Molecular Targeting of Lymph Nodes with L-Selectin Ligand-specific US Contrast Agent: A Feasibility Study in Mice and Dogs

[Experimental Environment in Radiology: Sustainable Research]

Research requires large sums of money that are indirectly provided by taxpayers. It is therefore important that research is sustainable and does not just serve the career development of individuals. The aim of this article is to discuss what sustainable research in radiology is, how it can be organised and, above all, to show that it is possible.There are various approaches to achieving sustainability, ranging from purely gaining knowledge to translated devices and contrast agents, and to new clinical applications. The first step is to clarify exactly what is intended to be achieved with the research and critically weigh up the novelty value and the expected impact. This should be followed by careful, long-term planning of the project over a period of 5-15 years with the definition of clear sub-steps. Securing funding is just as important here as regular communication of the results. It often makes sense to involve the regulatory authorities and commercialisation partners in the project at an early stage.Academic radiology should not limit itself to serving as a test platform for imaging devices and contrast agents from industry, but should try to realise its own ideas and developments. Many academic centres around the world have shown that this is possible. Examples from my own research, particularly in relation to the development and translation of super-resolution ultrasound imaging and the development of diagnostics and nanopharmaceuticals, are explained in this article and challenges at various stages of development are discussed. Young radiologists are encouraged to set bigger and more long-term goals in order to influence and develop our field in a sustainable way. · Sustainable research requires creativity and careful planning. · Sustainable research can start at several stages of the technical readiness level. · Long-term planning of the overall concept (5-15 years) with clear intermediate steps is essential. · Cooperation with industry is often useful. · Acquisition of third-party funding must be ensured at the same time.

Polymeric materials for ultrasound imaging and therapy

Ultrasound (US) is routinely used for diagnostic imaging and increasingly employed for therapeutic applications. Materials that act as cavitation nuclei can improve the resolution of US imaging, and facilitate therapeutic US procedures by promoting local drug delivery or allowing temporary biological barrier opening at moderate acoustic powers. Polymeric materials offer a high degree of control over physicochemical features concerning responsiveness to US, e.g. via tuning chain composition, length and rigidity. This level of control cannot be achieved by materials made of lipids or proteins. In this perspective, we present key engineered polymeric materials that respond to US, including microbubbles, gas-stabilizing nanocups, microcapsules and gas-releasing nanoparticles, and discuss their formulation aspects as well as their principles of US responsiveness. Focusing on microbubbles as the most common US-responsive polymeric materials, we further evaluate the available chemical toolbox to engineer polymer shell properties and enhance their performance in US imaging and US-mediated drug delivery. Additionally, we summarize emerging applications of polymeric microbubbles in molecular imaging, sonopermeation, and gas and drug delivery, based on refinement of MB shell properties. Altogether, this manuscript provides new perspectives on US-responsive polymeric designs, envisaging their current and future applications in US imaging and therapy.

Recent advancement of imaging strategies of the lymphatic system: Answer to the decades old questions

The role of the lymphatic system in maintaining tissue homeostasis and a number of different pathophysiological conditions has been well established. The complex and delicate structure of the lymphatics along with the limitations of conventional imaging techniques make lymphatic imaging particularly difficult. Thus, in-depth high-resolution imaging of lymphatic system is key to understanding the progression of lymphatic diseases and cancer metastases and would greatly benefit clinical decisions. In recent years, the advancement of imaging technologies and development of new tracers suitable for clinical applications has enabled imaging of the lymphatic system in both clinical and pre-clinical settings. In this current review, we have highlighted the advantages and disadvantages of different modern techniques such as near infra-red spectroscopy (NIRS), positron emission tomography (PET), computed tomography (CT), magnetic resonance imaging (MRI) and fluorescence optical imaging, that has significantly impacted research in this field and has led to in-depth insights into progression of pathological states. This review also highlights the use of current imaging technologies, and tracers specific for immune cell markers to identify and track the immune cells in the lymphatic system that would help understand disease progression and remission in immune therapy regimen.

Sentinel Lymph Node Characterization with a Dual-Targeted Molecular Ultrasound Contrast Agent

PURPOSE

The purpose of this study was to assess the performance of molecular ultrasound with dual-targeted microbubbles to detect metastatic disease in the sentinel lymph nodes (SLNs) in swine model of naturally occurring melanoma. The SLN is the first lymph node in the lymphatic chain draining primary tumor, and early detection of metastatic SLN involvement is critical in the appropriate management of melanoma.

PROCEDURE

Nine Sinclair swine (weight 3-7 kg; Sinclair BioResources, Columbia, MO, USA) with naturally occurring melanoma were examined. Siemens S3000 scanner with a 9L4 probe was used for imaging (Siemens Healthineers, Mountain View, CA). Dual-targeted contrast agent was created using Targestar SA microbubbles (Targeson, San Diego, CA, USA) labeled with α_νβ₃-integrin and P-selectin antibodies. Targestar SA microbubbles labeled with IgG-labeled were used as control. First, peritumoral injection of Sonazoid contrast agent (GE Healthcare, Oslo, Norway) was performed to detect SLNs. After that, dual-targeted and IGG control Targestar SA microbubbles were injected intravenously with a 30-min interval between injections. Labeled Targestar SA microbubbles were allowed to circulate for 4 min to enable binding. After that, two sets of image clips were acquired several seconds before and after a high-power destruction sequence. The mean intensity difference pre- to post-bubble destruction within the region of interest placed over SLN was calculated as a relative measure of targeted microbubble contrast agent retention. This process was repeated for non-SLNs as controls. All lymph nodes evaluated on imaging were surgically removed and histologically examined for presence of metastatic involvement.

RESULTS

A total of 43 lymph nodes (25 SLNs and 18 non-SLNs) were included in the analysis with 18 SLNs demonstrating metastatic involvement greater than 5 % on histology. All non-SLNs were benign. The mean intensity (± SD) of the dual-targeted microbubbles for metastatic SLNs was significantly higher than that of benign LNs (18.05 ± 19.11 vs. 3.30 ± 6.65 AU; p = 0.0008), while IgG-labeled control microbubbles demonstrated no difference in retained contrast intensity between metastatic and benign lymph nodes (0.39 ± 1.14 vs. 0.03 ± 0.24 AU; p = 0.14).

