A predictive assay for human tumor cellular response to hyperthermia using dansyl lysine staining and flow cytometry

The heat response of five human tumor biopsies has been examined using the fluorescent probe dansyl lysine and multiparameter flow cytometry. Dansyl lysine has previously been shown to possess specificity for heat killed mammalian cells. The human tumors tested included a cervical squamous cell carcinoma, malignant melanoma, colon adenocarcinoma, ovarian carcinoma, and a mesothelioma. The samples were excised, mechanically disrupted into single cell suspensions and heated in vitro for various lengths of time at 45 degrees C. The cells were returned to 37 degrees C incubation for 12 to 15 hours prior to staining with dansyl lysine. The fraction of cells staining dansyl lysine was quantitated by flow cytometry after gating on high forward angle light scatter and 90 degrees C light scatter. This gate excluded much of the normal cell contamination within the tumor sample. The data show that the heat response of human tumor biopsies varied significantly, with cervical carcinoma and malignant melanoma being the most resistant and the mesothelioma and ovarian carcinoma the most heat sensitive. Finally, evidence is presented for the expression of thermotolerance in ovarian carcinoma and mesothelioma biopsies pre-heated in vitro. Dansyl lysine appears to be useful in measuring the intrinsic cellular heat sensitivity of human tumors and in determining the kinetics of decay of thermotolerance following an initial heat exposure.

Stanford University institutional report. Phase I evaluation of equipment for hyperthermia treatment of cancer

From September 16, 1981, through April 4, 1986, a total of 21 radiative electromagnetic (microwave and radiofrequency), ultrasound and interstitial radio-frequency hyperthermia applicators and three types of thermometry systems underwent extensive phantom and clinical testing at Stanford University. A total of 996 treatment sessions involving 268 separate treatment fields in 131 patients was performed. Thermal profiles were obtained in 847 of these treatment sessions by multipoint and/or mapping techniques involving mechanical translation. The ability of these devices to heat superficial, eccentrically located and deep-seated tumours at the major anatomical locations is evaluated and the temperature distributions, acute and subacute toxicities, and chronic complications compared. Average measured tumour temperatures between 42 degrees C and 43 degrees C were obtained with many of the devices used for superficial heating; average tumour temperatures of 39.6 degrees C to 42.1 degrees C were achieved with the three deep-heating devices. When compared to the goal of obtaining minimum tumour temperatures of 43.0 degrees C, all devices performed poorly. Only 14 per cent (118/847) of treatments with measured thermal profiles achieved minimum intratumoural temperatures of 41 degrees C. Fifty-six per cent of all treatments had associated acute toxicity; 14 per cent of all treatments necessitated power reduction resulting in maximum steady-state temperatures of less than 42.5 degrees C. Direct comparisons between two or more devices utilized to treat the same field were made in 67 instances, including 19 treatment fields in which two or more devices were compared at the same treatment session. The analyses from direct comparisons consistently showed that the static spiral and larger area scanning spiral applicators resulted in more favourable temperature distributions. Three fibreoptic thermometry systems (Luxtron single channel, four channel and eight channel multiple [four] probe array), the BSD Bowman thermistor system and a thermocouple system were evaluated with respect to accuracy, stability and artifacts. The clinical reliability, durability, and patient tolerance of the thermometry systems were investigated. The BSD Bowman and third generation Luxtron systems were found clinically useful, with the former meeting all of our established criteria.

Prognostic factors and sites of failure in FIGO Stage I, Grade 3 endometrial carcinoma

The results of therapy and patterns of failure were analyzed for 60 patients with Stage I, Grade 3 endometrial cancer seen at Yale-New Haven Hospital between 1960 and 1980. Fifty-eight patients were treated with a combination of surgery and radiation; one was treated with surgery only; and one received radiation only. The overall absolute 5-year survival rate was 72.9% with poorer prognosis noted for patients greater than 65 years of age, older at time of their menopause, and with Stage IA disease. Of the 14 patients who recurred, distant sites were involved in 93% (13/14), with the lung the most common site of distant failure (5/14), followed by the upper abdomen (4/14). Pelvic sites were involved in 43% (6/14) of the treatment failures. The use of pelvic external beam radiation resulted in a reduction in pelvic recurrences, but did not improve overall survival. The predominance of distant failures despite pelvic radiation suggests the possibility of early vascular and transcoelomic spread in Stage I, Grade 3 endometrial adenocarcinomas. Thorough exploration of the upper abdomen, paraaortic nodes, and the obtaining of pelvic washings for cytology at the time of initial surgery, are recommended in addition to chest CT scans to help identify those patients with occult metastases. Prospective randomized trials in Stage I, Grade 3 patients employing adjuvant cytotoxic chemotherapy, hormonal therapy, and/or whole abdominal-pelvic radiation, should be considered in an attempt to improve survival in high-risk patients.

