Efficacy of adjuvant hyperthermia in the treatment of superficial recurrent breast cancer: confirmation and future directions

Efficient focusing of microwave hyperthermia for small deep-seated breast tumors treatment using particle swarm optimization

Focused microwave hyperthermia is a technique with advantage of high accuracy and low side effects for breast tumor treatments. In this study, an efficient focusing technique for noninvasive microwave hyperthermia treatment for breast tumors is presented. Particle Swarm Optimization (PSO) is used to find the optimum excitations (phases and amplitudes) of a three dimension (3D) Micro-Strip Patch (MSP) antenna array operating at 2.45 GHz. The antenna excitations are optimized to maximize the power loss density and the Specific Absorption Rate (SAR) at the tumor location, to reach the required hyperthermia temperature (above 42 °C) at the tumor location without causing hot spots in healthy tissues. The technique is tested on a challenging scenario of a 3D realistic breast model having a tumor less than 1 cm³ volume and embedded in different locations deep in the glandular tissue of a very dense breast. The results confirmed the capability of the focusing technique.

Design, Implementation, Evaluation and Application of a 32-Channel Radio Frequency Signal Generator for Thermal Magnetic Resonance Based Anti-Cancer Treatment

Thermal Magnetic Resonance (ThermalMR) leverages radio frequency (RF)-induced heating to examine the role of temperature in biological systems and disease. To advance RF heating with multi-channel RF antenna arrays and overcome the shortcomings of current RF signal sources, this work reports on a 32-channel modular signal generator (SG_PLL). The SG_PLL was designed around phase-locked loop (PLL) chips and a field-programmable gate array chip. To examine the system properties, switching/settling times, accuracy of RF power level and phase shifting were characterized. Electric field manipulation was successfully demonstrated in deionized water. RF heating was conducted in a phantom setup using self-grounded bow-tie RF antennae driven by the SG_PLL. Commercial signal generators limited to a lower number of RF channels were used for comparison. RF heating was evaluated with numerical temperature simulations and experimentally validated with MR thermometry. Numerical temperature simulations and heating experiments controlled by the SG_PLL revealed the same RF interference patterns. Upon RF heating similar temperature changes across the phantom were observed for the SG_PLL and for the commercial devices. To conclude, this work presents the first 32-channel modular signal source for RF heating. The large number of coherent RF channels, wide frequency range and accurate phase shift provided by the SG_PLL form a technological basis for ThermalMR controlled hyperthermia anti-cancer treatment.

Microwave beamforming for non-invasive patient-specific hyperthermia treatment of pediatric brain cancer

We present a numerical study of an array-based microwave beamforming approach for non-invasive hyperthermia treatment of pediatric brain tumors. The transmit beamformer is designed to achieve localized heating-that is, to achieve constructive interference and selective absorption of the transmitted electromagnetic waves at the desired focus location in the brain while achieving destructive interference elsewhere. The design process takes into account patient-specific and target-specific propagation characteristics at 1 GHz. We evaluate the effectiveness of the beamforming approach using finite-difference time-domain simulations of two MRI-derived child head models from the Virtual Family (IT'IS Foundation). Microwave power deposition and the resulting steady-state thermal distribution are calculated for each of several randomly chosen focus locations. We also explore the robustness of the design to mismatch between the assumed and actual dielectric properties of the patient. Lastly, we demonstrate the ability of the beamformer to suppress hot spots caused by pockets of cerebrospinal fluid (CSF) in the brain. Our results show that microwave beamforming has the potential to create localized heating zones in the head models for focus locations that are not surrounded by large amounts of CSF. These promising results suggest that the technique warrants further investigation and development.

Conformal microwave array (CMA) applicators for hyperthermia of diffuse chest wall recurrence

PURPOSE

This article summarises the evolution of microwave array applicators for heating large area chest wall disease as an adjuvant to external beam radiation, systemic chemotherapy, and potentially simultaneous brachytherapy.

METHODS

Current devices used for thermotherapy of chest wall recurrence are reviewed. The largest conformal array applicator to date is evaluated in four studies: (1) ability to conform to the torso is demonstrated with a CT scan of a torso phantom and MR scan of the conformal water bolus component on a mastectomy patient; (2) specific absorption rate (SAR) and temperature distributions are calculated with electromagnetic and thermal simulation software for a mastectomy patient; (3) SAR patterns are measured with a scanning SAR probe in liquid muscle phantom for a buried coplanar waveguide CMA; and (4) heating patterns and patient tolerance of CMA applicators are characterised in a clinical pilot study with 13 patients.

