Pulsed-wave low-dose ultrasound hyperthermia selectively enhances nanodrug delivery and improves antitumor efficacy for brain metastasis of breast cancer

Nanoparticle drug delivery to target breast cancer brain metastasis: Current and future trends

Breast cancer brain metastasis (BCBM) is rapidly becoming an impediment to continuing survival gains seen in breast cancer patients. Drug delivery across the blood-brain barrier is the main issue hindering systemic therapy against BCBM. This review details recent advances in nanoparticle (NP) drug delivery systems to target BCBM. Their primary benefits are: enhanced circulating and intra-BCBM drug biodistribution, BCBM targeting through NP functionalization, opportunities for gene manipulation and their theragnostic applications. Multiple NPs have been synthesized to deliver therapeutic HER2 blockade, which is particularly important given HER2-positive breast cancer's tendency to form BCBM. Finally, we review the clinical context in which NP-based therapeutics have been investigated in BCBM patients. While a breakthrough in improving patient outcomes remain awaited, these clinical trials represent positive steps in the changing attitude towards BCBM as a treatable illness. Although multiple challenges remain in the clinical translation of BCBM-directed NP therapies, ongoing research in the field offers promising avenues for novel targeting of this devastating disease.

Exercise improves the outcome of anticancer treatment with ultrasound-hyperthermia-enhanced nanochemotherapy and autophagy inhibitor

It has been shown that exercise has a direct impact on tumor growth along with functional improvement. Previous studies have shown that exercise decreases the risk of cancer recurrence across various types of cancer. It was indicated that exercise stimulates the immune system to fight cancer. Previous study demonstrated that pulsed-wave ultrasound hyperthermia (pUH) combined with PEGylated liposomal doxorubicin (PLD) and chloroquine (CQ) inhibits 4T1 tumors growth and delays their recurrence. In this study, we investigated if the combinatorial treatment with high-intensity interval training (HIIT) combined with pUH-enhanced PLD delivery and CQ improved the outcome. The mouse experiment composed of three groups, HIIT+PLD+pUH+CQ group, PLD+pUH+CQ group, and the control group. HIIT+PLD+pUH+CQ group received 6 weeks of HIIT (15 min per day, 5 days per week) before 4T1 tumor implantation. Seven days later, they received therapy with PLD (10 mg/kg) + pUH (3 MHz, 50% duty cycle, 0.65 W/cm2, 15min) + CQ (50 mg/kg daily). Results showed that HIIT+PLD+pUH+CQ significantly reduced the tumor volumes and brought about longer survival of tumor-bearing mice than PLD+pUH+CQ did. Blood cell components were analyzed and showed that neutrophil and reticulocytes decreased while lymphocytes increased after exercise.

Large-Volume Focused-Ultrasound Mild Hyperthermia for Improving Blood-Brain Tumor Barrier Permeability Application

Mild hyperthermia can locally enhance permeability of the blood-tumor barrier in brain tumors, improving delivery of antitumor nanodrugs. However, a clinical transcranial focused ultrasound (FUS) system does not provide this modality yet. The study aimed at the development of the transcranial FUS technique dedicated for large-volume mild hyperthermia in the brain. Acoustic pressure, multiple-foci, temperature and thermal dose induced by FUS were simulated in the brain through the skull. A 1-MHz, 114-element, spherical helmet transducer was fabricated to verify large-volume hyperthermia in the phantom. The simulated results showed that two foci were simultaneously formed at (2, 0, 0) and (−2, 0, 0) and at (0, 2, 0) and (0, −2, 0), using the phases of focusing pattern 1 and the phases of focusing pattern 2, respectively. Switching two focusing patterns at 5 Hz produced a hyperthermic zone with an ellipsoid of 7 mm × 6 mm × 11 mm in the brain and the temperature was 41–45 °C in the ellipsoid as the maximum intensity was 150 W/cm² and sonication time was 3 min. The phased array driven by switching two mode phases generated a 41 °C-contour region of 10 ± 1 mm × 8 ± 2 mm × 13 ± 2 mm in the phantom after 3-min sonication. Therefore, we have demonstrated our developed FUS technique for large-volume mild hyperthermia.

