Enhanced ultrasound-induced apoptosis and cell lysis by a hypotonic medium

Cancer cell response to extrinsic and intrinsic mechanical cue: opportunities for tumor apoptosis strategies

Increasing studies have revealed the importance of mechanical cues in tumor progression, invasiveness and drug resistance. During malignant transformation, changes manifest in either the mechanical properties of the tissue or the cellular ability to sense and respond to mechanical signals. The major focus of the review is the subtle correlation between mechanical cues and apoptosis in tumor cells from a mechanobiology perspective. To begin, we focus on the intracellular force, examining the mechanical properties of the cell interior, and outlining the role that the cytoskeleton and intracellular organelle-mediated intracellular forces play in tumor cell apoptosis. This article also elucidates the mechanisms by which extracellular forces guide tumor cell mechanosensing, ultimately triggering the activation of the mechanotransduction pathway and impacting tumor cell apoptosis. Finally, a comprehensive examination of the present status of the design and development of anti-cancer materials targeting mechanotransduction is presented, emphasizing the underlying design principles. Furthermore, the article underscores the need to address several unresolved inquiries to enhance our comprehension of cancer therapeutics that target mechanotransduction.

Ultrasound-nanovesicles interplay for theranostics

Nanovesicles (NVs) are widely used in the treatment and diagnosis of diseases due to their excellent vascular permeability, good biocompatibility, high loading capacity, and easy functionalization. However, their yield and in vivo penetration depth limitations and their complex preparation processes still constrain their application and development. Ultrasound, as a fundamental external stimulus with deep tissue penetration, concentrated energy sources, and good safety, has been proven to be a patient-friendly and highly efficient strategy to overcome the restrictions of traditional clinical medicine. Recent research has shown that ultrasound can drive the generation of NVs, increase their yield, simplify their preparation process, and provide direct therapeutic effects and intelligent control to enhance the therapeutic effect of NVs. In addition, NVs, as excellent drug carriers, can enhance the targeting efficiency of ultrasound-based sonodynamic therapy or sonogenetic regulation and improve the accuracy of ultrasound imaging. This review provides a detailed introduction to the classification, generation, and modification strategies of NVs, emphasizing the impact of ultrasound on the formation of NVs and summarizing the enhanced treatment and diagnostic effects of NVs combined with ultrasound for various diseases.

An in-vivo study of the combined therapeutic effects of pulsed non-thermal focused ultrasound and radiation for prostate cancer

PURPOSE

The purpose of this study was to investigate the in vivo combined effects of pulsed focused ultrasound (pFUS) and radiation (RT) for prostate cancer treatment.

MATERIALS AND METHODS

An animal prostate tumor model was developed by implanting human LNCaP tumor cells in the prostates of nude mice. Tumor-bearing mice were treated with pFUS, RT or both (pFUS + RT) and compared with a control group. Non-thermal pFUS treatment was delivered by keeping the body temperature below 42 °C as measured real-time by MR thermometry and using a pFUS protocol (1 MHz, 25 W focused ultrasound; 1 Hz pulse rate with a 10% duty cycle for 60 sec for each sonication). Each tumor was covered entirely using 4-8 sonication spots. RT treatment with a dose of 2 Gy was delivered using an external beam (6 MV photon energy with dose rate 300MU/min). Following the treatment, mice were scanned weekly with MRI for tumor volume measurement.

RESULTS

The results showed that the tumor volume in the control group increased exponentially to 142 ± 6%, 205 ± 12%, 286 ± 22% and 410 ± 33% at 1, 2, 3 and 4 weeks after treatment, respectively. In contrast, the pFUS group was 29% (p < 0.05), 24% (p < 0.05), 8% and 9% smaller, the RT group was 7%, 10%, 12% and 18% smaller, and the pFUS + RT group was 32%, 39%, 41% and 44% (all with p < 0.05) smaller than the control group at 1, 2, 3, and 4 weeks post treatment, respectively. Tumors treated by pFUS showed an early response (i.e. the first 2 weeks), while the RT group showed a late response. The combined pFUS + RT treatment showed consistent response throughout the post-treatment weeks.

CONCLUSIONS

These results suggest that RT combined with non-thermal pFUS can significantly delay the tumor growth. The mechanism of tumor cell killing between pFUS and RT may be different. Pulsed FUS shows early tumor growth delay, while RT contributes to the late effect on tumor growth delay. The addition of pFUS to RT significantly enhanced the therapeutic effect for prostate cancer treatment.

Aquaporin 11 alleviates retinal Müller intracellular edema through water efflux in diabetic retinopathy

Retinal Müller glial dysfunction and intracellular edema are important mechanisms leading to diabetic macular edema (DME). Aquaporin 11 (AQP11) is primarily expressed in Müller glia with unclear functions. This study aims to explore the role of AQP11 in the pathogenesis of intracellular edema of Müller glia in diabetic retinopathy (DR). Here, we found that AQP11 expression, primarily located at the endfeet of Müller glia, was down-regulated with diabetes progression, accompanied by intracellular edema, which was alleviated by intravitreal injection of lentivirus-mediated AQP11 overexpression. Similarly, intracellular edema of hypoxia-treated rat Müller cell line (rMC-1) was aggravated by AQP11 inhibition, while attenuated by AQP11 overexpression, accompanied by enhanced function in glutamate metabolism and reduced cell death. The down-regulation of AQP11 was also verified in the Müller glia from the epiretinal membranes (ERMs) of proliferative DR (PDR) patients. Mechanistically, down-regulation of AQP11 in DR was mediated by the HIF-1α-dependent and independent miRNA-AQP11 axis. Overall, we deciphered the AQP11 down-regulation, mediated by miRNA-AQP11 axis, resulted in Müller drainage dysfunction and subsequent intracellular edema in DR, which was partially reversed by AQP11 overexpression. Our findings propose a novel mechanism for the pathogenesis of DME, thus targeting AQP11 regulation provides a new therapeutic strategy for DME.