Correlations of thermal washout rate, steady state temperatures, and tissue type in deep seated recurrent or metastatic tumors

The rates of cooling ("thermal washout") in selected sites in tumor and adjacent normal tissues following the completion of clinical hyperthermia sessions were analyzed in ten patients treated with combined radiation and hyperthermia for deep seated recurrent or metastatic tumors. The temperatures were recorded at 10 second intervals for at least 2 minutes after the cessation of microwave power at the end of the 30-60 minute duration hyperthermia treatments. These thermal washouts were characterized by the slope of a log-linear relation between temperature elevation above the oral baseline temperature and time. Washout rates (expressed as a perfusion rate in ml/100g-min) significantly correlated with tissue categories as noted on CAT scan (i.e., tumor, normal tissue, tumor/normal tissue interface, hypodense tumor areas). Relationships between thermal washout rate and steady-state temperature elevation were tested and also showed significant correlations in general and for some specific tissue categories. The implications of these findings in explaining inhomogeneities in heating patterns, and in hyperthermia treatment modeling will be presented.

Radiotherapy with curative intent: an option in selected patients relapsing after chemotherapy for advanced Hodgkin's disease

Thirteen patients who had relapsed or failed to obtain a complete remission after combination chemotherapy for the treatment of advanced Hodgkin's disease were treated with subtotal or total lymphoid irradiation with curative intent. Twelve of the 13 patients achieved a complete response (CR). Five of the 12 CRs subsequently relapsed at 3, 9, 9, 12, and 19 months. One patient died of leukemia 11 months following radiotherapy. The actuarial relapse-free survival at 1 year was 60%, and six patients (50%) remain disease-free with a median follow-up of 34 months (range, 10 to 115 months) following the completion of radiotherapy. Patients who failed to obtain a CR to their initial chemotherapy, whose chemotherapy CR was of short duration, or who relapsed initially in extranodal sites, tended to have a worse outcome with radiotherapy. Patients who had long disease-free intervals after initial chemotherapy or relapsed only in nodal sites tended to do relatively well. Radiation therapy was well tolerated with no major toxicity. Potentially curative radiation therapy should be considered an option in the management of selected patients who relapse following combination chemotherapy for advanced Hodgkin's disease.

Therapeutic approaches to uterine papillary serous carcinoma: a preliminary report

Uterine papillary serous carcinoma (UPSC) is a recently identified and characterized unique histopathologic subtype of endometrial cancer. Unlike the more common types of endometrial cancer, UPSC has a high likelihood of transperitoneal seeding and upper abdominal recurrence. Since our initial report of 26 patients with UPSC, an additional 10 patients with FIGO stage I disease have been diagnosed, operatively staged, and managed by an individualized approach. Operative staging revealed 5 of the 10 patients to have more advanced disease than had been determined clinically. Adjuvant postoperative abdominopelvic radiation was administered to 6 patients, 4 of whom remain free of disease within the treated area. Two patients received adjunctive hormonal and chemotherapy; neither has recurred. Two patients received no adjunctive therapy. One of these failed initially in the vagina with subsequent recurrence in the lungs and supraclavicular nodes. The value of operative staging and selection of appropriate adjunctive therapy awaits additional patient accrual and follow-up.

Heating deep seated eccentrically located tumors with an annular phased array system: a comparative clinical study using two annular array operating configurations

Regional heating administered with an annular array to 12 patients with deep-seated advanced malignant disease eccentrically located in the lower abdomen and pelvis is compared based on the annular array operating configuration. One configuration (4 quadrants active) delivers radiofrequency power with relative uniformity throughout the patient cross-section. The other (2 quadrants active) allows the radiofrequency power deposition to be shifted preferentially into the eccentrically located treatment volume. Phantom measurements have been made to demonstrate the redistribution of radiofrequency power that results when the annular array is operated in these respective configurations. Systemic responses (i.e. oral temperature rise, changes in blood pressure, and heart rate) to these regional hyperthermia applications are compared and are not significantly different with respect to these heating configurations. Temperature data obtained during treatment sessions using these two annular array operating configurations are analyzed based on the fraction of measured tumor and normal tissue temperatures exceeding or equal to a given index temperature. Although the two quadrant configuration is more efficient in delivering power to the treatment volume, this analysis does not indicate a significant gain in therapeutic heating as a result of this preferential power deposition. Treatment tolerance and heterogeneity with respect to tissue type and blood flow remained the dominant limiting factors with regard to temperatures achieved.

