Heat-induced damage to HeLa-S3 cells: correlation of viability, permeability, osmosensitivity, phase-contrast light-, scanning electron- and transmission electron-microscopical findings

Thermal Protection Techniques for Image-guided Musculoskeletal Ablation

Percutaneous image-guided thermal ablation has gained wide acceptance among physicians for the treatment of benign and malignant tumors of the musculoskeletal system. Increasing evidence to support the efficacy of thermal ablation techniques in primary and adjuvant treatment of soft-tissue sarcomas, treatment of oligometastatic disease to bone and soft tissue, and metastatic pain palliation has positioned interventional oncology alongside surgery, systemic therapies, and radiation therapy as the fourth pillar of modern comprehensive cancer care. Despite the expanding indications and increasing use in clinical practice, thermal ablation carries a significant risk of injury to the adjacent vulnerable structures, predominantly the skin, bowel, and neural structures. Knowledge of the mechanism of action of each thermal ablation modality informs the physician of the attendant risks associated with a particular modality. Thermal ablation mechanisms can be divided into hypothermic (cryoablation) and hyperthermic (radiofrequency ablation, microwave ablation, high-intensity focused US, or laser). Active thermal protection techniques include hydrodissection, pneumodissection, direct skin thermal protection, and physical displacement techniques. Passive thermal protection techniques include temperature monitoring, biofeedback, and neurophysiologic monitoring. The authors provide an overview of the mechanism of action of the most commonly used thermal ablation modalities, review the thermal injury risks associated with these modalities, and introduce the active and passive thermal protective techniques critical to safe and effective musculoskeletal ablative therapy. ©RSNA, 2025 See the invited commentary by Tomasian and Jennings in this issue.

The role of hyperthermia in the treatment of tumor

Despite recent advancements in the diagnosis and treatment options for cancer, it remains one of the most serious threats to health. Hyperthermia (HT) has emerged as a highly promising area of research due to its safety and cost-effectiveness. Currently, based on temperature, HT can be categorized into thermal ablation and mild hyperthermia. Thermal ablation involves raising the temperature within the tumor to over 60°C, resulting in direct necrosis in the central region of the tumor. In contrast, mild hyperthermia operates at relatively lower temperatures, typically in the range of 41-45°C, to induce damage to tumor cells. Furthermore, HT also serves as an immune adjuvant strategy in radiotherapy, chemotherapy, and immunotherapy, enhancing the effectiveness of radiotherapy, increasing the uptake of chemotherapy drugs, and reprogramming the tumor microenvironment through the induction of immunogenic cell death, thereby promoting the recruitment of endogenous immune cells. This article reviews the current status and development of hyperthermia, outlines potential mechanisms by which hyperthermia inhibits tumors, describes clinical trial attempts combining hyperthermia with radiotherapy, chemotherapy, and immunotherapy, and discusses the relationship between nanoparticles and hyperthermia.

Cell stress and phase separation stabilize the monomeric state of pseudoisocyanine chloride employed as a self-assembly crowding sensor

Cellular stress and ageing involve an increase in crowding and aggregation of amylogenic proteins. We here investigate if crowding is the intrinsic cause of aggregation and utilise a previously established non-protein aggregation sensor, namely pseudoisocyanine chloride (PIC). PIC shows fibrillization in cells into a highly fluorescent J-aggregated state and is sensitive to crowding. Surprisingly, cell stress conditions stabilise the monomeric rather than the aggregated state of PIC both in the cytoplasm and in stress granules. Regarding the different physiochemical changes of the cytoplasm occurring upon cell stress, involving volume reduction, phase separation and solidification, the intrinsic crowding effect is not the key factor to drive associated self-assembly processes.

Local Destruction of Tumors and Systemic Immune Effects

Current immune-based therapies signify a major advancement in cancer therapy; yet, they are not effective in the majority of patients. Physically based local destruction techniques have been shown to induce immunologic effects and are increasingly used in order to improve the outcome of immunotherapies. The various local destruction methods have different modes of action and there is considerable variation between the different techniques with respect to the ability and frequency to create a systemic anti-tumor immunologic effect. Since the abscopal effect is considered to be the best indicator of a relevant immunologic effect, the present review focused on the tissue changes associated with this effect in order to find determinants for a strong immunologic response, both when local destruction is used alone and combined with immunotherapy. In addition to the T cell-inflammation that was induced by all methods, the analysis indicated that it was important for an optimal outcome that the released antigens were not destroyed, tumor cell death was necrotic and tumor tissue perfusion was at least partially preserved allowing for antigen presentation, immune cell trafficking and reduction of hypoxia. Local treatment with controlled low level hyperthermia met these requisites and was especially prone to result in abscopal immune activity on its own.

Closed-Loop Temperature Control Based on Fiber Bragg Grating Sensors for Laser Ablation of Hepatic Tissue

Laser ablation (LA) of cancer is a minimally invasive technique based on targeted heat release. Controlling tissue temperature during LA is crucial to achieve the desired therapeutic effect in the organs while preserving the healthy tissue around. Here, we report the design and implementation of a real-time monitoring system performing closed-loop temperature control, based on fiber Bragg grating (FBG) spatial measurements. Highly dense FBG arrays (1.19 mm length, 0.01 mm edge-to-edge distance) were inscribed in polyimide-coated fibers using the femtosecond point-by-point writing technology to obtain the spatial resolution needed for accurate reconstruction of high-gradient temperature profiles during LA. The zone control strategy was implemented such that the temperature in the laser-irradiated area was maintained at specific set values (43 and 55 °C), in correspondence to specific radii (2 and 6 mm) of the targeted zone. The developed control system was assessed in terms of measured temperature maps during an ex vivo liver LA. Results suggest that the temperature-feedback system provides several advantages, including controlling the margins of the ablated zone and keeping the maximum temperature below the critical values. Our strategy and resulting analysis go beyond the state-of-the-art LA regulation techniques, encouraging further investigation in the identification of the optimal control-loop.

