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Kaushik A, Khan AH, Pratibha, Dalvi SV, Shekhar H. Effect of temperature on the acoustic response and stability of size-isolated protein-shelled ultrasound contrast agents and SonoVue. THE JOURNAL OF THE ACOUSTICAL SOCIETY OF AMERICA 2023; 153:2324. [PMID: 37092939 DOI: 10.1121/10.0017682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/09/2023] [Indexed: 05/03/2023]
Abstract
Limited work has been reported on the acoustic and physical characterization of protein-shelled UCAs. This study characterized bovine serum albumin (BSA)-shelled microbubbles filled with perfluorobutane gas, along with SonoVue, a clinically approved contrast agent. Broadband attenuation spectroscopy was performed at room (23 ± 0.5 °C) and physiological (37 ± 0.5 °C) temperatures over the period of 20 min for these agents. Three size distributions of BSA-shelled microbubbles, with mean sizes of 1.86 μm (BSA1), 3.54 μm (BSA2), and 4.24 μm (BSA3) used. Viscous and elastic coefficients for the microbubble shell were assessed by fitting de Jong model to the measured attenuation spectra. Stable cavitation thresholds (SCT) and inertial cavitation thresholds (ICT) were assessed at room and physiological temperatures. At 37 °C, a shift in resonance frequency was observed, and the attenuation coefficient was increased relative to the measurement at room temperature. At physiological temperature, SCT and ICT were lower than the room temperature measurement. The ICT was observed to be higher than SCT at both temperatures. These results enhance our understanding of temperature-dependent properties of protein-shelled UCAs. These findings study may guide the rational design of protein-shelled microbubbles and help choose suitable acoustic parameters for applications in imaging and therapy.
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Affiliation(s)
- Anuj Kaushik
- Electrical Engineering, Indian Institute of Technology, Gandhinagar, Gujarat 382355, India
| | - Aaqib H Khan
- Chemical Engineering, Indian Institute of Technology, Gandhinagar, Gujarat 382355, India
| | - Pratibha
- Physics, Indian Institute of Technology, Gandhinagar, Gujarat 382355, India
| | - Sameer V Dalvi
- Chemical Engineering, Indian Institute of Technology, Gandhinagar, Gujarat 382355, India
| | - Himanshu Shekhar
- Electrical Engineering, Indian Institute of Technology, Gandhinagar, Gujarat 382355, India
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2
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Taneja N, Alam A, Patnaik RS, Taneja T. Current Trends in Anticancer Drug Delivery System for Oral Cancer- A PRISMA complaint Systematic Review. Open Dent J 2022. [DOI: 10.2174/18742106-v16-e2206275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background:
Oral cancer is a deadly disease affecting worldwide. Despite developments of conventional cancer therapy, there has been little improvement in the survival rates. This culminated in the evolution of a targeted. New Drug Delivery System, discovering novel objectives for successful drug delivery and synergistic combination of anticancer agents to minimize side effects.
Objective:
The main focus was on understanding the various aspects of different targeted drug delivery vehicles used in the treatment of oral cancer including advantages, disadvantages, and future perspectives.
Materials and Methods:
A literature search was accomplished from 2005 to 2020 via Google scholar. PubMed, EBSCO, Embase, and Scopus databases along with Clinical trials registries using the terms oral buccal thin films, Hyperthermia and Thermoablation, Intra-tumoral, Photodynamic, Immunotherapy, photothermal, and ultrasound therapy in oral cancer. The articles were scrutinized and those which were not relevant to our search were omitted. Clinical trials on targeted drug delivery systems for Oral Cancer being conducted or completed around the world from various registries of clinical trials have also been searched out and the findings were tabulated in the end. The PRISMA 2020 guidelines were followed.
Results:
The treatment of oral squamous cell carcinoma (OSCC) mostly depends upon the location, type, and stage of the tumor. Vivid targeted drug delivery systems are being used in the therapeutic interventions of oral cancer as they aim for specific target site delivery and are the most appropriate treatment. Active Pharmacological Ingredient (API) is taken to the targeting site, sparing non-target organs or cells, triggering selective and efficient localization, thereby maximizing the therapeutic index with minimizing toxicity. The successful targeted drug delivery system works on four principles i.e. Retain, Evade, Target and Release, which means loading of sufficient drug into a suitable drug carrier, does not affect body secretions, long duration in circulation, reaching the targeted site and, drug release within the time for effective functioning of the drug. All techniques described in this paper have proven to show effective results.
Conclusion:
Oral Cancer is an emerging public health problem worldwide. Various conventional therapies are used for treating oral cancer, but they enclose variable degrees of side effects both on the body as well as the cellular microenvironment. With advanced technology, many other aids have been introduced in the field of oncology to treat oral cancer with minimal side effects. All techniques described in this paper have proven to show effective results in the therapeutic interventions of oral cancer. Moreover, they can be used even in combination with conventional drug therapy to show beneficial outcomes. Several clinical trials are being conducted and completed in this aspect to investigate definite results of these therapies, yet robust research is needed for further confirmation.