Second Neoplasms in Patients With Hodgkin's Disease Following Combined Modality Therapy—The Yale Experience

In the article by Koletsky et al "Second Neoplasms in Patients With Hodgkin's Disease Following Combined Modality Therapy—The Yale Experience" (Journal of Clinical Oncology 4:311–317, 1986), an error was made in the footnote on page 311 which described the composition of MVVPP. The corrected footnote appears below.

*MVVPP = nitrogen mustard (0.4 mg/kg on day 1 of cycle); vinblastine (6 mg/m2 on days 22, 29, and 36); vincristine (1.4 mg/m2, 2 mg maximum dose, on days 1, 8, and 15); procarbazine (100 mg/d on days 22 through 42); prednisone (40 mg/m2 on days 1 through 15 for cycles 1, 3, and 5 only).

N3 (TNM-UICC) metastatic neck nodes managed by combined radiation therapy and hyperthermia: clinical results and analysis of treatment parameters

In an attempt to improve the control of N3 (TNM-UICC) fixed and inoperable metastatic nodes, local microwave hyperthermia (HT) was combined with radiation therapy (RT). From February 1981 to January 1985, 34 patients, with N3 metastatic nodes from primary tumours in the head and neck, were treated according to two different prospective, non-randomized protocols: 23 patients received HT combined with the first course of conventionally fractionated radical RT (40 Gy + HT--2 week interval--20-30 Gy), and 11 patients received HT combined with palliative RT (20-50 Gy + HT). All the patients were treated with the same microwave applicator (MA-150) on the BSD-1000 unit, at a frequency of 280-300 MHz. Temperatures were measured by means of 2-3 Bowman probes placed within the tumour (core and periphery) and 5-6 probes on the skin surface. HT sessions were delivered after RT (less than 20 min), 2 or 3 times weekly, for a duration of 30 min after steady-state temperatures were obtained. Twenty-seven patients out of 34 were evaluable, with a follow-up of at least 3 months (range 3-39 months; median 10 months). Clinical results at 3 months revealed 59 per cent complete responses, 30 per cent partial responses, and 11 per cent with progressive disease. Analyses of response rates showed: a marginally significant difference (P = 0.095) between RT alone (historical control) and the entire group of patients treated with RT plus HT; a significant difference (P = 0.034) if RT alone is compared with Protocol A (RT greater than or equal to 60 Gy + HT); no significant difference between the two protocols employing HT, despite the different RT doses utilized; no significant differences in response rates, as a function of minimal intratumoural temperatures achieved, number of weekly HT sessions or total number of HT sessions; and a significantly lower response rate for nodes with maximum diameter greater than 6 cm (P = 0.043). No important differences in acute side effects between irradiated and heated regions in the same patient were noted. Late side effects in patients treated with RT plus HT included three cases (9 per cent) of severe fibrosis, possibly as a consequence of excessive maximum tumour temperature (greater than 46 degrees C).

Site and disease selection for hyperthermia clinical trials

Significant progress has been made in the past 20 years in understanding the biological basis of hyperthermia-induced cytotoxicity, thermoenhancement of radiation therapy and chemotherapy, and in the development of clinically applicable microwave, radiofrequency, ultrasound and thermometry equipment. Numerous uncontrolled trials have suggested strongly that hyperthermia in conjunction with radiation therapy or chemotherapy may contribute to improved local control rates for recurrent or metastatic cancer without excessive morbidity. Carefully designed and well-controlled site and disease-specific prospective randomized trials with standardized hyperthermia and radiation therapy techniques, adequate thermometry, precise end points for tumour control and normal tissue toxicity are now essential to establish the role of hyperthermia in cancer management. Criteria for tumour site selection will be explored for trials employing radiation therapy and local-regional hyperthermia. Examples of sites selected will be presented which represent areas that can, with current technology, usually be adequately heated, and in which significant patient benefit may result from improved local-regional control.

