The use of ultrasound for drug delivery

A Refined Hot Melt Printing Technique with Real-Time CT Imaging Capability

Personalised drug delivery systems with the ability to offer real-time imaging and control release are an advancement in diagnostic and therapeutic applications. This allows for a tailored drug dosage specific to the patient with a release profile that offers the optimum therapeutic effect. Coupling this application with medical imaging capabilities, real-time contrast can be viewed to display the interaction with the host. Current approaches towards such novelty produce a drug burst release profile and contrasting agents associated with side effects as a result of poor encapsulation of these components. In this study, a 3D-printed drug delivery matrix with real-time imaging is engineered. Polycaprolactone (PCL) forms the bulk structure and encapsulates tetracycline hydrochloride (TH), an antibiotic drug and Iron Oxide Nanoparticles (IONP, Fe₃O₄), a superparamagnetic contrasting agent. Hot melt extrusion (HME) coupled with fused deposition modelling (FDM) is utilised to promote the encapsulation of TH and IONP. The effect of additives on the formation of micropores (10-20 µm) on the 3D-printed surface was investigated. The high-resolution process demonstrated successful encapsulation of both bioactive and nano components to present promising applications in drug delivery systems, medical imaging and targeted therapy.

Recent advances in remotely controlled pulsatile drug delivery systems

Pharmaceutical technology is drastically developing to enhance the efficacy and safety of drug therapy. Pulsatile delivery systems, in turn, gained attraction for their ability to deliver the right drug amount to the right body site, at the right time which is advantageous over conventional dosage forms. Their use is associated with increased patient compliance and allows on-demand drug delivery as well as customizable therapy. Recent technologies have been implemented to further develop pulsatile delivery systems for more precise determination of the dosage timing and duration as well as the location of drug release. Great interests are directed towards externally regulated pulsatile release systems which will be the focus of this review. The recent advances will be highlighted in remotely controlled delivery systems. This includes electro responsive, light-responsive, ultrasound responsive, and magnetically induced pulsatile systems as well as wirelessly controlled implantable systems. The current status of these technologies will be discussed as well as the recent investigations and future applications.

Combining sonodynamic therapy with chemoradiation for the treatment of pancreatic cancer

Treatment options for patients with pancreatic cancer are limited and survival prospects have barely changed over the past 4 decades. Chemoradiation treatment (CRT) has been used as neoadjuvant therapy in patients with borderline resectable disease to reduce tumour burden and increase the proportion of patients eligible for surgery. Antimetabolite drugs such as gemcitabine and 5-fluorouracil are known to sensitise pancreatic tumours to radiation treatment. Likewise, photodynamic therapy (PDT) has also been shown to enhance the effect of radiation therapy. However, PDT is limited to treating superficial lesions due to the attenuation of light by tissue. The ability of the related technique, sonodynamic therapy (SDT), to enhance CRT was investigated in two murine models of pancreatic cancer (PSN-1 and BxPC-3) in this study. SDT uses low intensity ultrasound to activate an otherwise non-toxic sensitiser, generating toxic levels of reactive oxygen species (ROS) locally. It is applicable to greater target depths than PDT due to the ability of ultrasound to propagate further than light in tissue. Both CRT and the combination of CRT plus SDT delayed tumour growth in the two tumour models. In the PSN-1 model, but not the BxPC-3 model, the combination treatment caused an increase in survival relative to CRT alone (p = 0.038). The improvement in survival conferred by the addition of SDT in this model may be related to differences in tumour architecture between the two models. MRI and US images showed that PSN-1 tumours were less well perfused and vascularised than BxPC-3 tumours. This poor vascularisation may explain why PSN-1 tumours were more susceptible to the effects of vascular damage exerted by SDT treatment.

Novel Antiretroviral Therapeutic Strategies for HIV

When the first cases of HIV infection appeared in the 1980s, AIDS was a deadly disease without any therapeutic alternatives. Currently, there is still no cure for most cases mainly due to the multiple tissues that act as a reservoir for this virus besides the high viral mutagenesis that leads to an antiretroviral drug resistance. Throughout the years, multiple drugs with specific mechanisms of action on distinct targets have been approved. In this review, the most recent phase III clinical studies and other research therapies as advanced antiretroviral nanodelivery systems will be here discussed. Although the combined antiretroviral therapy is effective in reducing viral loading to undetectable levels, it also presents some disadvantages, such as usual side effects, high frequency of administration, and the possibility of drug resistance. Therefore, several new drugs, delivery systems, and vaccines have been tested in pre-clinical and clinical trials. Regarding drug delivery, an attempt to change the route of administration of some conventional antiretrovirals has proven to be successful and surpassed some issues related to patient compliance. Nanotechnology has brought a new approach to overcoming certain obstacles of formulation design including drug solubility and biodistribution. Overall, the encapsulation of antiretroviral drugs into nanosystems has shown improved drug release and pharmacokinetic profile.

Acoustothermal Nucleation of Surface Nanobubbles

Ultrasonic surface vibration at high frequencies (O(100 GHz)) can nucleate bubbles in a liquid within a few nanometres from a surface, but the underlying mechanism and the role of surface wettability remain poorly understood. Here, we employ molecular simulations to study and characterize this phenomenon, which we call acoustothermal nucleation. We observe that nanobubbles can nucleate on both hydrophilic and hydrophobic surfaces, and molecular energy balances are used to identify whether these are boiling or cavitation events. We rationalize the nucleation events by defining a physics-based energy balance, which matches our simulation results. To characterize the interplay between the acoustic parameters, surface wettability, and nucleation mechanism, we produce a regime map of nanoscopic nucleation events that connects observed nanoscale results to macroscopic experiments. This work provides insights to better design a range of industrial processes and clinical procedures such as surface treatments, mass spectroscopy, and selective cell destruction.