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de Maar JS, Rousou C, van Elburg B, Vos HJ, Lajoinie GPR, Bos C, Moonen CTW, Deckers R. Ultrasound-Mediated Drug Delivery With a Clinical Ultrasound System: In Vitro Evaluation. Front Pharmacol 2021; 12:768436. [PMID: 34737709 PMCID: PMC8560689 DOI: 10.3389/fphar.2021.768436] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 10/05/2021] [Indexed: 12/22/2022] Open
Abstract
Chemotherapy efficacy is often reduced by insufficient drug uptake in tumor cells. The combination of ultrasound and microbubbles (USMB) has been shown to improve drug delivery and to enhance the efficacy of several drugs in vitro and in vivo, through effects collectively known as sonopermeation. However, clinical translation of USMB therapy is hampered by the large variety of (non-clinical) US set-ups and US parameters that are used in these studies, which are not easily translated to clinical practice. In order to facilitate clinical translation, the aim of this study was to prove that USMB therapy using a clinical ultrasound system (Philips iU22) in combination with clinically approved microbubbles (SonoVue) leads to efficient in vitro sonopermeation. To this end, we measured the efficacy of USMB therapy for different US probes (S5-1, C5-1 and C9-4) and US parameters in FaDu cells. The US probe with the lowest central frequency (i.e. 1.6 MHz for S5-1) showed the highest USMB-induced intracellular uptake of the fluorescent dye SYTOX™ Green (SG). These SG uptake levels were comparable to or even higher than those obtained with a custom-built US system with optimized US parameters. Moreover, USMB therapy with both the clinical and the custom-built US system increased the cytotoxicity of the hydrophilic drug bleomycin. Our results demonstrate that a clinical US system can be used to perform USMB therapy as efficiently as a single-element transducer set-up with optimized US parameters. Therefore, future trials could be based on these clinical US systems, including validated US parameters, in order to accelerate successful translation of USMB therapy.
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Affiliation(s)
- Josanne S de Maar
- Imaging and Oncology Division, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Charis Rousou
- Department of Pharmaceutical Sciences, Utrecht Institute for Pharmaceutical Sciences (UIPS), Utrecht University, Utrecht, Netherlands
| | - Benjamin van Elburg
- Physics of Fluids Group, MIRA Institute of Biomedical Technology and Technical Medicine, University of Twente, Enschede, Netherlands
| | - Hendrik J Vos
- Laboratory of Acoustical Wavefield Imaging, Faculty of Applied Sciences, Delft University of Technology, Delft, Netherlands
| | - Guillaume P R Lajoinie
- Physics of Fluids Group, MIRA Institute of Biomedical Technology and Technical Medicine, University of Twente, Enschede, Netherlands
| | - Clemens Bos
- Imaging and Oncology Division, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Chrit T W Moonen
- Imaging and Oncology Division, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Roel Deckers
- Imaging and Oncology Division, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
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4
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Perrotti V, Caponio VCA, Mascitti M, Lo Muzio L, Piattelli A, Rubini C, Capone E, Sala G. Therapeutic Potential of Antibody-Drug Conjugate-Based Therapy in Head and Neck Cancer: A Systematic Review. Cancers (Basel) 2021; 13:3126. [PMID: 34206707 PMCID: PMC8269333 DOI: 10.3390/cancers13133126] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Antibody-drug conjugates (ADCs) are designed to deliver potent cytotoxic agents into tumor tissues. During the last two decades, a plethora of ADCs have been successfully developed and used for several indications, including hematologic and solid tumors. In this work, we systematically reviewed the progress in ADC development for the treatment of HNC. METHODS This review was registered in PROSPERO database. A comprehensive search was conducted following PRISMA guidelines and using PubMed, Scopus and Web of Science database. RESULTS In total, 19 studies were included. Due to the significant heterogeneity of the outcome measures, meta-analysis was not performed, and data were summarized in tables. HNC results are poorly represented in the cohorts of completed clinical trials; published data are mostly focused on safety evaluation rather than efficacy of ADCs. CONCLUSIONS Although several novel agents against a wide range of different antigens were investigated, showing promising results at a preclinical level, most of the targets reported in this review are not specific for HNC; hence, the development of ADCs tailored for the HNC phenotype could open up new therapeutic perspectives. Moreover, the results from the present systematic review call attention to how limited is the application of current clinical trials in HNC.
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Affiliation(s)
- Vittoria Perrotti
- Department of Medical, Oral and Biotechnological Sciences, Gabriele d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy;
| | - Vito Carlo Alberto Caponio
- Department of Clinical and Experimental Medicine, University of Foggia, 71100 Foggia, Italy; (V.C.A.C.); (L.L.M.)
| | - Marco Mascitti
- Department of Clinical Specialistic and Dental Sciences, Marche Polytechnic University, 60121 Ancona, Italy;
| | - Lorenzo Lo Muzio
- Department of Clinical and Experimental Medicine, University of Foggia, 71100 Foggia, Italy; (V.C.A.C.); (L.L.M.)
| | - Adriano Piattelli
- Department of Medical, Oral and Biotechnological Sciences, Gabriele d’Annunzio University of Chieti-Pescara, 66100 Chieti, Italy;
- Fondazione Villa Serena per la Ricerca, Città S. Angelo, 65121 Pescara, Italy
- Casa di Cura Villa Serena, Città S. Angelo, 65121 Pescara, Italy
| | - Corrado Rubini
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy;
| | - Emily Capone
- Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara, 66100 Chieti, Italy; (E.C.); (G.S.)
- Center for Advanced Studies and Technology (CAST), Via Polacchi 11, 66100 Chieti, Italy
| | - Gianluca Sala
- Department of Innovative Technologies in Medicine & Dentistry, University of Chieti-Pescara, 66100 Chieti, Italy; (E.C.); (G.S.)
