Thermochemotherapy: synergism between hyperthermia (42-43 degrees) and adriamycin (of bleomycin) in mammalian cell inactivation

Encapsulation of doxorubicin into thermosensitive liposomes via complexation with the transition metal manganese

In the present study, doxorubicin was encapsulated into two thermosensitive liposome formulations which were composed of DPPC/MSPC/DSPE-PEG(2000) (90/10/4 mole ratio) or DPPC/DSPE-PEG(2000) (95/5 mole ratio). Doxorubicin loading was achieved through the use of a pH gradient or a novel procedure that involved doxorubicin complexation with manganese. Regardless of the initial drug-to-lipid ratios (D:L), the final D:L reached a maximum of 0.05 (w/w) when doxorubicin was encapsulated via a pH gradient for both thermosensitive liposome formulations. In contrast, the final maximum D:L achieved through manganese complexation was 0.2 (w/w), and this loading method did not affect temperature-induced drug release, with 85% of drug released from MSPC-containing liposomes within 10 min at 42 degrees C but <5% released over 60 min at 37 degrees C. When the thermosensitive liposomes prepared via the two different loading methods were injected into mice, similar plasma elimination profiles were observed. Cryo-transmission electron microscopy analysis indicated the presence of doxorubicin fiber bundles in liposomes loaded via pH gradient, compared to a stippled and diffuse morphology in those loaded via manganese complexation. To investigate the effect of intraliposomal pH on drug precipitate morphology, the A23187 ionophore (mediates Mn(2+)/H(+) exchange) was added to liposomes loaded with doxorubicin-manganese complex, and the stippled and diffuse appearance could be converted to one exhibiting fiber bundles after acidification of the liposome core. This suggests that the formation of doxorubicin-manganese complex is favored when the intraliposomal pH is >6.5. During the conversion to the fiber bundle morphology, no doxorubicin release was observed when A23187 was added to liposomes exhibiting a 0.05 (w/w), whereas a significant release was noted when the initial D:L was 0.2 (w/w). Following acidification of the liposomal interior and establishment of an apparent new D:L equilibrium, the measured D:L ratio was 0.05 (w/w). In conclusion, the manganese complexation loading method increased the encapsulation efficiency of doxorubicin in thermosensitive liposomes with no major impact on temperature-triggered drug release or pharmacokinetics.

In vivo efficacy and toxicity of intratumorally delivered mitomycin C and its combination with doxorubicin using microsphere formulations

The efficacy and toxicity of intratumorally (i.t.) administered anticancer drugs mitomycin C (MMC) and doxorubicin (Dox) incorporated in polymeric microspheres were investigated. Biodegradable sulfopropyl dextran microspheres and their oxidized products were used to load Dox and MMC, respectively. EMT6 mouse mammary cancer cells were injected into the hind leg of BALB/c mice. MMC microspheres, alone or combined with Dox microspheres, were injected i.t. once tumors had reached around 0.3 g. The tumor-plus-leg diameter was measured daily and the delay in time for the tumor to grow to 1.13 g relative to control (TGD) was employed as an indication of therapeutic effect. General toxicity was determined by monitoring weight, appearance and behavior of the mice. Morphology and histology of tumor and heart tissues were also examined. An average 79% TGD was observed after i.t. injection of MMC microspheres. The i.t. co-administration of MMC and Dox microspheres resulted in a 185% TGD. The i.t. injections of the microsphere formulations did not result in visible signs of toxicity in animals. In contrast, systemic (i.e. i.p.) injections of MMC solutions caused considerable general toxicity. This study suggests that i.t. delivery of anticancer drugs by polymeric microspheres is an effective way of improving the therapeutic index for cancer chemotherapy of selected solid tumors under special conditions.

Effect of heat preconditioning on the uptake and permeability of R123 in brain microvessel endothelial cells during mild heat treatment

The purpose of this study was to assess the effect of mild heat and heat preconditioning on the uptake and permeability of a P-glycoprotein (P-gp) substrate, rhodamine 123 (R123), in a cell culture model of the blood-brain barrier (BBB). An immediate goal was to determine whether prior mild heat treatment could render brain microvessel endothelial cells more resistant to future heat stress and affect BBB drug permeation by future ultrasound-induced mild heat (USMH) treatment. To address this issue, the expression level of two proteins, P-gp and heat shock protein 70 (Hsp70), and their effects on uptake of R123 and permeability of R123 and [14C]-sucrose in combination with mild heat and P-gp modulator PSC833 during and after mild heat treatment in heat-preconditioned and heat-unconditioned bovine brain microvessel endothelial cell (BBMEC) monolayers were studied. Mild heat caused a significant increase in BBB permeability of R123 and [14C]-sucrose when compared with control and PSC833. Exposure of BBMECs to heat preconditioning caused a slight but insignificant decrease in cellular uptake of R123 both during and immediately after mild heat treatment. Heat preconditioning also caused a slight but insignificant decrease in permeability of R123 and [14C]-sucrose in BBMEC monolayers during mild heat treatment. Because exposure of BBMEC monolayers to mild heat did not affect P-gp expression but slightly affected Hsp70 expression, a heat preconditioning that results in a reinforcement of the BBB other than increased expression of P-gp is suggested. However, heat preconditioning is not sufficient to override the permeation-enhancing effects of mild heat because mild heat caused a significant increase in R123 uptake and permeability of R123 and [14C]-sucrose in both heat-preconditioned and heat-unconditioned cells. Because Hsp70 is known to play a major role in cellular repair and protective mechanisms, our results would imply a relative benign nature of mild heat treatment. Because heating produced by ultrasonic waves can be controlled and localized to a small volume within the tissue, the present results also suggest that USMH could play a pivotal role in the treatment of brain tumors and other brain-related diseases.

Pharmacokinetics of intraperitoneal cisplatin and doxorubicin

Intraperitoneal chemotherapy, mainly when performed during HIIC after cytoreductive surgery, is considered potentially curative for the treatment of solid tumors with spread to the peritoneal surface. When selecting antiblastic agents to be administered intraperitoneally, it is important to bear in mind that a low lipophility and a high molecular weight are the ideal drug characteristics. Drugs with these features allow a favorable ratio to be achieved between peritoneal and plasma concentrations, due to the reduced tendency to diffuse through the plasma-peritoneal barrier, even after extensive removal of the peritoneum. Moreover, a low rate of diffusion through the tumor capillaries implies a low rate of drug clearance, with a higher intratumoral drug accumulation. Among the drugs used so far for intraperitoneal chemotherapy, the combination of CDDP and DXR appears to be one of the most effective available regimens with acceptable local-regional toxicity. CDDP has also been extensively employed as a single agent for ovarian and gastrointestinal cancers, under both normal and hyperthermic conditions, while intraperitoneally administered DXR appears to be of greater potential efficacy when associated with CDDP and hyperthermia (41.5 degrees C) following cytoreductive surgery. In our clinical experience with this drug combination, DXR showed a much more advantageous plasma/peritoneal AUC ratio than CDDP (162 +/- 113 and 20 +/- 6, respectively). On the other hand, it has been demonstrated that very high intraperitoneal concentrations of CDDP can be achieved without incurring significant systemic toxicity by using intravenous injection of sodium thiosulphate during HIIC. Penetration of the tumor mass by CDDP is greater than DXR. This phenomenon is enhanced by hyperthermia and by hypotonic solutions of sodium chloride used as the perfusate. Following experimental and clinical results of TNF alpha-based isolated limb perfusion for locally advanced soft tissue sarcoma or melanoma, greater efforts are being made to exploit the potential effect of this cytokine used in association with hyperthermia and other drugs (i.e., CDDP and DXR) suitable for intraperitoneal infusion/perfusion. However, it is not yet clear whether the observed effect of TNF alpha on the peritoneal-plasma barrier, which seems to favor the passage of both drugs into the systemic circulation, is overcome by the positive effect of this agent on drug penetration into tumor. Further pharmacologic studies should be undertaken to clarify whether or not these interactions will be of benefit to the patient. Likewise, liposomes, which in animal models seem to favor tumor uptake of encapsulated DXR, should now be tested in the clinical setting.

