Reirradiation and hyperthermia in rectal carcinoma: a retrospective study on palliative effect

Palliative management of patients with locally recurrent rectal cancer: Clinical presentation, treatment strategies, and overall survival

INTRODUCTION

Locally recurrent rectal cancer (LRRC) occurs in 6-12 % of the patients after curative treatment for primary rectal cancer. Palliative treatment plays a critical role, as over half of the patients are ineligible for curative treatment. However, data on patients treated with palliative intent is limited. This study aims to evaluate palliative treatment strategies and overall survival (OS) in LRRC patients.

METHODS

We retrospectively included all LRRC discussed at the multidisciplinary team in a tertiary referral center, between May 2018 and June 2023. Patients treated with palliative intent were categorized as palliative due to locally unresectable disease, metastatic disease, frailty, or patient preference. Outcomes were OS, treatment response, duration of treatment effect, and hospital admissions. Local control was defined as response or stable disease on imaging.

RESULTS

Out of 188 patients, 58 (30.9 %) were treated with palliative intent. Palliative treatments included systemic therapy, chemoradiotherapy and radiotherapy. The median OS for patients treated with palliative intent was 22 months. 3-year OS was 27.1 %, compared to 73.1 % for curative intent patients. Patients with locally unresectable disease had a significantly better OS compared to patients with distant metastases (31 versus 12 months). Local control was achieved in 53.3 % of patients after any palliative treatment, with a median effect duration of 9 months. Chemoradiotherapy was associated with best results for local control.

CONCLUSION

LRRC patients treated with palliative intent can experience substantial survival, particularly those with unresectable disease. Local control due to palliative treatment is feasible, possibly improving survival. Individualized palliative treatment is crucial.

Combined Hyperthermia and Re-Irradiation in Non-Breast Cancer Patients: A Systematic Review

PURPOSE

This systematic literature review summarizes clinical studies and trials involving combined non-ablative hyperthermia and re-irradiation in locoregionally recurrent cancer except breast cancer.

METHODS

One database and one registry, MEDLINE and clinicaltrials.gov, respectively, were searched for studies on combined non-ablative hyperthermia and re-irradiation in non-breast cancer patients. Extracted study characteristics included treatment modalities and re-irradiation dose concepts. Outcomes of interest were tumor response, survival measures, toxicity data and palliation. Within-study bias assessment included the identification of conflict of interest (COI). The final search was performed on 29 August 2022.

RESULTS

Twenty-three articles were included in the final analysis, reporting on 603 patients with eight major tumor types. Twelve articles (52%) were retrospective studies. Only one randomized trial was identified. No COI statement was declared in 11 studies. Four of the remaining twelve studies exhibited significant COI. Low study and patient numbers, high heterogeneity in treatment modalities and endpoints, as well as significant within- and across-study bias impeded the synthesis of results.

CONCLUSION

Outside of locoregionally recurrent breast cancer, the role of combined moderate hyperthermia and re-irradiation can so far not be established. This review underscores the necessity for more clinical trials to generate higher levels of clinical evidence for combined re-irradiation and hyperthermia.

Practical effectiveness of re-irradiation with or without surgery for locoregional recurrence of rectal cancer: A meta-analysis and systematic review

BACKGROUND AND PURPOSE

Re-irradiation might yield local control (LC) or palliation for locoregionally recurrent rectal cancer (LRRC), but iatrogenic complications are a possible hindrance. We aimed to evaluate the efficacy of re-irradiation to determine optimal treatment of LRRC.

METHODS

We performed a systematic review of PubMed, MEDLINE, Cochrane Library, and Embase.

