Oxidative stress as a precursor to the irreversible hepatocellular injury caused by hyperthermia

Heat-induced hepatotoxicity accompanying hyperthermic liver perfusion was studied in the isolated, haemoglobin-free perfused rat liver. Trypan blue uptake, a sensitive indicator of cell death, was used to examine the relationship between the efflux of oxidized glutathione (oxidative stress), the appearance of cytosolic enzymes in the perfusate and cell death. Livers were perfused at 37, 42, 42.5 and 43 degrees C. The efflux of total glutathione (GSH) and oxidized glutathione (GSSG) increased with time and temperature. Differences between temperature groups were significant for both parameters for 37 versus 42, 42.5 and 43 degrees C (p less than 0.05). Temperature-related differences in GSH levels appeared at 15 min for 37 versus 42 degrees C and in GSSG levels at 30 min for 37 versus 42 and 42.5 degrees C. Biliary excretion of total GSH increased from 72 nmol at 37 degrees C to 144 nmol at 42 degrees C, 160 nmol at 42.5 degrees C and 124 nmol at 43 degrees C, which was significant for 37 versus 42 and 42.5 degrees C (p less than 0.05). The release of allantoin into the perfusate, a measure of purine catabolism and flux through xanthine oxidase, was increased at 42, 42.5 and 43 degrees C compared to 37 degrees C (p less than 0.05). Liver injury was assessed by measuring the release of asportate aminotransferase (AST) and lactate dehydrogenase (LDH) and uptake of trypan blue after perfusion at each temperature. There was a pronounced release of LDH and AST into the perfusate after 60 min of perfusion at 42, 42.5 and 43 degrees C, the levels of which were significantly different from the 37 degrees C mean level. There was no uptake of trypan blue after 60 min perfusion at 37 degrees C. Perfusion at 42, 42.5 and 43 degrees C resulted in the uptake of trypan blue in the pericentral areas, but the dye uptake was significant (p less than 0.05) compared to 37 degrees C at 42.5 and 43 degrees C only. These data show that heat-induced pericentral cell death is minimal after 60 min at 42-43 degrees C, and that the biochemical process which occurred during this period suggest 'oxidative stress' as a causative factor in hyperthermic hepatotoxicity. In addition, this liver toxicity is probably related to xanthine oxidase activity or the depletion of GSH as the initiating event which leads to lipid peroxidation and cellular damage.     

Oxidative stress as a precursor to the irreversible hepatocellular injury caused by hyperthermia

Heat-induced hepatotoxicity accompanying hyperthermic liver perfusion was studied in the isolated, haemoglobin-free perfused rat liver. Trypan blue uptake, a sensitive indicator of cell death, was used to examine the relationship between the efflux of oxidized glutathione (oxidative stress), the appearance of cytosolic enzymes in the perfusate and cell death. Livers were perfused at 37, 42, 42.5 and 43°C. The efflux of total glutathione (GSH) and oxidized glutathione (GSSG) increased with time and temperature. Differences between temperature groups were significant for both parameters for 37 versus 42, 42.5 and 43°C (p < 0.05). Temperature-related differences in GSH levels appeared at 15 min for 37 versus 42 °C and in GSSG levels at 30 min for 37 versus 42 and 42.5°C. Biliary excretion of total GSH increased from 72 nmol at 37°C to 144 nmol at 42°C, 160 nmol at 42.5°C and 124 nmol at 43°C, which was significant for 37 versus 42 and 42.5°C (p < 0.05). The release of allantoin into the perfusate, a measure of purine catabolism and flux through xanthine oxidase, was increased at 42, 42.5 and 43°C compared to 37°C (p < 0.05). Liver injury was assessed by measuring the release of asportate aminotransferase (AST) and lactate dehydrogenase (LDH) and uptake of trypan blue after perfusion at each temperature. There was a pronounced release of LDH and AST into the perfusate after 60 min of perfusion at 42, 42.5 and 43°C, the levels of which were significantly different from the 37°C mean level. There was no uptake of trypan blue after 60 min perfusion at 37°C. Perfusion at 42, 42.5 and 43°C resulted in the uptake of trypan blue in the pericentral areas, but the dye uptake was significant (p < 0.05) compared to 37°C at 42.5 and 43°C only. These data show that heat-induced pericentral cell death is minimal after 60 min at 42–43°C, and that the biochemical processes which occurred during this period suggest ‘oxidative stress’ as a causative factor in hyperthermic hepatotoxicity. In addition, this liver toxicity is probably related to xanthine oxidase activity or the depletion of GSH as the initiating event which leads to lipid peroxidation and cellular damage.     

