used as a loco-regional treatment for primary and secondary hepatic tumors. While ¹⁶⁶Ho presents both gamma and beta emission and can be therefore considered a real "theragnostic" agent, for ⁹⁰Y-microspheres theragnostic approach is realized at the diagnostic phase through the utilization of macroaggregates of human albumin, labeled with ^99mTc as "biosimilar" agent respect to microspheres. The aim of the present review was to cover theragnostic applications of ⁹⁰Y/¹⁶⁶Ho-labeled microspheres in clinical practice. Furthermore, we report the preliminary data concerning the potential role of some emerging theragnostic biomarkers for hepatocellular carcinoma, such as glypican-3 (GPC3) and prostate specific membrane antigen (PSMA).

Using Stock-Flow Diagrams to Visualize Theranostic Approaches to Solid Tumors in Personalized Nanomedicine

Personalized nanomedicine has rapidly evolved over the past decade to tailor the diagnosis and treatment of several diseases to the individual characteristics of each patient. In oncology, iron oxide nano-biomaterials (NBMs) have become a promising biomedical product in targeted drug delivery as well as in magnetic resonance imaging (MRI) as a contrast agent and magnetic hyperthermia. The combination of diagnosis and therapy in a single nano-enabled product (so-called theranostic agent) in the personalized nanomedicine has been investigated so far mostly in terms of local events, causes-effects, and mutual relationships. However, this approach could fail in capturing the overall complexity of a system, whereas systemic approaches can be used to study the organization of phenomena in terms of dynamic configurations, independent of the nature, type, or spatial and temporal scale of the elements of the system. In medicine, complex descriptions of diseases and their evolution are daily assessed in clinical settings, which can be thus considered as complex systems exhibiting self-organizing and non-linear features, to be investigated through the identification of dynamic feedback-driven behaviors. In this study, a Systems Thinking (ST) approach is proposed to represent the complexity of the theranostic modalities in the context of the personalized nanomedicine through the setting up of a stock-flow diagram. Specifically, the interconnections between the administration of magnetite NBMs for diagnosis and therapy of tumors are fully identified, emphasizing the role of the feedback loops. The presented approach has revealed its suitability for further application in the medical field. In particular, the obtained stock-flow diagram can be adapted for improving the future knowledge of complex systems in personalized nanomedicine as well as in other nanosafety areas.

Nanomaterials as Novel Cardiovascular Theranostics

Cardiovascular diseases (CVDs) are a group of conditions associated with heart and blood vessels and are considered the leading cause of death globally. Coronary heart disease, atherosclerosis, myocardial infarction represents the CVDs. Since CVDs are associated with a series of pathophysiological conditions with an alarming mortality and morbidity rate, early diagnosis and appropriate therapeutic approaches are critical for saving patients’ lives. Conventionally, diagnostic tools are employed to detect disease conditions, whereas therapeutic drug candidates are administered to mitigate diseases. However, the advent of nanotechnological platforms has revolutionized the current understanding of pathophysiology and therapeutic measures. The concept of combinatorial therapy using both diagnosis and therapeutics through a single platform is known as theranostics. Nano-based theranostics are widely used in cancer detection and treatment, as evident from pre-clinical and clinical studies. Nanotheranostics have gained considerable attention for the efficient management of CVDs. The differential physicochemical properties of engineered nanoparticles have been exploited for early diagnosis and therapy of atherosclerosis, myocardial infarction and aneurysms. Herein, we provided the information on the evolution of nano-based theranostics to detect and treat CVDs such as atherosclerosis, myocardial infarction, and angiogenesis. The review also aims to provide novel avenues on how nanotherapeutics’ trending concept could transform our conventional diagnostic and therapeutic tools in the near future.

