Improved response of a murine fibrosarcoma (Meth-A) to interstitial radiation when combined with hyperthermia

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.

Continuous, pulsed or single acute irradiation of a transplanted rodent tumour model

BACKGROUND

Recent advances in remote afterloading pulsed mode brachytherapy have provided a much needed tool for the radiation oncologist. It has the versatility of optimised physical dose distribution along with improved staff radiation protection and patient nursing.

PURPOSE

This preliminary study was designed to explore the radiobiological equivalence between conventional continuous low dose rate tumour irradiation (CLDR) and the new technique of pulsed dose irradiation (PDR).

MATERIALS AND METHODS

Subcutaneous isogenic sarcomas transplanted in female John's Strain Wistar rats were irradiated locally with acute, pulsed or continuous interstitial low dose-rate exposures at 9-11 mm mean diameter.

RESULTS

As expected, single acute doses (5-40 Gy) were more effective (P < 0.01) in achieving tumour growth delay (1.4 days/Gy) than CLDR exposure (4-51 Gy) over 24-48 h (0.93 days/Gy). However, PDR treatment (8 hourly fractions/day) at high dose-rate (8-48Gy) over 8-72 h was significantly (P = 0.01) more effective (1.66 days/Gy) than CLDR but not acute exposures.

CONCLUSIONS

These data suggest that, clinically a significantly improved therapeutic ratio may also be achievable with pulsed high dose rate brachytherapy, and that further radiobiological studies with in-vivo tumour models are needed.

Interstitial radiation and hyperthermia in the Dunning R3327 prostate tumour model: therapeutic efficacy depends on radiation dose-rate, sequence and frequency of heating

To determine the most effective means by which to apply the combined treatments of local tumour hyperthermia (LTH) with interstitial low dose-rate irradiation (IRT) we examined the significance of such factors as dose-rate of radiation, and the sequence and frequency of hyperthermia applications in the anaplastic Dunning prostate tumour subline R3327-AT1. IRT was carried out by the insertion of a single Ir-192 seed into the center of the tumour. For LTH treatments, the tumour-bearing leg was positioned in a circulating constant temperature water bath (43.5 +/- 0.1 degrees C) for 35 min. Neither LTH treatment alone nor the insertion of a dummy seed produced any change in tumour growth compared with sham-treated controls. With regard to the sequence of heating and IRT our results showed that during a 72-h treatment time (30 Gy, 40 cGy/h) a single heat treatment given just before the start of IRT was more efficient (TER = 1.47) in terms of growth delay than LTH given in the middle or the end of radiation treatment (TER approximately 1.0). The growth delay for both the 20 and 40 cGy/h groups appear to be linear with increasing dose for the IRT as well as the IRT + LTH groups. The higher dose-rate was more effective especially with respect to long-term delay in tumour growth in some of the animals. As TER at 40 cGy/h decreased subsequently with increasing treatment time from 1.47 to 1.25 at 60 Gy, we conclude that for treatment times > 72 h, one LTH just before IRT might not be sufficient. If multiple heat treatments are applied during a comparable time course, two LTH treatments one just before the start, the other at the end yielded the greatest local tumour control. In contrast, three LTH given daily were not more effective than the one LTH given just before the start of IRT. These data indicate a clear thermal enhancement of low dose-rate irradiation, with maximal sensitization when hyperthermia was given just before IRT. For multiple heatings a better understanding of the underlying mechanisms of sequencing and timing hopefully provides guidelines how to apply optimally both modalities in the treatment of cancer.

Increased tumour response of a murine fibrosarcoma to low temperature hyperthermia and low dose rate brachytherapy

The present animal tumour study was carried out to determine the effectiveness of low temperature hyperthermia combined with low dose rate radiation based on the cell culture studies of our laboratory and others that demonstrated a significant radiosensitization obtained by low temperature hyperthermia and low dose rate radiation. Well-oxygenated murine fibrosarcoma Meth-A tumours growing in Balb/c mice were treated with heat (41 degrees C tumour temperature) by immersion of the tumour-bearing leg in a waterbath concurrently with low dose rate radiation. Radiation was delivered using 192Ir interstitial implantation at absolute dose rates of 0.416-0.542 Gy/h. The effect of heat alone on tumour growth and normal tissue was minimal. Tumour growth delay following 30 Gy radiation was 4.9 days. Significant delay in tumour growth was observed with the addition of low temperature hyperthermia delivered concurrently. Enhancement in radiation response was seen with increasing duration of heat treatment; tumour growth delays were 9.5 days following 4 h heat (41 degrees C) treatment and 16 days following 6 h treatment. Three sessions of fractionated hyperthermia 4 h/day during the course of low dose-rate radiation significantly delayed tumour growth to 18.6 days. The results indicate that fractionated heat treatment in conjunction with low dose rate radiation has potential for improving tumour response without adversely affecting normal tissue reaction. This in vivo study represents an extension of the cell culture data and provides further radiobiological basis for the combined use of low temperature hyperthermia and low dose rate radiation.