Involvement of xanthine oxidase in oxidative stress and iron release during hyperthermic rat liver perfusion.

The hepatotoxic effects of hyperthermia have been proposed to be related to lipid peroxidation as a consequence of oxidative stress. This can result from exposure of the cell to "radical oxygen" species such as the superoxide and hydrogen peroxide generated by the activity of the oxidase form (type O) of xanthine oxidase (XO), which is converted to that form by perfusion of the liver at hyperthermic temperatures. These radical species are not reactive enough in themselves to cause cell damage but require the presence of a catalyst such as low molecular weight chelated iron. In these studies, ferritin was shown to be a source of iron for the oxidative stress of hyperthermia. (a) Iron was released from ferritin in vitro by the activity of rat liver XO. The rate of iron release from ferritin in this incubation system was a function of the amount of type O XO present and the temperature. Inclusion of allopurinol or superoxide dismutase in the incubation resulted in significantly lower rates of iron release. (b) Livers from Sprague-Dawley rats were perfused at 42.5 degrees and 37 degrees C for 1 h. During the recirculating perfusion, loss of iron from the liver into the perfusate was significantly greater (P less than 0.05) at 42.5 degrees C than at 37 degrees C. Also, there was a pronounced increase in the lactate dehydrogenase and aspartate aminotransferase enzymes in the perfusate during perfusion at 42.5 degrees C. Furthermore, intrahepatic levels of low molecular weight chelated iron were significantly (P less than 0.05) increased following perfusion at 42.5 degrees C. All these responses were abrogated by the inclusion of allopurinol in the perfusate. (c) Oxidative stress, assessed by the efflux of glutathione and oxided glutathione from the liver at 42.5 degrees and 37 degrees C, was significantly (P less than 0.05) increased at the hyperthermic temperature. This oxidative stress was inhibited by iron chelation and allopurinol. These results demonstrate that there is a causal relationship between the generation of superoxide by type O XO produced by hyperthermic perfusion and mobilization of iron from ferritin to form a pool of low molecular weight chelated iron. This iron pool in combination with active oxygen species leads to oxidative stress and lipid peroxidation.     

Intrinsic thermal response, thermotolerance development and stepdown heating in murine bone marrow progenitor cells.

Thermal response, thermotolerance development and stepdown heating (SDH) in the murine bone marrow granulocyte-macrophage (CFU-GM) progenitors were determined in vitro. Marrow was removed from femora and tibia, heated in McCoy's 5A medium plus 15% FBS and cultured in soft agar in the presence of three different sources of colony stimulating factor. D0's (+/- SE) for survival curves of CFU-GM heated in vitro were 147 +/- 13, 71 +/- 9, 37 +/- 2, 19 +/- 0.7, 11 +/- 1, and 4.3 +/- 0.3 min, for temperatures of 41.8, 42, 42.3, 42.5, 43 and 44 degrees C, respectively. Arrhenius analysis showed inactivation enthalpies of 812 +/- 9 KJoules/mole (193 +/- 2 Kcal/mole) above, and 2142 +/- 157 KJoules/mole (509 +/- 37 Kcal/mole) below, an inflection at 42.5 degrees C. Thermotolerance development was evident during prolonged hyperthermia exposure at temperatures below 42.5 degrees C (chronic hyperthermia) as a change in the slope of the survival curves after approximately 110 min of heating. Thermotolerance development at 37 degrees C after exposure to temperatures of 43 degrees C or greater (acute hyperthermia) was assessed by fractionated heat treatments consisting of an initial heat treatment (15 min at 44 degrees C) followed by incubation at 37 degrees C and challenge with 15 min or 25 min at 44 degrees C. Maximum thermotolerance occurred after 210 and 330 min at 37 degrees C, respectively. The half-time for maximum thermotolerance development was 36 min. Depending on the amount of heat damage and the maximum amount of thermotolerance development, the decay of thermotolerance was complete after approximately 48-72 h at 37 degrees C. An exposure of 10 min at 44 degrees C before incubation at 40 or 41 degrees C (stepdown heating) reduced the slope of the 40 or 41 degrees C survival curves by inhibiting thermotolerance development that would have otherwise occurred. D0's were 100 +/- 19 and 45 +/- 5 min for 40 and 41 degrees C incubation preceded by 10 min at 44 degrees C, respectively. These studies indicate that whole-body or regional hyperthermia protocols designed either to treat solid tumours or to purge leukemic stem cells from marrow ex vivo should avoid inadvertent temperature elevations to large volumes of marrow. Although, marrow progenitors are capable of thermotolerance development during exposure to temperatures up to 42.3 degrees C, results suggest that conditions of stepdown heating may prevent thermotolerance development.     

