The kinetics of vascular thermotolerance in SCK tumors of A/J mice

Augmentation of the EPR effect by mild hyperthermia to improve nanoparticle delivery to the tumor

The clinical translation of the nanoparticle (NP)-based anticancer therapies is still unsatisfactory due to the heterogeneity of the enhanced permeability and retention (EPR) effect. Despite the promising preclinical outcome of the pharmacological EPR enhancers, their systemic toxicity can limit their clinical application. Hyperthermia (HT) presents an efficient tool to augment the EPR by improving tumor blood flow (TBF) and vascular permeability, lowering interstitial fluid pressure (IFP), and disrupting the structure of the extracellular matrix (ECM). Furthermore, the HT-triggered intravascular release approach can overcome the EPR effect. In contrast to pharmacological approaches, HT is safe and can be focused to cancer tissues. Moreover, HT conveys direct anti-cancer effects, which improve the efficacy of the anti-cancer agents encapsulated in NPs. However, the clinical application of HT is challenging due to the heterogeneous distribution of temperature within the tumor, the length of the treatment and the complexity of monitoring.

Tumour thermotolerance, a physiological phenomenon involving vessel normalisation

The purpose of this study was to delineate the mechanisms by which stromal components of cancer may induce tumour thermotolerance and exploit alterations in stromal and tumour physiology to enhance radiation therapy. The vascular thermoresponse was monitored by daily one-hour 41.5°C heatings in two murine solid tumour models, SCK murine mammary carcinoma and B16F10 melanoma. A transient increase was seen in overall tumour oxygenation for 2-3 days, followed by a progressive decline in tumour pO(2) upon continued daily heatings. Vascular thermotolerance was further studied by treating tumours with different heating strategies, i.e. (1) a single 60 min 41.5°C treatment; (2) two consecutive daily treatments of 41.5°C for 60 min; (3) a single 60 min 43°C treatment or (4) two days of 41.5°C for 60 min followed by treatment with 43°C for 60 min on the third day. Pre-heating tumours with mild temperature hyperthermia induced vascular thermotolerance, which was accompanied by evidence of vessel normalisation, i.e. a decrease in microvessel density and an increase in pericyte coverage. Rational scheduling of fractionated radiation during heat-induced increases in tumour oxygen levels rendered a significantly greater, synergistic, tumour growth inhibition. In vitro clonogenic survival responses of the individual cell types associated (endothelial cells, fibroblasts, pericytes and tumour cells) indicated only a direct cellular thermotolerance in endothelial cells. Overall, this suggests that tumour thermotolerance is a physiological phenomenon mediated through improvement of functional vasculature.

Mild temperature hyperthermia and radiation therapy: role of tumour vascular thermotolerance and relevant physiological factors

Here we review the significance of changes in vascular thermotolerance on tumour physiology and the effects of multiple clinically relevant mild temperature hyperthermia (MTH) treatments on tumour oxygenation and corresponding radiation response. Thus far vascular thermotolerance referred to the observation of significantly greater blood flow response by the tumour to a second hyperthermia exposure than in response to a single thermal dose, even at temperatures that would normally cause vascular damage. New information suggests that although hyperthermia is a powerful modifier of tumour blood flow and oxygenation, sequencing and frequency are central parameters in the success of MTH enhancement of radiation therapy. We hypothesise that heat treatments every 2 to 3 days combined with traditional or accelerated radiation fractionation may be maximally effective in exploiting the improved perfusion and oxygenation induced by typical thermal doses given in the clinic.

Hypoxia-driven immunosuppression: a new reason to use thermal therapy in the treatment of cancer?

Hypoxia within the tumour microenvironment is correlated with poor treatment outcome after radiation and chemotherapy, and with decreased overall survival in cancer patients. Several molecular mechanisms by which hypoxia supports tumour growth and interferes with effective radiation and chemotherapies are now well established. However, several new lines of investigation are pointing to yet another ominous outcome of hypoxia in the tumour microenvironment: suppression of anti-tumour immune effector cells and enhancement of tumour escape from immune surveillance. This review summarises this important information, and highlights mechanistic data by which hypoxia incapacitates several different types of immune effector cells, enhances the activity of immunosuppressive cells and provides new avenues which help 'blind' immune cells to detect the presence of tumour cells. Finally, we discuss data which indicates that mild thermal therapy, through its physiologically regulated ability to alter vascular perfusion and oxygen tensions within the tumour microenvironment, as well as its ability to enhance the function of some of the same immune effector activities that are inhibited by hypoxia, could be used to rapidly and safely release the tight grip of hypoxia in the tumour microenvironment thereby reducing barriers to more effective immune-based therapies.

