Outcomes of single fraction or multifraction external beam radiotherapy for painful bone metastases.
\r\n\tThe major pathogenetic mechanisms resulting from RAAS overactivity include activation of the sympathetic nervous system, endothelial dysfunction, proinflammatory, and procoagulant states.
\r\n\tEmerging from basic science evidence, major clinical trials established the beneficial effects of inhibitors of the different components of RAAS such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), aldosterone antagonists. These effects range from treatment of hypertension, diabetic nephropathy, CHF, as well as improvement of outcomes after myocardial infarction and improvement in glucose homeostasis and prevention of type 2 diabetes with some agents.
\r\n\tIn this book, written by a world-renowned scholar, we will address the major concepts and topics related to RAAS activation including the pathogenetic mechanisms underlying the deleterious effects of activated RAAS and the role of local tissue RAAS in various organ systems such as the heart and vasculature, the skeletal muscle, adipose tissues, pancreas and the angiotensinergic pathways in the brain. Cutting-edge information is provided that will address the need for a wide range of readers including a medical student, clinical practitioner, and basic science investigators alike. This book will be bridging the gap between basic science and clinical practice regarding the RAAS system, which is imminently critical and highly relevant to the practice of medicine.
\r\n\r\n\tFinally, with data emerging from the COVID-19 pandemic indicating overrepresentation of people with diseases associated with RAAS activation such as hypertension, chronic kidney disease, and diabetes, the role of RAAS activation and RAAS inhibition in the pathogenesis and clinical outcomes in COVID-19 has garnered a great deal of interest. In this book, we will dedicate a chapter addressing this topical and highly critical subject.
\r\n\t
Bone metastases are a common manifestation of malignancies that can cause severe and debilitating effects, including pain, spinal cord compression, hypercalcemia and pathologic fractures. Proper care of patients with bone metastasis requires interdisciplinary treatments delivered by orthopedic surgeons, radiation oncologists, rehabilitation specialists, medical oncologists, pain medicine specialists, radiologists and palliative care professionals. Radiotherapy (RT) has played a central role for palliation of painful bone metastasis, leading to complete pain relief at the treated site in up to one‐third of patients [1]. The role of RT and radiotherapeutic techniques using a multidisciplinary approach for the treatment of bone metastases have been discussed recently.
\nExternal beam RT (EBRT) continues to be the mainstay treatment for painful, uncomplicated, bone metastases. EBRT can provide rapid successful palliation of painful bone metastasis in 50–80% of patients, is associated with very few adverse effects and leads to complete pain relief at the treated site in up to one‐third of patients. Although various fractionation schemes can provide good palliation rates, numerous prospective randomized trials have shown that 30 Gy in 10 fractions, 24 Gy in 6 fractions, 20 Gy in 5 fractions, or 8 Gy in a single fraction provide excellent pain control with minimal side effects (\nTable 1\n) [2–7]. Longer fractionated courses have the advantage of a lower incidence of repeat irradiation to the same site, whereas single fractions have proved more convenient for patients and caregivers. In addition, repeat irradiation with EBRT might be safe, effective and less commonly necessary in patients with a short life expectancy.
\nAuthor | \nPatients (n) | \nDose and fractions | \nOverall pain relief (%) | \nComplete response (%) | \nAcute toxicity (%) | \nLate toxicity (%) | \nRepeat treatment rate (%) | \n
---|---|---|---|---|---|---|---|
BPTWP [2] | \n775 | \n8 Gy in 1 Fx | \n78 | \n57 | \n30 | \n2 | \n23 | \n
\n | \n\n | \n20 Gy in 5 Fx/30 Gy in 10 Fx | \n78 | \n58 | \n32 | \n1 | \n10 | \n
Foro [3] | \n160 | \n8 Gy in 1 Fx | \n75 | \n15 | \n13 | \nNA | \n28 | \n
\n | \n\n | \n30 Gy in 10 Fx | \n86 | \n13 | \n18 | \nNA | \n2 | \n
Hartsell [4] | \n898 | \n8 Gy in 1 Fx/30 Gy in 10 Fx | \n66 | \n15 | \n10 | \n4 | \n18 | \n
Nielsen [5] | \n241 | \n8 Gy in 1 Fx | \n62 | \n15 | \n35 | \n5 | \n21 | \n
\n | \n\n | \n20 Gy in 4 Fx | \n71 | \n15 | \n35 | \n5 | \n12 | \n
Roos [6] | \n272 | \n8 Gy in 1 Fx | \n53 | \n26 | \n5 | \n5 | \n29 | \n
\n | \n\n | \n20 Gy in 5 Fx | \n61 | \n27 | \n11 | \n4 | \n24 | \n
Steenland [7] | \n1171 | \n8 Gy in 1 Fx | \n72 | \n37 | \nEquivalent | \n4 | \n25 | \n
\n | \n\n | \n24 Gy in 6 Fx | \n69 | \n33 | \nEquivalent | \n2 | \n7 | \n
Outcomes of single fraction or multifraction external beam radiotherapy for painful bone metastases.
BPTWP, Bone Pain Trial Working Party; NA, not assessed; Fx, fraction(s).
For metastatic spinal cord compression (MSCC), EBRT is the standard of care. Although a total of 30 Gy in 10 fractions is the most frequently employed fractionation schedule, multiple fractionation schemes have been reported, which undoubtedly reflect the heterogeneity in patient populations and tumor histologies (\nTable 2\n) [8–11]. In a retrospective study, Rades et al. [11] suggested that dose escalation beyond 30 Gy in 10 fractions did not improve motor function and local control in patients with MSCC who had radioresistant tumors such as renal cell carcinomas, colorectal cancers and malignant melanomas. However, in patients with breast cancer, prostate cancer, myeloma or lymphoma and others who had a favorable prognosis, dose escalation beyond 30 Gy provided better local control and extended overall survival [10]. Therefore, the use of 30 Gy in 10 fractions could be regarded as the standard therapeutic dose for MSCC, although the available evidence is limited. In patients with a favorable survival prognosis, dose escalation beyond 30 Gy might improve local control and overall survival, but it might not improve functional outcome and dose escalation to 40 Gy in 20 fractions might be insufficient against radioresistant tumors.
\nAuthor | \nStudy design | \nState of disease | \nDose | \nAmbulatory rate before treatment (%) | \nMotor function improvement (%) | \nLocal control | \nOverall survival | \n
---|---|---|---|---|---|---|---|
Maranzano [8] | \nRCT | \nUnfavorable prognosis | \n8 Gy in 1 Fx | \n64 | \n12 | \nNA | \n4 months (median) | \n
16 Gy in 2 Fx | \n67 | \n21 | \nNA | \n4 months (median) | \n|||
Rades [9] | \nProspective non‐RCT | \nVarious tumors | \n8 Gy in 1 Fx/20 Gy in 4 Fx | \n61 | \n37 | \n61% at 1 year | \n23% at 1 year | \n
30–40 Gy in 10–20 Fx | \n62 | \n39 | \n81% at 1 year | \n30% at 1 year | \n|||
Rades [10] | \nMatched cohort | \nFavorable prognosis tumors | \n30 Gy in 10 Fx | \n85 | \n40 | \n71% at 2 years | \n53% at 2 years | \n
37.5 Gy in 15 Fx/40 Gy in 20 Fx | \n85 | \n41 | \n92% at 2 years | \n68% at 2 years | \n|||
Rades [11] | \nRetrospective | \nRadioresistant tumors | \n30 Gy in 10 Fx | \n62 | \n18 | \n76% at 1 year | \nNA | \n
\n | \n | \n | 37.5 Gy in 15 Fx 40 Gy in 20 Fx | \n63 | \n22 | \n80 % at 1 year | \nNA | \n
External beam radiotherapy outcomes for metastatic spinal cord compression.
RCT, randomized controlled trial; Fx, fraction(s); NA, not assessed.
Recently, intensity‐modulated RT (IMRT) or stereotactic body RT (SBRT) has been applied for spinal bone metastases and the development of systemic treatments has improved survival in patients with bone metastasis. However, in such cases, the standard regimens for bone metastases including 30 Gy in 10 fractions, 20 Gy in 5 fractions, or 8 Gy in a single fraction were insufficient for long‐term pain management. Therefore, to increase the duration of pain control, it might be necessary to consider more intense RT or treatment regimens.