- Center for Advanced Studies and Technology (CAST), Via Polacchi 11, 66100 Chieti, Italy
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Ketabat F, Pundir M, Mohabatpour F, Lobanova L, Koutsopoulos S, Hadjiiski L, Chen X, Papagerakis P, Papagerakis S. Controlled Drug Delivery Systems for Oral Cancer Treatment-Current Status and Future Perspectives. Pharmaceutics 2019; 11:E302. [PMID: 31262096 PMCID: PMC6680655 DOI: 10.3390/pharmaceutics11070302] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 06/25/2019] [Accepted: 06/26/2019] [Indexed: 12/18/2022] Open
Abstract
Oral squamous cell carcinoma (OSCC), which encompasses the oral cavity-derived malignancies, is a devastating disease causing substantial morbidity and mortality in both men and women. It is the most common subtype of the head and neck squamous cell carcinoma (HNSCC), which is ranked the sixth most common malignancy worldwide. Despite promising advancements in the conventional therapeutic approaches currently available for patients with oral cancer, many drawbacks are still to be addressed; surgical resection leads to permanent disfigurement, altered sense of self and debilitating physiological consequences, while chemo- and radio-therapies result in significant toxicities, all affecting patient wellbeing and quality of life. Thus, the development of novel therapeutic approaches or modifications of current strategies is paramount to improve individual health outcomes and survival, while early tumour detection remains a priority and significant challenge. In recent years, drug delivery systems and chronotherapy have been developed as alternative methods aiming to enhance the benefits of the current anticancer therapies, while minimizing their undesirable toxic effects on the healthy non-cancerous cells. Targeted drug delivery systems have the potential to increase drug bioavailability and bio-distribution at the site of the primary tumour. This review confers current knowledge on the diverse drug delivery methods, potential carriers (e.g., polymeric, inorganic, and combinational nanoparticles; nanolipids; hydrogels; exosomes) and anticancer targeted approaches for oral squamous cell carcinoma treatment, with an emphasis on their clinical relevance in the era of precision medicine, circadian chronobiology and patient-centred health care.
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Affiliation(s)
- Farinaz Ketabat
- Laboratory of Oral, Head and Neck Cancer - Personalized Diagnostics and Therapeutics, Department of Surgery - Division of Head and Neck Surgery, College of Medicine, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada
- Laboratory of Precision Oral Health and Chronobiology, College of Dentistry, University of Saskatchewan, Saskatoon, SK S7N 5E4, Canada
- Division of Biomedical Engineering, University of Saskatchewan, Saskatoon, SK S7K 5A9, Canada
| | - Meenakshi Pundir
- Laboratory of Oral, Head and Neck Cancer - Personalized Diagnostics and Therapeutics, Department of Surgery - Division of Head and Neck Surgery, College of Medicine, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada
- Laboratory of Precision Oral Health and Chronobiology, College of Dentistry, University of Saskatchewan, Saskatoon, SK S7N 5E4, Canada
- Division of Biomedical Engineering, University of Saskatchewan, Saskatoon, SK S7K 5A9, Canada
| | - Fatemeh Mohabatpour
- Laboratory of Oral, Head and Neck Cancer - Personalized Diagnostics and Therapeutics, Department of Surgery - Division of Head and Neck Surgery, College of Medicine, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada
- Laboratory of Precision Oral Health and Chronobiology, College of Dentistry, University of Saskatchewan, Saskatoon, SK S7N 5E4, Canada
- Division of Biomedical Engineering, University of Saskatchewan, Saskatoon, SK S7K 5A9, Canada
| | - Liubov Lobanova
- Laboratory of Precision Oral Health and Chronobiology, College of Dentistry, University of Saskatchewan, Saskatoon, SK S7N 5E4, Canada
| | - Sotirios Koutsopoulos
- Center for Biomedical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Lubomir Hadjiiski
- Departmnet of Radiology, School of Medicine, University of Michigan, Ann Arbor, MI 48109, USA
| | - Xiongbiao Chen
- Division of Biomedical Engineering, University of Saskatchewan, Saskatoon, SK S7K 5A9, Canada
- Department of Mechanical Engineering, University of Saskatchewan, Saskatoon, SK S7K 5A9, Canada
| | - Petros Papagerakis
- Laboratory of Precision Oral Health and Chronobiology, College of Dentistry, University of Saskatchewan, Saskatoon, SK S7N 5E4, Canada
- Division of Biomedical Engineering, University of Saskatchewan, Saskatoon, SK S7K 5A9, Canada
| | - Silvana Papagerakis
- Laboratory of Oral, Head and Neck Cancer - Personalized Diagnostics and Therapeutics, Department of Surgery - Division of Head and Neck Surgery, College of Medicine, University of Saskatchewan, Saskatoon, SK S7N 5E5, Canada.
- Division of Biomedical Engineering, University of Saskatchewan, Saskatoon, SK S7K 5A9, Canada.
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
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6
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Zhang J, Song L, Zhou S, Hu M, Jiao Y, Teng Y, Wang Y, Zhang X. Enhanced ultrasound imaging and anti-tumor in vivo properties of Span–polyethylene glycol with folic acid–carbon nanotube–paclitaxel multifunctional microbubbles. RSC Adv 2019; 9:35345-35355. [PMID: 35528086 PMCID: PMC9074749 DOI: 10.1039/c9ra06437k] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 09/27/2019] [Indexed: 11/21/2022] Open
Abstract
With Span and polyethylene glycol (PEG) as the membrane material, the as-prepared folate–carbon nanotube–paclitaxel (FA–CNT–PTX) complex was added to the reaction system under sound vibration cavitation and Span–PEG with FA–CNT–PTX microbubbles was obtained.
