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Ferioli M, Perrone AM, Buwenge M, Arcelli A, Vadala’ M, Fionda B, Malato MC, De Iaco P, Zamagni C, Cammelli S, Tagliaferri L, Morganti AG. Combination of Electrochemotherapy with Radiotherapy: A Comprehensive, Systematic, PRISMA-Compliant Review of Efficacy and Potential Radiosensitizing Effects in Tumor Control. Curr Oncol 2023; 30:9895-9905. [PMID: 37999139 PMCID: PMC10670517 DOI: 10.3390/curroncol30110719] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 10/27/2023] [Accepted: 10/31/2023] [Indexed: 11/25/2023] Open
Abstract
Radiotherapy (RT) and electrochemotherapy (ECT) are established local treatments for cancer. While effective, both therapies have limitations, especially in treating bulky and poorly oxygenated tumors. ECT has emerged as a promising palliative treatment, raising interest in exploring its combination with RT to enhance tumor response. However, the potential benefits and challenges of combining these treatments remain unclear. A systematic review was conducted following PRISMA guidelines. PubMed, Scopus, and Cochrane libraries were searched. Studies were screened and selected based on predefined inclusion and exclusion criteria. Ten studies were included, comprising in vitro and in vivo experiments. Different tumor types were treated with ECT alone or in combination with RT. ECT plus RT demonstrated superior tumor response compared to that under single therapies or other combinations, regardless of the cytotoxic agent and RT dose. However, no study demonstrated a clear superadditive effect in cell survival curves, suggesting inconclusive evidence of specific ECT-induced radiosensitization. Toxicity data were limited. In conclusion, the combination of ECT and RT consistently improved tumor response compared to that with individual therapies, supporting the potential benefit of their combination. However, evidence for a specific ECT-induced radiosensitization effect is currently lacking. Additional investigations are necessary to elucidate the potential benefits of this combination therapy.
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Affiliation(s)
- Martina Ferioli
- Radiation Oncology, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (A.M.P.); (M.B.); (A.A.); (M.C.M.); (P.D.I.); (S.C.); (A.G.M.)
| | - Anna M. Perrone
- Radiation Oncology, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (A.M.P.); (M.B.); (A.A.); (M.C.M.); (P.D.I.); (S.C.); (A.G.M.)
- Division of Oncologic Gynaecology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Milly Buwenge
- Radiation Oncology, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (A.M.P.); (M.B.); (A.A.); (M.C.M.); (P.D.I.); (S.C.); (A.G.M.)
| | - Alessandra Arcelli
- Radiation Oncology, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (A.M.P.); (M.B.); (A.A.); (M.C.M.); (P.D.I.); (S.C.); (A.G.M.)
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Maria Vadala’
- Nuclear Medicine, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Bruno Fionda
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, 00168 Roma, Italy; (B.F.); (L.T.)
| | - Maria C. Malato
- Radiation Oncology, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (A.M.P.); (M.B.); (A.A.); (M.C.M.); (P.D.I.); (S.C.); (A.G.M.)
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Pierandrea De Iaco
- Radiation Oncology, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (A.M.P.); (M.B.); (A.A.); (M.C.M.); (P.D.I.); (S.C.); (A.G.M.)
- Division of Oncologic Gynaecology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Claudio Zamagni
- Oncologia Medica Addarii, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Silvia Cammelli
- Radiation Oncology, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (A.M.P.); (M.B.); (A.A.); (M.C.M.); (P.D.I.); (S.C.); (A.G.M.)
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Luca Tagliaferri
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, UOC di Radioterapia Oncologica, 00168 Roma, Italy; (B.F.); (L.T.)
| | - Alessio G. Morganti
- Radiation Oncology, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, 40138 Bologna, Italy; (A.M.P.); (M.B.); (A.A.); (M.C.M.); (P.D.I.); (S.C.); (A.G.M.)
