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Zhong J, Huang L, Su M, Wu M, Lin X, Shui X, Jiang Y, Zhang X. Ultrasound Microvessel Visualization in Cervical Cancer: Association Between Novel Ultrasound Techniques and Histologic Microvessel Densities. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:2537-2547. [PMID: 37730477 DOI: 10.1016/j.ultrasmedbio.2023.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 07/27/2023] [Accepted: 08/23/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVE The aim of the work described here was to evaluate the feasibility of superb microvascular imaging (SMI) and vascular endothelial growth factor receptor 2 (VEGFR2)-targeted microbubble (MBVEGFR2)-based ultrasound molecular imaging (USMI) for visualizing microvessels in cervical cancer. METHODS Hela cells were used to establish subcutaneous cervical cancer models. SMI and MBVEGFR2-based USMI were performed, and the results were compared with intratumoral microvessel density (MVD) in four groups based on tumor diameter (<3 mm, 3-5 mm, 5-7 mm and ≥7 mm). The vascularization index (VI, %) was evaluated for SMI, and the normalized intensity difference (NID) for USMI. RESULTS Tumors with diameters ranging from 3 to 5 mm had the highest VI (39.07 ± 1.58) in SMI, and VI significantly decreased with increasing tumor size (all p values <0.001). The strongest signal intensity was observed in very early tumors (d < 3 mm: 43.80 ± 3.58%) after MBVEGFR2 administration; the NID gradually decreased with increasing diameter of tumors (all p values = 0.007). However, no significant differences were observed in NID after administration of non-targeted (control) microbubbles (MBCon) (all p values = 0.125). MBVEGFR2-based USMI had the strongest correlation with MVD in displaying microvessels of cervical cancer compared with SMI and MBCon (R2 = 0.78 vs. R2 = 0.40 and R2 = 0.38). CONCLUSION These findings validate the superiority and accuracy of MBVEGFR2-based USMI for microvessel imaging and monitoring of angiogenesis in cervical cancer compared with SMI and MBCon. Nonetheless, SMI remains an alternative to microvessel imaging when ultrasonic contrast agent use is contraindicated.
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Affiliation(s)
- Junlin Zhong
- Department of Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Licong Huang
- Department of Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Manting Su
- Department of Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Manli Wu
- Department of Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xin Lin
- Department of Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xing Shui
- Department of Cardiovascular Medicine, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Ye Jiang
- Department of Pathology, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Xinling Zhang
- Department of Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China.
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Zhong J, Su M, Jiang Y, Huang L, Chen Y, Huang Z, Zhang X. VEGFR2 targeted microbubble-based ultrasound molecular imaging improving the diagnostic sensitivity of microinvasive cervical cancer. J Nanobiotechnology 2023; 21:220. [PMID: 37438780 DOI: 10.1186/s12951-023-01984-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 07/05/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND The current diagnostic methods of microinvasive cervical cancer lesions are imaging diagnosis and pathological evaluation. Pathological evaluation is invasive and imaging approaches are of extremely low diagnostic performance. There is a paucity of effective and noninvasive imaging approaches for these extremely early cervical cancer during clinical practice. In recent years, ultrasound molecular imaging (USMI) with vascular endothelial growth factor receptor type 2 (VEGFR2) targeted microbubble (MBVEGFR2) has been reported to improve the early diagnosis rates of breast cancer (including ductal carcinoma in situ), pancreatic cancer and hepatic micrometastases. Herein, we aimed to assess the feasibility of MBVEGFR2-based USMI in extremely early cervical cancer detection to provide an accurate imaging modality for microinvasive cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) Stage IA1 and IA2). RESULTS We found MBVEGFR2-based USMI could successfully distinguish extremely early lesions in diameter < 3 mm from surrounding normal tissues (all P < 0.05), and the sensitivity gradually decreased along with increasing tumor diameter. Moreover, normalized intensity difference (NID) values showed a good linear correlation with microvessel density (MVD) (R2 = 0.75). In addition, all tumors could not be identified from surrounding muscles in subtracted ultrasound images when mice were administered MBCon. CONCLUSIONS Overall, MBVEGFR2-based USMI has huge potential for clinical application for the early detection of microinvasive cervical cancer (FIGO Stage IA1 and IA2), providing the foothold for future studies on the imaging screening of this patient population.
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Affiliation(s)
- Junlin Zhong
- Department of Ultrasound, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong, China
| | - Manting Su
- Department of Ultrasound, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong, China
| | - Ye Jiang
- Department of Pathology, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong, China
| | - Licong Huang
- Department of Ultrasound, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong, China
| | - Ying Chen
- Department of Ultrasound, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong, China
| | - Zhuoshan Huang
- Department of Cardiovascular Medicine, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong, China
| | - Xinling Zhang
- Department of Ultrasound, The Third Affiliated Hospital of Sun Yat-sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong, China.