Effect of hyperthermia on cisplatin pharmacokinetics in normal dogs

In vitro and in vivo cisplatin pharmacokinetic studies were conducted at 37 degrees C and 42-43 degrees C in dogs. Cisplatin at 1, 2, 3, 4 and 5 micrograms/ml was incubated with canine serum at 37 degrees and 43 degrees C. Aliquots were processed immediately for atomic absorption spectrophotometry to determine total as well as free, ultrafilterable cisplatin concentrations. Thirteen healthy, average-sized mongrel dogs received 1 mg/kg cisplatin as an intravenous bolus. Four were maintained unanaesthetized at 37 degrees C, two were anaesthetized and maintained at 37 degrees C and seven were anaesthetized and maintained at a rectal temperature of 42 degrees C for 60 min. Serum samples were obtained and processed for free and total cisplatin. There were no detectable concentration effects present in either in vitro group. The rate constant reflecting the decay of free cisplatin at 37 degrees C was 0.0035 +/- 0.0007 min-1 and increased significantly (P less than 0.0001) to 0.0053 +/- 0.001 min-1 at 43 degrees C. In vivo pharmacokinetic analysis consisted of model-independent parameters (total body clearance, volume of distribution, half-life and mean residence time). A significant increase (P less than or equal to 0.05) in all parameters was observed with free-cisplatin at 42 degrees C. This data would indicate that at the elevated temperatures encountered in whole body hyperthermia, the rate of formation of reactive metabolites from parent cisplatin is increased.(ABSTRACT TRUNCATED AT 250 WORDS)     

Liver hyperthermia and oxidative stress: role of iron and aldehyde production

Hyperthermia has been used to treat cancer in the liver. However, significant hepatotoxicity occurs at a therapeutic temperature of 42-43°C. We have proposed that heat toxicity is the result of oxidative stress from superoxide generation with resultant lipid peroxidation. Further, iron release from liver iron stores (ferritin) appears to play a central role in hyperthermic toxicity. In this study, rat livers were perfused in situ at 37 or 42°5°C with and without deferoxamine for 1 h with an asanguinous perfusate. Oxidative stress was assessed by the efflux of glutathione (GSH) into the perfusage. Prior studies by Skibba et al. (1989a, 1991) showed that perfusage equivalents of GSH were primarily present as oxidized glutathione (GSSG). Lipid peroxidation was assessed by the measurement of aldehydes appearing in the perfusate and formation of hydrocarbon gases (ethane and pentane) in the perfusion chamber head space. Liver injury was assessed by the leakage of cytosolic enzymes, AST and LDH, into the perfusate. Livers perfused at 42°5°C showed significant rises (p < 0°05) in AST and LDH after 60 min of perfusion but perfusion at 42°5°C with deferoxamine added, was not significantly different from perfusion at 37°C. Perfusion at 42°5°C caused an increase in GSH into the perfusate at a level significantly (p < 0°05) greater than at 37°C. GSH levels in the liver after 60 min of perfusion decreased from 4°82 ° 0°76 μM/gm at 37°C to 1°48°0°54μM/gm at 425°C (p < 0°05) but only fell to 3°42 ° 1°23 μM/gm at 42°5°C with deferoxamine added. Efflux of iron into the perfusate increase significantly with time and temperature. Low molecular weight chelated iron within the liver after perfusion increased from 5°88 ° 1°46 nM/gm at 37°C to 25°8 nM/gm at 42°5°C (p < 0°05). Perfusate total aldehyde levels increased from 0°085 ° 0°056 to 0°32 ° 0°09 μM/ml after 60 min at 37°C and 0°87 ° 0°45 to 201 ° 0°90 μM/ml at 42°5°C (n = 8). There was a significant decrease in total aldehyde levels at 42°5°C with the addition of deferoxamine to the perfusate, 0°36 ° 0°14 to 0°86 ° 0°27 μM/ml, when compared to 42°5°C levels (p < 0°05). Levels of ethane and pentane in the perfusion chamber head space showed no significnt changes with time or temperature of perfusion. The data suggest that lipid peroxidation may play a causal role in hyperthermia induced liver toxicity and that iron plays a major role in this injury. Failure of hydrocarbon analysis to support this conclusion appears related to the use of membrane oxygenators.     

