1
|
Fletcher SMP, Zhang Y, Chisholm A, Martinez S, McDannold N. The impact of pulse repetition frequency on microbubble activity and drug delivery during focused ultrasound-mediated blood-brain barrier opening. Phys Med Biol 2024; 69:145002. [PMID: 38914104 DOI: 10.1088/1361-6560/ad5b47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/24/2024] [Indexed: 06/26/2024]
Abstract
Objective.Pulsed focused ultrasound (FUS) can deliver therapeutics to the brain by using intravenous microbubbles (MBs) to open the blood-brain barrier (BBB). MB emissions indicate treatment outcomes, like BBB opening (harmonics) and damage (broadband). Typically, a pulse repetition frequency (PRF) of 1 Hz is used, but the effect of PRF on MBs is not fully understood. We investigated the effect of PRF on MB activity and tracer delivery.Approach.The effect of PRF (0.125, 0.25, 0.5, 1, and 2 Hz) on MB activity was monitored through harmonic and wideband emissions during FUS sonications of the rat brain at 274.3 kHz. BBB opening was quantified through fluorescence imaging to estimate the concentration of Trypan Blue (TB) dye following a 75-pulse FUS exposure for PRFs of 1 and 0.25 Hz.Main results.At a fixed acoustic pressure, the percentage change in maximum harmonic amplitude compared to the control (PRF = 1 Hz) decreased with increasing PRF, with a median change of 73.8% at 0.125 Hz and -38.3% at 2 Hz. There was no difference in the pressure threshold for broadband emissions between PRFs of 0.25 and 1 Hz. PRF = 0.25 Hz, led to a 68.2% increase in the mean concentration of TB measured after FUS, with a 53.9% increase in the mean harmonic sum, compared with PRF = 1 Hz. Harmonic emissions-based control at PRF = 0.25 Hz yielded similar TB delivery, with less damage at histology, compared with 1 Hz.Significance.For a fixed number of FUS pulses, reducing the PRF was shown to increase the magnitude of harmonic emissions and TB delivery, but not the threshold for broadband emissions. While further research is necessary to understand the mechanisms involved, these results may be useful to improve clinical safety margins and sensitivity to detecting small harmonic signals from cavitating MBs.
Collapse
Affiliation(s)
- Stecia-Marie P Fletcher
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, United States of America
- Department of Radiology, Harvard Medical School, Boston, MA, United States of America
| | - Yongzhi Zhang
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, United States of America
- Department of Radiology, Harvard Medical School, Boston, MA, United States of America
| | - Amanda Chisholm
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Sofia Martinez
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, United States of America
| | - Nathan McDannold
- Department of Radiology, Brigham and Women's Hospital, Boston, MA, United States of America
- Department of Radiology, Harvard Medical School, Boston, MA, United States of America
| |
Collapse
|
2
|
Chen KT, Huang CY, Pai PC, Yang WC, Tseng CK, Tsai HC, Li JC, Chuang CC, Hsu PW, Lee CC, Toh CH, Liu HL, Wei KC. Focused ultrasound combined with radiotherapy for malignant brain tumor: a preclinical and clinical study. J Neurooncol 2023; 165:535-545. [PMID: 38060066 DOI: 10.1007/s11060-023-04517-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/17/2023] [Indexed: 12/08/2023]
Abstract
INTRODUCTION Blood-brain barrier (BBB) remains to be the major obstacle to conquer in treating patients with malignant brain tumors. Radiation therapy (RT), despite being the mainstay adjuvant modality regardless of BBB, the effect of radiation induced cell death is hindered by the hypoxic microenvironment. Focused ultrasound (FUS) combined with systemic microbubbles has been shown not only to open BBB but also potentially increased regional perfusion. However, no clinical study has investigated the combination of RT with FUS-BBB opening (RT-FUS). METHODS We aimed to provide preclinical evidence of RT-FUS combination in GBM animal model, and to report an interim analysis of an ongoing single arm, prospective, pilot study (NCT01628406) of combining RT-FUS for recurrent malignant high grade glioma patients, of whom re-RT was considered for disease control. In both preclinical and clinical studies, FUS-BBB opening was conducted within 2 h before RT. Treatment responses were evaluated by objective response rate (ORR) using magnetic resonance imaging, progression free survival, and overall survival, and adverse events (AE) in clinical study. Survival analysis was performed in preclinical study and descriptive analysis was performed in clinical