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Mikic N, Gentilal N, Cao F, Lok E, Wong ET, Ballo M, Glas M, Miranda PC, Thielscher A, Korshoej AR. Tumor-treating fields dosimetry in glioblastoma: Insights into treatment planning, optimization, and dose-response relationships. Neurooncol Adv 2024; 6:vdae032. [PMID: 38560348 PMCID: PMC10981464 DOI: 10.1093/noajnl/vdae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Tumor-treating fields (TTFields) are currently a Category 1A treatment recommendation by the US National Comprehensive Cancer Center for patients with newly diagnosed glioblastoma. Although the mechanism of action of TTFields has been partly elucidated, tangible and standardized metrics are lacking to assess antitumor dose and effects of the treatment. This paper outlines and evaluates the current standards and methodologies in the estimation of the TTFields distribution and dose measurement in the brain and highlights the most important principles governing TTFields dosimetry. The focus is on clinical utility to facilitate a practical understanding of these principles and how they can be used to guide treatment. The current evidence for a correlation between TTFields dose, tumor growth, and clinical outcome will be presented and discussed. Furthermore, we will provide perspectives and updated insights into the planning and optimization of TTFields therapy for glioblastoma by reviewing how the dose and thermal effects of TTFields are affected by factors such as tumor location and morphology, peritumoral edema, electrode array position, treatment duration (compliance), array "edge effect," electrical duty cycle, and skull-remodeling surgery. Finally, perspectives are provided on how to optimize the efficacy of future TTFields therapy.
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Affiliation(s)
- Nikola Mikic
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Nichal Gentilal
- Instituto de Biofísica e Engenharia Biomédica, Faculdade de Ciências da Universidade de Lisboa, Lisboa, Portugal
| | - Fang Cao
- Department of Health Technology, Center for Magnetic Resonance, Technical University of Denmark, Kgs. Lyngby, Denmark
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | - Edwin Lok
- Brain Tumor Center and Neuro-Oncology Unit, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Eric T Wong
- Division of Hematology/Oncology, Department of Medicine, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Matthew Ballo
- Department of Radiation Oncology, West Cancer Center and Research Institute, Memphis, Tennessee, USA
| | - Martin Glas
- Division of Clinical Neurooncology, Department of Neurology and German Cancer Consortium (DKTK) Partner Site, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Pedro C Miranda
- Instituto de Biofísica e Engenharia Biomédica, Faculdade de Ciências da Universidade de Lisboa, Lisboa, Portugal
| | - Axel Thielscher
- Department of Health Technology, Center for Magnetic Resonance, Technical University of Denmark, Kgs. Lyngby, Denmark
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital Amager and Hvidovre, Hvidovre, Denmark
| | - Anders R Korshoej
- Department of Neurosurgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Tumor Treating Fields (TTFields) Therapy Concomitant with Taxanes for Cancer Treatment. Cancers (Basel) 2023; 15:cancers15030636. [PMID: 36765594 PMCID: PMC9913762 DOI: 10.3390/cancers15030636] [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: 12/14/2022] [Revised: 01/13/2023] [Accepted: 01/16/2023] [Indexed: 01/22/2023] Open
Abstract
Non-small cell lung cancer, ovarian cancer, and pancreatic cancer all present with high morbidity and mortality. Systemic chemotherapies have historically been the cornerstone of standard of care (SOC) regimens for many cancers, but are associated with systemic toxicity. Multimodal treatment combinations can help improve patient outcomes; however, implementation is limited by additive toxicities and potential drug-drug interactions. As such, there is a high unmet need to develop additional therapies to enhance the efficacy of SOC treatments without increasing toxicity. Tumor Treating Fields (TTFields) are electric fields that exert physical forces to disrupt cellular processes critical for cancer cell viability and tumor progression. The therapy is locoregional and is delivered noninvasively to the tumor site via a portable medical device that consists of field generator and arrays that are placed on the patient's skin. As a noninvasive treatment modality, TTFields therapy-related adverse events mainly consist of localized skin reactions, which are manageable with effective acute and prophylactic treatments. TTFields selectively target cancer cells through a multi-mechanistic approach without affecting healthy cells and tissues. Therefore, the application of TTFields therapy concomitant with other cancer treatments may lead to enhanced efficacy, with low risk of further systemic toxicity. In this review, we explore TTFields therapy concomitant with taxanes in both preclinical and clinical settings. The summarized data suggest that TTFields therapy concomitant with taxanes may be beneficial in the treatment of certain cancers.
