Long-term improvement in treatment outcome after radiotherapy and hyperthermia in locoregionally advanced cervix cancer: an update of the Dutch Deep Hyperthermia Trial

Laser heating of gold nanospheres functionalized with octreotide: in vitro effect on HeLa cell viability

OBJECTIVE

The aim of this study was to assess the effect of laser heating a well-characterized gold nanoparticle (AuNP)-octreotide system on HeLa cell viability, to evaluate its potential as a suitable agent for plasmonic photothermal therapy.

BACKGROUND DATA

Octreotide is a synthetic peptide derivative of somatostatin with an effect on the survival of HeLa cells. Peptides bound to AuNPs are biocompatible and stable multimeric systems with target-specific molecular recognition.

METHODS

Octreotide was conjugated to AuNPs (∼20 nm) by spontaneous reaction with the thiol groups. The nanoconjugate was characterized by transmission electron microscopy (TEM), Fourier transform infrared spectroscopy (FT-IR), ultraviolet visible spectroscopy (UV-Vis), X-ray photoelectron spectroscopy (XPS), and Raman spectroscopy. Irradiation experiments were conducted using an Nd:YAG laser pulsed for 5 ns at 532 nm with a repetition rate of 10 Hz for up to 6 min while delivering an average irradiance of 0.65 W/cm(2). HeLa cells were incubated at 37°C (1) with AuNP-citrate, (2) with AuNP-octreotide, or (3) without nanoparticles.

RESULTS

After laser irradiation, the presence of AuNP caused a significant increase in the temperature of the medium (48°C vs. 38.3°C of that without AuNP). The AuNP-octreotide system resulted in a significant decrease in cell viability of up to 6 % compared with the AuNP-citrate system (15.8±2.1%). Two possible mechanisms could be at play: (1) octreotide alone exerts an effect on survival HeLa cells, or (2) the release of heat (∼727°C per nanoparticle) in the membranes or cytoplasm of the cells caused by the interaction between AuNP-octreotide and somatostatin receptors reduced viability.

CONCLUSIONS

The AuNP-octreotide system exhibited properties suitable for plasmonic photothermal therapy in the treatment of cervical cancer.

Neoadjuvant chemotherapy followed by radiotherapy and concurrent hyperthermia in patients with advanced-stage cervical cancer: a retrospective study

OBJECTIVE

To evaluate the efficacy of neoadjuvant chemotherapy, followed by radiotherapy and concurrent hyperthermia (triple therapy) in patients with advanced-stage cervical cancer.

METHODS

We selected 43 patients from our hyperthermia database, who were treated from 1996 to 2010 with triple therapy for large primary tumours (>6 cm) or para-aortic lymph node metastases. All patients received platinum-based chemotherapy followed by full-dose radiotherapy, brachytherapy and five hyperthermia treatments. The response was evaluated by gynaecological examination and a CT-scan. Time-to-event variables were estimated using the Kaplan Meier method and the Cox regression method.

RESULTS

The mean age of the patients was 50.4 years (range 29-80). The median tumour size was 5.6 cm at diagnosis (range 2.6-8.2), positive lymph nodes were present in 90.7%. A total of 67% of the patients completed all six planned courses of chemotherapy. After completion of neoadjuvant chemotherapy, 83.7% of patients achieved a complete or partial response. At the end of treatment, the complete response rate was 81.4% (95%CI 69.2-93.5). Grade 2, 3 and 4 acute vascular toxicity occurred in 17 patients. The incidence of grade 3-4 haematological toxicity did not exceed 10% and no neutropenic fever occurred. For grade 1-2 renal toxicity, a switch to carboplatin was made (n = 6). No acute grade 3-4 renal toxicity was observed. No treatment-related deaths were recorded. The median follow-up time was 29.8 months (range 4.1-124.8). Overall survival rate at 12 months was 79% (95%CI 57.4-92.3).

