Modeling tissue-selective cavitation damage

Nanoparticle-Mediated Histotripsy Using Dual-Frequency Pulsing Methods

OBJECTIVE

Nanoparticle-mediated histotripsy (NMH) is a novel ablation method that combines nanoparticles as artificial cavitation nuclei with focused ultrasound pulsing to achieve targeted, non-invasive, and cell-selective tumor ablation. The study described here examined the effect of dual-frequency histotripsy pulsing on the cavitation threshold, bubble cloud characteristics, and ablative efficiency in NMH. High-speed optical imaging was used to analyze bubble cloud characteristics and to measure ablation efficiency for NMH inside agarose tissue phantoms containing perfluorohexane-filled nanocone clusters, which were previously developed to reduce the histotripsy cavitation threshold for NMH.

METHODS

Dual-frequency histotripsy pulsing was applied at a 1:1 pressure ratio using a modular 500 kHz and 3 MHz dual-frequency array transducer. Optical imaging results revealed predictable, well-defined bubble clouds generated for all tested cases with similar reductions in the cavitation thresholds observed for single-frequency and dual-frequency pulsing.

RESULTS

Dual-frequency pulsing was seen to nucleate small, dense clouds in agarose phantoms, intermediate in size of their component frequencies but closer in area to that of the higher component frequency. Red blood cell experiments revealed complete ablations were generated by dual-frequency NMH in all phantoms in <1500 pulses. This result was a significant increase in ablation efficiency compared with the ∼4000 pulses required in prior single-frequency NMH studies.

CONCLUSION

Overall, this study indicates the potential for using dual-frequency histotripsy methods to increase the ablation efficacy of NMH.

Histotripsy: A Method for Mechanical Tissue Ablation with Ultrasound

Histotripsy is a relatively new therapeutic ultrasound technology to mechanically liquefy tissue into subcellular debris using high-amplitude focused ultrasound pulses. In contrast to conventional high-intensity focused ultrasound thermal therapy, histotripsy has specific clinical advantages: the capacity for real-time monitoring using ultrasound imaging, diminished heat sink effects resulting in lesions with sharp margins, effective removal of the treated tissue, a tissue-selective feature to preserve crucial structures, and immunostimulation. The technology is being evaluated in small and large animal models for treating cancer, thrombosis, hematomas, abscesses, and biofilms; enhancing tumor-specific immune response; and neurological applications. Histotripsy has been recently approved by the US Food and Drug Administration to treat liver tumors, with clinical trials undertaken for benign prostatic hyperplasia and renal tumors. This review outlines the physical principles of various types of histotripsy; presents major parameters of the technology and corresponding hardware and software, imaging methods, and bioeffects; and discusses the most promising preclinical and clinical applications.

Cavitation-induced pressure saturation: a mechanism governing bubble nucleation density in histotripsy

Objective.Histotripsy is a noninvasive focused ultrasound therapy that mechanically disintegrates tissue by acoustic cavitation clouds. In this study, we investigate a mechanism limiting the density of bubbles that can nucleate during a histotripsy pulse. In this mechanism, the pressure generated by the initial bubble expansion effectively negates the incident pressure in the vicinity of the bubble. From this effect, the immediately adjacent tissue is prevented from experiencing the transient tension to nucleate bubbles. Approach.A Keller-Miksis-type single-bubble model was employed to evaluate the dependency of this effect on ultrasound pressure amplitude and frequency, viscoelastic medium properties, bubble nucleus size, and transducer geometric focusing. This model was further combined with a spatial propagation model to predict the peak negative pressure field as a function of position from a cavitating bubble.Main results. The single-bubble model showed the peak negative pressure near the bubble surface is limited to the inertial cavitation threshold. The predicted bubble density increased with increasing frequency, tissue viscosity, and transducer focusing angle. The simulated results were consistent with the trends observed experimentally in prior studies, including changes in density with ultrasound frequency and transducerF-number.Significance.The efficacy of the therapy is dependent on several factors, including the density of bubbles nucleated within the cavitation cloud formed at the focus. These results provide insight into controlling the density of nucleated bubbles during histotripsy and the therapeutic efficacy.

A. Mhjoob A, Raja A. Histotripsy: an innovative approach for minimally invasive tumour and disease treatment

Histotripsy is a noninvasive medical technique that uses high-intensity focused ultrasound (HIFU) to treat liver tumours. The two main histotripsy methods are boiling histotripsy and cavitation cloud histotripsy. Boiling histotripsy uses prolonged ultrasound pulses to create small boiling bubbles in the tissue, which leads to the breakdown of the tissue into smaller subcellular fragments. Cavitation cloud histotripsy uses the ultrasonic cavitation effect to disintegrate target tissue into precisely defined liquefied lesions. Both methods show similar treatment effectiveness; however, boiling histotripsy ensures treatment stability by producing a stable boiling bubble with each pulse. The therapeutic effect is ascribed to mechanical damage at the subcellular level rather than thermal damage. This article discusses the mechanisms, treatment parameters, and potential of histotripsy as a minimally invasive procedure that provides precise and controlled subcellular damage.

