The response of the mouse ear to heat applied alone or combined with X rays

Time-temperature Thresholds and Safety Factors for Thermal Hazards from Radiofrequency Energy above 6 GHz

ABSTRACT

Two major sets of exposure limits for radiofrequency (RF) radiation, those of the International Commission on Nonionizing Radiation Protection (ICNIRP 2020) and the Institute of Electrical and Electronics Engineers (IEEE C95.1-2019), have recently been revised and updated with significant changes in limits above 6 GHz through the millimeter wave (mm-wave) band (30-300 GHz). This review compares available data on thermal damage and pain from exposure to RF energy above 6 GHz with corresponding data from infrared energy and other heat sources and estimates safety factors that are incorporated in the IEEE and ICNIRP RF exposure limits. The benchmarks for damage are the same as used in ICNIRP IR limits: minimal epithelial damage to cornea and first-degree burn (erythema in skin observable within 48 h after exposure). The data suggest that limiting thermal hazard to skin is cutaneous pain for exposure durations less than ≈20 min and thermal damage for longer exposures. Limitations on available data and thermal models are noted. However, data on RF and IR thermal damage and pain thresholds show that exposures far above current ICNIRP and IEEE limits would be required to produce thermally hazardous effects. This review focuses exclusively on thermal hazards from RF exposures above 6 GHz to skin and the cornea, which are the most exposed tissues in the considered frequency range.

Fast and high temperature hyperthermia coupled with radiotherapy as a possible new treatment for glioblastoma

Background

A new transcranial focused ultrasound device has been developed that can induce hyperthermia in a large tissue volume. The purpose of this work is to investigate theoretically how glioblastoma multiforme (GBM) can be effectively treated by combining the fast hyperthermia generated by this focused ultrasound device with external beam radiotherapy.

Methods/Design

To investigate the effect of tumor growth, we have developed a mathematical description of GBM proliferation and diffusion in the context of reaction–diffusion theory. In addition, we have formulated equations describing the impact of radiotherapy and heat on GBM in the reaction–diffusion equation, including tumor regrowth by stem cells. This formulation has been used to predict the effectiveness of the combination treatment for a realistic focused ultrasound heating scenario.

Our results show that patient survival could be significantly improved by this combined treatment modality.

Discussion

High priority should be given to experiments to validate the therapeutic benefit predicted by our model.

Electronic supplementary material

The online version of this article (doi:10.1186/s40349-016-0078-3) contains supplementary material, which is available to authorized users.

Rationale for different approaches to combined melphalan and hyperthermia in regional isolated perfusion

The addition of hyperthermia (HT) to regional isolated perfusion (RIP) with Melphalan theoretically has two advantages. Firstly, heat can selectively kill cells in poorly vascularised areas that are usually not reached by the drug. Secondly, in vitro data have revealed that the effect of Melphalan is enhanced at temperatures 39-45 degrees C. However, for the simultaneous application of Melphalan and HT, as it is given in most institutes, both normal and tumour tissues within the volume are treated with both modalities. It is unclear whether--for the same heat dose--the cytotoxicity of Melphalan is enhanced more in tumour tissue than in normal tissues. As the applied dose of Melphalan in RIP is selected on maximum acceptable toxicity, any enhancement of toxicity is undesired. Indeed, Melphalan application at temperatures > 41 degrees C has resulted in unacceptable toxicity. In most institutes, the hyperthermia dose is reduced in comparison to application as a single-modality treatment, to allow simultaneous combination without unacceptable toxicity. In this review, the rationale for two different approaches is summarised which may make it possible to improve the benefit from the theoretical advantage of the use of HT in RIP. It is meant to stimulate discussion as a possible first step in the design of new treatment protocols.

Induction thermochemotherapy increases therapeutic gain factor for the fractionated radiotherapy given to a mouse fibrosarcoma

PURPOSE

It has been shown that thermochemotherapy (TC) given prior to radiation reduces the number of clonogens, with a resultant decrease in the tumor control radiation dose. The purpose of this article was to investigate using an animal tumor model how this clonogen reduction affects subsequent fractionated radiotherapy, including repopulation of surviving clonogens, and whether the induction TC can increase the therapeutic gain factor (TGF).

METHODS AND MATERIALS

The single-cell suspensions prepared from the fourth-generation isotransplants of a spontaneous fibrosarcoma, FSa-II, were transplanted into the C3Hf/Sed mouse foot. TC was given by heating tumors at 41.5 degrees C for 30 min immediately after an intraperitoneal injection of cyclophosphamide (200 mg/kg) when tumors reached an average diameter of 4 mm. Fractionated radiotherapy (R) with equally graded daily doses was initiated 24 h after TC either in air (A) or under hypoxic conditions (H). The 50% tumor control dose (TCD50) and the radiation dose to induce a score 2.0 reaction (complete epilation with fibrosis) in one-half of irradiated animals, RD50(2.0), were obtained, and the TGF was calculated. Our previous results on the fractionated radiotherapy using the same tumor system served as controls.