Rationale for hyperthermia with intraoperative intraperitoneal chemotherapy agents

Hyperthermia is selectively cytotoxic for malignant cells due to inhibition of oxidative metabolism causing lower pH in the microenvironment of the malignant cells and tumor. The increased acidity increases lysosymal activity and subsequent cell death. Hyperthermia alone as a primary treatment modality for malignancy has largely been abandoned due to high morbidity and mortality and high recurrence rates. Advances in administration and monitoring of hyperthermia, especially for regional applications, has allowed for the use of hyperthemia in conjunction with other modalities of antineoplastic therapy. Hyperthermia has been shown to potentiate chemotherapy and radiation by several different mechanisms. HIIC uses the advantages of hyperthermia in conjunction with chemotherapy for the management of peritoneal carcinomatosis. Several different chemotherapy agents have been shown to have improved therapeutic index and efficacy when used with hyperthermia in the management of peritoneal carcinomatosis.

TNFalpha-based isolated perfusion for limb-threatening soft tissue sarcomas: state of the art and future trends

The management of limb-threatening soft tissue sarcomas has not yet been standardized. Although local disease control does not affect overall survival, amputation or highly mutilating surgery may be required, which impairs the patient's quality of life. Various neoadjuvant approaches have been proposed to allow limb-sparing surgery for these locally advanced tumors. With TNFalpha-based hyperthermic isolated limb perfusion, the majority of patients can be spared amputation, with acceptable rates of locoregional and systemic complications. As yet, no other available treatment seems to give comparable results when applied to limb-threatening soft tissue sarcomas. Nevertheless, several issues remain to be addressed, such as the type and dose of drugs, repeatability of the procedure, association with radiotherapy, further indications, and evaluation of response. The authors describe the principles underlying TNFalpha-based hyperthermic isolated limb perfusion, review the worldwide experience so far published, and discuss the above issues. The potential future developments of this locoregional therapeutic approach will also be reported.

Cytoreductive surgery combined with hyperthermic intraperitoneal intraoperative chemotherapy for peritoneal carcinomatosis arising from colon adenocarcinoma

BACKGROUND

Hyperthermic intraoperative intraperitoneal chemotherapy (HIIC) has been recently proposed to treat peritoneal carcinomatosis arising from colon adenocarcinoma, which is usually regarded as a lethal clinical entity. The purpose of this study was to evaluate the clinical outcome of this combined treatment.

METHODS

A retrospective study of 46 patients treated for peritoneal carcinomatosis from colon adenocarcinoma was performed. Thirty-four patients were treated with complete cytoreductive surgery immediately followed by intraoperative HIIC with mitomycin C and cisplatin. The clinical outcome of these 34 patients was analyzed; the median follow-up period was 14.5 months.

RESULTS

No postoperative deaths were reported. The postoperative morbidity rate was 35%. No severe locoregional or systemic toxicity was observed. The 2-year overall survival was 31%, and the median survival time and the median time to local disease progression were 18 and 13 months, respectively. Survival and local disease control in patients with well- and moderately differentiated colon adenocarcinoma were significantly better than in those with poorly differentiated tumors.

CONCLUSIONS

Considering the dismal prognosis of this condition, HIIC seems to achieve encouraging results in a selected group of patients affected with resectable peritoneal carcinomatosis arising from colon adenocarcinoma. These findings support the conduction of formal phase III randomized trials.

Surgical treatment of malignant pleural mesothelioma: a review

Despite many years of clinical research, there is still no effective therapy for malignant pleural mesothelioma (MPM). Untreated, the prognosis is poor, with a median survival of < 1 year. Single-agent or combination chemotherapy as well as radiotherapy have not shown persistent improvements in response or survival. In general, MPM is a disease confined to the pleural cavity for a long time before metastasizing. Therefore, focus on local treatment seems rational. Surgical resection has been considered the mainstay of treatment by some. However, surgery alone results in high recurrence rates, and the survival benefit remains questionable. In recent years, the emphasis has been on surgery combined with adjuvant therapies. In this article, the present state of surgical management of MPM will be reviewed.

Pharmacokinetics of doxorubicin and cisplatin used in intraoperative hyperthermic intrathoracic chemotherapy after cytoreductive surgery for malignant pleural mesothelioma and pleural thymoma

Cytoreductive surgery combined with intraoperative hyperthermic intrathoracic chemotherapy (HITHOC) is studied in a phase I study in the treatment of malignant pleural mesothelioma and pleural thymoma. We studied the pharmacokinetics of doxorubicin and cisplatin used during the HITHOC procedure. Furthermore, the penetration characteristics of doxorubicin were examined. Between 1998 and 2001, 24 perfusions were performed with a solution containing doxorubicin and cisplatin for 90 min at 40-41 degrees C. The dose was first based on square meters body surface, whereas in later studies a fixed concentration of the perfusion fluid was used. Samples of blood and perfusion fluid were collected for doxorubicin and cisplatin measurements. The penetration characteristics of doxorubicin in tissue were determined by fluorescence microscopy. The mean AUC(perfusate):AUC(plasma) ratios for doxorubicin and cisplatin (ultrafiltration for plasma) were 99 and 59, respectively. During perfusion the concentration in the perfusate declined essentially according to first-order elimination kinetics for both doxorubicin and cisplatin with half-lives of 74 and 138 min, respectively. At the end of the perfusion, about 35 and 52% of the dose of doxorubicin and cisplatin, respectively, was recovered in the perfusion fluid. One patient developed a nephrotoxicity grade II. No leukopenia or hair loss was seen. Doxorubicin penetrated into the intercostal muscle specimen, albeit that there was considerable variation in distribution throughout the specimen. We conclude that HITHOC with doxorubicin and cisplatin is relatively a safe procedure with the advantage of high intrathoracic cytostatic drug concentrations, while having limited systemic side effects.

Temperature-dependent quinone cytotoxicity in platelets involves arylation

Menadione (MEN), a representative quinone compound, produces cytotoxicity in many cells by arylation with protein thiols and oxidative stress due to redox cycling. Previously it was demonstrated that protein arylation appears to be a primary mechanism for MEN-induced toxicity in platelets. To test the hypothesis that temperature conditions may be important in MEN-induced cytotoxicity in noncancer cells, platelets were incubated with menadione at 25, 37, or 42 degrees C. As temperature was increased, MEN significantly enhanced lactate dehydrogenase (LDH) leakage. MEN-induced depletion of protein thiol levels also increased as temperature was elevated. To investigate the mechanism of temperature-dependent MEN cytotoxicity, MEN-induced platelet toxicity was compared to two other quinone substances. Benzoquinone (BQ), which acts via arylation, produced cytotoxic effects similar to those of MEN. Dimethoxy-1,4-naphthoquinone (DMNQ), which exerts toxicity via oxidative radical generation, failed to produce cytotoxicity at all three temperatures. While MEN and DMNQ enhanced O(2) consumption in a temperature-dependent manner, BQ did not affect this parameter. MEN, which possesses an electrophilic 3-position, was found to react with thiols to form a thioether linkage, a direct indicator of arylation. In the case of MEN uptake kinetics, the amount of cellular uptake was not different at various temperatures, but concentration of MEN in extracellular medium decreased temperature dependently. This might be due to increased arylation capacity binding to cellular proteins as temperature rises. These data suggest that MEN-induced platelet cytotoxicity involves arylation that is temperature related.

Enhancement of hyperthermia-induced apoptosis by non-thermal effects of ultrasound

To determine the effect of ultrasound on hyperthermia-induced apoptosis, we exposed U937 cells (in air-saturated suspension) to continuous 1 MHz ultrasound at intensities 0.5 or 1.0 W/cm(2), considered non-thermal and sub-threshold for inertial cavitation, while at 44.0 degrees C for 10 min. We found that 0.5 W/cm(2), in combination with hyperthermia, synergistically induced apoptosis. On the other hand, 1.0 W/cm(2) in combination with hyperthermia showed an augmented instant cell lysis but no significant change in the ratio of apoptosis. This result might be useful when apoptosis induction is desired over instant cell killing in cancer therapy.

Ultrasound-Induced hyperthermia increases cellular uptake and cytotoxicity of P-glycoprotein substrates in multi-drug resistant cells

PURPOSE

Localized hyperthermia has been shown previously to augment the cytotoxicity of some lipophilic anticancer drugs. Because many of the substrates for the multi-drug resistance (MDR) transporter P-glycoprotein (P-gp) are lipophilic in nature, studies were conducted to test the hypothesis that hyperthermia induced by ultrasound could also increase cellular uptake and cytotoxicity of P-gp substrates by P-gp-expressing cells.

