Innovative techniques in radiation oncology. Clinical research programs to improve local and regional control in cancer

Cervical cancer: Radiotherapy and hyperthermia

BACKGROUND

For many years, the standard treatment of advanced cervical cancer has been radiotherapy (RT), including brachytherapy. The achievement of locoregional tumour control is essential for cure. Results of RT in early stages are reasonably satisfactory, but locoregional failure rates for stage IIIb and IVa are high. In several randomized trials, the addition of hyperthermia (HT) to RT has been investigated.

RANDOMIZED TRIALS

The Dutch Deep Hyperthermia Trial was completed in 1996. In this trial a beneficial effect of additional hyperthermia was clearly demonstrated. Three-year locoregional control and overall survival rates were significantly higher in the RT + HT group than in the RT alone group, while radiation toxicity was not affected. Cost-per-life-year-gained was less than 4,000 Euros. The results of this trial have led to the acceptance of RT plus HT as standard treatment for advanced cervical cancer in the Netherlands. Five trials conducted in Asia have been published, of which three showed significant better complete response, locoregional tumour control and/or disease-free survival rates. One trial showed a trend of better locoregional tumour control and one did not show any benefit.

CONCLUSION

Hyperthermia added to standard radiotherapy of locally advanced cervical tumours results in considerable therapeutic gain and is cost-effective. For a beneficial effect, the use of an adequate heating technique is an important requirement.

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

PURPOSE

The local failure rate in patients with locoregionally advanced cervical cancer is 41-72% after radiotherapy (RT) alone, whereas local control is a prerequisite for cure. The Dutch Deep Hyperthermia Trial showed that combining RT with hyperthermia (HT) improved 3-year local control rates of 41-61%, as we reported earlier. In this study, we evaluate long-term results of the Dutch Deep Hyperthermia Trial after 12 years of follow-up.

METHODS AND MATERIALS

From 1990 to 1996, a total of 114 women with locoregionally advanced cervical carcinoma were randomly assigned to RT or RT+HT. The RT was applied to a median total dose of 68 Gy. The HT was given once weekly. The primary end point was local control. Secondary end points were overall survival and late toxicity.

RESULTS

At the 12-year follow-up, local control remained better in the RT+HT group (37% vs. 56%; p=0.01). Survival was persistently better after 12 years: 20% (RT) and 37% (RT+HT; p=0.03). World Health Organization (WHO) performance status was a significant prognostic factor for local control. The WHO performance status, International Federation of Gynaecology and Obstetrics (FIGO) stage, and tumor diameter were significant for survival. The benefit of HT remained significant after correction for these factors. European Organization for Research and Treatment of Cancer Grade 3 or higher radiation-induced late toxicities were similar in both groups.

CONCLUSIONS

For locoregionally advanced cervical cancer, the addition of HT to RT resulted in long-term major improvement in local control and survival without increasing late toxicity. This combined treatment should be considered for patients who are unfit to receive chemotherapy. For other patients, the optimal treatment strategy is the subject of ongoing research.

Comparison of radiotherapy alone with radiotherapy plus hyperthermia in locally advanced pelvic tumours: a prospective, randomised, multicentre trial. Dutch Deep Hyperthermia Group

BACKGROUND

Local-control rates after radiotherapy for locally advanced tumours of the bladder, cervix, and rectum are disappointing. We investigated the effect of adding hyperthermia to standard radiotherapy.

METHODS

The study was a prospective, randomised, multicentre trial. 358 patients were enrolled from 1990 to 1996, in cancer centres in the Netherlands, who had bladder cancer stages T2, T3, or T4, NO, MO, cervical cancer stages IIB, IIIB, or IV, or rectal cancer stage M0-1 were assessed. Patients were randomly assigned radiotherapy (median total dose 65 Gy) alone (n=176) or radiotherapy plus hyperthermia (n=182). Our primary endpoints were complete response and duration of local control. We did the analysis by intention to treat.