Functional Nanoparticles for Enhanced Cancer Therapy

Cancer is the leading cause of death in people worldwide. The conventional therapeutic approach is mainly based on chemotherapy, which has a series of side effects. Compared with traditional chemotherapy drugs, nanoparticle-based delivery of anti-cancer drugs possesses a few attractive features. The application of nanotechnology in an interdisciplinary manner in the biomedical field has led to functional nanoparticles achieving much progress in cancer therapy. Nanoparticles have been involved in the diagnosis and targeted and personalized treatment of cancer. For example, different nano-drug strategies, including endogenous and exogenous stimuli-responsive, surface conjugation, and macromolecular encapsulation for nano-drug systems, have successfully prevented tumor procession. The future for functional nanoparticles is bright and promising due to the fast development of nanotechnology. However, there are still some challenges and limitations that need to be considered. Based on the above contents, the present article analyzes the progress in developing functional nanoparticles in cancer therapy. Research gaps and promising strategies for the clinical application are discussed.

Closed-loop trans-skull ultrasound hyperthermia leads to improved drug delivery from thermosensitive drugs and promotes changes in vascular transport dynamics in brain tumors

Effective drug delivery in brain tumors remains a major challenge in oncology. Although local hyperthermia and stimuli-responsive delivery systems, such as thermosensitive liposomes, represent promising strategies to locally enhance drug delivery in solid tumors and improve outcomes, their application in intracranial malignancies remains unexplored. We hypothesized that the combined abilities of closed-loop trans-skull Magnetic Resonance Imaging guided Focused Ultrasound (MRgFUS) hyperthermia with those of thermosensitive drugs can alleviate challenges in drug delivery and improve survival in gliomas.

Methods: To conduct our investigations, we first designed a closed loop MR-guided Focused Ultrasound (MRgFUS) system for localized trans-skull hyperthermia (ΔT < 0.5 °C) in rodents and established safety thresholds in healthy mice. To assess the abilities of the developed system and proposed therapeutic strategy for FUS-triggered chemotherapy release we employed thermosensitive liposomal Dox (TSL-Dox) and tested it in two different glioma tumor models (F98 in rats and GL261 in mice). To quantify Dox delivery and changes in the transvascular transport dynamics in the tumor microenvironment we combined fluorescent microscopy, dynamic contrast enhanced MRI (DCE-MRI), and physiologically based pharmacokinetic (PBPK) modeling. Lastly, to assess the therapeutic efficacy of the system and of the proposed therapeutic strategy we performed a survival study in the GL261 glioma bearing mice.

Results: The developed closed-loop trans-skull MRgFUS-hyperthermia system that operated at 1.7 MHz, a frequency that maximized the brain (FUS-focus) to skull temperature ratio in mice, was able to attain and maintain the desired focal temperature within a narrow range. Histological evidence (H&E and Nissl) suggests that focal temperature at 41.5 ± 0.5 °C for 10 min is below the threshold for tissue damage. Quantitative analysis of doxorubicin delivery from TSLs with MRgFUS-hyperthermia demonstrated 3.5-fold improvement in cellular uptake in GL261 glioma mouse tumors (p < 0.001) and 5-fold increase in delivery in F98 glioma rat tumors (p < 0.05), as compared to controls (TSL-Dox-only). Moreover, PBPK modeling of drug transport that was calibrated using the experimental data indicated that thermal stress could lead to significant improvement in the transvascular transport (2.3-fold increase in the vessel diffusion coefficient; P < 0.001), in addition to promoting targeted Dox release. Prospective experimental investigations with DCE-MRI during FUS-hyperthermia, supported these findings and provided evidence that moderate thermal stress (≈41 °C for up to 10 min) can promote acute changes in the vascular transport dynamics in the brain tumor microenvironment (K^trans value for control vs. FUS was 0.0097 and 0.0148 min^-1, respectively; p = 0.026). Crucially, survival analysis demonstrated significant improvement in the survival in the TSL-Dox-FUS group as compared to TSL-Dox-only group (p < 0.05), providing supporting evidence on the therapeutic potential of the proposed strategy.