CONCLUSION

The triple therapy seems feasible and effective in the treatment of advanced-stage, high-risk cervical cancer. However, chemotherapy-induced vascular toxicity occurred frequently, which may warrant the use of prophylactic anticoagulants. We recommend a phase II trial for prospective confirmation for comparison with standard chemoradiation and the use of anticoagulants.

Mapping of hyperthermic tumor cell death in a microchannel under unidirectional heating

Hyperthermia can be used as an adjunctive method of chemotherapy, radiotherapy, and gene therapy to improve cancer treatment. In this study, we investigate the hyperthermic cell death of cervix cancer CaSki cells in a microchannel integrated with a directional heating scheme. Heat was applied from the inner end to the outer end of the channel and a temperature distribution from 60 °C to 30 °C was established. A three dimensional (3D) numerical model was conducted for the heat transfer simulation, based on which a simple fitting method was proposed to easily estimate the temperature distribution along the channel. Cell death along the channel was mapped 22 h after the heating treatment by dual fluorescent labeling and phase-contrast microscopy imaging. Upstream, where the temperature is higher than 42 °C, we observe necrotic death, late-stage and early stage apoptotic death in sequence along the channel. Downstream and in the middle of the channel, where the temperature is lower than 42 °C, significant cell detachment was noted. Vigorous detachment was observed even in the non-hyperthermic zone (temperature lower than 37 °C), which we believe is due to the direct effect of the hyperthermic zones (higher than 37 °C). The present work not only gives a vivid map of cell responses under a temperature gradient, but also reveals the potential interactions of the heated tumor cells and non-heated tumor cells, which are seldom investigated in conventional petri-dish experiments.

Inhibition of B16 murine melanoma metastasis and enhancement of immunity by fever-range whole body hyperthermia

PURPOSE

Whole body hyperthermia (WBH) has been regarded as a promising alternative therapy to cure late stage cancer with metastasis. As the final biological and therapeutic effects are dependent on the specific protocol, the potential of using a microwave-based WBH approach for metastasis inhibition is established and its typical results are discussed.

MATERIALS AND METHODS

The effectiveness of a 30-min whole body hyperthermia (WH) on animals, raised to a rectal temperature of 40.2° ± 0.3°C for 30  min followed by 84 h observation by 2450 MHz microwave irradiation, were evaluated. In an experimental lung metastasis model by injection of B16-F10 melanoma, lungs were removed from sacrificed mice 16 days after tumour implantation, and the expression of heat shock protein, inter-cellular adhesion molecule 1 (ICAM-1), proliferating cell nuclear antigen (PCNA) and cyclin D(1) was examined. CD4(+), CD8(+) and NK cell subpopulation in peripheral blood were measured by flow cytometry before and after the last treatment.

RESULTS

The best therapeutic effect was obtained when the mice were treated with WBH in combination with the initial chemotherapy with cis-diaminodichloroplatinum (CDDP) and dacarbazine (DTIC) (p < 0.05). The WBH alone has an advantage of reduced toxicity and lower cost. Heat shock protein (HSP) expression increased in the hyperthermia groups. Reduction of PCNA and cyclin D(1) was observed in the mice treated with WH alone or in combination with chemotherapy. In the hyperthermia groups, CD4(+)/CD8(+) decreased while the NK increased slightly.

CONCLUSIONS

The whole body hyperthermia protocol described in this work inhibits B16 tumour metastasis by inhibiting cell proliferation, neovascularisation and stimulating favourable immune responses. It demonstrated that WBH treatment benefits therapy of metastasis cancers.

The role of hyperthermia in the battle against cancer

Aims and background

Hyperthermia, the heating of tumors to 41.5–43 °C, could be today considered the fourth pillar of the treatment of cancer. Employed for 20 years in Europe, the USA and Asia, hyperthermia, used in addition to radiotherapy, chemotherapy and surgery, increases both local control and overall survival, restores the chance of the surgery for inoperable tumors and allows a new low-dosage treatment of relapsed cancers previously treated with high radiotherapy dosage without increasing toxicity.

