Stereotactic Body Radiation Therapy for Operable Early-Stage Lung Cancer: Findings From the NRG Oncology RTOG 0618 Trial

Importance

Stereotactic body radiation therapy (SBRT) has become a standard treatment for patients with medically inoperable early-stage lung cancer. However, its effectiveness in patients medically suitable for surgery is unclear.

Objective

To evaluate whether noninvasive SBRT delivered on an outpatient basis can safely eradicate lung cancer and cure selected patients with operable lung cancer, obviating the need for surgical resection.

Design, Setting, and Participants

Single-arm phase 2 NRG Oncology Radiation Therapy Oncology Group 0618 study enrolled patients from December 2007 to May 2010 with median follow-up of 48.1 months (range, 15.4-73.7 months). The setting was a multicenter North American academic and community practice cancer center consortium. Patients had operable biopsy-proven peripheral T1 to T2, N0, M0 non-small cell tumors no more than 5 cm in diameter, forced expiratory volume in 1 second (FEV1) and diffusing capacity greater than 35% predicted, arterial oxygen tension greater than 60 mm Hg, arterial carbon dioxide tension less than 50 mm Hg, and no severe medical problems. The data analysis was performed in October 2014.

Interventions

The SBRT prescription dose was 54 Gy delivered in 3 18-Gy fractions over 1.5 to 2.0 weeks.

Main Outcomes and Measures

Primary end point was primary tumor control, with survival, adverse events, and the incidence and outcome of surgical salvage as secondary end points.

Results

Of 33 patients accrued, 26 were evaluable (23 T1 and 3 T2 tumors; 15 [58%] male; median age, 72.5 [range, 54-88] years). Median FEV1 and diffusing capacity of the lung for carbon monoxide at enrollment were 72.5% (range, 38%-136%) and 68% (range, 22%-96%) of predicted, respectively. Only 1 patient had a primary tumor recurrence. Involved lobe failure, the other component defining local failure, did not occur in any patient, so the estimated 4-year primary tumor control and local control rate were both 96% (95% CI, 83%-100%). As per protocol guidelines, the single patient with local recurrence underwent salvage lobectomy 1.2 years after SBRT, complicated by a grade 4 cardiac arrhythmia. The 4-year estimates of disease-free and overall survival were 57% (95% CI, 36%-74%) and 56% (95% CI, 35%-73%), respectively. Median overall survival was 55.2 months (95% CI, 37.7 months to not reached). Protocol-specified treatment-related grade 3, 4, and 5 adverse events were reported in 2 (8%; 95% CI, 0.1%-25%), 0, and 0 patients, respectively.

Conclusions and Relevance

As given, SBRT appears to be associated with a high rate of primary tumor control, low treatment-related morbidity, and infrequent need for surgical salvage in patients with operable early-stage lung cancer.

Trial Registration

ClinicalTrials.gov Identifier: NCT00551369.

Safety and Efficacy of a Five-Fraction Stereotactic Body Radiotherapy Schedule for Centrally Located Non-Small-Cell Lung Cancer: NRG Oncology/RTOG 0813 Trial

PURPOSE

Patients with centrally located early-stage non-small-cell lung cancer (NSCLC) are at a higher risk of toxicity from high-dose ablative radiotherapy. NRG Oncology/RTOG 0813 was a phase I/II study designed to determine the maximum tolerated dose (MTD), efficacy, and toxicity of stereotactic body radiotherapy (SBRT) for centrally located NSCLC.

MATERIALS AND METHODS

Medically inoperable patients with biopsy-proven, positron emission tomography-staged T1 to 2 (≤ 5 cm) N0M0 centrally located NSCLC were accrued into a dose-escalating, five-fraction SBRT schedule that ranged from 10 to 12 Gy/fraction (fx) delivered over 1.5 to 2 weeks. Dose-limiting toxicity (DLT) was defined as any treatment-related grade 3 or worse predefined toxicity that occurred within the first year. MTD was defined as the SBRT dose at which the probability of DLT was closest to 20% without exceeding it.

RESULTS

One hundred twenty patients were accrued between February 2009 and September 2013. Patients were elderly, there were slightly more females, and the majority had a performance status of 0 to 1. Most cancers were T1 (65%) and squamous cell (45%). Organs closest to planning target volume/most at risk were the main bronchus and large vessels. Median follow-up was 37.9 months. Five patients experienced DLTs; MTD was 12.0 Gy/fx, which had a probability of a DLT of 7.2% (95% CI, 2.8% to 14.5%). Two-year rates for the 71 evaluable patients in the 11.5 and 12.0 Gy/fx cohorts were local control, 89.4% (90% CI, 81.6% to 97.4%) and 87.9% (90% CI, 78.8% to 97.0%); overall survival, 67.9% (95% CI, 50.4% to 80.3%) and 72.7% (95% CI, 54.1% to 84.8%); and progression-free survival, 52.2% (95% CI, 35.3% to 66.6%) and 54.5% (95% CI, 36.3% to 69.6%), respectively.

CONCLUSION

The MTD for this study was 12.0 Gy/fx; it was associated with 7.2% DLTs and high rates of tumor control. Outcomes in this medically inoperable group of mostly elderly patients with comorbidities were comparable with that of patients with peripheral early-stage tumors.

Present and future technology for simultaneous superficial thermoradiotherapy of breast cancer

This paper reviews systems and techniques to deliver simultaneous thermoradiotherapy of breast cancer. It first covers the clinical implementation of simultaneous delivery of superficial (microwave or ultrasound) hyperthermia and external photon beam radiotherapy, first using a Cobalt-60 teletherapy unit and later medical linear accelerators. The parallel development and related studies of the Scanning Ultrasound Reflector Linear Arrays System (SURLAS), an advanced system specifically designed and developed for simultaneous thermoradiotherapy, follows. The performance characteristics of the SURLAS are reviewed and power limitation problems at high acoustic frequencies (>3 MHz) are discussed along with potential solutions. Next, the feasibility of simultaneous SURLAS hyperthermia and intensity modulated radiation therapy/image-guided radiotherapy (IMRT/IGRT) is established based on published and newly presented studies. Finally, based on the encouraging clinical results thus far, it is concluded that new trials employing the latest technologies are warranted along with further developments in treatment planning.

Transfection of human tumour cells with Mre11 siRNA and the increase in radiation sensitivity and the reduction in heat-induced radiosensitization

Double-strand DNA breaks (DSBs) are potentially lethal DNA lesions induced by ionizing radiation. In eukaryotes, DSBs can be repaired by homologous recombination (HR) or non-homologous end-joining (NHEJ). DNA repair protein Mre11 participates in both the NHEJ and HR DNA repair pathways. Hyperthermia has been used clinically as a radiosensitizer. However, the mechanisms by which radiosensitization is induced by hyperthermia, especially moderate hyperthermia (41 degrees C) are not fully understood. Previous studies suggest that 41 degrees C reduces the nuclear Mre11 protein level in a manner that correlates with heat-induced changes in radiation sensitivity. Therefore, siRNA technology was used in the present study to reduce Mre11 gene expression to determine if reduced Mre11 protein levels induced radiosensitization and if such radiosensitization is similar to that induced by moderate hyperthermia. The results show that (1) the cellular level of the Mre11 protein was reduced about 60 +/- 18% by a 24-h treatment with siRNA. Results from the Mre11 protein turnover assay showed a half-life of 11.6 +/- 0.5 h for the Mre11 protein, which is consistent with reduction in protein level in 24 h after Mre11 siRNA treatment assuming a delay of 4-8 h to reduce RNA levels. After 48 h in siRNA, cellular Mre11 protein levels increased to approximately pretreatment levels. NSY cells were sensitized to ionizing radiation after 24 h of treatment with Mre11 siRNA. Two hours at 41 degrees C did not increase the radiation sensitivity of cells with a reduced Mre11 protein level following a 24-h siRNA treatment. These data support the conclusion that the DSB repair protein, Mre11, appears to be a target for radiosensitization by moderate hyperthermia.

