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Xu H, Liu Z, Du M, Chen Z. Progression in low-intensity ultrasound-induced tumor radiosensitization. Cancer Med 2024; 13:e7332. [PMID: 38967145 PMCID: PMC11224918 DOI: 10.1002/cam4.7332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 07/06/2024] Open
Abstract
BACKGROUND Radiotherapy (RT) is a widely utilized tumor treatment approach, while a significant obstacle in this treatment modality is the radioresistance exhibited by tumor cells. To enhance the effectiveness of RT, scientists have explored radiosensitization approaches, including the use of radiosensitizers and physical stimuli. Nevertheless, several approaches have exhibited disappointing results including adverse effects and limited efficacy. A safer and more effective method of radiosensitization involves low-intensity ultrasound (LIUS), which selectively targets tumor tissue and enhances the efficacy of radiation therapy. METHODS This review summarized the tumor radioresistance reasons and explored LIUS potential radiosensitization mechanisms. Moreover, it covered diverse LIUS application strategies in radiosensitization, including the use of LIUS alone, ultrasound-targeted intravascular microbubble destruction, ultrasound-mediated targeted radiosensitizers delivery, and sonodynamic therapy. Lastly, the review presented the limitations and prospects of employing LIUS-RT combined therapy in clinical settings, emphasizing the need to connect research findings with practical applications. RESULTS AND CONCLUSION LIUS employs cost-effective equipment to foster tumor radiosensitization, curtail radiation exposure, and elevate the quality of life for patients. This efficacy is attributed to LIUS's ability to utilize thermal, cavitation, and mechanical effects to overcome tumor cell resistance to RT. Multiple experimental analyses have underscored the effectiveness of LIUS in inducing tumor radiosensitization using diverse strategies. While initial studies have shown promising results, conducting more comprehensive clinical trials is crucial to confirm its safety and effectiveness in real-world situations.
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Affiliation(s)
- Haonan Xu
- Key Laboratory of Medical Imaging Precision Theranostics and Radiation Protection, College of Hunan Province, The Affiliated Changsha Central Hospital, Hengyang Medical SchoolUniversity of South ChinaChangshaHunan ProvinceChina
- Institute of Medical Imaging, Hengyang Medical School, University of South ChinaHengyangHunan ProvinceChina
| | - Zichao Liu
- Institute of Medical Imaging, Hengyang Medical School, University of South ChinaHengyangHunan ProvinceChina
- The Seventh Affiliated Hospital, Hunan Veterans Administration Hospital, Hengyang Medical SchoolUniversity of South ChinaChangshaHunan ProvinceChina
| | - Meng Du
- Key Laboratory of Medical Imaging Precision Theranostics and Radiation Protection, College of Hunan Province, The Affiliated Changsha Central Hospital, Hengyang Medical SchoolUniversity of South ChinaChangshaHunan ProvinceChina
- Institute of Medical Imaging, Hengyang Medical School, University of South ChinaHengyangHunan ProvinceChina
| | - Zhiyi Chen
- Key Laboratory of Medical Imaging Precision Theranostics and Radiation Protection, College of Hunan Province, The Affiliated Changsha Central Hospital, Hengyang Medical SchoolUniversity of South ChinaChangshaHunan ProvinceChina
- Institute of Medical Imaging, Hengyang Medical School, University of South ChinaHengyangHunan ProvinceChina
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Moore-Palhares D, Saifuddin M, Dasgupta A, Anzola Pena ML, Prasla S, Ho L, Lu L, Kung J, Karam I, Poon I, Bayley A, McNabb E, Stanisz G, Kolios M, Czarnota GJ. Radiation enhancement using focussed ultrasound-stimulated microbubbles for head and neck cancer: A phase 1 clinical trial. Radiother Oncol 2024; 198:110380. [PMID: 38879128 DOI: 10.1016/j.radonc.2024.110380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/22/2024] [Accepted: 06/05/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND AND PURPOSE Preclinical research demonstrated that the exposure of microbubbles (intravascular gas microspheres) to focussed ultrasound within the targeted tumour upregulates pro-apoptotic pathways and enhances radiation-induced tumour cell death. This study aimed to assess the safety and efficacy of magnetic resonance (MR)-guided focussed ultrasound-stimulated microbubbles (MRgFUS-MB) for head and neck cancers (HN). MATERIALS AND METHODS This prospective phase 1 clinical trial included patients with newly diagnosed or recurrent HN cancer (except nasopharynx malignancies) for whom locoregional radiotherapy with radical- or palliative-intent as deemed appropriate. Patients with contraindications for microbubble administration or contrast-enhanced MR were excluded. MR-coupled focussed ultrasound sonicated intravenously administered microbubbles within the MR-guided target volume. Patients receiving 5-10 and 33-35 radiation fractions were planned for 2 and 3 MRgFUS-MB treatments, respectively. Primary endpoint was toxicity per CTCAEv5.0. Secondary endpoint was tumour response at 3 months per RECIST 1.1 criteria. RESULTS Twelve patients were enrolled between Jun/2020 and Nov/2023, but 1 withdrew consent. Eleven patients were included in safety analysis. Median follow-up was 7 months (range, 0.3-38). Most patients had oropharyngeal cancer (55 %) and received 20-30 Gy/5-10 fractions (63 %). No systemic toxicity or MRgFUS-MB-related adverse events occurred. The most severe acute adverse events were radiation-related grade 3 toxicities in 6 patients (55 %; dermatitis in 3, mucositis in 1, dysphagia in 6). No radiation necrosis or grade 4/5 toxicities were reported. 8 patients were included in the 3-month tumour response assessment: 4 had partial response (50 %), 3 had complete response (37.5 %), and 1 had progressive disease (12.5 %). CONCLUSIONS MRgFUS-MB treatment was safe and associated with high rates of tumour response at 3 months.