Second neoplasms in patients with Hodgkin's disease following combined modality therapy--the Yale experience

From 1969 to 1982, 183 patients with previously untreated stages IIIB and IV Hodgkin's disease and relapsing Hodgkin's disease after radiation therapy were treated with combination chemotherapy plus low-dose irradiation (CRT). One hundred fifty patients who achieved a complete response (CR) were analyzed for risk of developing a second neoplasm. Median follow-up has been 8.3 years. Actuarial survival of all patients is 74% at 10 years with a relapse-free survival of 68%. An additional 24 patients with stage IIIA disease were also treated with CRT. There were 22 CRs at risk who were analyzed. Median follow-up has been 3+ years with an actuarial survival of 90% at five years and a relapse-free survival of 83%. Second neoplasms have developed in 14 of 172 patients at risk: acute nonlymphocytic leukemia (ANLL; five patients); aggressive histology non-Hodgkin's lymphoma (NHL; three patients); and a variety of solid neoplasms (six patients). Time to second neoplasm diagnosis after initial treatment ranged from 12 to 141 months. Five patients were older than 40 years. At the time of diagnosis of the second malignancy, 11 patients were free of Hodgkin's disease (for 36 to 141 months) and three were receiving therapy for recurrent Hodgkin's disease. The 10-year actuarial risk (%) of developing ANLL was 5.9 +/- 2.8; for NHL, the risk was 3.5 +/- 2.4, and for solid neoplasms, 5.8 +/- 3.0. Our results suggest that combination chemotherapy plus low-dose irradiation does not appear to significantly increase the risk of developing second neoplasms above that already reported for combination chemotherapy when administered as either initial or salvage treatment of Hodgkin's disease.

Axillary-subclavian vein thrombosis following combination chemotherapy and radiation therapy in lymphoma

Four patients with deep venous thrombosis of the upper extremity (DVTUE) following combined modality therapy (mantle radiotherapy and chemotherapy) for either Hodgkin's disease or non-Hodgkin's lymphoma were seen at Stanford University Medical Center between March 1980 and April 1984. A total of 235 patients had received similar combined modality therapy during this time period. Three patients presented with acute onset of DVTUE and were anticoagulated. One patient who was referred with a several month history of DVTUE was observed closely after diagnostic evaluation revealed no evidence of recurrent Hodgkin's disease. All patients remained without evidence of their original lymphoma and had developed adequate venous collateralization. These cases of DVTUE were felt to be treatment related, a previously unreported late complication of combined irradiation and chemotherapy. Methods of diagnosis and therapeutic options are discussed.

Stage IIIA carcinoma of the uterine cervix

Carcinoma of the uterine cervix presenting with extension to the lower third of the vagina but without hydronephrosis or fixation to the pelvic sidewall is uncommon. It is classified as stage IIIA by the criteria of the International Federation of Gynecology and Obstetrics (FIGO) and accounts for less than 2% of all cervical cancer cases seen in our institution. Because of the paucity of such cases, the results of treatment of FIGO stage IIIA cervical cancer are generally not reported separately. The radiation therapy treatment program at Yale--New Haven Hospital for stage IIIA patients includes intracavitary and vaginal brachytherapy plus external beam radiation therapy, with a strong emphasis on individualization of treatment. The results of treatment in 17 stage IIIA patients were reviewed. Local--regional tumor control was achieved in 12 of the 17 patients (71%) treated. The actuarial 5-year disease-free survival rate was 58%. Our results suggest that FIGO stage IIIA carcinoma of the cervix has a much better prognosis than FIGO stage IIIB cervical cancer, and we recommend that the results of treatment for FIGO stage IIIA be reported separately.