A moderate elevation of blood glucose level increases the effectiveness of thermoradiotherapy in a rat tumor model. I. Relative contributions of glucose and heating to tumor acidification

PURPOSE: To establish dose-effect relationships for tumor acidification induced by heat and glucose as a basis for testing the value of adding glucose administration to combined heat and x-ray treatment at clinically achievable glucose and temperature levels. METHODS AND MATERIALS: Rhabdomyosarcoma BA1112 was grown s.c. in the upper leg of 16-20-week-old Wag/Rij rats. Animals were given 2 consecutive 100-min periods of saline (S) or glucose (G) infusion, while keeping tumor temperature at 37 degrees, 42 degrees, or 43 degrees C for 1 or 2 periods, in various combinations, each involving 6 animals. Glucose was infused i.v. as a 20% solution at 2.4-3 g/kg/h. Tumors were heated using 2,450-MHz electromagnetic radiation, and tumor pH was measured using a 0.7 mm fiberoptic probe. RESULTS: Mean overall baseline pH was 7.00 (SD 0.10). The change induced by G37G43 (i.e., glucose infusion for a full 200 min, first 100 min at 37 degrees C, final 100 min at 43 degrees C) was -0.48 +/- 0.03 (SEM) pH units, and -0.17 +/- 0.03 for S37S43. The effect of G37G42 was -0.37 +/- 0.03 pH units, compared with -0.08 +/- 0.02 for S37S42 and -0.28 +/- 0.04 for glucose alone (G37G37). Glucose was less effective when given after or fully parallel to heating: -0.21 +/- 0.02 pH units for S43G37 and -0.37 +/- 0.02 for G43G43. CONCLUSION: The glucose-induced tumor pH drop is much more pronounced than that induced by heat, both of which are dose dependent. The effects of glucose and heat seem additive if heating is started when glucose-induced acidification has reached its plateau level, but the overall effect is diminished if administration is fully simultaneous or in reversed order. Schedule G37G43 is optimal with respect to tumor acidification. Its predicted superiority in thermoradiotherapy as compared with S37S42, S37S43, and G37G42 treatment regimens was confirmed in a subsequent experimental tumor control study.     

Glutathione elevation during thermotolerance induction and thermosensitization by glutathione depletion

Chinese hamster V79 cells were made thermotolerant by either continuous heating at 42.5 degrees or by fractionated 43 degrees exposures with interfraction incubation at 37 degrees. For both methods of thermotolerance induction, elevations in cellular glutathione (GSH) were observed. Additionally, GSH was also shown to be elevated following a 1-hr exposure to 6% ethanol, which also induces thermotolerance. These elevations in cellular GSH preceded thermotolerance induction in regard to cell survival. To determine if a reduction in cellular GSH prior to or during heating at 42.5 degrees would influence thermotolerance, GSH levels were reduced by either pretreatment with diethylmaleate, an agent that binds GSH, or treatment during heating with buthionine sulfoximine, an agent that inhibits GSH synthesis. Both depleting protocols resulted in thermosensitization. These data suggest that GSH may be important in the early cellular response to thermal stress.     

Phosphorus NMR study of the response of a murine tumour to hyperthermia as a function of treatment time and temperature

Evaluating the response of tumours to therapy promises to become one of the major applications of in vivo phosphorus (31P) nuclear magnetic resonance spectroscopy. Decreases in the levels of organic phosphates in favour of inorganic phosphate (Pi) as occur in murine tumours after hyperthermia treatment, can be quantified by the ratio ATP/Pi. In this study the relationship between the time of heating (15, 30 and 60 min) and the temperature (43 and 44 degrees C) was investigated in mice with NU-82 tumours by considering the changes in ATP/Pi ratio as a function of both variables. After 30 min treatment at 43 degrees C the percentage decrease in ATP/Pi ratio was similar to that observed after 15 min at 44 degrees C (42 +/- 9 vs. 48 +/- 9); after 60 min at 43 degrees C the decrease was similar to that after 30 min at 44 degrees C (75 +/- 7 vs. 74 +/- 4). These results give further evidence for the validity of a current working definition of thermal dose: thermal dose = t integral of 0 2T-43 dt. In addition this study shows that in vivo 31P NMR spectroscopy can be a useful means for assessment of thermal dose.     

