Enhancement of ultrasound-induced apoptosis and cell lysis by echo-contrast agents

Activation of Bak in ultrasound-induced, JNK- and p38-independent apoptosis and its inhibition by Bcl-2

The molecular mechanisms underlying ultrasound-induced apoptosis remain poorly understood. We have demonstrated that in Jurkat cells, the over-expression of the anti-apoptotic protein Bcl-2 inhibited ultrasound-induced apoptosis, but not necrosis. Inhibition of caspase activity also protected the cells from apoptosis, but not from necrosis, showing the involvement of different mechanisms in ultrasound-induced apoptosis and necrosis. Bak, a pro-apoptotic member of the Bcl-2 family proteins, was activated by ultrasound and its activation was completely inhibited by Bcl-2 over-expression, but not by caspase inhibition. Antioxidant N-acetyl cysteine did not protect the cells from ultrasound-induced apoptosis or necrosis, nor did the inhibition of either c-Jun N-terminal kinase or p38, key factors in the radical oxygen species (ROS)-mediated cell stress response, suggesting that ROS do not play a crucial role in ultrasound-induced apoptosis. Our results confirm that ultrasound induces apoptosis via a pathway that involves Bak, Bcl-2, and caspases, but not ROS.

An echo-contrast agent, Levovist, lowers the ultrasound intensity required to induce apoptosis of human leukemia cells

To verify the effect of echo-contrast agent (ECA) on apoptosis induced by ultrasound, leukemia cell lines (Jurkat, Molt-4 and U937) were sonicated at intensities previously shown to induce optimal apoptosis with or without Levovist, an ECA. The results showed that loss of viability and apoptosis can be induced in all three cell lines, apoptosis highest with Molt-4, based on viability and DNA fragmentation assay. Such finding was supported by corresponding increase of cells with low mitochondrial membrane potential, high superoxide production, increased intracellular calcium concentration, and phosphorylation of histone H2AX after sonication. Optimal ultrasound condition was 0.3W/cm(2), 1MHz, 10% duty factor pulsed at 100Hz; but in the presence of Levovist, an apparent shift of cell killing induction was observed at 0.2W/cm(2). While these results further confirmed previous findings on ultrasound-induced apoptosis, they also suggest that use of an enhancing factor, such as addition of ECA, may be useful in cancer therapy when a much lower intensity is desired.

Acoustic activation of targeted liquid perfluorocarbon nanoparticles does not compromise endothelial integrity

Perfluorocarbon nanoparticles consisting essentially of liquid perfluoro-octyl bromide (PFOB) core surrounded by a lipid monolayer can serve as highly specific site-targeted contrast and therapeutic agents after binding to cellular biomarkers. Based on previous findings that ultrasound applied at 2 MHz and 1.9 mechanical index (MI) for a 5-min duration dramatically enhances the cellular interaction of targeted PFOB nanoparticles with melanoma cells in vitro without inducing apoptosis or other harmful effects to cells that are targeted, we sought to define mechanisms of interaction and the safety profile of ultrasound used in conjunction with liquid perfluorocarbon nanoparticles for targeted drug delivery, as compared with conventional microbubble ultrasound contrast agents under identical insonification conditions. Cell-culture inserts were used to grow a confluent monolayer of human umbilical vein endothelial cells. Definity in conjunction with continuous wave ultrasound (2.25 MHz for 1 and 5 min) increased the permeability of monolayer by four to six times above the normal, decreased transendothelial electrical resistance (a sign of reduced membrane integrity), and decreased cell viability by approximately 50%. Histological evaluation demonstrated extensive disruptions of cell monolayers. Nanoparticles (both nontargeted and targeted) elicited no changes in these different measures under similar insonification conditions and did not disrupt cell monolayers. We hypothesize that ultrasound facilitates drug transport from the perfluorocarbon nanoparticles not by cavitation-induced effects on cell membrane but rather by direct interaction with the nanoparticles that stimulate lipid exchange and drug delivery.

