Recent advances of sonodynamic therapy in cancer treatment

The crosstalk between sonodynamic therapy and autophagy in cancer

As a noninvasive treatment approach for cancer and other diseases, sonodynamic therapy (SDT) has attracted extensive attention due to the deep penetration of ultrasound, good focusing, and selective irradiation sites. However, intrinsic limitations of traditional sonosensitizers hinder the widespread application of SDT. With the development of nanotechnology, nanoparticles as sonosensitizers or as a vehicle to deliver sonosensitizers have been designed and used to target tissues or tumor cells with high specificity and accuracy. Autophagy is a common metabolic alteration in both normal cells and tumor cells. When autophagy happens, a double-membrane autophagosome with sequestrated intracellular components is delivered and fused with lysosomes for degradation. Recycling these cell materials can promote survival under a variety of stress conditions. Numerous studies have revealed that both apoptosis and autophagy occur after SDT. This review summarizes recent progress in autophagy activation by SDT through multiple mechanisms in tumor therapies, drug resistance, and lipid catabolism. A promising tumor therapy, which combines SDT with autophagy inhibition using a nanoparticle delivering system, is presented and investigated.

Investigation of Sonosensitizers Based on Phenothiazinium Photosensitizers

The main advantage of sonodynamic therapy (SDT), the combining of ultrasound with a sonosensitizer, over photodynamic therapy (PDT) is that ultrasound penetrates deeper into tissues to activate the sonosensitizer, which offers noninvasive therapy for tumors in a site-oriented approach. In this study, we synthesized two symmetrical phenothiazine derivatives in which the methyl groups of MB (methylene blue) have been replaced by a hexyl and hydroxyethyl chains, named 3,7-bis(dihexylamino)-phenothiazin-5-ium iodide (MB6C) and 3,7-bis(di(2-hydroxyethyl)amino)-phenothiazin-5-ium iodide (MBOH), respectively. We explore the efficiency differences between PDT and SDT induced by these phenothiazine derivatives based on the standard of methylene blue (MB). Spectral studies indicate that these MB analogs exhibit sonosensitization ability with a similar tendency to the photosensitization ability. This means that MB, MBOH, and MB6C can be potential photosensitizers and sonosensitizers. After biological evaluation, we conclude that compound MB6C is a potential PDT and SDT candidate because it exhibits higher uptake, efficient intracellular phototoxicity and sonotoxicity over MB and MBOH, with IC50 values of ~2.5 µM and ~5 µM, respectively.

Recent Progress Toward Imaging Application of Multifunction Sonosensitizers in Sonodynamic Therapy

Sonodynamic therapy (SDT) is a rapidly developing non-surgical therapy that initiates sensitizers’ catalytic reaction using ultrasound, showing great potential for cancer treatment due to its high safety and non-invasive nature. In addition, recent research has found that using different diagnostic and therapeutic methods in tandem can lead to better anticancer outcomes. Therefore, as essential components of SDT, sonosensitizers have been extensively explored to optimize their functions and integrate multiple medical fields. The review is based on five years of articles evaluating the combined use of SDT and imaging in treating cancer. By developing multifunctional sonosensitive particles that combine imaging and sonodynamic therapy, we have integrated diagnosis into the treatment of precision medicine applications, improving SDT cell uptake and antitumor efficacy utilizing different tumour models. This paper describes the imaging principle and the results of cellular and animal imaging of the multifunctional sonosensitizers. Efforts are made in this paper to provide data and design references for future SDT combined imaging research and clinical application development and to provide offer suggestions.

Chemotherapy and Physical Therapeutics Modulate Antigens on Cancer Cells

Cancer cells possess specific properties, such as multidrug resistance or unlimited proliferation potential, due to the presence of specific proteins on their cell membranes. The release of proliferation-related proteins from the membrane can evoke a loss of adaptive ability in cancer cells and thus enhance the effects of anticancer therapy. The upregulation of cancer-specific membrane antigens results in a better outcome of immunotherapy. Moreover, cytotoxic T-cells may also become more effective when stimulated ex-vivo toward the anticancer response. Therefore, the modulation of membrane proteins may serve as an interesting attempt in anticancer therapy. The presence of membrane antigens relies on various physical factors such as temperature, exposure to radiation, or drugs. Therefore, changing the tumor microenvironment conditions may lead to cancer cells becoming sensitized to subsequent therapy. This paper focuses on the therapeutic approaches modulating membrane antigens and enzymes in anticancer therapy. It aims to analyze the possible methods for modulating the antigens, such as pharmacological treatment, electric field treatment, photodynamic reaction, treatment with magnetic field or X-ray radiation. Besides, an overview of the effects of chemotherapy and immunotherapy on the immunophenotype of cancer cells is presented. Finally, the authors review the clinical trials that involved the modulation of cell immunophenotype in anticancer therapy.

Atomically Precise Water-Soluble Graphene Quantum Dot for Cancer Sonodynamic Therapy

Although water-soluble graphene quantum dots (GQDs) have shown various promising bio-applications due to their intriguing optical and chemical properties, the large heterogeneity in compositions, sizes, and shapes of these GQDs hampers the better understanding of their structure-properties correlation and further uses in terms of large-scale manufacturing practices and safety concerns. It is shown here that a water-soluble atomically-precise GQD (WAGQD-C₉₆ ) is synthesized and exhibits a deep-red emission and excellent sonodynamic sensitization. By decorating sterically hindered water-soluble functional groups, WAGQD-C₉₆ can be monodispersed in water without further aggregation. The deep-red emission of WAGQD-C₉₆ facilitates the tracking of its bio-process, showing a good cell-uptake and long-time retention in tumor tissue. Compared to traditional molecular sonosensitizers, WAGQD-C₉₆ generates superior reactive oxygen species and demonstrates excellent tumor inhibition potency as an anti-cancer sonosensitizer in in vivo studies. A good biosafety of WAGQD-C₉₆ is validated in both in vitro and in vivo assays.

Simultaneous chemotherapy/sonodynamic therapy of the melanoma cancer cells using a gold-paclitaxel nanostructure

Nanodrug delivery systems are novel strategies for tumor treatment since delivery of chemotherapy drugs such as paclitaxel (PTX) is associated with substantial challenges due to its poor aqueous solubility. In addition, sonodynamic therapy (SDT) is a promising approach that can increase the uptake, accumulation, and dispersion of desirable amounts of the drugs by activating sonosensitizer and enhancing cell membrane permeability. Herein, gold-paclitaxel nanoparticles (Au-PTX NPs) were synthesized and characterized to evaluate the cytotoxicity toward C540 cancer cells in comparison of free PTX, AuNPs, and AuNPs+free PTX in the absence and presence of ultrasound radiation. Evidence shows that AuNPs have a median diameter size of 95.0 ± 15.4, while the size of Au-PTX NPs is roughly 219.7 ±  40.4 nm. Negative zeta-potential results indicate high stability and good dispersion of nanoparticles. 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay results revealed that Au-PTX NPs increased the cytotoxicity compared to other treatment groups that ensure the great potential of AuNPs as a promising nano-carrier for PTX drug delivery. Moreover, the viability of C540 cells treated by Au-PTX NPs under ultrasound radiation was decreased significantly by generating more reactive oxygen species (ROS) upon STD, with representing synergism effects confirming the role of gold nanoparticles as an excellent sonosensitizer and the role of SDT as an adjunctive treatment method with chemotherapy.

One-Step Fabrication of Multifunctional PLGA-HMME-DTX@MnO2 Nanoparticles for Enhanced Chemo-Sonodynamic Antitumor Treatment

Background

Sonodynamic therapy (SDT) and its synergistic cancer therapy derivatives, such as combined chemotherapy-SDT (chemo-SDT), are promising approaches for tumor treatment. However, the main drawbacks restricting their applications are hypoxia in tumors and the reducing microenvironment or high glutathione (GSH) levels.

Methods

In this study, a hybrid metal MnO₂ was deposited onto nanoparticles fabricated using poly(lactic-co-glycolic acid) (PLGA), carrying docetaxel (DTX) and the sonosensitizer hematoporphyrin monomethyl ether (HMME) (PHD@MnO₂) via a one-step flash nanoprecipitation (FNP) method. Characterization and in vitro and in vivo experiments were conducted to explore the chemo-SDT effect of PHD@MnO₂ and evaluate the synergetic antitumor treatment of this nanosystem.

Results

When low-power ultrasound is applied, the acquired PHD@MnO₂, whether in solution or in MCF-7 cells, generated ROS more efficiently than other groups without MnO₂ or those treated via monotherapy. Specifically, GSH-depletion was observed when MnO₂ was introduced into the system. PHD@MnO₂ presented good biocompatibility and biosafety in vitro and in vivo. These results indicated that the PHD@MnO₂ nanoparticles overcame hypoxia in tumor tissue and suppressed the expression of hypoxia-inducible factor 1 alpha (HIF-1α), achieving enhanced chemo-SDT.

