Persistent and/or late complications of combined radiation therapy and hyperthermia

A translational review of hyperthermia biology

This review was written to be included in the Special Collection 'Therapy Ultrasound: Medicine's Swiss Army Knife?' The purpose of this review is to provide basic presentation and interpretation of the fundamentals of hyperthermia biology, as it pertains to uses of therapeutic ultrasound. The fundamentals are presented but in the setting of a translational interpretation and a view toward the future. Subjects that require future research and development are highlighted. The effects of hyperthermia are time and temperature dependent. Because intra-tumoral temperatures are non-uniform in tumors, one has to account for differential biologic effects in different parts of a tumor that occur simultaneously during and after hyperthermia.

Improved Swallow Outcomes with Early Intervention using Combined Swallow Therapy in Advanced Oropharyngeal Carcinoma

Objective

To evaluate the impact of early intervention using combined swallow therapy, consisting of traditional swallow exercises and transcutaneous neuromuscular electrical stimulation, on patients with advanced oropharyngeal squamous cell carcinoma.

Methods

A cohort study of 60 prospectively enrolled patients was performed. Thirty patients with advanced oropharyngeal squamous cell carcinoma starting combined swallow therapy two weeks after surgery that continued throughout chemoradiotherapy were compared with a matched cohort of 30 patients starting combined swallow therapy after cancer treatment completion. Gastrostomy tube status, modified barium swallow, and Functional Oral Intake Scale scores were assessed before and after therapy.

Results

Both cohorts demonstrated a statistically significant improvement in Functional Oral Intake Scale scores. All patients in the early intervention cohort discontinued gastrostomy tube use, compared with one-third in the control cohort, with greater improvements in Functional Oral Intake Scale scores. The tongue base was the site of greatest improvement in the early intervention group.

Conclusion

Early initiation of combined swallow therapy may optimise swallow outcomes in patients with advanced oropharyngeal squamous cell carcinoma.

Fascio-cutaneous-free flaps as primary reconstruction in salvage total laryngectomy

INTRODUCTION

Salvage total laryngectomy (STL) is the most common treatment for recurrent laryngeal cancer after (chemo)-radiotherapy [(C)RT]. In this scenario, a higher rate of local wound complications, such as pharyngo-cutaneous fistula (PCF) and pharyngo-esophageal stenosis (PES), is generally expected. The aim of the present study is to evaluate outcomes using a standardized reconstructive protocol.

METHODS

Between 2009 and 2019, patients undergoing STL after (C)RT were collected at two referral hospitals with the objective of evaluating surgical outcomes using a standardized reconstructive policy based on the use of fascio-cutaneous free flaps as inlay patch grafts and a long-lasting salivary bypass stent.

RESULTS

Fifty-five patients (mean age, 66 years; male-to-female ratio, 8:1) were included in the study. Previous treatments were RT in 22 (40%) patients, CRT in 21 (38.2%), and partial laryngeal surgery followed by adjuvant (C)RT in 12 (21.8%). Reconstruction was accomplished by radial forearm and anterolateral thigh free flaps in 16 (29.1%) and 39 (70.9%) patients, respectively. Flap success rate was 98.2%. Concerning postoperative complications, we encountered 3 PCFs (5.4%) and 1 PES (1.8%).

CONCLUSION

The standardized reconstructive protocol analyzed herein granted significantly lower rates of PCF and PES after STL compared with data available in the literature.

Temperature and thermal dose during radiotherapy and hyperthermia for recurrent breast cancer are related to clinical outcome and thermal toxicity: a systematic review

Objective: Hyperthermia therapy (HT), heating tumors to 40-45 °C, is a known radiotherapy (RT) and chemotherapy sensitizer. The additional benefit of HT to RT for recurrent breast cancer has been proven in multiple randomized trials. However, published outcome after RT + HT varies widely. We performed a systematic review to investigate whether there is a relationship between achieved HT dose and clinical outcome and thermal toxicity for patients with recurrent breast cancer treated with RT + HT. Method: Four databases, EMBASE, PubMed, Cochrane library and clinicaltrials.gov, were searched with the terms breast, radiotherapy, hyperthermia therapy and their synonyms. Final search was performed on 3 April 2019. Twenty-two articles were included in the systematic review, reporting on 2330 patients with breast cancer treated with RT + HT. Results: Thirty-two HT parameters were tested for a relationship with clinical outcome. In studies reporting a relationship, the relationship was significant for complete response in 10/15 studies, in 10/13 studies for duration of local control, in 2/2 studies for overall survival and in 7/11 studies for thermal toxicity. Patients who received high thermal dose had on average 34% (range 27%-53%) more complete responses than patients who received low thermal dose. Patients who achieved higher HT parameters had increased odds/probability on improved clinical outcome and on thermal toxicity. Conclusion: Temperature and thermal dose during HT had significant influence on complete response, duration of local control, overall survival and thermal toxicity of patients with recurrent breast cancer treated with RT + HT. Higher temperature and thermal dose improved outcome, while higher maximum temperature increased incidence of thermal toxicity.

