Induction of the apoptosis of cancer cell by sonodynamic therapy: a review
Review Article

Induction of the apoptosis of cancer cell by sonodynamic therapy: a review

Wen-Kun Bai1,2, E Shen1, Bing Hu1

1Department of Ultrasound In Medicine, Shanghai Jiao tong University Affiliated 6th People’s Hospital, Shanghai Institute of Ultrasound In Medicine, Shanghai 200233, China; 2Department of Ultrasound In Medicine, Shandong University Affiliated Qian Fo Shan Hospital, Ji Nan 250014, China

Corresponding to:
Bing Hu. Department of Ultrasound In Medicine, Shanghai Jiaotong University Affiliated 6th People’s Hospital, Shanghai Institute of Ultrasound In Medicine, Yishan Road 600, Shanghai 200233, China.

Abstract: Ultrasound can be used not only in the examination, but also in the therapy, especially in the therapy of cancer, which has got effect in the treatment. Sonodynamic therapy is an experimental cancer therapy which uses ultrasound to enhance the cytotoxic effects of drugs known as sonosensitizers. It has been tested in vitro and in vivo. The ultrasound could penetrate the tissue and cell under some of conditions which directly changes the cell membranes permeability, thereby allowing the delivery of exogenous molecules into the cells in some degree. Ultrasound could inhibit the proliferation or induce the apoptosis of the cancer cell in vitro or in vivo. Recent research indicated low frequency and low intensity ultrasound could induce cells apoptosis, and which could be strengthened by sonodynamic sensitivities, microbubbles, chemotherapeutic drugs and so on. Most kinds of ultrasound suppressed the proliferation of cancer cell through inducing the apoptosis of cancer cell. The mechanism of apoptosis is not clear. In this review, we will focus on and discuss the mechanisms of the induction of the apoptosis of cancer cell by ultrasound.

Key words: Sonodynamic therapy; apoptosis; cancer; mechanism

Submitted Jul 19. Accepted for publication Aug 06, 2012.
DOI: 10.3978/j.issn.1000-9604.2012.08.03


Ultrasound is widely used for soft tissue imaging because of its perceived safety, noninvasiveness and low cost. It is also used in therapy, which has shown effect on the suppression of the proliferation of bacteria, the improvement of the therapeutical effect of the drug, and in thrombolysis in vitro and so on (1-3). This effect of ultrasound can be strengthened by microbubbles (4,5). Microbubble is a blood contrast medium, and it can not be permeated to the outside of the blood vessel. For that reason, microbubble can be used in the ultrasound examination to observe the blood stream information of the organs, and large or small vessels. The diameter of the common microbubble is from 2 to 6 µm, which is similar to that of the red cell. After jet injection from the peripheral vein, and getting into the body, microbubble can pass pulmonary circulation and go into circulation system, also can strengthen the imaging of the organ (6,7). Cell permeabilization using microbubbles (MB) and ultrasound (US) have the potential of delivering molecules into the cytoplasm. The collapsing MB and cavitation bubbles created by this collapse generate impulsive pressures that cause transient membrane permeability, allowing exogenous molecules to enter the cells. Collapsed MB or cavitation bubbles generated by collapsed MB induce impulsive pressures such as liquid jets and shock waves, and these pressures affect the neighboring cells. The shock wave propagation distance from the center of a cavitation bubble that has the potential to damage the cell membrane is considerably larger than the maximum radius of the cavitation bubble (8). Several generations of the microbubble agents have also been developed. Early microbubbles contained an air core and were stabilized by a coating of albumin, starting with AlbunexR. Agents with a fluorinated gas core were then developed, including OptisonTM with a protein shell and perfluoropropane gas core and DefinityR with a phospholipid shell and perfluoropropane core. Microbubbles are typically manufactured by mechanical agitation, although microfluidic methods to engineer precise size distributions are in development (9). Cancer cells are more susceptible than normal cells to Sonodynamic therapy (SDT) (10,11), which serves as the experimental foundation for the application of SDT to the treatment of cancer. Recently SDT has been widely used in the therapy of cancer and has shown the effect of mediating apoptosis in many experimental systems in vitro or in vivo, but the detailed mechanism of this process is unclear. Moreover, the effect of ultrasound-induced apoptosis could be enhanced by porphyrin, anticancer drugs and other chemical compounds. The synergistic effect of SDT and other chemical compounds are referred to as sonodynamic therapy. In this review we will discuss the mechanism of the induction of the apoptosis of cancer cell by SDT.


