Dose uniformity in MECS interstitial hyperthermia: the impact of longitudinal control in model anatomies

Design of the novel ThermoBrachy applicators enabling simultaneous interstitial hyperthermia and high dose rate brachytherapy

OBJECTIVE

In High Dose Rate Brachytherapy for prostate cancer there is a need for a new way of increasing cancer cell kill in combination with a stable dose to the organs at risk. In this study, we propose a novel ThermoBrachy applicator that offers the unique ability to apply interstitial hyperthermia while simultaneously serving as an afterloading catheter for high dose rate brachytherapy for prostate cancer. This approach achieves a higher thermal enhancement ratio than in sequential application of radiation and hyperthermia and has the potential to decrease the overall treatment time.

METHODS

The new applicator uses the principle of capacitively coupled electrodes. We performed a proof of concept experiment to demostrate the feasibility of the proposed applicator. Moreover, we used electromagnetic and thermal simulations to evaluate the power needs and temperature homogeneity in different tissues. Furthermore we investigated whether dynamic phase and amplitude adaptation can be used to improve longitudinal temperature control.

RESULTS

Simulations demonstrate that the electrodes achieve good temperature homogeneity in a homogenous phantom when following current applicator spacing guidelines. Furthermore, we demonstrate that by dynamic phase and amplitude adaptation provides a great advancement for further adaptability of the heating pattern.

CONCLUSIONS

This newly designed ThermoBrachy applicator has the potential to revise the interest in interstitial thermobrachytherapy, since the simultaneous application of radiation and hyperthermia enables maximum thermal enhancement and at maximum efficiency for patient and organization.

Utility of treatment planning for thermochemotherapy treatment of nonmuscle invasive bladder carcinoma

PURPOSE

A recently completed Phase I clinical trial combined concurrent Mitomycin-C chemotherapy with deep regional heating using BSD-2000 Sigma-Ellipse applicator (BSD Corporation, Salt Lake City, UT, U.S.A.) for the treatment of nonmuscle invasive bladder cancer. This work presents a new treatment planning approach, and demonstrates potential impact of this approach on improvement of treatment quality.

METHODS

This study retrospectively analyzes a subset of five patients on the trial. For each treatment, expert operators selected "clinical-optimal" settings based on simple model calculation on the BSD-2000 control console. Computed tomography (CT) scans acquired prior to treatment were segmented to create finite element patient models for retrospective simulations with Sigma-HyperPlan (Dr. Sennewald Medizintechnik GmbH, Munchen, Germany). Since Sigma-HyperPlan does not account for the convective nature of heat transfer within a fluid filled bladder, an effective thermal conductivity for bladder was introduced. This effective thermal conductivity value was determined by comparing simulation results with clinical measurements of bladder and rectum temperatures. Regions of predicted high temperature in normal tissues were compared with patient complaints during treatment. Treatment results using "computed-optimal" settings from the planning system were compared with clinical results using clinical-optimal settings to evaluate potential of treatment improvement by reducing hot spot volume.

RESULTS

For all five patients, retrospective treatment planning indicated improved matches between simulated and measured bladder temperatures with increasing effective thermal conductivity. The differences were mostly within 1.3 °C when using an effective thermal conductivity value above 10 W/K/m. Changes in effective bladder thermal conductivity affected surrounding normal tissues within a distance of ∼1.5 cm from the bladder wall. Rectal temperature differences between simulation and measurement were large due to sensitivity to the sampling locations in rectum. The predicted bladder T90 correlated well with single-point bladder temperature measurement. Hot spot locations predicted by the simulation agreed qualitatively with patient complaints during treatment. Furthermore, comparison between the temperature distributions with clinical and computed-optimal settings demonstrated that the computed-optimal settings resulted in substantially reduced hot spot volumes.

