Design of an ultrasonic therapy system for breast cancer treatment

Quality assurance guidelines for superficial hyperthermia clinical trials : II. Technical requirements for heating devices

Quality assurance (QA) guidelines are essential to provide uniform execution of clinical trials with uniform quality hyperthermia treatments. This document outlines the requirements for appropriate QA of all current superficial heating equipment including electromagnetic (radiative and capacitive), ultrasound, and infrared heating techniques. Detailed instructions are provided how to characterize and document the performance of these hyperthermia applicators in order to apply reproducible hyperthermia treatments of uniform high quality. Earlier documents used specific absorption rate (SAR) to define and characterize applicator performance. In these QA guidelines, temperature rise is the leading parameter for characterization of applicator performance. The intention of this approach is that characterization can be achieved with affordable equipment and easy-to-implement procedures. These characteristics are essential to establish for each individual applicator the specific maximum size and depth of tumors that can be heated adequately. The guidelines in this document are supplemented with a second set of guidelines focusing on the clinical application. Both sets of guidelines were developed by the European Society for Hyperthermic Oncology (ESHO) Technical Committee with participation of senior Society of Thermal Medicine (STM) members and members of the Atzelsberg Circle.

Lipid-Based Drug Delivery Systems in Cancer Therapy: What Is Available and What Is Yet to Come

Cancer is a leading cause of death in many countries around the world. However, the efficacy of current standard treatments for a variety of cancers is suboptimal. First, most cancer treatments lack specificity, meaning that these treatments affect both cancer cells and their normal counterparts. Second, many anticancer agents are highly toxic, and thus, limit their use in treatment. Third, a number of cytotoxic chemotherapeutics are highly hydrophobic, which limits their utility in cancer therapy. Finally, many chemotherapeutic agents exhibit short half-lives that curtail their efficacy. As a result of these deficiencies, many current treatments lead to side effects, noncompliance, and patient inconvenience due to difficulties in administration. However, the application of nanotechnology has led to the development of effective nanosized drug delivery systems known commonly as nanoparticles. Among these delivery systems, lipid-based nanoparticles, particularly liposomes, have shown to be quite effective at exhibiting the ability to: 1) improve the selectivity of cancer chemotherapeutic agents; 2) lower the cytotoxicity of anticancer drugs to normal tissues, and thus, reduce their toxic side effects; 3) increase the solubility of hydrophobic drugs; and 4) offer a prolonged and controlled release of agents. This review will discuss the current state of lipid-based nanoparticle research, including the development of liposomes for cancer therapy, different strategies for tumor targeting, liposomal formulation of various anticancer drugs that are commercially available, recent progress in liposome technology for the treatment of cancer, and the next generation of lipid-based nanoparticles.

Overview of bladder heating technology: matching capabilities with clinical requirements

Moderate temperature hyperthermia (40-45°C for 1 h) is emerging as an effective treatment to enhance best available chemotherapy strategies for bladder cancer. A rapidly increasing number of clinical trials have investigated the feasibility and efficacy of treating bladder cancer with combined intravesical chemotherapy and moderate temperature hyperthermia. To date, most studies have concerned treatment of non-muscle-invasive bladder cancer (NMIBC) limited to the interior wall of the bladder. Following the promising results of initial clinical trials, investigators are now considering protocols for treatment of muscle-invasive bladder cancer (MIBC). This paper provides a brief overview of the devices and techniques used for heating bladder cancer. Systems are described for thermal conduction heating of the bladder wall via circulation of hot fluid, intravesical microwave antenna heating, capacitively coupled radio-frequency current heating, and radiofrequency phased array deep regional heating of the pelvis. Relative heating characteristics of the available technologies are compared based on published feasibility studies, and the systems correlated with clinical requirements for effective treatment of MIBC and NMIBC.