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Affiliation(s)
- Jie Zhang
- Pharmacy College
- Jiamusi University
- Jiamusi 154007
- China
| | - Limei Song
- Pharmacy College
- Jiamusi University
- Jiamusi 154007
- China
| | - Shujing Zhou
- Pharmacy College
- Jiamusi University
- Jiamusi 154007
- China
| | - Ming Hu
- College of Materials Science & Engineering
- Jiamusi University
- Jiamusi 154007
- China
| | - Yufeng Jiao
- College of Materials Science & Engineering
- Jiamusi University
- Jiamusi 154007
- China
| | - Yang Teng
- Pharmacy College
- Jiamusi University
- Jiamusi 154007
- China
| | - Ying Wang
- Pharmacy College
- Jiamusi University
- Jiamusi 154007
- China
| | - Xiangyu Zhang
- Pharmacy College
- Jiamusi University
- Jiamusi 154007
- China
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Hirabayashi F, Iwanaga K, Okinaga T, Takahashi O, Ariyoshi W, Suzuki R, Sugii M, Maruyama K, Tominaga K, Nishihara T. Epidermal growth factor receptor-targeted sonoporation with microbubbles enhances therapeutic efficacy in a squamous cell carcinoma model. PLoS One 2017; 12:e0185293. [PMID: 28938010 PMCID: PMC5609770 DOI: 10.1371/journal.pone.0185293] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 09/08/2017] [Indexed: 11/18/2022] Open
Abstract
Sonoporation is a drug and gene delivery system using ultrasonication that allows the intracellular delivery of foreign molecules that cannot enter cells under normal conditions. We previously reported that sonoporation with microbubbles (MBs) could achieve effective intracellular drug delivery to human gingival squamous carcinoma Ca9-22 cells. In this study, we developed anti-epidermal growth factor receptor (EGFR) antibody-conjugated MBs (EGFR-MBs) and evaluated their capacity to enhance anti-cancer drug toxicity in vitro and in vivo. We first assessed the effect of sonoporation with EGFR-MBs on Ca9-22 cells by the WST-8 assay, flow cytometry and Hoechst's staining in vitro. Sonoporation and EGFR-MB had a strong cytotoxic effect on Ca9-22 cells with low-dose bleomycin. Furthermore, bleomycin delivery using sonoporation with EGFR-MBs remarkably increased the number of apoptotic cells. We next examined the effect of EGFR-MBs in a murine squamous cell carcinoma model. Bleomycin delivery by sonoporation with EGFR-MBs exhibited remarkable antitumor activity. Together, our results show that EGFR-MBs and ultrasound treatment increases the efficacy and specificity of intracellular drug uptake, suggesting this could be a novel drug-targeting modality for oral squamous cell carcinoma chemotherapy treatment.
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Affiliation(s)
- Fumika Hirabayashi
- Division of Infections and Molecular Biology, Department of Health Promotion, Kyushu Dental University, Kitakyushu, Japan
- Division of Oral and Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Kitakyushu, Japan
| | - Kenjiro Iwanaga
- Division of Oral and Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Kitakyushu, Japan
| | - Toshinori Okinaga
- Division of Infections and Molecular Biology, Department of Health Promotion, Kyushu Dental University, Kitakyushu, Japan
| | - Osamu Takahashi
- Division of Oral and Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Kitakyushu, Japan
| | - Wataru Ariyoshi
- Division of Infections and Molecular Biology, Department of Health Promotion, Kyushu Dental University, Kitakyushu, Japan
| | - Ryo Suzuki
- Laboratory of Drug Delivery System, Faculty of Pharma-Sciences, Teikyo University, Tokyo, Japan
| | - Mutsumi Sugii
- Laboratory of Drug Delivery System, Faculty of Pharma-Sciences, Teikyo University, Tokyo, Japan
| | - Kazuo Maruyama
- Laboratory of Drug Delivery System, Faculty of Pharma-Sciences, Teikyo University, Tokyo, Japan
| | - Kazuhiro Tominaga
- Division of Oral and Maxillofacial Surgery, Department of Science of Physical Functions, Kyushu Dental University, Kitakyushu, Japan
| | - Tatsuji Nishihara
- Division of Infections and Molecular Biology, Department of Health Promotion, Kyushu Dental University, Kitakyushu, Japan
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8
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Affiliation(s)
- S T Sonis
- Brigham and Women's Hospital, Dana-Farber Cancer Institute, Biomodels LLC, Boston, MA, USA
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9
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Okunaga S, Takasu A, Meshii N, Imai T, Hamada M, Iwai S, Yura Y. Entry of Oncolytic Herpes Simplex Virus into Human Squamous Cell Carcinoma Cells by Ultrasound. Viruses 2015; 7:5610-8. [PMID: 26516901 PMCID: PMC4632398 DOI: 10.3390/v7102890] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 09/22/2015] [Accepted: 10/09/2015] [Indexed: 01/21/2023] Open
Abstract
Low-intensity ultrasound is a useful method to introduce materials into cells due to the transient formation of micropores, called sonoporations, on the cell membrane. Whether oncolytic herpes simplex virus type 1 (HSV-1) can be introduced into oral squamous cell carcinoma (SCC) cells through membrane pores remains undetermined. Human SCC cell line SAS and oncolytic HSV-1 RH2, which was deficient in the 134.5 gene and fusogenic, were used. Cells were exposed to ultrasound in the presence or absence of microbubbles. The increase of virus entry was estimated by plaque numbers. Viral infection was hardly established without the adsorption step, but plaque number was increased by the exposure of HSV-1-inoculated cells to ultrasound. Plaque number was also increased even if SAS cells were exposed to ultrasound and inoculated with RH2 without the adsorption step. This effect was abolished when the interval from ultrasound exposure to virus inoculation was prolonged. Scanning electron microscopy revealed depressed spots on the cell surface after exposure to ultrasound. These results suggest that oncolytic HSV-1 RH2 can be introduced into SAS cells through ultrasound-mediated pores of the cell membrane that are resealed after an interval.