Implications of increased tumor blood flow and oxygenation caused by mild temperature hyperthermia in tumor treatment

In many past clinical studies in which hyperthermia enhanced the efficacy of radiotherapy, the tumor temperatures could be raised only to 40-42 degrees C range in most cases. The heat-induced cell death, cellular radiosensitization, and vascular damage induced by such mild temperature hyperthermia (MTH) are likely to be insignificant despite the increased response of tumors to radiotherapy. Heating rodent tumors at 40-42 degrees C was found to cause an enduring increase in blood flow and oxygenation in the tumors. Recent studies with canine soft tissue sarcoma and human tumor clinical studies also demonstrated that MTH improves tumor oxygenation, and enhances response of the tumors to radiotherapy or chemoradiotherapy. The increased blood flow and vascular permeability caused by MTH may also improve the delivery of various therapeutic agents such as chemotherapy drugs, immunotherapeutic agents and genetic constructs for gene therapy to tumor cells. MTH as a means to potentiate the efficacy of radiotherapy and others warrants further investigation.

Physiological mechanisms underlying heat-induced radiosensitization

The objective of this review is to evaluate hyperthermia related changes in tumor physiologic parameters and their relevance for tumor radiosensitization with particular emphases on tumor oxygenation. Elevation of temperature above the physiological level causes changes in blood flow, vascular permeability, metabolism, and tumor oxygenation. These changes in addition to the cellular effects such as direct cytotoxicity, inhibition of potentially lethal damage and sublethal damage repair, have an important influence on the efficacy of radiotherapy. There is now clear evidence that in a variety of rodent and canine, as well as human tumors, the changes in tumor oxygenation status caused by hyperthermia are temperature dependent and this relationship may greatly influence the response of tumors to thermoradiotherapy. The improvement of tumor oxygenation after mild hyperthermia, which often lasts for as long as 24-48 h after heating, may increase the likelihood of a positive response of tumors to radiation therapy. Furthermore, the activity of some chemotherapy drugs is also oxygen dependent, therefore, the heat-induced increase in tumor oxygenation may significantly increase the effectiveness of thermoradiotherapy in combination with certain chemotherapy drugs. Further investigations remain to be conducted to obtain clearer insights into the relationship between thermal parameters, oxygenation and response of human tumors to hyperthermia in combination with radiotherapy and/or chemotherapy.

Improvement of tumor oxygenation by mild hyperthermia

There is now abundant evidence that oxygenation in rodent, canine and human tumors is improved during and for up to 1-2 days after heating at mild temperatures. An increase in tumor blood perfusion along with a decline in the oxygen consumption rate appears to account for the improvement of tumor oxygenation by mild hyperthermia. The magnitude of the increase in tumor pO(2), determined with oxygen-sensitive microelectrodes, caused by mild hyperthermia is less than that caused by carbogen breathing. However, mild hyperthermia is far more effective than carbogen breathing in increasing the radiation response of experimental tumors, probably because mild hyperthermia oxygenates both (diffusion-limited) chronically hypoxic and (perfusion-limited) acutely hypoxic cells, whereas carbogen breathing oxygenates only the chronically hypoxic cells. Mild hyperthermia is also more effective than nicotinamide, which is known to oxygenate acutely hypoxic cells, in enhancing the radiation response of experimental tumors. The combination of mild hyperthermia with carbogen or nicotinamide is highly effective in reducing the hypoxic cell fraction in tumors and increasing the radiation response of experimental tumors. A primary rationale for the use of hyperthermia in combination with radiotherapy has been that hyperthermia is equally cytotoxic toward fully oxygenated and hypoxic cells and that it directly sensitizes both fully oxygenated and hypoxic cells to radiation. Such cytotoxicity and such a radiosensitizing effect may be expected to be significant when the tumor temperature is elevated to at least 42-43 degrees C. Unfortunately, it is often impossible to uniformly raise the temperature of human tumors to this level using the hyperthermia devices currently available. However, it is relatively easy to raise the temperature of human tumors into the range of 39-42 degrees C, which is a temperature that can improve tumor oxygenation for up to 1-2 days. The potential usefulness of mild hyperthermia to enhance the response of human tumors to radiotherapy by improving tumor oxygenation merits continued investigation.