Blood vessels of cancer were influenced by SDT

Angiogenesis, the process by which the existing vascular network expands to form new blood vessels, is required for the growth of solid tumors (12). Angiogenesis, the development of new blood vessels from the endothelium of a pre-existing vasculature, is a critical process required by most solid tumors to support their growth and metastasis. Therefore, anti-angiogenic therapy has been demonstrated to be an attractive strategy for cancer treatment. SDT could influence the vascular to induce cancer cell apoptosis in vivo (13). SDT combined with microbubbles also has effect on the vascular of cancer. Because the microbubbles are compressible, they alternately contract and expand in the acoustic field, a phenomenon referred to as cavitation. At low peak negative acoustic pressures are usually less than 0.2 MPa. As a result, microbubbles usually grow and shrink rhythmically and symmetrically around their equilibrium size, which is a phenomenon known as stable cavitation. At higher acoustic pressures, typically greater than 0.60 MPa, however, the expansion and contraction of microbubbles usually become unequal and markedly exaggerated, leading to vessel destruction. This activity is termed inertial cavitation, which induced the improvement of the cells membrane permeability and angiorrhexis of small vessels (14). When microbubbles are irradiated by ultrasound, they may induce the destruction of the vascular, and that of the vascular endothelium, causing thrombopoiesis in the vessels. It blocked the blood supply of the malignant tumor to induce the cancer apoptosis (15). Another study has found that SDT can facilitate anti-angiogenic gene delivery and inhibit prostate tumor growth in vitro and in vivo (16,17). Since glucose, oxygen, and other requirements are not evenly delivered through the tumor vasculature, the blood vessels develop and harbor hypoxic regions, the cells undergo oxidative stress and the vessels fail to mature, inducing the apoptosis of cancer cell (18).

SDT induced the apoptosis of cancer cell through the influence of the genes that have correlation with apoptosis

Modulating the expression of key molecular components of the apoptotic processes that comprise cell death is an attractive antineoplastic approach. In some experiments, it was found that SDT could influence the gene expression to induce apoptosis. In a study, human myelomonocytic lymphoma cell line U937 cells were exposed to the frequency of 1.0 MHz with 100 Hz pulse repetition frequency ultrasound. After that, cell viability and apoptosis, and gene expression were analyzed. This study showed that SDT could induce apoptosis, and down-regulate 193 genes and up-regulate 201 genes. For down-regulated genes, the significant genetic network was associated with cellular growth and proliferation, gene expression, or cellular development. For up-regulated genes, the significant genetic network was associated with cellular movement, cell morphology, and cell death. The present results indicate that SDT affect the expression of many genes and will provide novel insight into the bio-molecular mechanisms of SDT in therapeutic application for cancer therapy (19).

SDT could also improve gene transfection to therapy cancer and induce cancer cell apoptosis. Survivin, a member of the mammalian inhibitor of apoptosis protein (IAP) family, possesses multiple functions, including apoptosis inhibition, proliferation, tumorigenesis, cell cycle promotion (20). In all in vitro and in vivo experiments, it was found that ultrasound with microbubbles could improve survivin gene transfection, and could induce more of the apoptosis than that of the control group (21,22). Silencing of survivin gene expression with shRNA could be facilitated by this non-viral technique, and lead to significant cell apoptosis. This novel method for RNA interference represents a powerful and promising non-viral technology that can be used in the tumor gene therapy and research.

SDT influences the genes which are apoptotic. There are two main apoptotic pathways: the extrinsic (receptor-mediated) and the intrinsic (mitochondria-mediated). The intrinsic pathway of apoptosis may be triggered by both internal and external stimuli, including many mediators, which either promote or inhibit the process (23). The most representative regulators of the mitochondria- mediated pathway are p53, an inducer of apoptosis, and bcl-2, a molecule with the opposite function (24-26). In a study, it was found that protein 53, Bcl-2 were involved in ultrasound-induced apoptosis. Apoptosis and G1 arrest were induced primarily in p53+ cells, while p53- cells showed less apoptosis but exhibited G2 arrest. Likewise, the proliferation of cancer cells were much more strongly inhibited in p53+ than in p53- cells (27), and Bcl-2 were shown to respond to ultrasound irradiation (28).

SDT could influence the cell signal pathway of cancer cell

Cell signal pathway plays an important role in the apoptosis of the cancer cell. The mitochondria-caspase signaling pathway was activated in the SDT-induced apoptosis of cancer cell, and ultrasound promotes the expression of pro-apoptotic proteins such as Bax and caspase-3 in cancer cell (29). In another study, the significant reduction in sonodynamically induced apoptosis, nitroxide generation, and caspase-3 activation by histidine suggested that active species such as singlet oxygen are important in the sonodynamic induction of apoptosis (30). Apoptosis induction has been reported to occur through a partial mediation of a Ca2+ dependent pathway. Calcium also has effect in the SDT induced cancer cell apoptosis. SDT can influence the cell ion pathway to induce apoptosis. Intracellular Ca2+ levels can vary depending on the bubble activity (31), which may be related to cell membrane damage and the amount of time required to repair this damage. Furthermore, some sonicated cells retain high levels of Ca2+ long after ultrasound exposure, which indicates a complete loss of cell membrane eintegrity (32). Ca2+ can improve the cell apoptosis level (33).

