Re-setting the biologic rationale for thermal therapy

In vivo particle tracking and photothermal ablation using plasmon-resonant gold nanostars

Gold nanostars offer unique plasmon properties that efficiently transduce photon energy into heat for photothermal therapy. Nanostars, with their small core size and multiple long thin branches, exhibit high absorption cross-sections that are tunable in the near-infrared region with relatively low scattering effect, making them efficient photothermal transducers. Here, we demonstrate particle tracking and photothermal ablation both in vitro and in vivo. Using SKBR3 breast cancer cells incubated with bare nanostars, we observed photothermal ablation within 5 minutes of irradiation (980-nm continuous-wave laser, 15 W/cm2). On a mouse injected systemically with PEGylated nanostars for 2 days, extravasation of nanostars was observed and localized photothermal ablation was demonstrated on a dorsal window chamber within 10 minutes of irradiation (785-nm continuous-wave laser, 1.1 W/cm2). These preliminary results of plasmon-enhanced localized hyperthermia are encouraging and have illustrated the potential of gold nanostars as efficient photothermal agents in cancer therapy.

FROM THE CLINICAL EDITOR

Gold nanostars are tunable in the near-infrared region with low scattering, thus enable photothermal therapy. Encouraging preliminary results of plasmon-enhanced localized hyperthermia both in vitro and in vivo demonstrate that Au nanostars may be efficient photothermal agents for cancer therapy.

Ultrasound increases nanoparticle delivery by reducing intratumoral pressure and increasing transport in epithelial and epithelial-mesenchymal transition tumors

Acquisition of the epithelial-mesenchymal transition (EMT) tumor phenotype is associated with impaired chemotherapeutic delivery and a poor prognosis. In this study, we investigated the application of therapeutic ultrasound methods available in the clinic to increase nanotherapeutic particle accumulation in epithelial and EMT tumors by labeling particles with a positron emission tomography tracer. Epithelial tumors were highly vascularized with tight cell-cell junctions, compared with EMT tumors where cells displayed an irregular, elongated shape with loosened cell-cell adhesions and a reduction in E-cadherin and cytokeratins 8/18 and 19. Without ultrasound, the accumulation of liposomal nanoparticles administered to tumors in vivo was approximately 1.5 times greater in epithelial tumors than EMT tumors. When ultrasound was applied, both nanoaccumulation and apparent tumor permeability were increased in both settings. Notably, ultrasound effects differed with thermal and mechanical indices, such that increasing the thermal ultrasound dose increased nanoaccumulation in EMT tumors. Taken together, our results illustrate how ultrasound can be used to enhance nanoparticle accumulation in tumors by reducing their intratumoral pressure and increasing their vascular permeability.

Non-invasive vesicoureteral reflux detection: heating risk studies for a new device

OBJECTIVE

To investigate a novel non-invasive device developed to warm bladder urine and to measure kidney temperature to detect vesicoureteral reflux.

MATERIALS AND METHODS

Microwave antennas focused energy within the bladder. Phantom experiments measured the results. The heating protocol was optimized in an in-vivo porcine model, and then tested once, twice and three times consecutively in three pigs followed by pathologic examinations.

RESULTS

Computer simulations showed a dual concentric conductor square slot antenna to be the best. Phantom studies revealed that this antenna easily heated a bladder phantom without over heating intervening layers. In-vivo a bladder heating protocol of 3 min with 30 W each to two adjacent antennas 45 s on 15 s off followed by 15 min of 15 s on and 45 s off was sufficient. When pigs were heated once, twice and three times with this heating protocol, pathologic examination of all tissues in the heated area showed no thermal changes. More intensive heating in the animal may have resulted in damage to muscle fibers in the anterior abdominal wall.

CONCLUSIONS

Selective warming of bladder urine was successfully demonstrated in phantom and animals. Localized heating for this novel vesicoureteral reflux device requires low-power levels and should be safe for humans.

Non-invasive, quantitative monitoring of hyperthermia-induced EGFR activation in xenograft tumours

PURPOSE

To examine the molecular mechanism of cellular EGFR activation during hyperthermia treatment.

MATERIALS AND METHODS

EGR activities in tumour cells were quantified through the use of a recently developed split-luciferase-based EGFR reporter system which allowed us to monitor EGFR activation in vitro as well as in vivo in a non-invasive manner.

RESULTS

We found that hyperthermia treatment of MDA-MB231 breast cancer cells resulted in a strong induction of EGFR activity in tissue culture as well as in xenograft tumours. Furthermore, we found that this induction is mediated by the heat shock protein Hsp90. Administration of the specific Hsp90 inhibitor geldanamycin as well as RNAi directed against HSP90 effectively inhibited EGFR activation, suggesting an essential role for Hsp90 in hyperthermia-induced EGFR activation. In addition, cells treated with geldanamycin were sensitised to heat treatment, suggesting that adding Hsp90 inhibitors to hyperthermia regimens might have a beneficial effect for cancer treatment.

CONCLUSIONS

Our bioluminescent imaging reporter provided a powerful tool to examine hyperthermia-induced EGFR activation in vitro as well as in vivo. Hsp90 was found to be a key factor mediating heat-induced EGFR activation in tumour cells.

Fast ultrasound beam prediction for linear and regular two-dimensional arrays

Real-time beam predictions are highly desirable for the patient-specific computations required in ultrasound therapy guidance and treatment planning. To address the longstanding issue of the computational burden associated with calculating the acoustic field in large volumes, we use graphics processing unit (GPU) computing to accelerate the computation of monochromatic pressure fields for therapeutic ultrasound arrays. In our strategy, we start with acceleration of field computations for single rectangular pistons, and then we explore fast calculations for arrays of rectangular pistons. For single-piston calculations, we employ the fast near-field method (FNM) to accurately and efficiently estimate the complex near-field wave patterns for rectangular pistons in homogeneous media. The FNM is compared with the Rayleigh-Sommerfeld method (RSM) for the number of abscissas required in the respective numerical integrations to achieve 1%, 0.1%, and 0.01% accuracy in the field calculations. Next, algorithms are described for accelerated computation of beam patterns for two different ultrasound transducer arrays: regular 1-D linear arrays and regular 2-D linear arrays. For the array types considered, the algorithm is split into two parts: 1) the computation of the field from one piston, and 2) the computation of a piston-array beam pattern based on a pre-computed field from one piston. It is shown that the process of calculating an array beam pattern is equivalent to the convolution of the single-piston field with the complex weights associated with an array of pistons. Our results show that the algorithms for computing monochromatic fields from linear and regularly spaced arrays can benefit greatly from GPU computing hardware, exceeding the performance of an expensive CPU by more than 100 times using an inexpensive GPU board. For a single rectangular piston, the FNM method facilitates volumetric computations with 0.01% accuracy at rates better than 30 ns per field point. Furthermore, we demonstrate array calculation speeds of up to 11.5 X 10(9) field-points per piston per second (0.087 ns per field point per piston) for a 512-piston linear array. Beam volumes containing 256(3) field points are calculated within 1 s for 1-D and 2-D arrays containing 512 and 20(2) pistons, respectively, thus facilitating future real-time thermal dose predictions.