The effects of 41°C hyperthermia on the DNA repair protein, MRE11, correlate with radiosensitization in four human tumor cell lines

PURPOSE

The goal of this study was to determine if reduced availability of the DNA repair protein, MRE11, for the repair of damaged DNA is a basis for thermal radiosensitization induced by moderate hyperthermia. To test this hypothesis, we measured the total amount of MRE11 DNA repair protein and its heat-induced alterations in four human tumor cell lines requiring different heating times at 41 degrees C to induce measurable radiosensitization.

MATERIALS AND METHODS

Human colon adenocarcinoma cell lines (NSY42129, HT29 and HCT15) and HeLa cells were used as the test system. Cells were irradiated immediately after completion of hyperthermia. MRE11 levels in whole cell extract, nuclear extract and cytoplasmic extracts were measured by Western blotting. The nuclear and cytoplasmic extracts were separated by TX100 solubility. The subcellular localization of MRE11 was determined by immunofluorescence staining.

RESULTS

The results show that for the human tumor cell lines studied, the larger the endogenous amount of MRE11 protein per cell, the longer the heating time at 41 degrees C required for inducing measurable radiosensitization in that cell line. Further, the residual nuclear MRE11 protein level, measured in the nuclear extract and in the cytoplasmic extract as a function of heating time, both correlated with the thermal enhancement ratio (TER).

CONCLUSIONS

These observations are consistent with the possibility that delocalization of MRE11 from the nucleus is a critical step in the radiosensitization by moderate hyperthermia.

Non-invasive estimation of hyperthermia temperatures with ultrasound

Ultrasound is an attractive modality for temperature monitoring because it is non-ionizing, convenient, inexpensive and has relatively simple signal processing requirements. This modality may be useful for temperature estimation if a temperature-dependent ultrasonic parameter can be identified, measured and calibrated. The most prominent methods for using ultrasound as a non-invasive thermometer exploit either (1) echo shifts due to changes in tissue thermal expansion and speed of sound (SOS), (2) variation in the attenuation coefficient or (3) change in backscattered energy from tissue inhomogeneities. The use of echo shifts has received the most attention in the last decade. By tracking scattering volumes and measuring the time shift of received echoes, investigators have been able to predict the temperature from a region of interest both theoretically and experimentally in phantoms, in isolated tissue regions in vitro and preliminary in vivo studies. A limitation of this method for general temperature monitoring is that prior knowledge of both SOS and thermal-expansion coefficients is necessary. Acoustic attenuation is dependent on temperature, but with significant changes occurring only at temperatures above 50 degrees C, which may lead to its use in thermal ablation therapies. Minimal change in attenuation, however, below this temperature range reduces its attractiveness for use in clinical hyperthermia. Models and measurements of the change in backscattered energy suggest that, over the clinical hyperthermia temperature range, changes in backscattered energy are dependent on the properties of individual scatterers or scattering regions. Calibration of the backscattered energy from different tissue regions is an important goal of this approach. All methods must be able to cope with motion of the image features on which temperature estimates are based. A crucial step in identifying a viable ultrasonic approach to temperature estimation is its performance during in vivo tests.

Modelling heat-induced radiosensitization: clinical implications

Clinically achievable minimum tumour temperatures are in the order of about 41 degrees C. Therefore, it is important to evaluate mechanisms by which temperatures in this range might enhance cytotoxicity. Previous in vitro studies have demonstrated that 1-4 h (depending on the sequencing of modalities) of heating at 41 degrees C produces substantial heat-induced radiosensitization with little or no cell killing by heat alone. The increased radiation sensitivity is best modelled as a change in the single hit, alpha, parameter (with no significant effect on the two-hit parameter, beta) of the cell survival curve. The implications of heat-induced radiosensitization being mediated by a change in alpha on the traditional thermal enhancement ratio (for various radiation doses/fraction and alpha/beta) are reviewed. Response rates for a cohort of 60 patients enrolled on a prospective thermal dose escalation study are modelled assuming that the thermal dose dependence of heat-induced radiosensitization is modulated by a heat-induced delta alpha. The clinical data are fitted with delta alpha about 0.05-0.1 Gy-1. Randomized trials reported in the literature and the implication for the design of future prospective trials are reviewed in light of these observations.

Measurement of DNA damage after acute exposure to pulsed‐wave 2450 MHz microwaves in rat brain cells by two alkaline comet assay methods

PURPOSE

To investigate the effect of 2450 MHz pulsed-wave microwaves on the induction of DNA damage in brain cells of exposed rats and to discover whether proteinase K is needed to detect DNA damage in the brain cells of rats exposed to 2450 MHz microwaves.

MATERIALS AND METHODS

Sprague-Dawley rats were exposed to 2450 MHz pulsed-wave microwaves and sacrificed 4 h after a 2-h exposure. Rats irradiated whole-body with 1 Gy (137)Cs were included as positive controls. DNA damage was assayed by two variants of the alkaline comet assay on separate aliquots of the same cell preparation.

RESULTS

Significant DNA damage was observed in the rat brain cells of rats exposed to gamma-rays using both versions of the alkaline comet assay independent of the presence or absence of proteinase K. However, neither version of the assay could detect any difference in comet length and/or normalized comet moment between sham- and 2450 MHz pulsed-wave microwave-exposed rats, regardless of the inclusion or omission of proteinase K in the comet assay.

CONCLUSIONS

No DNA damage in brain cells was detected following exposure of rats to 2450 MHz microwaves pulsed-wave at a specific absorption rate of 1.2 W kg(-1) regardless of whether or not proteinase K was included in the assay. Thus, the results support the conclusion that low-level 2450 MHz pulsed-wave microwave exposures do not induce DNA damage detectable by the alkaline comet assay.

Dosimetric evaluation of heterogeneity corrections for RTOG 0236: stereotactic body radiotherapy of inoperable stage I-II non-small-cell lung cancer

PURPOSE

Using a retrospective analysis of treatment plans submitted from multiple institutions accruing patients to the Radiation Therapy Oncology Group (RTOG) 0236 non-small-cell stereotactic body radiotherapy protocol, the present study determined the dose prescription and critical structure constraints for future stereotactic body radiotherapy lung protocols that mandate density-corrected dose calculations.

METHOD AND MATERIALS

A subset of 20 patients from four institutions participating in the RTOG 0236 protocol and using superposition/convolution algorithms were compared. The RTOG 0236 protocol required a prescription dose of 60 Gy delivered in three fractions to cover 95% of the planning target volume. Additional requirements were specified for target dose heterogeneity and the dose to normal tissue/structures. The protocol required each site to plan the patient's treatment using unit density, and another plan with the same monitor units and applying density corrections was also submitted. These plans were compared to determine the dose differences. Two-sided, paired Student's t tests were used to evaluate these differences.

RESULTS

With heterogeneity corrections applied, the planning target volume receiving >/=60 Gy decreased, on average, 10.1% (standard error, 2.7%) from 95% (p = .001). The maximal dose to any point >/=2 cm away from the planning target volume increased from 35.2 Gy (standard error, 1.7) to 38.5 Gy (standard error, 2.2).

CONCLUSION

Statistically significant dose differences were found with the heterogeneity corrections. The information provided in the present study is being used to design future heterogeneity-corrected RTOG stereotactic body radiotherapy lung protocols to match the true dose delivered for RTOG 0236.