METHODS

To test this hypothesis, we studied the effects of hyperthermia and ultrasound on cellular accumulation of putative P-gp substrates, rhodamine 123 (R123) and doxorubicin (DOX), and cytotoxicity of DOX in the parent and MDR variants of two human cancer cell lines.

RESULTS

Treatment of cells with hyperthermia or ultrasound (20 min at 41 degrees C) both caused a significant increase over controls (no ultrasound treatment) in R123 and DOX accumulation in the parent and MDR lines of MV522 and KB cells. Ultrasound also substantially increased the antiproliferative effects of DOX in both the parent and MDR variants of MV522 and KB cell lines when compared with controls. Our results also indicated that ultrasound exerted a much greater effect on cellular accumulation of R123 and DOX and cytotoxicity enhancement of DOX in the MDR variants than putative P-gp antagonist such as verapamil.

CONCLUSION

The present results point to the potential use of ultrasound-induced hyperthermia as a much safer alternative to P-gp antagonist for reversal of MDR.

Enhancement of heat-induced heat shock protein (hsp)72 accumulation by doxorubicin (Dox) in vitro

Previous studies have shown that cellular thermotolerance develops in response to exposure to doxorubicin (Dox) and treatment with hyperthermia. In the present study, we evaluated the induction of thermotolerance and the accumulation of heat shock protein (hsp)72 after treatment with Dox and/or hyperthermia at 44 degrees C in Chinese hamster V-79 cells. Thermotolerance developed after exposure to Dox at 37 degrees C for 2 h in a dose-dependent manner. Western blot analysis showed no accumulation of hsp72 after exposure to Dox (0.2 microg/ml) for 2 h (lethal dose (LD)(15)). Hsp72 accumulated 12 h after hyperthermia at 44 degrees C for 35 min (LD(15)). However, when the cells were exposed to Dox (0.1 microg/ml) followed by heating at 44 degrees C for 25 min (LD(15)), accumulation of hsp72 was observed after 6 h. These results suggest that enhancement of induction of hsp72 accumulation by Dox may be involved in the development of thermotolerance induced by sequential treatment with Dox and hyperthermia.

Effects of PEMF on a murine osteosarcoma cell line: drug-resistant (P-glycoprotein-positive) and non-resistant cells

After pulsed exposure of Dunn osteosarcoma cells (nonresistant cells) to Adriamycin (ADR) at increasing concentrations and single-cell cloning of surviving cells, ADR-resistant cells were obtained. These resistant cells expressed P-glycoprotein and had resistance more than 10 times that of their nonresistant parent cells. Compared to the nonresistant cells not exposed to pulsing electromagnetic fields (PEMF) in ADR-free medium, their growth rates at ADR concentrations of 0.01 and 0.02 micrograms/ml, which were below IC50, were 83.0% and 61.8%, respectively. On the other hand, in the nonresistant cells exposed to PEMF (repetition frequency, 10 Hz; rise time, 25 microsec, peak magnetic field intensity, 0.4-0.8 mT), the growth rate was 111.9% in ADR-free medium, 95.5% at an ADR concentration of 0.01 micrograms/ml, and 92.2% at an ADR concentration of 0.02 micrograms/ml. This promotion of growth by PEMF is considered to be a result of mobilization of cells in the non-proliferative period of the cell cycle due to exposure to PEMF. However, at ADR concentrations above the IC50, the growth rate tended to decrease in the cells not exposed to PEMF. This may be caused by an increase in cells sensitive to ADR resulting from mobilization of cells in the non-proliferative period to the cell cycle. The growth rate in the resistant cells exposed to PEMF was significantly lower than that in the non-exposed resistant cells at all ADR concentrations, including ADR-free culture (P</=0.0114). Therefore, this study suggests that PEMF promotes the growth of undifferentiated cells but progressively suppresses the growth of more differentiated cells, i.e., PEMF controls cell growth depending on the degree of cell differentiation. This study also shows the potentiality of PEMF as an adjunctive treatment method for malignant tumors.

Inhibition of antioxidants and hyperthermia enhance bleomycin-induced cytotoxicity and lipid peroxidation in Chinese hamster ovary cells

Regional hyperthermia has potential for human cancer treatment, particularly in combination with systemic chemotherapy or radiotherapy. Heat enhances the cytotoxic effect of certain anticancer agents such as bleomycin, but the mechanisms involved in cell killing are currently unknown. Bleomycin generates reactive oxygen species. It is likely that hyperthermia itself also increases oxidative stress in cells. We evaluate whether oxidative stress has a role in the mechanism of cell death caused by bleomycin and heat in Chinese hamster ovary cells. Heat (41 to 44 degrees C) increased cytotoxicity of bleomycin, evaluated by clonogenic cell survival. Decreased levels of cellular antioxidants should create an imbalance between prooxidant and antioxidant systems, thus enhancing cytotoxic responses to heat and to oxidant-generating drugs. We determine the involvement of four major cellular antioxidant defenses, superoxide dismutase (SOD), the glutathione redox cycle (GSH cycle), catalase, and glutathione S-transferase (GST), in cellular sensitivity to bleomycin, alone or combined with hyperthermia. These cellular defenses were inhibited by diethyldithiocarbamate, l-buthionine sulfoximine, aminotriazole, and ethacrynic acid, respectively. We show that levels of antioxidants (SOD, GSH cycle, and GST) affect cellular cytotoxic responses to bleomycin, at normal and elevated temperatures (41 to 44 degrees C), suggesting the involvement of oxidative stress. Bleomycin and iron caused oxidative damage to membrane lipids in intact cells, at 37 and 43 degrees C. Lipid peroxidation was evaluated by fluorescence detection of thiobarbituric acid-reactive products. There was an increase in damage to membrane lipids when the antioxidant defenses, SOD and catalase, were inhibited. The differing effects of antioxidant inhibitors on bleomycin-induced cytotoxicity and membrane lipid damage suggest that different mechanisms are involved in these two processes. However, free radicals appear to be involved in both cases. The marked sensitization of cells by diethyldithiocarbamate, to both bleomycin-induced cytotoxicity and lipid peroxidation, suggests that superoxide could be involved in both of these processes.

Heat-induced membrane damage combined with adriamycin on prostate carcinoma PC-3 cells: correlation of cytotoxicity, permeability and P-glycoprotein or metallothionein expression

OBJECTIVE

To assess heat-induced membrane damage in a prostate cancer cell line when combined with adriamycin treatment.

MATERIALS AND METHODS

The changes in intracellular adriamycin accumulation, cell proliferation and cell-cycle fractions were examined after human prostate carcinoma PC-3 cells were exposed to heat and/or further treatment with adriamycin. Proliferation and the cell cycle were determined using adherent cell analysis and sorting laser cytometry (ACAS) or flow cytometry. P-glycoprotein (PGP) and metallothionein (MT) expression, which may have a physiological role in the transport of or reduction in cytotoxicity of some anticancer drugs, were also analysed after cells were exposed to heat, using immunohistochemical or flow cytometric methods.

RESULTS

There was a significant increase in intracellular adriamycin accumulation, related to both influx (P<0.05) and efflux (P<0.01), in cells treated with adriamycin, especially after heating them at 44 degrees C for 1 h. There was a significant decrease in cell proliferation of preheated cells when exposed to adriamycin, especially at 44 degrees C (P<0.05). In the cell-cycle analysis, cells preheated at 44 degrees C showed partial accumulation in the debris or apoptotic fraction at 24 h, and many cells accumulated in these fractions at 48 h. There was significantly less PGP or MT expression in cells preheated at 44 degrees C than in control cells or cells preheated at 41 degrees C (P<0.01). This reduction in PGP or MT level by heating may inhibit drug efflux and thus increase intracellular drug level at elevated temperatures.

CONCLUSIONS

These results suggest that hyperthermia may damage the drug-exclusion mechanism in these cells and thus increase the effectiveness of drug action.