Endocervical ultrasound applicator for integrated hyperthermia and HDR brachytherapy in the treatment of locally advanced cervical carcinoma

PURPOSE

The clinical success of hyperthermia adjunct to radiotherapy depends on adequate temperature elevation in the tumor with minimal temperature rise in organs at risk. Existing technologies for thermal treatment of the cervix have limited spatial control or rapid energy falloff. The objective of this work is to develop an endocervical applicator using a linear array of multisectored tubular ultrasound transducers to provide 3-D conformal, locally targeted hyperthermia concomitant to radiotherapy in the uterine cervix. The catheter-based device is integrated within a HDR brachytherapy applicator to facilitate sequential and potentially simultaneous heat and radiation delivery.

METHODS

Treatment planning images from 35 patients who underwent HDR brachytherapy for locally advanced cervical cancer were inspected to assess the dimensions of radiation clinical target volumes (CTVs) and gross tumor volumes (GTVs) surrounding the cervix and the proximity of organs at risk. Biothermal simulation was used to identify applicator and catheter material parameters to adequately heat the cervix with minimal thermal dose accumulation in nontargeted structures. A family of ultrasound applicators was fabricated with two to three tubular transducers operating at 6.6-7.4 MHz that are unsectored (360 degrees), bisectored (2 x 180 degrees), or trisectored (3 x 120 degrees) for control of energy deposition in angle and along the device length in order to satisfy anatomical constraints. The device is housed in a 6 mm diameter PET catheter with cooling water flow for endocervical implantation. Devices were characterized by measuring acoustic efficiencies, rotational acoustic intensity distributions, and rotational temperature distributions in phantom.

RESULTS

The CTV in HDR brachytherapy plans extends 20.5 +/- 5.0 mm from the endocervical tandem with the rectum and bladder typically <8 mm from the target boundary. The GTV extends 19.4 +/- 7.3 mm from the tandem. Simulations indicate that for 60 min treatments the applicator can heat to 41 degrees C and deliver > 5EM(43 degrees C) over 4-5 cm diameter with Tmax < 45 degrees C and 1 kg m(-3) s(-1) blood perfusion. The 41 degrees C contour diameter is reduced to 3-4 cm at 3 kg m(-3) s(-1) perfusion. Differential power control to transducer elements and sectors demonstrates tailoring of heating along the device length and in angle. Sector cuts are associated with a 14-47 degrees acoustic dead zone, depending on cut width, resulting in a approximately 2-4 degrees C temperature reduction within the dead zone below Tmax. Dead zones can be oriented for thermal protection of the rectum and bladder. Fabricated devices have acoustic efficiencies of 33.4%-51.8% with acoustic output that is well collimated in length, reflects the sectoring strategy, and is strongly correlated with temperature distributions.

CONCLUSIONS

A catheter-based ultrasound applicator was developed for endocervical implantation with locally targeted, 3-D conformal thermal delivery to the uterine cervix. Feasibility of heating clinically relevant target volumes was demonstrated with power control along the device length and in angle to treat the cervix with minimal thermal dose delivery to the rectum and bladder.

Magnetic resonance imaging: a potential tool in assessing the addition of hyperthermia to neoadjuvant therapy in patients with locally advanced breast cancer

The poor overall survival for patients with locally advanced breast cancers has led over the past decade to the introduction of numerous neoadjuvant combined therapy regimens to down-stage the disease before surgery. At the same time, more evidence suggests the need for treatment individualisation with a wide variety of new targets for cancer therapeutics and also multi modality therapies. In this context, early determination of whether the patient will fail to respond can enable the use of alternative therapies that can be more beneficial. The purpose of this review is to examine the potential role of magnetic resonance imaging (MRI) in early prediction of treatment response and prognosis of overall survival in locally advanced breast cancer patients enrolled on multi modality therapy trials that include hyperthermia. The material is organised with a review of dynamic contrast (DCE)-MRI and diffusion weighted (DW)-MRI for characterisation of phenomenological parameters of tumour physiology and their potential role in estimating therapy response. Most of the work published in this field has focused on responses to neoadjuvant chemotherapy regimens alone, so the emphasis will be there, however the available data that involves the addition of hyperthermia to the regimen will be discussed The review will also include future directions that include the potential use of MRI imaging techniques in establishing the role of hyperthermia alone in modifying breast tumour microenvironment, together with specific challenges related to performing such studies.

Present and future technology for simultaneous superficial thermoradiotherapy of breast cancer

This paper reviews systems and techniques to deliver simultaneous thermoradiotherapy of breast cancer. It first covers the clinical implementation of simultaneous delivery of superficial (microwave or ultrasound) hyperthermia and external photon beam radiotherapy, first using a Cobalt-60 teletherapy unit and later medical linear accelerators. The parallel development and related studies of the Scanning Ultrasound Reflector Linear Arrays System (SURLAS), an advanced system specifically designed and developed for simultaneous thermoradiotherapy, follows. The performance characteristics of the SURLAS are reviewed and power limitation problems at high acoustic frequencies (>3 MHz) are discussed along with potential solutions. Next, the feasibility of simultaneous SURLAS hyperthermia and intensity modulated radiation therapy/image-guided radiotherapy (IMRT/IGRT) is established based on published and newly presented studies. Finally, based on the encouraging clinical results thus far, it is concluded that new trials employing the latest technologies are warranted along with further developments in treatment planning.

