Theranostics 2018; 8(2):314-327. doi:10.7150/thno.19010

Research Paper

Tumour Vascular Shutdown and Cell Death Following Ultrasound-Microbubble Enhanced Radiation Therapy

Ahmed El Kaffas2,3,4, Mehrdad J. Gangeh2,3, Golnaz Farhat1,2, William Tyler Tran2, Amr Hashim1, Anoja Giles1, Gregory J. Czarnota1,2,3✉

1. Physical Sciences, Sunnybrook Research Institute, Toronto, ON, M4N 3M5 Canada;
2. Department of Radiation Oncology, Sunnybrook Health Sciences Centre, Toronto, ON, M4N 3M5 Canada;
3. Departments of Medical Biophysics, and Radiation Oncology, University of Toronto, Toronto, ON, M4N 3M5 Canada;
4. Department of Radiology, School of Medicine, Stanford University, 1201 Welch Rd., Palo Alto, CA, 94304.


High-dose radiotherapy effects are regulated by acute tumour endothelial cell death followed by rapid tumour cell death instead of canonical DNA break damage. Pre-treatment with ultrasound-stimulated microbubbles (USMB) has enabled higher-dose radiation effects with conventional radiation doses. This study aimed to confirm acute and longitudinal relationships between vascular shutdown and tumour cell death following radiation and USMB in a wild type murine fibrosarcoma model using in vivo imaging.

Methods: Tumour xenografts were treated with single radiation doses of 2 or 8 Gy alone, or in combination with low-/high-concentration USMB. Vascular changes and tumour cell death were evaluated at 3, 24 and 72 h following therapy, using high-frequency 3D power Doppler and quantitative ultrasound spectroscopy (QUS) methods, respectively. Staining using in situ end labelling (ISEL) and cluster of differentiation 31 (CD31) of tumour sections were used to assess cell death and vascular distributions, respectively, as gold standard histological methods.

Results: Results indicated a decrease in the power Doppler signal of up to 50%, and an increase of more than 5 dBr in cell-death linked QUS parameters at 24 h for tumours treated with combined USMB and radiotherapy. Power Doppler and quantitative ultrasound results were significantly correlated with CD31 and ISEL staining results (p < 0.05), respectively. Moreover, a relationship was found between ultrasound power Doppler and QUS results, as well as between micro-vascular densities (CD31) and the percentage of cell death (ISEL) (R2 0.5-0.9).

Conclusions: This study demonstrated, for the first time, the link between acute vascular shutdown and acute tumour cell death using in vivo longitudinal imaging, contributing to the development of theoretical models that incorporate vascular effects in radiation therapy. Overall, this study paves the way for theranostic use of ultrasound in radiation oncology as a diagnostic modality to characterize vascular and tumour response effects simultaneously, as well as a therapeutic modality to complement radiation therapy.

Keywords: ultrasound therapy and imaging, ultrasound treatment monitoring, power Doppler, quantitative ultrasound spectroscopy, ultrasound-stimulated microbubbles, radiation therapy, vascular targeting.

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How to cite this article:
El Kaffas A, Gangeh MJ, Farhat G, Tran WT, Hashim A, Giles A, Czarnota GJ. Tumour Vascular Shutdown and Cell Death Following Ultrasound-Microbubble Enhanced Radiation Therapy. Theranostics 2018; 8(2):314-327. doi:10.7150/thno.19010. Available from