A review of ultrasound-mediated microbubbles technology for cancer therapy: a vehicle for chemotherapeutic drug delivery

Background:

The unique behaviour of microbubbles under ultrasound acoustic pressure makes them useful agents for drug and gene delivery. Several studies have demonstrated the potential application of microbubbles as a non-invasive, safe and effective technique for targeted delivery of drugs and genes. The drugs can be incorporated into the microbubbles in several different approaches and then carried to the site of interest where it can be released by destruction of the microbubbles using ultrasound to achieve the required therapeutic effect.

Methods:

The objective of this article is to report on a review of the recent advances of ultrasound-mediated microbubbles as a vehicle for delivering drugs and genes and its potential application for the treatment of cancer.

Conclusion:

Ultrasound-mediated microbubble technology has the potential to significantly improve chemotherapy drug delivery to treatment sites with minimal side effects. Moreover, the technology can induce temporary and reversible changes in the permeability of cells and vessels, thereby allowing for drug delivery in a spatially localised region which can improve the efficiency of drugs with poor bioavailability due to their poor absorption, rapid metabolism and rapid systemic elimination.

Ultrasound-controlled DOX-SiO2 nanocomposites enhance the antitumour efficacy and attenuate the toxicity of doxorubicin

The toxicity of doxorubicin (DOX), especially in terms of cardiotoxicity, has been a common problem in its clinical use. In our studies, we synthesized and characterized DOX-SiO2 nanocomposites. In the in vitro experiments, DOX-SiO2 nanocomposites could more effectively induce apoptosis, inhibit colony formation, and inhibit the proliferation of the cancer cell line HeLa compared with free DOX. Furthermore, ultrasound could dramatically enhance these abilities of DOX-SiO2 nanocomposites. The in vivo studies showed that DOX-SiO2 nanocomposites increased the concentration of DOX in the tumour region and decreased the concentration of DOX in normal tissues. Additionally, DOX-SiO2 nanocomposites under ultrasound could inhibit growth and increase the apoptosis of xenograft tumour cells more effectively than DOX-SiO2 nanocomposites alone. Meanwhile, the cardiotoxicity of DOX was significantly reduced by DOX-SiO2 nanocomposites. The difference was more obvious in DOX-SiO2 nanocomposites under ultrasound. Moreover, prolonging the ultrasound time augments the antitumour efficacy and attenuates the toxicity of DOX-SiO2 nanocomposites. In summary, we concluded that DOX-SiO2 nanocomposites under ultrasound decrease DOX-induced toxicity in normal tissues and increase the antitumour effect of DOX by targeted delivery and controllable release, which shows the great potential of DOX-SiO2 nanocomposites for the delivery of DOX in the clinic.

Microbubble-Mediated Delivery for Cancer Therapy

Despite an overall improvement in survival rates for cancer, certain resistant forms of the disease still impose a significant burden on patients and healthcare systems. Standard chemotherapy in these cases is often ineffective and/or gives rise to severe side effects. Targeted delivery of chemotherapeutics could improve both tumour response and patient experience. Hence, there is an urgent need to develop effective methods for this. Ultrasound is an established technique in both diagnosis and therapy. Its use in conjunction with microbubbles is being actively researched for the targeted delivery of small-molecule drugs. In this review, we cover the methods by which ultrasound and microbubbles can be used to overcome tumour barriers to cancer therapy.

Calcium-dependent ultrasound stimulation of secretory events from pancreatic beta cells

BACKGROUND

Our previous studies have indicated that ultrasound can stimulate the release of insulin from pancreatic beta cells, providing a potential novel treatment for type 2 diabetes. The purpose of this study was to explore the temporal dynamics and Ca2+-dependency of ultrasound-stimulated secretory events from dopamine-loaded pancreatic beta cells in an in vitro setup.

METHODS

Carbon fiber amperometry was used to detect secretion from INS-1832/13 beta cells in real time. The levels of released insulin were also measured in response to ultrasound treatment using insulin-specific ELISA kit. Beta cells were exposed to continuous wave 800 kHz ultrasound at intensities of 0.1 W/cm2, 0.5 W/cm2 and 1 W/cm2 for several seconds. Cell viability tests were done with trypan blue dye exclusion test and MTT analysis.

RESULTS

Carbon fiber amperometry experiments showed that application of 800 kHz ultrasound at intensities of 0.5 and 1 W/cm2 was capable of stimulating secretory events for durations lasting as long as the duration of the stimulus. Furthermore, the amplitude of the detected peaks was reduced by 64% (p < 0.01) when extracellular Ca2+ was chelated with 10 mM EGTA in cells exposed to ultrasound intensity of 0.5 W/cm2. Measurements of released insulin in response to ultrasound stimulation showed complete inhibition of insulin secretion by chelating extracellular Ca2+ with 10 mM EGTA (p < 0.01). Viability studies showed that 800 kHz, 0.5 W/cm2 ultrasound did not cause any significant effects on viability and metabolic activity in cells exposed to ultrasound as compared to sham-treated cells.

CONCLUSIONS

Our results demonstrated that application of ultrasound was capable of stimulating the release of insulin from pancreatic beta cells in a safe, controlled and Ca2+-dependent manner.

Getting Drugs Across Biological Barriers

The delivery of drugs to a target site frequently involves crossing biological barriers. The degree and nature of the impediment to flux, as well as the potential approaches to overcoming it, depend on the tissue, the drug, and numerous other factors. Here an overview of approaches that have been taken to crossing biological barriers is presented, with special attention to transdermal drug delivery. Technology and knowledge pertaining to addressing these issues in a variety of organs could have a significant clinical impact.

A drug delivery system based on switchable photo-controlled p-coumaric acid derivatives anchored on mesoporous silica

Mesoporous silica modified by p-coumaric acid derivatives as photo-switchable ligands was studied for the delivery of a non-steroidal anti-inflammatory drug.

