High energy shock waves suppress tumor growth in vitro and in vivo

Shock wave-induced permeabilization of mammalian cells

Controlled permeabilization of mammalian cell membranes is fundamental to develop gene and cell therapies based on macromolecular cargo delivery, a process that emerged against an increasing number of health afflictions, including genetic disorders, cancer and infections. Viral vectors have been successfully used for macromolecular delivery; however, they may have unpredictable side effects and have been limited to life-threatening cases. Thus, several chemical and physical methods have been explored to introduce drugs, vaccines, and nucleic acids into cells. One of the most appealing physical methods to deliver genes into cells is shock wave-induced poration. High-speed microjets of fluid, emitted due to the collapse of microbubbles after shock wave passage, represent the most significant mechanism that contributes to cell membrane poration by this technique. Herein, progress in shock wave-induced permeabilization of mammalian cells is presented. After covering the main concepts related to molecular strategies whose applications depend on safer drug delivery methods, the physics behind shock wave phenomena is described. Insights into the use of shock waves for cell membrane permeation are discussed, along with an overview of the two major biomedical applications thereof-i.e., genetic modification and anti-cancer shock wave-assisted chemotherapy. The aim of this review is to summarize 30 years of data showing underwater shock waves as a safe, noninvasive method for macromolecular delivery into mammalian cells, encouraging the development of further research, which is still required before the introduction of this promising tool into clinical practice.

In vivo effects of focused shock waves on tumor tissue visualized by fluorescence staining techniques

Shock waves can cause significant cytotoxic effects in tumor cells and tissues both in vitro and in vivo. However, understanding the mechanisms of shock wave interaction with tissues is limited. We have studied in vivo effects of focused shock waves induced in the syngeneic sarcoma tumor model using the TUNEL assay, immunohistochemical detection of caspase-3 and hematoxylin-eosin staining. Shock waves were produced by a multichannel pulsed-electrohydraulic discharge generator with a cylindrical ceramic-coated electrode. In tumors treated with shock waves, a large area of damaged tissue was detected which was clearly differentiated from intact tissue. Localization and a cone-shaped region of tissue damage visualized by TUNEL reaction apparently correlated with the conical shape and direction of shock wave propagation determined by high-speed shadowgraphy. A strong TUNEL reaction of nuclei and nucleus fragments in tissue exposed to shock waves suggested apoptosis in this destroyed tumor area. However, specificity of the TUNEL technique to apoptotic cells is ambiguous and other apoptotic markers (caspase-3) that we used in our study did not confirmed this observation. Thus, the generated fragments of nuclei gave rise to a false TUNEL reaction not associated with apoptosis. Mechanical stress from high overpressure shock wave was likely the dominant pathway of tumor damage.

Extracorporeal shockwave therapy in musculoskeletal disorders

The sources of shockwave generation include electrohydraulic, electromagnetic and piezoelectric principles. Electrohydraulic shockwaves are high-energy acoustic waves generated under water explosion with high voltage electrode. Shockwave in urology (lithotripsy) is primarily used to disintegrate urolithiasis, whereas shockwave in orthopedics (orthotripsy) is not used to disintegrate tissues, rather to induce tissue repair and regeneration. The application of extracorporeal shockwave therapy (ESWT) in musculoskeletal disorders has been around for more than a decade and is primarily used in the treatment of sports related over-use tendinopathies such as proximal plantar fasciitis of the heel, lateral epicondylitis of the elbow, calcific or non-calcific tendonitis of the shoulder and patellar tendinopathy etc. The success rate ranged from 65% to 91%, and the complications were low and negligible. ESWT is also utilized in the treatment of non-union of long bone fracture, avascular necrosis of femoral head, chronic diabetic and non-diabetic ulcers and ischemic heart disease. The vast majority of the published papers showed positive and beneficial effects. FDA (USA) first approved ESWT for the treatment of proximal plantar fasciitis in 2000 and lateral epicondylitis in 2002. ESWT is a novel non-invasive therapeutic modality without surgery or surgical risks, and the clinical application of ESWT steadily increases over the years. This article reviews the current status of ESWT in musculoskeletal disorders.

Enhanced shock wave-assisted transformation of Escherichia coli

The objective of the study was to demonstrate that shock wave-induced transfer of DNA into bacteria can be increased by enhancing cavitation using dual-pulse (tandem) shock waves. Escherichia coli and plasmid were transferred to test vials. Competent cells were prepared at different concentrations of CaCl(2). Single pulses and tandem shock waves were compared as were three treatment temperatures: 0, 10 and 25 °C. Three delays (250, 500, 750 μs) between double pulses were tested. Characterization was achieved by using a plasmid that provided green fluorescent protein expression. At 0 °C double pulses generated at a delay of 750 μs significantly increased the number of fluorescent colonies compared with single pulses. In general, the lowest temperature enhanced the mean number of transformants compared with the two higher temperatures. A strong influence of the CaCl(2) concentration on the transformation efficiency was also found. The main conclusion is that gene transfer to target cells may be increased up to 50 times at 0 °C by enhancing cavitation using pairs of shock waves.

High energy shock waves activate 5'-aminolevulinic Acid and increase permeability to Paclitaxel: antitumor effects of a new combined treatment on anaplastic thyroid cancer cells

OBJECTIVE

Multimodal treatments do not meaningfully improve survival of anaplastic thyroid cancer. Consequently, new effective therapeutic modalities are needed. The use of paclitaxel is under clinical investigation; it shows about a 50% response rate, but it is not able to alter the fatal outcome for patients with anaplastic carcinoma. High energy shock waves (HESW) have been shown to cause a transient increase in the permeability of cell membranes thus allowing higher intracellular drug concentrations. 5-Aminolevulinic acid (ALA) is used in the photodynamic therapy (PDT) of cancer, and HESW are under evaluation for their use as an activator in ALA-PDT.

