Feasibility of US-guided high-intensity focused ultrasound treatment in patients with advanced pancreatic cancer: initial experience

The study was approved by the university ethics committee, and informed consent was obtained from all patients. The purpose of this study was to prospectively evaluate ultrasonographically guided high-intensity focused ultrasound in the treatment of patients with advanced-stage pancreatic cancer. Eight patients underwent high-intensity focused ultrasound ablation, and laboratory and radiologic examinations were performed after intervention. Changes in symptoms and survival time were noted at follow-up. No complications were observed, and preexisting severe back pain disappeared after intervention. Follow-up images revealed an absence of tumor blood supply and shrinkage of the ablated tumor. Four patients died, and four patients were alive at the time of this writing, with a median survival time of 11.25 months. The authors conclude that high-intensity focused ultrasound ablation is safe and feasible in the treatment of advanced pancreatic cancer.

Extracorporeal high intensity focused ultrasound treatment for patients with breast cancer

PURPOSE

To investigate the safety, efficacy and feasibility of using high-intensity focused ultrasound (HIFU) as a non-invasive treatment for patients with breast cancer.

PATIENTS AND METHODS

Twenty-two patients with breast cancer were enrolled into this non-randomized prospective trial. Disease TNM stage was classified as stage I in 4 patients, stage II(A) in 9 patients, stage II(B) in 8 patients, and stage IV in 1 patient. Tumor size ranged from 2 to 4.8 cm in diameter (mean 3.4 cm). All patients received chemotherapy, radiation and tamoxifen, following HIFU for the primary lesions. Outcome measures included radiological and pathologic assessment of the treated tumor, cosmesis, and local recurrence. A cumulative survival rate is calculated by using the Kaplan-Meier method.

RESULTS

No severe complications were encountered after HIFU. Post-operative imaging demonstrated positive response and regression of all treated lesions. Follow-up biopsy revealed coagulation necrosis of target tumor and subsequent replacement by fibroblastic tissue. After a median follow-up of 54.8 months, 1 patient died, 1 was lost to follow-up, and 20 were still alive. Two of 22 patients developed local recurrence. Five-year disease-free survival and recurrence-free survival were 95% and 89%, respectively. Cosmetic result was judged as good to excellent in 94% of patients.

CONCLUSIONS

HIFU treatment is safe, effective, and feasible for patients with breast cancer. But, large-scale, multiple-center clinical trials will be needed to determine the future role of this novel modality.

Advanced hepatocellular carcinoma: treatment with high-intensity focused ultrasound ablation combined with transcatheter arterial embolization

PURPOSE

To evaluate ultrasonographically (US)-guided high-intensity focused ultrasound ablation combined with transcatheter arterial chemoembolization (TACE) in the treatment of stage IVA hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Institutional review board approval and informed consent were obtained. From November 1998 to May 2000, 50 consecutive patients with stage IVA HCC (TNM classification, T4N0-1M0) were alternately enrolled in one of two treatment groups: group 1 (n = 26), in which TACE was performed alone, and group 2 (n = 24), in which transcutaneous ablation of HCC with high-intensity focused ultrasound was performed 2-4 weeks after TACE. The tumors were 4-14 cm in diameter (mean, 10.5 cm). Immediate therapeutic effects were assessed at follow-up with Doppler US and computed tomography or magnetic resonance imaging. All patients were followed up for 3-24 months (mean, 8 months) to observe long-term therapeutic effects and complications in both groups. Tumor reduction rates, median survival time, and cumulative survival rates in both groups were calculated by using the unpaired Student t test and Kaplan-Meier method.

RESULTS

No severe complication was observed after focused ultrasound ablation, and no unexpected side effects were noted after TACE. Follow-up images showed absence or reduction of blood supply in the lesions after focused ultrasound ablation when compared with blood supply after TACE alone. The median survival time was 11.3 months in group 2 and 4.0 months in group 1 (P = .004). The 6-month survival rate was 80.4%-85.4% in group 2 and 13.2% in group 1 (P = .002), and the 1-year survival rate was 42.9% and 0%, respectively. Median reductions in tumor size as a percentage of initial tumor volume at 1, 3, 6, and 12 months after treatment, respectively, were 28.6%, 35.0%, 50.0%, and 50.0% in group 2 and 4.8%, 7.7%, 10.0%, and 0% in group 1 (P < .01).