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Miao X, Sha T, Zhang W, Zhou H, Qiu C, Deng H, You Y, Ren J, Zhang X, Zheng R, Yin T. Liver Fibrosis Assessment by Viewing Sinusoidal Capillarization: US Molecular Imaging versus Two-dimensional Shear-Wave Elastography in Rats. Radiology 2022; 304:473-482. [PMID: 35503015 DOI: 10.1148/radiol.212325] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background US elastography is a first-line assessment of liver fibrosis severity; however, its application is limited by its insufficient sensitivity in early-stage fibrosis detection and its measurements are affected by inflammation. Purpose To assess the sensitivity of US molecular imaging (USMI) in early-stage liver fibrosis detection and to determine whether USMI can specifically distinguish fibrosis regardless of inflammation when compared with two-dimensional (2D) shear-wave elastography (SWE). Materials and methods USMI and 2D SWE were performed prospectively (January to June 2021) in 120 male Sprague-Dawley rats with varying degrees of liver fibrosis and acute hepatitis and control rats. Liver sinusoidal capillarization was viewed at CD34-targeted USMI and quantitatively analyzed by the normalized intensity difference (NID). Data were compared by using a two-sided Student t test or one-way analysis of variance. Linear correlation analyses were used to evaluate the relationships between collagen proportionate area values and NID and liver stiffness measurement (LSM) values. Receiver operating characteristic curves were used to assess the diagnostic performance in detecting liver fibrosis. Results Both NID and LSM values showed good linear correlation with collagen proportionate area values (r = 0.91 and 0.87, respectively). No difference was observed between the areas under the receiver operating characteristic curve in detecting stage F0-F1 between USMI and 2D SWE (0.97 vs 0.91, respectively; P = .20). USMI depicted liver fibrosis at an early stage more accurately than 2D SWE (area under the curve, 0.97 vs 0.82, respectively; P = .01). Rats with hepatitis had higher liver stiffness values than control rats (9.83 kPa ± 0.79 vs 6.55 kPa ± 0.38, respectively; P < .001), with no difference in the NID values between control rats and rats with hepatitis (6.75% ± 1.43 vs 6.74% ± 0.86, respectively; P = .98). Conclusion Sinusoidal capillarization viewed at US molecular imaging helped to detect early-stage liver fibrosis more accurately than two-dimensional shear-wave elastography and helped assess fibrosis regardless of inflammation. © RSNA, 2022 Online supplemental material is available for this article. See also the editorial by Barr in this issue.
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Affiliation(s)
- Xiaoyan Miao
- From the Department of Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Tingting Sha
- From the Department of Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Wei Zhang
- From the Department of Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Huichao Zhou
- From the Department of Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Chen Qiu
- From the Department of Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Huan Deng
- From the Department of Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Yujia You
- From the Department of Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Jie Ren
- From the Department of Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Xinling Zhang
- From the Department of Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Rongqin Zheng
- From the Department of Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Tinghui Yin
- From the Department of Ultrasound, Laboratory of Novel Optoacoustic (Ultrasonic) Imaging, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
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Fan CH, Lee YH, Ho YJ, Wang CH, Kang ST, Yeh CK. Macrophages as Drug Delivery Carriers for Acoustic Phase-Change Droplets. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:1468-1481. [PMID: 29685589 DOI: 10.1016/j.ultrasmedbio.2018.03.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 03/06/2018] [Accepted: 03/14/2018] [Indexed: 05/19/2023]
Abstract
The major challenges in treating malignant tumors are transport of therapeutic agents to hypoxic regions and real-time assessment of successful drug release via medical imaging modalities. In this study, we propose the use of macrophages (RAW 264.7 cells) as carriers of drug-loaded phase-change droplets to penetrate ischemic or hypoxic regions within tumors. The droplets consist of perfluoropentane, lipid and the chemotherapeutic drug doxorubicin (DOX, DOX-droplets). The efficiency of DOX-droplet uptake, migration mobility and viability of DOX-droplet-loaded macrophages (DLMs) were measured using a transmembrane cell migration assay, the alamarBlue assay and flow cytometric analysis, respectively. Our results indicate the feasibility of utilizing macrophages as DOX-droplet carriers (DOX payload of DOX-droplets: 459.3 ± 35.8 µg/mL, efficiency of cell uptake DOX-droplets: 88.8 ± 3.5%). The migration mobility (total number of migrated microphages) of DLMs decreased to 32.3% compared with that of healthy macrophages, but the DLMs provided contrast-enhanced ultrasound imaging (1.7-fold enhancement) and anti-tumor effect (70.9% cell viability) after acoustic droplet vaporization, suggesting the potential theranostic applications of DLMs. Future work will assess the tumor penetration ability of DLMs, mechanical effect of droplet vaporization on in vivo anti-tumor therapy and the release of the carried drug by ultrasound-triggered vaporization.
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Affiliation(s)
- Ching-Hsiang Fan
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - Ya-Hsuan Lee
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - Yi-Ju Ho
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - Chung-Hsin Wang
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - Shih-Tsung Kang
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - Chih-Kuang Yeh
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan.
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Abstract
The mouse is the mammalian model of choice for investigating cardiovascular biology, given our ability to manipulate it by genetic, pharmacologic, mechanical, and environmental means. Imaging is an important approach to phenotyping both function and structure of cardiac and vascular components. This review details commonly used imaging approaches, with a focus on echocardiography and magnetic resonance imaging and brief overviews of other imaging modalities. We also briefly outline emerging imaging approaches but caution that reliability and validity data may be lacking.