Hyperthermia treatment advances for brain tumors

Hyperthermia therapy (HT) of cancer is a well-known treatment approach. With the advent of new technologies, HT approaches are now important for the treatment of brain tumors. We review current clinical applications of HT in neuro-oncology and ongoing preclinical research aiming to advance HT approaches to clinical practice. Laser interstitial thermal therapy (LITT) is currently the most widely utilized thermal ablation approach in clinical practice mainly for the treatment of recurrent or deep-seated tumors in the brain. Magnetic hyperthermia therapy (MHT), which relies on the use of magnetic nanoparticles (MNPs) and alternating magnetic fields (AMFs), is a new quite promising HT treatment approach for brain tumors. Initial MHT clinical studies in combination with fractionated radiation therapy (RT) in patients have been completed in Europe with encouraging results. Another combination treatment with HT that warrants further investigation is immunotherapy. HT approaches for brain tumors will continue to a play an important role in neuro-oncology.

Is there a role for perfusion imaging in assessing treatment response following ablative therapy of small renal masses-A systematic review

Aims

Ablation therapies are an innovative nephron-sparing alternative to radical nephrectomy for early stage renal cancers, although determination of treatment success is challenging. We aimed to undertake a systematic review of the literature to determine whether assessment of tumour perfusion may improve response assessment or alter clinical management when compared to standard imaging.

Material and Methods

Two radiologists performed independent primary literature searches for perfusion imaging in response assessment following ablative therapies (radiofrequency ablation and cryotherapy) focused on renal tumours.

Results

5 of 795 articles were eligible, totaling 110 patients. The study designs were heterogeneous with different imaging techniques, perfusion calculations, reference standard and follow-up periods. All studies found lower perfusion following treatment, with a return of ‘high grade’ perfusion in the 7/110 patients with residual or recurrent tumour. One study found perfusion curves were different between successfully ablated regions and residual tumour.

Conclusions

Studies were limited by small sample size and heterogeneous methodology. No studies have investigated the impact of perfusion imaging on management. This review highlights the current lack of evidence for perfusion imaging in response assessment following renal ablation, however it suggests that there may be a future role. Further prospective research is required to address this.

Quantifying optical properties with visible and near-infrared optical coherence tomography to visualize esophageal microwave ablation zones

Microwave ablation is a minimally invasive image guided thermal therapy for cancer that can be adapted to endoscope use in the gastrointestinal (GI) tract. Microwave ablation in the GI tract requires precise control over the ablation zone that could be guided by high resolution imaging with quantitative contrast. Optical coherence tomography (OCT) provides ideal imaging resolution and allows for the quantification of tissue scattering properties to characterize ablated tissue. Visible and near-infrared OCT image analysis demonstrated increased scattering coefficients (μ_s ) in ablated versus normal tissues (Vis: 347.8%, NIR: 415.0%) and shows the potential for both wavelength ranges to provide quantitative contrast. These data suggest OCT could provide quantitative image guidance and valuable information about antenna performance in vivo.

An injectable ionic hydrogel inducing high temperature hyperthermia for microwave tumor ablation

Microwave tumor ablation is of clinical significance and has been considered as a promising cancer minimally invasive therapy.

Recognition-Mediated Hydrogel Swelling Controlled by Interaction with a Negative Thermoresponsive LCST Polymer

Most polymeric thermoresponsive hydrogels contract upon heating beyond the lower critical solution temperature (LCST) of the polymers used. Herein, we report a supramolecular hydrogel system that shows the opposite temperature dependence. When the non-thermosesponsive hydrogel NaphtGel, containing dialkoxynaphthalene guest molecules, becomes complexed with the tetra cationic macrocyclic host CBPQT4+ , swelling occurred as a result of host-guest complex formation leading to charge repulsion between the host units, as well as an osmotic contribution of chloride counter-ions embedded in the network. The immersion of NaphtGel in a solution of poly(N-isopropylacrylamide) with tetrathiafulvalene (TTF) end groups complexed with CBPQT4+ induced positive thermoresponsive behaviour. The LCST-induced dethreading of the polymer-based pseudorotaxane upon heating led to transfer of the CBPQT4+ host and a concomitant swelling of NaphtGel. Subsequent cooling led to reformation of the TTF-based host-guest complexes in solution and contraction of the hydrogel.

Selective imaging and cancer cell death via pH switchable near-infrared fluorescence and photothermal effects

Accurately locating and eradicating sporadically distributed cancer cells whilst minimizing damage to adjacent normal tissues is vital in image-guided tumor ablation. In this work, we developed four heptamethine cyanine based theranostic probes, IR1-4, that demonstrated unique pH switchable near-infrared (NIR) fluorescence and photothermal efficiency. While their fluorescence quantum yields increased up to 1020-fold upon acidification from pH 7.4 to 2.4, their photothermal efficiencies decreased up to 7.1-fold concomitantly. Theoretical calculations showed that protonation of the probes in an acidic environment increased the orbital energy gaps and reduced the intramolecular charge transfer efficiency, resulting in the conversion of absorbed light energy to NIR fluorescence instead of hyperthermia. Substitutions at the terminal indole of the probes fine-tuned their pKafluo values to a narrow physiological pH range of 4.0-5.3. IR2, with a pKafluo of 4.6, not only specifically illuminated cancer cells by sensing their more acidic lysosomal lumen, but also selectively ablated cancer cells via its maximized photothermal effects in the alkaline mitochondrial matrix. As far as we are aware, these probes not only offer the highest physiological acidity triggered NIR fluorescence enhancement as small molecules, but are also the first to specifically visualize and eradicate cancer cells by sensing their altered pH values in cellular organelles. Considering that a disordered pH in organelle lumen is a common characteristic of cancer cells, these theranostic probes hold the promise to be applied in image-guided tumor ablation over a wide range of tumor subtypes.