Ultrasonically triggered drug delivery: breaking the barrier

The adverse side-effects of chemotherapy can be minimized by delivering the therapeutics in time and space to only the desired target site. Ultrasound offers one fairly non-invasive method of accomplishing such precise delivery because its energy can disrupt nanosized containers that are designed to sequester the drug until the ultrasonic event. Such containers include micelles, liposomes and solid nanoparticles. Conventional micelles and liposomes are less acoustically sensitive to ultrasound because the strongest forces associated with ultrasound are generated by gas-liquid interfaces, which both of these conventional constructs lack. Acoustically activated carriers often incorporate a gas phase, either actively as preformed bubbles, or passively such as taking advantage of dissolved gasses that form bubbles upon insonation. Newer concepts include using liquids that form gas when insonated. This review focuses on the ultrasonically activated delivery of therapeutics from micelles, liposomes and solid particles. In vitro and in vivo results are summarized and discussed. Novel structural concepts from micelles and liposomes are presented. Mechanisms of ultrasonically activated release are discussed. The future of ultrasound in drug delivery is envisioned.

The use of ultrasound to release chemotherapeutic drugs from micelles and liposomes

Several drug delivery systems have been investigated to reduce the side effects of chemotherapy by encapsulating the therapeutic agent in a nanosized carrier until it reaches the tumor site. Many of these particles are designed to be responsive to the mechanical and thermal perturbations delivered by ultrasound. Once the nanoparticle reaches the desired location, ultrasound is applied to release the chemotherapy drug only in the vicinity of the targeted (cancer) site, thus avoiding any detrimental interaction with healthy cells in the body. Studies using liposomes and micelles have shown promising results in this area, as these nanoparticles with simple, yet effective structures, showed high efficiency as drug delivery vehicles both in vitro and in vivo. This article reviews the design and application of two novel nanosized chemotherapeutic carriers (i.e. micelles and liposomes) intended to be actuated by ultrasound.

SonoKnife: feasibility of a line-focused ultrasound device for thermal ablation therapy

PURPOSE

To evaluate the feasibility of line-focused ultrasound for thermal ablation of superficially located tumors.

METHODS

A SonoKnife is a cylindrical-section ultrasound transducer designed to radiate from its concave surface. This geometry generates a line-focus or acoustic edge. The motivation for this approach was the noninvasive thermal ablation of advanced head and neck tumors and positive neck nodes in reasonable treatment times. Line-focusing may offer advantages over the common point-focusing of spherically curved radiators such as faster coverage of a target volume by scanning of the acoustic edge. In this paper, The authors report studies using numerical models and phantom and ex vivo experiments using a SonoKnife prototype.

RESULTS

Acoustic edges were generated by cylindrical-section single-element ultrasound transducers numerically, and by the prototype experimentally. Numerically, simulations were performed to characterize the acoustic edge for basic design parameters: transducer dimensions, line-focus depth, frequency, and coupling thickness. The dimensions of the acoustic edge as a function of these parameters were determined. In addition, a step-scanning simulation produced a large thermal lesion in a reasonable treatment time. Experimentally, pressure distributions measured in degassed water agreed well with acoustic simulations, and sonication experiments in gel phantoms and ex vivo porcine liver samples produced lesions similar to those predicted with acoustic and thermal models.

CONCLUSIONS

Results support the feasibility of noninvasive thermal ablation with a SonoKnife.

Focused microwave thermotherapy for preoperative treatment of invasive breast cancer: a review of clinical studies

BACKGROUND

Preoperative focused microwave thermotherapy (FMT) is a promising method for targeted treatment of breast cancer cells. Results of four multi-institutional clinical studies of preoperative FMT for treating invasive carcinomas in the intact breast are reviewed.

METHODS

Externally applied wide-field adaptive phased-array FMT has been investigated both as a preoperative heat-alone ablation treatment and as a combination treatment with preoperative anthracycline-based chemotherapy for breast tumors ranging in ultrasound-measured size from 0.8 to 7.8 cm.

RESULTS

In phase I, eight of ten (80%) patients receiving a single low dose of FMT prior to receiving mastectomy had a partial tumor response quantified by either ultrasound measurements of tumor volume reduction or by pathologic cell kill. In phase II, the FMT thermal dose was increased to establish a threshold dose to induce 100% pathologic tumor cell kill for invasive carcinomas prior to breast-conserving surgery (BCS). In a randomized study for patients with early-stage invasive breast cancer, of those patients receiving preoperative FMT at ablative temperatures, 0 of 34 (0%) patients had positive tumor margins, whereas positive margins occurred in 4 of 41 (9.8%) of patients receiving BCS alone (P = 0.13). In a randomized study for patients with large tumors, based on ultrasound measurements the median tumor volume reduction was 88.4% (n = 14) for patients receiving FMT and neoadjuvant chemotherapy, compared with 58.8% (n = 10) reduction in the neoadjuvant chemotherapy-alone arm (P = 0.048).

