Assessing the development and treatment of rheumatoid arthritis using multiparametric photoacoustic and ultrasound imaging

Utilising Hyperspectral Autofluorescence Imaging in the Objective Assessment of Disease State and Pain in Patients with Rheumatoid Arthritis

Rheumatoid Arthritis (RA) is a chronic inflammatory disease resulting in joint swelling and pain. Treatment options can be reliant on disease activity scores (DAS) incorporating patient global assessments, which are quantified via visual analogue scales (VAS). VAS can be subjective and not necessarily align with clinical symptoms, such as inflammation, resulting in a disconnect between the patient's and practitioners' experience. The development of more objective assessments of pain would enable a more targeted and personalised management of pain within individuals with RA and have the potential to improve the reliability of assessments in research. Using emerging light-based hyperspectral autofluorescence imaging (HAI) technology, we aimed to objectively differentiate disease and pain states based on the analysis of synovial tissue (ST) samples from RA patients. In total, 22 individuals with RA were dichotomised using the DAS in 28-joint counts (DAS-28) into an inactive (IA) or active disease (active-RA) group and then three sub-levels of pain (low, mid, high) based on VAS. HAI was performed on ST sections to identify and quantify the most prominent fluorophores. HAI fluorophore analysis revealed a distinct separation between the IA-RA and active-RA mid-VAS cohort, successfully determining disease state. Additionally, the separation between active-RA Mid-VAS and active RA High-VAS cohort suggests that HAI could be used to objectively separate individuals based on pain severity.

Towards in vivo photoacoustic human imaging: Shining a new light on clinical diagnostics

Multiscale visualization of human anatomical structures is revolutionizing clinical diagnosis and treatment. As one of the most promising clinical diagnostic techniques, photoacoustic imaging (PAI), or optoacoustic imaging, bridges the spatial-resolution gap between pure optical and ultrasonic imaging techniques, by the modes of optical illumination and acoustic detection. PAI can non-invasively capture multiple optical contrasts from the endogenous agents such as oxygenated/deoxygenated hemoglobin, lipid and melanin or a variety of exogenous specific biomarkers to reveal anatomy, function, and molecular for biological tissues in vivo, showing significant potential in clinical diagnostics. In 2001, the worldwide first clinical prototype of the photoacoustic system was used to screen breast cancer in vivo, which opened the prelude to photoacoustic clinical diagnostics. Over the past two decades, PAI has achieved monumental discoveries and applications in human imaging. Progress towards preclinical/clinical applications includes breast, skin, lymphatics, bowel, thyroid, ovarian, prostate, and brain imaging, etc., and there is no doubt that PAI is opening new avenues to realize early diagnosis and precise treatment of human diseases. In this review, the breakthrough researches and key applications of photoacoustic human imaging in vivo are emphatically summarized, which demonstrates the technical superiorities and emerging applications of photoacoustic human imaging in clinical diagnostics, providing clinical translational orientations for the photoacoustic community and clinicians. The perspectives on potential improvements of photoacoustic human imaging are finally highlighted.

Simultaneous photoacoustic and ultrasound imaging: A review

Photoacoustic imaging (PAI) is an emerging biomedical imaging technique that combines the advantages of optical and ultrasound imaging, enabling the generation of images with both optical resolution and acoustic penetration depth. By leveraging similar signal acquisition and processing methods, the integration of photoacoustic and ultrasound imaging has introduced a novel hybrid imaging modality suitable for clinical applications. Photoacoustic-ultrasound imaging allows for non-invasive, high-resolution, and deep-penetrating imaging, providing a wealth of image information. In recent years, with the deepening research and the expanding biomedical application scenarios of photoacoustic-ultrasound bimodal systems, the immense potential of photoacoustic-ultrasound bimodal imaging in basic research and clinical applications has been demonstrated, with some research achievements already commercialized. In this review, we introduce the principles, technical advantages, and biomedical applications of photoacoustic-ultrasound bimodal imaging techniques, specifically focusing on tomographic, microscopic, and endoscopic imaging modalities. Furthermore, we discuss the future directions of photoacoustic-ultrasound bimodal imaging technology.