Temperature-dependent changes in physiologic parameters of spontaneous canine soft tissue sarcomas after combined radiotherapy and hyperthermia treatment

PURPOSE

The objectives of this study were to evaluate effects of hyperthermia on tumor oxygenation, extracellular pH (pHe), and blood flow in 13 dogs with spontaneous soft tissue sarcomas prior to and after local hyperthermia.

METHODS AND MATERIALS

Tumor pO2 was measured using an Eppendorf polarographic device, pHe using interstitial electrodes, and blood flow using contrast-enhanced magnetic resonance imaging (MRI).

RESULTS

There was an overall improvement in tumor oxygenation observed as an increase in median pO2 and decrease in hypoxic fraction (% of pO2 measurements <5 mm Hg) at 24-h post hyperthermia. These changes were most pronounced when the median temperature (T50) during hyperthermia treatment was less than 44 degrees C. Tumors with T50 > 44 degrees C were characterized by a decrease in median PO2 and an increase in hypoxic fraction. Similar thermal dose-related changes were observed in tumor perfusion. Perfusion was significantly higher after hyperthermia. Increases in perfusion were most evident in tumors with T50 < 44 degrees C. With T50 > 44 degrees C, there was no change in perfusion after hyperthermia. On average, pHe values declined in all animals after hyperthermia, with the greatest reduction seen for larger T50 values.

CONCLUSION

This study suggests that hyperthermia has biphasic effects on tumor physiologic parameters. Lower temperatures tend to favor improved perfusion and oxygenation, whereas higher temperatures are more likely to cause vascular damage, thus leading to greater hypoxia. While it has long been recognized that such effects occur in rodent tumors, this is the first report to tie such changes to temperatures achieved during hyperthermia in the clinical setting. Furthermore, it suggests that the thermal threshold for vascular damage is higher in spontaneous tumors than in more rapidly growing rodent tumors.

Vascular thermal adaptation in tumors and normal tissue in rats

PURPOSE

The vascular thermal adaptation in the R3230 adenocarcinoma, skin and muscle in the legs of Fischer rats was studied.

METHODS AND MATERIALS

The legs of Fischer rats bearing the R3230 AC adenocarcinoma (subcutaneously) were heated once or twice with a water bath, and the blood flow in the tumor, skin and muscle of the legs was measured with the radioactive microsphere method.

RESULTS

The blood flow in control R3230 AC tumors was 23.9 ml/100 g/min. The tumor blood flow increased about 1.5 times in 30 min and then markedly decreased upon heating at 44.5 degrees C for 90 min. In the tumors preheated 16 h earlier at 42.5 degrees C for 60 min, reheating at 44.5 degrees C increased the tumor blood flow by 2.5-fold in 30 min. Contrary to the decline in blood flow following an initial increase during the 44.5 degrees C heating without preheating, the tumor blood flow remained elevated throughout the 90 min reheating at 44.5 degrees C. These results indicated that thermal adaptation or thermotolerance developed in the tumor vasculatures after the preheating at 42.5 degrees C for 60 min. The magnitude of vascular thermal adaptation in the tumors 24 h and 48 h after the preheating, as judged from the changes in blood flow, were smaller than that 16 h after the preheating. Heating at 42.5 degrees C for 60 min induced vascular thermal adaptation also in the skin and muscle, which peaked in 48 h and 24 h, respectively, after the heating.

CONCLUSION

Heating at 42.5 degrees C for 1 h induced vascular thermal adaptation in the R3230 AC tumor, skin, and muscle of rats that peaked 16-48 h after the heating. When the tumor blood vessels were thermally adapted, the tumor blood flow increased upon heating at temperatures that would otherwise reduce the tumor blood flow. Such an increase in tumor blood flow may hinder raising the tumor temperature while it may increase tumor oxygenation.

Comparison of tumour blood flow changes induced by step-up and step-down heating

The changes in the blood flow in SCC-VII tumours after step-down and step-up heating (SDH and SUH) were compared. SDH was carried out by initial treatment of tumours in a water bath at 44.5 degrees C for 10 min, immediately followed by heating at 41.5 degrees C for 60 min. For SUH, the sequence of these high- and low-temperature treatments was reversed. Tumour perfusion was evaluated by laser Doppler flowmetry (LDF) at 1, 2, and 24h after finishing the hyperthermia. It was shown that the decrease in the blood flow in tumours was more substantial after SDH than after SUH; in the former case, the drop in LDF values was both faster and larger than in the latter. It is concluded that such a "physiological' component may be involved in the difference in the antitumour effect between SDH and SUH.