Theragnostic ultrasound using microbubbles in the treatment of prostate cancer

The use of gas-filled microbubbles in perfusion monitoring as intravascular ultrasound contrast agents has recently become more common. Additionally, microbubbles are employed as carriers of pharmaceutical substances or genes. Microbubbles have great potential to improve the delivery of therapeutic materials into cells and to modify vascular permeability, causing increased extravasation of drugs and drug carriers. Prostate cancer is the most common neoplasm in Europe and America, with an incidence twice to three times that of lung and colorectal cancer. Its incidence is still rising in Asian countries, including Japan and Korea. In this review, we present current strategies regarding the synthesis of microbubbles with targeted ligands on their surfaces, with a focus on prostate cancer.

Ultrasound and microbubble mediated drug delivery: acoustic pressure as determinant for uptake via membrane pores or endocytosis

Although promising results are achieved in ultrasound mediated drug delivery, its underlying biophysical mechanisms remain to be elucidated. Pore formation as well as endocytosis has been reported during ultrasound application. Due to the plethora of ultrasound settings used in literature, it is extremely difficult to draw conclusions on which mechanism is actually involved. To our knowledge, we are the first to show that acoustic pressure influences which route of drug uptake is addressed, by inducing different microbubble-cell interactions. To investigate this, FITC-dextrans were used as model drugs and their uptake was analyzed by flow cytometry. In fluorescence intensity plots, two subpopulations arose in cells with FITC-dextran uptake after ultrasound application, corresponding to cells having either low or high uptake. Following separation of the subpopulations by FACS sorting, confocal images indicated that the low uptake population showed endocytic uptake. The high uptake population represented uptake via pores. Moreover, the distribution of the subpopulations shifted to the high uptake population with increasing acoustic pressure. Real-time confocal recordings during ultrasound revealed that membrane deformation by microbubbles may be the trigger for endocytosis via mechanostimulation of the cytoskeleton. Pore formation was shown to be caused by microbubbles propelled towards the cell. These results provide a better insight in the role of acoustic pressure in microbubble-cell interactions and the possible consequences for drug uptake. In addition, it pinpoints the need for a more rational, microbubble behavior based choice of acoustic parameters in ultrasound mediated drug delivery experiments.

Prospects for enhancement of targeted radionuclide therapy of cancer using ultrasound

Ultrasound-mediated drug delivery is a promising means of enhancing delivery, distribution and effectiveness of drugs within tumours. In this review, prospects for exploiting ultrasound to improve the tumour delivery and distribution of radiolabelled antibodies for radioimmunotherapy and to overcome barriers imposed by tumour microenvironment are discussed.

Combining microbubbles and ultrasound for drug delivery to brain tumors: current progress and overview

Malignant glioma is one of the most challenging central nervous system (CNS) diseases, which is typically associated with high rates of recurrence and mortality. Current surgical debulking combined with radiation or chemotherapy has failed to control tumor progression or improve glioma patient survival. Microbubbles (MBs) originally serve as contrast agents in diagnostic ultrasound but have recently attracted considerable attention for therapeutic application in enhancing blood-tissue permeability for drug delivery. MB-facilitated focused ultrasound (FUS) has already been confirmed to enhance CNS-blood permeability by temporally opening the blood-brain barrier (BBB), thus has potential to enhance delivery of various kinds of therapeutic agents into brain tumors. Here we review the current preclinical studies which demonstrate the reports by using FUS with MB-facilitated drug delivery technology in brain tumor treatment. In addition, we review newly developed multifunctional theranostic MBs for FUS-induced BBB opening for brain tumor therapy.

Generation of uniform polymer eccentric and core-centered hollow microcapsules for ultrasound-regulated drug release

Uniform polydimethylsiloxane microcapsules with eccentric and core-centered internal hollow structures show controlled-release behaviour for site-specific drug delivery under ultrasound regulation.

[Focused ultrasound therapy: current status and potential applications in neurosurgery]

High Intensity Focused Ultrasound (HIFU) therapy is an innovative approach for tissue ablation, based on high intensity focused ultrasound beams. At the focus, HIFU induces a temperature elevation and the tissue can be thermally destroyed. In fact, this approach has been tested in a number of clinical studies for the treatment of several tumors, primarily the prostate, uterine, breast, bone, liver, kidney and pancreas. For transcranial brain therapy, the skull bone is a major limitation, however, new adaptive techniques of phase correction for focusing ultrasound through the skull have recently been implemented by research systems, paving the way for HIFU therapy to become an interesting alternative to brain surgery and radiotherapy.

Multifunctional superparamagnetic iron oxide nanoparticles: design, synthesis and biomedical photonic applications

Superparamagnetic iron oxide nanoparticles (SPIONs) have shown great promise in biomedical applications. In this review, we summarize the recent advances in the design and fabrication of core-shell and hetero-structured SPIONs and further outline some exciting developments and progresses of these multifunctional SPIONs for diagnosis, multimodality imaging, therapy, and biophotonics.

Ultrasound-mediated drug/gene delivery in solid tumor treatment

Ultrasound is an emerging modality for drug delivery in chemotherapy. This paper reviews this novel technology by first introducing the designs and characteristics of three classes of drug/gene vehicles, microbubble (including nanoemulsion), liposomes, and micelles. In comparison to conventional free drug, the targeted drug-release and delivery through vessel wall and interstitial space to cancerous cells can be activated and enhanced under certain sonication conditions. In the acoustic field, there are several reactions of these drug vehicles, including hyperthermia, bubble cavitation, sonoporation, and sonodynamics, whose physical properties are illustrated for better understanding of this approach. In vitro and in vivo results are summarized, and future directions are discussed. Altogether, ultrasound-mediated drug/gene delivery under imaging guidance provides a promising option in cancer treatment with enhanced agent release and site specificity and reduced toxicity.