Culture temperature affects human chondrocyte messenger RNA expression in monolayer and pellet culture systems

Cell-based therapy has been explored for articular cartilage regeneration. Autologous chondrocyte implantation is a promising cell-based technique for repairing articular cartilage defects. However, there are several issues such as chondrocyte de-differentiation. While numerous studies have been designed to overcome some of these issues, only a few have focused on the thermal environment that can affect chondrocyte metabolism and phenotype. In this study, the effects of different culture temperatures on human chondrocyte metabolism- and phenotype-related gene expression were investigated in 2D and 3D environments. Human chondrocytes were cultured in a monolayer or in a pellet culture system at three different culture temperatures (32°C, 37°C, and 41°C) for 3 days. The results showed that the total RNA level, normalized to the threshold cycle value of internal reference genes, was higher at lower temperatures in both culture systems. Glyceraldehyde-3-phosphate dehydrogenase (GAPDH) and citrate synthase (CS), which are involved in glycolysis and the citric acid cycle, respectively, were expressed at similar levels at 32°C and 37°C in pellet cultures, but the levels were significantly lower at 41°C. Expression of the chondrogenic markers, collagen type IIA1 (COL2A1) and aggrecan (ACAN), was higher at 37°C than at 32°C and 41°C in both culture systems. However, this phenomenon did not coincide with SRY (sex-determining region Y)-box 9 (SOX9), which is a fundamental transcription factor for chondrogenesis, indicating that a SOX9-independent pathway might be involved in this phenomenon. In conclusion, the expression of chondrocyte metabolism-related genes at 32°C was maintained or enhanced compared to that at 37°C. However, chondrogenesis-related genes were further induced at 37°C in both culture systems. Therefore, manipulating the culture temperature may be an advantageous approach for regulating human chondrocyte metabolic activity and chondrogenesis.

Culture temperature affects redifferentiation and cartilaginous extracellular matrix formation in dedifferentiated human chondrocytes

To date, there have been few studies on how temperature affects the phenotype and metabolism of human chondrocytes. Thus, the purpose of this study was to elucidate the effects of culture temperature on chondrocyte redifferentiation and extracellular matrix (ECM) formation using dedifferentiated mature human chondrocytes in vitro. Dedifferentiated chondrocytes were cultured in a pellet culture system for up to 21 days. The pellets were randomly divided into three groups with different culture temperature (32, 37, and 41°C). Chondrocyte redifferentiation and ECM formation were evaluated by wet weight, messenger ribonucleic acid (mRNA), histological, and biochemical analyses. The results showed that the wet weight and the mRNA expressions of collagen type II A1 and cartilage oligomeric matrix protein at 37°C were higher than the corresponding values at 32°C. The histological and biochemical analyses revealed that the syntheses of type II collagen and proteoglycan were promoted at 37°C compared to those at 32°C, whereas they were considerably inhibited at 41°C. In conclusion, the results obtained herein indicated that temperature affects chondrocyte redifferentiation and ECM formation, and modulation of temperature might thus represent an advantageous means to regulate the phenotype and biosynthetic activity of chondrocytes.

Effects of the thermal environment on articular chondrocyte metabolism: a fundamental study to facilitate establishment of an effective thermotherapy for osteoarthritis

AIM

To facilitate establishment of an effective thermotherapy for osteoarthritis (OA), we investigated the effects of the thermal environment on articular chondrocyte metabolism in vitro.

METHODS

Chondrocytes were isolated from porcine knee joints, and cultured at 32°C, 37°C and 41°C. Cell proliferation and viability were assessed at Days 2, 4 and 8. In addition, TdT-mediated dUTP nick end labeling (TUNEL) assay was performed at Day 3 to determine the proportion of apoptotic chondrocytes. Analysis of genes specific for factors related to the cartilage extracellular matrix (ECM), cartilage destruction, and cartilage protection was performed at Day 2. Furthermore, evaluation of heat stress tolerance, and heat shock protein 70 (HSP70) mRNA expression and protein synthesis was performed at Day 2 and 3, respectively.

RESULTS

Cell proliferation was more at 37°C than at 32°C and 41°C. Cell viability and the number of TUNEL-positive cells were not affected until Day 8 and 3, respectively. The expression of the ECM-related genes was up-regulated at higher temperature. The expression of MMP13, a type II collagen destructive enzyme, and that of TIMP1 and TIMP2, which are MMP inhibitors, were up-regulated at higher temperatures. Finally, the chondrocytes cultured at 41°C may acquire heat stress tolerance, in part, due to the up-regulation of HSP70, and may inhibit apoptosis induced by various stresses, which is observed in OA.

CONCLUSIONS

The thermal environment affects articular chondrocyte metabolism, and a heat stimulus of approximately 41°C could enhance chondrocyte anabolism and induce heat stress tolerance.

New thermosensitive nanoparticles prepared by biocompatible pegylated aliphatic polyester block copolymers for local cancer treatment

Objective

New pegylated thermosensitive polymers were developed to study them as drug vehicles in targeting release nanoparticulate systems of anticancer drugs.

Methods

The drug vehicles were prepared in the form of core-shell nanoparticles using novel polymeric materials synthesized by copolymerization of poly(propylene adipate) (PPAd) and methoxy-polyethylene glycol (mPEG) with different molecular weights. The physical and chemical properties of the synthesized mPEG-PPAd copolymers were studied using several techniques, and their cytocompatibility was evaluated. For drug nanoencapsulation, a water in oil (W/O) emulsification and solvent evaporation technique was used and the prepared nanoparticles were studied for their physical properties, morphology, drug release and anticancer efficacy against cancer cell lines.

Key findings

The size of the nanoparticles lied in a range suitable for tumour targeting. Drug release was affected by the composition of polymer, the temperature and pH of the release medium. The release results obtained indicate that judicious selection of nanoparticles composition may allow for enhanced drug delivery to the tumours following application of local hyperthermia.

Conclusions

The paclitaxel-loaded mPEG-PPAd nanoparticles were found to be cytotoxic against to the human hepatoma HepG2) and the human epithelial (HeLa) cancer cell lines. Enhanced cytotoxicity against the HeLa cells was observed at elevated temperature (42°C compared with 37°C), providing support for the potential usefulness of the mPEG-PPAd nanoparticles for the development of thermo-sensitive anticancer drug delivery systems.

Evaluation of reference genes for human chondrocytes cultured in several different thermal environments

PURPOSE

The purpose of this study was to identify reference genes showing stable expression in chondrocytes cultured under several different thermal environments and in different culture systems.

MATERIALS AND METHODS

Human articular chondrocytes were cultured by monolayer or pellet culture system at 32 °C, 37 °C, and 41 °C for 3 days. Thereafter, the total RNA was extracted, and quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR) was performed. The qRT-PCR data was analysed using three different algorithms (geNorm, NormFinder, and BestKeeper) to identify reference genes exhibiting stable expression from among the seven candidate reference genes (B2M, ACTB, GAPDH, HSPCB, RPL13a, YWHAZ, and 18S).