RESULTS

CT and MR scans demonstrate excellent conformity of CMA applicators to contoured anatomy. Simulations demonstrate effective control of heating over contoured anatomy. Measurements confirm effective coverage of large treatment areas with no gaps. In 42 hyperthermia treatments, CMA applicators provided well-tolerated effective heating of up to 500 cm(2) regions, achieving target temperatures of T(min) = 41.4 ± 0.7°C, T(90) = 42.1 ± 0.6°C, T(ave) = 42.8 ± 0.6°C, and T(max) = 44.3 ± 0.8°C as measured in an average of 90 points per treatment.

CONCLUSION

The CMA applicator is an effective thermal therapy device for heating large-area superficial disease such as diffuse chest wall recurrence. It is able to cover over three times the treatment area of conventional hyperthermia devices while conforming to typical body contours.

Design of a water coupling bolus with improved flow distribution for multi-element superficial hyperthermia applicators

A water bolus used in superficial hyperthermia couples the electromagnetic (EM) or acoustic energy into the target tissue and cools the tissue surface to minimise thermal hotspots and patient discomfort during treatment. Parametric analyses of the fluid pressure inside the bolus computed using 3D fluid dynamics simulations are used in this study to determine a bolus design with improved flow and surface temperature distributions for large area superficial heat applicators. The simulation results are used in the design and fabrication of a 19 x 32 cm prototype bolus with dual input-dual output (DIDO) flow channels. Sequential thermal images of the bolus surface temperature recorded for a step change in the circulating water temperature are used to assess steady state flow and surface temperature distributions across the bolus. Modelling and measurement data indicate substantial improvement in bolus flow and surface temperature distributions when changing from the previous single input-single output (SISO) to DIDO configuration. Temperature variation across the bolus at steady state was measured to be less than 0.8 degrees C for the DIDO bolus compared to 1.5 degrees C for the SISO water bolus. The new DIDO bolus configuration maintains a nearly uniform flow distribution and low variation in surface temperature over a large area typically treated in superficial hyperthermia.

Multilayer conformal applicator for microwave heating and brachytherapy treatment of superficial tissue disease

PURPOSE

The purpose of this study was to construct and perform preliminary functionality evaluations of a multilayer conformal applicator with provisions for thermal monitoring, tight conformity and simultaneous microwave heating and brachytherapy treatment of large-area contoured surfaces.

MATERIALS AND METHODS

The multilayer conformal applicator consists of thermal monitoring catheters for fibre-optic monitoring of skin temperatures, a waterbolus, a PCB microwave antenna array, a dielectric spacer for brachytherapy considerations, brachytherapy catheters for delivering HDR radiation and an inflatable air bladder for improving conformity to contoured surfaces. The applicator also includes an elastic attachment structure to hold the applicator securely in place on the patient. The conformity of the applicator to irregular surfaces was evaluated through CT imaging of the applicator fitted onto a life-sized human torso phantom. The fluid flow dynamics of the waterbolus, which impact the effectiveness of temperature control, were evaluated with thermometry during a 19 degrees C step change temperature of the circulating water.

RESULTS

CT imaging showed improved conformity to the torso phantom surface following the application of gentle inward pressure from inflating the outer air bladder. Only a small number of 1-5 mm sized air gaps separated the conformal applicator and tissue surface. Thermometry testing of the bolus fluid flow dynamics demonstrated temperature uniformity within +/-0.82 degrees C across a 19 x 34 x 0.6 cm area bolus and +/-0.85 degrees C across a large 42 x 32 x 0.6 cm area bolus.

CONCLUSION

CT scans of the applicator confirmed that the applicator conforms well to complex body contours and should maintain good conformity and positional stability even when worn on a mobile patient. Thermometry testing of two different waterbolus geometries demonstrated that uniform circulation and temperature control can be maintained throughout large, complex bolus shapes.

Progress on ThermoBrachytherapy Surface Applicator for Superficial Tissue Diseases

This work reports the ongoing development of a combination applicator for simultaneous heating of superficial tissue disease using a 915 MHz DCC (dual concentric conductor) array and High Dose Rate (HDR) brachytherapy delivered via an integrated conformal catheter array. The progress includes engineering design changes in the waterbolus, DCC configurations and fabrication techniques of the conformal multilayer applicator. The dosimetric impact of the thin copper DCC array is also assessed. Steady state fluid dynamics of the new waterbolus bag indicates nearly uniform flow with less than 1°C variation across a large (19×32cm) bolus. Thermometry data of the torso phantom acquired with computer controlled movement of fiberoptic temperature probes inside thermal mapping catheters indicate feasibility of real time feedback control for the DCC array. MR (magnetic resonance) scans of a torso phantom indicate that the waterbolus thickness across the treatment area is controlled by the pressure applied by the surrounding inflatable airbladder and applicator securing straps. The attenuation coefficient of the DCC array was measured as 3± 0.001% and 2.95±0.03 % using an ion chamber and OneDose^™ dosimeters respectively. The performance of the combination applicator on patient phantoms provides valuable feedback to optimize the applicator prior use in the patient clinic.