Conclusion

This study provides a paradigm that rationally engineered multifunctional metal-hybrid nanoparticles can serve as an effective platform for augmenting the antitumor therapeutic efficiency of chemo-SDT.

Ultrasound Triggers Hypericin Activation Leading to Multifaceted Anticancer Activity

The use of ultrasound (US) in combination with a responsive chemical agent (sonosensitizer) can selectively trigger the agent's anticancer activity in a process called sonodynamic therapy (SDT). SDT shares some properties with photodynamic therapy (PDT), which has been clinically approved, but sets itself apart because of its use of US rather than light to achieve better tissue penetration. SDT provides anticancer effects mainly via the sonosensitizer-mediated generation of reactive oxygen species (ROS), although the precise nature of the underpinning mechanism is still under debate. This work investigates the SDT anticancer activity of hypericin (Hyp) in vitro in two- (2D) and three-dimensional (3D) HT-29 colon cancer models, and uses PDT as a yardstick due to its well-known Hyp phototoxicity. The cancer cell uptake and cellular localization of Hyp were investigated first to determine the proper noncytotoxic concentration and incubation time of Hyp for SDT. Furthermore, ROS production, cell proliferation, and cell death were evaluated after Hyp was exposed to US. Since cancer relapse and transporter-mediated multidrug resistance (MDR) are important causes of cancer treatment failure, the US-mediated ability of Hyp to elicit immunogenic cell death (ICD) and overcome MDR was also investigated. SDT showed strong ROS-mediated anticancer activity 48 h after treatment in both the HT-29 models. Specific damage-associated molecular patterns that are consistent with ICD, such as calreticulin (CRT) exposure and high-mobility group box 1 protein (HMGB1) release, were observed after SDT with Hyp. Moreover, the expression of the ABC transporter, P-glycoprotein (P-gp), in HT-29/MDR cells was not able to hinder cancer cell responsiveness to SDT with Hyp. This work reveals, for the first time, the US responsiveness of Hyp with significant anticancer activity being displayed, making it a full-fledged sonosensitizer for the SDT of cancer.

The Role of Nonapoptotic Programmed Cell Death — Ferroptosis, Necroptosis, and Pyroptosis — in Pancreatic Ductal Adenocarcinoma Treatment

Pancreatic ductal adenocarcinoma (PDAC) is the most lethal cancer, with a dismal 5-year survival rate of less than 10%. It is estimated that approximately 80% of pancreatic ductal carcinoma (PDAC) patients are diagnosed at an advanced or metastatic stage. Hence, most patients are not appropriate candidates for surgical resection and therefore require systemic chemotherapy. However, it has been reported that most patients develop chemoresistance within several months, partly because of antiapoptotic mechanisms. Hence, inducing alternative programmed cell death (PCD), including ferroptosis, necroptosis or pyroptosis, seems to be a promising strategy to overcome antiapoptosis-mediated chemoresistance. In this review, we shed light on the molecular mechanisms of ferroptosis, necroptosis and pyroptosis and suggest several potential strategies (e.g., compounds and nanoparticles [NPs]) that are capable of triggering nonapoptotic PCD to suppress PDAC progression. In conclusion, these strategies might serve as adjuvants in combination with clinical first-line chemotherapies to improve patient survival rates.

Metallic phase enabling MoS2 nanosheets as an efficient sonosensitizer for photothermal-enhanced sonodynamic antibacterial therapy

Two-dimensional (2D) transition metal dichalcogenide (TMD) nanosheets (e.g., MoS₂) with metallic phase (1T or 1T´ phase) have been proven to exhibit superior performances in various applications as compared to their semiconducting 2H-phase counterparts. However, it remains unclear how the crystal phase of 2D TMD nanosheets affects their sonodynamic property. In this work, we report the preparation of MoS₂ nanosheets with different phases (metallic 1T/1T´ or semiconducting 2H) and exploration of its crystal-phase effect on photothermal-enhanced sonodynamic antibacterial therapy. Interestingly, the defective 2D MoS₂ nanosheets with high-percentage metallic 1T/1T´ phase (denoted as M-MoS₂) present much higher activity towards the ultrasound-induced generation of reactive oxygen species (ROS) as compared to the semiconducting 2H-phase MoS₂ nanosheets. More interestingly, owing to its metallic phase-enabled strong absorption in the near-infrared-II (NIR-II) regime, the ultrasound-induced ROS generation performance of the M-MoS₂ nanosheets can be further enhanced by the photothermal effect under a 1064 nm laser irradiation. Thus, after modifying with polyvinylpyrrolidone, the M-MoS₂ nanosheets can be used as an efficient sonosensitizer for photothermal-enhanced sonodynamic bacterial elimination under ultrasound treatment combining with NIR-II laser irradiation. This study demonstrates that metallic MoS₂ nanosheets can be used as a promising sonosensitizer for antibacterial therapy, which might be also promising for cancer therapies.

Hematoporphyrin Is a Promising Sensitizer for Dual-Frequency Sono-photodynamic Therapy in Mice Breast Cancer

Background: The combination of sonodynamic and photodynamic therapy (SPDT) may be a new hopeful non-invasive method for cancer treatment, which incorporates a combination of low-intensity ultrasound, laser radiation, and a sensitizer agent. Objectives: This study aimed at evaluating the effects of hematoporphyrin (HP)-mediated SPDT (dual-frequency ultrasound and laser radiation) in the management of mice breast adenocarcinoma. Methods: One hundred and thirty-two female mice with implanted tumors were divided into 22 groups, including sham, laser, 4 groups of dual-frequency ultrasound/laser radiation, 8 groups of HP-mediated SPDT (2.5 and 5 mg/kg), and 8 groups of HP encapsulated in mesoporous silica nanoparticles (HP-MSNs)-mediated SPDT. The sensitizer was administered by intraperitoneal injection and after a 24-hour delay, tumor grafted mice were treated with a combination of dual-frequency ultrasound and laser light. The tumor growth factors were used to assess the treatment outcome. Results: The results indicated that HP or HP-MSNs-mediated SPDT had a delaying tumor growth effect. In the groups treated with dual-frequency ultrasound and laser radiation, the maximum tumor growth inhibition (TGI) ratio was 47.5%, while the maximum TGI ratio in the SPDT groups was 61.6%. The time of T2 and T5 in the case of HP-MSNs-mediated SPDT groups was increased compared with sham and that of HP-mediated SPDT groups (P < 0.05). The inhibition ratio on tumor growth increased in all SPDT groups at 12 days after the treatment. Analysis of experimental data demonstrates that this increase was not declined and persisted over 30 days of treatment. The results indicated that SPDT is effective in relative tumor volume when compared with the sham group (339.1 ± 161 and 1510.8 ± 160, respectively). HP or HP-MSNs-mediated SPDT groups had Grade I (low), while others had Grade III (high) malignancy in the histological study of mice breast adenocarcinoma. Conclusions: The results revealed that when sensitized by dual-frequency SPDT, hematoporphyrin (with and without MSNs), has a promising effect at delaying tumor growth on mice breast cancer. Therefore, it can be appreciated that careful selection of the sensitizer with SPDT will play an eminent role in the success of cancer therapies.

Exploiting Shock Waves to Trigger the Anticancer Sonodynamic Activity of 5-Aminolevulinc Acid-Derived Protoporphyrin IX on In Vitro 2D and 3D Cancer Models

Sonodynamic therapy (SDT) is a noninvasive method for cancer treatment based on selective activation of a sonosensitiser by ultrasound (US), which results in the generation of reactive oxygen species (ROS) and cancer cell death. SDT uses a similar approach to photodynamic therapy (PDT), but can overcome the main drawback of PDT, i.e., poor tissue penetration of light. This research work investigated the anticancer effect of SDT on various two- (2D) and three-dimensional (3D) in vitro tumour models, using PDT as a reference treatment. Sonodynamic experiments were performed with pulsed US, specifically with shock waves (SW) and the prodrug 5-aminolevulinic acid (Ala), which is converted—at the mitochondrial level—into the sonosensitiser protoporphyrin IX (PPIX). SW-mediated PPIX sonodynamic activation resulted in a significant decrease in cell proliferation, especially on human fibrosarcoma (HT-1080) cells, where PPIX accumulation was higher compared to human melanoma (A2058) and neuroblastoma (SH-SY5 Y) cells. Moreover, SW-mediated SDT showed significant ROS generation, cell line-dependent in its amount, probably due to differences in Ala-induced PPIX synthesis. In all cancer cell lines, apoptosis was highlighted as the main cancer cell death pathway determined by SW-mediated SDT, along with significant cytochrome c release, and a consequent increase in DNA damage. The efficacy of SDT with SW and Ala in halting cancer cell proliferation was also confirmed in 3D cancer spheroids. The present study suggests that SW-mediated SDT is a valuable approach to slow down tumour proliferation, thus opening an innovative scenario in cancer treatment.