RESULTS

The candidate reference genes, except for HSPCB and YWHAZ, showed systematic variations in expression. In the monolayer culture, RPL13a was the most stable gene identified using NormFinder and BestKeeper; on using geNorm, ACTB and GAPDH showed the highest expression stability. In the pellet culture, ACTB was the most stable gene identified using NormFinder and BestKeeper, whereas GAPDH and RPL13a were the most stable reference genes as determined using geNorm. In the combined group, B2M and GAPDH were the most stable genes identified using geNorm, whereas RPL13a and YWHAZ were the most stable as per NormFinder and BestKeeper, respectively. The best combination of two candidate reference genes among all the groups determined using NormFinder was RPL13a and YWHAZ.

CONCLUSION

The combination of RPL13a and YWHAZ might be suitable as reference genes for human chondrocytes cultured at 32 °C, 37 °C, and 41 °C in monolayer, pellet, or combined cultures.

High intensity focused ultrasound: A noninvasive therapy for locally advanced pancreatic cancer

The noninvasive ablation of pancreatic cancer with high intensity focused ultrasound (HIFU) energy is received increasingly widespread interest. With rapidly temperature rise to cytotoxic levels within the focal volume of ultrasound beams, HIFU can selectively ablate a targeted lesion of the pancreas without any damage to surrounding or overlying tissues. Preliminary studies suggest that this approach is technical safe and feasible, and can be used alone or in combination with systemic chemotherapy for the treatment of patients with locally advanced pancreatic cancer. It can effectively alleviate cancer-related abdominal pain, and may confer an additional survival benefit with few significant complications. This review provides a brief overview of HIFU, describes current clinical applications, summarizes characteristics of continuous and pulsed HIFU, and discusses future applications and challenges in the treatment of pancreatic cancer.

Thermal ablation of tumours: biological mechanisms and advances in therapy

Minimally invasive thermal ablation of tumours has become common since the advent of modern imaging. From the ablation of small, unresectable tumours to experimental therapies, percutaneous radiofrequency ablation, microwave ablation, cryoablation and irreversible electroporation have an increasing role in the treatment of solid neoplasms. This Opinion article examines the mechanisms of tumour cell death that are induced by the most common thermoablative techniques and discusses the rapidly developing areas of research in the field, including combinatorial ablation and immunotherapy, synergy with conventional chemotherapy and radiation, and the development of a new ablation modality in irreversible electroporation.

PEGylated carbon nanoparticles for efficient in vitro photothermal cancer therapy

PEGylated carbon nanoparticles possess strong heat-producing ability and exhibit great potential in photothermal cancer therapy.

High intensity focused ultrasound ablation and antitumor immune response

The ideal cancer therapy not only induces the death of all localized tumor cells without damage to surrounding normal tissue, but also activates a systemic antitumor immunity. High intensity focused ultrasound (HIFU) has the potential to be such a treatment, as it can non-invasively ablate a targeted tumor below the skin surface, and may subsequently augment host antitumor immunity. This paper is to review increasing pre-clinical and clinical evidence linking antitumor immune response to HIFU ablation, and to discuss the potential mechanisms involved in HIFU-enhanced host antitumor immunity. The seminal studies performed so far indicate that although it is not possible to conclude definitively on the connection between HIFU treatment and antitumor immune response, it is nonetheless important to conduct extensive studies on the subject in order to elucidate the processes involved.

Ablation of hypoxic tumors with dose-equivalent photothermal, but not photodynamic, therapy using a nanostructured porphyrin assembly

Tumor hypoxia is increasingly being recognized as a characteristic feature of solid tumors and significantly complicates many treatments based on radio-, chemo-, and phototherapies. While photodynamic therapy (PDT) is based on photosensitizer interactions with diffused oxygen, photothermal therapy (PTT) has emerged as a new phototherapy that is predicted to be independent of oxygen levels within tumors. It has been challenging to meaningfully compare these two modalities due to differences in contrast agents and irradiation parameters, and no comparative in vivo studies have been performed until now. Here, by making use of recently developed nanostructured self-quenched porphysome nanoparticles, we were able to directly compare PDT and PTT using matched light doses and matched porphyrin photosensitizer doses (with the photosensitizer being effective for either PTT or PDT based on the existence of nanostructure or not). Therefore, we demonstrated the nanostructure-driven conversion from the PDT singlet oxygen generating mechanism of porphyrin to a completely thermal mechanism, ideal for PTT enhancement. Using a novel hypoxia tumor model, we determined that nanostructured porphyrin PTT enhancers are advantageous to overcome hypoxic conditions to achieve effective ablation of solid tumors.

Laser ablation for small hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide and is increasingly detected at small size (<5 cm) owing to surveillance programmes in high-risk patients. For these cases, curative therapies such as resection, liver transplantation, or percutaneous ablation have been proposed. When surgical options are precluded, image-guided tumor ablation is recommended as the most appropriate therapeutic choice in terms of tumor local control, safety, and improvement in survival. Laser ablation (LA) represents one of currently available loco-ablative techniques: light is delivered via flexible quartz fibers of diameter from 300 to 600 μm inserted into tumor lesion through either fine needles (21g Chiba needles) or large-bore catheters. The thermal destruction of tissue is achieved through conversion of absorbed light (usually infrared) into heat. A range of different imaging modalities have been used to guide percutaneous laser ablation, but ultrasound and magnetic resonance imaging are most widely employed, according to local experience and resource availability. Available clinical data suggest that LA is highly effective in terms of tumoricidal capability with an excellent safety profile; the best results in terms of long-term survival are obtained in early HCC so that LA can be proposed not only in unresectable cases but, not differently from radiofrequency ablation, also as the first-line treatment.

Changes in immunocompetent cells after interstitial laser thermotherapy of breast cancer

BACKGROUND

Local tumour destruction has been shown to give rise to changes in immunocompetent cells. The aim of this study was to describe the effect of interstitial laser thermotherapy (ILT) of breast carcinoma in the tumour and in regional lymph nodes.

METHODS

Seventeen women that underwent radical surgical excision after non-radical ILT were studied. ILT was performed at a steady-state temperature of 48°C for 30 min. Surgical excision was performed 12 (6-23) days after ILT. Six patients with breast cancer not treated with ILT before surgery served as controls. Immunohistological reactions were performed on core needle biopsies prior to treatment and on the excised specimens.

