Patients with Advanced Pancreatic Cancer Treated with Mistletoe and Hyperthermia in Addition to Palliative Chemotherapy: A Retrospective Single-Center Analysis

This retrospective analysis investigated the influence of integrative therapies in addition to palliative chemotherapy in patients with advanced pancreatic cancer, treated at a single institution specialized in integrative oncology between January 2015 and December 2019. In total, 206 consecutive patients were included in the study, whereof 142 patients (68.9%) received palliative chemotherapy (gemcitabine/nab-paclitaxel 33.8%; FOLFIRINOX 35.9%; gemcitabine 30.3%) while the remainder were treated with best supportive and integrative care. Integrative therapies were used in 117 of 142 patients (82.4%) in addition to conventional chemotherapy, whereby mistletoe was used in 117 patients (82.4%) and hyperthermia in 74 patients (52.1%). A total of 107/142 patients (86.3%) died during the observation period, whereby survival times differed significantly depending on the additional use of integrative mistletoe or hyperthermia: chemotherapy alone 8.6 months (95% CI 4.7-15.4), chemotherapy and only mistletoe therapy 11.2 months (95% CI 7.1-14.2), or a combination of chemotherapy with mistletoe and hyperthermia 18.9 months (95% CI 15.2-24.5). While the survival times observed for patients with advanced pancreatic cancer receiving chemotherapy alone are consistent with pivotal phase-III studies and German registry data, we found significantly improved survival using additional mistletoe and/or hyperthermia.

Tumor Necrosis Factor Alpha: Implications of Anesthesia on Cancers

Cancer remains a major public health issue and a leading cause of death worldwide. Despite advancements in chemotherapy, radiation therapy, and immunotherapy, surgery is the mainstay of cancer treatment for solid tumors. However, tumor cells are known to disseminate into the vascular and lymphatic systems during surgical manipulation. Additionally, surgery-induced stress responses can produce an immunosuppressive environment that is favorable for cancer relapse. Up to 90% of cancer-related deaths are the result of metastatic disease after surgical resection. Emerging evidence shows that the interactions between tumor cells and the tumor microenvironment (TME) not only play decisive roles in tumor initiation, progression, and metastasis but also have profound effects on therapeutic efficacy. Tumor necrosis factor alpha (TNF-α), a pleiotropic cytokine contributing to both physiological and pathological processes, is one of the main mediators of inflammation-associated carcinogenesis in the TME. Because TNF-α signaling may modulate the course of cancer, it can be therapeutically targeted to ameliorate clinical outcomes. As the incidence of cancer continues to grow, approximately 80% of cancer patients require anesthesia during cancer care for diagnostic, therapeutic, or palliative procedures, and over 60% of cancer patients receive anesthesia for primary surgical resection. Numerous studies have demonstrated that perioperative management, including surgical manipulation, anesthetics/analgesics, and other supportive care, may alter the TME and cancer progression by affecting inflammatory or immune responses during cancer surgery, but the literature about the impact of anesthesia on the TNF-α production and cancer progression is limited. Therefore, this review summarizes the current knowledge of the implications of anesthesia on cancers from the insights of TNF-α release and provides future anesthetic strategies for improving oncological survival.

