Safety and feasibility of ultrasound-triggered targeted drug delivery of doxorubicin from thermosensitive liposomes in liver tumours (TARDOX): a single-centre, open-label, phase 1 trial

BACKGROUND: Previous preclinical research has shown that extracorporeal devices can be used to enhance the delivery and distribution of systemically administered anticancer drugs, resulting in increased intratumoural concentrations. We aimed to assess the safety and feasibility of targeted release and enhanced delivery of doxorubicin to solid tumours from thermosensitive liposomes triggered by mild hyperthermia, induced non-invasively by focused ultrasound. METHODS: We did an open-label, single-centre, phase 1 trial in a single UK hospital. Adult patients (aged ≥18 years) with unresectable and non-ablatable primary or secondary liver tumours of any histological subtype were considered for the study. Patients received a single intravenous infusion (50 mg/m2) of lyso-thermosensitive liposomal doxorubicin (LTLD), followed by extracorporeal focused ultrasound exposure of a single target liver tumour. The trial had two parts: in part I, patients had a real-time thermometry device implanted intratumourally, whereas patients in part II proceeded without thermometry and we used a patient-specific model to predict optimal exposure parameters. We assessed tumour biopsies obtained before and after focused ultrasound exposure for doxorubicin concentration and distribution. The primary endpoint was at least a doubling of total intratumoural doxorubicin concentration in at least half of the patients treated, on an intention-to-treat basis. This study is registered with ClinicalTrials.gov, number NCT02181075, and is now closed to recruitment. FINDINGS: Between March 13, 2015, and March 27, 2017, ten patients were enrolled in the study (six patients in part I and four in part II), and received a dose of LTLD followed by focused ultrasound exposure. The treatment resulted in an average increase of 3·7 times in intratumoural biopsy doxorubicin concentrations, from an estimate of 2·34 μg/g (SD 0·93) immediately after drug infusion to 8·56 μg/g (5·69) after focused ultrasound. Increases of two to ten times were observed in seven (70%) of ten patients, satisfying the primary endpoint. Serious adverse events registered were expected grade 4 transient neutropenia in five patients and prolonged hospital stay due to unexpected grade 1 confusion in one patient. Grade 3-4 adverse events recorded were neutropenia (grade 3 in one patient and grade 4 in five patients), and grade 3 anaemia in one patient. No treatment-related deaths occurred. INTERPRETATION: The combined treatment of LTLD and non-invasive focused ultrasound hyperthermia in this study seemed to be clinically feasible, safe, and able to enhance intratumoural drug delivery, providing targeted chemo-ablative response in human liver tumours that were refractory to standard chemotherapy. FUNDING: Oxford Biomedical Research Centre, National Institute for Health Research

Long-term radiological and histological outcomes following selective internal radiation therapy to liver metastases from breast cancer.

Liver metastasis from breast cancer is associated with poor prognosis and is a major cause of early morbidity and mortality. When liver resection is not feasible, minimally invasive directed therapies are considered to attempt to prolong survival. Selective internal radiation therapy (SIRT) with yttrium-90 microspheres is a liver-directed therapy that can improve local control of liver metastases from colorectal cancer. We present a case of a patient with a ductal breast adenocarcinoma, who developed liver and bone metastasis despite extensive treatment with systemic chemotherapies. Following SIRT to the liver, after an initial response, the patient ultimately progressed in the liver after 7 months. Liver tumor histology obtained 20 months after the SIRT intervention demonstrated the presence of the resin microspheres in situ. This case report demonstrates the long-term control that may be achieved with SIRT to treat liver metastases from breast cancer that is refractory to previous chemotherapies, and the presence of microspheres in situ long-term

The significance of shape and orientation in single-particle weak-scatterer models.

Particles that have a density and compressibility comparable to those of the surrounding medium (weak scatterers) are often modeled as spherical scatterers of equivalent volume. The simplicity and symmetry of the spherical model does not however account for the effect of the angle of incidence of the incident field onto the particle. By performing a comparative study of scattering models for the case of a fluid sphere, it is shown that models derived using the Born approximation closely match the exact solution for weak scatterers. This approximation is therefore applied to produce a model for the fluid disk, which is used to investigate the significance of particle shape and orientation. Scattering by a red blood cell of given volume modeled as a sphere is compared to the result obtained by approximating its shape as a disk of varying aspect ratio and orientation. The spherical model is shown to provide a good description for frequencies up to 20 MHz, beyond which particle shape becomes significant. This effect could go undetected if the scattered field is only observed at 90 degrees relative to the direction of the incident field. Nevertheless, the significance of particle shape and orientation might form the basis of a novel detection technique

Applications of acoustics and cavitation to noninvasive therapy and drug delivery

Biomedical acoustics is rapidly evolving from a diagnostic modality to a therapeutic tool, and acoustic cavitation is often the common denominator in a wide range of new therapeutic applications. High-intensity focused ultrasound (HIFU) waves generated outside the body can be used to deposit heat deep within the body. Through a quantitative analysis of heat deposition by ulrasound, it is shown that inertial cavitation can help address some of the major challenges of HIFU therapy by providing a means of enhancing and monitoring treatment noninvasively. In the context of drug delivery, both inertial and stable cavitation play rates in enhancing drug activity and uptake. In particular, shape oscillations arising during stable cavitation provide an effective micropumping mechanism for enhanced mass transport across inaccessible interfaces. Copyright © 2008 by Annual Reviews. All rights reserved

Quantitative observations of cavitation activity in a viscoelastic medium.