RESULTS

ILT resulted in more CD8 lymphocytes and CD68 macrophages within the tumour (P < 0.05 and P < 0.01, respectively) and higher counts of CD20 (P < 0.05), CD68 (P < 0.001) and CD83 (P < 0.01) at the tumour border, when compared to pre-treatment values. In the control patients not receiving ILT, CD8 cells increased within the tumour after resection (P < 0.05). With the probable exception of CD25 Foxp3 cells, the presence of cancer in a lymph node influenced the findings in lymph nodes (examined for CD1a, CD25, Foxp3 CD25, CD83 cells). Thus, comparisons between ILT and control patients were restricted to patients without lymph node metastases. In these patients, ILT and resection were followed by a decrease in CD25 Foxp3 lymphocytes (P < 0.05), when compared to surgical resection alone.

CONCLUSIONS

ILT induced changes in immunocompetent cells in patients with breast cancer. The stimulation of the immune system is an added feature of ILT in treatment of patients with breast cancer.

[Nonoperative ablation for liver metastases. Possibilities and limitations as a curative treatment]

Under the term "nonoperative ablation" are grouped a number of heterogeneous approaches for the treatment of liver metastases, including laser-induced thermotherapy (LITT), radio-frequency therapy (RF), and cryotherapy. In general these procedures had been intended only for palliative purposes. The establishment of clinically relevant lesion size and a lack of long-term survival data were regarded as main limitations to using them with curative intention. During the last years however, new application systems have demonstrated remarkable results in RF and LITT, and some clinical studies have shown long-term survival in selected patients comparable to that for hepatic resection. We review possibilities and limitations of nonoperative ablation procedures with curative intent, highlighting the histopathological bases of thermal ablation techniques and clinical aspects such as R0 ablation and long-term survival.

Resistance to tumour challenge after tumour laser thermotherapy is associated with a cellular immune response

Previous studies in our laboratory have shown that interstitial laser thermotherapy (ILT) of an experimental liver tumour is superior to surgical excision, at least partly due to a laser-induced immunological effect. The aim of the present study was to investigate the time-response relationship of the ILT-induced immunisation and the cellular response of macrophages and lymphocytes. A dimethylhydrazine-induced adenocarcinoma was transplanted into the liver of syngeneic rats. Rats with tumour were treated 6-8 days later (tumour size 0.25-0.40 cm(3)) with ILT of tumour or resection of the tumour-bearing lobe. Two groups of rats without tumour were treated with resection of a normal liver lobe or ILT of normal liver. A challenging tumour was implanted into the liver of each rat 2, 5 or 10 weeks after primary treatment. Rats were killed 6, 12 and 48 days (or earlier due to their condition) after challenge (n = 8 in all groups). Immunohistochemical techniques were used to determine lymphocytes (CD8, CD4) and macrophages (ED1, ED2) in rats having had treatment of a primary tumour. Interstitial laser thermotherapy of the first tumour was followed by eradication of challenging tumour and absence of tumour spread. This contrasted with rapid growth and spread of challenging tumour in the other groups. In the challenging vital tumour tissue and in the interface between the tumour and surroundings, the number of ED1 macrophages and CD8 lymphocytes was higher in rats having been treated with the ILT of tumour than in those having undergone resection of the tumour-bearing lobe. The number of ED2 macrophages and CD4 lymphocytes was low and did not vary between these two groups. Interstitial laser thermotherapy elicited an immune response that eradicated a challenging tumour and was associated with increased numbers of tumour-infiltrating macrophages and CD8 lymphocytes.

Mechanisms of Focal Heat Destruction of Liver Tumors

BACKGROUND

Focal heat destruction has emerged as an effective treatment strategy in selected patients with malignant liver tumors. Radiofrequency ablation, interstitial laser thermotherapy, and microwave treatment are currently the most widely applied thermal ablative techniques. A major limitation of these therapies is incomplete tumor destruction and overall high recurrences. An understanding of the mechanisms of tissue injury induced by focal hyperthermia is essential to ensure more complete tumor destruction. Here, the currently available scientific literature concerning the underlying mechanisms involved in the destruction of liver tumors by focal hyperthermia is reviewed.

METHODS

Medline was searched from 1960 to 2004 for literature regarding the use of focal hyperthermia for the treatment of liver tumors. All relevant literature was searched for further references.

RESULTS

Experimental evidence suggests that focal hyperthermic injury occurs in two distinct phases. The first phase results in direct heat injury that is determined by the total thermal energy applied, tumor biology, and the tumor microenvironment. Tumors are more susceptible to heat injury than normal cells as the result of specific biological features, reduced heat dissipating ability, and lower interstitial pH. The second phase of hyperthermic injury is indirect tissue damage that produces a progression of tissue injury after the cessation of the initial heat stimulus. This progressive injury may involve a balance of several factors, including apoptosis, microvascular damage, ischemia-reperfusion injury, Kupffer cell activation, altered cytokine expression, and alterations in the immune response. Blood flow modulation and administration of thermosensitizing agents are two methods currently used to increase the extent of direct thermal injury. The processes involved in the progression of thermal injury and therapies that may potentially modulate them remain poorly understood.

CONCLUSION

Focal hyperthermia for the treatment of liver tumors involves complex mechanisms. Evidence suggests that focal hyperthermia produces both direct and indirect tissue injury by differing underlying processes. Methods to enhance the effects of treatment to achieve complete tumor destruction should focus on manipulating these processes.

Progressive microvascular injury in liver and colorectal liver metastases following laser induced focal hyperthermia therapy

BACKGROUND AND OBJECTIVES

Focal hyperthermia by laser or radiofrequency is currently the preferred method for local ablation of liver tumors. The underlying mechanism of action of focal hyperthermia, in particular the relationship between the microvascular and tissue effect is uncertain and was investigated in a murine model.

STUDY DESIGN/MATERIALS AND METHODS

Focal hyperthermia produced by a Neodymium-Yttrium-Aluminium-Garnet laser (wavelength 1,064 nm) was applied to the normal liver and colorectal cancer liver metastases in inbred male CBA strain mice at 2 W for 50 seconds (100 J). Tissue injury was assessed at 0, 24, 48, 72, 120, and 168 hours following therapy by measurements of necrosis in tissue sections stained for nicotinamide adenine dinucleotide (NADH) diaphorase activity. Characteristics of microvascular injury were assessed at the various time points by scanning electron microscopy (SEM) of vascular resin casts, Laser Doppler flowmetry, and confocal in vivo microscopy.