RESULTS

A total of 17 studies involving 744 patients with LRRC were included; median OS ranging from 10 to 45 months (median: 24.5 months). Pooled 1-, 2-, and 3-year OS rates for all patients were 76.1%, 49.1%, and 38.3%, respectively. For patients who underwent re-irradiation and surgery (OP group), these pooled rates were 85.9%, 71.8%, and 51.7%, respectively. For patients who underwent re-irradiation but not surgery (non-OP group), pooled 1-, 2-, and 3-year OS rates were 63.5%, 34.2%, and 23.8%, respectively. The OS difference between both groups was significant for all 3 years (P < 0.05). Pooled 1-, 2-, and 3-year LC rates for the OP group were 84.4%, 63.8%, and 46.9%, and for the non-OP group were 72.0%, 54.8%, and 44.6%, respectively, without significant differences. Pooled grade ≥3 acute and late complication rates were 11.7% and 25.5% in the OP and non-OP groups, respectively. Patients who underwent surgery had a higher risk of grade ≥3 late complications (odds ratio: 6.39). Pooled symptomatic palliation rate was 75.2%.

CONCLUSIONS

Re-irradiation with or without surgery for LRRC showed oncologic and palliative efficacy. Salvage treatment including re-irradiation and surgery showed higher survival, but the late complication was significantly increased with concomitant surgery.

Neoadjuvant Treatment Strategies: Advanced Radiation Alternatives

Long-course chemoradiation therapy (CRT) has been the standard approach for locally advanced rectal tumors. Neoadjuvant CRT is associated to improved local disease control, with less toxicity when compared with adjuvant CRT, as well as the chance for pathologic complete response. The CRT regimens have improved over the past years. This article will examine selected controversies, including novel chemoradiation regimens, duration of radiation (short vs. long course), and radiation techniques such as intensity-modulated radiation therapy (IMRT).

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.

Response to chemotherapy in patients with recurrent rectal cancer in previously irradiated area

BACKGROUND

Tumor lesions in previously irradiated area may have a less favorable response to chemotherapy compared to tumor sites outside the radiation field. The aim of the present study was to evaluate the response to chemotherapy of locally recurrent rectal cancer (LRRC) within the previous radiation field compared to the response of distant metastases outside the radiation field.

PATIENTS AND METHODS

All patients with LRRC referred between 2000 and 2012 to our tertiary university hospital were reviewed. The response to chemotherapy of LRRC within previously irradiated area was compared to the response of synchronous distant metastases outside the radiation field according to the Response Evaluation Criteria in Solid Tumors (RECIST).

RESULTS

Out of 363 cases with LRRC, 29 previously irradiated patients with distant metastases were treated with chemotherapy and eligible for analysis. Twenty-six patients (89 %) suffered a first recurrence and three patients (11 %) a second recurrence. These patients were followed with a median of 22 months (IQR, 9-40 months) and had a median survival of 33 months (IQR, 14-42). In 23 patients (79 %), the local recurrence showed stable disease, but the overall response rate of the local recurrences in the previously irradiated area was significantly lower than the response rate of distant metastases outside the radiation field (10 vs. 41 %,p = 0.034).

CONCLUSIONS

Previously irradiated patients with LRRC have a lower response rate to chemotherapy of the local recurrence within the radiation field compared to the response rate of distant metastases outside the radiation field. This suggests that chemotherapy for local palliation may not have the desired effect.

Hyperthermia improves immune function and radiotherapy efficacy in patients with recurrent colorectal cancer

AIM: To investigate the efficacy and safety of three-dimensional conformal radiotherapy combined with pelvic hyperthermia and their impact on the immune function in patients with recurrent colorectal cancer.

METHODS: Forty-six patients with recurrent colorectal cancer were divided into two groups in a chronological order. Patients in group A received three-dimensional conformal radiotherapy combined with pelvic hyperthermia, while patients in group B received three-dimensional conformal radiation therapy only. The efficacy, adverse reactions and the immune function were compared between the two groups.

RESULTS: The median local progression-free survival in group A was significantly longer than that in group B (16.3 mo vs 14.1 mo, P < 0.05). Compared with pre-treatment values, the percentages of CD3⁺ and CD4⁺ lymphocytes and CD4⁺/CD8⁺ ratio in group A increased significantly (CD3⁺: 65.40% ± 6.18% vs 56.90% ± 6.16%; CD4⁺: 32.70% ± 6.37% vs 28.30% ± 6.33%; CD4⁺/CD8⁺ ratio: 1.24 ± 0.23 vs 0.96 ± 0.28, P < 0.05 for all), while there were no significant changes in these indicators in group B. In both groups, adverse reactions, mainly acute rectal radiation reactions, could be tolerated. There were no significant differences in partial remission rate, one- and two-year survival rates between the two groups.