Investigation of the ultrasound-induced collapse of air bubbles near soft materials

A numerical investigation into the ultrasound-induced collapse of air bubbles near soft materials, utilizing a novel multi-material diffuse interface method (DIM) model with block-structured adaptive mesh refinement is presented. The present work expands from a previous five-equation DIM by incorporating Eulerian hyperelasticity. The model is applicable to any arbitrary number of interacting fluid and solid material. A single conservation law for the elastic stretch tensor enables tracking the deformations for all the solid materials. A series of benchmark cases are conducted, and the solution is found to be in excellent agreement against theoretical data. Subsequently, the ultrasound-induced bubble-tissue flow interactions are examined. The bubble radius was found to play a crucial role in dictating the stresses experienced by the tissue, underscoring its significance in medical applications. The results reveal that soft tissues primarily experience tensile forces during these interactions, suggesting potential tensile-driven injuries that may occur in relevant treatments. Moreover, regions of maximal tensile forces align with tissue elongation areas. It is documented that while early bubble dynamics remain relatively unaffected by changes in shear modulus, at later stages of the penetration processes and the deformation shapes, exhibit notable variations. Lastly, it is demonstrated that decreasing standoff distances enhances the interaction between bubbles and tissue, thereby increasing the stress levels in the tissue, although the behavior of the bubble dynamics remains largely unchanged.

Bubble cloud characteristics and ablation efficiency in dual-frequency intrinsic threshold histotripsy

Histotripsy is a non-thermal focused ultrasound ablation method that destroys tissue through the generation and activity of acoustic cavitation bubble clouds. Intrinsic threshold histotripsy uses single-cycle pulses to generate bubble clouds when the dominant negative pressure phase exceeds an intrinsic threshold of ∼25-30 MPa. The ablation efficiency is dependent upon the size and density of bubbles within the bubble cloud. This work investigates the effects of dual-frequency pulsing schemes on the bubble cloud behavior and ablation efficiency in intrinsic threshold histotripsy. A modular 500 kHz:3 MHz histotripsy transducer treated agarose phantoms using dual-frequency histotripsy pulses with a 1:1 pressure ratio from 500 kHz and 3 MHz frequency elements and varying arrival times for the 3 MHz pulse relative to the arrival of the 500 kHz pulse (-100 ns, 0 ns, and +100 ns). High-speed optical imaging captured cavitation effects to characterize bubble cloud and individual bubble dynamics. The effects of dual-frequency pulsing on lesion formation and ablation efficiency were also investigated in red blood cell (RBC) phantoms. Results showed that the single bubble and bubble cloud size for dual-frequency cases were intermediate to published results for the component single-frequencies of 500 kHz and 3 MHz. Additionally, bubble cloud size and dynamics were shown to be altered by the arrival time of the 3 MHz pulse with respect to the 500 kHz pulse, with more uniform cloud expansion and collapse observed for early (-100 ns) arrival. Finally, RBC phantom experiments showed that dual-frequency exposures were capable of generating precise lesions with smaller areas and higher ablation efficiencies than previously published results for 500 kHz or 3 MHz. Overall, results demonstrate dual-frequency histotripsy's ability to modulate bubble cloud size and dynamics can be leveraged to produce precise lesions at higher ablation efficiencies than previously observed for single-frequency pulsing.

Clinical translation of abdominal histotripsy: a review of preclinical studies in large animal models

Histotripsy is an emerging noninvasive, non-thermal, and non-ionizing focused ultrasound (US) therapy that can be used to destroy targeted tissue. Histotripsy has evolved from early laboratory prototypes to clinical systems which have been comprehensively evaluated in the preclinical environment to ensure safe translation to human use. This review summarizes the observations and results from preclinical histotripsy studies in the liver, kidney, and pancreas. Key findings from these studies include the ability to make a clinically relevant treatment zone in each organ with maintained collagenous architecture, potentially allowing treatments in areas not currently amenable to thermal ablation. Treatments across organ capsules have proven safe, including in anticoagulated models which may expand patients eligible for treatment or eliminate the risk associated with taking patients off anti-coagulation. Treatment zones are well-defined with imaging and rapidly resorb, which may allow improved evaluation of treatment zones for residual or recurrent tumor. Understanding the effects of histotripsy in animal models will help inform physicians adopting histotripsy for human clinical use.

Investigation of interaction effects on dual-frequency driven cavitation dynamics in a two-bubble system