Size reduction and radiation pattern shaping of multi-fed DCC slot antennas used in conformal microwave array hyperthermia applicators

The use of conformal antenna array in the treatment of superficial diseases can significantly increase patient comfort while enhancing the local control of large treatment area with irregular shapes. Originally a regular square multi-fed slot antenna (Dual Concentric Conductor - DCC) was proposed as basic unit cell of the array. The square DCC works well when the outline of the treatment area is rectangular such as in the main chest or back area but is not suitable to outline diseases spreading along the armpit and neck area. In addition as the area of the patch increases, the overall power density decreases affecting the efficiency and thus the ability to deliver the necessary thermal dose with medium power amplifier (<50W). A large number of small efficient antennas is preferable as the disease is more accurately contoured and the lower power requirement for the amplifiers correlates with system reliability, durability, linearity and overall reduced cost. For such reason we developed a set of design rules for multi-fed slot antennas with irregular contours and we implemented a design that reduce the area while increasing the perimeter of the slot, thus increasing the antenna efficiency and the power density. The simulation performed with several commercial packages (Ansoft HFSS, Imst Empire, SemcadX and CST Microwave Studio) show that the size reducing method can be applied to several shapes and for different frequencies. The SAR measurements of several DCCs are performed using an in-house high resolution scanning system with tumor equivalent liquid phantom both at 915 MHz for superficial hyperthermia systems in US) and 433 MHz (Europe). The experimental results are compared with the expected theoretical predictions and both simulated and measured patterns of single antennas of various size and shapes are then summed in various combinations using Matlab to show possible treatment irregular contours of complex diseases. The local control is expected to significantly improve while maintaining the patient comfort.

A thermal monitoring sheet with low influence from adjacent waterbolus for tissue surface thermometry during clinical hyperthermia

This paper presents a complete thermal analysis of a novel conformal surface thermometer design with directional sensitivity for real-time temperature monitoring during hyperthermia treatments of large superficial cancer. The thermal monitoring sheet (TMS) discussed in this paper consists of a 2-D array of fiberoptic sensors embedded between two layers of flexible, low-loss, and thermally conductive printed circuit board (PCB) film. Heat transfer across all interfaces from the tissue surface through multiple layers of insulating dielectrics surrounding the small buried temperature sensor and into an adjacent temperature-regulated water coupling bolus was studied using 3-D thermal simulation software. Theoretical analyses were carried out to identify the most effective differential TMS probe configuration possible with commercially available flexible PCB materials and to compare their thermal responses with omnidirectional probes commonly used in clinical hyperthermia. A TMS sensor design that employs 0.0508-mm Kapton MTB and 0.2032-mm Kapton HN flexible polyimide films is proposed for tissue surface thermometry with low influence from the adjacent waterbolus. Comparison of the thermal simulations with clinical probes indicates the new differential TMS probe design to outperform in terms of both transient response and steady-state accuracy in selectively reading the tissue surface temperature, while decreasing the overall thermal barrier of the probe between the coupling waterbolus and tissue surface.

Construction of a conformal water bolus vest applicator for hyperthermia treatment of superficial skin cancer

Large area chestwall recurrence of breast carcinoma can be treated with moderate temperature hyperthermia in combination with radiation or chemotherapy. For diffuse chestwall disease, hyperthermia is best delivered with a conformal microwave array (CMA) applicator using a temperature-controlled water bolus designed specifically to fit complex contours and maintain contact with the tissue surface to prevent air gaps which distort the microwave power deposition pattern. In order to maintain the desired temperature range of 41-45 degrees C during local hyperthermia treatments, it is necessary to have an effective fluid flow system to serve as a buffer and prevent overheating of skin, which can lead to small blisters or, in rare cases, deeper burns. The fluid flow dynamics of a vest shaped open water bag design is evaluated with thermometry during a step temperature change of circulating water. The data confirm the feasibility of uniform circulation and temperature control throughout complex bolus shapes. This water bolus design should improve temperature uniformity of current treatments for superficial tissue disease.

Evolving technology for thermal therapy of cancer

This paper is intended as a succinct review of technology used for clinical hyperthermia therapy for cancer, as culled from a presentation at the special workshop on Thermal Medicine, Heat Shock Proteins, and Cancer at the Society for Thermal Medicine conference in Spring 2005. Following a brief overview of thermal therapy treatment options and available mechanisms for heating tissue, the paper focuses on the evolution of equipment from basic single element heating devices of the early 1980s to adjustable multi-element heating devices currently in use or in final stages of development. Representative devices from the past, present and near future are cited for further investigation by the interested reader. The paper concludes with a summary of general trends in the evolution of clinical hyperthermia techniques and a statement of current challenges remaining for the field.