FINDINGS

Complete-response rates were 39% after radiotherapy and 55% after radiotherapy plus hyperthermia (p<0.001). The duration of local control was significantly longer with radiotherapy plus hyperthermia than with radiotherapy alone (p=0.04). Treatment effect did not differ significantly by tumour site, but the addition of hyperthermia seemed to be most important for cervical cancer, for which the complete-response rate with radiotherapy plus hyperthermia was 83% compared with 57% after radiotherapy alone (p=0.003). 3-year overall survival was 27% in the radiotherapy group and 51% in the radiotherapy plus hyperthermia group. For bladder cancer, an initial difference in local control disappeared during follow-up.

INTERPRETATION

Hyperthermia in addition to standard radiotherapy may be especially useful in locally advanced cervical tumours. Studies of larger numbers of patients are needed for other pelvic tumour sites before practical recommendations can be made.

Transvaginal color Doppler for predicting pathological response to preoperative chemoradiation in locally advanced cervical carcinoma: a preliminary study

To evaluate the role of transvaginal color Doppler ultrasonography (TCD) in predicting pathological response to preoperative chemoradiation in patients with locally advanced cervical cancer, 10 patients (mean age: 45.2 y, range: 31 to 75 y) with histologically proven locally advanced cervical cancer who were scheduled for preoperative chemoradiation were evaluated by TCD prior to beginning the treatment protocol. Tumor volume, number of vessels within the tumor, lowest resistance index (RI), maximum peak systolic velocity (PSV), and the ratio between the number of vessels and tumor volume (tumor vascular density, TVD) were calculated. All patients underwent preoperative chemoradiation and radical surgery. Complete pathological response (pathCR) was considered when no residual tumor was found on surgical specimens. Partial pathological response (pathPR) was considered when residual tumor was found. PathCR was achieved in three patients (30%), whereas 7 (70%) had pathPR. Mean tumoral volume was not statistically different between those with pathCR (33.2 cm3) and those with pathPR (20.3 cm3) (p = 0.305). Those tumors with pathCR had lower mean number of vessels (3.3 vs. 5.3, p = 0.01), lower TVD (0.1 vs. 1.1, p = 0.05) and higher RI (0.41 vs. 0.29, p = 0.03). No differences were found in PSV. Although these data are preliminary, our results suggest that TCD may be used to predict pathological response to preoperative chemoradiation in patients with locally advanced cervical cancer.

Accelerated radiotherapy, carbogen and nicotinamide (ARCON) in locally advanced head and neck cancer: a feasibility study

BACKGROUND AND PURPOSE

ARCON (Accelerated Radiotherapy, CarbOgen, Nicotinamide) achieves a large therapeutic gain in rodents. A phase I/II study was therefore undertaken to determine its feasibility in patients with locally advanced head and neck cancer.

MATERIALS AND METHODS

The accelerated regime CHART was used in 35 patients given carbogen and/or nicotinamide with 11 small volume fractions. Eight patients received carbogen, 12 received nicotinamide and 15 were treated with ARCON. Treatment compliance, side-effects and acute mucositis were monitored in all cases.

RESULTS

All patients underwent CHART as intended. In the 23 patients receiving carbogen, two failed to complete treatment. Compliance with nicotinamide was much lower. Out of 25 patients, only 52% received 10-11 doses of the 80 mg/kg/day of the drug. The most common side-effect was nausea and vomiting, which responded to standard anti-emetics in almost half of the patients. Historical comparisons with the CHART head and neck trials indicate that there was no increase in the severity of acute mucositis in any of these patients. Although the observation period is not sufficiently long to be definitive (median 20 months) there is no evidence of an increase in late normal tissue reactions.

CONCLUSIONS

ARCON using CHART as the radiotherapy protocol is feasible in patients with advanced head and neck cancer. However, we are concerned about the low compliance rate in our patients, which is far lower than that reported elsewhere. The implications are discussed together with identifying strategies for increasing compliance.