study. RESULTS In mouse GBM model, the survival analysis showed RT-FUS (2 Gy) group was significantly longer than RT (2 Gy) group and control, but not RT (5 Gy) group. In the pilot clinical trial, an interim analysis of six recurrent malignant high grade glioma patients underwent a total of 24 RT-FUS treatments was presented. Three patients had rapid disease progression at a mean of 33 days after RT-FUS, while another three patients had at least stable disease (mean 323 days) after RT-FUS with or without salvage chemotherapy or target therapy. One patient had partial response after RT-FUS, making the ORR of 16.7%. There was no FUS-related AEs, but one (16.7%) re-RT-related grade three radiation necrosis. CONCLUSION Reirradiation is becoming an option after disease recurrence for both primary and secondary malignant brain tumors since systemic therapy significantly prolongs survival in cancer patients. The mechanism behind the synergistic effect of RT-FUS in preclinical model needs further study. The clinical evidence from the interim analysis of an ongoing clinical trial (NCT01628406) showed a combination of RT-FUS was safe (no FUS-related adverse effect). A comprehensive analysis of radiation dosimetry and FUS energy distribution is expected after completing the final recruitment.
Collapse
Affiliation(s)
- Ko-Ting Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Neuroscience Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chiung-Yin Huang
- Neuroscience Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Department of Neurosurgery, Gung Medical Foundation, New Taipei Municipal Tucheng Hospital, Chang Gung Medical Foundation, New Taipei, Taiwan
| | - Ping-Ching Pai
- Department of Radiation Oncology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Wen-Chi Yang
- Department of Radiation Oncology, National Taiwan University Cancer Center, Taipei, Taiwan
- Gratitude Institute of Oncology, National Taiwan University College of Medicine, National Taiwan University, Taipei, Taiwan
- Division of Radiation Oncology, Department of Oncology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chen-Kan Tseng
- Department of Radiation Oncology, Chang Gung Memorial Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Hong-Chieh Tsai
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jui-Chin Li
- Neuroscience Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
- Department of Neurosurgery, Gung Medical Foundation, New Taipei Municipal Tucheng Hospital, Chang Gung Medical Foundation, New Taipei, Taiwan
| | - Chi-Cheng Chuang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Peng-Wei Hsu
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Cheng-Chi Lee
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Cheng-Hong Toh
- Department of Diagnostic Radiology and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Hao-Li Liu
- Department of Electrical Engineering, National Taiwan University, Taipei, Taiwan.
| | - Kuo-Chen Wei
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.
- Neuroscience Research Center, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.
- School of Medicine, Chang Gung University, Taoyuan, Taiwan.
- Department of Neurosurgery, Gung Medical Foundation, New Taipei Municipal Tucheng Hospital, Chang Gung Medical Foundation, New Taipei, Taiwan.
| |
Collapse
|
3
|
Navarro-Becerra JA, Borden MA. Targeted Microbubbles for Drug, Gene, and Cell Delivery in Therapy and Immunotherapy. Pharmaceutics 2023; 15:1625. [PMID: 37376072 DOI: 10.3390/pharmaceutics15061625] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/18/2023] [Accepted: 05/26/2023] [Indexed: 06/29/2023] Open
Abstract
Microbubbles are 1-10 μm diameter gas-filled acoustically-active particles, typically stabilized by a phospholipid monolayer shell. Microbubbles can be engineered through bioconjugation of a ligand, drug and/or cell. Since their inception a few decades ago, several targeted microbubble (tMB) formulations have been developed as ultrasound imaging probes and ultrasound-responsive carriers to promote the local delivery and uptake of a wide variety of drugs, genes, and cells in different therapeutic applications. The aim of this review is to summarize the state-of-the-art of current tMB formulations and their ultrasound-targeted delivery applications. We provide an overview of different carriers used to increase drug loading capacity and different targeting strategies that can be used to enhance local delivery, potentiate therapeutic efficacy, and minimize side effects. Additionally, future directions are proposed to improve the tMB performance in diagnostic and therapeutic applications.