Radiation dosimetry of a conformal heat-brachytherapy applicator

The purpose of this paper is to report the radiation dosimetric characteristics of a new combination applicator for delivering heat and radiation simultaneously to large area superficial disease <1.5 cm deep. The applicator combines an array of brachytherapy catheters (for radiation delivery) with a conformal printed circuit board microwave antenna array (for heat generation), and a body-conforming 5-10 mm thick temperature-controlled water bolus. The rationale for applying both modalities simultaneously includes the potential for significantly higher response rate due to enhanced synergism of modalities, and lower peak toxicity due to temporal extension of heat and radiation induced toxicities. Treatment plans and radiation dosimetry are calculated with IPSA (an optimization tool developed at UCSF) for 15 x 15 cm(2) and 35 x 24 cm(2) applicators, lesion thicknesses of 5 to 15 mm, flat and curved surfaces, and catheter separation of 5 and 10 mm. The effect on skin dose of bolus thickness and presence of thin copper antenna structures between radiation source and tissue are also evaluated. Results demonstrate the ability of the applicator to provide conformal radiation dose coverage for up to 15 mm deep target volumes under the applicator. For clinically acceptable plans, tumor coverage is > 98%, homogeneity index > 0.95 and the percentage of normal tissue irradiated is < 20%. The dose gradient at the skin surface varies from 3 to 5 cGy/mm depending on bolus thickness and lesion depth. Attenuation of the photon beam by the printed circuit antenna array is of the order 0.25% and secondary electron emissions are absorbed completely within 5 mm of water bolus and plastic layers. Both phenomena can then be neglected in dose calculations allowing commercial software to be used for treatment planning. This novel applicator should prove useful for the treatment of diffuse chestwall disease located over contoured anatomy that may be difficult to treat with single field external beam therapy. By delivering heat and radiation simultaneously, increased synergism is expected with a TER in the range of 2-5. Lowering radiation dose by an equivalent factor may produce lower radiation toxicity with similar efficacy, while preserving the option of subsequent retreatment(s) with thermoradiotherapy in order to further extend patient survival.

Thermal contribution of compact bone to intervening tissue-like media exposed to planar ultrasound

The presence of bone in the ultrasound beam path raises concerns, both in diagnostic and therapeutic applications, because significant temperature elevations may be induced at nearby soft tissue-bone interfaces due the facts that ultrasound is (i) highly absorbed in bone and (ii) reflected at soft tissue-bone interfaces in various degrees depending on angle of incidence. Consequently, in ultrasonic thermal therapy, the presence of bone in the ultrasound beam path is considered a major disadvantage and it is usually avoided. However, based on clinical experience and previous theoretical studies, we hypothesized that the presence of bone in superficial unfocused ultrasound hyperthermia can actually be exploited to induce more uniform and enhanced (with respect to the no-bone situation) temperature distributions in superficial target volumes. In particular, we hypothesize that the presence of underlying bone in superficial target volume enhances temperature elevation not only by additional direct power deposition from acoustic reflection, but also from thermal diffusion from the underlying bone. Here we report laboratory results that corroborate previous computational studies and strengthen the above-stated hypothesis. Three different temperature measurement techniques, namely, thermometric (using fibre-optic temperature probes), thermographic (using an infrared camera) and magnetic resonance imaging (using proton resonance frequency shifts), were used in high-power short-exposure, and in low-power extended-exposure, experiments using a 19 mm diameter planar transducer operating at 1.0 and 3.3 MHz (frequencies of clinical relevance). The measurements were performed on three technique-specific phantoms (with and without bone inclusions) and experimental set-ups that resembled possible superficial ultrasound hyperthermia clinical situations. Results from all three techniques were in general agreement and clearly showed that significantly higher heating rates (greater than fourfold) were induced in soft tissue-like phantom materials adjacent (within approximately 5 mm) to a bovine bone as compared to similar experiments without bone inclusions. For low-power long-exposure experiments, where thermal conduction effects are significant, the thermal impact of bone reached at distances > 10 mm from the bone surface (upstream of the bone). Therefore, we hypothesize that underlying bone exposed to planar ultrasound hyperthermia creates a high-temperature thermal boundary at depth that compensates for beam attenuation, thus producing more uniform temperature distribution in the intervening tissue layers. With appropriate technology, this finding may lead to improved thermal doses in superficial treatment sites such as the chest wall and the head/neck.

Local hyperthermia, radiation, and chemotherapy in recurrent breast cancer is feasible and effective except for inflammatory disease

PURPOSE

To investigate the feasibility and effectiveness of radiochemothermotherapy (triple-modality therapy) in patients with inoperable recurrent breast cancer.

PATIENTS AND METHODS

Patients with inoperable recurrent lesions, World Health Organization (WHO) performance status of 2 or greater, life expectancy of more than 3 months, adequate bone marrow, hepatic and renal function were eligible for this Phase I/II study. Conventionally fractionated or hyperfractionated radiotherapy (RT) was performed. Once-weekly local hyperthermia (HT) combined with chemotherapy (CT; epirubicin 20 mg/m(2), ifosfamide 1.5 g/m(2)) was applied within 30 min after RT.