CONCLUSION: Compared with three-dimensional conformal radiotherapy alone, three-dimensional conformal radiotherapy combined with pelvic hyperthermia can prolong median local progression-free survival and improve immune function in patients with recurrent colorectal cancer, and is well tolerated.

Re-irradiation: outcome, cumulative dose and toxicity in patients retreated with stereotactic radiotherapy in the abdominal or pelvic region

The purpose of the present study was to explore the outcome, cumulative dose in tumor and organs at risk and toxicity after extra-cranial stereotactic re-irradiation. Twenty-seven patients were evaluated who had been re-irradiated with stereotactic body radiotherapy (SBRT) after conventional radiotherapy (CRT). The dose summation of the SBRT and CRT plans was done by dose point calculations accounting for fraction size by the linear-quadratic model. Efficacy and toxicity was scored by looking at the reduction in tumor size, pain and bleeding. Symptomatic response was observed in 96% of the patients. The median maximum SBRT dose to the tumor was 90 Gy₃ (range: 42-420 Gy₃). The median cumulative dose for the rectum, bowel and bladder resulted in 104 Gy₃, 98 Gy₃ and 113 Gy₃, respectively. No grades 5, 4 and 3 acute and late toxicity was observed. In conclusion: re-irradiation to the same region using extra-cranial stereotactic radiotherapy is feasible and resulted in a 96% symptomatic response with low toxicity.

Multimodal approaches including three-dimensional conformal re-irradiation for recurrent or persistent esophageal cancer: preliminary results

The purpose of this study was to assess the toxicity and efficacy of multimodal approaches, including three-dimensional conformal re-irradiation, for patients with recurrent or persistent esophageal cancer after radiotherapy. Thirty-one patients with esophageal cancer treated with three-dimensional conformal re-irradiation were retrospectively analyzed. Of the 31 patients, 27 patients received concurrent chemotherapy, and 14 patients underwent regional hyperthermia during the re-irradiation. We divided the patients into two groups on the basis of their clinical condition: the curative group (n = 11) or the palliative group (n = 20). Severe toxicities were detected in one patient with Grade 3 esophageal perforation in the curative group, and 5 patients had a Grade 3 or higher toxicity of the esophagus in the palliative group. Advanced T stage at the time of re-irradiation was found to be significantly correlated with Grade 3 or higher toxicity in the esophagus. For the curative group, 10 (91%) of 11 patients had an objective response. For the palliative group, symptom relief was recognized in 8 (57%) of 14 patients with obvious swallowing difficulty. In conclusion, in the curative group with early-stage recurrent or persistent esophageal cancer, the multimodal approaches, including three-dimensional conformal re-irradiation, may be feasible, showing acceptable toxicity and a potential value of promising results, although further evaluations especially for the toxicities of the organs at risk are required. In the palliative group, the benefit of our therapy may be restrictive because severe esophageal toxicities were not uncommon in the patients with advanced T stage at the time of re-irradiation.

Robotic image-guided reirradiation of lateral pelvic recurrences: preliminary results

Background

The first-line treatment of a pelvic recurrence in a previously irradiated area is surgery. Unfortunately, few patients are deemed operable, often due to the location of the recurrence, usually too close to the iliac vessels, or the associated surgical morbidity. The objective of this study is to test the viability of robotic image-guided radiotherapy as an alternative treatment in inoperable cases.

Methods

Sixteen patients previously treated with radiotherapy were reirradiated with CyberKnife^® for lateral pelvic lesions. Recurrences of primary rectal cancer (4 patients), anal canal (6), uterine cervix cancer (4), endometrial cancer (1), and bladder carcinoma (1) were treated. The median dose of the previous treatment was 45 Gy (EqD2 range: 20 to 96 Gy). A total dose of 36 Gy in six fractions was delivered with the CyberKnife over three weeks. The responses were evaluated according to RECIST criteria.

