Effect of 8-MHz radiofrequency-capacitive regional hyperthermia with strong superficial cooling for unresectable or recurrent colorectal cancer

Validation and practical use of Plan2Heat hyperthermia treatment planning for capacitive heating

BACKGROUND

Capacitive devices are used for hyperthermia delivery, initially mainly in Asia, but nowadays also increasingly in Europe. Treatment planning can be very useful to determine the most effective patient-specific treatment set-up. This paper provides a validation of GPU-based simulations using Plan2Heat for capacitive hyperthermia devices.

METHODS

Validation was first performed by comparing simulations with an analytical solution for a spherical object placed inside a uniform electric field. Resolution was 5, 2.5 or 1 mm. Next, simulations for homogeneous and inhomogeneous phantom setups were performed for Thermotron RF8 and Celsius TCS capacitive heating devices at 2.5 mm resolution. Also different combinations of electrode sizes were evaluated. Normalized SAR profiles were compared to phantom measurements from the literature. Possible clinical use of treatment planning was demonstrated for an anal cancer patient, evaluating different treatment set-ups in prone and supine position.

RESULTS

Numerical and analytical solutions showed excellent agreement. At the center of the sphere, the error was 5.1%, 2.9% and 0.2% for a resolution of 5, 2.5 and 1 mm, respectively. Comparison of measurements and simulations for both Thermotron RF8 and Celsius TCS showed very good agreement within 5% for all phantom set-ups. Simulations were capable of accurately predicting the penetration depth; a very relevant parameter for clinical application. The patient case illustrated that planning can provide insight by comparing effectiveness of different treatment strategies.

CONCLUSION

Plan2Heat can rapidly and accurately predict heating patterns generated by capacitive devices. Thus, Plan2Heat is suitable for patient-specific treatment planning for capacitive hyperthermia.

Treatment planning facilitates clinical decision making for hyperthermia treatments

Background: Treatment quality is important in clinical hyperthermia. Guideline-based treatment protocols are used to determine system settings and treatment strategies to ensure effective tumor heating and prevent unwanted treatment-limiting normal tissue hot spots. Realizing both these goals can prove challenging using generic guideline-based and operator-dependent treatment strategies. Hyperthermia treatment planning (HTP) can be very useful to support treatment strategies. Although HTP is increasingly integrated into the standard clinical workflow, active clinical application is still limited to a small number of hyperthermia centers and should be further stimulated.Purpose: This paper aims to serve as a practical guide, demonstrating how HTP can be applied in clinical decision making for both superficial and locoregional hyperthermia treatments.HTP in clinical decision making: Seven problems that occur in daily clinical practice are described and we show how HTP can enhance insight to formulate an adequate treatment strategy. Examples use representative commercially available hyperthermia devices and cover all stages during the clinical workflow. Problems include selecting adequate phase settings, heating ability analysis, hot spot suppression, applicator selection, evaluation of target coverage and heating depth, and predicting possible thermal toxicity in case of an implant. Since we aim to promote a general use of HTP in daily practice, basic simulation strategies are used in these problems, avoiding a need for the application of dedicated advanced optimization routines that are not generally available.Conclusion: Even fairly basic HTP can facilitate clinical decision making, providing a meaningful and clinically relevant contribution to maintaining and improving treatment quality.

Heating technology for malignant tumors: a review

The therapeutic application of heat is very effective in cancer treatment. Both hyperthermia, i.e., heating to 39-45 °C to induce sensitization to radiotherapy and chemotherapy, and thermal ablation, where temperatures beyond 50 °C destroy tumor cells directly are frequently applied in the clinic. Achievement of an effective treatment requires high quality heating equipment, precise thermal dosimetry, and adequate quality assurance. Several types of devices, antennas and heating or power delivery systems have been proposed and developed in recent decades. These vary considerably in technique, heating depth, ability to focus, and in the size of the heating focus. Clinically used heating techniques involve electromagnetic and ultrasonic heating, hyperthermic perfusion and conductive heating. Depending on clinical objectives and available technology, thermal therapies can be subdivided into three broad categories: local, locoregional, or whole body heating. Clinically used local heating techniques include interstitial hyperthermia and ablation, high intensity focused ultrasound (HIFU), scanned focused ultrasound (SFUS), electroporation, nanoparticle heating, intraluminal heating and superficial heating. Locoregional heating techniques include phased array systems, capacitive systems and isolated perfusion. Whole body techniques focus on prevention of heat loss supplemented with energy deposition in the body, e.g., by infrared radiation. This review presents an overview of clinical hyperthermia and ablation devices used for local, locoregional, and whole body therapy. Proven and experimental clinical applications of thermal ablation and hyperthermia are listed. Methods for temperature measurement and the role of treatment planning to control treatments are discussed briefly, as well as future perspectives for heating technology for the treatment of tumors.