CONCLUSIONS

The results indicate that dual-targeted microbubbles labeled with P-selectin and α_νβ₃-integrin antibodies may aid in detecting metastatic involvement in SLNs of melanoma.

Molecular Ultrasound Imaging of the Spinal Cord for the Detection of Acute Inflammation

Molecular ultrasound imaging provides the ability to detect physiologic processes non-invasively by targeting a wide variety of biological markers in vivo. The current study investigates the novel application of molecular ultrasound imaging for the detection of neural inflammation. Using a murine model with acutely injured spinal cords (n=31), subjects were divided into four groups, each being administered ultrasound contrast microbubbles bearing antibodies against various known inflammatory molecules (P-selectin, vascular cell adhesion protein 1 [VCAM-1], intercellular adhesion molecule 1 [ICAM-1], and isotype control) during molecular ultrasound imaging. Upon administration of the targeted contrast agent, ultrasound imaging of the injured spinal cord was performed at 40MHz for seven minutes, followed by a bursting pulse. We observed significantly enhanced signals from contrast targeted to P-selectin and VCAM-1, using a variety of outcome measures. These findings provide preclinical evidence that molecular ultrasound imaging could be a useful tool in the detection of neural inflammation.

Quantification of Endothelial αvβ3 Expression with High-Frequency Ultrasound and Targeted Microbubbles: In Vitro and In Vivo Studies

Angiogenesis is a critical feature of plaque development in atherosclerosis and might play a key role in both the initiation and later rupture of plaques. The precursory molecular or cellular pro-angiogenic events that initiate plaque growth and that ultimately contribute to plaque instability, however, cannot be detected directly with any current diagnostic modality. This study was designed to investigate the feasibility of ultrasound molecular imaging of endothelial αvβ3 expression in vitro and in vivo using αvβ3-targeted ultrasound contrast agents (UCAs). In the in vitro study, αvβ3 expression was confirmed by immunofluorescence in a murine endothelial cell line and detected using the targeted UCA and ultrasound imaging at 18-MHz transmit frequency. In the in vivo study, expression of endothelial αvβ3 integrin in murine carotid artery vessels and microvessels of the salivary gland was quantified using targeted UCA and high-frequency ultrasound in seven animals. Our results indicated that endothelial αvβ3 expression was significantly higher in the carotid arterial wall containing atherosclerotic lesions than in arterial segments without any lesions. We also found that the salivary gland can be used as an internal positive control for successful binding of targeted UCA to αvβ3 integrin. In conclusion, αvβ3-targeted UCA allows non-invasive assessment of the expression levels of αvβ3 on the vascular endothelium and may provide potential insights into early atherosclerotic plaque detection and treatment monitoring.

RGD-Targeted Ultrasound Contrast Agent for Longitudinal Assessment of Hep-2 Tumor Angiogenesis In Vivo

OBJECTIVE

To prepare arginine-glycine-aspartate (RGD)-targeted ultrasound contrast microbubbles (MBs) and explore the feasibility of their use in assessing dynamic changes in αvβ3 integrin expression in a murine model of tumor angiogenesis.

METHODS

RGD peptides were conjugated to the surfaces of microbubbles via biotin-avidin linkage. Microbubbles bearing RADfK peptides were prepared as controls. The RGD-MBs were characterized using an Accusizer 780 and optical microscopy. The binding specificity of the RGD-MBs for ανβ3-expressing endothelial cells (bEnd.3) was demonstrated in vitro by a competitive inhibition experiment. In an in vivo study, mice bearing tumors of three different stages were intravenously injected with RGD-MBs and subjected to targeted, contrast-enhanced, high-frequency ultrasound. Subsequently, tumors were harvested and sectioned for immunofluorescence analysis of ανβ3 expression.

RESULTS

The mean size of the RGD-MBs was 2.36 ± 1.7 μm. The RGD-MBs showed significantly higher adhesion levels to bEnd.3 cells compared to control MBs (P < 0.01). There was rarely binding of RGD-MBs to αvβ3-negative MCF-7 cells. Adhesion of the RGD-MBs to the bEnd.3 cells was significantly inhibited following treatment with anti-alpha(v) antibodies. The quantitative acoustic video intensity for high-frequency, contrast-enhanced ultrasound imaging of subcutaneous human laryngeal carcinoma (Hep-2) tumor xenografts was significantly higher in small tumors (19.89 ± 2.49) than in medium tumors (11.25 ± 2.23) and large tumors (3.38 ± 0.67) (P < 0.01).

CONCLUSIONS

RGD-MBs enable noninvasive in vivo visualization of changes in tumor angiogenesis during tumor growth in subcutaneous cancer xenografts.

Sulfonated Polyethylenimine for Photosensitizer Conjugation and Targeting

Polysulfonated macromolecules are known to bind selectins, adhesion membrane proteins which are broadly implicated in inflammation. Commercially available branched polyethylenimine (PEI) was reacted with chlorosulfonic acid to generate sulfonated PEI with varying degrees of sulfonation. Remaining unreacted amine groups were then used for straightforward conjugation with pyropheophoribide-a, a near-infrared photosensitizer. Photosensitizer-labeled sulfonated PEI conjugates inhibited blood coagulation and were demonstrated to specifically bind to cells genetically programmed to overexpress L-selectin (CD62L) or P-selectin (CD62P). In vitro, following targeting, selectin-expressing cells could be destroyed via photodynamic therapy.