CONCLUSIONS

Wide-field adaptive phased-array FMT can be safely administered in a preoperative setting, and data from randomized studies suggest both a reduction in positive tumor margins as a heat-alone treatment for early-stage breast cancer and a reduction in tumor volume when used in combination with anthracycline-based chemotherapy for patients with large breast cancer tumors. Larger randomized studies are required to verify these conclusions.

Thermal therapy for breast tumors by using a cylindrical ultrasound phased array with multifocus pattern scanning: a preliminary numerical study

The purpose of this study is to investigate the feasibility of using a 1 MHz cylindrical ultrasound phased array with multifocus pattern scanning to produce uniform heating for breast tumor thermal therapy. The breast was submerged in water and surrounded by the cylindrical ultrasound phased array. A multifocus pattern was generated and electrically scanned by the phased array to enlarge the treatment lesion in single heating. To prevent overheating normal tissues, a large planning target volume (PTV) would be divided into several planes with several subunits on each plane and sequentially treated with a cooling phase between two successive heatings of the subunit. Heating results for different target temperatures (T(tgt)), blood perfusion rates and sizes of the PTV have been studied. Furthermore, a superficial breast tumor with different water temperatures was also studied. Results indicated that a higher target temperature would produce a slightly larger thermal lesion, and a higher blood perfusion rate would not affect the heating lesion size but increase the heating time significantly. The acoustic power deposition and temperature elevations in ribs can be minimized by orienting the acoustic beam from the ultrasound phased array approximately parallel to the ribs. In addition, a large acoustic window on the convex-shaped breast surface for the proposed ultrasound phased array and the cooling effect of water would prevent the skin overheating for the production of a lesion at any desired location. This study demonstrated that the proposed cylindrical ultrasound phased array can provide effective heating for breast tumor thermal therapy without overheating the skin and ribs within a reasonable treatment time.

Investigation of a scanned cylindrical ultrasound system for breast hyperthermia

This paper investigates the feasibility of a scanned cylindrical ultrasound system for producing uniform heating from the central to the superficial portions of the breast or localized heating within the breast at a specific location. The proposed system consists of plane ultrasound transducer(s) mounted on a scanned cylindrical support. The breast was immersed in water and surrounded by this system during the treatment. The control parameters considered are the size of the transducer, the ultrasound frequency, the scan angle and the shifting distance between the axes of the breast and the system. Three-dimensional acoustical and thermal models were used to calculate the temperature distribution. Non-perfused phantom experiments were performed to verify the simulation results. Simulation results indicate that high frequency ultrasound could be used for the superficial heating, and the scan angle of the transducer could be varied to obtain an appropriate high temperature region to cover the desired treatment region. Low frequency ultrasound could be used for deep heating and the high temperature region could be moved by shifting the system. In addition, a combination of low and high frequency ultrasound could result in a portion treatment from the central to the superficial breast or an entire breast treatment. Good agreement was obtained between non-perfused experiments and simulation results. The findings of this study can be used to determine the effects of the control parameters of this system, as well as to select the optimal parameters for a specific treatment.

Treatment time reduction for large thermal lesions by using a multiple 1D ultrasound phased array system

To generate large thermal lesions in ultrasound thermal therapy, cooling intermissions are usually introduced during the treatment to prevent near-field heating, which leads to a long treatment time. A possible strategy to shorten the total treatment time is to eliminate the cooling intermissions. In this study, the two methods, power optimization and acoustic window enlargement, for reducing power accumulation in the near field are combined to investigate the feasibility of continuously heating a large target region (maximally 3.2 x 3.2 x 3.2 cm3). A multiple 1D ultrasound phased array system generates the foci to scan the target region. Simulations show that the target region can be successfully heated without cooling and no near-field heating occurs. Moreover, due to the fact that there is no cooling time during the heating sessions, the total treatment time is significantly reduced to only several minutes, compared to the existing several hours.

The impact of ultrasonic parameters on chest wall hyperthermia

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

Effects of magnetic thermoablation in muscle tissue using iron oxide particles: an in vitro study

RATIONALE AND OBJECTIVES

To study the effects of magnetic thermoablation in muscle tissue from cow to assess interrelations that might be relevant for a minimally invasive therapy system in the long term.

