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Massaccesi M, Fontana A, Palumbo I, Argenone A, De Santis MC, Masiello V, Pontoriero A, Ciabattoni A. Pattern of practice of re-irradiation for ipsilateral breast tumor recurrence in Italy: a survey by the Italian Association of Radiotherapy and Clinical Oncology (AIRO). Clin Transl Oncol 2024; 26:644-652. [PMID: 37515701 DOI: 10.1007/s12094-023-03289-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 07/17/2023] [Indexed: 07/31/2023]
Abstract
PURPOSE The Re-irradiation and the Breast Cancer Working Groups of the Italian Association of Radiotherapy and Clinical Oncology (AIRO) conducted a survey to provide an overview of the policies for breast cancer (BC) re-irradiation (re-RT) among the Italian radiotherapy (RT) centers. METHODS In October 2021, 183 RT centers were invited to answer a survey: after an initial section about general aspects, the questionnaire focused on radiation oncologists' (ROs) attitude toward re-RT in three different scenarios: ipsilateral breast tumor recurrence (IBTR) treated with second conservative surgery, IBTR treated with mastectomy and inoperable IBTR. Surveyed ROs were also asked to express their interest in being involved in a prospective trials. RESULTS Seventy-seven/183 (42.0%) centers answered the Survey, only one RO per center was requested to answer. In particular, 86.5% ROs declared to have performed "curative" re-RT for IBTR during the previous two years (2019-2020): 76.7% respondents administered re-RT after second BCS, 50.9% after mastectomy, and 48.1% for inoperable IBTR. Re-RT practice varied widely among centers in terms of treatment volumes, dose and fractionation schedules, techniques and dose-volume constraints for organs at risks (OARs). Forty-six participants (59.7%) expressed their interest in participating in a prospective study investigating BC re-RT. CONCLUSIONS About one out of three RT centers in Italy delivered re-RT for IBTR. Nevertheless, practice of re-RT varied widely among centers highlighting the needs for prospective studies to improve knowledge in this field.
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Affiliation(s)
- Mariangela Massaccesi
- Radiation Oncology Unit, Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonella Fontana
- Radiotherapy Department, Santa Maria Goretti Hospital, Latina, Italy
| | - Isabella Palumbo
- Radiation Oncology Section, Department of Medicine and Surgery, Sant'Andrea delle Fratte, University of Perugia and Perugia General Hospital, 06156, Perugia, Italy.
| | | | - Maria Carmen De Santis
- Radiation Oncology, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Valeria Masiello
- Radiation Oncology Unit, Department of Radiology, Radiation Oncology and Hematology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Antonio Pontoriero
- Radiation Oncology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
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Salvage Perioperative Interstitial High-Dose-Rate Interventional Radiotherapy (Brachytherapy) for Local Recurrences of the Chest Wall Following Mastectomy and Previous External Irradiation. Cancers (Basel) 2023; 15:cancers15030614. [PMID: 36765571 PMCID: PMC9913130 DOI: 10.3390/cancers15030614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/09/2023] [Accepted: 01/13/2023] [Indexed: 01/20/2023] Open
Abstract
(1) Background: To investigate the technical feasibility, safety, and efficacy of interstitial perioperative high-dose-rate interventional radiotherapy (HDR-IRT, brachytherapy) as a local salvage treatment combined with surgery for local chest wall recurrences following mastectomy and subsequent external beam radiation treatment (EBRT). (2) Methods: A retrospective analysis of 56 patients treated with interstitial HDR-IRT in combination with local surgery of a chest wall recurrence of breast cancer after previous treatment with mastectomy and EBRT from 2008 to 2020. (3) Results: Local recurrence following HDR-IRT was encountered in seven (12.5%) patients. The 1-year local recurrence-free survival (RFS), 3-year RFS, and 5-year RFS were 91%, 82%, and 82%, respectively. The 1-year overall survival (OS), 3-year OS, and 5-year OS was 85.5%, 58%, and 30%, respectively. Acute grade 1-2 radiation dermatitis was observed in 22 (39.3%) patients. Late ≥grade 3 toxicities were encountered in five (8.9%) patients. (4) Conclusions: Salvage perioperative interstitial high-dose-rate interventional radiotherapy (brachytherapy) combined with surgery seems to be an effective interdisciplinary management with acceptable treatment-related toxicity for local recurrences of the chest wall following mastectomy and previous external irradiation.