Arterial blood flow changes after hyperthermia on normal liver, normal brain, and normal small intestine

Arterial blood flow changes are studied after hyperthermia on normal liver, normal brain, and normal small intestine. A small part in left lateral lobe of rat liver was heated by RF capacity heating. Arterial blood flow in heated area of liver decreased to 69.2 +/- 8.1 and 51.3 +/- 6.6 ml/min/100 g dry weight respectively after heating at 43 degrees C for 30 min and 45 min, from 83.1 +/- 2.6 ml/min/100 g dry weight at 37 degrees C. To heat a small part in left hemisphere of rat cerebral tissue, RF interstitial heating device was utilized. Arterial blood flow in heated area increased to 289.1 +/- 41.5 ml/min/100 g dry weight after heating at 42 degrees C for 30 min from 223.6 +/- 18.8 ml/min/100 g dry weight at 37 degrees C. For small intestine heating, water bath was used. Arterial blood flow increased to 6.60 +/- 1.36, 7.44 +/- 1.16, and 11.6 +/- 2.2 ml/min/g dry weight respectively after heating at 39 degrees C, 41 degrees C, and 43 degrees C for 30 min, from 5.04 +/- 0.85 ml/min/g dry weight at 37 degrees C. These data suggest that blood flow changes after hyperthermia differ from tissue to tissue, and require further investigation on the effect of hyperthermia on blood flow changes in liver, brain, small intestine, and other normal tissues.     

Heterogeneity in heat sensitivity and development of thermotolerance of cloned cell lines derived from a single human melanoma xenograft

One uncloned and five cloned cell lines were isolated from a single human melanoma xenograft in passage 39 in athymic mice. Cells from passages 7-12 in vitro were heated at 42.5, 43.5 or 44.5 degrees C and the colony forming ability of the cells was assayed in soft agar. The six cell lines showed individual and characteristic responses to heat treatment. The D0 values of the survival curves were in the ranges 76 +/- 5 to 131 +/- 13 min (42.5 degrees C), 12.5 +/- 1.1 to 22.2 +/- 1.9 min (43.5 degrees C) and 9.4 +/- 1.0 to 15.6 +/- 1.5 min (44.5 degrees C). Cells from all lines developed thermotolerance during protracted treatments at 42.5 degrees C. Thermotolerance was also studied by giving the cells a priming treatment of 43.5 degrees C for 90 min and then, after different fractionation intervals at 37 degrees C, second graded treatments at 43.5 degrees C. Thermotolerance ratio (TTR), i.e. the ratio of the slopes of the survival curves for preheated and single-heated cells, was used as a quantitative measure of the thermotolerance. Thermotolerance developed rapidly for all lines, reached a maximum at 12 or 16 h, and then decayed slowly. Maximum TTR varied among the lines from 4.2 +/- 0.5 to 6.0 +/- 0.9, i.e. within a factor of about 1.4. The survival curves and the TTR-curve for the uncloned line were positioned in the midst of those of the cloned lines. A linear correlation between maximum TTR and heat sensitivity was found for the six lines; maximum TTR decreased with increasing D0 value at 43.5 degrees C. Nevertheless, the lines which were most resistant before thermotolerance developed were also most resistant at maximum thermotolerance.     