A simulation model for ultrasonic temperature imaging using change in backscattered energy

Ultrasound backscattered from tissue has previously been shown theoretically and experimentally to change predictably with temperature in the hyperthermia range, i.e., 37 degrees C to 45 degrees C, motivating use of the change in backscattered ultrasonic energy (CBE) for ultrasonic thermometry. Our earlier theoretical model predicts that CBE from an individual scatterer will be monotonic with temperature, with, e.g., positive change for lipid-based scatterers and negative for aqueous-based scatterers. Experimental results have previously confirmed the presence of these positive and negative changes in one-dimensional ultrasonic signals and in two-dimensional images acquired from in vitro bovine, porcine and turkey tissues. In order to investigate CBE for populations of scatterers, we have developed an ultrasonic image simulation model, including temperature dependence for individual scatterers based on predictions from our theoretical model. CBE computed from images simulated for populations of randomly distributed scatterers behaves similarly to experimental results, with monotonic variation for individual pixel measurements and for image regions. Effects on CBE of scatterer type and distribution, size of the image region and signal-to-noise ratio have been examined. This model also provides the basis for future work regarding significant issues relevant to temperature imaging based on ultrasonic CBE such as effects of motion on CBE, limitations of motion-compensation techniques and accuracy of temperature estimation, including tradeoffs between temperature accuracy and available spatial resolution.

Treatment delivery software for a new clinical grade ultrasound system for thermoradiotherapy

A detailed description of a clinical grade Scanning Ultrasound Reflector Linear Array System (SURLAS) applicator was given in a previous paper [Med. Phys. 32, 230-240 (2005)]. In this paper we concentrate on the design, development, and testing of the personal computer (PC) based treatment delivery software that runs the therapy system. The SURLAS requires the coordinated interaction between the therapy applicator and several peripheral devices for its proper and safe operation. One of the most important tasks was the coordination of the input power sequences for the elements of two parallel opposed ultrasound arrays (eight 1.5 cm x 2 cm elements/array, array 1 and 2 operate at 1.9 and 4.9 MHz, respectively) in coordination with the position of a dual-face scanning acoustic reflector. To achieve this, the treatment delivery software can divide the applicator's treatment window in up to 64 sectors (minimum size of 2 cm x 2 cm), and control the power to each sector independently by adjusting the power output levels from the channels of a 16-channel radio-frequency generator. The software coordinates the generator outputs with the position of the reflector as it scans back and forth between the arrays. Individual sector control and dual frequency operation allows the SURLAS to adjust power deposition in three dimensions to superficial targets coupled to its treatment window. The treatment delivery software also monitors and logs several parameters such as temperatures acquired using a 16-channel thermocouple thermometry unit. Safety (in particular to patients) was the paramount concern and design criterion. Failure mode and effects analysis (FMEA) was applied to the applicator as well as to the entire therapy system in order to identify safety issues and rank their relative importance. This analysis led to the implementation of several safety mechanisms and a software structure where each device communicates with the controlling PC independently of the others. In case of a malfunction in any part of the system or a violation of a user-defined safety criterion based on temperature readings, the software terminates treatment immediately and the user is notified. The software development process consisting of problem analysis, design, implementation, and testing is presented in this paper. Once the software was finished and integrated with the hardware, the therapy system was extensively tested. Results demonstrated that the software operates the SURLAS as intended with minimum risk to future patients.

Laboratory study on the immobilization of bacterial spores in arid environments

In this study, two effective, non-toxic, wind erosion palliative materials were analyzed for their efficacy in preventing the spread of bacterial spores. Desert sand was employed in a laboratory setting with a non-toxic simulant bacterium in an attempt to accurately represent the spreadability of the hantavirus. Spore simulants were used instead of viruses due to availability, decreased susceptibility to desiccation and detection ability without involving tissue cultures. The simulant was used to contaminate sand in a controlled environment, and an artificial turbulence was introduced using compressed air to generate airflow that could be expected in a desert environment. The airborne spores were identified both qualitatively and quantitatively through microscopy, Gram staining, plating, and incubation to monitor effectiveness. A water-based polysaccharide product, Surtac, was found to be most effective for the immobilization of bacteria on sand and greatly reduced the amount of contaminant that becomes airborne. The results suggest that the two wind erosion products used in this study may be successfully employed to reduce the ability of bacterial spores to spread in arid regions.

Experience with a small animal hyperthermia ultrasound system (SAHUS): report on 83 tumours

An external local ultrasound (US) system was developed to induce controlled hyperthermia of subcutaneously implanted tumours in small animals (e.g., mice and rats). It was designed to be compatible with a small animal positron emission tomography scanner (microPET) to facilitate studies of hyperthermia-induced tumour re-oxygenation using a PET radiopharmaceutical, but it is applicable for any small animal study requiring controlled heating. The system consists of an acrylic applicator bed with up to four independent 5 MHz planar disc US transducers of 1 cm in diameter, a four-channel radiofrequency (RF) generator, a multiple thermocouple thermometry unit, and a personal computer with custom monitoring and controlling software. Although the system presented here was developed to target tumours of up to 1 cm in diameter, the applicator design allows for different piezoelectric transducers to be exchanged and operated within the 3.5-6.5 MHz band to target different tumour sizes. Temperature feedback control software was developed on the basis of a proportional-integral-derivative (PID) approach when the measured temperatures were within a selectable temperature band about the target temperature. Outside this band, an on/off control action was applied. Perfused tissue-mimicking phantom experiments were performed to determine optimum controller gain constants, which were later employed successfully in animal experiments. The performance of the SAHUS (small animal hyperthermia ultrasound system) was tested using several tumour types grown in thighs of female nude (nu/nu) mice. To date, the system has successfully treated 83 tumours to target temperatures in the range of 41-43 degrees C for periods of 65 min on average.

Temperature dependence of ultrasonic backscattered energy in motion-compensated images

Noninvasive temperature imaging would enhance the ability to uniformly heat tumors at therapeutic levels. Ultrasound is an attractive modality for this purpose. Previously, we predicted monotonic changes in backscattered energy (CBE) of ultrasound with temperature for certain subwavelength scatterers. We also measured CBE values similar to our predictions in bovine liver, turkey breast, and pork muscle in one dimension (1-D). Those measurements were corrected manually for changes in the axial position of echo signals with temperature. To investigate the effect of temperature on CBE in 2-D, we imaged 1-cm thick samples of bovine liver, turkey breast, and pork muscle during heating in a water bath. Images were formed by a phased-array imager with a 7 MHz linear probe. Using radio frequency (RF) signals permitted the use of cross correlation as a similarity measure for automatic tracking of feature displacement as a function of temperature. Feature displacement across the specimen was nonuniform with typical total displacements of 0.5 mm in both axial and lateral directions. Apparent movement in eight image regions in each specimen was tracked from 37 to 50 degrees C in 0.5 degrees C steps. Envelopes of motion-compensated image regions were found then smoothed with a 3 x 3 running average filter before forming the backscattered energy at each pixel. Our measure of CBE compared means of both the positive and negative changes in the backscattered energy (BE) images. CBE was monotonic and differed by about 4 dB at 50 degrees C from its value at 37 degrees C. Relatively noise-free CBE curves from tissue volumes of less than 1 cm3 supports the use of CBE for temperature estimation.