Dual-modal Photoacoustic and Ultrasound Imaging: from preclinical to clinical applications

Photoacoustic imaging is a novel biomedical imaging modality that has emerged over the recent decades. Due to the conversion of optical energy into the acoustic wave, photoacoustic imaging offers high-resolution imaging in depth beyond the optical diffusion limit. Photoacoustic imaging is frequently used in conjunction with ultrasound as a hybrid modality. The combination enables the acquisition of both optical and acoustic contrasts of tissue, providing functional, structural, molecular, and vascular information within the same field of view. In this review, we first described the principles of various photoacoustic and ultrasound imaging techniques and then classified the dual-modal imaging systems based on their preclinical and clinical imaging applications. The advantages of dual-modal imaging were thoroughly analyzed. Finally, the review ends with a critical discussion of existing developments and a look toward the future.

Niche preclinical and clinical applications of photoacoustic imaging with endogenous contrast

In the past decade, photoacoustic (PA) imaging has attracted a great deal of popularity as an emergent diagnostic technology owing to its successful demonstration in both preclinical and clinical arenas by various academic and industrial research groups. Such steady growth of PA imaging can mainly be attributed to its salient features, including being non-ionizing, cost-effective, easily deployable, and having sufficient axial, lateral, and temporal resolutions for resolving various tissue characteristics and assessing the therapeutic efficacy. In addition, PA imaging can easily be integrated with the ultrasound imaging systems, the combination of which confers the ability to co-register and cross-reference various features in the structural, functional, and molecular imaging regimes. PA imaging relies on either an endogenous source of contrast (e.g., hemoglobin) or those of an exogenous nature such as nano-sized tunable optical absorbers or dyes that may boost imaging contrast beyond that provided by the endogenous sources. In this review, we discuss the applications of PA imaging with endogenous contrast as they pertain to clinically relevant niches, including tissue characterization, cancer diagnostics/therapies (termed as theranostics), cardiovascular applications, and surgical applications. We believe that PA imaging's role as a facile indicator of several disease-relevant states will continue to expand and evolve as it is adopted by an increasing number of research laboratories and clinics worldwide.

Photoacoustic clinical applications: Musculoskeletal and abdominal imaging

Photoacoustic (PA) imaging has been extensively investigated in application in biomedicine over the last decade. This article reviews the motivation, significance, and system configuration of a few ongoing studies of implementing photoacoustic technology in musculoskeletal imaging, abdominal imaging, and interstitial sensing. The review then summarizes the methodologies and latest progress of relevant projects. Finally, we discuss our expectations for the future of translation research in PA imaging.

Photoacoustic Imaging and Characterization of Bone in Medicine: Overview, Applications, and Outlook

Photoacoustic techniques have shown promise in identifying molecular changes in bone tissue and visualizing tissue microstructure. This capability represents significant advantages over gold standards (i.e., dual-energy X-ray absorptiometry) for bone evaluation without requiring ionizing radiation. Instead, photoacoustic imaging uses light to penetrate through bone, followed by acoustic pressure generation, resulting in highly sensitive optical absorption contrast in deep biological tissues. This review covers multiple bone-related photoacoustic imaging contributions to clinical applications, spanning bone cancer, joint pathologies, spinal disorders, osteoporosis, bone-related surgical guidance, consolidation monitoring, and transsphenoidal and transcranial imaging. We also present a summary of photoacoustic-based techniques for characterizing biomechanical properties of bone, including temperature, guided waves, spectral parameters, and spectroscopy. We conclude with a future outlook based on the current state of technological developments, recent achievements, and possible new directions.

Full-view LED-based optoacoustic tomography

Optoacoustic tomography is commonly performed with bulky and expensive short-pulsed solid-state lasers providing high per-pulse energies in the millijoule range. Light emitting diodes (LEDs) represent a cost-effective and portable alternative for optoacoustic signal excitation that can additionally provide excellent pulse-to-pulse stability. Herein, we introduce a full-view LED-based optoacoustic tomography (FLOAT) system for deep tissue in vivo imaging. It is based on a custom-made electronic unit driving a stacked array of LEDs, which attains 100 ns pulse width and highly stable (0.62 % standard deviation) total per-pulse energy of 0.48 mJ. The illumination source is integrated into a circular array of cylindrically-focused ultrasound detection elements to result in a full-view tomographic configuration, which plays a critical role in circumventing limited-view effects, enhancing the effective field-of-view and image quality for cross-sectional (2D) imaging. We characterized the FLOAT performance in terms of pulse width, power stability, excitation light distribution, signal-to-noise and penetration depth. FLOAT of the human finger revealed a comparable imaging performance to that achieved with the standard pulsed Nd:YAG laser. It is anticipated that this compact, affordable and versatile illumination technology will facilitate optoacoustic imaging developments in resource-limited settings for biological and clinical applications.