Quantification of bound microbubbles in ultrasound molecular imaging

Molecular markers associated with diseases can be visualized and quantified noninvasively with targeted ultrasound contrast agent (t-UCA) consisting of microbubbles (MBs) that can bind to specific molecular targets. Techniques used for quantifying t-UCA assume that all unbound MBs are taken out of the blood pool few minutes after injection and only MBs bound to the molecular markers remain. However, differences in physiology, diseases, and experimental conditions can increase the longevity of unbound MBs. In such conditions, unbound MBs will falsely be quantified as bound MBs. We have developed a novel technique to distinguish and classify bound from unbound MBs. In the post-processing steps, first, tissue motion was compensated using block-matching (BM) techniques. To preserve only stationary contrast signals, a minimum intensity projection (MinIP) or 20th-percentile intensity projection (PerIP) was applied. The after-flash MinIP or PerIP was subtracted from the before-flash MinIP or PerIP. In this way, tissue artifacts in contrast images were suppressed. In the next step, bound MB candidates were detected. Finally, detected objects were tracked to classify the candidates as unbound or bound MBs based on their displacement. This technique was validated in vitro, followed by two in vivo experiments in mice. Tumors (n = 2) and salivary glands of hypercholesterolemic mice (n = 8) were imaged using a commercially available scanner. Boluses of 100 μL of a commercially available t-UCA targeted to angiogenesis markers and untargeted control UCA were injected separately. Our results show considerable reduction in misclassification of unbound MBs as bound ones. Using our method, the ratio of bound MBs in salivary gland for images with targeted UCA versus control UCA was improved by up to two times compared with unprocessed images.

Lymphatic imaging: focus on imaging probes

In view of the importance of sentinel lymph nodes (SLNs) in tumor staging and patient management, sensitive and accurate imaging of SLNs has been intensively explored. Along with the advance of the imaging technology, various contrast agents have been developed for lymphatic imaging. In this review, the lymph node imaging agents were summarized into three groups: tumor targeting agents, lymphatic targeting agents and lymphatic mapping agents. Tumor targeting agents are used to detect metastatic tumor tissue within LNs, lymphatic targeting agents aim to visualize lymphatic vessels and lymphangionesis, while lymphatic mapping agents are mainly for SLN detection during surgery after local administration. Coupled with various signal emitters, these imaging agents work with single or multiple imaging modalities to provide a valuable way to evaluate the location and metastatic status of SLNs.

Lymphatic system: a prospective area for advanced targeting of particulate drug carriers

INTRODUCTION

The lymphatic system has a critical role in the immune system's recognition and response to disease and it is an additional circulatory system throughout the entire body. Extensive multidisciplinary investigations have been carried out in the area of lymphatic delivery, and lymphatic targeting has attracted a lot of attention for providing preferential chemotherapy and improving bioavailability of drugs that undergo hepatic first-pass metabolism.

AREAS COVERED

This review focuses on progress in the field of lymphatic therapeutics and diagnosis. Moreover, the anatomy and physiology of the lymphatic system, particulate drug carriers and different physicochemical parameters of both modified and unmodified particulate drug carriers and their effect on lymphatic targeting are addressed.

EXPERT OPINION

Particulate drug carriers have encouraged lymphatic targeting, but there are still challenges in targeting drugs and bioactives to specific sites, maintaining desired action and crossing all the physiological barriers. Lymphatic therapy using drug-encapsulated lipid carriers, especially liposomes and solid lipid nanoparticles, emerges as a new technology to provide better penetration into the lymphatics where residual disease exists. Size is the most important criteria when designing nanocarriers for targeting lymphatic vessels as the transportation of these particles into lymphatic vessels is size dependent. By increasing our understanding of lymphatic transport and uptake, and the role of lymphatics in various diseases, we can design new therapeutics for effective disease control.

Delivery Systems for Lymphatic Targeting

The lymphatic system has a critical role in the immune system’s recognition and response to disease, and it is an additional circulatory system throughout the entire body. Most solid cancers primarily spread from the main site via the tumour’s surrounding lymphatics before haematological dissemination. Targeting drugs to lymphatic system is quite complicated because of its intricate physiology. Therefore, it tends to be an important target for developing novel therapeutics. Currently, nanocarriers have encouraged the lymphatic targeting, but still there are challenges of locating drugs and bioactives to specific sites, maintaining desired action and crossing all the physiological barriers. Lymphatic therapy using drug-encapsulated colloidal carriers especially liposomes and solid lipid nanoparticles emerges as a new technology to provide better penetration into the lymphatics where residual disease exists. Optimising the proper procedure, selecting the proper delivery route and target area and making use of surface engineering tool, better carrier for lymphotropic system can be achieved. Thus, new methods of delivering drugs and other carriers to lymph nodes are currently under investigation.

Ultrasound-mediated drug/gene delivery in solid tumor treatment

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

Ultrasonic imaging of endothelial CD81 expression using CD81-targeted contrast agents in in vitro and in vivo studies

This study is designed to investigate the feasibility for molecular imaging of endothelial CD81 expression in vitro and in vivo using the CD81-targeted ultrasound contrast agents (UCA). In the in vitro study, murine bEnd.3 cells were stimulated with phenazine methosulfate (PMS), an oxidative stress inducer. Changes in CD81 expression after stimulation were confirmed by Western blotting, tracked by using the targeted UCA and further imaged under ultrasound imaging system with 5 MHz transmit frequency. In the in vivo study, expression of endothelial CD81 proteins in murine carotid artery vessels was studied using high-frequency ultrasound system with 40 MHz transmit frequency. Our results showed that endothelial CD81 expression was gradually up-regulated with the increase of PMS concentration. Correspondingly, the accumulation of targeted UCA was gradually improved and could be inhibited significantly upon addition of free anti-CD81 antibodies. The mean video intensity (grey-level) of stimulated cells and vessels from backscatter of the CD81-targeted UCA was 17.2 (interquartile range [IQR] 15.4-19.8) and 27.2 (IQR 22.4-29.8), significantly greater than that of non-stimulated cells with 9.0 (IQR 8.6-10.8) (p < 0.01) and non-stimulated vessels with 11.3 (IQR 10.4-13.2) (p < 0.01), respectively. In conclusion, CD81-targeted UCA allows noninvasive assessment of the expression levels of CD81 on the vascular endothelium and may provide potential insights into early atherosclerotic plaque detection and treatment monitoring.