Systems Genetics Approaches in Mouse Models of Group A Streptococcal Necrotizing Soft-Tissue Infections

Mouse models are invaluable resources for studying the pathogenesis and preclinical evaluation of therapeutics and vaccines against many human pathogens. Infections caused by group A streptococcus (GAS, Streptococcus pyogenes) are heterogeneous ranging from mild pharyngitis to severe invasive necrotizing fasciitis, a subgroup of necrotizing soft-tissue infections (NSTIs). While several strains of mice including BALB/c, C3H/HeN, CBA/J, and C57BL/10 offered significant insights, the human specificity and the interindividual variations on susceptibility or resistance to GAS infections limit their ability to mirror responses as seen in humans. In this chapter, we discuss the advanced recombinant inbred (ARI) BXD mouse model that mimics the genetic diversity as seen in humans and underpins the feasibility to map multiple genes (genetic loci) modulating GAS NSTI. GAS produces a myriad of virulence factors, including superantigens (SAg). Superantigens are potent immune toxins that activate T cells by cross-linking T cell receptors with human leukocyte antigen class-II (HLA-II) molecules expressed on antigen-presenting cells. This leads to a pro-inflammatory cytokine storm and the subsequent multiple organ damage and shock. Inbred mice are innately refractive to SAg-mediated responses. In this chapter, we discuss the versatility of the HLA-II transgenic mouse model that allowed the biological validation of known genetic associations to GAS NSTI. The combined utility of ARI-BXD and HLA-II mice as complementary approaches that offer clinically translatable insights into pathomechanisms driven by complex traits and host genetic context and novel means to evaluate the in vivo efficiency of therapies to improve outcomes of GAS NSTI are also discussed.

Liposomes: Biomedical Applications

Liposomes, with their flexible physicochemical and biophysical properties, continue to be studied as an important potential a critical drug delivery system. Liposomes have overcome the challenges of conventional free drug therapy by encapsulating therapeutic agents, thereby improving in vivo biodistribution and reducing systemic toxicity. New imaging modalities and interpretation techniques, as well as new techniques for targetable system formulation technique, and tumor environmental information, have affected the search for a means of overcoming the difficulties of conventional liposome formulation. In this review, we briefly discuss how liposomal formulation has been applied across the biomedical field, particularly as a therapy, and the role it may play in the future, when paired with new developments in diagnosis and theranostics. The biological challenges that still remain and the translational obstacles are discussed.

Plantamajoside inhibits the proliferation and epithelial-to-mesenchymal transition in hepatocellular carcinoma cells via modulating hypoxia-inducible factor-1α-dependent gene expression

As a potential antitumor herbal medicine, plantamajoside (PMS) benefits the treatment of many human malignances. However, the role of PMS in the progression of hepatocellular carcinoma (HCC) and the related molecular mechanisms is still unknown. Here, we proved that the cell viabilities of HepG2 cells were gradually decreased with the increasing concentrations of CoCl₂ and/or PMS via cell counting kit-8 assay. Meanwhile, 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2H-tetrazolium bromide (MTT) and western blot assays were used to further confirm that PMS inhibited the CoCl₂ -induced cell proliferation in HepG2 cells via suppressing the Ki67 and proliferating cell nuclear antigen expressions. We also performed wound-healing and transwell assays and demonstrated that PMS inhibited CoCl₂ -induced migration and invasion in HepG2 cells via suppressing the epithelial-mesenchymal transition (EMT) process. In addition, the use of 3-(5'-hydroxymethyl-2'-furyl)-1-benzylindazole further proved that PMS inhibited the malignant biological behaviors of HepG2 cells under hypoxic condition by suppressing the hypoxia-inducible factor-1α (HIF-1α) expression. Besides, we further confirmed that PMS suppressed the growth and metastasis of implanted tumors in vivo. Given that PMS suppressed the proliferation and EMT induced by CoCl₂ in HCC cells via downregulating HIF-1α signaling pathway, we provided evidence that PMS might be a novel anti-cancer drug for HCC treatment.