Physicochemical properties of liposomes as potential anticancer drugs carriers. Interaction of etoposide and cytarabine with the membrane: spectroscopic studies

The interactions between etoposide, cytarabine and 1,2-dihexadecanoyl-sn-glycerol-3-phosphocholine bilayers were studied using differential scanning calorimetry (DSC), Fourier transform infrared spectroscopy (FT-IR) and nuclear magnetic resonance (NMR). These techniques have proven to be a very powerful tool in studying the structure and dynamics of phospholipid bilayers. In particular, DSC can provide information on the phase transition temperature and cooperativity of the lipid molecules in the absence and presence of the drug. Vibrational spectroscopy is well suited to the study of drug-lipid interactions, since it allows for an investigation of the conformation of phospholipid molecules at different levels in lipid bilayers and follows structural changes that occur during the gel to liquid-crystalline phase transition. NMR supported the determination of the main phase transition temperatures (TC) of 1,2-dihexadecanoyl-sn-glycerol-3-phosphocholine (DPPC). The main phase transition temperature (TC) determined by (1)H NMR is comparable with values obtained by DSC for all studied liposomes. The location of cytarabine and etoposide in liposomes was also determined by NMR. Atomic force microscopy (AFM) images, acquired immediately after sample deposition on a mica surface, revealed the spherical shape of lipid vesicles.

Nanoscale Drug Delivery and Hyperthermia: The Materials Design and Preclinical and Clinical Testing of Low Temperature-Sensitive Liposomes Used in Combination with Mild Hyperthermia in the Treatment of Local Cancer

The overall objective of liposomal drug delivery is to selectively target drug delivery to diseased tissue, while minimizing drug delivery to critical normal tissues. The purpose of this review is to provide an overview of temperature-sensitive liposomes in general and the Low Temperature-Sensitive Liposome (LTSL) in particular. We give a brief description of the material design of LTSL and highlight the likely mechanism behind temperature-triggered drug release. A complete review of the progress and results of the latest preclinical and clinical studies that demonstrate enhanced drug delivery with the combined treatment of hyperthermia and liposomes is provided as well as a clinical perspective on cancers that would benefit from hyperthermia as an adjuvant treatment for temperature-triggered chemotherapeutics. This review discusses the ideas, goals, and processes behind temperature-sensitive liposome development in the laboratory to the current use in preclinical and clinical settings.

Imaging of the Head and Neck following Radiation Treatment

Squamous cell carcinoma of the head and neck occurs in approximately 40,000 patients annually in the United States and is often treated with radiation therapy. Radiological studies are obtained following treatment for head and neck malignancies to assess for recurrent tumor, posttreatment changes, and associated complications. Radiation treatment creates a difficult clinical picture for oncologists, head and neck surgeons, neuroradiologists, and neuropathologists. As post-treatment imaging studies are often discussed at radiology/pathology working conferences, knowledge of the imaging appearance of radiation-associated changes in the head and neck and the terminology used by neuroradiologists may not only aid in interpretation of the pathologic specimen, but also assist in communications with neuroradiologists and referring clinicians.

Effects of Chemoradiotherapy on Tongue Function in Patients With Head and Neck Cancer

In this review article, the effects of radiotherapy ± chemotherapy on tissues and on oropharyngeal swallowing are reviewed. In addition, normal tongue function for swallowing is reviewed, as are the effects of tongue exercise programs designed to improve tongue strength and swallow functioning. Current literature on swallow exercise programs for head and neck cancer patients is provided. Also discussed are potential new avenues for research in this population.

Benign ulceration as a manifestation of soft tissue radiation necrosis: imaging findings

BACKGROUND AND PURPOSE

The purpose of this study was to review CT imaging findings of soft tissue mucosal ulceration in patients following radiation treatment for head and neck malignancies and to correlate these with patient outcomes.