Molecular imaging of vasa vasorum neovascularization via DEspR-targeted contrast-enhanced ultrasound micro-imaging in transgenic atherosclerosis rat model

PURPOSE

Given that carotid vasa vasorum neovascularization is associated with increased risk for stroke and cardiac events, the present in vivo study was designed to investigate molecular imaging of carotid artery vasa vasorum neovascularization via target-specific contrast-enhanced ultrasound (CEU) micro-imaging.

PROCEDURES

Molecular imaging was performed in male transgenic rats with carotid artery disease and non-transgenic controls using dual endothelin1/VEGFsp receptor (DEspR)-targeted microbubbles (MB(D)) and the Vevo770 micro-imaging system and CEU imaging software.

RESULTS

DEspR-targeted CEU-positive imaging exhibited significantly higher contrast intensity signal (CIS)-levels and pre-/post-destruction CIS-differences in seven of 13 transgenic rats, in contrast to significantly lower CIS-levels and differences in control isotype-targeted microbubble (MB(C))-CEU imaging (n = 8) and in MB(D) CEU-imaging of five non-transgenic control rats (P < 0.0001). Ex vivo immunofluorescence analysis demonstrated binding of MB(D) to DEspR-positive endothelial cells; and association of DEspR-targeted increased contrast intensity signals with DEspR expression in vasa vasorum neovessel and intimal lesions. In vitro analysis demonstrated dose-dependent binding of MB(D) to DEspR-positive human endothelial cells with increasing %cells bound and number of MB(D) per cell, in contrast to MB(C) or non-labeled microbubbles (P < 0.0001).

CONCLUSION

In vivo DEspR-targeted molecular imaging detected increased DEspR-expression in carotid artery lesions and in expanded vasa vasorum neovessels in transgenic rats with carotid artery disease. Future studies are needed to determine predictive value for stroke or heart disease in this transgenic atherosclerosis rat model and translational applications.

Non-invasive assessment for endothelial CD81 expression via targeted microbubbles

The aim of our study was to investigate the use of targeted ultrasound microbubbles (MBs) for molecular imaging of murine endothelial CD81 expression. In the study, the anti-CD81-coated MBs was successfully prepared and characterizated. Murine bEnd.3 cells were stimulated with phenazine methosulfate (PMS) to induce the up-regulation of CD81 expression. Changes in CD81 expression after stimulation were tracked with anti-CD81-coated MBs and imaged by using SONIX RP ultrasound imaging system. Our results showed that endothelial CD81 expression was gradually up-regulated with the increase of PMS concentration. Correspondingly, the accumulation of targeted MBs was also gradually improved and could be inhibited competitively. The mean video intensity of stimulated cells from backscatter of the CD81-targeted MBs was significantly higher than that of the non-stimulated control (mean ± SD: 17.5 ± 3.6 versus 12.1 ± 2.9 pixel intensity; P < 0.01). In conclusion, CD81-targeted MBs allows non-invasive assessment of the expression levels of CD81 on the bEnd.3 cells and may provide potential insights into early atherosclerotic plaque detection and treatment monitoring using molecular ultrasound imaging.

Preclinical lymphatic imaging

Noninvasive in vivo imaging of lymphatic vessels and lymphatic nodes is expected to fulfill the purpose of analyzing lymphatic vessels and their function, understanding molecular mechanisms of lymphangiogenesis and lymphatic spread of tumors, and utilizing lymphatic molecular markers as a prognostic or diagnostic indicator. In this review, we provide a comprehensive summary of in vivo imaging modalities for detecting lymphatic vessels, lymphatic drainage, and lymphatic nodes, which include conventional lymphatic imaging techniques such as dyes and radionuclide scintigraphy as well as novel techniques for lymphatic imaging such as optical imaging, computed tomography, magnetic resonance imaging, ultrasound, positron emission tomography using lymphatic biomarkers, photoacoustic imaging, and combinations of multiple modalities. The field of lymphatic imaging is ever evolving, and technological advances, combined with the development of new contrast agents, continue to improve the research of lymphatic vascular system in health and disease states as well as to improve the accuracy of diagnosis in the relevant diseases.

Advanced characterization and refinement of poly N-butyl cyanoacrylate microbubbles for ultrasound imaging

We aimed to develop and characterize poly n-butylcyanoacrylate (PBCA) microbubbles (MBs) with a narrow size distribution. MBs were synthesized by established emulsion polymerization techniques, size-isolated by centrifugation and functionalized for molecular imaging by coating their surface with streptavidin. The physical and acoustic properties of the parent solution, different-size isolated populations and functionalized MBs were measured and compared. As expected from negative zeta potentials at pH 7, cryo scanning electron microscopy showed no aggregates. In phantoms MBs were destructible at high mechanical indices and showed a frequency-dependent attenuation and backscattering. The MBs were stable in solution for more than 14 weeks and could be lyophilized without major damage. However, for injection, small needle diameters and high injection rates are shown to be critical because both lead to MB destruction. In summary, when being handled correctly, size-isolated PBCA MBs are promising candidates for preclinical functional and molecular ultrasound imaging.

Polymeric microbubbles for ultrasonic molecular imaging and targeted therapeutics

Gas-filled microbubbles ultrasound agent have received wide attention, not only because they can improve ultrasound signals, but also they can be used as drug/gene carriers. Among all types of microbubbles fabricated by different membrane materials and core gases, polymer-shell microbubbles are highly promising. Polymeric microbubbles are more stable than other soft shell microbubbles in vivo. Under destructive ultrasound, polymer-stabilized microbubbles disintegrate and emit a strong non-linear signal, which enables ultrasound imaging with superior sensitivity. Except for ultrasound imaging, polymeric microbubbles could also be applied as drug/gene-delivery system. The thick polymeric shells allow loading a large amount of drugs. Meanwhile, site-specific targeting and controlled drug release in the area of interest can be realized through chemical and physical modification. In this review, we highlight some of the recent examples on polymeric microbubbles and their applications in ultrasound molecular imaging and drug delivery.