\nIMRT delivers high doses to tumor targets while decreasing the dose to organs‐at‐risk and, therefore, presents a major dosimetric advantage over three‐dimensional conformal RT. IMRT took radiation treatment planning and delivery to a higher level by combining technologies. It utilizes movement of the multileaf collimator (MLC) during the actual beam‐on time to modulate, or alter, the radiation beam as it leaves the radiation treatment unit. Such beam modulation allows the application of concave dose distributions. The computer system calculates an IMRT plan incorporating several beams, or, alternatively, a moving arc arrangement with the movement of the MLC to create a plan that achieves the radiation‐dosing goals (\nFigure 1\n). On the other hand, SBRT is emerging as an alternative RT technique to deliver dose‐escalated radiation to tumor targets. Due to the application of several nonisocentric beams, SBRT delivers highly conformal large radiation dose fractions to target volumes with precision (<1 mm) and steep dose gradients. This allows for planning target volume reductions, thereby minimizing exposure to critical adjacent organs, which produces a toxicity profile comparable with that of conventionally fractionated RT, despite the use of higher doses per fraction (\nFigure 2\n).
\nComparison of radiation dose distributions between conventional radiotherapy and intensity‐modulated radiotherapy (IMRT). (A) The osteolytic change in the lumbar vertebral body and infiltration into the spinal canal. (B) The dose distribution of conventional radiotherapy (two‐directional anteroposterior‐posteroanterior opposed irradiation at 30 Gy in 10 fractions). (C) The distribution of IMRT using volumetric modulated arc therapy (50 Gy in 10 fractions).
A 70‐year‐old male patient suffering from lung cancer with cervical vertebral bone metastasis. The schema and dose distribution of SBRT for bone metastasis using CyberKnife treatment system. (A) The blue line indicates the beam directions. (B) Representative dose distribution.
Three important factors should be considered for the decision to utilize IMRT or SBRT. First, IMRT or SBRT must be adapted for the treatment of oligometastasis in the bone. Long‐term survival has been noted in patients diagnosed with isolated bone metastasis [12–15]. Therefore, successful control of oligometastasis of the bone due to the delivery of higher doses might contribute to improved treatment outcomes and quality of life (QOL). Second, IMRT or SBRT can be performed for reirradiation of the same site. It is technically difficult to reirradiate the same site using conventional RT. However, with IMRT or SBRT the dose to the spinal cord or adjacent organs can be reduced to within the tolerable range, facilitating reirradiation. Third, IMRT or SBRT can be applied for radioresistant bone metastases. Therefore, when indicating IMRT or SBRT for metastatic bone tumors, oncologists should consider the disease behavior and estimated life expectancy of the patient.
\nThe treatment outcomes of previous studies that utilized IMRT or SBRT for bone metastases [16–19] are compared in \nTable 3\n. Each study performed IMRT or SBRT using various dose or fractionation protocols because standard regimens have not yet been proposed. The majority of studies demonstrated excellent local control without serious harmful phenomenon such as myelopathy. However, because most previous studies were retrospective and sufficient evidence has not yet been accumulated, any adaptation of IMRT or SBRT to deliver higher doses must be carefully discussed for individual patients. A multidisciplinary team comprising radiation oncologists, orthopedists, medical oncologists, radiologists, rehabilitation physicians and palliative care medicine doctors would be ideal for discussing and deciding treatment options including the application of higher dose RT.
\nAuthors | \nMachine/type | \nDose | \nLCR | \nAdverse events | \n
---|---|---|---|---|
Murai [16] | \nTomotherapy/IMRT | \n40 Gy in 8 fx/48 Gy in 16 fx | \n84% (1‐year) | \nNo radiation‐induced myelopathy | \n
Yamada [17] | \nLinear accelerator/IMRT | \n18–24 Gy in 1 fx | \n90% | \nNo radiation‐induced myelopathy | \n
Guckenberger [18] | \nLinear accelerator/SBRT | \nMedian 24 Gy in 3 fx | \n84% (2‐year) | \nNo radiation‐induced myelopathy | \n
Degen [19] | \nCyberKnife/SBRT | \n24 Gy in 1 fx | \n90% | \nNo radiation‐induced myelopathy | \n
Outcomes of IMRT or SBRT in bone metastasis.
IMRT, intensity modulated radiotherapy; SBRT, stereotactic body radiotherapy; LCR, local control rate.
Oncologic care is improving and the survival rates of patients with various malignancies are increasing. Since the advent of recent technologic advancements in the detection methods used to locate new lesions and metastasis, orthopedic surgeons have been confronted with an increasing number of patients with spinal metastasis. Such patients can develop sudden paraplegia due to pathological fracture or tumor invasion into the spinal canal. Patients with symptomatic spinal metastasis present with severe pain and poor QOL [20].
\nIf a multidisciplinary conference between radiation oncologist, spinal surgeons, physiotherapists and medical oncologists was developed, appropriate treatment strategies could be discussed and implemented. For example, a patient who develops sudden paraplegia sometimes needs urgent treatment including surgical decompression. Therefore, a simple classification method with easily assigned radiographic and patients factors could be helpful to facilitate communication and appropriate referral among the multidisciplinary oncology team, ensuring prompt and optimal treatment decisions.
\nMost cases of spinal metastasis occur in the vertebral body, intervertebral disc and anterior and/or posterior longitudinal ligament, whereas the involvement of anatomical structures related to spinal motion is rare. Batson\'s venous plexus and the avalvular vein of the vertebral venous system play an important mechanistic role in the pathology of spinal metastasis. Namely, all cancers with a preference toward bone metastasis, such as bronchial, breast and prostate cancers are disseminated to the spine via these vessels. Consequently, the anterior spinal column is the most frequent site of spinal metastases, with ∼80% of lesions appearing in the vertebral body [21].
\nInstability has been classified as segmental instability, which is mostly the result of trauma or degenerative changes, or component instability, which is caused by tumor invasion in the vertebral body. The type of instability present should be determined when considering the therapeutic management of spinal metastases. Therefore, specific criteria for stability assessments are required. In 2010, Fisher et al. [22] reported a novel classification system for spinal instability in neoplastic disease, which was established using the best evidence provided by systematic reviews and expert opinions. The spine instability neoplastic score (SINS) is a comprehensive classification system based on patient symptoms and radiographic criteria without consideration of neurologic status, histology, or general physical condition. The SINS considers spinal metastasis location, type, pain and lesion quality, spinal alignment, the extent of vertebral body collapse and posterolateral spinal element involvement. Furthermore, the predictive value of the SINS was validated by the analysis of the clinical and radiographic data of 30 patients. The SINS score is categorized into a three‐tier system with 0–6 being stable, 7–12 being potentially unstable and 13–18 being unstable [23]. A surgical consultation is recommended for patients with a SINS score greater than 7.
\nSurgical treatment decisions are broadly based on spinal stability and patient‐specific factors including patient health, prognosis and tumor histology [24]. The surgical approach is indicated for pathological fractures and sudden onset of neurological symptoms. The current indications for spinal surgery are radioresistant tumors, progressive neurologic deficits lasting no longer than 24 hours, bone fragments in the spinal canal and spinal instability due to pathologic fracture. In addition, life expectancy should be at least 3 months. Survival duration in patients with bone metastases is largely dependent upon controllability of the primary tumor. Several prognostic scoring systems have been reported in an attempt to indicate the appropriate surgical strategy [24–26]. Tokuhashi et al. [24] and Tomita et al. [25] recommended that patients expected to have a good prognosis should undergo wide excision including total en bloc spondylectomy, those expected to have an intermediate prognosis should undergo marginal or intralesional excision and spinal stabilization (\nFigure 3\n) and those expected to have a poor prognosis should be managed conservatively. However, it should be emphasized that local spinal pathology, rather than tumor histology, determines the degree of pain or severity of neurologic deficits. The ultimate surgical goals are to obtain good QOL and activity of daily living (ADL) scores by relieving pain and improving neurologic status (\nTables 4\n and \n5\n).
\nLaminectomy and posterior stabilization in a 76‐year‐old male with C5 metastasis of thyroid cancer. A patient presented with right deltoid muscle weakness and intractable pain in the right shoulder. The Tomita and Tokuhashi scores were 7 and 9 points, respectively. He underwent combination spinal surgery with a C5 laminectomy and C2 to T2 posterior stabilization, and postoperative conventional radiation therapy (30 Gy in 10 fractions). (a) Preoperative computed tomography. (b) and (c): Preoperative magnetic resonance imaging with T1‐weighted and T2‐weighted images, respectively. (d): Intraoperative image. (e) and (f): Postoperative radiographs.