RESULTS

Twenty-five patients, all heavily pretreated (18/25 preirradiated), received a mean total dose of 49 Gy. The median number of HT/CT sessions was 4. Skin toxicity was low, whereas bone marrow toxicity was significant (leucopenia Grade 3/4 in 14/1 patients). The overall response rate was 80% with a complete response (CR) rate of 44%. Response rates in patients with noninflammatory disease (n = 14; CR 10 patients, partial response [PR] 3 patients) were far better than in patients with inflammatory disease (n = 11; CR 1 patient, PR 6 patients).

CONCLUSIONS

In patients with recurrent breast cancer, triple-modality therapy is feasible with acceptable toxicity. High remission rates can be achieved in noninflammatory disease, however, local control is limited to a few months. Whether the addition of chemotherapy has a clear-cut advantage to radiothermotherapy alone remains an open question.

Dual-mode antenna design for microwave heating and noninvasive thermometry of superficial tissue disease

Hyperthermia therapy of superficial skin disease has proven clinically useful, but current heating equipment is somewhat clumsy and technically inadequate for many patients. The present effort describes a dual-purpose, conformal microwave applicator that is fabricated from thin, flexible, multilayer printed circuit board (PCB) material to facilitate heating of surface areas overlaying contoured anatomy. Preliminary studies document the feasibility of combining Archimedean spiral microstrip antennas, located concentrically within the central region of square dual concentric conductor (DCC) annular slot antennas. The motivation is to achieve homogeneous tissue heating simultaneously with noninvasive thermometry by radiometric sensing of blackbody radiation from the target tissue under the applicator. Results demonstrate that the two antennas have complimentary regions of influence. The DCC ring antenna structure produces a peripherally enhanced power deposition pattern with peaks in the outer corners of the aperture and a broad minimum around 50% of maximum centrally. In contrast, the Archimedean spiral radiates (or receives) energy predominantly along the boresight axis of the spiral, thus confining the region of influence to tissue located within the central broad minimum of the DCC pattern. Analysis of the temperature-dependent radiometer signal (brightness temperature) showed linear correlation of radiometer output with test load temperature using either the spiral or DCC structure as the receive antenna. The radiometric performance of the broadband Archimedean antenna was superior compared to the DCC, providing improved temperature resolution (0.1 degree C-0.2 degree C) and signal sensitivity (0.3 degree C-0.8 degree C/degree C) at all four 500 MHz integration bandwidths tested within the frequency range from 1.2 to 3.0 GHz.

The impact of ultrasonic parameters on chest wall hyperthermia

A transient, three-dimensional acousto-thermal numerical model for chest wall anatomies was developed to evaluate the impact of ultrasonic parameters on thermal coverage. The following independent variables were considered: (1) the relative output intensities of the low and high frequency components of an unfocused dual-frequency ultrasonic beam (xi1); (2) the depths of the soft-tissue bone (d(b)) and soft-tissue-lung (d(u)) interfaces; (3) the intensity reflectivities of these interfaces; and (4) the intensity attenuation coefficient of bone. Several important results were obtained. First, acoustic reflections from the underlying bone and lung surfaces may contribute significantly to heating of the overlying soft-tissue. Secondly, a strong dependence of optimal xi1 values on d(b) and d(u) values was found. Chest wall volumes with 2-3 cm of soft-tissue overlying the ribs were optimal targets for unfocused ultrasound hyperthermia. Thirdly, the maximum steady state temperature in bone also strongly depended on xi1. Finally, the largest difference between the maximum temperature in bone and the maximum temperature in soft-tissue during initial transient heating was between -1.4 degrees C and 0.8 degrees C. That is, the maximum temperature in the field, either during the transient period or at steady state, did not always occur in bone. It is concluded that control of power deposition penetrability offers great potential for improving hyperthermia to chest wall targets in real time.

Thermal and SAR characterization of multielement dual concentric conductor microwave applicators for hyperthermia, a theoretical investigation

Six aperture array dual concentric conductor (DCO) microwave hyperthermia applicators were studied using theoretical models to characterize power deposition (SAR) and steady state temperature distributions in perfused tissue. SAR patterns were calculated using the finite difference time domain (FDTD) numerical method, and were used as input to a finite difference thermal modeling program based on the Pennes Bio-Heat Equation in order to calculate corresponding temperature distributions. Numerous array configurations were investigated including the use of different size DCC apertures (2, 3, and 4 cm), different spacing between apertures (1.0-2.0 cm), and different water bolus thicknesses (5-15 mm). Thermal simulations were repeated using blood perfusion values ranging from 0.5 to 5 kg/m3 s. Results demonstrate the ability of DCC array applicators to effectively and uniformly heat tissue down to a depth of 7.5-10 mm below the skin surface for a large number of different combinations of DCC element size, spacing, and water bolus thickness. Results also reveal the close correlation between SAR patterns and corresponding temperature distributions, verifying that design studies of the applicator can be performed confidently by analysis of SAR, from which the thermal behavior can be estimated. These simulations are useful in the design optimization of large microwave DCC array applicators for superficial tissue heating and for identifying appropriate aperture spacing and bolus thickness parameters for different size DCC aperture arrays and tissue blood perfusion conditions.