Intraoperative radiation therapy and Mohs micrographic surgery on an outpatient basis

BACKGROUND

Intraoperative radiation therapy (IORT) is used to deliver therapeutic doses of radiation to a surgically exposed tumor or tumor bed while minimizing the radiation dose to adjacent normal tissue. It is traditionally given with the patient under general anesthesia.

OBJECTIVE

To report a case of a recurrent squamous cell carcinoma treated with Mohs micrographic surgery and IORT on an outpatient basis.

METHODS

Mohs surgery was used to clear the tumor in all fields except for the area of the spinal accessory nerve, which was preserved. IORT was then delivered to the area of nerve with possible residual tumor.

RESULTS

The patient remains clinically tumor free 42 months posttreatment. There were no complications.

CONCLUSION

Intraoperative radiation therapy can be effectively used in the outpatient setting as an adjunctive therapy after Mohs micrographic surgery.

Concurrent irradiation and intratumoral chemotherapy with cisplatin: a pilot study in dogs with spontaneous tumors

PURPOSE

A preliminary study was undertaken to determine whether the addition of a collagen gel in the formulation of cisplatin for intratumoral administration of cisplatin affected platinum plasma concentrations. A second study was undertaken to determine the local effects of intratumoral administration of cisplatin mixed with collagen given concurrently with irradiation.

METHODS AND MATERIALS

Twelve dogs with advanced stage tumors were administered a dose of 0.25 mg of cisplatin per kg of body weight intratumorally with or without collagen using a two-period crossover design. Twelve additional dogs received concurrent irradiation (48 Gy) delivered in 12 fractions over 4 weeks and intratumoral cisplatin chemotherapy given the first day of each week at a dose of 0.5 mg of cisplatin per cm3 of tissue.

RESULTS

The cumulative cisplatin plasma concentrations varied over time from dog to dog, but the use of collagen in the formulation significantly reduced the systemic exposure of cisplatin. For the dogs given intratumoral cisplatin and irradiation, complete responses were observed in 10 dogs. Seven dogs had local recurrence. One dog had tumor recurrence in the radiochemotherapy field and six dogs had recurrence at the margin of the radiochemotherapy field, but within the irradiation field. Normal tissue reactions were similar in the radiochemotherapy field and in the margin treated with radiation only. Cumulative effect of repeated intratumoral administration on plasma concentration of cisplatin was not observed.

CONCLUSIONS

These findings provide support for an extended investigation of this combined regimen. The lack of systemic toxicity associated with intratumoral administration of cisplatin mixed with collagen may allow a safe clinical evaluation of the interaction between cisplatin and radiation.

Report of long-term follow-up in a randomized trial comparing radiation therapy and radiation therapy plus hyperthermia to metastatic lymph nodes in stage IV head and neck patients

PURPOSE

The treatment of inoperable metastatic lymph nodes in patients with head and neck cancer represents a therapeutic challenge. Clinical results using conventional radiation therapy are disappointing; on the other hand, the evaluation of recent innovative radiotherapeutic methods is still pending. The end points of this analysis were focused on long-term local control, on its potential influence on survival, and on late toxicity of a previously reported randomized Phase III study comparing conventionally fractionated radical irradiation alone or combined with local hyperthermia in fixed and inoperable metastatic neck lymph nodes.

METHODS AND MATERIALS

The medical records of 41 patients (44 nodes) with advanced locoregional Stage IV squamous cell cancer of the head and neck and randomized to treatment in the period 1985-1986 with irradiation alone (22/23 evaluable nodes) or combined with external hyperthermia (18/21 evaluable nodes), were re-evaluated.