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De-Colle C, Beller A, Gani C, Weidner N, Heinrich V, Lamprecht U, Gaupp S, Voigt O, Dohm O, Zips D, Müller AC. Radiotherapy and hyperthermia for breast cancer patients at high risk of recurrence. Int J Hyperthermia 2022; 39:1010-1016. [PMID: 35902116 DOI: 10.1080/02656736.2022.2103593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
PURPOSE To evaluate the long-term efficacy of combined radiotherapy (RT) and hyperthermia (HT) in a large mono-institutional cohort of breast cancer (BC) patients affected by recurrent, newly diagnosed non-resectable or high risk resected tumor. MATERIALS AND METHODS Records of BC patients treated with RT + HT between 1995 and 2018 were retrospectively analyzed. RT doses of 50-70 Gy concurrent to a twice per week superficial HT were applied. For HT, a temperature between 41 and 42 °C was applied for approximately 1 h. Primary endpoint was local control (LC), secondary endpoints comprised toxicity, overall survival (OS), and progression-free survival (PFS). RESULTS A total of 191 patients and 196 RT + HT treatments were analyzed. In 154 cases (78.6%) RT + HT was performed for patients with recurrent BC. Among these, 93 (47.4% of the entire cohort) had received RT prior to RT + HT. Median follow up was 12.7 years. LC at 2, 5, and 10 years was 76.4, 72.8, and 69.5%, respectively. OS at 2, 5, and 10 years was 73.5, 52.3, and 35.5%, respectively. PFS at 2, 5, and 10 years was 55.6, 41, and 33.6%, respectively. Predictive factors for LC were tumor stage, distant metastases, estrogen/progesterone receptor expression, resection status and number of HT fractions. At multivariate analysis tumor stage and receptor expression were significant. No acute or late toxicities higher than grade 3 were observed. CONCLUSION Combined RT + HT offers long-term high LC rates with acceptable toxicity for patients with recurrent, newly diagnosed non-resectable or resected BC at high risk of relapse.
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Affiliation(s)
- Chiara De-Colle
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Anna Beller
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Cihan Gani
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Nicola Weidner
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Vanessa Heinrich
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Ulf Lamprecht
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Stephan Gaupp
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Otilia Voigt
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Oliver Dohm
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Daniel Zips
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany.,German Cancer Research Center (DKFZ), Heidelberg and German Cancer Consortium (DKTK) Partner Site Tübingen, Tübingen, Germany
| | - Arndt-Christian Müller
- Department of Radiation Oncology, University Hospital and Medical Faculty Tübingen, Eberhard Karls University Tübingen, Tübingen, Germany.,Clinic of Radiation Oncology, Ludwisburg Hospital, Ludwisburg, Germany
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Pattyn A, Kratkiewicz K, Alijabbari N, Carson PL, Littrup P, Fowlkes JB, Duric N, Mehrmohammadi M. Feasibility of ultrasound tomography-guided localized mild hyperthermia using a ring transducer: Ex vivo and in silico studies. Med Phys 2022; 49:6120-6136. [PMID: 35759729 DOI: 10.1002/mp.15829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 06/06/2022] [Accepted: 06/10/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND As of 2022, breast cancer continues to be the most diagnosed cancer worldwide. This problem persists within the United States as well, as the American Cancer Society has reported that ∼12.5% of women will be diagnosed with invasive breast cancer over the course of their lifetime. Therefore, a clinical need continues to exist to address this disease from a treatment and therapeutic perspective. Current treatments for breast cancer and cancers more broadly include surgery, radiation, and chemotherapy. Adjuncts to these methods have been developed to improve the clinical outcomes for patients. One such adjunctive treatment is mild hyperthermia therapy (MHTh), which has been shown to be successful in the treatment of cancers by increasing effectiveness and reduced dosage requirements for radiation and chemotherapies. MHTh-assisted treatments can be performed with invasive thermal devices, noninvasive microwave induction, heating and recirculation of extracted patient blood, or whole-body hyperthermia with hot blankets. PURPOSE One common method for inducing MHTh is by using microwave for heat induction and magnetic resonance imaging for temperature monitoring. However, this