Effect of complex bolus-tissue load configurations on SAR distributions from dual concentric conductor applicators. Specific absorption rate

Power deposition [specific absorption rate (SAR)] distributions from a two-element array configuration of 4-cm-square 915-MHz dual concentric conductor (DCC) microwave antennas were characterized theoretically for several clinically realistic complex bolus-tissue load models using the finite difference time domain (FDTD) numerical method. The purpose of this effort was to determine the perturbing effects on SAR of three often unavoidable heterogeneities in the bolus-tissue load. The three cases studied in this work consist of bone (two ribs spaced 1 cm apart) embedded 5-mm or 1-cm deep in muscle or layered fat-muscle tissue, small air bubbles trapped between the coupling bolus and tissue surface, and variable thickness water bolus layer due to sharply contoured anatomy. Results of the FDTD simulations demonstrate rather small effects on SAR distribution for both rib-sized bones > or = 5-mm deep in muscle and small air pockets < or = 1-mm thick. Larger air bubbles > 1-cm diameter by 3-mm depth showed a distinct concentration of SAR near the lateral sides of the air bubbles, and a blocking effect under the bubbles when located directly under the center of a DCC aperture where there is a higher normal E-field component. Variation from 2.5- to 7.5-mm bolus thickness under the two aperture array produced only minor perturbation of the uniformity and penetration of SAR, along with minor reduction in SAR under the thicker bolus which should be accommodated sufficiently by changes in applied power to the array elements.

Ultrasound power deposition model for the chest wall

An ultrasound power deposition model for the chest wall was developed based on secondary-source and plane-wave theories. The anatomic model consisted of a muscle-ribs-lung volume, accounted for wave reflection and refraction at muscle-rib and muscle-lung interfaces, and computed power deposition due to the propagation of both reflected and transmitted waves. Lung tissue was assumed to be air-equivalent. The parts of the theory and numerical program dealing with reflection were experimentally evaluated by comparing simulations with acoustic field measurements using several pertinent reflecting materials. Satisfactory agreement was found. A series of simulations were performed to study the influence of angle of incidence of the beam, frequency, and thickness of muscle tissue overlying the ribs on power deposition distributions that may be expected during superficial ultrasound (US) hyperthermia of chest wall recurrences. Both reflection at major interfaces and attenuation in bone were the determining factors affecting power deposition, the dominance of one vs. the other depending on the angle of incidence of the beam. Sufficient energy is reflected by these interfaces to suggest that improvements in thermal doses to overlying tissues are possible with adequate manipulation of the sound field (advances in ultrasonic heating devices) and prospective treatment planning.

Enhanced cytotoxicity and suppression of glucose transport rate by combined treatment of recombinant human tumour necrosis factor-alpha and hyperthermia on L929 cells

Combined treatment with human recombinant TNF-alpha (rhTNF-alpha) and hyperthermia at 43 degrees C arrested the growth of mouse fibrosarcoma L929 cells in vitro. The cytotoxic effect was enhanced in combined treatment compared with that following administration of rhTNF-alpha or hyperthermia alone. When the cells were subjected to hyperthermia at 43 degrees C for 3 hours and then incubated with 0.4 ng/ml rhTNF-alpha at 37 degrees C for 24 hours, a statistically significant 65% decrease in the rate of cellular glucose uptake was observed. This suppressive effect was synergistic in terms of effect achieved by rhTNF-alpha or hyperthermia individually. Since the growth of tumour cells depends mainly on catabolism of glucose, our findings indicate that one manner by which combined rhTNF-alpha and hyperthermia treatment inhibits L929 cell growth may be by reducing the supply of glucose to the cells.

An investigation of the flow dependence of temperature gradients near large vessels during steady state and transient tissue heating