Improved hyperthermia treatment control using SAR/temperature simulation and PRFS magnetic resonance thermal imaging

PURPOSE

This article explores the feasibility of using coupled electromagnetic and thermodynamic simulations to improve planning and control of hyperthermia treatments for cancer. The study investigates the usefulness of preplanning to improve heat localisation in tumour targets in treatments monitored with PRFS-based magnetic resonance thermal imaging (MRTI).

METHODS

Heating capabilities of a cylindrical radiofrequency (RF) mini-annular phased array (MAPA) applicator were investigated with electromagnetic and thermal simulations of SAR in homogeneous phantom models and two human leg sarcomas. High frequency structure simulator (HFSS) (Ansoft) was used for electromagnetic simulations and SAR patterns were coupled into EPhysics (Ansoft) for thermal modelling with temperature-dependent variable perfusion. Simulations were accelerated by integrating tumour-specific anatomy into a pre-gridded whole body tissue model. To validate this treatment planning approach, simulations were compared with MR thermal images in both homogenous phantoms and heterogeneous tumours.

RESULTS

SAR simulations demonstrated excellent agreement with temperature rise distributions obtained with MR thermal imaging in homogeneous phantoms and clinical treatments of large soft-tissue sarcomas. The results demonstrate feasibility of preplanning appropriate relative phases of antennas for localising heat in tumour.

CONCLUSIONS

Advances in the accuracy of computer simulation and non-invasive thermometry via MR thermal imaging have provided powerful new tools for optimisation of clinical hyperthermia treatments. Simulations agree well with MR thermal images in both homogeneous tissue models and patients with lower leg tumours. This work demonstrates that better quality hyperthermia treatments should be possible when simplified hybrid model simulations are performed routinely as part of the clinical pretreatment plan.

Thermal enhancement with optically activated gold nanoshells sensitizes breast cancer stem cells to radiation therapy

Breast cancer metastasis and disease recurrence are hypothesized to result from residual cancer stem cells, also referred to as tumor-initiating cells, which evade initial treatment. Using both syngeneic mouse and human xenograft models of triple-negative breast cancer, we have demonstrated that a subpopulation enriched in cancer stem cells was more resistant to treatment with 6 gray of ionizing radiation than the bulk of the tumor cells, and accordingly their relative proportion increased 48 to 72 hours after ionizing radiation treatment. In contrast, we achieved a larger reduction in tumor size without a concomitant increase in the percentage of cancer stem cells by treating with local hyperthermia for 20 minutes at 42°C after ionizing radiation using intravenously administered, optically activated gold nanoshells. Forty-eight hours after treatment, cells derived from the tumors treated with ionizing radiation plus hyperthermia exhibited both a marked decrease in tumorigenicity and a more differentiated phenotype than mock- and ionizing radiation-treated tumors. Thus, we have confirmed that these cancer stem cells are responsible for accelerated repopulation in vivo and demonstrated that hyperthermia sensitizes this cell population to radiation treatment. These findings suggest that local hyperthermia delivered by gold nanoshells plus radiation can eliminate radioresistant breast cancer stem cells.

Hyperthermia combined with radiation for the treatment of locally advanced prostate cancer: long-term results from Dana-Farber Cancer Institute study 94-153

BACKGROUND

The authors present long-term results from a phase 2 study that assessed the efficacy of transrectal ultrasound hyperthermia plus radiation with or without androgen suppression for the treatment of locally advanced prostate cancer.

METHODS

Patients with clinical T2b-T3bN0M0 disease (according to 1992 American Joint Committee on Cancer [AJCC] criteria) received radiation plus 2 transrectal ultrasound hyperthermia treatments. After the first 4 patients, 6 months of androgen suppression were allowed. The study was designed to assess absolute improvement in the 2-year disease-free survival rate compared with the short-term androgen suppression arm in Radiation Therapy Oncology Group (RTOG) study 92-02.

RESULTS

Thirty-seven patients received a total of 72 hyperthermia treatments. The mean cumulative equivalent minutes (CEM) T₉₀ 43°C was 8.4 minutes. According to the 1992 AJCC classification, there were 19 patients with T2b tumors, 8 patients with T2c tumors, 5 patients with T3a tumors, and 5 patients with T3b tumors. The median Gleason score was 7 (range, 6-9), and the median prostate-specific antigen (PSA) level was 13.3 ng/mL (range, 2-65 ng/mL). Thirty-three patients received androgen suppression. At a median follow-up of 70 months (range, 18-110 months), the 7-year overall survival rate was 94%, and 61% of patients remained failure free (according to the American Society for Therapeutic Radiology and Oncology definition for failure free survival). The absolute rate of disease-free survival at 2 years, which was the primary study endpoint, improved significantly (84%) compared with a rate of 64% for similar patients on the 4-month androgen suppression arm of RTOG 92-02. When Phoenix criteria (PSA nadir + 2 ng/mL) were used to define biochemical failure, 89% of patients were failure free at 2 years.

CONCLUSIONS

Hyperthermia combined with radiation for the treatment of locally advanced prostate cancer appeared to be promising. The current results indicated that further study of hyperthermia for the treatment of prostate cancer with optimal radiation and systemic therapy is warranted.

The functional roles of poly(ethylene glycol)-lipid and lysolipid in the drug retention and release from lysolipid-containing thermosensitive liposomes in vitro and in vivo

Triggered release of liposomal contents following tumor accumulation and mild local heating is pursued as a means of improving the therapeutic index of chemotherapeutic drugs. Lysolipid-containing thermosensitive liposomes (LTSLs) are composed of dipalmitoylphosphatidylcholine (DPPC), the lysolipid monostearoylphosphatidylcholine (MSPC), and poly(ethylene glycol)-conjugated distearoylphosphatidylethanolamine (DSPE-PEG(2000)). We investigated the roles of DSPE-PEG(2000) and lysolipid in the functional performance of the LTSL-doxorubicin formulation. Varying PEG-lipid concentration (0-5 mol%) or bilayer orientation did not affect the release; however, lysolipid (0-10 mol%) had a concentration-dependent effect on drug release at 42 degrees C in vitro. Pharmacokinetics of various LTSL formulations were compared in mice with body temperature controlled at 37 degrees C. As expected, incorporation of the PEG-lipid increased doxorubicin plasma half-life; however, PEG-lipid orientation (bilayer vs. external leaflet) did not significantly improve circulation lifetime or drug retention in LTSL. Approximately 70% of lysolipid was lost within 1 h postinjection of LTSL, which could be due to interactions with the large membrane pool of the biological milieu. Considering that the present LTSL-doxorubicin formulation exhibits significant therapeutic activity when used in conjunction with mild heating, our current study provided critical insights into how the physicochemical properties of LTSL can be tailored to achieve better therapeutic activity.