\n | \nTreatment | \nBaseline | \n1 month | \n3 months | \n6 months | \n
---|---|---|---|---|---|
Median PS | \nSurgery | \n4 | \n2 | \n1 | \n1 | \n
Nonsurgery | \n3 | \n4 | \n4 | \n4 | \n|
Mean BI | \nSurgery | \n43.8 ± 28.0 | \n74.2 ± 26.7 | \n74.9 ± 31.8 | \n82.5 ± 28.1 | \n
\n | Nonsurgery | \n48.5 ± 31.9 | \n37.9 ± 34.1 | \n35.5 ± 31.0 | \n31.7 ± 10.4 | \n
Surgical outcome of performance score and activities of daily life in patients with spinal metastases.
Surgery patients (
\n | \nTotal | \nSurgery | \nNonsurgery | \n
---|---|---|---|
\n | \nNo. (%) ( | \nNo. (%) ( | \nNo. (%) ( | \n
\n | \n|||
Improved | \n49 (70.0) | \n45 (97.8) | \n4 (16.7) | \n
Unchanged | \n13 (18.6) | \n1 (2.2) | \n12 (50.0) | \n
Deteriorated | \n8 (11.4) | \n0 (0.0) | \n8 (33.3) | \n
Redeteriorated | \n9 (12.9) | \n9 (20.0) | \n0 (0.0) | \n
\n | \n|||
Improved | \n45 (64.3) | \n44 (95.7) | \n1 (4.2) | \n
Unchanged | \n14 (20.0) | \n2 (4.3) | \n12 (50.0) | \n
Deteriorated | \n11 (15.7) | \n0 (0.0) | \n11 (45.8) | \n
Redeteriorated | \n9 (12.9) | \n9 (20.5) | \n0 (0.0) | \n
Outcomes of endpoints in patients undergoing surgical treatment and nonsurgical treatment.
PS, Eastern Cooperative Oncology Group Performance Status; ADL, activities of daily living.
Recently, a prospective analysis of the surgical outcome in 70 patients with symptomatic spinal metastasis was conducted [27]. Laminectomy and posterior stabilization following RT significantly improved the performance status and ADL in >95% of patients, with sustained improvement for at least 6 months in >80%. In a randomized, multicenter, nonblinded trial in 101 patients, Patchell et al. [28] revealed a major breakthrough for surgical treatment followed by RT. They compared the efficacy of surgery followed by RT with that of RT alone. Fifty patients were assigned to surgery followed by RT and 51 to RT alone. Significantly more patients were able to walk after surgery followed by RT (84%) compared with after RT alone (57%). Moreover, the duration of walking ability maintenance was significantly longer in the surgery followed by RT Arm (median, 122 days) compared with the RT alone Arm (median, 13 days).
\nThe complication rate after surgery can be as high as 20–30% and this must be weighed against the intended benefits. Postsurgical complication and mortality rates were evaluated in 26,233 patients included in the National Inpatient Sample of United States [29]. The in‐hospital mortality rate was 5.6% and the complication rate was 21.9%. Pulmonary (6.7%) and postoperative (5.9%) hemorrhage or hematoma were the most commonly reported complications. Complication rates were higher in older patients and those with comorbidities including hypertension, chronic lung disease and diabetes mellitus; having a single comorbidity increased the risk of in‐hospital death by ∼4 fold. In a retrospective series of 123 patients treated for spinal metastases, the rate of major wound complications (dehiscence or wound infection) was 32% in the group that underwent RT before surgery, whereas it was 12% in the group of patients first treated using surgery. Therefore, in patients with symptomatic MSCC, postoperative RT appeared to be more beneficial than preoperative RT [30].
\nIn patients with spinal bone metastasis, the goals of spinal surgery are to restore spinal stabilization, preserve neurologic function and provide pain relief. For appropriately indicated patients, spinal surgery can provide significant improvements in both QOL and ADL, possibly leading to the administration of adjuvant systemic therapies.
\nBecause of the advances in diagnostic and therapeutic technologies, the overall survival of cancer patients has been prolonged, although the cancer survivors treated with RT has increasing. Patients during/after RT often suffer from the RT‐related toxicities including radiation sickness, fatigue, nausea, vomiting, mucous membrane disorder, etc. These symptoms markedly reduce the physical activity level of patients and lead to deconditioning, such as muscular weakness, flexibility deterioration, cardiorespiratory dysfunction and psychological symptoms. Therefore, the rehabilitation intervention which increases the physical activity level and prevents deconditioning is important. Mock et al. reported that the walking exercise program during RT improved the physical functions, fatigue, emotional distress and difficulty sleeping in breast cancer patients during RT [31]. And Segal et al. showed that the resistance/aerobic training improved the QOL, aerobic fitness and strength in prostate cancer patients during RT [32]. Also in the guidelines from American College of Sports Medicine (ACSM) [33], the rehabilitation intervention recommended to improve physical function, aerobic fitness, QOL and fatigue in cancer patients during/after RT.
\nFurthermore, the number of elderly cancer patients treated with RT has been recently increasing. The elderly patients who have sarcopenia and frailty easily suffer from RT‐related toxicities and deconditioning, then, decrease the completion rate of treatment [34], so the rehabilitation should be positively applied to cancer patients during/after RT, especially for elderly patients.
\nMoreover, the incidence of cancer survivors with bone metastasis has increased. Troublesome bone metastasis develops in 10–20% of patients with cancer. The majority of these patients have an increased risk for skeletal‐related events (SREs) including pathologic fractures, spinal cord compression, the need for surgery, the need for RT and hypercalcemia [35]. SREs have been associated with significant morbidity, limited function and a decreased QOL [36–38]. In particular, pathologic fractures and spinal cord compression restrict ADL. Therefore, multidisciplinary team management of SREs (so‐called bone management) is paramount in these patients. In these patients, rehabilitation over the course of treatment for the prevention of SREs and improvement of ADL and QOL is a key aspect of “bone management”.
\nThe essential points of the rehabilitative interventions for patients with bone metastasis are as follows [39]. (1) Rehabilitation aims to prevent patients from becoming bed‐bound and helps them to maintain as much independence as possible with regard to ADL. (2) Rehabilitation commonly focuses on training patients to use their residual functions or to develop compensatory techniques by training in the use of assistive equipment or orthoses and educating both patients and their family members to help them adjust to the altered way of life. (3) Rehabilitation has inherent risks such as pathologic fractures and spinal cord compression. Improvements in physical function and physical activity levels due to rehabilitation might lead to an increased risk of pathologic fracture during ADL. However, bed rest, as an alternative, has various complications including muscle contractures, weakness and atrophy, orthostatic hypotension, pressure sores, pneumonia, confusion and disorientation (so‐called disuse syndrome). Therefore, rehabilitation with the management of SREs risk would be more beneficial compared with bed rest.
\nFor patients with bone metastasis, rehabilitation mostly provides the adequate settlement of bed rest angles, training for the use of orthoses, instructions for adequate movements for ADL and exercises to maintain and increase physical function and ADL through discussion at bone metastasis board.
\nIn cases of pathologic fracture or fragility in the vertebral body (high risk of paralysis), the head end of the Gatch bed should be raised by 30 degrees and patients wear a rigid spinal brace. Patients are moved using the logroll technique without flexion or rotation of the spine. In cases with a low risk of pathologic fracture (bone cortex remains), patients should wear a rigid spinal brace, but there is no restriction on the bed rest angle.
\nIn the case of pathologic fracture or fragility in weight‐bearing bones or joints, patients are advised to avoid weight‐bearing on the affected bone or joint. In patients with remaining bone cortex and an absence of pain, there are no restrictions in ADL.
\nIn patients with bone metastasis, orthoses are applied to decrease bone pain, prevent or treat pathologic fractures and paralysis and to improve physical function. In patients with cervical metastasis, in stable cases, a soft cervical collar is applied to restrict flexion and extend the cervical vertebrae. In unstable cases, a Philadelphia collar and halo vest is applied to inhibit flexion, extension, rotation and lateral bending of the cervical vertebrae. In patients with thoracolumbar metastasis, spinal orthoses are applied to facilitate local rest by restricting the flexion, extension, rotation and lateral bending of the spinal column, which helps to reduce bone pain and inflammation, thereby reducing adverse psychological effects.