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Affiliation(s)
- Daniel Moore-Palhares
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada; Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | | | - Archya Dasgupta
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada; Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | | | - Shopnil Prasla
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Ling Ho
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Canada
| | - Lin Lu
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Canada
| | - Joseph Kung
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Canada
| | - Irene Karam
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Ian Poon
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Andrew Bayley
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Evan McNabb
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Greg Stanisz
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada; Department of Biophysics, University of Toronto, Canada; Department of Neurosurgery, Medical University, Lublin, Poland
| | | | - Gregory J Czarnota
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Canada; Physical Sciences, Sunnybrook Research Institute, Toronto, Canada; Department of Biophysics, University of Toronto, Canada.
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Moore-Palhares D, Dasgupta A, Saifuddin M, Anzola Pena ML, Prasla S, Ho L, Lu L, Kung J, McNabb E, Sannachi L, Vesprini D, Chen H, Karam I, Soliman H, Szumacher E, Chow E, Gandhi S, Trudeau M, Curpen B, Stanisz GJ, Kolios M, Czarnota GJ. Radiation enhancement using focussed ultrasound-stimulated microbubbles for breast cancer: A Phase 1 clinical trial. PLoS Med 2024; 21:e1004408. [PMID: 38758967 PMCID: PMC11146716 DOI: 10.1371/journal.pmed.1004408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 06/03/2024] [Accepted: 04/25/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Preclinical studies have demonstrated that tumour cell death can be enhanced 10- to 40-fold when radiotherapy is combined with focussed ultrasound-stimulated microbubble (FUS-MB) treatment. The acoustic exposure of microbubbles (intravascular gas microspheres) within the target volume causes bubble cavitation, which induces perturbation of tumour vasculature and activates endothelial cell apoptotic pathways responsible for the ablative effect of stereotactic body radiotherapy. Subsequent irradiation of a microbubble-sensitised tumour causes rapid increased tumour death. The study here presents the mature safety and efficacy outcomes of magnetic resonance (MR)-guided FUS-MB (MRgFUS-MB) treatment, a radioenhancement therapy for breast cancer. METHODS AND FINDINGS This prospective, single-center, single-arm Phase 1 clinical trial included patients with stages I-IV breast cancer with in situ tumours for whom breast or chest wall radiotherapy was deemed adequate by a multidisciplinary team (clinicaltrials.gov identifier: NCT04431674). Patients were excluded if they had contraindications for contrast-enhanced MR or microbubble administration. Patients underwent 2 to 3 MRgFUS-MB treatments throughout radiotherapy. An MR-coupled focussed ultrasound device operating at 800 kHz and 570 kPa peak negative pressure was used to sonicate intravenously administrated microbubbles within the MR-guided target volume. The primary outcome was acute toxicity per Common Terminology Criteria for Adverse Events (CTCAE) v5.0. Secondary outcomes were tumour response at 3 months and local control (LC). A total of 21 female patients presenting with 23 primary breast tumours were enrolled and allocated to intervention between August/2020 and November/2022. Three patients subsequently withdrew consent and, therefore, 18 patients with 20 tumours were included in the safety and LC analyses. Two patients died due to progressive metastatic disease before 3 months following treatment completion and were excluded from the tumour response analysis. The prescribed radiation doses were 20 Gy/5 fractions (40%, n = 8/20), 30 to 35 Gy/5 fractions (35%, n = 7/20), 30 to 40 Gy/10 fractions (15%, n = 3/20), and 66 Gy/33 fractions (10%, n = 2/20). The median follow-up was 9 months (range, 0.3 to 29). Radiation dermatitis was the most common acute toxicity (Grade 1 in 16/20, Grade 2 in 1/20, and Grade 3 in 2/20). One patient developed grade 1 allergic reaction possibly related to microbubbles administration. At 3 months, 18 tumours were evaluated for response: 9 exhibited complete response (50%, n = 9/18), 6 partial response (33%, n = 6/18), 2 stable disease (11%, n = 2/18), and 1 progressive disease (6%, n = 1/18). Further follow-up of responses indicated that the 6-, 12-, and 24-month LC rates were 94% (95% confidence interval [CI] [84%, 100%]), 88% (95% CI [75%, 100%]), and 76% (95% CI [54%, 100%]), respectively. The study's limitations include variable tumour sizes and dose fractionation regimens and the anticipated small sample size typical for a Phase 1 clinical trial. CONCLUSIONS MRgFUS-MB is an innovative radioenhancement therapy associated with a safe profile, potentially promising responses, and durable LC. These results warrant validation in Phase 2 clinical trials. TRIAL REGISTRATION clinicaltrials.gov, identifier NCT04431674.