Ultrasound versus Light: Exploring Photophysicochemical and Sonochemical Properties of Phthalocyanine-Based Therapeutics, Theoretical Study, and In Vitro Evaluations

Photodynamic therapy (PDT) applications carried out with the assistance of ultrasound have attracted significant attention in recent years. The use of phthalocyanines, which are an important component as photosensitizers in PDT, is becoming more important day by day. In therapeutic applications, phthalocyanines can promote the production of reactive oxygen species. Motivated by this fact, the syntheses of metal-free (2), gallium (3), and indium (4) phthalocyanines have been achieved by substituting 4-(cinnamyloxy)phthalonitrile for the first time to evaluate their therapeutic applications. Additionally, photophysicochemical, sonophotochemical, and in vitro evaluations of phthalocyanines have been reported. To the best of our knowledge, this is the first study of the use of phthalocyanines with different metal ions as potential photosensitizers for sonophotodynamic therapy (SPDT) applications in gastric cancer cell lines. The results show that the quantum yield of the generation of singlet oxygen increased in sonophotochemical studies (Φ_Δ = 0.55 (2), 0.85 (3), 0.96 (4)), compared to photochemical studies (Φ_Δ = 0.22 (2), 0.61 (3), 0.78 (4)). The density functional theory (DFT) results are in good agreement with the experimental results and suggest increased reactivity of phthalocyanines 3 and 4 in various redox processes, thus implying their applicability and usefulness as potential therapeutic agents. These phthalocyanines are effective sensitizers for PDT, sonodynamic therapy (SDT), and SPDT against MKN-28 gastric cancer cell line in vitro. All three treatments decreased cell viability and induced apoptosis in the gastric cancer cell line. However, indium phthalocyanine (4)-mediated SPDT was a more effective treatment modality compared to indium phthalocyanine (4)-mediated PDT and SDT. Also, indium phthalocyanine (4) was found to be a more effective sensitizer to activate apoptosis compared to the other phthalocyanines. To sum up, phthalocyanine-mediated SPDT enhances the cytotoxic effect on gastric cancer cells more than the effect of SDT or PDT alone.

Applications of the ROS-Responsive Thioketal Linker for the Production of Smart Nanomedicines

Reactive oxygen species (ROS)-sensitive drug delivery systems (DDS) specifically responding to altered levels of ROS in the pathological microenvironment have emerged as an effective means to enhance the pharmaceutical efficacy of conventional nanomedicines, while simultaneously reducing side effects. In particular, the use of the biocompatible, biodegradable, and non-toxic ROS-responsive thioketal (TK) functional group in the design of smart DDS has grown exponentially in recent years. In the design of TK-based DDS, different technological uses of TK have been proposed to overcome the major limitations of conventional DDS counterparts including uncontrolled drug release and off-target effects. This review will focus on the different technological uses of TK-based biomaterials in smart nanomedicines by using it as a linker to connect a drug on the surface of nanoparticles, form prodrugs, as a core component of the DDS to directly control its structure, to control the opening of drug-releasing gates or to change the conformation of the nano-systems. A comprehensive view of the various uses of TK may allow researchers to exploit this reactive linker more consciously while designing nanomedicines to be more effective with improved disease-targeting ability, providing novel therapeutic opportunities in the treatment of many diseases.

Biological Utility of Fluorinated Compounds: from Materials Design to Molecular Imaging, Therapeutics and Environmental Remediation

The applications of fluorinated molecules in bioengineering and nanotechnology are expanding rapidly with the controlled introduction of fluorine being broadly studied due to the unique properties of C-F bonds. This review will focus on the design and utility of C-F containing materials in imaging, therapeutics, and environmental applications with a central theme being the importance of controlling fluorine-fluorine interactions and understanding how such interactions impact biological behavior. Low natural abundance of fluorine is shown to provide sensitivity and background advantages for imaging and detection of a variety of diseases with ¹⁹F magnetic resonance imaging, ¹⁸F positron emission tomography and ultrasound discussed as illustrative examples. The presence of C-F bonds can also be used to tailor membrane permeability and pharmacokinetic properties of drugs and delivery agents for enhanced cell uptake and therapeutics. A key message of this review is that while the promise of C-F containing materials is significant, a subset of highly fluorinated compounds such as per- and polyfluoroalkyl substances (PFAS), have been identified as posing a potential risk to human health. The unique properties of the C-F bond and the significant potential for fluorine-fluorine interactions in PFAS structures necessitate the development of new strategies for facile and efficient environmental removal and remediation. Recent progress in the development of fluorine-containing compounds as molecular imaging and therapeutic agents will be reviewed and their design features contrasted with environmental and health risks for PFAS systems. Finally, present challenges and future directions in the exploitation of the biological aspects of fluorinated systems will be described.

New Perspectives for Eye-Sparing Treatment Strategies in Primary Uveal Melanoma

Simple Summary

Uveal melanoma is the most common intraocular cancer. The current eye-sparing treatment options include mostly plaque brachytherapy. However, the effectiveness of these methods is still unsatisfactory. In this article, we review several possible new treatment options. These methods may be based on the physical destruction of the cancerous cells by applying ultrasounds. Another approach may be based on improving the penetration of the anti-cancer agents. It seems that the most promising technologies from this group are based on enhancing drug delivery by applying electric current. Finally, new advanced nanoparticles are developed to combine diagnostic imaging and therapy (i.e., theranostics). However, these methods are mostly at an early stage of development. More advanced studies on experimental animals and clinical trials would be needed to introduce some of these techniques to routine clinical practice.

Abstract

Uveal melanoma is the most common intraocular malignancy and arises from melanocytes in the choroid, ciliary body, or iris. The current eye-sparing treatment options include surgical treatment, plaque brachytherapy, proton beam radiotherapy, stereotactic photon radiotherapy, or photodynamic therapy. However, the efficacy of these methods is still unsatisfactory. This article reviews several possible new treatment options and their potential advantages in treating localized uveal melanoma. These methods may be based on the physical destruction of the cancerous cells by applying ultrasounds. Two examples of such an approach are High-Intensity Focused Ultrasound (HIFU)—a promising technology of thermal destruction of solid tumors located deep under the skin and sonodynamic therapy (SDT) that induces reactive oxygen species. Another approach may be based on improving the penetration of anti-cancer agents into UM cells. The most promising technologies from this group are based on enhancing drug delivery by applying electric current. One such approach is called transcorneal iontophoresis and has already been shown to increase the local concentration of several different therapeutics. Another technique, electrically enhanced chemotherapy, may promote drug delivery from the intercellular space to cells. Finally, new advanced nanoparticles are developed to combine diagnostic imaging and therapy (i.e., theranostics). However, these methods are mostly at an early stage of development. More advanced and targeted preclinical studies and clinical trials would be needed to introduce some of these techniques to routine clinical practice.

Sonodynamic Effects of a Novel Ether-Group Modified Porphyrin Derivative Combined With Pulsed Low-Intensity Ultrasound on PC-9 Cells

Sonodynamic therapy (SDT) is a developing modality for cancer treatment based on the synergistic effect of ultrasound and chemical compounds which are known as sonosensitizers. The development of more efficient sonosensitizers has become an urgent issue in this field. In this study, a novel porphyrin derivative (BBTPP) mediated SDT was evaluated on PC-9 cells. Pulsed low-intensity ultrasound (PLIU) was used for its little thermal and mechanical damage. The accumulation of drugs in cells was evaluated through porphyrin fluorescence, and the cytotoxicity of BBTPP was evaluated using a cell counting kit-8 assay. The sonodynamic effect was investigated by Hoechst 33342/PI and Annexin V-FITC/PI double staining, which showed an apoptotic rate of 18.87% in the BBTPP-SDT group, as compared with 1.71%, 1.4%, 1.57%, 3.61%, 11.18% in the control, BBTPP, hematoporphyrin monomethyl ether (HMME), ultrasound, and HMME-SDT groups, respectively. The sono-toxic effect of BBTPP was significantly superior to HMME. Our results showed that BBTPP-SDT resulted in much higher intracellular reactive oxygen species (ROS) and lipid peroxidation levels which were evaluated by 2′,7′-dichlorodihydrofluorescein diacetate (H₂DCFDA) and Liperfluo assay, respectively. The expressions of Bax, Bcl-2, caspase-9, caspase-8, and cleaved caspase-3 proteins were evaluated to investigate the apoptotic mechanism of BBTPP-SDT. The results of this study showed that the combination of BBTPP and PLIU induced the generation of ROS, resulting in lipid peroxidation, and activated both the extrinsic and intrinsic apoptotic pathways of PC-9 cells. Our results also suggested that the ether group introduced in the side chain of porphyrin could enhance the sono-toxicity of porphyrin-based sensitizers under the sonication of PLIU. These results supported the possibility of BBTPP as a promising sonosensitizer, and an appropriate side chain could enhance the sono-sensitivity of porphyrins.