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Affiliation(s)
- Shusuke Okunaga
- Department of Oral and Maxillofacial Surgery, Osaka University Graduate School of Dentistry, 1-8 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Ayako Takasu
- Department of Oral and Maxillofacial Surgery, Osaka University Graduate School of Dentistry, 1-8 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Noritoshi Meshii
- Dental and Oral Surgery, Izumisano Municipal Hospital, 2-23 Rinkuoraikita, Izumisano, Osaka 598-8577, Japan.
| | - Tomoaki Imai
- Department of Oral and Maxillofacial Surgery, Osaka University Graduate School of Dentistry, 1-8 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Masakagu Hamada
- Department of Oral and Maxillofacial Surgery, Osaka University Graduate School of Dentistry, 1-8 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Soichi Iwai
- Department of Oral and Maxillofacial Surgery, Osaka University Graduate School of Dentistry, 1-8 Yamadaoka, Suita, Osaka 565-0871, Japan.
| | - Yoshiaki Yura
- Department of Oral and Maxillofacial Surgery, Osaka University Graduate School of Dentistry, 1-8 Yamadaoka, Suita, Osaka 565-0871, Japan.
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10
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Ultrasound as a method to enhance antitumor ability of oncolytic herpes simplex virus for head and neck cancer. Cancer Gene Ther 2015; 22:163-8. [PMID: 25656776 DOI: 10.1038/cgt.2015.3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 12/26/2014] [Accepted: 12/29/2014] [Indexed: 11/08/2022]
Abstract
Low-intensity ultrasound is a useful method to enhance the delivery of drugs to target cells via a range of mechanisms including the transient formation of micropores in the cell membrane, a process known as sonoporation. The effect of ultrasound on oncolytic herpes simplex virus type-1 (HSV-1) infection in oral squamous cell carcinoma (SCC) was examined. Human SCC cell line SAS and oncolytic HSV-1 RH2, which was deficient in the neurovirulent γ134.5 gene and exhibited cell fusion actions, were used. Cells grown in multi-well plates were infected with HSV-1 and exposed to ultrasound in the presence or absence of microbubbles after an adsorption period. The number of plaques was significantly greater than that of the untreated control. SAS cells were inoculated subcutaneously into nude mice and tumors were produced. Tumors were injected with HSV-1 RH2 with or without microbubbles and then exposed to ultrasound through the covering skin. The amount of the virus in tumor tissues 3 days after the injection was higher in tumors treated with HSV-1 RH2 and ultrasound than in tumors treated with RH2 only. The expression of the HSV-1 antigen was also increased by ultrasound and microbubbles. Tumor growth was suppressed with HSV-1 RH2 in combination with ultrasound, especially with microbubbles. These results indicated that ultrasound increased the efficiency of the HSV-1 infection in SAS cells and nude mouse tumors. This method can potentially be useful to enhance the antitumor effects of oncolytic HSV-1 on head and neck cancer treatment.
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11
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Lee ES, Lee JY, Kim H, Choi Y, Park J, Han JK, Choi BI. Pulsed high-intensity focused ultrasound enhances apoptosis of pancreatic cancer xenograft with gemcitabine. ULTRASOUND IN MEDICINE & BIOLOGY 2013; 39:1991-2000. [PMID: 23972483 DOI: 10.1016/j.ultrasmedbio.2013.06.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Revised: 05/08/2013] [Accepted: 06/06/2013] [Indexed: 06/02/2023]
Abstract
We sought to investigate whether concurrent exposure to pulsed high-intensity focused ultrasound (HIFU) and the chemotherapeutic drug gemcitabine would enhance apoptosis in pancreatic cancer. A pancreatic cancer xenograft model was established using BALB/c nude mice and human pancreatic cancer cells (PANC-1). In the first study, mice were randomly allocated into one of four groups: control (n = 4), HIFU alone (n = 4), gemcitabine (GEM) alone (n = 28) and concurrent treatment with HIFU and gemcitabine (HIGEM) (n = 28). The GEM and HIGEM groups were subdivided into four subgroups (16 mice) according to the drug dose injected (50-200 mg/kg) and another four subgroups (16 mice) according to the time interval between drug injection and HIFU treatment (each subgroup, n = 4). Apoptosis rates were evaluated using the TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling) assay and percentage of necrosis, as evaluated with Harris' hematoxylin solution and eosin Y stain, 3 d after treatment. The second study was performed to evaluate tumor growth rates of the four groups. Each group was treated weekly for 3 wk, and tumor size was periodically measured for up to 4 wk from the beginning of treatment. In the first study, overall rates of apoptosis were significantly higher in the HIGEM group than in the GEM group (p = 0.02). In a subgroup analysis, HIGEM was superior to GEM in enhancing apoptosis at gemcitabine dosages of 150-200 mg/kg gemcitabine and intervals between gemcitabine and HIFU less than 2 h (p = 0.01). In the second study, HIGEM treatment resulted in the slowest tumor growth. However, despite a visible distinction, none of the differences found between the HIGEM and GEM groups were statistically significant (p > 0.05). Treatment with both HIFU and gemcitabine might enhance cell apoptosis and reduce tumor growth in pancreatic carcinoma. For this concurrent treatment, a high dosage of gemcitabine and a short-term delay before HIFU are recommended to maximize the therapeutic effect.