RESULTS

The TCD50(A, single dose) and TCD50(H, single dose) following TC+R were 52.2 and 57.3 Gy, respectively, which were 14.0 and 20.4 Gy lower than those following radiation alone. The TCD50(A, TC+R) increased only slightly when the number of fractions was increased from one to 10 doses, and all TCD50s were significantly lower than the TCD50(A, R alone). Both TCD50(H, TC+R) and TCD50(H, R alone) increased consistently from a single dose to 20 doses, but all TCD50(H, TC+R) were significantly lower than the TCD50(H, R alone). Regarding the normal tissue reaction, the RD50 values both following TC+R and R alone increased consistently from a single dose to 20 daily doses. However, the RD50(TC+R) and RD50(R alone) for each corresponding number of fractions was not significantly different, resulting in the TGFs significantly > 1.0 for combined TC+R treatments, with the exception of 20 daily doses given in air.

CONCLUSION

The induction TC decreased the TCD50 values substantially without altering the RD50 for a late reaction, resulting in an significant increase in the TGF. These results encourage the use of TC as an induction treatment prior to fractionated radiotherapy.

Transurethral balloon laser prostatectomy in the canine: medium-term, follow-up results

BACKGROUND AND OBJECTIVE

To demonstrate surgical complications in transurethral balloon laser prostatectomy by medium-term, follow-up observation.

STUDY DESIGN/MATERIALS AND METHODS

Three dogs were treated with transurethral laser irradiation using 15 watts for 20 minutes at 60 degrees C at a 5 mm depth of the prostate, one dog was for 5 minutes with same parameters, and one dog was with only laser balloon probe as a control. All animals were followed for 24 weeks.

RESULTS

A large cavity in the prostatic urethra was formed in laser-treated animals 4 weeks later, whereas the cavity in the balloon-treated animals was not shown. Cavity volume did not significantly change for 6 months, and there was no bladder neck stricture or urethral stenosis observed in any case. An increase in collagen fibers in the periurethral tissue was barely observed by Mallory staining.

CONCLUSION

The risk of bladder neck stricture and urethral stenosis was estimated to be low for transurethral balloon laser prostatectomy.

Thermal changes in the canine prostate after transurethral balloon laser prostatectomy

The histological changes by transurethral balloon laserthermia were examined on 23 canine prostates. Immediately after treatment, three zones were observed; the coagulative zone treated over 60 degrees C for 20 min formed an inner layer, the degenerative zone treated between 60 to 46.1 degrees C surrounded the coagulative zone, and the intact zone treated below 46.1 degrees C formed the outer layer. Coagulative necrosis of the gland, swelling of collagen fibers, and thrombus of the vessels occurred in the coagulative zone, shedding and vacuolation around the nuclei of the epithelial cells and stromal edema were observed in the degenerative zone, while thermal changes were minimal in the intact zone. Both coagulative and degenerative zones developed necrosis and started to slough off within 1 week, forming a cavity in the central portion of the prostate. Reepithelialization of the cavity was complete at 4 weeks and the ducts of the prostate gland opened to the surface of the cavity. This treatment preserved the excretory tract of the prostate gland.

In vivo effects of transurethral balloon laser prostatectomy on the canine prostate

Twenty-three dogs received prostatectomy by transurethral balloon laserthermia, and the in vivo effects and morbidity were evaluated. The prostate was heated transurethrally, and tissue temperature at a depth of 5 mm. from the urethral mucosa was maintained at 60C for 20 minutes. Immediately after the treatment, coagulative necrosis was observed around the urethra to an average depth of 5 mm., and the tissue started to slough off within 1 week. Cavity formation and reepithelialization were complete after 4 weeks. Histologically, no tissue damage was found in the bladder neck or the urethral sphincter. The cavity formation threshold was 46.1C for 20 minutes. There was no incontinence or macroscopic hematuria in any case. No abnormality was found in hematological or biological examinations after treatment. From these data, the clinical use of transurethral balloon laserthermia for prostatectomy is considered both safe and effective.

Hyperthermia in cancer growth regulation

With present techniques, hyperthermia used alone can cause complete clinical regression in 10-15% of tumours but the duration of response is very short. The greatest advantage for hyperthermia at the present time appears to be in combination with radiation in the local control of cancer growth. Currently, large randomised phase III studies are in progress to determine whether the addition of local hyperthermia to radiation or chemotherapy yields significant advantage. Phase III studies of wholebody hyperthermia in combination with chemotherapy are planned for the future and will include tumours with a high growth fraction such as small cell lung cancer and high grade non Hodgkins lymphoma.

Histopathological changes in the skin and subcutaneous tissues of mouse legs after treatment with hyperthermia

The right hind legs of mice wee heated in a waterbath at 44 degrees C. The animals were killed at various time intervals after exposure. Tissue damage was studied histologically. After 15 min exposure light and reversible changes were seen including oedema and some neutrophilic inflammatory infiltration immediately after treatment. After 30 min exposure an extensive inflammatory infiltrate and strong oedema were seen during the first days after treatment. Adjacent to areas in the skin with strong oedema extensive muscular necrosis was observed. The muscular tissue regenerated almost completely in three weeks. After 60 min heating the histological picture was dominated by massive necrosis of muscle, subcutaneous fat tissue and skin during the first week after treatment followed by local ulceration. From about the 7th day after treatment regeneration of the epithelium started and granulation tissue could be observed in the margin of the ulceration. Healing of the skin was completed at about day 21 after treatment. Our results indicate that heat induced tissue damage in some tissues is due to a direct effect on the cells composing the tissue (e.g., fat cells in subcutaneous fat) but that, in most other tissues (e.g., muscle and skin) it is a consequence of damage to the vasculature.