Conclusions: Our investigations demonstrated that spatially controlled thermal stress can be attained and sustained in the mouse brain, using a trans-skull closed-loop MRgFUS system, and used to promote the effective delivery of chemotherapy in gliomas from thermosensitive drugs. This system also allowed us to conduct mechanistic investigations that resulted in the refinement of our understanding on the role of thermal stress in augmenting mass and drug transport in brain tumors. Overall, our study established a new paradigm for effective drug delivery in brain tumors based on closed-loop ultrasound-mediated thermal stress and thermosensitive drugs.

Numerical analysis of the pulsating heat source effects in a tumor tissue

BACKGROUND AND OBJECTIVES

Hyperthermia treatment is nowadays recognized as the fourth additional cancer therapy technique following surgery, chemotherapy, and radiation; it is a minimally or non-invasive technique which involves fewer complications, a shorter hospital stay, and fewer costs. In this paper, pulsating heat effects on heat transfer in a tumor tissue under hyperthermia are analyzed. The objective of the paper is to find and quantify the advantages of pulsatile heat protocols under different periodical heating schemes and for different tissue morphologies.

METHODS

The tumor tissue is modeled as a porous sphere made up of a solid phase (tissue, interstitial space, etc.) and a fluid phase (blood). A Local Thermal Non-Equilibrium (LTNE) model is employed to consider the local temperature difference between the two phases. Governing equations with the appropriate boundary conditions are solved with the finite-element code COMSOL Multiphysics®. The pulsating effect is modeled with references to a cosine function with different frequencies, and such different heating protocols are compared at equal delivered energy, i. e. different heating times at equal maximum power.

RESULTS

Different tissue properties in terms of blood vessels sizes and blood volume fraction in tissue (porosity) are investigated. The results are shown in terms of tissue temperature and percentage of necrotic tissue obtained. The most powerful result achieved using a pulsating heat source instead of a constant one is the decreasing of maximum temperature in any considered case, even reaching about 30% lower maximum temperatures. Furthermore, the evaluation of tissue damage at the end of treatment shows that pulsating heat allows to necrotize the same tumoral tissue area of the non-pulsating heat source.

CONCLUSIONS

Modeling pulsating heat protocols in thermal ablation under different periodical heating schemes and considering different tissues morphologies in a tumor tissue highlights how the application of pulsating heat sources allows to avoid high temperature peaks, and simultaneously to ablate the same tumoral area obtained with a non-pulsating heat source. This is a powerful result to improve medical protocols and devices in thermal ablation of tumors.

Feasibility study of greater occipital nerve blocks by focused ultrasound - an animal study

OBJECTIVE

Greater occipital nerve (GON) block may provide substantial relief for headache in the occipital location. This study tested the feasibility of focused ultrasound (FUS) to induce the conduction block of GONs in rats.

APPROACH

For in vitro experiments, the nerve was dissected and cut from C2 to the site near the ear of the rats and preserved in Ringer's solution. Pulsed FUS was used for the block, and sensory action potentials were recorded in the GON. For in vivo experiments, the GONs of the rats were surgically exposed for precise ultrasonic treatment. All data are expressed as the mean ± the standard deviation.

MAIN RESULTS

A single ultrasonic treatment temporarily suppressed the amplitude of action potentials of the in vitro nerves to 42 ± 14% of the baseline values, and the time to recovery was 55 min. The in vivo results showed that FUS acutely inhibited the amplitude of action potentials to 41 ± 8% of the baseline value in rat GONs, and the time to recovery was 67 min. Histological examination revealed no appreciable changes in the nerve morphology caused by FUS. Therefore, FUS reversibly blocked the conduction of the rat GON when the sonication parameters were appropriate.

SIGNIFICANCE

Noninvasive FUS may be a novel treatment paradigm for occipital headache by blocking the occipital nerve, and the procedure is repeatable if indicated.

