Kadota Fund International Forum 2004. Application of thermal stress for the improvement of health, 15-18 June 2004, Awaji Yumebutai International Conference Center, Awaji Island, Hyogo, Japan. Final report

Nanoparticle-Mediated Photothermal Therapy Limitation in Clinical Applications Regarding Pain Management

The development of new effective cancer treatment methods has attracted much attention, mainly due to the limited efficacy and considerable side effects of currently used cancer treatment methods such as radiation therapy and chemotherapy. Photothermal therapy based on the use of plasmonically resonant metallic nanoparticles has emerged as a promising technique to eradicate cancer cells selectively. In this method, plasmonic nanoparticles are first preferentially uptaken by a tumor and then selectively heated by exposure to laser radiation with a specific plasmonic resonant wavelength, to destroy the tumor whilst minimizing damage to adjacent normal tissue. However, several parameters can limit the effectiveness of photothermal therapy, resulting in insufficient heating and potentially leading to cancer recurrence. One of these parameters is the patient's pain sensation during the treatment, if this is performed without use of anesthetic. Pain can restrict the level of applicable laser radiation, cause an interruption to the treatment course and, as such, affect its efficacy, as well as leading to a negative patient experience and consequential general population hesitancy to this type of therapy. Since having a comfortable and painless procedure is one of the important treatment goals in the clinic, along with its high effectiveness, and due to the relatively low number of studies devoted to this specific topic, we have compiled this review. Moreover, non-invasive and painless methods for temperature measurement during photothermal therapy (PTT), such as Raman spectroscopy and nanothermometry, will be discussed in the following. Here, we firstly outline the physical phenomena underlying the photothermal therapy, and then discuss studies devoted to photothermal cancer treatment concerning pain management and pathways for improved efficiency of photothermal therapy whilst minimizing pain experienced by the patient.

Deep photothermal effect induced by stereotactic laser beams in highly scattering media

Plasmonic photothermal therapy (PPTT), as an increasingly studied treatment alternative, has been widely regarded mostly as a surface tissue treatment choice. Although some techniques have been implemented for interstitial tumors, these involve some grade of invasiveness, as the outer skin is usually broken to introduce light-delivering optical fibers or even catheters. In this work, we present a potential non-invasive strategy using the stereotactic approach, long employed in radiosurgery, by converging multiple near infrared laser beams for PPTT in tissue-equivalent optical phantoms that enclose small gel spheres and simulate interstitial tissue impregnated with plasmonic nanoparticles. The real-time in-depth monitoring of temperature increase is realized by an infrared camera face-on mounted over the phantom. Our results show that a significant reduction in the surface heating can be achieved with this configuration while remarkably increasing the interstitial reach of PPTT, assuring a ∼6^∘C temperature increase for the simulated tumors at 10 mm depth and ∼4^∘C at 15 mm depth and opening up new possibilities for future clinical applications.

Treatment of Breast Cancer-Bearing BALB/c Mice with Magnetic Hyperthermia using Dendrimer Functionalized Iron-Oxide Nanoparticles

The development of novel nanoparticles for diagnostic and therapeutic applications has been one of the most crucial challenges in cancer theranostics for the last decades. Herein, we functionalized iron oxide nanoparticles (IONPs) with the fourth generation (G₄) of poly amidoamine (PAMAM) dendrimers (G₄@IONPs) for magnetic hyperthermia treatment of breast cancer in Bagg albino strain C (BALB/c)mice. The survival of breast cancer cells significantly decreased after incubation with G₄@IONPs and exposure to an alternating magnetic field (AMF) due to apoptosis and elevation of Bax (Bcl-2 associated X)/Bcl-2(B-cell lymphoma 2) ratio. After intratumoral injection of G₄@IONPs, tumor-bearing BALB/c mice were exposed to AMF for 20 min; this procedure was repeated three times every other day. After the last treatment, tumor size was measured every three days. Histopathological and Immunohistochemical studies were performed on the liver, lung, and tumor tissues in treated and control mice. The results did not show any metastatic cells in the liver and lung tissues in the treatment group, while the control mice tissues contained metastatic breast cancer cells. Furthermore, the findings of the present study showed that magnetic hyperthermia treatment inhibited tumor growth by increasing cancer cell apoptosis, as well as reducing the tumor angiogenesis.