The effect of hyperthermia on the early and late appearing mouse foot reactions and on the radiation carcinogenesis: effect on the early and late appearing reactions

The effect of hyperthermia on radiation-induced early- and late-appearing foot reactions was studied in C3Hf/Sed mice derived from our defined flora mouse colony. The animal foot was irradiated with 137Cs gamma-rays under hypoxic, air, or hyperbaric oxygen (O2 30 psi) conditions. Hyperthermia of 43.5 degrees C for 45 min was given locally in a water bath where a constant temperature +/- 0.1 degrees C was maintained. Treatment intervals between the 2 treatments were 20 min and 2 days. For the early-appearing reactions scores taken between the 14th and 35th post-irradiation days were averaged. Late-appearing reactions became apparent after approximately the 200th post-treatment day and increased with time. The foot reaction was enhanced by hyperthermia given 20 min before or after irradiation. Dose response curves for radiation given 20 min after hyperthermia for acute-appearing reactions lacked shoulders, whereas those following the same treatment schedule for late-appearing reactions showed significant shoulders. The thermal enhancement ratios (TER) for score 2.0 (complete epilation) early- and late-appearing reactions depended on the treatment interval and sequence. The TER values were greater for a short treatment interval (20 min.) than for a long treatment interval (2 days). Thermal enhancement was greater for hyperthermia given before irradiation compared to the reverse sequence. The TER values were always smaller for the late-appearing reactions than for the acute-appearing reactions. The relationships between early reaction scores and late reaction scores showed that the late reactions following combined heat and radiation are less extensive than those following radiation alone if they were compared at radiation doses which induced an equal level of early reactions. This difference was most significant at low early reaction scores and decreased with increasing score level.

Stromal sensitivity to radiation and hyperthermia

The influence on stroma of heat alone, X-rays alone or the combined treatment, has been studied using the tumour bed effect (TBE) as an assay. Ca NT cells have been implanted into previously treated subcutaneous sites as an angiogenic stimulus. The vascular damage is then assessed by the reduced tumour growth rate, which results from inadequate vascular proliferation. A range of X-ray doses was used and large alterations in latent period for growth to 2 mm diameter were followed by smaller alterations in the growth rate of established tumours. A dose response relationship was seen for latency (0-20 Gy) and for growth rate (0-16 Gy). A range of subcutaneous temperatures was obtained by immersion in a water bath for 60 minutes at 40 degrees, 41.5 degrees, 43 degrees or 44.5 degrees C. A slight retardation of tumour growth was seen after 41.5 degrees C, but an unexpected acceleration resulted from the highest heat treatment. Combined heat and X-ray treatments showed thermal sensitization of the X-ray induced TBE at 41.5 degrees C, with a reversal at higher temperatures. At 43 degrees C and 44.5 degrees C a mild thermal burn was induced and this appeared to elicit neovascularisation that could be utilized by the implanted tumour cells. Delayed implantation of tumour cells (at 4 weeks instead of 1 day) abolished this effect.

Effects of 434 MHz microwave hyperthermia applied to the rat in the region of the cervical spinal cord

Hyperthermia was applied in the region of the vertebral column between the cervical vertebrae 5 and thoracic 2, using a ring-shaped applicator operating at a microwave frequency of 434 MHz. This region was focally heated, including spinal cord, vertebrae, intervertebral discs and nerve roots. In all experiments temperature was measured at a 'reference' thermocouple probe which was placed against one of the cervical vertebrae 6, 7 or thoracic 1. Temperatures inside the vertebral canal were measured separately and proved to be below the 'reference' temperature: at 42 degrees, 43 degrees, 44 degrees and 45 degrees C (+/- 0.1 degree C) respectively the temperature in the canal was 41.2 degrees, 42.3 degrees, 42.9 degrees and 43.2 degrees C (+/- 0.4 degree C). Temperatures in tissues close to the vertebrae (e.g. within 2 mm lateral to the vertebrae, in the region of the brachial plexus) did not differ significantly from the temperature inside the canal. The temperature inside the intervertebral disc was as high as the 'reference' temperature. Temperatures measured at other sites, e.g. in the oesophagus, rectally and in the cervical muscles 5 or 10 mm lateral from the vertebral column showed that these sites were only slightly heated. The effects of hyperthermia at temperatures inside the spinal canal ranging from 41.2-43.2 degrees C for 30-120 min were investigated. One day after treatment at 41.2 degrees C for 120 min or 42.3 degrees C for 60 min neither neurological symptoms nor deaths were observed. Minor neurological symptoms were observed one day after 75 min at 42.3 degrees C. The incidence and severity of the neurological symptoms (ranging from unco-ordinated use of the forelegs to paralysis) increased with increasing temperature and duration of the hyperthermic treatment. Thermal damage even resulted in lethality: 74 per cent of the rats that died did so between 2 and 42 h after treatment. The LD50 value at 60 days at 43.2 degrees C was 30 min, at 42.9 degrees C, 41 min, and at 42.3 degrees C, 92 min. In most rats with neurological symptoms after treatment, recovery from motor dysfunctions took place within about two weeks. Even severe neurological symptoms which did not lead to lethality recovered completely. At day 60 no neurological symptoms were observed.