DESIGN

We investigated the effect of HESW produced by a piezoelectric generator on the sensitivity to paclitaxel and ALA treatments of two different anaplastic thyroid cancer cell lines (ARO and CAL-62). Cells, treated sequentially with ALA and paclitaxel were exposed to HESW; thereafter, cell viability and apoptosis induction were evaluated.

MAIN OUTCOME

Combined exposure to ALA, paclitaxel, and shock waves resulted in a significant enhancement of cytotoxicity and induction of apoptosis in thyroid cancer cells with respect to cells treated with paclitaxel alone.

CONCLUSIONS

These preliminary data suggest the possibility of using HESW and ALA in combination with paclitaxel as a promising new therapy in the treatment of anaplastic thyroid cancer.

Shock wave induced cytoskeletal and morphological deformations in a human renal carcinoma cell line

Effects of shock waves on the morphology and cytoskeleton of a human renal carcinoma cell line (ACHN) were investigated in vitro. ACHN monolayer cultured on a cover slide glass was treated with 10 shots of focused underwater shock waves, with 16 MPa peak pressure at the focal area of a piezoceramic shock wave generator. After exposure to the shock wave, based on the severity of morphological deformations of the treated cells, the monolayer was divided into three morphological areas; focal, marginal and intact. Morphological deformations were found to be associated with disorganization of the intracellular cytoskeletal filaments. Deformation of the cytoskeletal proteins in the treated cells were separately studied with respect to the location of the cells within the three morphological areas. Among three major cytoskeletal proteins, actin and tubulin, but not vimentin, were affected by the shock waves. The deformed cells reorganized their cytoskeletal network within 3 h with a pattern similar to the control, indicating the transient characteristic of the shock wave induced cytoskeletal damage in the surviving cells. The remaining cell fragments on the slide glass, which contained short actin filaments, indicated the important role of shear stress in damaging the cytoskeletal fibers by shock waves.

High Energy Shock Waves (HESW) Enhance Paclitaxel Cytotoxicity in MCF-7 Cells

High energy shock waves (HESW) produced by a piezoelectric generator were studied for their effect on human breast cancer cell (MCF-7) viability and sensitivity to paclitaxel. A dose-dependent impairment of cell viability was observed after HESW treatment (250-2000 shock waves, rate = 4/s, energy flux density = 0.25 mJ/mm2). Single treatment with shock waves produced no significant growth inhibition. Combined exposure to paclitaxel (ranging 0.1 nM to 20 microM) and shock waves (100, 500 and 1000 shots, respectively) resulted in a significant reduction of MCF-7 cell proliferation at day 3 after treatment in respect with cells treated with paclitaxel alone. Notably, a cell viability reduction of about 50% was obtained after combined treatment with HESW and 10 nM paclitaxel, in front of a reduction of only 40% using 10 microM paclitaxel alone. Moreover, an earlier induction as well as an enhancement of apoptotis was observed in cells subjected to combined treatment with shock waves and paclitaxel (200 nM; 20 microM). In conclusion, HESW can enhance paclitaxel cytotoxicity in MCF-7 cells, thus allowing the treatment with lower doses of drug.

Tumor cytotoxicity in vivo and radical formation in vitro depend on the shock wave-induced cavitation dose

Local tumor therapy using focused ultrasonic waves may become an important treatment option. This technique exploits the ability of mechanical waves to induce thermal and nonthermal effects noninvasively. The cytotoxicity to cultured cells and biological tissues in vivo that results from exposure to ultrasonic shock waves is considered to be a nonthermal effect that is partly a consequence of ultrasound-induced cavitation. Cavitation is defined as the formation of bubbles during the negative wave cycle; their subsequent oscillation and/or violent implosion can affect surrounding structures. To investigate cavitational effects in cells and tissues, defined cavitation doses must be applied while ideally holding all other potential ultrasound parameters constant. The application of independent cavitation doses has been difficult and has yielded little knowledge about quantitative cavitation-tissue interactions. By using a special shock-wave pulse regimen and laser optical calibration in this study, we were able to control the cavitation dose independently of other physical parameters such as the pressure amplitudes, and averaged acoustic intensity. We treated Dunning prostate tumors (subline R3327-AT1) transplanted into Copenhagen rats with shock waves at three cavitation dose levels and then determined the tumor growth delay and the histopathological changes. All of the treated animals exhibited a significant tumor growth delay compared to the controls. Higher cavitation doses were associated with a greater delay in the growth of the tumor and more severe effects on tumor histopathology, such as hemorrhaging, tissue disruption, and necrosis. In vitro, the cavitation dose level correlated with the amount of radical formation. We concluded that the process of acoustic cavitation was responsible; higher cavitation doses caused greater effects in tumors both in vivo and in vitro. These findings may prove important in local tumor therapy and other applications of ultrasound such as ultrasound-mediated drug delivery.

Shock wave therapy (Orthotripsy) in musculoskeletal disorders

Extracorporeal shock wave therapy, which now is used routinely for urolithiasis, has gained increasing acceptance in Europe for some musculoskeletal problems and has led to the inception of clinical studies in the United States. The authors have reviewed the available literature to assess the biologic effects of shock waves on human musculoskeletal tissues, the credibility of published studies on therapeutic applications, and the potential for more widespread application of this modality to various skeletal and near-skeletal disorders. The primary advantage of extracorporeal shock wave therapy is its noninvasive nature and seemingly minimal complications when applied to musculoskeletal tissues.