A cellular automaton model for spheroid response to radiation and hyperthermia treatments

Thermo-radiosensitisation is a promising approach for treatment of radio-resistant tumours such as those containing hypoxic subregions. Response prediction and treatment planning should account for tumour response heterogeneity, e.g. due to microenvironmental factors, and quantification of the biological effects induced. 3D tumour spheroids provide a physiological in vitro model of tumour response and a systems oncology framework for simulating spheroid response to radiation and hyperthermia is presented. Using a cellular automaton model, 3D oxygen diffusion, delivery of radiation and/or hyperthermia were simulated for many ([Formula: see text]) individual cells forming a spheroid. The iterative oxygen diffusion model was compared to an analytical oxygenation model and simulations were calibrated and validated against experimental data for irradiated (0-10 Gy) and/or heated (0-240 CEM43) HCT116 spheroids. Despite comparable clonogenic survival, spheroid growth differed significantly following radiation or hyperthermia. This dynamic response was described well by the simulation ([Formula: see text] > 0.85). Heat-induced cell death was implemented as a fast, proliferation-independent process, allowing reoxygenation and repopulation, whereas radiation was modelled as proliferation-dependent mitotic catastrophe. This framework stands out both through its experimental validation and its novel ability to predict spheroid response to multimodality treatment. It provides a good description of response where biological dose-weighting based on clonogenic survival alone was insufficient.

A comprehensive model for heat-induced radio-sensitisation

Combined radiotherapy (RT) and hyperthermia (HT) treatments may improve treatment outcome by heat induced radio-sensitisation. We propose an empirical cell survival model (AlphaR model) to describe this multimodality therapy. The model is motivated by the observation that heat induced radio-sensitisation may be explained by a reduction in the DNA damage repair capacity of heated cells. We assume that this repair is only possible up to a threshold level above which survival will decrease exponentially with dose. Experimental cell survival data from two cell lines (HCT116, Cal27) were considered along with that taken from the literature (baby hamster kidney [BHK] and Chinese hamster ovary cells [CHO]) for HT and combined RT-HT. The AlphaR model was used to study the dependence of clonogenic survival on treatment temperature, and thermal dose R2 ≥ 0.95 for all fits). For HT survival curves (0-80 CEM43 at 43.5-57 °C), the number of free fit AlphaR model parameters could be reduced to two. Both parameters increased exponentially with temperature. We derived the relative biological effectiveness (RBE) or HT treatments at different temperatures, to provide an alternative description of thermal dose, based on our AlphaR model. For combined RT-HT, our analysis is restricted to the linear quadratic arm of the model. We show that, for the range used (20-80 CEM43, 0-12 Gy), thermal dose is a valid indicator of heat induced radio-sensitisation, and that the model parameters can be described as a function thereof. Overall, the proposed model provides a flexible framework for describing cell survival curves, and may contribute to better quantification of heat induced radio-sensitisation, and thermal dose in general.

Deep hyperthermia with the HYPERcollar system combined with irradiation for advanced head and neck carcinoma - a feasibility study

PURPOSE

Radiotherapy (RT) treatment of locally-advanced and recurrent head and neck carcinoma (HNC) results in disappointing outcomes. Combination of RT with cisplatin or cetuximab improves survival but the increased toxicity and patient's comorbidity warrant the need for a less-toxic radiosensitizer. Stimulated by several randomized studies demonstrating the radio-sensitizing effect of hyperthermia, we developed the HYPERcollar. Here, we report early experience and toxicity in patients with advanced HNC.

METHODS AND MATERIALS

119 hyperthermia treatments given to 27 patients were analyzed. Hyperthermia was applied once a week by the HYPERcollar aimed at achieving 39-43 °C in the target area, up to patients' tolerance. Pre-treatment planning was used to optimize treatment settings. When possible, invasive thermometry catheters were placed.