The cavitation dynamics of a two-bubble system in viscoelastic media excited by dual-frequency ultrasound is studied numerically with a focus on the effects of inter-bubble interactions. Compared to the isolated bubble cases, the enhancement or suppression effects can be exerted on the amplitude and nonlinearity of the bubble oscillations to different degrees. Moreover, the interaction effects are found to be highly sensitive to multiple paramount parameters related to the two-bubble system, the dual-frequency ultrasound and the medium viscoelasticity. Specifically, the larger bubble of a two-bubble system shows a stronger effect on the smaller one, and this effect becomes more pronounced when the larger bubble undergoes harmonic and/or subharmonic resonances as well as the two bubbles get closer (e.g., d0 < 100 μm). For the influences of the dual-frequency excitation, the results show that the bubbles can achieve enhanced harmonic and/or subharmonic oscillations as the frequency combinations with small frequency differences (e.g., Δf < 0.2 MHz) close to the corresponding resonance frequencies of bubbles, and the interaction effects are consequently intensified. Similarly, the bubble oscillations and the interaction effects can also be enhanced as the acoustic pressure amplitude of each frequency component is equal and the pressure amplitude pA increases. Above a pressure threshold (pA = 215 kPa), a larger bubble undergoes period 2 (P2) oscillations, which can force a smaller bubble to change its oscillation pattern from period 1 (P1) into P2 oscillations. In addition, it is found that the medium viscosity dampens the bubble oscillations while the medium elasticity affects the bubble resonances, accordingly exhibiting stronger interaction effects at smaller viscosities (e.g., μ < 4 mPa·s) or certain elasticities (approximately G = 70-120 kPa, G = 160-200 kPa and G = 640-780 kPa) at which the bubble resonances occur. The study can contribute to a better understanding of the complex dynamic behaviors of interacting cavitation bubbles in viscoelastic tissues for high efficient cavitation-mediated biomedical applications using dual-frequency ultrasound.

Bubble Cloud Characteristics and Ablation Efficiency in Dual-Frequency Intrinsic Threshold Histotripsy

Histotripsy is a non-thermal focused ultrasound ablation method that destroys tissue through the generation and activity of acoustic cavitation bubble clouds. Intrinsic threshold histotripsy uses single-cycle pulses to generate bubble clouds when the dominant negative pressure phase exceeds an intrinsic threshold of ~25-30 MPa. The ablation efficiency is dependent upon the size and density of bubbles within the bubble cloud. This work investigates the effects of dual-frequency pulsing schemes on the bubble cloud behavior and ablation efficiency in intrinsic threshold histotripsy. A modular 500 kHz:3 MHz histotripsy transducer treated agarose phantoms using dual-frequency histotripsy pulses with a 1:1 pressure ratio from 500 kHz and 3 MHz frequency elements and varying arrival times for the 3 MHz pulse relative to the arrival of the 500 kHz pulse (-100 ns, 0 ns, and +100 ns). High-speed optical imaging captured cavitation effects to characterize bubble cloud and individual bubble dynamics. The effects of dual-frequency pulsing on lesion formation and ablation efficiency were also investigated in red blood cell (RBC) phantoms. Results showed that the single bubble and bubble cloud size for dual-frequency cases were intermediate to published results for the component single frequencies of 500 kHz and 3 MHz. Additionally, bubble cloud size and dynamics were shown to be altered by the arrival time of the 3 MHz pulse with respect to the 500 kHz pulse, with more uniform cloud expansion and collapse observed for early (-100 ns) arrival. Finally, RBC phantom experiments showed that dual-frequency exposures were capable of generating precise lesions with smaller areas and higher ablation efficiencies than previously published results for 500 kHz or 3 MHz. Overall, results demonstrate dual-frequency histotripsy's ability to modulate bubble cloud size and dynamics can be leveraged to produce precise lesions at higher ablation efficiencies than previously observed for single-frequency pulsing.

Catheter-Based Medical Device Biofilm Ablation Using Histotripsy: A Parameter Study

OBJECTIVE

Biofilm formation in medical catheters is a major source of hospital-acquired infections which can produce increased morbidity and mortality for patients. Histotripsy is a non-invasive, non-thermal focused ultrasound therapy and recently has been found to be effective at removal of biofilm from medical catheters. Previously established histotripsy methods for biofilm removal, however, would require several hours of use to effectively treat a full-length medical catheter. Here, we investigate the potential to increase the speed and efficiency with which biofilms can be ablated from catheters using histotripsy.

METHODS

Pseudomonas aeruginosa (PA14) biofilms were cultured in in vitro Tygon catheter mimics and treated with histotripsy using a 1 MHz histotripsy transducer and a variety of histotripsy pulsing rates and scanning methods. The improved parameters identified in these studies were then used to explore the bactericidal effect of histotripsy on planktonic PA14 suspended in a catheter mimic.

RESULTS

Histotripsy can be used to remove biofilm and kill bacteria at substantially increased speeds compared with previously established methods. Near-complete biofilm removal was achieved at treatment speeds up to 1 cm/s, while a 4.241 log reduction in planktonic bacteria was achieved with 2.4 cm/min treatment.

CONCLUSION

These results represent a 500-fold increase in biofilm removal speeds and a 6.2-fold increase in bacterial killing speeds compared with previously published methods. These findings indicate that histotripsy shows promise for the treatment of catheter-associated biofilms and planktonic bacteria in a clinically relevant time frame.