METHODS

Magnetite particles (50-180 mg) were placed in muscle tissue. Temperature elevations as a function of time and distance from the center of the magnetite deposition area were measured during the exposure (up to 304 seconds) to an alternating magnetic field (frequency 400 kHz, amplitude 6.5 kA/m) generated by a circular coil (diameter 90 mm). Measured curves were reproduced by numerical calculations. Tissue alterations, macroscopically visible as light-brown discoloration, were recorded by volume estimations and histopathologic studies.

RESULTS

Significant temperature elevations (up to 87 degrees C) were reported within a distance of less than 15 mm from the magnetite deposition area. High initial heating rates were observed during the first 150 seconds of heating. The reproduction of the measured curves by numerical calculations was good (SD = 0.7 degrees C). The theoretical simulation was verified and applied to situations beyond the range of experimental conditions. Damaged tissue comprised pyknotic cell nuclei and degenerated myofibrils. Corresponding volumes were found to be up to 10 times higher than the volume of iron oxide dispersion.

CONCLUSIONS

The data demonstrate the applicability of local magnetic thermoablation for therapy of muscle lesions in the long term.

Ultrasound technology for hyperthermia

Hyperthermia (HT) is used in the clinical management of cancer and benign disease. Numerous biological and clinical investigations have demonstrated that HT in the 41-45 degrees C range can significantly enhance clinical responses to radiation therapy, and has potential for enhancing other therapies, such as chemotherapy, immunotherapy and gene therapy. Furthermore, high-temperature hyperthermia (greater than 50 degrees C) alone is being used for selective tissue destruction as an alternative to conventional invasive surgery. The degree of thermal enhancement of these therapies is strongly dependent on the ability to localize and maintain therapeutic temperature elevations. Due to the often heterogeneous and dynamic properties of tissues, most notably blood perfusion and the presence of thermally significant blood vessels, therapeutic temperature elevations are difficult to spatially and temporally control during these forms of HT therapy. However, ultrasound technology has significant advantages that allow for a higher degree of spatial and dynamic control of the heating compared to other commonly utilized heating modalities. These advantages include a favorable range of energy penetration characteristics in soft tissue and the ability to shape the energy deposition patterns. Thus, heating systems have been developed for interstitial, intracavitary, or external approaches that utilize properties such as multiple transducer arrays, phased arrays, focused beams, mechanical and/or electrical scanning, dynamic frequency control and transducers of various shapes and sizes. This article provides a general review of a selection of ultrasound hyperthermia systems that are either in clinical use or currently under development, that utilize these advantages as a means to better localize and control HT for the aforementioned therapies.

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

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

Specific absorption rate ratio patterns of cylindrical ultrasound transducers for breast tumors

The purpose of this paper is to examine the optimal driving frequency and to configure the ultrasound energy deposition schema for a various size and location of breast tissues when a portion or the entire cylindrical ultrasound transducer is employed for breast hyperthermia treatments. This work employs a computer simulation program based on an ideal ultrasound power deposition from a cylindrical transducer. The ultrasound power within the breast is assumed to be exponentially attenuated according to the penetration depth of the ultrasound beam and a uniform absorption for the entire breast is also assumed. The distribution of the specific absorption rate (SAR) ratio is employed to determine the heating pattern of a set of given parameters. The control parameters considered are the ultrasound frequency in the breast tissue, the active portion of cylindrical transducer, and the shifting distance between the central axes of the breast and the transducer. The effect of the breast size on the SAR ratio is also considered. Simulation results demonstrate that the breast size, the ultrasound frequency in breast tissue, the shifting distance, and the active portion of the cylindrical transducer are the potential parameters for influencing the distribution of the SAR ratio. High frequencies should be used for the superficial heating treatments and the active portion of the transducer can be changed to obtain a region with an appropriate SAR ratio to cover the treatment region. Low frequencies are used for deep heating treatments and the region of the high SAR ratio can be moved by shifting the transducer and its pattern is varied with the transducer's active portion. The distribution of the SAR ratio indicates the domain of treatable tumor size and tumor depth for a given set of parameters (driving frequency, shifting distance and active portion of the transducer, as well as breast diameter). Findings of this study can be used to know whether or not the tumor is treatable as well as to select the optimal driving frequency and the appropriate active portion of the cylindrical transducer for a treatment, and hopefully to design an appropriate cylindrical ultrasound heating system for breast tumors.