CONCLUSIONS

Determination of an effective thermal conductivity value for fluid filled bladder was essential for matching simulation and treatment temperatures. Prospectively planning patients using the effective thermal conductivity determined in this work can potentially improve treatment efficacy (compared to manual operator adjustments) by potentially lower discomfort from reduced hot spots in normal tissue.

Hyperthermia in combined treatment of cancer

Hyperthermia, the procedure of raising the temperature of tumour-loaded tissue to 40-43 degrees C, is applied as an adjunctive therapy with various established cancer treatments such as radiotherapy and chemotherapy. The potential to control power distributions in vivo has been significantly improved lately by the development of planning systems and other modelling tools. This increased understanding has led to the design of multiantenna applicators (including their transforming networks) and implementation of systems for monitoring of E-fields (eg, electro-optical sensors) and temperature (particularly, on-line magnetic resonance tomography). Several phase III trials comparing radiotherapy alone or with hyperthermia have shown a beneficial effect of hyperthermia (with existing standard equipment) in terms of local control (eg, recurrent breast cancer and malignant melanoma) and survival (eg, head and neck lymph-node metastases, glioblastoma, cervical carcinoma). Therefore, further development of existing technology and elucidation of molecular mechanisms are justified. In recent molecular and biological investigations there have been novel applications such as gene therapy or immunotherapy (vaccination) with temperature acting as an enhancer, to trigger or to switch mechanisms on and off. However, for every particular temperature-dependent interaction exploited for clinical purposes, sophisticated control of temperature, spatially as well as temporally, in deep body regions will further improve the potential.

Determination and validation of the actual 3D temperature distribution during interstitial hyperthermia of prostate carcinoma

To determine the thermal dose of a hyperthermia treatment, knowledge of the three-dimensional (3D) temperature distribution is mandatory. The aim of this paper is to validate an interstitial hyperthermia treatment planning system with which the full 3D temperature distribution can be obtained in individual patients. Within a phase I study, 12 patients with prostate cancer were treated with interstitial hyperthermia using our multi electrode current source interstitial hyperthermia treatment (MECS IHT) system. The temperature distribution was measured from within the heating devices and by additional thermometry. The perfusion level was estimated and the heating implant reconstructed. The steady-state temperature distribution was calculated using our interstitial hyperthermia treatment planning system. The simulated temperature distribution was validated by individually comparing the measured and simulated thermo-sensors, both for the thermometry integrated with the heating applicators and the additional thermometry. The entire procedure was also performed on a no-flow agar-agar phantom. It was shown that the calculated temperature distribution of an individual patient during MECS interstitial hyperthermia is very heterogeneous. The validation indicates that the calculated temperature elevations match the measurements within approximately 1 degrees C. Possible improvements are more precise reconstruction, incorporation of discrete vasculature and using a temperature-dependent, heterogeneous perfusion distribution. Further technical improvements of the MECS-IHT system may also result in better temperature calculations.

Clinical thermometry, using the 27 MHz multi-electrode current-source interstitial hyperthermia system in brain tumours

BACKGROUND AND PURPOSE

In interstitial hyperthermia, temperature measurements are mainly performed inside heating applicators, and therefore, give the maximum temperatures of a rather heterogeneous temperature distribution. The problem of how to estimate lesion temperatures using the multi-electrode current-source interstitial hyperthermia (MECS-IHT) system in the brain was studied.

MATERIALS AND METHODS

Temperatures were measured within the electrodes and in an extra catheter at the edge of a 4 x 4 x 4.5 cm(3) glioblastoma multiforme resection cavity. From the temperature decays during a power-off period, information was obtained about local maximum and minimum tissue temperatures. The significance of these data was examined through model calculations.

RESULTS

Maximum tissue temperatures could be estimated roughly by switching off all electrodes for about 5 s. Model calculations showed that the minimum tissue temperatures near a certain afterloading catheter correspond well with the temperature of the applicator inside, about 1 min after this applicator was switched off.