leads to a complex, expensive, and inaccessible therapy platform. Therefore, in this work we aim to show the feasibility of a novel all-acoustic MHTh system that uses focused ultrasound (US) to induce heating while also using US tomography (UST) to provide temperature estimates. Changes in sound speed (SS) have been shown to be strongly correlated with temperature changes and can therefore be used to indirectly monitor heating throughout the therapy. Additionally, these SS estimates allow for heterogeneous SS-corrected phase delays when heating complex and heterogeneous tissue structures. METHODS Feasibility to induce localized heat in tissue was investigated in silico with a simulated breast model, including an embedded tumor using continuous wave US. Here, both heterogenous acoustic and thermal properties were modeled in addition to blood perfusion. We further demonstrate, with ex vivo tissue phantoms, the feasibility of using ring-based UST to monitor temperature by tracking changes in SS. Two phantoms (lamb tissue and human abdominal fat) with latex tubes containing varied temperature flowing water were imaged. The measured SS of the water at each temperature were compared against values that are reported in literature. RESULTS Results from ex vivo tissue studies indicate successful tracking of temperature under various phantom configurations and ranges of water temperature. The results of in silico studies show that the proposed system can heat an acoustically and thermally heterogenous breast model to the clinically relevant temperature of 42°C while accounting for a reasonable time needed to image the current cross section (200 ms). Further, we have performed an initial in silico study demonstrating the feasibility of adjusting the transmit waveform frequency to modify the effective heating height at the focused region. Lastly, we have shown in a simpler 2D breast model that MHTh level temperatures can be maintained by adjusting the transmit pressure intensity of the US ring. CONCLUSIONS This work has demonstrated the feasibility of using a 256-element ring array transducer for temperature monitoring; however, future work will investigate minimizing the difference between measured SS and the values shown in literature. A hypothesis attributes this bias to potential volumetric average artifacts from the ray-based SS inversion algorithm that was used, and that moving to a waveform-based SS inversion algorithm will greatly improve the SS estimates. Additionally, we have shown that an all-acoustic MHTh system is feasible via in silico studies. These studies have indicated that the proposed system can heat a tumor within a heterogenous breast model to 42°C within a narrow time frame. This holds great promise for increasing the accessibility and reducing the complexity of a future all-acoustic MHTh system.
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Affiliation(s)
- Alexander Pattyn
- Department of Biomedical Engineering, Wayne State University, Detroit, Michigan, USA
| | - Karl Kratkiewicz
- Department of Biomedical Engineering, Wayne State University, Detroit, Michigan, USA.,Department of Oncology, Wayne State University, Detroit, Michigan, USA
| | - Naser Alijabbari
- Department of Biomedical Engineering, Wayne State University, Detroit, Michigan, USA
| | - Paul L Carson
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Peter Littrup
- Delphinus Medical Technologies, Novi, Michigan, USA.,Ascension Providence Rochester Radiology, Rochester, Michigan, USA
| | - J Brian Fowlkes
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA.,Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Nebojsa Duric
- Delphinus Medical Technologies, Novi, Michigan, USA.,Department of Imaging Sciences, University of Rochester, Rochester, New York, USA
| | - Mohammad Mehrmohammadi
- Department of Biomedical Engineering, Wayne State University, Detroit, Michigan, USA.,Department of Electrical and Computer Engineering, Wayne State University, Detroit, Michigan, USA.,Barbara Ann Karmanos Cancer Institute, Detroit, Michigan, USA
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The Effect of Hyperthermia and Radiotherapy Sequence on Cancer Cell Death and the Immune Phenotype of Breast Cancer Cells. Cancers (Basel) 2022; 14:cancers14092050. [PMID: 35565180 PMCID: PMC9103710 DOI: 10.3390/cancers14092050] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/25/2022] [Accepted: 04/10/2022] [Indexed: 02/06/2023] Open
Abstract
