Ultrasound-induced immune responses in tumors: A systematic review and meta-analysis.

Ultrasound is widely used in the diagnosis and therapy of cancer. Tumors can be treated by thermal or mechanical tissue ablation. Furthermore, tumors can be manipulated by hyperthermia, sonodynamic therapy and sonoporation, e.g., by increasing tumor perfusion or the permeability of biological barriers to enhance drug delivery. These treatments induce various immune responses in tumors. However, conflicting data and high heterogeneity between experimental settings make it difficult to generalize the effects of ultrasound on tumor immunity. Therefore, we performed a systematic review to answer the question: "Does ultrasound alter the immune reaction of peripheral solid tumors in humans and animals compared to control conditions without ultrasound?" A systematic literature search was performed in PubMed, EMBASE, and Web of Science and 24,401 potentially relevant publications were identified. Of these, 96 publications were eligible for inclusion in the systematic review. Experiments were performed in humans, rats, and mice and focused on different tumor types, primarily breast and melanoma. We collected data on thermal and non-thermal ultrasound settings, the use of sono-sensitizers or sono-enhancers, and anti-tumor therapies. Six meta-analyses were performed to quantify the effect of ultrasound on tumor infiltration by T cells (cytotoxic, helper, and regulatory T cells) and on blood cytokines (interleukin-6, interferon-γ, tumor necrosis factor-α). We provide robust scientific evidence that ultrasound alters T cell infiltration into tumors and increases blood cytokine concentrations. Furthermore, we identified significant differences in immune cell infiltration based on tumor type, ultrasound settings, and mouse age. Stronger effects were observed using hyperthermia in combination with sono-sensitizers and in young mice. The latter may impair the translational impact of study results as most cancer patients are older. Thus, our results may help refining ultrasound parameters to enhance anti-tumor immune responses for therapeutic use and to minimize immune effects in diagnostic applications.

Transferrin Receptor-Targeted Nonspherical Microbubbles for Blood-Brain Barrier Sonopermeation.

Microbubbles (MB) are widely used for ultrasound (US) imaging and drug delivery. MB are typically spherically shaped, due to surface tension. When heated above their glass transition temperature, polymer-based MB can be mechanically stretched to obtain an anisotropic shape, endowing them with unique features for US-mediated blood-brain barrier (BBB) permeation. It is here shown that nonspherical MB can be surface-modified with BBB-specific targeting ligands, thereby promoting binding to and sonopermeation of blood vessels in the brain. Actively targeted rod-shaped MB are generated via 1D stretching of spherical poly(butyl cyanoacrylate) MB and via subsequently functionalizing their shell with antitransferrin receptor (TfR) antibodies. Using US and optical imaging, it is demonstrated that nonspherical anti-TfR-MB bind more efficiently to BBB endothelium than spherical anti-TfR-MB, both in vitro and in vivo. BBB-associated anisotropic MB produce stronger cavitation signals and markedly enhance BBB permeation and delivery of a model drug as compared to spherical BBB-targeted MB. These findings exemplify the potential of antibody-modified nonspherical MB for targeted and triggered drug delivery to the brain.

Nonspherical ultrasound microbubbles.

Surface tension provides microbubbles (MB) with a perfect spherical shape. Here, we demonstrate that MB can be engineered to be nonspherical, endowing them with unique features for biomedical applications. Anisotropic MB were generated via one-dimensionally stretching spherical poly(butyl cyanoacrylate) MB above their glass transition temperature. Compared to their spherical counterparts, nonspherical polymeric MB displayed superior performance in multiple ways, including i) increased margination behavior in blood vessel-like flow chambers, ii) reduced macrophage uptake in vitro, iii) prolonged circulation time in vivo, and iv) enhanced blood-brain barrier (BBB) permeation in vivo upon combination with transcranial focused ultrasound (FUS). Our studies identify shape as a design parameter in the MB landscape, and they provide a rational and robust framework for further exploring the application of anisotropic MB for ultrasound-enhanced drug delivery and imaging applications.

[Super-resolution ultrasound imaging : Methods and applications]. / Superresolution-Ultraschallbildgebung : Methoden und Anwendungen.

CLINICAL/METHODICAL ISSUE: The microvasculature plays an important role in many pathologic conditions but cannot be characterized in high resolution via conventional ultrasound methods. STANDARD RADIOLOGICAL METHODS: Doppler-based techniques, contrast-enhanced sonography as well as dynamic contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI) are commonly used to characterize tissue vascularization. However, these techniques cannot visualize the microvasculature adequately. METHODICAL INNOVATION: Ultrasound localization microscopy (ULM) consists of contrast-enhanced ultrasound measurements in combination with a complex post-processing algorithm which detects microbubbles with high precision. The vasculature can then be visualized by accumulating the microbubble positions in a final image. PERFORMANCE: Compared to conventional ultrasound techniques, ULM improves the image resolution by a factor of more than 10. This currently results in resolutions down to 10 µm and allows, therefore, the visualization of capillaries and the assessment of their perfusion. Also, this does not lead to a reduction of the penetration depth or the signal-to-noise ratio (SNR). ACHIEVEMENT: The method enables the visualization of vascular structures in unsurpassed detail and has the potential to offer new possibilities for the diagnosis of various diseases and for gaining insights into physiological processes. However, ULM is not commercially available yet but is intensely being tested in clinical studies. PRACTICAL RECOMMENDATIONS: ULM could potentially be applied to all fields in which the vasculature is relevant. Current fields of application include oncology, nephrology, and neurological research.

Development of a Systematic Review Protocol and a Scoping Review of Ultrasound-Induced Immune Effects in Peripheral Tumors.

PURPOSE: Publication numbers reporting that ultrasound can stimulate immune reactions in tumors steadily increase. However, the presented data are partially conflicting, and mechanisms are difficult to identify from single publications. These shortcomings can be addressed by a systematic review and meta-analysis of current literature. As a first step, we here present the methodology and protocol for a systematic review to answer the following research question: Does ultrasound alter the immune reaction of peripheral solid tumors in humans and animals compared to control conditions without ultrasound? PROCEDURES: We designed a protocol to perform a systematic review and meta-analysis. The suitability of the protocol to detect and sort relevant literature was tested using a subset of publications. We extracted study characteristics, ultrasound parameters, and study outcomes to pre-evaluate the differences between publications and present the data as a scoping review. RESULTS: From 6532 publications detected by our preliminary literature search, 320 were selected for testing our systematic review protocol. Of the latter, 15 publications were eligible for data extraction. There, we found large differences between study characteristics (e.g., tumor type, age) and ultrasound settings (e.g., wavelength 0.5-9.5 MHz, acoustic pressure 0.0001-15,000 W/cm2). Finally, study outcomes included reports on cells of the innate (e.g., dendritic cells, macrophages) and adaptive immune system (e.g., CD8-/CD4-positive T cells). CONCLUSION: We designed a protocol to identify relevant literature and perform a systematic review and meta-analysis. The differences between extracted features between publications show the necessity for a comprehensive search and selection strategy in the systematic review to get a complete overview of the literature. Meta-analyses of the extracted outcomes can then enable evidence-based conclusions.