Evaluation of antimicrobial effects of photo-sonodynamic antimicrobial chemotherapy based on nano-micelle curcumin on virulence gene expression patterns in Acinetobacter baumannii

BACKGROUND

Abaumannii baumannii rapidly resistance to a wide range of antimicrobial agents. The combination of antimicrobial photodynamic therapy (aPDT) and sonodynamic antimicrobial chemotherapy (SACT) known as photo-sonodynamic antimicrobial chemotherapy (PSACT) has received considerable attention as one of the emerging and promising strategies against microbial infections.

OBJECTIVE

This study aimed to investigate the antimicrobial effects of PSACT based on nano-micelle curcumin (N-MCur) on the virulence gene expression patterns in A. baumannii.

MATERIALS AND METHODS

N-MCur as a photo-sonosensitizer was synthesized and confirmed. To determine sub-significant reduction dose of PSACT, sub-significant reduction dose of N-MCur and blue laser light during aPDT, and ultrasound power output during SACT were assessed. Finally, changes in the expression of genes involved in treated A. baumannii by minimum sub-significant reduction dose of PSACT were determined using quantitative real-time-PCR (qRT-PCR).

RESULTS

PSACT using 12.5 mM N-MCur at the ultrasound power outputs of 28.7, 36.9, and 45.2 mW/cm2 with 4 min irradiation time of blue laser, as well as, 6.2 mM N-MCur at an ultrasound power output of 45.2 mW/cm2 plus 3 min blue laser irradiation time exhibited the significant dose-dependent reduction against A. baumannii cell viability compared to the control group (P<0.05). After treatment of A. baumannii using 3.1 mM N-MCur + 2 min blue laser irradiation time + 28.7 mW/cm2 ultrasound as the minimum sub-significant reduction doses of PSACT, mRNA expression was significantly upregulated to 6.0-, 11.2-, and 13.7-folds in recA, blsA, and dnaK and downregulated to 8.6-, 10.1-, and 14.5-folds in csuE, espA, and abaI, respectively.

CONCLUSIONS

N-MCur-mediated PSACT could regulate the expression of genes involved in A. baumannii pathogenesis. Therefore, PSACT can be proposed as a promising application to treat infections caused by A. baumannii.

Recent ultrasound advancements for the manipulation of nanobiomaterials and nanoformulations for drug delivery

Recent advances in ultrasound (US) have shown its great potential in biomedical applications as diagnostic and therapeutic tools. The coupling of US-assisted drug delivery systems with nanobiomaterials possessing tailor-made functions has been shown to remove the limitations of conventional drug delivery systems. The low-frequency US has significantly enhanced the targeted drug delivery effect and efficacy, reducing limitations posed by conventional treatments such as a limited therapeutic window. The acoustic cavitation effect induced by the US-mediated microbubbles (MBs) has been reported to replace drugs in certain acute diseases such as ischemic stroke. This review briefly discusses the US principles, with particular attention to the recent advancements in drug delivery applications. Furthermore, US-assisted drug delivery coupled with nanobiomaterials to treat different diseases (cancer, neurodegenerative disease, diabetes, thrombosis, and COVID-19) are discussed in detail. Finally, this review covers the future perspectives and challenges on the applications of US-mediated nanobiomaterials.

Gas-filled protein nanostructures as cavitation nuclei for molecule-specific sonodynamic therapy

Sonodynamic therapy (SDT) is a promising alternative for cancer therapy, understood to exert cytotoxicity through cavitation and subsequent production of large amounts of reactive oxygen species (ROS). Gas-filled protein nanostructures (gas vesicles or GVs) produced by cyanobacteria have a hollow structure similar to microbubbles and have demonstrated comparable enhancement of ultrasound imaging contrast. We thus hypothesized that GVs may act as stable nuclei for inertial cavitation to enhance SDT with improved enhanced permeability and retention (EPR) effects due to their nanometer scale. The function of GVs to mediate cavitation, ROS production, and cell-targeted toxicity under SDT was determined. In solution, we found that GVs successfully increased cavitation and enhanced ROS production in a dose- and time-dependent manner. Then, GV surfaces were modified (FGVs) to specifically target CD44⁺ cells and accumulate preferentially at the tumor site. In vitro sonodynamic therapy (SDT) showed ROS production and tumor cell toxicity substantially elevated in the presence of FGVs, and the addition of FGVs was found to enhance cavitation and subsequently inhibit tumor growth and exert greater damage to tumors under SDT in vivo. Our results thus demonstrate that FGVs can function as stable, nanosized, nuclei for spatially accurate and cell-targeted SDT. STATEMENT OF SIGNIFICANCE: The initiation of inertial cavitation is critical for ROS generation and subsequent cellular toxicity in SDT. Thus, precise control of the occurrence of cavitation is a key factor in increasing SDT's therapeutic efficacy. We explored nanometer-sized gas vesicles (GVs) as a new class of cavitation nuclei for molecule-specific sonodynamic therapy. Our results showed that GV-mediated SDT treatment enabled targeted disruption of specific cells expressing a known surface marker within the area of insonation, providing a spatially specific and targeted SDT treatment.

Immunotherapy for Triple-Negative Breast Cancer

Triple-negative breast cancer (TNBC) is characterized by extensive tumor heterogeneity at both the pathologic and molecular levels, particularly accelerated aggressiveness, and terrible metastasis. It is responsible for the increased mortality of breast cancer patients. Due to the negative expression of estrogen receptors, progesterone receptors, and human epidermal growth factor receptor 2, the progress of targeted therapy has been hindered. Higher immune response in TNBCs than for other breast cancer types makes immunotherapy suitable for TNBC therapy. At present, promising treatments in immunotherapy of TNBC include immune checkpoints (ICs) blockade therapy, adoptive T-cell immunotherapy, and tumor vaccine immunotherapy. In addition, nanomedicines exhibit great potential in cancer therapy through the enhanced permeability and retention (EPR) effect. Immunotherapy-involved combination therapy may exert synergistic effects by combining with other treatments, such as traditional chemotherapy and new treatments, including photodynamic therapy (PTT), photodynamic therapy (PDT), and sonodynamic therapy (SDT). This review focuses on introducing the principles and latest development as well as progress in using nanocarriers as drug-delivery systems for the immunotherapy of TNBC.

Metallic Nanoparticle-Mediated Immune Cell Regulation and Advanced Cancer Immunotherapy

Cancer immunotherapy strategies leveraging the body's own immune system against cancer cells have gained significant attention due to their remarkable therapeutic efficacy. Several immune therapies have been approved for clinical use while expanding the modalities of cancer therapy. However, they are still not effective in a broad range of cancer patients because of the typical immunosuppressive microenvironment and limited antitumor immunity achieved with the current treatment. Novel approaches, such as nanoparticle-mediated cancer immunotherapies, are being developed to overcome these challenges. Various types of nanoparticles, including liposomal, polymeric, and metallic nanoparticles, are reported for the development of effective cancer therapeutics. Metallic nanoparticles (MNPs) are one of the promising candidates for anticancer therapy due to their unique theranostic properties and are thus explored as both imaging and therapeutic agents. In addition, MNPs offer a dense surface functionalization to target tumor tissue and deliver genetic, therapeutic, and immunomodulatory agents. Furthermore, MNPs interact with the tumor microenvironment (TME) and regulate the levels of tumor hypoxia, glutathione (GSH), and reactive oxygen species (ROS) for remodulation of TME for successful therapy. In this review, we discuss the role of nanoparticles in tumor microenvironment modulation and anticancer therapy. In particular, we evaluated the response of MNP-mediated immune cells, such as dendritic cells, macrophages, T cells and NK cells, against tumor cells and analyzed the role of MNP-based cancer therapies in regulating the immunosuppressive environment.

Pro-oxidant drug-loaded porphyrinic zirconium metal-organic-frameworks for cancer-specific sonodynamic therapy

Sonodynamic therapy, which utilizes ultrasound (US) to produce cytotoxic reactive oxygen species (ROS), can overcome the critical drawbacks of photodynamic therapy, such as limited tissue penetration depth. However, the development of sonosensitizers having superior sonodynamic effects and desirable biocompatibility remains a major challenge. In this study, nanoscale zirconium-based porphyrinic metal organic frameworks (MOFs) (PCN-222) were developed as safe and effective nanosonosensitizers. Polyethylene glycol (PEG)-coated PCN-222 (PEG-PCN) was loaded with a pro-oxidant drug, piperlongumine (PL), to enable tumor-specific chemo-photodynamic combination therapy. Both PEG-PCN and PL-incorporated PEG-PCN (PL-PEG-PCN) showed high colloidal stability in biological media. In addition, nanoscale PL-PEG-PCN was efficiently internalized by breast cancer cells, leading to substantially increased ROS generation under US exposure. The effective intracellular delivery of PL by PEG-PCN further elevated the level of intracellular ROS in breast cancer cells owing to the pro-oxidative activity of PL. Therefore, PL-PEG-PCN revealed significantly higher sonotoxicity than free PL and PEG-PCN. Owing to the cancer-specific apoptosis triggered by PL, PL-PEG-PCN showed cancer-selective cell death in breast cancer cells compared with normal fibroblast cells. This study demonstrates that pro-oxidant drug-loaded porphyrinic MOFs are biocompatible and effective sonosensitizers for cancer-targeted chemo-sonodynamic combination therapy.