Decreased intracellular glutathione concentration and increased hyperthermic cytotoxicity in an acid environment

Chinese hamster ovary (CHO) cells were heated at either pH 7.2 to 7.4 or 6.7 to 6.8 in order to determine if conditions which suppress the development of thermotolerance (pH 6.7 to 6.8) reduce intracellular levels of glutathione (GSH). When the pH of the growth medium was reduced from 7.2 to 6.7, a 25 to 30% reduction in GSH was observed in cells maintained at 37 degrees. Cells heated at 42 degrees in medium adjusted to pH 6.7 had lower levels of GSH compared to cells heated at pH 7.2. Cells were also heated for 1 hr at 43 degrees and then incubated at 37 degrees for up to 9.5 hr prior to GSH measurement. The GSH levels of cells treated at pH 7.3 increased approximately 20% above control, whereas treatment at pH 6.7 resulted in a 20% reduction compared to control. Chinese hamster ovary cells were exposed to 5 mM buthionine sulfoximine (BSO) prior to and during 42 degrees heat treatment. BSO exposure at either pH 7.3 or 6.8 reduced the GSH concentration to approximately 65% of control and increased thermal cytotoxicity. The thermal sensitivity of cells incubated at 42 degrees and pH 7.3 was compared to that of cells incubated at pH 6.8. Decreasing the pH from 7.3 to 6.8 increased sensitivity by a factor of 1.87 in the absence of BSO, whereas decreasing the pH in the presence of BSO increased sensitivity by only 1.50. In summary, these results suggest that the increase in thermal sensitivity observed when Chinese hamster ovary cells are heated in acid medium is due partly to the depletion of GSH.     

In vitro thermo-chemosensitivity screening of spontaneous human tumors: significant potentiation for cisplatin but not adriamycin

The in vitro thermal enhancement of Adriamycin (ADR) and Cisplatin (CDDP) was investigated in 18 surgical biopsy specimens of human tumors cultured in the Adhesive Tumor Cell Culture System. Experimental conditions were adopted to simulate "therapeutic" trials: (a) temperature of 37.0 degrees C, 40.5 degrees C or 42.5 degrees C; (b) hyperthermic duration of 30, 60, or 120 min; and (c) 4-dose drug range normalized to human bone marrow toxicity. Drug concentrations that inhibited 90% of tumor growth (IC90) at 37.0 degrees C were compared to the IC90 at 40.5 degrees C and 42.5 degrees C, adjusted for the effect of heat alone. CDDP plus heat was a better combination than ADR plus heat, regardless of the temperature and the exposure duration: significant synergism (p less than 0.001) occurred in 37% of heat-CDDP combinations, as compared with 15% of heat-ADR combinations, and antagonism was significantly lower (p less than 0.001) for heat-CDDP than for heat-ADR (4.4% versus 21% of combinations, respectively). Within the CDDP group, higher temperature and longer heat exposure resulted in an increased incidence of chemosensitivity. No specific pattern of synergism was evident within the ADR group, but a trend toward a higher incidence of antagonistic effects with increasing hyperthermic duration was observed.     

Prerequisites for effective isolated limb perfusion using tumour necrosis factor alpha and melphalan in rats.

An isolated limb perfusion (ILP) model using soft tissue sarcoma-bearing rats was used to study prerequisites for an effective ILP, such as oxygenation of the perfusate, temperature of the limb, duration of the perfusion and concentration of tumour necrosis factor (TNF). Combination of 50 microg TNF and 40 microg melphalan demonstrated synergistic activity leading to a partial and complete response rate of 71%. In comparison to oxygenated ILP, hypoxia was shown to enhance anti-tumour activity of melphalan alone and TNF alone but not of their combined use. Shorter perfusion times decreased anti-tumour responses. At a temperature of 24-26 degrees C, anti-tumour effects were lost, whereas temperatures of 38-39 degrees C or 42-43 degrees C resulted in higher response rates. However, at 42-43 degrees C, local toxicity impaired limb function dramatically. Synergy between TNF and melphalan was lost at a dose of TNF below 10 microg in 5 ml perfusate. We conclude that the combination of TNF and melphalan has strong synergistic anti-tumour effects in our model, just as in the clinical setting. Hypoxia enhanced activity of melphalan and TNF alone but not the efficacy of their combined use. For an optimal ILP, minimal perfusion time of 30 min and minimal temperature of 38 degrees C was mandatory. Moreover, the dose of TNF could be lowered to 10 microg per 5 ml perfusate, which might allow the use of TNF in less leakage-free or less inert perfusion settings.     