Expression of heme oxygenase-1 due to intracellular reactive oxygen species induced by ultrasound

The present study was undertaken to elucidate the mechanism by which ultrasound induces the expression of heme oxygenase-1 (HO-1). When human lymphoma U937 cells were exposed to a 1 MHz continuous wave for 1 min, HO-1 expression examined by real-time quantitative polymerase chain reaction and immunoblotting was observed at intensities above the cavitational threshold. No induction of HO-1 expression was observed in the cells exposed for 1 min to 42 degrees C, a temperature higher than that during sonication. When a potent antioxidant, N-acetyl-l-cysteine, was added to the culture medium before or after sonication, the induction was attenuated, indicating that reactive oxygen species (ROS) are involved. However, the addition of catalase did not affect the induction, and no HO-1 was observed on the addition of pre-sonicated medium, suggesting that hydrogen peroxide due to the recombination of hydroxyl radicals generated extracellularly was not involved. The addition of free radical scavengers, glutathion-monoethyl ester, dimethyl sulfoxide and D(-)-mannitol, suppressed the induction. A decrease in mitochondrial membrane potential and the generation of superoxide were also observed in the sonicated cells, suggesting that mitochondria were the source of intracellularly generated ROS. These results indicate that superoxide secondarily generated from damaged mitochondria, not hydroxyl radicals generated in medium directly by sonication, give rise to intracellular oxidative stress inducing HO-1 expression.

Transfection effect of microbubbles on cells in superposed ultrasound waves and behavior of cavitation bubble

The combination of ultrasound and ultrasound contrast agents (UCAs) is able to induce transient membrane permeability leading to direct delivery of exogenous molecules into cells. Cavitation bubbles are believed to be involved in the membrane permeability; however, the detailed mechanism is still unknown. In the present study, the effects of ultrasound and the UCAs, Optison on transfection in vitro for different medium heights and the related dynamic behaviors of cavitation bubbles were investigated. Cultured CHO-E cells mixed with reporter genes (luciferase or beta-gal plasmid DNA) and UCAs were exposed to 1 MHz ultrasound in 24-well plates. Ultrasound was applied from the bottom of the well and reflected at the free surface of the medium, resulting in the superposition of ultrasound waves within the well. Cells cultured on the bottom of 24-well plates were located near the first node (displacement node) of the incident ultrasound downstream. Transfection activity was a function determined with the height of the medium (wave traveling distance), as well as the concentration of UCAs and the exposure time was also determined with the concentration of UCAs and the exposure duration. Survival fraction was determined by MTT assay, also changes with these values in the reverse pattern compared with luciferase activity. With shallow medium height, high transfection efficacy and high survival fraction were obtained at a low concentration of UCAs. In addition, capillary waves and subsequent atomized particles became significant as the medium height decreased. These phenomena suggested cavitation bubbles were being generated in the medium. To determine the effect of UCAs on bubble generation, we repeated the experiments using crushed heat-treated Optison solution instead of the standard microbubble preparation. The transfection ratio and survival fraction showed no additional benefit when ultrasound was used. These results suggested that cavitation bubbles created by the collapse of UCAs were a key factor for transfection, and their intensities were enhanced by the interaction of the superpose ultrasound with the decreasing the height of the medium. Hypothesizing that free cavitation bubbles were generated from cavitation nuclei created by fragmented UCA shells, we carried out numerical analysis of a free spherical bubble motion in the field of ultrasound. Analyzing the interaction of the shock wave generated by a cavitation bubble and a cell membrane, we estimated the shock wave propagation distance that would induce cell membrane damage from the center of the cavitation bubble.

Effect of 5-fluorouracil, Optison and ultrasound on MCF-7 cell viability

The aim of this study was to analyze cell viability and expression of apoptotic-related signaling proteins in MCF-7 breast cancer cells induced by combinations of ultrasound, the anticancer drug 5-fluorouracil (5-FU) and the ultrasound contrast agent Optison. MCF-7 cells were treated with 5-FU and sonicated at the frequency of 3.0 MHz and intensity of 3.0 W/cm2 for 1 min in the presence of Optison. The cells were analyzed for lactate dehydrogenase (LDH) release (a measure of cytotoxicity) and cell proliferation (by MTT assays). The LDH/MTT ratio was used for assessment of cell death. Expression of the apoptotic-related proteins, Bax and p27kip1, as well as phosphorylated forms of ERK and Akt proteins was assessed by Western blot analysis. We demonstrate that, immediately after treatment, cell death was most dependent on Optison; however, 24 h after treatment, cell death was more dependent on 5-FU. Ultrasound duty cycle increased cell death associated with either Optison or 5-FU. Furthermore, we show that treatment with 5-FU and ultrasound increased the levels of the Bax and p27kip1 proteins, but the addition of Optison appears to suppress apoptotic protein expression.

