Jurriaan F. Bakker

The HYPERcollar: A novel applicator for hyperthermia in the head and neck

The purpose of this work was to define all features, and show the potential, of the novel HYPERcollar applicator system for hyperthermia treatments in the head and neck region. The HYPERcollar applicator consists of (1) an antenna ring, (2) a waterbolus system and (3) a positioning system. The specific absorption rate (SAR) profile of this applicator was investigated by performing infra-red measurements in a cylindrical phantom. Mandatory patient-specific treatment planning was performed as an object lesson to a patient with a laryngeal tumour and an artificial lymph node metastasis. Comfort tests with healthy volunteers have revealed that the applicator provides sufficient comfort to maintain in treatment position for an hour: the standard hyperthermia treatment duration in our centre. By phantom measurements, we established that a central focus in the neck can be obtained, with 50% iso-SAR lengths of 3.5 cm in transversal directions (x/y) and 9–11 cm in the axial direction (z). Using treatment planning by detailed electromagnetic simulations, we showed that the SAR pattern can be optimised to enable simultaneous encompassing of a primary laryngeal tumour and a lymph node metastasis at the 25% iso-SAR level. This study shows that the applicator enables a good control, and sufficient possibilities for optimisation, of the SAR pattern. In an ongoing clinical feasibility study, we will investigate the possibilities of heating various target regions in the neck with this apparatus.

The clinical feasibility of deep hyperthermia treatment in the head and neck: new challenges for positioning and temperature measurement.

To apply high-quality hyperthermia treatment to tumours at deep locations in the head and neck (H&N), we have designed and built a site-specific phased-array applicator. Earlier, we demonstrated its features in parameter studies, validated those by phantom measurements and clinically introduced the system. In this paper we will critically review our first clinical experiences and demonstrate the pivotal role of hyperthermia treatment planning (HTP). Three representative patient cases (thyroid, oropharynx and nasal cavity) are selected and discussed. Treatment planning, the treatment, interstitially measured temperatures and their interrelation are analysed from a physics point of view. Treatments lasting 1 h were feasible and well tolerated and no acute treatment-related toxicity has been observed. Maximum temperatures measured are in the range of those obtained during deep hyperthermia treatments in the pelvic region but mean temperatures are still to be improved. Further, we found that simulated power absorption correlated well with measured temperatures illustrating the validity of our treatment approach of using energy profile optimizations to arrive at higher temperatures. This is the first data proving that focussed heating of tumours in the H&N is feasible. Further, HTP proved a valuable tool in treatment optimization. Items to improve are (1) the transfer of HTP settings into the clinic and (2) the registration of the thermal dose, i.e. dosimetry.

Assessment of induced SAR in children exposed to electromagnetic plane waves between 10 MHz and 5.6 GHz

To avoid potentially adverse health effects of electromagnetic fields (EMF), the International Commission on Non-Ionizing Radiation Protection (ICNIRP) has defined EMF reference levels from the basic restrictions on the induced whole-body-averaged specific absorption rate (SAR(wb)) and the peak 10 g spatial-averaged SAR (SAR(10g)). The objective of this study is to assess if the SAR in children remains below the basic restrictions upon exposure at the reference levels. Finite difference time domain (FDTD) modeling was used to calculate the SAR in six children and two adults when exposed to all 12 orthogonal plane wave configurations. A sensitivity study showed an expanded uncertainty of 53% (SAR(wb)) and 58% (SAR(10g)) due to variations in simulation settings and tissue properties. In this study, we found that the basic restriction on the SAR(wb) is occasionally exceeded for children, up to a maximum of 45% in small children. The maximum SAR(10g) values, usually found at body protrusions, remain under the limit for all scenarios studied. Our results are in good agreement with the literature, suggesting that the recommended ICNIRP reference levels may need fine tuning.

A Patch Antenna Design for Application in a Phased-Array Head and Neck Hyperthermia Applicator

In this paper, we describe a specifically designed patch antenna that can be used as the basis antenna element of a clinical phased-array head and neck hyperthermia applicator. Using electromagnetic simulations we optimized the dimensions of a probe-fed patch antenna design for operation at 433 MHz. By several optimization steps we could converge to a theoretical reflection of -38 dB and a bandwidth (-15 dB) of 20 MHz (4.6%). Theoretically, the electrical performance of the antenna was satisfactory over a temperature range of 15degC-35degC, and stable for patient-antenna distances to as low as 4 cm. In an experimental cylindrical setup using six elements of the final patch design, we measured the impedance characteristics of the antenna 1) to establish its performance in the applicator and 2) to validate the simulations. For this experimental setup we simulated and measured comparable values: -21 dB reflection at 433 MHz and a bandwidth of 18.5 MHz. On the basis of this study, we anticipate good central interference of the fields of multiple antennas and conclude that this patch antenna design is very suitable for the clinical antenna array. In future research we will verify the electrical performance in a prototype applicator.