SURLAS: A new clinical grade ultrasound system for sequential or concomitant thermoradiotherapy of superficial tumors: Applicator description

A new ultrasound applicator with three-dimensional power distribution control was developed for simultaneous thermoradiotherapy. The system was named SURLAS for Scanning Ultrasound Reflector Linear Arrays System. In this paper, the hardware of the first clinical grade SURLAS applicator is described with emphasis on clinically important static acoustic characteristics and on construction aspects not reported before. Functionally, the SURLAS applicator consists of two parallel opposed ultrasound linear arrays aiming their acoustic beams to a V-shape scanning ultrasound reflector, which deflects the beams coming from opposite directions toward the treatment area. The reciprocating motion of the reflector in-between the arrays spreads the ultrasonic energy over the target area scanned. Control of power deposition over the 16 cm by 16 cm treatment window area is achieved by adjusting the power input into the transducer elements of the arrays as a function of the position of the scanning reflector. Furthermore, the arrays operate at significantly different frequencies (1.9 and 4.9 MHz) so that intensity modulation of beams of different frequencies can be exploited to adjust the depth of energy penetration. With this design, external electron or photon beams can be concurrently delivered with hyperthermia by irradiating through the applicator's body. Safety features were implemented into the applicator's design to monitor its performance during operation. A detailed description of the applicator including impedance matching circuits/filters, radiation force balance power measurements, hydrophone pressure field distribution measurements, as well as safety test results are reported.

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

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

Measurement of DNA Damage and Apoptosis in Molt-4 Cells afterIn VitroExposure to Radiofrequency Radiation

To determine whether exposure to radiofrequency (RF) radiation can induce DNA damage or apoptosis, Molt-4 T lymphoblastoid cells were exposed with RF fields at frequencies and modulations of the type used by wireless communication devices. Four types of frequency/modulation forms were studied: 847.74 MHz code-division multiple-access (CDMA), 835.62 MHz frequency-division multiple-access (FDMA), 813.56 MHz iDEN(R) (iDEN), and 836.55 MHz time-division multiple-access (TDMA). Exponentially growing cells were exposed to RF radiation for periods up to 24 h using a radial transmission line (RTL) exposure system. The specific absorption rates used were 3.2 W/kg for CDMA and FDMA, 2.4 or 24 mW/kg for iDEN, and 2.6 or 26 mW/kg for TDMA. The temperature in the RTLs was maintained at 37 degrees C +/- 0.3 degrees C. DNA damage was measured using the single-cell gel electrophoresis assay. The annexin V affinity assay was used to detect apoptosis. No statistically significant difference in the level of DNA damage or apoptosis was observed between sham-treated cells and cells exposed to RF radiation for any frequency, modulation or exposure time. Our results show that exposure of Molt-4 cells to CDMA, FDMA, iDEN or TDMA modulated RF radiation does not induce alterations in level of DNA damage or induce apoptosis.

Measurements of Alkali-Labile DNA Damage and Protein–DNA Crosslinks after 2450 MHz Microwave and Low-Dose Gamma IrradiationIn Vitro

In vitro experiments were performed to determine whether 2450 MHz microwave radiation induces alkali-labile DNA damage and/or DNA-protein or DNA-DNA crosslinks in C3H 10T(1/2) cells. After a 2-h exposure to either 2450 MHz continuous-wave (CW) microwaves at an SAR of 1.9 W/kg or 1 mM cisplatinum (CDDP, a positive control for DNA crosslinks), C3H 10T(1/2) cells were irradiated with 4 Gy of gamma rays ((137)Cs). Immediately after gamma irradiation, the single-cell gel electrophoresis assay was performed to detect DNA damage. For each exposure condition, one set of samples was treated with proteinase K (1 mg/ml) to remove any possible DNA-protein crosslinks. To measure DNA-protein crosslinks independent of DNA-DNA crosslinks, we quantified the proteins that were recovered with DNA after microwave exposure, using CDDP and gamma irradiation, positive controls for DNA-protein crosslinks. Ionizing radiation (4 Gy) induced significant DNA damage. However, no DNA damage could be detected after exposure to 2450 MHz CW microwaves alone. The crosslinking agent CDDP significantly reduced both the comet length and the normalized comet moment in C3H 10T(1/2) cells irradiated with 4 Gy gamma rays. In contrast, 2450 MHz microwaves did not impede the DNA migration induced by gamma rays. When control cells were treated with proteinase K, both parameters increased in the absence of any DNA damage. However, no additional effect of proteinase K was seen in samples exposed to 2450 MHz microwaves or in samples treated with the combination of microwaves and radiation. On the other hand, proteinase K treatment was ineffective in restoring any migration of the DNA in cells pretreated with CDDP and irradiated with gamma rays. When DNA-protein crosslinks were specifically measured, we found no evidence for the induction of DNA-protein crosslinks or changes in amount of the protein associated with DNA by 2450 MHz CW microwave exposure. Thus 2-h exposures to 1.9 W/ kg of 2450 MHz CW microwaves did not induce measurable alkali-labile DNA damage or DNA-DNA or DNA-protein crosslinks.

The effect of chronic exposure to 835.62 MHz FDMA or 847.74 MHz CDMA radiofrequency radiation on the incidence of spontaneous tumors in rats

This study was designed to determine whether chronic exposure to radiofrequency (RF) radiation from cellular phones increased the incidence of spontaneous tumors in F344 rats. Eighty male and 80 female rats were randomly placed in each of three irradiation groups. The sham group received no irradiation; the Frequency Division Multiple Access (FDMA) group was exposed to 835.62 MHz FDMA RF radiation; and the Code Division Multiple Access (CDMA) group was exposed to 847.74 MHz CDMA RF radiation. Rats were irradiated 4 h per day, 5 days per week over 2 years. The nominal time-averaged specific absorption rate (SAR) in the brain for the irradiated animals was 0.85 +/- 0.34 W/kg (mean +/- SD) per time-averaged watt of antenna power. Antennas were driven with a time-averaged power of 1.50 +/- 0.25 W (range). That is, the nominal time-averaged brain SAR was 1.3 +/- 0.5 W/kg (mean +/- SD). This number was an average from several measurement locations inside the brain, and it takes into account changes in animal weight and head position during irradiation. All major organs were evaluated grossly and histologically. The number of tumors, tumor types and incidence of hyperplasia for each organ were recorded. There were no significant differences among final body weights or survival days for either males or females in any group. No significant differences were found between treated and sham-exposed animals for any tumor in any organ. We conclude that chronic exposure to 835.62 MHz FDMA or 847.74 MHz CDMA RF radiation had no significant effect on the incidence of spontaneous tumors in F344 rats.

Noninvasive temperature estimation based on the energy of backscattered ultrasound

Hyperthermia has been used as a cancer treatment in which tumors are elevated to cytotoxic temperatures to aid in their control. A noninvasive method for volumetrically determining temperature distribution during treatment would greatly enhance the ability to uniformly heat tumors at therapeutic levels. Ultrasound is an attractive modality for this purpose. We investigated changes in backscattered energy (CBE) from pulsed ultrasound with temperature. Our predicted changes in backscattered energy were matched by in vitro measurements in samples of bovine liver, turkey breast, and pork rib muscle. We studied CBE in tissue regions with multiple scatterers, of isolated individual scatterers, and in collections of individual scatterers. The latter appears to have the most potential. We measured the CBE with a focused circular transducer with a center frequency of 7.5 MHz. The standard deviation of the CBE of 75-125 scattering regions from 0.3 to 0.5 cm3 volumes increased nearly monotonically from 37 degrees C to 50 degrees C in each tissue type. Although the slopes were different, the curve for each type of tissue was well matched by a second-degree polynomial, with a correlation coefficient of 0.99 in each case. Thus the use of the CBE of ultrasound for temperature estimation may have clinical promise with a convenient, low cost modality. Because our approach exploits the inhomogeneities present in tissue, we believe that if it is successful in vitro, it holds promise for in vivo application.