Photoacoustic/ultrasonic dual-mode imaging for monitoring angiogenesis and synovial erosion in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by the formation of new vessels, synovial proliferation and destruction of articular cartilage. However, characteristic early diagnostic and therapeutic monitoring methods are still lacking. We report a study using a photoacoustic/ultrasound (PA/US) dual-mode imaging for RA disease. By establishing a collagen-induced (CIA) RA mouse model to classify disease states based on a subjective grading system, PA/US imaging allows real-time assessment of synovial erosion and vascular opacification within the knee joint in different disease states at high spatial resolution. The system also quantitatively monitors subcutaneous vascular physiology and morphology in the hind paw of mice, measuring the area and photoacoustic signal intensity of vascular proliferation and showing a positive correlation with disease grading. Compared to traditional subjective scoring of arthritis severity, the PA/US imaging is more sensitive i.e., vascular signals and synovial erosion can be observed early in the course of arthritis.

Synovial Oxygenation at Photoacoustic Imaging to Assess Rheumatoid Arthritis Disease Activity

Background Synovial hypoxia is a hallmark of rheumatoid arthritis (RA). Photoacoustic (PA) imaging, based on the use of laser-generated US, can detect the oxygenation status of tissue in individuals with RA. However, large studies are lacking, with few investigating the correlation between oxygenation status and disease activity. Purpose To measure synovial oxygenation status in participants with RA by using a multimodal PA US imaging system and to determine the correlation between PA imaging-measured oxygen saturation (SO₂) and disease activity. Materials and Methods In this prospective observational cohort study, multimodal PA US imaging examinations were performed on small joints of consecutive participants with RA, who were treated at two outpatient rheumatology clinics from 2019 to 2021, and healthy controls. The SO₂ values of the synovium were measured with dual-wavelength PA imaging and classified into three categories-hyperoxia, intermediate oxygenation status, or hypoxia-based on the signal coloration and clustering analysis of the SO₂ values. The correlations of oxygenation status with power Doppler US (PDUS) scoring and clinical disease activity index were evaluated with one-way analysis of variance and the Kruskal-Wallis test with Bonferroni correction. Results A total of 118 participants with RA (median age, 55 years [IQR, 41-62 years]; 92 women) and 15 healthy control participants (median age, 37 years [IQR, 33-41 years]; 11 women) were included. The wrist synovium was categorized as hyperoxic in 36 participants with RA, of intermediate oxygenation status in 48 participants, and hypoxic in 34 participants. All control participants had hyperoxic synovial tissues. For participants with RA, hyperoxic synovium had more affluent Doppler US-depicted vasculature than those with hypoxia and intermediate oxygenation status (mean PDUS grade: hyperoxia, 2.7 ± 0.6 [SD]; intermediate, 1.3 ± 0.7; hypoxia, 1.1 ± 0.8; P < .001). Participants with intermediate status synovium had a lower clinical disease activity index than those with hypoxia (intermediate, 11.0 [IQR, 5.0-21.5] vs hypoxia, 26.0 [IQR, 18.0-39.0]; P = .001). Conclusion Photoacoustic imaging-detected hypoxia in thickened synovium correlated with less vascularization and higher disease activity in participants with rheumatoid arthritis. Clinical trial registration no. NCT04297475 © RSNA, 2022 Online supplemental material is available for this article.