A head and neck hyperthermia applicator: Theoretical antenna array design

Purpose: Investigation into the feasibility of a circular array of dipole antennas to deposit RF-energy centrally in the neck as a function of: (1) patient positioning, (2) antenna ring radius, (3) number of antenna rings, (4) number of antennas per ring and (5) distance between antenna rings. Materials and Methods: Power absorption (PA) distributions in realistic, head and neck, anatomy models are calculated at 433 MHz. Relative PA distributions corresponding to different set-ups were analysed using the ratio of the average PA (aPA) in the target and neck region. Results: Enlarging the antenna ring radius from 12.5 cm to 25 cm resulted in a ∼21% decrease in aPA. By changing the orientation of the patients with respect to the array an increase by ∼11% was obtained. Increase of the amount of antenna rings led to a better focussing of the power (1 → 2/3: ∼17%). Increase of the distance between the antenna rings resulted in a smaller (more target region conformal) focus but also a decreased power penetration. Conclusions: A single optimum array setup suitable for all patients is difficult to define. Based on the results and practical limitations a setup consisting of two rings of six antennas with a radius of 20 cm and 6 cm array spacing is considered a good choice providing the ability to heat the majority of patients.

A literature survey on indicators for characterisation and optimisation of SAR distributions in deep hyperthermia, a plea for standardisation

Purpose: To evaluate the predictive value of SAR indicators by assessing the correlation of a SAR indicator with the corresponding predicted temperature. Ultimately, this should lead to a number of verified SAR indicators for characterization and optimization of a predicted SAR distribution. Methods: A literature survey is followed by an evaluation of the SAR indicators on their functionality, using a set of heuristic classification criteria. To obtain an objective assessment of the predictive value for SAR characterisation, all SAR indicators are evaluated by correlating the value of the SAR indicator to the predicted target temperature when heated with the BSD2000 Sigma 60 applicator. Two methods were followed. First, the specificity of the SAR indicator to target temperature was assessed for each of the 36 patient-specific models, using 30 randomly chosen phase and amplitude settings. Secondly, each SAR indicator was used as a goal function to assess its suitability for optimisation purposes. Results: Only a selected number of SAR indicators correlate well with tumour/target-temperature. Hence, for target-related properties, an adequate set of SAR indicators is found in the literature. For hotspots, modifications are desirable. For optimisation purposes, improved objective functions have been defined. Conclusions: From the correlation of the SAR indicators with tumour temperature, a preferred set of SAR indicators is derived: For target heating, ‘average SAR ratio’, ‘Hotspot-target SAR ratio’, and ‘homogeneity coefficient’ provide suitable objective criteria, while for hotspot reduction, ‘Hotspot-target SAR ratio’ is considered the most useful indicator. For optimisation procedures, ‘Hotspot-target SAR ratio’ is currently the most suitable objective function.

Clinical integration of software tool VEDO for adaptive and quantitative application of phased array hyperthermia in the head and neck.

Abstract Background and purpose: In Rotterdam, patient-specific hyperthermia (HT) treatment planning (HTP) is applied for all deep head and neck (H&N) HT treatments. In this paper we introduce VEDO (the Visualisation Tool for Electromagnetic Dosimetry and Optimisation), the software tool required, and demonstrate its value for HTP-guided online complaint-adaptive (CA) steering based on specific absorption rate (SAR) optimisation during a H&N HT treatment. Materials and methods: VEDO integrates CA steering, visualisation of the SAR patterns and mean tumour SAR (SARtarget) optimisation in a single screen. The pre-calculated electromagnetic fields are loaded into VEDO. During treatment, VEDO shows the SAR pattern, overlaid on the patients’ CT-scan, corresponding to the actually applied power settings and it can (re-)optimise the SAR pattern to minimise SAR at regions where the patient senses discomfort while maintaining a high SARtarget. Results: The potential of the quantitative SAR steering approach using VEDO is demonstrated by analysis of the first treatment in which VEDO was used for two patients using the HYPERcollar. These cases show that VEDO allows response to power-related complaints of the patient and to quantify the change in absolute SAR: increasing either SARtarget from 96 to 178 W/kg (case 1); or show that the first SAR distribution was already optimum (case 2). Conclusion: This analysis shows that VEDO facilitates a quantitative treatment strategy allowing standardised application of HT by technicians of different HT centres, which will potentially lead to improved treatment quality and the possibility of tracking the effectiveness of different treatment strategies.