Drug chemotherapy could enhance the SDT induced cancer cell apoptosis

The drug chemotherapy is a very important method in the therapy of cancer (34). We constantly study how to enhance the sensitivity of the drug to reduce the therapeutic dose of the drug, and reduce the toxic and side-effect of the chemo-therapeutic drug. Ultrasound increases the membrane permeability without causing complete cell destruction which provides the experimental foundation for the enhancement of the drug osmosis of SDT in the treatment of cancer (35). In vitro study, MCF-7 cells were treated with 5-FU and sonicated at the frequency of 3.0 MHz and intensity of 3.0 W/cm2 for 1 min in the presence of Optison. Immediately after the treatment, cell death was mostly dependent on Optison, however, 24 h after treatment, cell death was more dependent on 5-FU. Ultrasound duty cycle increased cell death associated with either Optison or 5-FU. Furthermore, the study showed that the treatment with 5-FU and ultrasound increase the levels of the Bax and p27kip1 proteins (36). These studies not only showed that ultrasound can enhance the chemo-therapeutic effect in vitro but also studied the mechanism of it.

The other studies in vitro and in vivo also showed the SDT enhance the drug chemo-therapeutic effect of induction cancer cell apoptosis (37,38). These findings showed that ultrasound exposure was a promising technique for cancer chemotherapy.

SDT reversed of chemo-drug resistance of the cancer cell

Experimental and clinical investigations demonstrate that the chemotherapy induced toxic effect and the development of drug-resistance are the main barriers to successful therapies (39,40). Investigators hope to overcome drug-resistance, whilst maintaining or even improving the therapeutic effects. Ultrasound exposure could make drug resistance cancer cells more sensitive to anticancer drugs, which is a noninvasive physical approach for the induction of chemo-drug resistance reversal in cancer cells. In a study, they showed that the ultrasound effect on multidrug resistance (MDR) cancer cell. They investigated the mechanisms of therapeutic ultrasound as a physical approach to overcoming MDR in a multidrug resistant human hepato-carcinoma cell line (HepG2/ADM). Their results demonstrated that ultrasound could reverse the chemo-drug resistance. Using RT-PCR technique, they found that US could significantly down-regulate the expression of P-glycoprotein (P-gp) and (MRP) at the mRNA level in HepG2/ADM cells (41).Through this study, it not only confirmed that the SDT could reverse the chemo-drug resistance of the cancer cell but also found its mechanism. The study provided the experimental foundation for the clinical application of SDT combination with drug to the treatment of drug-resistance cancer.

Microbubble could enhance the SDT effect on inducing cancer cell apoptosis together with drugs

One recent approach targeting solid tumors is the application of microbubbles, which loaded with chemotherapeutic drugs. These advanced drug carriers could be safely administered to the patient by intravenous infusion, and would circulate through the entire vasculature. Their drug load could be locally released by ultrasound targeted microbubble destruction. In addition, tumors could be precisely localized by diagnostic ultrasound since microbubbles act as contrast agents (42). Microbubble combined with ultrasound could release the drug in specific position to save the drug and reduce the toxic and side-effect of the drug (43).


SDT can induce the apoptosis of cancer cell, and SDT permeabilizes the cell membrane directly, thereby allowing the delivery of exogenous molecules into the cells (44). It could also make bio-effects through physical methods, which gives us a new method to cure cancer.

Future direction

SDT has been widely used in the therapy of the cancer, and has got curative effect. Microbubbles combined with ultrasound have showed superiority in the therapy of the cancer. Especially microbubbles together with drugs or genes can even cure the cancer. However, the mechanisms of that are not yet clear, and in the future, it still needs to be studied. The best concentration of microbubbles and the frequency of the ultrasound in the treatment also need to be studied. Therefore, a better microbubble that can cure cancer together with drugs or genes is required. Furthermore, it must be stable and exhibit high performance in the delivery of the drugs or genes. The mechanisms of the apoptosis which SDT induces in the cancer cell in vitro, whether it still occurs in vivo or not, also need to be studied. We think that in the future SDT will be used more effectively in the treatment of cancer.


This study is supported by National Natural Science Foundation of China under grant No.81271597 and major infrastructure projects of Shanghai Science and Technology under grant No. 10JC1412600.

Disclosure: The authors declare no conflict of interest.


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Cite this article as: Bai WK, Shen E, Hu B. The induction of the apoptosis of cancer cell by sonodynamic therapy: a review. Chin J Cancer Res 2012;24(4):368-373. DOI: 10.3978/ j.issn.1000-9604.2012.08.03