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Affiliation(s)
- Daniel Moore-Palhares
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Archya Dasgupta
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | | | | | - Shopnil Prasla
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | - Ling Ho
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Lin Lu
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Joseph Kung
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Evan McNabb
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
| | | | - Danny Vesprini
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hanbo Chen
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Irene Karam
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Hany Soliman
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Ewa Szumacher
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Edward Chow
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Sonal Gandhi
- Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Maureen Trudeau
- Division of Medical Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Belinda Curpen
- Department of Medical Imaging, Sunnybrook Health Sciences, Toronto, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Greg J. Stanisz
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
- Department of Biophysics, University of Toronto, Toronto, Canada
- Department of Neurosurgery, Medical University, Lublin, Poland
| | | | - Gregory J. Czarnota
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, Canada
- Physical Sciences, Sunnybrook Research Institute, Toronto, Canada
- Department of Biophysics, University of Toronto, Toronto, Canada
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Nene LC, Abrahamse H. Design consideration of phthalocyanines as sensitizers for enhanced sono-photodynamic combinatorial therapy of cancer. Acta Pharm Sin B 2024; 14:1077-1097. [PMID: 38486981 PMCID: PMC10935510 DOI: 10.1016/j.apsb.2023.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/08/2023] [Accepted: 11/25/2023] [Indexed: 03/17/2024] Open
Abstract
Cancer remains one of the diseases with the highest incidence and mortality globally. Conventional treatment modalities have demonstrated threatening drawbacks including invasiveness, non-controllability, and development of resistance for some, including chemotherapy, radiation, and surgery. Sono-photodynamic combinatorial therapy (SPDT) has been developed as an alternative treatment modality which offers a non-invasive and controllable therapeutic approach. SPDT combines the mechanism of action of sonodynamic therapy (SDT), which uses ultrasound, and photodynamic therapy (PDT), which uses light, to activate a sensitizer and initiate cancer eradication. The use of phthalocyanines (Pcs) as sensitizers for SPDT is gaining interest owing to their ability to induce intracellular oxidative stress and initiate toxicity under SDT and PDT. This review discusses some of the structural prerequisites of Pcs which may influence their overall SPDT activities in cancer therapy.
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Affiliation(s)
- Lindokuhle Cindy Nene
- Laser Research Centre, Faculty of Health Sciences, University of Johannesburg, Doornfontein 2028, South Africa
| | - Heidi Abrahamse
- Laser Research Centre, Faculty of Health Sciences, University of Johannesburg, Doornfontein 2028, South Africa
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Villalobos A, Lee J, Westergaard SA, Kokabi N. Impact of Hypoxia on Radiation-Based Therapies for Liver Cancer. Cancers (Basel) 2024; 16:876. [PMID: 38473237 DOI: 10.3390/cancers16050876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 03/14/2024] Open
Abstract
Background: Hypoxia, a state of low oxygen level within a tissue, is often present in primary and secondary liver tumors. At the molecular level, the tumor cells' response to hypoxic stress induces proteomic and genomic changes which are largely regulated by proteins called hypoxia-induced factors (HIF). These proteins have been found to drive tumor progression and cause resistance to drug- and radiation-based therapies, ultimately contributing to a tumor's poor prognosis. Several imaging modalities have been developed to visualize tissue hypoxia, providing insight into a tumor's microbiology. Methods: A systematic literature search was conducted in PubMed, EMBASE, Cochrane, and Google Scholar for all reports related to hypoxia on liver tumors. All relevant studies were summarized. Results: This review will focus on the impact of hypoxia on liver tumors and review PET-, MRI-, and SPECT-based imaging modalities that have been developed to predict and assess a tumor's response to radiation therapy, with a focus on liver cancers. Conclusion: While there are numerous studies that have evaluated the impact of hypoxia on tumor outcomes, there remains a relative paucity of data evaluating and quantifying hypoxia within the liver. Novel and developing non-invasive imaging techniques able to provide functional and physiological information on tumor hypoxia within the liver may be able to assist in the treatment planning of primary and metastatic liver lesions.