Thermoradiotherapy of intraocular tumors in an animal model: concurrent vs. sequential brachytherapy and ferromagnetic hyperthermia

PURPOSE

To compare concurrent vs. sequential ferromagnetic thermoradiotherapy in vivo.

METHODS AND MATERIALS

Greene melanomas were implanted subretinally in rabbits and observed until they were 3-5 mm in diameter. Episcleral plaques were assembled with 125I seeds for radiation therapy, or with ferromagnetic (FM) thermoseeds and nonradioactive I seeds for hyperthermia. Rabbits were implanted by centering a plaque over the intraocular melanoma. After a given dose of radiation had been delivered, the plaque was removed and a nonradioactive plaque containing FM thermoseeds was inserted into the same extrascleral space. One hour later, hyperthermia (46-47 degrees C at the plaque-scleral interface) was initiated and continued for a period of 1 h by placing the rabbits in a magnetic induction coil powered to 1200 W. Tumor size was determined at 1- to 2-week intervals by indirect ophthalmoscopy and by ultrasound.

RESULTS

Dose-response analysis of 27 treated eye melanomas showed 50% local tumor control at 43 Gy for 125I alone and 29.4 Gy for 125I followed by FM hyperthermia. The thermal enhancement ratio was 1.4.

CONCLUSION

Comparison with a previously published thermal enhancement ratio of 4.4 (for concurrent 125I and FM hyperthermia) leads us to conclude that thermal enhancement of 125I brachytherapy is more efficient in this tumor model system when hyperthermia is delivered during, rather than after, the irradiation process.

Interstitial hyperthermia and interstitial radiotherapy of a rat rhabdomyosarcoma; effects of sequential treatment and consequences for clonogenic repopulation

Animal tumour experiments have been performed to elucidate the interactions between interstitial hyperthermia (IHT) and interstitial radiotherapy (IRT), and to obtain information about the most effective sequence of these treatment modalities. Experimental tumours, transplanted in the flank of Wag/Rij rats, were treated with IHT for 0.5 h at 44 degrees C, and with IRT using low dose-rate (LDR) iridium-192 sources. Both tumour cure probability and the fraction of clonogenic cells in vitro after different IHT and IRT treatments in vivo, were used as endpoints. The sequence of a short (0.5 h) IHT treatment followed by an extended LDR-IRT treatment lasting up to 10 days appeared to be very effective, and resulted in a significant thermal enhancement ratio of 1.34 at the 50% tumour cure probability level. A not significantly increased thermal enhancement of 1.06 was found when the same IHT treatment followed IRT. The level of clonogenic cell survival after IHT alone is high (0.24 +/- 0.08) compared with that after an IRT dose of 20 Gy (0.017 +/- 0.004). Clonogenic cell repopulation started 2-4 days after the in vivo treatment irrespective of the type of treatment. The in vivo combination of IHT and LDR-IRT resulted in lower surviving fractions compared with IRT alone, regardless of the time interval between the end of treatment and in vitro clonogenic assay. IHT followed by LDR-IRT appeared to be the most effective treatment in terms of tumour cure. The in vivo/in vitro studies indicated that the effect of hyperthermia is mainly attributed to radiosensitization, possibly by partial inhibition of sublethal damage repair processes during the subsequent irradiation. The hyperthermia-induced cytotoxicity was of minor importance as estimated from the surviving clonogenic fraction.

Concurrent ferromagnetic hyperthermia and 125I brachytherapy in a rabbit choroidal melanoma model

Ferromagnetic (FM) thermoseeds and radioactive (125I) seeds were combined in an episcleral plaque to give concurrent hyperthermia and irradiation for enhanced tumour destruction. A Greene melanoma cell line was utilized to study the interaction between these treatment modalities. We attached five FM thermoseeds (with an operating temperature of 48 degrees C) in parallel with alternating rows of 125I seeds onto the inner surface of each 14 mm Silastic plaque. Plaques were centred over a 3-6 mm (diameter) intraocular melanoma in each rabbit. Some rabbits were then placed within a heating coil, and their eye tumours were warmed rapidly to therapeutic temperatures (43.6 degrees C across the tumour base) while the temperature of normal conjunctiva across the globe did not exceed 38.5 degrees C. Analysis of 49 treated eye melanomas showed 50% local tumour control at 41.7 Gy for 125I alone, whereas only 9.5 Gy were needed to give the same local control rate after 125I with concurrent FM hyperthermia. Thus, a thermal enhancement ratio of 4.4 was obtained. Hyperthermia alone gave a 20% tumour response rate, but responses were only temporary. We conclude that FM thermoseeds can be used to deliver biologically effective hyperthermia concurrently with radiation, thereby reducing the dose of radiation needed for tumour control.