The promising interplay between sonodynamic therapy and nanomedicine

Sonodynamic therapy (SDT) is a non-invasive approach for cancer treatment in which chemical compounds, named sonosensitizers, are activated by non-thermal ultrasound (US), able to deeply penetrate into the tissues. Despite increasing interest, the underlying mechanisms by which US triggers the sonosensitizer therapeutic activity are not yet clearly elucidate, slowing down SDT clinical application. In this review we will discuss the main mechanisms involved in SDT with particular attention to the sonosensitizers involved for each described mechanism, in order to highlight how much important are the physicochemical properties of the sonosensitizers and their cellular localization to predict their bioeffects. Moreover, we will also focus our attention on the pivotal role of nanomedicine providing the sonodynamic anticancer approach with the ability to shape US-responsive agents to enhance specific sonodynamic effects as the sonoluminescence-mediated anticancer effects. Indeed, SDT is one of the biomedical fields that has significantly improved in recent years due to the increased knowledge of nanosized materials. The shift of the nanosystem from a delivery system for a therapeutic agent to a therapeutic agent in itself represents a real breakthrough in the development of SDT. In doing so, we have also highlighted potential areas in this field, where substantial improvements may provide a valid SDT implementation as a cancer therapy.

Ultrasound-Induced DNA Damage and Cellular Response: Historical Review, Mechanisms Analysis, and Therapeutic Implications

The biological effects of ultrasound may be classified into thermal and nonthermal mechanisms. The nonthermal effects may be further classified into cavitational and noncavitational mechanisms. DNA damage induced by ultrasound is considered to be related to nonthermal cavitations. For this aspect, many in vitro studies on DNA have been conducted for evaluating the safety of diagnostic ultrasound, particularly in fetal imaging. Technological advancement in detecting DNA damage both in vitro and in vivo have elucidated the mechanism of DNA damage formation and their cellular response. Damage to DNA, and the residual damages after DNA repair are implicated in the biological effects. Here, we discuss the historical evidence of ultrasound on DNA damage and the mechanism of DNA damage formation both in vitro and in vivo, compared with those induced by ionizing radiation. We also offer a commentary on the safety of ultrasound over X-ray-based imaging. Also, understanding the various mechanisms involved in the bioeffects of ultrasound will lead us to alternative strategies for use of ultrasound for therapy.

Low-intensity ultrasound inhibits melanoma cell proliferation in vitro and tumor growth in vivo

PURPOSE

To determine the effect of low-intensity ultrasound on cancer cell proliferation in vitro and tumor growth in vivo.

METHODS

In vitro, several cancer cell lines were exposed to low-intensity ultrasound at 0.11 W/cm² for 2 min. Of the cell lines screened, melanoma C32 is one of the cell lines that showed sensitivity to growth inhibition by ultrasound and was therefore used in succeeding experiments. In vivo, under the same ultrasound conditions used in vitro, C32 tumors in mice were exposed to ultrasound daily for 2 weeks, and the tumor volumes were monitored weekly using sonography.

RESULTS

In vitro, C32 cell growth was inhibited, attaining 43.2% inhibition on the 3rd day. In vivo, tumor growth was significantly inhibited, with the treated tumors exhibiting 2.7-fold slowed tumor growth vs. untreated tumors at week 2. Such inhibition was not associated with increased cell death. Several genes related to the cell cycle and proliferation were among those significantly regulated.

CONCLUSION

These findings highlight the potential of low-intensity ultrasound to inhibit tumor growth in a noninvasive, safe, and easy-to-administer way. In addition, this may suggest that the mechanical stress induced by ultrasound on C32 cells may have affected the intrinsic biomolecular mechanism related to the cell growth of this particular cell line. Further research is needed to identify which of the regulated genes played key roles in growth inhibition.

Low-Intensity Pulsed Ultrasound Effect on MIO-M1 Cell Viability: Setup Validation and Standing Waves Analysis

Low-intensity pulsed ultrasound (LIPUS) has been proposed for novel therapies still under study, where similar parameters and protocols have been used for producing opposite effects that range from increasing cell viability to provoking cell death. Those divergent outcomes make the generalization of expected effects difficult for cell models not yet studied. This paper presents the effect of LIPUS on the viability of the MIO-M1 cell line for two well-established setups and different protocols; the acoustic intensities, duty factors, and treatment duration were varied. Measurements and models for acoustic and thermal analysis are included for proposing a solution to improve the reproducibility of this kind of experiments. Results indicate that MIO-M1 viability is less affected for the cells treated through a dish that is partially immersed in water; in these conditions, the cells neither show detrimental nor proliferative effects at intensities lower than 0.4 W/cm2 at 20% duty factor. However, cell viability was reduced when LIPUS was followed by cell subculturing. Treating the cells through a gel, with the culture dish placed on the transducer, increases cell mortality by the production of standing waves and mixed vibration-acoustical effects. Using the water-based setup with a 1° dish inclination reduces the effects of standing waves.

Sonodynamic therapy (SDT): a novel strategy for cancer nanotheranostics

Sonodynamic therapy (SDT) is a promising non-invasive therapeutic modality. Compared to photo-inspired therapy, SDT provides many opportunities and benefits, including deeper tissue penetration, high precision, less side effects, and good patient compliance. Thanks to the facile engineerable nature of nanotechnology, nanoparticles-based sonosensitizers exhibit predominant advantages, such as increased SDT efficacy, binding avidity, and targeting specificity. This review aims to summarize the possible mechanisms of SDT, which can be expected to provide the theoretical basis for SDT development in the future. We also extensively discuss nanoparticle-assisted sonosensitizers to enhance the outcome of SDT. Additionally, we focus on the potential strategy of combinational SDT with other therapeutic modalities and discuss the limitations and challenges of SDT toward clinical applications.