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Affiliation(s)
- Colin K L Phoon
- Division of Pediatric Cardiology, Department of Pediatrics, New York University School of Medicine, New York, New York
| | - Daniel H Turnbull
- Departments of Radiology and Pathology, New York University School of Medicine, New York, New York.,Skirball Institute of Biomolecular Medicine, New York University School of Medicine, New York, New York
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Arosio D, Casagrande C. Advancement in integrin facilitated drug delivery. Adv Drug Deliv Rev 2016; 97:111-43. [PMID: 26686830 DOI: 10.1016/j.addr.2015.12.001] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 11/27/2015] [Accepted: 12/03/2015] [Indexed: 02/06/2023]
Abstract
The research of integrin-targeted anticancer agents has recorded important advancements in ingenious design of delivery systems, based either on the prodrug approach, or on nanoparticle carriers, but for now, none of these has reached a clinical stage of development. Past work in this area has been extensively reviewed by us and others. Thus, the purpose and scope of the present review is to survey the advancement reported in the last 3years, with focus on innovative delivery systems that appear to afford openings for future developments. These systems exploit the labelling with conventional and novel integrin ligands for targeting the interface of cancer cells and of endothelial cells involved in cancer angiogenesis, with the proteins of the extracellular matrix, in the circulation, in tissues, and in tumour stroma, as the site of progression and metastatic evolution of the disease. Furthermore, these systems implement the expertise in the development of nanomedicines to the purpose of achieving preferential biodistribution and uptake in cancer tissues, internalisation in cancer cells, and release of the transported drugs at intracellular sites. The assessment of the value of controlling these factors, and their combination, for future developments requires support of biological testing in appropriate mechanistic models, but also imperatively demand confirmation in therapeutically relevant in vivo models for biodistribution, efficacy, and lack of off-target effects. Thus, among many studies, we have tried to point out the results supported by relevant in vivo studies, and we have emphasised in specific sections those addressing the medical needs of drug delivery to brain tumours, as well as the delivery of oligonucleotides modulating gene-dependent pathological mechanism. The latter could constitute the basis of a promising third branch in the therapeutic armamentarium against cancer, in addition to antibody-based agents and to cytotoxic agents.
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Affiliation(s)
- Daniela Arosio
- Istituto di Scienze e Tecnologie Molecolari (ISTM), CNR, Via C. Golgi 19, I-20133 Milan, Italy.
| | - Cesare Casagrande
- Università degli Studi di Milano, Dipartimento di Chimica, Via C. Golgi 19, I-20133 Milan, Italy.
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Barsanti C, Lenzarini F, Kusmic C. Diagnostic and prognostic utility of non-invasive imaging in diabetes management. World J Diabetes 2015; 6:792-806. [PMID: 26131322 PMCID: PMC4478576 DOI: 10.4239/wjd.v6.i6.792] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 12/23/2014] [Accepted: 04/14/2015] [Indexed: 02/05/2023] Open
Abstract
Medical imaging technologies are acquiring an increasing relevance to assist clinicians in diagnosis and to guide management and therapeutic treatment of patients, thanks to their non invasive and high resolution properties. Computed tomography, magnetic resonance imaging, and ultrasonography are the most used imaging modalities to provide detailed morphological reconstructions of tissues and organs. In addition, the use of contrast dyes or radionuclide-labeled tracers permits to get functional and quantitative information about tissue physiology and metabolism in normal and disease state. In recent years, the development of multimodal and hydrid imaging techniques is coming to be the new frontier of medical imaging for the possibility to overcome limitations of single modalities and to obtain physiological and pathophysiological measurements within an accurate anatomical framework. Moreover, the employment of molecular probes, such as ligands or antibodies, allows a selective in vivo targeting of biomolecules involved in specific cellular processes, so expanding the potentialities of imaging techniques for clinical and research applications. This review is aimed to give a survey of characteristics of main diagnostic non-invasive imaging techniques. Current clinical appliances and future perspectives of imaging in the diagnostic and prognostic assessment of diabetic complications affecting different organ systems will be particularly addressed.
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van Rooij T, Luan Y, Renaud G, van der Steen AFW, Versluis M, de Jong N, Kooiman K. Non-linear response and viscoelastic properties of lipid-coated microbubbles: DSPC versus DPPC. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:1432-45. [PMID: 25724308 DOI: 10.1016/j.ultrasmedbio.2015.01.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 01/09/2015] [Accepted: 01/16/2015] [Indexed: 05/21/2023]
Abstract
For successful in vivo contrast-enhanced ultrasound imaging (CEUS) and ultrasound molecular imaging, detailed knowledge of stability and acoustical properties of the microbubbles is essential. Here, we compare these aspects of lipid-coated microbubbles that have either 1,2-distearoyl-sn-glycero-3-phosphocholine (DSPC) or 1,2-dipalmitoyl-sn-glycero-3-phosphocholine (DPPC) as their main lipid; the other components were identical. The microbubbles were investigated in vitro over the frequency range 1-4 MHz at pressures between 10 and 100 kPa, and their response to the applied ultrasound was recorded using ultrahigh-speed imaging (15 Mfps). Relative to DPPC-coated microbubbles, DSPC-coated microbubbles had (i) higher acoustical stability; (ii) higher shell elasticity as derived using the Marmottant model (DSPC: 0.26 ± 0.13 N/m, DPPC: 0.06 ± 0.06 N/m); (iii) pressure amplitudes twice as high at the second harmonic frequency; and (iv) a smaller amount of microbubbles that responded at the subharmonic frequency. Because of their higher acoustical stability and higher non-linear response, DSPC-coated microbubbles may be more suitable for contrast-enhanced ultrasound.