Optimization of the Clinical Setting Using Numerical Simulations of the Electromagnetic Field in an Obese Patient Model for Deep Regional Hyperthermia of an 8 MHz Radiofrequency Capacitively Coupled Device in the Pelvis

Background: The purpose of this study was to evaluate the effectiveness of the clinical setting for deep regional hyperthermia of an 8 MHz radiofrequency (RF) capacitively coupled device in the pelvis by using numerical simulations of the electromagnetic field. Methods: A three-dimensional patient model of cervical cancer of the uterus in an obese patient was reconstructed with computed tomography data. The specific absorption rate (SAR) and temperature distributions among the various heating settings were evaluated using numerical simulations. Results: The averaged SAR value of the deep target tumor was similar between with or without overlay boluses (OBs), and that of the subcutaneous fat (SF) at the edges of cooling boluses with OBs was lower than that of the SF without OBs. The use of OBs reduced the overheating of the SF. The 0.5% salt solution in the OB produced the least overheated areas outside the deep target tumor compared with the other concentrations. The insertion of the intergluteal cleft (IGC) bolus could improve the temperature concentration of the deep target tumor. Conclusions: The use of OBs and the salt solution concentration in the OB were important to optimize the temperature distribution. IGC bolus might contribute to temperature optimization. Further studies with individualized numerical simulations in each patient are expected.

Locoregional peritoneal hyperthermia to enhance the effectiveness of chemotherapy in patients with peritoneal carcinomatosis: a simulation study comparing different locoregional heating systems

Introduction: Intravenous chemotherapy plus abdominal locoregional hyperthermia is explored as a noninvasive alternative to hyperthermic intraperitoneal chemotherapy (HIPEC) in treatment of peritoneal carcinomatosis (PC). First clinical results demonstrate feasibility, but survival data show mixed results and for pancreatic and gastric origin results are not better than expected for chemotherapy alone. In this study, computer simulations are performed to compare the effectiveness of peritoneal heating for five different locoregional heating systems.Methods: Simulations of peritoneal heating were performed for a phantom and two pancreatic cancer patients, using the Thermotron RF8, the AMC-4/ALBA-4D system, the BSD Sigma-60 and Sigma-Eye system, and the AMC-8 system. Specific absorption rate (SAR) distributions were optimized and evaluated. Next, to provide an indication of possible enhancement factors, the corresponding temperature distributions and thermal enhancement ratio (TER) of oxaliplatin were estimated.Results: Both phantom and patient simulations showed a relatively poor SAR coverage for the Thermotron RF8, a fairly good coverage for the AMC-4/ALBA-4D, Sigma-60, and Sigma-Eye systems, and the best and most homogeneous coverage for the AMC-8 system. In at least 50% of the peritoneum, 35-45 W/kg was predicted. Thermal simulations confirmed these favorable peritoneal heating properties of the AMC-8 system and TER values of ∼1.4-1.5 were predicted in at least 50% of the peritoneum.Conclusion: Locoregional peritoneal heating with the AMC-8 system yields more favorable heating patterns compared to other clinically used locoregional heating devices. Therefore, results of this study may promote the use of the AMC-8 system for locoregional hyperthermia in future multidisciplinary studies for treatment of PC.

Quo Vadis Oncological Hyperthermia (2020)?