Weakly nonlinear focused ultrasound in viscoelastic media containing multiple bubbles

To facilitate practical medical applications such as cancer treatment utilizing focused ultrasound and bubbles, a mathematical model that can describe the soft viscoelasticity of human body, the nonlinear propagation of focused ultrasound, and the nonlinear oscillations of multiple bubbles is theoretically derived and numerically solved. The Zener viscoelastic model and Keller-Miksis bubble equation, which have been used for analyses of single or few bubbles in viscoelastic liquid, are used to model the liquid containing multiple bubbles. From the theoretical analysis based on the perturbation expansion with the multiple-scales method, the Khokhlov-Zabolotskaya-Kuznetsov (KZK) equation, which has been used as a mathematical model of weakly nonlinear propagation in single phase liquid, is extended to viscoelastic liquid containing multiple bubbles. The results show that liquid elasticity decreases the magnitudes of the nonlinearity, dissipation, and dispersion of ultrasound and increases the phase velocity of the ultrasound and linear natural frequency of the bubble oscillation. From the numerical calculation of resultant KZK equation, the spatial distribution of the liquid pressure fluctuation for the focused ultrasound is obtained for cases in which the liquid is water or liver tissue. In addition, frequency analysis is carried out using the fast Fourier transform, and the generation of higher harmonic components is compared for water and liver tissue. The elasticity supresses the generation of higher harmonic components and promotes the remnant of the fundamental frequency components. This indicates that the elasticity of liquid suppresses shock wave formation in practical applications.

Effects of medium viscoelasticity on bubble collapse strength of interacting polydisperse bubbles

Due to its physical and/or chemical effects, acoustic cavitation plays a crucial role in various emerging applications ranging from advanced materials to biomedicine. The cavitation bubbles usually undergo oscillatory dynamics and violent collapse within a viscoelastic medium, which are closely related to the cavitation-associated effects. However, the role of medium viscoelasticity on the cavitation dynamics has received little attention, especially for the bubble collapse strength during multi-bubble cavitation with the complex interactions between size polydisperse bubbles. In this study, modified Gilmore equations accounting for inter-bubble interactions were coupled with the Zener viscoelastic model to simulate the dynamics of multi-bubble cavitation in viscoelastic media. Results showed that the cavitation dynamics (e.g., acoustic resonant response, nonlinear oscillation behavior and bubble collapse strength) of differently-sized bubbles depend differently on the medium viscoelasticity and each bubble is affected by its neighboring bubbles to a different degree. More specifically, increasing medium viscosity drastically dampens the bubble dynamics and weakens the bubble collapse strength, while medium elasticity mainly affects the bubble resonance at which the bubble collapse strength is maximum. Differently-sized bubbles can achieve resonances and even subharmonic resonances at high driving acoustic pressures as the elasticity changes to certain values, and the resonance frequency of each bubble increases with the elasticity increasing. For the interactions between the size polydisperse bubbles, it indicated that the largest bubble generally has a dominant effect on the dynamics of smaller ones while in turn it is almost unaffected, exhibiting a pattern of destructive and constructive interactions. This study provides a valuable insight into the acoustic cavitation dynamics of multiple interacting polydisperse bubbles in viscoelastic media, which may offer a potential of controlling the medium viscoelasticity to appropriately manipulate the dynamics of multi-bubble cavitation for achieving proper cavitation effects according to the desired application.

Dynamics of an oscillating microbubble in a blood-like Carreau fluid

A numerical model for cavitation in blood is developed based on the Keller-Miksis equation for spherical bubble dynamics with the Carreau model to represent the non-Newtonian behavior of blood. Three different pressure waveforms driving the bubble oscillations are considered: a single-cycle Gaussian waveform causing free growth and collapse, a sinusoidal waveform continuously driving the bubble, and a multi-cycle pulse relevant to contrast-enhanced ultrasound. Parameters in the Carreau model are fit to experimental measurements of blood viscosity. In the Carreau model, the relaxation time constant is 5-6 orders of magnitude larger than the Rayleigh collapse time. As a result, non-Newtonian effects do not significantly modify the bubble dynamics but do give rise to variations in the near-field stresses as non-Newtonian behavior is observed at distances 10-100 initial bubble radii away from the bubble wall. For sinusoidal forcing, a scaling relation is found for the maximum non-Newtonian length, as well as for the shear stress, which is 3 orders of magnitude larger than the maximum bubble radius.

Monitoring cavitation dynamics evolution in tissue mimicking hydrogels for repeated exposures via acoustic cavitation emissions

A 700 kHz histotripsy array is used to generate repeated cavitation events in agarose, gelatin, and polyacrylamide hydrogels. High-speed optical imaging, a broadband hydrophone, and the narrow-band receive elements of the histotripsy array are used to capture bubble dynamics and acoustic cavitation emissions. Bubble radii, lifespan, shockwave amplitudes are noted to be measured in close agreement between the different observation methods. These features also decrease with increasing hydrogel stiffness for all of the tested materials. However, the evolutions of these properties during the repeated irradiations vary significantly across the different material subjects. Bubble maximum radius initially increases, then plateaus, and finally decreases in agarose, but remains constant across exposures in gelatin and polyacrylamide. The bubble lifespan increases monotonically in agarose and gelatin but decreases in polyacrylamide. Collapse shockwave amplitudes were measured to have different-shaped evolutions between all three of the tested materials. Bubble maximum radii, lifespans, and collapse shockwave amplitudes were observed to express evolutions that are dependent on the structure and stiffness of the nucleation medium.