\nIn the case of conservative treatment, a functional brace is applied to the humeral diaphyseal fracture and a patellar tendon‐bearing orthosis is applied to the weight‐bearing bone or joint below the lower leg. It takes a long time to increase bone strength, even after RT and long‐term nonweight bearing is necessary. Therefore, surgery should be considered for the bone metastasis in the weight‐bearing bones of the lower extremities.
\nIn the rehabilitation setting, to decrease the risk of the pathologic fractures and pain, patients are instructed on how to move when conducting ADL. The examples are shown in \nTable 6\n.
\nExamples | \n|
---|---|
Daily life behaviors | \n·For patients with spinal bone metastasis, excess flexion, and rotation of the trunk should be avoided in rolling over and getting up from bed. | \n
·For patients with bone metastasis of the weight‐bearing bones in the lower extremities and pelvis, the transfer of motion with non‐weight bearing should be instructed. | \n|
·In getting up from the bed, patients should use the automatic bed Gatch up function. | \n|
Assistive device | \n·A cane, crutch, or walker should be used to decrease pain and weight‐bearing. | \n
·A wheelchair should be used to decrease the physical burden in moving long distances. | \n|
·Self‐help devices, such as a Sox aid, should be used to avoid the pain caused by trunk flexion. | \n|
Living environment | \n·Install handrails to decrease pain with ambulation. | \n
adjustment | \n·Install handrails and higher toilet seats in the restroom to decrease pain and assist with standing up from a seated position. | \n
Examples of instructions of movements for activities of daily living.
Under the concept of “bone management,” the multidisciplinary team approach is necessary to achieve the early detection and treatment of bone metastasis and the clinical practice of multidisciplinary therapy. In the treatment of bone metastasis, surgery, radiation therapy, rehabilitation and pain control should be considered, so the multidisciplinary team should discuss and decide the treatment plan in bone metastasis board. The necessity of rehabilitation and orthosis, settlement of bed rest level and risk management are also discussed in bone metastasis board, so the rehabilitation intervention can be safely provided to the bone metastatic patients.
\nPrevious studies have reported that rehabilitation during multidisciplinary therapy improved pain, physical function, ADL, QOL and prognosis in patients with bone metastasis (\nTable 7\n). Ruff et al. [40] showed that patients with spinal epidural metastasis who underwent rehabilitation had less pain, consumed less pain medication, were less depressed and had a greater satisfaction with life, compared with those who did not undergo rehabilitation. Other studies have reported that the rehabilitative intervention in patients with bone metastases improved functional independence measure scores, prognosis, physical function (muscle strength, submaximal aerobic exercise capacity and ambulation), physical activity level and QOL [41–44]. The rehabilitation with risk management by the multidisciplinary team could be effective in preventing SREs and improving pain, ADL, QOL and prognosis in patients with bone metastases. However, reports on the efficacy of rehabilitation in patients with bone metastasis are limited and were usually conducted in small populations. Therefore, further studies in larger populations are needed to validate the efficacy of rehabilitation.
\nAuthor | \nSubjects | \nStudy design | \nIntervention | \nPrimary outcome | \nMajor results | \n
---|---|---|---|---|---|
Ruff [40] | \n42, spinal epidural metastasis | \nControlled retrospective study | \nTraining in transfers, bowel and bladder care, incentive spirometry, nutrition, and skin care | \nPain, depression, life satisfaction | \nIntervention group had less pain, consumed less pain medication, were less depressed, and had greater life satisfaction. | \n
Tang [41] | \n63, metastatic spinal cord compression | \nRetrospective descriptive study | \nNeuro‐oncology rehabilitation, tailored to the needs of the patient | \nFunctional independence measure scores, Tokuhashi score | \nFunctional independence measure score improved. Longer survival in patients with high Tokuhashi scores. | \n
Cormie [42] | \n20, bone metastatic prostate cancer | \nRandomized controlled study | \nAerobic exercise and resistance exercise | \nFatigue, physical function, body composition | \nPhysical function, physical activity level, and lean mass improved. | \n
Jane [43] | \n72, bone metastasis | \nRandomized controlled study | \nMassage: 3‐month training program | \nPain intensity, sleep quality, symptom distress scale | \nBeneficial effects on pain, mood, muscle relaxation, and sleep quality. | \n
Rief [44] | \n60, bone metastasis | \nRandomized controlled study | \nIsometric resistance training of the muscles along the entire vertebral column | \nPain, concurrent medication, oral morphine equivalent dose | \nPain relief over a 6‐months period and reduced oral morphine equivalent dose, as well as concomitant pain medication. | \n
Details of previous reports concerning rehabilitation for bone metastasis patients.
RT is one of the most useful modalities for pain relief in patients with bone metastases. Although the American Society for Therapeutic Radiology and Oncology guidelines recommend 8 Gy in a single fraction as the standard method for palliative RT in uncomplicated painful bone metastases, reirradiation is required in 20–40% of cases [45, 46]. The reirradiation rates are 2.5‐fold higher after single fraction RT compared with after multifraction RT [1]. Single fraction RT is commonly used for reirradiation. According to the prospective randomized trial of reirradiation undertaken by the National Cancer Institute of Canada Clinical Trial Group, single fraction RT of 8 Gy seemed to be noninferior and less toxic than multifraction RT of 20 Gy [47]. The pain relief response rate following reirradiation is 60–70%, with complete and partial responses of about 20 and 50%, respectively [46, 48], which are similar to the response rates seen with an initial effective RT. Although initial responders are more likely to respond to reirradiation than initial nonresponders, about half of the nonresponders can be expected to respond to retreatment [48].
\nReirradiation is also effective to maintain walking abilities of patients with MSCC. However, the median duration of response is relatively short (about 4–5 months) [49, 50]. The degree of motor function after reirradiation is associated with the walking ability before RT. More than 80% of ambulant patients before RT will be expected to maintain the walking ability, whereas less than 20% of not ambulant patients will recover the function [49, 50]. SBRT is well suited for reirradiation of the spine due to its superiority of dose distribution compared with conventional techniques. SBRT has a major potential to provide superior local control without increasing toxicity (\nTable 8\n) [51–54]. A care must be taken when SBRT is applied to patients with MSCC, because the existence of tumor too close to the spinal cord is a risk factor for local recurrence due to underdose [51]. Relatively little is known regarding the long‐term toxicities of reirradiation. Because reirradiation has the potential to exceed normal tissue tolerance, it might be appropriate to sum the biologically effective doses (BEDs) from the initial and repeat treatment regimens to estimate the safety of treatment. The BED is calculated according to the liner‐quadratic model [BED =
Author (year) | \nPatients/lesions (n) | \nPrevious EBRT dose/Fx | \nMedian dose/Fx (range) | \nLocal control | \nOverall survival | \nNeural toxicity | \n
---|---|---|---|---|---|---|
Garg [52] | \n59/63 | \nNA | \n30 Gy in 5 fx, 27 Gy in 3 fx | \n76% at 1 year | \n76% at 1 year | \n2 of G3 Radiculopathy | \n
Mahadevan[53] | \n60/81 | \n30 Gy in 10 fx (median) | \n24 Gy in 3 fx, 25–30 Gy in 5 fx | \n93% at last follow‐up | \n11 month (median) | \nNone | \n
Hashmi [54] | \n215/247 | \n30 Gy in 10 fx (median) | \n8‐22 Gy in 1 fx, 14–50 Gy in 3(2–20) fx | \n93% at 6 months | \n64% at 6 months | \nNone | \n
Outcomes of reirradiation by spinal SBRT.
SBRT, Stereotactic body radiotherapy; EBRT, external beam radiotherapy; Fx, fraction; NA, not available; G3, grade3
Metallic surgical implants are commonly used in patients who undergo RT for bone metastasis. In computed tomography, metallic hardware can dramatically attenuate the X‐ray beam and severe beam hardening effect and lead to faulty or inconsistent projection data [57, 58]. Consequently, so‐called metallic artifacts or bright and dark streak artifacts can dramatically degrade the image quality. \nFigure 4\n illustrates a typical case of a patient who underwent spine‐stabilization before adjacent RT. Strong artifacts induced by the titanium‐based pedicle screws make it difficult to distinguish target lesions from surrounding normal tissues.
\nArtifacts of metallic surgical implants. (A) 2D radiography image shows a patient with implanted titanium pedicle screws. (B) Computed tomography image of a patient with titanium pedicle screws. Streak artifacts are present around the metallic implants.