Thermotolerance induced by fractionated hyperthermia: dependence of the interval between fractions

The induction of thermotolerance by fractionated hyperthermia was investigated in the mouse ear. Ears were heated at 43.5 degrees C by immersion in water. One to ten treatments of 20 min were followed by test treatments. Thermotolerance was assessed as the increase in the duration of the test treatment required for a thermal response in 50 per cent of the ears (NT50). A single treatment induced thermotolerance which reached a maximum at 24 h when the NT50 was increased by a factor of 2.4. The same maximum was observed after each fractionated treatment used in the present study. The time course of development, however, depended on the interval between fractions. (1) When the interval was too short to allow development of thermotolerance after a single fraction (4 h), thermotolerance was not induced during fractionated treatment but it developed during the first 24 h after treatment. (2) When the interval between fractions allowed the maximal development of thermotolerance (24 h), this maximum was maintained during fractionated treatment and persisted for 24 h after treatment. (3) When the interval allowed some decay of thermotolerance (72 or 168 h) there was a further increase to maximal thermotolerance after each fraction. The decay of thermotolerance from the maximum did not depend on the interval between fractions. These results indicate that the degree of thermotolerance may fluctuate during fractionated hyperthermia.

Studies relevant to a means of quantifying the effects of hyperthermia

There is as yet no fully satisfactory method of defining 'thermal dose'. However, in order to relate different hyperthermal treatments it has been suggested that the relationship between heating time and temperature be used to derive an isoeffect parameter which might be useful in this context. The equation t2/t1 = RT1-T2, where t is the treatment time, T the temperature, R = 2 for T greater than 42.5 degrees C and R = approximately 6 for T less than 42.5 degrees C, has been shown to fit the isoeffect data from many studies both in vivo and in vitro. Whether or not this relationship is applicable when the temperature is varying has been tested using an animal model system, i.e. the response of the baby rat tail. It has shown that the relationship between time and temperature is indeed characterized by the above equation, and the phenomena of thermotolerance and step-down sensitization were clearly demonstrated. Tails were then alternated between waterbaths at different temperatures in order to simulate varying temperature. The measured effects were, in general, in good agreement with those derived from the formula. The maximum difference between the observed and predicted effect, obtained under rather extreme conditions unlikely to be experienced clinically, amounted to an under-estimate of the effective temperature by approximately 0.3 degrees C, i.e. a net small effect of thermotolerance. It is therefore suggested that the above formula for 'heat dose' provides a reasonable interim method for comparing clinical hyperthermic treatments. The formula does not, however, account for differing absolute sensitivities between tissues nor for effects of fractionating heat treatments.

1985 Douglas Lea memorial lecture. Hyperthermia in the treatment of cancer

There are sound biological reasons for using hyperthermia in the treatment of malignant disease. This review includes a discussion of this rationale and describes effects of hyperthermia either given alone or in combination with ionising radiation to cells in vitro, tumours or normal tissues. Topics discussed include thermotolerance, step-down sensitisation, fractionation, re-treatment of previously irradiated sites, thermal enhancement ratio and thermal dose. Problems of heat delivery and temperature measurement are considered and the current status of clinical studies is stated briefly.

A long-term effect of prior irradiation on the thermal enhancement of radiation damage in the mouse ear

The responses of the mouse ear to heat alone, X-rays alone or X-rays combined with heat were measured at 10 months after initial X-ray treatments (19 Gy or 10 X 3.8 Gy), which caused similar acute reactions. Fractionating the initial dose had little effect on the response to retreatment. Prior irradiation increased thermal sensitivity so that the heating time at 43.5 degrees C required to cause necrosis was about 65 per cent that in age-matched controls. Prior irradiation also increased the response to X-rays alone, but had different effects on the susceptibilities to develop acute radiodermatitis and late deformity. For acute radiodermatitis, the second X-ray dose required to cause a given response in previously irradiated ears was 80-90 per cent that in age-matched controls and for late deformity it was 60-65 per cent. Prior irradiation had the same effects on the responses to X-rays given 6 min before mild hyperthermia (43.5 degrees C, 12 min) as on those to X-rays alone but had little effect on the responses to X-rays given 6 min after hyperthermia. Consequently, the thermal enhancement ratios for heat given after X-rays did not depend on prior irradiation whereas those for heat given before X-rays were reduced. This reduction may be due to a reduced ability of irradiated blood vessels to elicit an hyperaemic response to heat.

Reversible injury after mild hyperthermia

Skin contraction and leg contracture resulted from immersion of mice legs in a water bath at temperatures of 42.5 degrees to 43.7 degrees C for 45 to 90 minutes. The maximum contracture was observed between 5 and 15 days after treatment, but little damage remained after about 30 days. After healing of the early tissue damage, there was no progression of residual damage in skin up to 490 days after treatment. In contrast, radiation-induced contracture develops rapidly after 14 days, and may continue to progress for 100 days or more. In the present studies, leg contracture could be attributed primarily to injury in the skin, because skinning the legs before measuring eliminated most of the contracture. Temperature differences between subcutaneous tissue and deep muscle were not consistently observed or statistically significant, and probably made little or no contribution to the difference in thermal response of these tissues.

Thermal enhancement of the radiation damage in the mouse foot at different heat and radiation dose: influence of thermotolerance

We studied the reaction of the mouse foot after combined X-irradiation and heat treatment. Acute reactions after heat differ from those after irradiation, however, after healing of the lesions, the same symptoms of deformity of the mouse foot remain. Prior heat treatment, 30 min at 43 degrees C, of the foot led to thermotolerance and this thermotolerance resulted in resistance to combined irradiation-heat treatments and hence to a decreased thermal enhancement of radiation effects. Resistance could be observed up to 168 h after prior heat treatment. The development of resistance to combined treatment at higher irradiation dose (15 or 20 Gy) and less severe heating was slower than at lower irradiation dose (10 Gy) and more severe heating. Thermal enhancement was confirmed to be dependent on the sequence of, and the interval between irradiation and heat treatment. When the mouse foot was made thermotolerant by prior heat treatment, thermal enhancement was always reduced, regardless of the sequence, when the combined heat and radiation treatments were given with an interval of less than 12 h. Thermotolerance led to an apparent decrease in the effective temperature employed in a combined treatment equivalent to approximately 1.0 degrees C, at temperatures above 43 degrees C in a 1 h heat treatment.