Dose-effect relation of interstitial low-dose-rate radiation (Ir192) in an animal tumor model

One way to deliver high doses of radiation to deep seated tumors without damaging the surrounding tissue is by interstitial techniques. This is commonly applied clinically; however, biological data of tumor response to interstitial low-dose-rate gamma irradiation are scarce. Therefore, we have studied the response of rhabdomyosarcoma R1 tumors implanted in the flanks of female Wag/Rij rats using an interstitial Ir192 afterloading system. A template was developed by which four catheters can be implanted in a square geometry with a fixed spacing. Subsequently four Ir192 wires of 2 cm length each are inserted. For dose prescription the highest isodose enveloping the tumor volume was chosen. Interstitial irradiation was performed using tumor volumes of 1500-2000 mm3. A range of minimum tumor doses of 20 up to 115 Gy were given at a mean dose-rate of 48 cGy/hr. Dose-effect relations were obtained from tumor growth curves and tumor cure data, and compared to data from external irradiation. The dose required for 50% cures with interstitial irradiation (TCD50) appears to be 95 +/- 9 Gy. The TCD50 for low-dose-rate interstitial gamma irradiation is 1.5 times the TCD50 for single dose external X ray irradiation at high dose rates, but is comparable to the TCD50 found after fractionated X ray irradiation at high dose rate. Sham treatment of the tumors had no effect on the time needed to reach twice the treatment volume. The growth rate of tumors regrowing after interstitial radiotherapy is not markedly different from the growth rate of untreated (control) tumors (volume doubting time 5.6 +/- 1 day), in contrast to the decreased growth rate after external X ray irradiation. It is argued that the absence of a clear tumor bed effect may be explained by some sparing of the stroma by the low-dose-rate of the interstitial irradiation per se as well as by the physical dose distribution of the interstitial Ir192 sources, giving a relative low dose of radiation to the surrounding normal tissues.

Thermal enhancement of low dose rate irradiation in a murine tumour system

The effects of localized hyperthermia (HT) in combination with low dose rate irradiation (brachytherapy) have been investigated in vivo using a murine mammary adenocarcinoma. Flank tumours were grown to 0.45-0.70 cm3 in volume, at which time their treatment course was initiated. Tumours were locally heated in a water bath for 15 min at either 44 or 45 degrees C. For tumour irradiations a non-invasive cap was devised to permanently house three iodine-125 sealed sources located at 120 degree intervals around the circumference of the hemispherical cap. During treatment, mice were secured in a modified syringe tube allowing mobility while restricting access to the cap which was placed over the tumour. Calculated dose rates ranged from 15 to 40 cGy/h. Brachytherapy (BT) was delivered for 48 or 72 h to obtain a dose range of 830-2378 cGy. Mice were randomized into one of 10 treatment protocols: BT alone, HT-BT, BT-HT, HT-BT-HT, 1/2BT-HT-1/2BT, four control groups of HT alone and a sham treatment group. Normalized tumour doubling volume growth delays (GDDv) were used to calculate the thermal enhancement ratios (TER). In the 44 degrees C experiments, HT before BT (TER = 1.33 +/- 0.071) was more efficacious than HT after BT (TER = 1.07 +/- 0.042). Two HT treatments, one given before and one after BT (TER = 1.38 +/- 0.152), were not different from a single HT treatment given before BT. However, a single HT treatment given in the middle of an interrupted course of BT resulted in the greatest thermal enhancement (TER = 1.64 +/- 0.072) compared to any other treatment sequence. These data suggest that potentiation of low dose rate irradiation by a single heat treatment may be maximized if the HT is given either in the middle of, or simultaneously with, the BT.

Implantable helical coil microwave antenna for interstitial hyperthermia

An implantable helical coil microwave antenna has been developed for improved localization and control of interstitial hyperthermia for deep-seated tumours. A helical coil structure was employed as an extension of the inner conductor at the terminal portion of a miniature semi-rigid coaxial cable. The antennas were constructed with three different connection configurations of the helical coil to the feedline, and with several coil turn densities during the optimization of heating characteristics. In order to compare relative antenna heating performance, a set of quantitative parameters was introduced. Power deposition profiles of 2450 MHz helical coil antennas were studied in both phantom models and muscle tissue in vivo, and compared to those of commonly used dipole antennas. Optimal antenna performance was obtained with a 10-turn per 1 cm helical coil connected to the inner conductor at the tip and separated from the outer conductor by a 0.1 cm gap (HCS-10). These antennas produced a well-localized heating pattern with a sharp falloff of temperature in both directions axially from the coil element. For half-wavelength insertion depths, the effective heating length (50 per cent of maximum SAR) of HCS-10 antennas matched that of standard dipole antennas, but was shifted down towards the tip. For shorter and deeper antenna insertion depths the HCS-10 heating pattern remained similarly localized to the region surrounding the helical coil with minimal cold zone at the tip. In contrast, the dipole antenna heating pattern changed significantly depending on insertion depth, with an unavoidable 0.2-0.7 cm cold region at the antenna tip and elevated surface temperatures for short insertion depths.