For modern‐era RT protocols, target delineation and dose calculation are performed on CT images using treatment‐planning systems. Therefore, metallic artifacts, that are commonly located directly adjacent to the target volume and organs‐at‐risk and that degrade the delineation accuracy and dose calculation might lead to poor local control and a high risk of complications. Several studies have investigated the metallic‐implant‐related dosimetric impact using Monte Carlo simulations. Spadea et al. [59] reported that low‐Z materials such as titanium might not cause relevant dose discrepancies, while high‐Z materials including gold and platinum might lead to underestimation of the delivered dose during photon beam irradiation. Verburg et al. [60] investigated the effect of titanium implants on dosimetric errors in photon therapy treatment planning. They revealed dose discrepancies of up to 10% with range differences of up to 10 mm in artifact‐contaminated areas. \nFigure 5\n illustrates examples of dose differences caused by titanium‐based artifacts introduced by Verburg [58]. Factors including the beam‐implant interaction, radiation beam type and the physical characteristics of the metals differ and eventually lead to dose uncertainties. For bone metastasis, especially in cases of infield recurrence of metastatic spinal lesions, the high dosimetric accuracy for organs‐at‐risk becomes clinically significant because of the limited spinal cord radiation tolerance. Recently, several promising approaches to reduce metallic artifacts have been proposed, such as metal artifact reduction (MAR) algorithms [61–63] and monoenergetic extrapolations from dual‐energy computed tomography (DECT) [64, 65]. \nFigure 6\n briefly illustrated reduction of metal artifacts using a frequency split MAR method introduced by Meyer et al. Antiartifact approaches have proven useful for improving target delineation and dose calculation in RT, but to date, they have not been widely implicated for routine clinical use.
\nDifferences in dose calculation of photon beams passing through the metal artifact region. (A) Dose calculation on the artifact‐affected computed tomography image. The arrow indicates the titanium insert. (B) Dose calculation on the ground truth computed tomography image without the artifact.
Reduction of metal artifacts using a frequency split MAR method. (A) Patient with implanted pedicle screws. (B) Patient with implanted unilateral hip endoprosthesis, Left: original computed tomography image; right: MAR corrected computed tomography image.
In conclusion, in cases of bone metastases, the impact of dose uncertainties due to metallic implants is critical in modern RT, especially in patients undergoing reirradiation. Promising antiartifact approaches might be useful options to achieve the anticipated magnitude of clinical benefit.
\nRT plays a central role in the management of painful bone metastasis. Compared with conventional RT, IMRT, or SBRT enables the delivery of higher doses to the target tumor while minimizing the dose to adjacent organs. Not only pain relief but also the restoration of spinal stability and preservation of neurologic function are associated with RT in patients with spinal bone metastases. A multidisciplinary team, especially one consisting of a spinal surgeon and rehabilitation physician, is particularly helpful for treating patients with spinal bone metastases characterized by spinal instability. Reirradiation using IMRT or SBRT is a valuable option for the management of bone metastasis. Future developments in surgical procedures and RT will likely improve the management protocols for bone metastases and technology to reduce metal artifacts in radiation planning might improve the efficacy and safety of combination therapy.
\nThermal management becomes increasingly important and challenging as the increase of power/heat density is taking place in many engineering applications, products, and industrial sectors. One example is the electronics industry. Advances in semiconductor manufacturing technology create more compact integrated circuits for electric devices. The latest Fin Field Effect Transistor (FinFET) technology contributes to the reduction of fabrication node from 22 nm in the year of 2012 to the current 10 nm, and even to 5 nm in 2021. Using a 10 nm FinFET manufacturing process, Apple A11 chip could contain 4.3 billion transistors on a die of ~87 mm2, which is 30% smaller than the last version A10. In addition, thermal design power of electric chips, the maximum amount of heat removal from the electric chips, shows an increasing trend. As heat power density continues to grow, heat removal, also referred to as thermal management, is important for maintaining the temperature to meet material and safety constraints. In turn, the development and maintenance of electric devices rely on how effectively the heat is dissipated from the devices. The choice of cooling technology is a complicated systems work in high-power electronic, not only for fitting in the heat removal requirement from low power density to high power density, but also for considering the cooling efficiency, power load, overall power consumption of the cooling subsystem, and the cost of cooling infrastructure. This chapter focuses on fundamental heat removal capacities of cooling technology.
\nDifferent cooling technologies vary in their heat removal capacities, which are summarized in Figure 1. For low heat flux removal requirement, air-cooling, which removes the heat from the hot surface by airflow, is widely applied. The cooling performance can be enhanced by expanding the surface area or increasing the flow of air over the surface. The first approach is known as air free convection, while the second approach is air-forced convection. In comparison with free convection, the fluid motion in forced convection is generated by external source, for enhancing the local convection. In computers, cooling fins are added to heat sink for expanding the surface area, while a fan is attached to the cooling fins to enhance air convection. Heat flux by forced air convection can reach ~35 W/cm2 while only ~15 W/cm2 by free air convection (see Figure 1). Due to the increase of power density, many micro-electronic and power electronic devices now are in the range of heat flux beyond the air cooling capacity. Effective liquid cooling solutions are needed for thermal management of the high-heat-flux devices.
\nHeat removal capacity by applying different cooling technologies that is characterized by two parameters: Highest heat flux and heat transfer coefficient [
Spray cooling is one effective solution, which has the huge potential in handling the high heat fluxes in high-power electronics such as supercomputer, lasers, and radars. Spray cooling has several advantages over other cooling techniques. In comparison with air-cooling and jet impingement cooling, spray cooling owns a high heat flux removal capacity. Spray cooling can transfer heat in excess of 100 W/cm2 using fluorinerts and more than 1000 W/cm2 using water (see Figure 1). Due to high heat flux removal capacity, spray cooling allows precise temperature control with low fluid inventory [5]. Besides, spray cooling has uniform cooling temperature distribution over the entire spray-covered surface. This is because the entire spray-cooled area is receiving fresh liquid coolant droplets. For jet impingement cooling, the coolant flows radially outwards from the impingement spot. The radial flow has non-uniform temperature, and the largest subcooling and the optimal local cooling occur at the stagnation point. The non-uniform cooling results in non-uniform surface temperature in the cooling area, which could be significant for high heat fluxes.
\nHowever, there are still some barriers for applying spray cooling for engineering applications. Significant pumping power is needed to achieve large pressure drop through spray nozzle to produce fine spray, but the low cost is first priority in commercial application of cooling technologies. Another fact that the design and fabrication of spray nozzle do not follow the identical industry standard makes the unpredictable spray characterization. Hence, it is hard to get a universal correlation of spray characterization to cooling performance, which also limits the implementation of spray cooling. Additionally, in comparison with the jet nozzle, nozzle orifice through the spray coolant is even smaller, increasing the possibility of orifice clogging and the occurrence of the dry-out area on the heated surface [6]. In spite of these barriers, spray cooling is still a popular cooling technology and many successful applications were reported for supercomputer (CRAY X-1) [7], laser diode laser arrays [8], microwave source components [9] and NASA’s reduced gravity aircraft [10].
\nIn spray cooling, liquid coolant is emitted from a pressurized nozzle and breaks up into numerous droplets. The small droplets land on the cooled surface, where the flow of droplets becomes a thin liquid film radially flowing on the surface (see Figure 2a). The cooling is achieved through the convection heat transfer from the cooled surface to the film flow being impacted by continuous flow of droplets, nucleate boiling on the cooled surface, liquid conduction inside the film flow, and interfacial evaporation from the liquid film to the surrounding air. Spray cooling provides uniform cooling that can handle high heat fluxes in both single phase and two phases. The cooling performance as a function of spray characterization, flow conditions, surface conditions, and nozzle positioning was widely discussed in past decades. These studies focused on the relationship between the spray cooling performance and the entire spray flow. However, in these spray-level studies, the understanding of cooling mechanism of spray droplets is missing. At the droplet level, the impact conditions are classified into a few categories (see Figure 2b): (a) impact of single droplet on dry surface appearing in nucleate boiling, transition boiling and film boiling, (b) impact of single droplet on stationary film where the radial velocity of the film is close to zero, such as stagnation zone, (c) impact of single droplet on radially flowing film and (d) impact of droplet burst on flowing film (droplet groups that frequently impact the surface). Although spray impingement cannot be simply considered as the superposition of single droplets due to the interaction of the neighboring droplets [11], the study of local cooling performance at droplet level is still significant to the understanding of spray cooling mechanism, especially for the condition of the local film dominated by the droplet flow. Therefore, the research outcomes of spray cooling are reviewed from two aspects: the spray level and the droplet level.