Time-temperature relationships for hyperthermal radiosensitisation in mouse intestine: influence of thermotolerance

Thermal enhancement of radiation injury to the crypt compartment of mouse small intestinal mucosa has been measured as a function of heating time for temperatures in the range 41.0-44.0 degrees C. All the hyperthermal treatments used were themselves subthreshold for gross tissue injury. With this limitation, thermoradiosensitisation increased linearly with duration of hyperthermia for temperatures in the range 42.3-44.0 degrees C. Using temperatures below 42.0 degrees C, there was a saturation in effect for treatments longer than approximately 40-90 min, possibly due to the development of thermotolerance. The thermoradiosensitisation isoeffect curve relating heating time with temperature was biphasic with the transition occurring between 41.8 and 42.0 degrees C. For temperatures above the transition, a 1 degree C change was equivalent to a factor of 2.6 in heating time; below the transition, a 1 degree C change was equivalent to a factor of 5.4. Time-temperature relationships for thermoradiosensitisation in other rodent tissues are reviewed and compared with the general relationships for direct thermal injury, previously derived from experimental studies. The results are discussed with relevance to the interpretation of in vivo thermal enhancement of radiation injury.

Hyperthermia in the treatment of cancer. Perspectives on its promise and its problems

The potential for the use of hyperthermia in the treatment of cancer is based on a strong and compelling biologic rationale. In the laboratory it has been shown in quantitative assays both in vitro and in vivo that (1) hyperthermia is cytotoxic to tumor cells as a function of time at temperatures above 42 degrees C; (2) cytotoxicity is relatively high for radioresistant S-phase cells and for cells that are nutritionally deprived and acidotic, conditions one might expect in regions of tumors containing large numbers of radioresistant hypoxic cells; and (3) heat is a radiosensitizer and a chemosensitizer. Clinical study is hampered by less than optimal physical heating methods and the need for invasive thermometry. Ultrasonic and electromagnetic approaches each have limitations and advantages. In spite of technical limitations, efficacy has been shown for superficial tumor sites treated by local hyperthermia and Phase I studies are underway investigating the more complicated problem of deep regional hyperthermia. Although whole body hyperthermia has the attractive capability of treating metastatic as well as more localized cancer, it is toxic therapy and its role in treatment remains undefined. Research advances in equipment design and treatment optimization are needed; however, there are studies underway utilizing existing methods and rationale which should further clarify the potential clinical usefulness of regional hyperthermia in combined modality approaches to cancer therapy.

Thermal dose determination in cancer therapy

With the rapid development of clinical hyperthermia for the treatment of cancer either alone or in conjunction with other modalities, a means of measuring a thermal dose in terms which are clinically relevant to the biological effect is needed. A comparison of published data empirically suggests a basic relationship that may be used to calculate a "thermal dose." From a knowledge of the temperature during treatment as a function of time combined with a mathematical description of the time-temperature relationship, an estimate of the actual treatment calculated as an exposure time at some reference temperature can be determined. This could be of great benefit in providing a real-time accumulated dose during actual patient treatment. For the purpose of this study, a reference temperature of 43 degrees C has been arbitrarily chosen to convert all thermal exposures to "equivalent-minutes" at this temperature. This dose calculation can be compared to an integrated calculation of the "degree-minutes" to determine its prognostic ability. The time-temperature relationship upon which this equivalent dose calculation is based does not predict, nor does it require, that different tissues have the same sensitivity to heat. A computer program written in FORTRAN is included for performing calculations of both equivalent-minutes (t43) and degree-minutes (tdm43). Means are provided to alter the reference temperature, the Arrhenius "break" temperature and the time-temperature relationship both above and below the "break" temperature. In addition, the effect of factors such as step-down heating, thermotolerance, and physiological conditions on thermal dose calculations are discussed. The equations and methods described in this report are not intended to represent the only approach for thermal dose estimation; instead, they are intended to provide a simple but effective means for such calculations for clinical use and to stimulate efforts to evaluate data in terms of therapeutically useful thermal units.

A study of the effects of prior heat treatment on the skin reaction of mouse feet after heat alone or combined with X-rays: influence of misonidazole

The skin of mouse feet was used to study the effects of hyperthermic treatment, either alone or combined with irradiation. The present experiments show that a priming heat treatment induces resistance both to a subsequent heat treatment and to a subsequent combined irradiation-heat treatment. The development of resistance to a combined irradiation-heat treatment after a priming heat treatment (30 min at 43 degrees C) was relatively slow (18-24 h) compared to development of resistance to a heat treatment without irradiation (6 h). Misonidazole, when administered prior to heat treatment only, did not influence the heat-induced skin reaction. However, when misonidazole was administered prior to combined irradiation-heat treatment, a slight but significant increase of the skin reaction was observed. Also, in combination with misonidazole resistance to combined treatment was observed by a priming heat treatment.