Quantitative experimental observations of single-bubble cavitation in viscoelastic media that would enable validation of existing models are presently lacking. In the present work, single bubble cavitation is induced in an agar gel using a 1.15 MHz high intensity focused ultrasound transducer, and observed using a focused single-element passive cavitation detection (PCD) transducer. To enable quantitative observations, a full receive calibration is carried out of a spherically focused PCD system by a bistatic scattering substitution technique that uses an embedded spherical scatterer and a hydrophone. Adjusting the simulated pressure received by the PCD by the transfer function on receive and the frequency-dependent attenuation of agar gel enables direct comparison of the measured acoustic emissions with those predicted by numerical modeling of single-bubble cavitation using a modified Keller-Miksis approach that accounts for viscoelasticity of the surrounding medium. At an incident peak rarefactional pressure near the cavitation threshold, period multiplying is observed in both experiment and numerical model. By comparing the two sets of results, an estimate of the equilibrium bubble radius in the experimental observations can be made, with potential for extension to material parameter estimation. Use of these estimates yields good agreement between model and experiment

Spatiotemporal assessment of the cellular safety of cavitation-based therapies by passive acoustic mapping

Many useful therapeutic bio-effects can be generated using ultrasound-induced cavitation. However, cavitation is also capable of causing unwanted cellular and vascular damage, which should be monitored to ensure treatment safety. In this work, the unique opportunity provided by passive acoustic mapping (PAM) to quantify cavitation dose across an entire volume of interest during therapy is utilised to provide setup-independent measures of spatially localised cavitation dose. This spatiotemporally quantifiable cavitation dose is then related to the level of cellular damage generated. The cavitation-mediated destruction of equine red blood cells mixed with one of two types of cavitation nuclei at a variety of concentrations is investigated. The blood is placed within a 0.5-MHz ultrasound field and exposed to a range of peak rarefactional pressures up to 2 MPa, with 50 to 50,000 cycle pulses maintaining a 5% duty cycle. Two co-planar linear arrays at 90° to each other are used to generate 400-µm-resolution frequency domain robust capon beamforming PAM maps, which are then used to generate estimates of cavitation dose. A relationship between this cavitation dose and the levels of haemolysis generated was found which was comparable regardless of the applied acoustic pressure, pulse length, cavitation agent type or concentration used. PAM was then used to monitor cellular damage in multiple locations within a tissue phantom simultaneously, with the damage–cavitation dose relationship being similar for the two experimental models tested. These results lay the groundwork for this method to be applied to other measures of safety, allowing for improved ultrasound monitoring of cavitation-based therapies

Cavitation and contrast: the use of bubbles in ultrasound imaging and therapy.

Microbubbles and cavitation are playing an increasingly significant role in both diagnostic and therapeutic applications of ultrasound. Microbubble ultrasound contrast agents have been in clinical use now for more than two decades, stimulating the development of a range of new contrast-specific imaging techniques which offer substantial benefits in echocardiography, microcirculatory imaging, and more recently, quantitative and molecular imaging. In drug delivery and gene therapy, microbubbles are being investigated/developed as vehicles which can be loaded with the required therapeutic agent, traced to the target site using diagnostic ultrasound, and then destroyed with ultrasound of higher intensity energy burst to release the material locally, thus avoiding side effects associated with systemic administration, e.g. of toxic chemotherapy. It has moreover been shown that the motion of the microbubbles increases the permeability of both individual cell membranes and the endothelium, thus enhancing therapeutic uptake, and can locally increase the activity of drugs by enhancing their transport across biologically inaccessible interfaces such as blood clots or solid tumours. In high-intensity focused ultrasound (HIFU) surgery and lithotripsy, controlled cavitation is being investigated as a means of increasing the speed and efficacy of the treatment. The aim of this paper is both to describe the key features of the physical behaviour of acoustically driven bubbles which underlie their effectiveness in biomedical applications and to review the current state of the art

Passive cavitation mapping for localization and tracking of bubble dynamics.

Current acoustic techniques for studying cavitation dynamics are only readily applicable to single-bubble activity, while optical methods can only be used in transparent media. However, multi-bubble cavitation often occurs in opaque media such as biological tissue. Here, the signals received passively by each of the 64 channels of a diagnostic ultrasound array are used to localize and separate emissions from several bubble clusters cavitating in agar gel, thereby providing a method of observing cavitation dynamics. The method has a high spatiotemporal resolution and is applicable to cavitation in opaque media

Broadband ultrasonic attenuation estimation and compensation with passive acoustic mapping

Several active and passive techniques have been developed to detect, localize and quantify cavitation activity during therapeutic ultrasound procedures. Much of the prior cavitation monitoring research has been conducted using lossless in vitro systems or small animal models in which path attenuation effects were minimal. However, the performance of these techniques may be substantially degraded by attenuation between the internal therapeutic target and the external monitoring system. As a further step towards clinical application of passive acoustic mapping (PAM), this paper presents methods for attenuation estimation and compensation based on broadband cavitation data measured with a linear ultrasound array. Soft tissue phantom experiment results are used to illustrate: 1) the impact of realistic attenuation on PAM images, 2) the possibility of estimating attenuation from cavitation data, 3) cavitation source energy estimation following attenuation compensation, and 4) the impact of sound speed uncertainty on PAM-related processing. Cavitation-based estimates of attenuation were within 1.5-6.2 % of the values found from conventional through-transmission measurements. Tissue phantom attenuation reduced the PAM energy estimate by an order of magnitude, but array data compensation using the cavitation-based attenuation spectrum enabled recovery of the PAM energy estimate to within 2.9-5.9% of the values computed in the absence of the phantom. Sound speed uncertainties were found to modestly impact attenuation-compensated PAM energies, inducing errors no larger than 28% for a 40 m/s path-averaged speed error. Together, the results indicate the potential to significantly enhance the quantitative capabilities of PAM for ensuring therapeutic safety and efficacy