- Radiation Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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Bachaud JM, Chatelut E, Canal P, Albin N, Yardeni E, David JM, Serrano E, Daly-Schveitzer N. Radiotherapy with concomitant continuous cisplatin infusion for unresectable tumors of the upper aerodigestive tract: results of a phase I study. Am J Clin Oncol 1997; 20:1-5. [PMID: 9020278 DOI: 10.1097/00000421-199702000-00001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
A phase I-II study was initiated in February 1991 of concomitant radiation and cisplatin (CDDP) in the treatment of unresectable head and neck squamous cell carcinomas (n = 12). The first patient was treated palliatively for a cervical recurrence of laryngeal cancer. The 11 other patients had locally advanced (stage IV) previously untreated carcinomas of the oropharynx (n = 9), hypopharynx (n = 1), or cervical node with unknown primary site (n = 1). Standard external radiation was carried out up to a total dose of 60 Gy/6 weeks (7 MeV electron beam) for the first patient and 72 Gy/8 weeks (Co60 beam) for the other 11 patients. CDDP was infused continuously during the entire radiation treatment, 5 days/week. The starting dose was 4 mg/m2/day and was escalated by increments of 1 mg/m2/day; dose-limiting toxicity was observed at 7 mg/m2/day. Neutropenia (grade 4, one patient; grade 3, three patients) and thrombocytopenia (grade 3, one patient; grade 2, one patient) were the limiting factors. Therefore, the recommended dose of CDDP is 6 mg/m2/day. All patients but one completed the scheduled radiation. For the entire group, mucositis was not more severe than that observed with radiotherapy alone. There was no nephro-, oto-, or neurotoxicity. A complete response was obtained in eight (66%) patients. Of these, four were free of disease 12-34 months after completion of treatment and one had a total glossectomy for a tongue necrosis. For the whole series, the mean overall survival was 16 months posttreatment. Pharmacokinetic analysis indicated the total cisplatin accumulation at the end of treatment to be 743-1551 ng/ml. Accumulation of ultrafilterable platin was noted in only one patient (137 ng/ml at the end of treatment).
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Affiliation(s)
- J M Bachaud
- Department of Radiotherapy, C.H.U. Rangueil, Toulouse, France
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Lara PC, Garcia-Puche JL, Pedraza V. Cisplatin-ifosfamide as neoadjuvant chemotherapy in stage IIIB cervical uterine squamous-cell carcinoma. Cancer Chemother Pharmacol 1990; 26 Suppl:S36-8. [PMID: 2347047 DOI: 10.1007/bf00685415] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Survival in patients with advanced cervical cancer (stage III B) treated by radical radiotherapy is low. In this study we attempted to assess the efficacy of the cis-diamminedichloroplatinum(II) (CDDP)-ifosfamide combination as neoadjuvant chemotherapy in advanced cervical cancer. The treatment schedule was: 20 mg/m2 CDDP on days 1-5; 1.5 g/m2 ifosfamide on days 1-5; and 900 mg/m2 mesna on days 1-5. Courses were given every 28 days. Radiotherapy was given 15 days after the completion of chemotherapy. A total of 26 patients were entered in this trial. Of the 24 patients evaluable for response, 15 (62.5%) achieved at least a 50% reduction in tumor volume, 6 (25%) showed stable disease, and three (12.5%) had progressive disease. At 38 months (mean follow-up) after completion of radiotherapy, 13 of the 24 (54%) evaluable patients were disease-free; 73% of the patients responding to chemotherapy vs 22% of the nonresponders remained free of disease (Fisher's exact test: P less than 0.02). Major hematologic depression occurred in 2 of the 26 patients evaluable for toxicity. No CNS toxicity was detected. These results are superior to those obtained by radical radiotherapy alone. Future treatment should be directed toward improving response rates as the best way of increasing both local and distant long-term disease control in these patients.