Antibacterial Sonodynamic Therapy: Current Status and Future Perspectives

Multidrug-resistant bacteria have emerged in both community and hospital settings, partly due to the misuse of antibiotics. The inventory of viable antibiotics is rapidly declining, and efforts toward discovering newer antibiotics are not yielding the desired outcomes. Therefore, alternate antibacterial therapies based on physical mechanisms such as light and ultrasound are being explored. Sonodynamic therapy (SDT) is an emerging therapeutic approach that involves exposing target tissues to a nontoxic sensitizing chemical and low-intensity ultrasound. SDT can enable site-specific cytotoxicity by producing reactive oxygen species (ROS) in response to ultrasound, which can be harnessed for treating bacterial infections. This approach can potentially be used for both superficial and deep-seated microbial infections. The majority of the sonosensitizers reported are nonpolar, exhibiting limited bioavailability and a high clearance rate in the body. Therefore, targeted delivery agents such as nanoparticle composites, liposomes, and microbubbles are being investigated. This article reviews recent developments in antibacterial sonodynamic therapy, emphasizing biophysical and chemical mechanisms, novel delivery agents, ultrasound exposure and image guidance strategies, and the challenges in the pathway to clinical translation.

Gene augmented nuclear-targeting sonodynamic therapy via Nrf2 pathway-based redox balance adjustment boosts peptide-based anti-PD-L1 therapy on colorectal cancer

Background

Colorectal cancer is known to be resistant to immune checkpoint blockade (ICB) therapy. Sonodynamic therapy (SDT) has been reported to improve the efficacy of immunotherapy by inducing immunogenic cell death (ICD) of cancer. However, the SDT efficacy is extremely limited by Nrf2-based natural redox balance regulation pathway in cancer cells in response to the increased contents of reactive oxygen species (ROS). Nuclear-targeting strategy has shown unique advantages in tumor therapy by directly destroying the DNA. Thus it can be seen that Nrf2-siRNA augmented nuclear-targeting SDT could boost ICB therapy against colorectal cancer.

Results

The nuclear-targeting delivery system TIR@siRNA (TIR was the abbreviation of assembled TAT-IR780) with great gene carrier capacity and smaller diameter (< 60 nm) was designed to achieve the gene augmented nuclear-targeting SDT facilitating the anti-PD-L1 (programmed cell death-ligand-1) therapy against colorectal cancer. In CT26 cells, TIR@siRNA successfully delivered IR780 (the fluorescent dye used as sonosensitizer) into cell nucleus and Nrf2-siRNA into cytoplasm. Under US (utrasound) irradiation, TIR@siRNA notably increased the cytotoxicity and apoptosis-inducing activity of SDT through down-regulating the Nrf2, directly damaging the DNA, activating mitochondrial apoptotic pathway while remarkably inducing ICD of CT26 cells. In CT26 tumor-bearing mice, TIR@siRNA mediated gene enhanced nuclear-targeting SDT greatly inhibited tumor growth, noticeably increased the T cell infiltration and boosted ^DPPA-1 peptide-based anti-PD-L1 therapy to ablate the primary CT26 tumors and suppress the intestinal metastases.

Conclusions

All results demonstrate that TIR@siRNA under US irradiation can efficiently inhibit the tumor progression toward colorectal CT26 cancer in vitro and in vivo by its mediated gene augmented nuclear-targeting sonodynamic therapy. Through fully relieving the immunosuppressive microenvironment of colorectal cancer by this treatment, this nanoplatform provides a new synergistic strategy for enhancing the anti-PD-L1 therapy to ablate colorectal cancer and inhibit its metastasis.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s12951-021-01094-x.

Titaniumdioxide mediated sonophotodynamic therapy against prostate cancer

In this study, we aimed to investigate of antitumor efficiency of titanium dioxide mediated photodynamic (PDT), sonodynamic (SDT), and sonophotodynamic (SPDT) therapies with a possible mechanism against the PC3 prostate cancer cell line. SPDT is a new approach to cancer treatment that combines sonodynamic and photodynamic therapies. On the other hand, Titanium dioxide (TiO₂) has been used in many applications in pharmaceutical products and cosmetics, industrial products, and medicines. TiO₂ nanoparticles will be useful for the treatment of cancer with PDT and SDT as the sensitizers in medicine. In this study, TiO₂ nanoparticles were used for an in vitro comparison between the PDT, SDT, SPDT damages on prostate cancer cell lines. For this purpose, the cells were incubated in RPMI-1640 media with various concentrations of TiO₂ and subjected to 0,5 W/cm² ultrasound and/or 0,5 mJ/cm² light irradiation. The prostate cancer cells were irradiated with light and exposed with the US and both for SPDT in the presence and/or absence of TiO₂. Cell viability was measured using by MTT test after treatments. Investigate to apoptosis mechanism, Propidium iodide and Hoechst 33342 staining were used and the results showed that apoptotic cell bodies were increased compared with other groups. According to western blot analyses, caspase-3, caspase-8, PARP, and Bax levels were decreased after treatments, whereas the expression levels of caspase-9 were increased. Biochemical results showed that after treatments MDA levels were increased while SOD, CAT, GSH levels were decreased. In conclusion, TiO₂-mediated SPDT may provide a promising approach for prostate cancer therapy and might play a key role in the apoptotic mechanism of these treatments.

Photo-sonodynamic combination activity of cationic morpholino-phthalocyanines conjugated to nitrogen and nitrogen-sulfur doped graphene quantum dots against MCF-7 breast cancer cell line in vitro

In this work, we explore the reactive oxygen species (ROS) generation abilities of cationic morpholino-substituted-phthalocyanine (Pc) conjugated to nitrogen (NGQDs) and nitrogen-sulfur (NSGQDs) doped-graphene quantum dots upon irradiation with light for photodynamic therapy (PDT), ultrasound for sonodynamic therapy (SDT) and the combination of both in photo-sonodynamic therapy (PSDT). The in vitro cytotoxicity studies were conducted using the Michigan Cancer Foundation-7 breast cancer cell lines (MCF-7 cells). For PDT treatments, only the ¹O₂ was detected for all the sensitizers, whereas both the ¹O₂ and ^•OH radicals were evident after SDT and PSDT treatments. An increase in the ¹O₂ generation was observed for the conjugates compared to the GQDs and the Pc alone. However, the ^•OH radicals were reduced in the conjugates compared to the GQDs and the Pc alone. The NGQDs generally showed better ROS generation efficacy compared to the NSGQDs, alone and in the conjugates. The combination therapy also shows improved efficacy compared to the monotherapies for the Pcs and Pc-GQDs conjugates.

Boosting Antitumor Sonodynamic Therapy Efficacy of Black Phosphorus via Covalent Functionalization

Sonodynamic therapy (SDT) triggered by ultrasound represents an emerging tumor therapy approach with minimally invasive treatment featuring nontoxicity and deep tissue-penetration, and its efficacy sensitively depends on the sonosensitizer which determines the generation of reactive oxygen species (ROS). Herein, for the first time covalently functionalized few-layer black phosphorus nanosheets (BPNSs) are applied as novel sonosensitizers in SDT, achieving not only boosted SDT efficacy but also inhibited cytotoxicity relative to the pristine BPNSs. Three different covalently functionalized-BPNSs are synthesized, including the first fullerene-functionalized BPNSs with C60 covalently bonded onto the surface of BPNSs (abbreviated as C60 -s-BP), surface-functionalized BPNSs by benzoic acid (abbreviated as BA-s-BP), and edge-functionalized BPNSs by C60 (abbreviated as C60 -e-BP), and the role of covalent functionalization pattern of BPNSs on its SDT efficacy is systematically investigated. Except C60 -e-BP, both surface-functionalized BPNSs (C60 -s-BP, BA-s-BP) exhibit higher SDT efficacies than the pristine BPNSs, while the highest SDT efficacy is achieved for BA-s-BP due to its strongest capability of generating the hydroxyl (·OH) radicals, which act as the dominant ROS to kill the tumor cells.