RESULTS

Mean power applied during the 119 hyperthermia treatments ranged from 120 to 1007 W (median 543 W). 15 (13%) hyperthermia treatments were not fully completed due to: pain allocated to hyperthermia (6/15), dyspnea from sticky saliva associated with irradiation (2/15) and unknown reasons (7/15). No severe complications or enhanced thermal or mucosal toxicities were observed. Excluding post-operative treatment, response rates after 3 months were 46% (complete) and 7% (partial).

CONCLUSION

Hyperthermia with the HYPERcollar proved to be safe and feasible with good compliance and promising outcome.

Response of breast cancer cells and cancer stem cells to metformin and hyperthermia alone or combined

Metformin, the most widely prescribed drug for treatment of type 2 diabetes, has been shown to exert significant anticancer effects. Hyperthermia has been known to kill cancer cells and enhance the efficacy of various anti-cancer drugs and radiotherapy. We investigated the combined effects of metformin and hyperthermia against MCF-7 and MDA-MB-231 human breast cancer cell, and MIA PaCa-2 human pancreatic cancer cells. Incubation of breast cancer cells with 0.5-10 mM metformin for 48 h caused significant clonogenic cell death. Culturing breast cancer cells with 30 µM metformin, clinically relevant plasma concentration of metformin, significantly reduced the survival of cancer cells. Importantly, metformin was preferentially cytotoxic to CD44(high)/CD24(low) cells of MCF-7 cells and, CD44(high)/CD24(high) cells of MIA PaCa-2 cells, which are known to be cancer stem cells (CSCs) of MCF-7 cells and MIA PaCa-2 cells, respectively. Heating at 42°C for 1 h was slightly toxic to both cancer cells and CSCs, and it markedly enhanced the efficacy of metformin to kill cancer cells and CSCs. Metformin has been reported to activate AMPK, thereby suppressing mTOR, which plays an important role for protein synthesis, cell cycle progression, and cell survival. For the first time, we show that hyperthermia activates AMPK and inactivates mTOR and its downstream effector S6K. Furthermore, hyperthermia potentiated the effect of metformin to activate AMPK and inactivate mTOR and S6K. Cell proliferation was markedly suppressed by metformin or combination of metformin and hyperthermia, which could be attributed to activation of AMPK leading to inactivation of mTOR. It is conclude that the effects of metformin against cancer cells including CSCs can be markedly enhanced by hyperthermia.

Tissue segmentation of head and neck CT images for treatment planning: a multiatlas approach combined with intensity modeling

PURPOSE

Hyperthermia treatment of head and neck tumors requires accurate treatment planning, based on 3D patient models that are derived from segmented 3D images. These segmentations are currently obtained by manual outlining of the relevant tissue regions, which is a tedious and time-consuming procedure (≈ 8 h) limiting the clinical applicability of hyperthermia treatment. In this context, the authors present and evaluate an automatic segmentation algorithm for CT images of the head and neck.

METHODS

The proposed method combines anatomical information, based on atlas registration, with local intensity information in a graph cut framework. The method is evaluated with respect to ground truth manual delineation and compared with multiatlas-based segmentation on a dataset of 18 labeled CT images using the Dice similarity coefficient (DSC), the mean surface distance (MSD), and the Hausdorff surface distance (HSD) as evaluation measures. On a subset of 13 labeled images, the influence of different labelers on the method's accuracy is quantified and compared with the interobserver variability.

RESULTS

For the DSC, the proposed method performs significantly better for the segmentation of all the tissues, except brain stem and spinal cord. The MSD shows a significant improvement for optical nerve, eye vitreous humor, lens, and thyroid. For the HSD, the proposed method performs significantly better for eye vitreous humor and brainstem. The proposed method has a significantly better score for DSC, MSD, and HSD than the multiatlas-based method for the eye vitreous humor. For the majority of the tissues (8/11) the segmentation accuracy of the proposed method is approaching the interobserver agreement. The authors' method showed better robustness to variations in atlas labeling compared with multiatlas segmentation. Moreover, the method improved the segmentation reproducibility compared with human observer's segmentations.