Production of systemic hyperthermia in the rat

The design of clinical trials employing whole-body hyperthermia in cancer therapy has been hampered due to lack of a suitable animal model. We describe a technique for reproducibly and efficiently inducing whole-body hyperthermia in Sprague-Dawley rats, using halothane and oxygen anesthesia and immersion in a hot water bath. Core body temperatures of between 41.5 and 43 degrees C were induced and maintained for periods of up to 200 min and survival curves were determined. The time of exposure at a given temperature that resulted in death in 50% of the animals within 24 hr after heating (LD50/24 hr) was calculated by linear logistic regression analysis. LD50 24 hr values of 115, 61, 57, 25 and 16 min were obtained for temperatures of 41.75, 42.0, 42.25, 42.5 and 42.75 degrees C respectively. This heating technique is compared to several more toxic methods for inducing whole-body hyperthermia with respect to possible pharmacological and physiological differences.

The induction of thermotolerance in the ear of the mouse by fractionated hyperthermia

The development of thermotolerance in ears of mice was investigated after fractionated hyperthermia. Ears were heated at 43.5 degrees C by immersion in a water bath and the response was measured in terms of the heating time required to cause thermal necrosis in 50% of the ears (NT50). Three types of treatment were given: (1) single treatments, for which the NT50 was 42 minutes; (2) priming treatments, which caused little visible effect but induced thermotolerance. These treatments were given as 1-10 daily fractions, the total heating time ranging from 20-630 minutes; (3) test treatments which were given at various times after priming and were varied to estimate the NT50. Thermotolerance was defined as an increase in the test NT50 for preheated ears relative to the single treatment NT50. It has been suggested that thermotolerance induced by a single priming treatment may be increased by giving additional heat treatments which would not be tolerated by normal cells. In the mouse ear, the maximum thermotolerance induced by a single priming treatment of 20 min at 43.5 degrees C was seen after 24 hr when the test NT50 was about 2.5 times the single NT50. The effect of giving up to nine additional daily treatments of 70 min, each of which would cause necrosis in ears that had not received prior hyperthermia, was measured. The maximum thermotolerance observed was equal to that after a single 20 minute priming treatment but thermotolerance decreased as the number of 70 min treatments was increased from four to nine. The effects of repeating a treatment (20 min or 5 min) which was tolerated by normal ears and induced maximal or less than maximal resistance were compared. The interval between each fraction (24 hr or 12 hr respectively) was equal to the time at which maximal thermotolerance was observed after one treatment. For each regimen, the degree of resistance seen after 2 to 10 exposures was similar to that after the appropriate single treatment. This resistance was maintained throughout the course of priming treatment and decayed after the last fraction. Thus for this regimen, thermotolerance depended on the duration of each treatment rather than on the number of treatments given.

Time-temperature relationship for hyperthermia induced stoppage of the microcirculation in tumors

The time-temperature dependence for microcirculation stoppage was investigated for the Rhabdomyosarcoma BA1112 growing in observation chambers ("sandwich chambers"). The tumor microcirculation could be observed continuously during the treatment, and the condition of the microcirculation was recorded every 15 minutes as "flowing" or "stoppage". By using large numbers of tumors, the 50% stoppage time (ST50) could be derived for the four temperatures investigated: 42 degrees, 42.5 degrees, 43 degrees and 43.5 degrees C. The respective ST50 values were 226, 152, 101 and 70 minutes. The results can be expressed as a log-linear relationship with a slope value of 0.4551 +/- 0.03 (SD) per degree centigrade. This value probably does not differ significantly from the "t 1/2 for every degree C" rule that has been found for the thermal response of many biological systems.

Effect of intestinal hyperthermia in the Chinese hamster

If hyperthermia is to become a useful cancer therapeutic modality, normal tissue response must be thoroughly understood. The hyperthermia response of Chinese hamster intestine was studied by immersion of the exteriorized small intestine in heated tissue culture medium. After heating, the small intestine was reinserted, the incision closed, and animals observed until death. Animals exposed to 42.5 degrees, 43.5 degrees, or 44.5 degrees C intestinal hyperthermia exhibited LD50/7 values (including 95% intervals) of 56 min (52.9-59.3), 29 min (26.4-31.8), or 14 min (13.2-14.6), respectively. An Arrhenius plot of LD50/7 vs 1/T degree K exhibited an inactivation energy of 139 kcal/mole, which corresponds well with values generally reported for cellular inactivation. Hamster intestine conditioned with a sublethal exposure of 8 min at 44.5 degrees C developed thermotolerance to subsequent 44.5 degrees C hyperthermia. Thermotolerance induction was maximal by 24 hr; the LD50/7 for the second dose of hyperthermia increased from 6 min at 44.5 degrees C at zero time to 21 min at 44.5 degrees C after a treatment interval of 24 hr (thermotolerance ratio of 3.5). The LD50/7 subsequently decreased from 21 min to 12 min at 44.5 degrees C (the control value) by 96 hr. The hyperthermia response of this tissue was predicated by previous results from the Chinese hamster ovary (CHO) fibroblast cell line in tissue culture, and is also similar to several mouse normal tissues.