CONCLUSION

The combination of high-intensity focused ultrasound ablation and TACE is a promising approach in patients with advanced-stage HCC, but large-scale randomized clinical trials are necessary for confirmation.

Extracorporeal high intensity focused ultrasound ablation in the treatment of patients with large hepatocellular carcinoma

BACKGROUND

High intensity focused ultrasound (HIFU) is a noninvasive treatment modality that induces complete coagulative necrosis of a deep tumor through the intact skin. The current study was conducted to determine the safety, efficacy, and feasibility of extracorporeal HIFU in the treatment of patients with hepatocellular carcinoma (HCC).

METHODS

A total of 55 patients with HCC with cirrhosis were enrolled in this prospective, nonrandomized clinical trial. Among them, 51 patients had unresectable HCC. Tumor size ranged from 4 to 14 cm in diameter with mean diameter of 8.14 cm. According to tumor, node, metastasis (TNM) classification, 15 patients corresponded to stage II, 16 to stage IIIA, and 24 to IIIC. All patients had HIFU, and the median number of HIFU session was 1.69. Safety and efficacy of HIFU were assessed in this trial.

RESULTS

No severe side effect was observed in the patients treated with HIFU. Follow-up imaging showed an absence of tumor vascular supply and the shrinkage of treated lesions. Serum alpha-fetoprotein returned to normal level in 34% of patients. The overall survival rates at 6, 12, and 18 months were 86.1%, 61.5%, and 35.3%, respectively. The survival rates were significantly higher in patients in stage II than those in stage IIIA (P = .0132) and in stage IIIC (P = .0265).

CONCLUSION

As a noninvasive therapy, HIFU appears to be effective, safe, and feasible in the treatment of patients with HCC. It may play an important role in the ablation of large tumors.

Activated anti-tumor immunity in cancer patients after high intensity focused ultrasound ablation

T cell-mediated immune responses represent the main cellular antitumor immunity in cancer patients. Recent studies have shown that that both surgical procedure and radiation therapy could cause the functional suppression of lymphocyte-mediated cellular immunity. The purpose of current study is to evaluate whether high intensity focused ultrasound (HIFU) might change a systemic antitumor immunity, particularly T lymphocyte-mediated immunity in cancer patients. A total of 16 patients with solid malignancies were treated with HIFU. Among them, six patients had osteosarcoma (Enneking stage, II(B)4, III(B) 2), five had hepatocellular carcinoma (TNM stage, III 3, IV 2), and five had renal cell carcinoma (TNM stage, III 2, IV 3). Using flow cytometry technique, T lymphocyte and subset, B lymphocyte and natural killer cell (NK) in the peripheral blood were measured in these patients on the day before HIFU and 7 to 10 d after HIFU. The statistical significance of any observed difference is evaluated by Student's t-test. The results showed a significance increase in the population of CD4(+) lymphocytes (p < 0.01) and the ratio of CD4(+) /CD8(+) (p < 0.05) in the circulation of cancer patients after HIFU treatment. The abnormal levels of CD3(+) lymphocytes returned toward the normal range in two patients, CD4(+)/CD8(+) ratio in 3, CD19(+) lymphocytes in one and cytotoxic NK in one, respectively, in comparison to control values. It is concluded that HIFU could enhance a systemic antitumor cellular immunity in addition to local tumor destruction in patients with solid malignancies.