Ultrasound-guided noninvasive pancreas ablation using histotripsy: feasibility study in an in vivo porcine model

Pancreatic cancer is a malignant disease associated with poor survival and nearly 80% present with unresectable tumors. Treatments such as chemotherapy and radiation therapy have shown overall improved survival benefits, albeit limited. Histotripsy is a noninvasive, non-ionizing, and non-thermal focused ultrasound ablation modality that has shown efficacy in treating hepatic tumors and other malignancies. In this novel study, we investigate histotripsy for noninvasive pancreas ablation in a pig model. In two studies, histotripsy was applied to the healthy pancreas in 11 pigs using a custom 32-element, 500 kHz histotripsy transducer attached to a clinical histotripsy system, with treatments guided by real-time ultrasound imaging. A pilot study was conducted in 3 fasted pigs with histotripsy applied at a pulse repetition frequency (PRF) of 500 Hz. Results showed no pancreas visualization on coaxial ultrasound imaging due to overlying intestinal gas, resulting in off-target injury and no pancreas damage. To minimize gas, a second group of pigs (n = 8) were fed a custard diet containing simethicone and bisacodyl. Pigs were euthanized immediately (n = 4) or survived for 1 week (n = 4) post-treatment. Damage to the pancreas and surrounding tissue was characterized using gross morphology, histological analysis, and CT imaging. Results showed histotripsy bubble clouds were generated inside pancreases that were visually maintained on coaxial ultrasound (n = 4), with 2 pigs exhibiting off-target damage. For chronic animals, results showed the treatments were well-tolerated with no complication signs or changes in blood markers. This study provides initial evidence suggesting histotripsy's potential for noninvasive pancreas ablation and warrants further evaluation in more comprehensive studies.

Engineering the Tumor Immune Microenvironment through Minimally Invasive Interventions

The tumor microenvironment (TME) is a unique landscape that poses several physical, biochemical, and immune barriers to anti-cancer therapies. The rapidly evolving field of immuno-engineering provides new opportunities to dismantle the tumor immune microenvironment by efficient tumor destruction. Systemic delivery of such treatments can often have limited local effects, leading to unwanted offsite effects such as systemic toxicity and tumor resistance. Interventional radiologists use contemporary image-guided techniques to locally deliver these therapies to modulate the immunosuppressive TME, further accelerating tumor death and invoking a better anti-tumor response. These involve local therapies such as intratumoral drug delivery, nanorobots, nanoparticles, and implantable microdevices. Physical therapies such as photodynamic therapy, electroporation, hyperthermia, hypothermia, ultrasound therapy, histotripsy, and radiotherapy are also available for local tumor destruction. While the interventional radiologist can only locally manipulate the TME, there are systemic offsite recruitments of the immune response. This is known as the abscopal effect, which leads to more significant anti-tumoral downstream effects. Local delivery of modern immunoengineering methods such as locoregional CAR-T therapy combined with immune checkpoint inhibitors efficaciously modulates the immunosuppressive TME. This review highlights the various advances and technologies available now to change the TME and revolutionize oncology from a minimally invasive viewpoint.

Development of Tough Hydrogel Phantoms to Mimic Fibrous Tissue for Focused Ultrasound Therapies

Tissue-mimicking gels provide a cost-effective medium to optimize histotripsy treatment parameters with immediate feedback. Agarose and polyacrylamide gels are often used to evaluate treatment outcomes as they mimic the acoustic properties and stiffness of a variety of soft tissues, but they do not exhibit high toughness, a characteristic of fibrous connective tissue. To mimic pathologic fibrous tissue found in benign prostate hyperplasia (BPH) and other diseases that are potentially treatable with histotripsy, an optically transparent hydrogel with high toughness was developed that is a hybrid of polyacrylamide and alginate. The stiffness was established using shear wave elastography (SWE) and indentometry techniques and was found to be representative of human BPH ex vivo prostate tissue. Different phantom compositions and excised ex vivo BPH tissue samples were treated with a 700-kHz histotripsy transducer at different pulse repetition frequencies. Post-treatment, the hybrid gels and the tissue samples exhibited differential reduction in stiffness as measured by SWE. On B-mode ultrasound, partially treated areas were present as hyperechoic zones and fully liquified areas as hypoechoic zones. Phase contrast microscopy of the gel samples revealed liquefaction in regions consistent with the target lesion dimensions and correlated to findings identified in tissue samples via histology. The dose required to achieve liquefaction in the hybrid gel was similar to what has been observed in ex vivo tissue and greater than that of agarose of comparable or higher Young's modulus by a factor >10. These results indicate that the developed hydrogels closely mimic elasticities found in BPH prostate ex vivo tissue and have a similar response to histotripsy treatment, thus making them a useful cost-effective alternative for developing and evaluating different treatment protocols.