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Affiliation(s)
- Alexander Villalobos
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
| | - Jean Lee
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA 30322, USA
| | | | - Nima Kokabi
- Department of Radiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27514, USA
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Boopathi E, Den RB, Thangavel C. Innate Immune System in the Context of Radiation Therapy for Cancer. Cancers (Basel) 2023; 15:3972. [PMID: 37568788 PMCID: PMC10417569 DOI: 10.3390/cancers15153972] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 07/24/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
Radiation therapy (RT) remains an integral component of modern oncology care, with most cancer patients receiving radiation as a part of their treatment plan. The main goal of ionizing RT is to control the local tumor burden by inducing DNA damage and apoptosis within the tumor cells. The advancement in RT, including intensity-modulated RT (IMRT), stereotactic body RT (SBRT), image-guided RT, and proton therapy, have increased the efficacy of RT, equipping clinicians with techniques to ensure precise and safe administration of radiation doses to tumor cells. In this review, we present the technological advancement in various types of RT methods and highlight their clinical utility and associated limitations. This review provides insights into how RT modulates innate immune signaling and the key players involved in modulating innate immune responses, which have not been well documented earlier. Apoptosis of cancer cells following RT triggers immune systems that contribute to the eradication of tumors through innate and adoptive immunity. The innate immune system consists of various cell types, including macrophages, dendritic cells, and natural killer cells, which serve as key mediators of innate immunity in response to RT. This review will concentrate on the significance of the innate myeloid and lymphoid lineages in anti-tumorigenic processes triggered by RT. Furthermore, we will explore essential strategies to enhance RT efficacy. This review can serve as a platform for researchers to comprehend the clinical application and limitations of various RT methods and provides insights into how RT modulates innate immune signaling.
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Affiliation(s)
- Ettickan Boopathi
- Center for Translational Medicine, Department of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Robert B. Den
- Department of Radiation Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA 19107, USA;
| | - Chellappagounder Thangavel
- Center for Translational Medicine, Department of Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA
- Department of Radiation Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA 19107, USA;
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Sharma D, Xuan Leong K, Palhares D, Czarnota GJ. Radiation combined with ultrasound and microbubbles: A potential novel strategy for cancer treatment. Z Med Phys 2023; 33:407-426. [PMID: 37586962 PMCID: PMC10517408 DOI: 10.1016/j.zemedi.2023.04.007] [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: 01/11/2023] [Revised: 03/31/2023] [Accepted: 04/11/2023] [Indexed: 08/18/2023]
Abstract
Cancer is one of the leading causes of death worldwide. Several emerging technologies are helping to battle cancer. Cancer therapies have been effective at killing cancer cells, but a large portion of patients still die to this disease every year. As such, more aggressive treatments of primary cancers are employed and have been shown to be capable of saving a greater number of lives. Recent research advances the field of cancer therapy by employing the use of physical methods to alter tumor biology. It uses microbubbles to enhance radiation effect by damaging tumor vasculature followed by tumor cell death. The technique can specifically target tumor volumes by conforming ultrasound fields capable of microbubbles stimulation and localizing it to avoid vascular damage in surrounding tissues. Thus, this new application of ultrasound-stimulated microbubbles (USMB) can be utilized as a novel approach to cancer therapy by inducing vascular disruption resulting in tumor cell death. Using USMB alongside radiation has showed to augment the anti-vascular effect of radiation, resulting in enhanced tumor response. Recent work with nanobubbles has shown vascular permeation into intracellular space, extending the use of this new treatment method to potentially further improve the therapeutic effect of the ultrasound-based therapy. The significant enhancement of localized tumor cell kill means that radiation-based treatments can be made more potent with lower doses of radiation. This technique can manifest a greater impact on radiation oncology practice by increasing treatment effectiveness significantly while reducing normal tissue toxicity. This review article summarizes the past and recent advances in USMB enhancement of radiation treatments. The review mainly focuses on preclinical findings but also highlights some clinical findings that use USMB as a therapeutic modality in cancer therapy.
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Affiliation(s)
- Deepa Sharma
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Departments of Radiation Oncology, and Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Kai Xuan Leong
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Daniel Palhares
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Departments of Radiation Oncology, and Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Gregory J Czarnota
- Physical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada; Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Departments of Radiation Oncology, and Medical Biophysics, University of Toronto, Toronto, Ontario, Canada.
