Quality assurance for radiofrequency regional hyperthermia

Long-Term Outcome in a Phase II Study of Regional Hyperthermia Added to Preoperative Radiochemotherapy in Locally Advanced and Recurrent Rectal Adenocarcinomas

Hyperthermia was added to standard preoperative chemoradiation for rectal adenocarcinomas in a phase II study. Patients with T3-4 N0-2 M0 rectal cancer or local recurrences were included. Radiation dose was 54 Gy combined with capecitabine 825 mg/m2 × 2 daily and once weekly oxaliplatin 55 mg/m2. Regional hyperthermia aimed at 41.5–42.5 °C for 60 min combined with oxaliplatin infusion. Radical surgery with total or extended TME technique, was scheduled at 6–8 weeks after radiation. From April 2003 to April 2008, a total of 49 eligible patients were recruited. Median number of hyperthermia sessions were 5.4. A total of 47 out of 49 patients (96%) had the scheduled surgery, which was clinically radical in 44 patients. Complete tumour regression occurred in 29.8% of the patients who also exhibited statistically significantly better RFS and CSS. Rate of local recurrence alone at 10 years was 9.1%, distant metastases alone occurred in 25.6%, including local recurrences 40.4%. RFS for all patients was 54.8% after 5 years and CSS was 73.5%. Patients with T50 temperatures in tumours above median 39.9 °C had better RFS, 66.7% vs. 31.3%, p = 0.047, indicating a role of hyperthermia. Toxicity was acceptable.

Multi-Channel RF Supervision Module for Thermal Magnetic Resonance Based Cancer Therapy

Glioblastoma multiforme (GBM) is the most lethal and common brain tumor. Combining hyperthermia with chemotherapy and/or radiotherapy improves the survival of GBM patients. Thermal magnetic resonance (ThermalMR) is a hyperthermia variant that exploits radio frequency (RF)-induced heating to examine the role of temperature in biological systems and disease. The RF signals' power and phase need to be supervised to manage the formation of the energy focal point, accurate thermal dose control, and safety. Patient position during treatment also needs to be monitored to ensure the efficacy of the treatment and avoid damages to healthy tissue. This work reports on a multi-channel RF signal supervision module that is capable of monitoring and regulating RF signals and detecting patient motion. System characterization was performed for a broad range of frequencies. Monte-Carlo simulations were performed to examine the impact of power and phase errors on hyperthermia performance. The supervision module's utility was demonstrated in characterizing RF power amplifiers and being a key part of a feedback control loop regulating RF signals in heating experiments. Electromagnetic field simulations were conducted to calculate the impact of patient displacement during treatment. The supervision module was experimentally tested for detecting patient motion to a submillimeter level. To conclude, this work presents a cost-effective RF supervision module that is a key component for a hyperthermia hardware system and forms a technological basis for future ThermalMR applications.

Some aspects of quality management in deep regional hyperthermia

The hyperthermia effect is based on its thermal influence on tumours. Therefore a controlled heating of the tumours must be achieved. In order to guarantee this, two points must be fulfilled at least: First, the hyperthermia equipment must have the necessary power and steering capability. Second, the distribution of the 'hyperthermic drug', the heat, has to be measured and controlled over the whole treatment time. To reach this aim both a sophisticated technique and a staff trained in hyperthermia are required. In treating patients such as those with cervical cancer, the volume to be exposed and the dosage must be clarified. This means that very special technical and medical conditions must be fulfilled in hyperthermia. To reach and maintain a certain level of quality, hyperthermia is embedded in a framework of procedures. These procedures are defined in the modules of quality management. Therefore quality management must contain specific guidelines for each application, i.e. coordinated standards have to be defined. When adapting these standards in hyperthermia, comparable and comprehensible results of the treatment are guaranteed. Furthermore, an analysis of the treatments under a scientific point of view will be possible and finally result in improvements of this method.

Evaluation of power and phase accuracy of the BSD Dodek amplifier for regional hyperthermia using an external vector voltmeter measurement system

PURPOSE

Accurate monitoring of RF (radio frequency) power and phase is a key part of quality assurance (QA) for phased-array hyperthermia systems. In order to assess the steering capability of the BSD 2000 3D facility, an independent measurement system has been implemented, using a vector voltmeter (VVM) as the measuring device.