Low-intensity pulsed ultrasound enhances cell killing induced by X-irradiation

To determine the effect of pulsed ultrasound (US) on radiation-induced cell killing, U937 and Molt-4 cell lines were exposed to 1.0 MHz US with 50% of duty factor at 0.3 W/cm(2) and pulsed at 1 Hz immediately after exposure to X-rays at 0, 0.5, 2.5 and 5 Gy. The cells were assayed 24 h after the treatments. The result showed significant enhancement of cell killing in the combined treatments. However, the ratio of apoptotic cells induced either by X-rays or US alone did not significantly change. These findings suggest that pulsed US can enhance the anticancer effect of X-irradiation due to US streaming under non-inertial cavitational condition. This combined treatment can potentially enhance the therapeutic effect of radiation therapy.

Effect of low-intensity focused ultrasound on the middle ear in a mouse model of acute otitis media

We hypothesized that low-intensity focused ultrasound (LIFU) increases vessel permeability and antibacterial drug activity in the mouse middle ear. We determined appropriate settings by applying LIFU to mouse ears with the external auditory canal filled with normal saline and performed histologic and immunohistologic examination. Acute otitis media was induced in mice with nontypable Haemophilus influenzae, and they were given ampicillin (50, 10, or 2 mg/kg) intraperitoneally once daily for 3 days with or without LIFU (1.0 W/cm(2), 20% duty cycle, 30 s). In the LIFU(+) groups receiving the 2- and 10-mg/kg doses, viable bacteria counts, number of inflammatory cells and IL-1β and TNF-α levels in middle ear effusion were significantly lower than in the LIFU(-) groups on the same doses. Severity of AOM also tended to be reduced more in the LIFU(+) groups than in the LIFU(-) groups. LIFU application with antibiotics may be effective for middle ear infection.

Use of ultrasound in drug delivery systems: emphasis on experimental methodology and mechanisms

Recent studies have shown that ultrasound energy could be applied for targeting or controlling drug release. This new concept of therapeutic ultrasound combined with drugs has induced a great amount of interest in various medical fields. In this paper, several experimental systems are cited in which ultrasound is being utilized to evaluate new application of this modality. The mechanisms of ultrasound-mediated drug delivery are discussed in addition to the review of current advances in the use of ultrasound in systems involving research in cancer therapy, gene therapy, microbubbles and other drug delivery in vitro and in vivo experiments.

Involvement of reactive oxygen species in sonodynamically induced apoptosis using a novel porphyrin derivative

In this study, we investigated the induction of apoptosis by ultrasound in the presence of the novel porphyrin derivative DCPH-P-Na(I). HL-60 cells were exposed to ultrasound for up to 3 min in the presence and absence of DCPH-P-Na(I), and the induction of apoptosis was examined by analyzing cell morphology, DNA fragmentation, and caspase-3 activity. Reactive oxygen species were measured by means of ESR and spin trapping technique. Cells treated with 8 μM DCPH-P-Na(I) and ultrasound clearly showed membrane blebbing and cell shrinkage, whereas significant morphologic changes were not observed in cells exposed to either ultrasound or DCPH-P-Na(I) alone. Also, DNA ladder formation and caspase-3 activation were observed in cells treated with both ultrasound and DCPH-P-Na(I) but not in cells treated with ultrasound or DCPH-P-Na(I) alone. In addition, the combination of DCPH-P-Na(I) and the same acoustical arrangement of ultrasound substantially enhanced nitroxide generation by the cells. Sonodynamically induced apoptosis, caspase-3 activation, and nitroxide generation were significantly suppressed by histidine. These results indicate that the combination of ultrasound and DCPH-P-Na(I) induced apoptosis in HL-60 cells. The significant reduction in sonodynamically induced apoptosis, nitroxide generation, and caspase-3 activation by histidine suggests active species such as singlet oxygen are important in the sonodynamic induction of apoptosis. These experimental results support the possibility of sonodynamic treatment for cancer using the induction of apoptosis.

Apoptotic cell death by the novel natural compound, cinobufotalin

Cinobufotalin (CB), one of the bufadienolides prepared from toad venom, was investigated for its cytotoxicity, and the underneath mechanism involved. We primarily utilized DNA fragmentation assay and microscopic observation to assess the effect of various doses of CB in human lymphoma U937 cells. Following that, we investigated other parameters involved in cell death mechanism such as reactive oxygen species (ROS), mitochondrial membrane potential (MMP), and apoptotic proteins activation. HeLa cells were concomitantly used to generalize the data observed. Our results show that CB caused significant DNA fragmentation, decrease of MMP, and an increase in the intracellular Ca(2+) ion and ROS production. In addition, CB induced upregulation of Fas protein, proteolytic activation of cytochrome c, caspase-2, -3, -8 and -9 together with the activation of Bid and Bax. Our findings were further validated using either Fas/FasL antagonist or pan-caspase inhibitor to significantly inhibit CB-induced DNA fragmentation. In our study, we suggest that CB induces caspase dependent cell death in U937 cells, and that Fas plays a role in CB-induced apoptosis. Altogether, our data provides novel insights of the mechanism of action of CB and its potential as a future chemotherapeutic agent.

Adjustment of ultrasound exposure duration to microbubble sonodestruction kinetics for optimal cell sonoporation in vitro

Cell sonoporation enables the delivery of various exogenous molecules into the cells. To maximize the percentage of reversibly sonoporated cells and to increase cell viability we propose a model for implicit dosimetry for adjustment of ultrasound (US) exposure duration. The Chinese hamster ovary cell suspension was supplemented with microbubbles (MB) and exposed to US, operating at the frequency of 880kHz, with a 100% duty cycle and with an output peak negative pressure (PNP) of 500kPa for durations ranging from 0.5 to 30s. Using diagnostic B-scan imaging we showed that the majority of the MB at 500kPa US peak negative pressure undergo sonodestruction in less than a second. During this time maximal number of reversibly sonoporated cells was achieved. Increase of US exposure duration did not increase sonoporated cell number, however it induced additional cell viability decrease. Therefore aiming to achieve the highest level of reversibly sonoporated cells and also to preserve the highest level of cell viability, the duration of US exposure should not exceed the duration needed for complete MB sonodestruction.