Molecular ultrasound imaging and its potential for paediatric radiology

US is a low-cost, real-time imaging modality that is the most used diagnostic tool in paediatric radiology. Reasons include the improved US image quality in children as compared to adults and the demand for avoiding X-rays as much as possible because children are more sensitive to radiation than adults. Stabilized microbubbles have been approved as US contrast agents for adults and show great potential in improving the diagnostic accuracy for many diseases. Initial studies show that in paediatric radiology contrast-enhanced US could also be beneficial for more than just the diagnosis of vesicoureteral reflux, if US contrast agents were approved for children. Molecular US imaging utilizes microbubbles conjugated to biomolecules that target intravascular disease-specific molecules. Many preclinical studies show that molecular US imaging is a highly sensitive tool to detect neovascularisation, inflammation and cardiovascular diseases. Its main advantages are the higher informative value, the longer persistence of the label at the target lesion and the chance to work with lower contrast agent dosages. Now, clinical translation of molecular US appears at the horizon. This review article reports on the current status of molecular US imaging and discusses its potential for paediatric radiology.

[Imaging of molecular structures of breasts with new sonography techniques]

Sonography has become one of the most important imaging methods in breast diagnostics. Through the development of high-frequency transducers and the use of ultrasound contrast agents, the number of indications for sonography of the breast has continued to increase in recent years. Visualization of very small vessels under 100 µm enables sensitive detection and quantification of tissue perfusion. Thus, breast ultrasound can play an essential role in answering questions about certain pathologies. Further technical advances, such as automated breast ultrasound systems, provide an essential step for standardization of investigations. Targeted ultrasound is a new important development of this technique. Specific markers which are conjugated with the surface of contrast medium microspheres allow targeted molecular endothelial structures to be selectively visualized and quantified. These developments will strengthen the role of sonography in the future as a non-invasive and easy to use method.

Molecular sonography with targeted microbubbles: current investigations and potential applications

Sonography using targeted microbubbles affords a variety of diagnostic and potentially therapeutic clinical applications. It provides a whole new world of functional information at the cellular and molecular level. This information can then be used to diagnose and possibly prevent diseases at early stages as well as devise therapeutic strategies at the molecular level. It is also useful in monitoring tumor response to therapy and devising treatment timing and plans based on the molecular state of an individual's health. Moreover, targeted microbubble-enhanced sonography has several advantages over other imaging modalities, including widespread availability, low cost, fast acquisition times, and lack of radiation risk. These traits are likely to advance it as one of the imaging methods of choice in future clinical trials examining the impact of molecular imaging on treatment outcome. This review describes the fundamental concepts of targeted microbubble-enhanced sonography as well as its potential clinical applications.

Progress in the development of ultrasound-mediated gene delivery systems utilizing nano- and microbubbles

Recently, ultrasound-mediated gene delivery with nano- and microbubbles was developed as a novel non-viral vector system. In this gene delivery system, microstreams and microjets, which are induced by disruption of nano/microbubbles exposed to ultrasound, are used as the driving force to transfer genes into cells by opening transient pores in the cell membrane. This system can directly deliver plasmid DNA and siRNA into cytosol without endocytosis pathway. Therefore, these genes are able to escape from degradation in lysosome and result in enhancing the efficiency of gene expression. In addition, it is expected that ultrasound-mediated gene delivery using nano/microbubbles would be a system to establish non-invasive and tissue specific gene expression because ultrasound can transdermally expose to target tissues and organs. This review focuses on the current ultrasound-mediated gene delivery system using nano/microbubbles. We discuss about the feasibility of this gene delivery system as novel non-viral vector system.

BR55: a lipopeptide-based VEGFR2-targeted ultrasound contrast agent for molecular imaging of angiogenesis

OBJECTIVES

BR55, an ultrasound contrast agent functionalized with a heterodimer peptide targeting the vascular endothelial growth factor receptor 2 (VEGFR2), was evaluated in vitro and in vivo, demonstrating its potential for specific tumor detection.

MATERIALS AND METHODS

The targeted contrast agent was prepared by incorporation of a biospecific lipopeptide into the microbubble membrane. Experiments were performed in vitro to demonstrate the binding capacities of BR55 microbubbles on immobilized receptor proteins and on various endothelial or transfected cells expressing VEGFR2. The performance of BR55 microbubbles was compared with that of streptavidin-conjugated microbubbles targeted to the same receptor by coupling them to a biotinylated antibody. The specificity of BR55 binding to human and mouse endothelial cells was determined in competition experiments with the free lipopeptide, vascular endothelial growth factor (VEGF), or a VEGFR2-specific antibody. Molecular ultrasound imaging of VEGFR2 was performed in an orthotopic breast tumor model in rats using a nondestructive, contrast-specific imaging mode.

RESULTS

BR55 was shown to bind specifically to the immobilized recombinant VEGFR2 under flow (dynamic conditions). BR55 accumulation on the target over time was similar to that of microbubbles bearing a specific antibody. BR55 avidly bound to cells expressing VEGFR2, and the pattern of microbubble distribution was correlated with the pattern of receptor expression determined by immunocytochemistry. The binding of targeted microbubbles on cells was competed off by an excess of free lipopeptide, the natural ligand (VEGF) and by a VEGFR2-specific antibody (P < 0.001). Although selected for the human receptor, the VEGFR2-binding lipopeptide was also shown to recognize the rodent receptor. Tumor perfusion was assessed during the vascular phase of BR55, and then the malignant lesion was highlighted by specific accumulation of the targeted microbubbles on tumoral endothelium. The presence of VEGFR2 was confirmed by immunofluorescence staining of tumor cryosections.

CONCLUSIONS

VEGFR2-targeted ultrasound contrast agents such as BR55 will likely prove useful in human for the early detection of tumors as well as for the assessment of response to specific treatments.