The application of hyperthermia in regional chemotherapy

To evaluate the role of hyperthermia combined with chemotherapy in the loco-regional treatment of tumors, a retrospective analysis was done with 228 limb melanoma patients treated with hyperthermic antiblastic perfusion (HAP). A series of treatment- and tumor-related prognostic factors was analyzed to establish their influence on tumor response, loco-regional control, and survival. Concerning tumor response, the logistic model showed that the number of lesions and the minimal tumor temperature (min T) maintained their individual predictive values (P < 0.000001 and P = 0.04, respectively). For loco-regional control, only the number of lesions had a significant predictive value. No direct correlation was found between the treatment-related variables and loco-regional control. However, the 5-year survival rate was significantly higher for patients who achieved a complete response (CR) (51.5%, P = 0.0033) as compared to those who did not (33.3%), providing indirect evidence of the role of the treatment. Multivariate analysis showed that both disease-free and overall survival are strongly influenced by numerous clinical variables and the min T always maintained its significance. When analyzing the subgroup of 119 patients evaluable for tumor response, the Cox model selected the tumor response as the dominant factor for both disease-free and overall survival. These data seem to demonstrate that the optimization of treatment parameters is crucial in determining the CR rate, which, in turn, positively affects the disease outcome. HAP is the treatment of choice for recurrent limb melanoma, and hyperthermia plays an important role in exploiting the efficacy of this technique.

Intraperitoneal cisplatin with regional hyperthermia in advanced ovarian cancer: pharmacokinetics and cisplatin-DNA adduct formation in patients and ovarian cancer cell lines

The purpose of this study was to investigate the influence of hyperthermia on cisplatin pharmacokinetics and DNA adduct formation. The latter was investigated both in tumour cell lines in vitro and in tumour cells and buccal cells from cancer patients. The patients had advanced ovarian carcinoma and were entered into a phase I study for cytoreductive surgery followed by hyperthermia in combination with intraperitoneal cisplatin administration. The cisplatin-DNA modifications in vivo and in vitro were studied by an immunocytochemical method with the polyclonal antiserum NKI-A59. The patient samples for pharmacokinetic determinations were analysed by flameless atomic absorption spectrometry. In vitro, the combination of hyperthermia and cisplatin enhanced cell killing compared with either treatment alone, such that the cisplatin-resistant ovarian cell line A2780/DDP became almost as sensitive as the parent A2780 cell line (resistance factor reduced from 30 to 2 at the IC50). In addition, increased cisplatin-DNA adducts were observed in the resistant cell line after the combined treatment compared with cisplatin alone. A good correlation was found between nuclear staining density and surviving fraction for all groups, indicating that the DNA adducts generated are an important determinant of toxicity and that the mechanism by which hyperthermia enhances kill is by increasing adduct levels. In the patients, the ratio of drug concentration in the peritoneal perfusate compared with that in plasma was found to be approximately 15, indicating a favourable pharmacokinetic ratio. Cisplatin-DNA adduct formation in tumour cells from patients was higher than in buccal cells, reflecting this higher drug exposure, i.e. local plus systemic versus systemic only. In addition, the tumour cells but not buccal cells were exposed to hyperthermia. The higher number of tumour adducts also suggests that a favourable therapeutic ratio could be achieved. Platinum-DNA adduct formation was found to decrease with distance from the surface of the tumour nodules. However, at a distance of 3-5 mm, the nuclear staining density levels were still measurable and higher than in buccal cells. In conclusion, the combined pharmacokinetic and adduct data in patients support the advantages of the intraperitoneal route for drug administration, and the addition of heat.

Thermal enhancement of pirarubicin (THP-adriamycin) by mild hyperthermia in vitro

It has been demonstrated that hyperthermia can enhance the cytotoxicity of several anticancer drugs. Pirarubicin (THP-adriamycin) is a less cardiotoxic derivative of adriamycin. The thermal enhancement of cytotoxicity of pirarubicin was studied at various elevated temperatures in vitro by using a Chinese hamster cell line, V79. Cell survival curves were obtained at elevated temperatures for V79 cells treated with heat given alone or in combination with pirarubicin, and D0, the treatment time to reduce cell survival from S to S/e, was obtained for each cell survival curve. The relationship between the logarithm of the D0 and the treatment temperature for cells treated with heat alone was biphasic with a breaking point at 43 degrees C, although that for cells treated with a combination of heat and pirarubicin was exponential with no breaking point. The slope of this relationship for heat alone > 43 degrees C was -0.72 +/- 0.094 h/degree C which was not significantly different from the slope for combined heat and pirarubicin, -0.64 +/- 0.032 h/degree C. The results indicated that the cytotoxicity of pirarubicin was thermally enhanced specifically by mild hyperthermia. Pirarubicin uptake into the V79 cells during hyperthermia was independent of the treatment temperature (37, 42, and 44 degrees C), suggesting that the thermal enhancement of pirarubicin was not due to the increased drug-uptake at elevated temperatures. Based on these results, it is predictable that hyperthermia combined with pirarubicin is more effective below 43 degrees C which is easily achievable clinically.

Laser chemotherapy of human carcinoma cells with three new anticancer drugs

A new experimental therapy for squamous carcinoma was tested by sensitizing human tumor cells with light-sensitive anticancer drugs followed by laser illumination at visible or infrared wavelengths. The anthrapyrazole DUP-941 and the isoquinoline derivative DUP-840 were compared with the dianthraquinone hypericin. P3 human squamous carcinoma cells were incubated for 2 h with the drugs at escalating doses ranging from 5 to 100 micrograms/ml, then exposed to visible green 532-nm or infrared 1064-nm light at 300 J output from a KTP/Nd:YAG laser. Tumor cell toxicity measured by in vitro MTT viability assays was minimal after DUP-840 uptake but was slightly enhanced by infrared laser emissions. By contrast, the strong tumoricidal effects seen after DUP-941 uptake were amplified over 10-fold by 532-nm light and up to 2-fold by 1064-nm light. Hypericin-sensitized tumor cells were killed after 532 nm irradiation even at the lowest drug dose but were not affected by 1064-nm illumination. The results suggest that laser chemotherapy with drugs sensitive to photothermal energy could become a useful new treatment modality for cancer.

Reduction of etoposide induced cell killing by hyperthermia can occur without changes in etoposide transport or DNA topoisomerase II activity

We investigated the modification of etoposide (i.e. VP-16)-induced cell killing by hyperthermia in a radioresistant human melanoma (Sk-Mel-3) and a human normal (AG1522) cell line. VP-16, a DNA topo II poison, was given as a 1 h exposure at variable doses up to 35 microM; hyperthermia was given either before or following VP-16 treatment. Hyperthermic treatment comprised one of the following: 41 degrees C for 8 h, 42 degrees C for 2 h or 45 degrees C for 15 min. Hyperthermia preceding VP-16 treatment reduced the cytotoxicity of the latter; the reduction of VP-16 cytotoxicity was directly proportional to the severity of the hyperthermic treatment. For a particular combination of hyperthermic dose and VP-16 concentration, generally similar responses were seen in both cell lines. There were no effects on VP-16 cytotoxicity when both Sk-Mel-3 and AG1522 cells were heated at 41 degrees C for 8 h following treatment with VP-16. However, heating both cell lines at 45 degrees C for 15 min following VP-16 treatment again reduced the amount of cytotoxicity associated with VP-16. In addition, we found that a preceding exposure to 45 degrees C, 15 min heating did not affect either cellular accumulation or efflux of [3H]VP-16 in both cell lines. This suggested that the reduction in VP-16 cytotoxicity observed under those conditions was not due to a modification of VP-16 transport. We found no differences between the catalytic activities of topo II extracted from nuclei of Sk-Mel-3 and AG1522 cells that were either heated at 45 degrees C for 15 min or that were not subjected to such treatment. These results therefore suggested that the substantial reduction of cytotoxicity seen when 45 degrees C, 15 min heating preceded VP-16 treatment was also not due to an effect on topo II catalytic activity. Our results therefore demonstrate that hyperthermia, given either before or after VP-16, can actually reduce the amount of VP-16 cytotoxicity and that this can occur without any overt changes in VP-16 accumulation and efflux or in topo II catalytic activity.

Laser photochemotherapy with anthracyclines on cultured human squamous carcinoma cells

A new treatment for cancer has been tested in vitro using light-sensitive anthracyclines followed by laser photoactivation, as described by several investigators. We previously reported 10-fold enhanced laser killing after 2 hours of incubation with daunomycin by cultured human carcinoma cells. This short-term uptake leads to drug localization in cytoplasmic and membrane sites prior to nuclear accumulation and topoisomerase inhibition. In the present study, daunomycin was incubated for 2 or 24 hours with P3 squamous carcinoma cells to directly compare cytoplasmic vs. nuclear drug targeting before and after KTP-532 laser activation. Monolayer cultures of the P3 cells sensitized with daunomycin for 2 hours, then chilled (4 degree C), and exposed to the KTP laser (532 nm, 94.2 J/cm2) had a 2- to 10-fold increased therapeutic response compared with drug or laser alone when measured by MTT tetrazolium assays. After 24 hours of incubation with daunomycin, the chemotherapeutic response of P3 tumor cells was amplified 2-fold by laser exposure. The results suggest that daunomycin and laser treatment can be combined for improved therapy of human cancer.