Methods

Hyperthermia can be either superficial, produced by a microwave generator, or regional, produced by a radiofrequency applicator with multiple antennas, which emanate a deep focalized or interstitial heating.

Results

The results are confirmed by phase III randomized trials, with level 1 evidence. A review of the international literature on hyperthermia, the experience of the University Hospital of Verona Radiotherapy Department (Italy) and a summary of the Symposium regarding the Evolution of Clinical Hyperthermia plus Radiotherapy during the Twentieth Congress of the French Society of Radiation Oncology (SFRO) are presented.

Conclusions

Hyperthermia is an important treatment modality in cancer treatment and its results are strongly supported by criteria of evidence-based medicine. Fifteen years of experience of the Radiation Oncology Department in Verona confirms the positive results obtained with international prospective trials, with level 1 evidence. Hyperthermia appears to be the fourth pillar beside surgery, radiotherapy and chemotherapy. Free full text available at www.tumorionline.it

Current devices for high-performance whole-body hyperthermia therapy

For late-stage cancer, whole-body hyperthermia (WBH) is highly regarded by physicians as a promising alternative to conventional therapies. Although WBH is still under scrutiny due to potential toxicity, its benefits are incomparable, as diversified devices and very promising treatment protocols in this area are advanced into Phase II and III clinical trials. Following the introduction of the WBH principle, this paper comprehensively reviews the state-of-art high-performance WBH devices based on the heat induction mechanisms - radiation, convection and conduction. Through analyzing each category's physical principle and heat-induction property, the advantages and disadvantages of the devices are evaluated. Technical strategies and critical scientific issues are summarized. For future developments, research directions worth pursuing are presented in this article.

Small cell carcinoma of vulva: curative multimodal treatment in face of resistance to initial standard chemotherapy

BACKGROUND AND PURPOSE

Extrapulmonary small cell carcinoma (EPSCC) is a rare disease, which has a slightly better prognosis than small cell lung cancer, but still dismal. Gynecologic small cell malignancies tend to show a better survival than similar histologies of other regions. However, of five reported cases of vulvar manifestation only one patient was disease-free at the time of publication with limited follow-up.

CASE REPORT

The authors describe a case of locally advanced small cell vulva carcinoma infiltrating the anal sphincter and urethra with spread to inguinal lymph nodes treated by radiochemotherapy and regional hyperthermia. After three cycles of carboplatin/ etoposide, computed tomography and magnetic resonance imaging indicated only little regressive transformations but overall stable disease. Surgical options were excluded. Therefore, curative radiotherapy to a total dose of > 65 Gy to macroscopic tumor, chemotherapy with cisplatin weekly, and regional hyperthermia were performed. Acute severe toxicity was limited to skin reactions. Despite the disadvantageous situation with inguinal lymph node metastases and chemoresistance, the multimodal therapy yielded a 5-year disease-free survival.

CONCLUSION

Thus, the trimodal regimen of radiochemotherapy plus regional hyperthermia offered a curative chance in spite of resistance to the standard chemotherapy for irresectable, locally advanced small cell carcinoma of the vulva. Therefore, this approach merits further evaluation for limited disease of EPSCC.

Design and test of a 434 MHz multi-channel amplifier system for targeted hyperthermia applicators

PURPOSE

For our head-and-neck hyperthermia (HT) applicator, an amplifier system with full amplitude and phase-control to deliver the radio-frequency signals, was not available. We therefore designed and tested a 433.92 MHz multi-channel amplifier system.

SYSTEM DESCRIPTION

The design consists of a direct digital synthesizer (DDS) system that generates 12 phase-controlled coherent 433.92 MHz signals, which are amplified to maximum 200 W output per channel. Directional couplers are placed at the amplifiers to couple a small portion of both forward and reflected signals to gain-and-phase detectors. The power setting is applied with a resolution of 2 W and for the phase it is 0.1 degrees . The channels are sequentially sampled at 100 Hz per channel.