Radiosensitization of heat resistant human tumour cells by 1 hour at 41.1 degrees C and its effect on DNA repair

The present study was undertaken to determine if short duration (1-2 h), moderate hyperthermia (41.1 degrees C) could radiosensitize human tumour cells. It was found that moderate hyperthermia (41.1 degrees C), for as little as 1 h, can radiosensitize heat resistant human adenocarcinoma cells, NSY42129 (NSY), provided the cells are irradiated 15 min prior to the end of the heat exposure. Analysis of the survival data showed a 2.5-3-fold increase in the alpha parameter with no significant change in the beta parameter of the survival curve, implying that the cells had become more susceptible to killing by single radiation energy deposition events as opposed to lethal events that require an interaction between two separate energy deposition events. 41.1 degrees C hyperthermia did not affect the induction or repair of alkaline labile DNA damage in a way that correlated with radiosensitivity. In contrast, heat-induced changes in the induction of micronuclei by radiation correlated with changes in cell killing. Therefore, the effect of 41.1 degrees C hyperthermia on the intracellular localization of the DNA double strand break repair protein, Mre11, was measured using in situ immunofluorescence and immunoblotting of soluble and insoluble cellular fractions. The results showed that Mre11 delocalizes from the nucleus as a function of time at 41.1 degrees C. It was then determined if 41.1 degrees C hyperthermia altered the association of Mre11 with its functional partner, Rad50. A significant decrease in the amount of Rad50 recovered with Mre11 occurred under the experimental conditions that produced significant radiosensitization. These results are consistent with the possibility that the heat-induced perturbation in Mre11 localization and its radiation-induced association with Rad50 contributes to an increase in radiosensitivity.

Entry of Vibrio harveyi and Vibrio fischeri into the viable but nonculturable state

AIMS

Physiological responses of marine luminous bacteria, Vibrio harveyi (ATCC 14216) and V. fischeri (UM1373) to nutrient-limited normal strength (35 ppt iso-osmolarity) and low (10 ppt hypo-osmolarity) salinity conditions were determined.

METHODS AND RESULTS

Plate counts, direct viable counts, actively respiring cell counts, nucleoid-containing cell counts, and total counts were determined. Vibrio harveyi incubated at 22 degrees C in nutrient-limited artificial seawater (ASW) became nonculturable after approximately 62 and 45 d in microcosms of 35 ppt and 10 ppt ASW, respectively. In contrast, V. fischeri became nonculturable at approximately 55 and 31 d in similar microcosms. Recovery of both culturability and luminescence of cells in the viable but nonculturable state was achieved by addition of nutrient broth or nutrient broth supplemented with a carbon source, including luminescence-stimulating compounds. Temperature upshift from 22 degrees C to 30 degrees C or 37 degrees C did not result in recovery from nonculturability.

CONCLUSIONS

The study confirms entry of V. harveyi and V. fischeri into the viable but nonculturable state under low-nutrient conditions and demonstrates nutrient-dependent resuscitation from this state.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study confirms loss of luminescence of V. harveyi and V. fischeri on entry into the viable but nonculturable state and suggests that enumeration of luminescent cells in water samples may be a rapid method to deduce the nutrient status of a water sample.

The effect of 835.62 MHz FDMA or 847.74 MHz CDMA modulated radiofrequency radiation on the induction of micronuclei in C3H 10T(1/2) cells

To determine if radiofrequency (RF) radiation induces the formation of micronuclei, C3H 10T(1/2) cells were exposed to 835.62 MHz frequency division multiple access (FDMA) or 847.74 MHz code division multiple access (CDMA) modulated RF radiation. After the exposure to RF radiation, the micronucleus assay was performed by the cytokinesis block method using cytochalasin B treatment. The micronuclei appearing after mitosis were scored in binucleated cells using acridine orange staining. The frequency of micronuclei was scored both as the percentage of binucleated cells with micronuclei and as the number of micronuclei per 100 binucleated cells. Treatment of cells with cytochalasin B at a concentration of 2 microg/ml for 22 h was found to yield the maximum number of binucleated cells in C3H 10T(1/2) cells. The method used for the micronucleus assay in the present study detected a highly significant dose response for both indices of micronucleus production in the dose range of 0.1-1.2 Gy and it was sensitive enough to detect a significant (P > 0.05) increase in micronuclei after doses of 0.3 Gy in exponentially growing cells and after 0.9 Gy in plateau-phase cells. Exponentially growing cells or plateau-phase cells were exposed to CDMA (3.2 or 4.8 W/kg) or FDMA (3.2 or 5.1 W/kg) RF radiation for 3, 8, 16 or 24 h. In three repeat experiments, no exposure condition was found by analysis of variance to result in a significant increase relative to sham-exposed cells either in the percentage of binucleated cells with micronuclei or in the number of micronuclei per 100 binucleated cells. In this study, data from cells exposed to different RF signals at two SARs were compared to a common sham-exposed sample. We used the Dunnett's test, which is specifically designed for this purpose, and found no significant exposure-related differences for either plateau-phase cells or exponentially growing cells. Thus the results of this study are not consistent with the possibility that these RF radiations induce micronuclei.

Radiofrequency electromagnetic fields do not alter the cell cycle progression of C3H 10T and U87MG cells

The effects of exposure to radiofrequency electromagnetic fields (RF EMFs) on cell cycle progression of mouse fibroblasts C3H 10T(1/2) and human glioma U87MG cells were determined by the flow cytometric bromodeoxyuridine pulse-chase method. Cells were exposed to a frequency-modulated continuous wave at 835.62 MHz or a code division multiple access RF EMF centered on 847.74 MHz at an average specific absorption rate of 0.6 W/kg. Five cell cycle parameters, including the transit of cells through G(1), G(2) and S phase and the probability of cell division, were examined immediately after the cells were placed in the fields or after they had been kept in the fields for up to 100 h. The only significant change observed in the study was that associated with C3H 10T(1/2) cell cultures moving into plateau phase toward the later times in the long-exposure experiment. No changes in the cell cycle parameters were observed in cells exposed to either mode of RF EMFs when compared to sham-exposed cells in either of the cell lines studied during the entire experimental period. The results show that exposure to RF EMFs, at the frequencies and power tested, does not have any effect on cell progression in vitro.

Micronuclei in the peripheral blood and bone marrow cells of rats exposed to 2450 MHz radiofrequency radiation

PURPOSE

To determine the incidence of micronuclei in peripheral blood and bone marrow cells of rats exposed continuously for 24h to 2450 MHz continuous wave radiofrequency radiation (RFR) at an average whole-body specific absorption rate (SAR) of 12W/kg.

MATERIALS AND METHODS

Eight adult male Sprague-Dawley rats were exposed to 2450 MHz RFR in circularly polarized waveguides. Eight sham-exposed rats were kept in similar waveguides without the transmission of RFR. Four rats were treated with mitomycin-C (MMC) and used as positive controls. All rats were necropsied 24h after the end of RFR and sham exposures, and after the 24h treatment with MMC. Peripheral blood and bone marrow smears were examined to determine the frequency of micronuclei (MN) in polychromatic erythrocytes (PCE).

RESULTS

The results indicated that the incidence of MN/2000 PCE were not significantly different between RFR- and sham-exposed rats. The group mean frequencies of MN in the peripheral blood were 2.3+/-0.7 in RFR-exposed rats and 2.1+/-0.6 in sham-exposed rats. In bone marrow cells, the average MN incidence was 3.8+/-1.0 in RFR-exposed rats and 3.4+/-0.7 in sham-exposed rats. The corresponding values in positive control rats treated with MMC were 23.5+/-4.7 in the peripheral blood and 33.8+/-7.4 in bone marrow cells.