The therapeutic potential of miRNAs in cardiac fibrosis: where do we stand?

Recent developments in basic and clinical science have turned the spotlight to miRNAs for their potential therapeutic efficacy. Since their discovery in 1993, it has become clear that miRNAs act as posttranscriptional regulators of protein expression. Their clinical potential was further highlighted by the results of miRNA-based interventions in small laboratory animals. More importantly, their therapeutic effectiveness has been shown recently in phase 2a clinical studies in patients with hepatitis C virus infection, where inhibition of miRNA-122 showed prolonged and dose-dependent viral suppression. A recent study surprisingly revealed the presence of plant-derived miRNAs in the blood of healthy humans. This finding opens up the possibility to explore miRNA-mediated therapeutics derived from (genetically modified) food. Having arrived at this point in our understanding of miRNAs, we provide an overview of current evidence and future potential of miRNA-based therapeutics, focusing on their application in cardiac fibrosis.

Delivery of cancer therapeutics using nanotechnology

Nanoparticles have been investigated as drug carriers, because they provide a great opportunity due to their advantageous features: (i) various formulations using organic/inorganic materials, (ii) easy modification of targeting molecules, drugs or other molecules on them, (iii) effective delivery to target sites, resulting in high therapeutic efficacy and (iv) controlling drug release by external/internal stimuli. Because of these features, therapeutic efficacy can be improved and unwanted side effects can be reduced. Theranostic nanoparticles have been developed by incorporating imaging agents in drug carriers as all-in-one system, which makes it possible to diagnose and treat cancer by monitoring drug delivery behavior simultaneously. Recently, stimuli-responsive, activatable nanomaterials are being applied that are capable of producing chemical or physical changes by external stimuli. By using these nanoparticles, multiple tasks can be carried out simultaneously, e.g., early and accurate diagnosis, efficient cataloguing of patient groups of personalized therapy and real-time monitoring of disease progress. In this paper, we describe various types of nanoparticles for drug delivery systems, as well as theranostic systems.

Ultrasound-enhanced delivery of antibiotics and anti-inflammatory drugs into the eye

Delivery of sufficient amounts of therapeutic drugs into the eye is often a challenging task. In this study, ultrasound application (frequencies of 400 KHz to 1 MHz, intensities of 0.3-1.0 W/cm(2) and exposure duration of 5 min) was investigated to overcome the barrier properties of cornea, which is a typical route for topical administration of ophthalmic drugs. Permeability of ophthalmic drugs, tobramycin and dexamethasone and sodium fluorescein, a drug-mimicking compound, was studied in ultrasound- and sham-treated rabbit corneas in vitro using a standard diffusion cell setup. Light microscopy observations were used to determine ultrasound-induced structural changes in the cornea. For tobramycin, an increase in permeability for ultrasound- and sham-treated corneas was not statistically significant. Increase of 46%-126% and 32%-109% in corneal permeability was observed for sodium fluorescein and dexamethasone, respectively, with statistical significance (p < 0.05) achieved at all treatment parameter combinations (compared with sham treatments) except for 1-MHz ultrasound applications for dexamethasone experiments. This permeability increase was highest at 400 kHz and appeared to be higher at higher intensities applied. Histologic analysis showed structural changes that were limited to epithelial layers of cornea. In summary, ultrasound application provided enhancement of drug delivery, increasing the permeability of the cornea for the anti-inflammatory ocular drug dexamethasone. Future investigations are needed to determine the effectiveness and safety of this application in in vivo long-term survival studies.

Ultrasound-mediated delivery of echogenic immunoliposomes to porcine vascular smooth muscle cells in vivo

Vascular smooth muscle cells (VSMCs) are important targets in the treatment of atherosclerosis. However, the arterial media, where the majority of VSMCs reside, have proven to be a difficult target for drug/gene delivery. We have demonstrated that ultrasound enhances drug/gene delivery to VSMCs in vitro by using echogenic immunoliposomes (ELIPs) as the vector. This study aimed to evaluate whether ultrasound can similarly enhance the delivery of an agent to VSMCs, particularly within the arterial media, in vivo, using ELIP. Anti-smooth-muscle cell actin-conjugated calcein-loaded ELIP were injected into the peripheral arteries of Yucatan miniswine (n = 8 arterial pairs). The right-sided porcine arteries were treated with 1-MHz continuous-wave ultrasound at a peak-to-peak pressure amplitude of 0.23 +/- 0.05 MPa for 2 minutes. The contralateral arteries served as controls. Arteries were harvested after 30 minutes and imaged with fluorescence microscopy. Image data were converted to grayscale and analyzed by using computer-assisted videodensitometry. There was significant improvement in calcein uptake in all three arterial layers in the arteries exposed to ultrasound (> 300%). This enhanced uptake was site specific and appeared limited to the ultrasound-treated arterial segment. We have demonstrated enhanced delivery of a small molecule to VSMCs in all arterial wall layers, particularly the arterial media, using ultrasound and targeted ELIP. The combined effect of ultrasound exposure and ELIP as a contrast agent and a drug/gene-bearing vector has the potential for site-specific therapy directed at VSMC function.

