Margarethus M. Paulides

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.

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.

Patient positioning in deep hyperthermia: influences of inaccuracies, signal correction possibilities and optimization potential

In this deep hyperthermia study, the robustness of SAR (specific absorption rate) patterns to patient-position variations is assessed, as well as the possibilities to correct for improper positioning and the benefits of non-standard positions. With a finite element model, the SAR distributions were predicted for ten patients at 33 positions. Position sensitivity is assessed for both SAR-focus steering, i.e. settings based on a calculated focus in a cylindrical patient representation, and HTP (hyperthermia treatment planning)-guided steering, i.e. model-based optimization of the SAR distribution. Position inaccuracies of less than 1 cm do not significantly affect SAR patterns. For SAR-focus steering, the SAR maximum is not always at the desired focus location, especially in the Y (anterior/posterior)- and Z (axial)-directions. For a maximum shift of 5 cm in all directions, both SAR-focus steering and HTP-guided steering are suitable to correct for improper positioning up to the level that none of the investigated positions appears preferable. Current positioning precision is sufficient in the X (right-left)-direction, but precision measurements are needed to reach the desired accuracy in the Y-direction. In the Z-direction, a cranial shift of the applicator is predicted to be beneficial. If the position is known accurately, correction of the treatment setting is possible without loss of heating efficiency. Additionally, no preferable positions exist.

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.

Children and adults exposed to electromagnetic fields at the ICNIRP reference levels: theoretical assessment of the induced peak temperature increase

To avoid potentially adverse health effects of electromagnetic fields (EMF), the International Commission on Non-Ionizing Radiation Protection (ICNIRP) has defined EMF reference levels. Restrictions on induced whole-body-averaged specific absorption rate (SAR(wb)) are provided to keep the whole-body temperature increase (T(body, incr)) under 1 °C during 30 min. Additional restrictions on the peak 10 g spatial-averaged SAR (SAR(10g)) are provided to prevent excessive localized tissue heating. The objective of this study is to assess the localized peak temperature increase (T(incr, max)) in children upon exposure at the reference levels. Finite-difference time-domain modeling was used to calculate T(incr, max) in six children and two adults exposed to orthogonal plane-wave configurations. We performed a sensitivity study and Monte Carlo analysis to assess the uncertainty of the results. Considering the uncertainties in the model parameters, we found that a peak temperature increase as high as 1 °C can occur for worst-case scenarios at the ICNIRP reference levels. Since the guidelines are deduced from temperature increase, we used T(incr, max) as being a better metric to prevent excessive localized tissue heating instead of localized peak SAR. However, we note that the exposure time should also be considered in future guidelines. Hence, we advise defining limits on T(incr, max) for specified durations of exposure.

Feasibility of multimodal deformable registration for head and neck tumor treatment planning

PURPOSE To investigate the feasibility of using deformable registration in clinical practice to fuse MR and CT images of the head and neck for treatment planning. METHOD AND MATERIALS A state-of-the-art deformable registration algorithm was optimized, evaluated, and compared with rigid registration. The evaluation was based on manually annotated anatomic landmarks and regions of interest in both modalities. We also developed a multiparametric registration approach, which simultaneously aligns T1- and T2-weighted MR sequences to CT. This was evaluated and compared with single-parametric approaches. RESULTS Our results show that deformable registration yielded a better accuracy than rigid registration, without introducing unrealistic deformations. For deformable registration, an average landmark alignment of approximatively 1.7 mm was obtained. For all the regions of interest excluding the cerebellum and the parotids, deformable registration provided a median modified Hausdorff distance of approximatively 1 mm. Similar accuracies were obtained for the single-parameter and multiparameter approaches. CONCLUSIONS This study demonstrates that deformable registration of head-and-neck CT and MR images is feasible, with overall a significanlty higher accuracy than for rigid registration.