Therapeutic hyperthermia is a procedure that involves heating tissues to a higher temperature level, typically ranging from 41oC to 45oC. Its combination with radiotherapy and/or chemotherapy has been performed for many years, with remarkable success in treating advanced and recurrent cancers. The current hyperthermia strate- gies generally include local, regional, and whole-body hyperthermia, which can be implemented by many heating methods, such as microwave, radiofrequency, laser, and ultrasound. There are several hyperthermic treatment modalities in conjunction with radiotherapy/chemotherapy. Numerous studies have attempted to explain the mechanisms of thermosensitization from radiation and chemotherapy; however, a generalized standard for determining an optimal hyperthermia modality combined with radiotherapy/chemotherapy has not been established, so more research is needed. Fortunately, phase II/III clinical trials have demonstrated that hyperthermia combination therapy is beneficial for local tumor control and survival in patients with high-risk tumors of different types. The aim of this article is to present a comprehensive review of the latest advances in tumor hyperthermia combined with radiotherapy and/ or chemotherapy. We specifically focus on synergistic cellular and molecular mechanisms, thermal dose, treatment sequence, monitoring and imaging, and clinical outcomes of the combination therapy. The role of nanoparticles in sensitization during radio-/chemotherapy is also evaluated. Finally, research challenges and future trends in the related areas are presented.

A review of hyperthermia combined with radiotherapy/chemotherapy on malignant tumors.

Mild hyperthermia (43 degrees C for 1 h) induces extensive double-stranded DNA fragmentation and, at a later time, cell death in murine thymocytes. The cleavage of DNA into oligonucleosome-sized fragments resembles that observed in examples of apoptosis including radiation-induced death of thymocytes. Following hyperthermia, incubation at 37 degrees C is necessary to detect DNA fragmentation, although protein and RNA synthesis do not seem to be required. Two protein synthesis inhibitors, cycloheximide and emetine, and two RNA synthesis inhibitors, actinomycin D and 5,6-dichloro-1-beta-D-ribofuranosylbenzimidazole, do not inhibit DNA fragmentation or cell death in heated thymocytes at concentrations which significantly block these effects in irradiated thymocytes. We have used this difference in sensitivity to show that the DNA fragmentation induced in thymocytes which are irradiated and then heated seems to be caused only by the heating and not by the irradiation.

Hyperthermia Induces Apoptosis in Thymocytes

Chinese hamster ovary cells were exposed to various heat treatments followed by X-irradiation, and the induction and repair of DNA strand breaks was studied using the alkaline unwinding technique. Heat treatments alone were found to cause DNA strand breakage only for temperatures ≥43°C, whereas the number of radiation-induced strand breaks was unaffected by additional heating.Strand break repair was studied for irradiated cells preheated at temperatures ranging from 42°C to 45°C. The total repair curve could be separated into three phases, a fast (t = 0–15 min), an intermediate (t = 15–120 min) and a slow (t ≥ 120 min) phase. All phases were altered when cells were heated either prior to or after irradiation. The fast and the intermediate phase could be well irradiation. The fast and the intermediate phase could be well interpreted by the assumption that irradiation leads to both primary and secondary single-strand breaks, the latter being generated by enzymatic incision at sites of damaged bases. For irr...

Effect of heat on induction and repair of DNA strand breaks in X-irradiated CHO cells.