Effects of waterbolus size, shape and configuration on the SAR distribution pattern of the Lucite cone applicator

The effects of waterbolus dimensions and configuration on the effective field size (EFS) of the Lucite cone applicator (LCA) for superficial hyperthermia are presented. The goal of the research is to develop guidelines which mark out a sub-set of optimal LCA-waterbolus set-ups. The effects of variations in (i) waterbolus thickness, (ii) waterbolus area, (iii) waterbolus length/width ratio and (iv) eccentric placement of the applicator have been investigated in an FDTD model study. The prominent effects are verified with IR thermography measurements. An optimal EFS value of 80 cm2 is found for waterbolus area of 200–400 cm2. A small (10 × 10 cm2) waterbolus area restricts the EFS to 25% of the optimal value. The sensitivity to sub-optimal waterbolus area and length/width ratio increases with waterbolus height. Eccentric placement of the LCA near the waterbolus edge reduces the EFS to up to 50% of the optimal value. The IR measurements confirm the model findings. Based on the results, the following guidelines for the clinical application of the LCA have been defined: the waterbolus (i) should extend the LCA aperture at least 2.5 cm, especially at the Lucite windows, and (ii) the height should not exceed 2 cm.

Children and adults exposed to low-frequency magnetic fields at the ICNIRP reference levels: theoretical assessment of the induced electric fields

To avoid potentially adverse health effects, the International Commission on Non-Ionizing Radiation Protection (ICNIRP) has defined reference levels for time varying magnetic fields. Restrictions on the electric fields induced in the human body are provided based on biological response data for peripheral nerve stimulation and the induction of phosphenes. Numerical modeling is commonly used to assess the induced electric fields for various exposure configurations. The objective of this study was to assess the variations of the electric fields induced in children and adults and to compare the exposure at reference levels with the basic restrictions as function of anatomy. We used the scalar potential finite element method to calculate the induced electric fields in six children and two adults when exposed to uniform magnetic fields polarized in three orthogonal directions. We found that the induced electric fields are within the ICNIRP basic restrictions in nearly all cases. In PNS tissues, we found electric fields up to 95% (upper uncertainty limit due to discretization errors, k = 2) of the ICNIRP basic restrictions for exposures at the general public reference levels. For occupational reference levels, we found an over-exposure of maximum 79% (k = 2) in PNS tissues. We further found that the ICNIRP recommendations on spatial averaging in 2 × 2 × 2 mm³ contiguous tissue volumes and removal of peak values by the 99th percentile cause the results to depend strongly on the grid discretization step (i.e. an uncertainty of more than 50% at 2 mm) and the number of distinguished tissues in the anatomical models. The computational results obtained by various research institutes should be robust for different discretization settings and various anatomical models. Therefore, we recommend considering alternative routines for small anatomical structures such as non-contiguous averaging without taking the 99th percentile in future guidelines leading to consistent suppression of peak values amongst different simulation settings and anatomical models. The peak electric fields depend on the local tissue distribution in the various anatomical models, and we could not find a correlation with the size of the anatomy. Therefore, we recommend extending the evaluation using a sufficient set of anatomies including other than standing postures to assess the worst-case exposure setting and correspondence to the basic restrictions.

Analysis of human brain exposure to low‐frequency magnetic fields: A numerical assessment of spatially averaged electric fields and exposure limits

Compliance with the established exposure limits for the electric field (E-field) induced in the human brain due to low-frequency magnetic field (B-field) induction is demonstrated by numerical dosimetry. The objective of this study is to investigate the dependency of dosimetric compliance assessments on the applied methodology and segmentations. The dependency of the discretization uncertainty (i.e., staircasing and field singularity) on the spatially averaged peak E-field values is first determined using canonical and anatomical models. Because spatial averaging with a grid size of 0.5 mm or smaller sufficiently reduces the impact of artifacts regardless of tissue size, it is a superior approach to other proposed methods such as the 99th percentile or smearing of conductivity contrast. Through a canonical model, it is demonstrated that under the same uniform B-field exposure condition, the peak spatially averaged E-fields in a heterogeneous model can be significantly underestimated by a homogeneous model. The frequency scaling technique is found to introduce substantial error if the relative change in tissue conductivity is significant in the investigated frequency range. Lastly, the peak induced E-fields in the brain tissues of five high-resolution anatomically realistic models exposed to a uniform B-field at ICNIRP and IEEE reference levels in the frequency range of 10 Hz to 100 kHz show that the reference levels are not always compliant with the basic restrictions. Based on the results of this study, a revision is recommended for the guidelines/standards to achieve technically sound exposure limits that can be applied without ambiguity.