Systematic review about complementary medical hyperthermia in oncology

Hyperthermia is a generic term for different techniques using heat in cancer therapies. Temperatures of about 42° Celsius in combination with chemo- or radiotherapy may improve the effectiveness of those treatments. Clinical benefit is shown in “standard hyperthermia” with tumour temperatures assessed during treatment. This systematic review thoroughly assesses the state of evidence concerning the benefits and side effects of electro hyperthermia or whole-body hyperthermia (“alternative hyperthermia”) in oncology. From 26 April 2021 to 09 May 2021, a systematic search was conducted searching five electronic databases (Embase, Cochrane, PsycINFO, CINAHL and Medline) to find studies concerning the use, effectiveness and potential harm of alternative medical hyperthermia therapy on cancer patients. From all 47,388 search results, 53 publications concerning 53 studies with 2006 patients were included in this systematic review. The patients were diagnosed with different types of cancer. The hyperthermic methods included whole-body hyperthermia (WBH) with different methods and electro hyperthermia (EH). The majority of the included studies were single-arm studies, counting in total 32 studies. Six studies were randomized controlled trials (RCT). In addition, one systematic review (SR) was found. The most critical endpoints were tumour response, survival data, pain relief, myelosuppression and toxicities. Outcome was heterogeneous, and considering the methodological limitations, clinical evidence for the benefit of alternative hyperthermia in cancer patients is lacking. Neither for whole-body hyperthermia nor for electro hyperthermia there is any evidence with respect to improvement of survival or quality of life in cancer patients.

The Role of Hyperthermia in the Treatment of Peritoneal Surface Malignancies

PURPOSE OF REVIEW

Hyperthermia is used to treat peritoneal surface malignancies (PSM), particularly during hyperthermic intraperitoneal chemotherapy (HIPEC). This manuscript provides a focused update of hyperthermia in the treatment of PSM.

RECENT FINDINGS

The heterogeneous response to hyperthermia in PSM can be explained by tumor and treatment conditions. PSM tumors may resist hyperthermia via metabolic and immunologic adaptation. The thermodynamics of HIPEC are complex and require computational fluid dynamics (CFD). The clinical evidence supporting the benefit of hyperthermia is largely observational. Continued research will allow clinicians to characterize and predict the individual response of PSM to hyperthermia. The application of hyperthermia in current HIPEC protocols is mostly empirical. Thus, modeling heat transfer with CFD is a necessary task if we are to achieve consistent and reproducible hyperthermia. Although observational evidence suggests a survival benefit of hyperthermia, no clinical trial has tested the individual role of hyperthermia in PSM.

The oncoprotective fever hypothesis: Have antibiotics, antimalarials and antipyrectics contributed to the global rise in cancer over the past century?

The adaptive and therapeutic nature of fever has been recognized for centuries and both local and systemic thermotherapy are now used to enhance the effectiveness of both chemotherapy and radiation therapy for cancer. We propose that the success of antiseptic, antibiotic, antipyretic and antimalarial strategies and medications over the past century and a half may have had the unintended effect of releasing precancerous growths and neoplastic foci from the inhibitory effects of intermittent fever. This may be a previously unrecognized factor in the overall rise in cancer rates in the late 19th and early 20th centuries.

Whole-body hyperthermia combined with chemotherapy and intensity-modulated radiotherapy for treatment of advanced nasopharyngeal carcinoma: a retrospective study with propensity score matching

BACKGROUND

Several studies have reported the combination of intracavity or cervical lymph node hyperthermia with chemoradiotherapy (CRT) to improve clinical outcomes in nasopharyngeal carcinoma (NPC), but the combination with whole-body hyperthermia (WBH) for treating NPC is unexplored. We aimed to assess the efficacy of the combination of radiotherapy, chemotherapy and WBH in patients with locoregionally advanced NPC.

METHODS

Between July 2008 and November 2012, 239 newly diagnosed NPC patients were enrolled in a pre-propensity score-matched cohort, including 193 patients who received CRT (CRT group) and 46 who underwent CRT with WBH (HCRT group). The feasibility and clinical outcomes of both groups were evaluated and toxicities assessed. Survival rates were assessed using the Kaplan-Meier method, log-rank test and Cox regression.

RESULTS

Following propensity score matching, 46 patients from each group were included. The 5-year overall survival (OS) rates were 65.2% in the CRT group and 80.3% in the HCRT group (p=.027). In contrast, the other survival outcomes at 5 years were similar between the groups: locoregional recurrence-free survival (LRRFS), 74.7% vs. 87.6% (p=.152); distant metastasis-free survival (DMFS), 67.4% vs. 77.9% (p=.125); and progression-free survival (PFS), 53.1% vs. 69.2% (p=.115). In the multivariate analyses, the only two independent predictors of OS were clinical stage and HCRT.

