Abstract B151: Exploring the induction of immunogenic cell death (ICD) by high-intensity focused ultrasound (HIFU)
Authors: Dewitte Heleen , Engelen Yanou , Lajoinie Guillaume , Gomes-da-Silva Lígia , Versluis Michel , Smedt Stefaan C. De , Kroemer Guido , Breckpot Karine , Lentacker Ine 
Published: February 2019

Abstract
Immunogenic cell death (ICD) is an intriguing concept within cancer immunotherapy. Indeed, by inducing a specific means of cellular demise, a protective immune response can be triggered against the dying cells. As such, the dying cancer cells are—in a way—turned into a vaccine, attracting immune cells to the site of cell death, and activating them to trigger an anticancer immune response. Since the early discovery of ICD, more mechanistic insights into the hallmarks of ICD have been unraveled and several state-of-the-art cancer therapies have been identified as bona fide ICD inducers (1, 2).One of the cancer therapies which could be a potential candidate to induce ICD is high-intensity focused ultrasound (HIFU) (3). HIFU is currently used as a way of debulking solid tumors in a non-invasive, image-controlled and precise way without the use of ionizing radiation. Depending on the ultrasound parameters, tumor tissue can be ablated either in a mechanical (tissue disruption) or thermal way (heating and coagulative necrosis). Interestingly, there are some indications that HIFU may also affect the immune system: experiments in mice and man have shown attraction/activation of immune cells to/in the tumor site (4, 5). Of note: these immunostimulating effects were reported to be more prominent for mechanical HIFU than thermal HIFU. However, neither the mechanisms behind these observations, nor the possible link to the induction of ICD have been investigated. Therefore, the key aim of work is to investigate the potential of HIFU to induce ICD. Using a custom-designed HIFU set-up, we were able to—in a precise, automated and controlled way—expose B16F0 melanoma cells to HIFU in vitro. The HIFU-exposed tumor cells were subsequently evaluated for the occurrence of apoptosis and ICD hallmarks. More specifically, we evaluated the exposure of calreticulin (CRT) on the cell membrane and release of high mobility group box 1 (HMGB-1) and adenosine triphosphate (ATP). Our data show that application of mechanical HIFU protocols (using short, repeated ultrasound bursts) induce a significant fraction of apoptotic cells (as measured by a loss of mitochondrial membrane potential) within 4h after treatment. Importantly, already within the first hour after HIFU exposure, high levels of the ICD hallmark and Toll-like receptor 4 agonist HMGB-1 were found in the supernatant of the HIFU-treated cells, compared to untreated controls. To determine the effect of HIFU on ATP release, a quinacrine assay was performed to stain intracellular ATP-containing vesicles. Using flow cytometry, we observed that HIFU triggered exocytosis of these vesicles, with 2- to 3-fold reductions in quinacrine fluorescence at 4h and 24h after HIFU exposure, respectively. In addition, at 24h after HIFU exposure, &gt;30% of the cells exposed CRT on the outer leaflet of the cell membrane, which was a drastic increase compared to blanks (&lt;1% CRT exposure). Taken together, these results indicate that 3 key hallmarks of ICD can be detected after treatment of B16F0 melanoma cells with an optimized mechanical HIFU protocol. Currently, vaccination experiments are ongoing to determine whether HIFU-treated cells induce protective immunity in mice. If we could identify mechanical HIFU as a true ICD inducer, this might have important repercussions to how HIFU ablative therapies are applied in the clinic: modified HIFU regimens that not only focus on full ablation, but also trigger ICD could be envisaged to simultaneously tackle primary tumors as well as distant metastasis. Moreover, this could provide a solid basis for the rational combination of HIFU with other immunotherapies to strengthen the evoked immune response. References: 1. Galluzzi L, et al. Nature Reviews Immunology 2017. 2. Kroemer G, et al. Annual Review of Immunology 2013. 3. Blana A, et al. European Urology 2008. 4. Liu F, et al. Journal of Translational Medicine 2010. 5. Lu P, et al. Surgery 2009.
Citation Format: Heleen Dewitte, Yanou Engelen, Guillaume Lajoinie, Lígia Gomes-da-Silva, Michel Versluis, Stefaan C. De Smedt, Guido Kroemer, Karine Breckpot, Ine Lentacker. Exploring the induction of immunogenic cell death (ICD) by high-intensity focused ultrasound (HIFU) [abstract]. In: Proceedings of the Fourth CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; Sept 30-Oct 3, 2018; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2019;7(2 Suppl):Abstract nr B151.