METHODS

We tested the performance of the designed amplifier system by measuring the RF spectrum, power and phase accuracy, and by characterising the feedback control by using highly accurate power and phase meters.

RESULTS

The spurious emission is less than 60 dBc and the first two harmonic frequencies are suppressed more than 45 dB. The measurement accuracy for the power (+/-5%) is valid for at least 20 days after calibration and for the phase (+/-5 degrees ) it is valid for at least 2 months.

CONCLUSIONS

The amplifier system operates according to our design criteria to support targeted HT. It can be used for both our in-house developed superficial and head-and-neck HT applicators or any other HT applicator that works on the same frequency of 433.92 MHz.

Use of combined radiation and hyperthermia for gynecological cancer

PURPOSE OF REVIEW

We reviewed all literature on the clinical use of combined radiation and hyperthermia for gynecologic malignancies.

RECENT FINDINGS

Combined radiation and hyperthermia should be considered an alternative to chemoradiation for patients with locally advanced cervix cancer and be the first treatment of choice for these patients when radiation cannot be combined with chemotherapy. Several randomized trials have shown an improvement by adding hyperthermia to radiation that is comparable to the improvement found with the addition of chemotherapy to radiation. Hyperthermia does not seem to add to treatment-induced toxicity and the results of hyperthermia are consistent even at 12 years follow-up and could be reproduced in a large, unselected group of cervix cancer patients. A novel indication for combined radiotherapy and hyperthermia is vaginal cancer. Recently, a cohort study showed that the addition of hyperthermia to radiation seems to improve overall survival for patients with vaginal cancer International Federation of Gynecology and Obstetrics stage III.

SUMMARY

Combined radiation and hyperthermia should be considered for patients with locally advanced cervix cancer (International Federation of Gynecology and Obstetrics stage IIb and upwards) as an alternative to chemoradiation for patients with a contraindication for chemotherapy. For other patients, the optimal treatment combination is the subject of randomized trials. For vaginal cancer, a prospective registration study is currently ongoing.

Combined use of hyperthermia and radiation therapy for treating locally advanced cervix carcinoma

BACKGROUND

Hyperthermia is a type of cancer treatment in which body tissue is exposed to high temperatures to damage and kill cancer cells. It was introduced into clinical oncology practice several decades ago. Positive clinical results, mostly obtained in single institutions, resulted in clinical implementation albeit in a limited number of cancer centres worldwide. Because large scale randomised clinical trials (RCTs) are lacking, firm conclusions cannot be drawn regarding its definitive role as an adjunct to radiotherapy in the treatment of locally advanced cervix carcinoma (LACC).

OBJECTIVES

To assess whether adding hyperthermia to standard radiotherapy for LACC has an impact on (1) local tumour control, (2) survival and (3) treatment related morbidity.

SEARCH STRATEGY

The electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL), (Issue 1, 2009) and Cochrane Gynaecological Cancer Groups Specialised Register, MEDLINE, EMBASE, online databases for trial registration, handsearching of journals and conference abstracts, reviews, reference lists, and contacts with experts were used to identify potentially eligible trials, published and unpublished until January 2009.

SELECTION CRITERIA

RCTs comparing radiotherapy alone (RT) versus combined hyperthermia and radiotherapy (RHT) in patients with LACC.

DATA COLLECTION AND ANALYSIS

Between 1987 and 2009 the results of six RCTs were published, these were used for the current analysis.

