The heterogeneity of pancreatic cancer renders many available general therapies ineffective holding the five-year survival rate close to 10% for decades. Surgical resection eligibility, resistance to chemotherapy and limited efficacy of immunotherapy emphasize the dire need for diverse and innovative treatments to combat this challenging disease. This study evaluates co-therapy strategies that combine non-thermal, minimally invasive ablation technology and targeted drug delivery to enhance treatment efficacy. Our research begins by uncovering the multifaceted potential of Irreversible Electroporation (IRE), a cutting-edge non-thermal tumor ablation technique. This study demonstrates IRE-mediated ability to trigger programmed necrotic cell death, induce cell cycle arrest, and modulate immune cell populations within the tumor microenvironment. This transformation from a pro-tumor state to a proinflammatory milieu, enriched with cytotoxic T lymphocytes and neutrophils. IRE-induced proinflammation in the tumor site renders immunologically "cold" tumor into immunologically "hot" tumor and holds significant promise of improving treatment efficacy. Notably, IRE-treated mice exhibited an extended period of progression-free survival, implying clinical potential. The transient nature of these effects suggests potential mechanisms of tumor recurrence highlighting the need for further studies to maximize the efficacy of IRE. Our mechanistic studies evaluated the IFN-STAT1-PD-L1 feedback loop as a possible reason for pancreatic tumor recurrence. Our data also suggest a stronger IFN-PD-L1 feedback loop compared to mammary, osteosarcoma and glioblastoma tumors rendering pancreatic cancer immunologically "cold". This study also investigates the use of histotripsy (a non-thermal, noninvasive, nonionizing ultrasound-guided ablation modality) to treat pancreatic cancer utilizing a novel immunocompromised swine model. We successfully generated human orthotopic pancreatic tumors in the immune deficient pigs, which allowed for consequent investigation of clinical challenges presented by histotripsy. While rigorous clinical studies are indispensable for validation, the promise of histotripsy offers new hope for patients. In parallel, we used our immunocompromised swine model of orthotopic pancreatic cancer to investigate the SonoTran® system, which employs ultrasound-activated oscillating particles to enhance drug delivery within hard-to-reach tumors. Our study demonstrates that SonoTran® significantly enhances the intratumoral penetrance of therapeutic agents, including commonly used chemotherapy drugs like paclitaxel and gemcitabine. Additionally, SonoTran® improved delivery of the anti-epidermal growth factor (EGFR) monoclonal antibody, cetuximab- which is frequently used in cancer immunotherapy. Together, our findings address challenges in the delivery of a range of therapeutics while simultaneously exposing challenges like off-target damage. In conclusion, this study presents a multifaceted approach to confront the complex characteristics of pancreatic cancer. Given the variations in patient response and the complexity of the disease, it is clear that a singular solution is unlikely. Our research, which combines IRE, histotripsy, and SonoTran®, to interrogate a promising array of tools to tackle different challenges to provide tailored treatments. In the ever-evolving landscape of pancreatic cancer therapy, this research opens new avenues to investigate deeper into molecular mechanisms, co-therapy treatment options, future preclinical and clinical studies which eventually encourage the potential for improved patient outcomes. / Doctor of Philosophy / Pancreatic cancer is a formidable disease, known for its late-stage diagnosis and limited treatment options with a poor 5-year survival rate of ~10%. However, a promising frontier in the battle against this lethal disease has emerged through combining mechanical, cell based and immunotherapies to attack the cancer from multiple angles at once. In my PhD research, I explored novel approaches to transform the landscape of pancreatic cancer treatment. We began by investigating Irreversible Electroporation (IRE), a non-thermal method to ablate tumors. Beyond its known function of reducing tumor size, IRE initiated programmed necrotic cell death, halted tumor cell division, and triggered changes in the immune landscape within the tumor. In response to IRE treatment, the immune environment shifted from pro-tumor to proinflammatory state, showing potential for clinical use. Mice treated with IRE experienced extended cancer progression-free survival temporarily, followed by eventual relapse. During relapse, we found that immune cells reverted back to their original, pre- IRE treated state. This observation logically implies combining IRE and immune checkpoint inhibitors aimed towards maintaining the IRE-altered immunological environment. Next, we developed and used novel pig models that closely resemble human pancreatic cancer patients to test histotripsy, a first phase toward making histotripsy as a non-invasive treatment approach for pancreatic cancer. Use of orthotopic tumor in a large animal model and clinical device allowed us to expose some challenges of ultrasound guidance of histotripsy. Notably, the treatment results in partial ablation and a reduction in stroma materials, which play a role in the tumor's resistance to commonly used treatments. While rigorous clinical studies are needed for validation, this approach offers hope in the quest for innovative pancreatic cancer treatment. Another promising approach we investigated involves SonoTran® particles, ultrasound-activated oscillating particles that can increase drug absorption in a targeted fashion. Our study demonstrated increased concentrations of commonly used therapeutic agents within tumors through SonoTran®-facilitated delivery, providing an effective means to overcome drug delivery issues within pancreatic tumors. There is no one size fits all treatment to address the complexity of pancreatic cancer. The future of treatment lies in the integration of IRE, histotripsy and SonoTran® into clinical practice. In summary, this PhD research identified promising novel technologies and combinations of treatments for pancreatic cancer, reaffirming the importance of exploring innovative solutions to combat pancreatic cancer. The dynamic nature of the pancreatic tumor microenvironment underscores the importance of further research to extend the positive impacts of these treatments and improve tumor debulking.