Simple Summary Hyperthermia (HT) is a cancer treatment which locally heats the tumor to supraphysiological temperature, and it is an effective sensitizer for radiotherapy (RT) and chemotherapy. HT is further capable of modulating the immune system. Thus, a better understanding of its effect on the immune phenotype of tumor cells, and particularly when combined with RT, would help to optimize combined anti-cancer treatments. Since in clinics, no standards about the sequence of RT and HT exist, we analyzed whether this differently affects the cell death and immunological phenotype of human breast cancer cells. We revealed that the sequence of HT and RT does not strongly matter from the immunological point of view, however, when HT is combined with RT, it changes the immunophenotype of breast cancer cells and also upregulates immune suppressive immune checkpoint molecules. Thus, the additional application of immune checkpoint inhibitors with RT and HT should be beneficial in clinics. Abstract Hyperthermia (HT) is an accepted treatment for recurrent breast cancer which locally heats the tumor to 39–44 °C, and it is a very potent sensitizer for radiotherapy (RT) and chemotherapy. However, currently little is known about how HT with a distinct temperature, and particularly, how the sequence of HT and RT changes the immune phenotype of breast cancer cells. Therefore, human MDA-MB-231 and MCF-7 breast cancer cells were treated with HT of different temperatures (39, 41 and 44 °C), alone and in combination with RT (2 × 5 Gy) in different sequences, with either RT or HT first, followed by the other. Tumor cell death forms and the expression of immune checkpoint molecules (ICMs) were analyzed by multicolor flow cytometry. Human monocyte-derived dendritic cells (moDCs) were differentiated and co-cultured with the treated cancer cells. In both cell lines, RT was the main stressor for cell death induction, with apoptosis being the prominent cell death form in MCF-7 cells and both apoptosis and necrosis in MDA-MB-231 cells. Here, the sequence of the combined treatments, either RT or HT, did not have a significant impact on the final outcome. The expression of all of the three examined immune suppressive ICMs, namely PD-L1, PD-L2 and HVEM, was significantly increased on MCF-7 cells 120 h after the treatment of RT with HT of any temperature. Of special interest for MDA-MB-231 cells is that only combinations of RT with HT of both 41 and 44 °C induced a significantly increased expression of PD-L2 at all examined time points (24, 48, 72, and 120 h). Generally, high dynamics of ICM expression can be observed after combined RT and HT treatments. There was no significant difference between the different sequences of treatments (either HT + RT or RT + HT) in case of the upregulation of ICMs. Furthermore, the co-culture of moDCs with tumor cells of any treatment had no impact on the expression of activation markers. We conclude that the sequence of HT and RT does not strongly affect the immune phenotype of breast cancer cells. However, when HT is combined with RT, it results in an increased expression of distinct immune suppressive ICMs that should be considered by including immune checkpoint inhibitors in multimodal tumor treatments with RT and HT. Further, combined RT and HT affects the immune system in the effector phase rather than in the priming phase.
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Fiorentini G, Sarti D, Gadaleta CD, Ballerini M, Fiorentini C, Garfagno T, Ranieri G, Guadagni S. A Narrative Review of Regional Hyperthermia: Updates From 2010 to 2019. Integr Cancer Ther 2021; 19:1534735420932648. [PMID: 33054425 PMCID: PMC7570290 DOI: 10.1177/1534735420932648] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
The role of hyperthermia (HT) in cancer therapy and palliative care has been discussed for years in the literature. There are plenty of articles that show good feasibility of HT and its efficacy in terms of tumor response and survival improvements. Nevertheless, HT has never gained enough interest among oncologists to become a standard therapy in clinical practice. The main advantage of HT is the enhancement of chemotherapy (CHT), radiotherapy (RT), chemoradiotherapy (CRT), and immunotherapy benefits. This effect has been confirmed in several types of tumors: esophageal, gastrointestinal, pancreas, breast, cervix, head and neck, and bladder cancers, and soft tissue sarcoma. HT effects include oxygenation and perfusion changes, DNA repair inhibition and immune system activation as a consequence of new antigen exposure. The literature shows a wide variety of randomized, nonrandomized, and observational studies and both prospective and retrospective data to confirm the advantage of HT association to CHT and RT. There are still many ongoing trials on this subject. This article summarizes the available literature on HT in order to update the current knowledge on HT use in association with RT and/or CHT from 2010 up to 2019.