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Affiliation(s)
- Eun Sun Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Korea
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Wang Y, Bai WK, Shen E, Hu B. Sonoporation by low-frequency and low-power ultrasound enhances chemotherapeutic efficacy in prostate cancer cells in vitro.. Oncol Lett 2013; 6:495-498. [PMID: 24137354 PMCID: PMC3789114 DOI: 10.3892/ol.2013.1389] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Accepted: 04/17/2013] [Indexed: 01/24/2023] Open
Abstract
Combination therapy is used to optimize anticancer efficacy and reduce the toxicity and side-effects of drugs upon systemic administration. Ultrasound (US) combined with micro-bubbles (UM) enhances the intracellular uptake of cytotoxic drugs by tumor cells, particularly drug-resistant cells. In the present study, low-frequency and low-energy US (US irradiation conditions: frequency, 21 kHz; power density, 0.113 W/cm2; exposure time, 2 min at a duty cycle of 70%; and valid treatment time, 84 sec) were used in combination with microbubbles (100 μl/ml) to deliver mitoxantrone HCl (MIT) to DU145 cells. The results showed that UM did not change the cell viability in the short- or long-term. However, UM statistically enhanced the therapeutic effects and up to 31.26±3.34% of the cells exposed to UM were permeabilized compared with 9.74±2.55% of cells in the control, when using calcein (MW, 622.53) as a fluorogenic marker. Notably, UM affected the migration capability of the DU145 cells at 6 h post-treatment. In conclusion, the ultrasonic parameters used in the present study enhanced the chemotherapeutic effect and reduced the unwanted side-effects of MIT.
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Affiliation(s)
- Yu Wang
- Department of Ultrasound in Medicine, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai Institute of Ultrasound in Medicine, Shanghai 200233, P.R. China
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Sorace AG, Saini R, Rosenthal E, Warram JM, Zinn KR, Hoyt K. Optical fluorescent imaging to monitor temporal effects of microbubble-mediated ultrasound therapy. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2013; 60:281-9. [PMID: 23357902 PMCID: PMC3628607 DOI: 10.1109/tuffc.2013.2564] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
Microbubble-mediated ultrasound therapy can noninvasively enhance drug delivery to localized regions in the body. This technique can be beneficial in cancer therapy, but currently there are limitations to tracking the therapeutic effects. The purpose of this experiment was to investigate the potential of fluorescent imaging for monitoring the temporal effects of microbubble-mediated ultrasound therapy. Mice were implanted with 2LMP breast cancer cells. The animals underwent microbubble-mediated ultrasound therapy in the presence of Cy5.5 fluorescent-labeled IgG antibody (large molecule) or Cy5.5 dye (small molecule) and microbubble contrast agents. Control animals were administered fluorescent molecules only. Animals were transiently imaged in vivo at 1, 10, 30, and 60 min post therapy using a small animal optical imaging system. Tumors were excised and analyzed ex vivo. Tumors were homogenized and emulsion imaged for Cy5.5 fluorescence. Monitoring in vivo results showed significant influx of dye into the tumor (p < 0.05) using the small molecule, but not in the large molecule group (p > 0.05). However, after tumor emulsion, significantly higher dye concentration was detected in therapy group tumors for both small and large molecule groups in comparison to their control counterparts (p <0.01). This paper explores a noninvasive optical imaging method for monitoring the effects of microbubble-mediated ultrasound therapy in a cancer model. It provides temporal information following the process of increasing extravasation of molecules into target tumors.