RESULTS

Focal hyperthermia produced progressive tissue and vascular injury. There was an initial reduction in blood flow and increased vascular permeability in the microcirculation of both tumor and liver tissue immediately following heat application as assessed by laser Doppler flowmetry and confocal in vivo microscopy, respectively. SEM of vascular casts showed heterogeneous regions of microvascular injury immediately following heat application. The extent of initial vascular disruption or occlusion on SEM of vascular resin casts (mean+/-SE) was significantly less than the tissue necrosis in liver (1.9+/-0.1 mm vs. 3.0 mm+/-0.2 mm P<0.001), but was equivalent to the tissue injury in tumor tissue (3.5 mm+/-0.2 mm vs. 3.6 mm+/-0.1 mm P = 0.907). This was followed by a progressive increase in both microvascular and tissue injury in liver and tumor that peaked by 72 hours following treatment. The peak microvascular injury and tissue damage in liver (6.6 mm+/-0.2 and 6.3 mm+/-0.2 mm, respectively) was significantly greater than the extent of microvascular and tissue damage in tumors (4.8 mm+/-0.2 mm and 4.5 mm+/-0.2 mm, respectively) (P<0.001). The progression of microvascular injury in liver and tumor at times preceded the tissue injury.

CONCLUSION

Focal hyperthermia produces both progressive microvascular and tissue damage in liver and colorectal liver metastases. An increase in tissue injury following focal hyperthermia may be a direct result of progressive microvascular damage. Tumor vessels appear more susceptible to direct focal hyperthermia destruction than liver sinusoids. The liver sinusoids are however more susceptible to progressive damage or occlusion following the initial laser thermal stimulus.

Percutaneous ablation of liver tumours

The goal of local ablation treatment of hepatic disease is to prolong survival for patients with unresectable tumours. Presently, influence on survival is difficult to estimate because of the heterogeneity of indications and treatments and short follow-up. This chapter therefore focuses on potential benefits and limitations, complications and solutions for improvement. The main problems with in situ ablation are the lack of good imaging techniques to determine the extent of disease and the lack of a method for real-time monitoring of irreversible tissue effect. With one exception, there are no prospective, randomized studies comparing local destruction methods. It appears that percutaneous ethanol injection and cryotherapy should be replaced by radiofrequency ablation (RFA) or interstitial laser thermotherapy (ILT) and that there is little difference in outcome between RFA and ILT. Intraoperative RFA or ILT is valuable as an adjunct to hepatic resection in order to increase the rate of resectability. The percutaneous approach needs further development. It might be valuable in a few truly unresectable or inoperable patients or in selected patients with neuroendocrine liver metastases. In the large majority of unresectable patients it should, however, presently be used and evaluated only in prospective, randomized studies.

Effective solitary hyperthermia treatment of malignant glioma using stick type CMC-magnetite. In vivo study

Various kinds of hyperthermic treatment for malignant glioma had been inhibited due to both their incomplete feverish action and strict cooling effect of the brain. The author shows an effective results of hyperthermia for the treatment of malignant glioma in an in vivo study using stick type carboxymethylcellulose (CMC)-magnetite, a newly manufactured magnetite-product. A stick type CMC-magnetite, containing magnetite particles, was inserted into the T-9 glioma in the rat brain stereotactically, and the rats were exposed to an alternative magnetic field (AMF). The application time of AMF, which measured 88.9 kHz and 380 Oe, was 30 min a day. The rats were divided into three groups: three AMF applications (group I), one AMF application (group II) and no application but only injection of CMC-magnetite (control). As a result, the mean survival in days of these three groups measured 44.2+/-10.9 (group I), 17.0+/-1.5 (group II) and 14.4+/-1.5 (control). This investigation showed both significant effectiveness in attacking malignant glioma and significant prolonging of the survival time in rats. It is also a characteristic feature of the magnetite particles to spread through the tumor diffusely after three applications of AMF. This feature seemed to be one of the main factors that caused greater hyperthermic effect on glioma in this study. This method of hyperthermic treatment could be a useful strategy in the treatment of malignant glioma.

Diffusion theory, the cell and the synapse

The possibility exists that the cell internum is far more highly organised right down to the molecular level than was hitherto appreciated, to the point where ideas of a relatively solid-state chemistry model have been entertained (Coulson, R.A., 1993. The flow theory of enzyme kinetics--a role of solid geometry in the control reaction velocity in live animals. Int. J. Biochem. 25, 1445-1474). This contrasts sharply with the traditional dogma that diffusion is the mechanism by which molecules interact within an aqueous solution of the cell internum, although it should have been clear from an early stage that diffusion could not play other than a very restricted role in metabolic regulation. When physicists began to question certain aspects of the fundamental Law of Heat Conductance formulated over 170 years ago by Fourier, Diffusion Theory was also implicated (Maddox, J., 1989. Heat conductance is a can of worms. Nature 338, 373), and application of Fick's Laws of Diffusion to living systems criticised (Agutter P.S., Malone, P.C., Wheatley, D.N., 1995. Intracellular transport mechanisms: a critique of diffusion theory. J. Theoret. Biol. 176, 261-272). While we have argued (Wheatley, D.N., Malone, P.C., 1993. Heat conductance, diffusion theory and intracellular metabolic regulation. Biol. Cell 79, 1-5) that diffusion cannot be prevented from occurring, we found that, irrespective of whether it was a valid theory, diffusion was of little relevance in most actively metabolising cell systems. However, diffusion is still perceived as essential for interacting molecules to demonstrate their specificities. Any new model of the internal state of the living cell has to resolve this dilemma. The question also relates to molecular movement and ligand-receptor interactions outside the cell. In looking at this situation, attention was paid to one site in the body in which diffusion has long been assumed to be essential, namely in the passage of the chemical transmitter between one neurone and the next across the synaptic cleft. A detailed examination of this assumption has helped to identify one possible place in which the importance of diffusion over a distance of no more than 20-30 nm occurs, although objections to diffusion being involved have been raised. The outcome, however, only re-enforces the conviction that diffusion has little role in metabolic activity and is normally 'assisted' in almost all aspects of cell physiology.