Sonic activation of molecularly-targeted nanoparticles accelerates transmembrane lipid delivery to cancer cells through contact-mediated mechanisms: implications for enhanced local drug delivery

Liquid perfluorocarbon nanoparticles serve as sensitive and specific targeted contrast and drug delivery vehicles by binding to specific cell surface markers. We hypothesized that application of acoustic energy at diagnostic power levels could promote nanoparticle-associated drug delivery by stimulating increased interaction between the nanoparticle's lipid layer and the targeted cell's plasma membrane. Ultrasound (mechanical index = 1.9) applied with a conventional ultrasound imaging system to nanoparticles targeted to alpha(v)beta3-integrins on C32 melanoma cancer cells in vitro produced no untoward effects. Within 5 min, lipid delivery from nanoparticles into cell cytoplasm was dramatically augmented. We also demonstrate the operation of a potential physical mechanism for this effect, the acoustic radiation force on the nanoparticles, which may contribute to the enhanced lipid delivery. Accordingly, we propose that local delivery of lipophilic substances (e.g., drugs) from targeted nanoparticles directly into cell cytoplasm can be augmented rapidly and safely with conventional ultrasound imaging devices through nondestructive mechanisms.

Microfluidic sonicator for real-time disruption of eukaryotic cells and bacterial spores for DNA analysis

Biologic agent screening is a three-step process: lysis of host cell membranes or walls to release their DNA, polymerase chain reaction to amplify the genetic material and screening for distinguishing genetic signatures. Macrofluidic devices commonly use sonication as a lysis method. Here, we present a piezoelectric microfluidic minisonicator and test its performance. Eukaryotic human leukemia HL-60 cells and Bacillus subtilis bacterial spores were lysed as they passed through a microfluidic channel at 50 microL/min and 5 microL/min, respectively, in the absence of any chemical denaturants, enzymes or microparticles. We used fluorescence-activated cell sorting and hematocytometry to measure 80% lysis of HL-60 cells after 3 s of sonication. Real-time polymerase chain reaction indicated 50% lysis of B. subtilis spores with 30 s of sonication. Advantages of the minisonicator over macrofluidic implementations include a small sample volume (2.5 microL), reduced energy consumption and compatibility with other microfluidic blocks. These features make this device an attractive option for "lab-on-a-chip" and portable applications.

Study of sonoporation dynamics affected by ultrasound duty cycle

Sonoporation is the ultrasound-induced membrane porosity and has been investigated as a means for intracellular drug delivery and nonviral gene transfection. The dynamic characteristics of sonoporation, such as formation, duration and resealing of the pores in the cell membrane, determine the process of intracellular uptake of molecules or agents of interest that are otherwise obstructed by the cell membrane barrier. Sonoporation dynamics is also important for postultrasound cell survival. In this study, we investigated the effects of ultrasound duty cycle on sonoporation dynamics using Xenopus oocyte as a model system. Transducer with a center frequency of 0.96 MHz was used to generate pulsed ultrasound of desired duty cycle (5%, 10% and 15%) at a pulse repetition frequency of 1 Hz and an acoustic pressure of 0.4 MPa in our experiments. Employing voltage clamp techniques, we measured the transmembrane current as the direct result of decreased membrane resistance due to pore formation induced by ultrasound application. We characterized the sonoporation dynamics from these time-resolved recordings of transmembrane current to indicate cell membrane status, including pore formation, extension and resealing. We observed that the transmembrane current amplitude increased with increasing duty cycle, while the recovering process of membrane pores and cell survival rate decreased at higher duty cycles.

Insonation facilitates plasmid DNA transfection into the central nervous system and microbubbles enhance the effect

Many of the diseases which affect the central nervous system are intractable to conventional therapies and therefore require alternative treatments such as gene therapy. Therapy requires safety, since the central nervous system is a critical organ. Choice of nonviral vectors such as naked plasmid DNA may have merit. However, transfection efficiencies of these vectors are low. We have investigated the use of 210.4 kHz ultrasound and found that 5.0 W/cm(2) of insonation for 5 s most effectively transfected a plasmid DNA into culture slices of mouse brain (147.68-fold increase compared with 0 W/cm(2) of insonation for 5 s). The effect was reinforced by combination with echo contrast agent, Levovist. One hundred fifty mg/mL of Levovist significantly increased gene transfection by ultrasound (5.23-fold when insonated at 5.0 W/cm(2) for 5 s). When DNA was intracranially injected, Levovist also enhanced gene transfection in newborn mice (4.49-fold increase when insonated at 5.0 W/cm(2) for 5 s). Since ultrasound successfully transfected naked plasmid DNA into the neural tissue and Levovist enhanced the effect, this approach may have a significant role in gene transfer to the central nervous system.