5-Aminolevulinic Acid Triggered by Ultrasound Halts Tumor Proliferation in a Syngeneic Model of Breast Cancer

Sonodynamic therapy is a bimodal therapeutic approach in which a chemical compound and ultrasound (US) synergistically act to elicit oxidative damage, triggering cancer cell death. Despite encouraging results, mainly for anticancer treatment, sonodynamics is still far from having a clinical application. Therefore, to close the gap between the bench and bedside, more in vivo studies are needed. In this investigation, the combined effect of 5-aminolevulinic acid (Ala), a natural porphyrin precursor, plus exposure to US, was investigated in vivo on a syngeneic breast cancer model. Real-time RT-PCR, Western blotting, and immunohistochemistry assays were performed to evaluate the effect of sonodynamic treatment on the main cancer hallmarks. The sonodynamic-treated group had a significant reduction (p ≤ 0.0001) in tumor size compared to the untreated group, and the Ala- and US-only treated groups, where a strong decrease (p ≤ 0.0001) in Ki67 protein expression was the most relevant feature of sonodynamic-treated cancer tissues. Moreover, oxidative stress was confirmed as the pivotal driver of the anticancer effect through cell cycle arrest, apoptosis, and autophagy; thus, sonodynamics should be explored further for cancer treatment.

Concise Nanoplatform of Phycocyanin Nanoparticle Loaded with Docetaxel for Synergetic Chemo-sonodynamic Antitumor Therapy

Combined chemotherapy and sonodynamic therapy (chemo-SDT) based on the nanoplatform/nanocarrier is a potential antitumor strategy that has shown higher therapeutic efficacy than any monotherapy. Therefore, a safe and effective multifunctional system with a concise design and simple preparation process is urgently needed. In this work, by using a one-step cross-linking method, a multifunctional nanosystem, which employs phycocyanin nanoparticles (PCNPs) as a nanocarrier to deliver the chemotherapy drug docetaxel (DTX) and a nanosonosensitizer to generate reactive oxygen species (ROS), was prepared and evaluated (PCNP-DTX). Under low-intensity ultrasound irradiation, PCNP-DTX retained the ROS generation ability of phycocyanin and caused the destruction of mitochondrial potential. PCNP was also revealed to be an acidic and ultrasound-sensitive carrier with good biocompatibility. In addition to its cumulation behavior in tumors, PCNP can achieve tumor-targeted delivery and release of DTX. PCNP-DTX has also been proven to have a significant chemo-SDT synergy effect when low-intensity ultrasound was applied, showing enhanced antitumor activity both in vitro and in vivo. This study provides a concise yet promising nanoplatform based on the natural protein phycocyanin for achieving an effective, targeted, and synergetic chemo-SDT for antitumor therapy.

Smart Shockwave Responsive Titania-Based Nanoparticles for Cancer Treatment

Nanomedicine is an emerging treatment approach for many cancers, characterized by having high sensitivity and selectivity for tumor cells and minimal toxic effects induced by the conventional chemotherapeutics. In these context, smart nanoparticles (NPs) are getting increasingly relevant in the development of new therapies. NPs with specific chemical composition and/or structure and being stimuli-responsive to magnetic, light or ultrasound waves are new promising tools. In the present work, amorphous-titania propyl-amine functionalized (a-TiO₂-NH₂) NPs, coated with bovine serum albumin (BSA), are stimulated with high energy shock waves to induce cytotoxic effects in cancer cells. First, a new method to coat a-TiO₂-NH₂ NPs with BSA (a-TiO₂-NH₂/BSA) was proposed, allowing for a high dispersion and colloidal stability in a cell culture media. The a-TiO₂-NH₂/BSA NPs showed no cancer cell cytotoxicity. In a second step, the use of shock waves to stimulate a-TiO₂-NH₂/BSA NPs, was evaluated and optimized. A systematic study was performed in in vitro cell culture aiming to impair the cancer cell viability: NP concentrations, time steps and single versus multiple shock waves treatments were studied. The obtained results highlighted the relevance of NPs design and administration time point with respect to the shock wave treatment and allow to hypothesize mechanical damages to cells.

Functional ultrasound-triggered phase-shift perfluorocarbon nanodroplets for cancer therapy

In recent years, because of their unique properties, the use of perfluorocarbon nanodroplets (PFC NDs) in ultrasound-mediated tumor theranostics has attracted increasing interest. PFC is one of the most stable organic compounds with high hydrophobicity. Phase-shift PFC NDs can be transformed into highly echogenic microbubbles for ultrasound and photoacoustic imaging by ultrasound and laser light. In addition, in the process of acoustic droplet vaporization, PFC NDs with cavitation nuclei can be combined with a variety of ultrasound technologies to produce cavitation effects for tumor ablation, antivascular therapy and release of therapeutic agents loaded in nanodroplets. Moreover, they can also be used to overcome tumor hypoxia by virtue of high oxygen solubility. In this review, first the preparation and stabilization of PFC NDs are summarized and then the issues and outlook are discussed. More importantly, multifunctional platforms based on PFC NDs for cancer diagnostics, therapy and theranostics are reviewed in detail.

Sonodynamic Treatment Induces Selective Killing of Cancer Cells in an In Vitro Co-Culture Model

Sonodynamic Therapy (SDT) is a new anticancer strategy based on ultrasound (US) technique and is derived from photodynamic therapy (PDT); SDT is still, however, far from clinical application. In order to move this therapy forward from bench to bedside, investigations have been focused on treatment selectivity between cancer cells and normal cells. As a result, the effects of the porphyrin activation by SDT on cancer (HT-29) and normal (HDF 106-05) cells were studied in a co-culture evaluating cell cytotoxicity, reactive oxygen species (ROS) production, mitochondrial function and plasma membrane fluidity according to the bilayer sonophore (BLS) theory. While PDT induced similar effects on both HT-29 and HDF 106-05 cells in co-culture, SDT elicited significant cytotoxicity, ROS production and mitochondrial impairment on HT-29 cells only, whereas HDF 106-05 cells were unaffected. Notably, HT-29 and HDF 106-05 showed different cell membrane fluidity during US exposure. In conclusion, our data demonstrate a marked difference between cancer cells and normal cells in co-culture in term of responsiveness to SDT, suggesting that this different behavior can be ascribed to diversity in plasma membrane properties, such as membrane fluidity, according to the BLS theory.

Induction Therapy of Retinoic Acid with a Temozolomide-Loaded Gold Nanoparticle-Associated Ultrasound Effect on Glioblastoma Cancer Stem-Like Colonies

Glioblastoma multiforme (GBM) is the most aggressive glioma. The treatment response is always low, and the condition is typically rapidly fatal. The undifferentiated and self-renewal characteristics of cancer stem cells (CSCs) have been reported, and their potential contribution may cause tumor initiation, recurrence, metastasis, and therapeutic resistance. In particular, glioblastoma stem-like cells exhibit highly invasive properties and drug resistance, serving as a model for the development of novel therapeutic strategies. Induction therapy provides an alternative therapeutic strategy to eliminate the stem cell properties of CSCs and enhance therapeutic sensitivity. The differentiated cells may lose their self-renewal ability, downregulate stem cell-related genes and drug resistance genes, and enhance anticancer drug sensitivity. Therefore, the purpose of this study is to establish a niche for glioblastoma stem-like cell selection as a platform and facilitate the assessment of differentiation therapy on GBM cancer stem-like colonies by retinoic acid (RA) with temozolomide (TMZ)-loaded gold nanoparticles (GNPs) associated with low-intensity ultrasound (LIUS). Herein, a hyaluronic acid-based material system was used to isolate GBM cancer stem-like colonies. Colony formation, size determination, stem cell-related marker expression, and GBM cancer stem-like cell marker expression with the culture period were identified. The effect of TMZ on GBM stem-like colonies on HA-based material systems was also determined, and the results revealed that drug resistance was highly enhanced in GBM colonies compared with that in the control cell population. In addition, GBM colonies also exhibited a significant increase in breast cancer resistance protein expression, which is consistent with the drug resistance effect. Furthermore, several factors, including LIUS, RA, and GNPs, were used to determine the possibility of induction therapy. RA with TMZ-loaded GNP-associated LIUS stimulation exhibited a significant and synergistic effect on the differentiation effect and drug sensitivity enhancement. The GBM cancer stem-like colony system presents an opportunity for the development of new therapeutic strategies, and this study provides an alternative differentiation therapy for malignant tumors.

Nanoparticle-Assisted Sonosensitizers and Their Biomedical Applications

As a non-invasive strategy, sonodynamic therapy (SDT) which utilizes sonosensitizers to generate reactive oxygen species (ROS) has received significant interest over recent years due to its ability to break depth barrier. However, intrinsic limitations of traditional sonosensitizers hinder the widespread application of SDT. With the development of nanotechnology, various nanoparticles (NPs) have been designed and used to assist sonosensitizers for SDT. This review first summarizes the possible mechanisms of SDT, then classifies the NPs-assisted sonosensitizers and discusses their biomedical applications in ultrasonography, drug delivery, high intensity focused ultrasound and SDT-based combination treatment. Finally, some challenges and future perspectives of NPs-assisted SDT has also been discussed.