Circulating tumor cells in patients with solid malignancy treated by high-intensity focused ultrasound

The theoretical possibility that exposure of a solid malignancy to high-intensity focused ultrasound (US), or HIFU, could lead to an increased rate of metastasis still remains. Using reverse transcriptase polymerase chain reaction (RT-PCR), the potential risk of hematogenous dissemination was assessed in HIFU-treated patients with solid malignancy. RT-PCR can demonstrate the presence or absence of specific RNA fragments. On the day before HIFU ablation, 5-mL peripheral blood samples were collected, and again 5 to 7 days after HIFU, from 26 enrolled patients (hepatocellular carcinoma, HCC: 10; osteosarcoma: 16). Total RNA was isolated and RT-PCR was performed to analyze the mRNA expression of (alpha-fetoprotein (AFP) and bone-specific alkaline phosphatase (BALP) genes. Positive AFP mRNA expression was preoperatively detected in 8 of 10 patients with HCC. In the postoperative specimens, positive expression was also detected in 8 of 10 patients. In 2 patients, circulating tumor cells were found preoperatively, but not postoperatively. Conversely, 2 patients with no circulating tumor cells preoperatively were found to have circulating tumor cells after HIFU. Of 16 osteosarcoma patients, 12 patients had circulating tumor cells and 4 had none. After HIFU treatment, 2 of the 12 patients had converted from presence to absence of circulating cells and the remaining 4 patients remained negative. It is concluded that patients undergoing complete HIFU ablation may demonstrate conversion from presence to absence of circulating tumor-specific marker mRNA, and that HIFU would not enhance the potential risk of metastasis in patients with malignant diseases.

Extracorporeal focused ultrasound surgery for treatment of human solid carcinomas: early Chinese clinical experience

The objective of this article is to introduce the early Chinese clinical experience of using extracorporeal focused ultrasound (US) surgery (FUS) for the treatment of solid tumors. From December 1997 to October 2001, a total of 1038 patients with solid tumors underwent FUS ablation in 10 Chinese hospitals. The tumors included primary and metastatic liver cancer, malignant bone tumors, breast cancer, soft tissue sarcomas, kidney cancer, pancreatic cancer, abdominal and pelvic malignant tumors, uterine myoma, benign breast tumors, hepatic hemangioma and other solid tumors. In this article, pathologic changes in tumors treated with FUS, real-time diagnostic imaging for targeting, monitoring and assessment of results by follow-up images are presented. Early clinical results and complications of the technique are also reported.

Changes in biologic characteristics of breast cancer treated with high-intensity focused ultrasound

Proliferation, invasion, immortalization and metastasis are the main malignant characteristics of cancer. Previous studies have shown that high-intensity focused ultrasound (US), or HIFU, can induce irreversible damage both to breast cancer cells and to tumor blood vessels. However, light microscopy alone may not always show this clearly. In this study, molecular biologic techniques were used to examine any changes in molecular markers associated with malignant behavior after exposure to HIFU. A total of 48 women with breast cancer were randomized to a control group (mastectomy) and a HIFU group (HIFU followed by mastectomy). Immunohistochemical staining, messenger RNA (mRNA) in situ hybridization and telomere-repeat amplification protocol-enzyme-linked immunosorbent assay (TRAP-ELISA) techniques were used to detect tumor expression of proliferating cell nuclear antigen (PCNA), cell adhesion molecule CD44v6, matrix metalloproteinase-9 (MMP-9), erbB2 mRNA, and to measure telomerase activity in both groups. The results demonstrated that there were significant alterations in expression of PCNA, CD44v6, MMP-9, erbB2 mRNA, and a dramatic decrease in telomerase activity in the HIFU group. It is concluded that malignant tumor characteristics are arrested by HIFU, and that biologic factors are potential markers for assessing HIFU efficacy.