CONCLUSIONS

These results suggest that WBH, when combined with CRT, can improve the OS of patients with advanced NPC.

Bioactive glasses and glass-ceramics for hyperthermia treatment of cancer: state-of-art, challenges, and future perspectives

Bioactive glasses and glass-ceramics are well-proven potential biomaterials for bone-tissue engineering applications because of their compositional flexibility. Many research groups have been focused to explore the utility of bioactive glass-ceramics beyond bone engineering to hyperthermia treatment of cancer. Hyperthermia refers to raising the temperature of tumor close to 44°C at which malignant cells perish with negligible harm to normal cells. Hyperthermia can be employed by many means such as by ultrasonic waves, electromagnetic waves, infrared radiations, alternating magnetic fields, etc. Magnetic bioactive glass-ceramics are advantageous over other potential candidates for thermoseeds such as nanofluids, superparamagnetic nanoparticles because they can bond not only to the natural bone but also with soft tissues in few cases, which helps regenerating the affected part due to its bioactive nature. Strict restrictions on clinical settings ( H × f < 5 × 10 9 ) force the research activities to be more focused on material characteristics to raise the implant temperature to required ranges. Lots of efforts have been made in past years to tackle these challenges and design best-suited glass-ceramics for hyperthermia treatment. This review aims to provide essential information on the concept of hyperthermia treatment of cancer and recent developments in the field of bioactive glass-ceramics for cancer treatment. The advantages and disadvantages of magnetic glass-ceramics over other potential thermoseed materials are highlighted. In this field, the major challenges are to develop magnetic glasses, which have fast and bulk crystallization with optimized magnetic phases with lower Curie and Neel temperatures.

Quo Vadis Oncological Hyperthermia (2020)?

Heating as a medical intervention in cancer treatment is an ancient approach, but effective deep heating techniques are lacking in modern practice. The use of electromagnetic interactions has enabled the development of more reliable local-regional hyperthermia (LRHT) techniques whole-body hyperthermia (WBH) techniques. Contrary to the relatively simple physical-physiological concepts behind hyperthermia, its development was not steady, and it has gone through periods of failures and renewals with mixed views on the benefits of heating seen in the medical community over the decades. In this review we study in detail the various techniques currently available and describe challenges and trends of oncological hyperthermia from a new perspective. Our aim is to describe what we believe to be a new and effective approach to oncologic hyperthermia, and a change in the paradigm of dosing. Physiological limits restrict the application of WBH which has moved toward the mild temperature range, targeting immune support. LRHT does not have a temperature limit in the tumor (which can be burned out in extreme conditions) but a trend has started toward milder temperatures with immune-oriented goals, developing toward immune modulation, and especially toward tumor-specific immune reactions by which LRHT seeks to target the malignancy systemically. The emerging research of bystander and abscopal effects, in both laboratory investigations and clinical applications, has been intensified. Our present review summarizes the methods and results, and discusses the trends of hyperthermia in oncology.

Combination Therapy with Cinnamaldehyde and Hyperthermia Induces Apoptosis of A549 Non-Small Cell Lung Carcinoma Cells via Regulation of Reactive Oxygen Species and Mitogen-Activated Protein Kinase Family