Mechanism of anti-tumor effect of combination of bleomycin and shock waves

We have previously reported marked enhancement of the cytocidal effect of bleomycin (BLM) on cancer cell suspensions in vitro by the combination with shock waves. In this study, we evaluated the synergistic effects on cancer cell proliferation and apoptosis in solid tumors. A spherical piezo-ceramic element was used as the shock wave source, with a pressure peak of 40 MPa. A human colon cancer cell line, SW480 was implanted onto the back of nude mice. Two thousand shock waves were administered to the tumor immediately following an intravenous injection of BLM at a dose of one-tenth of the LD(50). The tumor was extirpated at 3, 6, 12, 24, 72 h and 1 week following shock exposure. Cell proliferation and apoptosis were detected by Ki-67 using antibody MIB-1 and by the terminal deoxynucleotidyl transferase (TdT)-mediated dUTP-biotin nick-end labeling (TUNEL) method. The lowest percentage (35.7%) of Ki-67-positive cells appeared 24 h following the treatment. The maximum apoptotic index was detected within 6 h following the treatment. Moreover, numerous large cells with enlarged nuclei were detected histologically. These results suggest that shock waves may enhance chemotherapeutic effects by increasing apoptosis and decreasing cell proliferation in the tumor tissue.

A comparison of shock wave and sinusoidal-focused ultrasound-induced localized transfection of HeLa cells

Both shock waves and sinusoidal continuous wave ultrasound can mediate DNA transfer into cells. The relative transfection efficiencies of different ultrasound modalities are unclear. The purpose of this paper is to compare the transfection efficiency of lithotripter shock waves and focused sinusoidal ultrasound in vitro. HeLa cells were transfected with beta-galactosidase and luciferase plasmid DNA reporter. Shock waves were generated by an electromagnetic sound source. Sixty to 360 pulses at 1 Hz pulse frequency were administered at 13, 16 or 19 kV capacitor voltage. Sinusoidal focused ultrasound was generated by a single focus piezoceramic air-backed disk transducer at a carrier frequency of 1.18 MHz operated in a pulsed mode. Compared to cells mixed with DNA only, shock waves induced up to eightfold more transfected cells at a cell viability of 5%, while sinusoidal-focused ultrasound induced up to 80-fold more transfected cells at a cell viability of 45%. The corresponding transfection efficiencies of the HeLa cells were 0.08% for shock waves and 3% for focused ultrasound. These results may contribute to the selection of the ultrasound modality as a localized, noninvasive and safe tool to mediate gene transfer.

Synergistic interaction of ultrasonic shock waves and hyperthermia in the Dunning prostate tumor R3327-AT1

Pulsed high-energy ultrasound shock waves (PHEUS), similar to those used for clinical lithotripsy, can deposit energy deep in tissue and thereby destroy the microvasculature of solid tumors. We investigated the potential of PHEUS, generated by an electromagnetic shockwave source (19 kV capacitor voltage, 1 Hz pulse frequency), as a local cancer-therapy modality alone and in combination with local tumor hyperthermia (43.5 +/- 0.1 degrees C, 30 min). Copenhagen rats transplanted with the anaplastic Dunning-prostate-tumor sub-line R3327-AT1 received 1000 PHEUS pulses, which delayed tumor growth by one tumor-doubling time (5 days). Histopathology revealed hemorrhage, disruption of tumor vasculature, and necrosis in the focus of the sound field. Bromodeoxyuridine (BUdR) incorporation was significantly lower in PHEUS-treated tumors than in controls. Dynamic magnetic resonance imaging (MRI) studies using gadolinium-DTPA as contrast agent showed a strong reduction of tumor perfusion after PHEUS treatment, although this effect was partly reversible within 3 days after PHEUS. While hyperthermia alone produced no significant delay in tumor growth, the combination of PHEUS and hyperthermia produced tumor-growth delay by 2 tumor-volume-doubling times. The maximum growth delay was achieved when PHEUS and hyperthermia were separated by 24 hr at the time of maximum perfusion reduction indicated by MRI. Thus, the cytotoxic effect of PHEUS was enhanced by hyperthermia in the anaplastic prostate tumor R3327-AT1 grown on Copenhagen rats in a synergistic manner, due to blood-flow reduction. In conjunction with other agents, such as hyperthermia, PHEUS might become a local cancer-therapy modality in solid tumors accessible to ultrasound.

Sonochemically induced radicals generated by pulsed high-energy ultrasound in vitro and in vivo

The aim of this study was to evaluate the role of radicals as a mechanism of tissue damage induced by pulsed high-energy ultrasound. Transient cavitation has proved to be an important mechanism for the generation of reactive radical species during pulsed high-energy ultrasound applications. The amount of radicals studied in in vitro experiments using a chemical dosimeter based on iodine release is proportional to the number of pulses. Sonications of the R3327-AT1 subline of the Dunning prostate rat tumor transplanted in the thigh of Copenhagen rats were performed applying 500 and 2000 pulses at a pulse repetition frequency of 1 Hz. Tumor growth after treatment was compared with sham-treated controls. We were able to assess a significant growth delay, but could not find a significant difference between the two groups treated. In conclusion, radical formation does not seem to be the major mechanism for tissue necrosis induced by pulsed high-energy ultrasound.

Comparison between the effects of cavitation induced by two different pressure-time shock waveform pulses

Acoustic cavitation generates very large localized pressures and temperatures, and thus provides a mechanism whereby physical and biological effects are produced in a high-intensity acoustic field. In this work, we studied the influence of the temporal form of a pressure pulse waveform on the destructive effects of transient cavitation. Two different shock pressure-time waveforms with nearly the same acoustic energy content were used. The first pressure waveform starts with a tensile wave followed by a compressive one, and the second pressure waveform starts with a compressive wave followed by a tensile one. These two pressure waveforms are called direct and inverse-mode pulses respectively. Based on the measurements presented in this work, we can state that, between the two types of shock pressure pulses studied, the direct-mode pulse amplifies systematically tile cavitation effect. This conclusion was achieved from a series of several quantitative and qualitative experiments: cavitation bubble collapse time, disintegration efficacy of plaster balls (a kidney stone-mimicking material), macroscopic study of lesions in agar gel and in vitro isolated rabbit liver tissue destruction. Considering these results and those obtained by other research groups, we can express that the temporal form of a shock pressure pulse has a major role on the cavitation effects.