Collapse
Affiliation(s)
| | - Mark A Borden
- Mechanical Engineering Department, University of Colorado Boulder, Boulder, CO 80309, USA
- Biomedical Engineering Program, University of Colorado Boulder, Boulder, CO 80309, USA
| |
Collapse
|
4
|
Past, present and future of Focused Ultrasound as an adjunct or complement to DIPG/DMG therapy: A consensus of the 2021 FUSF DIPG meeting. Neoplasia 2023; 37:100876. [PMID: 36709715 PMCID: PMC9900434 DOI: 10.1016/j.neo.2023.100876] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/12/2022] [Accepted: 01/09/2023] [Indexed: 01/29/2023]
Abstract
Diffuse Intrinsic Pontine Glioma (DIPG), now known as Diffuse Midline Glioma (DMG) is a devastating pediatric brain tumor with limited treatment options and a very poor prognosis. Despite more than 250 clinical trials aimed to treat children diagnosed with DMG, no curative therapies currently exist for this patient population. A major obstacle has been the intact blood brain barrier (BBB) which prevents most therapeutics from crossing into the tumor bed. Focused Ultrasound (FUS) is an emerging, noninvasive medical technology which has been shown in both preclinical and clinical research to disrupt the blood brain barrier safely and temporarily. FUS blood brain barrier opening has been studied in combination with chemotherapies in preclinical DMG models, and this technology is now being investigated in clinical trials for the treatment of pediatric brain tumors. Focused ultrasound has additional mechanisms of action, including sonodynamic therapy and radiation sensitization, that hold promise as future DMG therapies as well. This paper, largely based off the proceedings from a workshop held by the Focused Ultrasound Foundation in October of 2021, summarizes the current state of the field of focused ultrasound for DIPG/DMG, including preclinical, technical, and clinical summaries in addition to recommended next steps for continued advancement of the game changing technology of Focused Ultrasound.
Collapse
|
5
|
Gorick CM, Breza VR, Nowak KM, Cheng VWT, Fisher DG, Debski AC, Hoch MR, Demir ZEF, Tran NM, Schwartz MR, Sheybani ND, Price RJ. Applications of focused ultrasound-mediated blood-brain barrier opening. Adv Drug Deliv Rev 2022; 191:114583. [PMID: 36272635 PMCID: PMC9712235 DOI: 10.1016/j.addr.2022.114583] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 09/01/2022] [Accepted: 10/14/2022] [Indexed: 01/25/2023]
Abstract
The blood brain barrier (BBB) plays a critically important role in the regulation of central nervous system (CNS) homeostasis, but also represents a major limitation to treatments of brain pathologies. In recent years, focused ultrasound (FUS) in conjunction with gas-filled microbubble contrast agents has emerged as a powerful tool for transiently and non-invasively disrupting the BBB in a targeted and image-guided manner, allowing for localized delivery of drugs, genes, or other therapeutic agents. Beyond the delivery of known therapeutics, FUS-mediated BBB opening also demonstrates the potential for use in neuromodulation and the stimulation of a range of cell- and tissue-level physiological responses that may prove beneficial in disease contexts. Clinical trials investigating the safety and efficacy of FUS-mediated BBB opening are well underway, and offer promising non-surgical approaches to treatment of devastating pathologies. This article reviews a range of pre-clinical and clinical studies demonstrating the tremendous potential of FUS to fundamentally change the paradigm of treatment for CNS diseases.
Collapse
Affiliation(s)
- Catherine M Gorick
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Victoria R Breza
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Katherine M Nowak
- Department of Microbiology, Immunology, and Cancer Biology, University of Virginia, Charlottesville, VA 22908, USA
| | - Vinton W T Cheng
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA; Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Delaney G Fisher
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Anna C Debski
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Matthew R Hoch
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Zehra E F Demir
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Nghi M Tran
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Mark R Schwartz
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Natasha D Sheybani
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA
| | - Richard J Price
- Department of Biomedical Engineering, University of Virginia, Charlottesville, VA 22908, USA.