Theranostic approaches in nuclear medicine: current status and future prospects

Introduction: Theranostics is an emerging field in which diagnosis and specific targeted therapy are combined to achieve a personalized treatment approach to the patient. In nuclear medicine clinical practice, theranostics is often performed utilizing the same molecule labeled with two different radionuclides, one radionuclide for imaging and another for therapy.Areas covered: The authors review the clinical applications of different radiopharmaceuticals in the field of interest, including the well-established use of radioactive iodine in differentiated thyroid cancer, radiolabeled metaiodobenzylguanidine (MIBG) in neuroblastoma and the clinical impact of peptide radionuclide receptorial therapy (PRRT) in the management of neuroendocrine tumors. Furthermore, the more cutting-edge and recently introduced theranostic approaches will be reviewed, such as the radioligand therapy with ¹⁷⁷Lu-prostate specific membrane antigen (PSMA) and targeted alpha therapy in castration-resistant prostate cancer. Finally, the main applications of PET for the imaging of biomarkers suitable for the non-radionuclide targeted therapy will be covered.Expert opinion: Theranostics is envisaging a revolutionary clinical approach which is deeply connected with the concept of personalized medicine and ruled by a 'patient-centered' vision. In this perspective, the theranostic applications will need well-trained specialists, capable to manage not only the technological aspects of the discipline, but also to deal with the more innovative oncological therapies in a multidisciplinary setting.

Dual Imaging Gold Nanoplatforms for Targeted Radiotheranostics

Gold nanoparticles (AuNPs) are interesting for the design of new cancer theranostic tools, mainly due to their biocompatibility, easy molecular vectorization, and good biological half-life. Herein, we report a gold nanoparticle platform as a bimodal imaging probe, capable of coordinating Gd³⁺ for Magnetic Resonance Imaging (MRI) and ⁶⁷Ga³⁺ for Single Photon Emission Computed Tomography (SPECT) imaging. Our AuNPs carry a bombesin analogue with affinity towards the gastrin releasing peptide receptor (GRPr), overexpressed in a variety of human cancer cells, namely PC3 prostate cancer cells. The potential of these multimodal imaging nanoconstructs was thoroughly investigated by the assessment of their magnetic properties, in vitro cellular uptake, biodistribution, and radiosensitisation assays. The relaxometric properties predict a potential T₁- and T₂- MRI application. The promising in vitro cellular uptake of ⁶⁷Ga/Gd-based bombesin containing particles was confirmed through biodistribution studies in tumor bearing mice, indicating their integrity and ability to target the GRPr. Radiosensitization studies revealed the therapeutic potential of the nanoparticles. Moreover, the DOTA chelating unit moiety versatility gives a high theranostic potential through the coordination of other therapeutically interesting radiometals. Altogether, our nanoparticles are interesting nanomaterial for theranostic application and as bimodal T₁- and T₂- MRI / SPECT imaging probes.

Indocyanine Green Loaded Polymeric Nanoparticles: Physicochemical Characterization and Interaction Studies with Caco-2 Cell Line by Light and Transmission Electron Microscopy

Biomedical applications of nanoparticles (NPs) have reached an increasing development in recent years. Recently, we demonstrated that newly synthesized poly (ethyl 2-cyanoacrylate) nanoparticles (PECA-NPs) are possible antitumor agents due to their cytotoxicity for cancer cells. Indocyanine green (ICG), an amphiphilic tricarbocyanine fluorescent dye, is widely used for the detection of tumoral extension in different organs during clinical surgery. Moreover, this fluorescent agent is unstable and it has a rapid clearance in physiological conditions in vivo. In this study, ICG was charged in PECA-NPs to improve its aqueous stability and make easier its use for the identification of tumor cells. Microscopic and ultrastructural aspects concerning the related in vitro interactions between ICG-loaded NPs and tumor cell culture were investigated. Obtained results showed an effective stabilization of ICG; furthermore, color inclusions inside the cells treated with ICG-loaded NPs demonstrated the internalization of NPs with associated ICG. Transmission electron microscopy (TEM) analysis demonstrated the cytoplasmic presence of coated vesicles (Ø ≤ 100 nm), hypothesizing their involvement in the mechanism of endocytosis. Therefore, ICG-loaded NPs could be proposed as agents for tumor diagnosis, hypothesizing also in the future a specific therapeutic treatment.