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Affiliation(s)
- Giammaria Fiorentini
- Azienda Ospedaliera "Ospedali Riuniti Marche Nord," Pesaro, Italy.,Private Clinic Ravenna33, Ravenna, Italy
| | - Donatella Sarti
- Azienda Ospedaliera "Ospedali Riuniti Marche Nord," Pesaro, Italy
| | - Cosmo Damiano Gadaleta
- Department of Interventional and Integrated Medical Oncology, National Cancer Research Centre, IRCCS Istituto Tumori "Giovanni Paolo II", Bari, Italy
| | | | | | | | - Girolamo Ranieri
- Department of Interventional and Integrated Medical Oncology, National Cancer Research Centre, IRCCS Istituto Tumori "Giovanni Paolo II", Bari, Italy
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Chen I, Botty Van den Bruele AM, Gillespie EF, Mueller BA, Xu AJ, Cuaron J, Khan AJ, McCormick B, Cahlon O, Powell SN, Cody H, Braunstein LZ. Salvage of locally recurrent breast cancer with repeat breast conservation using 45 Gy hyperfractionated partial breast re-irradiation. Breast Cancer Res Treat 2021; 188:409-414. [PMID: 33770311 DOI: 10.1007/s10549-021-06206-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/19/2021] [Indexed: 01/22/2023]
Abstract
PURPOSE Mastectomy has long been the preferred approach for local salvage of recurrent breast cancer following breast-conservation therapy (BCT). Growing interest in avoiding mastectomy prompted RTOG 1014, a landmark phase two study demonstrating the feasibility of repeat BCT using a novel radiotherapy (RT) regimen (i.e., 45 Gy administered in 30 fractions of 1.5 Gy twice-daily to the partial breast, "rePBI"). We adopted this regimen as our institutional standard and report our observations regarding the safety and efficacy of rePBI as salvage therapy. METHODS All patients at our institution who underwent repeat BCT and subsequently received rePBI from 2011 to 2019 were identified. Clinicopathologic features and treatment characteristics for both primary breast cancers and recurrences were collected, as were rates of subsequent recurrence and treatment-associated toxicities. RESULTS The cohort included 34 patients with a median age of 65.8 (46.2-78.2) at the time of rePBI. At a median follow-up of 23.5 months, there were two subsequent locoregional recurrences (2-year local control rate 97%). There was no grade ≥ 3 toxicity. The most common acute toxicity (< 3 months) was radiation dermatitis (100%), and common grade 1-2 late toxicities (> 3 months) included fibrosis in 14 (41%), breast asymmetry in 12 (35%), and chest wall pain in 11 (32%). CONCLUSIONS Repeat breast conservation using the hyperfractionated partial breast RT regimen defined by RTOG 1014 (45 Gy administered in 30 1.5 Gy twice-daily fractions) appears effective and well tolerated. No grade 3 or higher toxicities were observed and local control was excellent. Longer term follow-up among larger cohorts will define whether salvage mastectomy should remain the preferred standard.
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Affiliation(s)
- Ishita Chen
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | | | - Erin F Gillespie
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Boris A Mueller
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | | | - John Cuaron
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Atif J Khan
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Oren Cahlon
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Simon N Powell
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA
| | - Hiram Cody
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lior Z Braunstein
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, 1275 York Ave, Box 22, New York, NY , 10044, USA.
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Neoadjuvant Chemoradiation Combined with Regional Hyperthermia in Locally Advanced or Recurrent Rectal Cancer. Cancers (Basel) 2021; 13:cancers13061279. [PMID: 33805731 PMCID: PMC8001688 DOI: 10.3390/cancers13061279] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 02/23/2021] [Accepted: 03/10/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary The HyRec trial was initially designed to optimize and standardize the treatment of locally recurrent rectal cancer (LRRC). An escalated neoadjuvant treatment schedule, consisting of curative radiotherapy, concurrent chemotherapy with 5-Fluorouracil and Oxaliplatin, and additional regional hyperthermia, was evaluated with the intention to increase the rate of curative resections. Primary endpoints were the feasibility rate defined by the number of therapy-limiting toxicity or treatment withdrawal, and the pathologically confirmed complete remission (pCR) rate. Between 2012 and 2018, 111 patients with Union for International Cancer Control (UICC) stage IIB-IV or any locally recurrent rectal cancer were included. The intensified neoadjuvant and multimodality treatment schedule was feasible and led to comparable early toxicity rates as described by other trials that used the similar chemoradiation protocol. The presented treatment regimen resulted in a very high pCR rate and appears as a promising option for patients with LRRC. Abstract Background: To prospectively analyze feasibility and pathological complete response (pCR) rates of neoadjuvant chemoradiotherapy combined with regional hyperthermia (RHT) in patients with locally advanced (LARC) or recurrent (LRRC) rectal cancer. Methods: between 2012 and 2018, 111 patients with UICC stage IIB-IV or any locally recurrent rectal cancer were included (HyRec-Trial, ClinicalTrials.gov Identifier: NCT01716949). Patients received radiotherapy with concurrent 5-Fluororuracil (5-FU)/Capecitabine and Oxaliplatin, and RHT. Stage 1 feasibility analysis evaluated dose-limiting toxicities (DLT) after 19 patients, stage 2 after 59 evaluable patients. Analysis of the pCR rate was based on histopathological reports. Results: the feasibility rates for stages 1 and 2 were 90% (17/19) and 73% (43/59), respectively. In the intention-to-treat population the pCR rate was 19% (20/105; 90% confidence interval (CI) 13.0–26.5). In the per-protocol-analysis, complete tumor regression was seen in 28% (18/64) and 38% (3/8) of the patients with LARC and LRRC, respectively. Complete resection rates (R0) among patients with LARC and LRRC who received surgery were 99% (78/84) and 67% (8/12). Conclusions: the intensified neoadjuvant and multimodality treatment schedule was feasible and led to comparable early toxicity rates as described by other trials that used the similar chemoradiation protocol. The presented treatment regimen resulted in a very high pCR rate and appears as a promising option for patients with LRRC.