The osteogenic potential of extracorporeal shock wave therapy. an in-vivo study

We studied the effects of extracorporeal shock wave therapy (ESWT) on the healing potential of osteotomies in rabbit radii. The results of sequential low dose shock wave therapy were compared prospectively with natural healing in the radii of New Zealand white rabbits. Our results suggest that ESWT causes new bone formation locally. However such exuberant callus formation does not equate with accelerated fracture healing and in fact implies a delay in the remodelling process.

The combined effects of high-energy shock waves and ionising radiation on a human bladder cancer cell line

The effects of high-energy shock waves (HESW) generated by an experimental Siemens lithotripter in combination with 137Cs gamma-rays were examined in vitro. Proliferation after treatment of immobilised pellets of either single cells or multicellular spheroids of the bladder cancer cell line RT4 was determined using colony-forming assays and cell cycle analysis. Surviving and cell cycle fractions were calculated for each shock wave and radiation application mode separately, and for sequential combination in different successions for the purpose of characterizing the interaction of both treatment modalities. Combination of HESW and ionising radiation turned out to act additively or slightly supra-additively on both biologic models.

Biophysical effects of high-energy pulsed ultrasound on human cells

Human benign and malignant cells of different human origin (pancreas, liver, kidney, pharynx, tongue, lip) were exposed to high-energy pulsed ultrasound (HEPUS) in vitro to evaluate the effects of various physical parameters and sonication conditions on cell viability. This included the number of pulses, focal pressure, pulse repetition rate, pulse shape, cell suspension volume, water level of the basin and cell density. Cell viability was found to depend significantly on the number of pulses (exponential), the focal pressure (linear) and the pulse repetition rate (minimum at 1 Hz). Other parameters showed no marked influence. Furthermore, electron microscopy revealed intracellular damage, and proliferation rates of cells surviving sonication were normal after HEPUS exposure. The experimental piezoelectric ultrasound transducer used in the experiments generated oscillating bipolar pulses with high negative pressure amplitudes. Measurements were made of the pulse shape and ultrasonic field of the experimental device and of a conventional lithotripter for comparison.

Mechanisms of shockwave action in the human kidney

The effects on the human kidney parenchyma of high-energy shockwaves (HESW) with different energy densities were examined. Kidneys of patients treated by radical nephrectomy for renal cell carcinoma were perfused with cold HTK solution immediately after nephrectomy and kept in hypothermia (8 degrees C) for a maximum of 4 hours. The tumor-free parenchyma was treated with 2000 shocks at energy outputs of 15 kV (16 MPa, 0.15 mJ/mm2), 17 kV (32 MPa, 0.25 mJ/mm2), 19 kV (50 MPa, 0.4 mJ/mm2), and 21 kV (65 MPa, 0.6 mJ/mm2) in an experimental electromagnetic shockwave system (Siemens Co., Erlanger, Germany). Resulting tissue effects were analyzed by histologic and immunohistochemical examinations and confocal laser scanning microscopy. Different sensitivities of cell components, blood vessels, and tubules were found. Laser scanning microscopy revealed nuclear alterations in the vicinity of the focus up to a distance of approximately 10 mm. Severe histologic changes were found in a smaller zone, while immunohistochemistry studies revealed negative collagen IV staining in an area of approximately 4 x 4 mm (all distances measured within the plane perpendicular to the acoustic axis). From these results, it can be concluded that HESW directly damage the tubules and the vascular system, which might explain the clinical changes after extracorporeal shockwave lithotripsy in human patients. The extent of these effects seems to be dependent on the applied energy.

The effect of high-energy shock wave therapy combined with cisplatin on mouse hepatoma

It is well documented that high-energy shock waves (HESW) can produce antitumor effects in vivo and in vitro. Furthermore, because HESW can be focused on a limited area, this therapy is considered applicable to the treatment of localized cancer. In this study, we investigated the effects of HESW therapy combined with cisplatin (CDDP) on MH134 hepatoma in a mouse model. Tumor growth was inhibited by 1 mg/kg CDDP treatment in combination with 2,000 HESW administration, but not by 1 mg/kg CDDP treatment only. Moreover, the CDDP concentration in the tumor increased after HESW administration. The active oxygen induced by HESW was then investigated by the electron spin resonance system, and it was found that HESW generated hydroxy-radicals. As oxygen radicals have been reported to change cell membrane potential, it is supposed that active oxygen induced by HESW changes cell membrane permeability, and that CDDP is concentrated in the tumor. Therefore, the combined therapy with HESW and CDDP showed synergistic inhibitory effects on tumor growth.

Enhancement of the antitumor effect by combined use of high-energy shock waves and ATX-70

The antitumor effects of high-energy shock waves (HESW) in combination with ATX-70 [a gallium-porphyrin complex, 2,4-bis(1-decyloxyethyl)-Ga(III)-1,3,5,8-tetramethylporphyrin++ +-6, 7-dipropionyl diaspartic acid [sequence: see text] were investigated. In vitro, the cell damage to mouse MH134 hepatoma after HESW treatment was enhanced by adding ATX-70. In vivo, HESW and ATX-70 combination therapy inhibited cell growth. However, neither HESW treatment alone nor ATX-70 treatment alone inhibited cell growth. These results imply that the antitumor effects of HESW and ATX-70 combined therapy are caused by activation of ATX-70 by HESW.

High-energy underwater shock wave treatment for internal iliac muscle metastasis of prostatic cancer: a first clinical trial

The first clinical trial of high-energy shock wave (SW) combined with chemotherapy to treat metastasis of prostate cancer in the internal iliac muscle was conducted. The patient, a 57-year-old man, diagnosed as having mucin-producing, poorly differentiated adenocarcinoma of the prostate invading the bladder wall, had been treated by total cystoprostatectomy. Five months later, metastatic tumors were found in the left axillar subcutaneous tissue and the right internal iliac muscles. For the axillar metastasis we performed radiation and left subclavicular arterial infusion of cisplatin 70 mg, THP-adriamycin (THP) 50 mg and methotrexate 50 mg. For the right internal muscular metastasis, 10,000 to 20,000 shots of SW and simultaneous intravenous injection of carboplatin 100 mg and THP 10 mg were carried out. Neither of the tumors decreased in size, but on magnetic resonance images, the SW-treated tumor exhibited a central low-intensity area. The SW-treated tumor was resected and central necrosis and a collection of mucin in the central area were observed. Hormone-resistant prostate cancer is well-known to be a multidrug-resistant tumor. It is noteworthy that SW and chemotherapy induced necrosis in such a refractory cancer without any significant side effects.