Stable cavitation induces increased cytoplasmic calcium in L929 fibroblasts exposed to 1-MHz pulsed ultrasound

An increase in cytoplasmic calcium (Ca(2+) increase) is a second messenger that is often observed under ultrasound irradiation. We hypothesize that cavitation is a physical mechanism that underlies the increase in Ca(2+) in these experiments. To control the presence of cavitation, the wave type was controlled in a sonication chamber. One wave type largely contained a traveling wave (wave type A) while the other wave type largely contained a standing wave (wave type B). Fast Fourier transform (FFT) analysis of a sound field produced by the wave types ascertained that stable cavitation was present only under wave type A ultrasound irradiation. Under the two controlled wave types, the increase in Ca(2+) in L929 fibroblasts was observed with fluorescence imaging. Under wave type A ultrasound irradiation, an increase in Ca(2+) was observed; however, no increase in Ca(2+) was observed under wave type B ultrasound irradiation. We conclude that stable cavitation is involved in the increase of Ca(2+) in cells subjected to pulsed ultrasound.

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.

Saving cells from ultrasound-induced apoptosis: quantification of cell death and uptake following sonication and effects of targeted calcium chelation

Applications of ultrasound for noninvasive drug and gene delivery have been limited by associated cell death as a result of sonication. In this study, we sought to quantify the distribution of cellular bioeffects caused by low-frequency ultrasound (24 kHz) and test the hypothesis that Ca(2+) chelation after sonication can shift this distribution by saving cells from death by apoptosis. Using flow cytometry, we quantitatively categorized sonicated cells among four populations: (i) cells that appear largely unaffected, (ii) cells reversibly permeabilized, (iii) cells rendered nonviable during sonication and (iv) cells that appear to be viable shortly after sonication, but later undergo apoptosis and die. By monitoring cells for 6 h after ultrasound exposure, we found that up to 15% of intact cells fell into this final category. Those apoptotic cells initially had the highest levels of uptake of a marker compound, calcein; also had highly elevated levels of intracellular Ca(2+); and contained an estimated plasma membrane wound radius of 100-300 nm. Finally, we showed that chelation of intracellular Ca(2+) after sonication reduced apoptosis by up to 44%, thereby providing a strategy to save cells. We conclude that cells can be saved from ultrasound-induced death by appropriate selection of ultrasound conditions and Ca(2+) chelation after sonication.

Sonodynamically induced apoptosis and active oxygen generation by gallium-porphyrin complex, ATX-70

In this study, we investigated the induction of apoptosis by ultrasound in the presence of the photochemically active gallium-porphyrin complex, 7,12-bis(1-decyloxyethyl)-Ga(III)-3,8,13,17-tetramethyl-porphyrin 2,18-dipropionyl diaspartic acid (ATX-70). HL-60 cells were exposed to ultrasound for up to 3 min in the presence and absence of ATX-70, and the induction of apoptosis was examined by analyzing cell morphology, DNA fragmentation, and caspase-3 activity. Cells treated with 80 μM ATX-70 and ultrasound clearly showed membrane blebbing and cell shrinkage, whereas significant morphologic changes were not observed in cells exposed to either ultrasound or ATX-70 alone. Also, DNA ladder formation and caspase-3 activation were observed in cells treated with both ultrasound and ATX-70 but not in cells treated with ultrasound or ATX-70 alone. In addition, the combination of ATX-70 and the same acoustical arrangement of ultrasound substantially enhanced nitroxide generation by the cells. Sonodynamically induced apoptosis, caspase-3 activation, and nitroxide generation were significantly suppressed by histidine. These results indicate that the combination of ultrasound and ATX-70 induces apoptosis in HL-60 cells. The significant reduction in sonodynamically induced apoptosis, nitroxide generation, and caspase-3 activation by histidine suggests that active species such as singlet oxygen are important in the sonodynamic induction of apoptosis.

The effects of power on–off durations of pulsed ultrasound on the destruction of cancer cells

PURPOSE

Low-intensity ultrasound irradiation is a potential method for suppressing cancer cell proliferation, inducing apoptosis and delivering specific cytotoxic genes or drugs into tumors topographically in future cancer therapies. However, ultrasound attenuates rapidly in tissue and produces heat. Pulsed ultrasound is frequently used to minimize pain and possible thermal damage to the surrounding normal tissue during therapy, since it results in smaller temperature increases. This study compared three pulsed-ultrasound strategies for destroying cancer cells, measuring their induced temperature increases to determine the optimal pulsing parameters.

MATERIALS AND METHODS

We performed three types of experiment, involving ultrasound with (1) a fixed duty cycle of 50% with variable on- and off-times, (2) a fixed off-time with variable on-times, and (3) a fixed on-time with variable off-times.

RESULTS

The results show that for different types of cultured cells (HeLa, HT-29, Ca9-22 and fibroblast) exposed to ultrasound of the same frequency (1 MHz) and energy, long pulses combined with off-times that are 5-10 times longer (on-/-off-times pairs of 5/25, 25/250, or 250/2500 ms/ms) cause significant cell destruction whilst avoiding temperature increases of more than 1.5 degrees C. Furthermore, the correlation between the temperature increase and the percentage of surviving cells is low.

CONCLUSIONS

Pulsed ultrasound with a long on-time and an even longer off-time exerts a high cytotoxic effect but a smaller temperature increase compared with non-pulsed ultrasound. This indicates that the cytotoxic effects observed in the current study were not purely due to the thermal effects of the ultrasound.