Diverse immune mechanisms may contribute to the survival benefit seen in cancer patients receiving hyperthermia

There is increasing documentation of significant survival benefits achieved in cancer patients treated with hyperthermia in combination with radiation and/or chemotherapy. Most evidence collected regarding the mechanisms by which hyperthermia positively influences tumor control has centered on in vitro data showing the ability of heat shock temperatures (usually above 42 degrees C) to result in radio- or chemosensitization. However, these high temperatures are difficult to achieve in vivo, and new thermometry data in patients reveal that much of the tumor and surrounding region is only heated to 40-41 degrees C or less as a result of vascular drainage from the target zone of the heated tumor. Thus, there is now a growing appreciation of a role for mild hyperthermia in the stimulation of various arms of the immune system in contributing to long term protection from tumor growth. Indeed, a review of recent literature suggests the existence of an array of thermally sensitive functions which may exist naturally to help the organism to establish a new "set point" of immune responsiveness during fever. This review summarizes recent literature identifying complex effects of temperature on immune cells and potential cellular mechanisms by which increased temperature may enhance immune surveillance.

Use of combined radiation and hyperthermia for gynecological cancer

PURPOSE OF REVIEW

We reviewed all literature on the clinical use of combined radiation and hyperthermia for gynecologic malignancies.

RECENT FINDINGS

Combined radiation and hyperthermia should be considered an alternative to chemoradiation for patients with locally advanced cervix cancer and be the first treatment of choice for these patients when radiation cannot be combined with chemotherapy. Several randomized trials have shown an improvement by adding hyperthermia to radiation that is comparable to the improvement found with the addition of chemotherapy to radiation. Hyperthermia does not seem to add to treatment-induced toxicity and the results of hyperthermia are consistent even at 12 years follow-up and could be reproduced in a large, unselected group of cervix cancer patients. A novel indication for combined radiotherapy and hyperthermia is vaginal cancer. Recently, a cohort study showed that the addition of hyperthermia to radiation seems to improve overall survival for patients with vaginal cancer International Federation of Gynecology and Obstetrics stage III.

SUMMARY

Combined radiation and hyperthermia should be considered for patients with locally advanced cervix cancer (International Federation of Gynecology and Obstetrics stage IIb and upwards) as an alternative to chemoradiation for patients with a contraindication for chemotherapy. For other patients, the optimal treatment combination is the subject of randomized trials. For vaginal cancer, a prospective registration study is currently ongoing.

Spatial and temporal-controlled tissue heating on a modified clinical ultrasound scanner for generating mild hyperthermia in tumors

A new system is presented for generating controlled tissue heating with a clinical ultrasound scanner, and initial in vitro and in vivo results are presented that demonstrate both transient and sustained heating in the mild-hyperthermia range of 37 ( degrees )C-42 ( degrees )C. The system consists of a Siemens Antares ultrasound scanner, a custom dual-frequency three-row transducer array and an external temperature feedback control system. The transducer has two outer rows that operate at 1.5 MHz for tissue heating and a center row that operates at 5 MHz for B-mode imaging to guide the therapy. We compare the field maps obtained using a hydrophone against calculations of the ultrasound beam based on monochromatic and linear assumptions. Using the finite-difference time-domain (FDTD) method, we compare predicted time-dependent thermal profiles to measured profiles for soy tofu as a tissue-mimicking phantom. In vitro results show differential heating of 6 ( degrees )C for chicken breast and tofu. In vivo tests of the system were performed on three mice bearing Met-1 tumors, which is a model of aggressive, metastatic, and highly vascular breast cancer. In superficially implanted tumors, we demonstrate controlled heating to 42 ( degrees )C. We show that the system is able to maintain the temperature to within 0.1 ( degrees )C of the desired temperature both in vitro and in vivo.

An analysis of the origin of differences between measured and simulated fields produced by a 15-element ultrasound phased array

Modeling provides an attractive approach for the design of phased array ultrasound transducers for hyperthermia. However, measurements on physical transducers reveal differences from the idealized field profiles predicted by simulation. In this paper we report a method of analyzing the origins of these differences. The measured performance of a 15-element sparse phased array is described and compared with simulated fields calculated using the point source method. It highlighted two notable differences: First, that the focal region was located closer to the surface of the physical transducer than in the simulated fields; and second, that numerous intensity maxima were present between the surface of the transducer and the focal zone in the experimental data, but not in the simulated fields. We identified six factors that could potentially affect the field but were not taken into account by the default simulations, and we performed a sensitivity analysis on these: (i) Variation in the amplitude of the output from each element, (ii) the presence of square-wave harmonics in the drive signals, (iii) nonpistonlike vibration of elements, (iv) quantization of the applied phases, (v) errors in the spatial positioning of each element; and (vi) interelement cross-coupling. Both the independent impact of each factor and the interactions between multiple factors were analyzed by using a full-factorial experimental design composed of 64 (2(6)) simulations. The results indicated that nonpistonlike motion of elements is likely to be the primary cause of differences between the measured and modelled fields. Determination of the precise vibrational modes of elements in an array is complex and would require full finite element analysis. However, the simple vibrational mode considered within the present work, corresponding to the addition of a surface Rayleigh wave originating at the element center and propagating radially, produced simulation results that were in good agreement with the measured data.

A literature survey on indicators for characterisation and optimisation of SAR distributions in deep hyperthermia, a plea for standardisation

PURPOSE

To evaluate the predictive value of SAR indicators by assessing the correlation of a SAR indicator with the corresponding predicted temperature. Ultimately, this should lead to a number of verified SAR indicators for characterization and optimization of a predicted SAR distribution.

METHODS

A literature survey is followed by an evaluation of the SAR indicators on their functionality, using a set of heuristic classification criteria. To obtain an objective assessment of the predictive value for SAR characterisation, all SAR indicators are evaluated by correlating the value of the SAR indicator to the predicted target temperature when heated with the BSD2000 Sigma 60 applicator. Two methods were followed. First, the specificity of the SAR indicator to target temperature was assessed for each of the 36 patient-specific models, using 30 randomly chosen phase and amplitude settings. Secondly, each SAR indicator was used as a goal function to assess its suitability for optimisation purposes.