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Affiliation(s)
- Tom van Rooij
- Department of Biomedical Engineering, Thorax Center, Erasmus MC, Rotterdam, The Netherlands.
| | - Ying Luan
- Department of Biomedical Engineering, Thorax Center, Erasmus MC, Rotterdam, The Netherlands
| | - Guillaume Renaud
- Department of Biomedical Engineering, Thorax Center, Erasmus MC, Rotterdam, The Netherlands; Sorbonne Universités, UPMC Univ Paris 06, CNRS UMR 7371, INSERM UMR S 1146, Laboratoire d'Imagerie Biomédicale, Paris, France
| | - Antonius F W van der Steen
- Department of Biomedical Engineering, Thorax Center, Erasmus MC, Rotterdam, The Netherlands; Laboratory of Acoustical Wavefield Imaging, Faculty of Applied Sciences, Technical University Delft, Delft, The Netherlands
| | - Michel Versluis
- Physics of Fluids Group, MIRA Institute for Biomedical Technology and Technical Medicine, University of Twente, Enschede, The Netherlands
| | - Nico de Jong
- Department of Biomedical Engineering, Thorax Center, Erasmus MC, Rotterdam, The Netherlands; Laboratory of Acoustical Wavefield Imaging, Faculty of Applied Sciences, Technical University Delft, Delft, The Netherlands; Interuniversity Cardiology Institute of the Netherlands, Utrecht, The Netherlands
| | - Klazina Kooiman
- Department of Biomedical Engineering, Thorax Center, Erasmus MC, Rotterdam, The Netherlands
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Abstract
Nanoparticles are frequently suggested as diagnostic agents. However, except for iron oxide nanoparticles, diagnostic nanoparticles have been barely incorporated into clinical use so far. This is predominantly due to difficulties in achieving acceptable pharmacokinetic properties and reproducible particle uniformity as well as to concerns about toxicity, biodegradation, and elimination. Reasonable indications for the clinical utilization of nanoparticles should consider their biologic behavior. For example, many nanoparticles are taken up by macrophages and accumulate in macrophage-rich tissues. Thus, they can be used to provide contrast in liver, spleen, lymph nodes, and inflammatory lesions (eg, atherosclerotic plaques). Furthermore, cells can be efficiently labeled with nanoparticles, enabling the localization of implanted (stem) cells and tissue-engineered grafts as well as in vivo migration studies of cells. The potential of using nanoparticles for molecular imaging is compromised because their pharmacokinetic properties are difficult to control. Ideal targets for nanoparticles are localized on the endothelial luminal surface, whereas targeted nanoparticle delivery to extravascular structures is often limited and difficult to separate from an underlying enhanced permeability and retention (EPR) effect. The majority of clinically used nanoparticle-based drug delivery systems are based on the EPR effect, and, for their more personalized use, imaging markers can be incorporated to monitor biodistribution, target site accumulation, drug release, and treatment efficacy. In conclusion, although nanoparticles are not always the right choice for molecular imaging (because smaller or larger molecules might provide more specific information), there are other diagnostic and theranostic applications for which nanoparticles hold substantial clinical potential.
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Affiliation(s)
- Fabian Kiessling
- From the Department of Experimental Molecular Imaging, RWTH-Aachen University, Aachen, Germany (F.K., M.E.M., T.L.); and Molecular Pharmacology and Chemistry Program, Memorial Sloan-Kettering Cancer Center, New York, NY (J.G.)
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Skachkov I, Luan Y, van der Steen AFW, de Jong N, Kooiman K. Targeted microbubble mediated sonoporation of endothelial cells in vivo. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2014; 61:1661-1667. [PMID: 25265175 DOI: 10.1109/tuffc.2014.006440] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Ultrasound contrast agents as drug-delivery systems are an emerging field. Recently, we reported that targeted microbubbles are able to sonoporate endothelial cells in vitro. In this study, we investigated whether targeted microbubbles can also induce sonoporation of endothelial cells in vivo, thereby making it possible to combine molecular imaging and drug delivery. Live chicken embryos were chosen as the in vivo model. αvß3-targeted microbubbles attached to the vessel wall of the chicken embryo were insonified at 1 MHz at 150 kPa (1 × 10,000 cycles) and at 200 kPa (1 × 1000 cycles) peak negative acoustic pressure. Sonoporation was studied by intravital microscopy using the model drug propidium iodide (PI). Endothelial cell PI uptake was observed in 48% of microbubble-vessel-wall complexes at 150 kPa (n = 140) and in 33% at 200 kPa (n = 140). Efficiency of PI uptake depended on the local targeted microbubble concentration and increased up to 80% for clusters of 10 to 16 targeted microbubbles. Ultrasound or targeted microbubbles alone did not induce PI uptake. This intravital microscopy study reveals that sonoporation can be visualized and induced in vivo using targeted microbubbles.