MATERIALS AND METHODS

The CT examinations in 20 patients with soft tissue ulceration after radiation therapy for treatment of head and neck cancer were reviewed. External beam radiation therapy was completed between 3 and 61 months (mean, 11.5 months) before the initial diagnosis of soft tissue ulceration. In all 20 patients, the initial diagnosis was made or confirmed on CT examination.

RESULTS

Of the 20 ulcerations, 12 did not demonstrate enhancement, and the results of biopsy in 9 of these 12 were negative. Of the 12 nonenhancing ulcerations, biopsy was not performed in 3, but they have been followed clinically and radiologically for 15.7 months without evidence of recurrence. Of the 20 ulcerations, 8 demonstrated adjacent enhancement, and the results of a biopsy in 4 were positive for recurrent cancer and negative in 2; these 2 have been followed for 16.3 months without evidence of recurrence. Biopsy was not performed in 2 ulcerations, but they have been followed for 15.0 months without evidence of recurrence.

CONCLUSION

For soft tissue ulceration occurring after radiation treatment, if there is no enhancement or clinical evidence of recurrence, it is likely benign and follow-up without biopsy seems warranted. If the ulceration is associated with adjacent enhancement, then differentiation between radiation necrosis and recurrent tumor is difficult. In these cases, correlation with clinical examination with close interval follow-up is necessary if a biopsy is not performed.

Effects of radiotherapy with or without chemotherapy on tongue strength and swallowing in patients with oral cancer

BACKGROUND

Oral tongue strength and swallowing ability are reduced in patients treated with chemoradiotherapy for oral and oropharyngeal cancer.

METHODS

Patients with oral or oropharyngeal cancer treated with high-dose chemoradiotherapy underwent tongue strength, swallowing, and dietary assessments at pretreatment and 1, 3, 6, and 12 months posttreatment. Tongue strength was assessed using the Iowa Oral Performance Instrument (IOPI). Oral and pharyngeal residue was evaluated utilizing videofluoroscopy.

RESULTS

Mean maximum tongue strength dropped a nonsignificant amount immediately after treatment, and then increased significantly at 6- and 12-months posttreatment completion. Analyses were adjusted for patient dropout. Tongue strength was not significantly correlated with swallow observations of percentage oral and pharyngeal residue. Ability to eat various diet consistencies was reduced after treatment but improved over time at a rate similar to changes in oral intake and type of diet.

CONCLUSIONS

Parallel but not significant changes in oral intake, diet, and tongue strength in the first year post chemoradiation therapy need further study in a larger population.

Evaluation and management of oropharyngeal Dysphagia in head and neck cancer

BACKGROUND

Dysphagia is a common symptom of head and neck cancer or sequelae of its management. Swallowing disorders related to head and neck cancer are often predictable, depending on the structures or treatment modality involved. Dysphagia can profoundly affect posttreatment recovery as it may contribute to aspiration pneumonia, dehydration, malnutrition, poor wound healing, and reduced tolerance to medical treatments.

METHODS

The author reviewed the normal anatomy and physiology of swallowing and contrasted it with the commonly identified swallowing deficits related to head and neck cancer management. Evaluation methods and treatment strategies that can be used to successfully manage the physical and psychosocial effects of dysphagia are also reviewed.

RESULTS

Evaluation of dysphagia by the speech pathologist can be achieved with instrumental and noninstrumental methods. Once accurate identification of the deficits is completed, a range of treatment strategies can be applied that may return patients to safe oral intake, improve nutritional status, and enhance quality of life.

CONCLUSIONS

To improve safety of oral intake, normalize nutritional status, reduce complications of cancer treatment and enhance quality of life, accurate identification of swallowing disorders and efficient management of dysphagia symptoms must be achieved in an interdisciplinary team environment.

Association of rectal toxicity with thermal dose parameters in treatment of locally advanced prostate cancer with radiation and hyperthermia

PURPOSE

Although hyperthermia has been used for more than two decades in the treatment of pelvic tumors, little is known about the potential impact of heat on rectal toxicity when combined with other treatment modalities. Because rectal toxicity is a concern with radiation and may be exacerbated by hyperthermia, definition of the association of thermal dose parameters with rectal toxicity is important. In this report, we correlate rectal toxicity with thermal dose parameters for patients treated with hyperthermia and radiation for prostate cancer.