Albumin-based nanoparticles as magnetic resonance contrast agents: I. Concept, first syntheses and characterisation

To develop a platform for molecular magnetic resonance imaging, we prepared gadolinium-bearing albumin-polylactic acid nanoparticles in the size range 20-40 nm diameter. Iterative cycles of design and testing upscaled the synthesis procedures to gram amounts for physicochemical characterisation and for pharmacokinetic testing. Morphological analyses showed that the nanoparticles were spheroidal with rough surfaces. Particle sizes were measured by direct transmission electron microscopical measurements from negatively contrasted preparations, and by use of photon correlation spectroscopy; the two methods each documented nanoparticle sizes less than 100 nm and generally 10-40 nm diameter, though with significant intrabatch and interbatch variability. The particles' charge sufficed to hold them in suspension. HSA retained its tertiary structure in the particles. The nanoparticles were stable against turbulent flow conditions and against heat, though not against detergents. MRI imaging of liquid columns was possible at nanoparticle concentrations below 10 mg/ml. The particles were non-cytotoxic, non-thrombogenic and non-immunogenic in a range of assay systems developed for toxicity testing of nanoparticles. They were micellar prior to lyophilisation, but loosely structured aggregated masses after lyophilisation and subsequent resuspension. These nanoparticles provide a platform for further development, based on non-toxic materials of low immunogenicity already in clinical use, not expensive, and synthesized using methods which can be upscaled for industrial production.

Regional nodal staging for early stage colon cancer in the era of endoscopic resection and N.O.T.E.S

Advanced endoscopic technologies and techniques capable of providing localized resection of colonic primaries are entering clinical practice. As much as Natural Orifice Transluminal Endoscopic Surgery (N.O.T.E.S.) may ultimately provide for transmural resection with narrow margins, intraluminal techniques such as endoscopic submucosal resection can now effect excision of early stage tumors from within the colon. However, the limit on the application of these approaches is oncological providence as current staging requires en bloc mesenteric resection in every case to ensure that adequate nodal assessment is assured. Furthermore, this requirement is also a limiting factor on the advance of innovative procedures such as Single-Incision Laparoscopic Surgery and N.O.T.E.S.-hybrid techniques as these approaches, while likely adept at the definitive management of the primary, have limitations regarding their ability to provide full base mesenteric resection (due mostly to constraints on retraction capacity as well as operating field space and exposure). Therefore a means to accurately and efficiently identify those patients who are truly node negative (and so in whom radical mesenteric lymphadenectomy could be avoided) would allow all of these techniques to advance with a clear focus on address of the primary. This review analyses the current state of the art of regional staging in the colonic mesentery in place of formal lymphadenectomy. It includes deliberation of both preoperative non-invasive testing as well as novel means of employing N.O.T.E.S. approaches to allow direct determination of lymph node status (in particular that of sentinel nodes) by either rapid histopathological examination or by emerging technologies such as Optical Coherence Tomography that may provide optical or 'virtual' biopsy.

New horizons for imaging lymphatic function

In this review, we provide a comprehensive summary of noninvasive imaging modalities used clinically for the diagnosis of lymphatic diseases, new imaging agents for assessing lymphatic architecture and cancer status of lymph nodes, and emerging near-infrared (NIR) fluorescent optical imaging technologies and agents for functional lymphatic imaging. Given the promise of NIR optical imaging, we provide example results of functional lymphatic imaging in mice, swine, and humans, showing the ability of this technology to quantify lymph velocity and frequencies of propulsion resulting from the contractility of lymphatic structures.

Microbubbles in ultrasound-triggered drug and gene delivery

Ultrasound contrast agents, in the form of gas-filled microbubbles, are becoming popular in perfusion monitoring; they are employed as molecular imaging agents. Microbubbles are manufactured from biocompatible materials, they can be injected intravenously, and some are approved for clinical use. Microbubbles can be destroyed by ultrasound irradiation. This destruction phenomenon can be applied to targeted drug delivery and enhancement of drug action. The ultrasonic field can be focused at the target tissues and organs; thus, selectivity of the treatment can be improved, reducing undesirable side effects. Microbubbles enhance ultrasound energy deposition in the tissues and serve as cavitation nuclei, increasing intracellular drug delivery. DNA delivery and successful tissue transfection are observed in the areas of the body where ultrasound is applied after intravascular administration of microbubbles and plasmid DNA. Accelerated blood clot dissolution in the areas of insonation by cooperative action of thrombolytic agents and microbubbles is demonstrated in several clinical trials.

Noninvasive quantitative imaging of lymph function in mice

BACKGROUND

Whereas functional lymph imaging in rodents is imperative for drug discovery of lymph therapeutics, noninvasive imaging of propulsive lymph function in rodents has not been reported previously. Herein, we present a noninvasive and rapid approach to measure lymphatic function in a rodent model using a near-infrared (NIR) dye to minimize background autofluorescence and maximize tissue penetration.

METHODS AND RESULTS

Mice were dynamically imaged following intradermal (i.d.) injection of 2 to 10 microL of 1.3 mM of indocyanine green (IC-Green) into the tail and the limb. Our results demonstrate the ability to image the IC-Green trafficking from the lymph plexus, through lymph vessels and lymphangions, to the ischial nodes in the tail, and to the axillary nodes in the limb. Our results show that lymph flow velocity from the propelled IC-Green "packet" in the lymph vessels in the tail ranged from 1.3 to 3.9 mm/s and the fluorescence intensity peaks repeated on an average of every 51.3 +/- 17.4 seconds in five animals. While pulsatile lymph flow was detected in the deep lymph vessels, lymph propulsion was not visualized in the superficial lymphatic network in the tail. In axillary lymphatic imaging, propulsive lymph flow was also detected. The intensity profile shows that the lymph flow velocity ranged from 0.28 to 1.35 mm/s at a frequency ranging from 0.72 to 11.1 pulses per minute in five animals.

CONCLUSIONS

Our study demonstrates the ability to noninvasively and quantitatively image propulsive lymph flow, which could provide a new method to investigate lymph function and its change in response to potential therapeutics.

Diffusion-weighted whole-body imaging with background body signal suppression (DWIBS): features and potential applications in oncology

Diffusion-weighted magnetic resonance imaging (DWI) provides functional information and can be used for the detection and characterization of pathologic processes, including malignant tumors. The recently introduced concept of "diffusion-weighted whole-body imaging with background body signal suppression" (DWIBS) now allows acquisition of volumetric diffusion-weighted images of the entire body. This new concept has unique features different from conventional DWI and may play an important role in whole-body oncological imaging. This review describes and illustrates the basics of DWI, the features of DWIBS, and its potential applications in oncology.