Formula to estimate the thermal enhancement ratio of a single simultaneous hyperthermia and radiation treatment

An experimental model composed of a C3H mammary carcinoma and its surrounding skin has been exposed to simultaneous radiation and hyperthermia given with different combinations of heating time and temperature. Based on the thermal enhancement ratio (TER) values obtained in the temperature range 41.5 to 43.5 degrees C, a linear relationship between TER and the heating time was achieved at each temperature. The slopes of the curves drawn at each temperature were found to have a log-linear relationship with the treatment temperature. With these relationships it was possible to make a formula expressing the TER as a function of treatment temperature and time. This formula gives a crude but probably acceptable estimate of the TER following a single simultaneous radiation and heat treatment. Although subject to several limitations, the formula represents an attempt to describe a heat dose concept for the radiosensitizing effect of hyperthermia. This may be useful to establish the tolerance level of a given radiation treatment when combined with hyperthermia.

Skin responses to step-up and step-down heating in C3H mice

The effects of step-up (42 leads to 44 degrees C sequence) and step-down (44 leads to 42 degrees C sequence) heating were studied on the skin of C3H/He mouse feet. Skin damage in mouse feet exposed to 44 degrees C alone became proportionally more severe with increasing exposure time, while it was slight or not observed at 42 degrees C for up to 2 hr. Preheating to 42 degrees C for 60 or 120 min (step-up) had little effect on the damage from 30-60 min exposure at 44 degrees C, but increased the damage seen with 90 min at 44 degrees C. However, skin damage was markedly enhanced by exposure to step-down heating. On the other hand, thermal resistance was induced in the mouse skin by 44 degrees C fractionated treatments. The induced thermal resistance reached a maximum with a 1 day interval, and then disappeared after a 3 day interval. In another fractionation schedule of step-down heating, the enhanced skin damage which was observed when here was no interval, recovered rapidly and attained an additive response within a 1 day interval. No thermal resistance was observed.

Effect of prolonged heating on the thermal enhancement ratio in X-irradiated murine intestine

When the jejunum in mice was heated for 20-180 min at temperatures between 40.3 and 42.3 degrees C, followed immediately by X-irradiation, the thermal enhancement ratio (TER) for crypt survival increased and then tended to decline with longer heating times. At the higher temperatures, the TER was higher and the peak value was reached with shorter heating times. The decline in TER with longer heating times may be due to the development of thermotolerance.

Site dependent response of tumours to combined heat and radiation

In previous experiments, large differences in thermal sensitisation were observed for tumours grown on the tails of the chest of mice. The present work reports the results of experiments to compare the response of tumours in four different sites to the radiosensitising effects of both heat and misonidazole. Factors influencing tumour response, e.g., tumour growth rate, blood flow, temperature uniformity, temperature increase during heating and drug availability, were also studied. Tumour response and most of the parameters measured varied according to the site of tumour implantation. Growth rate, blood flow and natural tumour temperature are all likely to be important. However, there appears to be no simple relationship by which tumour response could be predicted, although heat dose, the product of temperature elevation above the natural level and treatment time, may be the most relevant parameter. Clearly the choice of implant site does influence response to treatment. Tumours grown on the extremities may be poor models for human tumours, because of their low natural temperatures.

Histology as a method for determining thermal gradients in heated tumours

It is proposed that histological assessment of tumours may be a useful biological thermal dosimeter. Assessment of nodules may give information about thermal gradients, and biopsies of treated tumours may serve as a prognostic indicator in clinical hyperthermia. Cell death after hyperthermia occurs rapidly and surviving cells are readily recognizable as small foci within 24 h. This contrasts with the delayed cell death and the more random distribution of survivors amongst killed cells after ionizing radiation. By 24 h, sections of tumours can demonstrate islands of apparently viable cells in a sea of necrosis after 44.8 degrees C/1 h. This technique has been used to identify regions of poor heating in mouse tumours treated by water immersion. Cells surrounding blood vessels and cells adjacent to underlying normal tissue were seen to be protected from thermal damage.

Effect of hyperthermia on a neurogenic rat cell line (BT4A) in vivo

The effect of hyperthermia alone on the growth of the BT4A neurogenic tumour implanted into the feet of BD IX rats has been investigated. Following treatment by immersion of the tumour-bearing leg in a water bath at 42.0 to 45.0 degrees C a temporary retardation of tumour growth was observed but no cure. The lag phase before regrowth occurred was temperature and time dependent. A log-liner correlation was found between the surviving fraction previously found in vitro and the heat sensitivity of the cell line in vivo.

Local hyperthermia and irradiation in cancer therapy

The preliminary experience at the Mallinckrodt Institute of Radiology with hyperthermia and irradiation is reported and current issues in clinical application of heat are reviewed. Twenty-nine lesions were treated with 400 rad fractions given every 72 hr (twice weekly) for a total dose of 2400 to 4000 rad followed by hyperthermia (1450-MHz or 915-MHz microwaves, 42.0 degrees -43 degrees, 90 min, every 72 h). Eight of 12 recurrent epidermoid carcinomas of the head and neck showed complete regression (67%) and one more than 50% response. Of 5 metastatic melanoma nodules treated with irradiation an hyperthermia, 4 (80%) showed complete regression of the tumors an 1 almost complete response. Of 9 recurrent adenocarcinoma of breast nodules in the chest wall treated with 3200 to 4000 rad 5 lesions exhibited complete regression and 2 others about 80%. Of 6 lesions treated with 1500 rad and hyperthermia (RTOG protocol), 2 metastatic melanomas showed complete regression (CR) and 3 tumors exhibited partial regression. Of the 35 sites treated, 4 (11%) developed blisters, 7 (20%) erythema only, 3 (8%) moist desquamation and 27 (77%) dry desquamation. Additional clinical trials are in progress to assess the potential value of hyperthermia alone or combined with irradiation in the treatment of selected cancer patients.