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Lascaud J, Parodi K. On the potential biological impact of radiation-induced acoustic emissions during ultra-high dose rate electron radiotherapy: a preliminary study. Phys Med Biol 2023; 68. [PMID: 36749987 DOI: 10.1088/1361-6560/acb9ce] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/07/2023] [Indexed: 02/09/2023]
Abstract
Ionizing radiation pulses delivered at ultra-high dose rates in emerging FLASH radiotherapy can result in high-intensity low-frequency thermoacoustic emissions that may have a biological impact. This study aims at providing insights into the thermoacoustic emissions expected during FLASH radiotherapy and their likelihood of inducing acoustic cavitation. The characteristics of acoustic waves induced by the energy deposition of a pulsed electron beam similar to previous pre-clinical FLASH radiotherapy studies and their propagation in murine head-like phantoms are investigated in-silico. The results show that the generated pressures are sufficient to produce acoustic cavitation due to resonance in the irradiated object. It suggests that thermoacoustics may, in some irradiation scenarios, contribute to the widely misunderstood FLASH effect or cause adverse effects if not taken into account at the treatment planning stage.
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Affiliation(s)
- Julie Lascaud
- Department of Medical Physics, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Katia Parodi
- Department of Medical Physics, Ludwig-Maximilians-Universität München, Munich, Germany
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Identification of Ultrasound-Sensitive Prognostic Markers of LAML and Construction of Prognostic Risk Model Based on WGCNA. JOURNAL OF ONCOLOGY 2023; 2023:2353249. [PMID: 36816364 PMCID: PMC9937759 DOI: 10.1155/2023/2353249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/03/2022] [Accepted: 11/25/2022] [Indexed: 02/12/2023]
Abstract
Background Acute myeloid leukemia (LAML) is the most widely known acute leukemia in adults. Chemotherapy is the main treatment method, but eventually many individuals who have achieved remission relapse, the disease will ultimately transform into refractory leukemia. Therefore, for the improvement of the clinical outcome of patients, it is crucial to identify novel prognostic markers. Methods The Cancer Genome Atlas (TCGA) and the Gene Expression Omnibus (GEO) databases were utilized to retrieve RNA-Seq information and clinical follow-up details for patients with acute myeloid leukemia, respectively, whereas samples that received or did not receive ultrasound treatment were analyzed using differential expression analysis. For consistent clustering analysis, the ConsensusClusterPlus package was utilized, while by utilizing weighted correlation network analysis (WGCNA), important modules were found and the generation of the coexpression network of hub gene was generated using Cytoscape. CIBERSORT, ESTIMATE, and xCell algorithms of the "IOBR" R package were employed for the calculation of the relative quantity of immune infiltrating cells, whereas the mutation frequency of cells was estimated by means of the "maftools" R package. The pathway enrichment score was calculated using the single sample Gene Set Enrichment Analysis (ssGSEA) algorithm of the "Gene Set Variation Analysis (GSVA)" R package. The IC50 value of the drug was predicted by utilizing the "pRRophetic." The indications linked with prognosis were selected by means of the least absolute shrinkage and selection operator (Lasso) Cox analysis. Results Two categories of samples were created as follows: Cluster 1 and Cluster 2 depending on the differential gene consistent clustering of ultrasound treatment. The prognosis of patients in Cluster 2 was better than that in Cluster 1, and a considerable variation was observed in the immune microenvironment of Cluster 1 and Cluster 2. Lasso analysis finally obtained an 8-gene risk model (GASK1A, LPO, LTK, PRRT4, UGT3A2, BLOCK1S1, G6PD, and UNC93B1). The model acted as an independent risk factor for the patients' prognosis, and it showed good robustness in different datasets. Considerable variations were observed in the abundance of immune cell infiltration, genome mutation, pathway enrichment score, and chemotherapeutic drug resistance between the low and high-risk groups in accordance with the risk score (RS). Additionally, model-based RSs in the immunotherapy cohort were significantly different between complete remission (CR) and other response groups. Conclusion The prognosis of people with LAML can be predicted using the 8-gene signature.
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Leong KX, Sharma D, Czarnota GJ. Focused Ultrasound and Ultrasound Stimulated Microbubbles in Radiotherapy Enhancement for Cancer Treatment. Technol Cancer Res Treat 2023; 22:15330338231176376. [PMID: 37192751 DOI: 10.1177/15330338231176376] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
Radiation therapy (RT) has been the standard of care for treating a multitude of cancer types. However, ionizing radiation has adverse short and long-term side effects which have resulted in treatment complications for decades. Thus, advances in enhancing the effects of RT have been the primary focus of research in radiation oncology. To avoid the usage of high radiation doses, treatment modalities such as high-intensity focused ultrasound can be implemented to reduce the radiation doses required to destroy cancer cells. In the past few years, the use of focused ultrasound (FUS) has demonstrated immense success in a number of applications as it capitalizes on spatial specificity. It allows ultrasound energy to be delivered to a targeted focal area without harming the surrounding tissue. FUS combined with RT has specifically demonstrated experimental evidence in its application resulting in enhanced cell death and tumor cure. Ultrasound-stimulated microbubbles have recently proved to be a novel way of enhancing RT as a radioenhancing agent on its own, or as a delivery vector for radiosensitizing agents such as oxygen. In this mini-review article, we discuss the bio-effects of FUS and RT in various preclinical models and highlight the applicability of this combined therapy in clinical settings.