Apoptosis induced by the sonomechanical effects of low intensity pulsed ultrasound in a human leukemia cell line

To obtain an optimal condition for ultrasound (US)-induced apoptosis that could be useful for cancer therapy, we applied low intensity pulsed US to sonicate U937 cells in vitro. Cells were then incubated at different time intervals before measuring apoptosis. The apoptosis was assessed by DNA fragmentation and phosphatidylserine externalization. The pattern of the decrease in mitochondrial membrane potential was determined by flow cytometry. Optimal apoptosis (70.0+/-13.8%) with minimal lysis was attained with 1 MHz ultrasound 0.3 W/cm2, 10% duty factor at 100 Hz for 1 min) at 12 h after sonication. Lack of US-induced free radical detection and absence of Heme oxygenase-1, an intracellular oxidative stress marker, up-regulation in cells, suggest that sonomechanical, not sonochemical, effects are the main mechanism involved.

Major factors involved in the inhibition of ultrasound-induced free radical production and cell killing by pre-sonication incubation or by high cell density

To identify the factors involved in the inhibition of ultrasound (US)-induced free radical production and cell killing by pre-sonication incubation or by high cell density, we used different densities of U937 cells, and with (up to 2 h) or without pre-sonication incubations, the cell suspensions were exposed to 1 MHz US (10% duty factor at 100 Hz pulse rate; intensities 0.1-0.5 W/cm(2) for 1 min). The intensity 0.3 W/cm(2) was used for cell killing experiments and 0.5 W/cm(2) for free radical experiments. Free radical production was determined by electron paramagnetic resonance (EPR)-spin trapping with DMPO while cell killing was determined by assays for lysis, loss of cell viability, apoptosis and necrosis. The results show that at higher cell densities, CO(2) in the medium rapidly increased, with shorter pre-sonication incubation required to attain complete inhibition of both free radical production and cell killing. Cell killing at 0.3 W/cm(2) and free radical production at 0.5 W/cm(2) were both inhibited at 10 million cells/ml without incubation, and at 2 million cells/ml incubated for 2 h before sonication. Level of CO(2) alone could not account for the inhibition; consumption of gases in the medium is also considered in the inhibitory effect of pre-sonication, while suppression of cavitational activities due to the "viscosity effect" is considered a more important factor in the inhibition by high cell density.

Vascular effects induced by combined 1-MHz ultrasound and microbubble contrast agent treatments in vivo

Previous in vivo studies have demonstrated that microvessel hemorrhages and alterations of endothelial permeability can be produced in tissues containing microbubble-based ultrasound contrast agents when those tissues are exposed to MHz-frequency pulsed ultrasound of sufficient pressure amplitudes. The general hypothesis guiding this research was that acoustic (viz., inertial) cavitation, rather than thermal insult, is the dominant mechanism by which such effects arise. We report the results of testing five specific hypotheses in an in vivo rabbit auricular blood vessel model: (1) acoustic cavitation nucleated by microbubble contrast agent can damage the endothelia of veins at relatively low spatial-peak temporal-average intensities, (2) such damage will be proportional to the peak negative pressure amplitude of the insonifying pulses, (3) damage will be confined largely to the intimal surface, with sparing of perivascular tissues, (4) greater damage will occur to the endothelial cells on the side of the vessel distal to the source transducer than on the proximal side and (5) ultrasound/contrast agent-induced endothelial damage can be inherently thrombogenic, or can aid sclerotherapeutic thrombogenesis through the application of otherwise subtherapeutic doses of thrombogenic drugs. Auricular vessels were exposed to 1-MHz focused ultrasound of variable peak pressure amplitude using low duty factor, fixed pulse parameters, with or without infusion of a shelled microbubble contrast agent. Extravasation of Evans blue dye and erythrocytes was assessed at the macroscopic level. Endothelial damage was assessed via scanning electron microscopy (SEM) image analysis. The hypotheses were supported by the data. We discuss potential therapeutic applications of vessel occlusion, e.g., occlusion of at-risk gastric varices.