Adjuvant therapy in mixed mullerian tumors of the uterus

We report 54 patients with mixed mullerian tumors of the uterus treated at Yale-New Haven Hospital from 1962 to 1983. Seven had previous pelvic irradiation. Twenty-five neoplasms were homologous and 29 were heterologous. The mainstay of therapy was surgery and radiation. By FIGO criteria 9 patients had stage IA disease, 31 stage IB, 6 stage II, and 8 patients had clinical extrauterine disease. Ten of forty-six patients (23%) with FIGO stage I and II disease had extrauterine disease found at surgery. No patient with extrauterine disease had prolonged survival. The 2-year disease-free survival with stage IA was 66%, with stage IB surgically confirmed 32%, and for stage II 33%. Surgically advanced disease in clinical stage I and II patients and recurrence were associated more frequently with a heterologous histology (67%). The small uterus with a less than 10-cm cavity had a better prognosis. Among 29 surgically confirmed stage I and II patients, 83% of recurrences appeared within 2 years (mean 16 months +/- 7 months). Patients who received both intracavitary radiation and external beam developed only 17.6% pelvic recurrence but this reduction in local recurrence was not associated with significant improved long-term survival. Six of eight patients treated with cis-platinum, Adriamycin, and dimethyl triazeno imidazole carboximide for persistent disease or for recurrence showed response for 4 to 24 months, none complete. Five patients were treated by radiation, surgery, and adjuvant chemotherapy (4 with Adriamycin-Cytoxan, 1 with Adriamycin-platinum). Four of the five (80%) are disease free from 36 to 60 months. These data and the experience of others support the need for a clinical trial with adjuvant platinum and Adriamycin in this disease.

Treatment selection for stage IIIA Hodgkin's disease patients

Two treatment policies for the therapy of patients with Stage IIIA Hodgkin's disease are compared. From 1969-1976, 49 newly diagnosed and pathologically staged IIIA patients received total nodal irradiation (TNI) alone (no liver irradiation). Although actuarial survival was 80% at 5 years and 68% at 10 years, actuarial freedom from relapse was only 38% at 5 years. Accordingly, a new treatment policy was instituted in 1976. Patients with either CS IIIA disease, multiple splenic nodules, IIIA with a large mediastinal mass or III2, received combined modality therapy (combination chemotherapy and irradiation). All others received TNI. Thirty-six patients have been treated under the new program. The actuarial survival is 90% at 5 years and the relapse-free survival is 87%, suggesting the superiority of this approach.

Acute bilobar collapse secondary to endobronchial metastatic seminoma

We report here a patient with tracheal and endobronchial metastatic seminoma who presented with acute respiratory failure with right upper and middle lobe collapse. Diagnosis of the etiology of the atelectasis was made by fiberoptic bronchoscopy. Radiation therapy caused a marked reversal of the atelectasis.

Fallopian tube carcinoma

Twenty-one patients with fallopian tube carcinoma from Yale-New Haven Medical Center are reviewed. Most patients who died of disease did so in the first two years after diagnosis, even following complete resection, clearly indicating the need for adjuvant therapy. Negative second-look surgery did not provide assurance of permanent remission. There was a high recurrence rate with Stage I and completely resected Stage II and III disease (8 of 14 patients). Some recurrences occurred late, up to nine years after initial diagnosis. We recommend whole abdomino-pelvic radiation if no disease greater than 2 cm3 bulk exists after surgery. Chemotherapy may be an alternative to radiation as primary adjuvant treatment in early stage disease. Chemotherapy for unresectable disease or recurrent disease has shown palliation with occasional prolonged survival but no patient with recurrent disease survived longer than two years.

Pure dysgerminoma of the ovary with elevated serum human chorionic gonadotropin: diagnostic and therapeutic considerations

Pure ovarian dysgerminomas with associated elevation of human chorionic gonadotropin (hCG) are rare, and their optimum management is unclear. We report here a 24-year-old woman with stage III dysgerminoma of the ovaries, with bulky intrapelvic disease, paraaortic adenopathy, and elevated pre- and postsurgical serum beta-hCG titers. Following administration of whole abdominal-pelvic and mediastinal irradiation therapy, the patient's adenopathy regressed, her serial beta-hCG titers returned to normal, and she has remained free of disease for the past 30 months. Histopathological studies revealed a pure dysgerminoma with scattered giant cells which were negative for hCG by immunoperoxidase staining. The literature is reviewed with reference to the significance of elevated hCG levels, the presence of giant cells in association with dysgerminoma of the ovary, and therapeutic implications. Serial determinations of beta-hCG titers may prove to be as valuable in the management of these patients as they are in patients with testicular tumors.