Histopathological findings in human choroidal melanomas after transpupillary thermotherapy

AIMS

The effect of transpupillary thermotherapy (TTT) on human choroidal melanomas was investigated by means of histopathology.

METHODS

Before enucleation TTT was performed in 11 eyes with a xenon are photocoagulator with a red filter or a diode laser at 810 nm. The exposure time was 1 minute; the estimated temperature at the top of the tumour was about 65 degrees C.

RESULTS

Seven of 11 tumours developed necrosis to a maximum depth of 3.9 mm with a sharp demarcation between the necrotic and the viable part of the tumour. The depth correlated with penetration of heat into the tumour. Scattered small haemorrhages in the transitional zone between the necrotic and the viable part of the tumour were observed in three eyes but large haemorrhages were absent. Ocular media were not affected owing to the low rate of absorption of radiation at 810 nm. TTT did not cause significant scleral damage. Intrascleral tumour cells with a viable appearance were observed in one eye, where the tumour was almost totally necrotic.

CONCLUSION

Results show that TTT has potential as a conservative therapeutic treatment for choroidal melanomas.

Regional differences in apoptosis in murine gliosarcoma (T9) induced by mild hyperthermia

There are several reports of apoptosis induced by mild hyperthermia both in vitro and in vivo. However, in tumour nodules, regional differences in apoptosis induced by hyperthermia have not been studied morphologically or quantified. In this study, apoptosis was identified on the basis of its characteristic morphology, and was quantified in different tumour regions (margin and centre) by light and electron microscopy and discussed the correlation with necrosis. Apoptosis was induced in solid nodules of gliosarcoma (T9) in vivo by heating for 30 min in a water bath at 43 degrees C. The gliosarcoma cells showed a rapid increase in the number of apoptotic cells following mild hyperthermia. There was a regional difference in the rate of apoptosis immediately after hyperthermia. Necrosis was markedly enhanced only in the centre of the tumour 3 and 6 h after hyperthermia. These combined responses of apoptosis and necrosis seem to be caused by the microenvironmental change in the intratumour location.

Effects of hyperthermia on the nucleolar proteins in tumour cells

The effects of hyperthermia at 41 degrees C and 43 degrees C on the nucleolar protein B23 in Ehrlich ascites tumour (EAT), human glioblastoma U-87 MG and U-373 MG cell lines were studied. Cellular localization of protein B23 was detected by an immunofluorescence technique using monoclonal antibody against protein B23. Diminution of fluorescence in the nucleoli occurred when the cells were treated at high temperature. The decrease in fluorescence level depends on the treatment temperature and duration. Among the three cell lines studied, the U-373 MG glioblastoma was the least responsive to hyperthermia followed by the U-87 MG glioblastoma. The decrease in nucleolar fluorescence of the EAT cells treated at 41 degrees C and 43 degrees C correlated with their subsequent cell survival. Dispersion of the nucleolar argyrophilic granules occurred in EAT cells after heating at 43 degrees C for 1 h. The possible implication of such effect is discussed in relation to the heat-sensitive elements in the nucleolus.

High-energy shock waves pyrotherapy. A new concept in extracorporeal tumour therapy

High-intensity shock waves (HISW) waves can produce rapid and intense tissue heating. We have studied a novel device capable of simultaneous shock wave generation, focusing and extracorporeal delivery along with imaging of the proposed target. Shock waves are generated by piezo-electric crystals and target a focal point of 10 x 2 mm. In a preliminary study, three groups of land race pigs received HISW to discrete points on the liver parenchyma. There was no mortality in any group. Cardiovascular monitoring revealed that HISW did not induce any haemodynamic changes during treatment and that core temperatures and liver function tests were unaffected by this therapy. Ultrasound monitoring during treatment demonstrated discreet hyperechoic areas with acoustic shadowing suggesting cavitation. Animals killed immediately after 48 h of HISW therapy had discrete necrotic cylinders within the liver with a mean diameter of 2 cm (+0.21 SD). Histological examination revealed a pattern of necrosis and vascular changes suggestive of ischaemia. In addition, there were areas of coagulative necrosis consistent with thermal injury. Animals killed at 2 months had necrotic cavities which had become surrounded by mature fibrosis. These early results indicate that high energy shock waves delivered extracorporeally can cause specific destruction of liver tissue by focused hyperthermia and cavitation. Clinical studies of this device are required to assess the possible virtue of HISW in the treatment of liver and other tumours.

Transpupillary thermotherapy (TTT) by infrared irradiation of choroidal melanoma

We studied the destructive effect of hyperthermia at sub-photocoagulation level of 45-60 degrees C on melanomas. Optimal conditions for spreading of heat into tissue are a wavelength of 700-900 nm, a temperature of 45-60 degrees C, an exposure time of 1 minute or more, and a beam diameter of several millimeters. In hamsters with subcutaneous melanomas we obtained a tumour necrosis of 6 mm depth at 60 degrees C and one minute exposure time. We performed transpupillary thermotherapy (TTT) with a diode laser at 810 nm in patients with choroidal melanomas prior to enucleation. Treatment is based on the fortunate situation that irradiation at this wavelength combines optimal tissue penetration with a low absorption by clear ocular media of 5% or less. In 3 TTT-treated eyes histopathology showed a depth of necrosis of 0.9, 3.4, and 3.9 mm. TTT may become a new useful treatment modality for choroidal melanoma but its ultimate value has yet to be assessed.

Multiple-fibre low-power interstitial laser hyperthermia: studies in the normal liver

Multiple four-fibre low-power interstitial laser hyperthermia was performed in the canine liver to establish the parameters with which large areas of thermal necrosis could be made. Using 1.5 W for 670 s (4020 J in total) and a fibre spacing of 1.5 cm, lesions with dimensions of 3.6 x 3.1 x 2.8 cm were achieved in 75 per cent of those attempted. There was no mortality and a low morbidity rate. These lesions could be visualized in both their development and resolution using ultrasonography. Healing occurred by 1 year. Temperatures in the centre of the heated region were 60 degrees C, which is more than enough to cause thermal cell death. There was good correlation between the temperatures recorded, the sonographic changes seen, and the pathological evidence of necrosis. Multiple-fibre low-power interstitial laser hyperthermia performed with ultrasonic guidance may be of use in the treatment of liver tumours.