Involvement of P4503A in the metabolism of 7,8-benzoflavone by human liver microsomes

1. The metabolism of 7,8-benzoflavone (ANF) was studied in human liver microsomal fractions. Five metabolites were generated and tentatively identified as ANF 5,6-oxide, 5,6-dihydrodiol, 7,8-dihydrodiol, 6-hydroxy ANF, and 7-hydroxy ANF based on UV and mass spectral analysis. 2. The involvement of P4503A in the metabolism of ANF was confirmed by the following observations: (1) correlation of ANF 5,6-oxide formation was noted with testosterone 6 beta-hydroxylation, an indicator of P4503A, in human liver microsomal fractions; (2) metabolism of ANF was inhibited by various selective P4503A enzyme inhibitors; (3) rabbit antibody raised against P4503A4 inhibited the ANF metabolism by > 80%; and (4) microsomal fractions that specifically expressed P4503A4 metabolized ANF to oxidized metabolites. 3. These results indicate that P4503A isoform(s) mainly metabolize ANF to oxidized derivatives in human liver microsomal fractions.

Cardiovascular and analgesic effects of a highly palatable diet in spontaneously hypertensive and Wistar-Kyoto rats

Ingestion of highly palatable diets (HPDs), rich in sucrose and fat, has been shown to lead to obesity and alterations in cardiovascular function in animal models. A hypothesis has been advanced which suggests that ingestion of an HPD increases hypothalamic beta-endorphin release, an effect which results in an increase in sympathetic nerve outflow during the development of obesity. The hypothesis was tested by chronic (10 weeks) feeding of male spontaneously hypertensive rats (SHRs) and Wistar-Kyoto rats (WKYs) with the HPD or normal rat chow (ND). Cardiovascular function (systolic blood pressure, heart rate) and body weight gain were monitored during the feeding period. Pain sensitivity was tested weekly by measuring tail-flick latency. Body weight gain was greater in WKY rats than in SHRs, but ingestion of the HPD had no effect in either strain. Terminal organ analysis indicated differences between strains of SHRs and WKYs in the heart, the adrenal and pituitary glands, peri-testicular fat pad, and testis weights expressed by organ weight/body weight. The heart weight was greater in SHRs on the HPD than in SHRs on the ND. The ingestion of the HPD significantly increased blood pressure only in SHRs, following 10 weeks of dietary intervention. However, tail-flick latency was prolonged in both SHRs and WKYs during ingestion of the HPD. Increases in tail-flick latency suggest that the HPD increases brain opiate levels in both SHRs and WKYs. Exaggerated increases in heart weight and blood pressure were noted in SHRs following feeding with the HPD, indicating enhanced sensitivity of SHRs to HPD-induced hypertension.

Sympathoadrenal control by paraventricular hypothalamic beta-endorphin in hypertension

The paraventricular hypothalamus regulates autonomic nerve outflow and is innervated with beta-endorphin-immunoreactive nerve terminals. This study examined the effects of beta-endorphin microinjected into the paraventricular hypothalamus on blood pressure, heart rate, and plasma catecholamine and glucose concentrations in conscious, unrestrained spontaneously hypertensive rats (SHR) and Wistar-Kyoto (WKY) rats at the age of about 9 weeks. Thirty minutes after paraventricular hypothalamic injection of [125I] beta-endorphin (3.5 micrograms), most of the recovered radioactivity was detectable within +/- 0.5 mm from the injection site in the coronal, sagittal, and horizontal planes. Unilateral paraventricular hypothalamic injections of beta-endorphin (1 and 0.1 microgram/0.1 microliter) increased blood pressure and heart rate in both strains in a dose-independent manner with significantly greater increases in SHR. Plasma catecholamine and glucose concentrations were measured 15, 30, and 60 minutes after beta-endorphin injection. Norepinephrine concentrations were not significantly altered in WKY rats but increased in SHR. Epinephrine concentrations increased in both strains with significantly greater increases in SHR. Increases in catecholamine concentrations were not dose-related. Glucose concentrations also increased in both strains with significantly greater increases in SHR only at the lower dose. Ganglionic blockade with pentolinium significantly reduced beta-endorphin-induced pressor and tachycardiac responses in SHR. Pretreatment of the paraventricular hypothalamus with naltrexone (1.1 micrograms) in SHR blocked the initial pressor and tachycardiac responses to beta-endorphin (0.1 microgram) and blunted increases in epinephrine and glucose levels. When the animals were anesthetized with alpha-chloralose 2-5 days after the study in conscious animals, there were no differences in blood pressure or heart rate between strains after beta-endorphin (0.1 microgram) injection. The results indicate that conscious SHR show enhanced cardiovascular and sympathoadrenal responses to beta-endorphin injected into the paraventricular hypothalamus, suggesting that alterations in the activity of the paraventricular hypothalamic beta-endorphin system can modulate the development of hypertension in SHR.