\nSpray cooling mechanism at the entire spray level (a) and droplet level (b).
Spray cooling can handle high heat flux in the constrictive space of electronic package when comparing to air-cooling, pool cooling, and jet cooling. This is because numerous fresh droplets generated by spray nozzle randomly affect the entire surface, and directly transfer the heat from surface to the coolant. The difference of fluid dynamics between spray impact and other cooling methods is a key factor affecting the mechanism of local heat transfer and resulting in different cooling performance. The first step of studying spray-cooling mechanism is to observe what happened on the heated surface. Numerous fundamental studies have been conducted theoretically and experimentally, which focus on the key parameters affecting impact dynamics and the relevant heat transfer mechanism. There are four aspects that have been demonstrated to significantly affect cooling performance, including spray characterization, nozzle positioning, phase change and enhanced surface [5, 6, 9].
\nSince the earliest study on spray cooling by Toda [12, 13], many researchers put effort on spray characterization, the relevant cooling performance and the critical heat flux (CHF) in spray cooling. Spray characterization mainly involves droplet size, impact velocity, droplet flux, and volumetric flux. However, in experimental studies it is difficult to change only one parameter and isolate the remaining parameters. For example, on the cooled surface the increase of flow rate of coolant spray is accompanied with the increase of impact velocity and volumetric flux with a constant impact area. That is reason that the conclusions made on the dominant impact parameter are not consistent in previous studies of spray cooling.
\nChen et al. [14] studied effects of three spray parameters of droplet size, droplet velocity and droplet flux on CHF. By adjusting spray nozzles, operating pressures, and spray distance between the nozzle exit and the heater surface, the effect of one spray parameter was studied while the others were kept constant. It was found that the mean droplet velocity is the most dominant parameter affecting CHF followed by the mean droplet flux, while the Sauter mean droplet diameter (\n
In single-phase spray cooling, spray droplets land on a radially flowing film. Some researchers studied the property of the flowing film and its relation to spray cooling performance. Pautsch and Shedd [17] used a non-intrusive optical technique to measure the local film thickness generated by sprays. The film thickness was found to remain constant when the heat transfer mechanism was dominated by single-phase convection. Beyond the spray impact area, the dry-out phenomena appear even when the CHF is not reached. In the nucleate boiling regime, Horacek et al. [18, 19] measured the dry-out area, which was characterized by the three-phase contact line length, and measured using a Total Internal Reflectance technique. The wall heat flux was found to correlate very well with the contact line length. This contact line heat transfer mechanism was summarized by Kim [20] as one of main heat transfer mechanisms in the two-phase regime.
\nCooling performance can be influenced by changing the spray positioning. There are two significant positioning parameters in the study of spray cooling (see Figure 3): nozzle-surface distance \n
(a) The 2D geometry is on the central plane (z-x plane) of the cone perpendicular to the impacted surface (x-y plane). The positioning of the nozzle is determined by inclination angle
Some researchers focus on the effects of spray inclination on heat transfer performance. The impact area is circular for normal impact \n
There are three reasons addressed for contradictory conclusion of spray inclination. One is regarding the different nozzle positioning. As illustrated in Figure 3, two key parameters, spray distance and inclination angle, determine the nozzle positioning. However, at a certain inclination angle some studies [23] applied the constant spray distance, while others [4, 24, 25] adjusted the distance for the constant impact length. Another reason is related to the assumption of one dimensional steady-state conduction through the neck of cartridge heater for the surface heat flux calculation. Inclined spray impact causes considerable temperature difference on the cooled surface (see Figure 4). Hence, the radial conduction should be taken into account for inclined spray cooling. The last reason is from the surface temperature measurement location. Different radial locations provide different temperature measurement due to significant temperature difference in inclined spray cooling.
\nLocal surface temperature distribution for normal impact (a1) and inclination affect with
To obtain surface temperature distribution in inclined spray, some researchers investigated local heat transfer by replacing cartridge heater with sputter-coated thin film heater, which enables infrared thermography for temperature measurement [21, 27, 28]. All of these studies found significant temperature difference on cooled surface for inclined spray cooling (one example in Figure 4b1). Gao and Li [27] compared the droplet impact velocity and heat transfer coefficient distribution along centerline for normal impact and inclined spray impact (see Figure 4a2 and b2). The impact velocity was captured by a Stereo-Particle Imaging Velocimetry system. The trend line of heat transfer coefficient and droplet velocity shows clear correlation. For both cases, the locations of maximum droplet velocity coincide with the locations of the highest heat transfer coefficient. The further study by Gao and Li [21] indicated the global cooling shows slight diminishment for small inclination angle and enhancement for large inclination angles. On the central plane of the spray cone, the enhancement and diminishment of the local cooling performance are in general agreement with the increase and decrease of the spray flux. Thin film heater is not reliable for the surface temperature greater than boiling point, and experiments are tested in single-phase region. This is the limitation of thin film heater, and the robust heater for boiling test is needed for future study.
\nSimilar to pool boiling curve, the heat transfer curve of spray cooling can be separated to four regimes: single phase regime, nucleate boiling regime, transition boiling regime and film boiling regime [12, 13]. In the single phase regime, the heat flux linearly increases with increasing surface temperature difference between heater surface and coolant. Forced convection by radially moving film and evaporation on unsteady interface of thin film layer, play dominant roles in single-phase regime [29]. In the nucleate boiling regime, bubbles begin to repeatedly occur at nucleation sites on the heated surface, and the heat flux sharply increases as compared to single-phase cooling. Once the nucleation sites cover the heated surface completely, average heat flux will reach a peak value, which is defined as Critical Heat Flux (CHF).
\nOnce reaching the CHF and coming to the transition boiling (decreasing region in the boiling curve), the efficiency of heat transfer on the heating surface significantly decreases. Liquid coolant absorbs heat from the surface and forms the vapor blanket, so the surrounding liquids are hard to get to the heater surface. That is the reason for the sharp decrease of heat flux in this regime. In the film, boiling regime an interesting phenomenon is an increasing trend of heat flux. Massive heat is generated from the heated surface and radiation heat transfer becomes a key heat transfer mechanism between the heated surface and the liquid, so the heat flux tends to increase from the Leidenfrost point. Considering the safety limit and fast implementation of electronic cooling, researchers’ attention is paid to the theoretical correlation in single phase regime and nucleation boiling regime.
\nIn the single phase regime, Rybicki and Mudawar [4] proposed the correlation for dielectric PF-5050 spray, which is
\nHere \n
The correlation has an accuracy of ±7.3% for varied pressure drops. Heieh and Tien [29] studied R-134a spray cooling, and correlated the Nusselt number to the Weber number, size distribution and sensible heat effects in the single phase regime, which is
\nIn the nucleate boiling regime of spray cooling, the heat flux increases with the surface temperature faster than that in single-phase regime. Yang et al. [31] proposed two reasons. In nucleation, boiling bubble appears and grows on nucleation sites as the liquid coolant changes to the vapor. During the phase change, a larger amount of heat is removed from the heated surface, resulting in a temperature drop on nucleation sites. The other reason is attributed to the influence of secondary nucleation and evaporation on the heat flux enhancement [32]. When the numerous droplets impinge on heated surface, air is entrained into the liquid film, forming an air layer underneath the droplets. The air layer reaches the liquid-covered surface and finally breaks up into many tiny gas nuclei, which serve as secondary nucleation sites. Hence, the number of secondary nucleation sites is proportional to the droplet flux across the surface, which was proved in Yang’s experiments [33]. Using water as coolant liquid, Mudawar and Valentine [16] proposed the CHF correlation with respect to the local volumetric flux \n
In another study by Estes and Mudawar [34], a universal CHF correlation was constructed for spray cooling by using Fluorinerts FC-72 and FC-87 as well as the water.