Antitumor effect of microbubbles enhanced by low frequency ultrasound cavitation on prostate carcinoma xenografts in nude mice

The aim of this study was to investigate the antitumor effect induced by low frequency (20 kHz) ultrasound (US) radiation combined with intravenous injection of microbubbles (Mbs) on prostate carcinoma Du145 xenografts in nude mice. Du145 prostate tumors were percutaneously implanted in 40 nude mice, which were randomly divided into 4 groups (n=10 each): US+Mbs, US, Mbs and control groups. The mice in the US+Mbs group were treated with 20 kHz, 200 mW/cm(2) US radiation and with 0.2 ml Mbs injected intravenously. Mice in the US and Mbs groups were only treated with US radiation and injection of Mbs, respectively. Tumors were measured with sonography, and the ratio of antitumor growth was calculated. The mice were sacrificed 14 days after treatment. Specimens of the tumor tissues were observed pathologically using light microscopy and transmission electron microscopy. Microvessel density and the average optical density of vascular endothelial growth factor were compared among groups by immunohistochemistry. The average gross tumor volume of the US+Mbs group was significantly reduced compared with the other groups following treatment (P<0.05). The ratio of the antitumor growth in the US+Mbs group was significantly greater than that of the US and Mbs group (P<0.05). Histological examination showed signs of tumor cell injury in the US+Mbs group. Examination by electron microscopy revealed vessel injury in the endothelium in the tumors treated with US+Mbs. Microvessel density and the average optical density of vascular endothelial growth factor in the US+Mbs group were significantly less than that of other groups (P<0.05). In conclusion, low frequency US of 20 kHz radiation combined with Mbs may be used to inhibit the growth of human prostate carcinoma xenografts in nude mice, and the effect is likely realized through microvessel destruction caused by cavitation.

Role of High-Intensity Focused Ultrasound in Treatment of Hepatocellular Carcinoma

About 70 per cent of patients with hepatocellular carcinoma are diagnosed at intermediate or advanced stages, and most of them are technically unresectable. As a novel, emerging therapeutic modality, high intensity focused ultrasound (HIFU) has a great potential for tumor treatment. In this review, principle of HIFU technique is introduced, and an overview of clinical applications and limitations of HIFU for HCC treatment, as well as prospects for future development, is provided. Consequently, HIFU has been considered a safe and feasible procedure for HCC treatment.

Clinical and future applications of high intensity focused ultrasound in cancer

High intensity focused ultrasound (HIFU) or focused ultrasound (FUS) is a promising modality to treat tumors in a complete, non invasive fashion where online image guidance and therapy control can be achieved by magnetic resonance imaging (MRI) or diagnostic ultrasound (US). In the last 10 years, the feasibility and the safety of HIFU have been tested in a growing number of clinical studies on several benign and malignant tumors of the prostate, breast, uterine, liver, kidney, pancreas, bone, and brain. For certain indications this new treatment principle is on its verge to become a serious alternative or adjunct to the standard treatment options of surgery, radiotherapy, gene therapy and chemotherapy in oncology. In addition to the now clinically available thermal ablation, in the future, focused ultrasound at much lower intensities may have the potential to become a major instrument to mediate drug and gene delivery for localized cancer treatment. We introduce the technology of MRI guided and ultrasound guided HIFU and present a critical overview of the clinical applications and results along with a discussion of future HIFU developments.

An MR-compliant phased-array HIFU transducer with augmented steering range, dedicated to abdominal thermotherapy

A novel architecture for a phased-array high intensity focused ultrasound (HIFU) device was investigated, aiming to increase the capabilities of electronic steering without reducing the size of the elementary emitters. The principal medical application expected to benefit from these developments is the time-effective sonication of large tumours in moving organs. The underlying principle consists of dividing the full array of transducers into multiple sub-arrays of different resonance frequencies, with the reorientation of these individual emitters, such that each sub-array can focus within a given spatial zone. To enable magnetic resonance (MR) compatibility of the device and the number of output channels from the RF generator to be halved, a passive spectral multiplexing technique was used, consisting of parallel wiring of frequency-shifted paired piezoceramic emitters with intrinsic narrow-band response. Two families of 64 emitters (circular, 5 mm diameter) were mounted, with optimum efficiency at 0.96 and 1.03 MHz, respectively. Two different prototypes of the HIFU device were built and tested, each incorporating the same two families of emitters, but differing in the shape of the rapid prototyping plastic support that accommodated the transducers (spherical cap with radius of curvature/aperture of 130 mm/150 mm and, respectively, 80 mm/110 mm). Acoustic measurements, MR-acoustic radiation force imaging (ex vivo) and MR-thermometry (ex vivo and in vivo) were used for the characterization of the prototypes. Experimental results demonstrated an augmentation of the steering range by 80% along one preferentially chosen axis, compared to a classic spherical array of the same total number of elements. The electric power density provided to the piezoceramic transducers exceeded 50 W cm(-2) CW, without circulation of coolant water. Another important advantage of the current approach is the versatility of reshaping the array at low cost.

Extracorporeal, low-energy focused ultrasound for noninvasive and nondestructive targeted hyperthermia

The benefits of hyperthermia are well known as both a primary treatment modality and adjuvant therapy for treating cancer. Among the different techniques available, high-intensity focused ultrasound is the only noninvasive modality that can provide local hyperthermia precisely at a targeted location at any depth inside the body using image guidance. Traditionally, focused ultrasound exposures have been provided at high rates of energy deposition for thermal ablation of benign and malignant tumors. At present, exposures are being evaluated in pulsed mode, which lower the rates of energy deposition and generate primarily mechanical effects for enhancing tissue permeability to improve local drug delivery. These pulsed exposures can be modified for low-level hyperthermia as an adjuvant therapy for drug and gene delivery applications, as well as for more traditional applications such as radiosensitization. In this review, we discuss the manner by which focused ultrasound exposures at low rates of energy deposition are being developed for a variety of clinically translatable applications for the treatment of cancer. Specific preclinical studies will be highlighted. Additional information will also be provided for optimizing these exposures, including computer modeling and simulations. Various techniques for monitoring temperature elevations generated by focused ultrasound will also be reviewed.