METHODS AND MATERIALS

Thirty patients with T2b-T3b disease (1992 American Joint Committee On Cancer criteria) enrolled in a Phase II study of external beam radiation +/- androgen-suppressive therapy with two transrectal ultrasound hyperthermia treatments were assessed for rectal toxicity. Prostatic and anterior rectal wall temperatures were monitored for all treatments. Rectal wall temperatures were limited to 40 degrees C in 19 patients, 41 degrees C in 3 patients, and 42 degrees C in 8 patients. Logistic regression was used to estimate the log hazard of developing National Cancer Institute Common Toxicity Criteria Grade 2 toxicity based on temperature parameters. The following were calculated: hazard ratios, 95% confidence intervals, p values for statistical significance of each parameter, and proportion of variability explained for each parameter.

RESULTS

Gastrointestinal toxicity was limited to Grade 2. The rate of acute Grade 2 proctitis was greater for patients with an allowable rectal wall temperature of >40 degrees C. In this group, 7 of 11 patients experienced acute Grade 2 proctitis, as opposed to 3 of 19 patients in the group with rectal wall temperatures limited to 40 degrees C (p = 0.004). Preliminary assessment of long-term toxicity revealed no differences in toxicity. Hazard ratios for acute Grade 2 proctitis for allowable rectal wall temperature, average rectal wall Tmax, and average prostate Tmax were 9.33 (p = 0.01), 3.66 (p = 0.03), and 2.29 (p = 0.08), respectively. A model combining these three parameters explained 48.6% of the variability among groups.

CONCLUSION

Rectal toxicity correlates with maximum allowable rectal wall temperature, average rectal wall Tmax, and average prostate Tmax for patients undergoing transrectal ultrasound hyperthermia combined with radiation for treatment of advanced clinically localized prostate cancer. Further definition of this association of thermal dose parameters with rectal toxicity in treatment of pelvic malignancies with hyperthermia should advance the goal of delivering thermal therapy in an effective yet safe manner.

Swallowing and tongue function following treatment for oral and oropharyngeal cancer

This study examined tongue function and its relation to swallowing in 13 subjects with oral or oropharyngeal cancer treated with primary radiotherapy +/- chemotherapy and 13 age- and sex-matched control subjects. Measures of swallowing and tongue function were obtained using videofluoroscopy, pretreatment and 2 months posttreatment. Maximum isometric strength and endurance at 50% of maximum strength were obtained with the Iowa Oral Performance Instrument (IOPI). Control subjects were tested once. All subjects with head and neck cancer were evaluated pretreatment and 2 months posttreatment. No significant differences were found for the tongue function measures pre- and 2 months posttreatment in the group with head and neck cancer. Significantly higher tongue strength was observed in the control than in the group with head and neck cancer both pre- and posttreatment. No significant differences were found for the 2 groups for tongue endurance measures. Significant correlations of tongue strength and endurance and some swallow measures were found pre- and posttreatment for the group with head and neck cancer and for the control group. These correlations included oral and pharyngeal temporal swallow measures and oropharyngeal swallow efficiency. Pretreatment differences between the 2 groups in tongue strength were likely related to tumor bulk, pain, and soreness. Two-month posttreatment differences were likely related to radiation +/- chemotherapy changes to the oral and pharyngeal mucosa. This study provides support for the hypothesis that tongue strength plays a role in oropharyngeal swallowing, particularly related to the oral phase of the swallow.

Chronic malignant pain in cancer patients

Although the incidence of cancer and cancer-related deaths has declined in recent years, undertreatment of cancer-related pain continues to be a significant problem. By thoroughly assessing chronic malignant pain (CMP) as it relates to cancer and achieving a more complete understanding of the CMP syndromes experienced by cancer patients, psychiatrists and neurologists can formulate accurate diagnoses of patients' clinical pain syndromes and construct well-defined, individual management plans for each patient.

Hyperthermia, radiation carcinogenesis and the protective potential of vitamin A and N-acetylcysteine