Molecular profiling of angiogenesis with targeted ultrasound imaging: early assessment of antiangiogenic therapy effects

Molecular ultrasound is capable of elucidating the expression of angiogenic markers in vivo. However, the capability of the method for volumetric "multitarget quantification" and for the assessment of antiangiogenic therapy response has rather been investigated. Therefore, we generated cyanoacrylate microbubbles linked to vascular endothelial growth factor receptor 2 (VEGFR2) and alphavbeta3 integrin binding ligands and quantified their accumulation in squamous cell carcinoma xenografts (HaCaT-ras-A-5RT3) in mice with the quantitative volumetric ultrasound scanning technique, sensitive particle acoustic quantification. Specificity of VEGFR2 and alphavbeta3 integrin binding microbubbles was shown, and changes in marker expression during matrix metalloproteinase inhibitor treatment were investigated. In tumors, accumulation of targeted microbubbles was significantly higher compared with nonspecific ones and could be inhibited competitively by addition of the free ligand in excess. Also, multimarker imaging could successfully be done during the same imaging session. Molecular ultrasound further indicated a significant increase of VEGFR2 and alphavbeta3 integrin expression during tumor growth and a considerable decrease in both marker densities after matrix metalloproteinase inhibitor treatment. Histologic data suggested that the increasing VEGFR2 and alphavbeta3 integrin concentrations in tumors during growth are related to an up-regulation of its expression by the endothelial cells, whereas its decrease under therapy is more related to the decreasing relative vessel density. In conclusion, targeted ultrasound appears feasible for the longitudinal molecular profiling of tumor angiogenesis and for the sensitive assessment of therapy effects in vivo.

Pharmacodynamics of streptavidin-coated cyanoacrylate microbubbles designed for molecular ultrasound imaging

OBJECTIVES

To assess the pharmacodynamic behavior of cyanoacrylate, streptavidin-coated microbubbles (MBs) and to investigate their suitability for molecular ultrasound imaging.

MATERIALS AND METHODS

Biodistribution of MBs was analyzed in tumor-bearing mice using gamma-counting, immunohistochemistry, flow cytometry, and ultrasound. Further, vascular endothelial growth factor receptor 2-antibody coupled MBs were used to image tumor neovasculature.

RESULTS

After 1 minute >90% of MBs were cleared from the blood and pooled in the lungs, liver, and spleen. Subsequently, within 1 hour a decent reincrease of MB-concentration was observed in the blood. The remaining MBs were removed by liver and spleen macrophages. About 30% of the phagocytosed MBs were intact after 48 hours. Shell fragments were found in the kidneys only. No relevant MB-accumulation was observed in tumors. In contrast, vascular endothelial growth factor receptor 2-specific MBs accumulated significantly within the tumor vasculature (P < 0.05).

CONCLUSIONS

The pharmacokinetic behavior of streptavidin-coated cyanoacrylate MBs has been studied. In this context, the low amount of MBs in tumors after >5 minutes is beneficial for specific targeting of angiogenesis.

Ultrasound contrast agents for molecular imaging

The successful use of targeted ultrasound contrast agents (USCAs) for qualitative US-based imaging has been shown by several academic and industrial research groups in different animal models. Furthermore, techniques have been developed that enable the in-vivo quantification of targeted microbubbles (MBs). USCAs for quantitative functional and molecular imaging in small animals can be used for a more detailed characterization of new and established disease models and provide quantitative biological insights into the interaction between drug and target or target and disease in living animals. The advantages of such contrast agents in research and development are seen to be as follows: new functional or molecular findings in the complex biology of disease development, these findings can lead to new therapeutic strategies or drug candidates, a better understanding of the treatment effects of new and existing drug candidates, a more sensitive and specific characterization of early treatment effects in living animals, identification of in-vivo biomarkers for translational medicine. Further outcomes are seen in speeding up the evaluation of new drug compounds and in a reduction of the number of animals used for biomedical research.

Preparing the "soil": the primary tumor induces vasculature reorganization in the sentinel lymph node before the arrival of metastatic cancer cells

Sentinel lymph node (SLN) metastasis is the first step in the spreading of cancer in many malignancies. Tumor-reactive lymphadenopathy in SLNs has been observed for decades, but alterations of the lymphatic channels and vasculature in these nodes before the arrival of metastatic tumor cells remain unexplored. Using animal models, we show here that, before the establishment of metastasis in the SLN, there are reorganizations of the lymphatic channels and the vasculature. The node becomes a functional blood vessel-enriched and lymph vessel/sinus-enriched organ before metastasis. The enlargement of the lymph sinuses is correlated with the primary tumor weight. The newly emerged functional blood vessels develop from high endothelial venules (HEV), in which the proliferation rate of the endothelial cells is also significantly increased. Similar alterations of the HEVs are also characterized in the axillary lymph nodes from human breast cancer patients without the evidence of metastasis. These findings support the hypothesis that modification of the microenvironment for a secondary tumor (i.e., vasculature reorganization in the SLN) can be initiated by a primary tumor before and independent of the physical presence of metastatic cancer cells.

Sentinel node detection in breast cancer using contrast-enhanced sonography with 25% albumin--Initial clinical experience

PURPOSE

To determine the clinical usefulness of a sentinel lymph node (SLN) identification technique using contrast-enhanced sonography (CEUS) with 25% albumin.

METHODS

The subjects were 23 women with breast cancer. Each was injected subcutaneously with 5 ml of 25% albumin solution as a negative contrast agent directly superficial to the breast tumor. The area was massaged, and the inferior axillary hairline was examined continuously using gray-scale sonography with a 7.5- or 10-MHz transducer. Any contrast-enhanced lymph node was considered a CEUS-detected SLN, was differentiated from other level I and II nodes, and was resected and pathologically assessed.