Lung cancer is the largest cause of cancer-induced deaths. Non-small cell lung cancer (NSCLC) is the most frequently observed subtype of lung cancer. Although recent studies have provided many therapeutic options, there is still a need for effective and safe treatments. This paper reports the combined effects of cinnamaldehyde (CNM), a flavonoid from cinnamon, together with hyperthermia, a therapeutic option for cancer treatment, on the A549 NSCLC cell line. A hyperthermia treatment of 43 °C potentiated the cytotoxicity of CNM in A549 cells. This was attributed to an increase in the apoptosis markers and suppression of the survival/protective factors, as confirmed by Western blot assays. Flow cytometry supported this result because the apoptotic profile, cell health profile, and cell cycle profile were regulated by CNM and hyperthermia combination therapy. The changes in reactive oxygen species (ROS) and its downstream target pathway, mitogen-activated protein kinases (MAPK), were evaluated. The CNM and hyperthermia combination increased the generation of ROS and MAPK phosphorylation. N-acetylcysteine (NAC), a ROS inhibitor, abolished the apoptotic events caused by CNM and hyperthermia co-treatment, suggesting that the cytotoxic effect was dependent of ROS signaling. Therefore, we suggest CNM and hyperthermia combination as an effective therapeutic option for the NSCLC treatment.

EPR hyperthermia of S. cerevisiae using superparamagnetic Fe3O4 nanoparticles

Presently we communicate a newly developed method of resonant radiofrequency heating, applicable in hyperthermal therapy. This method uses electron paramagnetic resonance (EPR) to transform the electromagnetic field energy into heat. We report the growth dynamics of the S. cerevisiae yeast cells exposed to EPR heating with superparamagnetic magnetite (Fe₃O₄) nanoparticles, with only 4% of yeast cells surviving hyperthermia. Given that EPR functions independently of type of the biologic species exposed, and produces spatially localized heating in conjunction with MRI hardware, it may be used in hyperthermal therapy of cancer and other diseases.

Water-filtered infrared-A (wIRA) overcomes swallowing disorders and hypersalivation - a case report

Case description: A patient with a Barrett oesophageal carcinoma and a resection of the oesophagus with gastric pull-up developed swallowing disorders 6 years and 2 months after the operation. Within 1 year and 7 months two recurrences of the tumor at the anastomosis were found and treated with combined chemoradiotherapy or chemotherapy respectively. 7 years and 9 months after the operation local tumor masses and destruction were present with no ability to orally drink or eat (full feeding by jejunal PEG tube): quality of life was poor, as saliva and mucus were very viscous (pulling filaments) and could not be swallowed and had to be spat out throughout the day and night resulting in short periods of sleep (awaking from the necessity to spit out). In total the situation was interpreted more as a problem related to a feeling of choking (with food or fluid) in the sense of a functional dysphagia rather than as a swallowing disorder from a structural stenosis. At that time acetylcysteine (2 times 200 mg per day, given via the PEG tube) and irradiation with water-filtered infrared-A (wIRA), a special form of heat radiation, of the ventral part of the neck and the thorax were added to the therapy. Within 1 day with acetylcysteine saliva and mucus became less viscous. Within 2 days with wIRA (one day with 4 to 5 hours with irradiation with wIRA at home) salivation decreased markedly and quality of life clearly improved: For the first time the patient slept without interruption and without the need for sleep-inducing medication. After 5 days with wIRA the patient could eat his first soft dumpling although drinking of fluids was still not possible. After 2½ weeks with wIRA the patient could eat his first minced schnitzel (escalope). Following the commencement of wIRA (with typically approximately 90-150 minutes irradiation with wIRA per day) the patient had 8 months with good quality of life with only small amounts of liquid saliva and mucus and without the necessity to spit out. During this period the patient was able to sleep during the night. Discussion: The main physiological effects of water-filtered infrared-A (wIRA) are: wIRA increases tissue temperature, tissue oxygen partial pressure and tissue perfusion markedly. The five main clinical effects of wIRA are: wIRA decreases pain, inflammation and exudation/hypersecretion, and promotes infection defense and regeneration, all in a cross-indication manner. Therefore there is a wide range of indications for wIRA. The effects of wIRA are based on both its thermal effects (relying on transfer of heat energy) and thermic effects (temperature-dependent effects, occurring together with temperature changes) as well as on non-thermal and temperature-independent effects like direct effects on cells, cell structures or cell substances. Conclusion: Besides in a variety of other indications for wIRA, in cases of swallowing disorders (functional dysphagia) and hypersalivation or hypersecretion of mucus the use of wIRA should be considered as part of the treatment regime for improving a patient's quality of life.