CONCLUSIONS

In conclusion, the proposed framework provides in an accurate automatic segmentation of head and neck tissues in CT images for the generation of 3D patient models, which improves reproducibility, and substantially reduces labor involved in therapy planning.

Vesicoureteral reflux in children: a phantom study of microwave heating and radiometric thermometry of pediatric bladder

We have investigated the use of microwave heating and radiometry to safely heat urine inside a pediatric bladder. The medical application for this research is to create a safe and reliable method to detect vesicoureteral reflux, a pediatric disorder, where urine flow is reversed and flows from the bladder back up into the kidney. Using fat and muscle tissue models, we have performed both experimental and numerical simulations of a pediatric bladder model using planar dual concentric conductor microstrip antennas at 915 MHz for microwave heating. A planar elliptical antenna connected to a 500 MHz bandwidth microwave radiometer centered at 3.5 GHz was used for noninvasive temperature measurement inside tissue. Temperatures were measured in the phantom models at points during the experiment with implanted fiberoptic sensors, and 2-D distributions in cut planes at depth in the phantom with an infrared camera at the end of the experiment. Cycling between 20 s with 20 Watts power for heating, and 10 s without power to allow for undisturbed microwave radiometry measurements, the experimental results show that the target tissue temperature inside the phantom increases fast and that the radiometer provides useful measurements of spatially averaged temperature of the illuminated volume. The presented numerical and experimental results show excellent concordance, which confirms that the proposed system for microwave heating and radiometry is applicable for safe and reliable heating of pediatric bladder.

The clinical feasibility of deep hyperthermia treatment in the head and neck: new challenges for positioning and temperature measurement

To apply high-quality hyperthermia treatment to tumours at deep locations in the head and neck (H&N), we have designed and built a site-specific phased-array applicator. Earlier, we demonstrated its features in parameter studies, validated those by phantom measurements and clinically introduced the system. In this paper we will critically review our first clinical experiences and demonstrate the pivotal role of hyperthermia treatment planning (HTP). Three representative patient cases (thyroid, oropharynx and nasal cavity) are selected and discussed. Treatment planning, the treatment, interstitially measured temperatures and their interrelation are analysed from a physics point of view. Treatments lasting 1 h were feasible and well tolerated and no acute treatment-related toxicity has been observed. Maximum temperatures measured are in the range of those obtained during deep hyperthermia treatments in the pelvic region but mean temperatures are still to be improved. Further, we found that simulated power absorption correlated well with measured temperatures illustrating the validity of our treatment approach of using energy profile optimizations to arrive at higher temperatures. This is the first data proving that focussed heating of tumours in the H&N is feasible. Further, HTP proved a valuable tool in treatment optimization. Items to improve are (1) the transfer of HTP settings into the clinic and (2) the registration of the thermal dose, i.e. dosimetry.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Flow patterns and heat convection in a rectangular water bolus for use in superficial hyperthermia

This paper investigates both numerically and experimentally the spatio-temporal effects of water flow in a custom-made water bolus used for superficial hyperthermia generated by a 915-MHz, 4 x 3 microwave applicator array. Similar hyperthermia models referenced in the literature use a constant water temperature and uniform heat flux to describe conduction and convection energy exchange within the heating apparatus available to cool the tissue surface. The results presented in this paper show that the spatially varying flow pattern and rate are vital factors for the overall heat control applicability of the 5 mm thick bolus under study. Regions with low flow rates and low heat convection clearly put restrictions on the maximum microwave energy possible within the limits of skin temperature rise under the bolus. Our analysis is illustrated by experimental flow front studies using a contrast liquid set-up monitored by high definition video and complemented by numerical analysis of liquid flow and heat exchange within the rectangular water bolus loaded by malignant tissue. Important factors for the improvement of future bolus designs are also discussed in terms of diameter and configuration of the water input and output tubing network.