METHODS

This paper describes the calibration of the RF signal paths from each of the 12 BSD Dodek amplifier outputs to the VVM instrument readout. Periodical network analyser measurements show that the uncertainty of the measured power using the VVM system is <4% for all channels, while the uncertainty of the phase measurements is <0.3 degrees. The values are comparable to those reported for similar monitoring systems and are considered adequate for monitoring of the BSD Dodek steering parameters.

RESULTS

Using the VVM system to investigate the accuracy of the BSD Dodek amplifier power and phase control, systematic differences were observed between the requested and the measured power for all channels: At a requested power level of 25 W per channel, the measured power level was on average 15% lower than nominal, whereas at 100 W it was nearly 20% higher. It was also observed that the absolute phase values are nearly 30 degree higher at 25W per channel than at power levels > or = 50W per channel. Under certain circumstances, these issues may reduce target steering accuracy for the BSD 2000 3D system; on the other hand, the Dodek power and phase control stability is found to be acceptable.

CONCLUSIONS

The results emphasize the need for accurate, independent online power and phase QA during regional hyperthermia treatments using phased array systems.

Current status of antivascular therapy and targeted treatment in the clinic

Antivascular and targeted therapy are now an integrated part of the treatment of myelogenous leukemias, GIST tumours, B-cell lymphomas and breast cancer. In various malignancies improved responses and prolongation of survival for several months is regularly reported. The progress in this field is relevant for hyperthermia. Heat has among other effects documented antivascular effects, and can be considered as one of the established methods in the field based on several randomised phase III studies. Hyperthermia should be considered for combination with other antiangiogenic agents.

An RF phased array applicator designed for hyperthermia breast cancer treatments

An RF phased array applicator has been constructed for hyperthermia treatments in the intact breast. This RF phased array consists of four antennas mounted on a Lexan water tank, and geometric focusing is employed so that each antenna points in the direction of the intended target. The operating frequency for this phased array is 140 MHz. The RF array has been characterized both by electric field measurements in a water tank and by electric field simulations using the finite-element method. The finite-element simulations are performed with HFSS software, where the mesh defined for finite-element calculations includes the geometry of the tank enclosure and four end-loaded dipole antennas. The material properties of the water tank enclosure and the antennas are also included in each simulation. The results of the finite-element simulations are compared to the measured values for this configuration, and the results, which include the effects of amplitude shading and phase shifting, show that the electric field predicted by finite-element simulations is similar to the measured field. Simulations also show that the contributions from standing waves are significant, which is consistent with measurement results. Simulated electric field and bio-heat transfer results are also computed within a simple 3D breast model. Temperature simulations show that, although peak temperatures are generated outside the simulated tumour target, this RF phased array applicator is an effective device for regional hyperthermia in the intact breast.

Antenna arrays in the SIGMA-eye applicator: interactions and transforming networks

OBJECTIVES

In multiantenna applicators such as the SIGMA-60 or SIGMA-Eye, which consist of 4 or 12 pairs of antennas shunt to 4 or 12 amplifiers ("antenna couplets"), phases and amplitudes in the feed points of these antennas under certain conditions can significantly differ from the values selected at the multichannel amplifier (forward parameters), mainly due to coupling. In the SIGMA-Eye, this interaction is particularly affected by the transforming networks between the generators and the feed points, thus hampering the control of the feed point parameters. In this work, we perform measurements at existing applicators, present a formalism to describe the facts numerically, and investigate modifications of the transforming networks to improve the performance.

METHODS AND MATERIALS

We prepared an experimental setup for the SIGMA-Eye applicator that is fed by forward waves of a 12-channel amplifier system. In this setup, we made the water bolus, the interior of the tissue-equivalent phantom, and the entire transforming network accessible for measuring probes. Then, we constructed various alternative transforming networks such as Pawsey loops, LC matching networks, and power dividers and compared them with the original matching network of the SIGMA-Eye applicator. In particular, we utilized a high-resistive probe to determine the disturbances and influences caused by some channels with respect to some selected feed points of the SIGMA-Eye dipoles.

