Sonographic Assessment of Tumor Response: From In Vivo Models to Clinical Applications

Novel Quantitative Contrast-Enhanced Ultrasound Detection of Hypoxic Ischemic Injury in Neonates and Infants: Pilot Study 1

OBJECTIVES

To investigate whether quantitative contrast-enhanced ultrasound (CEUS) can accurately identify neonates and infants with hypoxic ischemic brain injury.

METHODS

In this prospective cohort study, 8 neonates and infants with a suspicion of hypoxic ischemic injury were evaluated with CEUS.

RESULTS

An interesting trend was observed in the central gray nuclei-to-cortex perfusion ratios. The ratios at the peak enhancement, wash-in area under the curve, perfusion index, and maximum wash-in slopes were lower in all of the affected cases compared to the normal group but not statistically significant given the small sample size (P = .0571). Additionally, when the central gray nuclei-to-cortex perfusion ratio was plotted for all time points along the time-intensity curve, it was observed that the affected cases showed a trend that was qualitatively different from that of the normal cases. In the affected cases, the ratio time-intensity curves either stayed below 1.0 for the entire enhancement period or reached 1.0 close to peak wash-in before falling just below 1.0 for the remaining period of enhancement. However, in the unaffected patients, there was a steep wash-in that crossed the 1.0 threshold and remained above 1.0 for most of the enhancement period.

CONCLUSIONS

Bedside CEUS is an easily obtainable brain-imaging modality that has the potential to effectively identify infants and neonates with evolving brain injury. A larger prospective study evaluating the correlation between CEUS findings and the reference standard of diffusion- and perfusion-weighted magnetic resonance imaging is needed to establish it as a diagnostic tool.

Cancer Measurement at Ultrasound: State of the Art

Reliable and reproducible tumor measurement is fundamental in the oncologic decision making. In this article, we first highlight the importance of a precise tumor measurement, reviewing the correct modality of measuring tumor lesions at ultrasound. Then we analyze the measurement discrepancies between ultrasound and pathology as well as the discrepancies reported between ultrasound and other imaging modalities. Thereafter, basing on the existent literature and on our experience, we discuss the factors influencing the tumor size measurements at ultrasound. Finally, we illustrate the current strategies to improve the effectiveness of cancer lesions measurement.

Efficiency of U.S. Tissue Perfusion Estimators

We measure the detection and discrimination efficiencies of conventional power-Doppler estimation of perfusion without contrast enhancement. The measurements are made in a phantom with known blood-mimicking fluid flow rates in the presence of clutter and noise. Efficiency is measured by comparing functions of the areas under the receiver operating characteristic curve for Doppler estimators with those of the ideal discriminator, for which we estimate the temporal covariance matrix from echo data. Principal-component analysis is examined as a technique for increasing the accuracy of covariance matrices estimated from echo data. We find that Doppler estimators are <50% efficient at directed perfusion detection between 0.1 and 2.0 mL/min per 2 cm(2) flow area. The efficiency was 20%-40% for the task of discriminating between two perfusion rates in the same range. We conclude that there are reasons to search for more efficient perfusion estimators, one that incorporates covariance matrix information that could significantly enhance the utility of Doppler ultrasound without contrast enhancement.

Dynamic contrast-enhanced ultrasonographic (DCE-US) assessment of the early response after combined gemcitabine and HIFU with low-power treatment for the mouse xenograft model of human pancreatic cancer

PURPOSE

To assess therapeutic efficacy of gemcitabine and HIFU for a mouse model of pancreatic cancer, and the role of DCE-US for predicting early treatment response compared with pathology.

MATERIALS AND METHODS

In 48 PANC-1- nude mice (G1, HIFU_higher power [n = 14]; G2, gemcitabine [n = 12]; G3, combined gemcitabine and HIFU_low power [n = 12]; and G4, control [n = 10]), pulsed HIFU or gemcitabine therapy was used. DCE-US was performed 1 day before and after first treatment. Seven DCE-US perfusion parameters were obtained. Therapeutic efficacy was estimated using necrotic fraction and apoptosis. Correlation between tumour size and US perfusion parameters was analysed.

RESULTS

Pathology results showed that combined gemcitabine and HIFU using low-power treatment had a more effective response than other treatments, including in the control group, i.e. necrotic fraction: 40.5 ± 4.9 vs. 16.9 ± 8.0, p = 0.000 and apoptosis: 44.3 ± 29.4 vs. 7.9 ± 4.9, p = 0.002. In this group, US perfusion parameters, including peak intensity (22.6 ± 22.6 vs. 9.6 ± 6.3, p = 0.002), AUC (961.8 ± 96.9 vs. 884.4 ± 91.4, p = 0.000), and AUCout (799.9 ± 75.6 vs. 747.1 ± 77.9, p = 0.000), had significantly decreased 1 day following first treatment (p < 0.05). In addition, peak intensity, AUC, and AUCout showed a tendency to decrease in treated groups. Alternatively, peak intensity, AUC, and AUCout showed a tendency to increase in control group.