Heating as a medical intervention in cancer treatment is an ancient approach, but effective deep heating techniques are lacking in modern practice. The use of electromagnetic interactions has enabled the development of more reliable local-regional hyperthermia (LRHT) techniques whole-body hyperthermia (WBH) techniques. Contrary to the relatively simple physical-physiological concepts behind hyperthermia, its development was not steady, and it has gone through periods of failures and renewals with mixed views on the benefits of heating seen in the medical community over the decades. In this review we study in detail the various techniques currently available and describe challenges and trends of oncological hyperthermia from a new perspective. Our aim is to describe what we believe to be a new and effective approach to oncologic hyperthermia, and a change in the paradigm of dosing. Physiological limits restrict the application of WBH which has moved toward the mild temperature range, targeting immune support. LRHT does not have a temperature limit in the tumor (which can be burned out in extreme conditions) but a trend has started toward milder temperatures with immune-oriented goals, developing toward immune modulation, and especially toward tumor-specific immune reactions by which LRHT seeks to target the malignancy systemically. The emerging research of bystander and abscopal effects, in both laboratory investigations and clinical applications, has been intensified. Our present review summarizes the methods and results, and discusses the trends of hyperthermia in oncology.

Recent technological advancements in radiofrequency- andmicrowave-mediated hyperthermia for enhancing drug delivery

Hyperthermia therapy is a potent enhancer of chemotherapy and radiotherapy. In particular, microwave (MW) and radiofrequency (RF) hyperthermia devices provide a variety of heating approaches that can treat most cancers regardless the size. This review introduces the physics of MW/RF hyperthermia, the current state-of-the-art systems for both localized and regional heating, and recent advancements in hyperthermia treatment guidance using real-time computational simulations and magnetic resonance thermometry. Clinical trials involving RF/MW hyperthermia as adjuvant for chemotherapy are also presented per anatomical site. These studies favor the use of adjuvant hyperthermia since it significantly improves curative and palliative clinical outcomes. The main challenge of hyperthermia is the distribution of state-of-the-art heating systems. Nevertheless, we anticipate that recent technology advances will expand the use of hyperthermia to chemotherapy centers for enhanced drug delivery. These new technologies hold great promise not only for (image-guided) perfusion modulation and sensitization for cytotoxic drugs, but also for local delivery of various compounds using thermosensitive liposomes.

Locoregional hyperthermia of deep-seated tumours applied with capacitive and radiative systems: a simulation study

BACKGROUND

Locoregional hyperthermia is applied to deep-seated tumours in the pelvic region. Two very different heating techniques are often applied: capacitive and radiative heating. In this paper, numerical simulations are applied to compare the performance of both techniques in heating of deep-seated tumours.

METHODS

Phantom simulations were performed for small (30 × 20 × 50 cm³) and large (45 × 30 × 50 cm³), homogeneous fatless and inhomogeneous fat-muscle, tissue-equivalent phantoms with a central or eccentric target region. Radiative heating was simulated with the 70 MHz AMC-4 system and capacitive heating was simulated at 13.56 MHz. Simulations were performed for small fatless, small (i.e. fat layer typically <2 cm) and large (i.e. fat layer typically >3 cm) patients with cervix, prostate, bladder and rectum cancer. Temperature distributions were simulated using constant hyperthermic-level perfusion values with tissue constraints of 44 °C and compared for both heating techniques.

RESULTS

For the small homogeneous phantom, similar target heating was predicted with radiative and capacitive heating. For the large homogeneous phantom, most effective target heating was predicted with capacitive heating. For inhomogeneous phantoms, hot spots in the fat layer limit adequate capacitive heating, and simulated target temperatures with radiative heating were 2-4 °C higher. Patient simulations predicted therapeutic target temperatures with capacitive heating for fatless patients, but radiative heating was more robust for all tumour sites and patient sizes, yielding target temperatures 1-3 °C higher than those predicted for capacitive heating.

CONCLUSION

Generally, radiative locoregional heating yields more favourable simulated temperature distributions for deep-seated pelvic tumours, compared with capacitive heating. Therapeutic temperatures are predicted for capacitive heating in patients with (almost) no fat.

Therapeutic hyperthermia

The term hyperthermia broadly refers to either an abnormally high fever or the treatment of a disease by the induction of fever. Its effect depends on the temperature and exposure time. The increasing number of applications and clinical trials at universities, clinics, and hospitals prove the feasibility and applicability of clinical therapeutic hyperthermia. This chapter aims to outline and discuss the means by which electromagnetic energy and other techniques can provide elevation of temperature within the human body. Because of the individual characteristic of each type of treatment, different modalities of heating systems have evolved. The chapter concludes with a discussion of challenges and opportunities for further improvement in technology and routine clinical application.