RESULTS

Only a selected number of SAR indicators correlate well with tumour/target-temperature. Hence, for target-related properties, an adequate set of SAR indicators is found in the literature. For hotspots, modifications are desirable. For optimisation purposes, improved objective functions have been defined.

CONCLUSIONS

From the correlation of the SAR indicators with tumour temperature, a preferred set of SAR indicators is derived: For target heating, 'average SAR ratio', 'Hotspot-target SAR ratio', and 'homogeneity coefficient' provide suitable objective criteria, while for hotspot reduction, 'Hotspot-target SAR ratio' is considered the most useful indicator. For optimisation procedures, 'Hotspot-target SAR ratio' is currently the most suitable objective function.

Absolute temperature imaging using intermolecular multiple quantum MRI

PURPOSE

A review of MRI temperature imaging methods based on intermolecular multiple quantum coherences (iMQCs) is presented. Temperature imaging based on iMQCs can provide absolute temperature maps that circumvent the artefacts that other proton frequency shift techniques suffer from such as distortions to the detected temperature due to susceptibility changes and magnetic field inhomogeneities. Thermometry based on iMQCs is promising in high-fat tissues such as the breast, since it relies on the fat signal as an internal reference. This review covers the theoretical background of iMQCs, and the necessary adaptations for temperature imaging using iMQCs.

MATERIALS AND METHODS

Data is presented from several papers on iMQC temperature imaging. These studies were done at 7T in both phantoms and in vivo. Results from phantoms of cream (homogeneous mixture of water and fat) are presented as well as in vivo temperature maps in obese mice.

RESULTS

Thermometry based on iMQCs offers the potential to provide temperature maps which are free of artefacts due to susceptibility and magnetic field inhomogeneities, and detect temperature on an absolute scale.

CONCLUSIONS

The data presented in the papers reviewed highlights the promise of iMQC-based temperature imaging in fatty tissues such as the breast. The change in susceptibility of fat with temperature makes standard proton frequency shift methods (even with fat suppression) challenging and iMQC-based imaging offers an alternative approach.

An optical and microPET assessment of thermally-sensitive liposome biodistribution in the Met-1 tumor model: Importance of formulation

The design of delivery vehicles that are stable in circulation but can be activated by exogenous energy sources is challenging. Our goals are to validate new imaging methods for the assessment of particle stability, to engineer stable and activatable particles and to assess accumulation of a hydrophilic model drug in an orthotopic tumor. Here, liposomes were injected into the tail vein of FVB mice containing bilateral Met-1 tumors and imaged in vivo using microPET and optical imaging techniques. Cryo-electron microscopy was applied to assess particle shape prior to injection, ex vivo fluorescence images of dissected tissues were acquired, excised tissue was further processed with a cell-digest preparation and assayed for fluorescence. We find that for a stable particle, in vivo tumor images of a hydrophilic model drug were highly correlated with PET images of the particle shell and ex vivo fluorescence images of processed tissue, R(2)=0.95 and R(2)=0.99 respectively. We demonstrate that the accumulation of a hydrophilic model drug is increased by up to 177 fold by liposomal encapsulation, as compared to accumulation of the drug at 24 hours.

Frontiers in biotransport: water transport and hydration

Biotransport, by its nature, is concerned with the motions of molecules in biological systems while water remains as the most important and the most commonly studied molecule across all disciplines. In this review, we focus on biopreservation and thermal therapies from the perspective of water, exploring how its molecular motions, properties, kinetic, and thermodynamic transitions govern biotransport phenomena and enable preservation or controlled destruction of biological systems.

Frontiers in Biotransport: Water Transport and Hydration

Biotransport, by its nature, is concerned with the motions of molecules in biological systems while water remains as the most important and the most commonly studied molecule across all disciplines. In this review, we focus on biopreservation and thermal therapies from the perspective of water, exploring how its molecular motions, properties, kinetic, and thermodynamic transitions govern biotransport phenomena and enable preservation or controlled destruction of biological systems.

Down-regulating cold shock protein genes impairs cancer cell survival and enhances chemosensitivity

The microenvironment of the cancer cell is pivotal to its phenotypic regulation. One of the central components of the microenvironment is temperature. An elevation in environmental temperature has been shown to increase the cancer cell's susceptibility to chemo- and radiation therapy. The goal of the studies described here was to identify some of the pathways that are modified by a mild increase in temperature in cancer cells. Using prostate cancer cells as a model system we found that in addition to the well described and anticipated up-regulation of the heat shock family of proteins, there is a significant down-regulation of certain members of the "cold shock" family of proteins such as, RNA binding motif protein 3 (RBM3) and cold inducible RNA binding protein (CIRBP). siRNA-mediated down-regulation of the cold shock protein (CSP) encoding mRNAs dramatically attenuates cell survival in the absence of any heat application. Furthermore, we also demonstrate that knocking down the CSPs can enhance the therapeutic response of prostate cancer cells to chemotherapy. Our findings suggest that down-regulating CSPs in cancer cells may "mimic" the stress response the cells experience when exposed to heat treatment rendering them more susceptible to therapy. Thus, the pharmacological modulation of RBM3 and CIRBP may represent novel therapeutic approaches for prostate cancer.

Integrated Treatment with Hyperthermia and Chemotherapy for Non-Muscle Invasive Bladder Cancer

Oncology-applied hyperthermia is a very old form of therapy. In recent years hyperthermia has been investigated with the aim of improving the treatment for non-muscle invasive bladder cancer to prevent relapse and disease progression, in association with mitomycin-C, a well-known chemotherapeutic agent, to enhance its effect. Target patients are those with non-muscle invasive transitional cell carcinoma, showing medium (Ta-T1, G1–2, multifocal, diameter >3 cm) or high (T1, G3, multifocal or rapidly relapsing, CIS) risk for recurrence or progression.

The treatment may be prophylactic following tumor eradication, or ablative when tumor cannot be otherwise eradicated.

Several studies have shown the benefits of thermochemotherapy with lower risk for relapse than other treatment options, and 66–80% complete responses following ablative treatment. This association of treatments has a synergic therapeutic effect, higher than administering hyperthermia and drug therapy as single treatment.