| |
Collapse
|
6
|
Kim C, Lim M, Woodworth GF, Arvanitis CD. The roles of thermal and mechanical stress in focused ultrasound-mediated immunomodulation and immunotherapy for central nervous system tumors. J Neurooncol 2022; 157:221-236. [PMID: 35235137 PMCID: PMC9119565 DOI: 10.1007/s11060-022-03973-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 02/16/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND Focused ultrasound (FUS) is an emerging technology, offering the capability of tuning and prescribing thermal and mechanical treatments within the brain. While early works in utilizing this technology have mainly focused on maximizing the delivery of therapeutics across the blood-brain barrier (BBB), the potential therapeutic impact of FUS-induced controlled thermal and mechanical stress to modulate anti-tumor immunity is becoming increasingly recognized. OBJECTIVE To better understand the roles of FUS-mediated thermal and mechanical stress in promoting anti-tumor immunity in central nervous system tumors, we performed a comprehensive literature review on focused ultrasound-mediated immunomodulation and immunotherapy in brain tumors. METHODS First, we summarize the current clinical experience with immunotherapy. Then, we discuss the unique and distinct immunomodulatory effects of the FUS-mediated thermal and mechanical stress in the brain tumor-immune microenvironment. Finally, we highlight recent findings that indicate that its combination with immune adjuvants can promote robust responses in brain tumors. RESULTS Along with the rapid advancement of FUS technologies into recent clinical trials, this technology through mild-hyperthermia, thermal ablation, mechanical perturbation mediated by microbubbles, and histotripsy each inducing distinct vascular and immunological effects, is offering the unique opportunity to improve immunotherapeutic trafficking and convert immunologically "cold" tumors into immunologically "hot" ones that are prone to generate prolonged anti-tumor immune responses. CONCLUSIONS While FUS technology is clearly accelerating concepts for new immunotherapeutic combinations, additional parallel efforts to detail rational therapeutic strategies supported by rigorous preclinical studies are still in need to leverage potential synergies of this technology with immune adjuvants. This work will accelerate the discovery and clinical implementation of new effective FUS immunotherapeutic combinations for brain tumor patients.
Collapse
Affiliation(s)
- Chulyong Kim
- School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Michael Lim
- Department of Neurosurgery, School of Medicine (Oncology), of Neurology, of Otolaryngology, and of Radiation Oncology, Stanford University, Paulo Alto, CA, USA
| | - Graeme F Woodworth
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland, Baltimore, MD, USA
| | - Costas D Arvanitis
- School of Mechanical Engineering, Georgia Institute of Technology, Atlanta, GA, USA.
- Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA.
| |
Collapse
|
7
|
Najem H, Khasraw M, Heimberger AB. Immune Microenvironment Landscape in CNS Tumors and Role in Responses to Immunotherapy. Cells 2021; 10:2032. [PMID: 34440802 PMCID: PMC8393758 DOI: 10.3390/cells10082032] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 07/30/2021] [Accepted: 08/03/2021] [Indexed: 12/14/2022] Open
Abstract
Despite the important evolution of immunotherapeutic agents, brain tumors remain, in general, refractory to immune therapeutics. Recent discoveries have revealed that the glioma microenvironment includes a wide variety of immune cells in various states that play an important role in the process of tumorigenesis. Anti-tumor immune activity may be occurring or induced in immunogenic hot spots or at the invasive edge of central nervous system (CNS) tumors. Understanding the complex heterogeneity of the immune microenvironment in gliomas will likely be the key to unlocking the full potential of immunotherapeutic strategies. An essential consideration will be the induction of immunological effector responses in the setting of the numerous aspects of immunosuppression and evasion. As such, immune therapeutic combinations are a fundamental objective for clinical studies in gliomas. Through immune profiling conducted on immune competent murine models of glioma and ex vivo human glioma tissue, we will discuss how the frequency, distribution of immune cells within the microenvironment, and immune modulatory processes, may be therapeutically modulated to lead to clinical benefits.
Collapse
Affiliation(s)
- Hinda Najem
- Department of Neurological Surgery and Northwestern Medicine Malnati Brain Tumor Institute of the Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA;
| | - Mustafa Khasraw
- The Preston Robert Tisch Brain Tumor Center, Duke University, Durham, NC 27710, USA;
| | - Amy B. Heimberger
- Department of Neurological Surgery and Northwestern Medicine Malnati Brain Tumor Institute of the Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA;
| |
Collapse
|