Results

Median follow-up was 10.6 months (1.9 to 20.5 months). The actuarial local control rate was 51.4% at one year. Median disease-free survival was 8.3 months after CyberKnife treatment. The actuarial one-year survival rate was 46%. Acute tolerance was limited to digestive grade 1 and 2 toxicities.

Conclusions

Robotic stereotactic radiotherapy can offer a short and well-tolerated treatment for lateral pelvic recurrences in previously irradiated areas in patients otherwise not treatable. Efficacy and toxicity need to be evaluated over the long term, but initial results are encouraging.

Robotic image-guided reirradiation of lateral pelvic recurrences: preliminary results

BACKGROUND

The first-line treatment of a pelvic recurrence in a previously irradiated area is surgery. Unfortunately, few patients are deemed operable, often due to the location of the recurrence, usually too close to the iliac vessels, or the associated surgical morbidity. The objective of this study is to test the viability of robotic image-guided radiotherapy as an alternative treatment in inoperable cases.

METHODS

Sixteen patients previously treated with radiotherapy were reirradiated with CyberKnife® for lateral pelvic lesions. Recurrences of primary rectal cancer (4 patients), anal canal (6), uterine cervix cancer (4), endometrial cancer (1), and bladder carcinoma (1) were treated. The median dose of the previous treatment was 45 Gy (EqD2 range: 20 to 96 Gy). A total dose of 36 Gy in six fractions was delivered with the CyberKnife over three weeks. The responses were evaluated according to RECIST criteria.

RESULTS

Median follow-up was 10.6 months (1.9 to 20.5 months). The actuarial local control rate was 51.4% at one year. Median disease-free survival was 8.3 months after CyberKnife treatment. The actuarial one-year survival rate was 46%. Acute tolerance was limited to digestive grade 1 and 2 toxicities.

CONCLUSIONS

Robotic stereotactic radiotherapy can offer a short and well-tolerated treatment for lateral pelvic recurrences in previously irradiated areas in patients otherwise not treatable. Efficacy and toxicity need to be evaluated over the long term, but initial results are encouraging.

Second re-irradiation: efficacy, dose and toxicity in patients who received three courses of radiotherapy with overlapping fields

PURPOSE

To explore the outcome, cumulative dose and toxicity in 23 patients after a third radiation treatment, with a partial or complete overlap of the previous two irradiated regions.

METHODS AND MATERIAL

The dose summation of the three radiation plans was made by the planning system. For patients treated with cyberknife or brachytherapy dose summation was done by dose point calculations. Efficacy and toxicity was scored by looking at the reduction of tumor, pain and bleeding.

RESULTS

Symptomatic response was observed in 81% and 73% of the patients after, respectively, the third and second radiation. The median cumulative maximum dose to the tumor and its regions was 133Gy(3) (range: 82-496Gy(3)). The median corrected cumulative dose for the rectum, bowel and bladder resulted in 91Gy(3), 73Gy(3) and 79Gy(3), respectively. Grade 3 acute skin toxicity was only seen in the third radiation course.

CONCLUSION

The constraints of 100Gy(3) for rectum, 90Gy(3) for bowel and 110Gy(3) for bladder are safe and can be used as guidelines in the decision for re-irradiation. Symptomatic relieve was seen in 81% of the patients with low grade 3 and no grade 4 acute and late toxicity.

Application of hyperthermia in addition to ionizing irradiation fosters necrotic cell death and HMGB1 release of colorectal tumor cells