Contrast-enhanced and targeted ultrasound

Ultrasonic imaging is becoming the most popular medical imaging modality, owing to the low price per examination and its safety. However, blood is a poor scatterer of ultrasound waves at clinical diagnostic transmit frequencies. For perfusion imaging, markers have been designed to enhance the contrast in B-mode imaging. These so-called ultrasound contrast agents consist of microscopically small gas bubbles encapsulated in biodegradable shells. In this review, the physical principles of ultrasound contrast agent microbubble behavior and their adjustment for drug delivery including sonoporation are described. Furthermore, an outline of clinical imaging applications of contrast-enhanced ultrasound is given. It is a challenging task to quantify and predict which bubble phenomenon occurs under which acoustic condition, and how these phenomena may be utilized in ultrasonic imaging. Aided by high-speed photography, our improved understanding of encapsulated microbubble behavior will lead to more sophisticated detection and delivery techniques. More sophisticated methods use quantitative approaches to measure the amount and the time course of bolus or reperfusion curves, and have shown great promise in revealing effective tumor responses to anti-angiogenic drugs in humans before tumor shrinkage occurs. These are beginning to be accepted into clinical practice. In the long term, targeted microbubbles for molecular imaging and eventually for directed anti-tumor therapy are expected to be tested.

Comparative study of the topical application of Aloe vera gel, therapeutic ultrasound and phonophoresis on the tissue repair in collagenase-induced rat tendinitis

The aim of our study was to compare topical use of Aloe vera gel, pulsed mode ultrasound (US) and Aloe vera phonophoresis on rat paw with collagenase-induced tendinitis. Edema size, tensile tendon strength, tendon elasticity, number of inflammatory cells and tissue histology were studied at 7 and 14 days after tendinitis induction. Pulse mode US parameters were: 1 MHz frequency, 100 Hz repetition rate, 10% duty cycle, and 0.5 W/cm(2) intensity, applied for 2 min each session. A 0.5 mL of Aloe vera gel at 2% concentration was applied for 2 min per session, topically and by phonophoresis. Topical application of Aloe vera gel did not show any statistically significant improvement in the inflammatory process, whereas phonophoresis enhanced the gel action reducing edema and number of inflammatory cells, promoting the rearrangement of collagen fibers and promoting also the recovery of the tensile strength and elasticity of the inflamed tendon to recover their normal pre-injury status. Results seem to indicate that Aloe vera phonophoresis is a promising technique for tendinitis treatment, without the adverse effect provoked by systemic anti-inflammatory drugs.

Modulation of intracellular Ca2+ concentration in brain microvascular endothelial cells in vitro by acoustic cavitation

Localized delivery of therapeutic agents through the blood-brain barrier (BBB) is a clinically significant task that remains challenging. Ultrasound (US) application after intravenous administration of microbubbles has been shown to generate localized BBB opening in animal models but the detailed mechanisms are not yet fully described. The current study investigates the effects of US-stimulated microbubbles on in vitro murine brain microvascular endothelial (bEnd.3) cells by monitoring sonoporation and changes in intracellular calcium concentration ([Ca(2+)](i)) using real-time fluorescence and high-speed brightfield microscopy. Cells seeded in microchannels were exposed to a single US pulse (1.25 MHz, 10 cycles, 0.24 MPa peak negative pressure) in the presence of Definity microbubbles and extracellular calcium concentration [Ca(2+)](o) = 0.9 mM. Disruption of the cell membrane was assessed using propidium iodide (PI) and change in the [Ca(2+)](i) was measured using fura-2. Cells adjacent to a microbubble exhibited immediate [Ca(2+)](i) changes after US pulse with and without PI uptake and the [Ca(2+)](i) changes were twice as large in cells with PI uptake. Cell viability assays showed that sonoporated cells could survive with modulation of [Ca(2+)](i) and uptake of PI. Cells located near sonoporated cells were observed to exhibit changes in [Ca(2+)](i) that were delayed from the time of US application and without PI uptake. These results demonstrate that US-stimulated microbubbles not only directly cause changes in [Ca(2+)](i) in brain endothelial cells in addition to sonoporation but also generate [Ca(2+)](i) transients in cells not directly interacting with microbubbles, thereby affecting cells in larger regions beyond the cells in contact with microbubbles.

MRI-guided focused ultrasound treatments

Focused ultrasound (FUS) allows noninvasive focal delivery of energy deep into soft tissues. The focused energy can be used to modify and eliminate tissue for therapeutic purposes while the energy delivery is targeted and monitored using magnetic resonance imaging (MRI). MRI compatible methods to deliver these exposures have undergone rapid development over the past 10 years such that clinical treatments are now routinely performed. This paper will review the current technical and clinical status of MRI-guided focused ultrasound therapy and discuss future research and development opportunities.

Electroporation and ultrasound enhanced non-viral gene delivery in vitro and in vivo

Non-viral vectors are less efficient than the use of viral vectors for delivery of genetic material to cells in vitro and especially in vivo. However, viral vectors involve the use of foreign proteins that can stimulate both the innate and acquired immune response. In contrast, plasmid DNA can be delivered without carrier proteins and is non-immunogenic. Plasmid gene delivery can be enhanced by the use of physical methods that aid the passage of the plasmid through the cell membrane. Electroporation and microbubble-enhanced ultrasound are two of the most effective physical delivery methods and these can be applied to a range of different cell types in vitro and a broad range of tissues in vivo. Both techniques also have the advantage that, unlike viral vectors, they can be used to target specific tissues with systemic delivery. Although electroporation is often the more efficient of the two, microbubble-enhanced ultrasound causes less damage and is less invasive. This review provides an introduction to the methodology and summarises the range of cells and tissues that have been genetically modified using these techniques.

Microbubble Compositions, Properties and Biomedical Applications

Over the last decade, there has been significant progress towards the development of microbubbles as theranostics for a wide variety of biomedical applications. The unique ability of microbubbles to respond to ultrasound makes them useful agents for contrast ultrasound imaging, molecular imaging, and targeted drug and gene delivery. The general composition of a microbubble is a gas core stabilized by a shell comprised of proteins, lipids or polymers. Each type of microbubble has its own unique advantages and can be tailored for specialized functions. In this review, different microbubbles compositions and physiochemical properties are discussed in the context of current progress towards developing novel constructs for biomedical applications, with specific emphasis on molecular imaging and targeted drug/gene delivery.