MAIN RESULTS

74% of patients had FIGO stage IIIB LACC. Treatment outcome was significantly better for patients receiving the combined treatment (Figures 4 to 6). The pooled data analysis yielded a significantly higher complete response rate (relative risk (RR) 0.56; 95% confidence interval (CI) 0.39 to 0.79; p < 0.001), a significantly reduced local recurrence rate (hazard ratio (HR) 0.48; 95% CI 0.37 to 0.63; p < 0.001) and a significantly better overall survival (OS) following the combined treatment with RHT(HR 0.67; 95% CI 0.45 to 0.99; p = 0.05). No significant difference was observed in treatment related acute (RR 0.99; 95% CI 0.30 to 3.31; p = 0.99) or late grade 3 to 4 toxicity (RR 1.01; CI 95% 0.44 to 2.30; p = 0.96) between both treatments.

AUTHORS' CONCLUSIONS

The limited number of patients available for analysis, methodological flaws and a significant over-representation of patients with FIGO stage IIIB prohibit drawing definite conclusions regarding the impact of adding hyperthermia to standard radiotherapy. However, available data do suggest that the addition of hyperthermia improves local tumour control and overall survival in patients with locally advanced cervix carcinoma without affecting treatment related grade 3 to 4 acute or late toxicity.

Hyperthermia MRI temperature measurement: evaluation of measurement stabilisation strategies for extremity and breast tumours

PURPOSE

MR thermometry using the proton resonance frequency shift (PRFS) method has been used to measure temperature changes during clinical hyperthermia treatment. However, frequency drift of the MRI system can add large errors to the measured temperature change. These drifts can be measured and corrected using oil references placed around the treatment region. In this study, the number and position of four or more oil references were investigated to obtain a practical approach to correct frequency drift during PRFS thermometry in phantoms and in vivo.

MATERIALS AND METHODS

Experiments were performed in a 140 MHz four antenna mini-annular phased array (MAPA) heat applicator (for treatment of extremity tumours) and an applicator for heating of the breast, with symmetric and asymmetric positioning of the oil references, respectively. Temperature change PRFS images were obtained during an hour or more of measurement with no application of heat. Afterwards, errors in calculating temperature change due to system drift were quantified with and without various oil reference correction arrangements.

RESULTS

Results showed good temperature correction in phantoms and in a human leg, with average errors of 0.28 degrees C and 0.94 degrees C respectively. There was further improvement in the leg when using eight or more oil references, reducing the average error to 0.44 degrees C, while the phantoms showed no significant improvement.

CONCLUSIONS

These results indicate that oil reference correction performs well in vivo, and that eight references can improve the correction by up to 0.5 degrees C compared to four references.

Combined use of hyperthermia and radiation therapy for treating locally advanced cervical carcinoma

BACKGROUND

Hyperthermia is a type of cancer treatment in which body tissue is exposed to high temperatures to damage and kill cancer cells. It was introduced into clinical oncology practice several decades ago. Positive clinical results, mostly obtained in single institutions, resulted in clinical implementation albeit in a limited number of cancer centres worldwide. Because large scale randomised clinical trials (RCTs) are lacking, firm conclusions cannot be drawn regarding its definitive role as an adjunct to radiotherapy in the treatment of locally advanced cervical carcinoma (LACC).

OBJECTIVES

To assess whether adding hyperthermia to standard radiotherapy for LACC has an impact on (1) local tumour control, (2) survival and (3) treatment related morbidity.

SEARCH STRATEGY

The electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL), (Issue 1, 2009) and Cochrane Gynaecological Cancer Groups Specialised Register, MEDLINE, EMBASE, online databases for trial registration, handsearching of journals and conference abstracts, reviews, reference lists, and contacts with experts were used to identify potentially eligible trials, published and unpublished until January 2009.

SELECTION CRITERIA

RCTs comparing radiotherapy alone (RT) versus combined hyperthermia and radiotherapy (RHT) in patients with LACC.

DATA COLLECTION AND ANALYSIS

Between 1987 and 2009 the results of six RCTs were published, these were used for the current analysis.