Colorectal cancer is the second leading cause of death in developed countries. Tumor therapies should on the one hand aim to stop the proliferation of tumor cells and to kill them, and on the other hand stimulate a specific immune response against residual cancer cells. Dying cells are modulators of the immune system contributing to anti-inflammatory or pro-inflammatory responses, depending on the respective cell death form. The positive therapeutic effects of temperature-controlled hyperthermia (HT), when combined with ionizing irradiation (X-ray), were the origin to examine whether combinations of X-ray with HT can induce immune activating tumor cell death forms, also characterized by the release of the danger signal HMGB1. Human colorectal tumor cells with differing radiosensitivities were treated with combinations of HT (41.5 degrees C for 1h) and X-ray (5 or 10Gy). Necrotic cell death was prominent after X-ray and could be further increased by HT. Apoptosis remained quite low in HCT 15 and SW480 cells. X-ray and combinations with HT arrested the tumor cells in the radiosensitive G2 cell cycle phase. The amount of released HMGB1 protein was significantly enhanced after combinatorial treatments in comparison to single ones. We conclude that combining X-ray with HT may induce anti-tumor immunity as a result of the predominant induction of inflammatory necrotic tumor cells and the release of HMGB1.

[Therapy of locally recurrent rectal carcinoma]

During the last decade no gastrointestinal tumor underwent such profound modifications in diagnostics and therapy as rectal cancer (total mesorectal excision, multimodal therapy). Despite all efforts and continuous improvements in the results of oncological treatment, local recurrence of rectal carcinoma is still a considerable problem. Optimized surgery methods and multimodal therapies allow a local recurrence rate lowered to about 6%. Without surgical intervention the 5-year survival rate after local recurrence is approximately 4%, and the median survival time in a palliative situation is about 13 months and often associated with considerable restriction of quality of life. Morbidity after complex pelvic surgery is still high, but its mortality rate in highly professional surgical centers has reached an acceptable level of about 6%. Surgical oncology today has the ability for remarkable improvement in the prognosis of locally recurrent rectal cancer. After R0 resection the 5-year survival rate is nearly 30%.

Reirradiation, surgery and IORT for recurrent rectal cancer in previously irradiated patients

A total of 11 patients with recurrent rectal cancer who had been previously irradiated were treated with preoperative reirradiation (median dose 30Gy), surgery and IORT. This treatment was related with high morbidity, a short pain-free survival (5 months) and poor local control (27% after 3 years), although some patients have long-term distant control and survival.

Prognostic Factors Affecting Locally Recurrent Rectal Cancer and Clinical Significance of Hemoglobin

PURPOSE

To investigate potential prognostic factors, including hemoglobin levels before and during radiotherapy, for associations with survival and local control in patients with unirradiated locally recurrent rectal cancer.

PATIENTS AND METHODS

Ten potential prognostic factors were investigated in 94 patients receiving radiotherapy for recurrent rectal cancer: age (<or=68 vs. >or=69 years), gender, Eastern Cooperative Oncology Group performance status (0-1 vs. 2-3), American Joint Committee on Cancer (AJCC) stage (<or=II vs. III vs. IV), grading (G1-2 vs. G3), surgery, administration of chemotherapy, radiation dose (equivalent dose in 2-Gy fractions: <or=50 vs. >50 Gy), and hemoglobin levels before (<12 vs. >or=12 g/dL) and during (majority of levels: <12 vs. >or=12 g/dL) radiotherapy. Multivariate analyses were performed, including hemoglobin levels, either before or during radiotherapy (not both) because these are confounding variables.

RESULTS

Improved survival was associated with better performance status (p<0.001), lower AJCC stage (p=0.023), surgery (p=0.011), chemotherapy (p=0.003), and hemoglobin levels>or=12 g/dL both before (p=0.031) and during (p<0.001) radiotherapy. On multivariate analyses, performance status, AJCC stage, and hemoglobin levels during radiotherapy maintained significance. Improved local control was associated with better performance status (p=0.040), lower AJCC stage (p=0.010), lower grading (p=0.012), surgery (p<0.001), chemotherapy (p<0.001), and hemoglobin levels>or=12 g/dL before (p<0.001) and during (p<0.001) radiotherapy. On multivariate analyses, chemotherapy, grading, and hemoglobin levels before and during radiotherapy remained significant. Subgroup analyses of the patients having surgery demonstrated the extent of resection to be significantly associated with local control (p=0.011) but not with survival (p=0.45).