Ultrasound-mediated gene transfection

Ultrasound-mediated gene transfection (sonotransfection) has been shown to be a promising physical method for gene therapy, especially for cancer gene therapy. The procedure being done in vitro uses several ultrasound exposure (sonication) setups. Although high transfection rates have been attained in some of these setups in vitro, replicating similar levels of transfection in vivo has been difficult. In vivo-simulated setups offer hope for a more consistent outcome in vivo. Presented in this chapter are typical methods of sonotransfection in vitro, methods when using a novel in vivo-simulated in vitro sonication setup and also sonotransfection methods when doing in vivo experiments. Factors that could potentially influence the outcome of an ultrasound experiment are cited. Several advantages of sonotransfection are recognized, although a low transfection rate is still considered a disadvantage of this method. To improve the transfection rate and the efficiency of sonotransfection, several studies are currently being undertaken. Particularly promising are studies using engineered microbubbles to carry the therapeutic genes into a particular target tissue in the body, then using ultrasound to release or deliver the genes directly into target cells, e.g., cancer cells.

Therapeutic potential of low-intensity ultrasound (part 2): biomolecular effects, sonotransfection, and sonopermeabilization

Part one of this review focused on the thermal and mechanical effects of low-intensity ultrasound (US). In this second and final part of the review, we will focus on and discuss various aspects of low-intensity US, with emphasis on the biomolecular effects, US-mediated gene transfection (sonotransfection), and US-mediated permeabilization (sonopermeabilization). Sonotransfection of different cell lines in vitro and target tissues in vivo have been reported. Optimization experiments have been done and different mechanisms investigated. It has also been found that several genes can be up-regulated or down-regulated by sonication. As to the potential therapeutic applications, systemic or local sonotransfection might also be a safe and effective gene therapy method in effecting the cure of local and systemic disorders. Gene regulation of target cells may be utilized in modifying cellular response to a treatment, such as increasing the sensitivity of diseased cells while making normal cells resistant to the side effects of a treatment. Advances in sonodynamic therapy and drug sonopermeabilization also offer an ever-increasing array of therapeutic options for low-intensity US.

Therapeutic potential of low-intensity ultrasound (part 1): thermal and sonomechanical effects

In this first part of the review, we will focus on and discuss various aspects of low-intensity ultrasound (US), with emphasis on mild thermal effects, apoptosis induction, and sonomechanical effects. Mild thermal effects of US have been commonly applied to physical therapy. Though US has clear beneficial effects, the advantage of using US over other heating modalities remains unclear. US has also been used in vivo and clinically in the treatment of wounds and fractures, with promising results. On the biomolecular level, studies have shown that US can induce apoptosis and that certain conditions can provide optimal apoptosis induction. As to potential therapeutic applications, in addition to the thermal and other physical effects, apoptosis induction by US may offer direct and rapid treatment of tumors or cancer tissues. Technological advances and rapidly accelerating research in this field are providing an ever-increasing array of therapeutic options for lowintensity US.

Sonodynamic therapy

Recently, there have been numerous reports on the application of non-thermal ultrasound energy for treating various diseases in combination with drugs. Furthermore, the introduction of microbubbles and nanobubbles as carriers/enhancers of drugs has added a whole new dimension to therapeutic ultrasound. Non-thermal mechanisms for effects seen include various forms of energy due to cavitation, acoustic streaming, micro jets and radiation force which increases possibilities for targeting tissue with drugs, enhancing drug effectiveness or even chemically activating certain materials. Examples such as enhancement of thrombolytic agents by ultrasound have proven to be beneficial for acute stroke patients and peripheral arterial occlusions. Non-invasive low intensity focused ultrasound in conjunction with anti-cancer drugs may help to reduce tumor size and lessen recurrence while reducing severe drug side effects. Chemical activation of drugs by ultrasound energy for treatment of atherosclerosis and tumors is another new field recently termed as "Sonodynamic therapy". Lastly, advances in molecular imaging have aroused great expectations in applying ultrasound for both diagnosis and therapy simultaneously. Microbubbles or nanobubbles targeted at the molecular level will allow medical doctors to make a final diagnosis of a disease using ultrasound imaging and then immediately proceed to a therapeutic ultrasound treatment.

Nanoelectroporation: a first look

As the medical field moves from treatment of diseases with drugs to treatment with genes, safe and efficient gene delivery systems are needed to make this transition. One such safe, nonviral, and efficient gene delivery system is electroporation (electrogenetherapy). Exciting discoveries by using electroporation could make this technique applicable to drug and vaccine delivery in addition to gene delivery. Typically, milli- and microsecond pulses have been used for electroporation. Recently, the use of nanosecond electric pulses (10-300 ns) at very high magnitudes (10-300 kV/cm) has been studied for direct DNA transfer to the nucleus in vitro. This article reviews the work done using high intensity, nanopulses, termed as nanoelectroporation (nano-EP), in electroporation gene delivery systems.

Sonodynamically-induced apoptosis, necrosis, and active oxygen generation by mono-l-aspartyl chlorin e6

In this study, we investigated the induction of apoptosis by ultrasound in the presence of a photochemically active chlorin, mono-l-aspartyl chlorin e6 (NPe6). HL-60 cells were exposed to ultrasound for up to 3 min in the presence and absence of NPe6, and the induction of apoptosis was examined by analyzing cell morphology, DNA fragmentation, and caspase-3 activity. Cells treated with 80 microM NPe6 and ultrasound clearly showed membrane blebbing and cell shrinkage, whereas significant morphologic changes were not observed in cells exposed to either ultrasound alone, at the same intensity, or NPe6 alone. Also, DNA ladder formation and caspase-3 activation were observed in cells treated with both ultrasound and NPe6 but not in cells treated with ultrasound or NPe6 alone. In addition, NPe6 substantially enhanced nitroxide generation by ultrasound in the same acoustical arrangement. Sonodynamically-induced apoptosis, caspase-3 activation, and nitroxide generation were significantly suppressed by histidine. These results suggest that the combination of ultrasound and NPe6 sonochemically induces apoptosis as well as necrosis in HL-60 cells. They further suggest that some ultrasonically-generated active species, deactivatable by histidine, are the major mediators to induce the observed apoptosis.