CONCLUSION

Gemcitabine and HIFU were more effective and safer than other treatments. US perfusion parameters were useful for predicting early therapeutic response 1 day following treatment.

KEY POINTS

Recently, treatment of pancreatic cancer has changed based on a multidisciplinary approach. Combined gemcitabine_HIFU demonstrated more effective therapeutic response than other treatments. DCE-US is useful for predicting early therapeutic response 1 day after treatment. In the combined group, PI, AUC, and AUC (out) decreased 1 day after treatment.

Early prediction of response to sorafenib in patients with advanced hepatocellular carcinoma: the role of dynamic contrast enhanced ultrasound

BACKGROUND & AIMS

Sorafenib has become the standard first-line treatment for patients with advanced HCC and acts by inducing alterations in tumor vascularity. We wanted to evaluate the feasibility of dynamic CEUS (D-CEUS) as a predictor of early tumor response to sorafenib and to correlate functional parameters with clinical efficacy end points.

METHODS

Twenty-eight HCC patients treated with sorafenib 400mg bid were prospectively enrolled. CEUS was performed at baseline (T0) and after 15 (T1) and 30 (T2) days of treatment. Tumor vasculature was assessed in a specific harmonic mode associated with a perfusion and quantification software (Q-Lab, Philips). Variations between T1/T2 and T0 were calculated for five D-CEUS functional parameters (peak intensity, PI; time to PI, TP; area under the curve, AUC; slope of wash in, Pw; mean transit time, MTT) and were compared for responders and non-responders. The correlation between D-CEUS parameters, overall survival (OS), and progression-free survival (PFS) was also assessed. A p value <0.05 was considered statistically significant.

RESULTS

The percentage variation at T1 significantly correlated with response in three D-CEUS parameters (AUC, PI and Pw; p=0.002, <0.001, and 0.003, respectively). A decrease of AUC (p=0.045) and an increased/unchanged value of TP (p=0.029) and MTT (p=0.010) were associated with longer survival. Three D-CEUS parameters (AUC, TP, Pw) were significantly associated with PFS.

CONCLUSIONS

D-CEUS provides a reliable and early measure of efficacy for anti-angiogenic therapies and could be an excellent tool for selecting patients who will benefit from treatment.

Interaction of two differently sized oscillating bubbles in a free field

Most real life bubble dynamics applications involve multiple bubbles, for example, in cavitation erosion prevention, ultrasonic baths, underwater warfare, and medical applications involving microbubble contrast agents. Most scientific dealings with bubble-bubble interaction focus on two similarly sized bubbles. In this study, the interaction between two oscillating differently sized bubbles (generated in tap water) is studied using high speed photography. Four types of bubble behavior were observed, namely, jetting toward each other, jetting away from each other, bubble coalescence, and a behavior termed the "catapult" effect. In-phase bubbles jet toward each other, while out-of-phase bubbles jet away from each other. There exists a critical phase difference that separates the two regimes. The behavior of the bubbles is fully characterized by their dimensionless separation distance, their phase difference, and their size ratio. It is also found that for bubbles with large size difference, the smaller bubble behaves similarly to a single bubble oscillating near a free surface.

Assessment and monitoring tumor vascularity with contrast-enhanced ultrasound maximum intensity persistence imaging

OBJECTIVES

Contrast-enhanced ultrasound imaging is increasingly being used in the clinic for assessment of tissue vascularity. The purpose of our study was to evaluate the effect of different contrast administration parameters on the in vivo ultrasound imaging signal in tumor-bearing mice using a maximum intensity persistence (MIP) algorithm and to evaluate the reliability of in vivo MIP imaging in assessing tumor vascularity. The potential of in vivo MIP imaging for monitoring tumor vascularity during antiangiogenic cancer treatment was further evaluated.

MATERIALS AND METHODS

In intraindividual experiments, varying contrast microbubble concentrations (5 × 10⁵, 5 × 10⁶, 5 × 10⁷, 5 × 10⁸ microbubbles in 100 μL saline) and contrast injection rates (0.6, 1.2, and 2.4 mL/min) in subcutaneous tumor-bearing mice were applied and their effects on in vivo contrast-enhanced ultrasound MIP imaging plateau values were obtained using a dedicated small animal ultrasound imaging system (40 MHz). Reliability of MIP ultrasound imaging was tested following 2 injections of the same microbubble concentration (5 × 10⁷ microbubbles at 1.2 mL/min) in the same tumors. In mice with subcutaneous human colon cancer xenografts, longitudinal contrast-enhanced ultrasound MIP imaging plateau values (baseline and at 48 hours) were compared between mice with and without antiangiogenic treatment (antivascular endothelial growth factor antibody). Ex vivo CD31 immunostaining of tumor tissue was used to correlate in vivo MIP imaging plateau values with microvessel density analysis.