Physical triggering strategies for drug delivery

Physically triggered systems hold promise for improving drug delivery by enhancing the controllability of drug accumulation and release, lowering non-specific toxicity, and facilitating clinical translation. Several external physical stimuli including ultrasound, light, electric fields and magnetic fields have been used to control drug delivery and they share some common features such as spatial targeting, spatiotemporal control, and minimal invasiveness. At the same time, they possess several distinctive features in terms of interactions with biological entities and/or the extent of stimulus response. Here, we review the key advances of such systems with a focus on discussing their physical mechanisms, the design rationales, and translational challenges.

Direct treatment versus indirect: Thermo-ablative and mild hyperthermia effects

Hyperthermia is a rapidly growing field in cancer therapy and many advances have been made in understanding and applying the mechanisms of hyperthermia. Secondary effects of hyperthermia have been increasingly recognized as important in therapeutic effects and multiple studies have started to elucidate their implications for treatment. Immune effects have especially been recognized as important in the efficacy of hyperthermia treatment of cancer. Both thermo-ablative and mild hyperthermia activate the immune system, but mild hyperthermia seems to be more effective at doing so. This may suggest that mild hyperthermia has some advantages over thermo-ablative hyperthermia and research into immune effects of mild hyperthermia should continue. This article is categorized under: Therapeutic Approaches and Drug Discovery > Nanomedicine for Oncologic Disease Therapeutic Approaches and Drug Discovery > Emerging Technologies Implantable Materials and Surgical Technologies > Nanoscale Tools and Techniques in Surgery.

Pulsed-wave Ultrasound Hyperthermia Enhanced Nanodrug Delivery Combined with Chloroquine Exerts Effective Antitumor Response and Postpones Recurrence

Autophagy is found to serve as a surviving mechanism for cancer cells. Inhibiting autophagy has been considered as an adjuvant anti-cancer strategy. In this study, we investigated the anti-tumor effect of combining pulsed-wave ultrasound hyperthermia (pUH) enhanced PEGylated liposomal doxorubicin (PLD) delivery with an autophagy inhibitor chloroquine (CQ). BALB/c mice bearing subcutaneous 4T1 tumor received intravenous injection of PLD (10 mg/kg) plus 15-minute on-tumor pUH on Day 5 after tumor implantation and were then fed with CQ (50 mg/kg daily) thereafter. Prolonged suppression of tumor growth was attained with PLD + pUH + CQ treatment, whereas in PLD + pUH group tumors quickly recurred after an initial inhibition. Treatment with CQ monotherapy had no benefit compared to the control group. Immunohistochemical staining and Western blotting showed that autophagy of cancer cells was blocked for the mice receiving CQ. It indicates that PLD + pUH + CQ is a promising strategy to treat cancer for a long-term inhibition.

Localized delivery of therapeutic doxorubicin dose across the canine blood-brain barrier with hyperthermia and temperature sensitive liposomes

Most drugs cannot penetrate the blood–brain barrier (BBB), greatly limiting the use of anti-cancer agents for brain cancer therapy. Temperature sensitive liposomes (TSL) are nanoparticles that rapidly release the contained drug in response to hyperthermia (>40 °C). Since hyperthermia also transiently opens the BBB, we hypothesized that localized hyperthermia can achieve drug delivery across the BBB when combined with TSL. TSL-encapsulated doxorubicin (TSL-Dox) was infused intravenously over 30 min at a dose of 0.94 mg/kg in anesthetized beagles (age ∼17 months). Following, a hyperthermia probe was placed 5–10 mm deep through one of four 3-mm skull burr holes. Hyperthermia was performed randomized for 15 or 30 min, at either 45 or 50 °C. Blood was drawn every 30 min to measure TSL-Dox pharmacokinetics. Nonsurvival studies were performed in four dogs, where brain tissue at the hyperthermia location was extracted following treatment to quantify doxorubicin uptake via high-performance liquid chromatography (HPLC) and to visualize cellular uptake via fluorescence microscopy. Survival studies for 6 weeks were performed in five dogs treated by a single hyperthermia application. Local doxorubicin delivery correlated with hyperthermia duration and ranged from 0.11 to 0.74 μg/g of brain tissue at the hyperthermia locations, with undetectable drug uptake in unheated tissue. Fluorescence microscopy demonstrated doxorubicin delivery across the BBB. Histopathology in Haematoxylin & Eosin (H&E) stained samples demonstrated localized damage near the probe. No animals in the survival group demonstrated significant neurological deficits. This study demonstrates that localized doxorubicin delivery to the brain can be facilitated by TSL-Dox with localized hyperthermia with no significant neurological deficits.