The usefulness of mobile insulator sheets for the optimisation of deep heating area for regional hyperthermia using a capacitively coupled heating method: phantom, simulation and clinical prospective studies

PURPOSE

To evaluate the feasibility and efficacy of deep regional hyperthermia with the use of mobile insulator sheets in a capacitively coupled heating device.

MATERIALS AND METHODS

The heat was applied using an 8-MHz radiofrequency-capacitive device. The insulator sheet was inserted between the regular bolus and cooled overlay bolus in each of upper and lower side of the electrode. Several settings using the insulator sheets were investigated in an experimental study using an agar phantom to evaluate the temperature distributions. The specific absorption rate (SAR) distributions in several organs were also computed for the three-dimensional patient model. In a clinical prospective study, a total of five heating sessions were scheduled for the pelvic tumours, to assess the thermal parameters. The conventional setting was used during the first, third and fifth treatment sessions, and insulator sheets were used during the second and fourth treatment sessions.

RESULTS

In the phantom study, the higher heating area improved towards the centre when the mobile insulator sheets were used. The subcutaneous fat/target ratios for the averaged SARs in the setting with the mobile insulator (median, 2.5) were significantly improved compared with those in the conventional setting (median, 3.4). In the clinical study, the thermal dose parameters of CEM43°CT90 in the sessions with the mobile insulator sheets (median, 1.9 min) were significantly better than those in the sessions using a conventional setting (median, 1.0 min).

CONCLUSIONS

Our novel heating method using mobile insulator sheets was thus found to improve the thermal dose parameters. Further investigations are expected.

Radiofrequency currents exert cytotoxic effects in NB69 human neuroblastoma cells but not in peripheral blood mononuclear cells

Recently, a number of electric and electrothermal therapies have been applied to the treatment of specific cancer types. However, the cellular and molecular mechanisms involved in the response to such therapies have not been well characterized yet. Capacitive-resistive electric transfer (CRET) therapy uses electric currents at frequencies within the 0.45–0.6 MHz range to induce hyperthermia in target tissues. Preliminary trials in cancer patients have shown consistent signs that CRET could slow down growth of tumor tissues in brain gliomas, without inducing detectable damage in the surrounding healthy tissue. Previous studies by our group have shown that subthermal treatment with 0.57-MHz electric currents can induce a cytostatic, not cytotoxic response in HepG2 human hepatocarcinoma cells; such effect being mediated by cell cycle alterations. In contrast, the study of the response of NB69 human neuroblastoma cells to the same electric treatment revealed consistent indications of cytotoxic effects. The present study extends the knowledge on the response of NB69 cells to the subthermal stimulus, comparing it to that of primary cultures of human peripheral blood mononuclear cells (PBMC) exposed to the same treatment. The results showed no sensitivity of PBMC to the 0.57 MHz subthermal currents and confirmed that the treatment exerts a cytotoxic action in NB69 cells. The data also revealed a previously undetected cytostatic response of the neuroblastoma cell line. CRET currents affected NB69 cell proliferation by significantly reducing the fraction of cells in the phase G₂/M of the cell cycle at 12 h of exposure. These data provide new information on the mechanisms of response to CRET therapy, and are consistent with a cytotoxic and/or cytostatic action of the electric treatment, which would affect human cells of tumor origin but not normal cells with a low proliferation rate.

Study on tumor microvasculature damage induced by alternate cooling and heating

Tumor vasculature damage induced by various thermal treatments has been studied in vivo via laser confocal microscopy. Murine mammary carcinoma 4T1 was implanted in the nude mice dorsal skin fold window chamber. The implanted tumor was treated by alternate cooling and heating. Results showed that the treatment was much more effective as compared with that of cooling or heating alone, especially in damaging the tumor vasculature. In general, tumor vascular response to thermal stimuli was heterogeneous. All the treatments of hyperthermia at 42 degrees C (for 1 h), alternate cooling at 1 degrees C and heating at 42 degrees C (for 1/2 h each) and that of -10 degrees C/42 degrees C (for 1/2 h each) enhanced liposome extravasation. Pre-cooling tumor at 1 degrees C preserved most of the vascular integrity but partially inhibited the effect of post-hyperthermia at 42 degrees C. On the other hand, cooling at -10 degrees C for 1/2 h before heating at 42 degrees C caused severe vessel damage. Histo-pathological analyses further confirmed the effect as rare tumor vessel recurrence and large necrotic tumor tissue areas shown on the 7th day after the treatment.