Sonosensitizer-Functionalized Graphene Nanoribbons for Adhesion Blocking and Sonodynamic Ablation of Ovarian Cancer Spheroids

Advanced stage ovarian cancer is challenging to treat due to widespread seeding of tumor spheroids throughout the mesothelial lining of the peritoneal cavity. In this work, a therapeutic strategy using graphene nanoribbons (GNR) functionalized with 4-arm polyethylene glycol (PEG) and chlorin e6 (Ce6), a sonosensitizer, to target metastatic ovarian cancer spheroids is reported. GNR-PEG-Ce6 adsorbs onto the spheroids and disrupts their adhesion to extracellular matrix proteins or LP-9 mesothelial cells. Furthermore, for spheroids that do adhere, GNR-PEG-Ce6 delays spheroid disaggregation and spreading as well as mesothelial clearance, key metastatic processes following adhesion. Owing to the sonodynamic effects of Ce6 and its localized delivery via the biomaterial, GNR-PEG-Ce6 can kill ovarian cancer spheroids adhered to LP-9 cell monolayers when combined with mild ultrasound irradiation. The interaction with GNR-PEG-Ce6 also loosens cell-cell adhesions within the spheroids, rendering them more susceptible to treatment with the chemotherapeutic agents cisplatin and paclitaxel, which typically have difficulty in penetrating ovarian cancer spheroids. Thus, this material can facilitate effective chemotherapeutic and sonodynamic combination therapies. Finally, the adhesion inhibiting and sonodynamic effects of GNR-PEG-Ce6 are also validated with tumor spheroids derived from the ascites fluid of ovarian cancer patients, providing evidence of the translational potential of this biomaterial approach.

Water-Soluble Iridic-Porphyrin Complex for Non-invasive Sonodynamic and Sono-oxidation Therapy of Deep Tumors

Due to conventional photodynamic therapy encountering serious problems of phototoxicity and low tissue-penetrating depth of light, other dynamic therapy-based therapeutic methods such as sonodynamic therapy (SDT) are expected to be developed. To improve the therapeutic response to SDT, more effective sonosensitizers are imperative. In this study, a novel water-soluble iridium(III)-porphyrin sonosensitizer (IrTMPPS) was synthesized and used for SDT. IrTMPPS generated ample singlet oxygen (¹O₂) under US irradiation and especially showed distinguished US-activatable abilities at more than 10 cm deep-tissue depths. Interestingly, under US irradiation, IrTMPPS sonocatalytically oxidized intracellular NADH, which would enhance SDT efficiency by breaking the redox balance in the tumor. Moreover, IrTMPPS displayed great sonocytotoxicity toward various cancer cells, and in vivo experiments demonstrated efficient tumor inhibition and anti-metastasis to the lungs in the presence of IrTMPPS and US irradiation. This report gives a novel idea of metal-based sonosensitizers for sonotherapy by fully taking advantage of non-invasiveness, water solubility, and deep tumor therapy.

Preclinical study to improve microbubble-mediated drug delivery in cancer using an ultrasonic probe with an interchangeable acoustic lens

Focused ultrasound with microbubbles (FUS-MBs) has shown that it can lead to an efficient drug delivery system (DDS) involving the oscillation and destruction of the MB but is limited in drug delivery due to its narrow pressure field. However, unfocused ultrasound with MBs (UUS-MBs) and an interchangeable acoustic lens can tune and enhance the pressure field for MB destruction to overcome the disadvantages of FUS-MB DDSs. We designed a lens suitable for an ultrasound-phased array probe and studied the optimal treatment conditions for MB destruction in vitro through an optical imaging setup. The DDS effects were evaluated in a rat hepatoma model using doxorubicin (DOX) treatment. A concave lens with a radius of curvature of 2.6 mm and a thickness of 4 mm was selected and fabricated. UUS-MBs with the acoustic lens at 60 V_pp for 32 cycles and a PRF of 1 kHz could induce MB destruction, promoting the DDS even under fluidic conditions. In the animal experiment, the UUS-MBs in the acoustic lens treatment group had a higher concentration of DOX in the tumor than the control group. Our system suggests uses an acoustic lens to increase DDS effectiveness by providing sufficient ultrasound irradiation to the MBs.

Sonodynamic therapy complements PD-L1 immune checkpoint inhibition in a murine model of pancreatic cancer

The emergence of immune checkpoint inhibitors (ICI's) in the past decade has proven transformative in the area of immuno-oncology. The PD-1/PD-L1 axis has been particularly well studied and monoclonal antibodies developed to block either the receptor (anti PD-1) or its associated ligand (anti PD-L1) can generate potent anti-tumour immunity in certain tumour models. However, many "immune cold" tumours remain unresponsive to ICI's and strategies to stimulate the adaptive immune system and make these tumours more susceptible to ICI treatment are currently under investigation. Sonodynamic therapy (SDT) is a targeted anti-cancer treatment that uses ultrasound to activate a sensitiser with the resulting generation of reactive oxygen species (ROS) causing direct cell death by apoptosis and necrosis. SDT has also been shown to stimulate the adaptive immune system in a pre-clinical model of colorectal cancer. In this manuscript, we investigate the ability of microbubble mediated SDT to control tumour growth in a bilateral tumour mouse model of pancreatic cancer by treating the target tumour with SDT and observing the effects at the off-target untreated tumour. The results demonstrated a significant 287% decrease in tumour volume when compared to untreated animals 11 days following the initial treatment with SDT, which reduced further to 369% when SDT was combined with anti-PD-L1 ICI treatment. Analysis of residual tumour tissues remaining after treatment revealed increased levels of infiltrating CD4⁺ and CD8⁺ T-lymphocytes (respectively 4.65 and 3.16-fold more) in the off-target tumours of animals where the target tumour was treated with SDT and anti-PD-L1, when compared to untreated tumours. These results suggest that SDT treatment elicits an adaptive immune response that is potentiated by the anti-PD-L1 ICI in this particular model of pancreatic cancer.

Safe and Targeted Sonodynamic Cancer Therapy Using Biocompatible Exosome-Based Nanosonosensitizers

Sonodynamic therapy (SDT), wherein sonosensitizers irradiated with ultrasound (US) produce cytotoxic reactive oxygen species (ROS), has garnered great attention as a promising alternative to photodynamic therapy owing to the significantly increased depth of tissue penetration. The development of nanocarriers that can selectively deposit sonosensitizers into tumor tissues without systemic toxicity is crucial to facilitate the translation of SDT to clinical use. In this study, exosomes, a class of naturally occurring nanoparticles, were utilized as nanocarriers for safe and cancer-targeted delivery of a sonosensitizer, indocyanine green (ICG). The exosomes were surface-engineered with an active cancer-targeting ligand, folic acid (FA), to increase the cancer specificity of the ICG-loaded exosomes (ExoICG). The FA-conjugated, ICG-loaded exosomes (FA-ExoICG) greatly improved aqueous stability and cellular uptake of ICG, resulting in significantly increased ROS generation in breast cancer cells. As a result, the FA-ExoICG demonstrated greater sonotoxicity against cancer cells than ExoICG and free ICG. The in vivo study revealed that compared to ExoICG, more FA-ExoICG accumulated in tumors, and their pharmacokinetic properties were superior. Notably, tumor growth in mice was significantly suppressed, without systemic toxicity, by a single intravenous injection of the FA-ExoICG and subsequent US irradiation. Therefore, this study demonstrated that active cancer-targeted FA-ExoICG could serve as effective nanosonosensitizers for safe and targeted cancer treatment.

The reversal of chemotherapy-induced multidrug resistance by nanomedicine for cancer therapy

Multidrug resistance (MDR) of cancer is a persistent problem in chemotherapy. Scientists have considered the overexpressed efflux transporters responsible for MDR and chemotherapy failure. MDR extremely limits the therapeutic effect of chemotherapy in cancer treatment. Many strategies have been applied to solve this problem. Multifunctional nanoparticles may be one of the most promising approaches to reverse MDR of tumor. These nanoparticles can keep stability in the blood circulation and selectively accumulated in the tumor microenvironment (TME) either by passive or active targeting. The stimuli-sensitive or organelle-targeting nanoparticles can release the drug at the targeted-site without exposure to normal tissues. In order to better understand reversal of MDR, three main strategies are concluded in this review. First strategy is the synergistic effect of chemotherapeutic drugs and ABC transporter inhibitors. Through directly inhibiting overexpressed ABC transporters, chemotherapeutic drugs can enter into resistant cells without being efflux. Second strategy is based on nanoparticles circumventing over-expressed efflux transporters and directly targeting resistance-related organelles. Third approach is the combination of multiple therapy modes overcoming cancer resistance. At last, numerous researches demonstrated cancer stem-like cells (CSCs) had a deep relation with drug resistance. Here, we discuss two different drug delivery approaches of nanomedicine based on CSC therapy.