Sonodynamically induced apoptosis with porfimer sodium in HL-60 cells

Sonodynamically induced apoptosis with porfimer sodium in HL-60 cells was investigated. HL-60 cells were exposed to ultrasound for up to 3 min in the presence and absence of porfimer sodium. After the exposure, sonodynamically induced apoptosis was assessed according to morphologic changes, DNA fragmentation and caspase-3 activation. The cells treated with 50 mug/ml porfimer sodium and ultrasound clearly showed membrane blebbing and cell shrinkage, whereas no significant morphologic change was observed in the cells exposed to either ultrasound alone or porfimer sodium alone. DNA ladder formation was observed in the cells treated with ultrasound in the presence of porfimer sodium. Activation of caspase-3 was also observed after the treatment with ultrasound and porfimer sodium. Both sonodynamically induced apoptosis and caspase-3 activation were significantly suppressed by histidine. These results indicate that combination treatment with ultrasound and porfimer sodium induced apoptosis in HL-60 cells. Significant reduction by histidine in both sonodynamically induced apoptosis and caspase-3 activation suggests that some ultrasonically generated active species, deactivatable by histidine, are the major mediators to induce the observed apoptosis.

Identification of genes responsive to low intensity pulsed ultrasound in a human leukemia cell line Molt-4

We examined the gene expression of human leukemia Molt-4 cells treated with non-thermal low intensity pulsed ultrasound. Six hours after 0.3W/cm(2) pulsed ultrasound treatment, apoptosis (24+/-3.3%, mean+/-SD) with minimal cell lysis was observed. Of approximately 16,600 genes analyzed, BCL2-associated athanogene 3 (BAG3), DnaJ (Hsp40) homolog, subfamily B, member 1 (DNAJB1), heat shock 70 kDa protein 1B (HSPA1B), and heat shock 70 kDa protein 6 (HSPA6) showed increased levels of expression while isopentenyl-diphosphate delta isomerase (IDI1) and 3-hydroxy-3-methylglutaryl-coenzyme A synthase 1 (HMGCS1) showed decreased levels in the cells 3h after the ultrasound treatment. The expression levels of these six genes were confirmed by a real-time quantitative polymerase chain reaction. To our knowledge, this is the first report of DNA microarray analysis of genes that are differentially expressed in response to apoptosis induced by non-thermal low intensity pulsed ultrasound in human leukemia cells. The present results will provide a basis for further understanding of the molecular mechanisms of effects of not only low intensity pulsed ultrasound but also that of mechanical shear stress in the cells.

Activation of Bak in ultrasound-induced, JNK- and p38-independent apoptosis and its inhibition by Bcl-2

The molecular mechanisms underlying ultrasound-induced apoptosis remain poorly understood. We have demonstrated that in Jurkat cells, the over-expression of the anti-apoptotic protein Bcl-2 inhibited ultrasound-induced apoptosis, but not necrosis. Inhibition of caspase activity also protected the cells from apoptosis, but not from necrosis, showing the involvement of different mechanisms in ultrasound-induced apoptosis and necrosis. Bak, a pro-apoptotic member of the Bcl-2 family proteins, was activated by ultrasound and its activation was completely inhibited by Bcl-2 over-expression, but not by caspase inhibition. Antioxidant N-acetyl cysteine did not protect the cells from ultrasound-induced apoptosis or necrosis, nor did the inhibition of either c-Jun N-terminal kinase or p38, key factors in the radical oxygen species (ROS)-mediated cell stress response, suggesting that ROS do not play a crucial role in ultrasound-induced apoptosis. Our results confirm that ultrasound induces apoptosis via a pathway that involves Bak, Bcl-2, and caspases, but not ROS.

Optimized ultrasound-mediated gene transfection in cancer cells

Ultrasound-mediated gene transfection (sonotransfection) is a promising physical method for gene therapy, especially for cancer gene therapy. To investigate the optimal sonotransfection conditions and to determine whether the optimal transfection rate using sonotransfection is comparable to that of electrotransfection or liposome-mediated transfection, we sonicated different cancer cell lines (U937, HeLa, PC-3, Meth A and T-24) using a 1-MHz unfocused ultrasound at different intensities, pulse repetition frequencies and exposure times. The ideal ultrasound conditions were noted to be at 1.5 Watt/cm(2) pulsed at 0.5 Hz with a duty factor of 50%. The results showed that transfection rate increased with the number of pulses, and peaked between 10 and 15 pulses before it started to decline. Using such optimal conditions, we have shown that sonotransfection is superior to electrotransfection and liposome-mediated transfection at the fixed conditions used in the present study. These findings suggest that sonotransfection could be a better alternative to other non-viral methods (e.g. electroporation and liposome-mediated transfection) of gene transfection, particularly in cancer gene therapy.

An echo-contrast agent, Levovist, lowers the ultrasound intensity required to induce apoptosis of human leukemia cells

To verify the effect of echo-contrast agent (ECA) on apoptosis induced by ultrasound, leukemia cell lines (Jurkat, Molt-4 and U937) were sonicated at intensities previously shown to induce optimal apoptosis with or without Levovist, an ECA. The results showed that loss of viability and apoptosis can be induced in all three cell lines, apoptosis highest with Molt-4, based on viability and DNA fragmentation assay. Such finding was supported by corresponding increase of cells with low mitochondrial membrane potential, high superoxide production, increased intracellular calcium concentration, and phosphorylation of histone H2AX after sonication. Optimal ultrasound condition was 0.3W/cm(2), 1MHz, 10% duty factor pulsed at 100Hz; but in the presence of Levovist, an apparent shift of cell killing induction was observed at 0.2W/cm(2). While these results further confirmed previous findings on ultrasound-induced apoptosis, they also suggest that use of an enhancing factor, such as addition of ECA, may be useful in cancer therapy when a much lower intensity is desired.