Preoperative thermochemotherapy of oral cancer using magnetic induction hyperthermia (Implant Heating System: IHS)

Eight patients with primary cancer of the oral cavity were preoperatively treated by combined treatment with hyperthermia and chemotherapy. They received two courses of chemotherapy, which included intra-arterial infusion of 100 mg of cisplatin (CDDP) and 25 mg of peplomycin (PEP) via the superficial temporal artery. The patients also received interstitial hyperthermia for 45 min once a week using the Implant Heating System (IHS) with chemotherapy. IHS consists of ferromagnetic implant, induction coil and generator to produce high frequency magnetic field. The ferromagnetic implant is made of Fe-Pt alloy (Fe: 73%, Pt: 27%), and has a Curie temperature of 68 degrees C. As a result, clinical complete response (CR) was observed in seven patients and partial response (PR) in one, and postoperative pathological examination showed no residual tumour cells in any specimen. Combined interstitial hyperthermia by IHS and chemotherapy is thus found to be an effective therapeutic method for treating oral cancers.

Modulation of daunorubicin intracellular accumulation in P-glycoprotein expressing MCF-7 human breast adenocarcinoma cells by thermosensitive-liposome encapsulation and hyperthermia

Intracellular accumulation of free or thermosensitive liposome-encapsulated daunorubicin (TLED) at 37 or 43 degrees C, was evaluated using flow cytometry in chemosensitive and P-glycoprotein expressing MCF-7 human breast adenocarcinoma cells. At 37 degrees C, liposome-encapsulation significantly increased intracellular daunorubicin accumulation (IDA) in resistant cells (P=0.005) and that effect was statistically comparable to that achieved in adding 15 micromol/l verapamil to free daunorubicin (DNR). Combining TLED and verapamil further enhanced significantly (P=0.004) this effect as compared to TLED alone. However, none of these treatments restored IDA to the level achieved in sensitive cells. Hyperthermia significantly increased IDA in the sensitive cell (P<0.05), whenever free-DNR or TLED was used, but had no significant effect in the resistant cells, suggesting that P-glycoprotein could efflux the additional drug uptaken in hyperthermic conditions. In all these experiments combining the use of a modulator (verapamil or TLED) and hyperthermia, IDA was statistically comparable to that achieved with free-DNR in sensitive cells at 37 degrees C, but still remained lower than the IDA in sensitive cells at 43 degrees C (P<0.05). The results also showed that hyperthermia affected the labelling of P-glycoprotein by MRK16 monoclonal antibody.

Interstitial laser photochemotherapy with new anthrapyrazole drugs for the treatment of xenograft tumors

Photodynamic therapy (PDT) with lasers and new dyes has gained popularity in recent years as a minimally invasive technique with high tumoricidal effects in vitro and in some cancer patients. However, because new laser dyes are not FDA approved at present, the clinical evaluation of PDT may be years away. During the past 6 years we have used laser alone for photothermal ablation in both preclinical studies and in a large number of patients with an observed 60% tumor response rate. The 40% treatment failure led us to explore the possibility of combined therapy with lasers and standard chemotherapeutic drugs. We have recently tested a promising preclinical alternative using implantation of a bare 600-microns KTP 532 laser fiberoptic in multiple tumor sites 30 min after intratumor injection of the anthrapyrazole DUP-941. As a control, this drug was injected in 3 sites of P3 human squamous cell tumor transplants in nude mice, which led to tumor stasis without regression. Similar 400-600 mm3 tumors exposed to laser illumination alone (0.8 W for 5 sec) at multiple sites resulted in tumor regrowth after 10 weeks in 80% of the animals. However, combining interstitial laser illumination with intratumor DUP-941 injections led to complete tumor regression in 85% of the mice. We propose that intratumor drug injection followed by interstitial laser fiberoptic treatment represents a potentially useful new method for tumor ablation in advanced cancer patients.

Effect of hyperthermia on the cytotoxicity of 2',2'-difluorodeoxycytidine (gemcitabine) in cultured SW1573 cells

Difluorodeoxycytidine (dFdCyd, gemcitabine) was tested for cytotoxicity in cultured human lung-cancer cells SW1573 in combination with 1 hr hyperthermia at 43 degrees C. The results show that the timing is extremely important. Simultaneous application led to decreased cytotoxicity, whereas an interval of 20 or 24 hr between exposure to dFdCyd and hyperthermia led to enhanced cell killing. The decrease in cytotoxicity after simultaneous hyperthermia and dFdCyd probably results from inhibition of activation of dFdCyd to the triphosphate metabolite. The enhanced cytotoxicity in sequential application of dFdCyd and hyperthermia is not caused by accumulation of cells in a sensitive cell-cycle phase. Our results show that the G1 phase becomes relatively abundant 20 hr after exposure to 0.1 microM dFdCyd, approximately 48% versus 31% in control cultures. Presumably, inhibition by hyperthermia of repair of DNA damage plays a role. Our results confirm earlier data with regard to reutilization of activated dFdCyd at high cell density. dFdCyd was clearly more toxic to SW1573 cells at 4 x 10(5) cells per dish than at 400 cells per dish. This reutilization of activated drug is evidently not a restricted property of a particular cell line and may add to the value of the drug in cancer treatment.

Effect of whole-body hyperthermia on lonidamine and doxorubicin pharmacokinetics and toxicity in dogs

Six cycles of the maximum tolerable intravenous doses of lonidamine (400 mg/m2) and doxorubicin (30 mg/m2) were administered to three normothermic dogs and three dogs undergoing whole-body hyperthermia (WBH) (42 degrees C X 90 min), at 3-week intervals. Lonidamine pharmacokinetics was unaltered by WBH. WBH increased doxorubicin clearance 1.6-fold, however this trend was not statistically significant. WBH resulted in a 2.4-fold increase in the volume of distribution (Vdss) of doxorubicin relative to dogs treated under euthermic conditions (p < 0.001). This finding suggests tissue extraction of doxorubicin was increased by WBH. The specific tissues in which this occurred is unknown, but myelosuppression and cardiotoxicity were only minimally increased. Therefore, doxorubicin uptake in critical normal tissues was probably unaffected. The biochemical and haematologic toxicities observed 6 h and 1 week after each treatment did not appear to differ in character or severity from that reported in dogs receiving lonidamine +/- WBH or doxorubicin +/- WBH. These results suggest WBH did not decrease the maximum tolerable dose of doxorubicin when given with lonidamine, and that the antitumour activity of this combination should be assessed.

Response of peritoneal solid tumours after intraperitoneal chemohyperthermia treatment with cisplatin or carboplatin

The combination of heat and chemotherapy was studied in an intraperitoneal tumour model. Rats bearing peritoneal CC531 tumours (2-6 mm) were treated i.p. with cDDP or CBDCA [maximal tolerated dose (MTD)] in combination with regional hyperthermia (41.5 degrees C, 1 h) of the peritoneal cavity. The addition of hyperthermia to the i.p. treatment led to a decrease in the MTD of cDDP by 33.3% at 41.5 degrees C. This was due to increased nephrotoxicity. The MTD of CBDCA did not change as a result of hyperthermia treatment. The chemo-hyperthermia treatment resulted in more cDDP or CBDCA DNA adducts in peritoneal tumours after the combined treatment than after chemotherapy alone. The increased tumour platinum concentrations, rising from 1.3 micrograms Pt g-1 tumour at 37 degrees C to 5.4 micrograms Pt g-1 tumour at 41.5 degrees C for cDDP and from 0.2 microgram Pt g-1 tumor to 0.7 microgram Pt g-1 tumour at 41.5 degrees C for CBDCA, contributed considerably to the enhanced numbers of cDDP or CBDCA DNA adducts. As a result of the latter, i.p. chemotherapy combined with regional hyperthermia led to an increase in tumour growth delay (TGD) after increasing the temperature to 41.5 degrees C for cDDP and CBDCA (by 40 days for cDDP, 22 days for CBDCA). These data were in agreement with the in vitro findings, i.e. that higher temperatures led to increased cytotoxicity.