Design and Challenges of Sonodynamic Therapy System for Cancer Theranostics: From Equipment to Sensitizers

As a novel noninvasive therapeutic modality combining low-intensity ultrasound and sonosensitizers, sonodynamic therapy (SDT) is promising for clinical translation due to its high tissue-penetrating capability to treat deeper lesions intractable by photodynamic therapy (PDT), which suffers from the major limitation of low tissue penetration depth of light. The effectiveness and feasibility of SDT are regarded to rely on not only the development of stable and flexible SDT apparatus, but also the screening of sonosensitizers with good specificity and safety. To give an outlook of the development of SDT equipment, the key technologies are discussed according to five aspects including ultrasonic dose settings, sonosensitizer screening, tumor positioning, temperature monitoring, and reactive oxygen species (ROS) detection. In addition, some state-of-the-art SDT multifunctional equipment integrating diagnosis and treatment for accurate SDT are introduced. Further, an overview of the development of sonosensitizers is provided from small molecular sensitizers to nano/microenhanced sensitizers. Several types of nanomaterial-augmented SDT are in discussion, including porphyrin-based nanomaterials, porphyrin-like nanomaterials, inorganic nanomaterials, and organic-inorganic hybrid nanomaterials with different strategies to improve SDT therapeutic efficacy. There is no doubt that the rapid development and clinical translation of sonodynamic therapy will be promoted by advanced equipment, smart nanomaterial-based sonosensitizer, and multidisciplinary collaboration.

Ultrasound-Responsive Nanocarriers in Cancer Treatment: A Review

The safe and effective delivery of anticancer agents to diseased tissues is one of the significant challenges in cancer therapy. Conventional anticancer agents are generally cytotoxins with poor pharmacokinetics and bioavailability. Nanocarriers are nanosized particles designed for the selectivity of anticancer drugs and gene transport to tumors. They are small enough to extravasate into solid tumors, where they slowly release their therapeutic load by passive leakage or biodegradation. Using smart nanocarriers, the rate of release of the entrapped therapeutic(s) can be increased, and greater exposure of the tumor cells to the therapeutics can be achieved when the nanocarriers are exposed to certain internally (enzymes, pH, and temperature) or externally (light, magnetic field, and ultrasound) applied stimuli that trigger the release of their load in a safe and controlled manner, spatially and temporally. This review gives a comprehensive overview of recent research findings on the different types of stimuli-responsive nanocarriers and their application in cancer treatment with a particular focus on ultrasound.

Pulmonary delivery of cationic liposomal hydroxycamptothecin and 5-aminolevulinic acid for chemo-sonodynamic therapy of metastatic lung cancer

Sonodynamic therapy (SDT) has been tried for cancer treatment; however, sonosensitizers are usually administered by injection, leading to low distribution in the tumor tissue and compromised therapeutic effect, even serious side effect. Here, we combined cationic liposomal hydroxycamptothecin (CLH) and 5-aminolevulinic acid (5-ALA) via intratracheal (i.t.) administration for the chemo-sonodynamic (Chemo-SDT) therapy of metastatic lung cancer. CLH was prepared from HCPT and the lipid mixture of soybean lecithin/cholesterol/octadecylamine with a film method. The optimal pre-incubation time of 5-ALA with tumor cells before ultrasound exposure was 4 h, for sake of sonosensitizer accumulation, i.e., protoporphyrin IX, the metabolite of 5-ALA. In vitro studies showed the higher cytotoxicity of Chemo-SDT compared to the other treatments, including i.t. CLH, intravenous (i.v.) CLH, and SDT alone. The combination of pulmonary delivery and Chemo-SDT showed the highest anticancer effect among the treatments on the metastatic lung tumor-bearing mice, which was judged according to the tumor appearance and pathological sections. The major anticancer mechanism of Chemo-SDT included the improved apoptosis of cancer cells and the enhanced production of reactive oxygen species, and more importantly, the synergy of chemotherapy and SDT. Pulmonary delivery of chemotherapeutics and sonosensitizers is a promising strategy for the treatment of lung cancer.

Engineering oxygen-deficient ZrO2-x nanoplatform as therapy-activated "immunogenic cell death (ICD)" inducer to synergize photothermal-augmented sonodynamic tumor elimination in NIR-II biological window

Nano-zirconia, as an amphoteric semiconductor, has been industrially exploited in photocatalytic reactions and as piezoelectric sensors. However, its biomedical applications, especially in antitumor therapeutics, have been seldom investigated to date. Here, oxygen-deficient zirconia (ZrO_2-x)-based nanoplatform with surface PEGylation and cyclic-Arg-Gly-Asp (cRGD) peptide functionalization (ZrO_2-x@PEG/cRGD, abbreviated as ZPR) was rationally designed and established for the first time, which was utilized as therapy-activated "immunogenic cell death (ICD)" inducer to boost photothermal-augmented sonodynamic tumor elimination in NIR-II biological window. As-synthesized ZPR nanoparticles (NPs) exhibited intense optical absorbance in the wavelength range of 900-1100 nm, which endowed ZPR NPs with a photothermal conversion efficiency as high as 45.8% for photothermal therapy (PTT). Moreover, owing to the abundant surface oxygen defects, ZPR NPs can serve as a category of high-performance nano-sonosensitizer based on the strengthened separation of electron (e^-)/hole (h⁺) pairs from the energy band under external ultrasound (US) activation. More importantly, cytotoxic reactive oxygen species (ROS) generated from sonodynamic therapy (SDT) can effectively induce immunogenic cell death (ICD), which is regarded to be significant to boost systemic anti-tumor immunity for rendering a complete tumor eradication post-treatment. In vivo experiments on tumor xenografts demonstrated the high therapeutic efficacy upon photothermal-augmented sonodynamic therapy, with the aid of photoacoustic (PA) imaging navigation. Remarkably, the level of inflammatory cytokines, including type I interferon (IFN), tumor necrosis factor α (TNF-α) as well as interleukin (IL-6) were systemically upgraded after NIR-II/US irradiation, verifying the promotion of immunogenicity. Taken together, this study delivers useful insights for extending the applications of zirconia as promising translational medicine for tumor theranostics in the near future.

Development of porphyrin and titanium dioxide sonosensitizers for sonodynamic cancer therapy

Sonodynamic therapy for malignant tumours has gained much attention for its deep penetration effect and efficient tumour killing ability. The design, modification, and utilization of sonosensitizers are important aspects of sonodynamic therapy. As an essential factor in this process, highly effective sonosensitizers should be developed to facilitate the clinical applications of sonodynamic therapy. This review takes porphyrin- and titanium dioxide (TiO₂)-based systems as representative organic and inorganic sonosensitizers respectively, and summarizes their characteristics and biological effects as sonodynamic therapy. Upon discovery of novel sonosensitizers, sonodynamic therapy becomes an efficient means of adjuvant therapy for the treatment of malignant tumours.

Nanotechnology assisted photo- and sonodynamic therapy for overcoming drug resistance

Drug resistance is considered the most important reason for the clinical failure of cancer chemotherapy. Circumventing drug resistance and improving the efficacy of anticancer agents remains a major challenge. Over the past several decades, photodynamic therapy (PDT) and sonodynamic therapy (SDT) have attracted substantial attention for their efficacy in cancer treatment, and have been combined with chemotherapy to overcome drug resistance. However, simultaneously delivering sensitizers and chemotherapy drugs to same tumor cell remains challenging, thus greatly limiting this combinational therapy. The rapid development of nanotechnology provides a new approach to solve this problem. Nano-based drug delivery systems can not only improve the targeted delivery of agents but also co-deliver multiple drug components in single nanoparticles to achieve optimal synergistic effects. In this review, we briefly summarize the mechanisms of drug resistance, discuss the advantages and disadvantages of PDT and SDT in reversing drug resistance, and describe state-of-the-art research using nano-mediated PDT and SDT to solve these refractory problems. This review also highlights the clinical translational potential for this combinational therapy.

New Approaches for Hydrogen Therapy of Various Diseases

Hydrogen therapy has recently received increasing attention as an emerging and promising therapeutic technology due to its selective antioxidant property and cell energy regulatory capability in vivo. To solve the low solubility issue of hydrogen, a variety of nanomaterials and devices for hydrogen supply have recently been developed, aiming to increase the concentration of hydrogen in the specific disease site and realize controlled hydrogen release and combined treatment. In this review, we mainly focus on the latest advances in using hydrogen-generating devices and nanomaterials for hydrogen therapy. These developments include sustained release of H2, controlled release of H2, versatile modalities of synergistic therapy, etc. Also, bio-safety issues and challenges are discussed to further promote the clinical applications of hydrogen therapy and the development of hydrogen medicine.