Functional and Transcriptomic Characterization of Peritoneal Immune-Modulation by Addition of Alanyl-Glutamine to Dialysis Fluid

Peritonitis remains a major cause of morbidity and mortality during chronic peritoneal dialysis (PD). Glucose-based PD fluids reduce immunological defenses in the peritoneal cavity. Low concentrations of peritoneal extracellular glutamine during PD may contribute to this immune deficit. For these reasons we have developed a clinical assay to measure the function of the immune-competent cells in PD effluent from PD patients. We then applied this assay to test the impact on peritoneal immune-competence of PD fluid supplementation with alanyl-glutamine (AlaGln) in 6 patients in an open-label, randomized, crossover pilot trial (EudraCT 2012-004004-36), and related the functional results to transcriptome changes in PD effluent cells. Ex-vivo stimulation of PD effluent peritoneal cells increased release of interleukin (IL) 6 and tumor necrosis factor (TNF) α. Both IL-6 and TNF-α were lower at 1 h than at 4 h of the peritoneal equilibration test but the reductions in cytokine release were attenuated in AlaGln-supplemented samples. AlaGln-supplemented samples exhibited priming of IL-6-related pathways and downregulation of TNF-α upstream elements. Results from measurement of cytokine release and transcriptome analysis in this pilot clinical study support the conclusion that suppression of PD effluent cell immune function in human subjects by standard PD fluid is attenuated by AlaGln supplementation.

Evaluation of the Septifast MGrade Test on Standard Care Wards--A Cohort Study

Background

The immediate need for appropriate antimicrobial therapy in septic patients requires the detection of the causative pathogen in a timely and reliable manner. In this study, the real-time PCR Septifast M^Grade test was evaluated in adult patients meeting the systemic inflammatory response syndrome (SIRS) criteria that were treated at standard care wards.

Methods

Patients with clinical suspected infection, drawn blood cultures (BC), the Septifast M^Grade test (SF) and sepsis biomarkers were prospectively screened for fulfillment of SIRS criteria and evaluated using the criteria of the European Centre of Disease Control (ECDC) for infection point prevalence studies.

Results

In total, 220 patients with SIRS were prospectively enrolled, including 56 patients with detection of bacteria in the blood (incidence: 25.5%). BC analysis resulted in 75.0% sensitivity (95% confidence interval, CI: 61.6%– 85.6%) with 97.6% specificity (CI: 93.9%– 99.3%) for detecting bacteria in the blood. In comparison to BC, SF presented with 80.4% sensitivity (CI: 67.6%– 89.8%) and with 97.6% specificity (CI: 93.9%– 99.3%). BC and SF analysis yielded comparable ROC-AUCs (0.86, 0.89), which did not differ significantly (p = 0.558). A trend of a shorter time-to-positivity of BC analysis was not seen in bacteremic patients with a positive SF test than those with a negative test result. Sepsis biomarkers, including PCT, IL-6 or CRP, did not help to explain discordant test results for BC and SF.

Conclusion

Since negative results do not exclude bacteremia, the Septifast M^Grade test is not suited to replacing BC, but it is a valuable tool with which to complement BC for faster detection of pathogens.