Laser flow cytometric studies on the intracellular accumulation of anthracyclines when combined with heat

The effects of heat on intracellular accumulation of anthracyclines were investigated by laser flow cytometry analysis. Sarcoma-180 cells were exposed to Adriamycin (ADM), epirubicin (EPIR), daunomycin (DM), THP-Adriamycin (THP), ME-2303 (ME) and KRN-8602 (KRN) at 37 degrees C and at higher temperatures. There was a dose-dependent increase in the fluorescence intensity of all drugs at 37 degrees C, but heat varied the fluorescence intensity of each drug. At 43 degrees C the cellular fluorescence of ADM and EPIR increased by approximately 200%, but for DM the increase was 110-130%. The cellular fluorescence of THP and ME was little affected by heat, and heat reduced that of KRN to 80-90%. Each drug showed was unique in the relationship between drug exposure time and the fluorescence intensity at 37 degrees C and 43 degrees C. Cytotoxicity determined by the MTT assay was enhanced with heat in the cases of ADM and EPIR, but not with DM, THP, ME, or KRN. Thus, ADM and EPIR are expected to show enhanced antitumor activities when given in combination with hyperthermia.

Sequence dependence of the hyperthermic potentiation of carboplatin-induced cytotoxicity and intracellular platinum accumulation in HeLa cells

We have examined the enhancement of cytotoxic effects of cis-diammine-1,1-cyclobutane dicarboxylate platinum(II) (carboplatin) by hyperthermia in HeLa cells using different regimes of timing and sequence. The results were compared with those obtained with cis-diamminedichloroplatinum(II) (cisplatin). We found that cisplatin simultaneously combined with heat was the most cytotoxic toward HeLa cells of the various timing and sequencing conditions studied. On the other hand, for carboplatin, drug treatment immediately following or during heat exposure showed the greatest effect. Intracellular platinum concentration in HeLa cells treated with heat before carboplatin showed a 2.75-fold increase over that in cells treated with the drug alone. The ratios for carboplatin given before, or during heating, were 0.67 and 1.42 respectively. Simultaneous exposure of cells to cisplatin and heat led to a 1.64-fold enhancement in cisplatin accumulation, compared to 0.92- and 1.24-fold increase for cells treated with cisplatin before and after heat respectively. Although each drug exposure prior to heat was less cytotoxic toward HeLa cells than any other heat/drug combination sequences, the platinum concentration was less than seen with each drug alone. Even though heat exposure prior to and during carboplatin showed a similar toxicity, platinum concentration in cells treated with heat prior to carboplatin was higher than that in cells treated with heat and carboplatin simultaneously. Thus, increased cytotoxicity cannot always be explained on the basis of intracellular platinum concentration. It is clear however that, differing from cisplatin, exposure of cells to heat prior to or during carboplatin administration results in the greatest cell kill.

Increased uptake and prolonged retention of actinomycin D by concomitant hyperthermia related to cytotoxic enhancement

We investigated the possible mechanisms of hyperthermic enhancement of actinomycin D (AMD) cytotoxicity in a neoplastic cell line. The hyperthermic enhancement of AMD cytotoxicity depended on both the temperature and the sequence of the administration. The percentage survival of simultaneous treatment of either 42 or 43 degrees C hyperthermia with 5 micrograms/ml AMD was 42% or 2.2%, respectively, and the amount of AMD in the DNA (DNA-bound AMD) of simultaneous hyperthermia at either 42 or 43 degrees C was 16.5 or 27.2 ng/10(6) cells, respectively. The percentage survival of sequential treatment of 5 micrograms/ml AMD following either 42 or 43 degrees C hyperthermia was 55 or 46%, respectively. The amount of DNA-bound AMD of sequential hyperthermia at either 42 or 43 degrees C was 10.8 or 21.7 ng/10(6) cells, respectively. In addition, the percentage survivals of the S-phase and G1-phase cells concomitantly treated with 43 degrees C hyperthermia and 5 micrograms/ml of AMD were 1.4 and 92%, respectively, and the amounts of DNA-bound AMD of these S-phase and G1-phase cells were 28.2 and 1.6 ng/10(6) cells. These findings suggested that an increased amount of AMD in DNA was responsible for the hyperthermic enhancement of AMD cytotoxicity. When the G1-phase cells were treated with 5 micrograms/ml AMD alone, without hyperthermia, the amount of AMD in acid-soluble fraction of the G1-phase cells was quite low (0.3 ng/10(6) cells). However, concomitant hyperthermia treatment with AMD at the G1-phase significantly increased the AMD amount (1.6 ng/10(6) cells at 42 degrees C, and 3.1 ng/10(6) cells at 43 degrees C) up to a level equal to that in asynchronous (1.7 ng/10(6) cells) and S-phase cells (2.1 ng/10(6) cells) simultaneously treated with hyperthermia and AMD. It was suggested that hyperthermia altered the membrane permeability of the G1-phase cells. The increase of the AMD amount in the DNA might thus be the result of higher intracellular drug concentration.

Heat sensitivity of bleomycin-sensitive CHO derivatives is not due to improper initialization of heat shock response

We have investigated whether differences in the heat shock response exist between CHO and three bleomycin-sensitive, heat-sensitive CHO derivatives. The binding of heat shock factor (HSF) in response to heat and varying concentrations of bleomycin in the four cell lines was examined using a gel shift assay and a synthetic heat shock element (HSE). Heat (45 degrees C, 10 min) and exposure to 1 micrograms/ml bleomycin for 1 h at 37 degrees C induced similar levels of HSF binding in all four cell lines. We also examined if bleomycin dose and the length of recovery from bleomycin treatment affected the induction of HSF binding. The level of activated HSF binding to HSE was higher in cells treated with low doses (1 ng/ml) of bleomycin than in cells treated with 1 or 25 micrograms/ml bleomycin. The amount of activated HSF was directly proportional to the time elapsed since bleomycin treatment. Our results therefore indicate no difference between CHO and its bleomycin-sensitive derivatives in the ability to initiate the heat shock response as determined by the production of activated HSF in response to either heat or bleomycin. We conclude that the intrinsic thermosensitivity of these cell lines is not related to the early response to heat shock, but either occurs later in the pathway or is unrelated to events after heating.

Predictive value of intracellular ATP level for cell viability after heating in malignant cells

An adenosine triphosphate (ATP) assay is known to be a useful chemosensitivity test, which correctly reflects cell viability. We investigated the usefulness of ATP assay as a thermosensitivity test by comparing two world-wide accepted assays which included a succinate dehydrogenase (SD) assay and a colony assay. We exposed KSE-1 and KSE-2 cell lines to various degrees of hyperthermia at 42, 43 and 44 degrees C for 0.5, 1, 2, 3 and 4 h, respectively. The ATP activity for the KSE-1 and KSE-2 cell lines was 2.0 and 0.7% in change of cell viability after heating at 44 degrees C for 4 h, respectively. Colony formation rates in the KSE-1 and KSE-2 cell lines were 0.9 and 0%, respectively, whereas the SD activity of each cell line was 24.1 and 22.8%. As a whole, the ATP assay showed a closer correlation to the colony assay than the SD assay because the latter revealed a more than 20% pseudo-viability due to the response between the base and residual enzyme even after the cells had died. Thus, the ATP assay was judged to be more sensitive than the SD assay; it was also quicker than the colony assay in evaluating cell viability after heating. We propose that the ATP assay should be included as another useful thermosensitivity test for malignant cells.

Doxorubicin and local hyperthermia in the microcirculation of skeletal muscle

Doxorubicin HCl (Doxo) is an established intercalating antitumor drug. Specific side effects of Doxo primarily affect the cardiac muscle tissue to cause cardiac arrhythmias and chronic cardiomyopathies. The mechanism of action of these side effects is incompletely understood. Thus, the first objective of the present study was to test whether Doxo might have a direct effect on the microcirculation of muscular tissue. We studied large and small arterioles and large venules in the cremaster muscle of rats before and after sequential infusion of 1 (low-dose) and 10 mg/kg (high-dose) Doxo. Large arterioles showed some constriction after low Doxo doses and pronounced constriction after high Doxo doses, whereas small arterioles showed a variable response to low Doxo doses. At high Doxo doses, small arterioles dilated almost maximally (80% of the maximal response to nitroprusside). The heart rate and the diameter of large venules did not change at high Doxo doses, although the blood pressure decreased. This indicates that Doxo directly affects skeletal muscle arterioles. The second purpose of this study was to determine whether local hyperthermia would influence the microcirculation of muscular tissue such that the systemic concentration of Doxo could be reduced. In this second series of experiments, we tested whether local hyperthermia would have an effect on the skeletal muscle microvasculature and whether Doxo would change that response. Local hyperthermia alone did not alter the diameter of small arterioles or large venules, but we observed constriction of large arterioles at temperatures above 37 degrees C and during continued (60-min) hyperthermia at 40 degrees C. The low dose of Doxo did not alter these microvascular diameters at 40 degrees C. However, local hyperthermia at 40 degrees C changed the response of small arterioles to low doxo doses (no vasodilation was observed). Large arterioles continued to constrict in response to Doxo during hyperthermia. These data suggest that large arteriolar responses could be partly responsible for the toxic effect of Doxo on cardiac muscle and that local hyperthermia potentiates that response.