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Affiliation(s)
- Kai Xuan Leong
- Physical Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Deepa Sharma
- Physical Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
| | - Gregory J Czarnota
- Physical Sciences, Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada
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11
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Dang Q, Yang J, Zha B, Li P, Cui H, Zheng Y. Sonodynamic Therapy for A Child with Recurrent Brainstem Glioma: A Case Report. INTERDISCIPLINARY NEUROSURGERY 2023. [DOI: 10.1016/j.inat.2023.101722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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12
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Pino PG, Moreo A, Lestuzzi C. Differential diagnosis of cardiac tumors: General consideration and echocardiographic approach. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:1177-1193. [PMID: 36218203 PMCID: PMC9828386 DOI: 10.1002/jcu.23309] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/21/2022] [Accepted: 08/23/2022] [Indexed: 06/16/2023]
Abstract
Cardiac tumors may be primary (either benign or malignant) or secondary (malignant) and are first detected by echocardiography in most cases. The cardiologist often challenges their identification, the differential diagnosis and the best therapeutic approach. Malignant tumors have usually a poor prognosis, which may be significantly improved by appropriate and timely therapies. The echocardiographic aspects of benign and malignant cardiac tumors described in this article, along with a clinical evaluation may orient the differential diagnosis and aid in choosing the further steps useful to define the nature of the mass.
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Affiliation(s)
- Paolo G. Pino
- Former Chief of Non Invasive Cardiovascular Diagnostics DepartmentOspedale San CamilloRomeItaly
| | - Antonella Moreo
- Cardiology IV, 'A.De Gasperis'DepartmentNiguarda Ca' Granda HospitalMilanItaly
| | - Chiara Lestuzzi
- Cardio‐oncological Rehabilitation Service, Azienda Sanitaria Friuli Occidentale (ASFO)c/o National Cancer Institute (CRO), IRCCSAvianoItaly
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13
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Tumoral Oxygenation and Biodistribution of Lonidamine Oxygen Microbubbles Following Localized Ultrasound-Triggered Delivery. Int J Pharm 2022; 625:122072. [PMID: 35932933 DOI: 10.1016/j.ijpharm.2022.122072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/27/2022] [Accepted: 07/30/2022] [Indexed: 12/24/2022]
Abstract
Prior work has shown that microbubble-assisted delivery of oxygen improves tumor oxygenation and radiosensitivity, albeit over a limited duration. Lonidamine (LND) has been investigated because of its ability to stimulate glycolysis, lactate production, inhibit mitochondrial respiration, and inhibit oxygen consumption rates in tumors but suffers from poor bioavailability. The goal of this work was to characterize LND-loaded oxygen microbubbles and assess their ability to oxygenate a human head and neck squamous cell carcinoma (HNSCC) tumor model, while also assessing LND biodistribution. In tumors treated with surfactant-shelled microbubbles with oxygen core (SE61O2) and ultrasound, pO2 levels increased to a peak 19.5±9.7 mmHg, 50 seconds after injection and returning to baseline after 120 seconds. In comparison, in tumors treated with SE61O2/LND and ultrasound, pO2 levels showed a peak increase of 29.0±8.3 mmHg, which was achieved 70 seconds after injection returning to baseline after 300 seconds (p<0.001). The co-delivery of O2andLNDvia SE61 also showed an improvement of LND biodistribution in both plasma and tumor tissues (p<0.001). In summary, ultrasound-sensitive microbubbles loaded with O2 and LND provided prolonged oxygenation relative to oxygenated microbubbles alone, as well as provided an ability to locally deliver LND, making them more appropriate for clinical translation.
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14
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Sharma D, Czarnota GJ. Involvement of Ceramide Signalling in Radiation-Induced Tumour Vascular Effects and Vascular-Targeted Therapy. Int J Mol Sci 2022; 23:ijms23126671. [PMID: 35743121 PMCID: PMC9223569 DOI: 10.3390/ijms23126671] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/31/2022] [Accepted: 06/06/2022] [Indexed: 02/04/2023] Open
Abstract
Sphingolipids are well-recognized critical components in several biological processes. Ceramides constitute a class of sphingolipid metabolites that are involved in important signal transduction pathways that play key roles in determining the fate of cells to survive or die. Ceramide accumulated in cells causes apoptosis; however, ceramide metabolized to sphingosine promotes cell survival and angiogenesis. Studies suggest that vascular-targeted therapies increase endothelial cell ceramide resulting in apoptosis that leads to tumour cure. Specifically, ultrasound-stimulated microbubbles (USMB) used as vascular disrupting agents can perturb endothelial cells, eliciting acid sphingomyelinase (ASMase) activation accompanied by ceramide release. This phenomenon results in endothelial cell death and vascular collapse and is synergistic with other antitumour treatments such as radiation. In contrast, blocking the generation of ceramide using multiple approaches, including the conversion of ceramide to sphingosine-1-phosphate (S1P), abrogates this process. The ceramide-based cell survival "rheostat" between these opposing signalling metabolites is essential in the mechanotransductive vascular targeting following USMB treatment. In this review, we aim to summarize the past and latest findings on ceramide-based vascular-targeted strategies, including novel mechanotransductive methodologies.