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Kooiman K, Kokhuis TJA, van Rooij T, Skachkov I, Nigg A, Bosch JG, van der Steen AFW, van Cappellen WA, de Jong N. DSPC or DPPC as main shell component influences ligand distribution and binding area of lipid-coated targeted microbubbles. EUR J LIPID SCI TECH 2014. [DOI: 10.1002/ejlt.201300434] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Klazina Kooiman
- Department of Biomedical Engineering; Thoraxcenter; Erasmus MC Rotterdam The Netherlands
| | - Tom J. A. Kokhuis
- Department of Biomedical Engineering; Thoraxcenter; Erasmus MC Rotterdam The Netherlands
- Interuniversity Cardiology Institute of the Netherlands; Utrecht The Netherlands
| | - Tom van Rooij
- Department of Biomedical Engineering; Thoraxcenter; Erasmus MC Rotterdam The Netherlands
| | - Ilya Skachkov
- Department of Biomedical Engineering; Thoraxcenter; Erasmus MC Rotterdam The Netherlands
| | - Alex Nigg
- Department of Pathology; Erasmus Optical Imaging Centre; Erasmus MC Rotterdam The Netherlands
| | - Johannes G. Bosch
- Department of Biomedical Engineering; Thoraxcenter; Erasmus MC Rotterdam The Netherlands
| | - Antonius F. W. van der Steen
- Department of Biomedical Engineering; Thoraxcenter; Erasmus MC Rotterdam The Netherlands
- Imaging Science and Technology, Applied Physics; Technical University Delft; Delft The Netherlands
| | | | - Nico de Jong
- Department of Biomedical Engineering; Thoraxcenter; Erasmus MC Rotterdam The Netherlands
- Interuniversity Cardiology Institute of the Netherlands; Utrecht The Netherlands
- Laboratory of Acoustical Wavefield Imaging; Faculty of Applied Sciences; Technical University Delft; Delft The Netherlands
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12
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Unger E, Porter T, Lindner J, Grayburn P. Cardiovascular drug delivery with ultrasound and microbubbles. Adv Drug Deliv Rev 2014; 72:110-26. [PMID: 24524934 DOI: 10.1016/j.addr.2014.01.012] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Revised: 01/23/2014] [Accepted: 01/29/2014] [Indexed: 01/14/2023]
Abstract
Microbubbles lower the threshold for cavitation of ultrasound and have multiple potential therapeutic applications in the cardiovascular system. One of the first therapeutic applications to enter into clinical trials has been microbubble-enhanced sonothrombolysis. Trials were conducted in acute ischemic stroke and clinical trials are currently underway for sonothrombolysis in treatment of acute myocardial infarction. Microbubbles can be targeted to epitopes expressed on endothelial cells and thrombi by incorporating targeting ligands onto the surface of the microbubbles. Targeted microbubbles have applications as molecular imaging contrast agents and also for drug and gene delivery. A number of groups have shown that ultrasound with microbubbles can be used for gene delivery yielding robust gene expression in the target tissue. Work has progressed to primate studies showing delivery of therapeutic genes to generate islet cells in the pancreas to potentially cure diabetes. Microbubbles also hold potential as oxygen therapeutics and have shown promising results as a neuroprotectant in an ischemic stroke model. Regulatory considerations impact the successful clinical development of therapeutic applications of microbubbles with ultrasound. This paper briefly reviews the field and suggests avenues for further development.
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Wildgruber M, Swirski FK, Zernecke A. Molecular imaging of inflammation in atherosclerosis. Am J Cancer Res 2013; 3:865-84. [PMID: 24312156 PMCID: PMC3841337 DOI: 10.7150/thno.5771] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 04/29/2013] [Indexed: 01/13/2023] Open
Abstract
Acute rupture of vulnerable plaques frequently leads to myocardial infarction and stroke. Within the last decades, several cellular and molecular players have been identified that promote atherosclerotic lesion formation, maturation and plaque rupture. It is now widely recognized that inflammation of the vessel wall and distinct leukocyte subsets are involved throughout all phases of atherosclerotic lesion development. The mechanisms that render a stable plaque unstable and prone to rupture, however, remain unknown and the identification of the vulnerable plaque remains a major challenge in cardiovascular medicine. Imaging technologies used in the clinic offer minimal information about the underlying biology and potential risk for rupture. New imaging technologies are therefore being developed, and in the preclinical setting have enabled new and dynamic insights into the vessel wall for a better understanding of this complex disease. Molecular imaging has the potential to track biological processes, such as the activity of cellular and molecular biomarkers in vivo and over time. Similarly, novel imaging technologies specifically detect effects of therapies that aim to stabilize vulnerable plaques and silence vascular inflammation. Here we will review the potential of established and new molecular imaging technologies in the setting of atherosclerosis, and discuss the cumbersome steps required for translating molecular imaging approaches into the clinic.