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Affiliation(s)
- Anna G. Sorace
- Department of Biomedical Engineering, University of Alabama at Birmingham, Birmingham, AL
| | - Reshu Saini
- Department of Biomedical Engineering, University of Alabama at Birmingham, Birmingham, AL
| | - Eben Rosenthal
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
| | - Jason M. Warram
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL
| | - Kurt R. Zinn
- Department of Radiology, University of Alabama at Birmingham, Birmingham, AL. Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
| | - Kenneth Hoyt
- Department of Biomedical Engineering, University of Alabama at Birmingham, Birmingham, AL. Department of Radiology, University of Alabama at Birmingham, Birmingham, AL. Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL
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Lamanauskas N, Novell A, Escoffre JM, Venslauskas M, Šatkauskas S, Bouakaz A. Bleomycin delivery into cancer cellsin vitrowith ultrasound and SonoVue® or BR14® microbubbles. J Drug Target 2013; 21:407-14. [DOI: 10.3109/1061186x.2012.761223] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Alzaraa A, Gravante G, Chung WY, Al-Leswas D, Bruno M, Dennison AR, Lloyd DM. Targeted microbubbles in the experimental and clinical setting. Am J Surg 2012; 204:355-66. [PMID: 22920405 DOI: 10.1016/j.amjsurg.2011.10.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 10/12/2011] [Accepted: 10/12/2011] [Indexed: 01/17/2023]
Abstract
BACKGROUND Microbubbles have improved ultrasonography imaging techniques over the past 2 decades. Their safety, versatility, and easiness of use have rendered them equal or even superior in some instances to other imaging modalities such as computed tomography and magnetic resonance imaging. Herein, we conducted a literature review to present their types, general behavior in tissues, and current and potential use in clinical practice. METHODS A literature search was conducted for all preclinical and clinical studies involving microbubbles and ultrasonography. RESULTS Different types of microbubbles are available. These generally improve the enhancement of tissues during ultrasonography imaging. They also can be attached to ligands for the target of several conditions such as inflammation, angiogenesis, thrombosis, apoptosis, and might have the potential of carrying toxic drugs to diseased sites, thereby limiting the systemic adverse effects. CONCLUSIONS The use of microbubbles is evolving rapidly and can have a significant impact on the management of various conditions. The potential for their use as targeting agents and gene and drug delivery vehicles looks promising.
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Affiliation(s)
- Ahmed Alzaraa
- Department of Hepatobiliary and Pancreatic Surgery, NHS Trust, Leicester General Hospital, Gwendolen Rd., Leicester, LE5 4PW, UK.
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Couture O, Urban A, Bretagne A, Martinez L, Tanter M, Tabeling P. In vivo targeted delivery of large payloads with an ultrasound clinical scanner. Med Phys 2012; 39:5229-37. [PMID: 22894447 DOI: 10.1118/1.4736822] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
PURPOSE Performing drug-delivery with an ultrasonic imaging scanner in situ could drastically simplify treatment and improve its specificity. Our objective is to deliver large amounts of an encapsulated agent in vivo using a clinical ultrasound scanner with a millimetric resolution. This study describes the encapsulation of fluorescein within ultrasound-inducible composite droplets and its targeted release in predefined zones in the liver of rats. METHODS An aqueous solution of fluorescein was encapsulated within perfluorocarbon liquid in 4 μm monodisperse droplets using a microfluidic system. The agent was then injected within the femoral vein of 12 rats. After exploratory ultrasound imaging, the sonographer defined five zones in the liver and a release sequence was initiated on the same apparatus. The surface of the liver was observed under fluorescence macroscopy and intraoperative fluorescence camera in vivo, before liver samples were sliced for pathology. RESULTS Following the conversion of the droplets, a 25 dB increase in contrast was observed in the zones selected by the sonographer. These hyperechoic regions were colocalized with the bright fluorescent spots observed on the surface of the liver. A minimum peak-negative pressure of 2.6 MPa, which is within regulations for imaging pulses, was required for the delivery of the content of the droplets. The tissue and cellular structures were not affected by the exposure to the release sequence. CONCLUSIONS Since composite droplets can carry various therapeutic and imaging agents, they could deliver such agents specifically in any organ accessible to ultrasound.
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Affiliation(s)
- Olivier Couture
- Institut Langevin, ESPCI, 10 rue Vauquelin, Paris 75005, France.
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Tamosiūnas M, Jurkonis R, Mir LM, Lukosevicius A, Venslauskas MS, Satkauskas S. Adjustment of ultrasound exposure duration to microbubble sonodestruction kinetics for optimal cell sonoporation in vitro. Technol Cancer Res Treat 2012; 11:375-87. [PMID: 22376133 DOI: 10.7785/tcrt.2012.500285] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- M Tamosiūnas
- Department of Biology, Faculty of Natural Sciences, Vytautas Magnus University, Vileikos 8, Kaunas LT-44404, Lithuania
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Lee NG, Berry JL, Lee TC, Wang AT, Honowitz S, Murphree AL, Varshney N, Hinton DR, Fawzi AA. Sonoporation enhances chemotherapeutic efficacy in retinoblastoma cells in vitro. Invest Ophthalmol Vis Sci 2011; 52:3868-73. [PMID: 21273549 DOI: 10.1167/iovs.10-6501] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
PURPOSE To study the ability of ultrasound (US) and microbubbles (MB) to enhance chemotherapeutic efficacy against retinoblastoma Y79 cells in vitro. METHODS The experiment was performed in three stages. The authors first compared cell viability of Y79 cells exposed to doxorubicin versus cells exposed to doxorubicin combined with low-intensity, low-frequency US + MB. They then evaluated enhanced cell permeability by studying the intensity of intracellular fluorescence in cells exposed to doxorubicin versus those exposed to doxorubicin with US + MB. Lastly they evaluated the morphologic characteristics of the cells by scanning electron microscopy (SEM) to identify the presence of pores. RESULTS The Y79 cells exposed to doxorubicin with US + MB showed a significant decrease in cell viability at 72 hours compared with those exposed to doxorubicin alone (P = 0.02). Cells also showed immediate increased permeability to doxorubicin with the addition of US + MB compared with doxorubicin alone, which continued to increase over 60 minutes. SEM did not demonstrate physical pores at the lowest US + MB intensity shown to enhance intracellular doxorubicin fluorescence. CONCLUSIONS US + MB facilitates the uptake of chemotherapy in retinoblastoma Y79 cells in vitro. This occurs in the absence of visible pores, suggesting a possible secondary mechanism for increased drug delivery. This experiment is the first step toward enhancing chemotherapy with sonoporation in the treatment of intraocular tumors. This technique may lead to more effective chemotherapy treatments with less collateral damage to ocular tissues and may allow reduced systemic dosage and systemic side effects.