Ultrasound field calculation in a water-soft tissue medium

An efficient numerical approximation for ultrasound field calculation in a two or three layer water-soft tissue medium is presented. It is extended from a method developed previously in a homogeneous medium. The emphasis of this study is to examine the conditions that are required for this approximation. Criteria are given for achieving an appropriate accuracy, which is verified by comparing it with the Rayleigh integral.

Evaluation of temperature increase with different amounts of magnetite in liver tissue samples

RATIONALE AND OBJECTIVES

The biologic effects of magnetically induced heating effects using iron oxide, magnetite, were examined in vitro in liver tissue samples as a first step toward potential applications in cancer therapy.

METHODS

For the determination of the temperature profile around an iron oxide sample, a cylinder containing 170 mg of magnetite was constructed and placed into pureed liver tissue from pig, together with thermocouples of copper and constantan wires positioned at defined distances from it. Temperature measurements were performed during the exposure to an alternating magnetic field (frequency: 400 kHz; amplitude: approximately 6.5 kA/m) generated by a circular coil (90 mm of diameter). Moreover, variable amounts of magnetite (dissolved in approximately 0.2 mL physiologic saline) were injected directly into carrageenan gels. During the exposure to a magnetic field for 4 minutes the temperature increase was determined in the area of iron oxide deposition using a thermocouple. Additionally, variable amounts of magnetite were injected directly into isolated liver tissue samples (diameter: 20 mm; height: 30 mm) and exposed to a magnetic field for 2 minutes. The extent of the induced macroscopically visible tissue alterations (light brown colorations caused by heating) was examined by means of volume estimations. The degrees of cellular necrosis were investigated by histopathologic studies.

RESULTS

The temperature profile around a magnetite cylinder revealed a significant decrease of temperature difference between the beginning and the end of heating, depending on increasing distance from the sample center. The extent of the temperature difference correlated with increasing heating time. No significant variations of temperature were observed at a distance of approximately 12 mm from the sample center. A good correlation (r = 0.98) between the injected amounts (31 to 200 mg) and the temperature increase since the start of heating (6.8-33.7 degrees C) in the area of iron oxide deposits was detected. The volume of damaged liver tissue was approximately seven times higher than the injected volume of iron oxide dispersion. Histologically different degrees of cellular necrosis were observed.

CONCLUSIONS

The parameters determined in this article show that iron oxides are able to induce considerable heating effects in the surroundings. After an adequate optimization of the technical procedure, it is conceivable that heating properties of magnetites can be used in future cancer treatments.

Factors affecting the permeability of Pseudomonas aeruginosa cell walls toward lipophilic compounds: effects of ultrasound and cell age

The objective of this research was to elucidate the factors effecting the permeability of cell membranes of gram-negative bacteria toward hydrophobic compounds. Ultrasound treatment, cell age, and the phase state of phospholipid membranes were considered. Spin-labeling EPR method was used to quantify the penetration and distribution of a lipophilic spin probe, 16-doxylstearic acid (16-DS), in Pseudomonas aeruginosa cell membranes. This bacterium was chosen because of its reported resistance to the action of hydrophobic antibiotics caused by the low permeability of the outer cell membrane for hydrophobic compounds. EPR spectra were collected from cell pellets and cell lysates. The overall spin probe uptake was measured in 10% SDS-cell lysates. Lysis with 0.6% SDS revealed the fraction of the probe located in membrane sites readily accessible to the surfactant. The results indicated a structural heterogeneity of P. aeruginosa membranes, with the presence of structurally "stronger" and "weaker" sites characterized by different susceptibility to the SDS treatment. The intracellular concentration of 16-DS was higher in insonated cells and increased linearly with the sonication power. EPR spectra indicated that ultrasound enhanced the penetration of the probe into the structurally stronger sites of the inner and outer cell membranes. The effect of ultrasound on the cell membranes was transient in that the initial membrane permeability was restored upon termination of the ultrasound treatment. These results suggest that the resistance of gram-negative bacteria to the action of hydrophobic antibiotics was caused by a low permeability of the outer cell membranes. This resistance may be reduced by the simultaneous application of antibiotic and ultrasound. This hypothesis was confirmed in our experiments with P. aeruginosa exposed to erythromycin.