Effect of pH and moderate hyperthermia on doxorubicin, epirubicin and aclacinomycin A cytotoxicity for Chinese hamster ovary cells

The influence of extracellular pH on the cytotoxicity of the anthracyclines doxorubicin, epirubicin, and aclacinomycin A was examined at 37 degrees C and 41 degrees C in tissue culture. Chinese hamster ovary (CHO) cells were exposed for a total of 24 h to anthracyclines at doses ranging between 0.12 and 0.69 nmol/ml at pH 7.4, 6.7, and 6.4 and at 37 degrees C. Temperature elevation to 41 degrees C was carried out for 3 h after the initiation of the drug treatment. Doxorubicin and epirubicin were about equally cytotoxic in the pH range examined at both temperatures. Aclacinomycin A demonstrated a higher cytotoxicity at pH 7.4 and 37 degrees C only at low doses. At low pH, however, aclacinomycin A was increasingly more effective with increasing dose as compared with doxorubicin and epirubicin. At 41 degrees C and at higher doses aclacinomycin A was even less cytotoxic than doxorubicin or epirubicin. Doxorubicin and epirubicin were less effective at lower pH. However, aclacinomycin A at doses of greater than 0.25 nmol/ml was more cytotoxic at low pH. Moderate hyperthermia did not increase the cytotoxicity of the three drugs at low pH, except for aclacinomycin A at doses of less than 0.25 nmol/ml. At pH 7.4, aclacinomycin A was even less effective at the elevated temperature. At doses of greater than 0.25 nmol/ml, moderate hyperthermia decreased the cytotoxicity of aclacinomycin A at low pH.

The role of reduced nicotinamide adenine dinucleotide phosphate in glucose- and temperature-dependent doxorubicin cytotoxicity

The mechanism of doxorubicin resistance induced by glucose deprivation was examined using an L929 cell system. Resistance developed even when the synthesis of glucose-regulated proteins was suppressed by supplementing glucose-deprived cultures with uridine. Resistance was also not correlated with pyruvate availability, with DNA strand breaks, or with intracellular drug or nucleotide levels. However, intracellular concentrations of reduced nicotinamide adenine dinucleotide phosphate (NADPH) decreased to undetectable levels in glucose-deprived cells with or without uridine supplementation. NADPH depletion induced by treating glucose-fed cells with low concentrations of methylene blue afforded the same degree of protection as glucose deprivation, and normal sensitivity could be restored to glucose-deprived cells by adding NADPH to the culture medium. These results suggest that decreased NADPH availability is responsible for the doxorubicin resistance induced by glucose deprivation. Although drug uptake and NADPH production increased with temperature, these effects could not fully account for the > 1000-fold decrease in clonogenic survival observed over the 25 degrees-37 degrees C temperature range. Similarly, manipulation of NADPH levels confirmed a role for drug bioreduction in the cytotoxic mechanism but did not suggest that NADPH availability was rate-limiting for this process at any temperature employed.

Lethal interaction between heat and methylene blue in Escherichia coli

Hyperthermia treatment is shown to act synergistically with methylene blue (MB), from the end point of lethality in Gram-negative Escherichia coli bacteria. That this lethality is correlated to the damage produced in DNA by the dye is deduced from the fact that bacteria differing in capacity for repair are almost equally sensitive to heat, but differ considerably in sensitivity to concomitant heat and dye treatment. It is demonstrated that the damage is repairable by the excision-repair system. The role of temperature seems to be that of facilitating the incorporation of the dye, which enables the latter to intercalate into the DNA. Ability of the outer membrane of E. coli AB1157 bacteria to act as a barrier to the penetration of MB remains almost intact up to 46 degrees C, but above this temperature it seems to disrupt abruptly (but reversibly), leading to inactivation of the cells by the dye. Since hyperthermia is in current use for the treatment of cancer, it is suggested that if this synergism also exists in mammalian cells, MB could eventually be used independently of its photodynamic action as an adjuvant in cancer therapy.

Hyperthermia enhances the inhibition of tumor growth by 1-(2-tetrahydrofuryl)-5-fluorouracil/uracil (1:4) in tumors in mice and humans

The cytotoxicity of several antitumor drugs is enhanced by hyperthermia (HT). Using mouse Sarcoma-180 (S-180) tumors, the authors examined the effects of 5-fluorouracil (5-FU) and a combined oral preparation of 1-(2-tetrahydrofuryl)-5-fluorouracil (FT) and uracil in a molar ratio of 1:4 (UFT), in combination with HT. The antitumor effect of 5-FU was not enhanced significantly by HT. Growth inhibition by UFT plus HT was significantly greater than that by UFT alone, whereas inhibition by UFT alone was significantly greater than that by 5-FU. The intracellular metabolism of 5-FU and FT in whole homogenates of S-180 cells, human tumor cell lines (SC-2 and Lu-99), and five fresh human tumor tissues also was investigated. Conversion of FT to 5-FU, phosphorylation, and degradation of 5-FU were assayed with [3H]FT or [3H]5-FU, and the products were separated by thin-layer chromatography. The conversion of FT to 5-FU and the phosphorylation of 5-FU were more rapid at 43 degrees C than at 37 degrees C, whereas the degradation of 5-FU to 2-fluoro-beta-alanine remained unchanged. This acceleration of the active metabolism of FT and 5-FU may be one explanation for the enhanced effect of UFT by HT.

In vitro and in vivo responses of doxorubicin ion exchange microspheres to hyperthermia

The utility of microspheres as targeted drug delivery agents is addressed with reference to using heat during formulation and to administration in combination with hyperthermia. It was demonstrated that rate of loading of the drug doxorubicin onto resin microspheres is enhanced under conditions of elevated temperature but this was shown to increase the incidence of microsphere aggregation. Total amount of drug loaded was related to time rather than temperature such that low temperature loading for up to 24 h produced optimum quality injectates. However, release of doxorubicin from microspheres was significantly increased during elevations of temperature to 43 degrees C. Thus, during hyperthermia doxorubicin release can be increased to provide periods of high drug availability targeted to tumour tissue for concomitant thermochemotherapy with microspheres. The therapeutic benefit derived from this combined therapy was assessed in 20 rabbits with VX2 carcinoma implanted in the liver. Hyperthermia was delivered by 2450 MHz microwave applicator to the exteriorized liver at 43 degrees C for 30 min, while chemotherapy was administered by intratumoural injection of doxorubicin microspheres (2.3 mg) into each tumour. Both hyperthermia and chemotherapy alone significantly reduced the size of tumours 10 days following treatment (p less than 0.01). However, in animals treated with both modalities, the size of tumours was significantly less than either treatment alone (p less than 0.05). These results provide a strong rationale for combining hyperthermia with targeted chemotherapy using microspheres.