Strategies for optimized application of annular-phased-array systems in clinical hyperthermia

A theoretical framework is presented for optimized heating of deep-seated tumours by phase and amplitude steering. The optimization problem for a specific tumour and perfusion case results in a functional dependency between power-level and maximum obtainable therapeutic efficiency. Different optimization criteria and strategies are outlined, which cause an increase of power or thermal dose in the tumour. Three tumour models (central pelvic tumour, eccentric abdominal tumour with or without necrosis) are analysed in detail. The simulation studies predict that appreciable parts of these tumours (50-100%) can be heated efficiently (42.5-43 degrees C) within the range of available and clinically tolerated power levels (1-5 kW/m), if tumour perfusion is less than 20-25 ml/100 g min. Some improvements are obtained by increasing the number of independent channels (from four to eight) and by the application of time-dependent (complementary) power-deposition patterns.     

Enhanced delivery of a monoclonal antibody F(ab')2 fragment to subcutaneous human glioma xenografts using local hyperthermia

The purpose of this study was to investigate the effects of tumor-localized hyperthermia at 42 degrees C on the tissue distribution of radioiodinated monoclonal antibody F(ab')2 fragments. Paired-label biodistribution measurements were performed in athymic mice bearing D-54 MG human glioma xenografts on one leg. Mice received both the 131I-labeled F(ab')2 fragment of Mel-14, reactive with human gliomas and melanomas, and nonspecific 125I-labeled RPC 5 F(ab')2. Tumor-bearing legs were placed in a 42 degrees C water bath or a 37 degrees C water bath (control) for 2 or 4 h. In mice sacrificed immediately after 2 h of heating, no hyperthermia-induced differences in the distribution of either fragment were observed. In the 4-h groups, tumor uptake of Mel-14 F(ab')2 increased from 7.04 +/- 1.59% injected dose (ID)/g at 37 degrees C to 20.65 +/- 4.53% ID/g at 42 degrees C (P less than 0.0001), and tumor localization of the control fragment rose from 5.23 +/- 1.35% ID/g to 14.51 +/- 1.37% ID/g (P less than 0.0001). In another experiment, F(ab')2 fragments were injected, tumors were heated for 4 h, and groups were sacrificed at 4, 8, and 16 h after injection. Statistically significant 2- to 3-fold higher uptake of both fragments in tumor were observed at all time points. Hyperthermic conditions also resulted in higher tumor:tissue ratios for both fragments. These results suggest that it may be possible to use tumor-localized hyperthermia to increase the therapeutic utility of radiolabeled monoclonal antibodies, particularly when labeled with short lived nuclides such as the 7.2-h alpha-emitter 211At.     

The effect of GSH depletion on thermal radiosensitization

Depletion of intracellular glutathione (GSH) increased aerobic thermal radiosensitization in Chinese hamster ovary (CHO) cells gamma irradiated and heated at 42 degrees C. The GSH concentration was decreased to various stable levels by exposure to increasing concentrations of diethylmaleate (DEM). Analysis of dose-response curves indicated that GSH depletion affected thermal sensitization and thermal radiosensitization at 42 degrees when greater than 95% of the GSH had been depleted. GSH depletion also increased the fixation of radiation damage. For example, survival after 10 Gy decreased from 0.012 to 0.006 if CHO cells were incubated in 100 microM DEM at 37 degrees for 2 hrs after irradiation. The results show that GSH might be an important agent for the protection of cells against thermal enhancement of radiation damage.     

Effect of pH, oxygenation, and temperature on the cytotoxicity and radiosensitization by etanidazole.

The effect of etanidazole was examined in vitro and in vivo in the FSaIIC tumor system. At pH 7.40 and 37 degrees C, etanidazole at 5-500 microM for 1 hr was minimally cytotoxic. At 42 degrees C and 43 degrees C, however, the cytotoxicity of etanidazole increased. Etanidazole was more cytotoxic at pH 6.45 and 37 degrees than at pH 7.40 by about 1 log. Increasing the temperature to 42 degrees C or 43 degrees C at pH 6.45 during drug exposure, however, caused little increase in drug killing above the lethality of hyperthermia. When the radiosensitizing abilities of etanidazole were tested in vitro, there was a radiation dose modifying factor of 2.40 at pH 7.40, but only 1.70 at pH 6.45. In vivo, etanidazole (1 g/kg) produced a radiation dose modifying factor of 1.47, whereas 43 degrees C for 30 min produced a radiation dose modifying factor of 1.38. The combination resulted in a radiation dose modifying factor of 2.29. When the cytotoxicities of hyperthermia (43 degrees C x 30 min), etanidazole (500 mg/kg or 1 mg/kg), and radiation (10 Gy) combinations were assayed by Hoechst 33342 dye selected tumor subpopulations, 43 degrees C x 30 min increased the killing of irradiated dim cells by approximately 9.2-fold but by only 2.9-fold in bright cells. Etanidazole (1 g/kg) increased radiation killing of bright cells by about 3-fold and dim cells by about 4.3-fold. The combination of hyperthermia and etanidazole increased the killing of both dim and bright cells exposed to radiation by approximately 10-fold versus 10 Gy alone.     