Sensitization to hyperthermia by 3,3'-dipentyloxacarbocyanine iodide: a positive correlation with DNA damage and negative correlations with altered cell morphology, oxygen consumption inhibition, and reduced ATP levels

The cyanine dye 3,3'-dipentyloxacarbocyanine iodide (DiOC5(3)) (concentrations of 0.5 microgram/ml to 5.0 micrograms/ml) was shown to be a potent sensitizer of Chinese hamster ovary (CHO) cells to hyperthermic cell killing at 43.0 degrees C or 45.5 degrees C, while exhibiting no cytotoxicity at 37.0 degrees C. Sensitization to hyperthermic cell killing was accompanied by an increase in damage to the DNA, as measured by DNA unwinding. The increased DNA damage correlated qualitatively with the enhanced heat killing induced by DiOC5(3). This correlation was better in cells heated at 43.0 degrees C than in those heated at 45.5 degrees C. DiOC5(3) is known to affect other cellular functions. It inhibits electron transport, uncouples oxidative phosphorylation, and inhibits calcium ATPases. The effects of DiOC5(3) on oxygen consumption and ATP content were therefore measured at 37.0 degrees C and at hyperthermic temperatures. The results demonstrated that inhibition of oxygen consumption and reduction of cellular ATP levels played no role in inducing heat sensitization in DiOC5(3)-treated cells, or in causing cell death in cells treated with heat alone.

Optimisation of intraperitoneal cisplatin therapy with regional hyperthermia in rats

The purpose of this study was to optimise intraperitoneal chemotherapy by combining this modality with regional hyperthermia. In vitro data demonstrated that both the uptake of cisplatin into CC531 tumour cells and cytotoxicity were increased at temperatures of 40 degrees C (factor 4) and 43 degrees C (factor 6) compared to 37 degrees C. The increase of intracellular platinum concentration correlated well with the decrease in survival of these cells. In vivo, rats were treated intraperitoneally with cisplatin (5 mg/kg) in combination with regional hyperthermia of the abdomen (41.5 degrees C, 1 h). The mean (S.D.) temperature in the peritoneal cavity was 41.5 (0.3) degrees C and outside the peritoneal cavity 40.5 (0.3) degrees C. Enhanced platinum concentrations were found in peritoneal tumours (factor 4.1) and kidney, liver, spleen and lung (all around a factor 2.0), after combined cisplatin-hyperthermia treatment. The platinum distribution in peritoneal tumours was more homogeneous after the combined treatment than after cisplatin alone, possibly due to increased penetration of cisplatin into peritoneal tumours. Pharmacokinetic data demonstrated an increased tumour exposure for unfiltered platinum in the peritoneal cavity (area under the curve [AUC] increased from 339 mumol/l/min to 486 mumol/l/min at 37 degrees C and 41.5 degrees C, respectively), and for total and ultrafiltered platinum in the blood. The AUC for total platinum increased from 97.9 to 325.8 mumol/min and for ultrafiltered platinum from 22.2 to 107 mumol/l/min at 37 degrees C and 41.5 degrees C respectively. The latter might be due to a slower elimination of platinum from the blood. The combined treatment, intraperitoneal cisplatin and regional hyperthermia, also increased toxicity. The thermal enhancement ratio (TER) using lethality as endpoint was 1.8.

Thermotolerance and the heat shock response in normal human keratinocytes in culture

Protective responses of normal human epidermal keratinocytes in culture, after exposure to elevated temperatures ("heat shock"), were examined. Cell viability, measured 24-48 h after a 20-min heat challenge at temperatures between 37 degrees C and 54 degrees C, declined sharply within a narrow 2 degrees-3 degrees C range. However, conditioning with a mild thermal pretreatment (40 degrees C or 42 degrees C for 1 h) protected the keratinocytes against a subsequent heat challenge. This induced thermotolerance was apparent when cells were challenged at 1, 3, and 6 h after the thermal pre-treatment, but disappeared by 24 h. Heating conditions that induce thermotolerance also stimulated the synthesis of heat-shock proteins (hsp) in these cells. Inductions of prominent 35S-methionine labeled bands at 70, 78, and 90 kDa were observed. However, the increases in synthesis of these heat-shock proteins did not correlate well with thermotolerance, because large increases were also observed at certain elevated temperatures that did not produce improved survival. Keratins observed in these cells (50 and 58 kDa classes) were not induced by heat shock. The development of thermotolerance, and the induction of hsp, were both completely blocked by 3'-deoxyadenosine (cordycepin), an inhibitor of newly synthesized messenger RNA, but not by adenosine, the normal analog. While heat-inducible mRNA apparently mediate some function important for the development of thermotolerance, the nature of that role remains speculative. Overall, our findings establish the existence of a functional thermal protective mechanism in human keratinocytes that appears to require the synthesis of new mRNA.

Combined effects of hyperthermia (to 45 degrees C) and ultrasound irradiation on the surface ultrastructure of HeLa cells

Hyperthermic treatment of HeLa cells in suspension combined with ultrasound irradiation produced alterations to the cell surfaces. The changes induced were related to ultrasound intensity in the standing wave and to heat treatments between 37 and 45 degrees C. Two transducers were used, driven at resonant frequencies of 0.75 and 1.5 MHz, and producing peak intensities up to 7 W/cm2. These intensities produced a negligible rise in temperature of the cell suspension medium. Ultrastructural damage in standing wave fields, as seen by scanning electron microscopy, progressed through stages. The first stage was characterized by the loss of microvilli and smooth appearance of the cell surface, e.g. after insonation at 41.5 degrees C for 10 min; damage increased to a final stage where the surface appeared heavily pitted and porous, with the cells showing signs of disintegration, e.g. after insonation at 45 degrees C for 10 min. The monitoring of ultrasound-induced cavitation suggested that damage was caused by bubble oscillations, not collapse cavitation. Shearing stresses accentuated by hyperthermia were considered the probable cause of such damage. Coulter counter studies of cell size distribution showed that the extent of cell damage depended on the geometry of the vessel in which insonation was carried out.