Nanoparticles and nanothermia for malignant brain tumors, a suggestion of treatment for further investigations

The current treatment for brain tumors, such as glioblastoma multiforme (GBM), has not been developed enough yet in order to fully heal them. The main causes are the lack of specificity of the treatments, the difficulty of passage of drugs through the blood-brain barrier, heterogeneity and tumor aggressiveness, and widespread dissemination in the brain. The application of nanoparticles (Nps) have been a breakthrough for both diagnostic imaging and targeted therapies. There have been numerous studies with different types of Nps in brain tumors, but we have focused on thermosensitive liposomes, which are characterized by releasing the chemotherapeutic agent included within its lipophilic membranes through heat. Furthermore, increasing the temperature in brain tumors through hyperthermia has been proven therapeutically beneficial. Nanothermia or modulated-electro-hyperthermia (MEHT) is an improved technique that allows to create hot spots in nanorange at the membrane rafts, specifically in tumor cells, theoretically increasing the selectivity of the damage. In scientific records, experiments that combine both techniques (thermosensitive liposomes and nanothermia) have never been conducted. We propose a hypothesis for further research.

Current status and future perspectives of sonodynamic therapy in glioma treatment

Malignant glioma is one of the most challenging central nervous system diseases to treat, and has high rates of recurrence and mortality. The current therapies include surgery, radiation therapy, and chemotherapy, although these approaches often failed to control tumor progression or improve patient survival. Sonodynamic therapy is a developing cancer treatment that uses ultrasound combined with a sonosensitizer to synergistically kill tumor cells, and has provided impressive results in both in vitro and in vivo studies. The ultrasound waves can penetrate deep tissues and reversibly open the blood-brain barrier to enhance drug delivery to the brain. Thus, sonodynamic therapy has a promising potential in glioma treatment. In this review, we summarize the studies that have confirmed the pre-clinical efficacy of sonodynamic therapy for glioma treatment, and discuss the future directions for this emerging treatment.

Anticancer effects of β-elemene with hyperthermia in lung cancer cells

β-elemene is a novel, plant-derived anticancer drug, which has been used to target multiple solid tumor types. Hyperthermia is an adjuvant therapeutic modality to treat cancer. However, the underlying mechanisms associated with the efficacy of these two treatments are largely unknown. The aim of the present study was to evaluate the effects of β-elemene combined with hyperthermia in lung cancer cell lines. An MTT assay was used to determine cell viability. The cell cycle and apoptosis were analyzed using flow cytometry. The morphology of cells during apoptosis was determined using a transmission electron microscope. The expression levels of P21, survivin, caspase-9, B-cell lymphoma 2 (Bcl-2) and Bcl-2-like protein 4 (Bax) mRNA were detected using quantitative polymerase chain reaction. β-elemene with hyperthermia treatment significantly inhibited the viability and increased the apoptosis rate of A549 cells compared with β-elemene treatment alone (P<0.01), and significantly decreased the proportion of cells in S phase compared with the control (P<0.01). Morphological observation using transmission electron microscopy indicated cross-sectional features of apoptosis: Chromatin condensation, reduced integrity of the plasma membrane, increased cellular granularity, nuclear collapse and the formation of apoptotic bodies. β-elemene with hyperthermia treatment significantly promoted P21 and Bax mRNA expression (P<0.01) and significantly decreased caspase-9, Bcl-2 and survivin mRNA expression (P<0.01) in A549 cells. In conclusion, β-elemene with hyperthermia has a significant inhibitory effect on A549 cells. This occurs through reducing S phase and inducing apoptosis, via an increase in P21 and Bax expression and a decrease in caspase-9, Bcl-2 and survivin expression.