The response of mouse intestine to combined hyperthermia and radiation: the contribution of direct thermal damage in assessment of the thermal enhancement ratio

The thermal enhancement of X-ray damage to mouse jejunum has been assessed when heating was achieved by immersion of an exteriorized loop of intestine in Krebs-Ringer solution. The results have been compared with those previously obtained following heating in situ. The primary effect of 1 hour of mild hyperthermia was to reduce the should of the crypt survival curve obtained following X-rays given alone. Thermal enhancement ratio (TER) values increased with increasing temperature, up to 42.3 degrees C, and were within the range reported for other normal tissues. However, when hyperthermia itself caused crypt loss and the contribution of hyperthermal killing to the overall tissue response was taken into account, there was little enhancement of radiation damage. There was no evidence of a large increase in TER at high temperatures, as is seen in some tumours and has been reported by Merino, Peters, Mason and Withers (1978) for intestine. It is possible that very high TER values which have previously been reported mainly reflect the heat-alone component of damage. Some of the implications of these results are discussed in relation to the combination of heat and radiation in therapy.

The relationship between heating time and temperature for inhibition of growth in baby rat cartilage by combined hyperthermia and X-rays

The relationship between the Thermal Enhancement Ratio (TER) for X-ray damage and time of heating has been investigated in epiphyseal rat cartilage. The TER at each temperature rises steeply with increasing heating time. Data obtained using various heat treatments with 8 Gy of X-rays have been analysed in terms of stunting "rate' as measured by the slope of the dose-effect curve obtained for each temperature. The "rate' of stunting per unit heating time, induced by thermally enhanced X-ray damage is compared with the "rate' of stunting induced by heat alone. The two are similar each having an activation energy of approximately 550kJ mole-1, as determined using the Arrhenius equation. Halving the heating time requires at 1 degrees C temperature increase to achieve the same degree of thermal enhancement of X-ray damage. Similar results have been reported previously for damage caused by heat alone. Over a range 42 degrees C-45 degrees C, the threshold heating time to cause direct thermal injury falls within the range of times used to enhance X-ray damage. It is suggested that a component of damage due to direct thermal injury, indistinguishable from radiation damage and thermally enhanced radiation damage, will contribute to TER assessments in some experimental systems.

Ultrasonic irradiation of mammalian cells in vitro at hyperthermic temperatures

Suspensions of V79 cells and HeLa cells have been irradiated with continuous 3 MHz ultrasound at a spatial average intensity of 3W cm-2. This irradiation condition did not give rise to cell lysis. When the cells were irradiated with ultrasound for up to six hours at 37 degrees C no cell killing was observed. However, at temperatures in the hyperthermia range 42--45 degrees C the increase in cell killing that resulted from the irradiation was greater than that which could be attributed to its heating effect alone.

Effects of hyperthermia on a neurogenic rat cell line (BT4C) in culture. Development of thermal tolerance during continuous heating

The malignant neurogenic rat cell line BT4C developed tolerance to further heat injury after continuous heating in culture at 41.0 and 42.0 degrees C for 8 and 2 hours, respectively. Survival was evaluated by colony forming ability. The proliferative capacity of the surviving cells was reduced after heating as shown by a decrease in size of the colonies.

Influence of hyperthermia on the oxygen enhancement ratio for x-rays, measured in vivo

The skin of mouse tail has been used to study the effect of hyperthermia on the oxygen enhancement ratio (OER). Heating was by immersion of a portion of the tail in hot water. Radiation was given either immediately before or after hyperthermia. The average skin reaction between 15 and 50 days after treatment was taken as the end-point. The OER in the absence of hyperthermia was 1.77, suggesting significant hypoxia of the skin. When hyperthermia was given after irradiation the measured value for the OER was not significantly different, but with prior hyperthermia the OER was increased to an average value of 2.3. This increase in OER is probably due to a transient increase in blood circulation following hyperthermia and causing improved tissue oxygenation during irradiation. As a consequence we would expect a greater thermal enhancement ratio for heat given before irradiation than afterwards, and this has frequently been observed with other normal tissues. There was no evidence that heat reduces OER, as has been reported by some authors on the basis of experiments performed on cells in vitro.

The effect of local hyperthermia on the small intestine of the mouse

Small loops of mouse jejunum were exteriorized and heated by immersion in a bath of Krebs-Ringer salt solution. Crypts were lost in the heated regions with a half-time of approximately six hours and reached a steady level of damage by 10--16 hours. There was no recovery in crypt number for one week after hyperthermia. Using a 24 hour assay, crypt survival curves were obtained using various heating times in the temperature range 37.5 degrees C--44.5 degrees C. These curves were qualitatively similar to those resulting from radiation damage, showing a shoulder followed by exponential killing. As the temperature was increased, progressive changes in shape of the curves indicated a proportional inhibition of accumulation of sublethal heat damage combined with increased rate of expression of lethal damage. Over the temperature range 42.3 degrees C--44.5 degrees C, a linear relationship was found between the rate of crypt loss and the reciprocal of the absolute temperature. An activation energy of 600 +/- 70 kJ mole-1 was calculated using the Arrhenius equation. In this temperature range, doubling the heating time had the same effect as increasing the temperature by 1 degree C. At temperatures below about 42.3 degrees C, the tissue became relatively less sensitive to increasing the treatment time.