A Review of Clinical Applications for Super-resolution Ultrasound Localization Microscopy

Microvascular structure and hemodynamics are important indicators for the diagnosis and assessment of many diseases and pathologies. The structural and functional imaging of tissue microvasculature in vivo is a clinically significant objective for the development of many imaging modalities. Contrast-enhanced ultrasound (CEUS) is a popular clinical tool for characterizing tissue microvasculature, due to the moderate cost, wide accessibility, and absence of ionizing radiation of ultrasound. However, in practice, it remains challenging to demonstrate microvasculature using CEUS, due to the resolution limit of conventional ultrasound imaging. In addition, the quantification of tissue perfusion by CEUS remains hindered by high operator-dependency and poor reproducibility. Inspired by super-resolution optical microscopy, super-resolution ultrasound localization microscopy (ULM) was recently developed. ULM uses the same ultrasound contrast agent (i.e. microbubbles) in CEUS. However, different from CEUS, ULM uses the location of the microbubbles to construct images, instead of using the backscattering intensity of microbubbles. Hence, ULM overcomes the classic compromise between imaging resolution and penetration, allowing for the visualization of capillary-scale microvasculature deep within tissues. To date, many in vivo ULM results have been reported, including both animal (kidney, brain, spinal cord, xenografted tumor, and ear) and human studies (prostate, tibialis anterior muscle, and breast cancer tumors). Furthermore, a variety of useful biomarkers have been derived from using ULM for different preclinical and clinical applications. Due to the high spatial resolution and accurate blood flow speed estimation (approximately 1 mm/s to several cm/s), ULM presents as an enticing alternative to CEUS for characterizing tissue microvasculature in vivo. This review summarizes the principles and present applications of CEUS and ULM, and discusses areas where ULM can potentially provide a better alternative to CEUS in clinical practice and areas where ULM may not be a better alternative. The objective of the study is to provide clinicians with an up-to-date review of ULM technology, and a practical guide for implementing ULM in clinical research and practice.

Nondestructive testing of native and tissue-engineered medical products: adding numbers to pictures

Traditional destructive tests are used for quality assurance and control within manufacturing workflows. Their applicability to biomanufacturing is limited due to inherent constraints of the biomanufacturing process. To address this, photo- and acoustic-based nondestructive testing has risen in prominence to interrogate not only structure and function, but also to integrate quantitative measurements of biochemical composition to cross-correlate structural, compositional, and functional variances. We survey relevant literature related to single-mode and multimodal nondestructive testing of soft tissues, which adds numbers (quantitative measurements) to pictures (qualitative data). Native and tissue-engineered articular cartilage is highlighted because active biomanufacturing processes are being developed. Included are recent efforts and prominent trends focused on technologies for clinical and in-process biomanufacturing applications.

Progress of clinical translation of handheld and semi-handheld photoacoustic imaging

Photoacoustic imaging (PAI), featuring rich contrast, high spatial/temporal resolution and deep penetration, is one of the fastest-growing biomedical imaging technology over the last decade. To date, numbers of handheld and semi-handheld photoacoustic imaging devices have been reported with corresponding potential clinical applications. Here, we summarize emerged handheld and semi-handheld systems in terms of photoacoustic computed tomography (PACT), optoacoustic mesoscopy (OAMes), and photoacoustic microscopy (PAM). We will discuss each modality in three aspects: laser delivery, scanning protocol, and acoustic detection. Besides new technical developments, we also review the associated clinical studies, and the advantages/disadvantages of these new techniques. In the end, we propose the challenges and perspectives of miniaturized PAI in the future.

On-Chip Multicolor Photoacoustic Imaging Flow Cytometry

On-chip imaging flow cytometry has been widely used in cancer biology, immunology, microbiology, and drug discovery. Pure optical imaging combined with flow cytometry to derive chemical, structural, and morphological features of cells provides systematic insights into biological processes. However, due to the high concentration and strong optical attenuation of red blood cells, preprocessing is necessary for optical flow cytometry while dealing with whole blood. In this study, we develop an on-chip photoacoustic imaging flow cytometry (PAIFC), which combines multicolor high-speed photoacoustic microscopy and microfluidics for cell imaging. The device employs a micro-optical scanner to achieve a miniaturized outer size of 30 × 17 × 24 mm³ and ultrafast cross-sectional imaging at a frame rate of 1758 Hz and provides lateral and axial resolutions of 2.2 and 33 μm, respectively. Using a multicolor strategy, PAIFC is able to differentiate cells labeled by external contrast agents, detect melanoma cells with an endogenous contrast in whole blood, and image melanoma cells in blood samples from tumor-bearing mice. The results suggest that PAIFC has sufficient sensitivity and specificity for future cell-on-chip applications.