A High-Resolution Voxel Model for Predicting Local Tissue Temperatures in Humans Subjected to Warm and Hot Environments

This work describes and presents results from a new three-dimensional whole-body model of human thermoregulation. The model has been implemented using a version of the “Brooks Man” anatomical data set, consisting of 1.3×108 cubic volume elements (voxels) measuring 0.2 cm/side. The model simulates thermoregulation through passive mechanisms (metabolism, blood flow, respiration, and transpiration) and active mechanisms (vasodilatation, vasoconstriction, sweating, and shivering). Compared with lumped or compartment models, a voxel model is capable of high spatial resolution and can capture a level of anatomical detail not achievable otherwise. A high spatial resolution model can predict detailed heating patterns from localized or nonuniform heating patterns, such as from some radio frequency sources. Exposures to warm and hot environments (ambient temperatures of 33–48°C) were simulated with the current voxel model and with a recent compartment model. Results from the two models (core temperature, skin temperature, metabolic rate, and evaporative cooling rate) were compared with published experimental results obtained under similar conditions. Under the most severe environmental conditions considered (47.8°C, 27% RH for 2 h), the voxel model predicted a rectal temperature increase of 0.56°C, compared with a core temperature increase of 0.45°C from the compartment model and an experimental mean rectal temperature increase of 0.6°C. Similar, good agreement was noted for other thermal variables and under other environmental conditions. Results suggest that the voxel model is capable of predicting temperature response (core temperature and skin temperature) to certain warm or hot environments, with accuracy comparable to that of a compartment model. In addition, the voxel model is able to predict internal tissue temperatures and surface temperatures, over time, with a level of specificity and spatial resolution not achievable with compartment models. The development of voxel models and related computational tools may be useful for thermal dosimetry applications involving mild temperature hyperthermia and for the assessment of safe exposure to certain nonionizing radiation sources.

Challenges in the development of magnetic particles for therapeutic applications

Certain iron-based particle formulations have useful magnetic properties that, when combined with low toxicity and desirable pharmacokinetics, encourage their development for therapeutic applications. This mini-review begins with background information on magnetic particle use as MRI contrast agents and the influence of material size on pharmacokinetics and tissue penetration. Therapeutic investigations, including (1) the loading of bioactive materials, (2) the use of stationary, high-gradient (HG) magnetic fields to concentrate magnetic particles in tissues or to separate material bound to the particles from the body, and (3) the application of high power alternating magnetic fields (AMF) to generate heat in magnetic particles for hyperthermic therapeutic applications are then surveyed. Attention is directed mainly to cancer treatment, as selective distribution to tumors is well-suited to particulate approaches and has been a focus of most development efforts. While magnetic particles have been explored for several decades, their use in therapeutic products remains minimal; a discussion of future directions and potential ways to better leverage magnetic properties and to integrate their use into therapeutic regimens is discussed.

Influence of PEG-conjugated hemoglobin on tumor oxygenation and response to chemotherapy

Hypoxic tumors are significantly more malignant, metastatic, radio- and chemoresistant. The use of artificial oxygen carriers represents a new approach to the problem of hypoxia. In the present study, female athymic BALB/c nude mice bearing the cervical carcinoma were untreated or treated with cisplatin to determine whether administration of artificial oxygen carrier (PEG-conjugated Hemoglobin, PEG-Hb) could improve the tumor oxygenation and enhance the anti-tumor efficacy of cisplatin. Pimonidazole staining was employed to detect tumor tissue oxygenation status. We found that the application of a higher dose (0.6 g/kg) PEG-Hb could significantly ameliorate the hypoxic condition in cervical carcinoma xenograft models. Co-administration of PEG-Hb (0.6 g/kg) with cisplatin produced significant tumor growth inhibition and pro-apoptotic and anti-proliferative effects as compared to cisplatin alone. These suggest the evaluated PEG-Hb in this experiment has positive effects on cisplatin or cisplatin-based chemotherapy, and further work to optimize its application is warranted.

Ecological therapy for cancer: defining tumors using an ecosystem paradigm suggests new opportunities for novel cancer treatments

We propose that there is an opportunity to devise new cancer therapies based on the recognition that tumors have properties of ecological systems. Traditionally, localized treatment has targeted the cancer cells directly by removing them (surgery) or killing them (chemotherapy and radiation). These modes of therapy have not always been effective because many tumors recur after these therapies, either because not all of the cells are killed (local recurrence) or because the cancer cells had already escaped the primary tumor environment (distant recurrence). There has been an increasing recognition that the tumor microenvironment contains host noncancer cells in addition to cancer cells, interacting in a dynamic fashion over time. The cancer cells compete and/or cooperate with nontumor cells, and the cancer cells may compete and/or cooperate with each other. It has been demonstrated that these interactions can alter the genotype and phenotype of the host cells as well as the cancer cells. The interaction of these cancer and host cells to remodel the normal host organ microenvironment may best be conceptualized as an evolving ecosystem. In classic terms, an ecosystem describes the physical and biological components of an environment in relation to each other as a unit. Here, we review some properties of tumor microenvironments and ecological systems and indicate similarities between them. We propose that describing tumors as ecological systems defines new opportunities for novel cancer therapies and use the development of prostate cancer metastases as an example. We refer to this as "ecological therapy" for cancer.

Accurate temperature imaging based on intermolecular coherences in magnetic resonance

Conventional magnetic resonance methods that provide interior temperature profiles, which find use in clinical applications such as hyperthermic therapy, can develop inaccuracies caused by the inherently inhomogeneous magnetic field within tissues or by probe dynamics, and work poorly in important applications such as fatty tissues. We present a magnetic resonance method that is suitable for imaging temperature in a wide range of environments. It uses the inherently sharp resonances of intermolecular zero-quantum coherences, in this case flipping up a water spin while flipping down a nearby fat spin. We show that this method can rapidly and accurately assign temperatures in vivo on an absolute scale.

Regional hyperthermia of the abdomen in conjunction with chemotherapy for peritoneal carcinomatosis: evaluation of two annular-phased-array applicators

BACKGROUND

Peritoneal carcinomatosis is a stage of gynecological and gastrointestinal malignancies with poor prognosis. Options for enhancing the effect of standard chemotherapy, such as aggressive surgery and intraperitoneal chemotherapy, have limitations. In this phase I/II study, we evaluated regional hyperthermia of the pelvis and abdomen using the annular-phased-array technique as an adjunct to chemotherapy.