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Wu Z, Curaj A, Fokong S, Liehn EA, Weber C, Lammers T, Kiessling F, Zandvoort van M. Rhodamine-Loaded Intercellular Adhesion Molecule–1-targeted Microbubbles for Dual-Modality Imaging Under Controlled Shear Stresses. Circ Cardiovasc Imaging 2013; 6:974-81. [DOI: 10.1161/circimaging.113.000805] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Background—
The ability to image incipient atherosclerosis is based on the early events taking place at the endothelial level. We hypothesized that the expression of intercellular adhesion molecule-1 even in vessels with high flow rates can be imaged at the molecular level using 2 complementary imaging techniques: 2-photon laser scanning microscopy and contrast-enhanced ultrasound.
Methods and Results—
Using 2-photon laser scanning microscopy and contrast-enhanced ultrasound, intercellular adhesion molecule-1–targeted and rhodamine-loaded microbubbles were shown to be specifically bound to tumor necrosis factor-α–stimulated human umbilical vein endothelial cells and murine carotid arteries (44 wild-type mice) at shear stresses ranging from 1.25 to 120 dyn/cm
2
. Intercellular adhesion molecule-1–targeted and rhodamine-loaded microbubbles bound 8× more efficient (
P
=0.016) to stimulated human umbilical vein endothelial cells than to unstimulated cells and 14× more than nontargeted microbubbles (
P
=0.016). In excised carotids, binding efficiency did not decrease significantly when increasing the flow rate from 0.25 to 0.6 mL/min. Higher flow rates (0.8 and 1 mL/min) showed significantly reduced microbubbles retention, by 38% (
P
=0.03) and 55% (
P
=0.03), respectively. Ex vivo results were translatable in vivo, confirming that intercellular adhesion molecule-1–targeted and rhodamine-loaded microbubbles are able to bind specifically to the inflamed carotid artery endothelia under physiological flow conditions and to be noninvasively detected using contrast-enhanced ultrasound.
Conclusions—
Our data provide groundwork for the implementation of molecular ultrasound imaging in vessels with high shear stress and flow rates, as well as for the future development of image-guided therapeutic interventions, and multiphoton microscopy as the appropriate method of validation.
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Affiliation(s)
- Zhuojun Wu
- From the Department of Experimental Molecular Imaging (Z.W., A.C., S.F., T.L., F.K.), Institute for Molecular Cardiovascular Research (Z.W., A.C., E.A.L., M.v.Z.), University Clinic, RWTH-Aachen University, Aachen, Germany; Department of Targeted Therapeutics, University of Twente, Enschede, The Netherlands (T.L.); Department of Genetics and Cell Biology, Section Molecular Cell Biology, School for Cardiovascular Diseases CARIM, Maastricht University, Maastricht, The Netherlands (M.v.Z.); and
| | - Adelina Curaj
- From the Department of Experimental Molecular Imaging (Z.W., A.C., S.F., T.L., F.K.), Institute for Molecular Cardiovascular Research (Z.W., A.C., E.A.L., M.v.Z.), University Clinic, RWTH-Aachen University, Aachen, Germany; Department of Targeted Therapeutics, University of Twente, Enschede, The Netherlands (T.L.); Department of Genetics and Cell Biology, Section Molecular Cell Biology, School for Cardiovascular Diseases CARIM, Maastricht University, Maastricht, The Netherlands (M.v.Z.); and
| | - Stanley Fokong
- From the Department of Experimental Molecular Imaging (Z.W., A.C., S.F., T.L., F.K.), Institute for Molecular Cardiovascular Research (Z.W., A.C., E.A.L., M.v.Z.), University Clinic, RWTH-Aachen University, Aachen, Germany; Department of Targeted Therapeutics, University of Twente, Enschede, The Netherlands (T.L.); Department of Genetics and Cell Biology, Section Molecular Cell Biology, School for Cardiovascular Diseases CARIM, Maastricht University, Maastricht, The Netherlands (M.v.Z.); and
| | - Elisa A. Liehn
- From the Department of Experimental Molecular Imaging (Z.W., A.C., S.F., T.L., F.K.), Institute for Molecular Cardiovascular Research (Z.W., A.C., E.A.L., M.v.Z.), University Clinic, RWTH-Aachen University, Aachen, Germany; Department of Targeted Therapeutics, University of Twente, Enschede, The Netherlands (T.L.); Department of Genetics and Cell Biology, Section Molecular Cell Biology, School for Cardiovascular Diseases CARIM, Maastricht University, Maastricht, The Netherlands (M.v.Z.); and