Comparison between sonodynamic effect and photodynamic effect with photosensitizers on free radical formation and cell killing

Although enhancement of ultrasound-induced cell killing by photodynamic reagents has been shown, the sonochemical mechanism in detail is still not clear. Here, comparison between sonodynamic effect and photodynamic effect with photosensitizers at a concentration of 10 microM on free radical formation and cell killing was made. When electron paramagnetic-resonance spectroscopy (EPR) was used to detect 2,2,6,6-tetramethyl-4-piperidone-N-oxyl (TAN) after photo-irradiation or sonication with 2,2,6,6-tetramethyl-4-piperidone (TMPD), the order of TAN formation in the photo-irradiated samples was as follows: rhodamine 6G (R6) > sulforhodamine B (SR) > hematoporphyrin (Hp) > rhodamine 123 (R123) > rose bengal (RB)>erythrosine B (Er) = 0; although there was time-dependent TAN formation when the samples were sonicated, no significant difference among these agents were observed. All these agents suppressed ultrasound-induced OH radical formation detected by EPR-spin trapping. Sensitizer-derived free radicals were markedly observed in SR, RB and Er, while trace level of radicals derived from R6 and R123 were observed. Enhancement of ultrasound-induced decrease of survival in human lymphoma U937 cells was observed at 1.5 W/cm(2) (less than inertial cavitation threshold) for R6, R123, SR and Er, and at 2.3 W/cm(2) for R6, R123, Er, RB and SR. On the other hand, photo-induced decrease of survival was observed for R6, Hp and RB at the same concentration (10 microM). These comparative results suggest that (1) (1)O(2) is not involved in the enhancement of ultrasound-induced loss of cell survival, (2) OH radicals and sensitizer-derived free radicals do not take part in the enhancement, and (3) the mechanism is mainly due to certain mechanical stress such as augmentation of physical disruption of cellular membrane by sensitizers in the close vicinity of cells and/or cavitation bubbles.

Ultrasound liberates nitric oxide (NO) from the caged NO compound N,N'-bis(carboxymethyl)-N,N'-dinitroso-p-phenylenediamine sodium salt

To determine whether nitric oxide (NO) can be released from a cage compound N,N'-bis(carboxymethyl)-N,N'-dinitroso-p-phenylenediamine sodium salt (BNN 5 Na), we sonicated different concentrations of BNN 5 Na solutions containing an NO spin trap, (MGD)2Fe2+, and then measured (MGD)2Fe2+-NO signal using electron paramagnetic resonance (EPR). We also investigated the role of cavitation by saturating the solutions with Ar, He or Xe gases before sonication. The result showed that ultrasound can liberate NO from caged NO compound at rates highest with Xe and lowest with He. These results suggest that high-temperature due to cavitations induced by ultrasound are capable of releasing NO from caged NO compounds. This finding also opens up to a new possibility for the use of ultrasound in a controlled release of active compound (e.g. drug) from its caged form for therapeutic purposes.

Expression of heme oxygenase-1 due to intracellular reactive oxygen species induced by ultrasound

The present study was undertaken to elucidate the mechanism by which ultrasound induces the expression of heme oxygenase-1 (HO-1). When human lymphoma U937 cells were exposed to a 1 MHz continuous wave for 1 min, HO-1 expression examined by real-time quantitative polymerase chain reaction and immunoblotting was observed at intensities above the cavitational threshold. No induction of HO-1 expression was observed in the cells exposed for 1 min to 42 degrees C, a temperature higher than that during sonication. When a potent antioxidant, N-acetyl-l-cysteine, was added to the culture medium before or after sonication, the induction was attenuated, indicating that reactive oxygen species (ROS) are involved. However, the addition of catalase did not affect the induction, and no HO-1 was observed on the addition of pre-sonicated medium, suggesting that hydrogen peroxide due to the recombination of hydroxyl radicals generated extracellularly was not involved. The addition of free radical scavengers, glutathion-monoethyl ester, dimethyl sulfoxide and D(-)-mannitol, suppressed the induction. A decrease in mitochondrial membrane potential and the generation of superoxide were also observed in the sonicated cells, suggesting that mitochondria were the source of intracellularly generated ROS. These results indicate that superoxide secondarily generated from damaged mitochondria, not hydroxyl radicals generated in medium directly by sonication, give rise to intracellular oxidative stress inducing HO-1 expression.

Scientific basis for the use of hypotonic solutions with ultrasonic liposuction

BACKGROUND

A number of plastic surgeons have advocated using hypotonic solution in ultrasound lipoplasty, theorizing that induced adipocyte swelling increases membrane susceptibility to ultrasonic disruption. Additionally, it has been theorized that potassium increases membrane permeability. This study aimed to determine the effect of solution osmolality on adipocyte diameter, the time course of hypotonic solution action, and the effect of potassium addition on adipocyte diameter.

METHODS

Base solutions with three different osmolalities were prepared: normal saline (NS) (154 mOsm/l), 1/2NS (77 mOsm/l), and 1/4NS (38.5 mOsm/l). Each solution was modified to contain 0, 5, and 10 mEq/l of potassium and adjusted to starting osmolality. Adipocytes of six patients were suspended in the nine solutions, and diameters were determined at 0, 15, 30, and 45 min. Diameters were measured using imaging software (Kodak ID 3.6).

RESULTS

At time 0, the average adipocyte diameter was 79 +/- 8 microm, and no difference was seen in any of the solutions. Cells in the NS group showed no significant increase in diameter over 45 min. The 1/2NS group achieved an 8% +/- 1.9% increase in diameter at 45 min (p < 0.05). The 1/4NS group showed an increase by 14% +/- 2.4% (p < 0.01) at 15 min, and 15% +/- 2.3% (p < 0.01) at 45 min. Potassium had no independent effect on cell diameter.

CONCLUSIONS

Hypotonic solution can significantly increase human adipocyte diameter. The findings showed that 1/2NS had a significant effect within 15 min. Tumescent solutions with an osmolality of 1/4NS may be useful in facilitating ultrasonic lipoplasty.