Influence of water temperature on pressure pulses generated by an electromagnetic type lithotripter

The need to survey and compare in vitro investigations on the effect of extracorporeally generated pressure pulses demands precise description of experimental conditions. We determined the effect of water temperature on the pressure characteristics in and around the focus area of an electromagnetic type lithotripter. The peak pressure amplitude at the geometrical focus of the lens was reduced to 60% of the original peak pressure if water at room temperature was used instead of water with human body temperature. By decreasing the temperature of the lithotripter's internal water, we observed shifting of the focus point at a rate of 1.4 mm per degree. This dramatic reduction of the peak pressure and the shifting of the focus point resulting from changes in the acoustic and thermal parameters of the propagation medium and of the focusing device could lead to differences of up to 80% of peak pressure amplitude.

Effect of shock waves and cisplatin on cisplatin-sensitive and -resistant rodent tumors in vivo

The effect of a combination of shock waves with cisplatin was examined in vivo with subcutaneously implanted amelanotic melanomas (A-Mel 3) in Syrian golden hamsters and cisplatin-sensitive or cisplatin-resistant fibrosarcoma (SSK2/0 and SSK2/R2) in C3H mice. In all 3 tumor models, 4 treatment modalities were compared: control, cisplatin treatment, shock waves and the combination of shock waves and cisplatin. Shock waves significantly delayed tumor growth in all 3 tumor models when compared to the respective control group. Cisplatin alone delayed the growth of A-Mel 3 and SSK2/0, whereas SSK2/R2 remained uninfluenced by the drug. In all 3 tumor models the combined treatment with shock waves and cisplatin additively and significantly delayed tumor growth. In A-Mel-3-bearing animals the combined treatment significantly increased survival time. The growth of SSK2/0 and SSK2/R2 tumors was delayed to a similar extent by the combined treatment modality as compared to shock-wave treatment alone. This indicates that the cisplatin resistance of SSK2/R2 tumors has been overcome by the simultaneous shock wave treatment. An increased intracellular cisplatin accumulation in the tumors due to shock wave exposure is suggested as the mechanism of interaction between shock waves and cisplatin.

Cytocidal effect of high energy shock wave on tumour cells enhanced with larger dose and multiple exposures

Cultured LLC-WRC256 (Walker rat carcinoma) cells were exposed to different doses of high energy shock waves (HESW). The immediate viabilities were 98% in the control cells, and 74%, 53% and 18% following 400, 800, and 1500 HESW treatment, respectively. Surviving cells in the 400 and 800-treated HESW demonstrated delayed upward growth rate curves, and the 1500 HESW-treated a downward curve. Agar clonogenic efficiencies for surviving cells were 36% (control), 20% (400 HESW), 15% (800 HESW) and 3% (1500 HESW). LLC-WRC256 tumours in Wistar rats were treated once every other day with 1500 HESW on a total of three occasions. Tumours treated with HESW grew more slowly (4.9 cm3) than those in the control (13.5 cm3). HESW fragmented cells and destroyed cell membranes and intracellular organelles. A histological examination of tumours treated with HESW demonstrated local haemorrhage with necrosis in the HESW focus area. Damage to the surrounding skin and soft tissue was slight and transient. These findings suggest that the growth of tumour cells can be suppressed in vitro and in vivo by treatment with HESW.

Proliferation of tumor spheroids after shock-wave treatment

Multicellular tumor spheroids (MCTS) grown from the bladder cancer cell line RT112 and from the prostate cancer cell line PCA were exposed to 200 or 800 electromagnetically generated focused ultrasound shock waves. RT112 cells showed a distinct but transient decrease in proliferation whereas the effect of PCA cells was less pronounced. Flow-cytometric measurements of DNA content and Ki67 expression revealed no significant changes in the cell cycle distribution. The capacity of RT112 cells exposed to 800 shock waves to re-grow as MCTS was markedly decreased, indicating an alteration of intercellular adhesion.

Focused liver ablation by cavitation in the rabbit: a potential new method of extracorporeal treatment

A new device was used to achieve focused tissue ablation by shockwave induced cavitation. The device produced a half cycle of negative pressure followed by a shock wave, thus enhancing cavitation. Twenty eight New Zealand rabbits were treated. Therapeutic ultrasound was targeted at the centre of the liver under ultrasound guidance. The focal volume was scanned with a computer operated x-y-z micropositioner. The number and frequency of bursts as well as the distance between two x-y-z displacements were preselected. The relation of tissue ablation seen to preselected parameters, effects on surrounding tissues, biological side effects, and mode of healing were studied. Macroscopy, planimetry, and quantitative microscopy were used. Focused and homogeneous tissue ablation was achieved within well defined limits. Maximal tissue ablation was seen in the centre of the target. Liver surrounding the target remained unaffected. Lesions were made of a-cellular spots surrounded by disorganised rims of necrotic hepatocytes; 24 hours after treatment, the changes (mean (SEM)) in alanine transaminase and haemoglobin were +225 (36)% and -2.4 (2)% respectively. Serum transaminases, haemoglobinaemia, and packed cell volume were normal 21 days after treatment and the target area was replaced by a fibrous scar. It is concluded that ultrasound cavitation may achieve extracorporeal intrahepatic tissue ablation inside a predetermined target. This technique should now be tested in an animal hepatic tumour model.

