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Hyperthermia review Article Oman Medical Journal [2016], Vol. 31, No. 2: 89–97 Hyperthermia: How Can It Be Used? Zhaleh Behrouzkia 1, Zahra Joveini2*, Behnaz Keshavarzi2, Nazila Eyvazzadeh3 and Reza Zohdi Aghdam4 1Medical Physics Department, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran 2Student Research Committee, Urmia University of Medical Science, Urmia, Iran 3Radiation Research Center, Faculty of Paramedicine, AJA University of Medical Sciences, Tehran, Iran 4Medical Physics Department, Faculty of ParaMedicine, Urmia University of Medical Sciences, Urmia, Iran ARTICLE INFO ABSTRACT Article history: Hyperthermia (HT) is a method used to treat tumors by increasing the temperature of the Received: 27 December 2015 cells. The treatment can be applied in combination with other verified cancer treatments Accepted: 25 January 2016 using several different procedures. We sought to present an overview of the different HT Online: tumor treatment, recent advances in the field, and combinational treatment sequences DOI 10.5001/omj.2016.19 and outcomes. We used a computer-aided search to identify articles that contained the keywords hyperthermia, cancer treatment, chemotherapy, radiotherapy, nanoparticle, and Keywords: Hyperthermia; Cancer cisplatin. There are three types of HT treatment, which each need the use of applicators Treatment Protocols; that are in contact with or in the proximity of the patient for the purpose of heating. Chemotherapy; Radiotherapy. Heating can be achieved using different types of energy (including microwaves, radio waves, and ultrasound). However, the source of energy will depend on the cancer type and location. The temperature used will also vary. HT is rarely used alone, and can be combined with other cancer treatments. When used in combination with other treatments, improved survival rates have been observed. However, despite in vitro and in vivo studies that support the use of concurrent hypothermia treatments, contradictory results suggest there is a need for more studies to identify other hidden effects of HT. yperthermia (HT) is a type of thermal therapies to a tumor to reach annihilation or cancer treatment along with surgery, significant tumor destruction.8 radiotherapy, chemotherapy, and The curative capacities, treatment outlay, gene and immunotherapy.1 In technical problems, and evidence of efficacy vary oncology,H HT uses an external heat source to increase depending on the HT approach.9 While treatment tissue temperature and kill cancer cells or impede of tumors with HT has been applied since the time their further growth.2 of the ancient Greeks, use of this technique has been The term ‘hyperthermia’ applies to several heat opposed due to limitations. These include failure to application techniques that are implemented in heat the target without damaging the nearby cells, addition to other cancer treatments (particularly difficulty achieving homogenous heat dispersion chemotherapy and radiotherapy).3 throughout the tumor, and inherent problems with High temperatures, as most studies revealed,4 targeting invisible micrometastases. cause direct injury to cancerous cells and sensitize In recent years, advances in nanoparticle-aided the cells to other treatment modalities, and augments thermal therapy hold the ability to overcome most radiation and chemotherapy with insignificant or of these problems, but there are still concerns about no injury to normal tissues.5 Hence, HT is generally the use of nanoparticles. While it was known that used as an adjuvant treatment for cancer.6,7 normal tissues exhibit enhanced thermotolerance HT treatment temperatures range between toward cancer cells,9,10 the mechanisms controlling 40–48 °C and the temperature is maintained at this are largely unknown.11 Depending on the site of a treated site for one hour or more.6 Because of the tumor (e.g., superficial or deep-seated) different the consequences high temperature may have on treatment modalities can be adopted. tissues, one can refer to use temperatures >50 °C as In this review, we present an overview of tumor coagulation, 60–90 °C as thermal ablation, and >200 HT therapy modalities, recent advances in the °C as charring.5 Ablation or high-temperature HT is field, and combinational treatment sequences and defined as the direct implementation of chemical or outcomes. *Corresponding author: [email protected] 90 Zhaleh Behrouzkia, et al. Treatment Methods peritoneal mesothelioma and gastric cancer. In There are three main clinical methods of high- this method, the heated chemotherapeutic agent is temperature applications, which depend on the organ inserted into the peritoneal cavity, increasing the to be targeted, the stage of cancer, and the energy tissue temperature inside the cavity