RESULTS

In vivo MIP imaging plateau values correlated significantly (P = 0.001) with contrast microbubble doses. At 3 different injection rates of 0.6, 1.2, and 2.4 mL/min, MIP imaging plateau values did not change significantly (P = 0.61). Following 2 injections with the same microbubble dose and injection rate, MIP imaging plateau values were obtained with high reliability with an intraclass correlation coefficient of 0.82 (95% confidence interval: 0.64, 0.94). In addition, in vivo MIP imaging plateau values significantly correlated (P = 0.01; R² = 0.77) with ex vivo microvessel density analysis. Tumor volumes in treated and nontreated mice did not change significantly (P = 0.22) within 48 hours. In contrast, the change of in vivo MIP imaging plateau values from baseline to 48 hours was significantly different (P = 0.01) in treated versus nontreated mice.

CONCLUSIONS

Contrast-enhanced ultrasound MIP imaging allows reliable assessment of tumor vascularity and monitoring of antiangiogenic cancer therapy in vivo, provided that a constant microbubble dose is administered.

A visible, targeted high-efficiency gene delivery and transfection strategy

BACKGROUND

To enhance myocardial angiogenic gene expression, a novel gene delivery strategy was tested. Direct intramyocardial injection of an angiogenic gene with microbubbles and insonation were applied in a dog animal model. Dogs received one of the four different treatments in conjunction with either the enhanced green fluorescence protein (EGFP) gene or the hepatocyte growth factor (HGF) gene: gene with microbubbles (MB) and ultrasound (US); gene with US; gene with MB; or the gene alone.

RESULTS

Distribution of MB and the gene in the myocardium was visualized during the experiment. Compared with the EGFP gene group, an average 14.7-fold enhancement in gene expression was achieved in the EGFP+MB/US group (P < 0.01). Compared with the HGF gene group, an average 10.7-fold enhancement in gene expression was achieved in the HGF+MB/US group (P < 0.01). In addition, capillary density increased from 20.8 ± 3.4/mm2 in the HGF gene group to 146.7 ± 31.4/mm2 in HGF+MB/US group (P < 0.01).

CONCLUSIONS

Thus, direct intramyocardial injection of an angiogenic gene in conjunction with microbubbles plus insonation synergistically enhances angiogenesis. This method offers an observable gene delivery procedure with enhanced expression efficiency of the delivered gene.

Molecular imaging: current status and emerging strategies

In vivo molecular imaging has a great potential to impact medicine by detecting diseases in early stages (screening), identifying extent of disease, selecting disease- and patient-specific treatment (personalized medicine), applying a directed or targeted therapy, and measuring molecular-specific effects of treatment. Current clinical molecular imaging approaches primarily use positron-emission tomography (PET) or single photon-emission computed tomography (SPECT)-based techniques. In ongoing preclinical research, novel molecular targets of different diseases are identified and, sophisticated and multifunctional contrast agents for imaging these molecular targets are developed along with new technologies and instrumentation for multi-modality molecular imaging. Contrast-enhanced molecular ultrasound (US) with molecularly-targeted contrast microbubbles is explored as a clinically translatable molecular imaging strategy for screening, diagnosing, and monitoring diseases at the molecular level. Optical imaging with fluorescent molecular probes and US imaging with molecularly-targeted microbubbles are attractive strategies as they provide real-time imaging, are relatively inexpensive, produce images with high spatial resolution, and do not involve exposure to ionizing irradiation. Raman spectroscopy/microscopy has emerged as a molecular optical imaging strategy for ultrasensitive detection of multiple biomolecules/biochemicals with both in vivo and ex vivo versatility. Photoacoustic imaging is a hybrid of optical and US techniques involving optically-excitable molecularly-targeted contrast agents and quantitative detection of resulting oscillatory contrast agent movement with US. Current preclinical findings and advances in instrumentation, such as endoscopes and microcatheters, suggest that these molecular imaging methods have numerous potential clinical applications and will be translated into clinical use in the near future.

Cinemechanometry (CMM): A method to determine the forces that drive morphogenetic movements from time-lapse images

Although cell-level mechanical forces are crucial to tissue self-organization in contexts ranging from embryo development to cancer metastases to regenerative engineering, the absence of methods to map them over time has been a major obstacle to new understanding. Here, we present a technique for constructing detailed, dynamic maps of the forces driving morphogenetic events from time-lapse images. Forces in the cell are considered to be separable into unknown active driving forces and known passive forces, where actomyosin systems and microtubules contribute primarily to the first group and intermediate filaments and cytoplasm to the latter. A finite-element procedure is used to estimate the field of forces that must be applied to the passive components to produce their observed incremental deformations. This field is assumed to be generated by active forces resolved along user-defined line segments whose location, often along cell edges, is informed by the underlying biology. The magnitudes and signs of these forces are determined by a mathematical inverse method. The efficacy of the approach is demonstrated using noisy synthetic data from a cross section of a generic invagination and from a planar aggregate that involves two cell types, edge forces that vary with time and a neighbor change.

Exploiting ultrasound-mediated effects in delivering targeted, site-specific cancer therapy

Although the concept of employing ultrasound for the treatment of cancer is not a new one, virtually all existing ultrasound-based clinical cancer treatments are based on hyperthermic ablation. This review seeks to highlight the potential offered by more subtle ultrasound-triggered phenomena such as sonoporation in delivering novel targeted cancer treatment modalities.