Ultrasonication-induced Amyloid Fibril Formation of β2-Microglobulin

To obtain insight into the mechanism of fibril formation, we examined the effects of ultrasonication, a strong agitator, on beta2-microglobulin (beta2-m), a protein responsible for dialysis-related amyloidosis. Upon sonication of an acid-unfolded beta2-m solution at pH 2.5, thioflavin T fluorescence increased markedly after a lag time of 1-2 h with a simultaneous increase of light scattering. Atomic force microscopy images showed the formation of a large number of short fibrils 3 nm in diameter. When the sonication-induced fibrils were used as seeds in the next seeding experiment at pH 2.5, a rapid and intense formation of long fibrils 3 nm in diameter was observed demonstrating seed-dependent fibril growth. We then examined the effects of sonication on the native beta2-m at neutral pH, conditions under which amyloid deposits occur in patients. In the presence of 0.5 mm sodium dodecyl sulfate, a model compound of potential trigger and stabilizer of amyloid fibrils in patients, a marked increase of thioflavin T fluorescence was observed after 1 day of sonication at pH 7.0. The products of sonication caused the accelerated fibril formation at pH 7.0. Atomic force microscopy images showed that the fibrils formed at pH 7.0 have a diameter of more than 7 nm, thicker than those prepared at pH 2.5. These results indicate that ultrasonication is one form of agitation triggering the formation of amyloid fibrils of beta2-m, producing fibrils adapted to the respective pH.

Can pulsed ultrasound increase tissue damage during ischemia? A study of the effects of ultrasound on infarcted and non-infarcted myocardium in anesthetized pigs

BACKGROUND

The same mechanisms by which ultrasound enhances thrombolysis are described in connection with non-beneficial effects of ultrasound. The present safety study was therefore designed to explore effects of beneficial ultrasound characteristics on the infarcted and non-infarcted myocardium.

METHODS

In an open chest porcine model (n = 17), myocardial infarction was induced by ligating a coronary diagonal branch. Pulsed ultrasound of frequency 1 MHz and intensity 0.1 W/cm2 (ISATA) was applied during one hour to both infarcted and non-infarcted myocardial tissue. These ultrasound characteristics are similar to those used in studies of ultrasound enhanced thrombolysis. Using blinded assessment technique, myocardial damage was rated according to histopathological criteria.

RESULTS

Infarcted myocardium exhibited a significant increase in damage score compared to non-infarcted myocardium: 6.2 +/- 2.0 vs. 4.3 +/- 1.5 (mean +/- standard deviation), (p = 0.004). In the infarcted myocardium, ultrasound exposure yielded a further significant increase of damage scores: 8.1 +/- 1.7 vs. 6.2 +/- 2.0 (p = 0.027).

CONCLUSION

Our results suggest an instantaneous additive effect on the ischemic damage in myocardial tissue when exposed to ultrasound of stated characteristics. The ultimate damage degree remains to be clarified.

Apoptosis induced by the sonomechanical effects of low intensity pulsed ultrasound in a human leukemia cell line

To obtain an optimal condition for ultrasound (US)-induced apoptosis that could be useful for cancer therapy, we applied low intensity pulsed US to sonicate U937 cells in vitro. Cells were then incubated at different time intervals before measuring apoptosis. The apoptosis was assessed by DNA fragmentation and phosphatidylserine externalization. The pattern of the decrease in mitochondrial membrane potential was determined by flow cytometry. Optimal apoptosis (70.0+/-13.8%) with minimal lysis was attained with 1 MHz ultrasound 0.3 W/cm2, 10% duty factor at 100 Hz for 1 min) at 12 h after sonication. Lack of US-induced free radical detection and absence of Heme oxygenase-1, an intracellular oxidative stress marker, up-regulation in cells, suggest that sonomechanical, not sonochemical, effects are the main mechanism involved.

Major factors involved in the inhibition of ultrasound-induced free radical production and cell killing by pre-sonication incubation or by high cell density

To identify the factors involved in the inhibition of ultrasound (US)-induced free radical production and cell killing by pre-sonication incubation or by high cell density, we used different densities of U937 cells, and with (up to 2 h) or without pre-sonication incubations, the cell suspensions were exposed to 1 MHz US (10% duty factor at 100 Hz pulse rate; intensities 0.1-0.5 W/cm(2) for 1 min). The intensity 0.3 W/cm(2) was used for cell killing experiments and 0.5 W/cm(2) for free radical experiments. Free radical production was determined by electron paramagnetic resonance (EPR)-spin trapping with DMPO while cell killing was determined by assays for lysis, loss of cell viability, apoptosis and necrosis. The results show that at higher cell densities, CO(2) in the medium rapidly increased, with shorter pre-sonication incubation required to attain complete inhibition of both free radical production and cell killing. Cell killing at 0.3 W/cm(2) and free radical production at 0.5 W/cm(2) were both inhibited at 10 million cells/ml without incubation, and at 2 million cells/ml incubated for 2 h before sonication. Level of CO(2) alone could not account for the inhibition; consumption of gases in the medium is also considered in the inhibitory effect of pre-sonication, while suppression of cavitational activities due to the "viscosity effect" is considered a more important factor in the inhibition by high cell density.

Biological effects of low intensity ultrasound: the mechanism involved, and its implications on therapy and on biosafety of ultrasound

The biological effects of low intensity ultrasound (US) in vitro; the mechanisms involved; and the factors that can enhance or inhibit these effects are reviewed. The lowest possible US intensities required to induce cell killing or to produce free radicals were determined. Following sonication in the region of these intensities, the effects of US in combination with either hyperthermia, hypotonia, echo-contrast agents (ECA), CO2, incubation time, high cell density or various agents were examined. The results showed that hyperthermia, hypotonia and microbubbles are good enhancers of the bioeffects, while CO2, incubation time and high cell density are good inhibitors. Cellular membrane damage is pivotal in the events leading to cell death, with the cellular damage-and-repair mechanism as an important determinant of the fate of the damaged cells. The optimal level of apoptosis (with minimal lysis) and optimal gene transfection efficiency were attained using a pulsed low intensity US. In summary, the findings suggest that low intensity US is potentially useful in therapy, while on the other hand, they also call for further investigation of such clinical scenarios as high-grade fever, edema or use of ECA which may lead to the lowering of the threshold for bioeffects with diagnostic US.