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Datta NR, Kok HP, Crezee H, Gaipl US, Bodis S. Integrating Loco-Regional Hyperthermia Into the Current Oncology Practice: SWOT and TOWS Analyses. Front Oncol 2020; 10:819. [PMID: 32596144 PMCID: PMC7303270 DOI: 10.3389/fonc.2020.00819] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 04/27/2020] [Indexed: 12/14/2022] Open
Abstract
Moderate hyperthermia at temperatures between 40 and 44°C is a multifaceted therapeutic modality. It is a potent radiosensitizer, interacts favorably with a host of chemotherapeutic agents, and, in combination with radiotherapy, enforces immunomodulation akin to “in situ tumor vaccination.” By sensitizing hypoxic tumor cells and inhibiting repair of radiotherapy-induced DNA damage, the properties of hyperthermia delivered together with photons might provide a tumor-selective therapeutic advantage analogous to high linear energy transfer (LET) neutrons, but with less normal tissue toxicity. Furthermore, the high LET attributes of hyperthermia thermoradiobiologically are likely to enhance low LET protons; thus, proton thermoradiotherapy would mimic 12C ion therapy. Hyperthermia with radiotherapy and/or chemotherapy substantially improves therapeutic outcomes without enhancing normal tissue morbidities, yielding level I evidence reported in several randomized clinical trials, systematic reviews, and meta-analyses for various tumor sites. Technological advancements in hyperthermia delivery, advancements in hyperthermia treatment planning, online invasive and non-invasive MR-guided thermometry, and adherence to quality assurance guidelines have ensured safe and effective delivery of hyperthermia to the target region. Novel biological modeling permits integration of hyperthermia and radiotherapy treatment plans. Further, hyperthermia along with immune checkpoint inhibitors and DNA damage repair inhibitors could further augment the therapeutic efficacy resulting in synthetic lethality. Additionally, hyperthermia induced by magnetic nanoparticles coupled to selective payloads, namely, tumor-specific radiotheranostics (for both tumor imaging and radionuclide therapy), chemotherapeutic drugs, immunotherapeutic agents, and gene silencing, could provide a comprehensive tumor-specific theranostic modality akin to “magic (nano)bullets.” To get a realistic overview of the strength (S), weakness (W), opportunities (O), and threats (T) of hyperthermia, a SWOT analysis has been undertaken. Additionally, a TOWS analysis categorizes future strategies to facilitate further integration of hyperthermia with the current treatment modalities. These could gainfully accomplish a safe, versatile, and cost-effective enhancement of the existing therapeutic armamentarium to improve outcomes in clinical oncology.
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Affiliation(s)
- Niloy R Datta
- Centre for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
| | - H Petra Kok
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Hans Crezee
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Udo S Gaipl
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stephan Bodis
- Centre for Radiation Oncology KSA-KSB, Kantonsspital Aarau, Aarau, Switzerland
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Hader M, Savcigil DP, Rosin A, Ponfick P, Gekle S, Wadepohl M, Bekeschus S, Fietkau R, Frey B, Schlücker E, Gaipl US. Differences of the Immune Phenotype of Breast Cancer Cells after Ex Vivo Hyperthermia by Warm-Water or Microwave Radiation in a Closed-Loop System Alone or in Combination with Radiotherapy. Cancers (Basel) 2020; 12:cancers12051082. [PMID: 32349284 PMCID: PMC7281749 DOI: 10.3390/cancers12051082] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 12/20/2022] Open
Abstract
The treatment of breast cancer by radiotherapy can be complemented by hyperthermia. Little is known about how the immune phenotype of tumor cells is changed thereby, also in terms of a dependence on the heating method. We developed a sterile closed-loop system, using either a warm-water bath or a microwave at 2.45 GHz to examine the impact of ex vivo hyperthermia on cell death, the release of HSP70, and the expression of immune checkpoint molecules (ICMs) on MCF-7 and MDA-MB-231 breast cancer cells by multicolor flow cytometry and ELISA. Heating was performed between 39 and 44 °C. Numerical process simulations identified temperature distributions. Additionally, irradiation with 2 × 5 Gy or 5 × 2 Gy was applied. We observed a release of HSP70 after hyperthermia at all examined temperatures and independently of the heating method, but microwave heating was more effective in cell killing, and microwave heating with and without radiotherapy increased subsequent HSP70 concentrations. Adding hyperthermia to radiotherapy, dynamically or individually, affected the expression of the ICM PD-L1, PD-L2, HVEM, ICOS-L, CD137-L, OX40-L, CD27-L, and EGFR on breast cancer cells. Well-characterized pre-clinical heating systems are mandatory to screen the immune phenotype of tumor cells in clinically relevant settings to define immune matrices for therapy adaption.