| | - Christian Weber
- From the Department of Experimental Molecular Imaging (Z.W., A.C., S.F., T.L., F.K.), Institute for Molecular Cardiovascular Research (Z.W., A.C., E.A.L., M.v.Z.), University Clinic, RWTH-Aachen University, Aachen, Germany; Department of Targeted Therapeutics, University of Twente, Enschede, The Netherlands (T.L.); Department of Genetics and Cell Biology, Section Molecular Cell Biology, School for Cardiovascular Diseases CARIM, Maastricht University, Maastricht, The Netherlands (M.v.Z.); and
| | - Twan Lammers
- From the Department of Experimental Molecular Imaging (Z.W., A.C., S.F., T.L., F.K.), Institute for Molecular Cardiovascular Research (Z.W., A.C., E.A.L., M.v.Z.), University Clinic, RWTH-Aachen University, Aachen, Germany; Department of Targeted Therapeutics, University of Twente, Enschede, The Netherlands (T.L.); Department of Genetics and Cell Biology, Section Molecular Cell Biology, School for Cardiovascular Diseases CARIM, Maastricht University, Maastricht, The Netherlands (M.v.Z.); and
| | - Fabian Kiessling
- From the Department of Experimental Molecular Imaging (Z.W., A.C., S.F., T.L., F.K.), Institute for Molecular Cardiovascular Research (Z.W., A.C., E.A.L., M.v.Z.), University Clinic, RWTH-Aachen University, Aachen, Germany; Department of Targeted Therapeutics, University of Twente, Enschede, The Netherlands (T.L.); Department of Genetics and Cell Biology, Section Molecular Cell Biology, School for Cardiovascular Diseases CARIM, Maastricht University, Maastricht, The Netherlands (M.v.Z.); and
| | - Marc Zandvoort van
- From the Department of Experimental Molecular Imaging (Z.W., A.C., S.F., T.L., F.K.), Institute for Molecular Cardiovascular Research (Z.W., A.C., E.A.L., M.v.Z.), University Clinic, RWTH-Aachen University, Aachen, Germany; Department of Targeted Therapeutics, University of Twente, Enschede, The Netherlands (T.L.); Department of Genetics and Cell Biology, Section Molecular Cell Biology, School for Cardiovascular Diseases CARIM, Maastricht University, Maastricht, The Netherlands (M.v.Z.); and
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Foygel K, Wang H, Machtaler S, Lutz AM, Chen R, Pysz M, Lowe AW, Tian L, Carrigan T, Brentnall TA, Willmann JK. Detection of pancreatic ductal adenocarcinoma in mice by ultrasound imaging of thymocyte differentiation antigen 1. Gastroenterology 2013; 145:885-894.e3. [PMID: 23791701 PMCID: PMC3783557 DOI: 10.1053/j.gastro.2013.06.011] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2012] [Revised: 05/14/2013] [Accepted: 06/14/2013] [Indexed: 12/23/2022]
Abstract
BACKGROUND & AIMS Early detection of pancreatic ductal adenocarcinoma (PDAC) allows for surgical resection and increases patient survival times. Imaging agents that bind and amplify the signal of neovascular proteins in neoplasms can be detected by ultrasound, enabling accurate detection of small lesions. We searched for new markers of neovasculature in PDAC and assessed their potential for tumor detection by ultrasound molecular imaging. METHODS Thymocyte differentiation antigen 1 (Thy1) was identified as a specific biomarker of PDAC neovasculature by proteomic analysis. Up-regulation in PDAC was validated by immunohistochemical analysis of pancreatic tissue samples from 28 healthy individuals, 15 with primary chronic pancreatitis tissues, and 196 with PDAC. Binding of Thy1-targeted contrast microbubbles was assessed in cultured cells, in mice with orthotopic PDAC xenograft tumors expressing human Thy1 on the neovasculature, and on the neovasculature of a genetic mouse model of PDAC. RESULTS Based on immunohistochemical analyses, levels of Thy1 were significantly higher in the vascular of human PDAC than chronic pancreatitis (P = .007) or normal tissue samples (P < .0001). In mice, ultrasound imaging accurately detected human Thy1-positive PDAC xenografts, as well as PDACs that express endogenous Thy1 in genetic mouse models of PDAC. CONCLUSIONS We have identified and validated Thy1 as a marker of PDAC that can be detected by ultrasound molecular imaging in mice. The development of a specific imaging agent and identification of Thy1 as a new biomarker could aid in the diagnosis of this cancer and management of patients.