Current role of extracorporeal shockwave therapy in surgery

In urology the introduction of extracorporeal shockwave therapy brought a revolutionary change to the management of urinary calculi. This inspired the introduction of shockwave therapy in several fields of surgery; it has been applied as a potential alternative to several operative procedures but is still experimental. So far, the major application of shockwave therapy has been lithotripsy of stones in the gallbladder, common bile duct, pancreatic duct and salivary gland ducts. Other applications are in the non-operative management of bone healing disturbances and in the inhibition of tumour growth. Steps towards selective thrombus ablation and pretreatment of heavily calcified arteries have also been made. In this review, the applications of extracorporeal shockwave therapy in several areas of surgery are discussed. It is concluded that, for selected patients, shockwave treatment may serve as a useful addition to the surgical armamentarium.

Tumor growth delay by laser-generated shock waves

The antiproliferative effect of laser-generated shock waves (L-SW) was investigated on a human renal cell carcinoma, RC-8, grown subcutaneously in the nu/nu mouse. The RC-8 is characterized by the syndrome of humoral hypercalcemia of malignancy (HHM) associated with profound cachexia, increase of serum Ca level, hypophosphatemia, and an enhancement of serum parathyroid-like peptides. In this model system, the effects on cachexia and tumor growth were studied after a series of pulses (3-200) generated by a Candela LFDL/3 equipped pulsed-dye laser with optical fiber guided through a hypodermic needle with a 45 degrees angle bended tip, stuck through the skin of the mouse, and positioned directly below the tumor. The antitumor effect, expressed as a delay of tumor growth, was found to be dependent on number of pulses applied, tumor size, and growth rate (alpha). Treatment of RC-8 with alpha = 0.21 was effective only after 200 pulses combined with a tumor volume smaller than 100 mm3. Under these conditions a growth delay of approximately 8 days was observed, paralleled by delay of animal weight loss (cachexia). Under conditions of a decreased growth rate of RC-8 (alpha = 0.13), the susceptibility toward L-SW was found to be increased, expressed by a suppression of tumor growth after 100 pulses. However, no L-SW-associated delay of cachexia was observed under these latter conditions.

In vivo detection of ultrasonically induced cavitation by a fibre-optic technique

The measurement of cavitation events in tissue in vivo would greatly assist us to better understand how pulsed high energy ultrasound (PHEUS) interacts with living tissues, especially with regard to cancer therapy. To accomplish this, we designed and built a fibre-optic hydrophone. The principle was to couple the light of a laser diode into a lightfibre and to register the ultrasound induced modification of the refractive index in tissue. In this manner, the cavitation event could be quantitatively investigated both in water and in vivo. The structure of the bubble dynamic is in reasonable agreement with theoretical predictions, and in vitro measurements. With the fibre-optic set-up, the pressure signal can also be detected. PHEUS was generated by an electromagnetic source adapted from a commercial lithotripter (Lithostar Siemens). As biological tissue we used the experimental R3327-AT1 Dunning prostate tumor growing subcutaneously in the thigh of male Copenhagen rats. The lifetime of the cavitation bubble in water increased with the energy level of the ultrasonic pulse from 250 microseconds at 13 kV capacitor voltage to 750 microseconds at 21 kV, while the lifetime inside the tumor tissue in vivo increased only from 100 microseconds at 13 kV to 220 microseconds at 21 kV capacitor voltage.

Complete local tumor remission after therapy with extra-corporeally applied high-energy shock waves (HESW)

High-energy shock waves (HESW) have recently been proposed as a means of non-invasive tumor therapy. Here we report the first successful local treatment of experimental tumors by means of multifocal and reported application of HESW. The experiments were performed on 29 Syrian golden hamsters bearing amelanotic hamster melanomas in the dorsal skin. HESW, generated electrohydraulically, were applied multifocally to the center and to 5 sites on the margin of the tumors. A group of animals undergoing surgical resection and an untreated group served as controls. Complete remission of local tumor was achieved in more than 90% of the HESW-treated hamsters and in the same number of surgically treated animals, while untreated tumors continued to grow. Frequency of metastasis was the same in both groups after HESW treatment or surgery. Tumor therapy with multifocally and repeatedly applied HESW was thus as successful as surgery.

Ischemia and loss of ATP in tumours following treatment with focused high energy shock waves

High energy shock waves (HESW) have been reported to be cytotoxic to tumour cells in vitro and in vivo. For that reason they are evaluated as a new modality for cancer treatment. In the present study we have quantified the effect of treatment with multifocal HESW on tumour blood flow and energy status. Blood flow and adenosine triphosphate (ATP) concentration were investigated simultaneously in tumour and adjacent tissue of six treated and six untreated amelanotic hamster melanomas (A-Mel-3) at 3, 12 or 24 h after multifocal application of HESW. 14C-iodoantipyrine autoradiography for blood flow measurements and quantitative ATP imaging bioluminescence were employed. Following treatment, tumour blood flow and ATP concentration were significantly reduced, as compared to control, over the entire period of observation. Three hours after HESW, blood flow and ATP concentration were at the background level. In adjacent tissue, blood flow and ATP concentration were distinctly diminished. We therefore conclude that multifocal HESW induce a breakdown of tumour-, and adjacent tissue perfusion which is accompanied by a significant decrease of intracellular ATP concentration.