CONCLUSION

Predictors for outcome in patients who received radiotherapy for locally recurrent rectal cancer were performance status, AJCC stage, chemotherapy, surgery, extent of resection, histologic grading, and hemoglobin levels both before and during radiotherapy.

Radiotherapy with 8 MHz radiofrequency-capacitive regional hyperthermia for pain relief of unresectable and recurrent colorectal cancer

PURPOSE

The purpose of this study was to assess the pain relief in patients with unresectable and recurrent colorectal cancer treated with radiation plus 8 MHz radiofrequency-capacitive regional hyperthermia and to identify predictors of the good outcome.

METHODS

Between February 1986-May 2003, 41 patients with primarily unresectable and recurrent colorectal cancer that caused pain were treated with thermoradiotherapy at the hospital and retrospectively analysed. Radiotherapy was administered with a mean total radiation dose of 56 Gy. Hyperthermia was usually applied within 30 min after radiotherapy once or twice a week. For cooling of the skin surface, the overlay boluses were applied in addition to regular boluses. The external cooling unit has been used to reinforce the cooling ability of the overlay bolus and achieve strong surface cooling to reduce the preferential heating of the subcutaneous fat tissue and treat with more RF-output in 17 patients since January 1997.

RESULTS

Pain relief was obtained in 83% of the patients. Multi-variate analysis by logistic regression to evaluate the effects of certain factors on pain relief (complete response + good response) was strongly correlated with the presence of radiating pain to leg(s) (p < 0.05). The median follow-up was 18 months. The median duration of pain relief was 7.0 months. For the 27 patients in whom the tumour temperature was estimated, the median duration of pain relief was 14.6 months for the patients with a mean average tumour temperature of > 42.5 degrees C and 5.7 months for those of < 42.5 degrees C (p < 0.05). In the 18 patients with radiating pain to leg(s), use of strong superficial cooling and the higher numbers of hyperthermia treatments were better prognostic factors for the duration of pain relief (p < 0.01 and p < 0.05, respectively).

CONCLUSIONS

Radiotherapy with 8 MHz radiofrequency-capacitive regional hyperthermia provided an efficient, effective means on pain relief of treating unresectable and recurrent colorectal cancer. The duration of pain relief can be prolonged, if an adequate heating is achieved, especially in the patients with radiating pain to the leg(s).

Noninvasive magnetic resonance thermography of soft tissue sarcomas during regional hyperthermia

BACKGROUND

The objective of this study was to evaluate noninvasive magnetic resonance (MR) thermography for the monitoring of regional hyperthermia (RHT) in patients with soft tissue sarcomas of the lower extremities and pelvis.

METHODS

Noninvasive MR monitoring during RHT was performed in 9 patients who had high-risk soft tissue sarcomas of the lower extremities or pelvis during neoadjuvant chemotherapy plus RHT in the scope of the European Organization for Research and Treatment of Cancer 62961/European Society for Hyperthermic Oncology RHT-95 study. Anatomic and temperature-sensitive data sets were acquired every 10 minutes before and during RHT (using gradient-echo-sequences with variable echo times). MR temperature distributions were derived from the phase differences by using the proton-resonance frequency shift method. A phase convolution setting phase shifts to zero in the fat tissue was performed as a drift correction. The mean MR temperatures in the tumor and muscles and the index temperatures (e.g., T90, which covers 90% of the target volume) and thermal doses were determined and compared with pathohistologic responses and direct temperature measurements if available.

RESULTS

Thirty of 72 MR-thermography data sets (>40% of heat sessions) were evaluable. A significant correlation was observed between pathohistologic response (defined as a necrosis rate >or=90%) and standardized thermal parameters, such as thermal dose cumulative equivalent minutes at 43 degrees C to 90% of the target volume (T90) (P = .050), mean T90 (P = .048), or T50 (P = .050). The correlation of 13 conventional temperature measurements performed in selected patients and sessions invasively in the tumor or noninvasively in rectum and bladder revealed an excellent correlation with MR temperatures (R2 = .96).

CONCLUSIONS

Noninvasive MR thermography of soft tissue sarcoma was feasible and suitable for validating the quality of heating during RHT.