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Affiliation(s)
- Deepa Sharma
- Physical Sciences, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada;
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Departments of Medical Biophysics and Radiation Oncology, University of Toronto, Toronto, ON M4N 3M5, Canada
- Correspondence: ; Tel.: +1-416-480-6100 (ext. 89533)
| | - Gregory J. Czarnota
- Physical Sciences, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada;
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada
- Departments of Medical Biophysics and Radiation Oncology, University of Toronto, Toronto, ON M4N 3M5, Canada
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15
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Application of Ultrasound Combined with Microbubbles for Cancer Therapy. Int J Mol Sci 2022; 23:ijms23084393. [PMID: 35457210 PMCID: PMC9026557 DOI: 10.3390/ijms23084393] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 02/07/2023] Open
Abstract
At present, cancer is one of the leading causes of death worldwide. Treatment failure remains one of the prime hurdles in cancer treatment due to the metastatic nature of cancer. Techniques have been developed to hinder the growth of tumours or at least to stop the metastasis process. In recent years, ultrasound therapy combined with microbubbles has gained immense success in cancer treatment. Ultrasound-stimulated microbubbles (USMB) combined with other cancer treatments including radiation therapy, chemotherapy or immunotherapy has demonstrated potential improved outcomes in various in vitro and in vivo studies. Studies have shown that low dose radiation administered with USMB can have similar effects as high dose radiation therapy. In addition, the use of USMB in conjunction with radiotherapy or chemotherapy can minimize the toxicity of high dose radiation or chemotherapeutic drugs, respectively. In this review, we discuss the biophysical properties of USMB treatment and its applicability in cancer therapy. In particular, we highlight important preclinical and early clinical findings that demonstrate the antitumour effect combining USMB and other cancer treatment modalities (radiotherapy and chemotherapy). Our review mainly focuses on the tumour vascular effects mediated by USMB and these cancer therapies. We also discuss several current limitations, in addition to ongoing and future efforts for applying USMB in cancer treatment.
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16
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Furusawa Y, Kondo T, Tachibana K, Feril LB. Ultrasound-Induced DNA Damage and Cellular Response: Historical Review, Mechanisms Analysis, and Therapeutic Implications. Radiat Res 2022; 197:662-672. [PMID: 35275998 DOI: 10.1667/rade-21-00140.1.s1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 02/22/2022] [Indexed: 11/03/2022]
Abstract
The biological effects of ultrasound may be classified into thermal and nonthermal mechanisms. The nonthermal effects may be further classified into cavitational and noncavitational mechanisms. DNA damage induced by ultrasound is considered to be related to nonthermal cavitations. For this aspect, many in vitro studies on DNA have been conducted for evaluating the safety of diagnostic ultrasound, particularly in fetal imaging. Technological advancement in detecting DNA damage both in vitro and in vivo have elucidated the mechanism of DNA damage formation and their cellular response. Damage to DNA, and the residual damages after DNA repair are implicated in the biological effects. Here, we discuss the historical evidence of ultrasound on DNA damage and the mechanism of DNA damage formation both in vitro and in vivo, compared with those induced by ionizing radiation. We also offer a commentary on the safety of ultrasound over X-ray-based imaging. Also, understanding the various mechanisms involved in the bioeffects of ultrasound will lead us to alternative strategies for use of ultrasound for therapy.