Specific targeting of human inflamed endothelium and in situ vascular tissue transfection by the use of ultrasound contrast agents

OBJECTIVES

We used human umbilical cord segments as an ex vivo model to investigate the possible clinical diagnostic and therapeutic applications of microbubbles (MBs).

BACKGROUND

Microbubbles are commonly used in clinical practice as ultrasound contrast agents. Several studies have addressed the in vivo applications of MBs for specific targeting of vascular dysfunction or sonoporation in animal models, but to date no human tissue model has been established.

METHODS

Primary venular endothelial cell monolayers were targeted with MBs conjugated to an antibody against a highly expressed endothelial marker (tetraspanin CD9), and binding was assessed under increasing flow rates (0.5 to 5 dynes/cm(2)). Furthermore, CD9-coupled MB endothelial targeting was measured under flow conditions by contrast-enhanced ultrasound analysis in an ex vivo human macrovascular model (umbilical cord vein), and the same tissue model was used for the detection of inflamed vasculature with anti-intercellular adhesion molecule (ICAM)-1-coated MBs. Finally, plasmids encoding fluorescent proteins were sonoporated into umbilical cord vessels.

RESULTS

Specific endothelial targeting in the in vitro and ex vivo models described previously was achieved by the use of MBs covered with an anti-CD9. Furthermore, we managed to induce inflammation in umbilical cord veins and detect it with real-time echography imaging using anti-ICAM-1-coupled MBs. Moreover, expression and correct localization of green fluorescent protein and green fluorescent protein-tagged ICAM-1 were assessed in this human ex vivo model without causing vascular damage.

CONCLUSIONS

In the absence of clinical trials to test the benefits and possible applications of ultrasound contrast agents for molecular imaging and therapy, we have developed a novel ex vivo human model using umbilical cords that is valid for the detection of inflammation and for exogenous expression of proteins by sonoporation.

Microbubble stability is a major determinant of the efficiency of ultrasound and microbubble mediated in vivo gene transfer

In the search for an efficient nonviral gene therapy approach for the treatment of genetic disorders of cardiac and skeletal muscle such as Duchenne muscular dystrophy, ultrasound in combination with contrast enhancing microbubbles has emerged as a promising tool for safe and site-specific enhancement of gene delivery. Indeed, microbubble-enhanced gene transfer (MBGT) has been investigated for a wide variety of target sites using both reporter and therapeutic genes. Although a range of different microbubbles have been used for MBGT studies, comparison of their efficiencies is difficult because microbubble concentration and the ultrasound settings used for the application vary considerably. Only two studies to date have attempted a direct comparison of commercially available microbubbles, and both concluded that not all microbubbles show the same efficiencies with MBGT. Thus far, the reason for this is unclear. Here, the efficiency of three commercially available microbubbles--Optison, SonoVue and Sonazoid--was analyzed to understand the microbubble properties that are important for their function as an effective enhancer for gene transfer in vivo. In this study, plasmid DNA or antisense oligonucleotides were delivered by systemic injection with MBGT, focused on the heart. Gene delivery to the heart with equalized concentrations of the three microbubbles showed that Optison and Sonazoid are more efficient in MBGT compared with SonoVue, which showed the weakest gene transfer to the myocardium. Investigations into the properties of these microbubbles showed that size and shell composition did not directly influence MBGT, whereas the microbubbles with increased stability in an ultrasound field showed better MBGT results than those degrading faster. Moreover, the microbubble concentration used for MBGT was also found to be an important factor influencing the efficiency of MBGT. In conclusion, the stability of a microbubble was shown to be a major influential factor for its performance in MBGT, as is the concentration of the microbubbles used. These findings emphasize the importance of detailed investigations into the properties of microbubbles to allow the production of a microbubble specifically designed for optimum performance with MBGT.

Effects of phonophoresis with Arnica montana onto acute inflammatory process in rat skeletal muscles: an experimental study

This study aimed at verifying the effects of phonophoresis associated with Arnica montana on the acute phase of an inflammatory muscle lesion. Forty Wistar male rats (300+/-50 g), of which the Tibialis Anterior muscle was surgically lesioned, were divided into four groups (n=10 each): control group received no treatment; the ultrasound group (US) was treated in pulsed mode with 1-MHz frequency, 0.5 W/cm(2) intensity (spatial and temporal average - SATA), duty cycle of 1:2 (2 ms on, 4 ms off, 50%), time of application 3 min per session, one session per day, for 3 days; the phonophoresis or ultrasound plus arnica (US+A) group was treated with arnica with the same US parameters plus arnica gel; and the arnica group (A) was submitted to massage with arnica gel, also for 3 min, once a day, for 3 days. Treatment started 24h after the surgical lesion. On the 4th day after lesion creation, animals were sacrificed and sections of the lesioned, inflamed muscle were removed for quantitative (mononuclear and polymorphonuclear cell count) and qualitative histological analysis. Collected data from the 4 groups were statistically analyzed and the significance level set at p<0.05. Results show higher mononuclear cell density in all three treated groups with no significant difference between them, but values were significantly different (p<0.0001) when compared to control group's. As to polymorphonuclear cell density, significant differences were found between control group (p=0.0134) and US, US+A and A groups; the arnica group presented lesser density of polymorphonuclear cells when compared (p=0.0134) to the other groups. No significant difference was found between US and US+A groups. While the massage with arnica gel proved to be an effective anti-inflammatory on acute muscle lesion in topic use, these results point to ineffectiveness of Arnica montana phonophoresis, US having seemingly checked or minimized its anti-inflammatory effect.