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Oberheim-Bush NA, Shi W, McDermott MW, Grote A, Stindl J, Lustgarten L. The safety profile of Tumor Treating Fields (TTFields) therapy in glioblastoma patients with ventriculoperitoneal shunts. J Neurooncol 2022; 158:453-461. [PMID: 35639236 PMCID: PMC9256561 DOI: 10.1007/s11060-022-04033-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/07/2022] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Tumor Treating Fields (TTFields, 200 kHz) therapy is a noninvasive, locoregional cancer treatment approved for use in newly diagnosed glioblastoma (GBM), recurrent GBM, and malignant pleural mesothelioma. GBM patients with hydrocephalus may require implantation of a ventriculoperitoneal (VP) shunt, however, the current TTFields therapy label does not include the use of VP shunts in GBM patients due to insufficient safety data. This analysis evaluates the safety of TTFields therapy use in this population. METHODS Unsolicited post-marketing global surveillance data from patients with GBM and a VP shunt (programmable/non-programmable) who received TTFields therapy between November 2012-April 2021 were retrospectively analyzed. Adverse events (AEs) were assessed using the Medical Dictionary for Regulatory Activities version 24.0. RESULTS Overall, 156 patients with VP shunts were identified and included in this analysis. In total, 77% reported ≥ 1 AE; the most common TTFields therapy-related AEs were non-serious and localized, beneath-array skin AEs (43%). The incidence and categories of AEs were comparable between patients with or without VP shunts. Six patients with VP shunts experienced seven serious TTFields therapy-related AEs: skin erosion at the shunt site (n = 3); wound dehiscence at the shunt site (n = 2) and at the resection scar (n = 2). No shunt malfunctions were deemed related to TTFields therapy. CONCLUSIONS In the real-world setting, TTFields therapy in GBM patients with VP shunts demonstrated good tolerability and a favorable safety profile. There was no evidence that TTFields therapy disrupted VP shunt effectiveness. These results suggest TTFields therapy may be safely used in patients with VP shunts.
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Affiliation(s)
- Nancy Ann Oberheim-Bush
- Division of Neuro-Oncology, UCSF Brain Tumor Center, University of California, 400 Parnassus Ave, A808, San Francisco, CA, 94143, USA.
| | - Wenyin Shi
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Michael W McDermott
- Division of Neurosurgery, Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
| | - Alexander Grote
- Department of Neurosurgery, University Hospital of Marburg, Marburg, Germany
| | | | - Leonardo Lustgarten
- Director of Neurooncology Global Medical Affairs , Novocure Inc, New York, NY, USA
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Gkika E, Grosu AL, Macarulla Mercade T, Cubillo Gracián A, Brunner TB, Schultheiß M, Pazgan-Simon M, Seufferlein T, Touchefeu Y. Tumor Treating Fields Concomitant with Sorafenib in Advanced Hepatocellular Cancer: Results of the HEPANOVA Phase II Study. Cancers (Basel) 2022; 14:cancers14061568. [PMID: 35326718 PMCID: PMC8946145 DOI: 10.3390/cancers14061568] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/07/2022] [Accepted: 03/12/2022] [Indexed: 11/24/2022] Open
Abstract
Advanced hepatocellular carcinoma (HCC) is an aggressive disease associated with poor prognosis. Tumor Treating Fields (TTFields) therapy is a non-invasive, loco-regional treatment approved for glioblastoma and malignant pleural mesothelioma. HCC preclinical and abdominal simulation data, together with clinical results in other solid tumors, provide a rationale for investigating TTFields with sorafenib in this patient population. HEPANOVA was a phase II, single arm, historical control study in adults with advanced HCC (NCT03606590). Patients received TTFields (150 kHz) for ≥18 h/day concomitant with sorafenib (400 mg BID). Imaging assessments occurred every 12 weeks until disease progression. The primary endpoint was the overall response rate (ORR). Safety was also evaluated. Patients (n = 27 enrolled; n = 21 evaluable) had a poor prognosis; >50% were Child−Turcotte−Pugh class B and >20% had a baseline Eastern Clinical Oncology Group performance status (ECOG PS) of 2. The ORR was higher, but not statistically significant, for TTFields/sorafenib vs. historical controls: 9.5% vs. 4.5% (p = 0.24), respectively; all responses were partial. Among patients (n = 11) with ≥12 weeks of TTFields/sorafenib, ORR was 18%. Common adverse events (AEs) were diarrhea (n = 15/27, 56%) and asthenia (n = 11/27, 40%). Overall, 19/27 (70%) patients had TTFields-related skin AEs; none were serious. TTFields/sorafenib improved response rates vs. historical controls in patients with advanced HCC, with no new safety concerns or related systemic toxicity.