MAIN RESULTS

74% of patients had FIGO stage IIIB LACC. Treatment outcome was significantly better for patients receiving the combined treatment (Figures 1 to 3). The pooled data analysis yielded a significantly higher complete response rate (relative risk (RR) 0.56; 95% confidence interval (CI) 0.39 to 0.79; p < 0.001), a significantly reduced local recurrence rate at 3 years (hazard ratio (HR) 0.48; 95% CI 0.37 to 0.63; p < 0.001) and a significanly better overall survival (OS) at three years following the combined treatment with RHT(HR 0.67; 95% CI 0.45 to 0.99; p = 0.05). No significant difference was observed in treatment related acute (RR 0.99; 95% CI 0.30 to 3.31; p = 0.99) or late grade 3 to 4 toxicity (RR 1.01; CI 95% 0.44 to 2.30; p = 0.96) between both treatments.

AUTHORS' CONCLUSIONS

The limited number of patients available for analysis, methodological flaws and a significant over-representation of patients with FIGO stage IIIB prohibit drawing definite conclusions regarding the impact of adding hyperthermia to standard radiotherapy. However, available data do suggest that the addition of hyperthermia improves local tumour control and overall survival in patients with locally advanced cervical carcinoma without affecting treatment related grade 3 to 4 acute or late toxicity.

Efficacy of HG-2000 regional high-frequency hyperthermia combined with TACE in treatment of patients with hepatocellular carcinoma: an analysis of 30 cases

AIM: The observe the effect of regional high-frequency hyperthermia combined with hepatic arterial chemoembolization (TACE) in patients with hepatocellular carcinoma.

METHODS: From April 2007 to July 2008, a total of 56 hepatocellular carcinoma patients were assigned to combined treatment group and control group. Thirty patients were in regional high-frequency hyperthermia combined with TACE group; 26 patients were in TACE alone control group. TACE involved Seldinger's puncture in the study. For patients in combined treatment group, regional high-frequency hyperthermia therapy was given 3-5 d after TACE and lasted 50-60 min each time.

RESULTS: According to WHO solid tumor evaluation standard, effective rate in combined treatment group was 51.7%, and it was 36% in control group. There was statistic difference between the two groups (P < 0.05). One-year survival rate was 58.8% in combined treatment group, and 47.35% in control group, and there was statistic difference between the two groups (P < 0.05). Meantime, pain relief was up to 75% in combined treatment group, and merely 28.6% in control group (P < 0.05).

CONCLUSION: Regional high-frequency hyperthermia combined with TACE is effective, safe, not invasive and is recommended for wide use in clinical practice.

Protein microarray analysis of apoptosis-related protein expression following heat shock in human tongue squamous cell carcinomas containing different p53 phenotypes

PURPOSE

Hyperthermia is useful in the treatment of human head and neck cancers, because it is relatively easy to regulate temperatures when compared to tumors located in deep organs. In this study, attention was focused on p53 as a possible predictive indicator for the efficacy of hyperthermic cancer therapy.

METHODS

Two kinds of cell lines were used. These were derived from a human squamous cell carcinoma (SAS) and had identical genetic backgrounds except for their p53 gene status. It was previously reported that the heat sensitivity and frequency of apoptosis in wild-type p53 cells (SAS/neo) were clearly elevated when compared with mutated p53 cells (SAS/mp53). In order to study the expression of apoptosis related proteins after heat treatment, protein microarray analysis was used.

RESULTS

The expression of apoptosis inhibitory proteins such as Bcl-2, Bcl-xL, NF-kappaB, COX2, STAT3, IL-6, and IKKalpha/1 was seen to increase after heat treatment in SAS/mp53 cells, but not in SAS/neo cells.

CONCLUSION

The result of these observations indicates that apoptosis inhibitory proteins (such as Bcl-2, Bcl-xL, IL-6, etc.) were highly induced in SAS/mp53 cells after heat treatment when compared to control SAS/neo cells.