CONCLUSION

There was no evidence for the induction of MN in peripheral blood and bone marrow cells of rats exposed for 24h to 2450 MHz continuous wave RFR at a whole body average SAR of 12 W/kg.

Measurement of DNA damage in mammalian cells exposed in vitro to radiofrequency fields at SARs of 3-5 W/kg

In the present study, we determined whether exposure of mammalian cells to 3.2-5.1 W/kg specific absorption rate (SAR) radiofrequency fields could induce DNA damage in murine C3H 10T(1/2) fibroblasts. Cell cultures were exposed to 847.74 MHz code-division multiple access (CDMA) and 835.62 frequency-division multiple access (FDMA) modulated radiations in radial transmission line (RTL) irradiators in which the temperature was regulated to 37.0 +/- 0.3 degrees C. Using the alkaline comet assay to measure DNA damage, we found no statistically significant differences in either comet moment or comet length between sham-exposed cells and those exposed for 2, 4 or 24 h to CDMA or FDMA radiations in either exponentially growing or plateau-phase cells. Further, a 4-h incubation after the 2-h exposure resulted in no significant changes in comet moment or comet length. Our results show that exposure of cultured C3H 10T(1/2) cells at 37 degrees C CDMA or FDMA at SAR values of up to 5.1 W/kg did not induce measurable DNA damage.

Dosimetry and techniques for simultaneous hyperthermia and external beam radiation therapy

An increased biological effect is realized when hyperthermia and radiation therapy are combined simultaneously. To take advantage of this effect, techniques have been developed that combine existing hyperthermia devices with a linear accelerator. This allows concomitant delivery of either ultrasound or microwave hyperthermia with photon radiation therapy. Two techniques have been used clinically: the orthogonal technique, in which the microwave or ultrasound beam and the radiation beam are orthogonal to one another, and the en face technique, in which the ultrasound or microwave beam and the radiation beam travel into the tumour through the same treatment window. The en face technique has necessitated the development of special attachments so that the hyperthermia device can be mounted to the linear accelerator and so that non-uniform portions of the hyperthermia device can be removed from the radiation beam. For microwave therapy, applicators are mounted onto the linear accelerator using the compensating filter tray holder. For ultrasound, special reflector devices are mounted to a frame that is mounted onto the compensating filter tray holder of the linear accelerator. Because the linear accelerator is an isocentric device, the height of the radiation source is fixed, and this has necessitated specially designed devices so that the ultrasound support system is compatible with the linear accelerator. The treatment setups for both the en face technique and the orthogonal technique require the interaction of both hyperthermia and radiation therapy personnel and equipment. The dosimetry and day-to-day operations for each technique are unique. The simulation for the en face technique is much different from the simulation of a normal radiation treatment and requires the presence of a hyperthermia physicist. Also, for the en face technique, the attenuation of the microwave applicator and the thickness and attenuation of the ultrasound reflector system are taken into account for radiation dosimetry. This paper presents details of the dosimetry and logistics of the techniques for simultaneous thermoradiotherapy based on 7 years of experience treating more than 50 patients.

Neoplastic transformation in C3H 10T(1/2) cells after exposure to 835.62 MHz FDMA and 847.74 MHz CDMA radiations

The effect of radiofrequency (RF) radiation in the cellular phone communication range (835.62 MHz frequency division multiple access, FDMA; 847.74 MHz code division multiple access, CDMA) on neoplastic transformation frequency was measured using the in vitro C3H 10T(1/2) cell transformation assay system. To determine if 835.62 MHz FDMA or 847.74 MHz CDMA radiations have any genotoxic effects that induce neoplastic transformation, C3H 10T(1/2) cells were exposed at 37 degrees C to either of the above radiations [each at a specific absorption rate (SAR) of 0.6 W/kg] or sham-exposed at the same time for 7 days. After the culture medium was changed, the cultures were transferred to incubators and refed with fresh growth medium every 7 days. After 42 days, the cells were fixed and stained with Giemsa, and transformed foci were scored. To determine if exposure to 835.62 MHz FDMA or 847.74 MHz CDMA radiation has any epigenetic effects that can promote neoplastic transformation, cells were first exposed to 4.5 Gy of X rays to induce the transformation process and then exposed to the above radiations (SAR = 0.6 W/kg) in temperature-controlled irradiators with weekly refeeding for 42 days. After both the 7-day RF exposure and the 42-day RF exposure after X irradiation, no statistically significant differences in the transformation frequencies were observed between incubator controls, the sham-exposed (maintained in irradiators without power to the antenna), and the 835.62 MHz FDMA or 847.74 MHz CDMA-exposed groups.

Cytogenetic studies in human blood lymphocytes exposed in vitro to radiofrequency radiation at a cellular telephone frequency (835.62 MHz, FDMA)

Freshly collected peripheral blood samples from four healthy human volunteers were diluted with RPMI 1640 tissue culture medium and exposed in sterile T-75 tissue culture flasks in vitro for 24 h to 835.62 MHz radiofrequency (RF) radiation, a frequency employed for customer-to-base station transmission of cellular telephone communications. An analog signal was used, and the access technology was frequency division multiple access (FDMA, continuous wave). A nominal net forward power of 68 W was used, and the nominal power density at the center of the exposure flask was 860 W/m(2). The mean specific absorption rate in the exposure flask was 4.4 or 5.0 W/kg. Aliquots of diluted blood that were sham-exposed or exposed in vitro to an acute dose of 1.50 Gy of gamma radiation were used as negative or positive controls. Immediately after the exposures, the lymphocytes were stimulated with a mitogen, phytohemagglutinin, and cultured for 48 or 72 h to determine the extent of genetic damage, as assessed from the frequencies of chromosomal aberrations and micronuclei. The extent of alteration in the kinetics of cell proliferation was determined from the mitotic indices in 48-h cultures and from the incidence of binucleate cells in 72-h cultures. The data indicated no significant differences between RF-radiation- and sham-exposed lymphocytes with respect to mitotic indices, incidence of exchange aberrations, excess fragments, binucleate cells, and micronuclei. In contrast, the response of the lymphocytes exposed to gamma radiation was significantly different from both RF-radiation- and sham-exposed cells for all of these indices. Thus, under the experimental conditions tested, there is no evidence for the induction of chromosomal aberrations and micronuclei in human blood lymphocytes exposed in vitro for 24 h to 835.62 MHz RF radiation at SARs of 4.4 or 5.0 W/kg.

The impact of ultrasonic parameters on chest wall hyperthermia

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

Use of a chiA probe for detection of chitinase genes in bacteria from the Chesapeake Bay(1)

PCR primers specific for the chiA gene were designed by alignment and selection of highly conserved regions of chiA sequences from Serratia marcescens, Alteromonas sp., Bacillus circulans and Aeromonas caviae. These primers were used to amplify a 225 bp fragment of the chiA gene from Vibrio harveyi to produce a chiA gene probe. The chiA PCR primers and probe were used to detect the presence of the chiA gene in an assemblage of 53 reference strains and gave consistent results. Selected chiA fragments amplified by PCR were cloned and sequenced from nine known strains and from Chesapeake Bay isolates 6d and 11d. This confirmed the specificity and utility of the primers for detection of chiA-positive environmental strains. Over 1000 bacterial isolates from Chesapeake Bay water samples were tested for the presence of the chiA gene which was found to be present in 5-41% (average 21%) of the culturable bacterial community. The approach developed in this study was valuable for isolation and enumeration of chiA-positive bacteria in environmental samples.

