Purpose In high intensity focused ultrasound (HIFU) therapy, an ultrasound beam is focused within the body to locally affect the targeted site without damaging intervening tissues. The most common HIFU regime is thermal ablation. Recently, there has been increasing interest in generating purely mechanical lesions in tissue (histotripsy). This paper provides an overview of several studies on the development of histotripsy methods toward clinical applications. Material and Methods Two histotripsy approaches and examples of their applications are presented. In one approach, sequences of high-amplitude, short (microsecond-long), focused ultrasound pulses periodically produce dense, energetic bubble clouds that mechanically disintegrate tissue. In an alternative approach, longer (millisecond-long) pulses with shock fronts generate boiling bubbles and the interaction of shock fronts with the resulting vapor cavity causes tissue disintegration. Results Recent pre-clinical studies on histotripsy are reviewed for treating benign prostatic hyperplasia (BPH), liver and kidney tumors, kidney stone fragmentation, enhancing antitumor immune response, and tissue decellularization for regenerative medicine applications. Potential clinical advantages of the histotripsy methods are discussed. Conclusions Histotripsy methods can be used to mechanically ablate a wide variety of tissues, whilst selectivity sparing structures such as large vessels. Both ultrasound and MR imaging can be used for targeting and monitoring the treatment in real time. Although the two approaches utilize different mechanisms for tissue disintegration, both have many of the same advantages and offer a promising alternative method of noninvasive surgery.

Recent studies have shown that shock wave heating and millisecond boiling in high intensity focused ultrasound (HIFU) fields can result in mechanical fractionation or emulsification of tissue - named boiling histotripsy. Visual observations of the change in color and contents indicated that the degree of thermal damage in the emulsified lesions can be controlled by varying the parameters of the exposure. The goal of this work was to examine thermal and mechanical effects in boiling histotripsy lesions using histological and biochemical analysis. The lesions were induced in ex vivo bovine heart and liver using a 2-MHz single-element transducer operating at duty factors of 0.005–0.01, pulse durations of 5–500 ms, and in situ shock amplitude of 73 MPa. Mechanical and thermal damage to tissue was evaluated histologically using conventional staining techniques (H&E and NADH-diphorase). Thermal effects were quantified by measuring denaturation of salt soluble proteins in the treated region. According to histology, the lesions that visually appeared as a liquid, contained no cellular structures larger than a cell nucleus and had a very sharp border of 1–2 cells. Both histology and protein analysis showed that lesions obtained with short pulses (< 10 ms) did not contain any thermal damage. Increasing the pulse duration resulted in an increase in thermal damage. However, both protein analysis and NADH-diaphorase staining showed less denaturation than visually observed as whitening of tissue. The number of HIFU pulses delivered per exposure did not change the lesion shape or the degree of thermal denaturation, whereas the size of the lesion showed a saturating behaviour thus suggesting optimal exposure duration. This study confirmed that boiling histotripsy offers an effective, predictable way to non-invasively fractionate tissue into subcellular fragments with or without inducing thermal damage.

Atomization and fountain formation is a well-known phenomenon that occurs when a focused ultrasound wave in liquid encounters an air interface. High intensity focused ultrasound (HIFU) has been shown to fractionate tissue into submicron-size fragments in a process termed boiling histotripsy, wherein the focused ultrasound wave superheats the tissue at the focus, producing a millimetre-size boiling or vapour bubble in several milliseconds. Yet the question of how this millimetre-size boiling bubble creates submicron-size tissue fragments remains. The hypothesis of this work is that tissue can behave as a liquid such that it forms a fountain and atomization within the vapour bubble produced in boiling histotripsy. We describe an experiment, in which a 2-MHz HIFU transducer (maximum in situ intensity of 24,000 W/cm2) was aligned with an air-tissue interface meant to simulate the boiling bubble. Atomization and fountain formation were observed with high-speed photography and resulted in tissue erosion. Histological examination of the atomized tissue showed whole and fragmented cells and nuclei. Air-liquid interfaces were also filmed. Our conclusion was that HIFU can fountain and atomize tissue. Although this process does not entirely mimic what was observed in liquids, it does explain many aspects of tissue fractionation in boiling histotripsy.

Significance High intensity focused ultrasound (HIFU) therapy is a promising, clinically adopted method of noninvasive tissue ablation used to treat both benign and malignant conditions. This work presents, to our knowledge, the first in vivo validation of a previously developed HIFU-based method that allows for noninvasive fractionation of targeted tissue into subcellular debris—boiling histotripsy—in a large animal model. While fractionating the targeted soft tissue, boiling histotripsy is shown to spare the adjacent connective tissue structures such as blood vessels. The process can be readily targeted and monitored by B-mode ultrasound. The resulting tissue debris are liquid, which provides a potential clinical benefit over thermal ablation in the treatment of tumors that exert uncomfortable pressure on surrounding tissues.