RESULTS

In all 23 patients, 1 or 2 CEUS-detected SLNs (mean, 1.3 SLNs) were identified. Their sizes ranged from 5 mm to 25 mm (mean, 11.3 mm), and their depths (from the skin surface) ranged from 5mm to 20 mm (mean, 12.6 mm). Pathologic examination revealed a metastasis in 5 of the 23 patients, all in CEUS-detected SLNs.

CONCLUSION

In a clinical study using CEUS with 25% albumin, contrast-enhanced nodes were identified in all subjects. The pathologic findings suggested that any metastatic nodes observed were SLNs, indicating that this technique may represent a new modality for SLN identification.

The influence of acoustic transmit parameters on the destruction of contrast microbubbles in vitro

In this study, the destruction of the contrast agent Sonazoid (GE Healthcare, Oslo, Norway) was measured in vitro as a function of centre frequency (2-3 MHz), acoustic amplitude (0.66-1.6 MPa), pulse length (2-16 cycles) and PRF (0.5-8.0 kHz). Up to 82% of microbubbles were destroyed after exposure to a single 1.6 MPa acoustic pulse (16 cycles, 2.5 MHz and PRF of 1.0 kHz), while at a low amplitude of 0.66 MPa, fractional destruction increased gradually from 0 to 40% after exposure to 9 (identical) pulses. Fractional destruction increased from approximately 8 to 66% as pulse length was changed from 2 to 16 cycles following exposure to a single 2.5 MHz, 1.3 MPa pulse. As the PRF was increased from 0.5 to 8.0 kHz, shorter exposure time intervals (from 4.8 to 1.2 ms) were needed to achieve the same fractional destruction of 80%. Conversely, as the transmit frequency was increased from 2 to 3 MHz the fractional destruction decreased (by more than half within the first 3 pulses). The influence of changes in acoustic pressure and duty cycle on the destruction of Sonazoid microbubbles was highly statistically significant (p < or = 0.01) with a threshold around 0.67 MPa for a duty cycle of 0.0064. In conclusion, the fractional destruction increases with the duty cycle and the acoustic pressure amplitude and decreases with ultrasonic transmit frequency. Better understanding of the influence of the ultrasound transmit parameters on the destruction of contrast microbubbles should help improve existing contrast-assisted imaging modalities and may help develop new techniques for better use of contrast agents.

Encapsulated ultrasound microbubbles: Therapeutic application in drug/gene delivery

Encapsulated gas microbubbles are well known as ultrasound contrast agents for medical ultrasound imaging. Nonetheless, not only do these microbubbles help to image, but they can also be used as drug/gene carriers. The microbubbles as drug/gene carriers have an average size less than that of red blood cells, i.e. they are capable of penetrating even into the small blood capillaries and releasing drug and genes under the action of ultrasound field. The application of ultrasound and microbubbles to targeted drug and gene delivery has been the subject of intense experimental research. Under exposure of sufficiently high-amplitude ultrasound, these targeted microbubbles would rupture, spewing drugs or genes, which are contained in its encapsulating layer, to targeted cells or tissues. Recently, targeting ligands are attached to the surface of the microbubbles (i.e. targeted-microbubbles), which have been widely used in cardiovascular system and tumor diagnosis and therapy. In this paper, the characterization of novel targeted ultrasonic contrast agents or microbubbles and their potential applications in drug delivery or gene therapy are reviewed.

Microbubble contrast agents: targeted ultrasound imaging and ultrasound-assisted drug-delivery applications

The use of microbubble contrast agents for general tissue delineation and perfusion enjoys steady interest in ultrasound imaging. Microbubbles as contrast materials require a small dosage and show excellent detection sensitivity. Targeting ligands on the surface of microbubbles permit the selective accumulation of these particles in the areas of interest, which show an up-regulated level of receptor molecules on vascular endothelium. Selective contrast imaging of inflammation, ischemia-reperfusion injury, angiogenesis, and thrombosis has been achieved in animal models. Ultrasound-assisted drug delivery and activation, performed by combining microbubble agent containing drug substances or coadministered with pharmaceutical agents (including plasmid DNA for transfection), has been achieved in multiple model systems in vitro and in vivo. Ultrasound and microbubbles-based targeted acceleration of the thrombolytic enzyme action already have reached clinical trials. Overall, microbubble targeting and ultrasound-assisted microbubble-based drug-delivery systems will offer a step toward the application of targeted personalized diagnostics and therapy.

Targeted Therapeutic Applications of Acoustically Active Microspheres in the Microcirculation

The targeted delivery of intravascular drugs and genes across the endothelial barrier with only minimal side effects remains a significant obstacle in establishing effective therapies for many pathological conditions. Recent investigations have shown that contrast agent microbubbles, which are typically used for image enhancement in diagnostic ultrasound, may also be promising tools in emergent, ultrasound-based therapies. Explorations of the bioeffects generated by ultrasound-microbubble interactions indicate that these phenomena may be exploited for clinical utility such as in the targeted revascularization of flow-deficient tissues. Moreover, development of this treatment modality may also include using ultrasound-microbubble interactions to deliver therapeutic material to tissues, and reporter genes and therapeutic agents have been successfully transferred from the microcirculation to tissue in various animal models of normal and pathological function. This article reviews the recent studies aimed at using interactions between ultrasound and contrast agent microbubbles in the microcirculation for therapeutic purposes. Furthermore, the authors present investigations involving microspheres that are of a different design compared to current microbubble contrast agents, yet are acoustically active and demonstrate potential as tools for targeted delivery. Future directions necessary to address current challenges and advance these techniques to clinical practicality are also discussed.

[Possible target specific molecular imaging with ultrasound contrast agents]

Non-invasive molecular imaging technologies provide researchers with the opportunity to study cellular and molecular processes. Among different imaging technologies, ultrasound based molecular imaging methods are also of interest, since the use of ultrasound contrast agents allows specific and sensitive depiction of molecular targets. Recent studies are encouraging and have demonstrated the feasibility of ultrasound based molecular imaging. This review summarizes current experiences and recent preclinical studies with target-specific ultrasound contrast agents.