Ultrasonic excitation of a bubble near a rigid or deformable sphere: implications for ultrasonically induced hemolysis

A number of independent studies have reported increased ultrasound bioeffects, such as hemolysis and hemorrhage, when ultrasound contrast agents are present. To better understand the role of cavitation in these bioeffects, one- and two-dimensional models have been developed to investigate the interactions between ultrasonically excited bubbles and model "cells." First, a simple one-dimensional model based on the Rayleigh-Plesset equation was developed to estimate upper bounds for strain, strain rate, and areal expansion of a simulated red blood cell. Then, two-dimensional boundary element models were developed (with DynaFlow Inc.) to obtain simulations of asymmetric bubble dynamics in the presence of rigid and deformable spheres. The deformable spherical "cell" was modeled using Tait's equation of state for water, with a membrane approximated by surface tension that increases linearly with areal expansion. The presence of a rigid or deformable sphere had little effect on the bubble expansion, but caused an asymmetric collapse and jetting for the conditions considered. Predicted membrane areal expansions were found to be below critical values for hemolysis reported in the literature for the cases considered near the inertial cavitation threshold.

The alteration of protein profile of Walker 256 carinosarcoma cells during the apoptotic process induced by ultrasound

The objective of this study was to investigate the alteration of the protein profile in cells after sonication and to identify the key proteins involved in the process of cell apoptosis. Walker 256 carinosarcoma cells were exposed to focused ultrasound (US) at the intensity of 2.0, 7.0, 10.2, 14.2 and 17.0 W/cm2 (I(spta)) for 10 min in vitro and the morphologic and functional changes of the cells were detected by hematoxylin & eosin staining and flow cytometry, with double staining of fluorescein isothiocyanate (FITC)-labeled Annexin V/propidium iodide (PI). The protein compositions in the cells after sonication were detected by 2-D SDS polyacrylamide gel electrophoresis. Our results showed that apoptosis of Walker 256 carinosarcoma cells could be induced by US. The percentage of early apoptosis and secondary necrosis increased with increasing intensity of US irradiation. Comparing with the protein patterns of cells before sonication, it was found that around 420 new protein spots were present in the gel after sonication. Among them, Hsp60 and Bcl-2 like protein 13 were found to be involved in the process of cell apoptosis and US-induced apoptosis of the cells was probably performed through the pathway of promoting the activation of caspase-3.

Grey scale enhancement of rabbit liver and kidney by intravenous injection of a new lipid-coated ultrasound contrast agent

AIM: To assess the grey scale enhancement of a new lipid-coated ultrasound contrast agent in solid abdominal organs as liver and kidney.

METHODS: Size distribution and concentration of the lipid-coated contrast microbubbles were analyzed by a Coulter counter. Two-dimensional (2D) second harmonic imaging of the hepatic parenchyma, the inferior vena cava and the right kidney of the rabbits were acquired before and after contrast agent injection. Images were further quantified by histogram in Adobe Photoshop 6.0. Time-intensity curves of hepatic parenchyma, inferior vena cava and renal cortex were generated from the original grey scale.

RESULTS: The 2D images of hepatic parenchyma and cortex of the kidney were greatly enhanced after injection and the peak time could last more than 50 min.

CONCLUSION: This new lipid ultrasound contrast agent could significantly enhance the grey scale imaging of the hepatic parenchyma and the renal cortex for more than 50 min.

Microbubble-enhanced sonoporation: efficient gene transduction technique for chick embryos

The gene transduction technique is a useful method to study gene functions that underlie vertebrate embryogenesis. In this study, a new gene transduction technique is reported using microbubble-enhanced sonoporation (hereafter referred to as sonoporation) to achieve ectopic and transient gene expression for several embryonic organs including embryonic chick limb bud mesenchymes. The technique proposed in this study has the advantages of 1) relatively simple gene transduction procedures, and 2) efficient exogenous gene transduction and expression with lower damages to embryos. Green fluorescent protein (GFP) or LacZ was misexpressed in limb bud mesenchymes by sonoporation, with the introduced expression transiently detected in the injected sites. Most of the transduced chick embryos survived without showing significant embryonic abnormalities or cell death after sonoporation. To demonstrate its efficacy for assessing the effect of transient gene transduction, the Shh (sonic hedgehog) was transduced into the developing chick limb bud. The transduced limb bud displayed limb malformations including partial digit duplication. Advantages and possible future applications in relation to this method are discussed.

