Improvement in quality of life in patients with nasopharyngeal carcinoma treated with non-invasive extracorporeal radiofrequency in combination with chemoradiotherapy

A Review of the Current Clinical Evidence for Loco-Regional Moderate Hyperthermia in the Adjunct Management of Cancers

Regional hyperthermia therapy (RHT) is a treatment that applies moderate heat to tumours in an attempt to potentiate the effects of oncological treatments and improve responses. Although it has been used for many years, the mechanisms of action are not fully understood. Heterogenous practices, poor quality assurance, conflicting clinical evidence and lack of familiarity have hindered its use. Despite this, several centres recognise its potential and have adopted it in their standard treatment protocols. In recent times, significant technical improvements have been made and there is an increasing pool of evidence that could revolutionise its use. Our narrative review aims to summarise the recently published prospective trial evidence and present the clinical effects of RHT when added to standard cancer treatments. In total, 31 studies with higher-quality evidence across various subsites are discussed herein. Although not all of these studies are level 1 evidence, benefits of moderate RHT in improving local tumour control, survival outcomes and quality of life scores were observed across the different cancer subsites with minimal increase in toxicities. This paper may serve as a reference when considering this technique for specific indications.

Chemoradiotherapy with hyperthermia versus chemoradiotherapy alone in locally advanced cervical cancer: a systematic review and meta-analysis

PURPOSE

Concurrent chemoradiotherapy (CCRT) is recommended as the standard treatment for locally advanced cervical cancer (LACC). However, the synergistic effect of hyperthermia (HT) with CCRT remains unclear. Therefore, we performed a meta-analysis to evaluate the effect of HT with CCRT on LACC patients.

METHODS AND MATERIALS

A systematic literature search was conducted on the MEDLINE, PubMed, Embase, Cochrane library and SCOPUS databases for articles that compared CCRT with HT and CCRT alone as treatments for LACC. Hazard ratios (HRs) and risk ratios (RRs) were used to compare five-year overall survival (OS), local relapse-free survival (LRFS) and incidence of acute and chronic toxicity between the two treatments.

RESULTS

Two articles out of 2860 were finally selected for analysis. A total of 536 patients were evaluated (CCRT with HT group: 268, CCRT group: 268). FIGO stages I-II and III-IV were found in 295 (55.0%) and 241 patients (45.0%), respectively. The CCRT with HT group had significantly better five-year OS than the CCRT group (HR 0.67, 95% confidence interval [CI] 0.47-0.96, p = 0.03). LRFS of patients was superior in the CCRT with HT group than in the CCRT group, but without significance (HR 0.74, 95% CI 0.49-1.12; p = 0.16). Moreover, there was no difference between the two groups regarding acute and chronic toxicity.

CONCLUSION

This systematic review and meta-analysis showed that CCRT with HT significantly improved OS in LACC patients without increasing acute and chronic toxicity. Therefore, tri-modality treatment could be a feasible approach for patients with LACC.

A Narrative Review of Regional Hyperthermia: Updates From 2010 to 2019

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.

Prognostic factors associated with a restricted mouth opening (trismus) in patients with head and neck cancer: Systematic review

Background

To prescribe early trismus therapy, prognostic factors influencing the restricted mouth opening should be identified first. Our aim is to present an overview of these factors in patients with head and neck cancer.

Methods

PubMed, Cochrane, EMBASE, and CINAHL were searched using terms related to head and neck cancer and mouth opening. Risk of bias was assessed using the “Quality in Prognosis Studies” tool. A best evidence synthesis was performed.

Results

Of the identified 1418 studies, 53 were included. Three studies contained a prognostic multivariate model for a restricted mouth opening.

Conclusions

Patients with head and neck cancer will most likely develop a restricted mouth opening when they have a large tumor near the masticatory muscles that requires extensive cancer treatment. A restricted mouth opening most likely occurs within 6 months after cancer treatment. Further research is necessary on factors related to healing tendency or pain intensity.

Recent technological advancements in radiofrequency- andmicrowave-mediated hyperthermia for enhancing drug delivery

Hyperthermia therapy is a potent enhancer of chemotherapy and radiotherapy. In particular, microwave (MW) and radiofrequency (RF) hyperthermia devices provide a variety of heating approaches that can treat most cancers regardless the size. This review introduces the physics of MW/RF hyperthermia, the current state-of-the-art systems for both localized and regional heating, and recent advancements in hyperthermia treatment guidance using real-time computational simulations and magnetic resonance thermometry. Clinical trials involving RF/MW hyperthermia as adjuvant for chemotherapy are also presented per anatomical site. These studies favor the use of adjuvant hyperthermia since it significantly improves curative and palliative clinical outcomes. The main challenge of hyperthermia is the distribution of state-of-the-art heating systems. Nevertheless, we anticipate that recent technology advances will expand the use of hyperthermia to chemotherapy centers for enhanced drug delivery. These new technologies hold great promise not only for (image-guided) perfusion modulation and sensitization for cytotoxic drugs, but also for local delivery of various compounds using thermosensitive liposomes.