METHODS

Forty-five patients with peritoneal carcinomatosis (with or without liver metastases) in colorectal cancer (CRC) (n = 16), ovarian cancer (OC) (n = 17), or gastric/pancreatic/biliary cancer (n = 12) underwent standard chemotherapy and regional hyperthermia. Most CRC patients received second-line chemotherapy. All OC patients were platinum resistant. Regional hyperthermia was applied using a SIGMA-60 applicator (OC), a SIGMA-Eye/MR applicator (CRC), or various ring applicators (gastric/pancreatic/biliary cancer).

RESULTS

Abdominal regional hyperthermia was well tolerated, with acceptable acute discomfort and no long-term morbidity. The SIGMA-Eye/MR applicator achieved higher systemic temperatures (associated with higher systemic stress) and more effective heating of the upper abdomen; the SIGMA-60 applicator achieved higher temperatures (and power densities) in the pelvis. Three-year overall survival was encouraging for patients with CRC (22%) and OC (29%) but not gastric/pancreatic/biliary cancer. For the SIGMA-60 applicator (patients with OC), higher measured temperatures at the vaginal stump correlated with better outcome. CONCLUSIONS. The SIGMA-60 and SIGMA-Eye/MR applicators are feasible for abdominal heating and have low toxicity. The SIGMA-60 applicator is specifically suitable for malignancies with high pelvic burden; the SIGMA-Eye/MR applicator better heats the upper abdomen, including the liver. Further randomized investigations are warranted.

Chromosome fragments have the potential to predict hyperthermia-induced radio-sensitization in two different human tumor cell lines

Cellular radiosensitivity, assessed by loss of clonogenicity, has been shown to correlate with the number of radiation-induced chromosomal aberrations. Also an increased radiosensitivity by hyperthermia has been shown to correlate with an increase in chromosomal aberrations. Therefore, determination of the number of chromosomal aberrations might be used as an assay to predict the radiosensitivity of tumors pre-treated with hyperthermia at clinically relevant temperatures. The use of premature chromosome condensation combined with fluorescent in situ hybridisation (PCC-FISH) has been shown to be clinically applicable. Therefore, the use of chromosomal aberrations as determined with PCC-FISH for the prediction of hyperthermia-induced radio-sensitization in human tumor cells was investigated. Confluent cultures of SW-1573 (human lung carcinoma) and RKO (human colorectal carcinoma) cells were treated with 1 h 41 degrees C or 43 degrees C hyperthermia prior to gamma-irradiation. Clonogenic cell survival and induction of chromosomal aberrations (unrejoined chromosomal fragments and translocations), by PCC-FISH, were studied at 24 h after treatment. Pre-treatment with hyperthermia at 41 degrees C for 1 h enhanced the radiosensitivity of RKO cells but not of SW-1573 cells. Increasing the temperature to 43 degrees C for 1 h enhanced the radiosensitivity of SW-1573 cells. When radio-sensitization was observed, a significant increase in the number of unrejoined chromosomal fragments was found but the frequency of translocations was not increased. Hyperthermia-induced radio-sensitization is correlated with an increase in unrejoined chromosomal fragments. This suggests that determination of the number of chromosomal fragments after hyperthermia and radiation treatment might be used for the prediction of combined treatment response in cancer patients.

Effect of variable heat transfer coefficient on tissue temperature next to a large vessel during radiofrequency tumor ablation

Background

One of the current shortcomings of radiofrequency (RF) tumor ablation is its limited performance in regions close to large blood vessels, resulting in high recurrence rates at these locations. Computer models have been used to determine tissue temperatures during tumor ablation procedures. To simulate large vessels, either constant wall temperature or constant convective heat transfer coefficient (h) have been assumed at the vessel surface to simulate convection. However, the actual distribution of the temperature on the vessel wall is non-uniform and time-varying, and this feature makes the convective coefficient variable.

Methods

This paper presents a realistic time-varying model in which h is a function of the temperature distribution at the vessel wall. The finite-element method (FEM) was employed in order to model RF hepatic ablation. Two geometrical configurations were investigated. The RF electrode was placed at distances of 1 and 5 mm from a large vessel (10 mm diameter).

Results

When the ablation procedure takes longer than 1–2 min, the attained coagulation zone obtained with both time-varying h and constant h does not differ significantly. However, for short duration ablation (5–10 s) and when the electrode is 1 mm away from the vessel, the use of constant h can lead to errors as high as 20% in the estimation of the coagulation zone.

Conclusion

For tumor ablation procedures typically lasting at least 5 min, this study shows that modeling the heat sink effect of large vessels by applying constant h as a boundary condition will yield precise results while reducing computational complexity. However, for other thermal therapies with shorter treatment using a time-varying h may be necessary.

p53 status-dependent sensitization of human tumour cells to hyperthermia by plant flavonol

PURPOSE

Quercetin (QCT), an important flavonol, is known to sensitize tumour cells to hyperthermia by suppressing heat shock protein 72 (Hsp72) induction, and is also reported to inhibit p53 accumulation. This study was conducted to examine the effects of QCT on the heat sensitivities of human tumour cell lines with different p53 statuses.

MATERIAL AND METHODS

Cell lines derived from human cancers and p53-inducible cells were used. After heat treatment at 43 degrees C for 2 h with or without QCT, cell survival was determined in a clonogenic assay. The cellular and nuclear content of Hsp72 as well as that of p53 was determined by Western blotting analysis.

RESULTS

Treatment of cells with 150 microM QCT, which completely abolished Hsp72 induction, potentiated the lethal effects of hyperthermia in all tumour cell lines. Particularly, remarkable enhancement of cell death was observed in tumour cell lines having little or no p53 proteins. Although nuclear translocation of Hsp72 is induced by hyperthermia, it was significantly compromised in p53-deficient cells.

CONCLUSIONS

These results indicate that p53 is a component for nuclear accumulation of Hsp72; therefore, p53 status is an important determinant of the sensitization of human tumour cells to hyperthermia by QCT.