Noninvasive ultrasonic glucose sensing with large pigs (approximately 200 pounds) using a lightweight cymbal transducer array and biosensors

BACKGROUND

To prevent complications in diabetes, the proper management of blood glucose levels is essential. Since conventional glucose meters require pricking fingers or other areas of the skin, a noninvasive method for monitoring blood glucose levels is desired. Using a lightweight cymbal transducer array, this study was conducted to noninvasively determine the glucose levels of pigs having a similar size to humans.

METHOD

In vivo experiments using eight pigs (approximately 200 pounds) were performed in five groups. A cymbal array with four biosensors was attached to the axillary area of the pig. The array was operated at 20 kHz at special peak-temporal peak intensity (I(sptp)) equal to 50 or 100 mW/cm(2) for 5, 10, or 20 minutes. After the ultrasound exposure, glucose concentrations of the interstitial fluid were determined using biosensors. For comparison, glucose levels of blood samples collected from the ear vein were measured by a commercial glucose meter.

RESULT

In comparison, glucose levels determined by a cymbal array and biosensor system were close to those measured by a glucose meter. After a 20-minute ultrasound exposure at I(sptp) = 100 mW/cm(2), the average glucose level determined by the ultrasound system was 175 +/- 7 mg/dl, which is close to 166 +/- 5 mg/dl measured by the glucose meter.

CONCLUSION

Results indicate the feasibility of using a cymbal array for noninvasive glucose sensing on pigs having a similar size to humans. Further studies on the ultrasound conditions, such as frequency, intensity, and exposure time, will be continued for effective glucose sensing.

High-intensity focused ultrasound therapy: an overview for radiologists

High-intensity focused ultrasound therapy is a novel, emerging, therapeutic modality that uses ultrasound waves, propagated through tissue media, as carriers of energy. This completely non-invasive technology has great potential for tumor ablation as well as hemostasis, thrombolysis and targeted drug/gene delivery. However, the application of this technology still has many drawbacks. It is expected that current obstacles to implementation will be resolved in the near future. In this review, we provide an overview of high-intensity focused ultrasound therapy from the basic physics to recent clinical studies with an interventional radiologist's perspective for the purpose of improving the general understanding of this cutting-edge technology as well as speculating on future developments.

Magnetic resonance acoustic radiation force imaging

Acoustic radiation force impulse imaging is an elastography method developed for ultrasound imaging that maps displacements produced by focused ultrasound pulses systematically applied to different locations. The resulting images are "stiffness weighted" and yield information about local mechanical tissue properties. Here, the feasibility of magnetic resonance acoustic radiation force imaging (MR-ARFI) was tested. Quasistatic MR elastography was used to measure focal displacements using a one-dimensional MRI pulse sequence. A 1.63 or 1.5 MHz transducer supplied ultrasound pulses which were triggered by the magnetic resonance imaging hardware to occur before a displacement-encoding gradient. Displacements in and around the focus were mapped in a tissue-mimicking phantom and in an ex vivo bovine kidney. They were readily observed and increased linearly with acoustic power in the phantom (R2=0.99). At higher acoustic power levels, the displacement substantially increased and was associated with irreversible changes in the phantom. At these levels, transverse displacement components could also be detected. Displacements in the kidney were also observed and increased after thermal ablation. While the measurements need validation, the authors have demonstrated the feasibility of detecting small displacements induced by low-power ultrasound pulses using an efficient magnetic resonance imaging pulse sequence that is compatible with tracking of a dynamically steered ultrasound focal spot, and that the displacement increases with acoustic power. MR-ARFI has potential for elastography or to guide ultrasound therapies that use low-power pulsed ultrasound exposures, such as drug delivery.

Delivery by shock waves of active principle embedded in gelatin-based capsules

PURPOSE

Delivering a drug close to the targeted cells improves its benefit versus risk ratio. A possible method for local drug delivery is to encapsulate the drug into solid microscopic carriers and to release it by ultrasound. The objective of this work was to use shock waves for delivering a molecule loaded in polymeric microcapsules.

MATERIAL AND METHODS

Ethyl benzoate (EBZ) was encapsulated in spherical gelatin shells by complex coacervation. A piezocomposite shock wave generator (120 mm in diameter, focused at 97 mm, pulse length 1.4 micros) was used for sonicating the capsules and delivering the molecule. Shock parameters (acoustic pressure, number of shocks and shock repetition frequency) were varied in order to measure their influence on EBZ release. A cavitation-inhibitor liquid (Ablasonic) was then used to evaluate the role of cavitation in the capsule disruption.

RESULTS

The measurements showed that the mean quantity of released EBZ was proportional to the acoustic pressure of the shock wave (r2 > 0.99), and increased with the number of applied shocks. Up to 88% of encapsulated EBZ could be released within 4 min only (240 shocks, 1 Hz). However, the quantity of released EBZ dropped at high shock rates (above 2Hz). Ultrasound imaging sequences showed that cavitation clouds might form, at high shock rates, along the acoustic axis making the exposure inefficient. Measurements done in Ablasonic showed that cavitation plays a major role in microcapsules disruption.

CONCLUSIONS

In this study, we designed polymeric capsules that can be disrupted by shock waves. This type of microcapsule is theoretically a suitable vehicle for carrying hydrophobic drugs. Following these positive results, encapsulation of drugs is considered for further medical applications.

Gene transduction by sonoporation

Gene transduction technologies are essential tools for understanding of gene functions or gene cascades underlying embryogenesis. In this review, we introduce a gene transduction method using microbubble and ultrasound (hereafter referred to as sonoporation). Sonoporation is carried out with relatively simple procedures and easily transduces genes into mesenchymal cells without significant damage to target tissues. Therefore, sonoporation is effective for gene transduction to study the molecular mechanisms of morphogenesis.