L'objectif de cette thèse était d'explorer de nouvelles applications cardiaques pour l'histotripsie et de développer les outils permettant leur mise en place non-invasive. La thérapie ultrasonore cardiaque est en effet encore assez peu développée aujourd’hui, à cause de la difficulté à traiter un organe en mouvement permanent, et très bien protégé derrière la cage thoracique.Nous avons d'abord montré in vivo, sur un modèle ovin, que l’on pouvait sectionner les cordages mitraux de manière non-invasive ainsi que traiter la sténose aortique calcifiée. Engendrer de la cavitation sur les feuillets valvulaires permet effectivement d’agir à distance sur les calcifications, et de globalement assouplir la valve.Simultanément, nous avons développé un dispositif pour la thérapie cardiaque non invasive, fondé sur le concept de cavité à retournement temporel. Ce dispositif permet l'émission d'impulsions ultrasonores de haute intensité dans un très grand volume d’intérêt. L’on peut ainsi déplacer le point de thérapie en 3 dimensions de manière entièrement électronique, et sans déplacer mécaniquement l’appareil. Après optimisation, ce dispositif a permis de créer des lésions mécaniques bien contrôlées dans une région d'intérêt de 2 000 cm3.Pour faire face au défi que représente la cage thoracique, nous avons développé une méthode de focalisation adaptative et l'avons mise en œuvre dans un prototype 2D du dispositif. Avec cette méthode, nous pouvons non seulement construire un front d'onde ultrasonore adaptatif qui se propage de manière préférentielle à travers les espaces intercostaux, mais grâce aux propriétés des cavités à retournement temporel, nous pouvons également augmenter la pression focale obtenue sur la cible de thérapie.Enfin, pour approfondir ce travail sur la focalisation adaptative, et nous avons considéré le cas de l'imagerie transcrânienne. Pour cette application, nous avons choisi d’utiliser la focalisation par retournement temporel dans le bruit de speckle, pour corriger les aberrations induites par le crâne. En simulations numériques, nous avons pu calculer les modulations de phase et d'amplitude induites par les os et améliorer le contraste et la résolution d'une image B-mode. / The objective of this thesis was to explore new applications for cardiac histotripsy, and to develop the tools making it possible non-invasively. Cardiac ultrasound therapy indeed still remains limited due to the tremendous challenge of treating a constantly and rapidly moving organ, well protected behind the ribcage.We first showed in vivo, on a large animal model, that histotripsy could be used non-invasively to cut mitral chordae, and to treat calcified aortic stenosis in a beating heart. Cavitation on the valve leaflets can indeed locally and remotely act on the calcifications, and globally soften the valve. Simultaneously, we developed a therapeutic device allowing completely non-invasive cardiac shock-wave therapy based on the time reversal cavity concept. In particular, this device allows the emission of high intensity ultrasound pulses, and provides 3D electronical steering of the therapy focal spot in a large volume. After a thorough optimisation process, this device was capable of creating well controlled mechanical lesions over a 2 000 cm3 region of interest. To tackle the challenge of ultrasound propagation through the rib cage, we developed an adaptive focusing method (DORT method through a time reversal cavity), and implemented it in a 2D prototype of the device. With this method, we not only could build an adaptive ultrasonic wavefront propagating preferentially through the intercostal spaces, but due to time reversal cavities properties, we could also increase the peak pressure obtained on target.Finally, we pushed our work on adaptive focusing further, and considered the case of transcranial imaging. For this application, we chose to use the time reversal of speckle noise technique, to correct the aberrations induced by the skull. In numerical simulations, we were able to derive the phase and amplitude modulations induced by the bones, and could improve the contrast and resolution of a B-mode image.