Immediate versus delayed hysterectomy for endometrial carcinoma: surgical morbidity and hospital stay

Presented is a retrospective review of the intraoperative complications, postoperative morbidity, and length of hospitalization in 138 patients with stage I endometrial carcinoma treated at Yale-New Haven Hospital from January 1, 1977 to December 31, 1981. One group (stage IA, grade 1) was treated with surgery alone; two groups were treated with preoperative intracavitary radium, followed with either an immediate or a delayed hysterectomy. The three groups were comparable in age, weight, and major preoperative medical problems. The mean estimated blood loss during surgery and transfusion requirements during hospitalization were similar for all three groups. The duration of the surgery in the immediate group was longer than the other two groups. The occurrence of febrile morbidity and major postoperative complications in the three groups was similar, except for bacteriuria, which was significantly more common in the immediate group. The length of the postoperative hospitalization was the same for each group; however, the delayed group as compared with the immediate group had a total hospitalization of two days longer. Hence, in the current study, immediate hysterectomy did not significantly increase the surgical or postoperative morbidity rate, compared with delayed hysterectomy. The single hospital stay in the former treatment group represented cost containment.

Cauda equina compression secondary to metastatic carcinoma of the uterine corpus: preservation of neurologic function and long-term survival following surgical decompression and radiation therapy

Spinal cord or cauda equina compression secondary to epidural metastasis rarely develops in patients with endometrial carcinoma and the early signs and symptoms of compression can therefore be inadvertently overlooked. A 78-year-old patient who developed bone metastasis with destruction of the fifth lumbar vertebral body and blockage of the cauda equina at L-4, L-5 as the only sites of metastasis is reported. This occurred 2 years after initial treatment of a stage IB, well-differentiated, grade I, adenosquamous carcinoma of the endometrium. The patient remains alive, with good neurological function and free of metastatic disease, 2 1/2 years following vertebrectomy, radiation therapy, and adjuvant Provera (medroxyprogesterone acetate) therapy. This patient represents the only case of metastatic endometrial cancer with cauda equina compression in the literature in whom long-term disease-free follow-up has been noted.

Oral cavity and oropharyngeal cancer in a younger population. Review of literature and experience at Yale

Oral cavity and oropharyngeal cancer in younger adults is a rare entity with an incidence of 2.7% among 1014 patients seen or treated at the Department of Therapeutic Radiology, Yale - New Haven Medical Center between 1958 and 1980. Although there are reports of contrastingly divergent therapeutic experiences, the authors contend that even early stage cancers frequently fail definitive therapy with a rampant course, causing a rapidly fatal outcome. The three-year actuarial survival was a mere 17% at Yale. The authors speculate that younger adult oral cavity and oropharyngeal cancers are possibly related to a genetic disorder or immunodeficiency, and recommend aggressive surgical and radiotherapeutic approaches combined with possible adjuvant immunotherapy.

Temperature elevation during brachytherapy for carcinoma of the uterine cervix: adverse effect on survival and enhancement of distant metastasis

Possible effects of fever during intracavitary radiation therapy on patient survival, local-regional control or metastatic spread of disease were analyzed in a group of 398 patients with previously untreated, invasive carcinoma of the uterine cervix, managed with a combination of external beam irradiation and intracavitary radium (ICR) applications at Yale-New Haven Medical Center and affiliated hospitals from January 1953 through December 1977. Cox step-wise proportional hazard models were used to test for the influence of elevated temperatures during ICR placements, controlling for the influence of other pretreatment patient parameters, including FIGO stage, age, blood count, prior supracervical hysterectomy and number of prior pregnancies. Increasing maximum temperatures noted during ICR placements were associated with: decreased patient survival (p = 0.014) and increased frequency with time of distant metastasis as the initial sites of treatment failure (p = 0.038). When patients were dichotomized on the basis of maximum temperature during ICR, distant metastasis as the initial site(s) of treatment failure was noted twice as frequently in patients with maximum temperatures greater than or equal to 101.0 degrees F (12.5%; 10/80 patients) than in those with maximum temperatures less than 101.0 degrees F during ICR placement (6.3%; 20/318 patients). No statistically significant differences were noted between the two groups in their distributions by stage, age, histology, year of diagnosis, or pretreatment hemoglobin, and the sites of distant metastasis and time course for clinical detection were similar in both groups. These results are in agreement with prior clinical studies in cancer of the uterine cervix which noted a poor prognosis in patients with cancer of cervix who developed fever during treatment. In addition, the finding of an association between an increased frequency of distant metastasis and temperature elevation during the ICR provides, for the first time, clinical data supporting the reports of an alteration or enhancement of distant metastasis following the application of whole body hyperthermia in murine, rabbit and canine tumors.