RESULTS

In the original SIGMA-Eye applicator, the influences of coupling channels on the phases and voltages in the feed point of a particular antenna are largest for adjacent longitudinal channels. Here, the +/- 10 degrees phase shift and +/- 30% voltage change were observed if the reference channel (i.e., the disturbed channel) and disturbing channel are equally powered. The changes eminently increased to -30 degrees to + 100 degrees phase shift and -80% to +50% voltage change if the reference channel is fed with much lower power (four to eight-fold) than the disturbing channel. The disturbance from distant channels is less but still significant, reaching shifts of -10 degrees to +50 degrees and -50% to +20%, respectively. Using Pawsey loops instead of the original ferrite rings in the SIGMA-Eye network, the efficacy of the baluns was improved by a more than a factor of 4. Using an LC matching network, dependencies on frequency and external arrangements can be reduced significantly. Applying a power divider circuit, the coupling between antennas combined to one channel is considerably diminished (down to <-25 dB).

CONCLUSION

Coupling between resonators (pairs of antennas including the matching network) reduces the control of the SIGMA-Eye applicator, i.e., it causes deviations between the selection of forward parameters at the amplifier and the total actual parameters in the feed points of the antennas. Modified transformation networks can improve the control, in particular by reducing sheath currents and asymmetries. There is a linear but variable relationship between selected (amplifiers) and actually given (feed points) parameters. This linear mapping (described by a matrix) and its characteristics need further investigation.

An on-line phase measurement system for quality assurance of the BSD 2000. Part II: results of the phase measurement system

Phase constancy and accuracy are significant for regional hyperthermia with phased array radiofrequency hyperthermia systems. They are both necessary for a precise target steering in therapy. For the BSD 2000 system (BSD Medical Corp. Salt Lake City, Utah, USA), the phase values of all channels are checked with a self-developed automatic on-line phase measurement system. On different days the phases are measured under identical conditions, where the output paths are cut off with 50 ohm dummy loads to suppress the influence of the radiation conditions of the antennae on the measurement values. The results show how the phase values of the four channels change in the first 30 min and from day to day. During this time interval after the start the phases drop down by up to 15 degrees. For the time later changes are very slight and the differences from day to day are negligible. The phase shift that occurs in the first 30 min is as high as a change of the target point by 1 cm. Earlier switching on of the amplifiers prevents this shift occurring during the treatment. The measurement system provides a good tool for determination of phase accuracy and is easy to realize.

Scanning E-field sensor device for online measurements in annular phased-array systems

PURPOSE

A measurement device for noninvasive and simultaneous control of antennas during regional radiofrequency (rf) hyperthermia and, subsequently, the estimation of the power distribution in the interior of patients are essential preconditions for further technological progress. Aiming at this, the feasibility of an electro-optical electric field sensor was investigated during clinical rf hyperthermia.

MATERIAL AND METHODS

The electro-optical electric field (E-field) sensor is based on lithiumniobate crystals and the Mach-Zehnder interferometer structure, and was tested in an earlier phantom study. For this study, a mechanical scanning device was developed allowing the registration of the E-field during clinical application. Data were recorded along a curve in the water bolus of the SIGMA 60 applicator of the annular phased-array system BSD-2000 (BSD Medical Corp., Salt Lake City, UT) close to the base points of the flat biconical dipole antennas. The results were compared with modeling calculations using the finite-difference time-domain (FDTD) method. For the latter, different antenna models were assumed. For systematic registration of the E-field curves in amplitude and phase, we employed an elliptical lamp phantom with fat-equivalent ring (filled with saline solution) and an elliptical polyacrylamide phantom with acrylic glass wall. Further measurements were carried out during the treatment of 5 patients with 20 hyperthermia treatments.

RESULTS

Data of both phantom and patient measurements can be satisfactorily described by the FDTD method, if the antenna model is refined by taking into account the conical form of the dipoles and the special dielectric environment of the feeding point. Phase deviations can be entered ex posteriori for correction in the calculation algorithm. A comparison of amplifier power measurement (forward and backward power) and bolus E-field scans near the antenna base points demonstrates that E-field measurements between antennas and patient are a necessity for the appropriate characterization of antenna radiation properties. These measurements are sensitive to variations of the lossy medium in position and shape, and can be correctly predicted with current models. However, the differences between different patients are moderate and unspecific in both calculations and measurements, with fluctuations at maximum of 30 degrees in phases and 40% in amplitudes.

CONCLUSIONS

The measurement method presented here turned out to be a practical tool for online registration of E-fields in phases and amplitudes along arbitrary curves in a water bolus or phantom. It can be utilized to evaluate antenna design and modeling calculations and leads, thus, to a better understanding of complicated multiantenna systems. In clinical routine, it can be employed as input for patient-specific hyperthermia planning and, finally, for the realization of online control with subsequent optimization of the power distribution in the patient.