In vivo effects of cavitation alone or in combination with chemotherapy in a peritoneal carcinomatosis in the rat

Cavitation (volume oscillations and collapse of gas bubbles), as generated by a co-administration of shockwaves (SW) and microbubbles (SWB), induces cytotoxicity in vitro. Moreover, cavitation potentiates the effects of Fluorouracil (FUra) on colon cancer cells. We aimed at reproducing such effects in vivo. A peritoneal carcinomatosis was induced in BDIX rats by intraperitoneal (IP) injection of DHDK12PROb cells. Cavitation was produced by various SW regimens (250 to 750SW) combined with bubbles (air/gelatin emulsion) infused through an IP catheter. In two consecutive experiments, microtumours (day 3 after cell injection) were submitted to various combinations of cavitation and/or Fluorouracil (FUra) and Cisplatinum (CDDP) at either high or low doses. After 30 days, 100% of control animals were dead or presented carcinomatosis with ascites, vs 60% after FUra 5 mg kg dy, day 4 through 8, and 0% after 250 SWB, day 4 and 6 + FUra 5 mg kg dy, day 4 through 8 (P < 0.001); similar differences were found with CDDP. Survival after low dose FUra + SWB was comparable to high dose FUra (25 mg kg dy day through 8) and was improved as compared to low-dose FUra alone. Only a high dose FUra + SWB schedule induced 40% long term (> 150 days) disease-free survival, but also a higher undesirable toxicity (40% toxic deaths within 1 month). It is concluded that cavitation is cytotoxic in vivo and that it potentiates the effects of FUra and CDDP in this animal model.

Determination of the energy-dependent extent of vascular damage caused by high-energy shock waves in an umbilical cord model

To determine the spatial extent of shock-wave-induced vascular damage human umbilical cords were exposed to electromagnetically generated, focused ultrasound waves of different energy densities. During treatment macroscopically visible hematoma and superficial holes appeared. Following exposure specimens were fixed and examined histologically. In addition to vessel wall necrosis and rupture, complete detachment of endothelial cells in defined regions was observed. A correlation of the extent of the damage with the energy density distribution revealed that a local energy density of 0.3 mJ/mm2 is the lower threshold for the occurrence of severe vascular damage.

The effects of focused extracorporeal pyrotherapy on a human bladder tumor cell line (647 V)

Human transitional cell bladder carcinoma cell-line 647 V has been used to evaluate the effects on tumor cells in vitro of a new technique: focused extracorporeal pyrotherapy (F.E.P.). The device is made of multi-sources of piezoelectric ceramics focused at 320 mm. The focal area is 10 mm. high on 1.5 mm. width, and shots of 0.25 to 0.50 seconds were delivered on 4 groups of cell pellets placed in a polyurethane tube at the focus. Trypan blue MTT cell growth curve and Colony forming tests were used. There was a significant reduction (Student's t test) of the cell variability rate on the Trypan Blue test, 5% (in the treated Group) against 95% (control Group). The growth curve was flattened whether 0.50 second shots were single or repeated. The colony formation test was also significantly altered: 5.7% (treated group) against 70% (control group).

CONCLUSION

focused extracorporeal pyrotherapy is able to alter or kill tumor cells in vitro.

A review of the physical properties and biological effects of the high amplitude acoustic field used in extracorporeal lithotripsy

Extracorporeal shockwave lithotripsy (ESWL) has now been used for more than a decade in the treatment of urinary stone disease. During this period there has been a wide range of studies on the physical properties of the high-amplitude focussed fields used in ESWL and the biological effects of exposure to such fields, including their ability to fragment hard concretions. These studies form a distinct body of knowledge whose relevance to the broader literature on biological effects from lower amplitude exposures has yet to be fully evaluated. This review attempts to present the main results of biological-effects studies in ESWL along with what is known of the physical properties of lithotripsy fields with the aim of assisting this evaluation. In general, the reported biological effects of lithotripsy fields are compatible with those that have been observed at those lower amplitudes of focussed pulsed ultrasound in which transient cavitation is the dominant mechanism of interaction. The relatively large amplitudes and low frequencies in ESWL, however, make it a more potent generator of transient cavitation than most other forms of medical ultrasound. Biological-effects studies with lithotripsy fields may, therefore, be expected to extend our understanding of the nature of transient cavitation and, in particular, its effects in mammalian tissue.

Biological effects of laser-induced shock waves: structural and functional cell damage in vitro

A new experimental design has been used to study the biological effects of laser-induced shock waves which minimizes or eliminates interference from ancillary effects such as bubble formation, ultraviolet (UV) radiation, or formation of radicals. The effects of these shock waves on human lymphocytes and red blood cells have been investigated. Three assays were used to determine cell injury: electron microscopy, ethidium bromide/fluorescein diacetate (EB/FDA) staining and incorporation of tritiated thymidine. The degree of cell damage was related to the pressure and the number of pulses. Cell damage was quantified and correlated using the three assays. Measurements of gross structural alterations as determined by transmission electron microscopy were less sensitive than assays of structural damage (e.g., EB/FDA assay) which were less sensitive than functional assays (e.g., incorporation of tritiated thymidine).

High-energy shock waves pyrotherapy. A new concept in extracorporeal tumour therapy

High-intensity shock waves (HISW) waves can produce rapid and intense tissue heating. We have studied a novel device capable of simultaneous shock wave generation, focusing and extracorporeal delivery along with imaging of the proposed target. Shock waves are generated by piezo-electric crystals and target a focal point of 10 x 2 mm. In a preliminary study, three groups of land race pigs received HISW to discrete points on the liver parenchyma. There was no mortality in any group. Cardiovascular monitoring revealed that HISW did not induce any haemodynamic changes during treatment and that core temperatures and liver function tests were unaffected by this therapy. Ultrasound monitoring during treatment demonstrated discreet hyperechoic areas with acoustic shadowing suggesting cavitation. Animals killed immediately after 48 h of HISW therapy had discrete necrotic cylinders within the liver with a mean diameter of 2 cm (+0.21 SD). Histological examination revealed a pattern of necrosis and vascular changes suggestive of ischaemia. In addition, there were areas of coagulative necrosis consistent with thermal injury. Animals killed at 2 months had necrotic cavities which had become surrounded by mature fibrosis. These early results indicate that high energy shock waves delivered extracorporeally can cause specific destruction of liver tissue by focused hyperthermia and cavitation. Clinical studies of this device are required to assess the possible virtue of HISW in the treatment of liver and other tumours.