Effects of paraventricular hypothalamic microinfusions of kainic acid on cardiovascular and renal excretory function in conscious rats

The effects of infusions of kainic acid (KA) into the paraventricular nucleus of the hypothalamus (PVH) on blood pressure (BP), heart rate (HR), baroreflex sensitivity, renal hemodynamics and urinary electrolyte (Na+, K+) excretion were examined in conscious rats. Provocative doses of KA (0.3, 1 and 3 ng/microliters.hr) were infused into the PVH to selectively stimulate neuronal cell bodies, but not fibers of passage. Unilateral PVH infusions of KA (1 ng/microliter.hr) produced excitatory behavior primarily consisting of occasional grooming and increased locomotor activity, and periodic increases in BP and HR. The mean slope of the baroreflex response (delta heart period/delta mean BP; phenylephrine infusion method) curves was decreased by 24% (P less than .01 vs. control) when measured 1 to 1.5 hr after initiation of PVH infusion. The extent of diffusion of [3H]KA (1 ng/microliter.hr) was examined 1 hr after PVH infusion. Radioactivity was detectable at levels above 3 x background 1.6, 2.0 and 3.5 mm, respectively, from the injection site in sagittal, coronal and horizontal planes, indicating fairly extensive distribution patterns. Paraventricular hypothalamic infusions of KA (3 ng/microliters.hr) produced more intense behavioral excitation with slightly greater increases in BP and HR as compared with 1 ng/microliter.hr infusions. Paraventricular hypothalamic infusions of KA (1 and 3 ng/microliters.hr) increased urine flow and urinary Na+ and K+ excretion without affecting urine osmolality, whereas infusions of KA (0.3 ng/microliters.hr) produced no alterations in behavior, BP, HR, renal hemodynamics or renal excretory function.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of estrogen on luteinizing hormone-releasing hormone binding sites in hypothalamic membranes

The binding sites for [125I]LHRH were characterized in membranes from the hypthalamus and the effect of estrogen on the binding characteristics was studied in ovariectomized female rats. The radioligand, [125I]LHRH, was found to bind specifically to membranes from the hypothalamus at a maximal level, with an optimal temperature of 0 degrees C and a pH between 7 and 8. The binding was enhanced by NaCl at a concentration of 0.1-0.2 M. The specifically bound [125I]LHRH was only displaced by LHRH, but not by sodium iodide (NaI), bovine serum albumin and other hormones, such as thyrotropin-releasing hormone, bradykinin, oxytocin, prolactin, luteinizing hormone and growth hormone. The divalent metal ions, copper (Cu2+) and mercury (Hg2+), inhibited the specific binding of [125I]LHRH completely, whereas magnesium (Mg2+) and calcium (Ca2+) caused a decrease in binding. As revealed from Scatchard plot analysis, the binding sites for [125I]LHRH in the hypothalamus had a dissociation constant of 0.40 +/- 0.03 microM and the maximum number of binding sites was 98.55 +/- 4.34 pmol/mg protein. Treatment of female rates (ovariectomized for 3 weeks) with 4 micrograms of estradiol benzoate caused a statistically significant decrease in the maximal number of binding sites without any significant effect on the dissociation constant. However, the direct addition of estradiol hemisuccinate to the membrane preparations had no statistically significant effect on the specific binding of [125I]LHRH. The present study provides the evidence that estrogen decreases the density of binding sites for [125I]LHRH in the hypothalamus in vivo.