Interventional oncology: new techniques and new devices

Interventional oncology is a rapidly emerging field in the treatment of cancer. Minimally invasive techniques such as transarterial embolization with chemotherapeutic and radioactive agents are established therapies and are found in multiple guidelines for the management of primary and metastatic liver lesions. Percutaneous ablation is also an alternative to surgery for small liver, renal, and pancreatic tumors. Recent research in the niche of interventional oncology has focused on improving outcomes of established techniques in addition to the development of novel therapies. In this review, we address the recent and current advancements in devices, technologies, and techniques of chemoembolization and ablation: thermal ablation, histotripsy, high-intensity focused ultrasound, embolization strategies, liquid embolic agents, and local immunotherapy/antiviral therapies.

Neuroinflammation associated with ultrasound-mediated permeabilization of the blood-brain barrier

The blood-brain barrier (BBB) continues to represent one of the most significant challenges for successful drug-based treatments of neurological disease. Mechanical modulation of the BBB using focused ultrasound (FUS) and microbubbles (MBs) has shown considerable promise in enhancing the delivery of therapeutics to the brain, but questions remain regarding possible long-term effects of such forced disruption. This review examines the evidence for inflammation associated with ultrasound-induced BBB disruption and potential strategies for managing such inflammatory effects to improve both the efficacy and safety of therapeutic ultrasound in neurological applications.

An ultrasonically actuated fine-needle creates cavitation in bovine liver

Ultrasonic cavitation is being used in medical applications as a way to influence matter, such as tissue or drug vehicles, on a micro-scale. Oscillating or collapsing cavitation bubbles provide transient mechanical force fields, which can, e.g., fractionate soft tissue or even disintegrate solid objects, such as calculi. Our recent study demonstrates that an ultrasonically actuated medical needle can create cavitation phenomena inside water. However, the presence and behavior of cavitation and related bioeffects in diagnostic and therapeutic applications with ultrasonically actuated needles are not known. Using simulations, we demonstrate numerically and experimentally the cavitation phenomena near ultrasonically actuated needles. We define the cavitation onset within a liver tissue model with different total acoustic power levels. We directly visualize and quantitatively characterize cavitation events generated by the ultrasonic needle in thin fresh bovine liver sections enabled by high-speed imaging. On a qualitative basis, the numerical and experimental results show a close resemblance in threshold and spatial distribution of cavitation. These findings are crucial for developing new methods and technologies employing ultrasonically actuated fine needles, such as ultrasound-enhanced fine-needle biopsy, drug delivery, and histotripsy.

Microcavitation dynamics in viscoelastic tissue during histotripsy process

Monitoring bubble cavitations and bubble dynamics are essential in enhancing non-invasive ultrasonic ablation methods like histotripsy that mechanically fractionates tissue into acellular debris using microcavitation. Histotripsy can totally fractionate tissue into a liquid-appearing homogenate with no cellular features with enough pulses. In this paper, we present the analysis of the dynamics of cavitation bubbles in a viscoelastic medium subjected to a histotripsy pulse using different fidelities in depicting compressibility and viscoelasticity effects. The mathematical formulation is described based on the Keller-Miksis equation in two models for cavitation bubbles in viscoelastic tissue through histotripsy process; the first model is in neo-Hookean, and the second is in quadratic law Kelvin-Voigt model. The governing model is solved analytically based on the modified Plesset-Zwick method. Analysis of the results reveals that the parameters of Young modulus, viscosity effects and stiffening parameter reduce the growth of cavitation microbubbles through the histotripsy process. The cavitation bubble growth increases when the gel concentration decreases during the histotripsy process.

Enhancing cavitation dynamics and its mechanical effects with dual-frequency ultrasound

Objective. Acoustic cavitation and its mechanical effects (e.g. stress and strain) play a primary role in ultrasound applications. Introducing encapsulated microbubbles as cavitation nuclei and utilizing dual-frequency ultrasound excitation are highly effective approaches to reduce cavitation thresholds and enhance cavitation effects. However, the cavitation dynamics of encapsulated microbubbles and the resultant stress/strain in viscoelastic tissues under dual-frequency excitation are poorly understood, especially for the enhancement effects caused by a dual-frequency approach. The goal of this study was to numerically investigate the dynamics of a lipid-coated microbubble and the spatiotemporal distributions of the stress and strain under dual-frequency excitation. Approach. The Gilmore–Zener bubble model was coupled with a shell model for the nonlinear changes of both shell elasticity and viscosity to accurately simulate the cavitation dynamics of lipid-coated microbubbles in viscoelastic tissues. Then, the spatiotemporal evolutions of the cavitation-induced stress and strain in the surrounding tissues were characterized quantitatively. Finally, the influences of some paramount parameters were examined to optimize the outcomes. Main results. We demonstrated that the cavitation dynamics and associated stress/strain were prominently enhanced by a dual-frequency excitation, highlighting positive correlations between the maximum bubble expansion and the maximum stress/strain. Moreover, the results showed that the dual-frequency ultrasound with smaller differences in its frequencies and pressure amplitudes could enhance the bubble oscillations and stress/strain more efficiently, whereas the phase difference manifested small influences under these conditions. Additionally, the dual-frequency approach seemed to show a stronger enhancement effect with the shell/tissue viscoelasticity increasing to a certain extent. Significance. This study might contribute to optimizing the dual-frequency operation in terms of cavitation dynamics and its mechanical effects for high-efficient ultrasound applications.