CONCLUSIONS

Although the electrode temperatures read during heating are not suitable to assess the temperature distribution, it is feasible to heat the brain adequately using the MECS-IHT system with extra sensors outside the electrodes and/or application of decay methods.

Hyperthermia treatment planning

The development of hyperthermia, the treatment of tumours with elevated temperatures in the range of 40-44 degrees C with treatment times over 30 min, greatly benefits from the development of hyperthermia treatment planning. This review briefly describes the state of the art in hyperthermia technology, followed by an overview of the developments in hyperthermia treatment planning. It particularly highlights the significant problems encountered with heating realistic tissue volumes and shows how treatment planning can help in designing better heating technology. Hyperthermia treatment planning will ultimately provide information about the actual temperature distributions obtained and thus the tumour control probabilities to be expected. This will improve our understanding of the present clinical results of thermoradiotherapy and thermochemotherapy, and will greatly help both in optimizing clinical heating technology and in designing optimal clinical trials.

Temperature simulations in tissue with a realistic computer generated vessel network

The practical use of a discrete vessel thermal model for hyperthermia treatment planning requires a number of choices with respect to the unknown part of the patient's vasculature. This work presents a study of the thermal effects of blood flow in a simple tissue geometry with a detailed artificial vessel network. The simulations presented here demonstrate that an incomplete discrete description of the detailed network results in a better prediction of the temperature distribution than is obtained using the conventional bio-heatsink equation. Therefore, efforts to obtain information on the positions of the large vessels in an individual hyperthermia patient will be rewarded with a more accurate prediction of the temperature distribution.

Treatment planning of brain implants using vascular information and a new template technique

A new template technique has been developed for implanting hyperthermia catheters in the treatment of brain tumors. The technique utilizes an imaging template and a drill template which can be rigidly secured to the head with three skull screws. The anatomic and vascular information needed for hyperthermia treatment planning may be assessed with three-dimensional magnetic resonance (MR) imaging and angiography acquisitions which use a surface coil. In the companioning treatment planning system the catheter positions and lengths and the electrodes in the catheter can be interactively manipulated relative to the anatomy and vasculature. The visualization of the blood vessels relative to the template allows the minimization of the risk on intracranial hemorrhages. This template technique is useful for any brain tumor implants, especially when a large number of catheters are involved. A phantom test has shown that this procedure has an accuracy in the order of 1 mm provided that the MR-related geometry distortions are minimized.

A flexible algorithm for construction of 3-D vessel networks for use in thermal modeling

A new algorithm for the construction of artificial blood vessel networks is presented. The algorithm produces three-dimensional (3-D) geometrical representations of both arterial and venous networks. The key ingredient of the algorithm is a 3-D potential function defined in the tissue volume. This potential function controls the paths by which points are connected to existing vessels, thereby producing new vessel segments. The potential function has no physiological interpretation, but, by adjustment of parameters governing the potential, it is possible to produce networks that have physiologically meaningful geometrical properties. If desired, the veins can be generated counter current to the arteries. Furthermore, the potential function allows fashioning of the networks to the presence of bone or air cavities. The resulting networks can be used for thermal simulations of hyperthermia treatment.

Comparison of temperature distributions in interstitial hyperthermia: experiments in bovine tongues versus generic simulations

Temperature distributions resulting from hyperthermia treatments on isolated perfused bovine tongues were compared with simulations by a treatment planning system. The aim was to test whether the discrete vessel model used for the treatment planning is able to predict correct generic temperature distributions. Tongues were heated with the multielectrode current source interstitial hyperthermia treatment (MECS IHT) system, while the steady-state temperature distribution was mapped by scanning 10 thermocouples along paths perpendicular to the interstitial implant. For simulations a tongue was defined with generic discrete vasculature and an electrode implant analogue to the experiments. To model vascular generations not described discretely, a local heatsink was implemented at the end of each terminating branch. The discretely modelled vasculature showed itself on the temperature distributions in two ways. Individual vessels caused very local, sharp wells in the tracked temperature profiles. In the presence of large vessels a collective behaviour was also seen, i.e. a regional lowering of temperature. Both phenomena can be recognized in the experimentally obtained temperature distributions too. Predicting correct generic temperature distributions is feasible with the discrete vessel model used.