"Reverse"-cigar smokers (who hold the burning end of cigars within the mouth), dippers (who place a mixture of Khaini-tobacco and slaked lime into the lower gingival groove) and users of tobacco-containing toothpaste (gudakhu) in Orissa, India, were examined for precancerous oral lesions, the frequency of micronucleated cells at 3 different intra-oral sites, and levels of tobacco-specific nitrosamines (TSNA) in the saliva. Among reverse-cigar smokers, a high incidence of leukokeratosis nicotina palati, an elevated frequency of micronucleated cells in the palate (2.5% as compared to 0.6% in non-smokers and non-chewers of tobacco) and tongue (2.1%) from which carcinomas preferentially develop, and up to 5890 ppb nitrosonornicotine and up to 1880 ppb N-nitrosoanatabine in the saliva were found. Among Khaini-tobacco chewers, the frequency of micronucleated cells was elevated to 2.1% in the gingival groove, and up to 1580 ng N-nitrosonornicotine, 690 ng N-nitrosoanatabine, 90 ng N-nitrosoanabasine, and 180 ng 4-(methyl-N-nitrosamino)-1-(3-pyridyl)-1-butanone) per ml of saliva were observed. The localized elevation of the frequency of micronuclei and cancer development is probably due to a synergistic effect of hyperthermia and tobacco-related carcinogens among reverse-cigar smokers, and to the close, prolonged contact between the mucosa and tobacco among Khaini-tobacco/slaked lime dippers. Neither pre-cancerous lesions nor an elevated frequency of micronuclei were seen in the oral mucosa of users of gudakhu, a tobacco-containing toothpaste, which may be due to the low amount of TSNA released from the gudakhu and the short exposure time, which is restricted to the period of tooth brushing.

Localized formation of micronuclei in the oral mucosa and tobacco-specific nitrosamines in the saliva of "reverse" smokers, Khaini-tobacco chewers and gudakhu users.

Strand breaks were detected in the DNA of Ehrlich ascites cells as well as in HeLa S3 cells directly after 1-5 hr at 43-45 degrees C by the use of the unwinding in high salt/hydroxylapatite method. The strand breaks found could not be attributed to the decay of incorporated tritiated thymidine. When the cells were incubated at 37 degrees C after the hyperthermic treatments, the amount of strand breaks formed remained at a constant level. Hyperthermia inhibited the repair of "radiation-induced" strand breaks. The repair curves obtained this way show a heat-dose-dependent decrease of the relative weight of the fast component of repair. Similar repair curves of "radiation-induced" strand breaks could be obtained by mixing heat inactivated and vital control cells prior to irradiation. In the latter case, however, the DNA repair was inhibited to a greater extent for identical levels of cell survival. The possible underlying molecular mechanisms are discussed.

The Occurrence of DNA Strand Breaks after Hyperthermic Treatments of Mammalian Cells with and without Radiation

Human peripheral white blood cells, freshly isolated from normal individual donors, were exposed to hyperthermia. Heat-generated DNA strand break damage and white blood cell capacity to repair radiation-induced breaks were determined by a fluorometric alkaline unwinding assay. Strand breaks could be readily detected when white blood cells were incubated in a physiological salt solution at temperatures between 41 degrees and 46 degrees C, for times up to 90 min. The time course of strand break induction at 45 degrees C was characterized by a short initial lag, followed by a period of rapid break induction and subsequently a lower rate. Evidence is presented which suggests that the induction of DNA damage involved a "triggering" mechanism; a short treatment at 45 degrees C (10 to 20 min) initiated a cellular event which led to a rapid increase in the number of strand breaks during subsequent incubation of 37 degrees C. Continuous incubation at 45 degrees C produced less DNA damage than an initial period at 45 degrees C followed by incubation at 37 degrees C. This apparent "triggering phenomenon" was not due to a triggering of the respiratory burst in phagocytic cells, since no O2- could be detected; in fact, a 30-min treatment at 45 degrees C largely blocked the capacity of the cells to respond normally to a soluble stimulator of the respiratory burst. Unlike gamma-ray-induced breaks, 45 degrees C hyperthermia-induced breaks did not rejoin during subsequent incubation for up to 1 h at 37 degrees C. Additionally, 45 degrees C hyperthermia treatment progressively inhibited the ability of the cells to repair subsequent gamma-ray-induced breaks (4 Gy). This inhibition occurred during the period in which 45 degrees C heat rapidly induced strand breaks. Hyperthermia (41 degrees C), which did not trigger strand breaks, did not cause detectable inhibition of this repair capacity. There was no indication that hyperthermia sensitized cells to radiation-induced strand breaks.

https://cancerres.aacrjournals.org/content/canres/45/5/2040.full.pdf

R. E. J. Mitchel

Papers

Triggering of DNA strand breaks by 45 degrees C hyperthermia and its influence on the repair of gamma-radiation damage in human white blood cells.