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Affiliation(s)
- P C Lara
- Department of Radiotherapy and Oncology, University Hospital, Granada, Spain
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Vokes EE, Panje WR, Weichselbaum RR, Schilsky RL, Moran WJ, Awan AM, Guarnieri CM. Concomitant hydroxyurea, 5-fluorouracil, and radiation therapy for recurrent head and neck cancer: early results. Otolaryngol Head Neck Surg 1988; 98:295-8. [PMID: 3132681 DOI: 10.1177/019459988809800404] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
We tested the combination of hydroxyurea (HU), 5-fluorouracil (5-FU), and concomitant radiotherapy (XRT) in a group of patients with advanced or recurrent head and neck cancer. Both drugs are effective single agents, have shown synergistic activity in vitro, and can act as radiation sensitizers. A 5-day course of radiotherapy, with simultaneous HU and continuous infusion 5-FU, was followed by a 9-day rest period; cycles were repeated until completion of XRT. Sixteen patients have completed their therapy. Eleven patients had recurrent disease after previous therapy with surgery (11 patients), radiotherapy (9 patients), and combination chemotherapy (4 patients). Five patients had not received previous local therapy. These patients had persistent disease after induction chemotherapy and/or were inoperable because of poor general medical condition. Of 15 patients evaluable for response, 9 had complete response, including 5 patients who had earlier local therapy; 5 had partial response; and 1 failed to respond. Toxicities included mild myelosuppression and mucositis. No unusual complication related to previous radiotherapy was observed. This regimen has shown impressive activity in a cohort of patients who are not usually responsive to other types of currently available therapy. We are continuing our investigation to further define efficacy, toxicity, and maximally tolerated doses of this regimen.
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Affiliation(s)
- E E Vokes
- Department of Medicine, University of Chicago, IL
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Abstract
The role of chemotherapy in the management of head and neck cancer includes treatment for recurrent disease and as an adjunct to conventional therapy with radiation and/or surgery in the primary treatment program. The best single agents, methotrexate and cisplatin, used for recurrent disease give response rates of 20 to 50 percent but of short duration. Results may be improved with combination chemotherapy, but often with increased toxicity. Prognostic factors that influence response are discussed. A newer role of chemotherapy in this disease is in the initial treatment program. Pretreatment chemotherapy can debulk these lesions prior to surgery and/or irradiation in up to 80 percent of patients. Controlled trials are in progress to determine the effect on cure rates. Chemotherapy utilized during radiotherapy has resulted in survival benefit in several studies. Post-treatment adjuvant chemotherapy still needs to be evaluated. The potential advantages and disadvantages of chemotherapy used in the initial treatment are discussed. Major strides have been made in the last decade in the treatment of head and neck cancer, and chemotherapy is assuming an increasingly important role.
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Forastiere AA, Vikram B, Spiro RH, Wittes RE. Radiotherapy and bleomycin-containing chemotherapy in the treatment of advanced head and neck cancer: report of six patients and review of the literature. Int J Radiat Oncol Biol Phys 1981; 7:1441-50. [PMID: 6172405 DOI: 10.1016/0360-3016(81)90042-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Abstract
Significant doses of ionizing radiation produce an acute skin reaction characterized by erythema, epilation, and dry or moist desquamation with or without erosions. These early acute changes are dose-dependent and reflect damage to the germinative cells of the epidermis and to the cutaneous vasculature. Studies in the pig, for example, have shown that the degenerative phase of cell loss (2-3 weeks) results from reproductive failure in germinative cells and a sharp reduction in the proliferation rate of basal cell "survivors." D0 values for epidermal cells in different species generally range from 100-140 rads. Cell maturation and ascension rates in the suprabasilar layers are largely unaffected. A regenerative phase of cell replacement, characterized by sharply increased cell replication rates, occurs from the 3rd to 5th postradiation weeks. The postregenerative phase of hyperplasia reflects a temporary overshoot of cell density above control levels; a subsequent decrease in hyperplasia indicates feedback control of cellular proliferation. Postradiation changes in the highly proliferative anagen hair matrix cell populations result in hair dysplasia, slowed growth rates, impaired metabolic processes, and alopecia. Dosages of 700-800 rads or more induce some degree of permanent hair loss. G0 telogen matrix cells are 2-3 times more radioresistant than proliferating anagen matrix cells, but may "store" radiation damage for prolonged periods. Altered matrix cell uptake of amino acids, the incidence of dysplasia, and the degree of alopecia occurring after irradiation have all been used as quantitative biological end-points for the general study of cellular radiation effects, as well as studies on the enhancement of or protection against radiation damage provided by certain pharmacologic or physical agents.