\nEnhancing spray cooling by changing the surface structure is one effective and low-cost approach, which benefits from optimal liquid management and enhancement of local cooling efficiency. According to the structure size, enhanced surface is classified into four categories: mini-structured surface, micro-structured surface, nano-structured surface, and hybrid-structured surface. Most of early studies of spray cooling have been conducted on flat surfaces. A few of them focus on the effects of surface roughness on cooling enhancement. Pais et al. [35] fabricated three rough surfaces using polishing grit with the size range of 0.3–22 μm and examined the roughness influence on heat removal capabilities. Tests showed that as the surface roughness decreases the CHF increases. CHF is up to 1200 W/cm2 on the surface by polishing grit of 0.3 μm while only 1000 W/cm2 on the surface by 22 μm grit. This is because the large surface roughness implies a thicker film thickness, leading to the later bubble breakup and departure, the impeding of vapor escape, the increased resistance to heat flux through evaporation on film surface, and the dampening of droplet impingement.
\nMini-textured surfaces feature structure size above 1 mm, and the structure types of cubic pin fins, pyramids, and straight fins and so on (see Figure 5a). Silk et al. [23] observed that addition of finned structure to cooled surface decreases the convective thermal resistance, and increases the convection heat transfer relative to the flat surface, since the total wetted surface area is larger on the enhanced surface. Although the cubic pin fins and straight fins have the same wetted surface area, cooling performance of straight fins surface exceeds that of the cubic pin fins surface. This is attributed to liquid management on the heated surface and cooling efficiency on the wetted surface area. Xie et al. [39] indicated that the fin arrangement is a dominant factor in enhancing heat transfer rather than the wetted surface area. The improper fin arrangement causes the thick and slow moving liquid film and thus worsens the local cooling performance. This point of view needs further validation by measuring the change of local surface temperature.
\n(a) Millimetric structured surface [
Micro/nano or hybrid structured surfaces have been attracted huge attention to spray cooling as micro fabrication technology advances new micro-/nano-engineered surface in the last decade (see Figure 5b, c, d). The experimental studies [36, 39, 40, 41] applied micro-textured surfaces with surface feature size from 25 to 480 μm, which is close to liquid film thickness but larger than average droplet size. Micro-textured surfaces showed slight effect on heat transfer enhancement in the flooded region, but greatly enhancing cooling performance in the thin film and partial dry-out regions as compared to the flat surface. The study by Zhang et al. [37] showed that nanostructured surface has better cooling performance since the contact angle is smallest on the nanostructured surface as compared to micro-structured surfaces and flat surfaces. Recently, Chen et al. [38] developed a hybrid micro/nano structured surface by growing the ZnO nanowire arrays on the top of etched micro-structured silicon wafer. Test results showed that cooling performance of hybrid surface is better than the micro-structured surface in boiling regime because of its great wetting capacity and reduction in dry-out surface area. If comparing performance of nanostructured surface [37] and hybrid surface [38], there is no significant difference in heat flux enhancement relative to the smooth surface.
\nThe impact dynamics during spray cooling is complicated as it involves many liquid phenomena, such as spreading, receding, splashing, droplet collision, generation of stationary film and radially flowing film, and liquid flooding. All of these impact phenomena result from the interaction of droplet flow and film flow on the impact surface. Droplet flow includes three types: single droplet, droplet train (continuous droplets formed from jet breakup), and droplet burst (portion of droplet train selected at a certain frequency). Similarly, film flow conditions involve dry surface (no film), stationary film, radially flowing film, or their combination on the cooling surface (see Figure 6).
\nSingle water droplets with same velocity and diameter (
The droplet and film flow conditions are two flow parameters directly determining the heat transfer mechanism of spray cooling. Coolant droplets bring significant temperature difference between the expanding droplet flow and flowing film, which contributes to the reduction of thermal resistance inside the film layer and enhancement of heat transfer from the heated surface to the flowing flow. Fluid dynamics on the impact surface is responsible for the local convection heat transfer. The fast flowing film transfers more heat to downstream. Thin film thickness reduces the thermal boundary layer and encourages evaporation from the liquid interface. Therefore, the fluid dynamics study of droplet affecting film enables us to get insight into thermal results of droplet impact on the film-cooled hot surface, and further understand spray cooling performance. The relevant literature is reviewed based on the droplet flow condition: single droplet impact, droplet train impact, and droplet burst impact.
\nThe dry surface usually appears in two-phase spray cooling, which is shown by the change of contact line length. The researchers reported that the critical heat flux in spray cooling is achieved at the greatest contact line length. On dry surface, droplet impact dynamics on droplet-covered surface area is essential to local cooling performance. The process of a liquid droplet impact was divided by Rioboo et al. [43] into five successive phases: kinematic, spreading, relaxation, wetting, and equilibrium. Most research work has been focused on spreading and relaxation. In the spreading phase, contact line expands radially until reaching a maximum spreading, which is determined by droplet initial diameter, impact velocity, surface tension, viscosity, and wettability of the solid surface (Li et al. [44]). The maximum spread diameter is of critical importance in spreading phase. Clanet et al. [45] found that on a super-hydrophobic surface the maximal spread is significantly dependent on the viscosity of liquid droplets and scales as a function of Weber number~We1/4. van Dam and Clerc [46] found a significant difference of maximum spread between substrates with small and large contact angles, showing the significant influence of wettability in the later stage of impact. A lower air pressure was found to suppress the droplet spreading, leading to a smaller maximum spread [47].
\nSome analytical models were proposed to predict impact process, most of which were based on the energy conservation of the impact droplet. Chandra and Avedisian [48] developed an empirical correlation of viscous dissipation, including estimated spreading time, simplified dissipation function, and estimated volume of viscous dissipation. Gao and Li [49] proposed a theoretical model based on the actual dynamic shape of the droplet that could successfully predict the maximum spreading diameter and receding diameter during the recoiling process. Some of the researchers put efforts on the investigation of splash using varied dry surfaces. Surface roughness and textures were demonstrated to influence the splash limit [50, 51]. Droplet impact on a moving surface was found to show different splash and non-splash phenomena as compared to stationary surfaces [52]. Previous studies on splash threshold under different surface conditions are summarized in Table 1.
\nSurface conditions | \nThreshold parameter | \nCritical value | \nReferences | \n
---|---|---|---|
Dry surface | \n( | \n57.7 | \nMundo et al. [50] | \n
0.8458 | \nVander Wal et al. [53] | \n||
Moving dry surface | \n5700 | \nBird et al. [52] | \n|
Stationary liquid film | \n( | \n2100 | \nCossali et al. [54] | \n
63 | \nVander Wal et al. [53] | \n||
Flowing liquid film | \n3378 | \nGao and Li [42] | \n
Summary of splash thresholds under different surface conditions [42].
On heated dry surface, Bernardin et al. [55] mapped the boiling curve of droplet impact cooling as the same as the spray cooling. In the regime of single-phase liquid cooling, Pasandideh-Fard et al. [56] observed that increasing impact velocity would enhance heat flux around the impact area. This is because the raising droplet velocity promotes droplet spreading, thus increasing the wetted area on the heated substrate. However, increasing droplet impact velocity slightly enhances heat flux at the impact point. Batzdorf et al. [57] proposed a theoretical mode to predict the heat transfer rate during the droplet impact. The theoretical prediction is more accurate when the liquid Prandtal number \n
On superheated surface with temperature over 200°C, Tran et al. [58] found three significant phenomena after droplet impact: contact boiling (droplet contacts with the surface), film boiling (vapor layer formed underneath the droplet), and spray film boiling (vapor layer and tiny droplets ejected upward) (see Figure 7a). Their experiments showed that the maximum spreading of a droplet impact follows a universal scaling with the Weber number (~We2/5), which is steeper than that on nonheated surface (~We1/4) [45]. The steeper curve on heated surface results from a driving mechanism, which is caused by the evaporating vapor radially expanding and pushing liquid outward. Staat et al. [59] indicated that the Leidenfrost transition temperature shows little dependence on the Weber number of affecting droplet, but the transition to splashing shows a strong dependence on the surface temperature. Adera et al. [60] reported the formation of non-wetting droplets on a super-hydrophilic micro-structured surface by slightly heating the surface above the saturation temperature of the droplet fluid, which is contributed by the increased thermal conductivity and decreased vapor permeability of the structured region. In experimental study of Jung et al. [61], the transient temperature distribution during droplet spread was detected using infrared thermography. In contact boiling, the droplet coolant contacts the surface and the maximum heat flux is quick to reach at early impact stage ~2 ms at impact point. In film boiling, non-wetting surface appears at the early impact, and the maximum heat flux is even lower than that in contact boiling due to the existence of vapor layer underneath the droplet. On heated surface, the study of simultaneous impact of multiple droplets is few, which needs further discussion of droplet collision influence on contact line and local evaporation. This benefits the understanding of two-phase spray cooling and optimization of cooling efficiency.