Temperature distributions measured during thermal therapy are a major prognostic factor of the efficacy and success of the procedure. Thermal models are used to predict the temperature elevation of tissues during heating. Theoretical work has shown that blood flow through large blood vessels plays an important role in determining temperature profiles of heated tissues. In this paper, an experimental investigation of the effects of large vessels on the temperature distribution of heated tissue is performed. The blood flow dependence of steady state and transient temperature profiles created by a cylindrical conductive heat source and an ultrasound transducer were examined using a fixed porcine kidney as a flow model. In the transient experiments, a 20 s pulse of hot water, 30 degrees C above ambient, heated the tissues. Temperatures were measured at selected locations in steps of 0.1 mm. It was observed that vessels could either heat or cool tissues depending on the orientation of the vascular geometry with respect to the heat source and that these effects are a function of flow rate through the vessels. Temperature gradients of 6 degrees C mm(-1) close to large vessels were routinely measured. Furthermore, it was observed that the temperature gradients caused by large vessels depended on whether the heating source was highly localized (i.e. a hot needle) or more distributed (i.e. external ultrasound). The gradients measured near large vessels during localized heating were between two and three times greater than the gradients measured during ultrasound heating at the same location, for comparable flows. Moreover, these gradients were more sensitive to flow variations for the localized needle heating. X-ray computed tomography data of the kidney vasculature were in good spatial agreement with the locations of all of the temperature variations measured. The three dimensional vessel path observed could account for the complex features of the temperature profiles. The flow dependences of the transient temperature profiles near large vessels during the pulsed experiments were consistent with the temperature distributions measured in the steady state experiments and provided unique insights into the process of convective heat transfer in tissues. Finally, it was shown that even for very short treatment times (3-20 s), large vessels had significant effects on the tissue temperature distributions.

Experimental assessment of power and temperature penetration depth control with a dual frequency ultrasonic system

A novel ultrasound applicator for superficial simultaneous thermoradiotherapy consisting of two parallel-opposed linear arrays and a double-sided scanning reflector was constructed and tested for penetration depth control. In this design the arrays operate at different frequencies (1 and 5 MHz, in this study) and the input power to each array element (five 2 X 2 cm2 elements per array) is computer adjustable. The ultrasonic beams from the arrays are aimed at the scanning reflector which in turn deflects them simultaneously and in parallel toward the treatment volume. Relative intensity distributions generated by the prototype were measured in a degassed water phantom using a thermal technique for a selected reflector position; these showed that the ultrasonic intensity distribution can be controlled in the lateral dimensions by varying the input power level to individual array elements. A fixed-perfused canine kidney phantom was employed to demonstrate experimentally that real time penetration depth control is possible by varying the excitation magnitude of one array (frequency) relative to that of the other. It is concluded that the dual-frequency scanned-reflected ultrasound applicator offers a degree of dynamic three-dimensional control of the power deposition pattern of clinical significance.

Reirradiation combined with hyperthermia in recurrent breast cancer results in a worthwhile local palliation

Both experimental and clinical research have shown that hyperthermia (HT) gives valuable additional effects when applied in combination with radiotherapy (RT). The purpose of this study was evaluation of results in patients with recurrent breast cancer, treated at the Daniel den Hoed Cancer Center (DHCC) with reirradiation (re-RT; eight fractions of 4 Gy twice weekly) combined with HT. All 134 patients for whom such treatment was planned were included in the analysis. The complete response rate in 119 patients with macroscopic tumour was 71%. Including the 15 patients with microscopic disease, the local control rate was 73%. The median duration of local control was 32 months, and toxicity was acceptable. The complete response (CR) rate was higher, and the toxicity was less with the later developed 433-MHz HT technique compared with the 2450-MHz technique used initially. With this relatively well-tolerated treatment, palliation by local tumour control of a worthwhile duration is achieved in the majority of patients. The technique used for hyperthermia appeared to influence the achieved results. The value of HT in addition to this re-RT schedule has been confirmed by a prospective randomized trial in a similar patient group. In The Netherlands, this combined treatment is offered as standard to patients with breast cancer recurring in previously irradiated areas.

Blood flow rate in normal and tumor-bearing rats in conscious state, under urethane anesthesia, and during systemic hypothermia

The blood flow rates of 14 tissues in the body were determined by microsphere method using normal and tumor-bearing rats kept conscious or under urethane anesthesia. The effects on the blood flow rate in the tissues were assessed for multimodal therapy, systemic hypothermia for ischemic brain injury, and local hyperthermia and angiotensin II-induced hypertensive chemotherapy for cancer. Urethane anesthesia showed no effect on cardiac output, while there was a tendency of decrease of blood flow rate and % of cardiac output in each tissue other than muscle tissue, in which they increased as a counterbalance, in normal and tumor-bearing rats. Systemic hypothermia gave results similar to those of urethane anesthesia in normal rats, but for tumor-bearing rats, it decreased cardiac output, and consequently the blood flow rate in most tissues. Brain blood flow rate was about half of that in the conscious rats. Local hyperthermia also decreased the cardiac output and blood flow rate in each tissue, including the tumor tissue. Angiotensin II-induced hypertension showed no effect on cardiac output, had various effects on blood flow rate in each tissue, and led to no increase in the tumor blood flow rate. Simulations based on the physiological pharmacokinetic modeling suggested that intramuscular injection of a lung-specific derivative of ceftazidime would provide the ideal biodistribution to ensure its optimal therapeutic efficacy during systemic hypothermia. This methodology, namely the pharmacokinetic simulation based on the physiological values of the body, will provide a useful piece of information on drug delivery systems under various conditions.