Numerical analysis of capacitively coupled electrodes for interstitial hyperthermia

Multi electrode current source interstitial hyperthermia (MECS-IHT) employs individually controlled, 27 MHz radiofrequency electrodes inserted into plastic brachytherapy catheters. In order to get a firm understanding of the physical behaviour of the electrodes and to verify the current source approximation in our hyperthermia treatment planning system we have investigated (1) the electrical properties of the electrode-catheter-tissue system, and (2) the impact of inhomogeneity of the electrical properties of the tissue in the vicinity of the electrodes. The results validate the use of the ideal current source approximation in the treatment planning SAR model. The models predict the presence of a significant heat source inside the electrode wall when lossy catheter materials are used, producing a conductive heating component in addition to the SAR in the tissue. For a given catheter spacing this conductive component will produce a more heterogeneous temperature distribution. Thus, low-loss catheter materials like polyethylene and Teflon are recommended. The SAR is highly localized near the catheter. Calculations concerning a fat-muscle interface show that the SAR is higher in the fatty tissue than in the muscle tissue; 3D SAR control by individually controlled electrode segments is essential in such a situation.

The influence of vasculature on temperature distributions in MECS interstitial hyperthermia: importance of longitudinal control

The quality of temperature distributions that can be generated with the Multi Electrode Current Source (MECS) interstitial hyperthermia (IHT) system, which allows 3D control of the temperature distribution, has been investigated. For the investigations, computer models of idealised anatomies containing discrete vessels, were used. A 7-catheter hexagonal implant geometry with a nearest neighbour distance of 15 mm was used. In each interstitial catheter with a diameter of 2.1 mm a number of 1 up to 4 electrodes were placed along an 'active section' with a length of 50 mm. The electrode segments had lengths of 50, 20, 12 and 9 mm respectively. Both single vessel and vessel network situations were analysed. This study shows that even in situations with discrete vasculature and perfusion heterogeneity it remains possible to obtain satisfactory temperature distributions with the MECS IHT system. Due to its 3D spatial control the temperature homogeneity in the implant can be made quite satisfactory.

Implications of using thermocouple thermometry in 27 MHz capacitively coupled interstitial hyperthermia

The 27 MHz Multi Electrode Current Source (MECS) interstitial hyperthermia system uses segmented electrodes, 10-20 mm long, to steer the 3D power deposition. This power control at a scale of 1-2 cm requires detailed and accurate temperature feedback data. To this end seven-point thermocouples are integrated into the probes. The aim of this work was to evaluate the feasibility and reliability of integrated thermometry in the 27 MHz MECS system, with special attention to the interference between electrode and thermometry and its effect on system performance. We investigated the impact of a seven-sensor thermocouple probe (outer diameter 150 microns) on the apparent impedance and power output of a 20 mm dual electrode (O.D. 1.5 mm) in a polyethylene catheter in a muscle equivalent medium (sigma 1 = 0.6 S m-1). The cross coupling between electrode and thermocouple was found to be small (1-2 pF) and to cause no problems in the dual-electrode mode, and only minimal problems in the single-electrode mode. Power loss into the thermometry system can be prevented using simple filters. The temperature readings are reliable and representative of the actual tissue temperature around the electrode. Self-heating effects, occurring in some catheter materials, are eliminated by sampling the temperature after a short power-off interval. We conclude that integrated thermocouple thermometry is compatible with 27 MHz capacitively coupled interstitial hyperthermia. The performance of the system is not affected and the temperatures measured are a reliable indication of the maximum tissue temperatures.