Role of intracellular calcium ions and reactive oxygen species in apoptosis induced by ultrasound

Recently, we have reported that ultrasound (US)-induced apoptosis is due to inertial cavitation and that extracellular reactive oxygen species (ROS) generated by inertial cavitation are not directly correlated with the apoptosis (Honda et al. 2002). The molecular mechanism of apoptosis induced by US is not yet sufficiently clear. Here, we examine the role of intracellular calcium ions and the intracellular ROS on apoptosis induced by US. Human myelomonocytic lymphoma U937 cells were exposed to continuous 1-MHz US at an intensity of 4.9 W/cm(2) (I(SPTA)) in the presence of air, and changes of intracellular calcium ion concentration ([Ca(2+)]i) in individual cells by digital imaging, various flow cytometric analyses of endpoints of apoptosis (early apoptosis, secondary necrosis, loss of mitochondria membrane potential, superoxide formation, caspase-3 activation) and DNA fragmentation were explored. Furthermore, the effects of an intracellular calcium ion chelator (BAPTA-AM), an antioxidant (N-acetyl-L-cysteine, NAC), a calcium channel blocker (verapamil), Ca(2+)-free buffer and Levovist were also investigated. These results indicate that: 1. the mitochondria-caspase pathway and the Ca(2+)-dependent pathway play cardinal roles in apoptosis induced by US because BAPTA-AM partially inhibited DNA fragmentation, loss of mitochondria membrane potential and caspase-3 activation; 2. intracellular ROS generated from mitochondria, rather than extracellular ROS (which were directly produced by inertial cavitation in the medium), are involved in the regulation of apoptosis induced by US because addition of NAC after sonication showed effective suppression of the apoptosis; and 3. increase of [Ca(2+)]i appears to be due to nonspecific influx from outside the cells because verapamil is not effective and no increase of [Ca(2+)]i due to sonication could be observed in the Ca(2+)-free buffer.

Ultrasound-induced cell membrane porosity

Recent studies of ultrasound (US) methods for targeted drug delivery and nonviral gene transfection revealed new, advantageous possibilities. These studies utilized US contrast agents, commonly stabilized microbubbles, to facilitate delivery and suggested that US delivery resulted from cell sonoporation, the formation of temporary pores in the cell membrane induced by US. Using voltage clamp techniques, we obtained real-time measurements of sonoporation of single Xenopus oocyte in the presence of Optison trade mark, an agent consisting of albumin-shelled C(3)F(8) gas bubbles (mean diameter 3.2 microm). Ultrasound increased the transmembrane current as a direct result of decreased membrane resistance due to pore formation. We observed a distinct delay of sonoporation following US activation and characteristic stepwise increases of transmembrane current throughout US duration. We discovered that the resealing of cell membrane following US exposure required Ca(2+) entering the cell through US-induced pores.

A review of research into the uses of low level ultrasound in cancer therapy

The use of low power ultrasound in therapeutic medicine is a developing field and this review will concentrate on the applications of this technology in cancer therapy. The effects of low power ultrasound have been evaluated in terms of the biological changes induced in the structure and function of tissue. The main fields of study have been in sonodynamic therapy, improving chemotherapy, gene therapy and apoptosis therapy. The range of ultrasonic power levels that can be effectively employed in therapy appears to be narrow and this may have hindered past research in the applications in cancer treatment.

Ultrasound-induced killing of monocytic U937 cells enhanced by 2,2'-azobis(2-amidinopropane) dihydrochloride

To determine the effect of 2,2'-azobis(2-amidinopropane) dihydrochloride (AAPH) on ultrasound (US)-induced cell killing, human monocytic leukemia cells (U937) were incubated at various temperatures (25.0, 37.0 and 40.0 degrees C) for 1 min in air-saturated phosphate-buffered solution (PBS) containing 50 mM AAPH before exposure to nonthermal 1 MHz US for 1 min at an intensity of 2.0 W/cm(2). Cell viability was determined by means of the Trypan blue dye exclusion test immediately after sonication. Apoptosis was measured after 6-h incubation post-sonication by flow cytometry. Free radicals generated by AAPH, a temperature-dependent free radical generator, or US or both were also investigated using electron paramagnetic resonance (EPR) spin trapping. The results showed that US-induced cell lysis and apoptosis were enhanced in the presence of AAPH regardless of the temperature at the time of sonication. At 40.0 degrees C, US alone induced increased cell killing, while AAPH alone is capable of inducing significant but minimal apoptosis at this temperature. Although free radicals were increased in the combined treatment, this increase did not correlate well with cell killing. The mechanism of enhancement points to the increased uptake of the agent during sonication rather than potentiation by AAPH. These findings suggest the clinical potential of temperature-dependent free radical generators in cancer therapy with therapeutic US.