Effect of practical layered dielectric loads on SAR patterns from dual concentric conductor microstrip antennas

Radiation patterns of 2 and 4cm square Dual Concentric Conductor (DCC) microstrip antennas were studied theoretically with Finite Difference Time Domain (FDTD) analysis and compared with experimental measurements of power deposition (SAR) in layered lossy dielectric loads. Single and array configurations were investigated with 915 MHz excitation applied across either one, two or four sides, or four corners of the square apertures. FDTD simulations were carried out for realistic models of a muscle tissue load coupled to the DCC antennas with a 5 mm thick bolus of either distilled water or low loss Silicone Oil. This study characterizes the effect on SAR of adding three additional thin dielectric layers which are necessary for clinical use of the applicator. These layers consist of a 0.1 mm thick dielectric coating on the array surface to provide electrical isolation of DCC apertures, and 0.15 mm thick plastic layers above and below the bolus to contain the liquid. Experimental measurements of SAR in a plane 1 cm deep in muscle phantom agree well with theoretical FDTD simulations in the multi-layered tissue models. These studies reveal significant changes in SAR for applicator configurations involving low dielectric constant (Er) layers on either side of a high Er water bolus layer. Prominent changes include a broadening and centring of the SAR under each aperture as well as increased SAR penetration in muscle. No significant differences are noted between the simple and complete load configurations for the low Er Silicone Oil bolus. Both theoretical and measured data demonstrate relatively uniform SAR distributions with > 50% of maximum SAR extending to the perimeter of single and multi-aperture array configurations of DCC applicators when using a thin 5 mm water or Silicone Oil bolus.

Radiation patterns of dual concentric conductor microstrip antennas for superficial hyperthermia

The finite difference time domain (FDTD) method has been used to calculate electromagnetic radiation patterns from 915-MHz dual concentric conductor (DCC) microwave antennas that are constructed from thin and flexible printed circuit board (PCB) materials. Radiated field distributions are calculated in homogeneous lossy muscle tissue loads located under variable thickness coupling bolus layers. This effort extends the results of previous investigations to consider more realistic applicator configurations with smaller 2-cm-square apertures and different coupling bolus materials and thicknesses, as well as various spacings of multiple-element arrays. Results are given for practical applicator designs with microstrip feedlines etched on the backside of the PCB antenna array instead of previously tested bulky coaxial-cable feedline connections to each radiating aperture. The results demonstrate that for an optimum coupling bolus thickness of 2.5-5 mm, the thin, flexible, and lightweight DCC antennas produce effective heating to the periphery of each aperture to a depth of approximately 1 cm, and may be combined into arrays for uniform heating of large area superficial tissue regions with the 50% power deposition contour conforming closely to the outer perimeter of the array.

Relationship between thermal dose and outcome in thermoradiotherapy treatments for superficial recurrences of breast cancer: data from a phase III trial

PURPOSE

The objective of this study was to determine whether the thermal dose delivered during hyperthermia treatments and other thermal factors correlate with outcome after combined radiation and hyperthermia of breast carcinoma recurrences. Data were from the combined hyperthermia and radiation treatment arms of four Phase III trials, which when pooled together, demonstrated a positive effect of hyperthermia.

METHODS AND MATERIALS

Four Phase III trials addressing the question of whether hyperthermia could improve the local response of superficial recurrent breast cancer to radiation therapy were combined into a single analysis. Thermal dosimetry data were collected from 120 of the 148 breast cancer recurrence patients who received hyperthermia. The data were analyzed for correlations between thermal parameters as well as important clinical parameters and outcome (complete response rate, local disease free survival, time to local failure, and overall survival).

RESULTS

Five thermal parameters were tested, all associated with the low regions of the measured temperature distributions. Max(TDmin) and Sum(TDmin) were associated with complete response where TDmin is the minimum thermal dose measured by any of the tumor temperature sensors during a treatment: Max(TDmin) is the maximum of TDmin over a series of treatments. Using a categorical relationship with a cutoff of 10 min for Sum(TDmin), the complete response rate was 77% for Sum(TDmin) > 10 min and 43% for Sum(TDmin) < or = 10 min (p = 0.022, adjusted for study center and significant clinical factors). The overall complete response rate for hyperthermia and radiation was 61% compared to 41% for radiation alone. Either Max(TDmin) or Sum(TDmin) were also associated with local disease free survival, time to local failure and overall survival.

CONCLUSIONS

An earlier report of this trial demonstrated a significant benefit when hyperthermia was added to radiation in the treatment of breast cancer recurrences. The analysis of thermal factors demonstrates that parameters representative of the low end of the measured temperature distributions are associated with initial complete response rate, local disease-free survival, time to local failure and overall survival.