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Affiliation(s)
- Michael Hader
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (M.H.); (D.P.S.); (R.F.); (B.F.)
- Chair for Ceramic Materials Engineering, Keylab Glass Technology, University of Bayreuth, 95447 Bayreuth, Germany; (A.R.); (P.P.)
| | - Deniz Pinar Savcigil
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (M.H.); (D.P.S.); (R.F.); (B.F.)
| | - Andreas Rosin
- Chair for Ceramic Materials Engineering, Keylab Glass Technology, University of Bayreuth, 95447 Bayreuth, Germany; (A.R.); (P.P.)
| | - Philipp Ponfick
- Chair for Ceramic Materials Engineering, Keylab Glass Technology, University of Bayreuth, 95447 Bayreuth, Germany; (A.R.); (P.P.)
| | - Stephan Gekle
- Biofluid Simulations and Modeling, Fachbereich Physik, University of Bayreuth, 95447 Bayreuth, Germany;
| | | | - Sander Bekeschus
- ZIK plasmatis, Leibniz Institute for Plasma Science and Technology, Felix-Hausdorff-Str. 2, 17489 Greifswald, Germany;
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (M.H.); (D.P.S.); (R.F.); (B.F.)
| | - Benjamin Frey
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (M.H.); (D.P.S.); (R.F.); (B.F.)
| | - Eberhard Schlücker
- Department of Chemical and Biological Engineering, Institute of Process Machinery and Systems Engineering (iPAT), Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany;
| | - Udo S. Gaipl
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (M.H.); (D.P.S.); (R.F.); (B.F.)
- Correspondence: ; Tel.: +49-9131-8544-258; Fax: +49-9131-8539-335
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Notter M, Thomsen AR, Nitsche M, Hermann RM, Wolff HA, Habl G, Münch K, Grosu AL, Vaupel P. Combined wIRA-Hyperthermia and Hypofractionated Re-Irradiation in the Treatment of Locally Recurrent Breast Cancer: Evaluation of Therapeutic Outcome Based on a Novel Size Classification. Cancers (Basel) 2020; 12:cancers12030606. [PMID: 32155740 PMCID: PMC7139693 DOI: 10.3390/cancers12030606] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 02/06/2023] Open
Abstract
Effective tumor control in patients suffering from unresectable locally recurrent breast cancer (LRBC) in pre-irradiated areas can be achieved by re-irradiation combined with superficial hyperthermia. Using this combined modality, total re-irradiation dose and toxicity can be significantly reduced compared to conventionally fractionated treatment schedules with total doses of 60–66 Gy. Applying contact-free, thermography-controlled water-filtered infrared-A superficial hyperthermia, immediately followed by hypofractionated re-irradiation, consisting of 4 Gy once per week up to a total dose of 20 Gy, resulted in high overall response rates even in large-sized tumors. Comparability of clinical data between different combined Hyperthermia (HT)/Radiotherapy (RT) treatment schedules is impeded by the highly individual characteristics of this disease. Tumor size, ranging from microscopic disease and small lesions to large-sized cancer en cuirasse, is described as one of the most important prognostic factors. However, in clinical studies and analyses of LRBC, tumor size has so far been reported in a very heterogeneous way. Therefore, we suggest a novel, simple and feasible size classification (rClasses 0–IV). Applying this classification for the evaluation of 201 patients with pre-irradiated LRBC allowed for a stratification into distinct prognostic groups.