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Affiliation(s)
- Yukihiro Furusawa
- Department of Liberal Arts and Sciences, Toyama Prefecture University, Toyama 939-0398, Japan
| | - Takashi Kondo
- Department of Radiological Sciences Graduate School of Medicine and Pharmaceutical Sciences, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan
| | - Katsuro Tachibana
- Department of Anatomy. Fukuoka University School of Medicine, Fukuoka 814-0180, Japan
| | - Loreto B Feril
- Department of Anatomy. Fukuoka University School of Medicine, Fukuoka 814-0180, Japan
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17
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Collado-Lara G, Heymans SV, Rovituso M, Carlier B, Toumia Y, Verweij M, Paradossi G, Sterpin E, Vos HJ, D'hooge J, de Jong N, Van Den Abeele K, Daeichin V. Spatiotemporal Distribution of Nanodroplet Vaporization in a Proton Beam Using Real-Time Ultrasound Imaging for Range Verification. ULTRASOUND IN MEDICINE & BIOLOGY 2022; 48:149-156. [PMID: 34629191 DOI: 10.1016/j.ultrasmedbio.2021.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 06/13/2023]
Abstract
The potential of proton therapy to improve the conformity of the delivered dose to the tumor volume is currently limited by range uncertainties. Injectable superheated nanodroplets have recently been proposed for ultrasound-based in vivo range verification, as these vaporize into echogenic microbubbles on proton irradiation. In previous studies, offline ultrasound images of phantoms with dispersed nanodroplets were acquired after irradiation, relating the induced vaporization profiles to the proton range. However, the aforementioned method did not enable the counting of individual vaporization events, and offline imaging cannot provide real-time feedback. In this study, we overcame these limitations using high-frame-rate ultrasound imaging with a linear array during proton irradiation of phantoms with dispersed perfluorobutane nanodroplets at 37°C and 50°C. Differential image analysis of subsequent frames allowed us to count individual vaporization events and to localize them with a resolution beyond the ultrasound diffraction limit, enabling spatial and temporal quantification of the interaction between ionizing radiation and nanodroplets. Vaporization maps were found to accurately correlate with the stopping distribution of protons (at 50°C) or secondary particles (at both temperatures). Furthermore, a linear relationship between the vaporization count and the number of incoming protons was observed. These results indicate the potential of real-time high-frame-rate contrast-enhanced ultrasound imaging for proton range verification and dosimetry.
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Affiliation(s)
- Gonzalo Collado-Lara
- Biomedical Engineering, Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Sophie V Heymans
- Biomedical Engineering, Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Department of Physics, KU Leuven Campus Kulak, Kortrijk, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | | | - Bram Carlier
- Department of Oncology, KU Leuven, Leuven, Belgium
| | - Yosra Toumia
- Department of Chemical Sciences and Technology, University of Rome Tor Vergata, Rome, Italy
| | - Martin Verweij
- Biomedical Engineering, Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Department of Medical Imaging, TU Delft, Delft, The Netherlands
| | - Gaio Paradossi
- Department of Chemical Sciences and Technology, University of Rome Tor Vergata, Rome, Italy
| | | | - Hendrik J Vos
- Biomedical Engineering, Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Department of Medical Imaging, TU Delft, Delft, The Netherlands
| | - Jan D'hooge
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Nico de Jong
- Biomedical Engineering, Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands; Department of Medical Imaging, TU Delft, Delft, The Netherlands
| | | | - Verya Daeichin
- Department of Medical Imaging, TU Delft, Delft, The Netherlands
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18
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Wang Y, Chen T, Li K, Mu W, Liu Z, Shi A, Liu J, Zhao W, Lian S, Huang S, Pan C, Zhang Z. Recent Advances in the Mechanism Research and Clinical Treatment of Anti-Angiogenesis in Biliary Tract Cancer. Front Oncol 2021; 11:777617. [PMID: 34778094 PMCID: PMC8581488 DOI: 10.3389/fonc.2021.777617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 10/11/2021] [Indexed: 12/25/2022] Open
Abstract
Biliary tract cancers (BTCs), including cholangiocarcinoma (CCA) and gallbladder cancer (GC), are malignancies originating from the biliary tract with poor prognosis. In the early stage of BTCs, surgery is the only choice for cure. Unfortunately, most patients with BTC are diagnosed at an advanced stage and lose the opportunity for surgery. For many advanced solid tumors, antiangiogenic therapy has achieved encouraging results. While most clinical studies on antiangiogenic therapy in advanced BTCs have shown an excellent disease control rate (DCR), the improvement in overall survival (OS) is controversial. Understanding how the relevant signaling molecules influence the angiogenic response and the functional interaction is necessary for the formulation of new treatment regimens and the selection of enrolled patients. In this review, we aim to summarize and discuss the latest advances in antiangeogenesis for BTCs, mainly focusing on the molecular mechanism of angiogenesis in BTCs and the therapeutic effects from clinical trials. Furthermore, the horizon of antiangiogenesis for BTCs is highlighted.
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Affiliation(s)
- Yue Wang
- Department of General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Tianli Chen
- Department of General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Kangshuai Li
- Department of General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wentao Mu
- Department of General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Zengli Liu
- Department of General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Anda Shi
- Department of General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jialiang Liu
- Department of General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Zhao
- Department of General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shuo Lian
- Department of General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Shaohui Huang
- Department of General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chang Pan
- Department of Emergency, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Zongli Zhang
- Department of General Surgery, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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