\n(a) Phase diagram of water droplet impact on a superheated surface [
Stationary film occurs in the center of normal spray impact, or locates where the spray nozzle axis insects with the impact surface in inclined spray (see Figure 2). On a stationary film, most researchers focused on spread process and splash formation mechanism after impact. Yarin and Weiss [62] developed a quasi-one-dimensional model, which predicts the existence of a kinematic discontinuity in the velocity and film thickness distribution. The discontinuity corresponds to the emergence of an uprising liquid sheet. Roisman and Tropea [63] generalized Yarin’s theory for the case of arbitrary velocity vectors in the liquid films both inside and outside the crown. Yarin and Weiss [62] experimentally found the crown radius from the impact center could be expressed as a function of the non-dimensional spreading time. Two empirical parameters existing in their model was given by the later study of Cossali et al. [64]. Droplet impact on a stationary film may or may not result in the splash. Finding the threshold condition for splash impact has been the focus of a few experimental studies. Cossali et al. [64] tested drops of various mixtures of water and glycerol affecting a thin liquid film and proposed an empirical parameter for predicting the occurrence of splash impact. For thick films, Cossali et al. [54] and Rioboo et al. [65] found a critical value of the threshold parameter, i.e. \n
The interaction between droplet flow and film flow is fundamental fluid dynamics in single-phase spray cooling or nucleate boiling (see Figure 2b). Impact dynamics was addressed in some researches. Alghoul et al. [66] presented an experimental investigation of a liquid droplet affecting onto horizontal moving liquid films. An asymmetrical crown shape was observed due to the effect of the moving film. Che et al. [67] demonstrated the on inclined falling flow asymmetrical crown shape is also formed after droplet impact. Gao and Li [42] further analyzed the early evolvement of droplet impact based on experiments and theoretical model (see Figure 6c). Once droplet lands on the film, the droplet flow quickly spreads and pushes the liquid outwards, causing the uprising liquid sheets. However, crown sheet is asymmetric owing to the collision mechanism on crown base. At the early stage of droplet impact, the direction of spreading flow is opposite to that of film flow at the upstream of impact point, while their direction is the same at the downstream. Uprising crown sheet may splash, which is dependent of the instability of the sheet rim. The stretching rate of crown sheet is a key factor influencing the rim instability. Analysis was conducted to derive equation of stretching rate, finding that the highest stretching rate appears at the location which droplet spreading flow is right opposite to the film flow, and the location is also the most probable location of splash. The value of splash threshold was provided to estimate whether splash occurs or not. The secondary droplets from splash fly away from the cooled surface, which do not contribute to the cooling performance. In other words, suppression of splash occurrence should benefit cooling enhancement.
\nThe late study of Gao and Li [68, 69] further observed the whole development of droplet impact on flowing film, and demonstrated its relation to the local cooling. The impact process is observed by high-speed video, showing two states: spreading state, replacing state. In spreading state, the droplet flow spreads and gradually slows down until reaching the maximum spread. After that, the droplet flow is pushed towards the downstream and eventually replaced by the film flow. The measured temperature also shows two stages: response stage when the temperature quickly decreases, and recovery stage in which the temperature recovers to the steady state. An enhancement factor was proposed to indicate convection enhancement relative to the steady-state cooling. The peak enhancement is used to consider enhancement influence of impact velocity, droplet size and film flow rate, which is proportional to the square root of the ratio of the droplet flow rate to the film flow rate~\n
One possible phenomenon in spray cooling is that fresh droplets continuously impact the surface at a certain frequency. The droplet flow is defined as the droplet train flow. The fluid dynamics behind this is the interaction of continuous droplet train flow with the flowing film formed on the heated surface. To investigate heat transfer of spray cooling from this aspect, a few studies have been conducted on the heat transfer of continuous droplet train impinging on hot surfaces. Qiu et al. [70] demonstrated surface temperature influence on the impact dynamics. Prior to the steady state, the droplet film spreads on the heated surface, and the surface temperature enhances the spreading rate of the flowing film when the surface temperature is over the boiling point. With the increase of the surface temperature the steady-state film-wetted area decreases, and eventually maintains constant after the temperature is greater than 190°C. Besides, the temperature also affects the splashing angle (see Figure 8). A stable splashing angle marked by red line is established at higher surface temperature greater than 192°C. The later study of Qiu et al. [71] showed that the inclination of the droplet train decreases the splashing angle and increases the averaged secondary droplet size.
\nThe impact dynamics of droplet train at different surface temperature and the droplet velocity is 15.2 m/s [
Soriano et al. [72] presented an experimental observation of multiple droplet train impingement. Impact spacing between multiple droplet streams would affect spreading and splashing in impact regimes, and the optimal cooling performance was achieved when the film velocity was not disturbed by adjacent droplet streams. Zhang et al. [73, 74] further demonstrated that both impact spacing and impingement pattern significantly affect local and global cooling performance on the hot surface. In comparison with the circular jet impingement cooling, the droplet train impingement achieves a better cooling performance for various impingement patterns. The same conclusion was made when comparing the cooling performance of droplet train and jet impingement on flowing film that cools the hot surface [75]. Through piezoelectric nozzles more groups of jet flow were generated and broke up to droplet train for cooling the hot surface [76], and the maximum heat flux reaches~ 170 W/cm2 with the nozzle diameter of 25 μm. However, unclear impact dynamics and its relation to local cooling need the further study.
\nOur recent studies try to understand spray cooling from droplet burst aspect [75, 77]. Different from droplet train cooling, it assumed that in spray cooling droplet groups impact the surface at a constant frequency rather than droplet train. Each droplet group is defined as a droplet burst, and each burst contains a constant number of droplets, which is called burst size. The frequency at which droplet bursts are generated is called the burst frequency. The generation mechanism of droplet burst was first proposed by Gao and Li [75, 77] and implemented in tests. A droplet generator combined with controlled interrupter is applied for droplet burst generation. A droplet train is ejected from droplet generator with droplet frequency \n
Droplet burst flows are generated by interrupting a droplet train flow (
For the impact of one droplet burst (see Figure 10), at \n
(a) Impact dynamics of a drop burst flow affecting the film flow; (b1) surface temperature distribution at
For the impact of one droplet burst flow, the temperature at impact point is measured. Temperature measurement shows that the burst flow causes the temperature to quickly decrease, and then the temperature fluctuates with the constant fluctuation frequency and amplitude in full-developed stage. The fluctuation frequency is equal to the burst impact frequency. The temperature at the impact point remains lower than the film cooling temperature without droplet burst impact. Heat transfer coefficient shows three development stages of the convection: affecting, restoring, and restored. During the restored stage, local cooling has returned to the film cooling. The restored stage may not exist if the time interval between bursts \n
The comparison of burst flows shows that the trough value of the fluctuating temperature, \n
Spray cooling is one effective cooling technology for handling high-power density and high heat flux removal requirement. In spray cooling, liquid coolant is emitted from a pressurized nozzle and breaks up into numerous secondary droplets affecting heated surface that is covered by radially flowing film. The cooling is achieved through the convection heat transfer from the heated surface to the film flow, nucleate boiling, liquid conduction inside the film flow, and interfacial evaporation from the liquid film. Based on research outcomes reported in the literature, spray cooling technology is reviewed from two aspects: the spray level and the droplet level. In the spray level, these studies emphasize the cooling performance to spray property. Some key properties are summarized in this chapter, involving spray characterization, nozzle positioning, phase change, and enhanced surface. In the droplet level, the studies focus on local heat transfer associated with droplet impact conditions, which are classified into a few categories: impact of single droplet on dry surface, stationary film, flowing film, impact of droplet train, and impact of droplet burst. Although spray impact cannot be simply considered as the superposition of single droplets, the studies in droplet level provide experimental and theoretical basis to explain what happened on heated surface and the relevant local heat transfer mechanism in spray cooling.
\nGeneral requirements for Open Access to Horizon 2020 research project outputs are found within Guidelines on Open Access to Scientific Publication and Research Data in Horizon 2020. The guidelines, in their simplest form, state that if you are a Horizon 2020 recipient, you must ensure open access to your scientific publications by enabling them to be downloaded, printed and read online. Additionally, said publications must be peer reviewed.
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