RESULTS

The statistically significant difference observed in "early" response (p = 0.0164) in favor of the combined treatment results in improved 5-year actuarial nodal control (p = 0.015). Clinical improvement noted in tumor control positively affects survival, leading to a statistically significant difference in survival at 5 years (p = 0.02). With respect to side effects, no clearly enhanced acute or late toxicity has been found; as severe late effects, two patients with bone necroses possibly related to the combined treatment have been observed. Thermal analysis failed to show a significant correlation between heating parameters and the end points of the study.

CONCLUSION

This report with 5-year follow-up confirms the efficacy and the absence of severe toxicity of the combination of radical radiation and hyperthermia in the treatment of metastatic lymph nodes in Stage IV squamous cell carcinoma of the head and neck.

Therapeutic advances in radiologic treatment of cancer

In 1993, roughly 1,170,000 new cases of invasive cancer will be diagnosed in the United States. A considerable portion of these patients who die will do so because of uncontrolled local and/or regional disease. Numerous advances in the radiologic treatment of cancer have led to improved local and regional control, as well as survival. These advances include improved radiologic imaging techniques, improved techniques of radiation therapy, innovative brachytherapeutic techniques, intraoperative electron beam therapy techniques, and stereotaxic radiosurgical techniques. In this paper, the authors discuss these techniques with specific attention to how they have lead to improved local and regional control, as well as cancer cure with organ preservation.

New advances in radiation oncology for gynecologic cancer

In 1992, the American Cancer Society anticipates that there will be 1,130,000 new cases of invasive cancer diagnosed in the United States. About 66,500 will be invasive cancers of the cervix, uterus, and ovary. About 22,400 patients will die during 1992, with 50-60% of those deaths being due to persistent local regional disease. Data are available to suggest that a reduction in local failure will be reflected by an increase in survival free of disease. In 1992, major efforts are being made to reduce the incidence of local failure. Three areas in this regard are innovative uses of brachytherapy, intraarterial chemotherapy and radiation therapy, and continuous infusion chemotherapy and radiation therapy. These new techniques show significant reduction in local failure with associated improvement in survival. The data will be presented to illustrate the impact of these techniques.

Anaesthesia for intraperitoneal hyperthermic perfusion

Intraperitoneal hyperthermic perfusion is a method of regional chemotherapy shown to be effective in the prevention and treatment of peritoneal metastases. General anaesthesia for a patient who required this procedure is described. Guidelines for management are suggested, with particular emphasis on temperature control, fluid and electrolyte balance and postoperative care.

The scientific bases of cancer management: at the interface between fundamental research and clinical practice

From 1950 to 1985 the 5-year survival rate of cancer patients in industrialized countries, has slowly increased from 25% in 1950 to 50% in 1985. This progress has been due to earlier diagnosis and to a gradual improvement of treatment modalities. Clinical needs have stimulated basic research and clinical investigation. In turn, biological research has introduced new concepts and new agents. Clinical investigation and applied research have brought about an improvement in therapeutic methods and a better understanding of the growth and progression of human cancers which has, in particular, led to the concept of adjuvant treatment of occult metastases. The major recent breakthroughs in fundamental research have reinforced the value of close cooperation between clinicians and fundamentalists. Most of the new biologic tools are specific and only active on tumors cells with well-defined characteristics. Furthermore some new techniques such as adoptive immunotherapy can induce complete tumor regression in some patients and have no detectable effects in other patients with apparently similar tumors. Some cytokines have different effects on experimental and human tumors. The cytokine network is so complex that the administration of one of them can induce unpredictable effects. It has been recognized that experimental tumors and in vitro studies can be misleading and there is no substitute for clinical studies on patients. Moreover clinical experience has documented the amazing ability of tumors to become resistant to all these new agents. Numerous new therapeutic methods are being explored, however with the current state of knowledge it appears that although they can help to control tumors, they still fail to eradicate them. We must therefore learn how to integrate them with conventional therapies. Advances in therapy shall be achieved only by well-designed clinical trials. Thus at the interface between fundamental research and clinical practice there is an urgent need for oncologists with a strong scientific background and laboratory scientists with a deep interest in clinical investigations.