to 41–42 °C.14 distribution technique. Local, regional, and whole- Regional or partial HT is a method for heating body HT distribute heat to localized, progressive large parts of the body. It is usually used to treat or deep-seated and dispersed malignancies, advanced tumors located in the pelvis, abdomen, or respectively.12 thighs. Three key methods can be described: intrinsic (tumors heated with peripheral applicators), thermal Local hyperthermia (organs or limbs heated with thermal perfusion), Local HT is devoted to relatively small tumors and constant hyperthermic peritoneal perfusion (≤3 cm up to 5–6 cm),6,13 located superficially or (CHPP). within an available body cavity such as the rectum Some of the most useful external applicators or esophagus. In local HT, superficial, intraluminal for regional HT contain coherent arrays of dipole applicators can be applied and, most frequently, antenna couples placed in a loop design around microwaves, radio waves, or ultrasound are used to the patient. The antennas produce microwave or convey heat to the tumors.9 radiofrequency energy to be absorbed in the target Superficial applicators of different shapes and tissue. With such apparatus, target tissue can be types (e.g., waveguide, spiral, and current sheet) are heated to 41–42 °C.15 Malignancies disturbing positioned on the surface of superficial tumors with arms or legs (e.g., melanoma) or other organs (e.g., a contacting layer called a bolus. To inhibit any side liver, lung) can be cured with regional HT. This effects, water boluses are concurrently used to keep technique, compared to whole body HT, presents the temperature of the skin at about 37 °C. These fewer systemic side effects.6 boluses also confirm the electromagnetic linking However, regional HT is more complicated from the applicator to the tissue. To record the than local heating, mainly because of widespread temperature, small thermometers are inserted into differences in the physical and physiological tubes or needles attached to the anesthetized tumor properties of different tissues. It needs more refined tissue.4 planning, temperature measuring, and quality Cancers located near body cavities, for example assurance. That said, the use of nontoxic and efficient in the prostate, rectum, vagina, cervix, or esophagus, regional HT was approved in phase III studies using can be treated via intracavitary or intraluminal slightly invasive thermometry catheters and no methods, bringing heat directly into these regions. significant side effects.16 The method for heating superficial tumors is devoted The lack of consistent temperature measurement to the spectrum of tumors able to be treated with approaches makes heating upper abdominal tumors brachytherapy (head and neck tumors, prostate difficult. Regional HT of other anatomical areas cancer, brain malignancies, and breast cancer). such as the thorax or neck exposes likely problems Compared to brachytherapy, interstitial HT is an and is not possible. Most clinical trials on regional invasive procedure and is appropriate for lesions no HT have applied the method in combination with more than 5 cm in size. This method requires an array radiotherapy.17 of applicators to be fixed under local or, occasionally, The Duke Medical Center, in Durham, North general anesthesia.7 Carolina, examined the use of preoperative radiotherapy in adjunct to regional HT.18 A simple Regional hyperthermia heat therapy is the treatment of pains, tensions, and In the regional perfusion HT procedure, part of the injuries via implementation of temperatures less than patient’s blood is removed, heated, and then pumped 41 °C for about an hour using physiological processes back into the limb or organ, typically along with for elevating metabolic rates and blood flow.19 anticancer drugs. Tumor cell properties, such as hypoxia, poor Hyperthermic intraperitoneal chemotherapy nutrition, and low pH, can be helpful in heat (HIPEC), has been recommended to treat cancers therapy. The acidic environment of tumor confers within the peritoneal cavity, such as primary resistance to radiation but favors cell death due to 90 Zhaleh Behrouzkia, et al. Zhaleh Behrouzkia, et al. 91 heat. The effect of HT depends on the exposure and calm, or general anesthesia. Whether intubation time and temperature. HT is considered to influence is essential for safe administration is still under tumor sensitivity to other treatments principally by debate.25 microenvironmental factors like pH. One hypothesis about the mechanism of HT is that tumor resistant Thermal dose and thermal isoeffect dose areas are eradicated under hyperthermic situations Nowadays cumulative equivalent minutes at a normal due to related hypervascularization, which arises at targeted treatment
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