Combined modality therapy with bleomycin, hyperthermia, and radiation

In an attempt to develop better combination therapies for use with local radiation, the interaction between bleomycin and hyperthermia +/- radiation was studied in the FSaIIC tumor system. In cells exposed in vitro to bleomycin at 37 degrees C and at pH 7.40, the drug was substantially more toxic toward normally oxygenated than hypoxic cells. At hyperthermic temperatures (42 degrees or 43 degrees C), however, the differential killing between the normally oxygenated and hypoxic cells disappeared and bleomycin became significantly more toxic. Exposure to bleomycin at pH 6.45 did not substantially alter the cytotoxicity of the drug at 42 degrees or 43 degrees C. In tumor growth delay experiments, combining bleomycin, hyperthermia, and radiation induced long delays, and the more successful sequences were bleomycin----radiation----hyperthermia or bleomycin----hyperthermia----radiation. If radiation was given prior to drug and hyperthermia, however, the sequence was significantly less effective. In tumor excision experiments performed 24 h after treatment, increasing doses of bleomycin produced a shallow, log-linear increase in tumor cell kill at 37 degrees C, but bleomycin followed by hyperthermia (43 degrees C, 30 min) led to about 1 log more cell killing. Administration of bleomycin just prior to treatment with a single dose of radiation was cytotoxically additive. In this assay the most effective trimodality treatment sequence was bleomycin----hyperthermia----radiation. In tumor subpopulations defined by Hoechst 33342 dye staining, bleomycin at 37 degrees C was about two-fold more toxic toward the bright (presumably well-oxygenated) cells than toward the dim (presumably hypoxic) cell subpopulation. The addition of hyperthermia following bleomycin produced nearly a log more tumor cell killing in both the bright and dim tumor cells. The combination of bleomycin followed by hyperthermia and then radiation was at least additive in the bright cells and caused a large cell kill, but in comparison, there was marked sparing of the dim cells. These results indicate that treatment with bleomycin and hyperthermia in conjunction with radiation can add substantially to tumor cell killing. This combination is significantly less effective in the hypoxic than oxic tumor regions, however, in spite of in vitro data which demonstrate that the cytotoxicity of bleomycin at hyperthermic temperatures is not oxygen-dependent.     

Potentiation of adriamycin cytotoxicity in P388 murine leukemia sensitive and resistant to adriamycin by use of lonidamine and hyperthermia

The in vitro effect of adriamycin (ADR) and lonidamine alone and in combination, at 37 degrees C and 43 degrees C, was investigated on murine leukemia P388 sensitive (P388/S) and resistant (P388/ADR) to adriamycin. The sensitive and the resistant cells were exposed in vitro with and without the drugs for 1 h at 37 degrees C and 43 degrees C. These cells were inoculated ip (10(6) cells/mouse) into groups of BDF1 mice. Cytotoxic effect of the treatment was assessed on the basis of percentage increase in life span (% ILS) of these animals, compared to the animals receiving cells which did not receive any treatment but exposed only to 37 degrees C for 1 h. It was observed that exposure of P388/ADR cells to lonidamine or adriamycin alone at 43 degrees C for 1 h resulted in greater cell kill, thus enhancing the % ILS of the experimental animals receiving those cells, compared to that of mice receiving the cells exposed to the same drugs for 1 h at 37 degrees C. However, the combination of lonidamine (0.02 mM) and adriamycin (10 micrograms/ml) at 43 degrees C for 1 h showed more than a synergistic effect, resulting in a % ILS of 120. Similar results were seen in the case of P388/S; however, the observations pertaining to P388/ADR are encouraging, since the mode of treatment has reversed the acquired resistance of P388 leukemia cells to adriamycin.