The new vascular disrupting agent combretastatin-A1-disodium-phosphate (OXi4503) enhances tumour response to mild hyperthermia and thermoradiosensitization

PURPOSE

The aim of this study was to investigate the anti-cancer effect of the novel vascular disrupting agent (VDA), combretastatin-A1-disodium-phosphate (OXi4503), when combined with mild hyperthermia and/or radiation.

MATERIALS AND METHODS

A C3H mammary carcinoma was grown subcutaneously in the rear right foot of female CDF1 mice, and treated when a volume of 200 mm(3) was reached. OXi4503 was administered intra-peritoneally at variable doses. Hyperthermia was administered locally to the tumour-bearing foot using a thermostat-controlled water bath. Radiation treatment was performed locally using a conventional X-ray machine. Tumour response was assessed with either a tumour growth time or a tumour control assay.

RESULTS

The optimal delay between administration of 50 mg/kg of OXi4503 and hyperthermia was found to be 3 hours. The linear relationship between tumour growth time (TGT) and heating time at a specific temperature resulted in slope values between -0.003 days/min and 0.09 days/min at temperatures between 40 degrees C and 42.5 degrees C. When combined with OXi4503 this was significantly increased to 0.008 days/min and 0.03 days/min at temperatures between 39.5 degrees C and 41 degrees C, respectively. Above 41 degrees C, combined treatment did not result in significantly greater slope values. The radiation dose required to control 50% of the tumours (TCD50) was 52 Gy. Combining radiation with either heat treatment at 41.5 degrees C for 1 hour or OXi4503 reduced the TCD50 to 47 Gy and 41 Gy, respectively. Combining radiation with heat and OXi4503 further reduced the TCD50 to 37 Gy.

CONCLUSIONS

OXi4503 is a highly potent VDA, which is capable of significantly enhancing the anti-cancer effect of mild hyperthermia. Mild temperature thermoradiosensitization was also enhanced.

Current status of antivascular therapy and targeted treatment in the clinic

Antivascular and targeted therapy are now an integrated part of the treatment of myelogenous leukemias, GIST tumours, B-cell lymphomas and breast cancer. In various malignancies improved responses and prolongation of survival for several months is regularly reported. The progress in this field is relevant for hyperthermia. Heat has among other effects documented antivascular effects, and can be considered as one of the established methods in the field based on several randomised phase III studies. Hyperthermia should be considered for combination with other antiangiogenic agents.

A review of stimuli-responsive nanocarriers for drug and gene delivery

Nanotechnology has shown tremendous promise in target-specific delivery of drugs and genes in the body. Although passive and active targeted-drug delivery has addressed a number of important issues, additional properties that can be included in nanocarrier systems to enhance the bioavailability of drugs at the disease site, and especially upon cellular internalization, are very important. A nanocarrier system incorporated with stimuli-responsive property (e.g., pH, temperature, or redox potential), for instance, would be amenable to address some of the systemic and intracellular delivery barriers. In this review, we discuss the role of stimuli-responsive nanocarrier systems for drug and gene delivery. The advancement in material science has led to design of a variety of materials, which are used for development of nanocarrier systems that can respond to biological stimuli. Temperature, pH, and hypoxia are examples of "triggers" at the diseased site that could be exploited with stimuli-responsive nanocarriers. With greater understanding of the difference between normal and pathological tissues and cells and parallel developments in material design, there is a highly promising role of stimuli-responsive nanocarriers for drug and gene delivery in the future.

Fever-range whole body hyperthermia increases the number of perfused tumor blood vessels and therapeutic efficacy of liposomally encapsulated doxorubicin

PURPOSE

Two major questions were addressed: (1) Can fever-range whole body hyperthermia (FR-WBH) affect the number of perfused tumor blood vessels? (2) Can pre-treatment with FR-WBH improve accumulation or anti-tumor efficacy of doxorubicin or DOXIL (liposomal doxorubicin)?

MATERIALS AND METHODS

Perfused blood vessels were visualized by intravenous injection of the fluorescent dye (DiOC7(3)) and the number of labeled vessels in tumors and normal organs of unheated mice and those previously heated to 39.5 degrees C for 6 hours were compared. Using three animal tumor models (one syngeneic murine model and two human tumor xenografts in SCID mice) we also compared tumor growth and amount of intratumoral doxorubicin (given as free drug or as DOXIL) in control mice or those given pre-treatment with FR-WBH.

RESULTS

FR-WBH had no effect on the number of CD-31 labeled blood vessels. However, in tumors, but not in normal organs of the same animals, FR-WBH resulted in a significant increase in those blood vessels which could take up dye over a prolonged period of time after heating. There was also an increase in DOXIL uptake in the tumors of mice given FR-WBH prior to drug injection as well as enhanced therapeutic efficacy in all three tumor models.

CONCLUSIONS

FR-WBH increases the number of perfused blood vessels in tumors over a prolonged period following FR-WBH and thus may be useful for improving tumor targeting of cancer therapeutics. We discuss these data in relation to long-conserved thermoregulatory features in normal vasculature, which may be deficient in tumor vasculature.

Computational feasibility of deformable mirror microwave hyperthermia technique for localized breast tumors

PURPOSE

Computational feasibility of a new non-invasive microwave hyperthermia technique that employs dual deformable mirror is investigated using simplified computational tools and anatomically realistic breast models.

MATERIALS AND METHODS

The proposed technique employs two pairs of electromagnetic sources and continuously deformable mirrors to focus the electromagnetic radiation at the target site for hyperthermia. The mirror functions like a continuum of radiating elements that offer effective scan coverage inside the breast with efficient field focusing at the target location. The electric field focusing and temperature mapping in the two-dimensional numerical simulations are investigated using wave propagation and bio-heat transfer models respectively. The method of moments, a popular numerical simulation tool, is used to model the electric field maintained by the deformable mirrors for continuous wave excitation. The electromagnetic (EM) energy deposited by the mirrors is used in the steady state bio-heat transfer equation to quantify the temperature distribution inside two-dimensional anatomically realistic breast models.

RESULTS

Feasibility of the proposed technique is evaluated using numerical breast models derived from magnetic resonance images of patients with variation in breast density, age and pathology.

CONCLUSIONS

The computational study indicates preferential EM energy deposition and temperature elevation inside tumor tissue with minimum collateral damage to the neighboring normal tissues. Simulation results obtained for the magnetic resonance (MR) breast data appear promising and indicate the merit in pursuing the investigation using 3D computational models.