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Affiliation(s)
- Markus Notter
- Department of Radiation Oncology, Lindenhofspital Bern, 3012 Bern, Switzerland; (M.N.); (K.M.)
| | - Andreas R. Thomsen
- Department of Radiation Oncology, Medical Center, University of Freiburg, 79106 Freiburg, Germany; (A.R.T.); (A.-L.G.)
- German Cancer Consortium (DKTK), Partner Site Freiburg and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Mirko Nitsche
- Center for Radiotherapy and Radiooncology Bremen and Westerstede, 28239 Bremen, Germany; (M.N.); (R.M.H.)
| | - Robert M. Hermann
- Center for Radiotherapy and Radiooncology Bremen and Westerstede, 28239 Bremen, Germany; (M.N.); (R.M.H.)
| | - Hendrik A. Wolff
- Department of Radiology, Nuclear Medicine and Radiotherapy, Radiology Munich, 80333 Munich, Germany; (H.A.W.); (G.H.)
- Department of Radiation Oncology, Medical Center, University of Regensburg, 93053 Regensburg, Germany
| | - Gregor Habl
- Department of Radiology, Nuclear Medicine and Radiotherapy, Radiology Munich, 80333 Munich, Germany; (H.A.W.); (G.H.)
- Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Karin Münch
- Department of Radiation Oncology, Lindenhofspital Bern, 3012 Bern, Switzerland; (M.N.); (K.M.)
| | - Anca-L. Grosu
- Department of Radiation Oncology, Medical Center, University of Freiburg, 79106 Freiburg, Germany; (A.R.T.); (A.-L.G.)
- German Cancer Consortium (DKTK), Partner Site Freiburg and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
| | - Peter Vaupel
- Department of Radiation Oncology, Medical Center, University of Freiburg, 79106 Freiburg, Germany; (A.R.T.); (A.-L.G.)
- German Cancer Consortium (DKTK), Partner Site Freiburg and German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany
- Correspondence: ; Tel.: +49-171-124-0073
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Oldenborg S, van Os R, Oei B, Poortmans P. Impact of Technique and Schedule of Reirradiation Plus Hyperthermia on Outcome after Surgery for Patients with Recurrent Breast Cancer. Cancers (Basel) 2019; 11:cancers11060782. [PMID: 31195763 PMCID: PMC6627207 DOI: 10.3390/cancers11060782] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 05/31/2019] [Accepted: 06/03/2019] [Indexed: 12/26/2022] Open
Abstract
Purpose: Combining reirradiation (reRT) with hyperthermia (HT) has shown to be of high therapeutic value for patients with loco-regionally recurrent breast cancer. The purpose of this study was to compare the long-term therapeutic effect and toxicity of reRT + HT following surgery of loco-regionally recurrent breast cancer using two different reRT regimens. Methods: The reRT regimen of the 78 patients treated in Institute A consisted of 8 × 4 Gy twice a week using mostly abutted photon-electron fields. The 78 patients treated in Institute B received a reRT regimen of 12 × 3 Gy, four times a week with single or multiple electron fields. Superficial hyperthermia was applied once a week in Institute A and twice a week in Institute B. Both institutes started HT treatment within 1 hour after reRT and used the same 434-MHz systems to heat the tumor area to 41–43 °C. Results: The 5-year-infield local control (LC) rates were similar; however, the 5-year-survival rates were 13% lower in Institute A. Most remarkable was the difference in risk with respect to 5-year ≥ grade 3 toxicity, which was more than twice as high in Institute A. Conclusion: The combination of reirradiation and hyperthermia after macroscopically complete excision of loco-regional breast cancer recurrences provides durable local control in patients at risk for locoregional recurrent breast cancer. Treatment is well tolerated with the 12 × 3 Gy schedule with limited-sized electron fields.
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Affiliation(s)
- Sabine Oldenborg
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam (AMC), 1105 AZ Amsterdam, The Netherlands.
| | - Rob van Os
- Department of Radiation Oncology, Amsterdam UMC, University of Amsterdam (AMC), 1105 AZ Amsterdam, The Netherlands.
| | - Bing Oei
- Department of Radiation Oncology, Institute Verbeeten (BVI), 5042 SB Tilburg, The Netherlands.
| | - Philip Poortmans
- Department of Radiation Oncology, Institute Verbeeten (BVI), 5042 SB Tilburg, The Netherlands.
- Department of Radiation Oncology, Institut Curie, Paris Sciences & Lettres-PSL University, 75248 Paris, France.
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