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Affiliation(s)
- Eleni Gkika
- Department for Radiation Oncology, University Medical Centre Freiburg, Robert-Koch-Straße 3, 79106 Freiburg, Germany;
- Correspondence: ; Tel.: +49-(0)-761-270-95200
| | - Anca-Ligia Grosu
- Department for Radiation Oncology, University Medical Centre Freiburg, Robert-Koch-Straße 3, 79106 Freiburg, Germany;
| | - Teresa Macarulla Mercade
- Department of Medical Oncology, Vall d’Hebrón University Hospital and Vall d’Hebrón Institute of Oncology, 08035 Barcelona, Spain;
| | - Antonio Cubillo Gracián
- Department of Medical Oncology, Centro Integral Oncológico Clara Campal HM CIOCC, Hospital Universitario HM Sanchinarro, 28050 Madrid, Spain;
| | - Thomas B. Brunner
- Department of Radiotherapy, University Hospital Magdeburg, 39120 Magdeburg, Germany;
| | - Michael Schultheiß
- Department of Medicine II, University Hospital Freiburg, 79106 Freiberg, Germany;
| | - Monika Pazgan-Simon
- Department of Infectious Diseases and Hepatology, Wroclaw Medical University, 50-367 Wrocław, Poland;
| | - Thomas Seufferlein
- Department of Internal Medicine, University Hospital Ulm, 89081 Ulm, Germany;
| | - Yann Touchefeu
- Nantes Université, CHU Nantes, Institut des Maladies de l’Appareil Digestif (IMAD), Hépato-Gastroentérologie, Inserm CIC 1413, F-44000 Nantes, France;
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Chandana S, Babiker HM, Mahadevan D. Therapeutic trends in pancreatic ductal adenocarcinoma (PDAC). Expert Opin Investig Drugs 2018; 28:161-177. [DOI: 10.1080/13543784.2019.1557145] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Sreenivasa Chandana
- Phase I program, START Midwest, Grand Rapids, MI, USA
- Department of Gastrointestinal Medical Oncology, Cancer and Hematology Centers of Western Michigan, Grand Rapids, MI, USA
- Department of Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Hani M. Babiker
- Early Phase Therapeutics Program, University of Arizona Cancer Center, Tucson, AZ, USA
| | - Daruka Mahadevan
- Early Phase Therapeutics Program, University of Arizona Cancer Center, Tucson, AZ, USA
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Mun EJ, Babiker HM, Weinberg U, Kirson ED, Von Hoff DD. Tumor-Treating Fields: A Fourth Modality in Cancer Treatment. Clin Cancer Res 2017; 24:266-275. [PMID: 28765323 DOI: 10.1158/1078-0432.ccr-17-1117] [Citation(s) in RCA: 210] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 06/11/2017] [Accepted: 07/26/2017] [Indexed: 11/16/2022]
Abstract
Despite major advances in therapy, cancer continues to be a leading cause of mortality. In addition, toxicities of traditional therapies pose a significant challenge to tolerability and adherence. TTFields, a noninvasive anticancer treatment modality, utilizes alternating electric fields at specific frequencies and intensities to selectively disrupt mitosis in cancerous cells. TTFields target proteins crucial to the cell cycle, leading to mitotic arrest and apoptosis. TTFields also facilitate an antitumor immune response. Clinical trials of TTFields have proven safe and efficacious in patients with glioblastoma multiforme (GBM), and are FDA approved for use in newly diagnosed and recurrent GBM. Trials in other localized solid tumors are ongoing. Clin Cancer Res; 24(2); 266-75. ©2017 AACR.
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Affiliation(s)
- Elijah J Mun
- University of Washington, Department of Internal Medicine, Seattle, Washington.
| | - Hani M Babiker
- Translational Genomics Research Institute (TGen), University of Arizona Cancer Center, Tucson, Arizona
| | - Uri Weinberg
- Novocure Ltd., Topaz Building, MATAM Center, Haifa, Israel
| | - Eilon D Kirson
- Novocure Ltd., Topaz Building, MATAM Center, Haifa, Israel
| | - Daniel D Von Hoff
- Virginia G. Piper Cancer Center Clinical Trials, HonorHealth Research Institute, Scottsdale, Arizona.,Translational Genomics Research Institute (TGen), Clinical Translational Research Division, Phoenix, Arizona
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