Detection of luciferase gene sequences in nonluminescent bacteria from the Chesapeake Bay

A 745-bp luxA fragment was amplified from Vibrio harveyi (UM 1503), radiolabeled, and used as a probe to detect and quantify luxA genotypes in culturable bacterial populations from the Chesapeake Bay. DNA samples from 53 reference strains were also examined for this gene. The luxA-positive bacteria comprised from 0-6% of the culturable heterotrophic bacterial community in samples from the Bay. Only those reference strains known to be luminescent contained the luxA gene, as indicated by PCR. Results in all cases were confirmed by PCR of DNA extracts and Southern hybridization analyses, using an internal probe for confirmation of luxA amplification products. Sequence analysis of luxA genes from three nonluminescent bacteria isolated from the Chesapeake Bay indicated little or no differences when compared with luxA sequences from known marine luminescent bacterial species. These three Chesapeake Bay strains and other luxA-positive strains were tested with a luminometer and confirmed to be nonluminescent. All of over 7800 bacterial colonies enumerated during this study from Chesapeake Bay samples were non-visibly luminescent. Our results indicate that luxA-positive bacteria isolated from the Chesapeake Bay are not generally luminescent on phenotypic examination, implying that gene probe techniques are required for examining luxA gene distribution in microbial populations present in environmental samples.

A compact shielded exposure system for the simultaneous long-term UHF irradiation of forty small mammals: I. Electromagnetic and environmental design

To carry out in vivo studies of the possible health effects of radiation from cellular telephone handsets, it is necessary to expose large numbers of small mammals at realistic power densities, modulations, and frequencies. Because even microwatt leakage could compromise the local cellular system, extreme care in shielding is required. Experimental logistics dictate, however, that the irradiated animals be easily accessed and that it be possible to irradiate them in small groups, while other groups are being loaded into or unloaded from the irradiators. This problem has been resolved by exposing the animals in aluminum-sheathed rectangular parallelepipeds, lined with microwave absorber and having doors that can be opened readily. Inside each of these microwave anechoic "chamberettes" is a vertical, four-element collinear array of dipole antennas; and around each antenna, 10 animal restrainers can be arranged like spokes on a wheel. The system has worked efficiently in studies of up to 480 rats. There is negligible coupling between antennas, and back reflection at an antenna's feed line is down 7-9 dB. Received CDMA power at the local base station is below the receiver's noise floor. Interior illumination reinforces the rats' diurnal rhythms, and the rats sleep during irradiation. Experimental logistics are excellent. In this paper, the irradiator design is presented.

The radial transmission line as a broad-band shielded exposure system for microwave irradiation of large numbers of culture flasks

The problem of simultaneously exposing large numbers of culture flasks at nominally equivalent incident power densities and with good thermal control is considered, and the radial transmission line (RTL) is proposed as a solution. The electromagnetic design of this structure is discussed, and an extensively bench-tested realization is described. Referred to 1 W of net forward power, the following specific absorption rate (SAR) data were obtained: at 835.62 MHz, 16.0+/-2.5 mW/kg (mean+/-SD) with range (11-22); at 2450 MHz, 245+/-50 mW/kg with range (130-323). Radio-frequency interference from an RTL driven at roughly 100 W is so low as to be compatible with a cellular base station only 500 m distant. To avoid potential confounding by temperature differences among as many as 144 T-75 flasks distributed over 9 RTLs (six irradiates and three shams), temperature within all flasks was controlled to 37.0+/-0.3 degrees C. Experience with over two years of trouble-free operation suggests that the RTL offers a robust, logistically friendly, and environmentally satisfactory solution to the problem of large-scale in vitro experiments in bioelectromagnetics.

Simplified model and measurement of specific absorption rate distribution in a culture flask within a transverse electromagnetic mode exposure system

In vitro experiments in bioelectromagnetics frequently require the determination of specific absorption rate (SAR) within a layer of cells on the bottom of a culture flask when the SAR has rapid spatial variation both horizontally within the cell layer and vertically in the medium bathing the cells. This problem has only recently been treated in the literature; and it is here approached differently for another irradiation system. It is shown that a simple two-dimensional frequency-domain guided-wave treatment yields results qualitatively comparable to those of more computationally intensive three-dimensional time-domain free-field scattering treatments. The problem of inferring local SARs from temperature-vs.-time curves is shown to be seriously confounded by thermal diffusion; and specific analytic and numerical results are presented to aid in understanding this effect. A novel experimental technique is introduced for measuring millikelvin temperature offsets with subsecond resolution, and illustrative experimental data are presented. Finally, present experimental and theoretical uncertainties are considered; and it is pessimistically asserted that, in a culture flask where spatial SAR variation is rapid, point SAR measurements by thermal methods may be in error by as much as +/- 3 dB. More reliable thermal determinations will require extreme care, challenging technological innovations, or both.

Compact shielded exposure system for the simultaneous long-term UHF irradiation of forty small mammals. II. Dosimetry

A four-antenna collinear array in an electromagnetically shielded chamber was designed and constructed to preferentially irradiate the brains of a large number of small mammals using cellular telephony microwave signals. Ten animals in special restrainers were positioned symmetrically around a centrally located antenna. These restrainers are resting on a circular structure made of acrylic plastic called a "carousel." Four carousels are stacked vertically, forming the array, inside a microwave anechoic chamber called a "chamberette." (Details of the design of this irradiator and of a 12-chamberette irradiation facility are given in a previous article.) In this article, the dosimetry on rats is reported. Both thermometric and thermographic measurements were performed. The average specific absorption rate (SAR) in brain tissue measured thermometrically was 0.85+/-0.34 W/kg per watt of net input power into the radiating antenna. This range agrees with the SAR levels reported in the literature for cellular telephones. Thermographic evaluation using splittable phantoms showed that most of the energy absorbed by the rats is concentrated in and around the brain. Moreover, it was found that the SAR in brain tissue can vary considerably for rats of similar weights, depending on position of the rats' heads inside the restrainers, and that there exists a significant dependence of SAR on animal weight. These variations may be of importance in the interpretation of results of lifelong studies. The data presented clearly show that the chamberette is, dosimetrically, a suitable irradiation system for electromagnetic bioeffects studies in the cellular communication frequency range, especially when a large number of laboratory animals is required.

Ultrasound field estimation method using a secondary source-array numerically constructed from a limited number of pressure measurements

A new and faster method for the accurate estimation of acoustic fields of underwater ultrasonic transducers was developed, tested experimentally, and compared to previously reported methods. Using a limited number of pressure measurements close to the transducer's face, the method numerically constructs a virtual secondary source-array whose acoustic field is similar to the field generated by the actual transducer (primary source). The measured data are used to obtain the normal particle velocity on the surface of the virtual secondary source-array, which in turn permits the calculation of the forward propagating field using the Rayleigh-Sommerfeld diffraction integral. The method is novel in that it constructs a virtual secondary source-array, thus eliminating the problems associated with obtaining the excitation source of a real transducer; and it is faster because it uses finite differences instead of a matrix inversion to obtain the excitation source. Results showed that predicted ultrasound fields agreed quantitatively and qualitatively with measured fields for three commonly used transducer types: two planar radiators (one circular, 0.5 MHz, 1.9-cm diam.; and one square, 1 MHz, 1.2 cm on a side), and a sharply focused radiator (1.5 MHz, 10-cm diam., 10-cm radius of curvature). The agreements suggest that the secondary source-array method (SSAM) is applicable to a wide range of radiator sizes, shapes, and operating frequencies. The SSAM was also compared to these authors' previous equivalent phased array methods (EPAM) [J. Acoust. Soc. Am. 102, 2734-2741 (1997); and Concentric ring equivalent phased array method (CREPAM), UFFC 46, 830-841 (1999)] which require matrix inversions. The SSAM proved to be much faster and equally or more nearly accurate than the previous methods.