HSP90 and Immune Modulation in Cancer

Heat-shock protein 90 (HSP90) is a highly conserved molecular chaperone that plays prominent functional roles in nearly all aspects of cell biology. As a chaperone, it interacts with literally hundreds of "clients," many of which are important drivers, regulators, and promoters of cancer. Thus, HSP90 is a high-value target in the development of anticancer therapeutics. Despite its popularity, our overall knowledge of HSP90 in immune function has lagged behind its well-recognized tumor-supportive roles. The use of inhibitors of HSP90 as chemical biological probes has been invaluable in revealing important roles for the chaperone in multiple aspects of immune function. Given this critical link, we must now consider the question of how immune outcomes may be affected by the HSP90 inhibitors currently in clinical development for the treatment of cancer. This chapter will review some of the immunological aspects of HSP90 function in terms of its intracellular and extracellular roles in antigen presentation, immune effector cell tasks, and regulation of inflammatory processes. This review will further examine the value of HSP90 inhibitors within the context of cancer immunotherapy and will discuss how these drugs might be optimally utilized in combination with immune stimulatory approaches against cancer.

The impact of tracheotomy on levels of procalcitonin in patients without sepsis: a prospective study

OBJECTIVE

Procalcitonin is a reliable biomarker of infection and sepsis. We aimed to determine whether tracheotomy influences the procalcitonin concentrations in patients without sepsis and assess whether operative duration and procedure affect the peak procalcitonin level.

METHODS

A total of 38 non-septic patients who required a tracheotomy underwent either a percutaneous dilatational tracheotomy (n=19) or a surgical tracheotomy (n=19). Procalcitonin levels were measured at the beginning of the tracheotomy and at 2 h, 4 h, 8 h, 24 h, 48 h and 72 h after the procedure.

RESULTS

The baseline procalcitonin concentration before the tracheotomy was 0.24 ± 0.13 ng/mL. The postoperative levels increased rapidly, with a 4-fold elevation after 2 h, reaching a peak 4 h later with a 5-fold increase over baseline. Thereafter, the levels gradually returned to 2-fold greater than the baseline level within 72 h. The peak levels of procalcitonin showed a significant positive correlation with operative durations (r=0.710, p<0.001) and procedures (rho=0.670, p<0.001).

CONCLUSION

In patients without sepsis, tracheotomy induces a rapid release of serum procalcitonin, and the operative duration and procedure have significant impacts on the peak procalcitonin levels. Thus, the nonspecific increase in procalcitonin levels following tracheotomy needs to be considered when this measure is used to evaluate infection.

Pyrexia: An update on importance in clinical practice

Pyrexic patients are usually attended with some scepticism by anaesthesiologists. Main reasons are the absence of comprehensible guidelines pertaining to anaesthesia in such patients and the presence of innumerable aetiologies of pyrexia. This article has tried to fill the existing void in the medical literature regarding anaesthesia in a patient with pyrexia. The article aims to discuss common and relevant causes of pyrexia, their pathophysiology in anaesthetic perspective, and the subsequent anaesthetic management, though a detailed discourse on all the entities causing pyrexia is beyond the scope of this article. This article will also touch upon the thermoregulatory alterations during anaesthesia. The literature search was performed manually using text and reference books, peer-reviewed journals, online and offline and through internet search engines Google, PubMed and Medline databases, using search terms ‘perioperative pyrexia or fever, anaesthesia and thermoregulation’. Articles from 1980 to 2013 in English language were selected.

Extreme Procalcitonin Elevation without Proven Bacterial Infection Related to Amphetamine Abuse

Systemic inflammatory response with rhabdomyolysis and consequent multiorgan failure is a known sequela of psychotropic drug abuse. However, in cases with uncertain past medical history the initial diagnosis can be challenging. Here we report the case of a 21-year-old male who was admitted to the intensive care unit with severe neurological impairment caused by amphetamine intoxication. First laboratory investigations revealed extremely high serum procalcitonin (PCT) levels reaching a maximum concentration of 1640 ng/mL on the second day of observation. Although PCT has high sensitivity and specificity in differentiating bacterial sepsis from nonbacterial inflammation, our case report shows for the first time that it can be extremely elevated following serious amphetamine intoxication without bacterial infection.