Heat shock proteins (HSP-72 kd) in thermotolerant rat sciatic nerves

Localized heating of the rat sciatic nerve over a length of 5 mm for 30 min at 43 degrees C resulted in the production of heat shock protein 72 kd in every nucleated cell and in the induction of thermotolerance in the heated area. HSP-72 kd was never detected in axons. Heat treatment (30 min, 45 degrees C) of thermotolerant nerves, 24 h after pretreatment, led to histopathological changes in the nerve, similar to those in non-thermotolerant nerves after a less strong treatment, i.e. heating for 30 min at 44 degrees C. Although axons did not contain HSPs after treatment at 43 degrees C, these structures tolerated treatment at 45 degrees C. Therefore we conclude that axons in the rat sciatic nerve are relatively heat-resistant and therefore we assume that axons do not need protection by HSPs; this is in contrast to endothelial cells and Schwann cells. Axons can be damaged indirectly as a consequence of vascular damage leading to ischaemia. Development of thermotolerance of the vasculature, ensuring a sufficient blood flow in the heated area, prevents this indirect damage.

Relationship between vascular thermotolerance and intratumor pH

The changes in blood flow, intratumor pH, and clonogenicity of tumor cells after one and two heatings were studied in SCK tumors of A/J mice. When SCK tumors were heated at 42.5 degrees C for 1 hr, vascular thermotolerance promptly developed and peaked at 18 hr post-heating. The intratumor pH was 7.05 +/- 0.14 (mean +/- S.D.) in control SCK tumors of A/J mice, with a significant decrease (p less than or equal to 0.001) to 6.86 +/- 0.08 and 6.70 +/- 0.08 when heated for 1 hr at 43.5 degrees C and 44.5 degrees C, respectively. However, when the vascular thermotolerance was at its peak, heating at the same doses caused little change in the intratumor pH. When SCK tumors were heated for the first time at 44.5 degrees C for 1 hr and left in situ, the number of clonogenic cells significantly declined. Such a secondary cell death could be attributed to the deterioration of the intratumor environment ensuing from the vascular damage. When the tumor vessels were thermotolerant, however, virtually no secondary cell death occurred after heating.

Thermal sensitivity and kinetics of thermotolerance in bovine aortic endothelial cells in culture

The effect of heat on the clonogenicity of bovine aortic endothelial (BAE) cells in vitro was measured. Continuous heating of cells at 43 degrees C or 43.5 degrees C produced survival curves exhibiting thermoresistant tails. When heated at 44 degrees C the survival curve of BAE cells was exponential except for a small shoulder. The BAE cells heated at 44 degrees C and 45 degrees C had D0 values of 33 min and 19 min, respectively. The development of thermotolerance in BAE cells was studied by measuring the sensitivity of cells to a 44 degrees C heating at various times following a priming heat treatment at 43 degrees C or 44 degrees C for 30 min. The thermotolerance ratio in BAE cells preheated at 43 degrees C for 30 min reached a peak of 3.8 at 3 h and declined to 1.9 at 24 h after the prime heating. After prime heating at 44 degrees C for 30 min the thermotolerance ratio increased rapidly to 5.4 in 5 h, remained elevated at 12 h and then declined to a value of 2.1 at 24 h. Thermotolerance in endothelial cells may be partially responsible for the thermotolerance in blood vessels of normal tissues and tumours.

The vascular architecture of human xenotransplanted tumors: histological, morphometrical, and ultrastructural studies

This study was designed to examine the vascular system of human xenotransplanted tumors on nude mice with different complementary morphometrical and morphological methods. The vascular system shows a chaotic arrangement. There is an extreme heterogeneity in the vascular distribution and density. Large avascular regions could be identified in several non-necrotic tumors. There was no clear difference in the vascular density between the center and the periphery of the tumors, nor was there any zonal correlation for the distribution of the necrosis. With three-dimensional corrosion casts it could be demonstrated that clusters of vessels were directly beneath areas almost free of vessels. In the center, vessels often form a sinusoidal system with numerous blind ends without clearly discernible endothelial cells. Numerous irregular tumor-cell-lined sinusoids are visible next to endothelial-lined vessels with transmission electron microscopy. With scanning electron microscopy it could be demonstrated that large-calibre endotheliazed vessels were found in the direct vicinity or in the center of non-viable zones. Even large-calibre vessels have a capillary wall structure. Sometimes, a basement membrane cannot be observed at all or only incompletely. There are numerous indications of vascular discontinuities and leaks with a widespread intercellular occurrence of blood cells.