Experimental and numerical determination of SAR distributions within culture flasks in a dielectric loaded radial transmission line

The effect of dielectric loading on the cell layer specific absorption rate (SAR) within a T-75 culture flask being irradiated within a transverse electromagnetic (TEM) cell was studied both experimentally and numerically. Direct thermal measurements of a T-75 containing 40 mL of culture medium and resting upon a 3-mm-thick slab of alumina ceramic (epsilon r = 9.6) revealed that, compared to the same flask resting upon a foam slab (epsilon r = 1.0) of the same thickness, the average SAR at the cell layer was increased roughly fourfold. This fourfold increase is significant experimentally because it allows biologists to perform experiments over a larger range of SAR values needed to determine possible dose-response curves without the costs and difficulties of a fourfold increase in amplifier power. Finite-difference time-domain (FDTD) simulations of the SAR distribution were in good quantitative agreement with the experimental measurements. It is concluded that FDTD modeling can be a cost effective and scientifically acceptable means of obviating the thermal measurement of SAR.

Radiofrequency electromagnetic fields have no effect on the in vivo proliferation of the 9L brain tumor

The intracranial 9L tumor model was used to determine if exposure to a radiofrequency (RF) electromagnetic field similar to those used in cellular telephone has any effects on the growth of a central nervous system tumor. Fischer 344 rats implanted with different numbers of 9L gliosarcoma cells were exposed to 835.62 MHz frequency-modulated continuous wave (FMCW) or 847.74 MHz code division multiple access (CDMA) RF field with nominal slot-average specific absorption rates in the brain of 0.75 +/- 0.25 W/kg. The animals were exposed to the RF field for 4 h a day, 5 days a week starting 4 weeks prior to and up to 150 days after the implantation of tumor cells. Among sham-exposed animals injected with 2 to 10 viable cells (group 1), the median survival was 70 days, with 27% of the animals surviving at 150 days. The median survival length and final survival fraction for animals injected with 11 to 36 viable cells (group 2) were 52 days and 14%, respectively, while the values for those injected with 37 to 100 cells (group 3) were 45 days and 0%. The animals exposed to CDMA or FMCW had similar survival parameters, and the statistical comparison of the survival curves for each of the groups 1, 2 and 3 showed no significant differences compared to sham-exposed controls.

Ultrasound power deposition model for the chest wall

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

A multi-user networked database for analysis of clinical and temperature data from patients treated with simultaneous radiation and ultrasound hyperthermia

A database was developed using commercially available development software that allows the entry of clinical data and automatically analyses temperature and power data from a commercial ultrasound hyperthermia system. The database can be accessed via network connections by more than one authorized user, thus facilitating the entry, management, and analysis of clinical data. The software automatically estimates ultrasound induced temperature artifacts and calculates thermal dose parameters such as T90s, equivalent minutes at 43 degrees, and time at or above index temperatures using the corrected temperatures. These parameters also become part of the database. Digital photographs of treatment setup, probe placement, and tumour or normal tissue response can be included in the database for documentation and reference. Ultrasound diagnostic images that document the depth and reproducibility of probe placement can be scanned into the PC and included in the database as well. This short communication documents experiences developing this tool that may be useful to other investigators.

Simultaneous superficial hyperthermia and external radiotherapy: report of thermal dosimetry and tolerance to treatment

BACKGROUND

In vitro and animal studies indicate that a moderate temperature of 41 degrees C maintained for approximately 1 h will provide radiosensitization if radiation (RT) and hyperthermia (HT) are delivered simultaneously, but not with sequential treatment. A minimum tumour temperature of 41 degrees C is a more feasible goal than the goal of >42 degrees C needed for sequential treatment.

METHODS AND MATERIALS

Forty-four patients with 47 recurrent superficial cancers received simultaneous external beam radiotherapy and superficial hyperthermia on successive IRB approved phase I/II studies. All lesions had failed previous therapy, 35 were previously irradiated (mean dose 52.7 Gy). Hyperthermia was delivered with 915 MHz microwave or 1-3.5 MHz ultrasound using commercially available applicators. The average dimensions of 19 lesions treated with microwave were 4.7 x 3.6 x 1.7 cm and the average dimensions of 28 lesions treated with ultrasound were 8.0 x 6.1 x 2.9 cm. The most common sites were chest wall (15 cases) and head and neck (21 cases). Temperatures were monitored at an average of six intratumoral locations using multisensor probes. The median number of hyperthermia treatments was three and the median radiation dose 30 Gy. Radiation dose per fraction was 4 Gy with hyperthermia and 2 Gy or 4 Gy (depending on protocol) on non-hyperthermia days.

RESULTS

Six different measures of minimum monitored temperature and duration were found to be highly correlated with each other. There was nearly a one-to-one correspondence between minimum tumour time at or above 41 degrees C (Min t41) and minimum tumour Sapareto Dewey equivalent time at 42 degrees C (Min teq42). After four sessions 63% of cases had a per session average Sapareto Dewey equivalent time at 41 degrees C which exceeded 60 min in all monitored tumour locations. The complete and partial response rate in evaluable lesions were respectively 21/41 (51%) and 7/41 (17%) and were best correlated with site (chest wall showing best response). Toxicity consisted of 10/47 (21%) slow healing soft tissue ulcers which healed in all cases but required a median of 7 months. The most important predictors for chronic ulceration were cumulative radiation dose >80 Gy and complete response to treatment.

CONCLUSIONS

Minimum tumour temperatures maintained for durations compatible in vitro with thermal radiosensitization (if RT and HT are delivered simultaneously) are clinically feasible and tolerable for broad but superficial lesions amenable to externally applied ultrasound or microwave hyperthermia. The current in-house protocol is evaluating the impact of more than four hyperthermia sessions on the overall thermal dose distribution and toxicity.

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

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

A two-parameter method for the estimation of ultrasound-induced temperature artifacts

A two-parameter method for the estimation of ultrasound-induced temperature artifacts was evaluated and compared with other commonly applied methods using analytical solutions to the bioheat equation. The two parameters are the exponent of the assumed temperature decay curve after power is turned off and the baseline temperature. These parameters are found by optimizing the fit of the temperature data from 30 to 60s after power is turned off. The artifact is modelled as a point source at the centre of a Gaussian temperature distribution. The blood flow, baseline temperature, and variance of the Gaussian temperature distribution were varied to simulate different clinical situations. Noise was added to the model to investigate the effects of thermometry resolution and sampling intervals. It was found that for artifacts of < 2 degrees C the two-parameter method had errors of less than 0.25 degrees C, whereas other methods generally had greater errors depending on the conduction rate and blood flow rate. The effects of the temperature sampling interval and resolution on the ability of the methods to estimate the artifact were also investigated, and it was found that the two-parameter method was much more sensitive to these parameters than other commonly applied methods.

A concentric-ring equivalent phased array method to model fields of large axisymmetric ultrasound transducers

An equivalent concentric-ring ultrasound phased array method was developed to estimate ultrasonic continuous wave fields generated by axisymmetric single-source transducers. The method models a given source as a concentric-ring phased array by mathematically segmenting it into many rings and subsequently finding the amplitude and phase for each ring that produces an acoustic field similar to the field of the single-source transducer. The excitation source of each ring was calculated using an inverse technique based on complex pressure measurements along a radial line close to the source. The predicting abilities of the method are evaluated by comparing measured and estimated ultrasound fields for six different transducers. The results show that the concentric-ring equivalent phased array method (CREPAM) is able to estimate quantitatively the ultrasound fields generated by large axisymmetric planar and focused transducers.