Endoscopic surgery for early-stage nasopharyngeal carcinoma: a justified initial option

OBJECTIVES

To assess the prognosis of initial endoscopic surgery in T1N0M0 and T2N0M0 staged NPC patients.

MATERIALS AND METHODS

Between 2002 and 2016, 10 previously untreated patients with T1N0M0 or T2N0M0 staged NPC volunteered to receive endoscopic surgery followed by four courses of TPF chemotherapy. EORTC QLQ-C30 and QLQ-H&N35 were used to evaluate the QOL after treatment.

RESULTS

With the median follow-up of 30 months (range, 9 months to 128 months), the 24-month survival rate was 100% (6/6), 90% (9/10) patients were still alive and well, 20% (2/10) patients reported tumor recurrence. One died of the disease at 128 months with nasopharyngeal recurrence. Another patient who refused preoperative PET-CT had a cervical recurrence at nine months, accepted nasopharynx and neck radiation two months later and was still alive and well at 50 months. In the post-treatment questionnaires, several NPC-specific (pain, swallowing, speech, social eating, opening mouth, dry mouth, sticky saliva) QOL domains were better preserved compared with radiotherapy alone or combined chemoradiotherapy in other surveys.

CONCLUSIONS

Initial endoscopic surgery combined with chemotherapy maybe justified in the hands of highly experienced surgeon in selected early-stage NPC cases and can improve their QOL. In addition, preoperative PET-CT should be included in case of possible minimal metastases.

Integrating Hyperthermia into Modern Radiation Oncology: What Evidence Is Necessary?

Hyperthermia (HT) is one of the hot topics that have been discussed over decades. However, it never made its way into primetime. The basic biological rationale of heat to enhance the effect of radiation, chemotherapeutic agents, and immunotherapy is evident. Preclinical work has confirmed this effect. HT may trigger changes in perfusion and oxygenation as well as inhibition of DNA repair mechanisms. Moreover, there is evidence for immune stimulation and the induction of systemic immune responses. Despite the increasing number of solid clinical studies, only few centers have included this adjuvant treatment into their repertoire. Over the years, abundant prospective and randomized clinical data have emerged demonstrating a clear benefit of combined HT and radiotherapy for multiple entities such as superficial breast cancer recurrences, cervix carcinoma, or cancers of the head and neck. Regarding less investigated indications, the existing data are promising and more clinical trials are currently recruiting patients. How do we proceed from here? Preclinical evidence is present. Multiple indications benefit from additional HT in the clinical setting. This article summarizes the present evidence and develops ideas for future research.

Status quo and directions in deep head and neck hyperthermia

The benefit of hyperthermia as a potent modifier of radiotherapy has been well established and more recently also the combination with chemotherapy was shown beneficial. Also for head and neck cancer, the impact of hyperthermia has been clinically demonstrated by a number of clinical trials. Unfortunately, the technology applied in these studies provided only limited thermal dose control, and the devices used only allowed treatment of target regions close to the skin. Over the last decade, we developed the technology for deep and controlled hyperthermia that allows treatment of the entire head and neck region. Our strategy involves focused microwave heating combined with 3D patient-specific electromagnetic and thermal simulations for conformal, reproducible and adaptive hyperthermia application. Validation of our strategy has been performed by 3D thermal dose assessment based on invasively placed temperature sensors combined with the 3D patient specific simulations. In this paper, we review the phase III clinical evidence for hyperthermia in head and neck tumors, as well as the heating and dosimetry technology applied in these studies. Next, we describe the development, clinical implementation and validation of 3D guided deep hyperthermia with the HYPERcollar, and its second generation, i.e. the HYPERcollar3D. Lastly, we discuss early clinical results and provide an outlook for this technology.

Local hyperthermia combined with radiotherapy and-/or chemotherapy: recent advances and promises for the future

Hyperthermia, one of the oldest forms of cancer treatment involves selective heating of tumor tissues to temperatures ranging between 39 and 45°C. Recent developments based on the thermoradiobiological rationale of hyperthermia indicate it to be a potent radio- and chemosensitizer. This has been further corroborated through positive clinical outcomes in various tumor sites using thermoradiotherapy or thermoradiochemotherapy approaches. Moreover, being devoid of any additional significant toxicity, hyperthermia has been safely used with low or moderate doses of reirradiation for retreatment of previously treated and recurrent tumors, resulting in significant tumor regression. Recent in vitro and in vivo studies also indicate a unique immunomodulating prospect of hyperthermia, especially when combined with radiotherapy. In addition, the technological advances over the last decade both in hardware and software have led to potent and even safer loco-regional hyperthermia treatment delivery, thermal treatment planning, thermal dose monitoring through noninvasive thermometry and online adaptive temperature modulation. The review summarizes the outcomes from various clinical studies (both randomized and nonrandomized) where hyperthermia is used as a thermal sensitizer of radiotherapy and-/or chemotherapy in various solid tumors and presents an overview of the progresses in loco-regional hyperthermia. These recent developments, supported by positive clinical outcomes should merit hyperthermia to be incorporated in the therapeutic armamentarium as a safe and an effective addendum to the existing oncological treatment modalities.