Phase I evaluation of doxorubicin and whole-body hyperthermia in dogs with lymphoma

Fifteen previously untreated dogs with histologically confirmed, high-grade multicentric lymphoma were entered into a phase I study to evaluate combined doxorubicin and whole-body hyperthermia (DOX/WBH). Groups of three, four, and eight dogs were treated with whole-body hyperthermia and concurrent doxorubicin at 12 mg/m2, 24 mg/m2 and 30 mg/m2, respectively, after one doxorubicin induction dose at 30 mg/m2. Plateau temperature (42 +/- 0.1 degree C) was maintained for 90 minutes using a radiant heating device. A total of five DOX/WBH treatments per dog were planned, and these were given every 21 days. Treatment-related toxicity was not seen in the 12-mg/m2 doxorubicin dose group. Tumor progression prohibited administration of more than three DOX/WBH treatments to any dog in the 12-mg/m2 group. Premature ventricular contractions developed after the fifth treatment in one of the four dogs treated with 24 mg/m2 of doxorubicin. Two dogs (25%) in the 30-mg/m2 dose group had treatment-related toxicity. One dog experienced acute serious myelosuppression 1 week after the third treatment. This dog received all planned DOX/WBH treatments. Asymptomatic cardiac toxicosis consisting of decreased ejection fraction and fractional shortening developed in the second dog. This dog received only two DOX/WBH treatments. The three dogs treated at 12 mg/m2 had partial responses of short duration (60-83 days). Four dogs treated at 24 mg/m2 had complete responses for 150, 164, 186, and 200 days. Eight dogs treated at 30 mg/m2 had complete responses with a mean and median duration of 241 and 190 days, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Cytocidal effects of bromocriptine, somatostatin analog, and heat on growth hormone-secreting pituitary adenoma in vitro

The effects of bromocriptine (BC), a somatostatin analog (SMS), and heat on the secretion of growth hormone (GH) and prolactin (PRL), and on the morphologic features of human GH-secreting pituitary adenoma were studied in vitro. The treatment with BC, SMS, or heat (41.5 degrees C and 42.5 degrees C) markedly suppressed the secretion of GH and PRL from the adenoma cells and reduced the number of cells immunoreactive with GH or PRL. The combined treatment with BC and heat induced a marked reduction in the number of GH and PRL cells consistent with the effect on the secretion of GH and PRL. These results suggest that BC, SMS, and heat treatments produced the cytotoxic effects on pituitary adenoma cells, and that the simultaneous treatment of BC and heat enhanced this effect.

In vitro study of the effect of hyperthermia on normal bladder cell line and on five different transitional cell carcinoma cell lines

Intraluminal hyperthermia is potentially useful in the management of superficial bladder cancer. The potential inhibitory effect of hyperthermia on various human bladder cancer cell lines, normal human bladder cells and the murine MBT-2 bladder cancer cell line has been studied in vitro. These cell lines were exposed for one hour to 43 +/- 0.5C and compared to controls. Cell survival was assessed comparing the cell growth curve and colony formation. The human transitional cell carcinoma (TCC) cell lines vary in their sensitivity to heat. MGH-U1 was the most heat sensitive cell line. The human A-1698, CUB-2, UM-UC-3 and the murine MBT-2 lines were heat insensitive. We conclude that the cytocidal effect of hyperthermia in bladder transitional cell carcinoma is variable. Further experiments using the combination of hyperthermia and intravesical anticancer agents are in progress.

Flow cytometric bromodeoxyuridine/DNA analysis of hyperthermia and/or adriamycin for human pancreatic adenocarcinoma cell line Capan-2

The effects of hyperthermia, adriamycin (ADM), and hyperthermia combined with ADM on pancreatic cancer cells were investigated from the viewpoint of cytokinetics using flow cytometric bromodeoxyuridine (BrdUrd)/DNA analysis. Human pancreatic adenocarcinoma cell line Capan-2 was used. The untreated cells could be clearly divided into G1, S, G2M phases on contour plots of BrdUrd/DNA distribution. After heat treatment at 41-43 degrees C, there was an accumulation of cells in the G2M phase which was correlated with the increase in temperature. After heat treatment at 44 or 45 degrees C, there was marked increase in non BrdUrd-labeled cells in the S phase. ADM caused no change in the percent of non BrdUrd-labeled cells in the S phase, even after treatment with a concentration of 1.0 micrograms/ml, though that concentration of ADM caused a marked increase in the percent of cells in the G2M phase. After hyperthermia combined with ADM, the accumulation of the G2M phase increased remarkably, and was significantly higher than that after each treatment alone (P less than 0.005); however, non BrdUrd-labeled cells in the S phase did not increase. In this study the synergistic effect of hyperthermia combined with ADM in increasing the percent of cells in the G2M phase could be observed by flow cytometry. The study illustrates the importance of performing in vitro flow cytometric BrdUrd/DNA analysis of combined therapy prior to the use of the combined therapy in patients.

Phase III evaluation of doxorubicin and whole-body hyperthermia in dogs with lymphoma

Sixty-one dogs with histologically confirmed, untreated, high-grade lymphoma were evaluated and treated with doxorubicin (DOX, 30 mg/m2) alone. Forty-seven dogs (77%) achieved a complete response. Forty-six of the 47 dogs were randomized to receive five additional treatments with doxorubicin +/- whole-body hyperthermia (WBH). Median disease-free survival for the group treated with DOX alone (n = 22) was 189 days and for the DOX plus WBH (n = 24) was 239 days (p = 0.17). After the analysis was adjusted for stratification variables (i.e. institution, weight, stage), the effect of heat on disease-free survival remained statistically insignificant (p = 0.10), but suggested a tendency towards increased disease-free survival in hyperthermic dogs. Intact male dogs had significantly shorter disease-free survival than neutered males and neutered females (178 days vs 266 days, respectively; p = 0.013). No intact females were treated. Body weight, when evaluated as a continuous variable, was found to be a negative prognostic factor (p = 0.036). Tumour volume, stage and institution were not significant. Clinical incidence of cardiac dysfunction was not increased in dogs receiving DOX and WBH; however, post-mortem histological analysis of cardiac tissue suggested that the combined therapy of DOX and WBH was associated with greater myocyte degeneration (p = 0.012) and a tendency for increased cardiac fibrosis (p = 0.08). We concluded that continued refinement of DOX-WBH protocols is warranted, and may ultimately result in significant therapeutic improvement.

Use of methotrexate, vinblastine, adriamycin, and cisplatin in combination with radiation and hyperthermia as neo-adjuvant therapy for bladder cancer

In an attempt to improve the poor prognosis of invasive and/or high-grade bladder cancer after total cystectomy, we tried a combination of regional irradiation with hyperthermia (RH) therapy and systemic M-VAC (methotrexate, vinblastine, Adriamycin, and cisplatin) chemotherapy followed by surgery. The short-term results of these treatments were evaluated. A total of 17 patients received the combination of RH and M-VAC therapy between January 1989 and July 1990, and 12 then underwent total cystectomy. Of the 17 patients, 14 were evaluable for tumor response. The objective response rate was 64% (9/14), with 4 patients achieving a complete remission that was confirmed by histological examination. Nausea and vomiting were inevitable, and 71% (12/17) of the patients developed leukopenia. However, these side effects were not serious. Considering the previous results obtained using RH therapy in the absence of chemotherapy for this disease, no significant difference in the tumor response was detected between the RH only group and the RH plus M-VAC group. The long-term results cannot yet be evaluated, but we will continue to follow these patients in the future so as to clarify the usefulness of M-VAC therapy as preoperative therapy.

Effect of whole-body hyperthermia on pharmacokinetics and tissue distribution of doxorubicin

The effect of whole-body hyperthermia (41.5 degrees C, 2 h) on doxorubicin (DOX) tissue distribution and plasma pharmacokinetics was examined in rats bearing a subcutaneous fibrosarcoma. Tumour response to the hyperthermia regimen alone was minimal, but the combination of heat with DOX (5.0 mg/kg, i.v.) enhanced tumour growth delay. The combined therapy, however, showed increased toxicity to normal tissue (especially renal and cardiac). Although DOX levels in spleen tissue were higher in rats exposed to hyperthermia than in control normothermic rats, both groups had comparable levels of drug in tumour, heart, kidney, and small intestine tissue at all time-points examined. Compared with normothermic animals, hyperthermia-treated rats showed decreased DOX in the mean area under the concentration-time curve (AUC) and decreased plasma DOX t1/2 but increased plasma drug clearance. These heat-mediated alterations in DOX pharmacokinetic parameters, however, do not account for the significant increases in thermochemotherapy-mediated cytotoxicities observed in tumour, and in normal renal and cardiac tissues.

External control of drug release and penetration: enhancement of the transdermal absorption of indomethacin by ultrasound irradiation

The effect of ultrasound (1 MHz) on transdermal absorption of indomethacin from an ointment has been studied in rats. Ultrasound energy was supplied for 10 min at a range of intensities (0.25, 0.5 and 0.75 W cm-2), energy levels commonly used for therapeutic purposes. The pronounced effect of ultrasound on transdermal absorption of indomethacin was observed for all three intensities studied. The mean AUC value (33.22 micrograms h mL-1) after irradiation at 0.75 W cm-2 was 3.4 times the control value (9.70 micrograms h mL-1).