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Affiliation(s)
- Kira Foygel
- Department of Radiology, Molecular Imaging Program at Stanford (MIPS); Stanford University, Stanford, California, USA
| | - Huaijun Wang
- Department of Radiology, Molecular Imaging Program at Stanford (MIPS); Stanford University, Stanford, California, USA
| | - Steven Machtaler
- Department of Radiology, Molecular Imaging Program at Stanford (MIPS); Stanford University, Stanford, California, USA
| | - Amelie M. Lutz
- Department of Radiology, Molecular Imaging Program at Stanford (MIPS); Stanford University, Stanford, California, USA
| | - Ru Chen
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Marybeth Pysz
- Department of Radiology, Molecular Imaging Program at Stanford (MIPS); Stanford University, Stanford, California, USA
| | - Anson W. Lowe
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Lu Tian
- Department of Health, Research & Policy, Stanford University, Stanford, California, USA
| | - Tricia Carrigan
- Translational Diagnostics, Ventana Medical Systems, INC, Tucson, Arizona, USA
| | | | - Jürgen K. Willmann
- Department of Radiology, Molecular Imaging Program at Stanford (MIPS); Stanford University, Stanford, California, USA
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Molecular Targeting of Imaging and Drug Delivery Probes in Atherosclerosis. ANNUAL REPORTS IN MEDICINAL CHEMISTRY 2013. [DOI: 10.1016/b978-0-12-417150-3.00008-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register]
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17
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Molecular Imaging of Selectins in Endothelial Activation. CURRENT CARDIOVASCULAR IMAGING REPORTS 2012. [DOI: 10.1007/s12410-012-9143-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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18
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Silindir M, Erdoğan S, Özer AY, Maia S. Liposomes and their applications in molecular imaging. J Drug Target 2012; 20:401-15. [DOI: 10.3109/1061186x.2012.685477] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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19
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Nanobody-coupled microbubbles as novel molecular tracer. J Control Release 2011; 158:346-53. [PMID: 22197777 DOI: 10.1016/j.jconrel.2011.12.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 12/05/2011] [Accepted: 12/07/2011] [Indexed: 11/21/2022]
Abstract
Camelid-derived single-domain antibody-fragments (~15kDa), called nanobodies, are a new class of molecular tracers that are routinely identified with nanomolar affinity for their target and that are easily tailored for molecular imaging and drug delivery applications. We hypothesized that they are well-suited for the design of targeted microbubbles (μBs) and aimed to develop and characterize eGFP- and VCAM-1-targeted μBs. Anti-eGFP (cAbGFP4) and anti-VCAM-1 (cAbVCAM1-5) nanobodies were site-specifically biotinylated in bacteria. This metabolic biotinylation method yielded functional nanobodies with one biotin located at a distant site of the antigen-binding region of the molecule. The biotinylated nanobodies were coupled to biotinylated lipid μBs via streptavidin-biotin bridging. The ability of μB-cAbGFP4 to recognize eGFP was tested as proof-of-principle by fluorescent microscopy and confirmed the specific binding of eGFP to μB-cAbGFP4. Dynamic flow chamber studies demonstrated the ability of μB-cAbVCAM1-5 to bind VCAM-1 in fast flow (up to 5 dynes/cm(2)). In vivo targeting studies were performed in MC38 tumor-bearing mice (n=4). μB-cAbVCAM1-5 or control μB-cAbGFP4 were injected intravenously and imaged using a contrast-specific ultrasound imaging mode. The echo intensity in the tumor was measured 10min post-injection. μB-cAbVCAM1-5 showed an enhanced signal compared to control μBs (p<0.05). Using metabolic and site-specific biotinylation of nanobodies, a method to develop nanobody-coupled μBs was described. The application of VCAM-1-targeted μBs as novel molecular ultrasound contrast agent was demonstrated both in vitro and in vivo.
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20
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Wang W, Liu GJ, Xie XY, Xu ZF, Chen LD, Huang GL, Zhou LY, Lu MD. Development and evaluation of lipid microbubbles targeted to alpha(v)beta(3)-integrin via biotin–avidin bridge. J Microencapsul 2011; 29:177-84. [DOI: 10.3109/02652048.2011.638993] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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21
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Caplice NM, Martin K. Contrast-enhanced ultrasound and the enigma of plaque neovascularization. JACC Cardiovasc Imaging 2011; 3:1273-5. [PMID: 21163456 DOI: 10.1016/j.jcmg.2010.11.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2010] [Accepted: 11/04/2010] [Indexed: 11/27/2022]
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22
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Zagorchev L, Mulligan-Kehoe MJ. Advances in imaging angiogenesis and inflammation in atherosclerosis. Thromb Haemost 2011; 105:820-7. [PMID: 21331441 DOI: 10.1160/th10-08-0562] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Accepted: 01/28/2011] [Indexed: 01/07/2023]
Abstract
Advances in imaging technology have provided powerful tools for dissecting the angiogenic and inflammatory aspects of atherosclerosis. Improved technology along with multi-modal approaches has expanded the utilisation of imaging. Recent advances provide the ability to better define structure and development of angiogenic vessels, identify relationships between inflammatory mediators and the vessel wall, validate biological effects of anti-inflammatory and anti-angiogenic drugs, delivery and/or targeting specific molecules to inflammatory regions of atherosclerotic plaques.
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Affiliation(s)
- L Zagorchev
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire, USA
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23
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Kerwin WS. Noninvasive Imaging of Plaque Inflammation. JACC Cardiovasc Imaging 2010; 3:1136-8. [DOI: 10.1016/j.jcmg.2010.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Accepted: 09/03/2010] [Indexed: 11/24/2022]
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24
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Marwick TH, Narula J. Contrast echocardiography: over-achievement in research, under-achievement in practice? JACC Cardiovasc Imaging 2010; 3:224-5. [PMID: 20159652 DOI: 10.1016/j.jcmg.2009.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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