Predicting complex nonspherical instability shapes of inertial cavitation bubbles in viscoelastic soft matter

Inertial cavitation in soft matter is an important phenomenon featured in a wide array of biological and engineering processes. Recent advances in experimental, theoretical, and numerical techniques have provided access to a world full of nonlinear physics, yet most of our quantitative understanding to date has been centered on a spherically symmetric description of the cavitation process in water. However, cavitation bubble growth and collapse rarely occur in a perfectly symmetrical fashion, particularly in soft materials. Predicting the onset of dynamically arising, nonspherical instabilities in soft matter has remained a significant, unresolved challenge, in part due to the additional constitutive complexities introduced by the surrounding nonlinear viscoelastic solid. Here, we provide a new theoretical framework capable of accurately predicting the onset of nonspherical instability shapes of a bubble in a soft material by explicitly accounting for all pertinent nonlinear interactions between the cavitation bubble and the solid surroundings. Comparison with high-resolution experimental images from laser-induced cavitation events in a polyacrylamide hydrogel show excellent agreement. Interestingly, and consistent with experimental findings, our model predicts the emergence of various dynamic instability shapes for circumferential bubble stretch ratios greater than 1, in contrast to most quasistatic investigations. Our new theoretical framework not only provides unprecedented insight into the cavitation dynamics in a soft, nonlinear solid, but also provides a quantitative means of interpreting bubble dynamics relevant to a wide array of engineering and medical applications as well as natural phenomena.

Effects of frequency on bubble-cloud behavior and ablation efficiency in intrinsic threshold histotripsy

Objective.Histotripsy is a non-thermal focused ultrasound ablation method that destroys tissue through the generation of a cavitation bubble cloud. Previous work studying intrinsic threshold histotripsy has shown that dense bubble clouds can be formed by a single-cycle pulse when the negative pressure exceeds an intrinsic threshold of ∼25-30 MPa, with the ablation efficiency dependent upon the size and density of bubbles within the cloud. This work investigates the effects of frequency on bubble-cloud behavior and ablation efficiency in intrinsic threshold histotripsy.Approach.A modular transducer was used to expose agarose tissue phantoms to 500 kHz, 1 MHz, or 3 MHz, histotripsy pulses. Optical imaging was used to measure the bubble-cloud dimensions, bubble density, and bubble size. The effects of frequency on ablation efficiency were also investigated by applying histotripsy to red blood cell (RBC) phantoms.Main results.Results revealed that the bubble-cloud size closely matched theoretical predictions for all frequencies. The bubble density, which is a measure of the number of bubbles per unit area, was shown to increase with increasing frequency while the size of individual bubbles within the cloud decreased at higher frequencies. Finally, RBC phantom experiments showed decreasing ablation efficiency with increasing frequency.Significance.Overall, results demonstrate the effects of frequency on histotripsy bubble-cloud behavior and show that lower frequency generates more efficient tissue ablation, primarily due to enhanced bubble expansion.

Mechanically Induced Cavitation in Biological Systems

Cavitation bubbles form in soft biological systems when subjected to a negative pressure above a critical threshold, and dynamically change their size and shape in a violent manner. The critical threshold and dynamic response of these bubbles are known to be sensitive to the mechanical characteristics of highly compliant biological systems. Several recent studies have demonstrated different biological implications of cavitation events in biological systems, from therapeutic drug delivery and microsurgery to blunt injury mechanisms. Due to the rapidly increasing relevance of cavitation in biological and biomedical communities, it is necessary to review the current state-of-the-art theoretical framework, experimental techniques, and research trends with an emphasis on cavitation behavior in biologically relevant systems (e.g., tissue simulant and organs). In this review, we first introduce several theoretical models that predict bubble response in different types of biological systems and discuss the use of each model with physical interpretations. Then, we review the experimental techniques that allow the characterization of cavitation in biologically relevant systems with in-depth discussions of their unique advantages and disadvantages. Finally, we highlight key biological studies and findings, through the direct use of live cells or organs, for each experimental approach.

Acoustic Measurements of Nucleus Size Distribution at the Cavitation Threshold

An understanding of the acoustic cavitation threshold is essential for minimizing cavitation bio-effects in diagnostic ultrasound and for controlling cavitation-mediated tissue ablation in focused ultrasound procedures. The homogeneous cavitation threshold is an intrinsic material property of recognized importance to biomedical ultrasound as well as a variety of other applications requiring cavitation control. However, measurements of the acoustic cavitation threshold in water differ from those predicted by classic nucleation theories. This persistent discrepancy is explained by combining recently developed methods for acoustically nucleating single bubbles at threshold with numerical modeling to obtain a nucleus size distribution consistent with first-principles estimates for ion-stabilized nuclei. We identify acoustic cavitation at threshold as a reproducible subtype of heterogeneous cavitation with a characteristic nucleus size distribution. Knowledge of the nucleus size distribution could inspire new approaches to achieving cavitation control in water, tissue and a variety of other media.