In vitro interaction of lithotripter shock waves and cytotoxic drugs

The effect of a combination of lithotripter shock waves and cytotoxic drugs was examined in vitro. L1210 cells in suspension were exposed to shock waves during incubation with cislatin, doxorubicin, daunorubicin, THP-doxorubicin, or aclacinomycin. Proliferation was determined using the 3-4,5 dimethylthiazol-2,5 diphenyl tetrazolium bromide assay. Dose enhancement ratios were calculated for each drug in order to determine the effect of the additional exposure to shock waves. In addition, partition coefficients and IC50s of the drugs were determined. It was found, that the dose enhancement ratios increased for the drugs with decreasing cytotoxicity. The effect of all five drugs was enhanced by shock waves to a higher degree at 7 min incubation as compared to 50 min incubation. The effect of cisplatin was most significantly enhanced, with a dose enhancement ratio of 6.7 at 7 min incubation. The enhancement increased with the operating voltage used for generating the shock waves, and was only present when cells were exposed to shock waves during the incubation with the drug. An increase in cellular membrane permeability is proposed as the mechanism of interaction between shock waves and drugs.

Altered neutrophil permeability following shock wave exposure in vitro

Human neutrophils were exposed to varying numbers of shock waves using the Dornier XL-1 experimental lithotripter. Cellular changes were observed with as few as 60 shock waves generated with 20 KV at a frequency of one per second. A graded reduction in cell numbers and cell viability was observed up to 300 SW. With exposure to 140 SW or above a decrease in mean cell size occurred. When cells were shocked in the presence of adriamycin or after loading with fluorescein, flow cytometry revealed that influx of extracellular components and efflux of cytoplasmic components had occurred. An ultrastructural and functional analysis of cells exposed to 60 SW, where cellular disruption and loss of viability were minimal, revealed several types of cellular changes which may precede SW-induced cell death. Electron microscopic examination revealed in some cells a loss of staining intensity. Plasma membrane rupture and leakage of cytoplasmic components were occasionally evident. The adherence of shocked cells to glass, and the spreading of cells that had adhered, were also reduced. From these studies, it is concluded that cellular permeability and other vital cellular functions in neutrophils are perturbed by SW exposure.

Shock wave and THP-adriamycin for treatment of rabbit's bladder cancer

Focused high-energy shock waves (6,000 to 10,000 shots) were targeted under ultrasound guidance onto implanted urinary bladder cancer in rabbits to elucidate its effect. Although only focal necrosis of the tumor was seen following 6,000 to 10,000 shots daily for 3 days or following chemotherapy (THP-adriamycin) alone, almost total tumor necrosis was observed following a combined shock-wave therapy for one day and THP-adriamycin administration, demonstrating an additive and/or synergetic effect on rabbit urinary bladder cancer.

The effect of isolated high-energy shock wave treatments on subsequent bacterial growth

To determine whether high-energy shock waves possess bactericidal potential, ATCC strains of Escherichia coli, Streptococcus faecalis, Pseudomonas aeruginosa and Staphylococcus aureus were suspended in solution at concentrations approximating 10(6) bacteria per milliliter, placed in polypropylene cryovials, and immersed in the water bath of a Dornier HM3 lithotriptor. Each cryovial was then fluoroscopically guided to the epicenter of the f2 focal point and 2000 shocks at 20 kV applied. Suspensions were then serially diluted and colony counts obtained. The procedure was then repeated with 4000 shocks at 20 kV from the Dornier HM3 and 4000 shocks at intensity level 4 from a Wolff Piezolith 2200 shock wave lithotriptor. Comparison of shock-wave-treated and sham-treated bacterial suspensions revealed no significant difference in bacterial growth according to the colony count technique. We conclude that high-energy shock waves, whether generated by spark gap or piezoelectric array, do not possess significant bactericidal activity.

Effects of lithotripter-generated high energy shock waves of mammalian cells in vitro

The effects of high energy shock waves on an established human prostatic carcinoma cell line (PC-3) were investigated. HESW were administered to PC-3 cell suspensions using an electrohydraulic lithotripter (Dornier HM3). Experimental variables included the number of shocks to which the cells were exposed, spark generator potential, and the position of the cell sample in the acoustic field. Two types of cellular damage were observed: immediate cell destruction (lysis) as measured by electronic particle counting and the loss of reproductive capacity (viability) among the remaining cells as determined by colony formation assay. Over the range of the experimental variables studied, cell lysis was dependent to a greater extent on the number of shocks administered than the generator potential. Viability was affected less but was also dependent on both the generator potential and shock number. Cell lysis was strongly dependent on the position of the sample in the acoustic field with the extent of damage increasing as the sample was moved along the central axis of the shock wave from the f2 focus towards the electrodes. Possible mechanisms of damage and the relationship of the in vitro effects to the damage observed in normal tissues of patients undergoing extracorporeal lithotripsy for kidney stone disease are discussed.

Effects of high-energy shock waves on murine renal cell carcinoma

The effects of high-energy shock waves (HESW) on a murine renal cell carcinoma (RenCa) was investigated. In vitro exposure of tumor cells to HESW resulted in a dose-dependent reduction in cell viability as determined by trypan blue dye exclusion, plating efficiency, growth curve, and soft agar clonogenic assays. Activity of lactic dehydrogenase (LDH) was detected in the supernatant after the HESW treatment due to cellular destruction, and a dose-dependent increase in cytocidal effect was demonstrated. Ultrastructural changes with swelling and distorted cristae of mitochondria, vacuolation, ribosomal lysis, and chromatinolysis were observed in HESW-treated RenCa cells. Flow cytometric (FCM) study revealed that DNA content of RenCa cells diminished after 200 HESW treatment, and RNA content of tumor cells decreased markedly after 400 HESW treatments. Partial or complete inhibition of tumor growth was shown in both animal modalities of subcutaneous inoculation and intravenous injection with sequential lung metastases. This study stressed again that HESW may play a role in combinational protocol for the treatment of human renal cell carcinoma in certain circumstances.