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Smith BL, Franz JL, Mira JG, Gates GA, Sapp J, Cruz AB. Simultaneous combination radiotherapy and multidrug chemotherapy for stage III and stage IV squamous cell carcinoma of the head and neck. J Surg Oncol 1980; 15:91-8. [PMID: 6158633 DOI: 10.1002/jso.2930150114] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Combined simultaneous radiotherapy and multidrug chemotherapy have been utilized in an attempt to eradicate or shrink tumors of the head and neck area in advanced stages to allow subsequent surgical extirpation. Thirty-six patients (1 stage II; 11 stage III; 24 stage IV; 1 unknown primary) were treated with simultaneous radiotherapy and fractionalized doses of bleomycin, adriamycin, and 5-fluorouracil. Thirty of 36 patients completed the treatment schedule. Twenty-nine of 30 (97%) had a 75% or greater response to treatment; 20/30 (66%) had 100% response; 9/30 (30%) had 75% response; and 1/30 had 50% response. Of the 30 patients completing the regimen, 19/30 (63%) are alive three to 27 months later, and 12 (40%) of these have no evidence of disease. Six patients died within four months of initiation of therapy, mostly from complications of their disease. This treatment regimen appears effective in the control of locoregional disease or to produce enough shrinkage of tumor to allow subsequent surgical extirpation.
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Carter SK. The old versus the new combinations: drugs and irradiation for head and neck cancer. Int J Radiat Oncol Biol Phys 1980; 6:641-4. [PMID: 6157661 DOI: 10.1016/0360-3016(80)90393-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Carter SK. Experimental design considerations in clinically combining radiation and drugs. Int J Radiat Oncol Biol Phys 1979; 5:1139-43. [PMID: 528262 DOI: 10.1016/0360-3016(79)90633-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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11
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Hellmann K, Ryall RD, Macdonald E, Newton KA, James SE, Jones S. Comparison of radiotherapy with and without razoxane (ICRF 159) in the treatment of soft tissue sarcomas. Cancer 1978; 41:100-7. [PMID: 414829 DOI: 10.1002/1097-0142(197801)41:1<100::aid-cncr2820410115>3.0.co;2-p] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Comparison of the recurrence rates of soft tissue sarcomas treated by radiotherapy (14 patients) or radiotherapy and synchronous administration of razoxane (19 patients) has shown a statistically significant benefit for those patients treated by the combination. No increase in tissue reactions or adverse side-effects (apart from a readily reversible leukopenia) was observed. The implication is that razoxane acts as a well tolerated adjuvant for radiotherapy.
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Bakowski MT, Macdonald E, Mould RF, Cawte P, Sloggem J, Barrett A, Dalley V, Newton KA, Westbury G, James SE, Hellmann K. Double blind controlled clinical trial of radiation plus razoxane (ICRF 159) versus radiation plus placebo in the treatment of head and neck cancer. Int J Radiat Oncol Biol Phys 1978; 4:115-9. [PMID: 344287 DOI: 10.1016/0360-3016(78)90125-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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14
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Lelieveld P, Smink T, van Putten L. Experimental studies on the combination of radiation and chemotherapy. Int J Radiat Oncol Biol Phys 1978; 4:37-41. [PMID: 273018 DOI: 10.1016/0360-3016(78)90112-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Busse JM, Goffinet DR, Bagshaw MA. Late local recurrences in patients with head and neck cancer treated by irradiation and intra-arterial infusion. Int J Radiat Oncol Biol Phys 1976; 1:839-48. [PMID: 977418 DOI: 10.1016/0360-3016(76)90107-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Abstract
Although experience with drug therapy of advanced or recurrent squamous cell carcinoma of the head and neck is limited, several agents have produced convincing and reproducible tumor regression in these patients. Methotrexate has had the widest usage, and produces 30-50% response rates; bleomycin, hydroxyurea, and adriamycin appear to be somewhat less effective. Location of the malignancy and previous x-ray treatment appear to be important determinants of responsiveness to methotrexate, while degree of differentiation has not yet been shown to be an important factor for response to this drug. Attempts to improve the response rate and duration of chemotherapeutic response by utilizing combinations of drugs, or use of drugs to sensitize the tumor to x-ray treatment, or to reduce the bulk of tumor before x-ray treatment, are reviewed; they have been only moderately encouraging. Intra-arterial chemotherapy appears to have a therapeutic advantage over intravenous treatment; however, the morbidity associated with the former approach limits its usefulness for routine usage. The use of drugs as adjuncts following surgery and/or radiation therapy or immunotherapy are newer approaches that have not been investigated sufficiently, but are promising areas for investigation.
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