The in vivo carcinogenic risk of hyperthermia, alone or in combination with irradiation, and the anti-carcinogenic potential of vitamin A and N-acetylcysteine (AcCys) were investigated. Starting 1 month before treatment, 160 rats were divided into four diet groups: no additives, vitamin A-enriched diet, AcCys and the combination vitamin A + AcCys. In 10 animals per diet group, the hind leg was treated with either X-irradiation alone (16 Gy), hyperthermia alone (60 min at 43 degrees C), hyperthermia 5 h prior to irradiation or hyperthermia 5 h after irradiation. Animals were observed for 2 years after treatment with regard to the development of tumours either inside or outside the treated volume. After 16 Gy alone 12 +/- 5% of the animals developed a tumour. Tumour incidence increased to 37 +/- 9% (borderline significance P = 0.07 versus treatment with X-rays alone) when hyperthermia was applied prior to X-rays, and to 24 +/- 8% (NS) with hyperthermia after irradiation. The relative risk ratio (RRR) for tumour induction was increased to 2.4 by hyperthermia if combined with X-irradiation. Pathological characterization of induced tumours showed that these were of the fibrosarcoma, osteosarcoma and carcinoma type. Vitamin A alone or in combination with AcCys slightly protected against the induction of tumours by X-rays without or with hyperthermia (RRR of 0.4). However, morphological changes such as lipid accumulation in hepatocytes and damage to the parenchyma were noticed in livers from all animals that were given a vitamin-A-enriched diet (P < 0.0001). Data from the present and past reports show that hyperthermia alone is not carcinogenic, but that it may increase radiation carcinogenesis. Treatment temperature and time of exposure to heat in addition to the radiation dose applied are important factors in the carcinogenic process. The enhancement of radiation carcinogenesis seems to occur independently of the sequence and time interval between irradiation and hyperthermia. However, not all data are consistent with this interpretation.

Randomised trial of hyperthermia as adjuvant to radiotherapy for recurrent or metastatic malignant melanoma. European Society for Hyperthermic Oncology

The value of hyperthermia as an adjuvant to radiotherapy in patients with malignant melanoma was studied in a European multicentre trial. 134 metastatic or recurrent lesions of malignant melanoma in 70 patients were randomly assigned to receive radiotherapy (three fractions of 8 Gy or 9 Gy in 8 days) alone or followed by hyperthermia (43 degrees C for 60 min). Overall, the 2-year actuarial local tumour control was 37 (SE 5)%. Univariate analysis showed a beneficial effect of hyperthermia (radiation alone 28% vs combined treatment 46%, p = 0.008) and radiation dose (24 Gy 25% vs 27 Gy 56%, p = 0.02), but no effect of tumour size (< or = 4 cm 42% vs > 4 cm 29%, p = 0.21). Cox multivariate regression analysis showed the most important prognostic variables to be hyperthermia (odds ratio for 2-year local control 1.73 [95% CI 1.07-2.78], p = 0.023), tumour size (0.91 [0.85-0.99], p = 0.05), and radiation dose (1.17 [1.01-1.36], p = 0.05). Addition of heat did not significantly increase acute or late radiation reactions. Heating was well tolerated, but because of difficulties with equipment only 14% of treatments achieved the protocol objective. The overall 5-year survival rate was 19%, but 38% of the patients for whom all known disease was controlled survived 5 years. Adjuvant hyperthermia significantly improved local tumour control when applied in association with radiation in treatment of malignant melanoma. Successful local treatment of patients with a single or a few metastatic malignant melanoma lesions has significant curative potential.

Hyperthermia and radiation therapy for inoperable or recurrent parotid carcinoma. A phase I/II study

BACKGROUND

The treatment of advanced, inoperable, or recurrent parotid tumors represents a clinical challenge. The results obtained with conventional radiotherapy are disappointing. To improve the early response and local control of parotid tumors, local microwave hyperthermia was used in combination with ionizing radiation in a biinstitutional Phase I/II study.

METHODS

From 1984 to 1991, 13 patients (20 lesions) with advanced (10 lesions) or recurrent (10 lesions) parotid tumors (15 primaries and the remaining 5 nodal metastases), were treated with 300-915 MHz of external hyperthermia after external irradiation. Heat was applied twice weekly at a minimum desired temperature of 42.0 degrees C for 30 minutes at steady state. Ionizing radiation was delivered using photon, electron, or mixed electron-photon beams; the prescribed total dose was 70 Gy and 30 Gy for untreated and previously treated lesions, respectively; the median computed total dose was 66 Gy for previously untreated patients (range, 56-70 Gy) and 30 Gy for previously irradiated patients (range, 28-32 Gy).

RESULTS

Acute side effects were limited. Major acute toxicities included three patients (15%) with superficial necrosis, two of three who healed spontaneously in 4 and 6 months. Clinical response evaluated during the third month after the completion of therapy found that 16/20 patients (80%) had a complete response (CR), and 4 (20%) had a partial response. Four out of 16 patients who had CRs (20%) had a local recurrence, resulting in an actuarial local control at 5 years of 62.3 +/- 13.2%.

CONCLUSIONS

The combined treatment of local microwave hyperthermia and ionizing radiation proved to be feasible and moderately toxic for patients with advanced, inoperable, or recurrent parotid tumors. Even if clinical result evaluation was not the study endpoint, early response, and 5-year local control rates were encouraging.