MBene as a Theranostic Nanoplatform for Photocontrolled Intratumoral Retention and Drug Release

Tumor-targeted drug delivery by nanomaterials is important to improve tumor therapy efficacy and reduce toxic side effects, but its efficiency is quite limited. In this work, a new type of MBene, zirconium boride nanosheet (ZBN), as a versatile nanoplatform to realize near-infrared (NIR)-controlled intratumoral retention and drug release is developed. ZBN exhibits high NIR-photothermal conversion efficiency (76.8%), surface modification with hyaluronic acid (HA) by polyol-borate esterfication endows ZBN-HA with good dispersion, and the photopyrolysis of borate ester causes HA detachment and ZBN aggregation, enabling NIR-controlled intratumoral retention to achieve high intratumoral accumulation. By virtue of surface borate esterfication, polyol chemotherapeutic drug (doxorubicin, DOX), and NO prodrug (β-galactosyl-diazeniumdiolate, Gal-NO) can be efficiently and stably conjugated on the surface of ZBN-HA (1.21 g DOX or 0.57 g Gal-NO per gram ZBN) without visible drug leakage, and the photopyrolysis of borate ester enables NIR-controlled drug release with high responsiveness and controllability. Combined chemothermal/gasothermal therapies based on ZBN-HA/DOX and ZBN-HA/NO nanomedicines eradicate primary tumors and interdict tumor metastasis by changing the tumor microenvironment and killing cancer cells in primary tumors. The developed NIR-photothermal MBene is confirmed as a versatile nanoplatform capable of high-efficacy tumor-targeted drug delivery and controlled drug release.

Tracking Osteoarthritis Progress through Cationic Nanoprobe-Enhanced Photoacoustic Imaging of Cartilage

A major obstacle in osteoarthritis (OA) theranostics is the lack of a timely and accurate monitoring method. It is hypothesized that the loss of anionic glycosaminoglycans (GAGs) in articular cartilage reflects the progression of OA. Thus, this study investigated the feasibility of photoacoustic imaging (PAI) applied for monitoring the in vivo course of OA progression via GAG-targeted cationic nanoprobes. The nanoprobes were synthesized through electrostatic attraction between poly-l-Lysine and melanin (PLL-MNPs). Cartilage explants with different concentrations of GAGs incubated with PLL-MNPs to test the relationship between GAGs content and PA signal intensity. GAG activity was then evaluated in vivo in destabilization of the medial meniscus (DMM) surgically-induced mouse model. To track OA progression over time, mice were imaged consistently for 10 weeks after OA-inducing surgery. X-ray was used to verify the superiority of PAI in detecting OA. The correlation between PAI data and histologic results was also analyzed. In vitro study demonstrated the ability of PLL-MNPs in sensitively detecting different GAGs concentrations. In vivo PAI exhibited significantly lower signal intensity from OA knees compared to normal knees. More importantly, PA signal intensity showed serial reduction over the course of OA, while X-ray showed visible joint destruction until 6 weeks. A decrease in GAGs content was confirmed by histologic examinations; moreover, histologic findings were well correlated with PAI results. Therefore, using cationic nanoprobe-enhanced PAI to detect the changes in GAG contents provides sensitive and consistent visualization of OA development. This approach will further facilitate OA theranostics and clinical translation. STATEMENT OF SIGNIFICANCE: The study of in vivo monitoring osteoarthritis (OA) is of high significance to tracking the trajectory of OA development and therapeutic monitoring. Here, we developed a cartilage-targeted cationic nanoprobe, poly-l-Lysine-melanin nanoparticles (PLL-MNPs), enhancing photoacoustic imaging (PAI) to monitor the progression of OA. The in vitro study demonstrated the ability of PLL-MNPs to detect different concentrations of GAGs with high sensitivity. We found that the contents of GAGs in vivo steadily decreased from the development of OA initial-stage to the end-point of our investigation via PAI; it reflected the course of OA in living subjects with high sensitivity. These results allow for further development in various aspects of OA research. It has potential for clinical translation and has a great impact on personalized medicine.