Steering in locoregional deep hyperthermia: evaluation of common practice with 3D-planning

PURPOSE

In Rotterdam, fifteen years of clinical experience with deep hyperthermia has sublimated in empirical treatment guidelines. In this paper, a hyperthermia treatment planning system (HTPS) is employed to investigate the effect of these guidelines on global power distribution, their effectiveness and the rationale behind each guideline.

MATERIALS AND METHODS

Four guidelines were investigated. The first two prescribe steering actions for balancing intraluminal temperatures and alleviating complaints of deep-seated pain or pressure. The third guideline handles superficial complaints of pain or heat sensation. The last guideline states that frequency should be increased from 77 MHz upwards in case of multiple, opposite, painful regions uncontrollable by the previous steering actions. For all steering actions it is assumed that input power is increased until complaints occur. Sigma Hyperplan was used to calculate specific absorption rate (SAR) distributions for five patient models with locally advanced cervical cancer. Absorbed power ratios of different regions of interest were evaluated to illustrate steering efficacy and complaint reduction.

RESULTS AND CONCLUSIONS

Phase steering is effective in shifting the central power distribution to the periphery, and is an appropriate method to balance temperatures or to handle deep-seated complaints. Reduction of amplitude is the proper action to alleviate superficial complaints of heat or pressure. Compression of the SAR distribution, mainly in the lateral direction, is predicted with increasing frequency. Hence, for complaints in the lower back or on the sides, a frequency increase should be considered. We conclude that the results of the HTPS are in close agreement with the empirical steering guidelines.

Radiotherapy and hyperthermia for treatment of primary locally advanced cervix cancer: results in 378 patients

PURPOSE

To report response rate, pelvic tumor control, survival, and late toxicity after treatment with combined radiotherapy and hyperthermia (RHT) for patients with locally advanced cervical carcinoma (LACC) and compare the results with other published series.

METHODS AND MATERIALS

From 1996 to 2005, a total of 378 patients with LACC (International Federation of Gynecology and Obstetrics Stage IB2-IVA) were treated with RHT. External beam radiotherapy (RT) was applied to 46-50.4 Gy and combined with brachytherapy. The hyperthermia (HT) was prescribed once weekly. Primary end points were complete response (CR) and local control. Secondary end points were overall survival, disease-specific survival, and late toxicity. Patient, tumor, and treatment characteristics predictive for the end points were identified in univariate and multivariate analyses.

RESULTS

Overall, a CR was achieved in 77% of patients. At 5 years, local control, disease-specific survival, and incidence of late toxicity Common Terminology Criteria for Adverse Events Grade 3 or higher were 53%, 47%, and 12%, respectively. In multivariate analysis, number of HT treatments emerged as a predictor of outcome in addition to commonly identified prognostic factors.

CONCLUSIONS

The CR, local control, and survival rates are similar to previously observed results of RHT in the randomized Dutch Deep Hyperthermia Trial. Reported treatment results for currently applied combined treatment modalities (i.e., RT with chemotherapy and/or HT) do not permit definite conclusions about which combination is superior. The present results confirm previously shown beneficial effects from adding HT to RT and justify the application of RHT as first-line treatment in patients with LACC as an alternative to chemoradiation.

Hyperthermia adds to chemotherapy

The hallmarks of hyperthermia and its pleotropic effects are in favour of its combined use with chemotherapy. Preclinical research reveals that for heat killing and synergistic effects the thermal dose is most critical. Thermal enhancement of drug cytotoxicity is accompanied by cellular death and necrosis without increasing its oncogenic potential. The induction of genetically defined stress responses can deliver danger signals to activate the host's immune system. The positive results of randomised trials have definitely established hyperthermia in combination with chemotherapy as a novel clinical modality for the treatment of cancer. Hyperthermia targets the action of chemotherapy within the heated tumour region without affecting systemic toxicity. In specific clinical settings regional hyperthermia (RHT) or hyperthermic perfusion has proved its value and deserve a greater focus and investigation in other malignancies. In Europe, more specialised centres should be created and maintained as network of excellence for hyperthermia in the field of oncology.