Acoustic cavitation rheometry

Characterization of soft materials is challenging due to their high compliance and the strain-rate dependence of their mechanical properties. The inertial microcavitation-based high strain-rate rheometry (IMR) method [Estrada et al., J. Mech. Phys. Solids, 2018, 112, 291-317] combines laser-induced cavitation measurements with a model for the bubble dynamics to measure local properties of polyacrylamide hydrogel under high strain-rates from 103 to 108 s-1. While promising, laser-induced cavitation involves plasma formation and optical breakdown during nucleation, a process that could alter local material properties before measurements are obtained. In the present study, we extend the IMR method to another means to generate cavitation, namely high-amplitude focused ultrasound, and apply the resulting acoustic-cavitation-based IMR to characterize the mechanical properties of agarose hydrogels. Material properties including viscosity, elastic constants, and a stress-free bubble radius are inferred from bubble radius histories in 0.3% and 1% agarose gels. An ensemble-based data assimilation is used to further help interpret the obtained estimates. The resulting parameter distributions are consistent with available measurements of agarose gel properties and with expected trends related to gel concentration and high strain-rate loading. Our findings demonstrate the utility of applying IMR and data assimilation methods with single-bubble acoustic cavitation data for measurement of viscoelastic properties.

Bubble Cloud Behavior and Ablation Capacity for Histotripsy Generated from Intrinsic or Artificial Cavitation Nuclei

The study described here examined the effects of cavitation nuclei characteristics on histotripsy. High-speed optical imaging was used to compare bubble cloud behavior and ablation capacity for histotripsy generated from intrinsic and artificial cavitation nuclei (gas-filled microbubbles, fluid-filled nanocones). Results showed a significant decrease in the cavitation threshold for microbubbles and nanocones compared with intrinsic-nuclei controls, with predictable and well-defined bubble clouds generated in all cases. Red blood cell experiments showed complete ablations for intrinsic and nanocone phantoms, but only partial ablation in microbubble phantoms. Results also revealed a lower rate of ablation in artificial-nuclei phantoms because of reduced bubble expansion (and corresponding decreases in stress and strain). Overall, this study demonstrates the potential of using artificial nuclei to reduce the histotripsy cavitation threshold while highlighting differences in the bubble cloud behavior and ablation capacity that need to be considered in the future development of these approaches.

Histotripsy: the first noninvasive, non-ionizing, non-thermal ablation technique based on ultrasound

Histotripsy is the first noninvasive, non-ionizing, and non-thermal ablation technology guided by real-time imaging. Using focused ultrasound delivered from outside the body, histotripsy mechanically destroys tissue through cavitation, rendering the target into acellular debris. The material in the histotripsy ablation zone is absorbed by the body within 1-2 months, leaving a minimal remnant scar. Histotripsy has also been shown to stimulate an immune response and induce abscopal effects in animal models, which may have positive implications for future cancer treatment. Histotripsy has been investigated for a wide range of applications in preclinical studies, including the treatment of cancer, neurological diseases, and cardiovascular diseases. Three human clinical trials have been undertaken using histotripsy for the treatment of benign prostatic hyperplasia, liver cancer, and calcified valve stenosis. This review provides a comprehensive overview of histotripsy covering the origin, mechanism, bioeffects, parameters, instruments, and the latest results on preclinical and human studies.

Effects of Histotripsy on Local Tumor Progression in an in vivo Orthotopic Rodent Liver Tumor Model

Objective and Impact Statement

This is the first longitudinal study investigating the effects of histotripsy on local tumor progression in an in vivo orthotopic, immunocompetent rat hepatocellular carcinoma (HCC) model.

Introduction

Histotripsy is the first noninvasive, nonionizing, nonthermal, mechanical ablation technique using ultrasound to generate acoustic cavitation to liquefy the target tissue into acellular debris with millimeter accuracy. Previously, histotripsy has demonstrated in vivo ablation of noncancerous liver tissue.

Methods

N1-S1 HCC tumors were generated in the livers of immunocompetent rats (n = 6, control; n = 15, treatment). Real-time ultrasound-guided histotripsy was applied to ablate either 100% tumor volume + up to 2mm margin (n = 9, complete treatment) or 50-75% tumor volume (n = 6, partial treatment) by delivering 1-2 cycle histotripsy pulses at 100 Hz PRF (pulse repetition frequency) with p - ≥30MPa using a custom 1MHz transducer. Rats were monitored weekly using MRI (magnetic resonance imaging) for 3 months or until tumors reached ~25mm.

Results

MRI revealed effective post-histotripsy reduction of tumor burden with near-complete resorption of the ablated tumor in 14/15 (93.3%) treated rats. Histopathology showed <5mm shrunken, non-tumoral, fibrous tissue at the treatment site at 3 months. Rats with increased tumor burden (3/6 control and 1 partial treatment) were euthanized early by 2-4 weeks. In 3 other controls, histology revealed fibrous tissue at original tumor site at 3 months. There was no evidence of histotripsy-induced off-target tissue injury.

Conclusion

Complete and partial histotripsy ablation resulted in effective tumor removal for 14/15 rats, with no evidence of local tumor progression or recurrence.