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Affiliation(s)
- Nahyoung G Lee
- Doheny Eye Institute, Keck School of Medicine, University of Southern California, Los Angeles, California 90033, USA
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Carson AR, McTiernan CF, Lavery L, Hodnick A, Grata M, Leng X, Wang J, Chen X, Modzelewski RA, Villanueva FS. Gene therapy of carcinoma using ultrasound-targeted microbubble destruction. ULTRASOUND IN MEDICINE & BIOLOGY 2011; 37:393-402. [PMID: 21256666 PMCID: PMC4111473 DOI: 10.1016/j.ultrasmedbio.2010.11.011] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2010] [Revised: 11/17/2010] [Accepted: 11/23/2010] [Indexed: 05/05/2023]
Abstract
When microbubble contrast agents are loaded with genes and systemically injected, ultrasound-targeted microbubble destruction (UTMD) facilitates focused delivery of genes to target tissues. A mouse model of squamous cell carcinoma was used to test the hypothesis that UTMD would specifically transduce tumor tissue and slow tumor growth when treated with herpes simplex virus thymidine kinase (TK) and ganciclovir. UTMD-mediated delivery of reporter genes resulted in tumor expression of luciferase and green fluorescent protein (GFP) in perivascular areas and individual tumor cells that exceeded expression in control tumors (p=0.02). The doubling time of TK-treated tumors was longer than GFP-treated tumors (p=0.02), and TK-treated tumors displayed increased apoptosis (p=0.04) and more areas of cellular drop-out (p=0.03). These data indicate that UTMD gene therapy can transduce solid tumors and mediate a therapeutic effect. UTMD is a promising nonviral method for targeting gene therapy that may be useful in a spectrum of tumors.
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Affiliation(s)
- Andrew R. Carson
- Center for Ultrasound Molecular Imaging and Therapeutics, Cardiovascular Institute, University of Pittsburgh Medical Center
| | - Charles F. McTiernan
- Center for Ultrasound Molecular Imaging and Therapeutics, Cardiovascular Institute, University of Pittsburgh Medical Center
| | - Linda Lavery
- Center for Ultrasound Molecular Imaging and Therapeutics, Cardiovascular Institute, University of Pittsburgh Medical Center
| | - Abigail Hodnick
- Center for Ultrasound Molecular Imaging and Therapeutics, Cardiovascular Institute, University of Pittsburgh Medical Center
| | - Michelle Grata
- Center for Ultrasound Molecular Imaging and Therapeutics, Cardiovascular Institute, University of Pittsburgh Medical Center
| | - Xiaoping Leng
- Center for Ultrasound Molecular Imaging and Therapeutics, Cardiovascular Institute, University of Pittsburgh Medical Center
| | - Jianjun Wang
- Center for Ultrasound Molecular Imaging and Therapeutics, Cardiovascular Institute, University of Pittsburgh Medical Center
| | - Xucai Chen
- Center for Ultrasound Molecular Imaging and Therapeutics, Cardiovascular Institute, University of Pittsburgh Medical Center
| | | | - Flordeliza S. Villanueva
- Center for Ultrasound Molecular Imaging and Therapeutics, Cardiovascular Institute, University of Pittsburgh Medical Center
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Monteiro LS, Diniz-Freitas M, Garcia-Caballero T, Forteza J, Fraga M. EGFR and Ki-67 expression in oral squamous cell carcinoma using tissue microarray technology. J Oral Pathol Med 2010; 39:571-8. [PMID: 20202087 DOI: 10.1111/j.1600-0714.2009.00876.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Our aim was to validate the use of tissue microarrays (TMA) in oral squamous cell carcinomas (OSCC) to analyse epidermal growth factor receptor (EGFR) and Ki-67 expression. We also analysed the relationship that the expression of these markers may have with clinical, pathological and survival variables. PATIENTS AND METHODS The study sample comprised 39 unselected patients diagnosed and treated for OSCC. We analysed Ki-67 and EGFR expression by immunohistochemistry on formalin-fixed, paraffin-embedded surgical specimens. Whole sections (WS) were compared with double 1.5 mm core-tissue microarrays. RESULTS High EGFR expression was observed both on TMA (in 98% of the cases) and WS (in 100% of the cases) with substantial agreement kappa value (0.720). EGFR expression was not significantly associated with clinical, pathological and survival variables on TMA and WS. Ki-67 analysis showed a Spearman correlation of 0.741 with a Ki-67 mean labelling index of 45% in TMA and 56.8% in WS. We found a significant relationship between gender and Ki-67 labelling index on WS (P = 0.022) and TMA (P = 0.002). Clinical stage was the only parameter in multivariate analysis that had a significant predictive value. CONCLUSION We demonstrate that dual 1.5 mm core TMA is a valid, rapid, economical and tissue-saving way to study OSCC biopsies and that it presents strong correlation with the WS. EGFR overexpression in OSCC suggests that these tumours may be a candidate for therapy investigation directed to EGFR.
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Affiliation(s)
- Luís Silva Monteiro
- Department of Oral Surgery and Oral Medicine, Higher Institute of Health Sciences, Paredes, Portugal.
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