An adaptive microwave phased array for targeted heating of deep tumours in intact breast: animal study results

It has previously been reported in phantoms, that an adaptive radiofrequency phased array can generate deep focused heating distributions without overheating the skin and superficial healthy tissues. The present study involves adaptive microwave phased array hyperthermia tests in animals (rabbits) with and without tumours. The design of the adaptive phased array as applied to the treatment of tumours in intact breast, is described. The adaptive phased array concept uses breast compression and dual-opposing 915 MHz air-cooled waveguide applicators with electronic phase shifters and electric-field feedback, to focus automatically by computer control the microwave radiation in deep tissue. Temperature measurements for a clinical adaptive phased array hyperthermia system demonstrate tissue heating at depth with reduced skin heating.

The measurement of fringing fields in a radio-frequency hyperthermia array with emphasis on bolus size

The limited aperture size through which the em-field of the applicator is emanated and the constraining of this em-field near the bolus' edge is related to the appearance of superficial 'hot spot' phenomena in radiative hyperthermia. Regarding systems based on the concept of the annular phased array two questions arise: (1) what is the relative strength of the radial component present in the incident field of the radiators, and (2) in what way are fringing fields related to the bolus size? To address both of the above questions, the spatial distribution of the em-field emanated through the aperture of an applicator of the Amsterdam four waveguide-array system has been investigated for a long bolus and a short bolus. The em vector field emanated by the applicator has been characterized in two perpendicular planes, i.e. the aperture midplane and the sagittal midplane. It should be noted that this distribution depends on the propagation conditions throughout the coupling bolus, the phantom and other volumes attached, such as other applicators. Therefore two sets of propagation conditions have been measured: (1) the minimum number of parameters determining the propagation of the em-field namely one single waveguide, one bolus and a homogeneous phantom, and (2) the propagation conditions as for the clinical setting. It is stressed that the study concerns one specific radiative hyperthermia system, namely the AMC four-waveguide array, but that, based on the similarities discussed above, results may be extrapolated towards other radiative hyperthermia systems. According to the current study, bolus prolongation might lead to a clear clinical improvement, which is due to a decrease of the fringing field amplitude compared to the field amplitude in the centre of the aperture midplane. Bolus prolongation will lead to an extended heating area, the field lines being more aligned to the patient's main axis.

Design and test of a new multi-amplifier system with phase and amplitude control

The clinical relevance of the radiofrequency regional hyperthermia (RF-RHT) as an adjuvant cancer therapy grows continuously. Simulation studies for optimization of RF-RHT based on the annular phased array systems have shown a significant improvement of power deposition patterns with increasing number of channels. However, this probably requires higher phase accuracy and amplitude stability than are provided by presently used clinical systems, e.g. BSD-2000. Measurements performed on the BSD-200 electronic revealed phase inaccuracies up to +/- 20 degrees and errors in the power registration of +/- 20 W (up to +/- 50 W in the low power range). These errors are further enhanced by the mismatching of the external load (antenna applicator) and thermal instabilities. To achieve the required phase accuracy and long-term stability in the prototype of a new amplifier system, single-sideband (SSB) mixing in combination with direct digital synthesizers (DDS), in-phase and quadrature-phase (IQ) processing and phase-lock loop (PLL) were used. In the DDS's the actual phase of the output signal of each channel is calculated in real-time. No analogue control loop is involved that may cause thermal offset or drift problems. Each DDS operates at a low intermediate frequency (IF) of 1 MHz. To transform the phase information of this IF signal into the desired RF band, SSB mixing-up is performed. A second frequency source, operating as a local oscillator (LO) in the RF band, is required for this technique. Also, the frequency adjustment of the desired RF signal is performed in the LO. These phase and frequency adjustment units are followed by the high efficiency AB-class solid state amplifier unit. The phase and power level stability of the amplifier are controlled by means of digital PLL structures in conjunction with look-up tables. For this control test signals are coupled out by means of directional couplers. The phase control is based on very sensitive phase comparison. These digital control loops are programmable and allow the implementation of different control algorithms. The achieved long-term accuracy (95% confidence interval) is +/- 1-3 W for output power levels ranging from 10-100 W, and +/- 1 degree for phase differences between each channel and a reference signal at a constant power level, and +/- 1.5 degrees for phase difference values at variable power levels between 10-100 W. In conclusion, the new amplifier system is smaller and more efficient than presently available commercial systems.