Numerical model for RF capacitive regional deep hyperthermia in pelvic tumors

A numerical model based on Finite Element Method (FEM) for the prediction of power density distribution and temperature during RF-capacitive hyperthermia treatment has been presented in the paper and the results are discussed. In particular the models are related to the treatment of pelvic tumors where it is more difficult to localize and focus heat in deep regions. The geometrical and physical model of the patient is reconstructed with a segmentation procedure by means of dedicated software. The geometrical meshed model has been used as input for the solution of coupled electromagnetic and thermal problems. A deep analysis of different configurations derived from specific scientific literature of the last years has been presented in the paper and discussed. The results obtained by FEM analyses have demonstrated the suitability of this method for the prediction of power and temperature distribution during RF capacitive hyperthermia and that the calculation procedure is an efficient mean to evaluate the efficacy of the heating system.

Hyperthermia applicator based on a reentrant cavity for localized head and neck tumors

A new applicator based on a reentrant cavity is proposed for treating localized tumors such as those of the head and neck. In order to effectively heat the localized tumor without causing dissipation of heat into the surrounding normal tissues, the electric field must be localized over the target region. Although a small applicator may produce an appropriate localized electric field, the higher resonant frequency due to downsizing of the equipment results in very poor heating distribution; this occurs due to the changes in electric permittivity and conductivity consequent upon an increase in the resonant frequency. In this article, we introduce a method for reducing the resonant frequency by inserting a dielectric material into the applicator; the efficacy of this method has been determined by calculating the electromagnetic field and heating distribution with the help of the finite element method. By using the proposed applicator, a reduction in the resonant frequency and localized heating over spherical regions 100 mm in diameter can be achieved.

Radiotherapy with 8 MHz radiofrequency-capacitive regional hyperthermia for pain relief of unresectable and recurrent colorectal cancer

PURPOSE

The purpose of this study was to assess the pain relief in patients with unresectable and recurrent colorectal cancer treated with radiation plus 8 MHz radiofrequency-capacitive regional hyperthermia and to identify predictors of the good outcome.

METHODS

Between February 1986-May 2003, 41 patients with primarily unresectable and recurrent colorectal cancer that caused pain were treated with thermoradiotherapy at the hospital and retrospectively analysed. Radiotherapy was administered with a mean total radiation dose of 56 Gy. Hyperthermia was usually applied within 30 min after radiotherapy once or twice a week. For cooling of the skin surface, the overlay boluses were applied in addition to regular boluses. The external cooling unit has been used to reinforce the cooling ability of the overlay bolus and achieve strong surface cooling to reduce the preferential heating of the subcutaneous fat tissue and treat with more RF-output in 17 patients since January 1997.

RESULTS

Pain relief was obtained in 83% of the patients. Multi-variate analysis by logistic regression to evaluate the effects of certain factors on pain relief (complete response + good response) was strongly correlated with the presence of radiating pain to leg(s) (p < 0.05). The median follow-up was 18 months. The median duration of pain relief was 7.0 months. For the 27 patients in whom the tumour temperature was estimated, the median duration of pain relief was 14.6 months for the patients with a mean average tumour temperature of > 42.5 degrees C and 5.7 months for those of < 42.5 degrees C (p < 0.05). In the 18 patients with radiating pain to leg(s), use of strong superficial cooling and the higher numbers of hyperthermia treatments were better prognostic factors for the duration of pain relief (p < 0.01 and p < 0.05, respectively).

CONCLUSIONS

Radiotherapy with 8 MHz radiofrequency-capacitive regional hyperthermia provided an efficient, effective means on pain relief of treating unresectable and recurrent colorectal cancer. The duration of pain relief can be prolonged, if an adequate heating is achieved, especially in the patients with radiating pain to the leg(s).